Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa Maria Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
Unlabeled and expired food items were found in the Nourishment Room, supplement refrigerator, and Dining Room, and one compartment of the steam table base was dirty. The Nourishment Room freezer and refrigerator contained expired and unlabeled items, including supplements, yogurt, marshmallows, and an opened supplement drink, while the Dining Room had opened, unlabeled bread products and expired crescent rolls. The DFD stated dietary aides and cooks were responsible for daily checks, but staff did not follow the facility procedure for food storage and cleanliness.
The facility failed to ensure accurate reconciliation of controlled substances at shift change. Review of narcotics and sedatives count sheets for three units showed multiple missed documentation entries across two months, and the DON stated the licensed nurse was responsible for completing the count at every shift change. The Controlled Substance policy required counts at receipt, administration, disposition, and the end of each shift, with the oncoming and offgoing nurses counting together.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
The facility did not consistently update or review resident care plans within the required timeframe following care conferences for three residents with complex medical and cognitive needs. Staff interviews confirmed that care plans were not revised as required and that care conferences were not always held quarterly, with no clear explanation for these lapses.
Multiple residents reported receiving cold food and insufficient portions, with direct temperature checks confirming that both hot and cold foods were served outside of safe and palatable temperature ranges. The Dietary Director acknowledged the issue, and observations showed that food not meeting temperature standards was still served to residents.
Two residents experienced deficiencies related to lack of timely physician notification: one resident with multiple comorbidities developed hypotension and respiratory symptoms after nitroglycerin administration, but staff did not notify the physician or reassess vital signs promptly; another resident did not receive prescribed Prozac for two days due to pharmacy delivery issues, and the LPN failed to notify the supervisor or physician about the missed doses.
Staff failed to promptly report allegations of sexual abuse and missing personal property involving three residents to the State Agency as required. In one case, a cognitively intact resident reported inappropriate behavior by a nurse aide, but the administrator did not notify authorities, dismissing the claim. In two other cases, residents' missing cell phones were reported to staff, but the incidents were not escalated or documented according to policy, resulting in delayed investigation and reporting.
A resident with multiple medical conditions and no cognitive impairment reported that a nurse aide exposed her breasts and acted inappropriately. The allegation was reported to supervisory staff and the Administrator, but no investigation was initiated, and the accused staff member remained on the facility schedule, contrary to policy. The incident was not addressed until brought to attention by surveyors.
Two residents experienced deficiencies in care when staff failed to follow professional standards and facility policy. In one case, a resident with obvious injuries from a fall was physically lifted by staff before EMS arrival, despite policy prohibiting movement prior to assessment. In another case, a resident with a significant change in condition, including hypotension and chest pain, did not receive an RN assessment or timely physician notification, and was sent for hemolytic treatment without appropriate evaluation.
A resident with end stage renal disease and multiple comorbidities experienced a significant change in condition, including chest pain and low blood pressure, but staff failed to communicate this to the dialysis center prior to the resident's scheduled treatment. Documentation and required information exchange between the facility and the dialysis center were not completed as required, resulting in the resident being sent to dialysis in an unstable condition and subsequently requiring emergency care.
A resident with lower limb wounds received wound care from an LPN who failed to perform hand hygiene between glove changes after removing soiled dressings and before cleansing and dressing the wounds. Interviews with facility leadership and review of policy confirmed that hand hygiene was required at these points, but the protocol was not followed, resulting in a deficiency.
Three residents with significant medical conditions did not have their COVID-19 vaccination status identified, were not offered the vaccine, and did not receive documented education about the vaccine. Care plans and health records lacked required information, and the Infection Preventionist confirmed that vaccination status and education were not tracked or provided, contrary to facility policy.
A resident with dementia and a history of right leg fractures, who required a hinged knee brace and assistive device for transfers, was assisted by two nurse aides after a shower without the knee brace being reapplied and without use of the designated device. The resident's knees buckled during the transfer, resulting in a fall and an acute proximal tibia fracture. Staff interviews revealed the aides did not review the care plan or Kardex and were unaware of the specific transfer requirements.
Unlabeled and Expired Food Items Found in Nourishment and Dining Areas
Penalty
Summary
Food and nutrition services failed to ensure that food and drink items were labeled, that expired food items were removed, and that the Dining Room steam cart was clean and sanitary. During a tour of the facility, the Nourishment Room freezer contained expired ice pops, an unidentified frozen item in a cup, pancakes, and a water bottle, and the Nourishment Room refrigerator contained expired yogurt cups and marshmallows, an unlabeled opened supplement drink, and multiple unlabeled supplements. The Nourishment Room supplement refrigerator also contained expired supplemental ice creams and shakes. In the Dining Room, bread, individually packaged rolls, waffles, and potato chips were opened and unlabeled, and crescent rolls had expired. An observation with the Director of Food Service identified one compartment of the base of the steam table as dirty, and the Director of Food Service stated it may have been caused by a spill of gravy. A Dietary Aide stated it was her responsibility to monitor the Nourishment Room and supplement refrigerator daily and to ensure food items were labeled and expired items removed, but she was not aware why unlabeled and expired items were present. The Director of Food Service stated dietary aides were responsible for checking unit refrigerators daily and cooks were responsible for kitchen refrigerators, while the Director was responsible for the cleanliness of food service equipment; the Director also stated staff did not follow the facility procedure for food storage and cleanliness. The staff expectation guidelines provided to new employees did not identify who was responsible for labeling all food items or checking for exposed items and the frequency of doing both.
