Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medicana Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with quadriplegia, bladder cancer history, and major depressive disorder with psychotic symptoms had psychotropic orders for Seroquel and Buspar, but the facility did not obtain a completed informed consent for the Seroquel order. The DON acknowledged the missing consent, the RN/UM said consent is obtained on admission and with medication changes, and the resident stated he did not sign anything for either medication.
The facility failed to timely monitor and address significant weight changes for multiple residents. A resident with dementia and diabetes had a significant early weight loss after admission and was later found at risk for malnutrition, but no intervention was implemented at that time. Other residents with COPD, CKD, malnutrition, cachexia, and dementia had significant weight loss or gain without required weekly admission weights, timely reweights, or prompt dietary follow-up, and one resident’s severe loss was not addressed until a later comprehensive assessment.
A resident with a gastrostomy, vascular dementia, and hemiplegia had a tube feeding order for Nepro 1.8 carbsteady at 50 mL/hr with specific on/off times, but the MAR showed multiple instances when the feeding was started or stopped more than 1 hour late. Observations also found the feeding bottle was not consistently labeled with a start time, and the amount remaining did not match the documented start time and infusion rate. An LPN stated the order was unclear, and the DON acknowledged the feeding was late on several occasions.
Failure to implement pharmacy recommendations for a resident receiving Metoclopramide. The resident had a history of CAD and GERD, was cognitively intact, and had orders for Metoclopramide for nausea/vomiting. The pharmacy report noted the drug could cause involuntary movements and that no AIMS, DISCUS, or similar assessment was documented. The DON and MD acknowledged the recommendation, but the resident was not monitored for behaviors while receiving the medication.
Failure to monitor psychotropic medication side effects: A resident with ESRD, DM2 with diabetic nephropathy, dementia, anxiety, and major depressive disorder was prescribed pregabalin and fluoxetine, with orders and care plan interventions to monitor for multiple psychoactive side effects. Psychiatry also recommended side-effect monitoring, but the MAR showed the resident was not monitored as ordered, and an LPN and the DON were unable to locate the monitoring order in the MAR system.
Incorrect Fluid Consistency Provided to a Resident with Dysphagia: A resident with Parkinson's disease, dementia, dysphagia, chronic respiratory failure, and a physician-ordered pureed diet with honey thick liquids was served a house shake that was observed to be nectar thick on multiple occasions. The meal ticket listed honey thick liquids, but the CNA who fed the resident confirmed the shake had not been thickened, and the DTR stated kitchen staff were responsible for preparing beverages at the ordered consistency.
Food Storage and Refrigeration Deficiencies: The facility failed to store food in accordance with professional standards in the Main Kitchen. Surveyors found open beverage cartons in the reach-in refrigerator with no clear opened dates, cottage cheese containers with unreadable labels due to water on the lids, sauerkraut stored under a refrigerator fan with water pouring from the lid when moved, and dessert pies in the walk-in freezer with significant ice buildup and frozen water accumulation under an evaporator fan.
PPE was not used correctly during resident care. Two CNAs assisted a resident on EBP with a Hoyer lift transfer and brief change without wearing gowns, even though the resident had a PEG tube and EBP signage was posted. In a separate event, an LPN performed wound care for a resident with a sacral wound and severe cognitive impairment but forgot to put on a gown, despite knowing gown use was required for wound care.
Failure to Post Daily Nurse Staffing Census: The daily nurse staffing post in the hallway near the nurses station did not include the facility census on multiple observed days. The HRM said she was responsible for entering and posting the staffing information, that the scheduler provided staffing hours, and that the census was based on midnight census. Review of staffing sheets showed the census was sometimes typed and sometimes handwritten, and the HRM stated she may add it later when reviewing the form for two-week staffing calculations.
Inaccurate scanning of medical records led to one resident’s file containing documents for multiple other residents. The resident was cognitively intact, on hospice for atherosclerotic heart disease, and had a care plan focused on monitoring for cardiac symptoms. A Health Information Clerk acknowledged that she did not number and identify each document before scanning, causing all of the documents to be filed under the first resident’s record.
Surveyors observed numerous live roaches in multiple kitchen areas, including under equipment and near food storage, despite ongoing monthly pest control treatments. The pest control technician and Dietary Manager confirmed persistent pest activity and cited structural and sanitation issues as contributing factors.
