Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rowan Community, Inc during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and diabetes, who was cognitively intact and dependent on staff for ADLs, had posted signs requesting staff to knock and wear a face mask before entering her room. Despite these clear instructions and the availability of masks, staff were observed entering without knocking or wearing a mask, and the resident's preferences were not included in her care plan. The resident expressed feeling disrespected by these actions, and staff interviews confirmed the failure to consistently honor her wishes.
A resident with a history of TBI, seizures, and chronic respiratory failure, who was cognitively intact and dependent on staff, was not assisted to return to his room despite repeated requests to multiple staff members. The resident waited over an hour in the dining room, becoming increasingly distressed, while staff either did not respond or failed to follow through on his requests.
Two dependent residents did not receive timely repositioning or incontinence care as required by their care plans. One resident with significant physical and cognitive needs remained in a saturated urine brief for nearly two hours without assistance, while another resident with severe cognitive impairment was left in the same wheelchair position for over two and a half hours. Staff interviews and documentation confirmed that care was not provided as frequently as protocols required.
A resident with a history of frequent falls and neurodegenerative disease experienced multiple falls due to the facility's failure to consistently review incidents in a timely manner, identify specific root causes, and ensure that care-planned interventions such as assistive devices and supervision were in place. Observations showed missing safety equipment and delayed staff response, while staff interviews revealed gaps in communication and documentation of fall prevention measures.
A resident with a history of bipolar disorder and suicidal ideation experienced multiple incidents of self-harm and suicidal thoughts after the facility failed to timely update the care plan with safety interventions recommended following hospitalizations. The care plan did not include crisis/safety plan measures, follow-up with behavioral health providers was lacking, and monitoring interventions were inconsistently documented, resulting in repeated behavioral health crises.
Two residents experienced a lack of privacy and dignity during care, with staff entering rooms without knocking or identifying themselves and leaving doors open during personal care. Both residents also faced significant delays in call light response, with documented waits exceeding 20 to 60 minutes and, in some cases, over an hour. Staff interviews confirmed inconsistent practices regarding privacy and call light response, and there was no immediate plan to address these issues.
A facility failed to document and resolve grievances submitted by a resident's representative, including concerns about staff communication and improper wheelchair positioning. Grievance forms lacked documentation of actions taken or communication with the representative, and staff had not been trained on proper positioning. Updated forms were later signed by the resident, but there was no evidence the representative was notified or approved the resolutions.
A resident with multiple diagnoses and limited ROM did not receive appropriate contracture management due to the facility's failure to implement and document a physician's order for a foot drop boot. The care plan lacked documentation for the boot, the order was not scheduled in the MAR/TAR, and staff did not consistently apply the device, resulting in missed preventive measures for the resident's right foot.
A resident who was cognitively intact and required assistance with daily activities did not receive timely dental services to address ill-fitting dentures and exposed dental implants. Although a dental provider recommended referral to a specialty clinic for implant removal and new dentures, there was no documented follow-up or communication to ensure the resident received the necessary care.
Two residents receiving hospice care did not have consistent documentation of hospice provider visits or communication between facility and hospice staff, resulting in missing records of care and unresolved equipment needs. Staff interviews revealed inconsistent practices for documenting hospice visits and challenges in accessing hospice notes, leading to gaps in the residents' medical records.
Housekeeping staff did not follow proper infection control procedures, including failing to disinfect all high-touch areas, not using separate rags for each resident area in double occupancy rooms, and not performing hand hygiene with glove changes. Supervisory staff confirmed these lapses, and the facility's policy requiring these practices was not followed.
A resident with significant neurodegenerative and communication impairments was subjected to verbal and physical abuse by two CNAs, who handled the resident roughly, used aggressive language, and failed to follow the care plan's communication and dignity interventions. Video evidence confirmed the rough handling and lack of privacy during care, and the facility substantiated the abuse allegation.
A resident on antipsychotic medication with a history of movement disorders exhibited involuntary lip-smacking movements, but staff failed to complete required quarterly AIMS assessments for eight months and did not document monitoring for medication side effects, resulting in a deficiency related to inadequate monitoring for tardive dyskinesia.
