Below 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 Water's Edge Center For Health & Rehab during CMS and state inspections, most recent first.
Failure to Protect Resident from Repeated Resident-to-Resident Sexual Contact: A resident with severe cognitive impairment was repeatedly exposed to another resident with a known history of sexually inappropriate behavior toward him/her. Despite a prior incident requiring immediate separation, 1:1 supervision, and relocation of the affected resident, both residents remained on the same unit, and the other resident again grabbed the resident’s shirt/chest area while under 1:1 supervision. The event was inconsistently reported, not documented in the resident’s chart, and not completed on a reportable event form, with delayed notification to leadership and the provider.
A resident with chronic respiratory failure and pain was ordered a Fentanyl 12 mcg transdermal patch every 72 hours. After an LPN removed a patch early, an RN supervisor obtained a verbal order to replace it but mistakenly entered Fentanyl 75 mcg into the eMAR and co‑signed the order alone. Nursing staff continued to administer 12 mcg patches while documenting 75 mcg on the MAR, without fully verifying the order against the medication packaging. Later, an APRN, not recognizing the erroneous increase in the record, refilled the prescription at 75 mcg, the pharmacy dispensed that strength, and a 75 mcg patch was applied. The resident subsequently developed decreased respirations and low oxygen saturation, and the discrepancy between the intended 12 mcg dose and the administered 75 mcg patch was identified as a clinically significant medication error.
A resident with severe cognitive impairment, incontinence, and dependence for bathing and dressing was observed with feces in the hair. A nurse aide moved the resident from the hallway into a locked stock room and tried to clean the hair by wetting a brush instead of washing the resident, while another aide observed. The record did not show any directive from the resident representative to avoid hair washing, and the unit manager stated the resident should have been offered or provided a shower after the fecal matter was found.
Failure to Notify Physician of Missed Rehab Services: A resident admitted with cervical spine and tibial fractures had orthopedic recommendations for PT/OT and outpatient rehab, but services were delayed or not provided as expected while the resident was non-compliant with a cervical collar. The record showed therapy was limited, later stopped, and the physician was not notified that rehab had not started or was not being provided according to the specialist’s recommendations.
Incomplete Background Checks for Two Nurse Aides: The facility failed to ensure criminal background checks were completed for 2 nurse aides before employment. Personnel records showed one aide’s ABCMS eligibility was still in process and another required a new application, with both files indicating fingerprinting had not been completed. The HR Director stated both aides had started work before the fingerprinting portion of the background check was finished, and the Administrator said he expected all state and federal screening requirements to be followed.
Failure to report alleged resident-to-resident abuse: A resident with dementia and severe cognitive impairment was reportedly touched inappropriately by another resident with schizophrenia, dementia, and a history of sexually inappropriate behavior while under 1:1 supervision. Staff described the other resident grabbing the resident's chest or shirt in the hall, but the incident was not documented as a reportable event and was not reported to the state agency as required by policy.
Failure to Investigate Alleged Resident-to-Resident Abuse: A resident with severe cognitive impairment and a history of aggression was involved in an alleged inappropriate touching incident with another resident who had schizophrenia, dementia, and wandering behaviors. Nursing and APRN notes described the second resident grabbing the first resident’s chest/shirt while under 1:1 supervision, and the first resident reported feeling uncomfortable. The record contained no incident documentation or completed investigation, and the DNS was initially unaware of the allegation despite policy requiring immediate notification, assessment, interviews, and a written investigation.
A resident with dementia and severe cognitive impairment was involved in repeated inappropriate physical/sexual contact with another resident who had schizophrenia, dementia, and impaired cognition. Staff documented that the second resident grabbed the other resident's shirt near the chest while under 1:1 supervision, with prior similar incidents reported, but the care plan for the affected resident was not revised to address or prevent further contact. The interdisciplinary care plan remained focused on existing behavior and mood issues rather than the resident-to-resident incident.
A resident with severe cognitive impairment and chronic respiratory failure received fentanyl patch care that did not match the ordered dose. An RN supervisor mistakenly entered a 75 mcg order into the eMAR instead of 12 mcg after an early patch removal, and staff then documented the higher dose while actually applying 12 mcg patches for several changes. Later, a 75 mcg patch was delivered and applied, and the resident was found with the incorrect dose in place and had a brief oxygen desaturation episode.
A resident with Alzheimer's disease, muscle weakness, and an ostomy was ordered to be transferred with a mechanical lift and 2 staff. An agency NA attempted the transfer alone, did not have the sling positioned properly, and the resident slipped out of the lift and fell to the floor. Interviews confirmed the NA knew 2 staff were required but proceeded without assistance.
A resident with cervical and tibial fractures had ortho recommendations for PT/OT, WBAT, ROM, and strengthening, but rehab services were not implemented in a timely manner. The resident’s PT/OT were interrupted when the cervical collar was not worn consistently, and after the collar was later discontinued, outpatient rehab was still delayed until weeks later. Nursing, the unit secretary, the DNS, and the APRN all described shared responsibility for consult follow-up and scheduling, but the lapse in starting rehab was not explained in the record.
Infection Control Lapse During Tracheostomy Care: An LPN provided tracheostomy care for a resident with a trach and severe cognitive and functional impairment, but after removing the inner cannula and gloves, she opened the sterile trach care kit without first performing hand hygiene. The facility policy directed staff to wash hands after the inner cannula is removed and apply clean gloves before continuing care.
A resident with osteoarthritis, anxiety, Alzheimer’s dementia, impaired cognition, incontinence, and unsteady gait was identified as a fall risk and care planned for supervise/touching assist with toileting and personal hygiene, use of a cane, and non-skid socks, but had no documented scheduled toileting or prompted voiding program. During one bathroom assist, a NA partially closed the door and turned away to provide privacy, after which the resident sustained an unwitnessed fall with head strike and a right distal humerus fracture. Documentation later described the resident as noncompliant with transfers and frequently ambulating without assistance or using the call light. The resident was subsequently found on the bathroom floor again after attempting to use the toilet, this time with severe left upper extremity pain and a left displaced comminuted distal humerus fracture, demonstrating that supervision and fall-prevention interventions were not effectively implemented for this high-risk, cognitively impaired resident.
