Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Davis Place during CMS and state inspections, most recent first.
A resident who was alert, oriented, and planned for discharge home was admitted with an automatic physician order prohibiting leave of absence (LOA), consistent with the facility’s practice of entering default no-LOA orders for all admissions. Multiple staff, including an LPN, RNs, social services, and PT, reported that residents could only leave on LOA if they specifically requested it, after which nursing would seek a one-time LOA order from a physician/APRN and require a PT assessment, a process that could take a day or more and was partly attributed to insurance reimbursement concerns. The resident expressed a desire to go on LOA to visit grandchildren and was unaware LOAs were permitted. Facility admission materials referenced LOA information on specific pages of the Admissions Agreement, but the pages were unnumbered and did not contain the referenced LOA details, and leadership confirmed there was no formal LOA policy, only this restrictive process, resulting in interference with the resident’s right to exercise LOA.
A resident with severe cognitive impairment and ambulating with a cane exited their room as a food service cart was being pushed by a NA. The resident's cane struck the cart's bumper, causing a fall and resulting in a left femoral fracture. The NA reported checking both sides but could not see over the cart, leading to the accident.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific circumstances or individuals involved.
A resident with severe cognitive impairment received a significant overdose of hydroxyurea after a nurse supervisor incorrectly transcribed hospital discharge orders into the EMR, resulting in administration of 30,000 mg more than ordered. The error was not detected by the provider or during the verification process, leading to critical lab abnormalities and hospitalization for neutropenic fever and multiple infections.
Two residents did not have their care plans updated to address significant clinical needs, including pain management, unauthorized medication use, seizure management, and a blood disorder, despite new diagnoses and physician orders. The care plans lacked measurable goals and interventions for these issues, and were not revised following changes in condition as required by facility policy.
Physician or APRN orders were not reviewed and signed monthly for multiple residents with chronic and complex conditions, as required by facility practice. Documentation showed that in several instances, monthly reviews were missed, and the ADNS could not explain the lapses. The facility also lacked a policy specifying the required frequency for these reviews.
Surveyors identified deficiencies involving two residents: one did not receive timely physician communication and lab result forwarding related to hematology care, and another was not administered an antibiotic as ordered, with the medication left unattended despite the resident's inability to self-administer. These issues were confirmed through record review and staff interviews.
The facility failed to provide residents with the opportunity for in-person dining in the main dining rooms, despite repeated requests during resident council meetings. Residents were observed eating in their rooms or small unit dining spaces. Staff cited illness outbreaks and staffing issues as reasons for the closure, although some units were unaffected by recent outbreaks. The dietary manager was working on logistics to reopen the dining rooms, but challenges persisted.
The facility failed to maintain a safe smoking area as the outdoor concrete patio had multiple holes, creating an uneven surface. The Administrator was unaware of the issue until it was pointed out, despite the Maintenance Director knowing about it for a week but not informing the necessary parties. This oversight led to the deficiency being identified.
A resident with severe cognitive impairment reported missing prescription glasses, but the facility failed to address the grievance promptly. The issue was communicated to the Director of Social Services, who misunderstood the situation, leading to delays in replacing the glasses. The facility did not follow its policy for handling reported losses.
A facility failed to develop a comprehensive care plan for a resident using oxygen therapy, despite the resident's COPD diagnosis and dependency on staff. The care plan lacked necessary interventions, and responsibility for care plan development was unclear. Additionally, another resident with dysphagia was repeatedly given unsafe food items, despite being on a minced/ground diet. The care plan was not updated to address safe food consumption, even after multiple incidents. The facility did not follow its policy for revising care plans as residents' conditions changed.
A facility failed to ensure blood sugar levels were monitored before administering morning insulin to a resident with diabetes. The resident had orders to hold insulin if blood sugar was below 90, but the blood sugar was checked after the insulin was given, not before. This discrepancy led to a deficiency as the facility did not comply with physician orders, potentially compromising the resident's safety.