The facility failed to maintain an effective infection control program, with deficiencies in housekeeping practices, staff hand hygiene, and handling of shared medical equipment. Housekeeping staff did not disinfect high-touch areas or perform hand hygiene appropriately. CNAs used vital signs machines and mechanical lifts without sanitizing them between residents. During meal service, residents were not offered hand hygiene, and a hospice volunteer assisted residents without performing hand hygiene. These lapses were confirmed through staff interviews.
The facility failed to properly secure medication rooms and carts, leaving them unlocked and unattended. A medication room and treatment cart were found unlocked, and a nurse left a medication cart unattended multiple times without ensuring it was properly locked, leaving drawers accessible. The DON confirmed the importance of locking medication storage areas when not in direct sight of a responsible nurse.
The facility failed to serve palatable and appropriately tempered food, as reported by residents and observed by surveyors. Residents complained of cold, bland, and unappetizing meals, with some not offered alternatives. A test tray evaluation confirmed poor food quality, and the dietary manager cited issues with a new distributor and budget constraints.
The facility failed to provide a resident and their legal representative timely access to medical records, taking approximately 30 days to respond to the first request and not providing all requested documents. Despite multiple requests and grievances, the facility did not meet the requirement of providing records within two working days.
The facility failed to promptly resolve grievances for two residents, including issues with cold meals and fear of retaliation. The grievance policy lacked necessary elements, and written responses were not provided.
A resident with schizophrenia and other health issues did not receive appropriate hygiene care due to the facility's failure to implement person-centered interventions. Despite the resident's preference for a male CNA and fear of falling, the facility did not ensure consistent assistance, leading to poor hygiene. Staff were aware of the resident's needs but did not document or implement effective strategies to address his refusals.
A resident with multiple sclerosis and functional quadriplegia did not receive the necessary assistance for personal hygiene, including scheduled showers and the use of prescribed medicated shampoo. Despite being cooperative, the resident only received five out of eight scheduled showers, and staff were unaware of the medicated shampoo order. Documentation did not reflect any refusals or interventions, indicating a failure to adhere to the care plan.
A resident with autism, dysphagia, and chronic respiratory failure did not receive appropriate care for enteral feeding. An RN failed to follow professional standards by not liquefying crushed medications, not flushing the gastric tube between medications, and using an outdated method to check tube placement. Additionally, the RN did not check for gastric residuals before starting tube feeding, contrary to physician's orders. These actions led to a deficiency in the resident's care.
A resident with chronic pain conditions, including cerebral palsy and diabetic polyneuropathy, reported severe pain levels but only received scheduled Tylenol without any non-pharmacological interventions. The facility's pain management policy was not followed, as staff failed to document or offer alternative pain relief methods, leading to inadequate pain management.
Failure to Honor Resident's Dignity and Preferences for Staff Conduct
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's right to dignity and respect by not adhering to her expressed preferences regarding staff conduct upon entering her room. The resident, who was under 65 years old with diagnoses including bipolar disorder, chronic respiratory failure, and type 2 diabetes mellitus, was cognitively intact and dependent on staff for activities of daily living. Despite clear handwritten signs on her door requesting that staff knock, announce themselves, and wear a face mask before entering (with masks readily available in her room), staff members were observed entering without knocking or wearing a mask. The resident reported feeling horrible and disrespected when staff entered without following her preferences, which were not documented in her care plan. Interviews with staff and the nursing home administrator confirmed that the resident's wishes were known but not consistently communicated or implemented in the care plan. The administrator acknowledged that staff should have knocked and worn masks as requested, and that these preferences should have been included in the resident's care plan to ensure consistent care.
Failure to Honor Resident's Choice to Return to Room
Penalty
Summary
A resident under the age of 65 with a history of traumatic brain injury, post-traumatic seizures, and chronic respiratory failure, who was cognitively intact and dependent on staff for activities of daily living, was not assisted to return to his room despite multiple requests. During a continuous observation in the dining room, the resident initially asked a staff member to help him return to his room and was told to wait 15 minutes due to room cleaning. Over the next hour, the resident made repeated requests to various staff members, including housekeeping, the activities director, and kitchen staff, but was not assisted. Some staff did not respond, while others said they would find help but did not follow through. The resident became increasingly distressed, eventually shouting and expressing a desire to leave the dining room. The resident later reported that he often had to wait long periods to return to his room, which made him feel bad. The nursing home administrator confirmed that the facility should have honored the resident's choices and indicated that the staff member who initially told the resident to wait likely forgot to follow up. The facility failed to facilitate the resident's self-determination and did not honor his choice to return to his room for over an hour after his initial request.
