Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Ravenwood Specialty Care during CMS and state inspections, most recent first.
Incomplete Wound Assessment and Documentation for a Resident With a Gangrenous Foot Wound: A resident with DM, PVD, and a diabetic foot ulcer had inconsistent and incomplete wound assessments, with missing measurements and variable documentation of progress while TAR entries also showed missed dressing/treatment occurrences. Podiatry documented necrotic tissue, severe pain, and the need for toe amputation, and the resident later transferred to the ED with sepsis, AKI, and septic shock; hospital records described a necrotic, gangrenous foot wound with exposed bone and the need for a BKA.
Inadequate post-fall response after resident fall with hip injury. A resident with a documented fall risk and impaired cognition fell while heading to the bathroom and reported severe hip pain with redness, swelling, and refusal to move the leg. Staff used a mechanical lift to move him from the floor into bed despite his pain complaints, and he was later sent to the ED where he was admitted with a hip fracture and possible surgery.
Delayed call light response affected multiple residents, including one who recently fell, one who vomited from acid reflux, and another who reported being forgotten in the bathroom several times. Residents said they often did not use the call light because staff took too long to answer, and one restroom call light was observed with a very short string positioned behind the armrest. Staff gave inconsistent response-time expectations, while the DON stated the maximum allowable time was 15 minutes.
Infection control and isolation procedures were not maintained for a resident with C. diff, prolonged diarrhea, and a positive stool test. An RN performed dressing care using the sink as a basin, reused a washcloth after rinsing it, washed hands without turning off the faucet with a paper towel, and used a disinfectant that did not list C. diff as an organism it killed. Staff interviews confirmed expectations for soap-and-water handwashing, room isolation signage, and use of a basin for wound care.
Call Lights Not Kept Within Reach or Accessible: The facility failed to keep call lights accessible for two residents reviewed. One resident was observed with the call light on the floor at the foot of the bed while seated in a wheelchair, and another resident reported not knowing where the bathroom call light was; it was observed behind the toilet armrest with a short string that made it inaccessible when seated. The DON stated call lights were expected to remain within easy reach, and the facility policy required staff to keep them within reach.
A resident receiving clopidogrel developed a nosebleed, nasal swelling, and facial edema, but staff did not document notifying the provider or family when the bleeding first occurred. The resident declined immediate doctor or ED contact, later required EMS transport after family noticed swelling, and was admitted to the hospital with a brain bleed. Staff stated the provider needed notification because the resident was on an antiplatelet medication.
Staff failed to follow a physician-ordered wound treatment for a resident’s right foot and performed dressing changes without verifying the order. Staff also failed to respond appropriately when another resident fell, had severe hip pain, redness, and swelling, and was later hospitalized with a hip fracture; staff used a mechanical lift to get him up despite his complaints of pain. The facility’s wound care and falls policies did not align with the actions taken by staff.
Dirty resident rooms and laundry room conditions: Several residents reported that their bathrooms and rooms had not been cleaned for weeks, and observations showed dirty floors, dirty toilets, unpleasant odors, and toilet seat risers left on the floor without a barrier. The Housekeeping Supervisor said the facility was short staffed and that bathrooms should be cleaned and mopped daily, while the DON said seat risers on the floor should be bagged. A pile of dirty resident clothing was also observed on the laundry room floor instead of in a bin.
Insufficient staffing led to delayed resident assistance, missed support during care, and residents being left unattended. Residents reported call lights taking 30 to 45 minutes or longer, with halls often staffed by only one CNA. A resident needing help with bathing and transfers was observed unattended in the shower room, and a dependent resident was left in wet, soiled clothing at the nurses' station while staff charted or watched the halls. Staff reported the workload was too much for one aide and that nurses did not help when extra CNA coverage was unavailable.
