Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Serenity Transitional Care during CMS and state inspections, most recent first.
Failure to Preserve Resident Dignity: Three residents were observed with hospital ID wristbands still on after admission, including residents with fractures, sepsis, respiratory failure, stroke, and DM. One resident stated staff used the band to identify her before giving meds, and the DON said the facility’s practice was to leave the bands on until the first care conference and did not consider it a dignity issue.
A facility failed to follow professional standards for bowel care for four residents with diagnoses including PLS, diabetes, cervical fracture, COPD, sepsis, MI, and interstitial pulmonary disease. Chart review showed extended periods without documented BMs and no nursing documentation of intervention despite physician orders for bisacodyl, suppositories, Fleet enemas, senna-docusate, and PEG 3350. The DON stated the required nurse intervention documentation was missing.
The facility failed to follow infection control practices involving hand hygiene, glucometer disinfection, oxygen equipment storage, and linen handling. A CNA did not offer hand hygiene before a resident ate, nurses stored glucometers after wiping them with sanitizer or an alcohol swab instead of disinfecting them after each use, a resident’s nebulizer equipment was left uncovered, clean linens were transported with the cart cover not down, and PPE such as gowns and eyewear was not being used or available at the hoppers.
A resident’s bathing preference was not honored. The resident, who needed partial/moderate help with bathing and had diagnoses including pneumonia and CKD, stated she wanted 2 showers per week but was usually only getting 1 because staff were too busy. Records showed she missed multiple scheduled showers and received fewer showers than documented on her task form, and the DON could not account for the missed showers.
PRN Psychotropic Medication Exceeded 14-Day Limit: A resident with PLS and diabetes had Lorazepam 0.5 mg PO q4h PRN for anxiety/agitation ordered and administered repeatedly over several months. Pharmacy consults twice recommended adding a stop date, but the provider declined both times, citing hospice status, and the DON later stated the medication should have had a stop date and not been used beyond 14 days.
A resident with acute cystitis without hematuria and COPD was transferred to the hospital, but the facility did not have documentation that a written bed-hold notice was provided to the resident or representative. The DON later stated she could not find any bed-hold data for the hospitalization, despite the facility policy requiring written notice within 24 hours or the next business day.
A resident admitted and readmitted with multiple fractured ribs and diabetes did not have documentation that the baseline care plan was provided or discussed with the resident or representative. The record also lacked a resident or representative signature showing the care plan summary had been offered, despite the facility policy requiring the supervising nurse or MDS nurse/designee to provide the written summary and obtain verification.
A resident with spinal stenosis, anxiety, and acute respiratory failure had a care plan that did not document ordered oxygen interventions. The medical record showed continuous O2 at 0-1 L/M via NC to keep sats at or above 88%, with O2 sat checks every shift, and the DON stated the care plan should have addressed these interventions.
Failure to Provide Ordered Restorative Nursing Services: A resident’s care plan called for restorative nursing with cues for ROM of all major joints and Sci-fit exercise 6 to 7 days per week, but the record showed restorative services were only provided on a few days and there was no documentation of refusals on the missed days. The DON confirmed the services should have been provided at least 6 times each week but were not.
IV Therapy Not Consistently Documented or Monitored: A resident with Parkinson’s Disease and acute respiratory failure had IV fluid and IV antibiotic orders, but the IV site was observed with a loose, unsecured, undated dressing and a dark red dry substance on it. Staff reported the IV was left in place after fluids were given, then restarted for more fluids, but IV insertion, removal, and restart attempts were not documented, and the resident’s chart lacked IV documentation for several days.
The facility failed to ensure nurse staffing information was accurate and posted daily for each shift. During review of the daily staffing sheets, the surveyor found the facility name was missing from all of the staffing sheets, and the CCO confirmed it should have been included.
Failure to monitor psychotropic medication use: A resident with PLS, DM, and psychotropic orders for duloxetine, lorazepam, and quetiapine had hospice notes showing decreased behaviors and hallucinations, yet pharmacy psychotropic reviews continued to question whether a GDR was indicated and the provider deferred to hospice. The resident’s TAR later documented ongoing anxiety/hallucination episodes, and the DON stated she needed to speak with the Medical Director and Hospice MD about the resident’s psychotropic meds.
