Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harmony Utica Ridge during CMS and state inspections, most recent first.
A resident with intact cognition and diagnoses including depression, anxiety, and insomnia asked to get out of bed into his wheelchair because he was in pain and anxious, but an LPN told him to take PRN hydroxyzine first instead of using non-pharmacological measures. The resident received the medication, later experienced hypersomnolence and grogginess, and staff acknowledged the non-pharmacological interventions in the care plan were not used first.
A resident admitted with intact cognition and multiple comorbidities had redness to the sacrum on admission, but weekly skin assessment outcomes were not fully documented and wound care orders were not implemented when ordered. The wound NP later identified an unstageable sacral pressure injury and a stage 3 left buttock pressure injury, stating the wounds were present before admission, while the DON and an LPN confirmed the ordered wound care was delayed and the skin assessments were incomplete.
Incorrect Portioning of Mechanical Soft Protein Entree: Staff served a 2-oz scoop of ground pork loin to residents ordered a mechanical soft diet, even though the approved menu directed a 3-oz portion. The CDM and Dietician confirmed staff should have followed the signed menu, and two residents on the diet were also listed as having significant weight loss.
Kitchen and kitchenette sanitation failures were observed in the LTC facility. Surveyors found heavy black/brown buildup on the stove, backsplash, walk-in cooler seal and threshold, and griddle, along with dirty coffee area shelving where clean carafes and pitchers were stored in direct contact with gritty residue. In a kitchenette, surveyors observed rust, peeling paint, crumbs, an open wall gash, and sticky residue. Staff interviews and cleaning records showed assigned cleaning tasks, but the observed soil and debris remained.
Failure to complete and document ordered wound treatments for a resident with MASD. The resident had intact cognition and reported missed treatments, while the TAR showed blank entries for several ordered skin treatments to the abdomen, buttocks, labia, and groin. An LPN and the DON stated that completed treatments are documented on the TAR and that blank entries mean the treatments were not provided.
A resident with hospice care and a heel pressure injury had repeated NP orders for frequent repositioning, heel protectors, and an alternating air mattress, but observations showed the resident’s heels in direct contact with the mattress and the heel boots left in a chair. Staff interviews confirmed the boots were not consistently offered, the bed did not have an air mattress in place, and the RN, DON, and Administrator acknowledged the ordered interventions were not being carried out as written.
A resident with intact cognition and diagnoses including stroke, AFib, and asthma had an albuterol inhaler at the bedside and stated she had been using it on her own. An LPN observed the inhaler on the overbed table, and the DON confirmed there was no order for bedside self-administration. Facility policy required an IDT evaluation and documented assessment before a resident could self-administer medication.
MDS assessments were coded inaccurately for two residents. One resident with neurogenic bladder, MS, and depression had an indwelling Foley catheter documented in the clinical record and physician orders, but the MDS showed no appliance. Another resident’s MDS listed depression but did not code antidepressant use even though the MAR showed trazodone and mirtazapine; the MDS Coordinator acknowledged the miscoding and stated antidepressants should be coded by pharmacological class.
Incomplete shaving care for two residents with severe cognitive impairment and ADL dependence was observed over multiple days. One resident with CAD and dementia and another with stroke, dementia, HTN, and aphasia were both found with unkempt, overgrown facial hair despite care plans directing assistance with grooming/shaving. Staff observations and interviews showed shaving was expected as needed and at least on shower/bath days, but the residents remained unshaven.
A resident with stroke, dementia, aphasia, and severe cognitive impairment was dependent for transfers and weighed about 183 pounds, but staff used a blue full-body mechanical lift sling during a Hoyer transfer. During the observed transfer, the resident’s bottom went too far through the sling opening and staff stated the sling was too big; the manufacturer guide showed the blue sling was for 308 to 440 pounds, while the green sling was for 154 to 264 pounds.
Delayed response to a resident’s call light occurred when a CNA turned off the light and left without meeting the resident’s need, and the call light later remained on for 24 minutes while the resident called out and banged for help. The resident had amputation, HF, and DM, was cognitively intact, and required assistance with transfers and ADLs. Staff and the DON described expected response times of 5 to 15 minutes, and the facility policy required timely response to call lights.
A resident with severe cognitive impairment and a stage 3 pressure injury was on EBP precautions, with the care plan directing staff to wear gowns and gloves during wound care and other high-contact care. During an observed treatment, an RN wore a gown, gloves, and a mask, but a CNA assisted with repositioning and brief removal without wearing a gown while the wound care was performed; the RN later acknowledged the CNA should have worn a gown, and the DON confirmed the resident was on EBP precautions.
Ineffective QAPI Program With Re-cited Deficiencies: The facility failed to ensure an effective QAPI program to address previously cited deficiencies, and five deficiencies were re-cited on the recertification survey, including F641, F684, F689, F812, and F880. The Administrator stated the facility had worked on the prior deficiencies in QAPI, but they remained ongoing and had been tracked for years. The QAPI policy assigned the Administrator and QAPI Committee responsibility for identifying priorities, using resident and staff input, and analyzing QAPI performance.
The facility did not accurately report weekend staffing hours in its PBJ submission for a quarter, resulting in a trigger for excessively low weekend staffing. The Administrator confirmed agency hours were not entered correctly, and the facility lacked a policy for PBJ reporting. The reported census was 88 residents.
