Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairway Oaks Center during CMS and state inspections, most recent first.
The facility failed to ensure dependent residents consistently received and had documented assistance with scheduled showers and bathing. A resident reported not having a shower since admission and had no shower documentation for nearly two weeks despite needing help with ADLs. Another cognitively intact resident with morbid obesity, diabetes, and kidney failure, who depended on staff for bathing, reported ongoing difficulty obtaining showers and had filed a grievance about shower care, while task logs showed questionable documentation practices. A third resident, dependent on staff for mobility and toileting, received only one shower during a period with multiple scheduled opportunities, with no recorded refusals, despite care plans and facility policy requiring assistance with hygiene and regular bathing.
A resident with multiple complex conditions, including CKD stage 4 and a nephrostomy, was admitted for skilled care, but the facility failed to complete the Admission/readmission Nursing Evaluation and did not perform required daily skilled documentation. Key sections of the admission assessment were left unsigned and missing critical information such as transfer method, weight-bearing status, presence of a nephrostomy tube, evaluation for mechanical lift use, and medication review/verification. Nursing documentation consisted mainly of eMAR entries for pain medications and a few brief notes on skin issues and a late entry describing a family-requested transfer to the hospital, with no admission note and no daily skilled notes despite the resident receiving PT/OT and skilled nursing. Leadership interviews confirmed that daily skilled notes should have been completed and that the admission evaluation was not finished, contrary to the facility’s own documentation policy.
A resident with multiple serious conditions, including HTN, COPD, stage 4 CKD, anemia, and terminal kidney atrophy, had a physician order for vital signs to be obtained every shift for five days. Review of the MAR showed missing BP entries and multiple instances where identical vital signs were documented across different shifts, despite the care plan directing staff to monitor vitals as ordered and PRN and to notify the MD of significant changes. During interviews, the ADON and NHA confirmed missing BPs and stated it was rare for a resident to have the same vitals on different shifts, while the interim DON acknowledged it was unlikely but not impossible, indicating that documentation was not complete or accurate as required by facility policy.
Two residents did not receive necessary outside professional services when staff failed to coordinate and follow through on podiatry and dermatology consults. One resident, who could not trim her own long, uncomfortable toenails, had a nursing note indicating need for a podiatry referral, but her name was never added to the podiatry visit list and no further action was documented. Another resident with morbid obesity, diabetes, and kidney failure had ongoing severe dry, itchy, scaly skin, with physician orders for dermatology consultation, follow-up, and ammonium lactate lotion, yet the MAR/TAR showed no treatment provided during the review period and there was no documentation of dermatology visits. The SSD reported relying on nursing to notify her of needed referrals, while nursing and leadership interviews revealed lack of awareness and verification of consult orders, resulting in missed or unconfirmed specialty services.
Three dependent residents were observed or reported with disheveled appearance and overgrown fingernails, including dirt under the nails. Family and resident interviews showed repeated concerns that nail care had not been provided, despite the residents’ dependence for toileting hygiene and shower/bathe care and staff statements that nail checks or trimming should occur during care or at least weekly. Records and shower sheets showed no consistent documentation of nail trimming or cleaning for the affected residents.
The facility failed to ensure a resident’s family representative was notified and gave consent before transfer. The resident had severe cognitive impairment with a BIMS score of 00, and staff stated there was no discharge note or documentation showing notification or consent. The transfer notice also did not list the transfer location and lacked the representative’s signature before the resident was moved to another facility.
A resident with severe cognitive impairment, aphasia, and multiple serious diagnoses had two falls, but the clinical record was incomplete. Documentation after the falls did not consistently include the circumstances of the events, required neuro checks, or timely notification of the physician and proxy/family. The DON and NHA acknowledged missing records and disorganized medical records storage, and the facility could not produce the neuro check documentation before survey exit.
The facility failed to maintain cleanliness and safety in two community shower rooms, with surveyors observing brown substances on floors and shower chairs, hair in drains, and an unlocked cabinet with cleaning solutions. Staff interviews revealed unclear cleaning responsibilities between CNAs and housekeeping, contributing to the deficiencies.
A facility failed to provide required abuse and neglect training to a CNA, leading to a deficiency. The CNA was involved in an incident with a resident who was found in a concerning state by their representative. The CNA admitted to certain actions, but had not received retraining before returning to work, despite the facility's policy requiring such training.
A facility failed to report an alleged abuse incident involving a resident with Alzheimer's and dementia, who was found by her family with her hands tied behind her back. The family reported the incident to the DON, but the facility did not include the restraint allegation in their federal report. The CNA involved was suspended, and the Adult Protective Agency and police were contacted, but the complaint was not substantiated.
