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 Regency Care Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and painful right knee complications had a care plan calling for routine pain monitoring and prompt response to pain, but the facility did not document pain assessments or provide pain meds on multiple days after hospice admission. Staff observed moaning, grimacing, crying, and restlessness during care, yet no medication was brought when the family asked for relief. The physician later documented uncontrolled pain, and hospice notes described significant discomfort and difficulty obtaining ordered morphine and Ativan.
A resident who was cognitively intact and fully incontinent reported being left in urine for hours after asking a CNA for peri-care. She said the CNA repeatedly failed to clean her up, yelled at her, used profanity, accused her of turning off her own call light, and moved toward her in a way that made her fear being hit. Staff interviews and the resident’s grandson’s statement supported that the resident remained uncleaned for an extended period and was eventually found to need a complete bed change, including bowel care.
Insufficient weekend CNA staffing led to missed care and incomplete resident services. PBJ data showed excessively low weekend staffing, and staffing sheets documented multiple day, evening, and night shifts below the facility assessment’s CNA needs. CNAs reported being short staffed, unable to complete showers as assigned, lacking time to chart, and struggling to provide care for residents needing Hoyer lifts and two-person assistance; the Administrator agreed with the staffing findings.
A resident’s initial BIMS was not completed as part of the MDS assessment. The record showed the resident was not assessed, and the Administrator stated the omission occurred because a PRN traveling MDS person worked remotely and a miscommunication kept the need for the assessment from being conveyed to the facility team. A later PRN BIMS showed moderately impaired cognition.
A resident with dementia, severe cognitive impairment, falls, and scheduled pain meds had a care plan for prior shoulder and arm pain, but it was not revised after she developed right leg/knee pain and pain with movement following hospitalization. A CNA reported the resident was in a lot of pain, vocalized pain when moved, and was often kept in bed because transfers caused pain; the DON acknowledged the care plan was not updated after the resident returned from the hospital.
Failure to provide needed nail care: A resident who needed ADL assistance repeatedly asked for toenail trimming, but staff had not addressed it and his toenails were long enough to snag on his socks and shoes. An LPN later found the nails had grown about 1/4 inch past the toes, and the Administrator stated nurses could trim nails and the facility should provide nail care regardless of skilled status.
A resident with intact cognition reported crushing chest pain overnight, but the LPN did not assess the resident and the record lacked documentation of assessment or provider notification. In a separate issue, another resident with a postoperative foot/ankle wound and NPWT had missed or delayed VAC changes, incorrect settings, a dead battery, saturated dressings, and a device that was not adhered to or functioning; podiatry notes and TARs showed repeated problems with wound VAC maintenance and documentation.
Failure to Assist With Medicaid and POA Documentation: A resident with severe cognitive impairment, multiple chronic diagnoses, and private-pay admission status did not receive timely social services support for Medicaid paperwork or POA documentation. Facility staff lacked the POA paperwork on file, did not promptly initiate the Medicaid application process, and there were repeated miscommunications with the contracted representative and POA regarding bank statements, financial documentation, and an attempted emergency conservatorship.
Infection control failures involved EBP and blood glucose monitoring. A resident with MDRO urine cultures and incontinence did not have EBP indicated in the room despite isolation-required results, and a CNA providing catheter care for another resident on EBP wore gloves but did not don the gown posted at the door. In a separate event, a CMA obtained a blood sugar sample and then left the room still wearing gloves and handling supplies before performing hand hygiene.
A resident with multiple chronic conditions and hospice care was left unsupervised with a cup of medications on his bedside stand. An LPN left the meds with the resident while assisting elsewhere, did not return to verify administration, and later documented the meds as given even though the resident was still holding them and stated he could take his own meds. The VP of Clinical Operations confirmed the resident had no order to self-administer.
Failure to notify the physician of a resident's chest pain episode. A resident with Parkinson's disease and intact cognition reported a crushing chest pain episode that lasted about 15 minutes, but there was no documented nursing assessment, provider notification, or family notification. The resident later raised the concern in a resident council meeting, and the DON acknowledged the complaint but no physician follow-up was documented.
Oxygen flow and equipment were not properly maintained for a resident with asthma and O2 dependence. The resident’s O2 was found running above the ordered rate, the humidifier bottle was dry or empty, and the tubing was not changed as required. Interviews showed CNAs were adjusting O2 flow and handling portable tanks even though they were not licensed to do so, while the LPN and admin described inconsistent expectations for tubing and humidifier changes.
Failure to Manage and Document PD Care: A resident with ESRD, dementia, and severe cognitive impairment received CCPD in the facility, but the chart lacked physician orders for the PD solution and lacked documentation of who connected and disconnected the cycler or completed required assessments. Nursing notes showed the resident's sons were doing the PD, while the dialysis provider stated family should not have been handling it in the nursing home. The resident later had PD catheter dysfunction with external tubing avulsion and was hospitalized for repair.
A resident was incorrectly documented as discharged on the MDS assessment, despite care plan notes and staff interviews confirming the resident remained in the facility. The error was identified when the DON and ADON verified the resident's continued presence and acknowledged the MDS did not accurately reflect the resident's status.
A resident with severe cognitive impairment and a pressure injury to the heel did not have her care plan updated to include physician-ordered interventions for heel offloading. Although staff provided heel protectors and pressure-reducing boots, the care plan lacked documentation of these measures, contrary to facility policy and assessment findings.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found gaps in staffing and leadership coverage during their review.