Surveyors found that expired lettuce and pre-filled salads were stored in the walk-in refrigerator, and the Dietary Manager could not confirm if expired lettuce had been used in meal preparation. Additionally, meal temperature logs were incomplete for several days, and the facility lacked policies for food storage and temperature monitoring.
A resident with heart failure, renal disease, and dementia experienced multiple significant weight fluctuations while on a diuretic, but staff failed to consistently notify the provider as ordered. Documentation of provider notification was lacking, and staff interviews revealed inconsistent practices regarding communication and record-keeping, contrary to facility policy.
Quarterly MDS assessments were not completed on time for four residents, with assessments finalized days to weeks after the required dates. Staff cited increased infection control duties as a reason for the delays and acknowledged the issue, while also noting the absence of a facility policy for MDS assessment procedures.
The facility did not accurately code medication use on MDS assessments for two residents, including one with intact cognition and another with severe cognitive impairment. The MDS indicated use of medications not supported by the medical record or physician orders, and staff confirmed these were coding errors. The facility also lacked a policy for MDS accuracy.
Two residents did not have their care plans updated to include essential treatments: one receiving regular dialysis and another prescribed an anticoagulant for atrial fibrillation and heart failure. Despite staff and policy indicating these interventions should be documented, the care plans lacked focus areas and interventions for these critical needs.
Staff failed to consistently use wheelchair foot pedals and implement fall prevention interventions, resulting in multiple residents being transported without proper safety measures and experiencing falls, despite care plans and staff education outlining these requirements.
A resident with a suprapubic catheter was repeatedly observed with their catheter bag and tubing resting on or dragging along the floor, both in their room and while moving in a wheelchair. Staff present did not intervene to correct the situation, and interviews revealed inconsistent understanding of proper catheter care. Facility policy requires catheter bags and tubing to be kept off the floor, but this was not followed, resulting in a deficiency.
The facility did not properly document the acceptance or refusal of the pneumococcal vaccine for three residents, including two with severe cognitive impairment and one with intact cognition. Records lacked dates of refusal and evidence that education or declination information was provided, and staff interviews confirmed inconsistent documentation practices.
A resident with a recent below-the-knee amputation did not receive wound care as ordered by the physician, as staff substituted Xeroform for Vashe Wound Cleanser without proper documentation or provider notification. The DON confirmed that staff are expected to follow active orders and notify the provider if a treatment is refused, but this process was not followed.
A resident admitted with a recent ankle fracture and a history of cancer and mood disorder experienced frequent, severe pain due to delays in receiving both scheduled and as-needed pain medications. Despite prescriptions for hydrocodone-acetaminophen and pregabalin, there were lapses in medication administration and pharmacy delivery, leading to inadequate pain relief and significant resident distress.
A resident with a suprapubic catheter did not receive proper Enhanced Barrier Precautions during catheter care, as a CNA failed to wear an isolation gown while emptying the catheter bag. This action was inconsistent with the resident's care plan and facility policy, which require both gown and gloves for high contact activities involving indwelling medical devices.
A resident with severe cognitive impairment and multiple wounds received wound care from an RN who failed to follow infection control protocols. The RN did not change gloves between tasks and exited the room wearing an isolation gown to access supplies, contrary to facility policy. Interviews with staff confirmed the expected procedures were not followed, resulting in a deficiency in infection control practices.
A resident at an LTC facility developed a severe pressure ulcer due to inadequate care and documentation. Despite being at risk, the resident's wound was not properly assessed or treated, leading to a severe infection and hospitalization. Staff interviews revealed issues with undocumented dressings and inconsistent wound care documentation, contributing to the resident's deteriorating condition and eventual death.
A facility failed to conduct necessary pre- and post-dialysis assessments for a resident with end-stage renal disease and diabetes. The resident's care plan lacked directions for these assessments, and the Treatment Administration Record showed multiple instances of missing documentation. The Director of Nursing acknowledged the expectation for such assessments, but the facility's policy did not provide clear guidance, leading to missed evaluations.
A facility failed to update a resident's PASRR after new diagnoses of bipolar 2 disorder and schizophrenia were identified. The resident, with moderate cognitive impairment, was experiencing hallucinations and had started counseling. The oversight was acknowledged by the administrator during the survey.
Failure to Use Non-Pharmacological Interventions Before PRN Anxiety Medication
Penalty
Summary
The facility failed to use non-pharmacological interventions before giving Resident #8 hydroxyzine HCL 25 mg for anxiety, and the resident experienced hypersomnolence after the medication was administered. Resident #8 had intact cognition with a BIMS score of 15 out of 15 and diagnoses including depression, adjustment disorder with mixed anxiety and depression, and insomnia. His care plan included interventions for pain and non-pharmacological measures such as repositioning, massage, relaxation techniques, counseling, warm/cool compresses, and positioning as indicated. On the evening of 06/01/2026 into the morning of 06/02/2026, Resident #8 reported pain and anxiety and asked staff to help him move from bed into his wheelchair because he felt it would help with both. He stated nursing staff told him no and instead offered medication, and that Staff A, LPN told him to take the PRN medication first and said she would help him into his wheelchair if it did not work. Staff A confirmed she suggested medication first and was unaware of the care plan interventions. The MAR showed hydroxyzine HCL 25 mg was given at 1:43 AM, and the resident later reported he did not remember the rest of the evening, woke up very late, and felt groggy and distressed because he had slept so long.
