Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Health And Rehabilitation Center during CMS and state inspections, most recent first.
Medication storage and labeling were not maintained correctly on multiple med carts. A LPN and the DON identified that several inhalers, insulin products, and other meds lacked open dates or expiration dates, some refrigerated items were kept in carts, a discontinued medication was still present, and chemicals or wipes were stored with medications. One expired Lorazepam card and a mislabeled insulin vial were also observed.
Missing informed consent for psychotropic medications: The facility did not document consent for psychotropic med changes for three residents. One resident with PTSD, depression, and insomnia lacked consent for a sertraline dose increase and the documented trazodone dose. A resident with Alzheimer’s disease and severe cognitive impairment lacked consent for lorazepam, ABHR gel, and a sertraline increase. A resident with MI, bipolar disorder, and cognitive impairment lacked consent for quetiapine dose increases and risperidone initiation. Staff and the DON confirmed consents were expected for admission, new psychotropics, and dose changes.
Unclean Resident Rooms and Laundry Area: The facility failed to maintain multiple resident rooms and a laundry room in a clean, sanitary, and homelike condition. Observations found stained toilets, unpainted plaster, peeling baseboards, ill-fitting flooring, a missing transition strip, a gap around a PTAC unit, stained walls, a hole in a wall, and a privacy curtain stained with brown substance. In the laundry room, the vent and ceiling area had gray fuzzy material and hanging paint. The DOM and housekeeping staff described maintenance and cleaning processes, but the observed issues were still present.
A facility failed to ensure accurate PASARR Level I screens for three residents. One resident with epilepsy later had documented mood disorder and dementia, another resident with Alzheimer's disease and depression had a PASARR that incorrectly marked no diagnoses and no dementia/Alzheimer's responses, and a third resident with alcohol-related cognitive impairment later had records showing bipolar disorder and alcohol use disorder, yet no diagnoses were marked on the PASARR. Staff interviews showed the DSS, MDS Coordinator, and DON did not have a clear or consistent process for updating diagnoses, and no PASARR policy was provided.
Food and storage areas were found unsanitary in the main kitchen and two nourishment rooms. Employee food and beverages were stored in food prep areas, discarded resident breakfast food was left on a steam table, multiple sealed food items in the fridge and freezer lacked labels and dates, nourishment room foods were unlabeled, and the kitchen ice machine had black biological growth and brown staining.
Failure to Notify Physician of Abnormal Catheter Output: A resident with recent coccyx surgery, chronic pain, and a catheter had dark orange-red, cloudy urine and reported thirst, weakness, and abdominal pain, but staff did not document a CIC or notify the physician. An LPN confirmed the urine was concentrated and miscolored, a CNA said changes should be reported to the nurse, and the DON stated the abnormal catheter findings should have been assessed and reported to the MD.
MDS did not accurately reflect a resident’s active dx. The chart and psych records documented bipolar disorder and alcohol use disorder, but the MDS Section I listed no psychiatric or mood disorder dxs even though the resident was receiving an antipsychotic and an antidepressant. Staff reviewed the record and confirmed the dxs were omitted, and the MDS Coordinator could not explain the current process for keeping diagnoses updated.
A resident with PTSD and later documented psychiatric diagnoses including MDD, GAD, insomnia due to another mental disorder, mood lability, borderline personality disorder, and psychotic disorder with delusions did not have evidence of a Level II PASARR review after the Level I PASARR identified mental illness diagnoses. Staff interviews showed an unclear and inconsistent process for reviewing PASARRs and updating diagnoses, and the facility did not provide a PASARR policy.
Failure to provide and document activities for a bedfast resident with severe cognitive impairment and hemiplegia. A resident whose preferences included music, news, group activities, outdoor time, and religious activities was reported by family to be left in the room watching TV most of the day, with no 1:1 activities offered. SSA and DOA described expected activity offerings for bedfast residents, but the DON and NHA confirmed the record lacked documentation showing activities were provided, with only two activities documented over a limited period and no documentation for group, music, outdoor, or religious activities.
The facility failed to respond timely to resident needs and a fall event. A resident with recent coccyx surgery, chronic pain, and pressure ulcers waited about an hour for repositioning after activating the call light, while staff turned off the light and assisted others nearby. Another resident with dementia and a TBI was left on the floor after a fall for about 45 minutes before help arrived, and the LPN did not complete timely fall documentation or notifications.
Enteral feeding was not provided as ordered for a resident with a G-tube and dysphagia. The resident’s tube feeding pump was observed off while the formula and water bags remained connected, and the MAR, RD, and RN interviews confirmed the ordered 1300 mL/day regimen required two bottles of formula and proper timing/documentation when feeds were interrupted.
Incorrect medication reconciliation resulted in delayed pain management for a resident admitted after surgery for leg ulcers and heel debridement. The resident’s hospital discharge order for Gabapentin 200 mg TID was transcribed as 100 mg TID, and the resident reported not receiving any medication on arrival and experiencing excruciating pain. The HCS and DON confirmed the incorrect dose and lack of pain medication, and pain scores reached 9/10 after admission.
