Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Skyview Rehab And Nursing during CMS and state inspections, most recent first.
A resident with bipolar disorder, dementia without behavioral disturbance, and anxiety, who was documented as alert, oriented, and independent in ADLs with intact cognition and no wandering behaviors, was initially assessed as not at risk for elopement and had a physician order permitting LOA with someone. Later, an LPN applied a Wanderguard to the resident’s ankle for reported exit-seeking, completed an elopement evaluation marking the resident at risk, but did not obtain consent from the resident’s conservator or document such contact, and the DON acknowledged that consent and less restrictive interventions should have preceded Wanderguard use. Despite the care plan subsequently labeling the resident an elopement risk and including Wanderguard use, the MAR and TAR did not show monitoring for wandering or exit-seeking behaviors, and the conservator later stated they had not been informed of prior exit-seeking, had not consented to the Wanderguard, and that the resident later described the facility as feeling like a jail.
A resident with bipolar disorder, dementia, and anxiety, who was independent with ADLs and identified as an elopement risk with a Wanderguard in place, left on an LOA with a friend after the conservator consented. The resident did not return as expected, staff were unable to reach involved parties, police were notified, and most of the resident’s belongings were found missing. The resident was then discharged without documentation that the departure was AMA or that AMA procedures were followed per facility policy. When the resident was later hospitalized and referrals were sent back, the facility had open beds but refused readmission, citing that the resident had left AMA and was placed on a corporate denial list, despite the administrator acknowledging that the resident’s return would not endanger others and lacking policies for handling non-return from LOA and readmissions.
A resident with bipolar disorder, dementia, and anxiety, who was independent in ADLs but care planned as an elopement risk, was allowed to go on LOA with a friend after the conservator consented. Nursing late entries documented the LOA, the resident’s failure to return, multiple unsuccessful attempts to contact involved parties, notification of police and clinical leadership, and discovery that most belongings were gone, while the census showed the resident as discharged. However, the Director of Social Services did not document the LOA outcome or the discharge in the clinical record and did not submit the required discharge notification to the State LTC Ombudsman portal, stating unawareness that non-return from LOA constituted a discharge, despite a facility policy requiring detailed discharge documentation.
A resident with bipolar disorder, dementia, and anxiety, who was care planned as an elopement risk and had a court-appointed conservator, was allowed to go on LOA with a friend after an RN obtained the conservator’s consent and an expected return time. The RN did not document the conservator communication or the anticipated return time in the clinical record before the end of the shift, and the LOA log did not capture an expected return time. The oncoming RN, unaware of when the resident was due back and noting that residents often return as late as 10:00 PM, did not begin attempts to locate the resident until that time, at which point calls to the friend, the resident, and family were unsuccessful and the conservator was first notified. This reflected a failure to maintain complete and accurate medical records and to facilitate communication about the resident’s LOA and expected return.
Residents were not provided clear information on how to file grievances, where grievance forms were located, or who the Grievance Official was. Resident council minutes did not show education on the grievance process, and residents stated they were unaware of the policy and resolution process. Several staff members also did not know where forms were kept or how grievances were handled, and one RN said complaints were written on blank paper because there were no grievance forms. An observation found grievance folders in an unlabeled bin placed too high for wheelchair access.
A resident with multiple chronic conditions and moderately impaired cognition had a missing electronic tablet after a hospital transfer, which the resident’s conservator reported to the Administrator as stolen and in need of investigation. A social worker acknowledged being told the device was missing and that a replacement was needed but did not document this communication in the medical record and stated she was not told it was stolen. Facility records showed no grievance, no investigation, and no State reportable event related to the missing device, despite facility policy requiring alleged violations to be reported to the Administrator and appropriate authorities.
A resident with moderately impaired cognition and multiple chronic conditions had a personal electronic tablet reported missing after a hospital stay. The resident’s representative reported the missing or stolen tablet to the Administrator, and the SW was informed that the device was missing and needed replacement, but this communication was not documented in the medical record. Review of records and interviews with the DNS, Administrator, and SW showed that no investigation into the alleged misappropriation was initiated or completed, despite facility policy requiring reporting and a written social service report for alleged violations.
A resident with CHF, DM2, major depression, and moderately impaired cognition was missing a cell phone and other personal items, and staff did not return the phone timely. The phone was moved from the nurse station to the supervisor's office because it was not holding a charge, then remained in the SW's office because staff did not want it misplaced and had not charged it, despite the resident reporting the missing items and the DON being aware.
A resident council repeatedly asked about using a hair dryer, but staff told residents it was not permitted because of fire-hazard concerns. The DOR recorded the requests, consulted maintenance once, and then repeated the denial when the issue came up again without escalating it to the Administrator. The Administrator later said she only learned of the request after reviewing the council minutes, and the facility handbook stated electrical personal items must be inspected and tagged by maintenance before use.
A resident with cardiac arrhythmia, ESRD, and DM2 had a signed Advance Directive indicating Full Code, but the chart contained a physician order for DNR/DNI instead. Staff, including an LPN, RN, and DON, confirmed the mismatch between the resident’s expressed wishes and the code status order, and the resident had intact cognition with a BIMS of 15.