Incomplete Skin Assessments and Delayed Wound Order Implementation
Penalty
Summary
The facility failed to document the outcome of weekly skin assessments and failed to implement a new wound care order in a timely manner for one resident who was admitted with intact cognition, heart failure, peripheral vascular disease, renal insufficiency, and multiple sclerosis, and who was identified as being at risk for pressure ulcers. The resident’s admission documentation noted redness to the sacrum, and the skin evaluation recorded a sacral skin alteration measuring 6 cm by 4 cm with pink, pale tissue and no drainage. The care plan identified risk for altered skin integrity and included interventions to administer treatment per physician orders, follow facility skin breakdown policies, and observe skin condition with ADL care. The record showed weekly skin assessment orders on the MAR/TAR, but the DON stated there were no skin assessments documented from the 9th through the 15th and believed the wound assessments were incomplete. The resident told surveyors that staff were aware of redness or an injury on her buttocks but did not treat it until days after the pain worsened, and she said treatment began about a week after she was seen by the wound nurse. Facility documentation also showed a sacral wound treatment order for cleansing and zinc oxide that remained in place until discontinued, and later wound documentation described the sacrum as healed and then identified a left gluteal cleft wound. The wound care NP first evaluated the resident and documented an unstageable pressure injury to the sacrum and a stage 3 pressure injury to the left buttock. The NP stated the wounds were present before the resident’s admission and that the sacral area could have been missed if not examined closely. However, the NP did not enter her recommended wound care orders until several days later because of a backlog, and staff stated the orders were not started when they were ordered. An LPN stated nothing had been done with the NP’s orders until they were entered later, and the DON confirmed the wound care NP orders were not started when ordered. Additional staff interviews reflected confusion about the wound’s appearance and staging, including one LPN who believed the coccyx wound was at least a stage 2 on admission and another who said the healed notation on the wound record was a mistake.
Incorrect Portioning of Mechanical Soft Protein Entree
Penalty
Summary
The facility failed to serve the correct portion size of the protein entree for 8 of 9 residents on a mechanical soft diet, including Residents #1, #31, #43, #54, #77, #79, #89, and #96. The Week 1 Wednesday Noon Menu, approved by the Dietician, directed that the mechanical altered diet receive a 3-ounce portion of pork loin. The Diet Roster identified those residents as receiving a mechanically altered diet, and the CMS Matrix listed Residents #43 and #96 as having significant weight loss. During observation of the Crow Creek Dining Room, Staff O used a #16 scoop, identified as a 2-ounce scoop, to serve ground pork loin to the eight residents on the mechanical soft diet. In interview, Staff O stated she used the #16 scoop and was not 100 percent sure it was the correct portion, but said it was the size scoop used to serve the mechanical soft meat. The CDM stated dietary staff should follow the serving sizes on the menu and that if there is significant weight loss, the full portion of each item should be served. The Dietician stated she had been told the cook pulled the wrong scoop size for the lunch meal and said the cook should have used the correct scoop according to the signed menu. The facility policy stated menus are planned to meet resident therapeutic diet requirements and nutritional parameters.
Kitchen and kitchenette sanitation failures
Penalty
Summary
The facility failed to maintain clean and sanitary food service equipment in the main kitchen and in a kitchenette. During the initial kitchen tour, surveyors observed dried black/brown buildup on the front and backsplash area of the stove, a black substance around the entire walk-in cooler door seal and a thick black substance along the cooler door threshold, and a black/brown/orange buildup running down the front of the griddle. On revisit, these same conditions remained, including a dirty skillet on the stove, a tacky black/brown substance along the front of the stove, stuck-down residue on the backsplash, and the same buildup on the cooler seal, threshold, and griddle. Surveyors also observed dirty storage conditions in the coffee area, where a two-tier shelf had black/brown gritty circular rings and a brown stuck-down gritty substance on a non-slip mat. Clean coffee carafes and pitchers were stored upside down in direct contact with the dirty surfaces. The Weekly Cleaning List showed the stove/oven and coffee area shelves were assigned for weekly cleaning, and staff had signed off on those tasks, but the observed soil remained. Staff interviews indicated the griddle was used mainly for grilled cheese sandwiches, and the CDM stated the cooler door seal and threshold were cleaned monthly by Maintenance, though she did not know whether a checklist existed. In the Crow Creek kitchenette, surveyors observed rust and peeling paint on the steam table supports, exposed metal and crumbly residue on the steam cart, food crumbs on steam pan lids, crumbs around a plate warmer unit, an open gash in the drywall, and sticky red residue on the countertop by the condiment holder. The CDM stated the facility did not have cleaning lists for the smaller serving kitchenettes and that dietary staff were supposed to clean the area after meals. The facility policy required food service areas to be maintained in a clean and sanitary condition, with cleaning schedules and recorded completion, and the 2017 US Food Code required cooking equipment and nonfood-contact surfaces to be kept free of encrusted grease, soil, dust, dirt, residue, and other debris.
