Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arcadia Care Toulon during CMS and state inspections, most recent first.
The facility did not maintain ceiling structures and plumbing in a safe and clean condition, resulting in long‑standing stained and bulging ceiling tiles above the nurses’ station and an actively leaking pipe in the ice machine/vending area. Surveyors observed missing ceiling tiles exposing insulation, wiring, and water pipes, standing water collected in a trash can, and soaked blankets and towels on the floor. An RN and an LPN reported that the ceiling tiles above the nurses’ station had been stained for months or longer, and that the ceiling had been leaking in the ice machine area for several days, where the ice machine is used for all residents. The Regional Maintenance Director confirmed the stained tiles and the leaking pipe and acknowledged that the tiles had not yet been replaced.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
A resident with dementia and gait abnormalities had a documented history of an unwitnessed fall after slipping from a vinyl or leather recliner. The IDT identified the need for non-skid material on the recliner seat, and this intervention was added to the resident’s fall care plan. However, during surveyor observation, the recliner lacked the required non-skid material. A CNA reported never having seen non-skid material on the chair, and the DON acknowledged that the recliner seat should have had it, demonstrating that the care-planned fall prevention intervention was not implemented.
The facility failed to maintain a safe, functional, and comfortable environment, with widespread physical plant disrepair and unsafe conditions throughout multiple halls and rooms. Surveyors observed missing floor tiles, loose baseboards, chipped paint, exposed and damaged drywall, exposed metal screws, and multiple resident room doors with scratched and chipped wood. Several rooms had exposed electrical cable wires running from wall vents to the ceiling, and long electrical cords were hanging from outlets onto walking pathways in more than one hall. A wall-mounted heating/cooling unit had its cover removed and lying outside on the ground amid debris, and other units had crumbling, discolored drywall and missing wood framing. The main dining room had exposed drywall without baseboards, and visitor bathrooms for men and women were posted as out of order during the survey period. The facility lacked available maintenance work orders for an extended period, and leadership acknowledged that many repairs were needed.
The facility failed to provide timely meals in accordance with posted meal times, resulting in several residents receiving breakfast and lunch trays significantly later than scheduled and interfering with at least one resident’s ability to attend an activity. Staff were observed delivering a large number of unserved room trays well past the designated meal periods, and residents reported that their trays had just been delivered while they were eating much later than the scheduled times. Facility documentation noted concerns about meal trays not being picked up from rooms and the need for CNAs to return trays promptly, while staff acknowledged that the kitchen was far behind and that there were too many room trays being delivered late.
Involuntary Seclusion and Improper Secured Unit Placement: A cognitively intact resident with PTSD and generalized anxiety was placed in a secured dementia unit despite no documented dementia or Alzheimer’s diagnosis and no clear exit-seeking behavior. Staff said the resident did not appear confused and had not tried to elope, but she repeatedly stated she did not want to be in the locked unit and wanted to return to the general population. The psych NP and MD both noted the resident did not meet criteria for the secured unit.
Facility-wide administrative failures affected resident dignity, assessments, medication safety, infection control, ADL care, and environmental safety. Residents were exposed during care, one resident was kept in a secured unit without meeting criteria, medications were given without clear supporting diagnoses or behaviors, and a resident’s change in condition was not properly assessed before hospitalization for RSV, COPD exacerbation, and acute hypoxic respiratory failure. The report also noted missed showers, unsafe room and bathroom conditions, improper medication handling, and missing staff training and competency documentation.
A resident with chronic respiratory failure, COPD-related issues, diabetes, and other diagnoses developed worsening respiratory symptoms, including wheezing, productive cough, chest heaviness, and shortness of breath. Although a chest x-ray was ordered and infection screening criteria were triggered, the x-ray was not completed and the record did not show ongoing vital sign or O2 saturation monitoring as the resident’s condition worsened. The resident later became lethargic, confused, and severely hypoxic, was sent to the hospital, and was diagnosed with RSV, acute bronchiolitis, acute COPD exacerbation, and acute hypoxic respiratory failure.
Lack of Staff Competency Documentation: Record review and interview showed the facility did not have documentation that RNs, LPNs, and CNAs completed required education, in-services, or competency assessments. The Administrator stated most required online training was incomplete or not completed, and the Regional Director of Operations confirmed there was no documentation showing all staff received the required education and training to ensure competence.
A facility failed to monitor stored fresh produce and discard spoiled zucchini found in the kitchen walk-in refrigerator. During observation, three squash had wrinkled, dark, white-spotted, and soft areas, and the Dietary Manager verified they were moldy and should not have been served to residents.
Improper garbage and refuse containment was observed in the dumpster area. The facility could not provide a waste disposal policy, and the Maintenance Director stated trash should be kept inside two covered dumpsters behind the facility. Instead, both dumpsters were uncovered, full, and overflowing, with six large bags of garbage on the ground around them and a foul odor in the area.
The facility failed to maintain infection control practices by not properly monitoring communicable illness and by allowing staff to wear masks incorrectly while providing care and serving residents. A resident with respiratory symptoms was observed in common areas without precautions, later developed severe hypoxia, and was hospitalized with RSV and acute respiratory failure. The facility also failed to follow EBP and hand hygiene requirements during catheter and wound care, and PPE was not readily available for residents on EBP.
Failure to repair damaged walls and room surfaces: Surveyors observed peeling wallpaper, exposed drywall, holes in drywall, and deteriorated caulking in multiple resident rooms and around an HVAC/window area. The Maintenance Director stated the rooms had not yet been addressed in the remodel attempt and that work requests were missed because the computer had been down, while work order records showed multiple repair requests for the affected hall.
Incomplete Infection Control Training Documentation: The facility failed to document that all staff received required infection control training and education. The Administrator stated the online education reports showed most required in-services were incomplete or not completed, and the RDO confirmed there was no documentation showing all staff received the required education and training.
Failure to Provide Required Compliance and Ethics Training: The facility did not ensure all staff received required education, in-services, and competency training related to Compliance and Ethics. The Administrator stated there was no documentation showing staff had completed the required training, and review of the online education platform showed most required in-services were incomplete or not completed. The RDO confirmed there was no documentation that all staff received the required training to ensure competence.
CNAs did not complete the required minimum of 12 hours of annual inservice training. The facility assessment identified required training in dementia management, abuse prevention, and maintaining CNA competence, but the Administrator stated there was no documentation that CNAs received the minimum education and that most required in-services in the online platform were incomplete or not completed. The RD of Ops confirmed there was no documentation showing all CNAs received the yearly minimum training.
Failure to provide and document pneumococcal immunizations for five residents. Two residents requested the vaccine on admission but had no record of receiving it, and three additional residents reviewed for immunizations also had no documented pneumococcal vaccine despite physician orders allowing it unless contraindicated. The facility could not produce admission packets with vaccination authorization forms for the three residents.
