Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Archbold Living Camilla during CMS and state inspections, most recent first.
A cognitively impaired resident with Alzheimer’s disease and a severely impaired BIMS score was not protected from sexual assault by another cognitively impaired resident. A CNA first saw the alleged perpetrator in his wheelchair at the doorway of the resident’s room, and later found the room door closed with him inside next to the bed. After an LPN and CNA re-entered the room, they discovered the resident’s brief near the pillow, the resident naked from the waist down, and blood on the sheets and in the vaginal area. The resident was later found on SANE exam to have vaginal penetration and a vaginal wall laceration. The other resident was found with dried blood on his right middle finger and told law enforcement he had inserted his fingers into the resident’s vagina, indicating the facility failed to effectively implement its abuse prevention and sexual abuse identification policies to protect the resident from non-consensual sexual contact.
Administration failed to protect a severely cognitively impaired resident from sexual assault by another severely cognitively impaired resident, despite policies requiring residents be free from abuse and that leadership maintain a safe, secure environment. A CNA and an LPN discovered the victim’s brief removed, the resident naked from the waist down, and blood on the sheets and in the vaginal area; a subsequent SANE exam confirmed vaginal penetration and a vaginal wall laceration. Law enforcement documented that the alleged perpetrator admitted placing his fingers into the resident’s vagina and noted dried blood on his finger, while the Administrator reported there had been no prior behavioral indications in the perpetrator’s history that would have led the facility to decline his admission.
The facility failed to follow its falls management policy by not consistently completing fall risk assessments, 3‑day post‑fall follow‑ups, and neurological checks for four residents with multiple witnessed and unwitnessed falls. Residents with conditions such as Alzheimer’s disease, dementia, cerebral infarction, hemiplegia, and unsteadiness on feet had falls documented in nursing notes, but required 3‑day post‑fall monitoring was often missing, and neuro checks were incomplete or not done per required timing. One resident identified by PT as a fall risk had no fall risk assessments in the record, and another had outdated fall risk assessments with none documented for two consecutive years. Staff interviews confirmed that policy required post‑fall follow‑up and neuro checks for unwitnessed falls or head injuries, yet documentation was absent or incomplete, and the DON reported that EMR issues prevented automatic triggering of post‑fall follow‑ups and electronic completion of neuro checks.
A resident with multiple comorbidities, moderate cognitive impairment, dependence in toileting hygiene, and a history of a sacral pressure ulcer was observed receiving perineal care from an LPN who did not follow infection control practices. The PPE container outside the room lacked gowns, and the LPN entered without a gown despite the presence of loose stool that had leaked from the resident’s brief. During incontinence care, the LPN used wipes in a manner that spread stool from soiled areas to previously cleaned buttock and sacral areas and did not re-clean those areas. In a later interview, the LPN confirmed she had reused a dirty wipe on a clean area, had no bag for soiled items, did not re-clean the sacral and buttock area, and acknowledged she had not performed the procedure correctly or worn the required gown.
An LPN was observed pre-setting medications in labeled cups for multiple residents, contrary to facility policy requiring individual administration and verification. This practice resulted in a medication error rate of 55.56%, including a missed dose of Atorvastatin for a resident. Interviews confirmed the LPN was aware of the policy and had been previously warned, and both the DON and Administrator reiterated that pre-setting medications is not permitted.
Surveyors identified expired OTC medications and prescription drugs in medication storage rooms and on medication carts in two facilities. Expired probiotics, suppositories, aspirin, thiamine, ibuprofen, ferrous sulfate, [NAME]-Vite tablets, and Lantus insulin were found. Staff interviews confirmed that nurses and a secretary were responsible for checking expiration dates, but expired medications remained accessible.
Kitchen staff did not allow pans to fully air-dry before stacking, resulting in wet pans being stored, and the dishwasher failed to dispense soap due to a clogged dispenser. These issues were confirmed by the NSD and DM, with expectations for proper cleaning and equipment function reiterated by the Administrator.
Facility A did not ensure that garbage and refuse were properly disposed of and contained in building B. Surveyors observed dumpsters with open lids and doors, trash including old chairs behind the dumpsters, a trash can filled with unbroken boxes, and empty oil jugs left on the ground instead of being placed in the dumpsters. These conditions were acknowledged by both the DM and the Administrator as not meeting facility policy.