A cognitively impaired resident with osteoarthritis, anxiety, and Alzheimer’s dementia, who was frequently incontinent and not on a toileting program, did not have a comprehensive, person-centered care plan that included scheduled toileting or prompted voiding despite documented fall risk and self-care deficits. The care plan called for supervised/touching assist with toileting and personal hygiene and general fall-prevention measures, but lacked a structured toileting program. The resident was assisted to the bathroom by a NA, who partially closed the door and turned away, then found the resident on the floor after an unwitnessed fall that resulted in a distal humerus fracture. Later documentation noted ongoing issues with transfers, unassisted ambulation without using the call light, and another bathroom fall causing a second distal humerus fracture, while facility policies required ADL assistance and fall-prevention interventions to be based on a person-centered evaluation and incorporated into the care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with atrial fibrillation was given Aspirin 81 mg daily instead of the prescribed twice-weekly dose due to a transcription error by a nurse, which was not caught by the orienting nurse or through the facility's required second-check process. The error resulted in the resident receiving the medication more frequently than ordered until the mistake was discovered after discharge.
A resident with severe cognitive impairment sustained a facial injury during care, and a nursing assistant later alleged that another staff member may have struck the resident. The allegation was not reported to a supervisor or the state agency until five days after the incident, contrary to facility policy requiring immediate reporting of abuse allegations.
A resident with severe cognitive impairment and total dependence for ADLs did not receive care according to their plan, which required two staff for assistance. Instead, a nurse aide provided care alone while the resident was agitated, resulting in the resident sustaining a left eye bruise and cut from a Hoyer lift sling attachment. Documentation and interviews confirmed the aide was aware of the two-person requirement but proceeded alone due to delays in obtaining help.
A resident with dementia experienced an unwitnessed fall, resulting in a minor head contusion. Despite facility policy requiring neurological monitoring, the medical record lacked documentation of completed assessments. The DNS confirmed monitoring was done but could not provide the records, indicating a failure to maintain accurate documentation.
A resident with dementia and traumatic brain injury, at high risk for elopement, was able to exit a secured unit unsupervised due to an expired wander guard. Despite weekly checks, the device was not replaced, allowing the resident to access the elevator and leave the facility. Staff failed to document elopement behaviors or conduct required monitoring, and the facility's policies on wander guard usage and elopement prevention were not followed.
The facility failed to maintain a clean, sanitary, and homelike environment across all units, with issues such as damaged and stained floors, walls, and ceilings observed. The Director of Maintenance was aware of some issues but did not document findings, while the ADNS and DNS were unaware of the extent of the problems. The facility's infection prevention program requires monthly rounds, but documentation was lacking.
A resident with dementia and other medical conditions experienced a significant delay in receiving dentures due to poor communication and follow-up by the facility. Despite initial steps taken in 2021 and 2022, the resident did not receive dentures for over two years, even though dental services were available. The facility failed to adhere to its policy of providing necessary dental care and documenting delays.
The facility failed to serve food at a safe temperature, as observed during a test tray evaluation. The main entree and peas were found to be below the required temperature of 140 degrees Fahrenheit. The FSD could not explain the temperature drop, despite meals being plated on a warming tray and delivered quickly. Facility policy requires action if food temperatures fall below 135 degrees Fahrenheit.
The facility failed to maintain sanitary conditions in the kitchen, with surveyors observing unsanitary conditions such as empty trash bags and boxes on countertops, opened and undated food items, and improperly stored non-resident items. The FSD cited short staffing as a challenge in adhering to cleaning schedules and storage expectations. The facility's policies on food storage and sanitation were not met, as confirmed by the DNS and Administrator.
The facility failed to notify resident representatives and physicians of significant changes in condition for two residents. One resident, at high risk for elopement, left a secured unit twice without proper notification or documentation. Another resident experienced eye discomfort and a rash, but the physician and representative were not promptly informed. Interviews revealed lapses in communication and adherence to facility policies.
The facility failed to monitor and document care for two residents, one with itchy skin and another with edema. The first resident did not receive prescribed anti-itch medication, and there was no behavior monitoring. The second resident was not assessed by an RN for eye discomfort and did not consistently receive compression stockings as ordered. Lack of policies and adherence to physician orders contributed to these deficiencies.
A resident with multiple diagnoses, including a fractured kneecap and gout, experienced inadequate pain management over a weekend due to a lack of prn medication orders and failure of staff to contact the physician for additional pain relief. Despite expressing significant pain, the resident was not provided further Acetaminophen, resulting in a sleepless night. The facility's Pain Management Policy, which requires prompt evaluation and treatment, was not adhered to, leading to unmanaged pain.
A facility failed to provide a bed hold notice to a resident with intact cognition during four hospital transfers, despite policy requirements. The resident, admitted with bowel obstruction and anemia, only signed the notice at admission. Interviews revealed that the RN Supervisor did not follow the procedure to send the notice with the resident, contrary to facility policy.