A resident with limited mobility and dementia was not provided with a wheelchair, despite being dependent on staff for transfers. Observations over several days showed the resident remained in bed, and staff interviews confirmed the absence of a wheelchair. The facility's policy on ADL care, which includes mobility support, was not followed.
Two residents were observed exposed in a high-traffic area without staff intervention. One resident was found with her gown pulled up, exposing her lower body, while another removed her top, exposing her upper body. Despite their cognitive impairments, staff did not promptly provide privacy or assistance, highlighting a deficiency in maintaining resident dignity and privacy.
A facility failed to ensure timely and accurate PASRR for a resident with schizoaffective disorder, major depressive disorder, and dementia. The Level I PASRR was incomplete, missing qualifying diagnoses. The RN MDS Director acknowledged the error and explained the facility's process for identifying residents with mental disorders, which involved the Admissions Department and nursing leadership. The facility lacked a PASRR policy.
The facility failed to develop and implement comprehensive care plans for residents with specific needs, leading to deficiencies in care. A resident with skin conditions did not have a care plan until prompted by surveyors. Two residents with cognitive impairments were observed with poor hygiene and inadequate assistance with activities of daily living, including bathing and feeding. Documentation inconsistencies and lack of staff adherence to care plans were noted.
Two residents in the facility did not receive adequate ADL care, including fingernail trimming and regular showers. One resident with severe cognitive impairment and multiple medical conditions was observed with long, unkempt fingernails and had not received a shower for nearly a month. Another resident with a history of cerebrovascular accident had long fingernails affecting her ability to eat and had only one shower in 30 days. The DON acknowledged the issues and noted discrepancies in care documentation.
A resident with severe cognitive impairment and skin conditions did not receive prescribed medication due to it being out of stock, and treatment records were inaccurately signed off by a nurse. The resident's representative reported inadequate follow-up on medical appointments, and facility staff acknowledged lapses in medication management and treatment responsibility.
The facility failed to provide proper catheter care for two residents, leading to deficiencies in infection prevention. One resident was observed with catheter tubing dragging on the floor while self-propelling in a wheelchair, and another had a catheter bag on the floor. Despite staff interactions, these issues were not addressed, posing contamination risks. The facility's catheter care policy was not consistently followed, resulting in care deficiencies.
A resident with PTSD did not receive trauma-informed care as their care plan lacked specific PTSD triggers, and staff were not trained annually as required. The resident expressed concerns about a person entering their room, which was not acknowledged by the attending LPN. Interviews revealed staff were unaware of the resident's care plan and psychiatric issues, and the facility's policy on trauma-informed care was not effectively implemented.
The facility failed to update the Daily Staffing Projection sheet for three days, leaving outdated information in the entrance lobby. The sheet, which should reflect current staffing numbers and resident census, was last updated on a weekday by the Staffing Coordinator, with the weekend supervisor responsible for updates on weekends. However, due to a lack of clarity and absence of a specific policy, the sheet remained unchanged, leading to inaccurate information being displayed.
A long-term care facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate. Errors included medications not administered as ordered or incorrectly documented for three residents with complex medical histories. The facility's policy on medication administration was not followed, leading to discrepancies in medication management.
The facility failed to maintain accurate medical records and ensure proper medication administration for several residents. Medications were documented as given but not observed being administered, and personal care records for a resident were inconsistent, leading to deficiencies in care standards.
Failure to Provide and Document Scheduled Showers and Bathing Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide and document assistance with bathing and showers for dependent residents in accordance with their care plans and facility policy. One resident reported not having had a shower since admission and only receiving one bed bath around the time of admission. Review of this resident’s admission record showed diagnoses including hypertensive heart disease without heart failure, unsteadiness of the feet, gait abnormalities, need for assistance with personal care, and blindness of the left eye. An MDS dated 2/8/2026 documented a BIMS score of 14, indicating the resident was cognitively intact. Review of the CNA task log for showers showed no documentation of showers or baths for 13 days, and the ADON and DON confirmed there were no shower sheets or task log entries, despite the care plan indicating the resident needed assistance with bathing and personal hygiene. Another resident was observed scratching and itching her arms and upper body, with scaly, dry, rough skin and large fishlike flakes. This resident stated she was supposed to see a dermatologist, that her family had discussed this with the facility, and that she was using regular store lotion without relief. She reported struggling to receive assistance with showers, stating that staff sometimes did not want to help and that she had filed a grievance about showers that she felt remained unresolved, although facility documentation showed the grievance as resolved after one shower was provided. Her admission record included morbid obesity due to excess calories, Type 2 diabetes, and unspecified kidney failure, and an MDS showed a BIMS score of 14. Her care plan documented an ADL self-care deficit and dependence on staff for bathing, including transfers into and out of the shower. The CNA task log for February 2026 showed a scheduled shower/bathing routine three evenings per week, but all entries had the same time stamp, which a CNA explained reflected documentation time rather than when care was actually provided. A third resident’s showering schedule indicated assistance with bathing was to be provided twice weekly on the evening shift. Review of documentation showed this resident received only one shower during the review period, despite three scheduled opportunities, and there was no documentation that the resident had refused bathing. The admission/readmission evaluation documented that this resident required extensive assistance with bed mobility and was dependent on staff for toileting and transferring. The care plan identified a potential ADL self-care deficit related to fatigue and chronic medical conditions, with interventions specifying the need for limited to extensive assistance of one to two staff for bathing. The ADON stated that residents are scheduled for showers twice a week and per preference, but at least twice weekly, and the facility’s ADL care and services policy required that residents unable to carry out ADLs independently receive appropriate support and assistance with hygiene, including bathing and showers.