Incomplete Skin Assessment and Missing Incident Documentation: A resident with intact cognition, HTN, HF, and DM had bruises on both hands, including a band-aid over part of the right hand, but the EHR did not document the bruises or the band-aid. The RN said weekly skin assessments were completed and CNAs reported new skin areas, but she was unaware of the hand findings. The record also lacked a Report of Incident/Accident, despite facility policy requiring one for a bruise.
A resident with CAD, pneumonia, COPD, pulmonary hypertension, and hypoxemia had an order for continuous O2 at 2 L via NC, but was observed without oxygen in place and with the concentrator and oxygen cannister not running. The resident said staff did not put on her oxygen after she got up and went to breakfast, later reporting she still did not have it on and felt a little SOB. Staff gave conflicting accounts about whether she requested oxygen, and the chart lacked documentation of refusals or removal of the NC despite ETAR entries showing continuous use.
The facility failed to ensure medications and biologicals were properly labeled with open dates. During med pass observations, an LPN and an RN removed opened Lantus and Artificial Tears that lacked dates opened, and multiple medication carts contained numerous opened stock items without open dates, including fiber supplements, eye drops, acetaminophen, vitamins, and other OTC medications. Staff acknowledged the items should have been dated when opened, and the DON also found an unlabeled Basaglar Kwik pen in the medication storage room.
A resident dependent on staff for oral care due to multiple medical conditions did not consistently receive required oral hygiene assistance, as shown by gaps in documentation and confirmed by interviews with the resident, family, and DON. Facility policy required such care, but it was not provided as specified in the care plan.
The facility failed to properly store and label food items and served meals on dirty dishes. Observations revealed undated and unlabeled food in the refrigerator and dirty dishes used during meal service. A resident reported frequently receiving dirty dishes. The CDM acknowledged the need for proper labeling and dishwashing procedures.
A resident's code status was inconsistently documented across physician orders, EHR, and Care Plan, leading to a deficiency. The resident, with intact cognition, had expressed a desire for CPR, but the Care Plan incorrectly listed a DNR status. Staff interviews confirmed the expectation for consistent documentation, which was not met, resulting in a failure to honor the resident's advanced directives.
A facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to a resident with moderately impaired cognition and multiple diagnoses, including cancer and heart failure. The resident transitioned from Medicare Part A skilled services to an intermediate care level, but the required SNF ABN was missing from their clinical record. The Social Worker responsible for reviewing the SNF ABN confirmed it was not provided, and the facility lacked a policy for Medicare-required notices.
A facility failed to update the PASRR for a resident with a new PTSD diagnosis. The resident had moderately impaired cognition and was diagnosed with anxiety, depression, psychotic disorder, and PTSD, receiving antipsychotic and depression medications. The PASRR did not reflect the PTSD diagnosis, and no new evaluation was completed. The Social Services Coordinator admitted the oversight, and the DON noted the absence of a specific PASRR policy.
The facility failed to ensure the use of two CNAs when operating a full-body mechanical lift for transferring residents, as required by their care plans. Two residents with functional limitations experienced transfers with only one aide, despite the policy requiring two. Staff interviews revealed inconsistencies in policy adherence, with some staff performing transfers alone due to staffing shortages. The DON was reportedly unaware of these incidents, although staff claimed to have informed her.
A resident with severely impaired cognition did not receive perineal care according to standards, as observed when two CNAs failed to perform hand hygiene, used the same wipe for multiple areas, and did not change gloves between tasks. Interviews revealed inconsistencies in staff understanding of the facility's perineal care policy, which requires cleaning from front to back and changing gloves when moving from dirty to clean tasks.
A resident with severe cognitive impairment was prescribed Risperdal without the facility obtaining informed consent. Although the resident's wife was informed of the new medication, the facility did not discuss the risks or obtain consent. Interviews confirmed the lack of informed consent, and the DON acknowledged the absence of a policy for psychotropic medications.
