Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkside At Budd Terrace Operating Company Llc during CMS and state inspections, most recent first.
Delayed and Incomplete MDS Discharge Assessments: The facility failed to complete and transmit required discharge MDS assessments in the required timeframe for seven residents. Several assessments remained in progress and not transmitted, one was marked accepted but was not actually completed and signed by the RN until later, and one resident had no discharge MDS opened at all. MDS staff acknowledged the delays and missing assessment, and the DON stated that MDS assessments should be completed according to the RAI Manual.
The facility failed to ensure that in-house and agency nursing staff were competent to provide TPN-related care, despite a policy and facility assessment stating that staff would be trained and evaluated for necessary competencies. Review of records showed no documented TPN training or competency validation for any in-house nurses and only one agency nurse with a self-attested TPN competency. A resident receiving TPN via a double-lumen PICC had orders for specific TPN infusion parameters and 10 ml normal saline flushes for each lumen before and after TPN. An agency RN, who reported receiving no TPN training from the facility or her agency, flushed only one lumen with 5 ml normal saline and did not stop the TPN infusion when the pump alarmed repeatedly and the TPN bag was empty. Facility leadership stated that all nursing staff were expected to be competent in TPN care, but this was not supported by training or competency documentation.
The facility failed to provide and document bathing services according to residents’ needs, care plans, and the established bathing schedule for three residents. A cognitively intact resident with quadriplegia and muscle wasting, care planned to need ADL assistance, had only a few documented baths over an extended period with no refusals or clinical justification for missed showers. Another severely cognitively impaired resident, totally dependent for bathing and scheduled for twice-weekly baths, was documented as bathed only four times in a month. A third cognitively intact resident requiring moderate assistance for bathing had no bathing care plan and no record of any bathing during the entire stay. A RN described a room-based shower schedule and a process where CNAs, including agency staff without EMR access, were to report completed care for documentation, but acknowledged this was not consistently followed, and the DON confirmed that documentation was lacking to show these residents had been bathed.
The facility failed to provide and document individualized activity programming for two residents, contrary to its policy requiring ongoing, preference-based activities to support physical, mental, and psychosocial well-being. One resident with moderate cognitive impairment had a care plan indicating participation in group and 1:1 activities, but EMR progress notes contained no evidence of any activity participation or quarterly activity assessments. Another resident with severe cognitive impairment, stroke, and epilepsy had a detailed activities care plan and assessment calling for 1:1 visits, music, socialization, sensory activities, and chaplain visits, yet there was no documentation of activity participation over several months, and repeated observations showed the resident lying in bed without engagement. The AD confirmed missing documentation and overdue assessments, while an activity assistant reported she did not document individual participation and was unfamiliar with the resident’s activity preferences and care plan.
Two residents dependent on TPN did not receive safe, appropriate IV nutrition care. One resident with COPD and atrial flutter had orders for TPN via a double-lumen PICC line over a set nighttime period with specific flush volumes, but was weighed only once, had daily skilled notes incorrectly documenting oral intake instead of IV nutrition, and was observed receiving care from an agency RN who failed to stop the TPN despite an empty bag and pump alarms, and flushed only one lumen with an insufficient volume contrary to orders. Another resident with Crohn’s disease and short bowel syndrome had TPN ordered over a set nighttime period, but there were no PICC care or flush orders, one ordered TPN dose was not given due to pharmacy unavailability, the PICC dressing was changed only once just before discharge, the resident was never weighed, and skilled notes were sparse and omitted TPN and PICC information. The DON stated expectations that PICC/TPN orders be entered on admission or treatment start, that documentation accurately reflect TPN and PICC status, and that weights be monitored weekly for residents on TPN.
A resident with bipolar disorder, depression, anxiety, and OCD, and intact cognition, received multiple psychotropic medications including an antidepressant, antipsychotic, and anti-anxiety agents. The record contained no documentation of informed consent for any of the psychotropic medications, and the RN UM confirmed the consent could not be found; the DON stated informed consent was expected before administration.
A resident’s record did not accurately reflect her CPR code status. The chart contained a DNR order, while the resident-signed POLST indicated Full Code, and the resident confirmed she wanted Full Code. The DON and RN/Unit Manager stated that each resident’s designated code status should be accurately reflected in the record so the resident’s wishes would be honored.