Failure to Provide Timely Repositioning and Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain activities of daily living (ADL) for two dependent residents. One resident, under 65 years old with diagnoses including traumatic brain injury, post-traumatic seizures, and chronic respiratory failure, was observed sitting in a geri chair in the dining room for nearly two hours without repositioning or incontinence care. Despite expressing discomfort and requesting assistance, staff did not respond promptly, and the resident remained in a saturated urine brief until a CNA arrived and provided care. Documentation and interviews confirmed that incontinence care was not provided as frequently as required by the resident's care plan, which specified perineal care after each incontinent episode and frequent checks. Another resident, over 65 years old with Huntington's disease, dementia, and other behavioral and movement disorders, was observed sitting in a wheelchair at a dining room table for over two and a half hours without being repositioned or offered repositioning. The resident's care plan indicated a need for assistance with repositioning, but staff interviews revealed a belief that the resident could offload her own weight and move herself if needed. However, observations contradicted this, as the resident remained in the same position for an extended period. These failures were documented through direct observation, record review, and staff and resident interviews. The deficiencies involved not adhering to care plans and established protocols for timely repositioning and incontinence care, resulting in prolonged periods without necessary assistance for both residents.
Failure to Provide Adequate Supervision and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a resident at high risk for falls received adequate supervision and assistive devices to prevent accidents, as required by policy. The resident, who had a history of progressive supranuclear ophthalmoplegia, repeated falls, muscle weakness, and cognitive communication deficits, experienced 21 falls over a four-month period. Despite the facility's interdisciplinary team (IDT) meeting after each fall to determine root causes and implement interventions, reviews were often delayed, and interventions were not always specific or consistently implemented. For 19 of the 21 falls, the root cause was repeatedly documented as "poor safety awareness" without further analysis to identify more precise contributing factors. Observations during the survey revealed that several care-planned interventions were not in place. The resident was found without a helmet, grip tape on the floor, or a "call don't fall" sign in the room, all of which were documented interventions. The resident's call light was found on the floor and out of reach, requiring the resident to move dangerously close to the edge of the bed to access it. Staff did not consistently notice or address the resident's proximity to fall hazards, and the resident reported that call lights were not answered in a timely manner. Additionally, there was no documentation that the medical director reviewed the resident's medications for fall risk after a significant fall, as was care-planned. Interviews with staff and the resident's representative highlighted further deficiencies in supervision and communication. The resident's representative reported long periods without staff checks and the removal of a transfer pole, which was not clearly documented or evaluated for effectiveness. Staff interviews revealed inconsistent understanding and documentation of fall risk interventions, and there was no system in place to track the completion of frequent checks. The facility lacked a specific fall committee, and floor staff were not included in daily discussions of falls and interventions, leading to gaps in communication and implementation of care plans.
Failure to Implement Timely Behavioral Health Safety Interventions
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of bipolar disorder, dissociative disorder, and previous suicidal ideation with self-harm. Despite documented behaviors such as agitation, verbal reactivity, and frequent calls to emergency services, the facility did not implement or update a safety plan in the resident's care plan after multiple hospitalizations for suicidal ideation and self-harm incidents. The resident experienced three separate incidents of suicidal ideation and two attempts to cut her wrists with scissors over a period of less than two months, yet crisis/safety plan interventions were not timely incorporated into her care plan following her returns from the hospital. The care plan in place addressed some behavioral concerns but failed to include specific safety interventions recommended after hospital discharges, such as identifying warning signs, internal coping strategies, and environmental safety measures like removing access to sharp objects. There was also a lack of documentation of follow-up with behavioral health providers after hospitalizations, and suicide risk assessments were not completed prior to the resident's suicide attempts. Monitoring interventions, such as frequent 15-minute checks, were inconsistently documented, and the care plan did not reflect changes in monitoring tools, such as the discontinuation of a wanderguard or camera, nor did it specify alternative safety measures. Staff interviews revealed uncertainty about the implementation of safety interventions and communication with behavioral health providers. The facility's own policy required individualized behavioral health services and timely updates to care plans based on comprehensive assessments, but these were not followed. The lack of timely coordination and implementation of person-centered behavioral and safety interventions resulted in repeated incidents of suicidal ideation and self-harm for the resident.