Failure to Document and Complete Ordered Wound Treatments
Penalty
Summary
The facility failed to complete physician-ordered treatments for a resident with intact cognition who had moisture associated skin damage (MASD) involving the groin, buttocks, perineum, and abdominal folds. The resident’s MDS identified the skin problem and the care plan directed staff to administer treatments per physician orders and apply barrier cream as needed. During an interview, the resident stated treatments had been missed. Review of the physician orders and May 2026 TAR showed multiple missing entries with no documentation that ordered treatments were completed, held, or refused. Missing documentation was identified for abdominal wound care with calcium alginate and boarded gauze, treatment to the left buttocks with foam dressing, treatment to the right buttocks with zinc oxide paste, treatment to the right labia with zinc and open-to-air care, and Nystatin powder to the groin. Progress notes also contained no explanation for the missed documentation. Staff and the DON stated that completed treatments are documented on the TAR, refusals are documented on the TAR and in progress notes, and a blank TAR box means the treatment was not completed.
Failure to Implement Ordered Pressure Injury Interventions
Penalty
Summary
The facility failed to implement pressure-reducing interventions ordered for a resident with a left heel pressure injury. The resident had multiple diagnoses including stroke, CAD, diabetes, dementia, anorexia, palliative care, and hospice services, and the MDS showed moderate cognitive impairment and need for partial to moderate assistance with side-to-side positioning in bed. The admission assessment documented a Stage 3 pressure injury to the right heel, while subsequent wound assessments tracked a left heel wound that progressed from Stage 3 to unstageable with slough present. The wound NP documented repeated recommendations for frequent repositioning, heel protectors, and later an alternating air mattress for pressure redistribution, with instructions to maintain proper settings and float the heels in bed using heel boots. Despite these orders, observations showed the resident lying in bed with her heels in direct contact with the mattress, the blue padded heel boots sitting in a chair across from the bed, and the resident’s bed without an air mattress in place. Staff interviews confirmed the boots were not consistently offered when the resident was lying down and that the resident had been using a regular mattress. During interviews, the resident stated staff did not offer the padded boots when she laid down and that she tried to lie on her side so her heels would not worsen. The hospice case manager stated the goal was for the wound to heal with no pain, and the NP stated the resident should have had an air mattress and heel boots. The RN, DON, and Administrator acknowledged the interventions were not implemented timely or consistently, and the RN stated it was her responsibility to monitor wound notes and ensure the interventions were carried out. The facility policy required active orders to be followed and carried out as written.
Failure to Assess Bedside Self-Administration of Inhaler
Penalty
Summary
The facility failed to determine whether Resident #4 could safely self-administer an inhaler that was kept at the bedside. Resident #4’s MDS dated 4/16/26 showed a BIMS score of 15 out of 15, indicating intact cognition, and listed diagnoses including stroke, atrial fibrillation, and asthma. Physician orders included ProAir RespiClick inhalation aerosol powder breath activated 108 (90 base) mcg/act (albuterol sulfate) inhaler, 2 puffs inhaled orally every 4 hours as needed for wheezing/SOB, with a start date of 3/2/26. The care plan identified asthma-related ineffective breathing pattern and included medications as ordered. During an observation on 5/13/26, Resident #4 had an albuterol sulfate inhaler resting on the bedside table and stated she had kept it there since last May and had been using it on her own. An LPN present during the observation acknowledged the inhaler on the overbed table and stated she had not previously seen it in the room. The LPN stated Resident #4 did not have an order to self-administer the inhaler. The DON later confirmed Resident #4 did not have an order to keep medication at bedside to self-administer. The facility policy required an IDT evaluation, a self-administration evaluation form, and a return demonstration to determine capability, and stated the resident may store medication at bedside only if there is a physician order to keep it there.
MDS Assessments Were Coded Incorrectly for Catheter Use and Antidepressant Use
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately for two residents. For one resident with neurogenic bladder, multiple sclerosis, and depression, the MDS dated 5/4/26 identified no appliance, even though the clinical record included a hospitalist note stating the resident was on a chronic Foley catheter, an admission/readmission assessment documenting an indwelling urinary catheter with an insertion date of 4/24/26, and a physician order for a Foley catheter. The MDS Coordinator stated the resident had an indwelling catheter and that the MDS had been coded incorrectly, and the DON stated the expectation was that MDS assessments accurately reflect the resident's condition. For another resident, the 4/27/26 MDS listed depression in the diagnoses but did not identify use of an antidepressant or indication for one in the medications section. The MAR showed trazodone administered for insomnia and later mirtazapine administered for depression during February through April 2026. The MDS Coordinator stated trazodone is an antidepressant and mirtazapine should have been coded as such on the MDS, and acknowledged the MDS was miscoded. The CMS RAI Manual states high-risk drug class medications, including antidepressants, are coded by pharmacological classification rather than how they are used, and facility staff reported there was no MDS policy and that they followed the RAI manual for coding.
