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 Hallmark Care Center during CMS and state inspections, most recent first.
Failure to Document Consent and Education for Psychotropic Medications: The facility did not document consent, resident education, or discussion of alternative treatments before giving psychotropic medications to four residents with diagnoses including dementia, anxiety, depression, PTSD, insomnia, and bipolar disorder. Records showed orders for antidepressants, antianxiety medications, antipsychotics, and hypnotic agents, but no progress notes or assessments reflected education on risks and benefits or that alternatives were offered, and the facility had no policy for psychotropic medication use.
The facility inaccurately coded several MDS assessments for medications, smoking, falls with major injury, and restraints. Records showed one resident received aspirin and clopidogrel for stroke prevention, but the MDS incorrectly coded anticoagulant use; another resident’s bed grab bar was coded as a restraint even though it was used for repositioning and bed mobility. Other MDSs failed to capture prescribed psychotropic medications, current tobacco use, and a fall with major injury, and the DON acknowledged some assessments were not accurate.
Failure to document vaccine education and consent. The facility did not provide documented education or obtain informed consent for influenza vaccination for four residents and pneumococcal vaccination for three residents. Review of EHRs showed several residents had not received the indicated vaccines, and the DON could not find records showing education was provided or signed refusals were obtained. The Infection Control Manual required education, consent, and EHR documentation for immunizations.
A resident received Medicare-covered skilled services, but the facility did not provide an accurate NOMNC with the correct end date and did not issue a SNF ABN when coverage ended and payor source changed to private pay. Chart review showed the resident’s spouse was concerned about discharge timing, yet the record lacked documentation explaining the delayed discharge, had no discharge summary, and included an incomplete discharge instruction assessment; the facility later noted the ABN was likely overlooked during a staff changeover.
Missing transfer documentation for hospitalized residents. The facility failed to keep records of the information sent with two residents during four hospital transfers. Review of progress notes and assessments showed no documentation of the MAR, TAR, IPOST, face sheet, bed hold form, vital signs, or verbal reports that the DON expected staff to provide to EMTs and the ER, and the DON and Administrator stated the facility did not have a written discharge policy or procedure.
A resident’s PASRR was not updated after PTSD was documented and psychotropic meds were ordered and given, while two other residents with PASRR Level II outcomes did not have the required specialized and rehabilitative services reflected in their care plans. The DON and SW reported uncertainty and lack of training related to PASRR completion and updates.
Care plans were not updated for two residents after hospital returns. One resident returned with a PICC line and antibiotics after treatment for kidney stones and a UTI, but the care plan did not reflect the hospitalization, antibiotic therapy, kidney stones, or PICC site maintenance. Another resident returned after treatment for hypernatremia, diabetes insipidus, aspiration pneumonia, acute respiratory failure, and electrolyte abnormalities, but the care plan did not include the recent hospitalization or monitoring for hypernatremia. The DON confirmed the care plans were not updated, and the facility policy lacked instructions for reviewing care plans after hospitalization.
A resident with HF and CKD stage 4 had a physician order for daily morning weights, but multiple weights were missing from the ETARs and vital sign records over several months. Staff said CNAs usually obtained the weights and nurses documented them, but the DON and Administrator reported the weights were likely not entered into the EHR vital sign area, and the facility policy required active orders to be followed as written.
QAPI process failed to address PASRR deficiencies after a prior F644 citation. A resident’s record showed a PASRR completed by a hospital that listed suspected anxiety disorder and use of antidepressant and antianxiety meds, but the resident was later admitted with PTSD and then started on Abilify without an updated PASRR evaluation in the record. The DON confirmed no updated PASRR had been completed since the hospital screening, while the Administrator stated tagged-area audits were to be tracked through QAPI.
The facility failed to ensure the Infection Preventionist attended quarterly QAPI meetings. QA sign-in sheets showed no documentation of attendance at two quarterly meetings, and the DON stated the Infection Preventionist may have been working the floor at those times. The Administrator confirmed the Infection Preventionist was not present, and the meeting notes did not show a significant quarterly review of the infection control program/tracking.
The facility failed to document COVID-19 vaccine education and informed consent for two residents. Review of the EHRs found no evidence that either resident received vaccine education or consent, and the DON could not locate documentation of education or signed refusal forms. The facility policy required staff to educate residents, obtain consent for available vaccines, and document all immunizations in the EHR.