Medication storage and security were not maintained when an open bottle of Ativan for a resident was found in an unlocked medication refrigerator on top of the narcotic lock box, and a discontinued medication had not been removed promptly. In a separate observation, an East Hall medication cart was left unlocked and unattended until an LPN returned and locked it; the DON and LPN both stated the cart should not have been left unsecured.
Food items were not dated and labeled as required. Surveyors observed a container of watermelon chunks in a resident unit refrigerator that was not dated or labeled while an RN was present, and the RN stated it should have been dated and labeled or discarded.
Improperly Covered Garbage and Refuse: The kitchen garbage can was observed with a hole cut out of the lid and not in use, and both outside dumpsters were observed with lids open. One dumpster had cardboard overflowing onto the ground, while the other had weed vegetation and paper trash on the ground near the dumpster and along the fence line. The Dietary Manager stated she was not aware the kitchen garbage cans needed tight-fitting lids or that the dumpster lids should have been closed.
Incomplete Oxygen Orders in Clinical Records: The facility failed to maintain accurate and complete records for residents receiving O2 therapy. A resident with multiple diagnoses, including respiratory failure, had an expired O2 order in the chart even though the DON said O2 had been re-ordered; two other residents were observed on O2 at 2 L/minute, but their records had no physician O2 orders, and the DON confirmed the orders were missing.
A resident with dementia and anxiety sustained pubic fractures after falling from a Hoyer lift during transfer when the lift's leg became stuck under a closet door and a sling strap slipped off due to inadequate planning and failure to move furniture by CNAs.
Surveyors found that food items in both refrigerated and dry storage areas were not properly labeled, sealed, or discarded by their use by dates. The CDM confirmed that expired ham, sausage, granola, and corn flakes were present, and that lettuce and cheese were not properly sealed, indicating a failure to follow required food storage and labeling standards.
Two residents with urinary drainage bags had their bags left uncovered and visible from the open doorway, and a resident with diabetes and major depressive disorder was addressed by an LPN using her room number instead of her name. The DON and ADON confirmed these actions did not meet expectations for resident dignity.
A resident with multiple chronic conditions was found self-administering Icy Hot for pain relief without a documented assessment of their ability to safely do so, as required by facility policy. The absence of this assessment was confirmed by the CCO.
A resident with obstructive sleep apnea was admitted without documentation of nightly CPAP use in the baseline care plan or a physician order for the device, despite staff assisting with its use. The omission was confirmed by facility leadership.
Controlled medications were not consistently tracked or secured due to missing nurse signatures on Narcotic Accountability Records for two medication carts. An LPN and the ADON confirmed that required signatures were not always documented when medication carts were accepted or released.
Medication and lab draw carts were found unlocked and unattended in multiple areas, with staff confirming these should have been secured. Additionally, a glucose test solution was not dated when opened, contrary to facility and manufacturer protocols.
The facility failed to serve meals on time, affecting several residents, including those with heart failure and dementia. Meals were delayed by up to 90 minutes, leading to complaints and meal refusals. The issue was attributed to staff shortages and time management problems following the departure of the previous dietary manager.
The facility failed to ensure accurate and timely MDS assessments for two residents. One resident's assessment did not reflect their hospice status and prognosis, while another's assessment was delayed due to a misunderstanding about therapy input. The MDS Coordinator and DON confirmed these discrepancies.
Two residents in an LTC facility did not receive adequate meal assistance, leading to potential harm. One resident, with severe cognitive impairment, experienced significant weight loss due to lack of supervision and feeding assistance. Another resident, with dysphagia, did not receive necessary meal cues, resulting in unsafe eating practices. Staff interviews revealed a lack of awareness and adherence to dietary needs and meal assistance requirements.
A facility failed to follow enhanced barrier precautions for a resident with an open wound, increasing the risk of spreading multidrug-resistant organisms. Despite EBP signage, staff did not wear gowns during high-contact care activities, as required by the facility's policy. Staff acknowledged the oversight, citing busyness and lack of awareness, despite having received EBP training.
