Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Crestview Specialty Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple risk factors developed a Stage 3 pressure ulcer after admission. Staff failed to follow physician orders for wound care, did not use infection control techniques, omitted required wound treatments, and did not implement pressure-relieving interventions such as an air mattress or regular repositioning. The resident was left in a wheelchair for hours without assistance, and staff were unaware of the resident's skin breakdown, resulting in the development of a new unstageable pressure ulcer.
Two residents did not receive wound care as ordered, with missed or undocumented treatments, improper dressing application, and lack of provider notification when care was refused. Staff interviews and record reviews confirmed that wound assessments and documentation were incomplete, and facility policy for wound care and communication was not consistently followed.
Several residents with severe cognitive impairment and mobility limitations experienced unsafe transfers and incomplete post-fall assessments. One resident fell from a mechanical lift due to improper sling attachment, resulting in fractures and a head injury. Another resident was assisted without a gait belt and fell, while a third was found on the floor without appropriate neurological evaluation. Additionally, a resident requiring two-person assistance was transferred by one CNA without a gait belt. Staff did not consistently follow care plans, manufacturer instructions, or facility policies, leading to injuries and inadequate supervision.
Surveyors found that mechanical lifts and a wheelchair remained visibly soiled over multiple days, and a soiled incontinence pad was left on a bed. CNAs confirmed responsibility for cleaning and stated that soiled items should be removed immediately, but these tasks were not completed as required by facility policy.
A resident with moderate cognitive impairment who required assistance with bathing and personal hygiene did not receive a bath or shower for 17 days due to insufficient staffing. Multiple staff members, including CNAs, RNs, and LPNs, reported being unable to complete required care tasks, such as wound care and scheduled baths, because of routine understaffing. Staff also described situations where residents received meals in their rooms and feeding assistance was delayed, highlighting ongoing staffing shortages despite facility policies intended to address such issues.
Infection control practices were not followed during insulin administration, peri-care, and wound care. An LPN administered insulin without gloves, two CNAs provided peri-care to a resident with a wound without gowns and did not change gloves or wash hands before continuing care, and an RN performed wound care for a resident with an indwelling catheter and Stage 3 sacral pressure ulcer without the required EBP PPE and without changing gloves between dirty and clean tasks.
Three residents experienced a lack of dignity and respect in their care, including not being offered meal choices, being left in soiled bedding and rooms with persistent odors, and being left undressed and exposed in bed. Staff failed to maintain a clean environment and did not consistently uphold residents' rights to a dignified existence.
A resident with moderate cognitive impairment and diagnoses of dementia and depression was administered risperidone, an antipsychotic medication, without documented informed consent from the responsible party. Staff interviews and record reviews confirmed that the required consent process was not followed, and the care plan did not reflect the use of the medication, contrary to facility policy.
Several residents, including those with cognitive impairments and incontinence, did not receive required assistance with bathing and personal hygiene, with some going extended periods without baths and one resident not receiving needed incontinence care. Staff interviews indicated that missed care was due in part to short staffing, and documentation did not reflect resident refusals or consistent attempts to provide care.
The facility failed to complete required annual performance reviews for 3 staff members, including an LPN and 2 CNAs. File review showed unsigned annual reviews and no additional evaluations beyond the last documented review for each employee. The Administrator stated there were no further evaluations for these staff members, despite expecting annual and as-needed reviews per policy.
Expired insulin was found in a medication cart for a resident, and an LPN reported there was no non-expired insulin available in the cart. The LPN obtained insulin from the emergency kit and dated it when opened. The facility also had incomplete medication refrigerator temperature documentation, with logs showing temperatures recorded on only part of the month, while the DON stated temperatures were expected to be checked and logged daily.
Failure to Post Daily Nurse Staffing Information: The facility failed to post the daily nurse staffing information on multiple observed days. The RN/DON, DON, and Administrator gave conflicting statements about who was responsible for the posting, and the DON reported he had not completed or tracked the postings. The Administrator also stated the facility did not have a policy addressing the daily staff posting.