Medication administration errors caused the facility’s error rate to exceed 5% for two residents. An LPN administered lorazepam to one resident but could not document it in the MAR at the time because the system would not allow it, and later entered it hours afterward. In a separate event, another LPN gave a resident metoprolol at the wrong dose compared with the physician order, and the DON found no documentation that the physician had been notified.
Failure to Provide Therapy and Restorative Services: Two residents did not receive ordered or indicated rehab-related services. One resident with ataxia and contractures said he had not received therapy since admission, and staff confirmed he was never screened or evaluated by PT/OT despite orders and a care plan calling for therapy assessment. Another resident with stroke-related deficits had OT discharge recommendations for a restorative/functional maintenance program and an order for ROM and palm guards, but staff and the DON found no restorative task, no completed evaluation, and no documentation that restorative care was provided.
Inaccurate TBP signage was posted outside a resident’s room even though the resident had an order for contact precautions for ESBL in urine. Staff interviews showed that nurses were responsible for posting the correct signage, but staff described inconsistent understanding of contact precautions versus enhanced barrier precautions, and the facility policy reviewed did not include guidance for contact-based precautions or enhanced barrier precautions.
Surveyors found two containers of expired cottage cheese in the refrigerator and observed a meat slicer covered as if clean but with visible food debris on its base and blade. The Dietary Manager confirmed both the expired food and the improper cleaning of the equipment, in violation of facility policies on food storage and sanitation.
Surveyors found that several residents did not receive respiratory care in accordance with physician orders and facility policy. Oxygen was administered at incorrect flow rates for two residents, and nebulizer equipment for two others was not stored in a hygienic, labeled manner as required. Staff interviews revealed a lack of awareness of proper oxygen settings and inconsistent adherence to respiratory care protocols.
A resident with type 2 diabetes did not receive insulin as ordered on several occasions, with documentation indicating the dose was held due to low blood sugar. An LPN held the morning insulin dose without notifying the provider, contrary to expectations. The DON and APRN both stated that insulin orders should be followed and the provider should be notified if insulin is withheld.
A resident with multiple chronic conditions received Metoprolol for hypertension on numerous occasions when their blood pressure readings were below the physician-ordered parameters. Medication administration records and staff interviews confirmed that the medication was given outside of the specified limits, and staff were not consistently aware of or adhering to the required parameters.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident's urinary catheter bag was left uncovered and visible in the room, causing embarrassment to the resident. The DON confirmed that all Foley catheter bags should have a dignity cover, and facility policy requires maintaining resident dignity. The failure to cover the catheter bag was contrary to both policy and the resident's expressed wishes.
A resident with multiple medical conditions was found to have unsupervised access to cigarettes and lighters in their room, contrary to facility policy requiring smoking materials to be secured and only distributed during supervised smoking times. Staff interviews and observations confirmed that the facility did not enforce its own procedures for securing smoking materials.
A resident with a midline catheter had a dressing with gauze that was not changed according to physician orders and professional standards, remaining in place for at least seven days instead of every two days as required. Facility staff, including an LPN and the DON, demonstrated a lack of knowledge regarding the correct frequency for changing such dressings, and no midline catheter policy was provided during the survey.
The facility did not ensure monthly medication regimen reviews were completed by a pharmacist for two residents, and physicians failed to provide clinical rationales when disagreeing with pharmacy recommendations regarding medication management. The DON confirmed missing documentation for both the reviews and the required physician rationales.
A resident with multiple health conditions did not receive timely incontinence care due to staffing shortages, leading to inadequate wound care and improper hygiene practices by a CNA. The facility's staffing adjustments based on census and an aide's absence resulted in fewer available aides, impacting the resident's care. The DON confirmed that the expected two-hour incontinence care schedule was not followed.
A resident with multiple wounds did not receive proper wound care and infection control practices. An LPN failed to clean the overbed table, use a barrier for supplies, and follow hand hygiene protocols during wound care. The resident's care plan was not followed, and the antifungal powder was not used correctly. Interviews with the NHA and DON confirmed that infection control policies were not adhered to, contributing to the deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medications and biologicals were not stored in accordance with accepted professional principles in four observed medication carts on the 100, 200, 300, and 400 halls. On the 400 hall cart, a box of micro kill wipes was stored next to cholestyramine powder packets and a ProAir RespiClick inhaler, and a fluticasone inhaler had no open or expiration date even though the instructions indicated it should be discarded 30 days after opening. Staff E, LPN stated the wipes should not have been stored with medications and the inhaler should have an opened date. On the 200 hall cart, a bottle labeled drug buster was stored with powdered fiber, liquid protein, and liquid valproic acid, and three fluticasone inhalers had no open or expiration date. Two unopened Lispro insulin vials and three unopened insulin pens were stored in the cart even though the instructions indicated refrigeration until opening, and four opened Lispro insulin vials and one opened Lyumjev Lispro insulin vial had no open date; one opened Lispro vial also had a resident label that did not match the box it was stored in. On the 100 hall cart, Repatha and Arformoterol Tartrate inhaled solution were stored in the medication cart despite refrigeration requirements, one medication card had residents’ names marked out and was stored with other residents’ medications, and inhalers had no open or expiration dates. On the 300 hall cart, a Lorazepam card was expired, one fluticasone inhaler had an open date but no expiration date, and two lidocaine vials had no open date or expiration date. The DON stated medications should be dated when opened, unopened insulins should be refrigerated, chemicals should be stored away from medications or oral supplements, and lidocaine was discontinued.