Failure to Document Controlled Substance Counts at Shift Change
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substances at the change of shift. Review of the Count Sheet Narcotics and Sedatives forms for three units showed that, in March 2026, controlled medications should have been counted during 279 shifts, but the count was not documented 54 times. In April 2026, controlled medications should have been counted during 270 shifts, but the count was not documented 67 times. The DON stated on interview that it was the licensed nurse's responsibility to complete the count sheet at every shift change and that she was not aware why this was not being done consistently. The DON also stated the facility failed to follow its Controlled Substance policy, which required controlled substances to be reconciled upon receipt, administration, disposition, and at the end of each shift, with the oncoming and offgoing nurses counting the medications together.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Timely Update and Review Resident Care Plans
Penalty
Summary
The facility failed to review and revise resident care plans (RCPs) and did not conduct care plan conferences as required for three sampled residents. For one resident with diagnoses including malignant neoplasm, chronic heart failure, and PTSD, the care plan was not updated within 5-7 days following several resident care conferences, despite the resident having no cognitive impairment and requiring significant assistance with daily activities. Interviews with facility staff confirmed that care plans were not updated in a timely manner after multiple care conferences, and staff could not provide reasons for these delays. Another resident, diagnosed with dementia, diabetes, and anxiety, had severe cognitive impairment and required moderate assistance with personal care. The care plan for this resident was also not updated within the required timeframe after several care conferences. Additionally, there was a significant gap between care conferences, exceeding the required quarterly schedule, which staff attributed to a change in staffing but could not otherwise explain. A third resident with hemiplegia, diabetes, and moderate cognitive impairment also experienced delays in care plan updates following care conferences. Facility policy requires care plans to be developed within 7 days of the comprehensive MDS and updated at least quarterly, but this was not consistently followed. Staff interviews confirmed the lapses in timely care plan updates and the inability to account for the missed deadlines.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported receiving cold food, including cold toast, coffee, eggs, and meat that was sometimes raw. One resident stated that he remained hungry after meals due to insufficient food portions. Direct temperature checks conducted by surveyors and the Dietary Director revealed that hot foods such as chicken nuggets and French fries were served below the recommended palatable temperature of 140°F, with recorded temperatures as low as 116.0°F and 96.2°F, respectively. Cold food items, such as coleslaw, were found to be served at 57.1°F, exceeding the safe maximum of 45°F for cold foods. Observations indicated that the coleslaw was not promptly removed from plates after it was found to be above the safe temperature, and it continued to be delivered to residents. The Dietary Director acknowledged the temperature issues, attributing the heat loss to inadequate plate lids. The Administrator confirmed awareness of resident complaints regarding cold food. Review of the facility's food preparation and serving policy showed a requirement to maintain proper hot and cold temperatures during food service, which was not met during the survey period.