A facility failed to conduct ongoing QAPI/QA activities and failed to implement effective plans to prevent repeat deficiencies identified during recertification survey. The facility had prior citations at F0686 and F0725, and a later survey again identified F0686 at IJ and F0725 at scope and severity E. The Administrator confirmed the repeat concerns and the pattern of deficiencies, while the facility’s QAPI plan outlined committee responsibilities for tracking data, identifying quality problems, using RCA, and coordinating performance improvement efforts.
A resident with severe cognitive impairment and a history of pressure ulcers developed a new Stage 2 ulcer on the left heel due to inconsistent use of prescribed protective boots. Despite a care plan requiring bilateral Prafo boots, the resident was observed wearing tennis shoes, leading to the ulcer's recurrence. Staff confusion and inconsistency regarding footwear contributed to the deficiency.
The facility failed to respond to call lights within 15 minutes for several residents, as observed during the survey. A resident with intact cognition and requiring assistance activated the call light, but personal care was delayed. Another resident with medical conditions also experienced delays in receiving assistance. Staffing levels did not meet the Facility Assessment requirements, contributing to the delays, particularly on weekends. The facility's outdated call light system further complicated the issue.
The facility failed to maintain proper hand hygiene during a meal service, as observed with staff not washing hands after handling food and touching various surfaces. Despite training and policy requirements, staff did not adhere to handwashing protocols, leading to potential cross-contamination.
The facility did not have a certified Infection Preventionist (IP) as required by their policy. The Assistant DON was still completing the necessary training. The DON, who is new and not certified, suggested regional personnel for the IP interview. The Regional Director of Operations, not being a nurse, stated that collaboration with the Regional Nurse Consultant and the DON was needed to decide on the interview process, as no IP was on staff.
A facility failed to notify the OSLTO of two hospital transfers for a resident with intact cognition and multiple diagnoses, including cancer and schizophrenia. The resident was transferred to the hospital four times, but the facility did not report two of these transfers. Staff interviews revealed that the social worker was responsible for notifications, and the decision to report was based on whether the transfer was overnight.
A resident with a history of heart and lung conditions returned from the hospital with new medication orders, which were not entered into the eMAR by the facility staff. This oversight led to the resident not receiving critical medications, resulting in worsening respiratory distress and rehospitalization. The error was discovered by a regional nurse, highlighting a breakdown in communication and procedure within the facility.
A resident with no cognitive impairment reported that staff searched her room without consent while she was away, leaving her belongings unorganized. The search was conducted to find a missing remote belonging to her roommate. The ADON and DON were aware of the incident, which violated the facility's Resident Rights policy emphasizing respect and dignity.
The facility failed to accurately assess and respond to the worsening conditions of two residents, leading to severe outcomes. One resident experienced worsening gastrointestinal symptoms over four days, resulting in death after emergent hospital treatment. Another resident experienced worsening edema and inability to urinate, leading to hospitalization. Additionally, a resident with diabetes missed insulin doses due to incorrect transcription of a physician's order, resulting in hospitalization for Diabetic Ketoacidosis.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, left femur fracture, and malnutrition was admitted to the facility without any pressure ulcers and was assessed as being at risk for developing them. The resident was dependent on staff for all transfers, bed mobility, dressing, and toilet hygiene, and had an indwelling urinary catheter with frequent bowel incontinence. Despite being identified as at risk, the care plan did not address the development of a Stage 3 pressure ulcer that was identified on the resident's sacrum. Physician orders were issued for wound treatments, an air mattress, and repositioning every two hours, but these interventions were not consistently implemented. Observations revealed multiple failures in following physician orders and standard care practices. The resident was found without a dressing on the pressure ulcer, and infection control techniques were not utilized during wound care. The air mattress, which was ordered to reduce pressure, was not in place on several occasions. Staff omitted key components of the wound care treatment, such as the application of calcium alginate, and failed to perform hand hygiene or change gloves during wound care. The resident was also left in a wheelchair for extended periods without repositioning or toileting assistance, and staff were unaware of the resident's skin impairments. Further observations documented that the resident's sacral wound was left without a dressing, and a new open area developed on the coccyx. The air mattress intervention continued to be unimplemented, and the resident was found with incontinent stool on the buttocks. Nursing staff admitted to being behind on treatments and not completing wound care as ordered. The care plan and Braden scale assessments were not updated to reflect the resident's changing condition, and the facility failed to ensure timely and appropriate interventions to prevent further skin breakdown.