Incomplete Wound Assessment and Documentation for a Resident With a Gangrenous Foot Wound
Penalty
Summary
The facility failed to assess and document complete wound assessments for a resident with a diabetic foot ulcer and significant vascular disease history, including stroke, peripheral vascular disease, and diabetes. The resident had intact cognition and no documented rejection of care behaviors. The record showed daily treatment and dressing changes on the TAR, with several omissions in April and May 2026, while the skin issue documentation for the right dorsum 1st interdigital space of the foot was inconsistent and often incomplete, with some entries lacking measurements and others documenting no undermining or tunneling. The wound was first documented as an in-house acquired skin issue with measurements, then later noted as deteriorated, and subsequently described in some entries as healed or closed despite continued monitoring. Podiatry records documented necrotic tissue debridement, a very painful wound, and the need for a right fifth toe amputation. After the toe amputation, the wound was again documented as a surgical wound with unknown progress, with some assessments lacking measurements and others showing variable wound size and progress. The resident’s condition worsened and he was transferred to the ED, where providers diagnosed sepsis with acute renal failure and septic shock. Hospital records described the foot as necrotic and gangrenous, with complete dehiscence and exposed metatarsal bones, along with erythema, lymphangitis, tenderness, and edema. The resident required a below-the-knee amputation, and the DON stated that no additional in-house assessments were completed for the resident’s foot.
Inadequate post-fall response after resident fall with hip injury
Penalty
Summary
The facility failed to provide an adequate intervention after a resident fell. Resident #1 had a documented fall risk, a history of falls, moderately impaired cognition, and care plan interventions that included using his call light, waiting for assistance, and following the facility fall protocol. On the day of the incident, he was found on the floor after reporting that he was headed to the bathroom and had lost his balance. He complained of severe left hip pain, had redness and mild swelling to the left hip, and did not want to bend his left leg because of the pain. Staff assessed him on the floor and then used a mechanical lift to move him from the floor into bed despite his complaints of hip pain and refusal to move the leg. The resident later reported that he did not use his call light because he felt staff took too long to answer it. He also stated that the nurse did not perform range of motion on him while he was on the floor before he was moved. Staff later confirmed that they used the mechanical lift to get him up and into bed after he complained of hip pain and would not bend or move the left leg. The resident was transferred to the emergency department by ambulance and the hospital admitted him for a hip fracture and possible surgery. The facility’s Falls-Clinical Protocol directed staff to assess and document musculoskeletal function and observe for changes in normal range of motion. The DON stated that if a resident complained of pain and did not want to move an extremity, staff should make the resident comfortable, leave the resident on the floor, and wait for EMTs to arrive. The PCP stated the fall and injury led her to assume the fracture resulted from the fall.
Delayed Call Light Response
Penalty
Summary
The facility failed to answer call lights in a timely manner for 4 of 5 residents reviewed for call light response, including Residents #1, #3, #10, and a confidential source. Resident #1 reported he recently had a fall and said he did not use his call light when he needed to use the restroom because there was no point, explaining it could take a couple of hours for staff to answer. Resident #3 reported that after she vomited from acid reflux and turned on her call light, no one came into her room for 4 hours until the next morning. A confidential resident stated staff often had to be called 3 to 4 times before help came and that staff had forgotten them in the bathroom multiple times in the last month and a half, leaving their buttocks numb; during the interview, the restroom call light was observed with a short string of about 5 inches at shoulder height behind the armrest. Resident #10 said he did not use his call light because it was faster to wave staff down or call out when they passed by. Staff interviews showed differing expectations for response times, ranging from right away to 15 minutes, while the DON stated the maximum allowable time frame was 15 minutes. The facility’s Answering the Call Light policy revised March 2021 instructed staff to ensure timely responses to residents’ requests and needs.