Failure to Preserve Resident Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity for 3 of 3 residents observed for dignity (#73, #77, and #79). The facility’s Nursing Facility Services and admission Agreement stated that resident care would maintain and enhance dignity, individuality, and quality of life, but survey observations and interviews showed that hospital identification wristbands remained on residents after transfer to the facility. Resident #73, who had diagnoses including multiple fractured ribs and diabetes, was observed on 6/22/26 at 12:07 PM with a hospital name band still on his wrist and stated he had recently been at the hospital before coming to the facility and no one had removed it. Resident #77, who had diagnoses including sepsis, respiratory failure, and diabetes, was observed on 6/22/26 at 1:52 PM with a hospital name band still on his wrist and stated he had come from the hospital a few days earlier and no one had removed it. Resident #79, who had diagnoses including stroke and diabetes, was observed on 6/22/26 at 2:02 PM with a hospital wristband still on her wrist and stated nursing staff used it each time they entered the room to identify her before giving medications. On 6/23/26 at 9:02 AM, the DON stated the facility’s practice was to leave the hospital ID bands on until the first care conference and did not think about it being a dignity issue.
Failure to Document and Provide Ordered Bowel Care
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for bowel and bladder care for 4 residents reviewed. Record review showed that Resident #4 had multiple diagnoses including post-laminectomy syndrome and diabetes, and the chart documented no bowel movement entries for 5/29/26 to 6/7/26, 6/8/26 to 6/11/26, and 6/19/26 to 6/23/26. The medication administration record had no documentation of nursing intervention for bowel movement-related issues during those periods, despite physician orders for bisacodyl tablets, bisacodyl suppositories, and a Fleet cleansing enema if constipation persisted. Resident #10, who had diagnoses including cervical fracture and diabetes, had no documented bowel movement from 6/10/26 to 6/22/26. The medication administration record showed bisacodyl was given on June 12, 2026, and the resident also had orders for bisacodyl tablets, bisacodyl suppositories, a Fleet cleansing enema, and senna-docusate sodium for constipation. Resident #19, with diagnoses including centrilobular emphysema and sepsis, had no documented bowel movement from 6/17/26 to 6/21/26, and the medication administration record had no documentation of nursing intervention for the bowel movement-related issues during those dates. Resident #44, who had diagnoses including myocardial infarction and interstitial pulmonary disease, had a last documented bowel movement on 6/17/26 and then not again until 6/22/26. The medication administration record had no documentation of nursing intervention for the bowel movement-related issues during the dates listed, despite orders for bisacodyl tablets, bisacodyl suppositories, a Fleet cleansing enema, and polyethylene glycol 3350. On 6/23/26, the DON stated there was no documentation of nurse intervention for bowel movement care for Residents #4, #10, #19, and #44 for the dates listed and that there should have been.
Infection Control Failures in Hand Hygiene, Equipment Cleaning, and Linen Handling
Penalty
Summary
The facility failed to maintain infection prevention and control practices related to hand hygiene, cleaning of medical equipment, oxygen equipment storage, and handling of clean and soiled linens. The facility’s policies stated that hand hygiene should be performed before eating and after restroom use, glucometers should be cleaned and disinfected after each use according to manufacturer instructions, oxygen delivery devices should be kept covered when not in use, and clean linens should be transported in covered carts. During observation, CNA #1 delivered and set up Resident #37’s meal tray and later brought orange juice without offering or encouraging hand hygiene, and the CNA stated she should have done so. Additional observations showed RN #1 and LPN #2 used glucometers to check residents’ blood sugars and then stored the devices in their shirt pockets and baggies after wiping them with hand sanitizer or an alcohol swab rather than following the facility’s disinfecting process. Resident #73’s nebulizer mask, tubing, and machine were observed sitting uncovered on a windowsill, and the CRN stated the equipment should have been covered when not in use. Laundry staff transported clean resident linens with the cart cover pulled up and lying on top of the cart, and the staff member stated the cover should have been pulled down. In the laundry room and East Hall soiled utility room, hoppers were observed with gloves nearby but no protective gowns or eyewear, and staff stated those items were not being used or available.