The facility failed to maintain a clean and sanitary kitchen, with observations of dried spillage, improper food storage, and inadequate cleaning practices. The FSD acknowledged the unsanitary conditions and lack of cleaning schedules, while the facility's policy directed proper cleaning and sanitizing to minimize microorganism growth.
Two residents did not receive the pneumococcal vaccine as per their requests and CDC guidelines. One resident, admitted with diabetes and hyperlipidemia, was not offered the updated PCV20 vaccine despite being eligible. Another resident, admitted with Parkinson's disease, did not receive the vaccine despite giving consent. The DNS acknowledged the oversight and noted reliance on electronic health records without an excel tracking sheet.
The facility failed to maintain kitchen equipment, with non-functional ovens and steam table wells, and a freezer operating above required temperatures. Interviews revealed delays in ordering replacements and repairs, and the maintenance policy was not followed.
The facility failed to provide a dignified dining experience for three residents during breakfast, as they were positioned in the hallway outside their rooms, with some feeding themselves and others being fed by staff. This practice was intended to allow staff to multitask but was not in line with the facility's Meal Service Policy, which emphasizes a quiet, pleasant dining environment. Concerns were raised by the Dietician and DNS about the appropriateness and safety of this practice.
A resident with a history of acute kidney failure and respiratory issues experienced vomiting and potential choking, but the facility failed to notify the physician or conduct an appropriate assessment. Despite the resident's family raising concerns, the nursing staff did not follow the facility's policy for significant changes in condition, leading to a deficiency in care.
A resident with cognitive impairment was found with a medication cup left at their bedside without an order or assessment for self-administration. The LPN admitted to leaving the medication and signing off on the MAR without ensuring the resident took it. The DNS confirmed that medication should not be left at the bedside without a self-administration assessment.
A facility failed to apply adaptive devices for a resident with hemiplegia and hemiparesis as per physician's orders. The resident's care plan required the application of left hand and elbow splints to prevent contractures, but observations showed these were not applied. Staff interviews revealed a lack of communication and verification regarding the resident's care, with no reported skin integrity issues to justify the omission.
A resident receiving IV antibiotics had an outdated peripheral IV line in the left forearm, which was not removed when a new line was placed in the right forearm. The facility failed to obtain physician orders for flushing and monitoring the IV site, contrary to its policy requiring catheter replacement every 72-96 hours and flushing every 12 hours.
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen therapy management. One resident used oxygen without a physician's order due to an oversight during readmission, while another resident's oxygen tubing was not changed weekly as required. Interviews with staff confirmed these lapses, and the DNS acknowledged the need for proper orders and equipment care.
The facility failed to implement proper infection control measures, as staff did not adhere to PPE protocols for a resident on contact precautions, and another resident with a history of MDROs was not placed on Enhanced Barrier Precautions. Observations showed staff entering rooms without required gowns, and the facility's MDRO log did not include a resident with a history of VRE and MRSA. Interviews revealed a lack of adherence to infection control policies despite annual education.
A resident admitted with Parkinson's disease and other conditions requested the pneumococcal vaccine upon admission. Despite being cognitively intact and consenting to the COVID-19 vaccine, the resident did not receive it. The DNS, also the infection preventionist, indicated it was the Infection Preventionist nurse's responsibility to select the vaccine and obtain a physician order, but could not explain why the vaccine was not administered.
The facility failed to submit discharge assessments to state and federal agencies on time for two residents. One resident's Death in Facility MDS was not submitted due to an incorrect setting, discovered 110 days late. Another resident's Discharge MDS was submitted 76 days late due to oversight. The RAI manual requires these assessments to be transmitted within 14 days.