Failure to Protect Resident from Repeated Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to protect a resident from repeated nonconsensual physical/sexual contact by another resident despite a known prior history of sexually inappropriate contact between the same two residents. Resident #22 had severe cognitive impairment, dementia, and required assistance with locomotion, while Resident #129 had schizophrenia, dementia, and a documented history of sexually inappropriate behaviors and wandering. A prior reportable event documented that Resident #129 placed an open hand on Resident #22’s left breast while the resident was in a wheelchair, and both residents’ care plans were revised to require immediate separation, psychiatric/social work referral, and indefinite 1:1 supervision for Resident #129, with Resident #22 to be moved to an alternate wing for safety. Despite the care plan directive, Resident #22 was not moved to another unit and both residents remained on the same unit with repeated exposure. Facility documentation and interviews showed that Resident #129 again made inappropriate physical contact with Resident #22 while under 1:1 supervision, grabbing the resident’s shirt/chest area as the residents passed in the hall. Staff accounts differed on whether the contact involved the breast or shirt, and the incident was not documented in Resident #22’s medical record or completed on a reportable event form. The DNS stated she was unaware of the alleged incident until later, and staff did not immediately report it to the DNS, administrator, or provider as required by the facility’s abuse and sexual interaction policies. Interviews further showed that the assigned 1:1 staff observed the contact and separated the residents, but also stated there had been other occasions when Resident #129 had grabbed Resident #22’s shirt in the past. APRN documentation noted Resident #129 had a history of sexually inappropriate behaviors and was under 1:1 supervision, while Resident #22 reported feeling uncomfortable after the incident. A psychiatric APRN later stated that repeated exposure to the same resident who had sexually mistreated him/her could have a negative psychological impact over time. The facility’s abuse and sexual interaction policies required immediate separation, notification of leadership and providers, evaluation for injury, and documentation, but the record reflected inconsistent reporting and lack of documentation for the event.
Significant Fentanyl Patch Dosing Error and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error related to Fentanyl transdermal patches. The resident had diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, chronic respiratory failure, and congestive heart failure, and had severely impaired cognition. Physician orders from early November through late February directed application of a Fentanyl 12 mcg patch every 72 hours for pain, and controlled substance disposition records showed that 12 mcg patches were dispensed and applied on that schedule. The resident’s care plan identified actual pain related to disease process and altered respiratory status related to chronic respiratory failure, with interventions to administer medications as ordered and monitor for effectiveness and side effects. On one shift, an agency LPN removed the resident’s Fentanyl patch a day earlier than scheduled and then realized there was no order to replace it. The LPN notified the RN supervisor, who contacted the APRN and obtained a verbal order to replace the patch and continue the 72‑hour cycle. When entering the new order into the electronic MAR, the RN supervisor inadvertently selected Fentanyl 75 mcg instead of 12 mcg and co‑signed the order herself rather than obtaining a second nurse verification. Subsequent review of controlled substance disposition records showed that no 75 mcg patches were dispensed at that time and that 12 mcg patches continued to be applied on multiple dates, while the February MAR reflected that staff were documenting administration of a 75 mcg patch on those same dates. Nursing staff continued to sign for Fentanyl 75 mcg on the MAR even though only 12 mcg patches were being dispensed and applied, and they did not fully read and verify the physician’s order against the medication packaging. Later, the APRN refilled the Fentanyl prescription and, not recognizing that the dose in the record had been erroneously increased, accidentally refilled the prescription for Fentanyl 75 mcg instead of 12 mcg. The pharmacy then dispensed 75 mcg patches, and the first 75 mcg patch was applied to the resident. After application of the 75 mcg patch, the resident experienced a change in condition characterized by a decreased respiratory rate and low oxygen saturation on room air, which improved with repositioning and supplemental oxygen. The event was identified as a clinically significant medication dose discrepancy, with the patch in place being Fentanyl 75 mcg while the intended dose was 12 mcg. Interviews with the DNS, APRN, RN supervisor, and pharmacist confirmed that the incorrect 75 mcg order had been entered into the eMAR, that the APRN later refilled the higher dose in error, and that nursing staff failed to follow the facility’s medication administration policy and the six rights of medication administration, resulting in the resident receiving a Fentanyl 75 mcg patch instead of the ordered 12 mcg dose.
Failure to Maintain Resident Dignity During Hair Care
Penalty
Summary
The facility failed to ensure Resident #43 was treated in a dignified manner when feces was identified in the resident’s hair. Resident #43 was admitted with diagnoses including Alzheimer’s disease, macular degeneration, and muscle weakness, and the quarterly MDS identified severely impaired cognition, bowel and bladder incontinence, and dependence on staff for toileting, bathing, and dressing. The care plan directed assistance of 2 staff members with showering and bathing. On observation, the resident was seated in a wheelchair in the hallway in front of the nurse’s station while a nurse aide brushed the resident’s hair, then called another aide to look at the hair before moving the resident behind a keypad-locked, unlabeled door into a stock room. Inside the room, the nurse aide attempted to wet the resident’s hair by wetting a hairbrush with water from a sink while another aide observed, and the resident remained in the wheelchair without clothing protection in place. The nurse aide stated she had seen feces in the resident’s hair and brought the resident to the stock room to use water to try to remove it, but she was unsure when the resident last had a shower and said she was not going to wash the resident’s hair. The clinical record did not show that the resident representative had directed staff not to wash the hair. The unit manager stated it was not acceptable for the resident not to be offered or provided a shower after feces was identified in the hair, and the resident was later showered after surveyor inquiry.
Failure to Notify Physician of Missed Rehabilitation Services
Penalty
Summary
The facility failed to notify the physician that rehabilitation services were not being provided according to specialty service recommendations for Resident #107, who was admitted with a nondisplaced fracture of the seventh cervical vertebra and a nondisplaced fracture of the right tibia after a motor vehicle accident. The resident’s admission assessment identified cognitive intactness and dependence for mobility and transfers, and the care plan included maintaining a cervical collar, orthopedic follow-up, and OT/PT evaluation per physician orders. Orthopedic recommendations on 1/5/26 included protected weight bearing as tolerated, ROM to both lower extremities, and PT three times weekly, and an APRN note the same day documented that ambulatory rehabilitation services had been reviewed and placed for scheduling. Although physician orders for PT 3-5 days per week were entered on 1/16/26 and therapy evaluations identified ongoing need for strengthening, balance, and toileting services, the resident’s therapy was later discontinued because of non-compliance with wearing the cervical collar. The record shows OT was limited to evaluation only and PT was stopped when the resident was deemed not safe to continue treatment due to refusal to wear the collar, with the resident remaining at wheelchair level until follow-up regarding the collar. The resident later received orthopedic clearance to discontinue the cervical collar on 2/20/26, and subsequent notes continued to reference progress in PT and awaiting outpatient PT. Despite the orthopedic recommendations and the resident’s ongoing need for rehabilitation, the physician was not notified that rehabilitative services had not started or were not being provided as expected. The resident stated that outpatient PT was expected to begin in January but did not occur until 3/13/26, and during a neurology visit on 3/4/26 providers were surprised to learn the resident had not been receiving services. The APRN stated she was unaware rehab had not started and would have referred the resident back to orthopedics sooner if she had known, while the DNS stated the physician should have been notified that rehabilitative services were not being provided.