Incomplete Shaving Care for Two Dependent Residents
Penalty
Summary
The facility failed to provide complete shaving care for 2 dependent residents who required assistance with personal hygiene. Resident #1 had diagnoses of coronary artery disease and non-Alzheimer's dementia, and the MDS showed a BIMS score of 2 out of 15 with severe cognitive impairment. The MDS also indicated partial/moderate assistance was needed for personal hygiene, including shaving, and the care plan directed assistance of 1 staff for grooming. During observations on 05/11/2026, 05/13/2026, and 05/14/2026, Resident #1 was seen with facial hair that appeared unkempt, long, and uneven, including several days' growth. Resident #67 had diagnoses of stroke, dementia, high blood pressure, and aphasia, and the MDS showed a BIMS score of 2 out of 15 with severe cognitive impairment. The MDS indicated partial/moderate assistance was needed for personal hygiene, including shaving, and the care plan directed 2 staff members to assist with dressing and grooming. During observations on 05/12/2026, 05/13/2026, and 05/14/2026, Resident #67 was seen with unkempt facial hair that increased to over a half inch in length on the face and neck. Staff P asked the resident when he was going to get a shave, and later the Unit Manager and CNA stated the razor needed to be found before shaving could be done. The facility policy directed staff to shave residents' facial area as needed, and the DON stated residents were expected to be assisted with shaving at least on shower/bath days, which was 2 times a week.
Incorrect Mechanical Lift Sling Size Used During Transfer
Penalty
Summary
The facility failed to use the correct size full-body mechanical lift sling based on resident weight during a transfer for Resident #67. The resident’s MDS identified diagnoses including stroke, dementia, and aphasia, and a BIMS score of 2 out of 15 indicating severe cognitive impairment. The resident was assessed as dependent for chair-to-bed transfer, and the MDS and nutrition record listed the resident’s weight as 183 pounds/183.5 pounds. The care plan directed assist of 2 with a Hoyer lift for transfers. During an observed transfer, two CNAs placed a full-body mesh sling with blue trim under the resident and hooked it to the mechanical lift. As the lift was started, the cushion under the resident began to slide off the wheelchair seat and the resident’s bottom appeared to go too far through the opening of the sling. One CNA stated the sling was too big for the resident and lowered him back into the wheelchair while adjusting the cushion and sling placement. Staff later stated the resident needed a sling with green trim, while the manufacturer’s sling guide showed the green sling was for residents weighing 154 to 264 pounds and the blue sling was for 308 to 440 pounds. Staff interviews also revealed the facility relied on staff knowledge and a chart that was not present when checked.
Delayed Response to Resident Call Light
Penalty
Summary
The facility failed to respond to a call light in a timely manner for one resident reviewed for call lights. Resident #3 had diagnoses including amputation, heart failure, and diabetes mellitus, and the MDS indicated intact cognition with a BIMS score of 14 out of 15. The resident’s care plan identified a need for assistance with ADLs, including transfers, with interventions for 1:1 slide board transfers and keeping the call light within reach. During observation, Resident #3’s call light was activated and remained on for an extended period while the resident called out for help and banging was heard from the room. Staff P, CNA entered the room, turned off the call light, and left after telling another CNA that the resident needed help. The call light later remained activated for 24 minutes before Staff Q, CNA entered the room and turned it off. Resident #3 stated he had been waiting for help for about half an hour and reported this had happened at least three times a month. Staff R, CNA stated call lights were expected to be answered in 10 to 15 minutes, while the DON stated the expectation was 5 minutes, with 15 minutes as the maximum. The facility’s call light policy stated call lights were to be answered in a timely manner and that staff should respond to the resident’s request when answering a call light.
Failure to Use EBP During Wound Care
Penalty
Summary
Enhanced Barrier Precautions were not implemented during wound care for Resident #83, who had a severe cognitive impairment with a BIMS score of 5 out of 15 and diagnoses including non-Alzheimer’s dementia, urinary tract infection, and a stage 3 pressure ulcer. The resident’s care plan identified EBP for the pressure injury and directed staff to wear a gown and gloves during high-contact care activities, including wound care. The facility also had EBP and Contact Precautions signage posted on the resident’s room door. During an observation, Staff A, RN and Staff B, CNA donned gloves and masks, and Staff A wore a gown, but Staff B assisted with repositioning the resident, lowered the resident’s pants and incontinent brief, and held the resident on her right side while the RN performed the pressure area treatment without Staff B wearing a gown. In interview, the RN stated she was not sure whether Staff B should have had a gown on, then acknowledged Staff B should have donned a gown after reviewing the signage. The DON stated the resident was on EBP precautions and that staff are to wear gloves and gowns when providing cares.
Ineffective QAPI Program With Re-cited Deficiencies
Penalty
Summary
The facility failed to ensure an effective QAPI program to address previously cited deficiencies. Review of the CMS CASPER report, facility policy, and staff interviews showed that five deficiencies cited in the 4/21/25 Statement of Deficiencies and Plan of Correction were re-cited during the 5/14/26 Health Recertification survey: F641 (Accuracy of Assessments), F684 (Quality of Care), F689 (Free of Accident Hazards/Supervision/Devices), F812 (Food Procurement, Store/Prepare/Serve-Sanitary), and F880 (Infection Prevention and Control). The facility reported a census of 89 residents. During an interview on 5/14/26 at 10:55 AM, the Administrator stated the facility worked on all previously cited deficiencies in QAPI and that all deficiencies continued to be ongoing and tracked for years. The facility’s QAPI Plan dated 11/10/2025 stated the Administrator, as chair of the QAPI Committee, is responsible and accountable for ensuring the QAPI is defined, implemented, maintained, sustained during transitions, adequately resourced, and used to identify and prioritize problems based on performance indicator data, resident and staff input, and other information. The policy also stated the QAPI Committee is responsible for identifying and prioritizing problems, including patient, patient representative, and staff input, ensuring corrective actions are effective, and analyzing QAPI performance to identify and follow up on areas of concern or opportunities for improvement.