Facility B did not maintain a Legionella Water Management Program as outlined in its policy, lacking both a water system diagram and a detailed description. Engineering staff acknowledged the absence of these required elements, and the administrator confirmed the expectation to follow policy and CMS guidelines.
Facility B did not maintain documentation of staff COVID-19 vaccination status. Interviews with the DON and Administrator confirmed that, despite providing education, the facility lacked records showing whether staff were immunized. This affected all residents and staff.
The facility did not properly monitor or evaluate antibiotic use for several residents, with antibiotics being prescribed without meeting McGeer Criteria or following appropriate diagnostic protocols. Staff interviews revealed a lack of oversight and understanding of antibiotic stewardship requirements, leading to noncompliance with both CDC guidance and facility policy.
Two residents were administered psychotropic medications without being informed of the risks and benefits, as required by facility policy. Consent forms were signed by representatives prior to admission but did not include specific information about medication risks and benefits. Facility staff confirmed that education on these medications was not documented or provided prior to administration.
Two residents who were cognitively intact were not invited to attend or participate in their care plan conferences, as required by facility policy. Both residents reported never being asked to attend, and care plan conference records lacked their signatures. The Activity Director confirmed that invitations were not distributed, despite expectations from the DON and Administrator that residents be included in these meetings.
A resident was not properly provided with the required CMS-10055 and CMS-10123 Medicare coverage notices when Part A services ended. The facility emailed the forms to the resident's POA but did not follow up after receiving no response, resulting in the resident or representative not being able to review the notices or make informed decisions about continued therapy or appeals.
A resident with hemiplegia and hemiparesis did not have their quarterly MDS assessment data submitted to CMS in a timely manner. The MDS Coordinator completed and initially submitted the assessment, but failed to confirm its acceptance and did not recognize the missing submission until prompted by a surveyor, resulting in a delay beyond the required timeframe.
Two residents using three-quarter bed rails did not have care plans addressing this intervention, despite facility policy and staff expectations that such use should be documented. Staff interviews confirmed the omission, and the absence of care plan documentation for bed rail use placed these residents at risk for unmet care needs and increased accident risk.
A resident's care plan was not updated to reflect healed pressure ulcers, discontinued use of a low air loss mattress, and a change to NPO status with tube feedings. Despite documentation and staff confirmation of these changes, the care plan continued to reference outdated interventions and needs, contrary to facility policy requiring timely care plan revisions.
A resident who was dependent on staff for ADLs did not receive showers as preferred, instead receiving repeated bed baths without documented refusals or requests for bed baths. Staff interviews confirmed that showers were not consistently offered and refusals were not documented, contrary to facility policy.
A resident with severe cognitive impairment and a gastrostomy developed a Stage II pressure ulcer at the PEG tube site, which was not identified during routine skin assessments or care. The ulcer was discovered only after a note prompted the wound care LPN to check under the plastic bumper, where no gauze or foam had been placed. Facility policy required regular skin inspections, but the deficiency occurred due to failure to detect and prevent the ulcer as per standard care.
A resident with multiple medical conditions repeatedly struck her hand on a protruding bathroom door protector after a temporary duct tape fix was not monitored or maintained. Staff were aware of the hazard, but the interim intervention was not checked, leaving the resident at risk until a permanent repair could be made.
Two residents were provided bed rails without prior assessment, risk/benefit review, or informed consent, as required by facility policy. Staff interviews confirmed a lack of awareness regarding the need for assessment and consent before bed rail use, and documentation was missing for both residents. One resident was unable to lower the bed rails independently, and another requested their use, but neither had the required evaluation or consent process completed.
A nurse crushed and administered Potassium Chloride ER, ferrous sulfate, and gabapentin to three residents, despite manufacturer and facility guidelines prohibiting this practice. This resulted in a medication error rate of 12%, exceeding the acceptable threshold. Staff interviews confirmed these medications should not have been crushed.
A resident with Alzheimer's disease under hospice care experienced a decline and was found deceased after receiving morphine. An LPN failed to document the resident's decline, death, and disposition in the EMR, contrary to facility policy. The administrator confirmed that documentation of the resident's condition and events up to the time of death was expected but not completed.