Missing informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure informed consent was documented for psychotropic medications for three residents. Review of records showed that Resident #7, who had diagnoses including PTSD, recurrent major depressive disorder, insomnia due to another mental disorder, and adjustment disorder with anxiety, had consent documented for sertraline 100 mg and trazodone 150 mg, but there was no consent for the increase in sertraline from 100 mg to 150 mg and no consent reflecting the prescribed trazodone dose of 150 mg. Resident #7’s BIMS score was 14, indicating minimal to no impairment with thinking or memory. Resident #25 was admitted with Alzheimer’s disease and depression and had a BIMS score of 3, with a family member listed as proxy. Her orders included sertraline 100 mg, lorazepam 0.5 mg PRN for anxiety, ABHR gel PRN for anxiety, and an increase in sertraline to 150 mg. The record showed consent for sertraline 100 mg from the family member, but there was no consent for initiation of lorazepam, no consent for initiation of ABHR gel, and no consent for the sertraline dose increase. Resident #73 was admitted with myocardial infarction and had additional diagnoses including alcohol use with alcohol-induced persisting amnestic disorder, mild cognitive impairment, and bipolar disorder. His BIMS score was 11, indicating moderate problems with thinking or memory. His orders included quetiapine ER 50 mg at bedtime, later increased to 100 mg and then 150 mg, and risperidone 0.5 mg twice daily. Consent was documented for the initial quetiapine ER order, but there was no consent for either quetiapine dose increase and no consent for initiation of risperidone. Staff interviews confirmed that psychotropic consents were expected on admission, with new psychotropic medications, and with dose changes, and that the DON and ADON were responsible for ensuring the consents were obtained and accurate.
Unclean Resident Rooms and Laundry Area
Penalty
Summary
The facility failed to provide a clean, sanitary, and homelike environment in units 200, 300, and 400, affecting resident rooms 207, 203, 201, 405, 305, and 307, and failed to maintain one observed laundry room in a sanitary manner. During an observation with the Director of Maintenance, room [ROOM NUMBER] had staining in the toilet, a large area of unpainted plaster in the bathroom, peeling baseboards, and ill-fitting linoleum. The DOM stated the bathroom had a large leak that needed repair, that a pumice stone had been ordered for the toilet stains, and that the facility planned to paint and replace the flooring but could not provide a completion timeline. The DOM also observed a bathroom flooring issue and toilet staining in another room, a missing flooring transition strip in another room, and a gap around a PTAC unit where outside light could be seen entering the room and the DOM agreed the gap could allow pest entry. Review of maintenance reports from 4/3/26 to 5/19/26 showed no maintenance reports documented for one of the affected rooms. Additional observations showed resident room walls stained with unknown brown and yellow substances, a hole in a wall near the baseboard, and a privacy curtain stained with a brown substance in multiple places. A CNA stated that holes in resident room walls and other maintenance needs should be reported to maintenance, but was unsure how long the hole had been present and unsure of the process for replacing stained privacy curtains. The DOM stated maintenance repairs begin when staff enter requests into the online system, but review of the previous 30 days of maintenance requests showed no request to repair the hole in the wall. The Housekeeping and Laundry Supervisor stated housekeeping is responsible for keeping privacy curtains clean and that curtains are washed in the facility laundry during monthly deep cleaning. In the laundry area, the vent above the folding table was covered with gray fuzzy material, a piece of which hung from the vent and moved in the air, and the washer room ceiling had hanging unattached pieces of paint and gray fuzzy material attached to piping.
Inaccurate PASARR Level I Screens
Penalty
Summary
The facility failed to ensure accurate Level I PASARR screening for three sampled residents. Resident #26 had an admission diagnosis of epilepsy, and a physician encounter note later documented mood disorder and dementia, but the Level I PASARR completed on 06/27/2025 did not identify a mental illness or suspected mental illness and only checked epilepsy. Resident #25 was admitted with a primary diagnosis of Alzheimer's disease and an additional diagnosis of depression, but the PASARR Level I screen dated 2/2/26 marked no diagnoses in section A and answered no to both dementia-related questions, including the question related to Alzheimer's disease. Resident #73 was admitted with alcohol use and alcohol-induced persisting amnestic disorder with mild cognitive impairment, and later records included a history and physical and psychiatry admission note documenting bipolar disorder and alcohol use disorder. However, the PASARR Level I screen dated 3/15/26 did not mark any diagnoses in section A. During interview, the DSS stated she reviews Level I screens on admission and notifies the DON as needed, but acknowledged she was behind and that the current process was something she was working on. The MDS Coordinator was unable to explain how she is notified to update diagnoses and could not outline a current process to ensure an accurate list of diagnoses. The DON stated she completes a new PASARR Level I when notified by social services. The facility did not provide a PASARR policy.