Resident Rights Restricted by Automatic No-LOA Orders and Unclear Leave of Absence Process
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s rights to self-determination and to exercise the right to take a leave of absence (LOA) without undue interference. One resident admitted with a right femur fracture and diabetes was alert, oriented, able to make needs known, and assessed as not at risk for elopement. The resident’s care plan anticipated discharge home in several weeks, and the admission MDS documented that going outside for fresh air in good weather was somewhat important to the resident. Despite this, a standing physician order entered at admission directed that the resident may not go out on LOA. The facility’s practice, as described by multiple staff, was to enter automatic “no LOA” orders for all residents upon admission, both short-term and long-term. Staff, including LPNs, RNs, social services, and PT, consistently reported that residents could only leave on LOA if they specifically requested it, at which point nursing would contact the physician/APRN for a one-time LOA order and then require a PT assessment before the resident could leave. Staff also indicated that this process could take a day or more and that the electronic medical record defaulted to no LOA orders for all residents. One nurse and a unit manager stated that the rationale for this automatic restriction was related to insurance reimbursement. The resident interviewed stated a desire to go on LOA to visit grandchildren and reported not being aware that LOAs were allowed. Review of the facility’s Welcome Book showed it referenced LOAs and directed residents to pages 2–3 of the Admissions Agreement for more information, but the Admissions Agreement pages were not numbered and did not contain the referenced information about LOA privileges or the requirement to request LOA 24 hours in advance. The Admissions Agreement did include a clause about the facility assuming no responsibility for injury or deterioration while a resident is temporarily absent, but there was no clear, accessible explanation of LOA rights or procedures. The DNS and ADNS confirmed there was no written LOA policy, only a process in which all residents received no LOA orders at admission and had to obtain physician approval and PT evaluation before any LOA, which interfered with the resident’s ability to exercise the right to leave the facility.
Resident Fall Due to Unsafe Food Cart Handling
Penalty
Summary
Staff failed to safely maneuver a food service cart, resulting in a resident fall with injury. The resident involved had diagnoses including dementia, glaucoma, and schizoaffective disorder, and was care planned to ambulate independently with a cane but required supervision due to severe cognitive impairment. On the day of the incident, the resident exited their room as a food service cart was being pushed down the hallway. The resident's cane came into contact with the bumper of the cart, causing the resident to lose balance and fall onto their left side. The staff member pushing the cart reported checking both sides for residents but was unable to see over the cart, and did not see the resident exiting the room before the collision occurred. The fall resulted in a left femoral fracture, requiring hospital transfer and surgical intervention. Prior to the incident, the resident had no history of falls. The facility's policy directed staff to make the environment as free from accident hazards as possible, but the staff member was unable to ensure the pathway was clear due to the size of the cart and limited visibility. The deficiency was identified through observations, interviews, and review of clinical records and facility documentation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Significant Medication Error Due to Incorrect Transcription of Chemotherapy Orders
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and multiple diagnoses, including dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies, was readmitted to the facility. The resident required substantial assistance with daily activities and had a care plan that included medication review and administration per physician order. Upon readmission, the hospital discharge summary specified hydroxyurea dosing by gastrostomy tube with different doses and frequencies for specific days of the week. However, the nurse supervisor responsible for entering the hospital discharge orders into the electronic medical record (EMR) failed to accurately transcribe the hydroxyurea orders. Instead of entering the correct number of doses per day as specified, the nurse entered significantly higher doses—three times the intended dose on some days and four times on others. The facility physician signed off on these orders, believing them to be accurate, and the error was not detected during the verification process. As a result, the resident received a total of 41,000 mg of hydroxyurea over a 14-day period, which was 30,000 mg in excess of the hospital's order. This overdose led to a critical decline in the resident's white blood cell and platelet counts, resulting in a change of condition that required hospitalization. The resident was admitted to the hospital with neutropenic fever and multiple infections, and laboratory results confirmed critically low blood counts. Interviews with facility staff and review of facility policy revealed that the required process for transcription and verification of medication orders was not properly followed, and the facility was unable to provide a policy specifically addressing the transcription/verification process.