Failure to Follow Physician Orders and Document Wound Care
Penalty
Summary
The facility failed to assess and follow physician treatment orders for non-pressure wound care for two residents. For one resident with peripheral vascular disease, traumatic compartment syndrome, diabetes, and atrial fibrillation, there was a lack of documentation regarding wound measurements or assessments for vascular wounds on both heels. The treatment administration record showed missed or undocumented wound care on scheduled days, and there was no evidence that the provider was notified when the resident refused wound care. Additionally, a vascular surgery clinic note indicated that the resident had not received proper wound care at the facility, and the family expressed distress over the lack of care during a medical appointment. For another resident with moderate cognitive impairment, esophageal obstruction, dysphagia, heart failure, and chronic kidney disease, the care plan required regular skin evaluations and specific wound care for a skin tear on the left calf. The treatment administration record revealed missed documentation of scheduled wound care, and during an observation, the dressing applied was not consistent with the physician's order. Staff interviews confirmed that the correct dressing was not used and that wound care was not always performed as ordered. Facility policy required verification of physician orders, adherence to care plans, and notification of supervisors if wound care was refused. However, staff interviews and record reviews demonstrated that these procedures were not consistently followed, resulting in missed or improper wound care and lack of appropriate documentation and communication regarding resident refusals and wound status.
Failure to Use Safe Transfer Techniques and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure safe transfer techniques and adequate supervision to prevent accidents for multiple residents, resulting in significant injuries and incomplete post-fall assessments. One resident with severe cognitive impairment and a history of fractures was transferred using a mechanical lift by a CNA who did not follow manufacturer instructions for sling attachment. The resident fell from the lift, sustaining a sacral fracture, tibial plateau fracture, and head injury. The CNA operated the lift alone, did not cross the sling straps as required, and the incident was not immediately reported to the state agency. The facility's own policy and the lift manufacturer's instructions were not followed during this transfer. Another resident with severe cognitive impairment and a history of falls was assisted from a dining room chair without the use of a gait belt, contrary to care plan requirements. The resident fell, complained of dizziness and back pain, and developed a chin bruise. Staff failed to check the resident's range of motion before moving her from the floor, and neurological assessments were not completed as required by facility protocol. Similarly, a third resident with severe cognitive impairment and a history of crawling on the floor was found on the floor by staff, but the event was not treated as an unwitnessed fall, and a neurological assessment was not initiated as required by policy. Additionally, another resident dependent on two staff for transfers was observed being transferred by a single CNA without a gait belt, in violation of the care plan and facility policy. Staff interviews confirmed that transfers were not performed according to established protocols, and staff were not consistently using required safety equipment. Facility policies on safe lifting, neurological assessment, and fall protocols were not followed, leading to preventable injuries and incomplete post-incident assessments for multiple residents.