Infection Control and Isolation Procedures Not Maintained for Resident with C. diff
Penalty
Summary
The facility failed to maintain effective infection control and isolation procedures for Resident #7, who had prolonged diarrhea, a history of C. diff infection, and a stool sample that was positive for C. diff after a verbal order was given on 5/7/26. The resident was placed on contact precautions and ordered to remain in contact isolation with treatments, medication passes, therapy, activities, and meals occurring in the room. Clinical notes documented ongoing treatment for C. diff, including continued medication use and reports of loose stool and abdominal tenderness on 5/11/26, followed by no loose stools and no abdominal pain reported on 5/13/26. During a dressing change on 5/13/26, an RN entered the room wearing a gown and gloves but filled the sink with soapy water and placed clean washcloths in the sink without a barrier, then drained and reused a washcloth to clean the resident’s legs, changing cloths only when moving to the other leg. The RN removed gloves, rinsed hands under running water, turned off the faucet with a wet hand, dried hands, and put on clean gloves before and after the procedure. At the end of the treatment, she removed her gloves and sprayed the sink with a disinfectant that did not list C. diff as an organism it killed. Staff interviews reflected that handwashing with soap and water was expected for C. diff, that the faucet should be turned off with a paper towel, that isolation signage belonged on the door, that the resident should have been placed on isolation when C. diff was suspected, and that a basin rather than the sink should be used to hold water during wound care.
Call Lights Not Kept Within Reach or Accessible
Penalty
Summary
The facility failed to ensure call lights were within reach and accessible for 2 of 5 residents reviewed for call light use, including Resident #9 and a confidential resident source. On 5/14/26, Resident #9 was observed sitting in a wheelchair in his room with his call light lying on the floor at the foot of his bed, while a reacher was on his bed. On 5/12/26, a confidential resident interview revealed staff had told the resident there was a call light in the bathroom, but the resident did not know where to find it; during the interview, the bathroom call light was observed behind the armrest on the toilet at about shoulder height, with a string approximately 5 inches long, making it inaccessible when the resident was seated on the toilet. The DON stated on 5/21/26 that call lights were expected to be in reach and remain accessible to all residents, and the facility policy instructed staff to ensure the call light remained within easy reach of the resident.
Failure to Notify Provider of Nosebleed in Resident on Antiplatelet Medication
Penalty
Summary
The facility failed to notify the provider when Resident #5, who had intact cognition and was receiving clopidogrel 75 mg daily as an antiplatelet medication, developed a nosebleed. The resident’s February 2026 MAR showed the medication was administered daily from 2/15/26 through 2/27/26. On 2/27/26 at 7:30 AM, staff documented blood from the nasal area, and the nurse noted the resident was in bed with the head elevated for assessment. After the bleeding stopped, the resident got into a wheelchair and continued morning activities. The nurse asked whether the resident wanted to call the doctor or go to the ED, but the resident declined and said her son would take her if needed. The note did not document notification of the resident’s family or provider. Later that day, staff documented that the resident had a swollen nose, a hairline scratch across the septum, and edema on both cheekbones below the eyes, and the resident reported a nosebleed earlier in the day. This note also lacked provider notification. Family then requested a medical evaluation before discharge because of the swelling under the resident’s eyes and requested EMS transport to the hospital. The resident was admitted to the hospital with a brain bleed. Staff later stated that because the resident was taking an antiplatelet medication, the provider needed to be notified when the bleeding occurred to determine whether the medication should be held. The facility policy on change in resident condition or status instructed staff to notify the attending physician or physician on call when there was an adverse reaction to a medication.