A resident with severe cognitive impairment did not receive privacy during a medication pass, as an LPN failed to close the door or draw the privacy curtain. The facility's policy requires maintaining privacy during personal care, but the LPN admitted to forgetting this practice. The Charge Nurse confirmed that the standard procedure is to ensure privacy by closing doors and using curtains.
The facility failed to develop comprehensive care plans for two residents with PTSD, despite policy requirements. One resident had a documented trigger, and the other expressed having triggers related to past war experiences. Staff interviews revealed a lack of awareness and understanding of PTSD and its management, indicating communication and training gaps.
A resident with moderate cognitive impairment did not receive antibiotics as ordered. The resident received an incorrect number of doses for Ertapenem, Ceftriaxone, and Zyvox, with no documentation of physician notification regarding these discrepancies.
The facility failed to complete required smoking evaluations for two residents identified as smokers. One resident, with diagnoses including COPD and diabetes, missed a smoking evaluation in July, while another resident with a tobacco use diagnosis missed evaluations in February and December. Staff interviews revealed inconsistencies in tracking and completing these evaluations, leading to the deficiency.
A resident was not seen by the primary physician within the required time frame, as visits were not alternated between the physician and APRN as mandated. The resident, with multiple health conditions, had not seen the physician since early in the year, and interviews revealed inconsistencies in documentation and visit frequencies.
A facility failed to coordinate care with hospice services for a resident with mild cognitive impairment who was dependent on activities of daily living. The resident's hospice records were missing essential documentation, such as assessments and visitation notes. The Nurse Manager acknowledged the absence of documentation, and the DON contacted hospice to obtain the necessary records.
The facility's QAPI/QAA failed to implement effective corrective actions for a previously identified deficiency related to F656, Comprehensive Resident Centered Care Plan. This deficiency was initially cited during a prior survey and was noted again during the current survey, indicating a repeated deficient practice. The lack of an effective corrective action plan was confirmed during a review with the Administrator, who acknowledged the deficiency. This repeated deficiency had the potential to affect all 85 residents in the facility.
The facility failed to follow up on a VRE infection and implement necessary precautions for a resident on antibiotic therapy. Additionally, a staff member did not adhere to Enhanced Barrier Precautions while providing care to another resident with a chronic wound, despite being aware of the procedures.
The facility's antibiotic stewardship program was ineffective, as antibiotics were prescribed without meeting McGreer criteria, and attending physicians were not informed of treatments. A resident received antibiotics for ESBL and VRE without the attending physician's knowledge, and another resident received a one-time antibiotic dose for elevated WBC without meeting criteria. The nurse practitioner did not use McGreer criteria or communicate with facility staff.
A resident was discharged from an LTC facility without receiving necessary medications, including Rosuvastatin and Carvedilol, due to a failure in the discharge process. The resident's family had to intervene with the insurance company to obtain the medications, which were only provided after a delay. This incident highlights a significant lapse in ensuring continuity of care during the discharge process.
Incomplete Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a completed informed consent was obtained for psychotropic medication for one resident reviewed for unnecessary medication. The resident was admitted with diagnoses including quadriplegia, personal history of malignant neoplasm of the bladder, and major depressive disorder recurrent severe with psychotic symptoms, and had a Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. Physician orders showed Quetiapine Fumarate (Seroquel) was ordered for psychosis and Buspirone was ordered for anxiety. The facility policy required a psychoactive medication consent signed by the resident or resident representative. Review of the psychoactive medication consent form for Quetiapine dated 03/30/26 showed no option was marked to indicate consent or refusal. During interviews, the DON stated informed consent was needed only for an increase in dosage or a change in medication and acknowledged there was no informed consent for the psychotropic medications. The RN/UM stated consent is obtained on admission and if a medication is increased or changed, and said it would be sent to medical records for upload. The HIC stated documents are uploaded daily, but when asked about the missing consent she did not answer and later provided a Buspirone consent with a check mark and a Quetiapine consent with no marked consent option. The resident stated he did not sign anything for Buspirone or Quetiapine and remembered receiving the Quetiapine quickly after he needed it.