Failure to Protect Cognitively Impaired Resident From Sexual Assault by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual assault by another cognitively impaired resident, despite policies on abuse prohibition and identifying sexual abuse and capacity to consent. The facility’s Abuse Prohibition Policy and Procedures required identification, correction, and intervention in situations where abuse was more likely to occur, including monitoring residents with aggressive or intrusive behaviors. The Identifying Sexual Abuse and Capacity to Consent policy stated that consent is not valid if a resident lacks capacity or if there is reason to suspect the resident does not wish to engage in sexual activity, and required investigation and protection when non-consensual sexual relations were suspected. The resident who was assaulted had Alzheimer’s disease and a BIMS score of three, indicating severe cognitive impairment, and therefore lacked capacity to consent to sexual activity under the facility’s own policy. On the day of the incident, a CNA initially observed the alleged perpetrator resident sitting in his wheelchair in the doorway of the cognitively impaired resident’s room while she was in bed watching television. Later, the CNA noticed that the resident’s door was closed and, upon opening it, saw the same resident in his wheelchair inside the room next to the bed. The CNA closed the door and went to get an LPN to verify whether it was appropriate for him to be in the room. When the CNA and LPN entered the room together, they saw the resident in bed with a jacket and shirt on and a sheet covering her from the waist down, and did not initially notice anything unusual. After they left the room, the CNA asked the LPN if she had seen a brief near the pillow; when the LPN said she had not, they re-entered the room and observed the brief by the pillow. During the subsequent assessment, the LPN pulled back the sheet and found the resident naked from the waist down, with blood noted on the sheets and a moderate amount of blood in the vaginal area, including dried blood on the outer vaginal skin. The CNA reported that when she began placing a new brief on the resident, blood began to leak onto the brief, and a second brief showed a yellow discharge. The resident was sent to the hospital, where a SANE examination documented vaginal penetration and a one-centimeter laceration to the left vaginal wall. The other resident involved, who had a BIMS score of five indicating severe cognitive impairment, was found to have dried red blood on his right middle finger, and later told law enforcement that he had placed his fingers into the resident’s vagina while in her room with the door closed. These events demonstrate that the facility did not effectively implement its abuse prevention and sexual abuse identification policies to protect the resident from non-consensual sexual contact.
Failure to Protect Resident From Sexual Assault by Another Resident
Penalty
Summary
Administration failed to ensure that a resident was protected from sexual assault and maintained in an environment free from abuse, as required by the facility’s Resident Rights policy and the performance standards for the Nursing Home Administrator and Director of Nursing. The resident (R1) had diagnoses including Alzheimer’s disease, hypothyroidism, and atherosclerotic heart disease, and an MDS BIMS score of three indicating severe cognitive impairment. On the date of the incident, a CNA observed R1’s room door closed, opened it, and saw another resident (R2) in his wheelchair next to R1’s bed. When the CNA returned with an LPN, they found R1’s brief lying next to her pillow, and R2 was removed from the room. Upon assessment, the LPN noted that R1 was naked from the waist down, with blood on the sheets, a moderate amount of blood in the vaginal area, and dried blood on the outer vaginal skin. R1 was sent to the hospital, where a SANE examination documented vaginal penetration with associated vaginal bleeding and a one-centimeter laceration to the left vaginal wall. R2’s medical record showed diagnoses including dependence on renal dialysis, end stage renal disease, cardiac arrhythmia, hypertension, and syncope and collapse, with an MDS BIMS score of five, also indicating severe cognitive impairment. A police department incident report documented that, when questioned by law enforcement, R2 stated he had positioned his wheelchair beside R1’s bed and placed his fingers into R1’s vagina, and the officer observed dried, stained blood on R2’s right finger. The Administrator stated there had been no indication of behaviors in R2’s past medical history that would have led the facility to decline his admission and that there was no indication of behaviors that would have triggered concern about such an outcome. The facility’s failure to ensure R1 was free from abuse and to maintain a safe and secure environment resulted in an Immediate Jeopardy determination related to the resident’s physical, mental, and psychosocial well-being.