Incomplete Admission Assessment and Lack of Daily Skilled Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records for a resident admitted with multiple complex medical conditions, including other artificial openings of urinary tract status, retroperitoneal fibrosis, stage 4 chronic kidney disease, unsteadiness on feet, generalized muscle weakness, need for assistance with personal care, and oropharyngeal dysphagia. The Admission/readmission Nursing Evaluation dated 1/30/26 at 5:41 p.m. was not completed and locked, with sections a, l, and n left unsigned. Section a lacked documentation of how the resident was transferred to the facility, whether there were weight-bearing restrictions, and did not document the presence of a nephrostomy tube. Section l did not include an evaluation for mechanical lift use or the resident’s ability to stand, pivot, or transfer with assistance, and section n did not show that medications were reviewed and verified. Record review showed that the Daily Skilled Note assessment had not been accessed or completed for this resident, despite the resident being on a skilled level of care and receiving specialized services and skilled nursing. The progress notes did not contain an admission note. Nursing documentation consisted primarily of eMAR entries related to administration of oral and topical pain medications and associated effectiveness checks, along with a single general note on 1/30/26 indicating a skin concern on the coccyx and notification of the emergency contact, and a skin/wound note on 2/2/26 documenting scar tissue to the sacrum, a surgical site to the right flank with minimal serous drainage and treatment in place, and scar tissue to the abdomen. There were no nursing eMAR or progress notes documenting the resident’s overall wellbeing on 2/4/26. A late entry note dated 2/7/26 for 2/6/26 at 9:30 a.m. documented that nursing was called to the resident’s room by administrative staff, that the resident did not appear to be in respiratory distress, and that a family friend and family member expressed concern and requested transfer to the hospital; EMS arrived before staff could obtain vital signs. Interviews with the Director of Rehab indicated the resident was receiving physical and occupational therapy in the room, had refused to go to the gym, and was status post nephrostomy placement. The ADON and Interim DON stated that, as a skilled resident, there should have been daily skilled charting notes, but these were not present. The NHA confirmed the Admission/readmission Evaluation was not completed and that there were no daily skilled notes other than a late entry for the resident’s departure. Staff C, an LPN, could not recall specific information about the resident from the chart. The facility’s documentation policy required objective, complete, and accurate documentation of services, assessments, treatments, and changes in condition, but there was no policy provided specific to completing an admission assessment or daily skilled notes.
Failure to Accurately Document and Monitor Ordered Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional nursing standards, and the resident’s person-centered care plan for one resident. A physician order dated 1/30/26 directed staff to obtain the resident’s vital signs every shift for five days, but the order was not fully carried out. The Medication Administration Record (MAR) showed that vital signs were recorded on multiple shifts between 2/1/26 and 2/4/26; however, there were missing blood pressure entries, and several sets of vital signs were documented as being exactly the same across different shifts. Specifically, the record showed identical vital signs on two consecutive shifts on 2/1, identical vital signs between the night shift on 2/1 and the afternoon shift on 2/2, and identical vital signs on two consecutive shifts on 2/3. The resident’s care plan identified altered cardiovascular status related to hypertension and directed staff to monitor vital signs and weights as ordered and as needed, and to notify the physician of significant abnormalities or changes. The resident’s admission record listed multiple serious diagnoses, including retroperitoneal fibrosis, unspecified COPD, stage 4 CKD, unspecified anemia, atrophy of kidney (terminal), and primary hyperparathyroidism. During interviews, the ADON and Nursing Home Administrator confirmed that blood pressures were missing and acknowledged that it was rare for a resident to have the same vital signs on different shifts, while the Interim DON stated she would not say it was impossible for vital signs to be identical over different shifts. The facility’s documentation policy required that services provided be documented in a manner that is objective, complete, and accurate, and that medical records facilitate communication about the resident’s condition and response to care, which was not met in this case.