Delayed Nutritional Monitoring and Intervention for Significant Weight Changes
Penalty
Summary
The facility failed to provide timely nutritional interventions and monitoring for residents with significant weight changes, including significant weight loss and weight gain. The deficiency involved 5 of 6 sampled residents reviewed for nutrition: Resident #30, Resident #27, Resident #36, Resident #49, and Resident #20. The facility policy titled "Weight Measurements" stated residents are to be weighed weekly, monthly, or per physician order, and that significant or progressive weight loss or gain is to be reported and documented. The policy also stated new admissions are to be weighed weekly for 30 days. Resident #30, admitted with diagnoses including sequelae of cerebral infarction, dementia, type 2 diabetes mellitus with hyperglycemia, and adjustment disorder with anxiety, was not weighed weekly for 30 days after admission as required by policy. His weight dropped from 160.9 pounds to 151.3 pounds in three weeks, a 5.96% loss, and an MNA on 02/03/26 found him at risk for malnutrition, but no interventions were implemented at that time. His weight later declined to 144.6 pounds, and the dietitian’s comprehensive evaluation documented ongoing weight loss and recommended weekly weights and a nutrition support drink. Resident #49, admitted with COPD, GERD, depression, anxiety, and osteoarthritis with absence of a right toe, was also not weighed weekly after admission. Her weight decreased from 129.5 pounds to 119.0 pounds in 20 days, an 8.1% loss, and no reweight was taken to confirm the loss. A later dietary note described small portions, refusal of supplements, and unavoidable weight loss related to toe amputation, but weekly weights were not recommended. Resident #36, admitted with dementia, mild protein-calorie malnutrition, and chronic kidney disease, was not weighed weekly for 30 days after admission. Her weights showed progressive loss from 116.0 pounds to 110.5 pounds and then to 107.1 pounds, including a 7.7% loss over two months, which was severe. The weight loss was not addressed when it began, reweights were not obtained to confirm the losses, and the severe loss was not addressed until a comprehensive assessment was completed after a significant change MDS. Resident #27, admitted with diabetes, cachexia, protein-calorie malnutrition, and dementia, had a 9.9-pound gain from 147.9 pounds to 157.8 pounds in one month, but no reweight had been taken 11 days later to confirm the significant change and it had not been addressed. The report also identified Resident #20 among the sampled residents reviewed for nutrition, contributing to the finding that nutritional interventions were not provided in a timely manner for multiple residents with significant weight changes.
Tube Feeding Not Administered as Ordered and Bottle Not Properly Labeled
Penalty
Summary
The facility failed to ensure tube feeding was administered as ordered and failed to ensure the enteral feeding bottle was labeled with a start time for one resident with a feeding tube. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, vascular dementia, and gastrostomy status. The resident’s mental status evaluation documented a score of 99, indicating the interview could not be completed. The physician’s orders directed Nepro 1.8 carbsteady continuous at 50 mL per hour with tube feed off at 10:00 AM and on at 2:00 PM, but the actual administration record showed multiple instances in May when the tube feeding was turned on or off more than one hour late. Examples included the feeding being turned on at 3:21 PM, 3:19 PM, 3:32 PM, 3:36 PM, 3:38 PM, and 3:48 PM, and being turned off at 11:22 AM, 11:07 AM, 11:06 AM, 11:50 AM, and 11:21 AM. Nursing progress notes from that period did not document any issues with the tube feeding or that it was not administered as ordered. Observations also showed the feeding bottle was not labeled correctly. On one occasion the bottle was dated with a start time of 7:00 PM, and on other observations the bottle had a date but no time documented. The amount remaining in the bottle did not match the expected amount based on the documented start time and infusion rate. During interview, an LPN stated the order was for Nepro 1.8 carbsteady at 50 mL per hour and acknowledged the order was unclear, and the DON later acknowledged the enteral feeding was more than one hour late from the prescribed time on several occasions in May.