Incomplete Background Checks for Two Nurse Aides
Penalty
Summary
The facility failed to ensure criminal background checks were completed for 2 of 7 nurse aides reviewed, NA #4 and NA #5, as required by the facility’s screening prospective employee policy. NA #4 was hired on [DATE], and the personnel file contained an undated ABCMS Person Summary showing the current eligibility determination was in process, along with an ABCMS Final Registry Results Form dated [DATE] stating NA #4 had not previously been determined eligible for employment and must be fingerprinted. NA #5 was hired on [DATE], and her personnel file contained an undated ABCMS Person Summary stating that a new application must be submitted, with an ABCMS Final Registry Results Form dated [DATE] also indicating she had not previously been determined eligible for employment and must be fingerprinted. During interview, the HR Director stated that after NA #4’s file was requested by the survey team, she discovered NA #4 had not completed the fingerprinting portion of the criminal background check and had not been determined eligible for employment. She stated this was an oversight and that NA #4 had begun employment before fingerprinting was completed. The HR Director also stated that after NA #5’s file was reviewed, it was identified that her ABCMS determination required a new application, which could mean she never completed fingerprinting or that the prior determination had expired. She stated both nurse aides had been hired during her tenure and that some employees had begun orientation before fingerprinting was completed. The Administrator stated he expected all state and federal guidelines to be followed regarding screening prospective employees.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency after an incident involving two residents. One resident had diagnoses including anoxic brain damage and dementia, with severely impaired cognition, required one-person assist for locomotion using a manual wheelchair, and had a care plan noting anxiety and aggression toward others. The other resident had diagnoses including schizophrenia and dementia, with moderately impaired cognition, was independent with ambulation, and had a care plan noting mood problems related to schizophrenia and a history of elopement and wandering behaviors. A medical APRN note documented that nursing reported the resident with a history of inappropriate behaviors had recently inappropriately touched the other resident, and a psychiatric APRN note documented evaluation for sexually inappropriate behaviors toward that same resident. The record for the resident who was touched contained no documentation of the incident and no completed reportable event form. Interviews described the event as the resident grabbing the other resident's chest or shirt in the hall while under 1:1 supervision, with staff separating them, and the DNS stated the incident was not reported because it was believed the resident grabbed the shirt rather than the breast and was not threatening. The facility policy required immediate notification to the Department of Public Health for allegations involving abuse, or within 24 hours if the event did not involve abuse and did not result in serious bodily injury.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents and failed to protect the resident during the investigation. Resident #22 had diagnoses including anoxic brain damage and dementia, with severely impaired cognition, required one-person assist for locomotion with a manual wheelchair, and had a care plan noting anxiety and aggression toward others. Resident #129 had diagnoses including schizophrenia and dementia, with moderately impaired cognition, was independent with ambulation, and had a care plan noting mood problems related to schizophrenia and a history of elopement and wandering behaviors. A medical APRN note documented that nursing reported Resident #129 had a history of inappropriate behaviors with indefinite 1:1 supervision and had recently inappropriately touched another resident’s body part, identified as Resident #22. The note stated Resident #129 was unable to provide information or cooperate with instructions or boundaries regarding appropriate behavior and was to be redirected as needed with continued 1:1 monitoring. A psychiatric APRN note later documented evaluation for sexually inappropriate behaviors, noting a history of sexually inappropriate behaviors toward Resident #22 and ongoing 1:1 staff supervision. The clinical record for Resident #22 contained no documentation of the incident and no completed reportable event form or investigation. The DNS stated she was unaware of the alleged incident and would have to investigate further. APRN #1 later stated she learned from the unit communication book and nursing staff that Resident #129 had grabbed Resident #22’s left chest while passing in the hall and would not let go until staff separated them, while Resident #22 reported feeling uncomfortable. The DNS stated the event was considered not threatening because Resident #129 grabbed the resident’s shirt, and no further follow-up was necessary. The facility policy required immediate notification, assessment, interviews, and a completed investigation within 5 days, but those steps were not documented for the incident.
Care Plan Not Updated After Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to keep the comprehensive care plan current after an incident involving non-consensual physical/sexual contact between two residents. Resident #22 had anoxic brain damage and dementia, with severely impaired cognition and dependence on one-person assistance for locomotion by manual wheelchair. The care plan for Resident #22 identified anxiety and aggression toward others, with interventions focused on monitoring behavior and giving medications as ordered, but it was not revised to address or prevent further physical or sexual contact with Resident #129. Resident #129 had schizophrenia and dementia, with moderately impaired cognition and independent ambulation. The care plan for Resident #129 addressed mood problems related to schizophrenia and a history of elopement and wandering, with interventions to monitor mood changes and offer diversional activities. A medical APRN note documented that nursing reported a history of inappropriate behaviors and that Resident #129 had recently inappropriately touched another resident, with 1:1 supervision in place and redirection as needed. A psychiatric APRN note later documented evaluation for sexually inappropriate behaviors toward Resident #22 and noted the resident remained under 1:1 staff supervision. Staff interviews described that Resident #129 grabbed Resident #22's shirt near the chest area while passing in the hall, and 1:1 staff intervened to separate them. Nursing staff reported there had been prior occasions when Resident #129 grabbed Resident #22's shirt and the behavior was redirected and reported. The DNS stated the facility was aware of the potential for future physical contact between the two residents, but Resident #22 remained on the same unit and the care plan was not revised to include interventions to reduce the risk of further contact.