Failure to Follow Treatment Orders and Respond Appropriately to a Fall
Penalty
Summary
Staff failed to follow the physician’s order for Resident #9’s right foot dressing treatment. The May 2026 TAR directed staff to apply Povidone-Iodine solution 10% to the right foot daily on the day shift and place gauze per podiatry, but the record showed the treatment was not documented on 5/1/26, 5/5/26, and 5/11/26. The documentation also directed staff to see progress notes on 5/12/26 and 5/17/26. Staff B, an LPN, stated she performed a dressing change to the resident’s right foot on 5/16/26 and confirmed in two interviews that she completed the dressing change at bedtime and that both dressing changes involved the iodine gauze treatment. The facility’s Wound Care policy instructed staff to verify the physician’s order for the procedure, and the DON stated staff should not perform dressing changes that lack an order. Staff also failed to respond appropriately when Resident #1 fell and complained of pain. The progress note documented that the resident fell in his room, had a 10/10 pain rating in his left hip, showed redness and mild swelling, and refused to bend his left leg due to pain. Later that day, the resident was admitted to the hospital for a hip fracture and possible surgery. The resident stated staff used a mechanical lift to get him up off the floor and that the nurse skipped range of motion before getting him up. Staff B stated the resident complained of left hip pain while on the floor and that staff used the mechanical lift to get him up and into bed, explaining that it was normal protocol to get someone up after a fall even if they complained of pain. The Falls - Clinical Protocol policy lacked direction for what to do when a resident fell with complaints of pain and swelling of a joint, and the DON stated she expected staff to make the resident comfortable, leave them on the floor, and wait for EMTs to arrive.
Dirty resident rooms and laundry room conditions
Penalty
Summary
The facility failed to ensure resident rooms were clean and sanitary for four residents who complained about the condition of their bathrooms and rooms. Resident #40 reported that housekeeping had seldom been in the room and said it had been about 3 weeks since the last cleaning; the bathroom had an unpleasant odor, a very dirty floor and toilet bowl, and a dirty seat riser sitting on the floor without a barrier. Resident #41 described the toilet and floor as dirty and said the facility had not had a housekeeper for about 2 1/2 weeks; observations showed the bathroom floor, toilet, and toilet seat riser were dirty, and the seat riser remained on the floor without a barrier. Resident #118 stated the room had gone weeks without cleaning and that staff had not returned to mop after sweeping, and Resident #122 reported her bathroom smelled and had a booster seat on the floor that she did not feel was sanitary. Repeated observations showed the bathrooms for Residents #40, #41, and #122 remained unchanged over several days, with dirty floors, dirty toilets, and dirty seat risers still on the floor. The Housekeeping Supervisor stated the department had been short staffed for the previous 3 to 4 months, that each room should be cleaned daily, and that bathrooms should be cleaned and mopped daily with trash taken out, but there were not enough staff. The DON stated that if a toilet seat riser was on the floor it should be in a plastic bag and that she would remove them from rooms if not used. The facility's Cleaning and Disinfecting Residents' Rooms procedure lacked information on how often rooms should be cleaned, while the Daily Check List directed staff to sweep and mop the room and restroom floor daily. The facility also failed to keep dirty laundry off the floor in the laundry room, where a pile of resident clothing was observed on the dirty side of the room on the floor without a barrier. The Laundry Aide stated dirty laundry should not be on the floor, and the Infection Preventionist stated dirty clothes should be placed in dirty linen bins and not on the floor.
Insufficient Staffing and Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient staffing to meet resident needs and ensure resident safety, with multiple residents and staff reporting long waits for assistance and limited CNA coverage on several halls. The facility had a census of 129 residents. Residents with intact cognition reported call lights taking 30 to 45 minutes, sometimes up to an hour, and stated that there was usually only one CNA on their hall. One resident reported the facility was short of help and staff could not answer as fast as needed, while another said the hall usually had only one CNA and that was not enough. A resident also reported that staff sometimes helped on the floor only when extra staff were present because state surveyors were in the building. The staffing concerns were also reflected in direct observations of resident care. One resident with diagnoses including hypertension, heart failure, and diabetes reported that food was cold and at times a tray was not delivered. Another resident with a limb prosthesis and care plan for assistance with bathing, transfers, and personal hygiene was observed unattended in the shower room while staff were working elsewhere; the resident later reported being left alone in the shower room for 2 to 5 minutes at times. A CNA stated that on a normal day there was only one aide on the hall, that showers were difficult for one person to manage, and that management knew about the staffing issue but did not change it. A severely cognitively impaired resident who was dependent for all ADLs was observed sitting at the nurses' station in wet clothing with liquid brown matter around the outer area that appeared to be drying. Staff were aware of the resident's condition, but the resident remained there for an extended period while staff at the nurses' station charted or watched hallways and no one assisted until later. The ADON stated nurses were to help staff when needed and that residents were not to be left unattended in the shower room. The DON stated nurses should assist with resident care when they could and answer call lights when they could, while staff and residents continued to report that the facility generally had only one CNA on several halls and that nurses did not help when a second aide was unavailable.