Inaccurate PBJ Weekend Staffing Reporting
Penalty
Summary
The facility failed to ensure accurate reporting of weekend staffing hours in its Payroll Based Journal (PBJ) submission for Quarter 1 2025, which covered the period from October 1 to December 31, 2024. Review of the PBJ report revealed that the facility triggered for excessively low weekend staffing during this time. During an interview, the Administrator acknowledged that agency hours had not been entered correctly. Additionally, when requested, the facility reported that they did not have a policy related to PBJ reporting. The facility reported a census of 88 residents during the period in question.
Failure to Discard Expired Food and Incomplete Meal Temperature Monitoring
Penalty
Summary
The facility failed to properly manage food storage and temperature monitoring in accordance with professional standards. During an inspection, surveyors observed that the walk-in refrigerator contained multiple trays of pre-filled side salads and a large container of shredded lettuce, both of which were past their labeled use-by dates. The Dietary Manager confirmed that the lettuce had expired and was unsure if it had been used in recent meal preparations. Additionally, a review of the facility's meal temperature logs revealed that temperatures for evening meals were not recorded for three out of seven days reviewed. The facility also lacked policies related to food storage, expiration, and monitoring of food temperatures. The census at the time of the survey was 88 residents. No specific residents or their medical conditions were mentioned in relation to the deficiency.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to notify the medical provider of significant weight changes, as ordered, for a resident with multiple complex medical conditions, including chronic systolic heart failure, renal insufficiency, end stage renal disease, and non-Alzheimer's dementia. The resident was on a diuretic and had specific physician orders requiring daily weights and immediate provider notification for a weight gain of 3 pounds or more in one day, or a loss of 3 pounds in one day. Clinical record review showed multiple instances where the resident's weight fluctuated by 3 pounds or more within a day, but there was no documented evidence that the provider was notified of these changes as required by the physician's order and facility policy. Staff interviews revealed inconsistent practices regarding provider notification and documentation. One LPN stated she notified the doctor via text message but did not document this in the resident's progress notes and deleted the messages after receiving a response. Another LPN claimed to have notified the provider and documented it, while the RN Unit Manager indicated that such notifications should be found in progress notes or paperwork submitted to the provider. The Director of Nursing confirmed that staff should notify the doctor after reweighing the resident and that the Unit Manager is responsible for auditing and educating staff. Facility policies reviewed required that active orders be followed and that significant changes in a resident's condition be immediately communicated to the provider.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for four residents, as required. Clinical record review showed that the MDS assessments for these residents were completed several days to weeks after the designated Assessment Reference Dates (ARDs). Staff interviews revealed that the MDS Coordinator was unable to complete the assessments on time due to increased infection control responsibilities and did not request additional assistance. The Director of Nursing acknowledged the issue with timeliness and stated that assessments should be completed within the appropriate timeframe. Additionally, the facility did not have a policy in place to address MDS assessment procedures.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Section N, Medications, on the Minimum Data Set (MDS) assessments for two residents. For one resident with intact cognition, the MDS indicated use of an antiplatelet medication, but review of the Medication Administration Record (MAR) for the relevant month showed no administration of such medication, and the MDS Coordinator confirmed the resident was not on an antiplatelet. For another resident with severely impaired cognition, the MDS assessment indicated use of a diuretic, but neither the physician orders nor the medical record supported this, and both the MDS Coordinator and Director of Nursing acknowledged the resident was not prescribed a diuretic and that this was likely a coding error. Additionally, the facility did not have a policy in place for ensuring MDS accuracy.
Failure to Include Dialysis and Anticoagulant Use in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all of the residents' needs, specifically omitting dialysis services and anticoagulant use for two residents. For one resident with a history of fluid overload, coronary artery disease, and renal insufficiency requiring dialysis, the clinical record and staff interviews confirmed that the resident was receiving dialysis three times a week. However, the care plan did not include any focus areas or interventions related to dialysis services, despite orders and staff acknowledgment of the ongoing treatment. Similarly, another resident with diagnoses including atrial fibrillation, heart failure, and a hip fracture was prescribed an anticoagulant (Rivaroxaban). The care plan for this resident did not address the use of the anticoagulant, even though the medication order was present in the record and staff confirmed that such interventions should be included. The facility's own policy requires that care plans be person-centered and developed after comprehensive assessment, but these requirements were not met for the two residents identified.