A resident with diabetes, who was receiving insulin and other diabetes medications and had experienced episodes of hyperglycemia requiring emergency care, did not have a comprehensive care plan addressing diabetes management. The care plan lacked focus areas, goals, and interventions for diabetes, and the diagnosis was not promptly entered into the EHR. There was also no documentation or monitoring for signs and symptoms of hyperglycemia or hypoglycemia, contrary to facility policy and staff expectations.
Staff did not complete required elopement risk assessments for a resident with severe cognitive impairment and ongoing wandering and behavioral symptoms. Despite frequent documentation of wandering, agitation, and hallucinations, the necessary evaluations were not performed quarterly or as needed, as confirmed by both the MDS coordinator and DON.
Staff did not clean or sanitize shared mechanical lift equipment after use with multiple residents, including those on EBP or TBP, and failed to disinfect the lift even after contact with bodily fluids. CNAs reported a lack of training and absence of sanitizing wipes on the lifts, and the DON confirmed that facility policy requires cleaning between residents.
A dietary staff member was observed handling glasses incorrectly during meal service by placing fingers inside empty glasses, touching the rims of full glasses, and carrying glasses against their apron. These actions did not follow facility policy, which requires glassware to be held by the handle, middle, bottom, or stem, and not by the rim.
The facility did not update care plans for two residents, resulting in inaccurate documentation of a urinary drainage bag type for one resident and an outdated code status for another. Staff and records confirmed that the care plans did not reflect the residents' current needs or physician orders.
A resident with severe cognitive impairment and respiratory failure did not receive oxygen therapy at the physician-ordered rate of 4 L/min; instead, observations and records showed the oxygen was frequently set at 2 L/min without documented physician approval, and staff were unclear about the correct order.
Two residents experienced medication administration errors when an LPN gave one resident a lower dose of Folic Acid than ordered and failed to administer Atorvastatin to another resident, resulting in a 7% medication error rate during the observed pass, exceeding the required threshold.
The facility failed to provide scheduled showers or bed baths for four residents, as required by their care plans. A resident with quadriplegia received no showers in October and only three in November, with no documentation of refusals or rescheduling. Another resident received only one shower in December, missing several in November. Two other residents also missed scheduled showers, with no rescheduling or documentation. Staff interviews revealed a lack of awareness and accountability in documentation and scheduling.
A resident with cognitive impairment reported that a CNA was rough during repositioning, allegedly putting him in a headlock and causing neck discomfort. The facility did not report the incident to the state survey agency within 24 hours, as required by their policy, because they did not consider it an allegation of abuse. Instead, the CNA received education on proper techniques.
A facility failed to provide routine perineal care for a resident requiring substantial assistance for toileting, as staff did not consistently check and change the resident within the required two-hour timeframe. Interviews revealed that CNAs lacked sufficient time and help to perform these tasks, leading to residents waiting up to 6 hours for care. The facility's policy did not specify the frequency for checking and changing residents, contributing to the inconsistency in care.
The facility failed to store and label food items properly, as observed in the refrigerators and freezers. Unlabeled bags of food and oxidized potato chunks were found, indicating non-compliance with food service safety standards. Staff interviews confirmed awareness of these issues, and the facility's policy requires proper labeling and daily checks.
A resident with Stage III kidney failure was not properly monitored for lab values while receiving medications that could affect kidney function. Despite warnings of potential drug interactions, necessary lab tests were not conducted, leading to severe hyperkalemia and acute renal failure, requiring hospitalization and emergent dialysis.
A facility failed to maintain a medication error rate below 5%, with errors observed during a survey. An LPN improperly primed an insulin pen, leading to potential dosing inaccuracies, and administered Levothyroxine outside the accepted time parameters. The Director of Nursing confirmed the latest acceptable administration time was exceeded.
Failure to Assess and Treat Resident Pain
Penalty
Summary
The facility failed to assess and provide pain management to adequately control the pain of a resident with dementia, severe cognitive impairment, repeated falls, difficulty walking, unsteadiness, and a history of right shoulder/arm pain and later right leg pain related to a periprosthetic fracture around a right knee prosthesis. The resident’s care plan identified pain risk and directed staff to anticipate pain relief needs, monitor and record pain severity every shift and as needed, and report non-verbal signs of pain such as grimacing, moaning, crying, restlessness, and changes in breathing or behavior. The care plan was not updated to include the resident’s later right leg pain after hospitalization, although the resident was non-weight bearing on the right lower extremity and required a knee immobilizer with skin checks. After the resident returned from the hospital, the EMR showed PRN acetaminophen was ordered and administered on several occasions for documented moderate pain levels. When hospice services were initiated, hospice comfort medications were ordered, including acetaminophen suppositories, morphine, and lorazepam. However, the record showed that on two days after hospice admission the facility did not monitor or record the resident’s pain severity, and no pain medications were administered those days. The resident’s paper record and EMR also showed no documentation of pain medication administration on one day when the resident was observed crying out, whimpering, and restless during care and while family members were present. During the family visit, the granddaughter asked staff for pain medication because the resident had been whimpering and crying in pain for hours, but no staff returned with medication. On another occasion, the resident cried out while being turned and changed, and the staff member told the granddaughter she would let the nurse know, but no pain medication was provided before the granddaughter left. The physician later documented that the resident still had uncontrolled pain to the right knee and appeared very uncomfortable. Hospice documentation also noted moaning and facial grimacing on entry, difficulty obtaining morphine and Ativan delivery, and that morphine had to be taken from the facility e-kit before being administered. Facility leadership acknowledged that pain monitoring had not been documented and that no pain medication had been given on the days in question.