Food Storage and Sanitation Lapses in Kitchen and Nourishment Rooms
Penalty
Summary
Food and food storage areas were not maintained in a sanitary manner in the main kitchen and in two nourishment rooms. During a kitchen tour, employee food was observed on a table next to the dessert cooler, a beverage was stored next to the juice dispenser on top of a table, and food to be discarded from resident breakfast was left on top of the steam table used to hold hot foods. In the freezer, a sealed bag containing an unknown green and red food item was present without a label or date of expiration or preparation. In the refrigerator, a sealed bag of a yellow block-like food item and a sealed bag with a round brown food item were also observed without labels, preparation dates, or expiration dates. Two nourishment rooms contained resident and staff food items that did not have resident or staff names and were not labeled with the date of procurement. The ice machine in the kitchen had black biological growth underneath the water spout and brown staining in the container beneath the water spout. The Dietary Manager and Regional Food Service Manager stated that items stored in the kitchen and nourishment rooms should be labeled and dated with use-by dates, that personal items should not be stored in work areas, and that discarded meals should not be stored on top of food preparation areas. A policy for maintaining the cleanliness of the ice machine was requested and not received.
Failure to Notify Physician of Abnormal Catheter Output
Penalty
Summary
The facility failed to ensure the physician was notified of a change in catheter output for one resident. During an observation and interview, the resident was grimacing in pain after recent coccyx surgery, reported feeling very thirsty and weak, and had a catheter with dark orange-red urine in the tubing. The resident stated staff never tell her what is going on and believed the catheter condition had not been checked. An LPN later observed the urine and confirmed it was concentrated and miscolored, but stated she had not been aware of the catheter condition because she had been off for part of the assignment. A CNA stated that changes should be reported to the nurse right away, but was unsure about documentation. The DON stated that when a catheter abnormality is observed, the CNA should notify the nurse, the nurse should assess the catheter and urine, and the physician should be contacted as soon as possible if an issue is found. The resident’s record showed admission for a sacral pressure ulcer, chronic pain syndrome, and depression, with a BIMS score of 14 indicating cognitive intactness. The care plan directed staff to monitor and report signs of dehydration and catheter complications, including decreased urine output, concentrated urine, fatigue, weakness, thirst, blood-tinged urine, cloudiness, deepening urine color, and discomfort. The chart contained no change in condition documentation and no progress notes regarding the urine output or color, and the DON confirmed the physician had not been notified about the abnormal urine and abdominal pain.
MDS Did Not Reflect Active Diagnoses
Penalty
Summary
Ensure each resident receives an accurate assessment. Record review and interviews revealed that the facility failed to ensure the Minimum Data Set (MDS) accurately reflected active diagnoses for one resident. The resident’s chart showed an admission diagnosis of myocardial infarction, along with alcohol use, unspecified with alcohol-induced persisting amnestic disorder and mild cognitive impairment of uncertain or unknown etiology. The resident’s history and physical and psychiatry admission note also documented bipolar disorder and alcohol use disorder. Review of the resident’s MDS showed no psychiatric or mood disorder diagnoses listed in Section I, even though Section N indicated the resident was taking an antipsychotic and antidepressant with an indication noted. During interviews, the DSS, SWA, MDS Coordinator, and RDCR reviewed the MDS and confirmed that bipolar disorder and alcohol use disorder were not included. The MDS Coordinator was unable to explain how she was notified to update diagnoses, and the facility did not provide a policy related to MDS and/or comprehensive assessments.
Failure to Refer Resident for Level II PASARR Review
Penalty
Summary
The facility failed to ensure a resident was referred for a Level II PASARR review after qualifying diagnoses were identified. Resident #51 had a diagnosis of PTSD, unspecified, with an admission date of 08/09/2025. Psychiatry progress notes dated 3/9/2026 and 4/10/2026 documented additional diagnoses including major depressive disorder, generalized anxiety disorder, insomnia due to other mental disorder, mood lability, borderline personality disorder, and psychotic disorder with delusions due to a known physiological condition. The Level I PASARR dated 08/13/2025 listed PTSD, unspecified, and anxiety disorder under mental illness diagnoses, but the facility did not provide evidence of a Level II consideration following those qualifying diagnoses. During interview, the DSS stated she reviews Level I PASARRs on admission and notifies the DON as needed, but said she was behind and that the current process was something she was working on. She also stated that in a previous building the team reviewed physician medication orders, psychiatry notes, psychology notes, and updated MDS diagnoses together. The MDS Coordinator stated she did not know when asked how she is notified to update resident diagnoses, and the RDCR stated diagnoses would be updated during weekly team meetings. The DON verified that she completes a new PASARR Level I when notified by social services. The facility did not provide a PASARR policy as requested.
Failure to Provide and Document Activities for a Bedfast Resident
Penalty
Summary
The facility failed to ensure that a bedfast resident with limited mobility received activities that met the resident’s interests and supported physical, mental, and psychosocial well-being. Resident #83 had diagnoses including frontal lobe and executive function deficit following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and arteritis. The resident’s quarterly MDS showed the resident was rarely or never understood, had short- and long-term memory problems, no recall ability, and was severely impaired for cognitive skills for daily decision making. The resident’s activity and routine preferences identified family or significant other involvement in care decisions, listening to music, keeping up with the news, doing things with groups of people, participating in favorite activities, spending time outdoors, and participating in religious activities or practices. However, the resident’s family member stated the facility did not do anything with the resident, left the resident in the room watching TV most of the day, and did not offer 1:1 activities. The family member also stated the resident was confined to the room and needed opportunities to get outside and do preferred activities. Facility interviews showed the SSA stated bedridden residents were provided reading materials and music, but was unaware of how often those residents received activities. The DOA stated 1:1 activities such as word searches, crossword puzzles, reading materials, chess, checkers, music, and stories were provided to residents unable to leave their beds and that activities should be documented daily, but the DOA had just met Resident #83 the day before the interview. The DON and NHA both acknowledged there was no documentation to determine whether activities were provided as expected, and the NHA confirmed the resident had only two activities documented from April 20 through 30 and no documentation for group, music, outdoor, or religious activities for months March through May 2026. The resident’s progress notes contained no documentation that activities were provided.