Failure to Implement Pharmacy Recommendation for Metoclopramide Monitoring
Penalty
Summary
The facility failed to implement physician response to pharmacy recommendations for one resident reviewed for medication regimen review. The resident was admitted with a history of atherosclerotic heart disease of native coronary artery without angina pectoris and gastro-esophageal reflux disease without esophagitis, and the MDS showed a BIMS score of 13, indicating the resident was cognitively intact. Physician orders included Metoclopramide HCL oral tablet three times daily for nausea/vomiting, with the medication later discontinued and the last administration documented on 05/08/2026. The care plan identified altered gastrointestinal status with episodes of nausea, vomiting, and abdominal pain, and included medication administration as ordered and observation for side effects. The pharmacy consultation report documented that Metoclopramide may cause involuntary movements, including tardive dyskinesia, and noted that an AIMS, DISCUS, or other appropriate assessment was not documented in the medical record. The recommendation was to monitor involuntary movements using a clinically validated scale at baseline, 3 months after initiation or dose increase, and at least every 6 months thereafter, with early detection and discontinuation of the offending agent noted as helpful to avoid tardive dyskinesia. During interviews, the DON stated the medical director reviewed the recommendation and made recommendations to the provider, while the medical director stated she accepted the recommendation for behavioral monitoring and added a recommendation to consider weaning off Metoclopramide. The resident was not monitored for behaviors while receiving Metoclopramide during the period after the recommendation was accepted and before the medication was discontinued.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor side effects for psychotropic medication for one resident who was admitted with end stage renal disease, type 2 diabetes mellitus with diabetic nephropathy, dementia, anxiety disorder, and major depressive disorder, recurrent, moderate. The resident’s MDS showed a BIMS of 15, indicating he was cognitively intact, and Section N identified use of antidepressant, opioid, hypoglycemic, and anticonvulsant medications. Physician orders included pregabalin for convulsive and fluoxetine for depression, and a later order directed staff to monitor for a wide range of side effects and adverse reactions related to psychoactive medications, including drowsiness, unsteady gait, frequent falls, depression, suicidal ideations, social isolation, diarrhea, fatigue, insomnia, loss of appetite, weight loss, nausea, vomiting, and behavior symptoms not usual to the person. The care plan also documented psychotropic medication therapy related to depression and anxiety, with interventions to observe for the same side effects and adverse reactions. Psychiatry consultations recommended monitoring for medication side effects as part of the treatment plan. However, review of the May 2026 MAR showed the resident had not been monitored for side effects as ordered. During interview, an LPN stated residents on psychotropic medications are monitored for behaviors and side effects and that she would document this in the MAR, but she could not find an order for side effect monitoring for the resident. The DON stated nurses were to check for side effects and document in the MAR, but during a side-by-side review she was unable to find the order and later stated the schedule for the order was not filled out.
Incorrect Fluid Consistency Provided to a Resident with Dysphagia
Penalty
Summary
The facility failed to provide the correct fluid consistency ordered for one resident with Parkinson's Disease, Dementia, Dysphagia, Chronic Respiratory Failure, and Atelectasis. The resident had a physician's order for a pureed texture diet with honey thick liquids, and the care plan included a goal for diet as ordered. The resident's MDS assessment showed moderate cognitive impairment, and the Director of Therapy stated the resident had significant swallowing issues, had been declining for years, was dependent on staff for eating and drinking, and had recent bouts of pneumonia, with the last pneumonia occurring in January 2026 while already on honey thick liquids. During observations in the dining room and in the resident's room, the house shake on the resident's tray was observed to have a nectar thick consistency instead of honey thick. The meal ticket identified the tray as pureed with honey thick liquids and a honey thick house shake, but the shake was poured into a cup and remained nectar thick. Staff A, the CNA who fed the resident, confirmed she had not added anything to thicken the shake. The Licensed Dietitian stated the kitchen provided all beverages at the appropriate consistency on the meal trays, and thickening of beverages was performed by kitchen staff only.
Food Storage and Refrigeration Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the Main Kitchen. During a tour of the main kitchen with the Dietary Manager, an open 32-ounce nectar thick beverage carton was found in the reach-in refrigerator with a handwritten date of 04/26/26, but the Dietary Manager could not determine how long it had been opened. A second open 32-ounce Silk Soy carton was also found in the refrigerator with no opened date identified, and the Dietary Manager was unable to determine when it had been opened. Additional storage concerns were observed in the refrigerator and freezer. Two 5-pound cottage cheese containers had sitting water on their lids, and the facility stickers on them had dissolved and were unreadable. A large gallon-sized container of sauerkraut was stored directly above the cottage cheese containers under a refrigerator fan, and when it was moved, water sitting on the lid poured onto the surveyor. In the walk-in freezer, 4 dessert pies were observed under an evaporator fan with significant ice accumulation, with the top pie showing the most ice buildup and water dripping and freezing over the side of the pie and onto the others so they were stuck together. The fan cover above the pies also had frost-like buildup and ice accumulation from water.