Resident Bathing Preference Not Honored
Penalty
Summary
The facility failed to ensure a resident’s preference for bathing schedule was honored. Resident #5, who was admitted with diagnoses including pneumonia and chronic kidney disease and required partial/moderate assistance with showering, had a care plan and task form indicating showers were to be provided on Tuesdays and Fridays on the day shift. During interview, the resident stated she usually only received one shower a week and wanted two showers a week, but staff were too busy to provide them. Record review showed the resident did not receive the scheduled showers as documented. In May 2026, she received three showers and refused two scheduled showers, although she should have received nine showers. In June 2026, she received three showers and refused one scheduled shower, although she should have received six showers. The DON stated residents should get two showers a week, but for this resident it depended because she went to dialysis, and later stated the resident should have been offered showers on Fridays and Tuesdays and could not account for the missed showers.
PRN Psychotropic Medication Exceeded 14-Day Limit
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders were limited to 14 days. Policy review showed that PRN psychotropic medications, excluding antipsychotics, must be limited to no more than 14 days unless the prescriber documents a rationale for extending the order and a specific duration in the medical record. The facility’s admission agreement also stated that psychoactive drugs would be avoided except as required to treat a resident’s medical symptoms on a temporary basis. Resident #4, who was admitted with diagnoses including post-laminectomy syndrome and diabetes, had Lorazepam 0.5 mg PO q4h PRN for anxiety/agitation ordered on 11/4/25. The medication administration record showed the medication was administered multiple times across several months, including 6 doses in December 2025, 3 in January 2026, 4 in March, 2 in April, 4 in May, and 2 in June. Pharmacy consultation reports on 11/12/25 and 5/10/26 both recommended adding a stop date to the Lorazepam order, but the provider declined each time, documenting that the resident was on hospice and that the hospice provider declined to change it. The DON stated on 6/23/26 that the Lorazepam should have had a stop date and should not have been used past 14 days for Resident #4, but it was.
Failure to Provide Bed-Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a written notice of transfer and bed-hold policy was provided to the resident or the resident's representative when a resident was transferred to the hospital. The facility's Bed Hold Notice policy dated 3/3/25 stated that in the event of an emergency transfer, the facility would provide written notice of its bed-hold policies to the resident and/or resident representative within 24 hours or the next business day, and would keep a signed and dated copy in the resident's file or medical record. Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including acute cystitis without hematuria and COPD. During record review on 6/22/26, there was no documentation of a bed hold for the resident's 4/17/26 hospitalization, and on 6/23/26 the DON stated she could not find any bed hold data for that hospitalization.
Baseline Care Plan Not Provided or Documented
Penalty
Summary
The facility failed to provide Resident #73’s baseline care plan to the resident or his representative after his initial admission and readmission. Resident #73 was admitted with multiple diagnoses including multiple fractured ribs and diabetes. The facility’s Baseline Care Plan policy stated that a supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative and obtaining a signature to verify it was provided. The resident’s medical record did not document that the baseline care plan had been provided or discussed, and it did not contain a signature from the resident or representative showing that a copy had been offered. The Social Worker stated the record should have documented a signature indicating the baseline care plan had been discussed or offered, and the DON stated the record should have documented that a copy of the baseline care plan had been offered and had not.
Failure to Include Oxygen Interventions in Care Plan
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan for Resident #76, who was admitted with multiple diagnoses including spinal stenosis, anxiety, and acute respiratory failure. Record review showed that on 6/22/26 at 2:06 PM, the resident’s care plan did not document oxygen interventions. A review of the medical record at 2:07 PM showed a provider order for oxygen at 0-1 L/M via nasal cannula continuously to keep oxygen saturations at or above 88%, with oxygen saturation checks every shift. On 6/24/26 at 8:46 AM, the DON stated the resident’s care plan should have addressed the oxygen interventions and had not.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to ensure Resident #12 received treatment and services to maintain or improve the ability to carry out ADLs. The resident’s care plan documented a Restorative Nursing Program to provide cues for movement through tolerated ROM of all major joints and Sci-fit exercise for 15 minutes at level 1-2 resistance, 6 to 7 days per week. However, the medical record showed restorative services were only provided on 6/15/26, 6/20/26, and 6/21/26, with no documentation of resident refusals on 6/16/26, 6/17/26, 6/18/26, 6/19/26, or 6/22/26. The DON stated restorative services for Resident #12 were only provided on 6/15/26, 6/20/26, and 6/21/26 and should have been done at least 6 times each week but were not.