Failure to Coordinate Podiatry and Dermatology Consults for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure outside professional resources were obtained and coordinated for required services, specifically podiatry for one resident and dermatology for another. One resident reported to nursing staff that her toenails were very long, that she could not cut them herself, and that they were uncomfortable. A nursing progress note documented on 2/16/2026 that this resident’s nails were very long and that she needed a referral to a podiatrist. However, there was no further follow-up in the medical record regarding a podiatry referral, and the resident’s name did not appear on the podiatry visit list for the provider’s 2/18/2026 visit. Another resident, who was cognitively intact and had diagnoses including morbid obesity, Type 2 diabetes, and unspecified kidney failure, was observed in bed scratching and itching her arms and upper body, with scaly, dry, rough skin and small fishlike flakes. The resident stated she was supposed to see a dermatologist, that her family had discussed this with the facility the previous Friday, and that she was only using regular store lotion, which was not helping, while her itching was getting worse. Physician orders included a dermatology consultation for body itching, a follow-up with dermatology, and an order for ammonium lactate lotion to be applied twice daily for dry skin. Review of the MAR and TAR showed the resident was not receiving any treatment for the ongoing itching condition during the reviewed period. The facility’s own consult policy stated that Social Services would coordinate most resident referrals (such as podiatry and vision), that referrals should be based on physician evaluation and orders, and that Social Services would document referrals and maintain a listing of referral agencies. In practice, the Social Services Director reported that nursing staff were expected to notify her of residents needing podiatry so they could be added to the list, but there was no evidence this occurred for the resident with long nails. For the resident with dermatologic issues, the Social Services Director stated dermatology appointments were scheduled by nursing and that she had not been informed of any concerns, family complaints, or need for dermatology, and no grievance had been initiated. Nursing staff and the ADON were not aware of or did not verify dermatology orders or visits, and record review showed no documented dermatology visits or physician notes beyond a single prior encounter, indicating a lack of coordination and follow-through with outside dermatology services despite existing orders and ongoing symptoms.
Failure to Provide Grooming and Nail Care
Penalty
Summary
The facility failed to provide ADL care related to grooming and personal hygiene for three dependent residents, including nail care and general appearance. Resident #4 had diagnoses including bullous pemphigoid, dementia, adult failure to thrive, muscle weakness, and reduced mobility. The resident’s family member reported concerns about overgrown fingernails and stated a grievance had been filed about ADL care and nail care. The resident’s MDS showed severe cognitive impairment and dependence for toileting hygiene and shower/bathe care, while the care plan did not include documentation for nail trimming assistance. Resident #6 was observed lying in bed in a clean gown and bed linen but disheveled in appearance with overgrown fingernails and dirt under the nails. The resident stated concern about the fingernails, preferred them short, and said staff had not trimmed them despite prior requests. The resident’s diagnoses included osteomyelitis of the vertebra, muscle weakness, muscle wasting and atrophy, intraspinal abscess and granuloma, and repeated falls. The MDS showed dependence for toileting hygiene and substantial/max assistance for shower/bathe care, and the care plan did not document a need for nail care assistance. Shower sheets showed some bath days with no documentation of nail trimming/cleaning, including one entry where the resident refused. Resident #7 was also observed disheveled with overgrown fingernails and dirt under the nails, and stated a preference for shorter nails and that staff had not trimmed them despite prior concerns. The resident reported that nail trimming had previously been done regularly but had not occurred in a long time. The resident’s diagnoses included unspecified atrial fibrillation, muscle weakness, muscle wasting and atrophy, and difficulty walking. The MDS showed dependence for toileting hygiene and substantial/max assistance for shower/bathe care, while shower sheets for multiple bed baths over October and November showed no documentation of nails being trimmed or cleaned. Staff interviews indicated varying practices for nail care, including that CNAs cleaned nails during showers or bath days, that staff should check nails at least weekly, and that diabetic residents required podiatry for nail trimming.
Failure to Notify Resident Representative Before Transfer
Penalty
Summary
The facility failed to ensure the resident representative was notified before the transfer of a resident with severe cognitive impairment. Resident #2’s MDS with a target date of 7/23/25 showed a BIMS score of 00, indicating severe cognitive impairment, and the resident’s representative was a family member. During an interview, the SSD stated there was no discharge note or documentation showing the representative was notified and said consent was not provided by the representative. The NHA later confirmed there was no paperwork showing the representative gave consent. Review of the Nursing Home Transfer and Discharge Notice showed a notice date of 7/21/2025 and an effective date of 8/19/2025, but the form did not list the transfer location and did not have the representative’s signature showing consent before the resident was transferred to another facility.