Incorrect fentanyl patch dose entered and administered
Penalty
Summary
The facility failed to administer a transdermal fentanyl patch according to the physician’s order for a resident with a history that included nontraumatic intracerebral hemorrhage in the brain stem, chronic respiratory failure, congestive heart failure, and severely impaired cognition. The resident’s orders directed fentanyl 12 mcg patches to be applied every 72 hours for pain, but the controlled substance records showed that 12 mcg patches were being applied and removed on schedule while the resident’s electronic medication record later reflected a different dose. On 2/13/26, an agency LPN removed a fentanyl patch one day early and notified the RN supervisor that there was no order to replace it. The RN supervisor contacted the APRN and then entered a verbal order into the eMAR, but she inadvertently selected fentanyl 75 mcg instead of 12 mcg. The RN supervisor stated she did not fully read the order before entry and co-signed it herself rather than obtaining a second nurse verification. After that entry, the eMAR showed fentanyl 75 mcg, and nursing staff continued signing that they applied the 75 mcg patch on subsequent change dates even though the controlled substance disposition records showed 12 mcg patches were actually applied. Multiple nurses later stated they applied 12 mcg patches while the eMAR reflected 75 mcg. One LPN stated she did not review the physician’s order in its entirety, and another agency LPN stated she did not recognize that the eMAR reflected a different dosage and did not fully adhere to the five rights of medication administration. The discrepancy remained in place until 2/28/26, when the first fentanyl 75 mcg patch was delivered and applied. The summary report stated that on 3/1/26 the resident was found with a fentanyl 75 mcg patch in place when the intended order was for 12 mcg, and the resident experienced a brief episode of oxygen desaturation that was addressed by the RN supervisor.
Unsafe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident who was ordered to be transferred with the assistance of 2 staff using a mechanical lift. The resident had diagnoses including Alzheimer's disease, colostomy, and muscle weakness, and the quarterly MDS identified severely impaired cognition, an ostomy, total dependence for transfers, and incontinence. The care plan and nurse aide care card both directed that the resident required an assist x 2 with a mechanical lift for transfers at wheelchair level. A witnessed fall occurred while the resident was being transferred in the mechanical lift when an agency nurse aide attempted the transfer alone. The aide stated she did not realize the lift pad was not positioned properly under the resident, and the resident slid out of the sling and fell, landing on the bottom. A nursing assessment documented that the resident slipped out of the sling while the aide was attempting the transfer by herself and that the resident was later assisted back to bed with the mechanical lift without difficulty. Interviews confirmed the aide knew the resident required 2 staff for transfers but attempted the transfer alone because she could not find another staff member and wanted to finish care.
Delayed Implementation of Rehab Services
Penalty
Summary
The facility failed to implement specialty rehabilitative service recommendations in a timely manner for Resident #107, who was admitted with a nondisplaced fracture of the seventh cervical vertebra and a nondisplaced fracture of the right tibia after a motor vehicle accident. The resident’s admission MDS identified cognitive intactness, need for extensive assistance with mobility and transfers, use of a manual wheelchair, and receipt of OT, PT, and speech therapy. The care plan included maintaining a cervical collar at all times, orthopedic follow-up as indicated, and OT/PT evaluation per physician orders. Orthopedic recommendations related to the tibial fracture were documented on 1/5/26 and included protected weight bearing as tolerated, ROM to both hips, knees, and ankles, and focused right knee ROM three times daily. An APRN note the same day documented that an ambulatory referral to rehabilitation services had been reviewed and placed for scheduling, with instructions to notify the provider of the orthopedic consult results and any new orders. However, physician orders for PT 3-5 days per week for 8 weeks were not entered until 11 days later, and the PT evaluation occurred on 1/16/26. OT evaluation on 1/23/26 was limited to evaluation only because the resident was not compliant with wearing the cervical collar, and therapy was not continued at that time. The record showed additional delays after the cervical collar was discontinued. Orthopedics cleared the collar on 2/20/26, but nursing progress notes through 3/3/26 continued to show the resident awaiting outpatient PT. Neurology and interdisciplinary notes on 3/4/26 and 3/5/26 documented that the resident needed rehabilitation therapy three times weekly and that the referral was faxed to a community outpatient rehabilitation service. The resident did not receive the first outpatient evaluation until 3/13/26, and the resident stated on interview that outpatient PT had been expected to begin in January but did not start until March. Interviews with nursing, the unit secretary, the DNS, and the APRN identified shared responsibility for reviewing consults and scheduling, but the lapse in implementing rehabilitation services from the orthopedic recommendation through the start of outpatient therapy was not explained in the record.
Infection Control Lapse During Tracheostomy Care
Penalty
Summary
The facility failed to maintain infection control standards during tracheostomy care for Resident #10, who was admitted in January 2020 with traumatic subarachnoid hemorrhage with loss of consciousness and persistent vegetative state. The quarterly MDS identified severely impaired cognition, dependence for bed mobility and transfers, and the presence of a tracheostomy. The care plan identified an ADL deficit with limitations in mobility and altered respiratory status related to the tracheostomy, with interventions for one to two staff for ADL care, deep suction as needed, and medication administration per physician orders. Physician orders directed changing the inner cannula of the Shiley #6.5 mm tracheostomy every shift and suctioning with a #10 French suction catheter every shift and as needed. During observation, an LPN removed the inner cannula, discarded it, removed her gloves, and then opened the sterile tracheostomy care kit without first performing hand hygiene. She then set up the basin, donned sterile gloves, and continued tracheostomy care. The LPN stated she thought she maintained sterile technique, while the regional nurse consultant stated sterile technique was not required but hand hygiene should have been performed after removal of the inner cannula and before opening the sterile kit and donning sterile gloves. The facility policy for tracheostomy care directed staff to wash hands once the inner cannula is removed and apply clean gloves before proceeding.