PPE Not Worn During EBP Care and Wound Treatment
Penalty
Summary
The facility failed to ensure staff wore appropriate PPE during care for a resident on Enhanced Barrier Precautions who had a PEG tube and required incontinence care. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and gastrostomy status. The physician's orders included Enhanced Barrier Precautions every 24 hours. During an observation, two CNAs assisted the resident back to bed using a Hoyer lift and then changed the resident's brief, but neither staff member wore a gown during the transfer or the incontinence care. An EBP sign was posted on the resident's door, and an LPN later stated that a gown and gloves are needed when providing care for a wound or PEG tube, transferring the resident, or changing briefs. The facility also failed to ensure PPE was worn during wound care for another resident with a sacral wound. That resident had diagnoses including cerebral infarction, COPD, and type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, and was severely cognitively impaired. The resident had an order for sacral wound treatment with cleansing, skin prep, calcium alginate, and border gauze. During wound care observation, the WCLPN washed hands, donned clean gloves, removed the soiled dressing, discarded gloves, used hand sanitizer, and continued the treatment, but realized she had forgotten to put on a gown. The WCLPN acknowledged she knew she was supposed to wear a gown while providing wound care.
Failure to Post Daily Nurse Staffing Census
Penalty
Summary
The facility failed to document the census on the daily nurse staffing post for 2 of 4 days reviewed. During an observation on 05/13/26 at 9:00 AM, the daily nursing staffing data was posted in the main hallway near the nurses station, but the form did not include the facility census. On 05/14/26 at 7:47 AM, the staffing post displayed was dated 05/13/26 and still did not have the census documented. A later observation on 05/14/26 at 10:12 AM found the staffing post dated 05/14/26, but the census was again missing. During interview, the Human Resource Manager stated she was responsible for entering and posting the information, that the scheduler provided staffing hours, and that the census number was based on midnight census. A side-by-side review of staffing sheets for 05/11/26, 05/12/26, and 05/13/26 showed the census was typed on the first two forms, while the 05/13/26 census was handwritten. The Human Resource Manager explained that she sometimes adds the census when generating the form, but if not, she fills it in when the form is taken down the following day when she reviews it and makes corrections for use in calculating the two-week staffing.
Inaccurate Scanning of Resident Medical Records
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident reviewed for resident records. The facility policy stated that medical records would be complete and accurate. The resident was admitted with a diagnosis of atherosclerotic heart disease of the native coronary artery without angina pectoris, was cognitively intact based on a BIMS score of 13, and was under hospice care according to the MDS. The care plan documented that the resident was readmitted on hospice services for atherosclerotic heart disease, with goals to decrease the risk of signs and symptoms of cardiac complications and interventions to observe for shortness of breath. Review of a hospice physician telephone order in the medical record showed six documents scanned together under the resident’s file, but only the first document belonged to that resident. During interview, the Health Information Clerk stated she was responsible for uploading scanned documents and verified the resident name on each document when scanning multiple documents, and she did not shred hard copies until she ensured they were successfully scanned. On follow-up review, several records for other residents were found included in the scanned document under the resident’s file, including records for five other residents. The clerk acknowledged that she did not number and identify each document for each resident before scanning, which caused all of the documents to be scanned under the first resident.
Failure to Maintain Effective Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple live roaches observed in various areas of the kitchen during a tour with the Dietary Manager. Specific findings included live mature and juvenile roaches on the door frame at the janitorial closet entrance, inside a container storing a bag of sauce, under the steamer around a floor drain with accumulated debris and residue, and on the floor under and around the hand washing sink and beverage station. The Dietary Manager confirmed that the pest control company had serviced the kitchen the previous week and that monthly treatments were standard practice. A review of recent pest control invoices revealed that cockroach activity had been documented in the kitchen during services in the two months prior to the observation. During an interview, the pest control technician acknowledged ongoing treatments and noted that structural issues and occasional sanitation problems, particularly around the dish pit, contributed to the pest presence. The technician also indicated that the building and equipment were aged, which may exacerbate the problem, and that night crews were more likely to identify sanitation issues after kitchen hours.