A facility failed to accurately report a resident's mental health diagnoses and medications in the PASRR process. The resident, diagnosed with depression, anxiety disorder, and PTSD, had a PASRR that omitted PTSD and certain medications. Staff interviews revealed a lack of awareness of the resident's diagnoses, and the DON acknowledged the oversight. The facility lacked a specific PASRR policy, contributing to the deficiency.
A resident with impaired cognition and a wrist injury experienced inadequate pain management following a fall. Despite high pain ratings, the care plan lacked focus on pain management, and documentation of follow-up assessments was inconsistent. Staff interviews indicated verbal assessments were conducted, but these were not documented, and the facility's pain policy was not consistently followed.
A facility failed to provide trauma-informed care for a resident with PTSD, depression, and anxiety. The resident's care plan did not address her mental health needs, and staff were unaware of her diagnoses and triggers. The resident expressed feeling frustrated and unsupported during health changes. The facility lacked a policy for trauma-informed care, and the care plan did not include necessary mental health information.
The facility failed to provide bed hold notices to two residents or their representatives before hospital transfers, as required by policy. One resident was transferred due to an unwitnessed fall with a head injury, and another due to a change in condition and viral infection. Documentation did not include whether bed hold notices were sent, violating the facility's policy.
A facility failed to submit a discharge MDS for a resident who was discharged to the community, with no return anticipated. The MDS was completed but not submitted to CMS, and the DON was unsure why the 'do not submit' indicator was triggered. The facility lacked a policy for MDS assessments and relied on the RAI manual, which requires submission within 14 days.
The facility failed to ensure food items were covered, dated, and stored to prevent possible cross-contamination. Uncovered drinks and pies without labels or dates were found in the walk-in refrigerator. Staff were unsure about the timing of food preparation and acknowledged the need for proper food storage practices.
The facility failed to complete a follow-up PASRR for a resident with a change in mental health status. The resident had psychiatric disorders and was receiving antipsychotic medications. The administrator acknowledged the oversight, noting that some diagnoses were discovered post-admission and a new PASRR should have been submitted.
Failure to Document Consent and Education for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments by not providing education on the risks and benefits of psychotropic medications and by not offering alternative treatment options before administration for 4 of 5 residents reviewed for unnecessary medications. Clinical record reviews showed that Resident #8, with diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression, was admitted on 7/23/25 and received escitalopram, buspirone, and quetiapine without documentation of consent, education on side effects or risk versus benefit, or alternative treatments. The Administrator stated on 4/7/26 that the DON had started in October 2025 and had been catching up psychotropic assessments that had previously been completed. Resident #18, admitted on 10/22/25 with anxiety disorder, PTSD, and insomnia, had orders for sertraline and trazodone in October 2025 and later Abilify and doxepin, but the EHR did not show consent before administration or documentation of education or alternative treatments. Resident #33, admitted on 9/25/25 with anxiety disorder, depression, bipolar disorder, and PTSD, had orders for bupropion, duloxetine, trazodone, and buspirone, and Resident #38, admitted on 9/3/25 with anxiety disorder and PTSD, had orders for Abilify, trazodone, buspirone, and duloxetine; for both residents, the EHR lacked consent, education on psychotropic medication risks and benefits, and documentation that alternative treatments were offered. On 4/8/26, the Administrator stated she had started her position about a month earlier and would speak with the DON regarding education and consents for psychotropic medications. The facility did not have a policy for use of psychotropic medications.