Resident Left in Urine and Subjected to Yelling and Threatening Behavior
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity when a CNA did not respond appropriately to the resident’s repeated requests for incontinence care and instead engaged in yelling and threatening behavior. Resident #18 had diagnoses including acute respiratory failure with hypoxia and cardiorespiratory conditions, was cognitively intact with a Brief Interview for Mental Status score of 13 out of 15, and was always incontinent of urine and bowel. Her care plan directed staff to provide peri-care with every incontinent episode, assist with toileting and bed mobility, and encourage her to express concerns. The resident reported that she had been left lying in urine for an extended period after asking Staff X to clean her up, and that the delay caused her pain. During interviews, Resident #18 stated that Staff X repeatedly came into her room but did not clean her up, left her lying flat in bed without access to bed controls, and became upset when the resident called her grandson. The resident reported that Staff X yelled at her, used profanity, accused her of turning off her own call light, and moved toward her in a way that made her fear she was going to be hit. She stated she told Staff X to get out of her room and not come back because she was scared. The resident also reported that she had been lying in urine for a while and later said she had also been left in feces, though she could not state exactly how long. Staff interviews and the resident’s grandson’s statement supported that the resident remained uncleaned for hours while Staff X was on the hall. Staff Z stated the resident reported needing to be changed for a while, and when Staff Z and Staff X finally changed her, it was a complete bed change and the resident had a bowel movement as well. Staff Y stated the resident said Staff X was raising her voice and acting sassy, and that Staff X remained in the doorway while the concern was discussed. The grandson stated that during a FaceTime call he heard Staff X yell at the resident to shut up and say she was going to get in trouble, and he said the staff member sounded threatening. Staff X acknowledged that she did not check on the resident until later in the shift and that the resident was not changed until after several hours had passed.
Insufficient Weekend Nursing Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs on 12 of 26 weekend days during October, November, and December 2025, based on CMS Payroll Based Journal staffing data, staff interviews, facility assessment review, and facility record review. The facility reported a census of 58 residents, and the PBJ Staffing Data Report for October 1 through December 31, 2025 showed the facility triggered the metric for Excessively Low Weekend Staffing, which required follow-up during the survey process. The facility assessment, revised in November 2025 and reviewed in April 2026, identified two nursing units and stated that CNAs were scheduled for three 8-hour shifts. It documented that the Day Shift required seven to eight CNAs total, the Evening Shift required six to eight CNAs total, and the Night Shift required three to four CNAs total. The assessment also identified licensed nurses scheduled for two 12-hour shifts, with two to four nurses or a combination of nurses and CMAs on each shift. Review of weekend Daily Staffing sheets showed multiple shifts where staffing fell below the facility assessment, including shortages on the larger unit and smaller unit across day, evening, and night shifts. Staff interviews described the impact of the staffing shortages. A CNA stated the facility was really short staffed and resident showers had not been completed as assigned. Another CNA stated the facility had gone from four CNAs to three and that staff were running around and did not have time to chart. A CNA assigned to one hall stated she was by herself with six residents requiring Hoyer lifts and at least eight residents needing two staff for care, and that incontinent pads were not always checked and changed every two hours per care plans. Another CNA stated staffing was stressful and that she sometimes stayed to work the next shift when another CNA called in. The Administrator reviewed the dates with excessively low staffing and agreed with the findings.
Initial BIMS Not Completed for MDS Assessment
Penalty
Summary
The facility failed to complete the initial Brief Interview of Mental Status (BIMS) for Resident #34 as part of the resident’s initial MDS assessment. The record review showed a BIMS dated 3/17/26 at 11:39 a.m. documenting that the resident was not assessed. On 5/7/26 at 12:41 p.m., the Administrator stated that the BIMS was not done with Resident #34’s initial MDS. The Administrator explained that the facility used a PRN traveling MDS person who worked remotely, and there was a miscommunication that resulted in the need for the MDS assessment not being conveyed to social services or anyone else on the facility team. The record also showed a PRN BIMS dated 5/7/26 at 11:30 p.m. with a score of 8 out of 15, indicating moderately impaired cognition for Resident #34. The facility policy stated that interviews such as the BIMS should be completed on or before the ARD, and that residents are to be assessed using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan.