Failure to Complete Fall Risk Assessments, Post‑Fall Follow‑Ups, and Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to follow its Falls and Falls Risk Management policy by not consistently completing fall risk assessments, 3‑day post‑fall follow‑ups, and neurological checks for four residents with documented falls. The policy requires staff, with physician input, to identify interventions based on evaluations and current data, and to monitor and document each resident’s response to interventions intended to reduce falls and fall risk. However, for multiple residents with diagnoses such as Alzheimer’s disease, dementia, cerebral infarction, hemiplegia, and unsteadiness on feet, the required assessments and monitoring were either missing or incomplete. One resident with Alzheimer’s disease, dementia, diabetes, and unsteadiness on feet experienced multiple unwitnessed falls in the hallway and in her room. Nursing notes documented falls on several dates, including one with redness to the left foot and a skin tear to the left elbow, but there was no evidence of any 3‑day post‑fall follow‑up for these events. Neurological checks initiated after one unwitnessed fall were incomplete and did not follow the required timing protocol, and there was no evidence of any fall risk assessments in the medical record despite a physical therapy assessment identifying the resident as a fall risk. Another resident with cerebral infarction, hemiplegia, hypertension, adult failure to thrive, and chronic pain had multiple unwitnessed falls in his room and bathroom. For these falls, neurological checks were incomplete and not done per timing protocol, and 3‑day post‑fall follow‑ups were not completed. Fall risk assessments were only documented in early 2023, with no evidence of updated assessments for 2024 and 2025. A third resident with palliative care needs, cerebral infarction, hypertension, and dysphasia had a witnessed fall documented in nursing notes, but there was no evidence of a 3‑day post‑fall follow‑up. An LPN confirmed that after a fall, a 3‑day post‑fall follow‑up should have been completed and that fall risk assessments were expected on admission and with monthly summaries, as well as neurological checks for unwitnessed falls or head injuries. A fourth resident with Alzheimer’s disease, dementia, and hypertension had unwitnessed falls documented in nursing notes, including one where a roommate called for help. Although the RN reported assessing the resident, obtaining vital signs, and documenting follow‑up under a fall charting tab, there was no evidence of a complete 3‑day post‑fall follow‑up for one of the falls, and neurological checks were incomplete and not done according to the required timing protocol. The care plan listed a fall but lacked additional documentation related to that fall. The DON and Administrator acknowledged expectations that assessments and neurological checks be completed per the fall policy and noted issues with the electronic medical record not triggering required follow‑ups and not allowing neuro checks to be completed electronically.
Improper Perineal Care and Infection Control During Incontinence Care
Penalty
Summary
Failure to provide sanitary perineal care occurred when a nurse did not follow infection prevention and control practices while cleaning a resident with loose stool and a history of a sacral pressure ulcer. The facility’s perineal care policy stated that dependent patients should receive cleansing of the perineum following voiding or defecation to promote healing and comfort. The resident involved had diagnoses including Alzheimer’s disease, heart failure, rhabdomyolysis, cerebral infarction, and hemiplegia/hemiparesis, and was assessed as having moderate cognitive impairment and dependence with toileting hygiene. The resident had a history of a sacral pressure ulcer that had been documented as resolving and then closed on weekly skin assessments. During an observation, an LPN entered the resident’s room, which had an enhanced barrier sign posted and an infection control PPE container on the door that contained only a partially filled bottle of hand sanitizer and no gowns. The resident was lying on an airflow mattress with loose stool between her thighs that had leaked from her brief. The LPN did not don a protective gown despite the presence of loose stool and proceeded to roll the soiled brief toward the back and begin cleaning the front perineal area. After turning the resident to her side, the LPN removed the rolled brief, used a clean wipe to clean the buttocks and sacral area, then used another wipe to clean between the thighs where loose stool had settled, and with that same soiled wipe wiped again over the buttocks and sacral area. In a subsequent interview, the LPN acknowledged that she did not have a bag for dirty items, confirmed she had wiped a clean area with a dirty wipe, did not re-clean the sacral and buttock area, and admitted she did not perform the procedure correctly and did not wear a gown as she was supposed to.