Failure to Update Comprehensive Care Plans for Residents with Changing Clinical Needs
Penalty
Summary
The facility failed to update and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies in addressing their clinical needs. For one resident with a history of periprosthetic fracture, left knee pain, and depression, the care plan did not identify pain as a problem or include goals and interventions for pain management, despite multiple physician orders for various pain medications and documented administration of these medications for moderate to severe pain. Additionally, the care plan did not address the resident's use of unauthorized controlled substances found in their room, nor did it include interventions for monitoring or education related to this issue. Another resident, admitted with diagnoses including dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies, had a care plan that failed to address seizure management and chronic myeloproliferative disorder, both of which were documented in hospital discharge records. The care plan did not include goals or interventions for seizure control or for the management and monitoring of the blood disorder, despite new orders for medication and the need for ongoing monitoring of blood cell and platelet counts. Interviews and policy reviews confirmed that the care plans were not updated following significant changes in the residents' conditions or upon receipt of new diagnoses and treatment orders. Facility policy required care plans to be revised to reflect changes in condition and to ensure continuity of care, but this was not done for the residents in question.
Failure to Complete Monthly Physician Order Reviews
Penalty
Summary
The facility failed to ensure that physician or advanced practice registered nurse (APRN) orders were reviewed and signed monthly for eleven out of sixteen residents reviewed for physician's orders. Clinical record reviews, interviews, and facility documentation revealed that for these residents, there were multiple months where medical orders were not reviewed or signed as required by the facility's standard practice. The residents involved had various diagnoses, including heart failure, dementia, anxiety, Alzheimer's disease, cerebral palsy, and other chronic conditions. Specific months were identified for each resident where the required monthly review and signature of medical orders did not occur. An interview with the Assistant Director of Nurses (ADNS) confirmed that it was the responsibility of the physician or APRN to review and sign orders monthly, and that this was the facility's standard of practice. However, the ADNS was unable to provide a reason for the missed reviews and signatures. Additionally, the facility could not provide a policy detailing the frequency for reviewing physician's orders, further contributing to the deficiency.
Deficiencies in Physician Communication and Medication Administration
Penalty
Summary
The facility failed to ensure timely and appropriate communication and response to physician orders and lab results for two residents. For one resident with a history of dysphagia, epilepsy, neurocognitive disorder, and myeloproliferative disorder, the facility did not respond promptly to a physician's inquiry regarding the resident's hydroxyurea dosage after a concerning drop in white blood cell count was noted. Additionally, the facility did not consistently forward lab results to the hematologist/oncologist in a timely manner, with some results delayed and others not received at all. The facility was unable to provide a policy regarding physician communications or faxes, and interviews confirmed that the standard practice was not followed in these instances. Another resident with dementia, diabetes, and major depressive disorder was not administered an ordered dose of Levaquin for pneumonia as prescribed. The medication was left unattended on the resident's bedside table and not given as required, despite the resident's inability to self-administer medications. The error was discovered the following morning by an LPN, who found the medication cup and reported the incident to the nurse supervisor. The facility's policy directed that medications be administered in a safe and effective manner, which was not followed in this case. These deficiencies were identified through review of clinical records, interviews with staff and physicians, and examination of facility documentation and policies. The failures included lack of timely response to physician requests, delayed or missing communication of lab results to consulting specialists, and improper medication administration practices.
Failure to Provide In-Person Dining Opportunities
Penalty
Summary
The facility failed to ensure residents had the opportunity to participate in their choice of in-person community dining, as identified during a resident council meeting. Residents expressed their concerns about the lack of in-person dining in the main dining rooms, which had been closed for approximately a year. Despite these concerns being raised multiple times in resident council meetings, the facility had not implemented in-person dining in the main dining rooms. Observations during lunch service showed residents eating in their rooms or in small dining spaces on the unit, rather than in the main dining areas. Interviews with residents and staff revealed that the main dining rooms had been closed since the previous year, with satellite dining areas being used for residents needing assistance or supervision. Residents who were independent ate in their rooms. The dietary manager, who started in July 2024, was working on a seating chart and identifying residents who wanted to eat in the dining rooms. However, the process was delayed due to various logistical challenges, including arranging trays and updating tickets. The facility's administrator and director of nursing cited outbreaks of illness and staffing issues in the dietary department as reasons for the prolonged closure of the main dining rooms. The director of nursing noted that outbreaks required isolating units to prevent the spread of infection, which limited group activities, including dining. Despite these challenges, some units were not affected by the most recent COVID outbreak, and in-person recreation activities had resumed. However, the main dining rooms remained closed, and no policy for Resident Council/Committees was provided upon request.