Delayed response to resident assistance and fall assessment
Penalty
Summary
The facility failed to provide timely care and assistance to residents needing staff help. Resident #132, who was cognitively intact with a BIMS of 14/15 and had diagnoses including a sacral pressure ulcer, chronic pain syndrome, and multiple fractures, was observed lying in bed grimacing and moaning in pain after recent coccyx surgery. The resident stated they were very thirsty, too weak to reposition themselves, and that staff often did not answer the call light. After the resident activated the call light and requested repositioning for coccyx pain, an OTA entered the room, turned off the call light, and said the resident’s care staff would be informed. The resident remained in discomfort while staff were observed answering other call lights and assisting other residents nearby, but no one came to reposition the resident for approximately one hour. Staff interviews showed the OTA said they only notify the nurse or aide and turn off the call light even when the task is not completed. The LPN initially did not recall the request for repositioning and then said they would let the aide know. The DON stated call lights and resident needs should be addressed timely, that rehabilitation staff can assist with repositioning, and that it was not proper to turn off the call light if the resident’s need could not be met at that time. Resident #132’s care plan directed staff to respond promptly to requests for assistance, assist with repositioning for comfort, and monitor for signs of discomfort or distress. The facility also failed to timely assess and document a fall involving Resident #109. Resident #109 had diagnoses including unspecified dementia and a history of traumatic brain injury, and their MDS showed a BIMS of 12/15. The resident and family member reported that after the resident fell from the bed, the resident was on the floor or on their knees for about 45 minutes calling for help because the call light was not within reach. The family member stated they had to call for staff and saw a CNA down the hall before help arrived. Staff interviews confirmed the CNA heard the resident calling, found the resident on the floor with the family member present, and got another staff member to help the resident back into bed. The LPN stated they assessed the resident and initiated skin and vital checks but did not document the fall or complete timely assessments because they were busy with admissions and forgot. The LPN also stated the DON was not notified in a timely manner. The DON and NHA stated the fall was not reported to them until six days later after a late entry CIC was entered, and the DON stated fall assessments, CIC documentation, and notifications were to occur the same shift the event occurred. The facility’s incident and falls policies required timely documentation, notification, and assessment when a resident is found on the floor.
Enteral Feeding Not Delivered as Ordered
Penalty
Summary
The facility failed to provide enteral nutrition as ordered for one resident with a feeding tube. Resident #34 was admitted with diagnoses including dysphagia following a non traumatic intracerebral hemorrhage, gastrostomy status, and oropharyngeal phase dysphagia. The resident’s nutrition evaluation documented that she was dependent on feeding assistance and was receiving continuous tube feeding at 65 mL/hour for 20 hours, with water flushes of 60 mL every hour. The physician order on the May 2026 MAR directed liquid nutrition at 65 mL/hour for 20 hours or until 1300 mL total volume was reached, with water flushes every hour while NPO. During observation on 05/17/2026, the resident’s tube feeding was connected but the pump was off and not running. The nutrition bottle was dated 5/16/2026 at 2:00 p.m., labeled 65 mL/hr, and still contained 375 mL of formula; a clear bag with 400 mL of water was also connected and the pump remained off. The MAR showed the nutrition had been administered at 1:07 p.m. that day, and staff interviews confirmed that two bottles were needed to provide the ordered 1300 mL volume, that the bottles should be dated and timed, and that if nutrition was off for a couple of hours a physician order and documentation were needed. The RD also confirmed the ordered volume required two bottles of formula.
Incorrect Medication Reconciliation Led to Delayed Pain Management
Penalty
Summary
Medication reconciliation was not completed correctly for a resident admitted after surgery for leg ulcers and heel debridement, with diagnoses including open wound left ankle, polyneuropathy, and spinal stenosis. The resident had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The hospital discharge medication list ordered Gabapentin 100 mg capsules to be taken as 200 mg three times daily, but the physician order was transcribed as Gabapentin 100 mg three times daily for neuropathy. The resident stated she did not receive any medication after arrival and reported excruciating pain on the first two days after admission. The HCS also reported that the resident did not receive the correct Gabapentin dose and did not receive any pain medication on the day of arrival. Documented pain assessments showed pain levels of 9/10 late on the day of arrival and again early the next morning, followed by additional 9/10 and 5/10 pain ratings later that day. The progress note documented that the resident arrived via stretcher and that the MD was notified and medications were confirmed. The DON confirmed the medications were not reconciled correctly upon arrival and stated the resident should have received pain medication after arriving at the facility, with the nurse needing to obtain the medication from the Pyxis. The facility policy stated medication reconciliation is intended to accurately account for medications on admission or readmission and to compare pre-discharge and post-discharge medications to prevent unintended changes or omissions.