Failure to complete quarterly elopement risk assessments for a resident with a Wander Guard. A resident with depression, anxiety, and a hx of stroke had a Wander Guard on the R ankle and was ambulating independently throughout the facility. Staff noted no current exit-seeking behaviors, yet the resident remained on the alarm despite stating he/she had not tried to leave in about a year and wanted the bracelet removed. The DON/DNS stated the last elopement assessment had been completed months earlier and could not explain why the required quarterly assessments were not done.
Failure to Follow BP Medication Parameters: An LPN administered amlodipine to a resident with CHF, CAD, and HTN without first checking BP or pulse, despite physician hold parameters for systolic BP and HR. The resident was moderately cognitively impaired and had a care plan for altered cardiovascular status. After the surveyor’s inquiry, the LPN reread the label, obtained vital signs, and the DON confirmed the LPN should have checked them before giving the medication.
Failure to provide scheduled showers for a resident with moderately impaired cognition and ADL assistance needs. The resident was ordered weekly showers with 1 staff assist, but NA flow sheets showed showers as N/A, the resident reported missing showers for weeks and requesting more frequent showers, and an NA admitted documenting showers without providing them. The DNS stated there was no record of refusal and that the resident was scheduled for weekly showers.
Failure to provide ordered divided plate for a resident with Parkinson's, dementia, and impaired cognition. The resident required set-up assistance for eating and had a physician order for a divided plate for all meals, but was observed eating lunch without the adaptive equipment. SLP and the DON confirmed the divided plate had not been provided, and dietary staff stated the tray should have been served on a divided plate per the ticket.
Incomplete and Inaccurate Documentation of Resident Shower Care: A resident with DM, heart disease, and moderately impaired cognition had orders for weekly showers with 1 staff assist, but the TAR was signed off as completed even though the LPN did not witness the showers or confirm them with CNAs. The resident said showers had not been received for weeks, and CNA flowsheets were inconsistent, including entries showing independence, N/A, and missing ADL documentation; staff later stated the charting did not match the care actually provided.
Failure to use required PPE during EBP care. A resident with quadriplegia, multiple stage 4 pressure ulcers, a suprapubic catheter, a colostomy, and MRSA/ESBL history was on EBP with signage directing gown and glove use during high-contact care. Two NAs provided personal care and a bed bath without isolation gowns, and both acknowledged they knew the resident was on EBP but forgot to wear the required PPE.
Failure to educate staff on COVID-19 vaccination and offer the vaccine. The IP stated the facility no longer offered the COVID-19 vaccine to staff, prior staff consent forms were shredded, and staff were not given education on the benefits and risks of vaccination or information on where to obtain it. The DON, Administrator, and IP could not provide documentation showing staff education, and the facility policy stated staff are to be fully vaccinated unless a documented medical or religious exemption is on file.
Survey results were not posted in areas readily accessible to residents, families, or legal representatives. Surveyors could not find any notice of availability, and resident council members said they did not know where the state survey results were or that staff had reviewed them with residents. Multiple staff members, including NAs, LPNs, an RN, the DNS, and the receptionist, were unsure where the results were kept; the Administrator later identified a binder behind the reception desk and a sign above the front desk that was not at wheelchair eye level.
A resident received two sets of medications in one evening, including another resident's medications, after an LPN placed a refused dose back in the med cart and later gave it to a NA to administer, who then gave it to the wrong resident. On another occasion, an LPN and an RN each administered medications without checking resident identification bands, relying instead on familiarity, despite facility policy requiring verification by wristband or photo and limiting medication preparation and administration to licensed staff.
A significant medication error occurred when an LPN pre-poured and stored a cup of evening medications for a resident who had initially refused them, then later handed that cup to a nursing assistant to administer, despite policy that only licensed staff prepare and give medications and that refused doses be discarded. The nursing assistant, aware that only licensed nurses should administer medications, took the cup into a shared room and gave the drugs to the wrong roommate, who had multiple chronic conditions including dementia, Parkinson’s disease, and diabetes and had already received a full set of scheduled evening medications. As a result, the resident received additional psychotropic, cardiac, antibiotic, and diabetic medications intended for the roommate, subsequently developed encephalopathy, and was found by the physician to have been exposed to excessive doses and combinations of metformin, tramadol, and beta-blockers with associated clinical effects.
A resident with chronic pain, depression, and anxiety, who was cognitively intact and dependent on staff for daily care, reported feeling fearful after a staff member shook their dinner tray. The resident informed an LPN, who said the concern would be reported to the DNS, but the DNS did not interview the resident or address the allegation promptly, resulting in a delayed investigation of the abuse claim.
Staff failed to use a gait belt and rolling walker during the transfer of a resident with significant mobility limitations and a history of fractures, despite care plan and facility policy requirements. Instead, staff used improper manual techniques, which was confirmed through interviews and documentation review. The resident was later found to have pain and bruising, and was diagnosed with a right humerus fracture, necessitating further medical intervention.