Unsafe Smoking Area Due to Uneven Patio Surface
Penalty
Summary
The facility failed to ensure that an outdoor concrete patio used as a smoking area was safe and free of accident hazards. On the specified date, observations revealed that the patio had multiple holes, resulting in an uneven surface. The Administrator, upon being shown the patio, acknowledged that both staff and residents used the area for smoking and admitted to being unaware of its condition. The Maintenance Director had been aware of the patio's condition for a week prior but had not informed the Administrator or the Director of Nursing Services (DNS), citing being busy and planning to acquire supplies for repairs. This lack of communication and delay in addressing the issue led to the deficiency being identified by surveyors.
Failure to Address Resident's Grievance on Missing Items
Penalty
Summary
The facility failed to address a resident's grievance regarding missing prescription glasses in a timely manner. The resident, who had severe cognitive impairment due to dementia and anxiety, reported the missing glasses to the Corporate Admission Staff, who then communicated the issue to the administrative staff, including the Director of Social Services. Despite this, there was no documentation in the nursing or social service progress notes about the missing items, and the Director of Social Services was not aware of the issue until much later. The Director of Social Services referred the matter to the Transportation Staff for scheduling a replacement, but there was a misunderstanding about the nature of the appointment, leading to a delay. The Director of Social Services did not follow up with the resident's family or the Transportation Staff to clarify the situation, resulting in the resident not receiving the replacement glasses promptly. The facility's policy for handling reported losses was not followed, as the Nursing Supervisor was not notified, and a Missing Item Report was not completed.
Deficiencies in Care Planning for Oxygen Therapy and Safe Food Consumption
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident utilizing oxygen therapy. The resident, diagnosed with chronic obstructive pulmonary disease (COPD), metabolic encephalopathy, and muscle wasting and atrophy, was observed using oxygen therapy without a corresponding care plan. The quarterly MDS assessment identified the resident as cognitively intact and dependent on staff for various needs, including oxygen therapy. However, the resident's care plan did not address the use of oxygen or include necessary interventions. Interviews with the nursing supervisor and MDS coordinator revealed that the responsibility for developing and reviewing care plans was not clearly defined, leading to the oversight. Another deficiency was identified for a resident with hemiplegia and dysphagia, who was repeatedly provided unsafe food items despite being on a minced/ground diet. The resident required total supervision with meals due to a swallowing disorder. Observations showed the resident consuming inappropriate food items, such as cookies and donuts, which were not permitted. Interviews with nursing staff and the Director of Rehabilitation indicated that education was provided to caregivers, but the care plan was not updated to include interventions for safe food consumption. The failure to revise the care plan after repeated incidents of unsafe food provision was noted. The facility's policy for care plans requires the development of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet residents' needs. The policy also mandates that care plans be revised as residents' conditions change. In both cases, the facility did not adhere to its policy, resulting in deficiencies related to the lack of appropriate care planning and monitoring for residents with specific medical needs.