Improper Pre-Setting of Medications by LPN Leads to High Medication Error Rate
Penalty
Summary
Facility B failed to ensure proper medication administration practices by allowing an LPN to pre-set medications in labeled cups for multiple residents on one hall. Observations revealed that the LPN placed six plastic cups labeled with room numbers and bed letters on top of the medication cart, each containing medications for specific residents. Review of physician orders and medication administration records showed that the LPN administered medications as indicated for several residents, but one resident did not receive a scheduled medication (Atorvastatin), resulting in a medication error rate of 55.56%. The facility's policy requires that medications be administered in a safe and timely manner, with verification of the right resident, medication, dosage, time, and route immediately before administration. During interviews, the LPN admitted to pre-setting medications and acknowledged being previously instructed by the pharmacist consultant not to do so. The DON and Administrator both confirmed that facility expectations prohibit pre-setting and labeling medication cups in advance, requiring nurses to administer medications individually per resident. The deficiency was identified through direct observation, record review, and staff interviews, confirming non-compliance with facility policy and standard medication administration procedures.
Expired Medications Found in Storage Rooms and Medication Carts
Penalty
Summary
Facility A failed to ensure that expired over-the-counter (OTC) medications were not present in the medication storage room and on two medication carts. During observations, surveyors found a bottle of probiotic formula and a jar of Fleet glycerin suppositories, both expired, in the medication storage room. On the Long Hall medication cart, several bottles of aspirin and thiamine B-1 vitamins were found to be expired. The Short Hall medication cart also contained expired aspirin, ibuprofen, and a bottle of ferrous sulfate with an illegible expiration date. Interviews with nursing staff and the Director of Nursing (DON) revealed that nurses were responsible for checking medication carts for expired medications, while a secretary was tasked with checking OTC medications in the storage room. Facility B was also found to have expired medications in one of its medication storage rooms and on a medication cart. In the Bluebird Hall medication storage room, a bottle of thiamine vitamin B-1 was expired. On the 100 Hall medication cart, expired [NAME]-Vite tablets and a vial of Lantus insulin past its expiration date were found. The DON confirmed the expired status of the insulin. These findings indicate that both facilities did not adhere to their own policies regarding the storage and timely removal of expired medications.
Improper Air-Drying of Pans and Dishwasher Soap Dispensing Failure
Penalty
Summary
Facility B failed to ensure that kitchen staff thoroughly cleaned and air-dried pans prior to storage, as required by facility policy. During an observation, 14 pans that had been cleaned and stacked for use were found to be wet and had not been allowed to completely air dry before stacking. The Nutritional Services Director confirmed that the pans should have been completely dry before being stacked and acknowledged that they needed to be re-washed. Additionally, the facility failed to ensure that soap was dispensing into the dishwasher after replacing the dish detergent. During an observation, it was noted that soap was not coming out of the dispenser into the dishwasher, and upon inspection, the dispenser was found to be clogged. After replacing the bottle, the soap flowed into the dishwasher. The Dietary Manager confirmed that the dishwasher had not dispensed soap as expected, and the Administrator stated that the expectation was for the dishwasher to be in working order and for dishes to be cleaned properly.
Improper Disposal and Containment of Garbage in Building B
Penalty
Summary
Facility A failed to ensure proper disposal and containment of garbage and refuse in one of its buildings, specifically building B. During an observation behind the kitchen, surveyors found two dumpsters with their lids and side compartment doors open, trash including old chairs behind the dumpsters, a trash can filled with unbroken boxes, and six empty 35-gallon plastic oil jugs lying on the ground instead of being disposed of in the dumpsters. The facility's policy requires dumpsters to be kept closed and the area to be kept clean to prevent contamination and pest transmission. Both the Dietary Manager and the Administrator confirmed that the observed conditions did not meet facility expectations or policy requirements.
Failure to Maintain Legionella Water Management Program
Penalty
Summary
Facility B failed to maintain a Legionella Water Management Program as required by its own policy. The facility's policy, dated 08/20/22, specifies the need for a detailed description and diagram of the water system to identify and control areas where Legionella bacteria could grow and spread. During interviews, the engineering staff confirmed that neither a water diagram nor a detailed description of the water system existed for the facility, acknowledging awareness of the requirement but stating it had not been completed. The administrator also confirmed the expectation that the facility should follow its policy and CMS guidelines.
Failure to Document Staff COVID-19 Vaccination Status
Penalty
Summary
Facility B failed to maintain documentation of current COVID-19 vaccination status for its staff members. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not have records indicating whether staff were immunized or not, and both were unaware of the requirement to keep such documentation. Although education on COVID-19 vaccination was provided, there was no system in place to track or document the vaccination status of staff members. This deficiency had the potential to affect all 132 residents and all staff in the facility.