Failure to Adequately Supervise High-Risk Resident During Toileting Leading to Recurrent Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention interventions for a cognitively impaired resident with incontinence and a known fall risk, resulting in two unwitnessed falls with major injuries. The resident had osteoarthritis of the knee, anxiety, and Alzheimer’s dementia, with a BIMS score of 5, was frequently incontinent of bowel and bladder, and was not on a toileting program. The resident’s care plan identified a self-care deficit related to weakness and deconditioning, with interventions including toileting and personal hygiene using a straight point cane with supervise/touching assist of one staff, and dementia-related interventions to anticipate and meet needs. The care plan also identified potential for falls due to unsteady gait, with interventions such as non-skid socks, monitoring for gait changes, and offering diversional activities including toileting and ambulating. However, the clinical record did not show a scheduled toileting or prompted voiding program to address incontinence and toileting needs. On one occasion, the resident was assisted to the bathroom by a nursing assistant, who opened the bathroom door and observed the resident place the cane in the sink. The nursing assistant, aware that the resident liked privacy, partially closed the door and turned away, after which a sound was heard and the resident was found on the floor with a head strike and painful right forearm, later diagnosed as a bicondylar intra-articular fracture of the distal humerus. The DNS stated that at the time of this first fall, the resident was care planned as a supervised assist of one for toileting and personal hygiene, meaning staff were to supervise the ADL to allow for cueing and assistance, and acknowledged that the nursing assistant did not provide constant supervision because his back was turned. Subsequent documentation noted the resident was noncompliant with transfers and was observed multiple times ambulating without assistance and not using the call light. Later, the resident was found lying on the bathroom floor on the left side after using the bathroom, complaining of severe left upper extremity pain and inability to move the arm, and was diagnosed with a left displaced comminuted fracture of the distal humerus. These events occurred despite the resident’s known cognitive impairment, incontinence, unsteady gait, and identified fall risk.
Failure to Develop Comprehensive Toileting and Fall-Risk Care Plan for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing a cognitively impaired resident’s toileting needs and fall risk, including the absence of a scheduled toileting or prompted voiding program. The resident had osteoarthritis of the knee, anxiety, and Alzheimer’s dementia, with a BIMS score of 5 indicating impaired cognition, and was frequently incontinent of bowel and bladder without being on a toileting program. The Resident Care Plan identified self-care deficits related to weakness and deconditioning, dementia with an intervention to anticipate and meet needs, and potential for falls due to unsteady gait, with interventions such as supervised/touching assist for toileting and personal hygiene, use of non-skid socks, monitoring gait changes, and offering diversional activities including toileting and ambulating. However, the care plan did not include a structured toileting schedule or prompted voiding program despite the resident’s incontinence and cognitive impairment. The resident experienced an unwitnessed fall in the bathroom with a head strike, resulting in a frontal head hematoma and a painful right forearm, and was later diagnosed in the ED with a bicondylar intra-articular fracture of the distal humerus. At the time of this fall, the resident was assisted to the bathroom by a NA, who opened the bathroom door, observed the resident place a cane in the sink, then partially closed the door to provide privacy and turned away, subsequently hearing a sound and finding the resident on the floor. The DNS stated that the resident was care planned as a supervised assist of one for toileting and personal hygiene, meaning staff were to supervise the ADL to allow for cueing and assistance, and acknowledged that the NA did not have constant supervision because his back was turned. Subsequent nursing notes documented the resident being noncompliant with transfers, being found in the bathroom after asking to lie down, ambulating multiple times without assistance and not using the call light, and later being found lying on the bathroom floor again after using the bathroom, with severe pain and inability to move the left upper arm, and an ED diagnosis of a left displaced comminuted fracture of the distal humerus. The facility’s ADL policy and Fall Prevention Program required assistance per the person-centered care plan and incorporation of risk-based interventions into the care plan, which were not fully implemented regarding scheduled toileting and fall prevention for this resident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Medication Order Transcription Error Leads to Incorrect Aspirin Administration
Penalty
Summary
A deficiency occurred when a physician's order for Aspirin 81 mg to be administered twice a week was incorrectly transcribed as a daily order for a resident with atrial fibrillation. The hospital discharge summary specified the correct dosing frequency, but during the admission process, a registered nurse transcribed the order into the electronic medical record as a daily dose. The medication was then administered daily for five consecutive days, rather than the intended twice-weekly schedule. The error was not identified until after the resident was discharged, when a medication incident report was completed. Interviews revealed that the nurse responsible for transcribing the order did not re-check the order before confirming it in the EMR and assumed her preceptor would review her work. The preceptor, who was orienting the nurse, did not verify the accuracy of the transcribed order. The Director of Nursing Services confirmed that the facility's process requires a second nurse to review and confirm new orders in the EMR, but this second check was not completed, resulting in the medication error.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Staff failed to report an allegation of abuse in a timely manner for a resident with dementia and severe cognitive impairment. The resident, who was dependent for activities of daily living and required assistance with mobility and transfers, sustained a left eye bruise and cut during care involving a mechanical lift. A nursing note documented the injury and indicated the resident was agitated and had banged their head, but later, a nursing assistant alleged that another staff member could have struck the resident during care. The allegation was not reported to a supervisor until five days after the incident, despite facility policy requiring immediate reporting of abuse allegations. Documentation and interviews confirmed that the delay in reporting occurred because the nursing assistant who heard the resident's accusation did not notify a supervisor until several days later. The incident was subsequently reported to the state agency five days after it occurred. The director of nursing acknowledged that the incident should have been reported immediately, in accordance with facility policy. The failure to promptly report the suspected abuse resulted in a deficiency finding during the survey.
Failure to Follow Two-Person Assist Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependent for activities of daily living (ADLs), and frequently incontinent, did not receive care in accordance with their plan of care. The resident's care plan and aide care card both directed that two staff members were required to assist with care, including bed mobility, repositioning, and transfers using a mechanical lift. Despite these directives, a nurse aide provided care alone while the resident was agitated, and only called for assistance when it was time to use the Hoyer lift for transfer. During this episode, the resident sustained a left eye bruise and cut, reportedly from the Hoyer lift sling attachment, after expressing pain and agitation. Interviews and documentation confirmed that the nurse aide was aware of the requirement for two-person assistance but proceeded alone due to delays in obtaining help. The Director of Nursing confirmed that the resident was care planned for two-person assistance and that care should not have been provided while the resident was agitated. The incident was identified through clinical record review, staff interviews, and facility documentation, which showed that care was not provided according to the resident's plan of care.