Incomplete documentation of resident falls and required notifications
Penalty
Summary
The facility failed to maintain complete clinical records for one resident whose record showed multiple serious diagnoses, including hemiplegia and hemiparesis following cerebral infarction, aphasia following cerebral infarction, systemic lupus erythematosus, myeloid leukemia, and need for assistance with personal care. The resident had a family member listed as emergency contact/proxy and a 5-day MDS showing a BIMS score of 3 out of 15, indicating severe cognitive impairment. The record also showed the resident had falls on 10/15/25 and 10/22/25 before being discharged to the community with a family member on 11/3/25. Following the 10/15/25 fall, the SBAR note stated the resident was observed on the floor and the provider recommended neuro checks and monitoring for further changes, but the record did not include documentation of the neuro checks. Progress notes documented that the resident was re-oriented to the call light and fall risk education was provided, but the education was unsuccessful. A late-entry SBAR did not show that the physician or family member was notified, and no progress note documented notification of the emergency contact/proxy. The interdisciplinary note reviewed the fall and the use of a communication board due to expressive aphasia and slurred speech, but it did not include details such as where the resident fell, whether the fall was witnessed or unwitnessed, who found the resident, or how the resident was found. After the 10/22/25 fall, the change in condition note documented that vital signs were taken and that the physician was called with no answer and a message left, but it did not show that the emergency contact/proxy was notified. The SBAR evaluation showed the fall occurred and that the physician was notified, but the nursing note for additional information was blank and did not describe the fall. The emergency contact/proxy was documented as notified 7 days later. The IDT note stated the fall was reviewed and no injury was noted, but it did not provide specific details about the event. During interview, the DON and NHA acknowledged that the facility did not have hard charts, that documentation was stacked in the medical records office awaiting upload, and that the neuro check evaluations from the 10/15/25 fall could not be produced prior to survey exit.
Deficiency in Shower Room Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain cleanliness and safety in two community shower rooms, as observed by surveyors. On two separate occasions, surveyors noted the presence of a brown substance on the floors, shower chairs, and underneath mats in the shower rooms. Additionally, hair and gauze were found in the shower drains, and a comb with hair was left on a shower chair. A dirty linen bin was found with its lid on the floor, and a cabinet containing cleaning solutions was unlocked, with no key in sight. These observations were made in the shower rooms located between the 100-200 rooms hallway and the 400 rooms hallway. Interviews with staff revealed a lack of clarity and execution in cleaning responsibilities. The housekeeper stated that CNAs were responsible for cleaning the shower area after resident use, while housekeeping was tasked with routine cleaning and disinfection. The housekeeping supervisor and environmental services director confirmed that CNAs were expected to disinfect the shower room and equipment after each use, with housekeeping performing deeper cleaning weekly. However, the environmental services director was unaware of the unlocked cabinet issue. The facility's policy outlined specific cleaning procedures, including debris removal, surface cleaning, and inspection, which were not adhered to, leading to the observed deficiencies.
Failure to Provide Abuse and Neglect Training to Staff
Penalty
Summary
The facility failed to provide abuse and neglect training to one of its staff members, Staff X, a Certified Nursing Assistant (CNA). This deficiency was identified during a review of records and interviews, where it was found that Staff X had not received the necessary training on abuse and neglect prevention and response. The facility's policy requires all staff, including new and existing employees, to undergo training on abuse, neglect, exploitation, misappropriation, mistreatment, and injury of unknown origin (ANEMMI). However, Staff X was not included in the sign-in sheet for the in-service education conducted on March 14, 2024, which covered these topics. The incident leading to the deficiency involved Resident #100, who had a lower BIMS score and was known to wander frequently. On March 13, 2024, the resident's representative (RR) visited and reported finding the resident in a concerning state, with two briefs, a hospital gown tucked around her, and her hands bound behind her. The RR also noted that the call light was out of reach and the TV was not working. Staff X, who was responsible for the resident's care, admitted to moving the call bell and using a liner in the resident's brief to prevent her from digging her hands into her pants. The RR accused Staff X of double briefing and inappropriate conduct, leading to an investigation. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of the allegations, and the case was reported to the abuse hotline and the police. The facility conducted evaluations on the resident, who was found to be in no pain and had no skin impairments. Despite the serious nature of the allegations, Staff X returned to work without completing any retraining or education on abuse and neglect, highlighting the facility's failure to ensure all staff received the necessary training as per their policy.