Inaccurate MDS Coding for Medications, Smoking, Falls, and Restraints
Penalty
Summary
The facility failed to accurately code resident assessments on the MDS for falls with major injury, medications, smoking, and restraints for 5 of 15 reviewed residents. Survey findings showed that the MDS coding did not match the clinical record, medication administration records, resident interviews, or staff interviews in several cases, and the facility’s DON and corporate MDS staff acknowledged that some assessments were not accurate. For one resident with a stroke diagnosis and moderate cognitive impairment, the record showed aspirin and clopidogrel were administered for secondary stroke prevention, but the MDS coded anticoagulant and antiplatelet medications despite the records lacking documentation of any anticoagulant administration. The CMS LTC RAI Manual specifically directed that aspirin and clopidogrel are not to be coded as anticoagulants. The DON stated she would verify whether any anticoagulant had been given and later reported that the MDS assessments were not accurate. For another resident, the MDS coded a bed rail as a restraint even though the resident used a grab bar to reposition in bed and to help with getting in and out of bed. The resident stated the grab bar helped her remain independent and did not restrict her movement, and staff reported there were no residents using restraints. The DON stated the grab bars were being coded as restraints and that she was trying to change care plans to reflect they were not restraints. Additional inaccuracies involved a resident whose MDS failed to document antianxiety and antipsychotic medications despite MAR documentation of Buspirone and Seroquel, a resident whose MDS failed to document current tobacco use despite the resident stating she was a smoker and the care plan reflecting smoking, and a resident whose MDS failed to code a fall with major injury despite documentation of a sacral fracture after an emergency department visit. The DON later stated staff should have coded tobacco use for one resident and a fall with major injury for another resident, and clarified that one resident’s bed bars were for mobility rather than restraint use.
Failure to Document Vaccine Education and Consent
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. Based on review of records, staff interviews, and facility policy, the facility failed to provide education and obtain informed consent for influenza vaccination for 4 of 4 residents reviewed (Resident #7, #12, #18, and #24) and for pneumococcal vaccination for 3 of 3 residents reviewed (Resident #7, #18, and #24). Review of the census and EHR showed Resident #7, Resident #18, and Resident #24 had not received influenza or pneumococcal vaccinations, and Resident #12 had not received influenza vaccination. The DON stated the current Infection Preventionist was on leave and, after reviewing past immunization records, could not find documentation that the residents were provided education or that any signed refusals were obtained. The facility’s Infection Control Manual, last revised in 10/2025, required staff to educate residents, obtain consent for available vaccines, and document all immunizations in the EHR.
Failure to Provide Accurate Medicare Non-Coverage and SNF ABN Notices
Penalty
Summary
The facility failed to ensure that Resident #50 received an accurate and timely Notice of Medicare Non-Coverage (NOMNC) and failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare-covered services ended and the resident’s payor source changed to private pay. Record review showed the resident received Medicare-covered services from 2/10/26 through 3/3/26, with private pay beginning on 3/4/26. However, the facility-provided NOMNC signed by the resident’s spouse/representative on 2/18/26 stated that Medicare coverage would end on 2/24/26, and the Administrator later stated she could not locate another NOMNC with the correct end date of 3/3/26. The chart also did not contain a SNF ABN for Resident #50. The facility documented on 4/7/26 that the ABN was not provided because the plan was for the resident to discharge home the day after skilled care ended, and that a staff changeover occurred at the same time and the ABN was likely overlooked. Notes from 2/20/26 and 2/27/26 showed the husband was concerned about the projected discharge date and that the resident was seen for therapy follow-up and discharge planning, but no chart notes explained that the original discharge date was delayed or why it changed. No discharge summary note was found, and the Instructions for Discharge assessment dated 3/5/26 was incomplete.
Missing Transfer Documentation for Hospitalized Residents
Penalty
Summary
The facility failed to maintain documentation of the information sent to the hospital during transfers for 4 of 4 hospitalizations reviewed for two residents. Resident #2 had hospital transfers documented on the census list from 1/19/26 to 1/23/26 and from 3/25/26 to 4/2/26, but review of progress notes and assessments showed no documentation of what information was sent to the hospital for either transfer. Resident #6 had hospital transfers documented from 2/18/26 to 2/27/26 and from 3/29/26 to 4/3/26, and again the progress notes and assessments did not show documentation of the information sent to the hospital for either hospitalization. During interview, the DON and Administrator stated the facility did not have a written discharge policy or procedure, and the DON said staff were expected to send the MAR, TAR, IPOST, face sheet, and bed hold form, along with vital signs and verbal reports to EMTs and the ER; however, they acknowledged the facility could not locate the documentation sent with either resident for any of the reviewed hospitalizations.