Medication Error Rate Exceeded 5% Due to Late Documentation and Wrong Dose Administration
Penalty
Summary
The facility did not ensure the medication error rate remained below 5% for two residents sampled for medication administration, resulting in 2 errors out of 29 medication administration opportunities for a 6.9% error rate. During an observation on 5/18/2026 at 8:20 A.M., Staff E, LPN prepared and administered lorazepam 0.5 mg to Resident #6. The resident’s physician order was for lorazepam 0.5 mg by mouth every 6 hours for anxiety, agitation, and restlessness. A later review of the medication audit report showed the last documented dose had been given at 5:16 A.M., and Staff E stated she could not locate documentation for the 8:20 A.M. dose in the EMR because the MAR would not allow documentation at that time; she said she documented it around 12:00 P.M. instead. During another observation on 5/18/2026 at 9:08 A.M., Staff G, LPN prepared and administered metoprolol 50 mg, giving 1/2 tablet to Resident #68. The physician order for Resident #68 was metoprolol tartrate 12.5 mg, 1 tablet by mouth one time a day for hypertension, to be given in the evening. The DON later stated the metoprolol dose should have been 12.5 mg and not 25 mg, and that the doctor should have been notified of the wrong dose. The DON also stated she did not find documentation that the doctor had been notified, and confirmed the expectation that nurses document medication administration on the MAR at the time the medication is given.
Failure to Provide Therapy and Restorative Services
Penalty
Summary
The facility did not ensure specialized rehabilitative or restorative services were provided for two residents. For one resident, an observation found the resident lying in bed with bilateral upper arm contractures, and the resident stated he was not receiving therapy services, had not received therapy since admission, wanted therapy, and did not have any braces or splints. The resident’s record showed diagnoses including early-onset cerebellar ataxia, Friedreich ataxia, and major depressive disorder, with a BIMS score of 15 out of 15. The physician order allowed the resident to be screened or evaluated by PT, OT, and/or ST as needed, and the care plan included PT/OT evaluation, treatment, or screening as indicated and/or ordered, but the MDS showed no therapy services were being utilized. Interviews confirmed the resident was not evaluated or screened by therapy. The PTA stated there were no therapy notes because the resident was not evaluated and said the resident was admitted with Medicaid services and was not evaluated due to not having a payor source. The NHA stated the resident was not screened by therapy because he was admitted for LTC services, but also said therapy ideally would at least assess the resident to determine whether therapy services were needed and acknowledged the resident was not evaluated or assessed upon admission. The DOT also stated the resident was not screened by PT or OT. The facility policy stated the physician, in coordination with facility staff, would determine the resident’s function and physical condition to determine whether therapy services were needed upon admission. For the second resident, the family member stated the resident was not receiving restorative exercise after discharge from PT and OT and that staff did not exercise the resident’s arms, legs, or hands, despite the family bringing in weights for bedside use. Staff interviews showed the LPN had not seen towel rolling, palm guards, or ROM therapy provided for the resident, and the DOR stated the resident had been discharged from PT, OT, and ST due to limited rehabilitation potential after a massive stroke, but had been ordered restorative care for ROM and palm guards as tolerated. The DON reviewed the record and found no restorative documentation in the portal, no active restorative task, and no completed restorative evaluation. The CNARA stated restorative care is normally assigned through a task in the resident’s profile, but this resident did not have a task and therefore no restorative/ROM care could be documented. The resident’s record showed significant cognitive impairment, inability to be verbally understood, impaired ROM in both upper and lower extremities, dependence for activities, and OT discharge recommendations for a restorative and functional maintenance program, yet the chart contained no documentation that restorative care was provided.
Inaccurate TBP Signage for Resident on Contact Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when Resident #18, who had an order for contact precautions for ESBL in urine, had inaccurate transmission-based precaution signage posted outside the room. On 05/18/2026 at 10:53 AM, the sign observed outside the resident’s room read "Enhanced Barrier Precautions" even though the record showed an order for contact precautions beginning 05/09/2026 and ending 05/19/2026. Staff interviews showed that staff understood door signage was used to determine the proper precautions before entering a resident’s room, and that nurses were responsible for assigning accurate TBP signage for residents on contact precautions. Interviews with CNA and LPN staff revealed that education on transmission-based precautions had been provided, but staff described differing understandings of contact precautions and the responsibilities for posting signage. One LPN stated ESBL in urine required contact precautions and that nurses were responsible for ensuring the correct signage was posted, while another LPN recalled being assigned to Resident #18 and identifying contact precautions due to ESBL in urine. The DON stated Resident #18 was on contact-based precautions due to a positive ESBL urine result, and review of the facility policy titled Infection Control-Infection, Prevention and Control Program did not reveal a policy for contact-based precautions or enhanced barrier precautions.