Failure to Report Alleged Abuse and Restraint
Penalty
Summary
The facility failed to report an alleged violation of abuse involving a resident to the State Survey Agency. The incident involved a resident with multiple medical diagnoses, including Alzheimer's disease and dementia, who was found by her family with her hands tied behind her back using a towel. The family also reported that the resident was double briefed and wet, with her call bell clipped to the curtain and the TV turned off. The family reported the incident to the Director of Nursing (DON), but the facility did not include the allegation of restraint in their federal reportable submission. During interviews, the Certified Nursing Assistant (CNA) involved stated that the resident was known to be active and that she had placed a liner in the resident's brief to prevent her from digging her hands into her pants. The CNA also mentioned that the resident's family was upset about the condition of the room and the resident's state. The CNA was suspended following the family's report, and the Adult Protective Agency and police were contacted, but the facility did not substantiate the complaint. The Nursing Home Administrator (NHA) acknowledged the report of the incident but stated that the allegation of restraint was not included in the federal report because there was no skin breakdown. The facility's policy requires immediate reporting of all allegations of abuse, neglect, or mistreatment, but the report did not reflect the full scope of the family's allegations. The facility's failure to report the alleged restraint and the conditions in which the resident was found constitutes a deficiency in adhering to reporting requirements.
Failure to Provide Wheelchair Mobility for Resident
Penalty
Summary
The facility failed to provide wheelchair mobility for a resident, identified as Resident #7, who was observed lying in bed during multiple observations over several days. The resident was admitted with diagnoses including dysphagia following cerebral infarction and unspecified dementia. The Minimum Data Set (MDS) indicated that the resident used a wheelchair for mobility, yet the care plan initiated on 09/10/2024 noted the resident's dependency on staff for transfers. Interviews with staff members, including CNAs and an RN, revealed that Resident #7 did not have a wheelchair and was not included on the list of residents to be assisted out of bed. Further interviews with the LPN/Unit Manager and the Rehab Director confirmed that Resident #7 was dependent, had limited mobility, and required a reclining wheelchair, which was not available. The Rehab Director mentioned that the resident was picked up for therapy services on 09/11/2024, but could not explain why the resident had not been provided with a wheelchair earlier. The facility's policy on ADL care and services emphasized the provision of appropriate support for mobility, which was not adhered to in this case.
Failure to Provide Resident Privacy
Penalty
Summary
The facility failed to provide privacy for two residents during a survey observation. Resident #76 was observed in her room with the door and privacy curtain fully open, lying in bed with her hospital gown pulled up, exposing her nude lower body. This occurred in a high-traffic hallway where staff, residents, and visitors frequently passed by, yet no staff intervened to provide privacy or assist the resident in covering up. The resident, who has cognitive impairments and various medical conditions, was unable to communicate her need for privacy. Despite being exposed for over ten minutes, staff did not take action until much later. Similarly, Resident #82 was observed seated in her wheelchair at the nurses' station, initially well-dressed and groomed. However, she later removed her top, exposing her upper body to staff and visitors passing by. A Personal Care Attendant (PCA) noticed the resident's actions but did not immediately assist her in redressing or moving her to a private area. Instead, the PCA eventually helped the resident put her shirt back on while she remained in the doorway, visible to others. The resident's medical records indicated a history of dementia and other conditions, but no prior incidents of disrobing were documented. Interviews with staff revealed that neither resident had a known history of disrobing, and staff were expected to provide privacy by closing doors or curtains and assisting residents in dressing. The facility lacked a specific privacy policy, relying instead on a general Resident Rights policy that emphasized treating residents with dignity and respect. Despite this, the staff failed to uphold these standards, resulting in the observed deficiencies.
Failure to Ensure Accurate PASRR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure timely and accurate Pre-Admission Screening and Resident Review (PASRR) for a resident with multiple mental health diagnoses. The resident was initially admitted with diagnoses including schizoaffective disorder bipolar type, major depressive disorder, dementia, and mood disorder due to a known physiological condition with depressive features. However, the Level I PASRR completed for this resident was found to be incomplete, as it did not indicate the qualifying diagnoses of depression, mood disorder, and dementia. During an interview, the RN MDS Director explained the facility's process for identifying residents with possible mental disorders or intellectual disabilities prior to admission. The process involved the Admissions Department and either the Director of Nursing or Assistant Director of Nursing reviewing clinical information to decide on admissions. The RN MDS Director was responsible for updating the PASRR when new diagnoses were identified or if the initial PASRR was incorrect. Upon reviewing the PASRR for the resident in question, the RN MDS Director acknowledged that it was incorrect and missing qualifying diagnoses. The facility did not have a PASRR policy in place.