PASRR reviews and care plans were not kept current with mental health diagnoses and Level II service needs
Penalty
Summary
The facility failed to ensure a resident’s mental health diagnosis and psychotropic medications were accurately reported to the designated state agency for PASRR review. Resident #38 was admitted after a hospital PASRR found no SMI, ID, or related condition and noted suspected anxiety disorder with antidepressant and anxiety medication use in the prior 6 months. The clinical record did not contain an updated PASRR after the resident’s discharge summary documented PTSD, follow-up with psychiatry and psychology, and an order for trazodone for PTSD. The resident’s EMAR showed trazodone was administered, the care plan later documented psychotropic medication use related to PTSD and behavior and psychosocial issues related to PTSD and anxiety, and a later referral for telehealth psychiatry listed anxiety disorder and PTSD along with antidepressant use for PTSD. A subsequent physician order added Abilify for PTSD, and the DON reported the facility did not have an updated PASRR for the resident; the Social Worker stated she was still working on conditional PASRR training and did not know whether PTSD or medication changes required rescreening. The facility also failed to implement PASRR Level II recommendations into the care plans for two residents. Resident #6’s PASRR Level II outcome identified her as Level II and directed specialized and rehabilitative services, but the current care plan did not include the Level II outcome or the implementation of those services. Resident #18’s PASRR Level II outcome also identified her as Level II and directed specialized and rehabilitative services, but the care plan review did not identify who would oversee the services, when they would begin, or whether necessary referrals had been completed. The Administrator stated the Social Worker completed PASRRs and had been in the role for nine months but had not received training on how to complete them.
Care Plans Not Updated After Hospitalizations
Penalty
Summary
The facility failed to implement interventions into the care plans for 2 of 2 residents following their return from hospitalizations. Resident #2 had two hospitalizations, first for acute respiratory failure with hypoxia due to Influenza A and a UTI, and later for kidney stones and a UTI. After the second return to the facility, he had a PICC line and was receiving antibiotics, but his current care plan had not been updated to include the recent hospitalization, antibiotic therapy, kidney stones, or PICC site maintenance. Resident #6 also had two hospitalizations, first for hypernatremia and diabetes insipidus, and later for aspiration pneumonia, acute respiratory failure, hypernatremia, and hyperkalemia. Her current care plan had not been updated to include the recent hospitalization or whether signs or symptoms could be monitored in the facility for hypernatremia. The DON confirmed that the care plans for Resident #2 and Resident #6 were not updated following their hospitalizations, and the facility’s care plan policy did not include instructions about whether care plans need to be reviewed following hospitalizations.
Missed Documentation of Ordered Daily Weights
Penalty
Summary
The facility failed to follow a physician order to obtain daily morning weights for a resident with heart failure and chronic kidney disease stage 4. The electronic health record showed an order for daily weights starting 11/25/25, and the care plan directed staff to monitor weights as ordered. Review of the 2026 ETARs and vital sign weight records showed multiple missing daily weights in January, February, March, and April for the resident. Staff interviews indicated the CNAs generally obtained the weights in the morning and gave them to the nurses, who documented them in the resident’s EHR. An LPN stated the resident required daily weights before and after dialysis treatments, while the DON reported that if the nurse did not enter the weight into the vital signs weight section, the weight was probably not documented. The Administrator stated nurses may not have known about a supplemental area in the EHR for entering the weight, and that most likely the weight was taken but not entered into the EHR vital sign area. The facility policy stated active orders should be followed and carried out as written.
QAPI Process Failed to Address PASRR Deficiencies
Penalty
Summary
The facility failed to implement effective quality assurance processes to address PASRR deficiencies, resulting in F644 being cited in 2025 and again during the current survey. The facility’s CASPER report showed a prior citation for F644 Coordination of PASRR and Assessments in March 2025. The CMS 2567 POC for that citation stated that Administrative Nurses and the Social Service Designee would continue reviewing PASRR assessments during the referral process to ensure new admissions had all mental health diagnoses included before admission, and that the Social Service Coordinator or designee would audit admissions monthly for three months to ensure all diagnoses were listed on the current PASRR. A review of Resident #38’s clinical record showed a PASRR completed by a local hospital on 9/02/25 before admission that listed suspected anxiety disorder and use of antidepressant and antianxiety medications. The resident was admitted with a physician order for antidepressant medication for PTSD, and on 12/19/25 a physician order was written to start Abilify every morning. During interview, the DON stated the facility did not have any updated PASRR evaluation for Resident #38 since 9/02/25. The Administrator stated that audits from tagged areas would be placed, completed, and tracked through the QAPI program for compliance, and the QAPI policy stated the Administrator was responsible for ensuring the program was defined, implemented, maintained, and addressed identified priorities, with regulatory outcomes and survey results monitored and trended.