A resident with bipolar disorder, depression, anxiety, and OCD was receiving multiple psychotropic medications, including an antidepressant, an antipsychotic, and two antianxiety medications. Although the care plan called for monitoring side effects and adverse reactions, the EMR had no documentation of side effect tracking or a recent AIMS test, and the RN/Unit Manager confirmed both were missing. The DON stated the expectation was for quarterly AIMS testing for residents on antipsychotics and side effect monitoring documented on the MAR/TAR.
Late Quarterly MDS Assessment: The facility failed to complete a quarterly MDS for one resident within the required 92-day timeframe. The resident’s assessment remained in progress in the EMR and was overdue on the tracking sheet. MDSC2 could not state the RAI timing requirement, MDSC1 acknowledged the assessment was not completed or transmitted on time, and the DON stated MDS assessments should be completed according to the RAI Manual.
Failure to Complete Baseline Care Plans Within Required Timeframe: The facility did not complete baseline care plans for three residents within the required 48-hour admission window. EMR review showed no documentation that the plans were developed, generated, provided, or reviewed for the residents, including one resident with diabetes mellitus, muscle weakness, dementia, major depressive disorder, and HTN. The MDSC and DON both confirmed the baseline care plans were not completed, and an LPN stated she did not know about completing a baseline care plan at admission.
A resident who was cognitively intact and identified on the MDS as being at risk for pressure ulcers had a triggered CAA for pressure ulcers, but the EMR care plan did not address that risk. The MDS Coordinator confirmed no care plan was developed for the pressure ulcer concern, and the DON stated her expectation was that triggered CAAs would be reflected in the care plan.
Failure to Provide Ordered Nephrostomy Tube Site Care: Nursing staff did not follow the physician’s order for a resident with bilateral nephrostomy tubes and a hx of UTIs. Although the MAR/TAR documented the treatment as completed, observation showed no dressing on either nephrostomy site, visible insertion sites, and dried crusted material near the left site. RN2 said she was unaware a dressing was required, RN3 said dressings should have been in place, and the DON confirmed staff were not aware of the dry dressing requirement.
The facility failed to consistently apply ordered splints for two residents with impaired ROM and mobility. One resident with a history of stroke, hemiplegia, and hemiparesis was ordered to wear a left hand splint and left elbow dynamic splint at all times, but repeated observations found him without either splint and the splints were not readily located in the room. Another resident with a history of stroke and severe cognitive impairment was ordered to wear a left hand palm guard splint at all times for contracture management, but repeated observations found her without the splint and the record lacked documentation that it was being applied or refused.
Failure to obtain an admission weight for a resident with CKD. The resident’s EMR lacked evidence of an initial weight in the weights section, the admission MDS did not show a weight per protocol, and the nutrition documentation noted low intake risk and malnutrition without recording a weight. RD and nursing leadership stated the admission weight was needed as the baseline for assessing nutritional status and care needs.
Two residents had bilateral 1/2 bed rails raised without documentation of a required assessment, physician order, care plan, or informed consent. One resident was cognitively intact with a history of stroke and hemiplegia, and the other had a history of stroke and epilepsy with severe cognitive impairment. RN confirmed the rails were in use, and the DON stated the needed documentation could not be located.
A medication error rate exceeded the allowed threshold after surveyors found four errors in 26 opportunities for one resident with COPD. An RN gave the inhaled steroid before the bronchodilator, did not have the resident rinse his mouth after the steroid, and did not complete the ordered PICC saline flushes as prescribed. The RN said she was unaware of the required inhaler sequence and wait time and routinely gave only part of the ordered flush; the RN/Unit Manager and DON confirmed the expected medication administration practices.
A resident with atrial flutter and intact cognition was ordered Xarelto 15 mg daily, but the MAR showed two missed doses because the medication was not available from the pharmacy. The DON and Administrator confirmed that ordered medications were expected to be available for administration as ordered.
A nurse administered a resident’s inhaled medication and then gave a normal saline flush through a PICC line without washing or sanitizing her hands or changing gloves in between. The resident was cognitively intact and had COPD, and the RN stated she only performed hand hygiene and donned gloves one time for each resident’s medications. The RN, unit manager, and DON confirmed staff were expected to perform hand hygiene and change gloves between different medication routes.