IV Therapy Not Consistently Documented or Monitored
Penalty
Summary
The facility failed to ensure that IV fluids were administered consistently with professional standards of practice for Resident #42, who was admitted with multiple diagnoses including Parkinson’s Disease and acute respiratory failure. The resident had physician orders for IV normal saline and IV ceftriaxone on 6/19/26, followed by another IV sodium chloride order on 6/20/26, and an order on 6/22/26 to inspect the IV catheter/site every day and night shift for signs or symptoms of infection or other complications. On 6/22/26 at 10:07 AM, the resident was observed with an IV in the right arm; the dressing had a dark red dry substance on it, the edges were loose, the IV line was not secured, and the dressing was not dated. Staff interviews and record review showed the IV was not consistently documented or monitored. LPN #1 stated the resident had received a bag of fluids and the IV was left in place in case more fluids were needed, and that the dressing should have been changed every three days and dated. The resident’s care plan did not document the IV, and the medical record lacked IV documentation from 6/19/26 through 6/21/26. The DON stated the IV was started on 6/19/26, removed after the bag of fluid, then restarted on 6/20/26 when more fluids were needed; the DON also stated there was no order for dressing changes or IV site monitoring because the original IV had been removed, and that monitoring orders were entered on 6/22/26. RN #1 stated he did not document the IV insertion on 6/20/26 and later made a late entry, and LPN #2 stated he removed the IV on 6/19/26 without documenting it and did not document the attempt to restart the IV on 6/20/26.
Missing Facility Name on Daily Staffing Sheets
Penalty
Summary
The facility failed to ensure nurse staffing information was accurate and posted daily for each shift. During review of the daily staffing sheets on 6/23/26 at 3:47 PM, the surveyor observed that the facility's name was missing from all of the daily staffing sheets. At 4:10 PM, the Chief Clinical Officer stated that the facility name should have been on the daily staffing sheets and was not.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents were monitored appropriately for medication, specifically for 1 of 2 residents reviewed for unnecessary medications. The facility’s Unnecessary Drugs policy dated 12/30/25 stated that documentation would be provided in the resident’s medical record to show adequate indications for the medication’s use and the diagnosed condition for which it was prescribed. Resident #4 was admitted with multiple diagnoses including post-laminectomy syndrome and diabetes, and had physician orders for duloxetine 60 mg daily for major depressive disorder, lorazepam 0.5 mg every 4 hours as needed for anxiety/agitation, and quetiapine 25 mg at bedtime for brief psychotic disorder. Resident #4’s hospice outside agency resident reports documented decreased behaviors on 12/1/25 and decreased behaviors and hallucinations on 1/2/26. A pharmacy psychotropic review dated 12/16/25 listed duloxetine, lorazepam, and quetiapine and asked whether a gradual dose reduction would be clinically indicated; the provider declined and documented “defer to hospice.” A later pharmacy psychotropic review dated 3/17/26 again listed psychotropic medications, including ativan PRN for hallucinations, duloxetine, lorazepam, and quetiapine, and again the provider declined with the same documentation. Resident #4’s TAR for May 2026 and June 2026 documented four occurrences of anxiety/hallucinations in May and two in June, and on 6/23/26 at 3:40 PM the DON stated she would need to visit with the Medical Director and the Hospice MD about Resident #4’s psychotropic medication.