Failure to maintain resident dignity during personal care and feeding. A resident with paraplegia was exposed during catheter prep when staff did not pull the privacy curtain before removing clothing and an incontinent brief; another resident received wound care with the room door open and only partial doorway coverage; and a confused resident was fed by a CNA who stood while repeatedly using pet names instead of the resident’s given name.
A resident with Alzheimer’s disease, dementia, and Parkinson’s disease who was dependent on staff for transfers and ADLs was not reasonably accommodated for toileting preferences. The resident’s RP reported the resident had difficulty having a BM while lying down, was more comfortable sitting upright, and had a history of constipation, but staff said the resident was incontinent and did not transfer the resident to a toilet or commode despite having mechanical lift slings available. The ADON acknowledged staff could use a lift to transfer the resident to a commode, but this was not being done because it would take too long.
Unsafe and Unclean Resident Environment: Housekeeping and maintenance failed to keep common areas and resident spaces clean, safe, and comfortable. Leaves were repeatedly left in a hallway by an exit, a resident room heater was not producing warm air and no work order was documented, and a shared bathroom sink used by two residents remained clogged for months. The unit also had unsecured floor drainage caps, one with an exposed screw, along with ceiling discoloration and dust-like buildup on vents and ceiling tiles.
A resident with Hereditary Spastic Paraplegia and poor trunk control was observed in a motorized wheelchair with a fastened seat belt that she could not release when prompted. Although the care plan described the device as a self-releasing belt/enabler and the MD order allowed a lap positioning device for positioning support, the resident stated she could not unfasten it, and a PT aide confirmed this. The EHR did not contain a restraint assessment since 2024.
Psychotropic medications were ordered for three residents without documented behavioral indications. One resident with severe dementia and anxiety was given Depakote and Seroquel despite no harmful behaviors being documented; another resident with dementia and depression was on lithium, mirtazapine, trazodone, and venlafaxine even though staff described her as social, friendly, and behavior-free; a third resident with Alzheimer’s disease was given mirtazepine and Depakote despite no behaviors, and the guardian stated there was no reason for mood-altering medication. The DON could not explain the medication use or provide supporting consent details.
Failure to document discharge status for a resident sent to the ER for wound evaluation. The record showed the resident was admitted with cellulitis to both legs and needed wound care, but it did not document whether he was admitted to the hospital, expired, or returned home. An LPN/ADON/IP stated she did not know what happened, and the spouse said the resident discharged to another facility after hospitalization.
A resident with dementia, depression, and HTN fell in her room while reaching into a freezer in her room refrigerator and hit her head on the door, with no injuries noted. The nurse documented a new intervention to ask for assistance due to unsteadiness, but the resident’s care plan only noted fall risk and did not include the fall or related intervention. An LPN/ADON/IP confirmed the care plan was missing the incident.
A facility failed to have supporting documentation for diagnoses for two residents. One resident’s record showed a dementia diagnosis added without a physician order despite notes showing no dementia or Alzheimer’s diagnosis, PASRR and physician documentation ruling it out, and family and physician staff stating the resident did not have dementia. Another resident’s record included schizoaffective disorder without prior supporting documentation, and the DON confirmed there was no record of that diagnosis or related mental health history before it appeared in the chart.
Failure to Provide Scheduled Showers: Three residents who needed assistance with ADLs did not receive showers as scheduled. One resident with COPD, DM2, and cellulitis had disheveled grooming and reported only a few showers over about a year, while two other residents with ADL self-care deficits said they were not getting their twice-weekly showers and did not feel clean. Shower records showed limited documentation and repeated missed showers, and the DON stated residents should receive showers twice weekly.
Failure to provide individualized activity programming for 2 residents. One resident with dementia, Parkinson’s disease, and total ADL dependence had documented preferences for 1:1 visits, music, poetry, and sensory items, but activity records showed very limited participation and observations found her alone in her room or common area without music or TV on. Another resident with Alzheimer’s disease, dementia, and paranoid personality had no documented activity preferences in the care plan, and records showed only music and TV, while the guardian reported she loved singing and music and had never seen her in formal activities.
Failure to carry out an ordered voiding trial for a resident with an indwelling catheter. After returning from a hospital stay for influenza and a UTI, the resident had an order to remove the catheter and begin a voiding trial, but CNAs and the assigned LPN denied knowledge of the trial or any need to track urinary output.
A resident with COPD and other diagnoses was observed receiving O2 at 2 L via NC with tubing and a humidification bottle both dated weeks earlier and the bottle dry. The resident said he had asked for the bottle to be filled for two days and his nose was starting to dry out. An RN said the facility was out of prefilled humidification bottles and that tubing is usually changed on Sundays; the SSD later verified the tubing date.
Unsafe bedside medication administration occurred when a resident with diagnoses including anemia, cervical/ovarian/uterine cancer, and CVA was observed with meds left on the bedside table despite no care plan indication, physician order, or interdisciplinary approval for self-administration. The RN stated meds were left at bedside if the resident requested it, while the DON stated the resident's meds should not have been left there.
Two residents with dementia-related diagnoses were involved in a physical altercation when one, known for aggressive behaviors, struck another in the eye while assisting with post-meal cleanup. Despite existing care plans and staff presence, the incident occurred in the Memory Care Unit, and both residents were assessed with no injuries noted. The event was reported according to policy, but the facility did not prevent the physical abuse.
A resident who consistently felt cold was deprived of his personal jacket by a CNA, who removed it in response to the resident's exit-seeking behaviors. The jacket was not returned, leaving the resident to use a blanket for warmth and causing ongoing discomfort. Staff and the DON were aware of the situation, but no further investigation was conducted, and the jacket was never recovered.
A resident's family and Power of Attorney observed the resident was cold and missing his jacket, which a CNA admitted to withholding to prevent the resident from leaving. The incident was documented, but the DON delayed notifying the Administrator, and the allegation was not reported to the state agency as required by policy.
A resident's family and Power of Attorney reported that the resident was left without his jacket and was cold after a CNA took it away due to exit-seeking behaviors, stating she would not return it. Despite the facility's policy requiring investigation of all abuse allegations, no investigation was documented, and the administrator confirmed that none was conducted.
Three residents with significant mobility impairments and care plans requiring full mechanical lift transfers were not consistently transferred using the required equipment. Staff manually transferred a resident when no clean slings were available, and others used alternative methods such as sit-to-stand lifts, despite documentation specifying full mechanical lift use. Staff interviews revealed confusion about transfer requirements and inconsistent communication regarding care plan updates.