Failure to Monitor Blood Sugar Before Insulin Administration
Penalty
Summary
The facility failed to ensure that the physician orders for blood sugar monitoring and insulin administration were aligned for a resident with diabetes. Resident #57, who had severe cognitive impairment and was insulin-dependent, had a physician's order to administer Tresiba insulin in the morning and evening. However, there was a directive to hold the insulin if the blood sugar was below 90, which was not checked before the morning dose was administered at 6:00 AM. Instead, the blood sugar was scheduled to be checked at 7:30 AM, an hour and a half after the insulin was given, which did not comply with the physician's order to ensure safe administration. Interviews with nursing staff revealed that the resident experienced low blood sugar in the morning, and the hypoglycemic protocol was followed to stabilize the blood sugar level. The facility's policy on physician orders did not specify how orders should be double-checked for accuracy in transcription to medication records. The discrepancy in the timing of blood sugar checks and insulin administration led to the deficiency, as the facility did not monitor blood sugars prior to administering the morning dose of insulin, potentially compromising the resident's safety.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour. The kitchen floor had an excessive amount of dried spillage buildup under all counters and work prep areas, and there was dried spillage along the side and front of the ovens. Food storage practices were inadequate, with a half bag of thawed mango loosely covered and placed on top of a bin of pineapple, leading to leakage. Additionally, opened bags of mozzarella cheese were found without dates. The dishwashing station had ceiling vent covers with a moderate amount of buildup, and the top of the dishwasher had brown crumb-like debris. Sanitizing buckets were improperly used, being stacked empty with cleaning supplies inside. Interviews revealed a lack of structured cleaning schedules for staff, who were only responsible for cleaning immediate surface areas after use. The Food Service Director (FSD), who had been employed for one month, acknowledged the unsanitary conditions and the absence of cleaning schedules. The FSD was aware that foods should be dated and not stacked to prevent leakage, and that a sanitization bucket should be used between food prep tasks. The facility's policy on Dietary Cleaning and Sanitation directed proper cleaning and sanitizing to minimize microorganism growth, but no policy on dating foods was provided.
Failure to Administer Pneumococcal Vaccine to Residents
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to two residents as per their requests and CDC guidelines. Resident #30, who was admitted in July 2022 with conditions including type 2 diabetes mellitus and hyperlipidemia, was cognitively intact and had previously received the pneumococcal vaccine 23 in 2008. Despite being a candidate for the updated PCV20 vaccine, which the facility began offering in the summer of 2023, there was no record of the vaccine being offered to Resident #30. The DNS, who was not the infection control nurse at the time, acknowledged the oversight and noted the lack of an excel tracking sheet for vaccines, relying instead on the electronic health record system. Resident #105, admitted in April 2024 with Parkinson's disease and muscle weakness, also did not receive the pneumococcal vaccine despite giving consent on 4/12/24. The DNS confirmed that the vaccine was not administered and attributed the responsibility to the Infection Preventionist nurse, who was different at the time. The facility's policy stated that the vaccine should be administered when informed consent is given unless contraindicated, already given, or refused, but this was not followed in Resident #105's case.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a safe and functional manner, as observed during a kitchen tour. Three out of four ovens in a double oven assembly were non-functional, and three of the four ovens lacked vent covers, with visible gray matter and dried brown spillage on exposed components. Additionally, one of the six wells on the steam table was not operational, and the large outdoor freezer had an internal temperature of 8 degrees Fahrenheit, with some frozen items found to be soft and indented. The freezer temperature log showed readings between 5 and 20 degrees Fahrenheit, which is above the required temperature. Interviews revealed that the ovens and steam table well had been non-functional for approximately three months, and the Director of Maintenance had not yet ordered new ovens despite receiving approval. The steam table part was obtained but not installed. The Food Service Director was unaware of the freezer issue until a vendor inspection revealed restricted airflow and a non-working condenser. The facility's maintenance policy requires the maintenance department to ensure equipment is safe and operable, which was not adhered to in this case.
Undignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during breakfast on the 2West unit. Observations revealed that nurses' aides were providing care and carrying dirty linens while the charge nurse was passing medications. Some residents were positioned in the entryway to their rooms, with two residents seated in wheelchairs in the hallway outside their rooms, feeding themselves breakfast. Another resident was being fed by a nurse aide in the hallway, while other residents watched. This practice was confirmed by a nurse aide who stated that residents needing supervision or assistance were placed in the hallway to allow staff to multitask. Interviews with the Dietician and the Director of Nursing Services (DNS) highlighted concerns about the dignity of the dining experience. The Dietician noted that the small dining areas on the units were intended for residents needing supervision or assistance, and expressed that eating in the hallway was not dignified. The DNS acknowledged that residents should not be fed in the hallway, as it could pose safety issues and that the satellite dining areas or residents' rooms were more appropriate settings. The facility's Meal Service Policy emphasizes providing a dining experience conducive to meal acceptance, including a quiet, pleasant room and positive staff attitudes, which was not adhered to in this instance.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced a change in condition, specifically vomiting and potential choking. The resident, who had a history of acute kidney failure, hypertension, and respiratory issues, vomited and sounded congested, with an oxygen saturation of 93% on room air. Despite these symptoms, the nursing staff did not notify the physician or the on-call provider, and the resident was not assessed until the following day after the family raised concerns. Interviews with staff revealed a lack of communication and appropriate response to the resident's condition. A nurse aide reported the incident to a nurse, but the nurse denied being informed of the vomiting and choking. The resident's family member had to shout for assistance, and although a nurse aide responded, the nurse did not follow up until after the shift change. The APRN, who assessed the resident the next day, expressed concern about the handling of the situation and the delay in notifying a provider. The facility's policy requires notifying the physician of significant changes in a resident's condition, but this protocol was not followed. The DNS confirmed that an assessment should have been conducted, including checking lung sounds, given the report of choking. The failure to notify the physician and conduct an appropriate assessment led to a deficiency in the care provided to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a medication was not left at the bedside of a resident without an order or assessment for self-administration. Resident #157, who had moderate cognitive impairment and was dependent on staff for certain activities, was observed with a medication cup containing 30 ml of a reddish liquid on the overbed table. The resident identified that the nurse would know more about the contents of the cup, as they had not taken any protein with their morning medication. The Charge Nurse confirmed that the liquid was a protein supplement given with the resident's morning medication. The review of the resident's clinical records did not show a physician's order for self-administration or a completed self-administration assessment. The Charge Nurse admitted to leaving the medication on the table and signing off on the medication administration record (MAR) without ensuring the resident took the supplement. The Director of Nursing Services (DNS) confirmed that medication should not be left at the bedside without a self-administration assessment. The Dietician noted that the resident was on a liquid protein supplement to aid wound healing, and not taking it daily could delay this process. The facility's policy stated that medications should be administered safely and documented in the MAR after administration.
Failure to Apply Adaptive Devices as Ordered
Penalty
Summary
The facility failed to ensure that adaptive devices for a resident with limited mobility were applied according to physician's orders. The resident, who had hemiplegia and hemiparesis following a stroke, was supposed to have a left hand and elbow splint applied to prevent contractures. The care plan and physician's orders specified the schedule for applying these splints. However, observations on two separate days revealed that the splints were not applied as required. On one occasion, the left-hand splint was not applied, and on another, the left elbow splint was missing. Interviews with staff revealed a lack of communication and verification regarding the resident's care. A nursing assistant mentioned hearing from another assistant that the splints were not applied due to skin integrity issues, but this information was not verified with a nurse. An LPN confirmed that there were no skin integrity issues reported, and the Director of Nursing stated that staff should follow the splinting schedule as per the physician's orders. The facility's policy required that any skin issues be reported by the nurse, and refusals documented, but this was not adhered to in this case.
Failure in IV Site Management and Physician Orders
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident receiving IV antibiotics. Resident #312, who had multiple pressure ulcers including in the sacral region, was prescribed Vancomycin HCL to be administered intravenously every 12 hours for a wound infection. On observation, it was found that the resident had peripheral IV lines in both forearms, with the line in the left arm being 6 days old and showing signs of blood under the dressing. This line should have been removed when a new IV line was placed in the right arm, as per the facility's policy which states that peripheral IV catheters should be replaced every 72-96 hours unless there is contamination or complication. Additionally, the facility did not ensure that physician orders addressed the flushing of the IV site. The facility's policy requires that a peripheral catheter used for intermittent infusion be flushed at least every 12 hours. However, there were no orders obtained for flushing or monitoring the IV site. RN #1 confirmed during an interview that the old IV line should have been discontinued and that orders for flushing and monitoring should have been obtained. This oversight indicates a failure to adhere to the facility's policies regarding IV therapy and site management.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen therapy management. Resident #6, diagnosed with chronic obstructive pulmonary disease (COPD) and other conditions, was observed using oxygen therapy without a corresponding physician's order. Despite being cognitively intact and dependent on staff for daily activities, the resident's medical records lacked an order for continuous or as-needed oxygen therapy. Interviews with nursing staff revealed that the omission occurred because the admitting nurse did not input the hospital discharge instructions into the resident's records upon readmission. The Director of Nursing Services (DNS) confirmed that a physician's order should have been in place for the resident's oxygen use. Resident #140, with a history of acute respiratory failure and hypoxia, was observed using oxygen with tubing that had not been changed according to physician orders. The resident's care plan indicated a need for weekly tubing changes, but the tubing was dated over two months prior. Interviews with the resident and nursing staff confirmed the daily use of oxygen and the expectation for weekly tubing changes. The DNS acknowledged the requirement for weekly changes, but the facility could not provide a policy for the care of respiratory equipment.