Care Plan Not Revised After Resident’s Pain Status Changed
Penalty
Summary
The facility failed to revise Resident #68’s care plan after a significant change in her pain status. Her MDS documented dementia, difficulty walking, unsteadiness on feet, repeated falls, need for assistance with personal care, a BIMS score of 5 indicating severe cognitive impairment, and pain management with scheduled pain medications. The existing care plan identified her as at risk for falls and having pain or potential for pain related to a history of right shoulder and arm pain, with interventions to anticipate pain, monitor pain severity every shift and as needed, and report signs or symptoms of non-verbal pain. The care plan was not updated to include right leg pain noted after the resident was hospitalized for that pain. A CNA stated the resident was in a lot of pain in late October to the date of death, had daily pain in her right knee, vocalized pain when moved, and was allowed to remain in bed because transferring caused pain. The DON stated the resident had been hospitalized for right lower extremity pain and experienced pain with movement after returning to the facility, and agreed the care plan had not been updated after that return. The facility policy required the MDS Coordinator and Interdisciplinary Team to review and revise the care plan when a resident experienced a change in status and to communicate new or modified interventions to staff.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to provide grooming for one resident who required assistance with activities of daily living. Resident #34’s MDS documented that he needed staff help with toileting hygiene, lower body dressing, showering/bathing, and putting on and taking off footwear. His care plan identified a self-care deficit and directed staff to encourage bathing twice weekly, inspect skin during showers, and check nail length and trim or clean nails on bath days and as needed. On 5/5/26, Resident #34 stated that he wanted his toenails clipped and said no one ever wanted to trim them. He reported that when he asked why his toenails were not trimmed, he was told he was not on the list, and he did not know how to get on the list. He repeated that he just wanted his toenails trimmed. On 5/6/26, an LPN checked his feet and found his large toenails had approximately 1/4 inch growth from the tip of his toes. Resident #34 stated it had been difficult to put on his socks and shoes because they kept snagging on his toenails. The LPN stated the resident had not been at the facility very long and that his wife had been on the podiatrist list, but she did not know whether anyone had talked with him about being on the list. The Administrator stated that nurses are able to trim nails and that the facility is to trim residents’ nails regardless of whether they are skilled care residents. The facility’s Nail Care Policy directed staff to assess nails on admission and readmission, provide routine cleaning and inspection during ADL care, and provide routine nail care on a regular schedule and as needed.
Failure to Assess Chest Pain and Maintain Wound VAC Therapy
Penalty
Summary
The facility failed to provide an assessment and timely intervention for a resident who reported chest pain overnight. The resident, who had Parkinson’s disease and intact cognition, stated that she experienced crushing chest pain for about 15 minutes, notified a CNA, and asked to see the LPN. She reported that the nurse did not respond, the pain subsided, and she did not tell the nurse the next day. The resident later raised the concern during a resident council meeting, and the grievance record documented that she had reported chest pain to the CNA and that the nurse did not come to check on her. The clinical record reviewed by surveyors contained no documentation of an assessment, provider notification, or family notification related to the chest pain episode. Interviews showed conflicting accounts about whether the chest pain was reported to nursing staff. The CNA denied being told about the chest pain, while another CNA stated the resident was clear in thought and believable. The LPN stated he had not been informed of chest pain and said he would have assessed the resident, notified the provider, and provided pain management if he had been told. The DON acknowledged awareness of the complaint and stated the CNA told the nurse, but when staff returned to assess the resident she was asleep. The DON also confirmed there was no documentation of the assessment or provider notification. The Administrator stated chest pain was a concern that would require immediate nurse assessment. The facility also failed to maintain and provide interventions for a resident with a wound VAC. The resident had diabetes, a foot infection, open lesions, and a postoperative left ankle wound with necrosis of bone after incision and drainage, hardware removal, external fixator placement, and wound VAC placement. Podiatry notes documented that the dressing had not been changed for the first several days at the facility, that the wound VAC was not applied correctly, that the dressing was saturated, and that the device was not adhered to the wound or functioning. One clinic note documented the battery was dead and the VAC could not be reapplied; another documented the VAC was set at 125 mmHg but was actually at 0 mmHg, the dressing was completely saturated in blood, the VAC was not adhered to the skin, and the surrounding tissue was macerated. The provider ultimately discontinued the VAC because the facility was unable to maintain it. The treatment records also showed missing documentation for wound VAC changes and other wound treatments. The TAR lacked entries for several scheduled VAC changes and for some ordered foot treatments. Staff interviews confirmed that wound VAC changes were missed or delayed, that one change was done on a Saturday after a Friday was missed, and that an order was not entered or signed in the EHR. A podiatry clinic nurse stated the facility had been told multiple times that the wound VAC was not functioning or not applied properly, including a dead battery and incorrect settings. The facility’s NPWT policy required the device to be functioning at prescribed settings, with monitoring of device function and documentation of therapeutic response.
Failure to Assist With Medicaid and POA Documentation
Penalty
Summary
The facility failed to provide medically-related social services to assist with obtaining Medicaid application materials and Power of Attorney documentation for Resident #57. Resident #57 was admitted as a private pay resident, had severe cognitive impairment on BIMS testing, and had diagnoses including UTI, diabetes, COPD, respiratory failure, anxiety, depression, and required substantial to maximal assistance with wheelchair use. The care plan documented impaired cognitive function and thought processes. Record review and interviews showed that the resident’s admission paperwork indicated an expected primary payor source of Medicare/Medicaid, but the facility did not have the resident’s POA paperwork on file when staff later discussed financial and legal matters. A family representative attended a care conference, and the facility documented a plan to check Medicaid status, but the Medicaid application process had not been initiated promptly after admission. Email communications showed repeated exchanges among the contracted representative, POA, and facility staff regarding bank statements, Medicaid documentation, and requests for the facility to recognize and use the POA information already available. The contracted representative stated she had been working on the Medicaid application before admission and had provided documents and attempted to communicate with the facility after admission, but reported no response and later learned the facility was pursuing an emergency conservatorship. The POA stated he had not been notified about the conservatorship efforts and requested records and clarification. Facility staff acknowledged that the Medicaid application process should have been started on admission and that POA documentation should have been obtained for the resident’s records, and staff described the missed steps and miscommunications surrounding the resident’s financial and legal documentation.