Deficiencies in Care Plan Implementation for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with specific needs, leading to deficiencies in care. Resident #45, who was admitted with conditions including hemiplegia, psoriasis, and lymphedema, was observed with untreated skin conditions. Despite being admitted with these diagnoses, a care plan addressing his skin condition was only created after the surveyor's inquiry, indicating a delay in addressing his needs. The resident was also noted to have cognitive deficits, further complicating his ability to communicate his needs. Resident #44, diagnosed with dementia and other chronic conditions, was observed with poor personal hygiene, including long, untrimmed fingernails and disheveled hair. The resident expressed a desire for a shower, which had not been provided according to her preferences. The care plan for her activities of daily living (ADL) was not adequately implemented, as evidenced by the lack of assistance during meals and the absence of regular showers. The documentation showed inconsistencies in the recording of showers and nail care, with several instances of refusal not being properly documented or addressed by nursing staff. Resident #51, with a history of cerebrovascular accident and severe cognitive impairment, was also found to have inadequate ADL care. Observations revealed long fingernails with substances underneath, and the resident struggled with self-feeding due to her condition. The care plan did not reflect her current needs, and there was a lack of consistent documentation regarding her bathing routine. The DON acknowledged the discrepancies in care and documentation, highlighting the need for improved oversight and adherence to care plans.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADLs) care for two residents, specifically in the areas of fingernail care and showering. Resident #44, who has severe cognitive impairment and multiple medical conditions including dementia and brain cancer, was observed with long, unkempt fingernails and disheveled hair. Despite her need for assistance, she had not received a shower from 08/13/2024 to 09/10/2024, and her fingernails were not trimmed, leading to discomfort and potential hygiene issues. The Director of Nursing (DON) acknowledged the oversight and noted that the aides were responsible for reporting such needs to the nurse, but this process was not followed. Resident #51, also with severe cognitive impairment and a history of cerebrovascular accident, was observed with long fingernails and wearing the same clothing for several days. She had only received one shower in a 30-day period, and her fingernails were not trimmed, which affected her ability to eat properly. The DON recognized the infection control issue posed by the long nails and the need for more assistance during meals. The documentation in the medical records did not match the actual care provided, indicating a lack of consistency in care delivery and record-keeping. The facility's policy on ADL care and services was not adhered to, as residents who were unable to perform ADLs independently did not receive the necessary support to maintain good hygiene and nutrition. The DON admitted that the aides required more education and that the care plans needed to be updated to reflect the residents' current needs. The failure to provide adequate ADL care and the discrepancies in documentation highlight significant deficiencies in the facility's care practices.
Deficiency in Medication and Skin Care Treatment
Penalty
Summary
The facility failed to provide quality care and services according to standards of practice related to medication administration and skin care treatment for a resident with severe cognitive impairment and multiple medical conditions, including psoriasis and stasis dermatitis. Observations revealed that the resident was left in a hospital gown for extended periods and had scabs on his legs leaking yellow fluid. The resident's representative expressed concerns about the lack of follow-up on medical appointments and the resident's deteriorating skin condition. The facility's records showed that the resident was prescribed Otezla for psoriasis, but the medication was not administered on several occasions due to it being out of stock. A registered nurse admitted to signing off on medication and treatment records without verifying their completion, assuming they were done. The wound care nurse confirmed that the resident was no longer under wound care supervision, and daily treatments were supposed to be administered by the assigned nurse. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nurses, highlighted a lack of communication and responsibility regarding the resident's medication and treatment administration. The Director of Nurses acknowledged the medication was missing and should have been reordered, but could not explain why it was unavailable. The facility's policy emphasized that medication and treatment orders should be consistent with safe and effective practices, which was not adhered to in this case.
Deficiencies in Catheter Care and Infection Prevention
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters, leading to deficiencies in catheter management and infection prevention. Resident #82 was observed multiple times with her catheter tubing dragging on the floor while she was self-propelling in her wheelchair. Despite staff passing by and interacting with her, the issue was not addressed, posing a risk of contamination and infection. The resident, who had cognitive impairments, was unable to advocate for herself, and her responsible party was unaware of the issue until informed during an interview. Resident #13 was also found with her catheter bag on the floor, which is against the facility's guidelines for catheter care. The resident expressed a desire to resume therapy to improve her mobility but was planning to transfer to another facility. Staff interviews revealed that the catheter bag should be placed below the bladder and not on the floor, yet this standard was not maintained for Resident #13. The facility's catheter care policy emphasizes infection control and proper positioning of catheter bags and tubing. However, observations and interviews indicated that these guidelines were not consistently followed, leading to potential risks for the residents involved. The staff's failure to adhere to these protocols resulted in deficiencies in the care provided to residents with indwelling urinary catheters.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's care plan did not include specific PTSD triggers, and staff were not trained annually on trauma-informed care as required by the facility's policy. The resident, who had a history of major depressive disorder, schizoaffective disorder, unspecified psychosis, PTSD, other specified persistent mood disorders, anxiety disorder, and dementia, was observed expressing concerns about a particular person entering his room, which was not acknowledged by the attending Licensed Practical Nurse (LPN). Interviews with staff revealed a lack of awareness and understanding of the resident's care plan and psychiatric issues. One LPN admitted to not reviewing care plans and was unaware of any psychiatric issues the resident might have. Another LPN incorrectly identified a different resident as having a PTSD diagnosis. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that nurses should be familiar with care plans and that changes in resident conditions should be communicated through care plan meetings and assessments. However, the DON admitted that there was no ongoing education for staff on trauma-informed care beyond initial orientation. The facility's policy on trauma-informed care, revised in January 2024, outlined procedures for assessing residents for PTSD, developing comprehensive care plans, and providing culturally competent care. Despite this, the policy was not effectively implemented, as evidenced by the lack of specific PTSD triggers in the resident's care plan and the absence of annual staff training. The MDS Coordinator noted that the care plan's focus on trauma was based on psychiatric evaluations, which did not specify the resident's PTSD triggers.