Failure to Ensure Resident Dignity and Timely Call Light Response
Penalty
Summary
The facility failed to ensure the right to a dignified existence and timely response to call lights for two residents. One resident, a 65-year-old with multiple neurodegenerative conditions and cognitive intactness, was observed without privacy during care, with staff entering his room without knocking or identifying themselves, and leaving his door open during personal care. The resident reported feeling disrespected, with staff speaking to him in an aggressive manner and not waiting for his responses, and his representative confirmed repeated instances of lack of privacy and long waits for assistance. Documentation showed that the call light was inaccessible at times and that response times exceeded 20 minutes in 39.3% of calls, and over 60 minutes in another 39.3% of calls, with one instance where the call light was not answered for over an hour and a half. Another resident, who was dependent on staff for all activities of daily living due to multiple sclerosis and other impairments, also experienced significant delays in call light response. The resident reported feeling that using the call light was pointless due to long wait times, sometimes resulting in being left soiled. The call light system data indicated that staff response time exceeded 30 minutes in 24.4% of calls, with some waits as long as 266 minutes. The resident's representative corroborated these concerns, stating that the resident would call her for help when staff did not respond, and that she had to contact the facility herself to request assistance for the resident. Staff interviews revealed inconsistent practices regarding privacy and call light response. Some CNAs stated they closed doors and provided privacy, while others did not consistently follow these procedures. Staff acknowledged that answering call lights promptly was challenging during certain times, such as meals or shift changes, and that there was a lack of clear direction or support for managing high call light volumes. The DON confirmed that everyone was responsible for answering call lights, but also noted that review of call light response times was not consistently performed, and there was no immediate plan to address the delays.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain a system for documenting grievances and demonstrating prompt actions to resolve them, as required by its own grievance policy. The policy stated that residents or their representatives must be informed of the findings of any grievance investigation and corrective actions within ten working days. However, for one resident, the facility did not document the steps taken to address or resolve grievances submitted by the resident's representative, nor did it show evidence of communication with the representative regarding the outcomes. The resident's representative reported filing several grievances, including concerns about staff communication and the resident's head support in her wheelchair. She stated that she was not informed of any resolutions and was unaware of who was responsible for handling grievances at the facility. Observations confirmed that the resident was poorly positioned in her wheelchair, and staff interviews revealed that the head support was not included in the care plan or Kardex, and staff had not been trained on proper positioning after the grievance was filed. A review of the grievance forms showed that while the concerns were documented, the sections for actions taken and follow-up were left blank. There was no documentation of outreach to the resident's representative or resolution of the grievances. Although updated forms were later provided with signatures and notes indicating resolution, these were signed by the resident rather than the representative who submitted the grievances, and there was no evidence that the representative was notified or approved the resolutions.
Failure to Provide and Document Ordered Foot Drop Boot for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services as required by facility policy and physician orders. The resident, who had multiple diagnoses including multiple sclerosis, peripheral vascular disease, and contractures, was dependent on staff for activities of daily living and had documented impairments in both upper and lower extremities. Although the care plan included restorative nursing interventions such as passive ROM and splint or brace assistance, it did not document the use of a foot drop boot for the right lower extremity, despite a physician's order for its use. Observations revealed that the resident had two soft heel boots in her room but was not wearing them, stating that only two staff members knew how to apply them correctly and that improper application by others caused her pain. On multiple occasions, the resident was observed in her wheelchair with only socks on her feet, and the boots remained unused on a chair. When offered the boot by the DON, the resident declined and instead accepted a pillow under her feet for comfort. Record review showed that the physician's order for the foot drop boot was not scheduled with a frequency, resulting in its omission from the MAR and TAR, and there was no documentation of administration or refusal of the boot in the EMR. Staff interviews confirmed that the order was not scheduled and therefore not tracked for administration, and that staff relied on the care plan and physician orders for restorative services. The lack of documentation and implementation of the physician's order for the foot drop boot constituted a failure to provide necessary preventive measures for the resident's right foot.