A resident was transferred twice to the ER for a leg rash later diagnosed as cellulitis, but the facility failed to complete a thorough and accurate assessment before the second transfer. The LPN used outdated vital signs and did not document current observations, evaluations, or notifications to the physician and family, as required by facility policy. The Assistant DON confirmed these documentation gaps.
A resident identified as at risk for falls did not have the required non-slip material in her wheelchair, as specified in her care plan. Observation confirmed the absence of this intervention, and an LPN verified that the non-slip material was not in place, despite the resident's history of being found in a position suggestive of a fall risk.
Four cognitively impaired residents were involved in two separate incidents of resident-to-resident physical abuse. In one case, a resident with a history of aggression placed his hands around another resident's neck and squeezed, while in another, a resident struck a peer in the face. Both aggressors had documented behavioral issues and prior aggressive episodes, but the facility did not prevent these altercations despite known risks.
A resident with a history of paraplegia, ESBL resistance, and urine retention did not have a urine sample collected in a timely manner as ordered by a physician. The DON completed a lab requisition but did not enter the order into the system, resulting in staff not being alerted to collect the specimen. The urine sample was collected several days late, despite the facility's policy requiring prompt entry of physician orders.
A resident with multiple diagnoses, including Dementia and Schizoaffective Disorder, was physically abused by an agency CNA in a LTC facility. The incident occurred when the resident became combative, and the CNA reflexively struck the resident on the head. The facility's administrator was notified, and the CNA was suspended pending investigation. The incident was reported to the police, and the resident was sent to a hospital for evaluation.
The facility failed to resolve resident grievances in a timely manner, with issues such as unchecked smoke detectors and CNAs using phones while feeding residents repeatedly documented in Resident Council Minutes. The Resident Council President noted that grievances are often unresolved, affecting all 64 residents.
The facility did not schedule a Registered Nurse (RN) for at least eight consecutive hours on specific days, as required by their staffing policy. Instead, only Licensed Practical Nurses (LPNs) were on duty, which was confirmed by the Administrator. This deficiency potentially affects the well-being of all 64 residents in the facility.
The facility did not inform residents that signing an arbitration agreement was not a condition of admission and that they could rescind the agreement within 30 days. This was confirmed through a review of agreements for two residents and an interview with a staff member, affecting all 64 residents.
The facility did not ensure the QAA Committee had the required members or met quarterly. The Administrator, employed for seven months, acknowledged no meetings occurred due to a lack of training. The Medical Director did not attend meetings, and there was no Infection Preventionist since January 2024, potentially affecting all 64 residents.
The facility failed to implement an Antibiotic Stewardship Program, affecting all 64 residents. Despite having a policy, the program was not executed, and there was no monitoring of infections. Two residents had antibiotic orders, but the Regional Director confirmed the absence of a stewardship program, infection monitoring, an Infection Preventionist, and necessary logs.
The facility failed to designate a qualified Infection Preventionist, impacting its ability to manage infection control for all 64 residents. Despite ongoing antibiotic treatments for infections in two residents, the facility lacked documentation for infection monitoring and tracking, and has not had an Infection Preventionist since January 2024.
The facility failed to provide influenza vaccines to eligible residents during the flu season, as required by their policy and state guidelines. Despite having physician orders for annual flu vaccines, no vaccines were administered, and none were available in the medication rooms. The Regional Director of Operations confirmed that an outside company contracted to provide the vaccines had not done so, and the facility had not ordered any vaccines.
A facility failed to complete a PASARR screening for a resident admitted with cerebral infarction, anxiety disorder, and major depressive disorder. The resident's medical record lacked the required screening, which the administrator and Business Office Manager acknowledged was not conducted prior to admission, as the hospital also did not perform it.
The facility did not update care plans for two residents as required. One resident's care plan lacked documentation of hospice services, while another's did not reflect a stage 2 pressure wound despite having wound care orders. The Regional Director of Operations confirmed these omissions.
Failure to Maintain Safe and Well-Repaired Ceilings and Plumbing
Penalty
Summary
The facility failed to maintain the physical environment in a safe, clean, and well‑repaired condition, specifically related to ceiling tiles and a cold water pipe. The Facility Maintenance Director job description required planning, organizing, and directing maintenance operations to ensure the building was safe and comfortable, including repairing facility property, coordinating outside vendors when needed, maintaining supplies and equipment, promptly reporting damage to the Administrator, and making weekly inspections. A former Maintenance Director was terminated for incompetence and unsatisfactory job performance, including failure to complete assigned tasks such as fixing or replacing stained ceiling tiles by an established deadline. At the time of the survey, the facility census was 72 residents, all potentially affected by the environmental deficiencies. On observation, surveyors noted an actively leaking water pipe in the ceiling of the ice machine/vending area, with a trash can placed beneath it containing about one inch of standing water, two soaked blankets and multiple wet towels on the floor, and a missing 2x2 ceiling tile exposing insulation, wiring, and water pipes. Twelve ceiling tiles above the nurses’ desk were brown‑stained and visibly bulging, suggesting ongoing water damage, and on a subsequent day the ice machine/vending area still had two missing 2x2 ceiling tiles with exposed insulation, wiring, and pipes. An RN reported that the ceiling tiles above the nurses’ station had been stained since she began working there months earlier, and an LPN stated the tiles had been stained for as long as she could remember and that the ceiling had been leaking in the ice machine area for several days, noting that the ice machine there was used for all residents. The Regional Maintenance Director confirmed the stained tiles above the nurses’ station and the leaking pipe in the ice machine/vending area, stating that the tiles had not yet been changed because they took time to cut and no one had done it.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Failure to Implement Care-Planned Fall Prevention Intervention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as being at risk for falls. The facility’s Fall Prevention Policy dated 01/26 states that residents at risk for falls will have appropriate safety interventions implemented based on individual assessment, and that accident/incident reports involving falls will be reviewed by the Interdisciplinary Team (IDT) to ensure appropriate care and services. The resident, an individual with dementia and abnormalities of gait, had an unwitnessed fall on 2/24/26, after slipping out of a vinyl or leather recliner while attempting to get up. Following this incident, the IDT identified the root cause as slipping from the recliner and determined that non-skid material should be applied to the recliner seat as an intervention. The resident’s current care plan documented that non-skid material was to be applied to the recliner to reduce the risk of sliding out of the chair. However, during an observation on 4/30/26, the resident’s recliner, located to the right side of the bed, did not have any non-skid material on the seat as required by the care plan. A CNA confirmed that the recliner did not have non-skid material and stated they had never seen such material on the resident’s recliner seat. The DON also stated that the recliner seat should have non-skid material, confirming that the planned fall prevention intervention had not been implemented as documented.