Medication Storage and Security Lapses
Penalty
Summary
Medications were not kept secure and inaccessible to unauthorized staff and residents, and discontinued medications were not destroyed in a timely manner. During an audit of the [NAME] side medication storage room with the DON present, an open bottle of Ativan Injection Solution for Resident #4 was observed in the medication storage refrigerator, lying on top of the narcotic lock box. The refrigerator did not have a lock, and the DON stated the Ativan should have been in the narcotic lock box in the refrigerator because there was no lock on the refrigerator. The facility’s policy stated medications must be under direct observation or locked in the medication storage area/cart, and Schedule II drugs and back-up stock III, IV, and V medications are stored under double-lock and key. Resident #4 was admitted with multiple diagnoses including post-laminectomy syndrome and diabetes. The medical record showed a physician’s order for Ativan Injection Solution 2 MG/ML, 0.5 ml IM every 6 hours as needed for hallucinations, and the order was discontinued on [DATE]. The DON stated discontinued medications should be removed as soon as they are discontinued. In a separate observation, the East Hall medication cart was found unlocked and unattended by staff, and LPN #3 later locked it after approaching from another hallway. LPN #3 and the DON both stated the medication cart should not have been left unlocked when unattended.
Food Item Not Dated or Labeled in Resident Refrigerator
Penalty
Summary
The facility failed to ensure food items were dated and labeled in accordance with its policy and the FDA Food Code. Surveyors observed a container of watermelon chunks in the resident unit refrigerator that was not dated or labeled while RN #2 was present. The facility's Date Marking for Food Safety policy stated that food shall be clearly marked to indicate the date or day by which it shall be consumed or discarded. When interviewed, RN #2 stated the container should have been dated and labeled or discarded and had not been.
Improperly Covered Garbage and Refuse
Penalty
Summary
The facility failed to ensure garbage and refuse were properly contained in the kitchen and outside dumpster area. Based on observation, review of the FDA Food Code, and staff interview, the kitchen's large garbage can was observed with a hole cut out of the lid and was not in use at the time. The outside dumpster area was also observed with two of two dumpsters having lids open; one dumpster had cardboard trash overflowing onto the ground around it, and the other had weed vegetation and paper trash on the ground near the dumpster and along the surrounding fence line. The Dietary Manager stated she was not aware the kitchen garbage cans had to have tight-fitting lids and that the dumpster lids should have been closed.
Incomplete Oxygen Orders in Clinical Records
Penalty
Summary
The facility failed to ensure accurate and complete clinical records were maintained for residents receiving oxygen therapy. The report states that the facility’s Oxygen Administration policy required oxygen to be administered under physician orders, and its Documentation in Medical Record policy required documentation to be accurate, relevant, and complete. During record review and staff interview, the Director of Nursing stated that Resident #76’s oxygen had been discontinued on 6/18/26 but had been re-ordered, and the new order had not been documented in the medical record even though the resident was observed wearing oxygen at 2 L/minute. Resident #76’s chart only showed an oxygen order dated 6/16/26 with an end date of 6/18/26. Resident #77 was observed wearing oxygen at 2 L/minute, but the medical record did not document an oxygen order, and the DON stated an order should have been written and had not been. Resident #79 was also observed using supplemental oxygen at 2 L/minute on three separate occasions, and the medical record did not contain any physician order for oxygen therapy. The DON stated an oxygen order should have been written for Resident #79 and had not been. The deficiency was identified for 3 of 3 residents reviewed for oxygen administration orders.