Failure to Arrange Timely Dental Services for Resident Needing Denture Replacement
Penalty
Summary
The facility failed to ensure timely dental services for one resident who required removal of permanent dental implants in order to be fitted with new lower dentures. The resident, who was cognitively intact and required assistance with daily activities, reported that her lower snap-in dentures did not fit properly and that her upper dentures were loose, making it difficult for her to chew. Observations confirmed that the resident had two screws implanted in her lower gums and had to frequently adjust her upper dentures. The care plan documented the resident as edentulous and included general interventions for dental care, but did not include any follow-up or plan to address the issues with her lower dentures or to replace the snap-in dentures. A dental provider's progress note indicated that the resident's upper and lower dentures were several years old, that she no longer wore the lower denture due to discomfort from exposed dental implants, and that she wanted the implants removed and new dentures made. The plan was to refer her to a specialty dental clinic for implant removal. However, a review of the electronic medical record did not reveal any documentation of communication with the specialty clinic or with the resident's representative to coordinate care for her dentures. Staff interviews confirmed that, although a referral was intended, there was no evidence of timely follow-up or documentation to ensure the resident received the necessary dental services.
Failure to Ensure Communication and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services provided to two residents met professional standards and principles, specifically in the areas of communication and documentation between the facility and the hospice provider. The facility did not establish a consistent process for documenting communication with the hospice agency, nor did it ensure that hospice staff notes were easily accessible to facility staff. For both residents, there was no documentation in the electronic medical record of hospice provider visits over a period of several weeks, despite care plans indicating regular hospice nurse and CNA visits. One resident, under the age of 65 with advanced Huntington's disease and other significant diagnoses, was noted to have severe cognitive impairment and was receiving hospice services. The resident's representative expressed frustration with the lack of communication regarding the replacement of a broken Broda chair, which had been unresolved for several weeks. Although a hospice nurse was observed interacting with the resident's representative, there was no documentation of this visit in the facility's records. Additionally, there was no documentation confirming the delivery of a new chair, despite care plan interventions and interdisciplinary notes indicating hospice was to provide one. Another resident, over the age of 65 with multiple chronic conditions and cognitive impairment, was also receiving hospice services. The care plan called for regular hospice nurse and CNA visits, but the facility's records did not contain documentation of any hospice provider visits for over a month. Staff interviews revealed inconsistent practices regarding hospice staff check-ins and documentation, with hospice staff sometimes unable to access the designated binder for notes and not consistently leaving progress notes. Facility leadership acknowledged that hospice notes were sent every two weeks but were not always available in the residents' electronic medical records, further contributing to the lack of accessible and consistent documentation.
Failure to Maintain Effective Infection Control in Housekeeping Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of two units, as evidenced by improper cleaning and disinfection practices by housekeeping staff. Observations revealed that a housekeeper did not follow correct cleaning techniques, such as failing to disinfect high-touch areas like bed remotes, call lights, and light switches, and not using separate clean rags for each side of a double occupancy room. The housekeeper also cleaned the toilet from bottom to top instead of the required top to bottom (clean to dirty) method, and did not consistently perform hand hygiene after glove removal and before donning new gloves. Interviews with the housekeeper and supervisory staff confirmed gaps in knowledge and practice. The housekeeper was unaware of the need to perform hand hygiene with every glove change and did not identify all required high-touch areas for disinfection. Supervisory staff, including the housekeeping supervisor, infection preventionist, and director of nursing, all acknowledged that the correct procedures were not followed, including the use of separate rags for each resident area, proper cleaning sequence for toilets, and the need for hand hygiene with glove changes. The facility's own policy required cleaning all high-touch personal use items with disinfectant and performing hand hygiene after glove removal, which was not adhered to during the observed cleaning process. These failures in cleaning technique, use of supplies, and hand hygiene contributed to the deficiency in the infection prevention and control program.