Unauthorized Use of Wanderguard Restraint and Inadequate Elopement Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraint and to obtain required consent from the resident’s conservator before applying a Wanderguard device. The resident had diagnoses of bipolar disorder, dementia without behavioral disturbance, and anxiety disorder, but on admission was documented as alert and oriented to person, place, time, and situation, verbally appropriate, and independent with all ADLs, bed mobility, transfers, and ambulation. An initial elopement risk scale completed at admission identified the resident as not at risk for elopement, and nursing notes and the MAR from admission through several days afterward did not document disorientation, verbalizations of wanting to leave, or exit-seeking behaviors. A physician’s order allowed the resident to go on leave of absence (LOA) with someone, and the admission MDS showed intact cognition (BIMS 15) and no wandering or behavioral symptoms. On a later date, LPN #1 documented that a Wanderguard was placed on the resident’s left ankle due to exit seeking and completed an elopement evaluation identifying the resident as at risk for elopement. However, the note did not indicate that the resident’s conservator of person had been contacted for approval prior to placement of the Wanderguard, and LPN #1 later stated she was unaware the resident was conserved and placed the device without contacting the conservator. The DON, who was the nursing supervisor that day, reported being aware that the resident wanted to leave and that the Wanderguard was applied, and acknowledged that the conservator should have been contacted for approval and that other interventions should have been attempted and documented before using a Wanderguard. Facility documentation, including the MAR and TAR, did not show monitoring for wandering or exit-seeking behaviors after the Wanderguard was applied, despite the care plan later identifying the resident as an elopement risk and including Wanderguard use as an intervention. Subsequently, the resident requested to go on LOA with a friend. At one point, an RN documented that the resident could not go on LOA because neither the resident nor the RN could reach the conservator. Later, a late entry note by another RN documented that the conservator consented to the LOA and that the resident left with a friend, with the LOA book signed. A further late entry note documented that the resident did not return from LOA as expected, attempts to contact the friend, the resident, the resident’s son, and the conservator were unsuccessful, and the police and facility leadership were notified; it was also noted that most of the resident’s belongings were gone. The conservator later reported that the facility had not obtained consent prior to placing the Wanderguard, had not reported prior exit-seeking or wandering behaviors, and that the resident later stated not wanting to return to the facility because it felt like a jail. The facility’s Wanderguard policy allowed placement when the care team decided a resident was at risk for wandering, but the facility did not provide requested policies on conservator notification and behavior monitoring.
Failure to Readmit Resident After LOA Without AMA Documentation or Safety Justification
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return following a Leave of Absence (LOA), despite having available beds and no documentation that the resident left Against Medical Advice (AMA) or that readmission would endanger others. The resident had diagnoses of bipolar disorder, dementia without behavioral disturbances, and anxiety disorder, and had a court-appointed conservator of person responsible for personal care and medical decisions. Upon admission, the resident was alert and oriented, verbally appropriate, and independent with ADLs, bed mobility, transfers, and ambulation. The care plan identified the resident as an elopement risk due to impaired safety awareness and exit-seeking behaviors, with interventions including monitoring for verbalizations about leaving and use of a Wanderguard on the left ankle. A physician’s order allowed the resident to go on LOA with someone. On the day of the LOA, a nurse documented (as a late entry) that the conservator consented to the LOA and that the resident left with a friend who stated they would return around 6:00 PM and signed the LOA book. Later that night, another late entry note documented that by 10:15 PM the resident had not returned from the LOA. Staff attempted to contact the friend, the resident, the resident’s son, and the conservator, left multiple voicemails and an email, notified the police, APRN, and DON, and discovered that most of the resident’s belongings were gone. The facility census showed the resident was discharged the following day, but the clinical record did not contain documentation that the resident left AMA or that an AMA discharge process was followed, as required by the facility’s discharge policy. Subsequently, when the resident was hospitalized and referrals were sent back to the facility, the Admissions Director reported that the facility had open female beds but declined readmission, citing that the resident had left AMA and refused to return, and that the resident was placed on a corporate denial list. The Administrator acknowledged that the resident’s return would not endanger other residents but cited the resident’s ambulatory status and ability to remove a Wanderguard as concerns, and also stated unawareness of requirements for readmissions after extended LOAs or AMA situations. Requested policies regarding residents not returning from LOA and readmission time frames were unavailable.
Failure to Document Discharge and Notify Ombudsman After Resident Does Not Return From LOA
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s discharge in the clinical record and to notify the State Long-Term Care Ombudsman of the discharge after the resident did not return from a leave of absence (LOA). The resident had diagnoses of bipolar disorder, dementia without behavioral disturbances, and anxiety disorder, and had a court-appointed conservator of person. On admission, the resident was documented as alert and oriented, verbally appropriate, and independent with all ADLs, bed mobility, transfers, and ambulation. The care plan later identified the resident as an elopement risk related to impaired safety awareness and exit-seeking behaviors, with interventions including use of a Wanderguard and monitoring. A physician’s order allowed the resident to go on LOA with someone. Late entry nursing notes documented that the RN obtained consent from the conservator for the resident to go on LOA with a friend, that the friend picked the resident up and signed the LOA book, and that by late evening the resident had not returned. Subsequent nursing documentation showed multiple unsuccessful attempts to contact the friend, the resident, and the resident’s son, as well as attempts to contact the conservator, and notification of the police, APRN, and DON. It was later identified that most of the resident’s belongings were gone from the room, and the police reported they were unable to contact the friend but would continue their search. The facility census reflected that the resident was discharged on that date. However, review of the clinical record did not show any documentation by the Director of Social Services regarding the outcome of the LOA or the resident’s discharge. The State Long-Term Care Ombudsman confirmed there was no discharge notice submitted through the required portal, including for a resident leaving against medical advice. Review of the Ombudsman portal with the Director of Social Services confirmed that the discharge was not reported, and the Director stated she was unaware that failure to return from LOA constituted a discharge and therefore did not document the LOA outcome or discharge, nor submit the required Ombudsman notification. The facility’s discharge policy required recording all pertinent documentation in the medical record and describing the sequence of events with timed notations, but there was no available policy on reporting discharges to the Ombudsman.