Incomplete Neurological Monitoring Documentation After Resident Fall
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate, specifically regarding documentation of neurological monitoring following an unwitnessed fall. The resident, who had a diagnosis of dementia and was severely cognitively impaired, experienced a fall resulting in a minor contusion to the head. Despite the facility's policy requiring neurological evaluations and monitoring after such incidents, the record review did not identify completed neurological assessments. The Director of Nursing Services (DNS) confirmed that neurological monitoring was conducted but was unable to provide documentation of the assessments, indicating a lapse in maintaining accurate medical records. The facility's Neurological Assessment/Evaluation Policy mandates that licensed nurses perform neurological evaluations and monitoring for residents who have experienced unwitnessed falls, especially those on anticoagulant therapy. The policy outlines a specific schedule for neurological checks, which was not documented in the resident's medical record. Additionally, the facility's Documentation Guidelines policy requires that services provided to residents be documented in the electronic medical record, with provisions for adding late notes if documentation is omitted. The absence of documented neurological assessments suggests non-compliance with these policies, leading to the identified deficiency.
Resident Elopement Due to Expired Wander Guard and Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident with dementia and traumatic brain injury, who was at high risk for elopement and falls. The resident, who was on a secured locked unit and wore a wander guard, was able to exit the unit unsupervised on two occasions. The wander guard had expired eight months prior, and despite being checked weekly, it was not replaced. The resident was able to access the elevator and leave the secured unit without the alarm system locking the elevator doors, allowing the resident to reach the first floor and exit the building. The facility's documentation and staff interviews revealed a lack of adequate supervision and failure to implement necessary interventions after the resident's initial elopement. The resident's care plan included the use of a wander guard and behavior monitoring for elopement, but these measures were not effectively executed. Staff failed to document the resident's elopement behaviors and did not conduct the required 15-minute checks or 1:1 monitoring after the incidents. Additionally, there was a lack of communication among staff regarding the malfunctioning wander guard and the resident's elopement risk. The facility's policies on wander guard usage and elopement prevention were not followed, contributing to the resident's ability to leave the secured unit and the facility. The wander guard system was supposed to lock doors when a monitored resident approached, but it failed to do so due to the expired device. The facility's failure to adhere to its own policies and procedures resulted in the resident being unsupervised and at risk in unsecured areas of the facility and outside the building.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment across all five units, as observed during a survey. The maintenance repair log from April to June 2024 did not document the condition of resident rooms, and environmental rounds conducted by RN #1 also lacked documentation regarding room conditions. Observations on July 2, 2024, revealed numerous issues, including damaged and stained floor tiles, walls, and ceilings, as well as dirty and debris-laden floors in various rooms and common areas across multiple floors. The Director of Maintenance, who has been employed since November 2023, acknowledged awareness of some issues and mentioned ongoing efforts to repair damaged walls, but did not document his rounds or findings. The Assistant Director of Nursing Services (ADNS) was unaware of the stained and dirty conditions of the floors and curtains and planned to discuss these issues with relevant staff. The Director of Nursing Services (DNS) was also unaware of the issues and intended to hold a meeting with key personnel to address the expectations for a homelike environment. Interviews with RN #1 and the Director of Housekeeping were not obtained. The facility's Infection Preventionist position description outlines responsibilities for maintaining a safe environment, and the facility's infection prevention rounds program requires monthly rounds by the Infection Prevention Committee and department heads. The janitor, housekeeper, and maintenance worker position descriptions emphasize routine tasks to ensure cleanliness and maintenance of the facility.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services to a resident, identified as Resident #57, who was admitted with diagnoses including dementia, stroke, hemiplegia, and diabetes. A physician's order was made in July 2021 to obtain a dental consult for dentures, and consent was given by the resident later that month. However, despite the initial steps taken, including dental evaluations and impressions made in early 2022, the process was delayed significantly. The resident was informed of the need for removal of dental roots before denture fabrication, but due to various reasons, including the resident's medical appointments and surgeries, the dentures were not provided. Throughout 2023 and into 2024, the resident expressed a desire to proceed with the denture process after completing hip surgeries. Despite being seen by dental services multiple times, the resident did not receive the dentures. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental needs. The resident repeatedly requested to be seen by dental services, but there was no effective system in place to ensure these requests were addressed promptly. The facility's policy required them to provide necessary dental services and document any delays, but this was not adhered to. The dental services were available in the facility on numerous occasions, yet the resident's needs were not prioritized. Interviews with the dental hygienist and dentist indicated that they were waiting for the resident to request further action, but the facility staff did not facilitate this communication effectively. As a result, the resident remained without dentures for over two years, impacting their ability to chew food.
Failure to Serve Food at Safe Temperature
Penalty
Summary
The facility failed to serve food at a safe and palatable temperature, as observed during a test tray evaluation. On the specified date, the Surveyor and Food Service Director (FSD) followed a meal cart to the 4th floor dining room and measured the temperature of the last meal on the cart. The main entree, turkey, was found to be at 124 degrees Fahrenheit, and the peas were at 127 degrees Fahrenheit. These temperatures were below the facility's guidelines, which require hot foods to be held at 140 degrees Fahrenheit or higher. The FSD was unable to explain the temperature drop, despite indicating that meals were plated on a warming tray and delivered relatively quickly by nurse aides. The facility policy states that foods are in the danger zone when below 135 degrees Fahrenheit and requires action to be taken if temperatures are not within the acceptable range.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure meals were distributed at a palatable temperature. During an initial walkthrough, surveyors observed several unsanitary conditions, including empty trash bags and boxes on countertops near food, opened and undated food items, and a discarded latex glove near a food mixer. Additionally, a rack with unused disposable lids was found near unused garbage bags, and a soiled orange safety cone was partially underneath the rack. The freezer contained opened, undated, and uncovered food items with signs of freezer burn, and non-resident items such as ice cream and a bottle of spring water were improperly stored. The refrigerator had undated sandwiches and a sleeve of turkey meat with a tear in the plastic wrapping. The Food Service Director (FSD) acknowledged the kitchen was short-staffed, making it difficult to adhere to the cleaning schedule and storage expectations. The facility's policy requires food from non-approved sources to be stored separately and mandates proper labeling and storage of refrigerated foods. Damaged food products should be kept away from usable stock, and the storeroom should be clean and rodent-proof. The policy also emphasizes the importance of cleaning and sanitizing food service equipment and surfaces to minimize contamination risks. Despite these policies, the facility did not meet the expected standards, as confirmed by interviews with the Director of Nursing Services (DNS) and the Administrator.