Failure to Maintain Clean Resident Equipment and Environment
Penalty
Summary
Surveyors observed multiple instances of unclean resident equipment and environmental surfaces within the facility. A full body mechanical lift in one hallway had a brown smear on its leg that remained uncleaned over two consecutive days. Similarly, a mechanical sit-to-stand lift in another hallway had a heavily soiled foot plate with debris that was not addressed over the same period. Additionally, a high back wheelchair was found in the hallway with a yellow-stained towel on its seat, which was not removed or cleaned throughout the day. In a resident room, brown spots and smears were noted on the bathroom floor near the toilet, and a soiled incontinence pad was left on the bed. Interviews with CNAs confirmed that staff were responsible for cleaning mechanical lifts, changing bed linens, and removing soiled incontinence pads. Both interviewed CNAs stated that soiled incontinence pads should not be left on beds and that cleaning of equipment and surfaces was part of their duties. Review of the facility's cleaning and disinfection policy indicated that environmental surfaces and equipment should be cleaned and disinfected regularly and when visibly soiled, in accordance with CDC and OSHA standards. The observations and staff interviews demonstrated a failure to maintain a clean and safe environment as required by facility policy.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the individualized needs of residents, as evidenced by clinical record review, staff interviews, and facility policy review. One resident with moderate cognitive impairment, requiring moderate assistance for bathing and partial assistance for personal hygiene, did not receive a bath or shower for a period of 17 days. Staff interviews revealed that certified nursing assistants (CNAs) and registered nurses (RNs) were unable to complete all required personal care tasks due to routine understaffing. Staff reported that these concerns had been brought to management multiple times without any observed improvement. Additional interviews with licensed practical nurses (LPNs), RNs, and CNAs indicated that wound care treatments and scheduled baths were often delayed or missed when medication aides were not available or when only one CNA was assigned to a hallway with approximately 25 residents, many of whom required two staff members for mechanical lift transfers. Staff also reported that, due to insufficient staffing, residents sometimes received meals in their rooms instead of the dining room, and feeding assistance was provided one at a time. The facility's assessment stated that staffing was based on resident acuity and that contingency plans existed for staff call-outs, but staff consistently reported that these measures were insufficient to address ongoing staffing shortages.
Infection Control Practices Not Followed During Insulin Administration, Peri-Care, and Wound Care
Penalty
Summary
The facility failed to ensure infection control practices were followed during insulin administration for a resident receiving Lantus and insulin pen injections. During observation, an LPN administered both injections without wearing gloves. Staff interviews later confirmed that nurses were expected to wear gloves during insulin administration because of the risk of blood borne pathogens, and the Infection Preventionist also stated gloves were expected for this task. The facility also failed to follow infection control practices during peri-care and wound care for residents with wounds or indwelling devices requiring Enhanced Barrier Precautions (EBP). Two CNAs provided peri-care to a resident with a wound without wearing gowns, and after care they did not change gloves or wash hands before assisting with clothing and repositioning. For another resident with an indwelling urinary catheter and a Stage 3 sacral pressure ulcer, the care plan identified EBP for the catheter but did not include the pressure ulcer, and during wound care an RN did not use additional PPE such as a gown. The RN also did not change gloves between dirty and clean tasks while cleansing and dressing the wound. Facility staff, including the DON and Infection Preventionist, stated EBP required gown and gloves for residents with indwelling catheters or chronic wounds, and the facility policy stated gloves were to be worn when contact with blood, body fluids, or other infectious materials was likely.