Failure to Use Wheelchair Foot Pedals and Inconsistent Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that foot pedals were utilized when residents were transported in wheelchairs and did not consistently implement fall prevention interventions for several residents. Multiple observations revealed that staff pushed residents in wheelchairs without foot pedals, requiring residents to hold their feet above the floor during transport. This occurred despite the facility's policy and repeated staff education on the requirement of using foot pedals during wheelchair transport. In several instances, staff acknowledged that the 'no pedals, no push' rule was not always followed, particularly by new staff members. For one resident with severely impaired cognition and a history of right hemiparesis due to a cerebrovascular accident, the care plan included specific fall prevention interventions such as the use of Dycem in the wheelchair, removal of the sling after transfers, and use of non-skid footwear. However, the resident experienced multiple falls, including one where he was found on the floor with a head laceration and another where he slid out of his chair while the sling was still under him. Observations and interviews confirmed that interventions like Dycem and gripper socks were not consistently in place at the time of these incidents. Other residents, including one with intact cognition and another requiring moderate assistance with transfers, were also observed being transported in wheelchairs without foot pedals. Staff interviews and documentation confirmed that these safety interventions were not reliably implemented, despite being included in care plans and discussed in staff education sessions. The facility census at the time was 88 residents.
Failure to Maintain Proper Positioning of Indwelling Catheter Bag and Tubing
Penalty
Summary
A deficiency was identified when a resident with a history of neurogenic bladder, scoliosis, and intestinal-genital tract fistulae, who utilized an indwelling suprapubic catheter, was repeatedly observed with their catheter bag and tubing resting on the floor. Multiple observations documented the catheter bag and tubing either on the floor or dragging as the resident self-propelled their wheelchair, both in the resident's room and in the hallway. Staff present during these incidents did not intervene to correct the position of the catheter bag and tubing. Interviews with nursing staff revealed inconsistent responses regarding the appropriate action when a catheter bag or tubing is found on the floor. Some staff indicated the bag should be replaced, while others stated it should be wiped off and repositioned. The facility's policy directs that catheter tubing should not be positioned above the bladder and that the drainage bag should be kept off the floor and in a dignity bag. Despite these guidelines, the observed failure to maintain the catheter bag and tubing in the correct position led to the deficiency.
Failure to Document Pneumococcal Vaccine Refusals and Education
Penalty
Summary
The facility failed to provide adequate documentation regarding the acceptance or refusal of the pneumococcal vaccine for three out of five residents reviewed. For two residents with severely impaired cognition, there was no documentation in the electronic medical record (EMR) of vaccine refusal, and the unit immunization tracking forms indicated declination without specifying dates. Additionally, there was no evidence that education or declination information was provided to the residents or their representatives. For a third resident with intact cognition, the EMR noted a refusal of the PCV13 vaccine, but again, no date was recorded, and the tracking form lacked a date as well. There was also no documentation of education or declination provided to this resident. Staff interviews revealed that attempts were made to contact family members for residents with low cognitive scores, but documentation of these efforts was inconsistent or missing. The Director of Nursing acknowledged that if refusals were not documented in the EMR, they should have been recorded on paper, indicating a lapse in following the facility's vaccination and screening policy. The policy required offering pneumococcal vaccines upon admission to residents who had never been vaccinated or had previously refused, but the facility did not maintain complete records as required.
Failure to Follow Physician Orders for Wound Care Treatment
Penalty
Summary
Staff failed to follow physician orders for wound care treatment for a resident with a left below-the-knee amputation surgical site. The resident had intact cognition and required specific wound care interventions as documented in the care plan and treatment administration record, including the use of Vashe Wound Cleanser and Vashe-moistened gauze as part of the dressing change protocol. During an observed dressing change, a registered nurse cleansed the wound with normal saline and applied Xeroform instead of the ordered Vashe treatment. The resident reported that Vashe had not been used for the past three days and that Xeroform was used instead. The nurse explained that the process for changing a treatment order involved documenting the resident's refusal of Vashe and notifying the provider to request a new order for Xeroform, with documentation required in the nursing progress notes. However, the director of nursing confirmed that Vashe was unavailable prior to the dressing change and emphasized the expectation that staff follow physician orders and notify the physician if a treatment is refused. Facility policy requires that active orders be followed as written and that any changes be properly documented and communicated.