Expired Food and Unclean Equipment in Kitchen
Penalty
Summary
During a kitchen tour with the Dietary Manager, surveyors observed two containers of cottage cheese in the walk-in refrigerator that were past their expiration date. Additionally, a covered meat slicer was found to have food particle debris on its base and blade, despite being covered as if it were clean. The Dietary Manager confirmed both the presence of expired food and the unclean condition of the meat slicer, acknowledging that expired foods should be disposed of by or on their expiration date and that equipment should not be covered until properly cleaned. A review of facility policies indicated that food should be stored according to safe food handling practices and that all utensils and equipment should be kept clean except during active use.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for four residents requiring oxygen therapy or nebulizer treatments. For one resident with COPD, the oxygen was not set at the physician-ordered rate of 2 liters via nasal cannula as needed for shortness of breath or oxygen saturation below 93%. The resident stated reliance on staff for oxygen management, and the LPN was unaware the oxygen setting was incorrect, attributing it to possible accidental adjustment during care. The DON confirmed there was no specific policy for oxygen administration. Another resident with Parkinson's disease and congestive heart failure was observed with an oxygen concentrator set at 4 liters per minute, contrary to the physician's order for continuous oxygen at 2 liters via nasal cannula. The oxygen concentrator was also placed out of the resident's reach. The LPN acknowledged the discrepancy and stated the need to follow physician orders. Additionally, two residents receiving nebulizer treatments had their nebulizer masks improperly stored. One resident's nebulizer mask was left unbagged and unlabeled on the bedside table, and another's was left on a blanket on a chair after use. Facility policy required nebulizer equipment to be stored hygienically, bagged, and labeled when not in use. The DON confirmed the expectation for proper storage of respiratory equipment, and facility policy supported this requirement.
Failure to Administer Insulin per Physician Orders and Notify Provider
Penalty
Summary
The facility failed to administer insulin according to physician orders for a resident diagnosed with type 2 diabetes mellitus. The physician's order specified that the resident should receive 50 units of Insulin Glargine at bedtime and 5 units in the morning. Review of the medication administration records showed that on multiple occasions, the morning dose of insulin was not administered, and a chart code indicating 'Pulse below 60/min Ineffective' was documented. During interviews, an LPN confirmed holding the morning insulin dose due to low blood sugar and referenced parameters for another insulin, but did not notify the physician as required. The DON stated that staff are expected to follow insulin orders, and the APRN confirmed that they expect to be notified if insulin is held and that parameters should be followed.
Failure to Follow Physician-Ordered Parameters for Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for antihypertensive medication administration were followed, resulting in the administration of unnecessary medications to a resident. The resident had multiple diagnoses, including atrial fibrillation, heart failure, malnutrition, COPD, diabetes, osteoarthritis, esophageal cancer, and atherosclerotic heart disease. The physician's order for Metoprolol Succinate ER specified that the medication should be held if the systolic blood pressure (SBP) was less than 100, diastolic blood pressure (DBP) was less than 60, or heart rate (HR) was less than 60. Despite these parameters, medication administration records showed that the resident received Metoprolol on multiple occasions when their blood pressure readings were below the specified thresholds. Interviews with staff revealed a lack of awareness and adherence to the ordered parameters. One LPN admitted to administering the medication even when the resident's blood pressure was outside the prescribed limits, stating they did not realize the error at the time. The Director of Nursing confirmed that all medications should be administered or held according to written parameters. This failure to follow physician orders led to the administration of unnecessary antihypertensive medication to the resident.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Resident Dignity by Leaving Catheter Bag Uncovered
Penalty
Summary
A deficiency was identified when a resident's urinary catheter collection bag was observed hanging uncovered on the left side of the bed, containing 300 milliliters of yellow fluid, with a towel placed underneath on the floor. The resident reported that the urine bag had not been covered, expressing embarrassment that it was visible to anyone entering or passing by the room. This observation was confirmed during an interview, and the resident's medical record indicated a history of urinary retention and other medical conditions requiring the use of an indwelling urinary catheter. The facility's Director of Nursing stated that all Foley catheter bags should have a dignity cover. Review of the facility's catheter care policy indicated that dignity should be maintained and catheter coverings are not required only when drainage bags are out of public sight or per resident preference. The facility's resident rights policy also emphasized the right to a dignified existence and to be treated with respect. In this case, the resident's dignity was not maintained as the catheter bag was left uncovered and visible, contrary to both facility policy and the resident's expressed wishes.
Failure to Secure Smoking Materials and Enforce Smoking Policy
Penalty
Summary
The facility failed to provide a safe environment and did not implement its policy on securing smoking materials for one resident. Observation revealed that the resident, who had multiple medical diagnoses including fractures, COPD, diabetes, heart failure, and hypertension, kept a pack of cigarettes and two lighters in a clear plastic bag attached to the bedside table. The resident confirmed during an interview that they kept their cigarettes and lighter in the room and stated that staff did not object to this practice. Further observation showed the resident moving independently in a wheelchair and inquiring about missing cigarettes, indicating unsupervised access to smoking materials. The facility's policy requires that residents with independent smoking privileges are not permitted to keep smoking materials or lighters in their possession and that these items must be secured by nursing personnel except during supervised smoking times. The Nursing Home Administrator confirmed that it is the facility's responsibility to ensure smoking materials are locked up and only distributed during scheduled smoking breaks, with staff responsible for returning them to secure storage afterward. Despite this policy, the resident was able to keep and access smoking materials unsupervised, constituting a failure to follow established safety procedures.