A resident with minimal cognitive impairment and significant physical care needs reported that staff frequently ignored her call light or left without assisting, resulting in incontinence. An observation confirmed improper care practices, as the resident was found triple diapered with a full brief, which was not standard protocol.
A facility failed to honor a resident's preference for evening showers, as outlined in their care plan and the facility's policy on Residents' Rights & Responsibilities. Despite the resident's diagnosis of Stage IV Ovarian Cancer and need for assistance with ADLs, night CNAs often did not provide showers at the preferred time, offering bed baths instead. Documentation showed only three out of seven scheduled showers were given in October, with no reasons recorded for the missed showers.
Delayed and Incomplete MDS Discharge Assessments
Penalty
Summary
The facility failed to ensure that MDS assessments were completed and transmitted to the CMS system within 14 days of completion for seven residents reviewed for accuracy of assessments: R56, R204, R248, R425, R426, R457, and R459. Review of the RAI Manual showed that OBRA-required MDS assessments are federally mandated and that discharge assessments must be completed within 14 days of discharge to accurately reflect functional status and close the record. The report states that these assessments are used for payment, quality measures, and ongoing clinical data analysis. Record review showed that R56, R204, R248, R425, and R426 each had a discharge assessment listed as in progress and not completed or transmitted as of 03/25/2026. R457 had a discharge assessment marked accepted, but further review showed it was not completed and signed by the RN until 03/05/2026 and was not transmitted to CMS until 03/05/2026. R459 had no discharge assessment opened, completed, or transmitted as of 03/25/2026, even though the resident was discharged to the hospital on [DATE]. During interviews, MDSC2 could not state the timing requirements in the RAI Manual, MDS1 acknowledged the assessments were not completed and transmitted in the required time frame and that R459 should have had a discharge MDS opened and completed, and the DON stated that all MDS assessments should be done in a timely manner according to the RAI Manual.
Failure to Ensure Nursing Staff Competency in TPN Care and PICC Line Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and nurse aides had appropriate competencies to provide Total Parenteral Nutrition (TPN) care and services, despite the facility’s own policy and facility assessment stating that staff would be trained and competent in this area. The facility’s Competency Evaluation Policy required that staff competencies be determined through the facility assessment, evaluated during orientation, and reassessed periodically using methods such as demonstration, testing, and direct observation, with documentation maintained in staff files. The facility assessment for 2025/2026 documented that the facility admitted residents receiving TPN and that nursing staff would be appropriately trained and competent to provide TPN-related care. However, review of the facility’s nurse training and competency documentation showed that none of the 83 in-house staff nurses had ever received training or demonstrated competency related to TPN care, and the facility could not provide documentation that 32 of 33 agency nurses working in the most recent 30 days had TPN-related training or competency verification. The surveyors identified one resident receiving TPN, who had physician’s orders for TPN electrolytes to be infused intravenously over 12 hours with a 1-hour taper up and 1-hour taper down, and for each lumen of the resident’s double-lumen PICC line to be flushed with 10 ml normal saline twice daily before and after TPN administration. During an observation, an agency RN provided TPN-related care to this resident and stated she had not received TPN training from the facility or her agency, though she claimed to have skills with TPN. The RN flushed only one lumen with 5 ml of normal saline instead of 10 ml for each lumen as ordered and did not discontinue the TPN infusion even when the pump alarm repeatedly sounded and the TPN bag was empty. In an interview, the RN/Unit Manager, DON, and Administrator stated their expectation that all nursing staff be competent to provide TPN-related care, as the facility routinely admitted residents receiving TPN, but the documentation and observations showed this had not been ensured.