Failure to Document LOA Details and Communicate Expected Return Time for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident with an identified elopement risk and a court-appointed conservator of person. The resident had diagnoses of bipolar disorder, dementia without behavioral disturbances, and anxiety disorder, and had been admitted alert, oriented, and independent with ADLs, mobility, and ambulation. A court of probate document showed that a conservator was appointed to ensure the resident’s personal care, safety, and medical or other professional care. The resident’s care plan identified the resident as an elopement risk due to impaired safety awareness and exit-seeking behaviors, with interventions including use of a Wanderguard and monitoring. A physician’s order allowed the resident to go on a Leave of Absence (LOA) with someone. On the day of the LOA, a nurse (RN #1) obtained consent from the conservator for the resident to go out with a friend and was informed by the friend that they would return around 6:00 PM. However, these communications and the anticipated return time were not documented in the clinical record prior to the end of RN #1’s shift. The LOA log recorded the time the resident was signed out but did not include a column for anticipated return time, and no nurse’s note was written at that time regarding the LOA. As a result, the oncoming nurse (RN #2), who worked the 3:00 PM to 11:00 PM shift, was not informed of the expected 6:00 PM return time and was unaware of when the resident was scheduled to return. RN #2 later noted that many residents return from LOAs as late as 10:00 PM and, lacking any documented anticipated return time, did not begin attempts to locate the resident until 10:00 PM when the resident had not returned. At that point, multiple unsuccessful attempts were made to contact the friend, the resident, and the resident’s son, and the conservator was notified by voicemail and email. The conservator reported being first notified at 10:00 PM and stated a preference to have been notified immediately. Facility policies required that staff inquire about anticipated LOA duration and that services and changes in the resident’s condition be documented in the medical record to facilitate communication among the interdisciplinary team. The failure to document the conservator communication and anticipated LOA return time, and to communicate this information during shift change, resulted in an incomplete and inaccurate clinical record and delayed recognition and response when the resident did not return as expected.
Residents Not Informed of Grievance Process
Penalty
Summary
The facility failed to ensure residents were provided information on how to file a grievance. Review of the Resident Council Monthly Meeting Minutes dated 1/27/25 through 2/10/26 did not show that residents were educated on the grievance policy, the location of grievance forms, how to file a grievance, or the resolution process. During a Resident Council Meeting on 3/9/26, Residents #17, #29, #40, #52, and #77 stated they were not aware of the grievance process, the policy, or how to file a grievance, and they did not know who the Grievance Official was or where grievance forms were located. Staff interviews showed inconsistent and limited knowledge of the grievance process and form availability. NA #7 and NA #6 stated they did not know where grievance forms were located or how grievances were handled. Housekeeper #1 said she had worked at the facility for 5 years and had never filled out a grievance form for a resident, and if asked, she did not know where the forms were located. RN #2 stated that when a resident or representative wanted to file a grievance, she wrote it on a blank piece of paper because there were no grievance forms, and she did not know who the Grievance Official was. Observation on 3/16/26 found an unlabeled smoke-colored bin with two folders labeled by hand as grievance, placed about 4 feet 3 inches off the floor and not visible or reachable from a wheelchair. The Administrator and SW #1 identified the grievance forms were outside the social worker's office, and RN #7 said residents or representatives would be told to speak with SW #1, or wait until Monday if it was a weekend. The facility grievance policy stated residents, families, and other interested parties are to be given a fair and proper procedure to voice complaints, grievances, or suggestions, but the policy did not identify timeframes for resolution.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of a resident’s personal property to the State Agency as required by its abuse policy. One resident with Type 2 diabetes, non-pressure chronic skin ulcers, a history of malignant neoplasm of the bladder, and a BIMS score of 12 indicating moderately impaired cognition had a care plan identifying risk for falls and the need to keep personal items within reach. The resident’s conservator reported that the resident’s electronic tablet was missing after a hospital transfer and stated that the device had been stolen while the resident was in the hospital. The conservator reported notifying the Administrator, who allegedly stated the facility would investigate the missing device. Despite this notification, facility records from early 2025 through early 2026 showed no grievance filed regarding missing items or the missing tablet, and no State Reportable event was completed for the missing device. A social worker acknowledged being informed by the conservator that the tablet was missing and that a replacement was needed, but stated she was never told it was stolen and did not document this communication in the resident’s medical record. In interviews, the DNS, Administrator, and social worker confirmed that no investigation was completed and no report was made to the State Agency regarding the missing tablet, contrary to the facility’s abuse policy requiring alleged violations to be reported to the Administrator with notification to the State Agency and other parties.