Failure to Protect Resident from Verbal and Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by two certified nurse aides (CNAs). The resident, who was cognitively intact but had significant physical and communication impairments due to multiple neurodegenerative conditions, required extensive assistance with transfers and toileting. According to interviews and video evidence provided by the resident's representative, the CNAs handled the resident roughly during care, including pulling on his arms, using an aggressive tone, and yanking his t-shirt to force him into a wheelchair. The resident reported feeling disrespected and that staff lacked compassion, often speaking to him aggressively and not allowing adequate time for him to respond due to his communication deficits. The resident's care plans specifically outlined the need for staff to allow adequate time for responses, avoid rushing, and use clear, patient communication methods due to his hearing and speech difficulties. Despite these interventions, the CNAs did not follow the care plan, instead providing care in a hurried and forceful manner. The video evidence also showed that care was provided with the door open and no privacy curtain, further compromising the resident's dignity. Staff interviews indicated that the expectation was to treat residents with respect and dignity, and that staff had received education on these topics. However, the actions of the two CNAs during the incident did not align with these expectations or the facility's abuse prevention policy, which prohibits verbal, mental, or physical abuse by anyone, including staff. The facility substantiated the allegation of physical abuse based on the evidence provided.
Failure to Monitor for Antipsychotic Side Effects and Tardive Dyskinesia
Penalty
Summary
The facility failed to ensure that a resident receiving antipsychotic medication was appropriately and timely monitored for side effects, specifically for signs and symptoms of tardive dyskinesia. The resident, who had diagnoses including depression, vascular dementia, neuroleptic induced parkinsonism, and drug-induced subacute dyskinesia, was observed exhibiting involuntary lip-smacking movements. Despite these symptoms, the facility did not complete the required Abnormal Involuntary Movement Scale (AIMS) assessments at the recommended quarterly intervals, resulting in an eight-month gap between assessments. Facility policy required baseline and quarterly AIMS assessments for residents on antipsychotic medications, as well as additional assessments as needed or as ordered by a physician. The resident's care plan also included monitoring for adverse reactions to psychotropic medications, such as tardive dyskinesia. However, the electronic medical record showed no documentation of monitoring for adverse reactions or side effects during the period in question, and there was no physician order for antipsychotic medication side effect monitoring in the resident's current orders. Staff interviews confirmed that AIMS assessments should be completed quarterly and that it was the responsibility of nursing staff, overseen by the DON, to ensure these assessments were performed. The DON acknowledged that the EMR system failed to alert staff when the assessment was due, resulting in the missed monitoring. The lack of timely and appropriate monitoring for antipsychotic side effects led to the deficiency identified during the survey.
Infection Control Deficiencies in Housekeeping and Staff Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies in housekeeping practices and staff hand hygiene. Observations revealed that housekeeping staff did not follow proper cleaning techniques, such as disinfecting high-touch areas like light switches and door handles. Additionally, the staff did not perform hand hygiene when appropriate, such as between glove changes and after cleaning tasks. These lapses were confirmed through interviews with the housekeeping staff and the maintenance director, who acknowledged the importance of hand hygiene and proper cleaning protocols. Further deficiencies were noted in the handling of shared medical equipment and during medication administration. Certified nurse aides (CNAs) were observed using vital signs machines and mechanical lifts without sanitizing them between uses with different residents. This practice was contrary to the facility's policy, which required sanitization of shared equipment to prevent healthcare-associated infections. Additionally, a registered nurse (RN) failed to perform hand hygiene between handling a resident's feeding tube and administering eye drops, and did not clean the blood pressure cuff or stethoscope after use. The facility also failed to ensure proper hand hygiene during meal service. Residents were not offered the opportunity to clean their hands before meals, and staff did not perform hand hygiene between assisting different residents. An unidentified woman, later identified as a hospice volunteer, assisted multiple residents with their meals without performing hand hygiene, and her actions went unaddressed by the facility staff present. These observations highlight significant lapses in infection control practices, which were corroborated by interviews with the director of nursing and other staff members.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored according to professional standards. Specifically, the medication room on the Aspen hallway was found unlocked, containing prescription medications for multiple residents without the medication nurse maintaining a direct line of sight. Additionally, a treatment cart with medicated supplies was also unlocked and not monitored by the responsible licensed nurse. On another occasion, a registered nurse left a medication cart unattended and unlocked while attending to a resident, and upon returning, failed to ensure the drawers were fully closed, leaving them accessible. Further observations revealed that the medication cart was left outside the dining room without supervision, with some drawers not fully closed and accessible despite the locking mechanism being engaged. The Director of Nursing was informed of the issue but was initially unable to secure the cart. Interviews with the DON, the nursing home administrator, and the corporate director of clinical services confirmed that medication rooms and carts should be locked when not in direct line of sight of the responsible nurse, emphasizing the importance of restricting access to medications to licensed nurses only.