Widespread Environmental Disrepair and Unsafe Conditions Throughout Facility
Penalty
Summary
The facility failed to provide a functional, safe, clean, and comfortable environment for residents, staff, and the public, affecting all 71 residents in the building. The Maintenance Director job description required planning, organizing, and directing maintenance operations, repairing facility and resident property, coordinating outside vendors when needed, maintaining supplies and equipment for a safe environment, promptly reporting damage to the Administrator, and conducting weekly inspections to ensure quality control. Despite these requirements, the former Maintenance Director was terminated for incompetence, substandard productivity, and unsatisfactory job performance, including failure to complete tasks related to facility environment issues identified during a health survey. Additionally, the Administrator in Training was unable to provide maintenance work orders for a period of over six weeks, indicating a lack of documented maintenance follow-through. Surveyor observations throughout multiple halls and rooms showed widespread physical plant deterioration and unsafe conditions. These included missing floor tiles at the entry to Hall A; loose and peeling baseboards; chipped paint and exposed drywall in several rooms; exposed metal screws; and multiple resident room doors with scratched, missing paint and chipped wood. In Hall B, rooms had chipped drywall, exposed black, white, and green electrical cable wires running from wall vents to the ceiling, and a wall-mount heating/cooling unit with its cover off and lying on the ground outside, covered with leaves and debris. Electrical cords approximately six feet long were hanging from outlets onto walking pathways in Halls B and D. Additional deficiencies included large exposed drywall patches, multiple drywall holes and scratches, crumbling and discolored drywall around heating/cooling units, missing wood framing, and exposed drywall without baseboards in the main dining room. The men’s and women’s visitor bathrooms were posted as out of order over two consecutive survey days, and the AIT acknowledged that the building needed many repairs and that the visitor bathrooms were not operational.
Delayed Meal Service and Tray Management Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide meals and snacks at appropriate times in accordance with residents’ needs and the posted meal schedule. The facility’s dietary menu for the week indicated set meal times of 8:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for dinner. Despite this, surveyors observed multiple residents receiving and consuming meal trays significantly later than these scheduled times. One resident reported still finishing breakfast at 11:09 a.m. and stated they missed a 10:00 a.m. activity because their breakfast tray was delivered late. Another resident was just beginning to eat a lunch tray at 2:11 p.m. and stated they had just received their lunch. Additional residents were observed eating lunch trays around 2:07–2:08 p.m. and reported that their trays had just been delivered. The facility’s own documentation reflected concerns with tray management and timeliness. A concern/compliment form noted that trays were not being picked up from rooms at night and that staff did not always pick up a specific resident’s meal tray. An in-service sign-in sheet documented training for CNAs emphasizing that breakfast, lunch, and dinner trays needed to be collected and returned to the kitchen and not left in residents’ rooms. During the survey, staff were observed pushing a dietary meal tray cart containing 13 unserved room trays, and the activity staff stated the kitchen was “really far behind” that day. The Administrator in Training acknowledged there were too many room trays and that residents should not be receiving trays so late, confirming the pattern of delayed meal service and tray pickup for multiple residents.
Involuntary Seclusion and Improper Secured Unit Placement
Penalty
Summary
The facility failed to ensure one resident was free from involuntary seclusion, failed to ensure the criteria were met for admission to the Secured Dementia Unit, and failed to follow physician guidance related to the resident’s wellbeing. The resident involved was cognitively intact by 2/3/26, had admitting diagnoses of Post-Traumatic Stress Disorder and Generalized Anxiety Disorder, and did not have a documented diagnosis of Dementia or Alzheimer’s Disease in the record. The resident’s PASRR Level 1 also documented no dementia or Alzheimer’s diagnosis and that Level 2 was not required. The resident was transferred to the Secured Dementia Unit for high elopement risk, even though the record and physician notes did not identify a dementia diagnosis. The facility’s own admission criteria stated the secured unit was for residents with cognitive or Alzheimer’s/Dementia-related diagnoses and for residents who display wandering or exit-seeking behavior that is not easily directed or poses a risk. Staff interviews indicated the resident did not appear confused, had not attempted to elope, and had not displayed exit-seeking behavior, but did express wanting to leave the locked unit and return to the general population. The resident stated she did not want to be there, believed she should not be locked in the unit, and said she had passed cognitive testing and was not going to leave the facility. The resident also reported distress related to being in the secured unit, including not participating in activities because she did not want to be with cognitively impaired residents and could not stand to see them that way. The resident stated she had not slept because another resident was crying and staff did not help that resident. The psychiatric NP documented that the resident would benefit from being out of the unit and that the resident requested to be out of the unit, while the medical director stated the resident did not have a dementia diagnosis and did not meet criteria for admission to the Secured Dementia Unit.
Facility-Wide Failures in Oversight, Resident Care, and Safety
Penalty
Summary
The facility failed to provide adequate administrative oversight across multiple areas of resident care, including dignity, assessments, medication administration, infection prevention, activities, ADL care, and environmental maintenance. The report states the facility had been without a permanent Administrator for about a year to a year and a half, with interim regional administrators filling in. The facility assessment identified staffing resources needed to provide competent support and care, including Administrator, Staff Development, QAPI, Infection Control and Prevention, Environmental Services, Social Services, Discharge Planning, Human Resources, and Compliance and Ethics, but the report states there was no documentation that staff received education or competencies related to facility standards, policies, and procedures. Several residents were observed or documented receiving care in ways that did not protect dignity or meet their needs. One resident was exposed during catheter care because a privacy curtain was not used, another resident’s door was not closed during wound care, and a CNA fed a resident while standing and repeatedly called the resident “honey” and “sweety.” A resident who preferred to be up in a chair to toilet was not accommodated because of staff time constraints. The facility environment was also described as unsafe and poorly maintained, including leaves piled in a hallway, dirty floors, a resident room with a broken heater, a clogged bathroom sink shared by two residents for about six months, unsecured floor drain caps with one screw sticking up about one inch, water-stained ceiling tiles, dust hanging from vents, holes in walls, torn wallpaper, exposed drywall, and garbage and refuse not properly contained in dumpsters. The report also describes failures in assessment, treatment, and medication management. One resident was transferred to a secured dementia unit to prevent elopement even though the resident did not meet admission criteria, had no dementia diagnosis, and the psychiatric NP and interdisciplinary team documented that the resident should be in the general population; the resident remained there until an immediate jeopardy for involuntary seclusion was identified. Another resident had a self-releasing seat belt order but was unable to release it when prompted. Residents were given medications without clear supporting diagnoses or behaviors in the record, including an antipsychotic for one resident with no behaviors documented and three antidepressants for another resident whose staff and the resident could not explain the need for them. One resident’s change in condition was not assessed or addressed and diagnostic tests were not completed as ordered, and the resident was hospitalized with lethargy, cough, shortness of breath, wheezing, confusion, RSV, acute bronchiolitis due to RSV, COPD exacerbation, and acute hypoxic respiratory failure. Other documented failures included lack of shower documentation for residents who reported not receiving scheduled showers, lack of a voiding trial monitoring process after catheter removal, oxygen tubing and humidification issues, medications left at a resident’s bedside without an order to self-administer, and missing documentation for staff training, infection prevention competencies, and CNA in-service hours.