Failure to Monitor and Evaluate Antibiotic Usage per Stewardship Program
Penalty
Summary
The facility failed to monitor and evaluate antibiotic usage for five of seven residents reviewed for antibiotic use, as required by both CDC guidance and the facility's own Antibiotic Stewardship policy. Specifically, antibiotics were prescribed and administered to residents without adherence to McGeer Criteria, and in several cases, laboratory results such as urine cultures were negative or contaminated, yet antibiotics were still initiated. For example, one resident was started on Amoxicillin despite a negative culture, another was given Bactrim after a contaminated culture that was not repeated, and others received antibiotics for respiratory or urinary issues without meeting established criteria or having appropriate diagnostic testing completed. Interviews with facility staff revealed a lack of questioning or oversight regarding physician antibiotic orders, with the Infection Preventionist acknowledging that antibiotics are often started before culture results are available and that there is a need to follow McGeer Criteria and educate staff. The Medical Director admitted to not fully understanding the purpose of antibiotic stewardship, and the Administrator recognized the need to track antibiotic usage and adhere to policies. These actions and inactions resulted in the facility not effectively monitoring or evaluating antibiotic use as required.
Failure to Inform Residents of Risks and Benefits of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the risks and benefits of psychotropic medication use prior to administration. According to the facility's policy, residents have the right to participate in decision-making regarding their care, which includes being informed about their health status, care, and treatments. However, for two residents reviewed, there was no evidence that the risks and benefits of psychoactive medications were explained to them or their representatives before the medications were administered. One resident, who was cognitively intact and admitted with diagnoses including major depressive disorder, anxiety, and dementia, received multiple psychotropic medications such as antipsychotics and antidepressants. The consent form on file was signed by a representative prior to admission and did not specify the risks and benefits of the medications. During an interview, the resident confirmed that no one had explained the risks and benefits of her medications to her, and she expected the facility's doctor to do so. Another resident, who was severely cognitively impaired and admitted with diagnoses of dementia and depression, also received several psychotropic medications. The consent form for this resident was similarly signed by a representative before admission and lacked information about the risks and benefits of the medications. Facility staff, including the Infection Preventionist and the DON, acknowledged during interviews that the consent forms did not include this information and that it was their expectation that such education should have been provided prior to medication administration.
Failure to Invite Residents to Participate in Care Plan Conferences
Penalty
Summary
Facility B failed to ensure that residents were informed in advance of their right to attend and participate in their care plan conferences, as required by facility policy and federal regulations. Specifically, two residents were not invited to their care plan meetings, and documentation showed that their signatures were absent from care plan conference records, indicating non-attendance. Both residents were assessed as cognitively intact at the time of the deficiency, and each expressed a desire to participate in their care planning but reported never being invited or attending such meetings since admission. Interviews with facility staff confirmed that the responsibility for notifying and inviting residents to care plan conferences was not fulfilled. The Activity Director acknowledged not distributing invitations to the residents, and both the DON and Administrator stated it was their expectation that residents be invited to these meetings. Facility policies reviewed also emphasized the importance of resident participation in care planning, but these procedures were not followed for the two residents in question.
Failure to Provide and Follow Up on Required Medicare Coverage Notices
Penalty
Summary
Facility A failed to obtain and properly follow up on the required CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and CMS-10123 Notice of Medicare Non-Coverage (NOMNC) for one resident when Medicare Part A services ended. According to facility policy, these forms are necessary to inform Medicare patients about their potential financial responsibility for noncovered services and their right to appeal. The resident's last covered day under Part A was documented, and the required forms were emailed to the resident's power of attorney (POA) prior to the end of coverage. However, there was no response from the POA, and the facility did not conduct any follow-up to ensure receipt or completion of the beneficiary notification paperwork. As a result, the resident or their representative was not given the opportunity to review the forms and make an informed decision regarding continued therapy services or to appeal the facility's decision to discontinue Medicare Part A therapy.