Incomplete Skin Assessment and Missing Incident Documentation
Penalty
Summary
The facility failed to complete an accurate skin assessment for one resident with intact cognition, hypertension, heart failure, and diabetes. Observation showed bruises on both hands, including a band-aid covering part of the bruised area on the right hand. The resident and his wife reported the bruises and covered area had been present for a few days, and the bruises were still present on a later observation with a new band-aid on the right hand. The RN stated she completed weekly skin assessments and documented them in the EHR, and that CNAs also informed nurses about new skin areas, but she did not know about the resident’s hand areas. The resident’s EHR did not contain documentation of the bruises or the band-aid, and it also lacked a Report of Incident/Accident for the areas. The DON stated nurses completed weekly skin assessments and should document any new areas, and the EHR should have an evaluation of the skin assessment. The facility policy directed staff to complete a Report of Incident/Accident after discovery of an abrasion, skin tear, or bruise.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and accurate delivery of oxygen therapy for one resident with CAD, pneumonia, COPD, pulmonary hypertension, and hypoxemia. The resident’s care plan and physician orders directed continuous oxygen at 2 L via nasal cannula to keep saturations above 90%, and the order also allowed oxygen to be removed or refused by the resident. However, the progress notes did not document the resident asking for oxygen, refusing oxygen, or removing the nasal cannula, and the September and October ETAR showed continuous oxygen use with no refusals for the prior 60 days. During observation, the resident was found without oxygen in place, with both the concentrator and oxygen container on the wheelchair not running. The resident stated she had gotten up early, went to breakfast, and returned without staff putting on her oxygen, and later reported she still did not have oxygen on and felt a little short of breath. Her granddaughter turned on the oxygen cannister and the resident put on the nasal cannula herself. Staff B stated the resident asked for her oxygen to be turned on, while an RN stated the resident must not have wanted oxygen because she did not ask for it. The DON stated residents with continuous oxygen orders have the right to remove it and said the resident took it off and put it on by herself, while also noting the care plan should match the current oxygen order. The facility’s oxygen administration policy directed staff to review physician orders and the care plan, but it did not address documentation of refusals or removal of oxygen.
Medications and Insulin Pen Found Without Required Open Dates or Labels
Penalty
Summary
The facility failed to ensure medications and biologicals were labeled with the date opened. During medication administration observations, Staff G, an LPN, removed a vial of Lantus for a resident from the D wing cart and identified it as opened, but the vial did not have an open date. Staff H, an RN, also removed a box of Artificial Tears for another resident with the top of the packaging removed, and neither the packaging nor the bottle had an opened date. Staff H acknowledged the bottle should have been dated when opened. Inspection of multiple medication carts found numerous opened stock medications without dates opened, including fiber supplements, calcium products, cranberry tablets, eye drops, acetaminophen, loperamide, famotidine, vitamins, polyethylene glycol, aspirin, ibuprofen, and melatonin. Staff I, RN, Staff G, Staff H, and Staff J, LPN, each acknowledged the items lacked open dates and stated they should be dated when opened. In the skilled medication storage room, an unlabeled Basaglar Kwik pen was found lying in a loose plastic basket, and the DON stated she had seen it earlier that morning but had not disposed of it at that time. The facility policy stated that when opening a multi-dose container, the date opened is recorded on the container, and insulin pens are clearly labeled with the resident's name or other identifying information.
Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
A deficiency was identified when a resident, who was assessed as having intact cognition but was dependent on staff for oral care and eating due to medical conditions including hypertension, stroke, hemiplegia, anxiety, and depression, did not consistently receive oral hygiene assistance as required. The resident's care plan specified maximum assistance with oral hygiene, but documentation for multiple days in February and March showed no record of oral care being provided. Interviews with the resident confirmed that oral care was inconsistently performed, depending on which staff were on duty, and the family expected oral care after every meal. The DON confirmed that the facility's expectation was for oral care to be provided twice daily, but acknowledged that this was not consistently done according to the documentation reviewed. Observation further revealed that the resident had missing teeth and experienced gum bleeding during oral care, although no pain was reported. The facility's policy required that residents unable to perform activities of daily living independently receive necessary assistance, including oral hygiene, in accordance with their care plan and assessed needs. The lack of consistent oral care and incomplete documentation indicated a failure to provide the required assistance for activities of daily living for this resident.
Food Storage and Dish Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as well as maintain cleanliness in dishware used for serving meals. During an observation in the drink area refrigerator, several items were found to be improperly stored, including an open, undated, and uncovered piece of cherry pie, an undated and unlabeled plate with a prior day's meal, and unlabeled and undated items in a clear plastic container. Additionally, two juice pitchers were found without labels or dates. The Certified Dietary Manager (CDM) acknowledged that staff should have covered, dated, and labeled these items according to facility policy. During a lunch meal service, staff served meals on dirty dishes containing dried food particles. Staff A served fish, hashbrown casserole, and mixed vegetables on dirty plates, while Staff B served tomato soup in dirty bowls. A resident reported receiving a bowl of soup with a dirty rim and mentioned that receiving dirty dishes was a frequent occurrence. An observation of the clean dish caddy revealed it was dirty, with dishes containing food particles. The CDM confirmed that dishes should be sent back through the dishwasher if not properly cleaned, as per the facility's sanitization policy.
Inconsistent Documentation of Advanced Directives
Penalty
Summary
The facility failed to maintain consistent documentation of a resident's code status across various records, leading to a deficiency in honoring the resident's advanced directives. The clinical record review revealed that Resident #101, who had intact cognition as indicated by a BIMS score of 14, had conflicting code status information. The physician orders and a signed CPR declaration form indicated the resident desired CPR, while the Care Plan incorrectly documented a DNR status. This inconsistency was not aligned with the facility's policy, which required consistent Plans of Care reflecting the resident's treatment preferences. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, confirmed the expectation for consistent advanced directives across the resident's physician orders, EHR, and Care Plan. Despite this expectation, the Care Plan for Resident #101 inaccurately reflected a DNR status, contrary to the resident's expressed wishes for CPR. The Director of Nursing acknowledged the discrepancy, highlighting a failure in the facility's process to ensure accurate and consistent documentation of advanced directives.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS 10055 to a resident, identified as Resident #372, who was under review. The resident had a Minimum Data Set (MDS) assessment indicating moderately impaired cognition and required supervision or assistance for various activities. The resident had multiple diagnoses, including cancer, coronary artery disease, heart failure, diabetes mellitus, stroke, wound infection, and non-Alzheimer's dementia. Despite the resident's transition from Medicare Part A skilled services to an intermediate care facility level of care, the clinical record lacked the required SNF ABN. The Social Worker, identified as Staff B, acknowledged responsibility for reviewing the SNF ABN and the Notice of Medicare Non-Coverage (NOMNC) with the resident or their responsible family member. However, Staff B confirmed that they did not provide the SNF ABN to Resident #372. The facility's administrator expected all required notifications to be completed as mandated, but the facility did not have a policy for providing Medicare-required notices. This oversight was identified during a review of the resident's clinical records and staff interviews.