Failure to Provide and Document Scheduled Bathing for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing services according to residents’ needs, care plans, and the established bathing schedule. One resident with quadriplegia, muscle wasting, and chronic pain syndrome, who was cognitively intact and care planned to require staff assistance with ADLs including bathing, had EMR documentation showing only five assisted baths over nearly a two‑month period. There was no documentation that this resident received showers on other assigned shower days, nor any documented refusals or clinical justification for missed showers. A RN explained that showers were scheduled by room number and that CNAs, including agency staff, were responsible for providing showers, but agency CNAs could not document directly in the EMR and were expected to report care to licensed staff or the next shift, a process the RN acknowledged was not consistently followed, leading to incomplete documentation and uncertainty about whether showers were provided as scheduled. Another resident with a history of stroke and epilepsy, who was severely cognitively impaired and totally dependent on staff for bathing, had a care plan requiring two staff to provide physical care with personal hygiene, bathing, dressing, and grooming, and was scheduled to be bathed twice weekly on specific days. Point-of-care documentation over a one‑month period showed the resident was bathed only four times, less than the scheduled frequency. A third cognitively intact resident with muscle wasting and atrophy, who required moderate assistance for bathing per the admission MDS, had no bathing-related care plan and no documentation of any bathing assistance during the entire admission. The DON stated that residents were expected to be assisted with bathing according to their preferences and plan of care, and that bathing or refusals were to be documented, and confirmed that documentation was lacking to indicate that these residents had been bathed.
Failure to Provide and Document Individualized Activity Programming
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the individual interests and needs of residents, as required by its own policy and regulatory standards. The facility’s Activities policy dated April 2025 stated that residents were to receive an ongoing program of group, individual, and independent activities based on comprehensive assessment, care plan, and preferences, designed to support physical, mental, and psychosocial well-being. However, surveyors found that for two residents reviewed for activities, there was no supporting documentation that planned activities were actually provided or that ongoing assessments were completed as required. One resident, identified as R349, had an annual MDS with a BIMS score of 10/15, indicating moderate cognitive impairment. The resident’s care plan, initiated in July 2024 and revised in October 2024, stated that the resident continued to engage in group activities such as bingo and travel/documentary videos, as well as self-directed and 1:1 activities in the room, and interacted daily with others. Despite these care plan statements, review of the EMR progress notes showed no evidence that the activities department conducted 1:1 activities with this resident or that the resident participated in any group activity programs during the assessment period. The Activity Director confirmed there was no documentation of activity participation and that no quarterly activity assessments had been completed for this resident. Another resident, identified as R299, had a history of stroke and epilepsy and a quarterly MDS BIMS score of 4/15, indicating severe cognitive impairment. The activities care plan documented that the resident was dependent on staff for assistance with activities, sensory stimulation, and social interaction, and included specific interventions such as providing opportunities for socialization with peers, individual music listening (gospel and jazz), assistance with TV and telephone use, FaceTime calls with the resident’s mother, and scheduled chaplain visits. The most recent activities assessment described ongoing 1:1 visits for wellness, reminiscence, orientation, inspirational reading, seasonal decorations, music listening, sensory activities, and Geri-chair rides, and noted that scheduled out-of-room group time was not accomplished. However, EMR review from early January through late March 2026 revealed no documentation of participation in any activity program, and repeated observations over several days showed the resident lying in bed without engagement in individual, 1:1, or group activities. The Activity Director confirmed the absence of documentation and that the last activities assessment was not updated quarterly, and the Activity Assistant stated she did not document individual participation, was unaware she was supposed to do so, and did not know the resident’s activity preferences or care plan. The Administrator stated her expectation was that activities be provided and documented per each resident’s needs and interests and that assessments occur on admission, quarterly, and with significant changes in status. This deficient practice had the potential to negatively affect the quality of life for the affected residents.