QAPI Meetings Lacked Infection Preventionist Attendance
Penalty
Summary
The facility failed to ensure the Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. Review of the QA sign-in sheets for 10/24/25 and 1/21/26 showed no documentation that the Infection Preventionist was present at either quarterly meeting. The DON stated on 4/08/26 that the Infection Preventionist was still employed by the facility and may have been working the floor, which she said may have prevented attendance at the QA meetings. The Administrator later reviewed the QA sign-in sheets and confirmed the Infection Preventionist did not attend the meetings, and also reviewed the QAPI meeting notes for those dates and found there was not significant information regarding a quarterly review of the infection control program/tracking. The facility’s QAPI Plan Policy, effective 2/18/20, identified the QA Committee members as including the Medical Director or designee, DON, Administrator or other leader, and the Infection Prevention and Control Officer.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to provide COVID-19 vaccination education and obtain informed consent for 2 of 5 residents reviewed, identified as Resident #7 and Resident #12. Review of the census list showed both residents were current residents of the facility, and review of their EHRs found no documentation that either resident received COVID-19 vaccination education or was provided informed consent. During an interview, the DON stated the current Infection Preventionist was on leave and, after reviewing past immunization records, was unable to find documentation that the two residents were educated about the vaccine. The DON also found no signed documentation showing that either resident refused the COVID-19 vaccination. The facility's Infection Control Manual, last revised 10/2025, required staff to educate residents, obtain consent for available vaccines, and document all immunizations in the EHR.
Failure to Accurately Report Mental Health Diagnoses in PASRR
Penalty
Summary
The facility failed to accurately report a resident's mental health diagnoses and medications to the designated state agency as part of the Pre-Admission Screening and Resident Review (PASRR) process. Resident #17, who was diagnosed with depression, anxiety disorder, and PTSD, had a PASRR Level I Screen Outcome that did not include PTSD and omitted certain medications such as Alprazolam and Lamotrigine. The resident's electronic health record confirmed these diagnoses and medications were present at admission, but the PASRR documentation submitted by the hospital was incomplete. Interviews with staff revealed a lack of awareness and understanding of the resident's mental health diagnoses. A Licensed Practical Nurse (LPN) was unaware of the resident's PTSD diagnosis and reported various behaviors such as manipulation and self-harm. The Director of Nursing (DON) acknowledged the oversight in the PASRR process and indicated that a new PASRR should have been initiated. The facility Administrator admitted that the facility did not have a specific PASRR policy and relied on regulations, which contributed to the oversight in addressing the resident's PTSD diagnosis in the PASRR documentation.
Inadequate Pain Management for Resident with Wrist Injury
Penalty
Summary
The facility failed to provide effective pain management for a resident following a fall that resulted in a right wrist injury. The resident, who had impaired cognition due to a traumatic brain injury, experienced significant pain rated as high as 9 out of 10. Despite the resident's high pain ratings, the care plan lacked a focused area for pain management, goals for pain relief, or identification of ongoing pain symptoms. The facility's documentation did not consistently reflect follow-up assessments or physician notifications for ineffective pain relief. Nursing notes and medication administration records indicated that the resident frequently required as-needed Tylenol for pain relief, with varying effectiveness. However, there was a lack of documentation regarding follow-up pain assessments after administering pain medication. Additionally, the treatment administration record showed that ice was applied to the resident's wrist as needed, which was noted to provide effective pain relief. Despite these interventions, the facility did not adjust the resident's pain management regimen or document consistent follow-up assessments. Interviews with staff revealed that the resident would request pain medication when needed, and staff would verbally assess the effectiveness of the medication. However, these verbal assessments were not documented in the resident's electronic health records. The facility's pain policy required staff to assess the effectiveness of pain medication and notify the physician if pain was unrelieved, but this was not consistently followed. The facility administrator acknowledged the need for better documentation but believed the resident's pain was being adequately managed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD, depression, and anxiety disorder. The resident's social history documented significant past trauma, including childhood abuse, and highlighted her preferences and triggers, such as not liking to sleep with her door closed and being nervous around people. Despite this, the resident's care plan did not address her mental health diagnoses, medications, triggers, goals, focus areas, or interventions. During interviews, the resident expressed feeling more down and frustrated when her health changed and reported that staff did not discuss how these changes affected her mental health. Staff interviews revealed a lack of awareness and understanding of the resident's mental health needs. A CNA was unaware of the resident's diagnoses or triggers, and an LPN described the resident as manipulative without acknowledging her mental health conditions. The Social Services staff indicated that trauma-informed care discussions were initiated at admission, but the Director of Nursing admitted that the care plan lacked necessary information about the resident's mental health. The facility did not have a policy for trauma-informed care, and the Administrator stated that they followed regulations, indicating a gap in addressing the resident's specific needs.