Failure to Provide Timely Pain Management and Medication Availability
Penalty
Summary
The facility failed to ensure the timely availability and administration of both scheduled and as-needed pain medications for a resident admitted with a tri-malleolar fracture and a history of malignant carcinoid tumors and adjustment disorder with depressed mood. Upon admission, the resident was prescribed hydrocodone-acetaminophen (Norco) as needed for moderate pain and pregabalin for nerve pain. Documentation showed that the resident experienced frequent, moderate to severe pain, with pain scores of 8-9 out of 10, and reported inadequate pain relief after receiving the as-needed medication. The Medication Administration Record indicated that pregabalin was not documented as given at bedtime on the day of admission, and only administered during the morning medication pass the following day. Nursing progress notes revealed that the resident expressed significant distress due to pain and the lack of timely medication, even considering leaving the facility against medical advice. Staff interviews confirmed delays in obtaining and administering the prescribed medications, with pharmacy deliveries not arriving as scheduled and the e-kit being accessed only after the resident's complaints. The facility's policy required that services needed by residents be readily available, and that prescriptions be obtained within a few hours of admission, but these expectations were not met in this case.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling suprapubic catheter. The resident was identified as cognitively intact and had diagnoses including neurogenic bladder and intestinal-genital tract fistulae. The care plan directed staff to wear a gown and gloves for high contact activities, such as emptying the catheter bag. During an observation of catheter care, a CNA donned a mask and gloves but did not wear an isolation gown while emptying the resident's catheter bag, despite the presence of PPE supplies and signage indicating EBP requirements in the resident's room. Interviews with staff and the Director of Nursing confirmed that EBP, including the use of gowns and gloves, should be followed for residents with indwelling catheters during high contact care activities. Review of the facility's policy also documented that gowns and gloves are required for such activities. The failure to don an isolation gown during catheter care was inconsistent with both the care plan and facility policy.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards during wound care for a resident with multiple wounds and severe cognitive impairment. The resident, who was dependent on staff for mobility and had a history of skin breakdown, was observed receiving wound care from a registered nurse (RN) who did not follow proper infection control protocols. The RN did not change gloves between different wound care tasks and exited the resident's room wearing an isolation gown to access supplies from a common medication cart, which compromised infection control measures. During the wound care observation, the RN was seen removing dressings, cleansing wounds, and applying new dressings without changing gloves between tasks. The RN also exited the room twice while wearing the isolation gown to retrieve supplies, allowing the gown to come into contact with the medication cart. This action was contrary to the facility's policy, which required the removal of isolation gowns and gloves, and hand hygiene before leaving the room. Interviews with other staff members, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the expected procedure was to change gloves when soiled and to remove isolation gowns and gloves before exiting the room. The facility's policies on dressing changes and enhanced barrier precautions were not followed, leading to a deficiency in infection control practices during the wound care of the resident.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for a resident, leading to severe health complications. The resident, who had diagnoses of Parkinson's, anxiety, and depression, was assessed as being at risk for pressure ulcers. Despite this, a wound on the resident's right buttocks was identified by nursing staff without prior documentation or provider notification for a treatment order. This oversight resulted in the resident developing a severe infection, including MRSA and E. coli, which ultimately required hospitalization for sepsis and a urinary tract infection. Interviews with staff and the resident's daughter revealed a lack of consistent wound assessment and documentation. The resident's daughter reported seeing a dressing applied to her mother's wound, which was initially described as a surface wound by the nursing staff. However, the wound worsened over time, and the resident's condition deteriorated, leading to hospitalization. Staff interviews indicated that there were instances of undocumented dressings found on residents, and there was frustration among staff regarding the lack of documentation and timely treatment orders. The facility's documentation showed inconsistencies in wound assessments and treatment records. Progress notes and skin sheets for the resident lacked timely and accurate documentation of the wound's condition and treatment. The resident's condition worsened, with the wound becoming unstageable and emitting a foul odor, which was not addressed promptly. The resident was eventually transferred to the hospital, where the wound was diagnosed as a Stage IV infected pressure ulcer, contributing to the resident's death.
Removal Plan
- Nurse education re-initiated to be completed 100% for all nurses prior to their next scheduled shift on skin practice guidelines that include direction on how to identify skin areas and wound care/dressing change, and Medical Director and family notification.
- Baseline audit of skin on current patients in house.
- Nursing education on skin preventative measures including repositioning.
Failure to Conduct Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete necessary nursing assessments and monitoring for a resident requiring dialysis care. Resident #72, who has end-stage renal disease and type 2 diabetes mellitus with diabetic chronic kidney disease, was not consistently assessed before and after outpatient dialysis sessions. The care plan for the resident did not include directions for pre- and post-dialysis assessments, despite the resident's condition and the physician's orders requiring such evaluations. Observations revealed bruising on the resident's arm near the fistula, and the resident reported that post-dialysis assessments were often missed due to staff being busy. The Treatment Administration Record (TAR) for May and June 2024 showed multiple instances where pre- and post-dialysis assessments, as well as fistula assessments, were not documented. The Director of Nursing stated that the expectation was to conduct assessments before and after dialysis, including checking vitals and the fistula site, as per physician orders. However, the facility's policy lacked clear instructions for pre-dialysis assessments, contributing to the oversight in care for Resident #72.
Failure to Update PASRR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a Change in Status Preadmission Screening and Resident Review (PASRR) assessment for a resident after two new mental health diagnoses were identified. The resident, who had a documented Brief Interview of Mental Status (BIMS) score indicating moderate cognitive impairment, was diagnosed with bipolar 2 disorder and schizophrenia during a physician visit. However, these diagnoses were not updated in the PASRR until the survey was conducted, several months later. The administrator acknowledged that the new diagnoses were overlooked, and the resident had been experiencing hallucinations and had started counseling, which should have prompted the PASRR update.
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 169 citations issued within 25 miles in the last 12 months — including the 6 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 Davenport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bettendorf Health Care Center | 1.3 mi | ★★★★★ | 8 | 0 |
| Kahl Home For The Aged & Infirmed | 1.7 mi | ★★★★★ | 9 | 0 |
| The Summit Of Bettendorf | 2.4 mi | ★★★★★ | 3 | 0 |
| Ivy At Davenport | 2.9 mi | ★★★★★ | 27 | 2 |
| Harmony Davenport | 3.1 mi | ★★★★★ | 16 | 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 August 2026) and official state health department websites.