Failure to Ensure Resident Dignity and Respect in Care and Environment
Penalty
Summary
The facility failed to provide a respectful and dignified environment for three residents, as evidenced by multiple observations and interviews. One resident, who was cognitively intact and dependent on staff for toileting and mobility, was not offered meal choices according to her preferences. Staff delivered an incorrect meal and, without asking the resident for her preference, substituted it with a food item not listed on the menu or alternative menu. The resident reported that she is never asked what she would like to eat and is typically given whatever is available, rather than being provided with options. Another resident with bowel incontinence and frequent diarrhea was observed multiple times in a room with a strong odor of feces and urine, and with visibly soiled sheets and floors. The resident confirmed that his sheets had been soiled since the previous night. Observations over several days revealed persistent dried feces on the bed sheets, floor, and bathroom surfaces. Staff interviews confirmed awareness of the soiled conditions, and the CNA job description included maintaining a clean and pleasant environment, which was not upheld in this case. A third resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found lying in bed without an incontinence product and with pants pulled down around her ankles. This condition persisted during subsequent observations until the DON intervened to provide care and clothing. The resident expressed feeling cold during this time. Facility policy requires residents to be treated with dignity and respect, which was not observed in these instances.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of an antipsychotic medication, risperidone, for one resident diagnosed with non-Alzheimer's dementia and depression. Clinical record review showed that the resident had moderate cognitive impairment, as indicated by BIMS scores of 9 and 11 on separate assessments. The resident began receiving risperidone on a routine basis, as documented in progress notes and the Minimum Data Set (MDS) assessments. However, there was no documentation of informed consent from the resident's responsible party for the use of this psychotropic medication during the period from when the medication was initiated through the time of the survey. Staff interviews confirmed that the process for obtaining consent was not followed, with the Licensed Practical Nurse stating that the nurse who received the order should have contacted the family or resident to obtain and document consent in the chart. The facility's policy on antipsychotic medication use, dated 12/2016, requires that informed consent be obtained, but review of the resident's evaluations and care plan revealed no such documentation. The care plan also failed to include the use of the antipsychotic medication.
Failure to Provide Required Bathing and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically in the areas of bathing and incontinence care, for several residents. One resident with severe cognitive impairment, non-Alzheimer's dementia, schizophrenia, and congestive heart failure was observed with visibly wet clothing and was not assisted by staff with changing or incontinence care, despite care plan interventions indicating the need for staff assistance. Staff acknowledged the resident's inability to perform self-care after incontinence and confirmed that staff should have reapproached and assisted the resident. Multiple residents did not receive the required twice-weekly bathing. One resident with intact cognition and no documented refusals had no baths recorded during their stay. Another resident with severe cognitive impairment and no history of care refusal went up to 14 days without a bath, with documentation showing missed or unattempted baths and only one recorded refusal. A third resident with intact cognition and no refusal behavior had no documented baths for 27 days, with only one recorded refusal, and staff interviews indicated that the resident rarely refused bathing and liked to be clean. Additionally, a resident with moderate cognitive impairment and frequent incontinence was observed to be unshaven, with greasy hair and dirty clothing on consecutive days, and staff reported that the resident did not refuse bathing. Bathing records for this resident showed missed or unattempted baths due to environmental limitations or lack of staff. Staff interviews revealed that short staffing contributed to missed baths, and the facility's policy required assistance with ADLs to maintain hygiene, which was not consistently provided.
Failure to Complete Required Annual Employee Performance Reviews
Penalty
Summary
The facility failed to complete 3 of 3 employee annual performance reviews for staff members reviewed. The nursing employee files showed that Staff C, an LPN hired on 3/11/2024, had an unsigned Annual Review with no other reviews completed; Staff D, a CNA hired on 5/4/2023, had an unsigned Annual Review showing her last annual review was completed on 5/22/2024; and Staff E, a CNA hired on 6/22/2014, had an unsigned Annual Review showing her last annual review was completed on 6/22/2024. During interviews, the Administrator stated there were no further evaluations for Staff C, D, and E, and also stated that employee evaluations were expected annually and as needed. The facility policy stated that supervisors will evaluate all team members on a timely and ongoing basis, with performance reviews completed on a team member's first anniversary date and annually thereafter.