Failure to Notify Physician of Change in Condition and Medication Omission
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident with end stage renal disease, diabetes, hypertension, and a history of cerebral infarction. The resident, who was alert and oriented, experienced chest pain and was administered nitroglycerin as ordered. Following this, the resident developed hypotension, with blood pressure readings dropping to 80/40 and remaining low for several hours. Despite these abnormal findings and the resident presenting with increased lethargy, mild shortness of breath, and diminished lung sounds, there was no documentation that the physician or hemolytic center was notified of these changes. Nursing staff did not reassess vital signs in a timely manner, and the resident was sent to hemolytic treatment without physician notification. Upon return, the resident was found to be unstable and was sent to the emergency room, where they were admitted for hypoxic respiratory failure and exhibited stroke-like symptoms. In a separate incident, the facility failed to notify the physician when a prescribed medication was not available for administration to another resident. The resident, who was cognitively intact and required psychotropic medication for depression, did not receive Prozac as ordered on two consecutive days due to the medication not being delivered by the pharmacy. The responsible LPN did not notify the nursing supervisor, contact the pharmacy, or inform the physician about the missed doses. The MAR and nursing notes did not provide an explanation for the missed medication administration, and the issue was only addressed after the RN supervisor was informed by the LPN on the following day. Facility policy required immediate reporting of changes in condition to the unit manager or shift supervisor, assessment and documentation of the resident's status, and prompt notification of the physician for non-emergent changes. Additionally, policy required that discrepancies or omissions in medication delivery be reported to the pharmacy and charge nurse. In both cases, staff failed to follow these policies, resulting in a lack of timely physician notification for significant changes in condition and medication administration issues.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of property to the State Agency as required by policy and regulation. In one instance, a resident with a history of malignant neoplasm, chronic heart failure, and post-traumatic stress disorder, who was cognitively intact, reported that a nurse aide had exposed herself and engaged in inappropriate behavior. The resident communicated this to another nurse aide, who then reported it to a registered nurse and the facility administrator. Despite these reports, the administrator did not notify the State Agency, dismissing the incident as a hallucination, and the nurse aide in question continued to work, only being removed from the resident's care assignment. Multiple staff interviews confirmed knowledge of the allegation, but no timely report was made to authorities as required by the facility's abuse policy. In another case, two residents with chronic medical and psychiatric conditions reported missing cell phones. One resident reported the missing phone to the Therapeutic Recreation Director, who searched for the phone but did not escalate the issue to the administrator or complete a grievance. The Director of Environmental Services was also informed but did not file a report, assuming the issue had already been addressed. The second resident reported the missing phone to a nurse aide, who searched for the phone but did not report the incident, believing others were already aware. In both cases, the missing property was not reported to the appropriate supervisory staff or the State Agency in a timely manner, as required by facility policy. Interviews with facility leadership, including the Director of Nursing and the administrator, revealed that staff were expected to report such incidents immediately, but this did not occur. The facility's abuse prohibition policy clearly directed staff to report any knowledge of abuse, neglect, or misappropriation of property to supervisors and the State Agency within specified timeframes. Despite this, staff failed to follow reporting protocols, resulting in delayed notification and investigation of the allegations.
Failure to Investigate and Remove Staff Following Sexual Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident with diagnoses including malignant neoplasm of the head, face, and neck, congestive heart failure, and post-traumatic stress disorder. The resident, who was cognitively intact and dependent on staff for personal hygiene and transfers, reported that a nurse aide had exposed her breasts and behaved inappropriately. The resident informed another nurse aide, who reported the incident to a registered nurse and the Administrator. Despite this, the Administrator dismissed the allegation as a hallucination and did not initiate an investigation. The nurse aide accused of abuse continued to work in the facility and was only removed from the resident's care assignment, not from the facility schedule. Multiple staff interviews confirmed that the allegation was reported up the chain of command, but neither the Director of Nursing Services nor the State Agency was notified at the time. The facility's abuse reporting policy required immediate notification of the Administrator, a thorough investigation, and removal of the alleged perpetrator from resident contact pending investigation. These steps were not followed, as the staff member remained on the schedule and the incident was not investigated until prompted by surveyor inquiry. The failure to act according to policy resulted in a lack of protection for the resident and a delay in addressing the abuse allegation.
Failure to Follow Professional Standards in Resident Assessment and Post-Fall Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in two separate incidents involving two residents. In the first incident, a resident with a history of dementia, depression, heart failure, and hypertension, who was at risk for falls, experienced a fall in the dining room. The resident was found on the floor with a head injury, visible deformity of the left wrist, and hip pain. Despite the presence of obvious injuries, including a shortened leg indicative of a hip fracture and a visible wrist deformity, three staff members physically lifted the resident from the floor to a chair before emergency medical services arrived. This action was contrary to the facility's policy, which directs staff not to move a resident with suspected injury until evaluated by a physician or EMS. Interviews with staff and review of facility policy confirmed that the resident should not have been moved, and the Director of Nursing was unable to explain why this occurred. In the second incident, another resident with end stage renal disease, diabetes, hypertension, and a history of stroke-like events, experienced a change in condition characterized by chest pain, hypotension, increased lethargy, mild shortness of breath, and diminished lung sounds. The resident was administered nitroglycerin for chest pain, but subsequent blood pressure readings revealed abnormally low values. Despite these findings, there was no documentation that a Registered Nurse assessed the resident or that the physician was notified of the change in condition. The resident was sent for hemolytic treatment without further assessment or notification to the treatment center regarding the change in condition. Interviews with LPNs and review of the clinical record confirmed that no RN assessment or provider notification occurred during this period. Both incidents demonstrate failures to follow established standards of practice and facility policies regarding the assessment and management of residents with injuries or changes in condition. The deficiencies were identified through observations, record reviews, staff interviews, and review of facility policies, which clearly outlined the required procedures that were not followed in these cases.