Infection Control Failures With EBP and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for a resident with multidrug-resistant organism (MDRO) urine cultures. Resident #24 had a BIMS of 11, diagnoses including MDRO bacteria and urinary tract infection, and was incontinent of bowel and bladder with substantial to maximal assistance needed for ambulation and use of a walker or wheelchair. The resident’s care plan addressed incontinence care and monitoring for UTI signs and symptoms, but observation of the resident’s room did not indicate EBP. Review of urine cultures showed MDRO-related results, including Proteus mirabilis/penneri and Klebsiella pneumoniae, with isolation required. The VP of Clinical Operations reviewed the cultures and acknowledged the resident should have been under EBP with incontinent cares. The facility also failed to ensure staff used appropriate PPE during EBP care for a resident with a catheter. Resident #8 had cerebral palsy, BPH, required maximal assistance with personal hygiene, was dependent for toileting, and had an indwelling catheter. The care plan directed staff to use EBP related to the catheter. During catheter care, a CNA wore gloves but did not put on the gown indicated on the EBP sign outside the resident’s door. The CNA also stabilized the urine graduate on her knee instead of releasing the straps from the resident’s leg and bringing the bag to the graduate when emptying it. PPE supplies were available outside the room. The facility further failed to follow infection control practices during blood sugar monitoring. A CMA entered a resident’s room, obtained a blood sample, and then picked up supplies and walked out of the room while still wearing gloves. When questioned, the CMA stated she should have removed her gloves and sanitized her hands before touching other objects. The President of Clinical Operations stated she had been informed of the event and understood the infection control concerns. The facility’s glucometer policy required gloves, hand hygiene, and cleaning and disinfection of the device after each use according to manufacturer instructions.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess whether a resident was appropriate to self-administer medications, and the resident was left unsupervised with medications. Resident #54 had diagnoses including heart dysrhythmia, high blood pressure, arthritis, depression, and long-term gall bladder inflammation, and the MDS noted antidepressant use and a BIMS score of 13. The care plan identified pain, altered mood, and hospice care, and the hospice plan directed licensed nursing staff to provide medications as ordered. During observation, the resident was found in bed with a medication cup on the bedside stand containing a large pink pill, a large white pill, and two smaller pills, with no licensed nurse in the room while CNAs assisted the roommate. The medication cup remained on the resident’s night stand during later observations, and the resident stated he could administer his own medication while still holding the cup. When the LPN was notified, she removed the cup and picked up a pill from the resident’s blanket, stating the medications were late and she would have to see what to do. The LPN stated the medications had been brought earlier in the morning, that she left them with the resident while assisting another resident, and that she did not return to see whether he had taken them. The MAR showed the morning medications were documented as administered and initialed by the LPN, while the progress note later documented the resident wanted only necessary pills and was refusing supplements. The VP of Clinical Operations stated the resident did not have an order to administer his own medication.
Failure to Notify Physician of Resident Chest Pain
Penalty
Summary
The facility nursing staff failed to notify the physician of a change in condition for Resident #11 after the resident reported a crushing episode of chest pain that lasted about 15 minutes during the night. Resident #11, who had Parkinson's disease and was independent with activities of daily living, had a BIMS score of 15 and denied pain during the MDS assessment. The care plan directed staff to monitor and document pain episodes and notify the physician if pain was a significant change from past experiences, but there was no documentation in the progress notes of the chest pain, no provider notification, and no family notification. Resident #11 told staff in a resident council meeting that she had chest pain overnight and that the nurse did not come to see her. Staff J, the Activities Director, completed a grievance form and gave it to the DON, but the DON did not follow up with the physician or document an assessment. Interviews with the LPN, charge nurse, Administrator, and DON showed conflicting accounts about whether the CNA reported the episode to nursing staff, but the record contained no documentation that the resident was assessed or that the provider was notified after the chest pain complaint.
Oxygen Flow and Equipment Not Properly Maintained
Penalty
Summary
Licensed nursing staff failed to appropriately set and maintain oxygen for Resident #20, who had asthma and dependence on oxygen delivery. The care plan identified oxygen at 2 liters, and the physician order directed oxygen at 2 liters with tubing changes every Wednesday. During an observation, Resident #20 was in bed with oxygen tubing dated 4/15/26 and a nasal cannula in place, while the oxygen concentrator was delivering 2.5 liters through a dry humidifier bottle dated 4/25/26. Resident #20 stated she felt dry in her nose and throat but was not in respiratory distress and could feel the oxygen. Later observations showed the concentrator still delivering 2.5 liters, the humidification bottle empty, and the tubing not exchanged. Staff interviews showed CNA staff were adjusting oxygen flow and handling portable tanks, despite stating they knew CNAs were not licensed to adjust oxygen. One CNA stated CNAs would turn oxygen on and off and adjust the amount when a resident was transferred to a portable tank, while another stated she would adjust the rate of oxygen flow but would not replace tubing or humidification bottles. The LPN stated she thought tubing would be changed weekly by night shift and that the humidification bottle would be changed when it became dry. The Administrator stated the tubing should be changed weekly by night nursing. The facility policy stated only physicians, RNs, LPNs, and respiratory therapists were authorized to initiate oxygen therapy, and that tubing and humidifier bottles were to be changed on a set schedule or as needed.