Failure to Ensure Safe TPN Administration and Monitoring for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration and monitoring of TPN for two residents who were dependent on IV nutrition. One resident with COPD and atrial flutter was admitted on TPN via a double-lumen PICC line, ordered to infuse a specified volume over 12 hours at bedtime with a 1-hour taper up and 1-hour taper down, and with orders to flush each lumen with 10 ml normal saline twice daily before and after TPN administration. The resident’s MDS documented that more than 50% of nutrition was received via IV and that the resident was NPO. However, vital sign records showed the resident was weighed only once during the admission, and daily skilled evaluation notes from admission through most of the stay incorrectly documented that all nutrition was taken by mouth and contained no information about TPN or the PICC line. During an observation of care, an agency RN provided TPN-related care to this resident and flushed only one lumen of the double-lumen PICC line with 5 ml of normal saline, contrary to the order for 10 ml flushes to each lumen. The RN did not stop the TPN infusion while providing care, even though the pump alarm repeatedly sounded and the TPN bag was empty. In an interview, the RN stated she believed the TPN was ordered to run continuously and that the lumen used for TPN did not need to be flushed, and she described a practice of flushing only the unused lumen with a total of 10 ml per shift. The unit manager later confirmed that the physician’s order was for TPN to infuse over 12 hours at night, not continuously, and that both lumens should have been flushed with 10 ml normal saline per orders; she also stated she did not know if the agency RN was competent to provide TPN-related care. A second resident with noninfective gastroenteritis and colitis, Crohn’s disease, and short bowel syndrome was also dependent on TPN, with an order for a specified volume of TPN to infuse at bedtime over 14 hours with a 1-hour taper up and 1-hour taper down. The order set did not include any orders for PICC line care, dressing changes, or flushing/maintenance of the double-lumen PICC line used for TPN. The MAR showed that this resident did not receive the ordered TPN on one date because it was not available from pharmacy, and the PICC line dressing was not changed until one day prior to discharge. The resident’s nutritional care plan identified nutritional and hydration risk related to TPN dependence, but vital sign records showed the resident was never weighed during the admission, and daily skilled evaluation notes were sparse and contained no documentation of TPN or PICC line care. In an interview, the DON stated her expectation that all PICC/TPN orders be entered on admission or initiation of treatment, that nurses accurately document route of nutrition and PICC/TPN care in daily notes, and that weights be obtained on admission and weekly for four weeks for residents receiving TPN.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of psychotropic medications for one resident who was reviewed for unnecessary medication. The resident was admitted with diagnoses of bipolar disorder, depression, anxiety, and obsessive-compulsive disorder, and had a BIMS score of 15 out of 15, indicating intact cognition. The resident’s record showed active orders for Paxil, quetiapine, buspirone, and Ativan, and the MARs/TARs showed these psychotropic medications were administered as ordered from 03/01/2026 through 03/27/2026. Review of the resident’s comprehensive record found no documentation that informed consent had been obtained for any of the psychotropic medications. During interview, the RN Unit Manager confirmed consent for the resident’s psychotropic medications could not be found. The DON stated her expectation was that informed consent was to be received for all psychotropic medication administered to any resident prior to administration.
Incorrect Code Status Documentation
Penalty
Summary
The facility failed to ensure one resident’s record accurately reflected her chosen CPR code status. Review of the facility policy stated that residents’ decisions regarding treatment and advance directives were to be documented in the medical record and communicated to the interdisciplinary team and staff responsible for care. In R49’s record, the Physician’s Order Report showed an order for Do Not Resuscitate (DNR), while the resident’s POLST form, signed by the resident, indicated Full Code. R49 was admitted with diagnoses of bipolar disorder, depression, anxiety, and obsessive-compulsive disorder. Her quarterly MDS showed a BIMS score of 15 out of 15, indicating she was cognitively intact. During interview, R49 confirmed she wanted her code status to be Full Code. The DON and RN/Unit Manager confirmed the expectation that each resident’s designated code status be accurately reflected in the record so the resident’s wishes would be honored in the event of a code.
Unnecessary Psychotropic Medication Monitoring Failure
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medications. The resident was admitted with diagnoses of bipolar disorder, depression, anxiety, and obsessive-compulsive disorder, and the quarterly MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The MDS also indicated the resident was receiving antidepressant, antianxiety, and antipsychotic medications. Physician orders showed the resident was receiving Paxil 20 mg daily for depression, quetiapine 75 mg in the morning, 100 mg at 2:00 PM, and 300 mg at bedtime for severe bipolar disorder with psychotic features, buspirone 5 mg three times daily for anxiety, and Ativan 0.25 mg twice daily for anxiety. Review of the resident’s psychotropic medication care plan showed the resident was receiving psychotropic medications and that side effects and adverse reactions were to be monitored and recorded. However, the EMR contained no documentation that side effects of the resident’s psychotropic medications were being monitored or that a recent AIMS test had been completed. During interview, the RN/Unit Manager confirmed that side effect tracking and a recent AIMS test could not be found. The DON stated her expectation was that an AIMS test would be performed at least quarterly for any resident receiving antipsychotic medications and that side effects related to all psychotropic medications would be done at least once per shift and documented on the MAR/TAR.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete quarterly MDS assessments not less than once every 3 months for one resident, R56, out of seven residents reviewed for assessment accuracy in a sample of 63 residents. Review of the RAI Manual showed that OBRA-required MDS assessments, including quarterly assessments, must be completed for all Medicare and/or Medicaid certified nursing home residents, and that a quarterly assessment must be completed at least every 92 days following the previous OBRA assessment of any type. Review of R56’s EMR showed an admission MDS completed on 11/11/2025 and a quarterly assessment due on 02/11/2026. The EMR also showed a quarterly assessment in the system that had not been completed and remained in progress, and the tracking sheet indicated the quarterly assessment was 27 days overdue. During interviews, MDSC2 could not state the timing requirements in the RAI Manual for completion and transmission of the quarterly assessment, MDSC1 stated the assessment was not completed or transmitted within the required timeframe, and the DON stated that all MDS assessments should be completed in a timely manner according to the RAI Manual.