Failure to Investigate Alleged Misappropriation of Resident’s Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete and thorough investigation into an allegation of misappropriation of a resident’s personal property. The resident had Type 2 diabetes, non-pressure chronic skin ulcers, and a history of malignant neoplasm of the bladder, with a BIMS score of 12 indicating moderately impaired cognition. The resident’s care plan identified a risk for falls and directed staff to anticipate needs and keep personal items within reach. A representative (Person #1) reported the resident’s missing electronic tablet to the Administrator approximately one month before the survey. However, review of the clinical record, facility documentation, and social service progress notes over a more than two-month period showed no documentation that an investigation into the missing tablet was initiated or completed. The social worker reported that the resident’s conservator (Person #2) informed her that the resident’s tablet was missing after a hospital stay and that a replacement was needed, but she stated she was never told the device was stolen and did not document this communication in the medical record. Person #2 stated that the tablet was stolen while the resident was in the hospital and that he/she notified the Administrator, who said the facility would investigate the missing device. Interviews with the DNS, Administrator, and social worker confirmed that no investigation had been completed regarding the missing tablet. This lack of investigation and documentation occurred despite the facility’s abuse policy requiring that alleged violations be reported to the Administrator, with notification to the state agency and others, and that the social service representative provide a written report of findings through social service progress notes in the medical record.
Delayed Return of Resident's Personal Phone
Penalty
Summary
The facility failed to ensure Resident #25 had timely access to personal property, specifically a cell phone and other missing personal items. Resident #25 had diagnoses including congestive heart failure, Type 2 diabetes, and major depression. The annual MDS identified a BIMS score of 11, indicating moderately impaired cognition, and the resident was dependent with transfers and required maximal assistance with bed mobility. The care plan identified the resident as at risk for falling and directed staff to keep personal items within reach and anticipate the resident's needs. Resident #25 reported to staff that multiple personal items, including a phone, were missing, and the Administrator was aware of the concern. The SW stated the resident notified her that items were missing and that the facility was still searching for them. NAs reported the phone had been sitting on the nurse's station counter for several days and was then moved to the supervisor's office because it was not holding a charge. The DNS stated the phone was not in the locked cabinet and initially believed it had already been returned, but later confirmed it had not been returned. The SW kept the phone in her office because it needed to be charged and she did not want it misplaced, and the phone was not returned to the resident until after surveyor inquiry.
Resident Council Hair Dryer Requests Not Addressed
Penalty
Summary
The facility failed to address the Resident Council’s repeated requests regarding the use of personal items for the group. Resident Council meeting minutes dated 12/10/25 showed residents asked about having and using a hair dryer, and minutes dated 1/13/26 showed the request was raised again. Staff told residents that blow dryers were not permitted because of fire-hazard risk. During a Resident Council meeting on 3/9/26, residents stated the hair-dryer issue had been discussed in prior meetings and that they were told each time that hair dryers were not permitted due to fire-hazard concerns. Interviews showed the Director of Recreation recorded the minutes and recalled an alert and oriented resident requesting a hair dryer, but after speaking with the Director of Maintenance she told residents the item was not allowed and did not consult him again when the issue was raised later. She also did not report the issue to the Administrator. The Assistant Maintenance Director stated he had been instructed that residents were not allowed to have hair dryers because they were fire hazards, but he could not identify a specific regulation. The Administrator stated she only became aware of the request after reviewing the Resident Council minutes and did not know whether residents were permitted to have a hair dryer. The Resident and Facility Handbook stated electrical personal possessions brought into the facility must be inspected and tagged by maintenance before use.
Advance Directive Not Matched to Code Status Order
Penalty
Summary
The facility failed to implement Advance Directives according to a resident’s expressed wishes. Resident #4 had diagnoses including cardiac arrhythmia, end-stage renal disease, and type 2 diabetes, and the clinical record showed a signed Advance Directives form dated 4/6/2025 indicating Full Code status. However, a physician’s order dated 2/21/2026 directed DNR and DNI, creating a mismatch between the resident’s signed directive and the code status order in the record. The quarterly MDS assessment identified the resident had a BIMS score of 15, indicating intact cognition. Interviews and record review showed staff were aware the code status did not match the signed Advance Directives form. An LPN stated nurses were responsible for placing signed Advance Directives in the paper chart and entering the order into the electronic health record, and an RN stated supervisors were responsible for ensuring the code status order matched the signed form. The DON stated the same process applied on re-admission and confirmed the resident’s code status did not match the signed Advance Directives form. The RN later entered a physician’s order for Full Code into the electronic health record and notified the dialysis center of the resident’s correct code status.