Failure to Monitor Respiratory Decline and Complete Ordered Chest X-Ray
Penalty
Summary
The facility failed to assess a resident’s change in condition and ensure a chest x-ray ordered for the resident was completed. The resident was admitted with diagnoses including orthopedic aftercare, fracture of femur shaft, morbid obesity, chronic respiratory failure, type 2 diabetes, and major depressive disorder, and was documented as cognitively intact. On 2/20/26, the resident had a new order for a chest x-ray after being weak, coughing up yellowish/greenish mucus, and having wheezing throughout the lung fields. The resident later stated the chest x-ray had not been done because contracted x-ray staff never came. The record also showed an infection screening evaluation on 2/20/26 that triggered Loeb’s Criteria for suspected lower respiratory tract infection and McGreer’s Criteria for suspected bronchitis or tracheobronchitis, but the evaluation was not completed until later by the regional nurse consultant. Progress notes documented ongoing wheezing on 2/21/26, 2/23/26, and 2/24/26, but did not document vital signs or oxygen saturation monitoring between 2/20/26 and the morning of 2/25/26. On 2/24/26, the resident stated she did not feel well, complained of chest heaviness and difficulty breathing, and reported coughing up yellow and green sputum. The next day, the resident appeared worse, had difficulty breathing, and said no one paid attention to her and that she was going to die. She was then found confused, lethargic, with shallow respirations, diminished lung sounds with rhonchi, and oxygen saturation of 53%. Oxygen was applied and increased, but saturations remained low, and the medical director ordered transfer to the hospital. The resident was diagnosed in the ED with RSV, acute bronchiolitis due to RSV, acute COPD exacerbation, and acute hypoxic respiratory failure, and hospital notes listed acute metabolic encephalopathy due to hypercarbia, acute and chronic hypoxemia and hypercarbic respiratory failure, acute COPD exacerbation secondary to RSV bronchiolitis, and acute kidney injury.
Lack of Staff Competency Documentation
Penalty
Summary
Nursing staff, including RNs, LPNs, and CNAs, were not shown to be competent to perform their job duties because the facility lacked documentation of education, in-service training, and competency assessments. The deficiency was identified through record review and interview, and the facility assessment for 11/1/2025-11/1/2026 stated that staff training and competencies were to include topics such as communication, residents' rights, abuse, neglect, exploitation, infection control, culture change, identification of resident changes in condition, cultural competency, person-centered care, ADLs, disaster planning, medication administration, vital signs, resident assessment, dementia care, specialized care, and care for residents with mental and psychosocial disorders. The Facility Resident Census Roster and Facility Matrix/802 dated 2/24/26 showed 67 residents in the facility. On 3/3/26, the Administrator stated she did not have documentation showing staff received education and competencies related to the facility's standards, policies, and procedures, and said her review of the online education platform showed most required in-services and education were either incomplete or not completed at all. The Regional Director of Operations later confirmed that all staff should receive regular training and education to ensure competence, and stated there was no documentation showing all staff received their required education and training.
Spoiled Produce Stored in Walk-In Refrigerator
Penalty
Summary
The facility failed to monitor stored fresh produce and destroy spoiled produce stored in the kitchen's walk-in refrigerator. During observation on 2/24/26 at 8:50am, a produce box in the kitchen's walk-in refrigerator containing whole individual zucchini squash included three zucchini squash with wrinkled areas, dark areas approximately 1/2-centimeter square, several open white spots approximately 1 centimeter square, and soft areas on each of the three squash. The Facility Resident Census Roster and Facility Matrix/802 documented that 67 residents resided in the facility. The facility's Food & Supplies: Storage policy dated 01/2026 stated that food and supply storage areas shall be maintained in a clean, safe and sanitary manner. At 8:50am, V14 Dietary Manager verified the three spoiled zucchini squash were moldy, should not be served to residents, and should have been thrown away.
Improper Garbage and Refuse Containment
Penalty
Summary
Improper garbage and refuse containment was identified in the facility’s dumpster area. The facility was unable to provide a waste disposal policy. The Facility Resident Census Roster and Facility Matrix/802 documented 67 residents in the facility. During interview, the Maintenance Director stated the facility disposes of garbage and refuse in two large dumpsters behind the facility and that the dumpsters should be closed with all garbage stored inside them and not on the ground around them. During observation, both dumpsters were uncovered, full, and overflowing with garbage bags and refuse, with six large bags of garbage on the ground around the dumpsters and a foul odor coming from the dumpster storage area.
Infection Control Failures With Improper Mask Use, Lack of Respiratory Illness Monitoring, and EBP/Hand Hygiene Lapses
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program by not ensuring residents and staff were monitored and tracked for communicable diseases and by not ensuring a process was in place to prevent spread of disease to other residents and staff. During observations, multiple staff members were seen in close proximity to residents with masks worn improperly, including a CNA feeding residents while coughing, sneezing, and rubbing her face, a dietary aide and activity aide with masks under their noses in the dining room, and other staff with masks under their noses or chin while providing care or passing medications. The facility had posted signs at the entrance about respiratory illness activity in the community, and the county respiratory illness level was documented as moderate for influenza and very high for RSV. A resident with diagnoses including orthopedic aftercare, femur fracture, morbid obesity, chronic respiratory failure, type 2 diabetes, and major depressive disorder was observed in common areas without a mask while reporting chest heaviness, shortness of breath, and productive cough with yellow and green sputum. The resident’s room did not indicate Transmission Based Precautions and no PPE was available for staff use. The resident’s infection screening documented new onset functional decline, lung exam abnormalities, increased cough, and purulent sputum, with suspected lower respiratory tract infection and suspected bronchitis or tracheobronchitis. Progress notes documented ongoing wheezing and cough, but vital signs and oxygen saturations were not documented between the initial screening and the morning the resident was found lethargic, confused, with shallow respirations and oxygen saturation of 53%, leading to transfer to the hospital where RSV, acute bronchiolitis, COPD exacerbation, and acute hypoxic respiratory failure were diagnosed. The facility also did not have a policy for testing communicable diseases, and the infection preventionist stated respiratory pathogen testing was not done unless ordered by a physician. The call-off symptom tracking log documented employees who called off with cough and runny nose, including one later positive for RSV and one positive for influenza, while others were not tested. The medical director stated RSV was currently very active in the county and could be fatal in the resident population. In addition, the facility failed to follow Enhanced Barrier Precautions and hand hygiene requirements for residents with wounds or indwelling devices: one nurse performed catheter and wound care without a gown, another performed intermittent catheterization using nonsterile gloves and changed to sterile gloves without hand hygiene, another changed gloves during wound care without hand hygiene, and two residents on EBP had no PPE available near their rooms and one had no EBP sign initially posted.