Failure to Provide Bed Hold Notices Before Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to two residents or their representatives prior to their transfer to the hospital, as required by the facility's policy. Resident #35 experienced an unwitnessed fall with a head injury and abnormal vital signs, leading to a hospital transfer. The facility's documentation did not include whether the resident or their representative wanted to hold the bed or if a bed hold notice was sent. Although a Private Pay Reserved Bed Form was signed by the resident after returning to the facility, it was not completed prior to the transfer. Similarly, Resident #27 was transferred to the hospital due to a change in condition, including adventitious lung sounds and edema, and was diagnosed with acute hypoxemia secondary to a viral infection. The facility lacked documentation of a bed hold notice being provided to the resident or their representative before the hospitalization. The facility's policy mandates that residents be informed of the bed hold and return policy upon admission and at the time of transfer or within 24 hours if the transfer is urgent, which was not adhered to in these cases.
Failure to Submit Discharge MDS for a Resident
Penalty
Summary
The facility failed to submit a discharge Minimum Data Set (MDS) for one resident, identified as Resident #25, who was reviewed during the survey. The resident was admitted to the facility on November 1, 2024, and discharged to the community on January 2, 2025, with no return anticipated. The facility's electronic health record indicated that billing stopped on the discharge date, and the MDS Summary screen noted that the MDS was completed but not submitted to the Centers for Medicare and Medicaid Services (CMS). During an interview, the Director of Nursing (DON) acknowledged that the MDS should have been submitted and was unsure why the 'do not submit' indicator was triggered or how the oversight occurred. The Administrator confirmed that the facility lacked a policy for MDS or Care Plan assessments and relied on the Resident Assessment Instrument (RAI) manual, which mandates that discharge assessments be submitted within 14 days after completion.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to ensure food items were covered, dated, and stored to prevent possible cross-contamination. During an initial tour of the kitchen, surveyors observed a walk-in refrigerator containing a four-wheeled cart with various poured drinks, including white milk, chocolate milk, apple juice, and orange juice, all of which were uncovered. Additionally, the cart had two opened milk jugs without open dates, and another larger tiered cart contained two trays of individual plated pie slices that were also uncovered and without labels or dates. Dietary staff were unsure when the pies were cut and acknowledged that the drinks on the cart should have been discarded. The Certified Dietary Manager and the Administrator confirmed that the milk jugs were not dated and that the pies should have been covered. The facility's policy on refrigerated food storage required food to be stored, properly labeled, and dated per regulatory requirements, which was not followed in this instance.
Failure to Complete Follow-Up PASRR Screening
Penalty
Summary
The facility failed to complete a follow-up Preadmission Screening and Resident Review (PASRR) for a resident who experienced a change in mental health status. The Minimum Data Set (MDS) assessment did not include a completed score for the Brief Interview for Mental Status (BIMS) and recorded the resident with psychiatric and mood disorders, including anxiety, depression, and bipolar disorder. The resident was also receiving antipsychotic medications on a routine basis. The care plan documented the use of psychotropic medications and potential adverse reactions. The administrator acknowledged that some mental health diagnoses were discovered after the resident's admission and that a new PASRR should have been submitted. The initial PASRR Level 1 screen indicated no major mental illness or psychotropic medications prescribed, and directed the facility to submit a status change for further evaluation with changes.
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 221 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehabilitation Center Of Lisbon | 1.7 mi | ★★★★★ | 5 | 0 |
| Solon Nursing Care Center | 8.6 mi | ★★★★★ | 0 | 0 |
| Mechanicsville Specialty Care | 8.8 mi | ★★★★★ | 4 | 0 |
| Silver Oak Nursing And Rehabilitation Center Llc | 11.2 mi | ★★★★★ | 14 | 0 |
| Linn Manor Care Center | 11.6 mi | ★★★★★ | 10 | 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.