Expired insulin and incomplete refrigerator temperature logs
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices when expired insulin was found in a medication cart for Resident #41. During an observation on 11/25/2025 at 7:45 AM, an LPN on the [NAME] wing found a Humalog insulin bottle dated 10/12/25 and a Lantus insulin dated 9/25 for the resident. The LPN looked for other opened insulin for the resident in the cart but did not locate any non-expired insulin, and reported that the expired insulin needed to be replaced. The LPN then obtained the needed insulin from the emergency kit and dated the insulin when it was opened. The facility also failed to check and document medication refrigerator temperatures on a scheduled basis. During an observation on 11/24/2025 at 10:37 AM, a refrigerator temperature log posted in the west hall medication room showed temperatures recorded on only 7 of the possible 24 days in 11/2025. The DON stated that refrigerator temperatures were expected to be taken and logged daily. The facility policy titled Refrigerators and Freezers, dated 2014, stated the facility would ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and that monthly tracking sheets for all refrigerators and freezers would be posted to record temperatures.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information on 4 of the 6 days observed during the survey, including 11/19/25, 11/25/25, 12/01/25, and 12/02/25, while the facility reported a census of 58 residents. During interviews on 12/02/2025, the traveling RN/DON stated she thought the facility DON, Business Office Manager, or Administrator completed and posted the daily staff information, while the Administrator said she did not know who completed the posting and later stated she needed the DON to get the staff posting from his computer. The DON later reported he failed to complete the staff postings, said the night shift nurse was expected to complete them, and stated he had not tracked whether the information was posted. He also reported the daily staff postings were hung on the wall near the other postings. The Administrator further reported the facility did not have a policy to address a daily staff posting.
Failure to Conduct Effective QAPI and Address Repeat Deficiencies
Penalty
Summary
The facility failed to conduct ongoing quality assessment and assurance activities and failed to develop and implement appropriate plans of action to prevent repeated quality deficiencies identified during the current recertification survey. The facility had a census of 58 residents. Review of the Summary Statement of Deficiencies dated 11/21/24 showed a citation at F0686 with a scope and severity of G and a citation at F0725 with a scope and severity of E. QA notes dated 12/18/24 reflected possible tags from a complaint and survey, including F0686 followed by the wound clinic at the hospital. The note stated that the facility assessment was updated to reflect the staffing needs of the residents. The survey dated 12/3/25 identified a concern at F0686 at Immediate Jeopardy and a concern at F0725 at scope and severity E. During an interview on 12/03/2025 at 2:22 PM, the Administrator confirmed the repeat concerns identified and the need to address the pattern of deficiencies. The facility provided a QAPI Plan dated 3/2020 stating that the QAPI Committee was responsible for collecting and analyzing performance indicator data, identifying and resolving negative outcomes and care quality problems, using root cause analysis, helping departments implement systems to correct issues, establishing benchmarks and goals, coordinating performance improvement projects, and communicating QAPI activities to the Administrator and governing body.
Failure to Prevent Recurrence of Pressure Ulcer
Penalty
Summary
The facility failed to prevent the recurrence of a pressure ulcer for a resident, identified as Resident #27, who had a history of severe cognitive impairment and was dependent on staff for dressing and footwear. The resident had previously healed from a Stage 4 pressure ulcer on the left heel, which was resolved in September. However, a new Stage 2 pressure ulcer developed in the same area by October. The resident was assessed as being at moderate to high risk for pressure injuries, as indicated by the Braden Scale scores. The care plan for the resident included the use of bilateral Protective Relief Ankle Foot Orthosis (Prafo) boots to prevent pressure ulcers. Despite this, observations and interviews revealed that the resident was not consistently wearing the prescribed protective boots. Instead, the resident was found wearing tennis shoes, which were not recommended by the wound care provider. Staff interviews indicated confusion and inconsistency regarding the resident's footwear, with some staff members unsure about when the resident should wear the protective boots. The Family Nurse Practitioner and the Director of Nursing both acknowledged that the recurrence of the pressure ulcer could have been prevented if the resident had consistently worn the protective boots. The facility's policy on wound care emphasized the importance of following physician orders and care plans, but this was not adhered to in the case of Resident #27. The lack of consistent application of the prescribed protective measures contributed to the recurrence of the pressure ulcer on the resident's left heel.