Failure to Repair Damaged Walls and Room Surfaces
Penalty
Summary
The facility failed to maintain or repair missing and peeling wall coverings and exposed drywall in the rooms of 8 residents, including R13, R16, R31, R39, R42, R44, R62, and R69. On 2/24/26, the surveyor observed a section of wallpaper approximately two feet by six inches peeling with exposed drywall in the room shared by R42 and R69, a six-inch by 1-1/2-inch hole through the drywall behind the door in the room shared by R39 and R62, a 1-1/2-foot by 8-inch area of peeling wallpaper and exposed drywall in the room shared by R13 and R44, and a four-foot by 2 1/2-foot area of exposed drywall with peeling wallpaper in R16's room. The facility also failed to repair the wall area between the HVAC unit and the window sill in the room shared by R30 and R37. The surveyor observed black spots in the caulking identified by the Maintenance Director as mildew, crumbling and missing caulking, broken wooden framing, and a hole through the drywall measuring approximately 3 inches by 2 1/2 inches exposing wire mesh. During the tour, the Maintenance Director stated the rooms had not yet been addressed in the remodel attempt and said the computer had been down for a while, so work requests were not received. A later review of work orders showed 11 repair requests for the hall where these residents' rooms were located, and the Regional Director of Operations verified the areas in need of repair.
Incomplete Infection Control Training Documentation
Penalty
Summary
The facility failed to ensure all staff received mandatory training and education for infection prevention and control. The Facility Assessment Tool for 11/1/2025-11/1/2026 stated that staff training, education, and competencies were to be addressed through Healthcare Academy, including infection control training as part of the facility’s infection prevention and control program. Review of the Facility Resident Census Roster and Facility Matrix/802 showed 67 residents in the facility. During interview, the Administrator stated there was no documentation demonstrating that staff employed at the facility received the required training, and she reviewed the online education reports showing that most required in-services and education for staff were either incomplete or not completed at all. The Regional Director of Operations also confirmed that all staff should receive regular training and education to ensure competence, and stated there was no documentation showing all staff received their required education and training.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure all staff were provided education, in-services, and training regarding the facility’s standards, policies, and procedures for Compliance and Ethics. The record review included the Facility Resident Census Roster and Facility Matrix/802, which documented 67 residents in the facility. The Facility Assessment Tool for 11/1/2025-11/1/2026 stated that staff training and education were to include topics such as communication, residents’ rights and facility responsibilities, abuse, neglect, exploitation, infection control, culture change, identification of resident changes in condition, cultural competency, person-centered care, activities of daily living, disaster planning and procedures, medication administration, resident assessment and examination, and care for residents with dementia and other specialized needs. On 3/3/26 at 11:00 AM, the Administrator stated there was no documentation showing staff employed at the facility received education and competencies related to Compliance and Ethics. The Administrator also stated that review of the online education platform showed most of the required in-services and education for staff members were either incomplete or not completed at all. On 3/3/26 at 3:45 PM, the Regional Director of Operations confirmed that all staff should receive regular training and education to ensure competence, and stated there was no documentation showing all staff received their required education and training.
CNAs Did Not Complete Required Annual Inservice Training
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants (CNAs) completed the required minimum of 12 hours of annual inservice training. The facility assessment for 11/1/2025-11/1/2026 identified required in-service training for nurse aides, including dementia management training, resident abuse prevention training, and training to ensure continuing competence. During interview, the Administrator stated there was no documentation showing the CNAs working at the facility received the minimum 12 hours of required education, and that review of the online education platform showed most required in-services were either incomplete or not completed at all. The Regional Director of Operations later confirmed CNAs should receive at least 12 hours of continuing education yearly and that there was no documentation showing all CNAs received the minimum yearly training.
Failure to Provide and Document Pneumococcal Immunizations
Penalty
Summary
The facility failed to provide pneumococcal immunizations to two residents who requested the vaccine and failed to offer pneumococcal immunizations to three additional residents reviewed for immunizations. The facility’s Influenza and Pneumococcal Immunizations Policy dated 12/2025 states that each resident is offered a pneumococcal immunization and that the medical record includes documentation showing the resident either received the immunization or did not receive it due to medical contraindication or refusal. R1 was admitted with diagnoses including chronic respiratory failure with hypoxia, COPD, diabetes, depression, and pneumonia. Her physician’s order stated she may have the pneumonia vaccine unless contraindicated, and her admission packet indicated she requested the pneumococcal vaccine, but her record did not document that she received it. R60 was admitted with diagnoses including COPD, depression, atrial fibrillation, and bipolar disorder; his physician’s order also stated he may have the pneumonia vaccine unless contraindicated, his admission packet indicated he requested the vaccine, and his record did not document a pneumococcal immunization. On 02/27/2026, R60 stated he had not received a pneumococcal vaccine and wanted one. R13, R52, and R55 each had physician orders stating they may have the pneumonia vaccine unless contraindicated, but their records did not document a pneumococcal immunization, and the facility could not find or provide their admission packets with the vaccination authorization forms.
Failure to Maintain Resident Dignity During Personal Care and Feeding
Penalty
Summary
The facility failed to treat three residents with dignity. R5, who was admitted with diagnoses including Spina Bifida, paraplegia, COPD, hydronephrosis, and urinary retention, was transferred by two CNAs from a wheelchair to bed on 2/25/26 at 2:15 PM. Before the resident’s pants and incontinent brief were pulled down for a catheter procedure, the privacy curtain was not pulled. An LPN then entered the room and pulled the privacy curtain between R5 and the roommate. R27, who was admitted with diagnoses including paraplegia, hypothyroidism, coarctation of the aorta, viral hepatitis C, and arthritis, was observed on 2/25/26 at 2:30 PM in a room with the door open while an LPN placed a treatment cart in front of the doorway and provided wound care to the resident’s right knee wound, but the cart did not cover the width of the doorway. R76, who was admitted with diagnoses including unspecified dementia, severe depression, and unspecified intellectual disabilities and was observed throughout the survey to be confused and unable to answer questions appropriately, was being fed lunch by a CNA on 02/25/2026 at 1:21 PM while the CNA repeatedly referred to the resident as "honey" and "sweetie." The CNA later acknowledged the comment and an LPN stated staff should sit when feeding residents and should not refer to residents by pet names unless requested by the resident.