Failure to Ensure Resident Privacy During Medication Pass
Penalty
Summary
The facility failed to ensure personal privacy during a medication pass for one of the sampled residents, affecting a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including pancytopenia, cirrhosis of the liver, type 2 diabetes mellitus, and unspecified dementia, did not receive privacy during a medication administration. The facility's policy on resident dignity and property privacy mandates that care should be provided in a manner that respects each resident's dignity and right to personal privacy, including using a closed door or drawn curtain during personal care and treatment procedures. During an observation, a Licensed Practical Nurse (LPN) did not close the door or pull the privacy curtain while administering medication to the resident. When interviewed, the LPN, who had been working at the facility for about a month, admitted to forgetting to provide privacy. Another LPN, the Charge Nurse, confirmed that the standard practice is to always close the door and pull the privacy curtain during such procedures.
Failure to Develop PTSD Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). The facility's policy requires that a comprehensive person-centered care plan be developed for each resident, including measurable objectives and timetables to meet their medical, nursing, mental, and psychosocial needs. However, upon review, it was found that no care plans addressing PTSD, including any identified triggers, were established for the two residents in question. Resident #1 was admitted with multiple diagnoses, including PTSD, and had a documented trigger of being approached too quickly. Despite this, no care plan was established to address the PTSD or the identified trigger. Similarly, Resident #86, who also had a PTSD diagnosis, did not have a care plan addressing PTSD, even though the resident expressed having triggers related to their past experiences in the war. Interviews with facility staff revealed a lack of awareness and understanding regarding the residents' PTSD diagnoses and triggers. The Social Service Manager indicated that the system should automatically create a care plan for PTSD if triggers are identified, but this did not occur for the residents in question. Additionally, other staff members, including nurses and nursing assistants, demonstrated a lack of knowledge about PTSD and where to find information about residents' triggers, indicating a gap in communication and training within the facility.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to administer antibiotics as ordered for a resident with moderate cognitive impairment who was dependent on activities of daily living. The resident had an order for Ertapenem to be administered intravenously every 24 hours for 7 days, but received 8 doses in 7 days, including two doses on one day. Another order for Ceftriaxone was to be administered every 24 hours for 5 days, but the resident only received one dose. Additionally, an order for Zyvox was to be administered twice daily for 7 days, but the resident received only 10 out of 14 doses. There was no documentation indicating that the physician was notified of these discrepancies in antibiotic administration.
Failure to Complete Smoking Evaluations for Residents
Penalty
Summary
The facility failed to ensure that smoking evaluations were completed for two residents identified as smokers. Resident #75, who is cognitively intact with a BIMS score of 15, was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Myalgia, and Type 2 Diabetes Mellitus. Although she had smoking evaluations on 04/26/24 and 10/31/24, there was no evaluation conducted in July 2024. During an interview, Resident #75 confirmed that the facility keeps her cigarettes and lighter in a locked cart and that she is supervised when smoking. The Director of Nurses and other staff members acknowledged the responsibility for conducting smoking evaluations but failed to ensure they were completed as required. Resident #66, also cognitively intact with a BIMS score of 15, was admitted with a diagnosis of Tobacco Use. The resident had smoking evaluations on 11/01/23, 05/13/24, 09/14/24, and 09/27/24, but missed evaluations in February 2024 and December 2024. The facility's policy requires smoking evaluations on admission, quarterly, annually, and upon significant changes, but these were not adhered to for Resident #66. Interviews with staff revealed a lack of consistent tracking and completion of smoking evaluations, contributing to the deficiency.
Failure to Conduct Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted within the required time frame for one resident. The resident, who was admitted with multiple diagnoses including Bullous Pemphigoid, Venous Insufficiency, and Morbid Obesity, had not been seen by the primary physician since January 22, 2024. The facility's policy requires that residents be seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter, with visits alternating between the primary physician and an APRN. However, the records showed that the resident was only seen by an APRN, and the required alternation of visits was not maintained. Interviews with the facility's administrator, the primary physician, and the APRN revealed inconsistencies in the documentation and understanding of visit frequencies. The primary physician stated that he rounds with the APRN and that she documents on his behalf, but he could not explain discrepancies in the progress notes. The resident did not recognize the names or photographs of the primary physician or the APRN, indicating a lack of direct interaction. This suggests that the required face-to-face visits with the physician were not occurring as mandated, leading to the deficiency noted in the report.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to coordinate care with hospice services for a resident who was receiving hospice care. The resident, who had mild cognitive impairment and was dependent on activities of daily living, was admitted to hospice services. The care plan included working cooperatively with the hospice team to meet the resident's various needs. However, a review of the hospice records at the facility revealed missing documentation, including assessments, visitation notes, and services provided. The Nurse Manager acknowledged the absence of documentation and indicated that hospice personnel usually leave documentation in the binder, but it was not present. The Director of Nursing contacted hospice to obtain copies of the resident's records and visits.