Failure to Update Daily Staffing Information
Penalty
Summary
The facility failed to provide up-to-date and accurate daily staffing information for residents and visitors, as required. During an observation on 9/8/2024, it was noted that the Daily Staffing Projection sheet displayed in the facility's entrance lobby was outdated, showing information from 9/5/2024. This sheet, which should have been updated daily to reflect the current staffing numbers for each shift and the resident census, had not been updated for three days. Interviews with the front desk receptionist and the weekend supervisor revealed a lack of clarity regarding who was responsible for updating the form, with the weekend supervisor unaware of the current resident census. The Nursing Home Administrator confirmed that the Staffing Coordinator was responsible for updating the sheet on weekdays, while the weekend supervisor was tasked with this duty on weekends. However, the sheet had not been updated since 9/5/2024, and the Staffing Coordinator was unaware of the lapse, as she was off on 9/6/2024. The facility did not have a specific policy regarding the daily nursing assignment posting, although it was their standard practice to keep the information current. This oversight resulted in the failure to provide accurate staffing information to residents and visitors for three consecutive days.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate for three of four sampled residents. This was observed during medication administration by nursing staff, where several medications were either not administered as ordered or incorrectly documented as given. For Resident #498, medications such as Azithromycin and Flonase were documented as administered but were not observed being given. This resident had a history of cerebrovascular accident, heart failure, and chronic respiratory issues, necessitating precise medication management. Resident #93 also experienced medication errors, with medications like MiraLax and Ranolazine documented as given but not observed during administration. The resident's medical history included conditions such as COVID-19, diabetes, and atherosclerotic heart disease, which required careful adherence to prescribed medication regimens. The facility's Director of Nursing (DON) acknowledged that medications were not administered as per orders and that the documentation was inaccurate. For Resident #14, a discrepancy was noted in the dosage of Calcium administered, which was 500 mg instead of the ordered 600 mg. This resident had a history of rheumatoid arthritis, severe malnutrition, and hypertension, highlighting the importance of accurate medication administration. The facility's policy on medication administration emphasized the need for medications to be given as prescribed and documented accurately, which was not adhered to in these cases.
Deficiencies in Medication Administration and Personal Care Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records for several residents, leading to deficiencies in medication administration and personal care. For Resident #498, medications such as Azithromycin, Flonase, and Fluticasone-Salmeterol were documented as administered but were not observed being given. This discrepancy was confirmed by the Director of Nursing (DON) and the Advanced Practice Registered Nurse (APRN), who stated that medications should be administered as ordered and documented accurately. Similarly, for Resident #93, medications including MiraLax, Ranolazine, and Sennosides were documented as given but were not observed being administered. The DON confirmed these discrepancies upon reviewing the Medication Administration Review (MAR) and acknowledged them as medication errors. The APRN emphasized the importance of notifying the provider if medications are not given or are administered late. Additionally, Resident #51's personal care was inadequately documented, with inconsistencies in the records regarding bathing and nail care. The resident was observed with long, unclean fingernails and reported not having her nails cleaned or clipped. The DON verified that the shower sheets did not consistently indicate whether the resident received a shower or bed bath, and the documentation did not match the medical record. This lack of accurate documentation and care was noted as a deficiency in maintaining professional standards for resident care.
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.
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What surveyors actually found near you
We read the 301 citations issued within 25 miles in the last 12 months — including the 19 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 Tampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Palms Health And Rehabilitation Center At Fle | 0.4 mi | ★★★★★ | 1 | 0 |
| Palm Garden Of Tampa | 0.5 mi | ★★★★★ | 1 | 0 |
| Excel Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| The Bristol Care Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Tampa Lakes Health And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.