Failure to Ensure Safe Hoyer Lift Transfer Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure resident safety during a Hoyer lift transfer, resulting in harm to a resident with dementia and anxiety. During the transfer, one of the Hoyer lift legs became stuck under a closet door, which caused a sling strap webbing loop to slip off one of the lift's six-point loop connections. This improper transfer led to the resident falling out of the Hoyer lift and sustaining left superior and inferior pubic fractures. The incident occurred because the CNAs did not move furniture or adequately plan the transfer process, as required by the Hoyer lift user manual. The lack of proper preparation and failure to ensure a clear path for the lift directly contributed to the accident and subsequent injury to the resident.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed multiple instances of improper food storage and labeling in the facility's kitchen and dry food storage areas. In the walk-in refrigerator, ham and sausage were found with use by dates that had already passed, and both an open bag of lettuce and sliced cheese were not properly sealed. In the dry food storage area, granola and corn flakes were also found in containers with use by dates that had expired. The Certified Dietary Manager (CDM) confirmed that these items should have been used or discarded by their respective use by dates and that the lettuce and cheese should have been properly sealed. These findings indicate that the facility failed to store, distribute, and label foods in accordance with professional standards and the FDA Food Code requirements.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity as evidenced by two residents with uncovered urinary drainage bags that were visible from the open doorway of their rooms. One resident, admitted with pneumonia and urinary tract infection, and another with a history of sepsis, both had their urinary drainage bags left uncovered during observations. The Director of Nursing confirmed that the bags should have been covered but were not. Additionally, a resident with diabetes and major depressive disorder was addressed by an LPN using her room number rather than her name while in the hallway, which was acknowledged by the Assistant Director of Nursing as not being the appropriate practice.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed and evaluated for cognitive and physical ability to self-administer medications, as required by facility policy. The policy stated that residents may only self-administer medications after an interdisciplinary team determines it is safe. A resident with chronic kidney disease, COPD, and immunodeficiency was observed with an open, uncapped bottle of Icy Hot on the bedside table and reported self-administering the medication for shoulder pain. Review of the resident's medical record showed no documentation of a self-administration assessment for the Icy Hot. The Chief Clinical Officer confirmed that an assessment should have been completed but was not.
Failure to Include CPAP Use in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included a resident's need for CPAP equipment upon admission. The resident, who had diagnoses including obstructive sleep apnea and bipolar disorder, was observed with a CPAP device in his room and reported that nursing staff assisted him with its use nightly. However, the baseline care plan did not document the use of the CPAP, and there was no physician order in the medical record for its nightly use. The Chief Clinical Officer confirmed that nursing staff did not request a physician's order or include the CPAP in the care plan at the time of admission.
Failure to Document Controlled Medication Accountability
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing licensed nurse signatures on Narcotic Accountability Records for two of four medication carts reviewed. During an audit of the [NAME] hall medication cart, it was observed that 11 required nurse signatures were not documented on the Narcotic Accountability Record covering a 20-day period. Additionally, an audit of the East hall medication cart revealed one missing nurse signature on the corresponding record. Interviews with an LPN and the ADON confirmed that two nurses were expected to sign the Narcotic Accountability Record when accepting or releasing the medication cart, but this procedure was not consistently followed.
Failure to Secure Medications and Properly Label Biologicals
Penalty
Summary
Surveyors observed that medication and lab draw carts were left unlocked and unattended in multiple locations within the facility, including the East hall and [NAME] hall. Staff interviews confirmed that these carts contained items such as needles, draw tubes, and medications, and that they should have been locked when not in use or when unattended, but were not. Additionally, a set of glucose test solutions was found without a date indicating when it was opened. Staff, including the ADON and DON, acknowledged that glucose test solutions should be dated upon opening and discarded after three months per manufacturer recommendations, but this was not done.
Delayed Meal Service in LTC Facility
Penalty
Summary
The facility failed to ensure that resident meals were served according to the designated meal schedule, impacting four out of five residents interviewed. The facility's policy required that residents receive at least three meals daily without extensive time lapses between meals. However, observations and interviews revealed that meals were consistently served late, with lunch and dinner being delayed by up to 90 minutes. This failure had the potential to impact residents at risk for nutritional compromise, hunger, low blood sugar levels, or inadequate nutritional support. Resident #111, with multiple diagnoses including heart failure and transient cerebral ischemic attack, reported that meals were often late, with lunch served 45 minutes late and dinner 62 minutes late. Resident #30, diagnosed with hepatic encephalopathy, also reported that dinner meals were served as late as 7:00 PM, and lunch as late as 2:00 PM. Resident #20, with a history of traumatic subdural hemorrhage and heart failure, declined a late lunch served at 3:00 PM, stating it was too late to eat. Resident #29, with dementia and other diagnoses, received meals 52 and 62 minutes late on separate occasions. The facility's Resident Council minutes and grievance reports indicated ongoing issues with meal service timing, including ingredient shortages and staff miscommunication. The new Certified Dietary Manager (CDM) acknowledged the problem, attributing it to staff shortages and time management issues following the departure of the previous dietary manager. The Registered Dietitian (RD) was also aware of the complaints and was working with the previous dietary manager to find a solution.