Failure to Notify Resident Representatives and Physicians of Changes in Condition
Penalty
Summary
The facility failed to notify the resident representative and physician in two separate incidents involving residents with significant changes in their conditions. Resident #78, who was admitted with dementia and a traumatic brain injury, was at high risk for elopement and had a wander guard device in place. Despite these precautions, the resident managed to leave a secured locked unit on two occasions, on 6/25/24 and 6/28/24, without the knowledge of the resident's representative or physician. The facility's documentation and interviews revealed discrepancies in the timing and handling of these incidents, including a lack of immediate notification to the appropriate parties and failure to document the elopement behaviors adequately. In the case of Resident #101, who was admitted with dementia, hypertension, and a stroke, the facility did not promptly notify the resident's representative or physician of a change in condition involving eye discomfort and a rash on the hands. The resident complained of eye discomfort on 6/22/24, but the physician was not notified until 6/25/24, and the resident's representative was only left a message without further follow-up. The facility's policy required immediate notification and documentation of such changes, which was not adhered to in this case. Interviews with facility staff, including the DNS and various nurses, highlighted lapses in communication and documentation. The DNS acknowledged that the facility's policies on change of condition and elopement were not followed, as the responsible parties were not notified in a timely manner, and documentation of attempts to reach the resident's representative was insufficient. These deficiencies indicate a failure to adhere to established protocols for resident safety and communication.
Deficiencies in Monitoring and Documentation of Resident Care
Penalty
Summary
The facility failed to adequately monitor and document the care of Resident #91, who had a history of dry, itchy skin and was prescribed Triamcinolone Acetonide lotion for itchiness. Despite the physician's order to apply the lotion as needed, the treatment administration records did not show any documentation of its application throughout June 2024. Observations revealed that Resident #91 had multiple areas of skin at various stages of healing, indicating ongoing scratching behavior. Interviews with staff indicated a lack of behavior monitoring and documentation, and the facility did not provide a policy for behavior monitoring or nursing documentation. Resident #101, who had diagnoses including dementia and edema, was not assessed by a registered nurse when complaints of eye discomfort were noted. The resident was also not consistently provided with compression stockings as per the physician's order. Observations showed that the resident was often without the prescribed stockings, leading to visible edema. Interviews with staff revealed confusion and lack of adherence to the physician's orders regarding the application of compression stockings, and there was no facility policy provided for the use of compression stockings. The facility's failure to monitor and document the care of these residents, as well as the lack of adherence to physician orders, highlights deficiencies in the facility's care processes. The absence of policies for behavior monitoring, nursing documentation, and compression stocking application contributed to these deficiencies, impacting the residents' care and treatment.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to meet the pain management needs of a resident, identified as Resident #289, who was admitted with multiple diagnoses including a fractured kneecap, polymyalgia rheumatica, fibromyalgia, and gout. The baseline care plan highlighted the need for pain management related to arthritis, with interventions such as administering medications per physician orders and responding immediately to complaints of pain. However, the facility did not adhere to these interventions, as evidenced by the resident's experience over a weekend when pain management was inadequate. On 6/29/24, Resident #289 received a one-time dose of Acetaminophen 650 mg for pain, as per a physician's order. Despite this, the resident reported a pain level of 6 out of 10 later that day and was unable to receive additional pain relief due to the absence of a prn pain medication order. The resident expressed frustration at not receiving further Acetaminophen, which resulted in a sleepless night due to pain. LPN #10, who was on duty, acknowledged the resident's pain but did not contact the physician for additional orders, instead placing a note in the APRN communication book without documenting the resident's pain or need for medication. Interviews with the APRN and MD revealed that the physician was not contacted over the weekend for additional pain management orders, although he was available and willing to provide them. The DNS confirmed that the charge nurse should have informed the supervisor and APRN of the resident's need for pain medication immediately. The facility's Pain Management Policy emphasizes prompt evaluation and treatment of pain, which was not followed in this instance, leading to the resident experiencing unmanaged pain over the weekend.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative prior to the resident's transfer to the hospital on four separate occasions. The resident, who had intact cognition, was admitted with diagnoses including bowel obstruction and anemia. Despite the facility's policy requiring a written bed hold notice to be given at the time of transfer, the resident only signed the notice at admission, and it was not provided during subsequent hospitalizations. Interviews with facility staff revealed that the RN Supervisor was responsible for sending the bed hold notice with residents during hospital transfers. However, this procedure was not followed for the resident's hospitalizations. The facility's policy mandates that a copy of the bed hold notice be given to the resident, maintained in their medical record, and provided to the business office, but these steps were not completed for the resident's transfers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 876 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Rehab Middletown | 1.3 mi | ★★★★★ | 5 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 1.3 mi | ★★★★★ | 13 | 0 |
| Portland Care & Rehab Centre, Inc | 1.8 mi | ★★★★★ | 19 | 0 |
| Autumn Lake Healthcare At Cromwell | 3.1 mi | ★★★★★ | 0 | 0 |
| Pilgrim Manor | 3.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Water's Edge Center For Health & Rehab.
100% money-back within 48 hours.
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.