Failure to Accommodate Resident Toileting Preferences
Penalty
Summary
The facility failed to reasonably accommodate a resident’s toileting needs and preferences for a resident with Alzheimer’s disease, non-Alzheimer’s dementia, and Parkinson’s disease who was dependent on staff for transfers and all ADLs, rarely or never understood, and unable to complete a BIMS. The care plan documented that the resident was dependent on staff for toileting and required a mechanical lift for transfers, and also included interventions to monitor voiding patterns and implement a toileting program if needed. The facility assessment also directed staff to learn resident preferences and routines and incorporate them into care planning. The resident’s responsible party stated that the resident had difficulty having a bowel movement while lying down, appeared uncomfortable when lying down and attempting to have a bowel movement, and had a history of constipation. The responsible party reported that staff were aware of the request to toilet the resident regularly and that the resident always had a bowel movement when seated upright in a shower chair on shower days. Staff stated the resident was incontinent and therefore was checked and changed rather than toileted, and staff confirmed they did not currently transfer the resident to a toilet or commode. The ADON acknowledged that staff could use a mechanical lift and appropriate sling to transfer a resident to a commode for toileting, that the slings were available, and that the resident was not being transferred to a commode because it would take a long time.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents in multiple areas of the building. Housekeeping and maintenance job descriptions stated that common areas and resident spaces were to be kept clean, safe, and comfortable, but leaves were repeatedly observed scattered in piles on the floor in the back of D Hall by the exit and extending into the hallway where R60 resided. R60 stated the leaves were always in the hallway and that the floors were frequently dirty, and an Activities Assistant stated the leaves blew in through the back door and were not being swept or cleaned as they should be. R58 reported that his room was cold and that his wall heater had not worked for a while. At the time of observation, his wall heating unit was not functioning and he was wearing a heavy winter coat in his room. A CNA later attempted to turn on the heater and it only blew cold air. The Maintenance Director verified the unit was not producing warm air and stated he was not aware of any maintenance request for the room, and the facility’s work order review showed no documented request for the heating unit. The shared bathroom sink used by R1 and R48 had been clogged for months and was observed standing in water. R1 stated she could not use the sink to brush her teeth or wash her hands after toileting, and R48 stated the sink had been unavailable since May 2025. Resident Council minutes also documented the sink remained clogged on prior dates. In addition, the Secured Dementia Care unit had two unsecured floor drainage caps, one with a screw sticking up about one inch, and multiple ceiling tiles with brown discoloration and dust-like material on vents and surrounding ceiling areas. The Maintenance Director acknowledged the sink problem, the roof leak history, and stated the exposed screw could easily cause a resident to trip or stub a toe.
Failure to Ensure Resident Could Self-Release Wheelchair Belt
Penalty
Summary
The facility failed to ensure one resident reviewed for physical restraints was free from a physical restraint unless needed for medical treatment. The facility’s restraint policy defined a physical restraint to include a self-release belt if the resident was physically incapable of releasing it, and it required restraint assessments with the initial application, changes in restraint type, changes in condition, and periodic review to reduce or eliminate restraints when possible. The resident involved had diagnoses including Hereditary Spastic Paraplegia and Lack of Coordination, and the physician’s order allowed use of a lap positioning device on the chair while up to enhance positioning because of poor trunk control related to spastic paraplegia, with release and repositioning every two hours and removal during meals every shift. The resident’s care plan documented use of an enabler/self-releasing belt while in a motorized wheelchair, but observation and interview showed the resident could not release the seat belt when prompted. On one observation, the resident was sitting in a motorized wheelchair in the hallway with the seat belt fastened and was unable to release it. On another occasion in physical therapy, the resident stated she could not unfasten the seat belt, and the PT aide confirmed this. The resident’s electronic health record did not contain a restraint assessment since 2024.
Psychotropic medications ordered without documented behavioral indications
Penalty
Summary
The facility failed to have appropriate indications for use for psychotropic medications for three residents reviewed for unnecessary medications. The facility’s Gradual Dose Reduction policy stated psychotropic drugs are to be used only when necessary to treat a specific or suspected condition and at the lowest therapeutic dose, but the records for three residents did not show documented behaviors supporting the medications ordered. One resident with diagnoses including metabolic encephalopathy, severe dementia, and unspecified mood disorder was ordered Depakote Sprinkles for dementia with anxiety and Seroquel for dementia, yet behavior monitoring for the past three months did not document harmful behaviors toward self or others, and an LPN stated the resident was anxious and tried to stand up often but had never hit staff or other residents. A second resident with dementia, depression, and COPD was ordered lithium, mirtazapine, trazodone, and venlafaxine for depression, but behavior monitoring documented no behaviors and staff stated the resident was social, friendly, alert, oriented, and engaged with peers; the DON stated she did not know why the resident was on so many medications for depression. A third resident with Alzheimer’s disease, paranoid personality, and hypertension was ordered mirtazepine for weight loss and Depakote for dementia, but behavior monitoring documented no behaviors, the legal guardian stated the resident had no behavior issues and no reason to be on mood-altering medications, and the DON could not provide details supporting the consent or documentation for the Depakote order.
Failure to Document Resident Discharge Status
Penalty
Summary
The facility failed to document the discharge status for one resident, R71, after the resident was sent to the emergency room for evaluation of wounds. The facility’s Notice of Transfer and Discharge policy stated that when a resident is transferred or discharged, the transfer or discharge must be documented in the medical record and appropriate information must be communicated to the receiving health care institution or provider. R71’s record showed admission with diagnoses including cellulitis to both legs and a need for assistance with wound care, with a plan to return home after the legs healed. The record also showed that the wound doctor sent R71 to the emergency room, but it did not document whether the resident was admitted to the hospital, expired, or went home from the hospital. During interview, the LPN/ADON/Infection Preventionist stated she did not know what happened to R71, and the resident’s spouse stated that R71 discharged to a different facility after hospitalization, but had no information about the diagnosis, current status, or why he did not return to the facility.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to update a resident’s care plan after an incident involving a fall. R7 was admitted with diagnoses including dementia, depression, and hypertension. Her nurse’s note documented that on 2/12/26 she fell in her room while trying to get something out of the freezer in her room refrigerator, hit herself in the head with the door, and fell to the ground with no injuries. The note also listed a new intervention to encourage her to ask for assistance with her freezer due to unsteadiness. However, R7’s current undated care plan identified her as being at risk for falls but did not include any information about the 2/12/26 fall. On 3/3/26 at 2:00 PM, the LPN/ADON/Infection Preventionist confirmed that the fall was not mentioned on the care plan and stated that it should have been included.