Failure to Change Midline Catheter Dressing with Gauze per Standards
Penalty
Summary
A deficiency was identified when a resident with a left upper arm single lumen midline catheter was observed with a dressing dated seven days prior, and gauze was present under the transparent semi-permeable dressing. According to the physician's order, the dressing was to be changed within 24 hours of admission, insertion, or reinsertion, and then every seven days or as needed, using sterile technique. The order also specified that dressings with gauze should be changed every two days. However, the dressing with gauze remained in place for at least seven days, contrary to both the physician's order and professional standards of practice. Interviews with facility staff revealed a lack of knowledge regarding the appropriate frequency for changing midline catheter dressings, particularly when gauze is used. The LPN interviewed was unaware that dressings with gauze required more frequent changes, and the DON confirmed that such dressings should be changed every two days. The facility was unable to provide a midline catheter policy and procedure upon request. Review of CDC guidelines also indicated that dressings should be replaced when soiled or when gauze is used, supporting the need for more frequent changes than what was observed.
Failure to Complete Monthly Medication Regimen Reviews and Document Physician Rationale
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews (MRRs) for residents, as required by policy and regulation. Specifically, for one resident, there was no documentation of a pharmacist-conducted MRR for three separate months, despite the resident being continuously admitted during that period. Additionally, a pharmacy review identified a significant drug interaction and made a recommendation regarding the resident's medication regimen, but while the physician disagreed with the recommendation, no clinical rationale was documented for this disagreement. For another resident, the consultant pharmacist recommended a gradual dose reduction of an antidepressant medication, but the physician disagreed without providing a clinical rationale either on the form or in a progress note. The facility's policy requires that physicians and staff identify and address potentially significant medication-related problems, and that consultant pharmacists use monthly reviews to identify problematic medications. Interviews with the DON confirmed the lack of required documentation and rationale in both cases.
Inadequate Incontinence Care Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that Activities of Daily Living (ADLs), specifically incontinence care, were adequately performed for a resident. During an observation, it was noted that the resident, who was sitting in a wheelchair, had not received timely incontinence care. Staff C, a CNA, admitted that she had been trying to change the resident since 11:00 a.m. but was unable to do so due to being pulled to other duties, such as passing meal trays. The resident was found with a saturated dressing on her buttocks, indicating a lack of timely wound care, and the CNA did not follow proper hand hygiene protocols during the care process. The resident involved had a medical history that included atrial fibrillation, morbid obesity, dementia, hypertension, osteoarthritis, and a disorder of the kidney and ureter. The resident was at risk for skin impairment due to fragile skin, incontinence, and decreased mobility. The care plan indicated that the resident required extensive assistance with ADLs, including toileting and transfers, and was at risk for complications related to bowel and bladder incontinence. Despite these needs, the facility's staffing issues led to inadequate care, as there were fewer aides available than usual, and the CNA responsible for the resident was assigned additional duties. Interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed that staffing was adjusted based on census, and an aide had called off for the shift, leading to a shortage. The DON stated that residents should receive incontinence care every two hours, but this was not adhered to in the case of the resident. The facility's policy on ADL care and services emphasized the importance of providing necessary care to maintain residents' ability to carry out ADLs, but this standard was not met due to the staffing challenges and the subsequent delay in providing incontinence care.
Inadequate Wound Care and Infection Control Practices
Penalty
Summary
The facility failed to provide adequate wound care and adhere to infection control practices for a resident with multiple wounds. During an observation, a Licensed Practical Nurse (LPN) was seen performing wound care without cleaning the overbed table or placing a barrier before setting down supplies. The LPN also failed to follow proper hand hygiene protocols, as she did not sanitize her hands between glove changes and handled contaminated items without changing gloves. The antifungal powder bottle lid fell on the floor, and the LPN picked it up and placed it back on the bottle without sanitizing her hands or changing gloves. The resident in question had a history of multiple medical conditions, including atrial fibrillation, morbid obesity, dementia, and moisture-associated skin damage (MASD) on the buttocks and coccyx. The resident's care plan included specific wound care orders, which were not followed during the observed procedure. The LPN used calcium alginate, which was not ordered for the resident, and failed to use the prescribed antifungal powder correctly. The resident's wounds were documented as not healed, with some showing signs of deterioration. Interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed that the facility's infection control policies were not followed. Supplies taken into the resident's room were not placed on a barrier, and contaminated items were not disposed of properly. The DON confirmed that hand hygiene should be performed before and after resident contact, between glove changes, and when handling contaminated items. The facility's failure to adhere to these protocols contributed to the deficiency in providing quality care and infection control for the resident.
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 165 citations issued within 25 miles in the last 12 months — including the 4 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 Zephyrhills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Zephyrhills | 1.1 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Lake Zephyr | 1.3 mi | ★★★★★ | 2 | 0 |
| Adventhealth Dade City | 6.9 mi | — | 0 | 0 |
| Royal Oak Nursing Center | 7.2 mi | ★★★★★ | 1 | 0 |
| Dade City Health And Rehabilitation Center | 7.7 mi | ★★★★★ | 4 | 4 |
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 August 2026) and official state health department websites.