Repeated Deficiency in Comprehensive Resident Centered Care Plan
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to implement effective corrective actions to address a previously identified deficiency related to F656, Comprehensive Resident Centered Care Plan. This deficiency was initially cited during the Recertification and Relicensure survey with an exit date of September 14, 2023. The deficiency was noted again during the current survey, indicating a repeated deficient practice. The lack of an effective corrective action plan was confirmed during a review of the QAPI program with the Administrator, who acknowledged the deficiency during an interview on January 16, 2025. This repeated deficiency had the potential to affect all 85 residents residing in the facility at the time of the survey.
Infection Control and Precaution Failures
Penalty
Summary
The facility failed to appropriately follow up on a Vancomycin Resistant Enterococcus (VRE) infection and implement necessary precautions for a resident undergoing antibiotic therapy. The resident, who had moderate cognitive impairment and was dependent on assistance for daily activities, was admitted with a history of multi-drug resistant organism in the urine. Despite a positive culture for VRE, there was no evidence of the resident being placed on any precautions or follow-up after the administration of the prescribed antibiotic, Zyvox. Additionally, the facility did not adhere to its own infection prevention and control policy regarding Enhanced Barrier Precautions (EBP) for another resident with a chronic wound. A staff member, aware of the EBP procedures, failed to wear a gown while providing direct care to the resident, who was receiving wound therapy. This breach of protocol was observed by a surveyor and later acknowledged by the staff member during an interview.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for two residents receiving antibiotic therapy. The facility's policy required a multidisciplinary approach to antibiotic use, involving the medical director, director of nursing, and consultant pharmacist. However, the medical director did not set standards for antibiotic prescribing, and the director of nursing did not establish standards for assessment and communication regarding infections. The consultant pharmacist was expected to review antibiotic orders, but there was no evidence of appropriate oversight or communication with attending physicians. For one resident, antibiotics were prescribed without meeting the McGreer criteria, and the attending physician was unaware of the treatments for ESBL and VRE. The nurse practitioner responsible for ordering antibiotics did not use the McGreer criteria and did not communicate with the facility's staff or attend meetings. Another resident received a one-time dose of antibiotics for an elevated white blood cell count without meeting the McGreer criteria, and the attending physician was not informed. These deficiencies highlight a lack of communication and oversight in the facility's antibiotic stewardship program.
Failure to Provide Medications at Discharge
Penalty
Summary
The facility failed to ensure a safe discharge for a resident, as evidenced by not providing necessary medications and not reconciling all pre-discharge medications with the resident's post-discharge medications. The facility's policy on transfer and discharge, dated August 2023, outlines the need for a safe and orderly discharge process, including medication reconciliation and communication with the resident and their representative. However, this process was not followed for the resident in question. The resident, who was cognitively intact and had diagnoses including hypertension, end-stage renal disease, and diabetes, was discharged without receiving all necessary medications. The clinical record showed that the resident was scheduled to receive several medications, including Rosuvastatin and Carvedilol, but these were not provided upon discharge. The facility's nursing progress notes indicated that the resident's family had to contact the insurance company to address the issue, and it was only after this intervention that the facility provided the medications on January 3rd. Interviews with the Director of Nursing and the resident's family member revealed that the facility did not provide the medications at the time of discharge, and the family had to return to the facility to collect them. The family member confirmed that the resident did not receive any medications from December 31st until January 3rd, highlighting a significant lapse in the discharge process and continuity of 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.
Illustrative
What surveyors actually found near you
We read the 161 citations issued within 25 miles in the last 12 months — including the 2 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 Lake Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terraces Of Lake Worth Care Center And Rehab | 0.6 mi | ★★★★★ | 0 | 0 |
| Lake Worth Rehabilitation Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Avante At Lake Worth, Inc. | 1.5 mi | ★★★★★ | 2 | 0 |
| Finnish-american Village | 1.8 mi | ★★★★★ | 0 | 0 |
| Vi At Lakeside Village | 2.5 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Medicana Nursing And Rehab Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.