Failure to Complete Quarterly Elopement Risk Assessments for Resident with Wander Guard
Penalty
Summary
The facility failed to conduct elopement risk assessments for Resident #8, who had diagnoses including depression, anxiety, and stroke and had a Wander Guard bracelet placed on the right ankle. The physician’s order directed staff to place the Wander Guard, check placement every shift, and check function daily on the night shift. The resident’s care plan identified a risk for elopement due to a history of attempts to leave the facility unattended, impaired safety, and awareness, and included use of the Wander Guard and structured activities. The quarterly MDS identified the resident had intact cognition, no behaviors, and required a wander/elopement alarm less than daily, while the annual MDS later identified moderately impaired cognition and daily use of a wander/elopement alarm. Observation and interview showed Resident #8 ambulating independently throughout the facility with the Wander Guard in place and stating he/she had attempted to leave the facility about one year earlier but had not attempted to leave since then. The resident stated he/she avoided the front entrance doors to prevent the alarm from activating and wanted the bracelet removed. RN #2 stated the resident had been identified at risk for elopement on admission, but she had not observed any exit-seeking behaviors and the Wander Guard was being used for safety because the resident ambulated independently. The DNS stated the last elopement assessment had been completed on 2/26/25 and that assessments were required at least quarterly, but she could not explain why quarterly assessments were not completed. After surveyor inquiry, the DNS completed an Elopement Risk Scale assessment identifying the resident was not at risk for elopement, and the physician discontinued the Wander Guard.
Failure to Follow BP Medication Parameters
Penalty
Summary
The facility failed to ensure medication administration parameters were followed for Resident #70 when Amlodipine besylate 2.5 mg was given without first obtaining the resident’s blood pressure or pulse. Resident #70 had diagnoses of congestive heart failure, coronary artery disease, and hypertension, and the physician’s order directed that the medication be held for systolic blood pressure less than 110 or heart rate less than 50 beats per minute. The quarterly MDS identified the resident as moderately cognitively impaired, and the care plan identified altered cardiovascular status with interventions to monitor vital signs and notify the physician of significant abnormalities. During observation and interview, the LPN administered the medication without checking vital signs and stated the resident did not have specific parameters required prior to administration. After surveyor inquiry, the LPN reread the medication label, identified the hold parameters, returned to the resident’s room, and obtained a blood pressure of 128/63 and a pulse of 66 beats per minute. The DON stated the LPN should have checked the resident’s blood pressure and pulse before administering the medication and should have followed the physician’s orders.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure showers were provided for Resident #22, who was admitted in July 2025 with diagnoses including diabetes and heart disease. The quarterly MDS identified moderately impaired cognition and need for supervision or touching assistance with showers, transfers, bathing, and lower-body dressing. The physician’s orders directed weekly showers with assistance from one staff member every Wednesday on the 3:00 PM to 11:00 PM shift, and the care plan identified the resident as at risk for falling with interventions to keep personal items and the call light within reach. Nurse aide flow sheets documented showers as N/A on multiple dates, indicating showers were not provided, and the resident stated on interview that he/she had not received a weekly shower for at least the last 3 weeks and had only received maybe 2 showers in the last few months. The resident reported requesting additional showers for several months and said the requests were ignored. NA #3 stated the resident required maximum assistance with showers and could not be left alone, and said she provided only one shower on 2/4/26. NA #4 stated she documented showers as given even though she did not provide them because she was pregnant and found it physically difficult. The DNS stated there was no documentation that the resident refused showers, that the resident was scheduled for weekly showers on Wednesday evenings, and that if a resident asks for a shower, it should be done.
Failure to Provide Ordered Divided Plate for Resident with Feeding Needs
Penalty
Summary
The facility failed to provide Resident #43 with physician-ordered adaptive eating equipment, specifically a divided plate for all meals. Resident #43 had diagnoses including Parkinson's Disease, dementia, and bilateral nuclear cataracts. The quarterly MDS identified a BIMS score of 12, indicating moderately impaired cognition, and the resident required set-up assistance for eating. The resident care plan identified risk for nutrition problems related to Parkinson's, dementia, impaired mental health, and a significant weight change, with interventions including monitoring and serving the diet as ordered. During an observation and interview, Resident #43 was seated in the dining room with lunch without the benefit of a divided plate, even though the meal ticket directed adaptive equipment consisting of a divided plate. SLP #1 confirmed the resident required the adaptive equipment and stated the divided plate had not been provided, identifying the kitchen as responsible. The Director of Dietary also confirmed the divided plate had not been provided and stated the cooks were responsible for providing adaptive equipment. A staff member responsible for tray line preparation stated she was made aware when a divided plate was needed and that Resident #43's lunch should have been served on a divided plate. The facility policy stated orders for feeding adaptive equipment should be included on pre-printed dietary tray tickets and staff should check tray accuracy before trays went to the units.