Failure to Complete Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for three residents, identified in the record as R98, R99, and R198. Facility policy titled "Baseline Care Plan" stated that the baseline care plan must be developed within 48 hours of a resident's admission and include the instructions needed to provide effective and person-centered care. Review of the electronic medical records showed no documentation that the baseline care plan had been completed for any of the three residents. R98 had an admission date of 12/12/2025, and no baseline care plan documentation was found in the Evaluation tab. R99 was admitted with diagnoses of diabetes mellitus, muscle weakness, dementia, major depressive disorder, and hypertension, but the Baseline Care section contained no documentation that the plan was developed, generated, provided, or reviewed with the resident or representative. R198 had an admission date of 12/29/2025, and no documentation of a completed baseline care plan was found in the Assessments tab. The MDSC stated the baseline care plan was done by the unit nurse and confirmed it had not been completed for R98, R99, and R189. The DON stated that an initial baseline care plan was generated on admission, but confirmed the baseline care plans for R98, R99, and R198 were not completed. An LPN stated she did not know about doing a baseline care plan at the time of admission.
Incomplete Care Plan for Pressure Ulcer Risk
Penalty
Summary
The facility failed to develop person-centered, comprehensive care plans with measurable goals and interventions for one resident, R162, who was admitted on [DATE]. Review of the admission MDS with an ARD of 02/28/2026 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The MDS also indicated the resident was at risk for pressure ulcers and had no pressure ulcers at the time of the assessment. The CAA for R162 triggered for pressure ulcers and directed clinical staff to develop a care plan, but review of the resident’s EMR care plan found no care plan addressing the resident’s potential for developing pressure ulcers. During interview, the MDS Coordinator confirmed that when the CAA was triggered it directed staff to develop a care plan and stated there was no care plan developed for R162 regarding the potential development of pressure ulcers. The DON stated her expectation was to have a care plan developed with the triggered CAAs so the care plan addressed the resident’s care needs.
Failure to Provide Ordered Nephrostomy Tube Site Care
Penalty
Summary
Nursing staff failed to follow the physician’s order for bilateral nephrostomy tube site care for a resident admitted with bilateral nephrostomy tubes and a history of urinary tract infections. The resident’s EMR showed an order dated 02/10/2026 for cleansing both nephrostomy tube sites with normal saline, patting dry, and applying a dry dressing twice weekly on Tuesday and Friday day shift, as needed, along with orders to flush the tubes every shift per protocol. The resident’s MDS indicated an indwelling urinary device and a BIMS score of 11 out of 15, showing moderately impaired cognition. Although the MAR/TAR documented the treatments as completed as ordered, an observation of the nephrostomy tube flush showed no dressing on either site. The insertion sites were visible, and the left site had a small amount of dark, dried, crusted material about one inch from the insertion site. The procedure observed focused on flushing the tubes, and no site care or dressing application was performed. During interviews, RN2 stated she was not aware a dressing was required and did not recall seeing the order, RN3 stated the resident should have had dressings in place and acknowledged the dried material, and the DON confirmed staff were not aware of the requirement to apply dry dressings to the nephrostomy sites.