Failure to Update PASRR for Resident with New PTSD Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a new mental health diagnosis. The resident, identified as having moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12, had diagnoses of anxiety, depression, psychotic disorder, and post-traumatic stress disorder (PTSD). Despite these diagnoses and the administration of antipsychotic and depression medications, the resident's Level 1 PASRR dated 11/20/23 did not include the PTSD diagnosis, and no subsequent PASRR was completed. The Social Services Coordinator acknowledged missing the PTSD diagnosis on the PASRR and the need for a new evaluation. The Director of Nursing reported that the facility did not have a specific policy for PASRR, instead following general regulations.
Failure to Use Two CNAs for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure the use of two certified nursing assistants (CNAs) when operating a full-body mechanical lift for transferring residents, as required by their care plans. This deficiency was identified for two residents, both of whom had functional limitations and required total staff assistance for transfers. Resident #12, with a history of cerebrovascular accident and intact cognition, reported that often only one staff member operated the lift, despite the care plan specifying the need for two. Similarly, Resident #34, who had diagnoses including stroke with hemiparesis and morbid obesity, also experienced transfers with only one aide, although she expressed feeling safer with two staff members present. Interviews with staff revealed inconsistencies in adhering to the policy requiring two staff members for lift operations. Some staff members admitted to performing transfers alone due to staffing shortages or difficulty finding assistance, despite knowing the policy and the risks involved. Staff members expressed varying levels of compliance, with some refusing to operate the lift alone, while others admitted to doing so when unable to find help. The Director of Nursing (DON) was reportedly unaware of these incidents, although staff claimed to have informed her about the issue. The facility lacked a specific policy for the use of full-body mechanical lifts, relying instead on the manufacturer's instructions, which suggested that two caregivers might be necessary depending on the situation. The DON emphasized the requirement for two staff members during transfers and expressed frustration upon learning that staff claimed to have reported the issue to her. Despite the lack of reported incidents or injuries, the deficiency highlights a failure to consistently follow established procedures for resident safety during transfers.
Failure to Follow Perineal Care Protocols
Penalty
Summary
The facility failed to provide clean perineal care according to standards of practice for one resident, identified as Resident #65, who had severely impaired cognition and required total staff assistance for toileting hygiene. During an observation, two Certified Nursing Assistants (CNAs), Staff C and Staff D, were seen performing perineal care on Resident #65 without following proper hygiene protocols. They did not perform hand hygiene before donning gloves, and Staff D used the same disposable wipe to clean multiple areas without changing or folding it. Additionally, Staff D did not change gloves or perform hand hygiene after handling soiled items and before touching clean supplies. Interviews with staff members revealed inconsistencies in understanding and implementing the facility's perineal care policy, which directs staff to clean from front to back using a one wipe, one swipe method, and to change gloves and perform hand hygiene when transitioning from dirty to clean tasks. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the expectations for perineal care, which were not met during the observed incident. The facility's policy, revised in February 2018, outlines specific steps for washing and drying the perineal area, which were not adhered to by the staff involved.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, Risperdal, for a resident with severe cognitive impairment. The resident, who had diagnoses of diabetes, Alzheimer's disease, depression, and anxiety, was prescribed Risperdal 0.25 mg twice daily. Although the resident's wife was informed of the new medication order, the facility did not discuss the associated risks or obtain informed consent. Interviews with the resident's family and staff confirmed that the facility did not complete the informed consent process. Additionally, the Director of Nursing acknowledged the absence of a policy for psychotropic medications and confirmed that the facility did not obtain informed consent for the medication in question.
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Illustrative
What surveyors actually found near you
We read the 157 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 Waterloo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village Retirement | 0.4 mi | ★★★★★ | 4 | 0 |
| Harmony Waterloo | 0.9 mi | ★★★★★ | 17 | 1 |
| Northcrest Specialty Care | 3.9 mi | ★★★★★ | 7 | 0 |
| Harmony House Health Care Center | 3.9 mi | ★★★★★ | 14 | 0 |
| Pinnacle Specialty Care | 4.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.