Incomplete and Inaccurate Documentation of Resident Shower Care
Penalty
Summary
The facility failed to ensure the clinical record was complete and accurate for Resident #22’s personal care. Resident #22 was admitted in July 2025 with diagnoses including diabetes and heart disease, had a care plan identifying fall risk with personal items and the call light to be kept within reach, and the quarterly MDS indicated moderately impaired cognition with supervision or touching assistance needed for showers, transfers, bathing, and lower-body dressing. Physician orders directed weekly showers with assistance from 1 staff member every Wednesday on the 3:00 PM to 11:00 PM shift, but the TAR showed LPN #3 signed off that the resident received weekly showers on multiple Wednesdays from January through March 2026. The resident stated on 3/5/26 that he/she had not received a weekly shower for at least the last 3 weeks and had only received maybe 2 showers in the last few months. LPN #3 later stated she was the charge nurse on those shifts, but she never witnessed the resident receiving a shower or confirmed with nurse aides that a shower was provided, yet still signed the TARs. The nurse aide flowsheets also did not accurately reflect the resident’s care. One flowsheet documented the resident as independent with showers, while other entries marked showers as N/A, and activities of daily living documentation was missing on multiple shifts in February and March 2026. NA #3 stated the resident required maximum assistance with showers and could not be left alone, and she said she provided only one shower on 2/4/26. NA #4 stated she did not give the resident any showers despite documenting that showers were given. NA #5 stated that a code of 6 meant independent with showers and that NA meant no shower was given that day, but she could not recall whether the resident received showers in February 2026. The DNS and Administrator stated documentation must be complete and accurate, and the facility policy required resident documentation to be objective, complete, and accurate.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to ensure staff wore appropriate PPE while providing care to a resident on Enhanced Barrier Precautions (EBP). The resident had diagnoses including quadriplegia, stage 4 pressure ulcers of the left and right buttock and sacral region, flaccid neuropathic bladder, and MRSA carrier or suspected carrier status. The annual MDS identified the resident as cognitively intact with a BIMS score of 15 and dependent for bed mobility and transfers, and also documented three stage 4 pressure ulcers. The physician’s order directed EBP related to chronic wounds, a suprapubic catheter, colostomy, history of ESBL and MRSA, with PPE use per signage on every shift, and the care plan identified the resident as on EBP with interventions to maintain EBP per facility policy. Observation showed signage outside the resident’s room directing that a gown and gloves be worn during high-contact activities, but two nurse aides were providing personal care and a bed bath without isolation gowns. Both nurse aides stated they were aware the resident was on EBP and acknowledged they forgot to put on gowns, which they should have worn. The DNS stated that for residents on EBP, nursing staff should don an isolation gown and gloves when providing personal care or during high-contact activity, and confirmed the nurse aides should have known the required PPE. The facility policy stated EBP is used for residents with infection or colonization of an MDRO, or with wounds or indwelling medical devices, and includes gown and glove use during high-contact resident care activities.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure staff were educated on the benefits and risks associated with COVID-19 vaccination and failed to ensure staff were offered the COVID-19 vaccine or information on how to obtain it. An interview with the Infection Preventionist identified the facility no longer offered COVID-19 vaccines to staff, previously completed staff consent forms were shredded, and staff were not provided COVID-19 vaccine education. When documentation was requested from the Administrator, DON, and IP, the facility did not provide records showing staff education on COVID-19 vaccination, including vaccine availability or where staff could receive the vaccine. The Director of Rehabilitation stated that during the facility’s influenza clinic, staff were informed the facility would no longer provide the COVID-19 vaccine. The facility policy stated all staff are to be fully vaccinated against COVID-19 unless there is a documented medical or religious exemption on file.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post notice of the availability of its survey results in areas readily accessible to residents, family members, and legal representatives. On multiple observations, surveyors could not locate any notices about where the survey results could be viewed. During interviews, Resident Council members stated they did not know what the state survey results were or where they were located, and they reported staff had never reviewed this information with them individually or during Resident Council meetings. Staff interviews showed inconsistent and limited knowledge about the location of the survey results. Several nursing staff members, including NA, LPN, and RN staff, did not know where the results were located, while one NA believed they should not be left out for residents or visitors and would direct requests to the DNS. The DNS initially stated the results were kept in the front lobby but could not locate them there, and the receptionist said they were not kept at the desk and did not know their location. The Administrator later identified the state inspection reports for the last three years as being kept behind the reception desk and retrieved a state survey binder containing complaint reports. The Administrator also pointed to a sign on a side wall above the front desk stating that the most recent copy of state results could be found at the reception desk, but the DNS had not noticed the sign, and it was posted above wheelchair eye level.
Failure to Follow Safe Medication Administration and Resident Identification Practices
Penalty
Summary
The deficiency involves failures in safe medication administration practices, including resident identification, proper disposal of refused medications, and limiting medication administration to licensed personnel. One resident received his or her scheduled medications at approximately 8:30 PM and then was given another resident's medications at about 10:15 PM, resulting in a reported medication error. At the time, the resident was described as alert, slightly lethargic, and able to respond verbally and appropriately. The error occurred after one resident initially refused medications, which were then labeled with that resident's name and placed back into the medication cart instead of being disposed of. Later, those medications were handed by an LPN to a nursing assistant to administer, and the nursing assistant gave them to the wrong resident. Additional observations on a later date showed that two nurses failed to verify resident identity before administering medications. One LPN administered medications to a resident without checking the wristband, stating that he or she was familiar with the resident, despite acknowledging that facility policy required checking the wristband. Similarly, an RN administered medications to another resident without confirming identity, also citing familiarity and acknowledging that policy required verification by wristband or photo. Interviews with the DNS and review of facility policy confirmed that only licensed personnel were to prepare and administer medications, refused medications were to be disposed of immediately with new doses prepared if needed later, and resident identification was to be verified by wristband or photo before each medication administration.