Failure to Timely Submit MDS Assessment Data
Penalty
Summary
Facility A failed to provide a timely submission of a quarterly Minimum Data Set (MDS) assessment for one resident with a history of hemiplegia and hemiparesis following a cerebral infarction. The resident was admitted to the facility and had a quarterly MDS assessment with an Assessment Reference Date (ARD) of 02/24/25, which was completed on 02/25/25. However, the MDS 3.0 Missing OBRA Assessment Report indicated that the last accepted MDS assessment for this resident was dated 12/03/24, showing a gap in timely data submission. The MDS Coordinator reported completing and submitting the quarterly MDS assessment as required, but did not verify its acceptance by CMS through the validation report. The coordinator misunderstood the missing assessment report and did not recognize that the quarterly assessment had not been accepted, resulting in a delay in resubmission until prompted by a surveyor. The Director of Nursing stated that the expectation was for MDS assessments to be transmitted within 14 days of completion and for validation reports to be checked to ensure acceptance by CMS, as outlined in the CMS LTC RAI 3.0 User's Manual.
Failure to Develop Care Plans for Bed Rail Use
Penalty
Summary
Facility B failed to develop and implement care plans addressing bed rail use for two of four residents reviewed for care planning. Observations showed that both residents were lying in bed with raised bilateral three-quarter bed rails, but their care plans did not include any information regarding the use of these bed rails. Review of the facility's policies indicated that the care planning team is responsible for creating individualized, comprehensive care plans based on resident assessments, and that these care plans should guide daily care routines and be accessible to staff. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the care plans for these residents did not reflect their use of bed rails, despite the expectation that such information should be included. The Administrator also acknowledged that residents with bed rails should have this reflected in their care plans. The lack of care plan documentation for bed rail use placed the residents at risk for unmet care needs and increased the risk of accidents.
Failure to Revise Care Plan Following Change in Resident Status
Penalty
Summary
Facility B failed to review and revise the care plan for one of four residents reviewed for care planning. Specifically, a resident who had previously been treated for pressure ulcers and was on a low air loss mattress had since healed and no longer had any wounds or pressure ulcers, as confirmed by a weekly skin assessment and staff interviews. Despite these changes, the resident's care plan continued to reference the presence of skin injuries, the use of a low air loss mattress, and indicated that the resident required assistance with eating by mouth, even though the resident was NPO and receiving tube feedings per physician orders. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the care plan did not accurately reflect the resident's current status. The care plan was not updated to remove references to healed wounds, the discontinued use of a low air loss mattress, or the resident's current nutritional status. This lack of timely review and revision of the care plan was inconsistent with the facility's own policy, which requires care plans to be updated to reflect changes in a resident's condition.
Failure to Provide Showers According to Resident Preference and Policy
Penalty
Summary
Facility B failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received showers according to her preference and the facility's policy. The facility's policy required that showers or baths be given per schedule and that refusals be documented, including the reason. Review of the resident's records showed that she received multiple bed baths over a period of more than two months, with only one documented shower. There was no evidence in the documentation that the resident refused showers or requested bed baths instead. Interviews with staff confirmed that the resident was often given bed baths, and refusals of showers were not documented as required. The resident in question was assessed as severely cognitively impaired on one assessment, but later assessed as cognitively intact. She expressed a preference for showers over bed baths, stating that aides only gave her bed baths. Staff interviews revealed that the resident sometimes screamed or complained during showers, and that staff found it easier to provide bed baths depending on the resident's mood. Both the DON and Administrator confirmed that showers should have been offered per the resident's preference and refusals should have been documented, but this was not done.
Failure to Prevent and Timely Identify Pressure Ulcer at PEG Tube Site
Penalty
Summary
Facility A failed to prevent the development of a facility-acquired pressure ulcer in one resident who was at risk, as identified through interviews, record reviews, and policy review. The resident, who had severe cognitive impairment and diagnoses including palliative care, stroke, and gastrostomy status, was admitted with no open skin areas documented in weekly skin assessments. However, wound care documentation later identified a Stage II pressure injury at the PEG tube site, which was not detected until it had progressed to that stage. The facility's policy required skin inspections every shift, especially under medical devices, but the pressure ulcer was not identified during routine care or weekly assessments. Interviews with staff revealed that the pressure ulcer was discovered only after a note was left for the wound care nurse to examine the area under the PEG tube's plastic bumper. It was found that no gauze or foam was placed under the bumper, which is considered standard care, although not explicitly required by facility policy. The DON acknowledged that proper gastrostomy care, including the use of gauze or sponge, is covered during orientation and is standard practice. The administrator recognized the need for proper skin checks and adherence to policy and standards, but the deficiency occurred due to the failure to identify and prevent the pressure ulcer in a timely manner.