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures, as evidenced by resident interviews, observations, and record reviews. Multiple residents reported dissatisfaction with the food, citing issues such as cold temperatures, bland taste, and unappetizing textures. One resident's family representative noted that the resident would stop eating when served food she did not like, and staff did not always offer alternatives. Observations during meal service showed that several residents ate only half or less of their meals without staff inquiring about their lack of appetite or offering alternative meal choices. A test tray evaluation by surveyors revealed that the food served was of poor quality, with mushy shrimp, tough noodles, flavorless green beans, and dry cake. The dietary manager acknowledged the issues, attributing some to a new food distributor and budget constraints. She also noted that tray delivery times were lengthy, contributing to the problem. Despite monthly food committee meetings to address resident concerns, the facility struggled to accommodate all requests, and the food committee notes were not provided during the survey process.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to ensure prompt action was taken to honor a request for the resident's personal and medical records by the resident and legal representative. Specifically, the facility did not allow Resident #52 and the resident's legal representative the right to obtain a copy of the resident's medical records or any portions of the electronically maintained record within two working days of a verbal or written request. Resident #52, who was cognitively intact and had a medical durable power of attorney (MDPOA) for healthcare decisions, experienced anxiety and worry when medical decisions were discussed without her MDPOA present. The MDPOA made multiple requests for medical records, but the facility took approximately 30 days to respond to the first request and did not provide all requested documents. Additionally, the facility did not provide an explanation for the incomplete records and did not resolve the grievance filed by the MDPOA regarding the records request. The MDPOA made another request for records, which was returned by the facility with instructions to rewrite the request on one sheet of paper. Despite the MDPOA's compliance, the facility still did not provide the requested records. The nursing home administrator acknowledged difficulties with records management and stated that a new director of medical records had been hired, but the facility still failed to meet the requirement of providing records within two working days. The facility's actions and inactions led to the deficiency of not honoring the resident's right to access their medical records promptly.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure that two residents were provided prompt efforts to resolve grievances. Resident #209, who was cognitively intact and had a diagnosis of bipolar disorder and generalized anxiety disorder, filed a grievance about meals being served cold. Despite the dietary manager's recommendation for the resident to eat in the dining room, the resident's preference to eat in her room was not taken into account, and no action was taken to address the complaint of cold and unpalatable food. Interviews with staff revealed that delays in meal delivery contributed to the issue, but no satisfactory resolution was provided to the resident. Resident #52, who was also cognitively intact and had diagnoses including bipolar disorder and cerebrovascular disorder, expressed fear of retaliation when filing grievances. The resident reported an incident where a CNA refused to adjust the room temperature and instead provided extra blankets, which was not the resident's preferred solution. The facility's leadership imposed care in pairs as a response, which made the resident anxious and worried about not being believed. The resident and her representative voiced several grievances, but the facility failed to provide written responses or satisfactory resolutions. The facility's grievance policy was found to be lacking in several areas, including the right to file grievances orally or anonymously and the requirement to provide written responses. The policy did not ensure that all written grievance decisions included necessary details such as the date the grievance was received, steps taken to investigate, and corrective actions. The facility's failure to address these grievances promptly and adequately led to the deficiency findings.
Failure to Provide Person-Centered Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #13, received appropriate treatment and services to maintain or improve his abilities in performing activities of daily living (ADL), specifically in maintaining personal hygiene. Resident #13, who is under the age of 65 and has diagnoses including schizophrenia, type II diabetes mellitus, obsessive-compulsive disorder, and morbid obesity, was cognitively intact with a BIMS score of 15 out of 15. Despite being independent with personal hygiene, the resident had not had a shower in over two weeks and was observed to have poor hygiene, including a strong smell of urine and dirty, matted facial hair. The facility's policy required staff to notify a supervisor if a resident refused a shower, but there was no evidence that person-centered interventions were implemented to address Resident #13's refusals. The resident expressed a preference for a male CNA to assist him due to a fear of falling and paranoia about female staff, but the preferred CNA was unavailable. The resident's care plan did not include interventions to address his specific needs and preferences, and the facility's records did not show that the resident was reapproached or that alternative interventions were attempted. Interviews with staff, including the SSA, DON, and ADON, revealed awareness of the resident's hygiene issues and his preferences for assistance. However, despite offering alternatives such as wet wipes and assistance from two staff members, the facility did not document these efforts in the resident's medical record. The medical director acknowledged the resident's hygiene habits were affected by his schizophrenia but had not yet addressed the issue with the resident. The facility's failure to provide consistent and person-centered care resulted in the resident not receiving adequate personal hygiene care.