Failure to Apply Ordered Splints for Two Residents
Penalty
Summary
The facility failed to ensure splints were consistently applied for two residents with impaired ROM and mobility. One resident was admitted with a history of stroke, hemiplegia, and hemiparesis affecting the left non-dominant side, and his care plan directed that a left hand splint and left elbow dynamic splint be worn at all times, per patient tolerance, with removal only for skin checks, hygiene, edema, redness, or skin breakdown. Review of the record showed no documentation that the splints were routinely applied, and multiple observations found him in bed without either splint. During an observation with RN6, the resident was confirmed not to be wearing the ordered splints, and the Director of Rehabilitation later found the left elbow dynamic splint under clothing in the room and could not locate the left-hand splint. The resident stated his splints had not been applied for a long time and that he would wear them if applied. A second resident was admitted with a history of stroke and had severe cognitive impairment with ROM impairment to both upper and lower extremities. Her physician's order required a left hand palm guard splint to be applied at all times for contracture management, and the care plan also directed that she wear the left hand palm guard at all times. The record contained no documentation that the splint was being applied as ordered, and repeated observations found her in bed without the splint. RN6 confirmed she was not wearing the left palm splint and stated the resident was supposed to be wearing it. The Director of Rehabilitation also confirmed the splint should have been worn at all times but was unable to locate it. The DON stated her expectation was that splints be applied as ordered and that either application of the splint or the resident's refusal to wear it be documented in the record.
Failure to Obtain Admission Weight
Penalty
Summary
The facility failed to ensure an admission weight was obtained for one resident, R224, out of eight residents reviewed for nutrition. The facility policy titled Weight Monitoring stated that weight is a useful indicator of nutritional status and that a comprehensive nutritional assessment should be completed upon admission, including weight. R224 was admitted with a diagnosis of chronic kidney disease, but the EMR weights section did not contain evidence that the resident was weighed upon admission, and the admission MDS did not have evidence of a weight taken per facility protocol. R224’s dietary profile showed that RD1 identified the resident as at risk for weight loss based on family report that the resident was not eating while in the hospital. The care plan identified the resident as at risk for low meal intake, and a mini-nutrition progress note stated the resident was malnourished, but it also failed to indicate that the resident was weighed. During interviews, RD1 stated she based the nutritional assessment on information from the family and hospital records and later stated that the initial weight was the baseline used to assess nutritional status going forward. The ADON and DON both stated that residents should have an initial weight upon admission and that obtaining the initial weight was important to establish a baseline and determine the need for care.
Bed Rails Used Without Assessment, Order, or Informed Consent
Penalty
Summary
The facility failed to ensure bed rails were necessary and that informed consent was obtained before bilateral 1/2 bed rails were used for two residents, R11 and R299. The facility policy titled, "Proper Use of Bed Rails or Enabler Bar," dated April 2025, stated that a person-centered approach should be used, alternative approaches should be attempted before bed rails are used, informed consent must be obtained prior to use, and a physician's order should be obtained after consent. However, review of the records for both residents showed no documentation of a bed rail assessment, no informed consent, no physician's order for bed rails, and no care plan addressing bed rail use. R11 was admitted with diagnoses including history of stroke and hemiplegia/hemiparesis affecting the left non-dominant side, and the MDS showed a BIMS score of 15 out of 15 with complete dependence for rolling and transferring in bed. R299 was admitted with diagnoses including history of stroke and epilepsy, and the MDS showed a BIMS score of 4 out of 15 with complete dependence for rolling and transferring in bed. Despite the absence of documentation showing bed rails were ordered or assessed, observations on multiple occasions showed both residents lying in bed with bilateral 1/2 bed rails raised. RN6 confirmed the bed rails were in use for both residents, and during interview the DON and RN6 stated that orders, a care plan, a recent assessment, and informed consent for bed rail use could not be located.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. Surveyors identified four medication errors out of 26 opportunities for one of eight observed residents, resulting in a 15.38 percent error rate. The facility policy required medications to be administered by authorized staff in accordance with professional standards and the six rights of medication administration, and the metered dose inhaler policy required the bronchodilator to be given before the corticosteroid, with a wait time between puffs and rinsing the mouth after corticosteroid use. For one resident with COPD and a BIMS score of 15 out of 15, the physician ordered Incruse Ellipta once daily, Advair once daily, and saline flushes of both PICC line lumens with 10 ml of normal saline twice daily before and after TPN. During observation, an RN administered Advair before Incruse Ellipta, did not direct the resident to rinse his mouth after the inhaled steroid, flushed only one PICC lumen with about 5 ml of saline, and did not flush the other lumen with the ordered 10 ml. The RN stated she was not aware of the required inhaler order or wait time and confirmed she forgot to have the resident rinse his mouth; she also stated she routinely flushed only the lumen not being used for TPN with 5 ml and planned to use the remaining saline later. The RN/Unit Manager and DON confirmed the expected inhaler sequence, mouth rinsing after steroid administration, and administration of saline flushes as ordered.