Infection Control Deficiencies in PPE Use and Precaution Tracking
Penalty
Summary
The facility failed to properly implement infection prevention and control measures, specifically in the use of personal protective equipment (PPE) for residents under transmission-based precautions. Resident #127, who had diagnoses including pneumonia, acute kidney failure, and stroke, was placed on contact precautions due to conjunctivitis. However, observations revealed that staff members, including LPN #7 and LPN #6, did not adhere to the required PPE protocols. LPN #7 entered the resident's room with only gloves, misinterpreting the signage, and LPN #6 also entered with only gloves despite the contact precaution sign indicating the need for both gloves and a gown. Additionally, the facility failed to appropriately track and implement Enhanced Barrier Precautions (EBP) for Resident #6, who had a history of urinary tract infections with vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). Despite the resident's history, there was no signage indicating the need for EBP, and the resident was not listed on the facility's MDRO log for August 2024. The DNS acknowledged that Resident #6 should have been on the MDRO list and that appropriate signage should have been posted. Interviews with staff, including the DNS and RN #12, highlighted a lack of adherence to infection control policies and procedures. The facility's policies required clear signage and appropriate PPE use for residents on transmission-based precautions, but these were not consistently followed. The DNS and staff development nurse confirmed that infection control education, including PPE use, was provided annually, yet the deficiencies in practice were evident during the survey observations.
Failure to Administer Requested Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident who requested it upon admission. The resident, who was admitted in April 2024, had diagnoses including Parkinson's disease with dyskinesia and fluctuation, muscle weakness, and hyperlipidemia, and was identified as cognitively intact. Despite giving consent for the COVID-19 vaccination on 4/12/24, the resident did not receive the vaccine as requested. An interview with the Director of Nursing Services (DNS), who also serves as the infection preventionist, revealed that the responsibility for selecting the appropriate vaccine and obtaining the physician order lay with the Infection Preventionist nurse. However, the DNS was unable to explain why the vaccine was not administered, noting that a different Infection Preventionist nurse was in place at the time.
Failure to Timely Submit Discharge Assessments
Penalty
Summary
The facility failed to ensure timely submission of discharge assessments to state and federal agencies for two residents. Resident #40 was admitted and later passed away at the facility. The Death in Facility Minimum Data Set (MDS) for this resident was completed but not submitted to the agencies, as the submission setting was incorrectly set to 'do not submit.' This error was identified 110 days after the resident's death. Similarly, Resident #134 was readmitted and later discharged from the facility. The Discharge MDS for this resident was submitted 76 days late, as it was overlooked by the staff. According to the Resident Assessment Instrument (RAI) manual, such assessments must be transmitted within 14 days of the event date.
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What surveyors actually found near you
We read the 296 citations issued within 25 miles in the last 12 months — including the 16 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 Danielson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pierce Memorial Baptist Home, Inc. | 4.2 mi | ★★★★★ | 6 | 0 |
| Westview Health Care Center | 5 mi | ★★★★★ | 3 | 0 |
| Matulaitis Rehabilitation & Skilled Care | 8.2 mi | ★★★★★ | 3 | 0 |
| Colonial Health & Rehab Center Of Plainfield, Llc | 9.1 mi | ★★★★★ | 3 | 0 |
| Villa Maria Nursing And Rehabilitation Community | 9.3 mi | ★★★★★ | 4 | 0 |
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.