Failure to Monitor and Maintain Bathroom Door Protector Creates Accident Hazard
Penalty
Summary
Facility A failed to adequately monitor and maintain a resident's bathroom door protector, resulting in a potential accident hazard. A resident with diagnoses including Type 2 diabetes mellitus with hyperglycemia and atherosclerotic heart disease, who was cognitively intact, reported repeatedly hitting her hand on a protruding edge of the bathroom door protector. The issue was reported to the Unit Secretary, who submitted a maintenance work order. The Facilities Management Supervisor applied duct tape as a temporary fix and awaited a replacement door, but did not continue to monitor the interim solution. Subsequent observations revealed that the duct tape was no longer in place, and the door protector continued to protrude, posing a risk to the resident. Interviews confirmed that neither the Facilities Management Supervisor nor the Unit Secretary monitored the effectiveness or presence of the temporary intervention. The resident expressed concern about potential injury, and the deficiency persisted until the new door could be installed.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
Facility B failed to assess residents for the use of bed rails, review the risks and benefits with the residents or their representatives, and obtain informed consent prior to installing bed rails for two of seven residents reviewed for accidents and hazards. The facility's policy required an interdisciplinary assessment, consultation with the attending physician, and input from the resident or legal representative before bed rails could be used, as well as documented consent and education about risks and benefits. However, interviews with staff, including the Administrator, DON, and MDS Coordinator, confirmed that no assessments or consents were obtained for the residents in question, and staff were unaware of the requirement to do so. Observations showed that both residents were found in bed with raised bilateral ¾ bed rails, and one resident was unable to independently lower the rails. Record reviews indicated that one resident was severely cognitively impaired according to a recent MDS, while a subsequent assessment showed cognitive intactness. Staff interviews confirmed that the bed rails were in use and that one resident requested them, but there was no documentation of assessment or consent. The facility's failure to follow its own policy and regulatory requirements placed these residents at risk for injury and restraint.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of Medications
Penalty
Summary
Facility B failed to maintain a medication error rate below five percent, as required, during a medication administration observation. Out of 25 opportunities for error, three medication errors were identified, resulting in a medication error rate of 12%. Specifically, a registered nurse crushed and administered Potassium Chloride Extended Release (ER) to a resident with hypokalemia, ferrous sulfate to a resident with iron deficiency anemia, and gabapentin to a resident with peripheral neuropathy. These medications were crushed and mixed with applesauce before administration. Interviews with nursing staff and the facility administrator confirmed that these medications should not have been crushed, as per manufacturer recommendations and facility policy. The facility's policy and the pharmaceutical guidelines for each medication explicitly state that Potassium Chloride ER, ferrous sulfate, and gabapentin should not be crushed due to the risk of altering their intended release and absorption. The actions observed were not in accordance with manufacturer specifications or accepted professional standards.
Failure to Document Resident Decline and Death
Penalty
Summary
Facility A failed to document the decline, death, and disposition of a resident who was under hospice care and had a diagnosis of Alzheimer's disease. The facility's policy requires that the medical record provide a comprehensive account of the patient's health status, care provided, and serve as a legal record. However, review of the electronic medical record (EMR) for the resident showed only a note indicating release to a funeral home, with no documentation of the resident's decline or the circumstances surrounding the death. An LPN who was caring for the resident reported that after administering morphine and returning to the room, the resident was found unresponsive and subsequently pronounced deceased by the hospice nurse. The LPN acknowledged that, due to the situation, they did not document the resident's decline or death as required. The facility administrator confirmed the expectation that nurses document the resident's condition at the time of death and all events leading up to it, which was not done in this case.
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 8 citations issued within 25 miles in the last 12 months — including the 7 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Camilla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinewood Health And Rehabilitation | 24.3 mi | ★★★★★ | 8 | 7 |
| Wynfield Park Health And Rehabilitation | 25.1 mi | ★★★★★ | 0 | 0 |
| Archbold Living Cairo | 25.2 mi | ★★★★★ | 2 | 0 |
| Pruitthealth - Sunrise | 25.8 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Palmyra | 25.9 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.