Significant Medication Error When One Resident Received Another Resident’s Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when one resident received medications prescribed for another resident. Resident #1, who had vascular dementia, Parkinson’s disease, and anxiety disorder, had moderately impaired cognition and required maximum assistance with personal care. Resident #1’s care plan included use of antipsychotic medications for Parkinson’s-related hallucinations, with directions to administer medications per physician orders and monitor for side effects and effectiveness. On the evening in question, Resident #1 received his or her scheduled medications, including multiple agents for cholesterol, diabetes, Parkinson’s disease, hypertension, constipation, pain, and neuropathy. Resident #2, who had bipolar disorder, Type 2 diabetes mellitus, and atherosclerotic heart disease, also had moderately impaired cognition and required moderate assistance with personal care. Resident #2’s care plan addressed mood problems related to major depressive disorder, bipolar disorder, and anxiety disorder, with directions to administer medications per physician orders and monitor for side effects and effectiveness. On the same evening, Resident #2 refused several medications, including atorvastatin, Belsomra, lurasidone, trazodone, buspirone, carvedilol, doxycycline, and metformin, and requested they be given later. The LPN labeled a medication cup with Resident #2’s name and placed it back into the medication cart instead of disposing of the refused medications. Later that night, the LPN gave the pre-poured, labeled cup of Resident #2’s medications to a nursing assistant and asked the assistant to administer them to Resident #2, despite facility policy and the DNS’s stated standard of practice that only licensed personnel prepare and administer medications and that refused medications be disposed of immediately. The nursing assistant, who acknowledged knowing that only licensed nurses were to administer medications, took the cup into the shared room and administered the medications to Resident #1 instead. This error was discovered after Resident #2 requested pain medication, and it was recognized that the medications given by the nursing assistant to Resident #1 were intended for Resident #2. Resident #1 was subsequently found to have received additional medications including trazodone, lurasidone, buspirone, carvedilol, doxycycline, and metformin, and developed encephalopathy, which the physician identified as more likely related to trazodone toxicity or possibly metabolic encephalopathy in the setting of RSV infection and hypoxia. The physician also identified that the total doses of metformin, tramadol, and the combination of carvedilol with previously administered metoprolol placed the resident at risk for low blood sugar, hypotension, drowsiness, lethargy, nausea/vomiting, and decreased blood pressure and heart rate.
Failure to Timely Investigate Alleged Abuse
Penalty
Summary
The facility failed to timely investigate an allegation of abuse involving a resident with chronic pain, depression, and anxiety, who was cognitively intact and required assistance with activities of daily living. The resident reported to the social worker that a staff member had shaken their dinner tray in a manner that made the resident feel fearful it might be thrown at them. The incident was said to have occurred on a Sunday, and the resident initially reported their concerns to an LPN, who stated she would inform the RN supervisor (DNS). However, the DNS did not visit the resident that day, and the resident indicated that no one else came to discuss the incident until days later. Interviews and documentation revealed that both the LPN and the aide involved informed the DNS about the resident's concerns on the day of the incident. The DNS acknowledged being aware of the situation but did not interview the resident at that time, only learning later during the investigation that the resident had felt afraid. Facility policy required prompt reporting and investigation of abuse allegations, including obtaining statements and completing a reportable event form, but these steps were not carried out in a timely manner, resulting in a delay in addressing the resident's report of potential abuse.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to utilize a gait belt and rolling walker during the transfer of a resident who required assistance from two staff members. The resident, who had diagnoses including osteoarthritis, a history of a healed traumatic fracture of the right arm, vascular dementia, and was identified as a fall risk with limited mobility, was care planned to receive assistance of two staff for transfers and to use safety equipment such as a gait belt. Despite these interventions being documented in the care plan and facility policy, staff transferred the resident by placing their arms under the resident's arm and grabbing the resident's pants, without using a gait belt, as confirmed by staff interviews. Following this improper transfer technique, the resident was noted to have pain and bruising on the right upper arm, which led to further medical evaluation. Imaging revealed an old, impacted fracture of the right humeral head and neck with evidence of osteopenia and osteoporosis. The resident was subsequently diagnosed with a right humerus fracture and required additional interventions, including a sling, non-weight bearing status, use of a Hoyer lift for transfers, pain management, and therapy evaluation. The facility's policy and staff interviews confirmed that a gait belt should have been used during the transfer, but it was not, directly leading to the deficiency.
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What surveyors actually found near you
We read the 720 citations issued within 25 miles in the last 12 months — including the 10 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wallingford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Masonicare Health Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Regency House Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Elim Park Baptist Home, Inc | 3.1 mi | ★★★★★ | 0 | 0 |
| Whitney Rehabilitation Care Center | 4.7 mi | ★★★★★ | 0 | 0 |
| Complete Care At Meriden | 5.1 mi | ★★★★★ | 13 | 0 |
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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.