Staffing Shortages Lead to Delayed Call Light Responses
Penalty
Summary
The facility failed to respond to call lights within 15 minutes for four residents, as observed during the survey. Resident #12, who had intact cognition and required assistance for various activities, activated the call light at 12:50 PM. Although an LPN turned off the call light and administered insulin, personal care was not provided, and the resident had to wait until 1:08 PM for a CNA to assist with toileting. Similarly, Resident #204, with intact cognition and medical conditions that required assistance, activated the call light at 9:12 AM. An LPN turned off the light at 9:25 AM, promising to send help, but the resident continued to wait until 9:45 AM for assistance from CNAs. Resident #6, with a history of falls and intact cognition, reported that call lights often took 20-30 minutes to be answered, occurring every other day across all shifts. Resident #50, also with intact cognition and dependent on staff for transfers and personal hygiene, confirmed that call lights took 20 minutes or more to be answered. The facility's policy on answering call lights did not specify a time frame, contributing to the delay in response times. The facility's staffing levels did not meet the requirements outlined in the Facility Assessment for several days. The Daily Staffing Plan required two licensed nurses, two medication aides, and six CNAs on the day shift, but records showed that staffing levels were often below these requirements. Interviews with staff and the Director of Nursing revealed that staffing shortages, particularly on weekends, contributed to the delays in responding to call lights. The facility's call light system was also outdated, preventing the production of call light records or logs, further complicating the issue.
Failure to Maintain Hand Hygiene During Meal Service
Penalty
Summary
During a noon meal service, the facility failed to adhere to proper hand hygiene practices, leading to potential cross-contamination of food. Observations revealed that Staff H wiped his hand on his shirt after handling a pan of food from the oven. Staff G, after touching various surfaces and handling food, did not wash her hands before returning to the serving line. She caught a spilled mixture of lettuce and cheese with her bare hand and returned it to the preparation pan. Additionally, Staff G handled meal request slips, disposed of them, and continued plating food without washing her hands. Both Staff G and Staff H were observed leaving and returning to the serving area without washing their hands. The Certified Dietary Manager (CDM) confirmed that handwashing was covered in both orientation and ongoing training, and expressed that staff should wash their hands before serving and after any contamination. The facility's handwashing policy, revised in 2020, mandates handwashing after contact with unclean surfaces and when moving between different areas, which was not followed during the observed meal service.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) who completed specialized training in infection prevention and control, as required by their policy. During an interview, the Director of Nursing (DON) and Regional Nurse Consultant confirmed that the facility did not have a certified IP. The Assistant DON was in the process of completing the necessary training but had not yet finished. The DON, being new to the position and not certified, suggested that the IP interview should be conducted with regional personnel. The Regional Director of Operations, who is not a nurse, indicated that collaboration with the Regional Nurse Consultant and the DON would be necessary to determine the appropriate person to conduct the interview, as no IP was currently on staff. The facility's policy, revised in September 2017, requires the IP to conduct ongoing surveillance for Healthcare-Acquired Infections (HAIs) and other significant infections that may impact resident outcomes and require preventative interventions.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Ombudsman (OSLTO) of two separate hospital transfers for a resident. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 13 out of 15, was diagnosed with cancer, schizophrenia, and an excoriation disorder. The resident's care plan included focus areas for impaired cognitive function, risk for skin and soft tissue infection, mental health support, and diabetic ulcers on eight fingers. The resident was transferred to the hospital on four occasions, but the facility did not include the May and June transfers in the notifications to the OSLTO. Interviews with facility staff revealed that the social worker was responsible for submitting discharge information to the OSLTO. The Administrator stated that the decision to report a transfer depended on whether it was an overnight stay. The Social Services Director confirmed that she did not include transfers if the resident returned the same day. This oversight resulted in the omission of a same-day return transfer and a five-day hospital visit from the required notifications.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medication as ordered by the physician for a resident who had recently returned from the hospital. The resident, who had a history of acute congestive heart failure, chronic kidney disease, atrial fibrillation, and pneumonia, was admitted to the emergency department with acute hypoxic respiratory failure. Upon discharge back to the facility, the resident received new physician orders for medications including albuterol, prednisone, Spiriva, and an increased dose of furosemide. However, these new orders were not entered into the electronic Medication Administration Record (eMAR) by the staff nurse, resulting in the resident not receiving the prescribed medications. The resident's condition worsened due to the lack of medication administration, leading to increased shortness of breath, lethargy, and low oxygen saturation levels. The resident was readmitted to the hospital, where it was discovered that the new medication orders had not been implemented since the resident's return to the facility. The failure to administer the medications as ordered was identified by the corporate regional nurse, prompting a self-report to the state and a subsequent investigation. Interviews with facility staff revealed that the new orders were not entered into the system due to a series of miscommunications and oversights. The agency nurse who assisted with the resident's readmission handed the paperwork to the Director of Nursing (DON), who then left the facility due to illness without ensuring the orders were processed. The Assistant Director of Nursing (ADON) later discovered the oversight but was unable to retrieve the orders in a timely manner, as they were locked in the DON's office. This chain of events led to a significant medication error, contributing to the resident's deterioration and eventual rehospitalization.