Failure to Manage and Document Peritoneal Dialysis
Penalty
Summary
The facility failed to obtain physician orders for peritoneal dialysis, failed to provide initial and ongoing assessment and oversight of the dialysis, and failed to maintain consistent documentation for a resident with ESRD who received PD in the facility. Resident #69 had diagnoses including ESRD, dependence on renal dialysis, diabetes, malnutrition, and non-Alzheimer's dementia, and a BIMS score of 4 out of 15 indicating severely impaired cognitive functioning. Her care plan identified that she required assistance with ADLs, had impaired balance, incontinence, and needed help with transfers and toileting. The care plan also directed staff to complete a dialysis flow sheet daily to observe for access site complications, but the facility could not produce that flow sheet. The resident's MAR/TAR lacked orders for connecting or disconnecting her from PD, and the facility could not produce documentation of dialysis administration. The physician orders in the record did not include the dialysis solution to be used; the only PD-related order was for gentamicin cream to the exit site. A hospital dialysis note from before admission documented CCPD orders including 1.5% dialysate, 2.5 L fills x 4 exchanges, and 9 hours, but those details were not reflected in the facility's orders. Nursing notes documented that the resident arrived with her sons present, that the son brought the PD machine and supplies, and that the sons were hooking up the PD at night. One note stated the son preferred to be the one to hook up and disconnect the PD machine, and another note documented that the resident would take a break from dialysis that night based on the sons' direction. Interviews showed that the sons were performing the PD in the facility instead of staff, despite the dialysis provider stating that family members should not have been doing the dialysis while the resident was in the nursing home. Staff and leadership acknowledged there were no physician orders for the PD solution, no documentation of who started and stopped the PD, and no documentation showing the sons were authorized to manage the dialysis. Staff also gave conflicting accounts about who was present when the resident's catheter problem occurred. The resident later required hospitalization after her external PD tubing avulsed, with pink drainage and a large fluid loss, and the hospital documented PD catheter dysfunction with external catheter revision. The resident's death certificate later listed septic shock due to respiratory failure and ESRD as the immediate cause of death.
Inaccurate MDS Assessment Documented Resident Discharge
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. According to the MDS assessment tool, the resident was documented as discharged to home/community on a specific date. However, review of the resident's care plan indicated that the resident and their responsible party had chosen long-term placement, and progress notes from the relevant period did not document any discharge. Direct observation confirmed that the resident was still present in the facility after the reported discharge date, and staff interviews verified that the resident had not been discharged. The Director of Nursing (DON) acknowledged that the MDS inaccurately documented the resident as discharged and confirmed the resident's continued presence in the facility. The Assistant Director of Nursing (ADON) stated there had been discussions about the resident discharging home, but the family ultimately decided against it. Facility policy requires that qualified staff conduct accurate assessments reflective of the resident's status at the time of assessment, and that each assessor certifies the accuracy of their portion of the assessment. In this case, the assessment did not accurately reflect the resident's status.
Failure to Update Care Plan with Heel Offloading Interventions
Penalty
Summary
The facility failed to update the care plan for one resident to include specific interventions for offloading her heels while in bed, despite clinical evidence and physician orders indicating the need for such measures. The resident, who had severe cognitive impairment and was at risk for pressure ulcers due to incontinence, debility, and Alzheimer's disease, returned from the hospital with a pressure injury to her heel. Although wound care orders from the hospital specified that her heels should be floated with heel protectors at all times, the care plan did not reflect this intervention for her right heel, which had a deep tissue injury. Staff interviews confirmed that the resident wore booties or pressure-reducing boots to offload her heels, but also noted that she sometimes removed them. The Director of Nursing acknowledged that the intervention should have been included in the care plan and attributed the oversight to staffing changes affecting care plan completion. Facility policies require that all relevant interventions identified in assessments be documented in the care plan and communicated to staff, but this was not done for the resident's heel offloading intervention.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Develop and Implement Comprehensive Diabetes Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a diagnosis of Diabetes Mellitus. Clinical record review showed that the resident had intact cognition and was prescribed multiple diabetes medications, including insulin, and had experienced episodes of hyperglycemia resulting in emergency department visits for falls and dizziness. Despite these events and ongoing medication management, the care plan did not include a focus area, goals, or interventions related to diabetes management. Additionally, the diagnosis of Diabetes Mellitus was not entered into the electronic health record (EHR) under the diagnosis section until a month after admission, and there was no documentation or monitoring for signs and symptoms of hyperglycemia or hypoglycemia in the Medication Administration Record (MAR) or EHR. Staff interviews confirmed that the Director of Nursing expected diabetes to be addressed in the care plan from admission, with appropriate monitoring and documentation for related symptoms, but acknowledged these elements were missing. Policy review indicated that the facility's comprehensive person-centered care plan policy required identification of problems, needs, strengths, preferences, and goals, as well as how the interdisciplinary team would provide care, but these requirements were not met for this resident.
Failure to Complete Timely Elopement Risk Assessments for Cognitively Impaired Resident
Penalty
Summary
Staff failed to complete an accurate and timely assessment for a resident identified as being at risk for elopement. The resident, who had severe cognitive impairment and multiple complex medical and psychiatric diagnoses, was documented as exhibiting frequent wandering behaviors and episodes of agitation, hallucinations, and delusions. Despite these ongoing behaviors and the resident's care plan identifying elopement risk, the required Elopement Risk Evaluations were not completed quarterly or as needed, as per facility protocol and standards of practice. The clinical record showed that after an initial Elopement Risk Evaluation was completed in March, no further evaluations were documented until August, despite multiple progress notes indicating continued and escalating wandering and behavioral symptoms. Both the MDS coordinator and the DON acknowledged that the evaluations were overdue and should have been completed in accordance with the facility's policy. The deficiency was identified through clinical record review and staff interviews, confirming that the resident's assessments were not conducted as required.