Inaccurate and Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected their status at the time of the assessment and were completed within the required timeframe. Resident #30 was admitted with multiple diagnoses, including hepatic encephalopathy, and was on hospice care from the time of admission. However, the admission MDS assessment inaccurately documented the resident as cognitively intact and did not reflect the resident's hospice status or prognosis of six months or less. This discrepancy was confirmed by the MDS Coordinator and the Director of Nursing (DON) during interviews. Resident #211, admitted with diagnoses including stroke, weight loss, and a cancerous tumor of the pancreas, had an admission MDS assessment that was not completed by the required date. The MDS Coordinator acknowledged that the assessment was not submitted on time due to a misunderstanding about the need for therapy input, despite the resident being on hospice and not requiring therapy. The Assistant Director of Nursing (ADON) expressed an expectation for timely submission of assessments but admitted to a lack of knowledge about MDS assessments.
Failure to Provide Adequate Meal Assistance
Penalty
Summary
The facility failed to provide adequate meal assistance and recommendations for two residents, leading to potential harm due to dehydration and unplanned weight loss. Resident #29, who was severely cognitively impaired and at risk for weight fluctuations, experienced significant weight loss over a two-month period. Despite recommendations for close supervision, verbal cues, and feeding assistance, staff did not assist Resident #29 during meals on multiple occasions. Observations showed that Resident #29 was not seated at the assistance table as required, and staff failed to provide necessary cues or cut up food, resulting in poor meal intake. Resident #39, diagnosed with moderate protein-calorie malnutrition and dysphagia, also did not receive the required meal assistance. Despite having specific recommendations for meal supervision and cueing, staff did not follow these guidelines during meal observations. Resident #39 was observed taking large bites and not drinking between bites, which led to coughing incidents. Staff failed to intervene or provide the necessary cues to ensure safe eating practices. Interviews with staff revealed a lack of awareness and adherence to the residents' dietary needs and meal assistance requirements. The Assistant Director of Nursing (ADON) and other staff members were not fully informed about the residents' conditions and the necessary interventions. The Speech Therapist and Registered Dietitian (RD) had provided recommendations and care plans, but these were not consistently implemented by the staff, contributing to the deficiencies observed.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed for a resident, increasing the risk of spreading multidrug-resistant organisms. The facility's policy required the use of gowns and gloves during high-contact resident care activities, such as changing briefs or assisting with toileting. Resident #48, who had multiple diagnoses including a stroke and an open wound on the right lower leg, was placed on EBP as per physician orders. The care plan for Resident #48 included EBP with signage posted outside the room indicating the need for gown and glove use during specific care activities. On the day of the observation, EBP signage was present outside Resident #48's door, but staff members CNA #1 and NA #1 did not adhere to the protocol. They assisted the resident with peri care while wearing gloves but failed to wear gowns as required. NA #1 acknowledged the oversight, stating they were busy and should have worn gowns. CNA #1, who also provided care, did not notice the EBP sign and was unaware of the need to wear a gown, despite having received EBP training. This lapse in following the facility's infection control policy was confirmed during interviews with the staff involved.
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What surveyors actually found near you
We read the 91 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Twin Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Falls Transitional Care Of Cascadia | 3.3 mi | ★★★★★ | 19 | 0 |
| Oak Creek Rehabilitation Center Of Kimberly | 7.4 mi | ★★★★★ | 27 | 0 |
| Bridgeview Estates | 10.1 mi | ★★★★★ | 0 | 0 |
| Cascades At Desert View | 13.2 mi | ★★★★★ | 24 | 0 |
| Lincoln County Care Center | 24.6 mi | ★★★★★ | 21 | 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 October 2026) and official state health department websites.