Failure to Provide Ordered Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that one resident, R311, was free from significant medication errors. R311 was admitted with a diagnosis of atrial flutter and had a BIMS score of 15 out of 15, indicating he was cognitively intact. His physician ordered Xarelto 15 mg once daily on 03/05/2026 for atrial flutter, but the MAR showed that the medication was not administered on 03/06/2026 and 03/25/2026. The Orders/Administration Notes documented that Xarelto was not given on those dates because the medication was not available from the pharmacy. During an interview, the DON and Administrator confirmed the expectation that all ordered medications should be available at the facility for administration to residents as ordered.
Hand Hygiene and Glove Change Not Performed Between Medication Routes
Penalty
Summary
The facility failed to ensure infection control practices were followed during medication administration for one resident who was cognitively intact and admitted with diagnoses of muscle wasting and atrophy and COPD. The resident had orders for Incruse Ellipta one puff inhaled once daily, Advair one puff inhaled once daily, and normal saline flushes through both lumens of a PICC line twice daily before and after TPN. During observation on 03/25/2026, RN7 administered the resident’s inhaled medication and then administered a 5 ml normal saline flush to one lumen of the resident’s PICC line without washing or sanitizing her hands or changing her gloves in between. RN7 stated she only washed her hands and donned gloves one time when administering each resident’s medication and never washed/sanitized her hands or changed her gloves between oral and/or inhaled medication and IV medication. RN1 and the DON confirmed staff were expected to wash/sanitize hands and change gloves between different routes of medication administration, and that RN7 should have done so before administering the PICC line flush.
Failure to Respond to Call Lights and Provide Timely Care
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not responding adequately to the call light system. The resident, who had a BIMS score indicating little to no cognitive impairment, required assistance with activities of daily living due to conditions such as osteoarthritis, chronic pain, and muscle weakness. Despite these needs, the resident reported that staff often ignored her call light or left without providing assistance, leading to episodes of incontinence. An interview with the resident confirmed that staff instructed her to relieve herself in her briefs, promising to clean her up later, which she found distressing. An observation revealed the resident was triple diapered with a full brief, which was not standard care protocol. This situation was corroborated by a registered nurse who acknowledged that some CNAs were not following proper care procedures.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred time for showers, as outlined in the facility's policy on Residents' Rights & Responsibilities. The policy emphasizes the importance of respecting each resident's personal dignity and their right to make informed decisions regarding their care. Despite this, the facility did not ensure that a resident, who preferred to have showers between 11:00 pm and 12:00 am, was accommodated. The resident, who has a diagnosis of Stage IV Ovarian Cancer and requires assistance with activities of daily living, reported that night CNAs were unwilling to provide showers at the preferred time, often offering only a bed bath instead. The resident's care plan specifically included the intervention to honor their wish for evening showers. However, a review of the shower schedule and documentation revealed that the resident received only three out of seven scheduled showers in October, with no documentation explaining the missed showers. An interview with the Unit Manager confirmed that CNAs are expected to document reasons for missed showers and report them for rescheduling, which was not done in this case. This lack of adherence to the resident's care plan and facility policy resulted in a deficiency in promoting and facilitating resident self-determination.
What surveyors are citing around you — mapped
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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 407 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.
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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 Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Virginia Park | 1.6 mi | ★★★★★ | 0 | 0 |
| A.g. Rhodes Home Wesley Woods | 1.7 mi | ★★★★★ | 5 | 0 |
| Westminster Commons | 2.8 mi | ★★★★★ | 0 | 0 |
| Decatur Center For Nursing And Healing Llc | 2.9 mi | ★★★★★ | 7 | 0 |
| Terraces At Peachtree Hills Place, The | 3 mi | ★★★★★ | 5 | 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.