Failure to Sanitize Mechanical Lift Equipment Between Resident Uses
Penalty
Summary
Staff failed to maintain a sanitary environment by not cleaning or sanitizing mechanical lift equipment after use with residents, including those on Enhanced Barrier Precautions (EBP) or Transmission Based Precautions (TBP). During multiple observed transfers, certified nursing assistants (CNAs) moved the mechanical lift from one resident to another and placed it in the hallway without disinfecting it, even after the equipment had come into contact with bodily fluids such as urine. The mechanical lifts did not have sanitizing agents available in their baskets, and staff reported that they had not been trained to clean the equipment after each use. Interviews with staff confirmed that the shared mechanical lifts were not sanitized between residents, and that sanitizing wipes were not available on the lifts. Staff also stated they had not observed others cleaning the lifts, and had not done so themselves, regardless of the resident's precaution status. The Director of Nursing (DON) stated that the expectation was for lifts to be cleaned and sanitized after each use, and facility policy required disinfection of lift surfaces and cleaning of non-critical medical equipment between residents.
Improper Handling of Glassware During Meal Service
Penalty
Summary
During a lunch service observation, a dietary staff member was seen handling resident glasses improperly by placing fingers inside empty glasses and touching the rims of full glasses on six occasions. Additionally, the staff member carried drinks back to resident tables with the glasses pressed against their apron three times. The Certified Dietary Manager confirmed that dietary staff are expected to carry drinks one at a time and to hold cups or glasses by the bottom, not the rim. Facility policy specifies that glassware should be held by the handle, middle, bottom, or stem, and that fingers should not be inside the glass or touching the rim. These observed actions were not in accordance with the facility's established procedures for handling dinnerware and glassware.
Failure to Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to update and revise care plans for two residents as required. For one resident with moderate cognitive impairment and multiple diagnoses, including a neurogenic bladder and use of an indwelling urinary catheter, the care plan inaccurately documented the use of a leg urinary drainage bag. Observations and staff interviews confirmed that the resident had not used a leg bag for approximately six months due to leakage issues, and instead carried a standard urinary drainage bag. Despite this change, the care plan continued to reference the leg bag and related interventions, which did not reflect the resident's current care needs or preferences. For another resident with intact cognition, the care plan listed the code status as Cardiopulmonary Resuscitation (CPR), with interventions to call an ambulance and transfer to the hospital. However, the physician order summary and the current Iowa Physician Order for Scope of Treatment (IPOST) both indicated a Do Not Resuscitate (DNR) status, which was also confirmed by staff. The care plan was not updated to reflect this change in code status, resulting in a discrepancy between the resident's documented wishes and the care plan interventions.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide oxygen therapy as prescribed by the physician for a resident with severe cognitive impairment and multiple diagnoses, including diabetes, heart failure, and respiratory failure. The resident was ordered to receive continuous oxygen at 4 liters per minute, but observations over multiple days showed the oxygen was consistently set at 2 liters, both in the dining room and in bed. Review of the electronic health record and medication administration records revealed discrepancies, with documentation often indicating the oxygen was set at 4 liters, while other records and direct observation showed it was set at 2 or 3 liters. There was no documentation supporting any physician-approved change in the oxygen setting from 4 liters to lower amounts during the review period. Staff interviews revealed confusion regarding the correct oxygen order, with a Certified Medication Aide stating the order was for 2 liters and a Registered Nurse confirming the order was actually for 4 liters. The Assistant Director of Nursing acknowledged the correct order was 4 liters and suggested staff may have missed the order. The Director of Nursing confirmed there was no facility policy related to oxygen therapy, stating that staff follow physician orders and standards of practice.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required. During a medication pass observation, a Licensed Practical Nurse (LPN) prepared and administered 17 medications to one resident, including Folic Acid. However, the resident was ordered to receive 1 mg of Folic Acid but was instead given only 400 mcg. For a second resident, the LPN prepared and administered nine medications, but failed to administer Atorvastatin 20 mg as ordered. Additionally, several of this resident's medications, scheduled for 8:00 am, were not administered until 9:21 am. A total of 28 ordered medications were reviewed during the observation, with two errors identified, resulting in a medication error rate of 7%. The facility's policy requires verification of the five rights of medication administration at three separate points and mandates the use of the medication administration record (MAR) during medication passes. Despite these policies, the observed errors occurred, and the facility's reported census at the time was 76 residents.
Failure to Provide Scheduled Showers or Baths
Penalty
Summary
The facility failed to provide at least two showers or bed baths per week for four residents, as required by their care plans. Resident #1, with moderate cognitive impairment and quadriplegia, was documented to have received no showers in October and only three out of six scheduled showers in November. The facility could not provide progress notes to support refusals or rescheduling, nor evidence of offering bed baths when showers were missed. Resident #2, who had no cognitive impairment, received only one shower between early and mid-December, missing several scheduled showers in November. Again, the facility lacked documentation to support refusals or rescheduling. Resident #5, with moderate cognitive impairment, missed several scheduled showers in November and December, with no rescheduling or documentation of refusals. Similarly, Resident #6, with severe cognitive impairment, was documented as not receiving showers for a period in December, with no alternative dates offered. Interviews with staff revealed a lack of awareness and accountability regarding the documentation and scheduling of showers. The Director of Nursing confirmed the use of a spreadsheet to track bathing, but the Administrator was unaware that CNAs were still using outdated methods for documentation. The facility's policy required nursing staff to be informed of refusals, but there was no evidence this was consistently followed.