Removal Plan
- Education provided to nursing staff
- Charge nurse responsible to complete on any admission or transfer in from the hospital followed by double noting by two nurses
Unauthorized Search of Resident's Belongings
Penalty
Summary
The facility failed to respect the personal property and possessions of a resident when staff searched the resident's room without consent. The incident involved a resident who had no cognitive impairment and used a wheelchair for mobility, with diagnoses including post-polio syndrome, rheumatoid arthritis, and paraplegia. The resident reported that while she was away for a physician's appointment, staff searched her belongings without her knowledge, leaving them unorganized. The search was conducted in an attempt to locate a missing television remote belonging to the resident's roommate. Staff interviews revealed that the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were aware of the incident. The ADON confirmed that the resident reported the unauthorized search, and the DON acknowledged instructing staff not to search residents' belongings without their knowledge. The facility's Resident Rights policy, revised in December 2016, emphasizes treating residents with respect and dignity, and ensuring they are free from misappropriation of property. Despite this policy, the staff's actions violated the resident's rights, as they conducted the search without obtaining the resident's consent.
Failure to Assess and Respond to Resident Conditions
Penalty
Summary
The facility failed to accurately assess and respond to the worsening conditions of two residents, leading to severe outcomes. One resident, with a history of traumatic brain injury, diabetes, and other conditions, experienced worsening gastrointestinal symptoms over four days, including stomach ache, abdominal tenderness, and emesis. Despite these symptoms, the facility staff did not notify the medical provider or seek treatment orders in a timely manner. The resident's condition deteriorated, requiring emergent medical treatment in the hospital emergency room, where they died within six hours of admission due to complications including acute respiratory distress syndrome, small bowel obstruction, and acute pancreatitis. Another resident, admitted with diagnoses including congestive heart failure and diabetes, experienced worsening edema and an inability to urinate over two days. The facility failed to document and assess these symptoms adequately, resulting in the resident's hospitalization for urinary retention, suspected bladder malignancy, and acute kidney injury. The facility also failed to administer the resident's prescribed medications promptly due to a delay in completing the admission assessment and entering medication orders into the system. Additionally, the facility failed to correctly transcribe a physician's order for insulin for a resident with diabetes, leading to missed insulin doses and the resident's hospitalization for Diabetic Ketoacidosis. The resident's care plan lacked focus on insulin administration and blood sugar monitoring, contributing to the oversight. The facility's failure to ensure accurate medication administration and timely medical intervention resulted in significant adverse outcomes for the residents involved.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 101 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Branch
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Iowa City Rehab & Health Care | 6.8 mi | ★★★★★ | 27 | 0 |
| Simpson Memorial Home | 8.2 mi | ★★★★★ | 6 | 0 |
| Briarwood Healthcare Center | 10.2 mi | ★★★★★ | 1 | 0 |
| Oaknoll Retirement Residence | 10.7 mi | ★★★★★ | 5 | 0 |
| Solon Nursing Care Center | 11.4 mi | ★★★★★ | 0 | 0 |
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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.