Failure to Communicate Resident Status to Dialysis Center
Penalty
Summary
The facility failed to ensure appropriate communication and documentation with the dialysis (hemolytic) treatment center for a resident with end stage renal disease, diabetes, hypertension, and a history of cerebral infarction. The resident required regular dialysis treatments and had a care plan in place that specified the need for communication with the dialysis center regarding medications, treatments, and coordination of care. However, a review of records from November 2024 through June 2025 revealed a lack of documentation from the dialysis center and no evidence that facility staff had communicated essential information such as diagnoses, current medications, dietary needs, assistance required for activities of daily living, fluid needs, or changes in condition. On one occasion, the resident experienced a significant change in condition, including chest pain, administration of nitroglycerin, and a drop in blood pressure. Despite these changes, the nurse on the following shift did not recheck vital signs or inform the dialysis center of the resident's unstable condition before sending the resident for treatment. Upon arrival at the dialysis center, the resident was noted to be lethargic, short of breath, and hypotensive, prompting the dialysis center to administer treatment at a minimal level and monitor the resident closely. After returning from dialysis, the resident remained unstable and was sent to the emergency department. Interviews with facility staff and the dialysis center nurse confirmed that there was no communication from the facility regarding the resident's change in condition. The facility's own communication tool and policy required that information about recent medications, signs of infection, and changes in condition be shared with the dialysis center, but this was not done. The Director of Nursing acknowledged that required documentation and communication had not been completed since the resident's admission.
Failure to Ensure Proper Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified in the facility's infection prevention and control program related to improper hand hygiene during wound care for a resident with multiple lower limb wounds, including cellulitis, chronic ulcers, and deep tissue injuries to both heels. The resident required significant assistance with mobility and had physician orders for daily wound care on both heels. During an observed wound care procedure, an LPN failed to perform hand hygiene between glove changes after removing soiled dressings and before cleansing and dressing the wounds. Specifically, the LPN removed gloves and donned new gloves multiple times without performing hand hygiene, despite being interrupted and acknowledging the correct procedure. Further interviews with facility leadership, including the Director of Nursing Services and the Infection Preventionist, confirmed that hand hygiene should be performed before care, with each glove change, and after care is complete. Review of the facility's policy also indicated that staff are required to wash or sanitize hands after removing soiled dressings and before applying clean dressings. The observed failure to follow these protocols during wound care led to the identified deficiency.
Failure to Identify, Offer, and Document COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to identify, offer, and document COVID-19 vaccination status and education for three residents with various medical conditions, including cellulitis, lymphedema, diabetes, end stage renal disease, protein calorie malnutrition, Alzheimer's disease, rheumatic tricuspid insufficiency, and chronic kidney disease. For each resident, the care plans and electronic health records did not reflect COVID-19 vaccination status, documentation of vaccine education, or evidence that the vaccine was offered. Additionally, there were no physician orders related to COVID-19 vaccination for these residents. During an interview and review of records with the Infection Preventionist, it was confirmed that the vaccination status and education for these residents had not been obtained or provided, and none of the residents appeared on the vaccination log. The Infection Preventionist indicated that staff were no longer required to offer or track COVID-19 vaccination for residents. This was inconsistent with the facility's own policy, which required education, offering the vaccine, and documentation of these actions.
Failure to Apply Required Knee Brace and Use Assistive Device Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to apply a required hinged knee brace to a resident's right leg prior to assisting the resident to stand, which resulted in the resident's leg buckling and a subsequent fall. The resident, who had a history of dementia, a lower end right femur fracture, osteoarthritis of the right knee, and generalized weakness, was dependent on staff for transfers and had physician orders and care plan interventions specifying the use of a hinged knee brace during weight-bearing activities and transfers. The care plan also required the use of a specific assistive device and assistance from two staff members for transfers. On the day of the incident, two nurse aides assisted the resident with a shower and removed the knee brace for the shower. After the shower, they attempted to help the resident stand to dry off without reapplying the knee brace and without using the designated assistive device. As the resident was assisted to stand, the knees buckled twice, and the aides lowered the resident to the floor. The resident was subsequently found to have sustained an acute fracture of the proximal tibia and required transfer to the hospital for evaluation and treatment. Interviews and facility documentation confirmed that the nurse aides did not review the resident's care requirements in the Kardex and were unaware of the orders for the knee brace and assistive device. The Director of Nursing confirmed that the aides failed to follow the plan of care, which led to the resident's fall and injury. Facility policies required staff to provide care in accordance with the resident's care plan and to prevent decline in functional status.
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What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Plainfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Health & Rehab Center Of Plainfield, Llc | 0.2 mi | ★★★★★ | 3 | 0 |
| Pierce Memorial Baptist Home, Inc. | 7.5 mi | ★★★★★ | 6 | 0 |
| Davis Place | 9.3 mi | ★★★★★ | 2 | 0 |
| Douglas Manor | 12.8 mi | ★★★★★ | 7 | 0 |
| Norwich Sub-acute And Nursing | 13 mi | ★★★★★ | 1 | 0 |
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