Failure to Report Alleged Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of abuse to the Department of Inspections, Appeals and Licensing (DIAL) within 24 hours as required by their policy. The incident involved a resident with moderately impaired cognitive skills, who reported that a Certified Nursing Assistant (CNA) was rough while repositioning him, allegedly putting him in a headlock and pulling on his neck. The resident expressed concerns about hearing cracking noises in his neck during the incident. Despite these allegations, the facility did not report the incident to the state survey agency, as they did not consider it an allegation of abuse. The facility's policy on abuse prevention requires immediate reporting of alleged abuse to the state survey office, but the administrator confirmed that this was not done. Instead, the CNA received education on proper positioning techniques and safe handling of residents. The facility's investigation concluded that the abuse could not be substantiated, and the incident was not reported to the state survey agency, contrary to the facility's policy.
Inadequate Incontinent Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide routine perineal care for incontinent residents, specifically for one resident who required substantial assistance for toileting. The resident, who had a BIMS score indicating no cognitive impairment, was diagnosed with malignant neoplasm of the colon and had difficulty walking. The care plan instructed staff to use an EZ stand with the assistance of two staff members for toileting and to observe the resident's incontinence pattern to initiate a toileting schedule if needed. However, a review of the Check and Change Audit forms revealed significant lapses in care, with staff failing to document and complete checks and changes within the required two-hour timeframe for 23 out of 35 days. The resident went up to 8 hours without care on some occasions, and there were instances of false documentation of overnight care. Interviews with staff members, including CNAs and the Director of Nursing, highlighted systemic issues with staffing and time management, which contributed to the deficiency. Staff reported not having enough time or help to consistently check and change residents every two hours, leading to residents waiting as long as 5-6 hours for care. The facility's policy on incontinent care did not specify the required frequency for checking and changing residents, further contributing to the inconsistency in care. The resident involved expressed dissatisfaction with the care received, stating that they were not changed for an extended period, which was corroborated by the lack of documentation for that time frame.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by observations of improperly stored food items in the facility's refrigerators and freezers. During a direct observation, surveyors found several bags of food, including broccoli, croissants, an oriental vegetable blend, and cake, stored in clear, unlabeled bags in the refrigerator. Additionally, the freezer contained chunks of oxidized potato frozen to the bottom, which were not contained. These observations indicate a lack of proper labeling and storage practices for food items. Interviews with facility staff, including a dietary cook and the Dietary Manager, revealed awareness of the improper storage practices. The dietary cook acknowledged that food should have been labeled before storage and that improperly stored food should be disposed of immediately. She was unaware of the spilled food in the freezer, which should have been cleaned up according to policy. The Dietary Manager also acknowledged the issues with unlabeled food and the need for immediate cleanup of spilled food. A review of the facility's refrigeration policy confirmed that food should be stored in an organized manner, labeled, and checked daily to ensure proper storage and timely disposal of leftovers.
Failure to Monitor Lab Values in Resident with Kidney Failure
Penalty
Summary
The facility failed to appropriately monitor and manage the laboratory values of a resident with Stage III kidney failure who was receiving medications that could affect kidney function. The resident was prescribed Cozaar, an ARB medication, along with potassium supplements and furosemide, which could potentially lead to hyperkalemia. Despite the presence of a software-generated warning about the risk of high potassium levels, the facility did not conduct necessary lab tests to monitor the resident's kidney function and potassium levels during her stay. The resident's clinical records showed that prior to admission, her potassium levels were within normal range, but her BUN and creatinine levels indicated potential kidney issues. However, no kidney function labs were drawn during her stay at the facility. The ARNP added potassium to the resident's medication regimen without considering the interaction with Cozaar and without ordering lab monitoring. This oversight was compounded by the administration of Bactrim, which further increased the risk of hyperkalemia. The resident eventually experienced symptoms such as nausea, vomiting, and diarrhea, leading to her hospitalization. Upon admission to the hospital, critical lab values indicated severe hyperkalemia and acute renal failure, necessitating emergent dialysis. Interviews with the ARNP and DON revealed a lack of routine lab monitoring and reliance on provider orders for lab tests, which contributed to the oversight in managing the resident's condition.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as observed during a survey. Specifically, two errors were identified out of 35 medications administered, resulting in a 5.7% error rate. One error involved a Licensed Practical Nurse (LPN) administering insulin to a resident without properly priming the insulin pen according to the manufacturer's instructions. The LPN primed the pen before attaching the needle, which is contrary to the correct procedure that requires priming after the needle is attached to ensure accurate dosing. The LPN was unaware that priming was necessary to ensure the pen was working correctly and to avoid administering too much or too little insulin. Another error was observed during the medication pass for a different resident. The LPN administered Levothyroxine, scheduled for 6:00 am, at a later time, which was outside the facility's accepted time parameters of one hour before and after the scheduled time. The Director of Nursing (DON) confirmed that the latest acceptable time for administering a medication scheduled for 6:00 am is 7:00 am. This deviation from the scheduled administration time contributed to the facility's medication error rate exceeding the acceptable threshold.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 404 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Norwalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norwalk Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 4 | 0 |
| Accura Healthcare Of South Des Moines | 4.3 mi | ★★★★★ | 0 | 0 |
| Greater Southside Health And Rehabilitation | 4.5 mi | ★★★★★ | 12 | 1 |
| Harmony West Des Moines | 6.2 mi | ★★★★★ | 21 | 0 |
| Wesley On Grand | 7.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.