Failure to Provide Scheduled Showers and Use Prescribed Shampoo
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living independently, specifically in maintaining personal hygiene. The resident, who had multiple sclerosis, dementia, and functional quadriplegia, required extensive assistance for transfers, toilet use, personal hygiene, and bathing. Despite having a physician's order to wash her hair with a medicated shampoo twice a week, the resident only received five showers out of eight scheduled opportunities over a period of several weeks. The resident reported not receiving the prescribed showers and expressed discomfort due to an itchy scalp and feeling unclean. Interviews with staff revealed inconsistencies in the care provided. A CNA admitted to using a different shampoo than prescribed and was unaware of the medicated shampoo order. The CNA also indicated that the resident was cooperative and did not refuse showers, contradicting the bathing record that documented refusals. The RN confirmed that the CNAs were supposed to use the prescribed shampoo, which was to be obtained from the nurse. The facility's documentation did not reflect any refusals or interventions for showering assistance, indicating a lack of adherence to the care plan and physician's orders.
Deficiency in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to provide appropriate care for a resident receiving enteral feeding, leading to a deficiency in the administration of medications and feeding procedures. The resident, who was under 65 years old and diagnosed with autism disorder, dysphagia, and chronic respiratory failure, required enteral feeding due to swallowing difficulties. The facility did not adhere to professional standards and physician's orders in administering medications and checking gastric residuals. During an observation, a registered nurse (RN) was seen administering medications to the resident without following proper procedures. The RN failed to liquefy crushed medications before administration, did not flush the gastric tube with water between medications, and used an outdated method to check tube placement by inserting air and listening with a stethoscope. Additionally, the RN did not check for gastric residuals before starting the tube feeding, as required by the physician's orders. The facility's policies and procedures, as well as professional standards, were not followed, resulting in the potential for complications in the resident's care. The director of nursing confirmed that the correct procedure involves checking gastric residuals before feeding and ensuring medications are properly dissolved and administered separately with adequate water flushes. These lapses in care were identified during interviews with facility staff, highlighting the failure to adhere to established protocols for enteral feeding and medication administration.
Inadequate Pain Management for Resident with Chronic Pain
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident #16, who was experiencing chronic pain due to multiple medical conditions including ataxic cerebral palsy, type 1 diabetes mellitus with diabetic polyneuropathy, chronic pain syndrome, and radiculopathy. Despite the resident's reports of severe pain levels, ranging from 8 to 10 on a scale of 1 to 10, the facility only administered scheduled Tylenol and did not offer any non-pharmacological interventions as outlined in their pain management policy. The facility's pain management policy, revised in May 2023, emphasizes the importance of both pharmacological and non-pharmacological interventions for effective pain management. However, the resident's electronic medical record lacked documentation of any non-pharmacological interventions being offered or attempted, despite the resident's frequent reports of high pain levels. Interviews with the resident revealed dissatisfaction with the pain management provided, as he felt the facility did not take his chronic pain seriously and failed to offer alternative interventions. Staff interviews further highlighted the deficiency in pain management practices. The medical director acknowledged the need for non-pharmacological interventions for certain types of pain, while the director of nursing admitted that the facility had not recently offered such interventions to the resident. Additionally, the certified nurse aide and registered nurse interviewed did not recall discussing the resident's pain in meetings or documenting non-pharmacological interventions, indicating a lack of adherence to the facility's pain management policy.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 513 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amberwood Post Acute | 0 mi | ★★★★★ | 4 | 0 |
| Brookshire Post Acute | 0 mi | ★★★★★ | 3 | 1 |
| South Valley Post Acute Rehabilitation | 0.5 mi | ★★★★★ | 17 | 0 |
| Holly Heights Care And Rehabilitation | 0.7 mi | ★★★★★ | 39 | 0 |
| Highline Post Acute | 0.7 mi | ★★★★★ | 1 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.