Unsupported Diagnoses Added to Resident Records
Penalty
Summary
The facility failed to have supporting documentation for diagnoses for two residents. For one resident, the record showed admission with PTSD and generalized anxiety, but later documentation added a dementia diagnosis without a physician order. The resident’s BIMS showed moderately impaired cognition on 1/29/26 and cognitively intact status from 2/3/26 onward. The PASRR Level 1 dated 1/27/26 stated the resident did not have a dementia or Alzheimer’s diagnosis and did not require a Level 2 assessment. The family physician’s notes from 8/22/25, 10/31/25, and 12/30/25 documented evaluation for dementia with testing that was passed, and no dementia or Alzheimer’s diagnosis was identified. The elopement/unauthorized leave risk review also documented no history of dementia. Despite this, the record showed a dementia diagnosis was added on 1/30/26 by the ADON, who later stated she reviewed the admission documents, found a dementia diagnosis, and added it to the diagnosis list without obtaining a physician order. The resident’s family member and the family physician’s CMA both stated the resident did not have dementia or Alzheimer’s, and the medical director stated that if the referring physician says the resident does not have dementia, then the resident does not have dementia. For the second resident, the medical record documented admission with diagnoses including Alzheimer’s, conversion disorder with seizures, and hypothyroidism, and a physician order sheet later added schizoaffective disorder dated 8/30/23. However, the resident’s first psychiatrist visit on 12/3/24 did not mention schizoaffective disorder. The DON stated she did not know where the diagnosis came from and confirmed there was no documentation of a history of schizoaffective disorder or any mental health diagnosis prior to 8/30/24, and no documentation of unwanted behaviors in the past 2 years reviewed. The resident’s legal POA stated he had known the resident for years and had no information about any mental health diagnosis, describing her as friendly prior to dementia. A clarification nurse’s note later documented that the psychiatrist stated the schizoaffective disorder diagnosis was present before the psychiatry group took over and that they removed it from their diagnosis list.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to assist and provide showers for three residents who required help with activities of daily living. Resident 6’s record showed diagnoses including COPD, Type II DM, and right lower leg cellulitis, and his MDS documented partial/moderate assistance needed with showering and bathing. On observation, he was sitting in a recliner with disheveled hair, wearing only shorts, with long jagged fingernails and facial hair. He stated he had been at the facility for about a year and had only had 5 showers. His admission was on 8/14/25, the first shower sheet was dated 10/21/25 and noted he gave himself a sponge bath, and there were no documented showers given; refusal of shower was documented on several dates with two signatures. Resident 43’s care plan documented an ADL self-care deficit requiring substantial assistance with personal hygiene and oral care, and Resident 48’s care plan documented the same need for substantial assistance with personal hygiene and oral care. Both residents stated they had not been getting their showers twice weekly, with Resident 43 saying she did not feel clean and Resident 48 saying she felt sticky from being sweaty and lying in bed. Shower sheets showed both residents were scheduled for twice-weekly showers, but the documentation reflected missed or limited showers over multiple months. The Resident Council Meeting Minutes also documented that residents were still not getting showers, and the DON stated that all residents should be given a shower twice weekly and that if a resident refuses, two staff members are to sign the shower sheet and indicate why the resident did not want to shower.
Failure to Provide Individualized Activity Programming
Penalty
Summary
The facility failed to assess, develop, and implement a care plan and provide an ongoing program of activities based on residents’ assessments and preferences for 2 of 4 residents reviewed for activities. The facility’s Activities Program Policy stated that residents should be identified and involved in an ongoing program of activities designed to appeal to their interests and needs, and that activity staff should record attendance and participation daily. The policy also stated that the Activities Director and/or designee should review records to determine emerging needs for resident assessment or care plan reviews. One resident was non-verbal, had Alzheimer’s disease, non-Alzheimer’s dementia, and Parkinson’s disease, and was dependent on staff for all ADLs. Her activity assessment documented that she was low functioning, non-verbal, and enjoyed listening to music and holding soft items. Her care plan listed preferences for 1:1 activity staff visits, sensory soft items, poetry, music, and daily visits from her family member/healthcare POA, with goals for cognitive stimulation and participation in preferred activities. However, activity documentation from late November 2025 through late February 2026 showed only 4 activities recorded, and multiple observations showed her sitting alone in her wheelchair in her room or in the common area with no music or television on. Her family member stated activity staff offered to read to her every day, but that it did not happen very often, and the Activity Director stated the resident received 1:1 activities two times a week. The second resident had Alzheimer’s disease, dementia, and paranoid personality, and was non-verbal and confused throughout the survey. Her activity preferences interview contained no responses, and her care plan did not document any activity preferences. Her activity documentation from November 2025 through February 2026 listed only music and TV as activities. Her legal guardian stated she loved singing and music and had never seen her in any formal type of activity, and an Activity Aide stated she was usually in her room by herself with the TV on or music playing.
Failure to Carry Out Ordered Voiding Trial
Penalty
Summary
The facility failed to complete a urinary voiding trial as ordered for one resident who was readmitted after a short hospitalization for influenza and a urinary tract infection and returned with an indwelling catheter. The physician order sheet dated February 2026 documented an order on 2/24/26 to remove the indwelling catheter and implement a voiding trial. On 2/25/26, two CNAs assisted the resident to bed with a mechanical lift and observed that the absorbent undergarment was dry, but both CNAs denied any knowledge of the voiding trial or that they needed to track the resident’s urinary patterns. Later that day, the LPN identified as responsible for the resident’s care also denied any knowledge of tracking the resident’s urinary output for any reason.
Oxygen Tubing Not Changed as Ordered
Penalty
Summary
The facility failed to ensure oxygen tubing was changed routinely for R55, who was admitted with diagnoses including COPD, diabetes, venous insufficiency, polyneuropathy, and schizophrenia. The facility’s policy dated 12/2025 states nasal cannulas are to be changed weekly and as needed, and R55’s physician order dated 11/26/25 also directed oxygen tubing to be changed weekly and as needed. During observation on 02/24/26, R55 was in bed receiving oxygen at 2 liters via nasal cannula, and the tubing was dated 02/14/2026 while the prefilled humidification bottle was dry and dated 02/14/26. R55 stated he had asked for the bottle to be filled for two days and that his nose was starting to dry out. The RN reported the facility was out of prefilled humidification bottles for oxygen use and that tubing is usually changed on Sundays. On 02/25/26, the Social Service Director observed R55’s room and verified the oxygen tubing was still dated 02/14/26.
Unsafe Bedside Medication Administration
Penalty
Summary
The facility failed to ensure medications were safely administered for one of seven residents observed during the medication administration pass. The cited policy stated licensed nurses may prepare, administer, and record medications, and that residents may self-administer only if the interdisciplinary team has determined it is safe. It also required medications to be administered according to physician's order to the right resident, right medication, right dose, right route, and right time. R48 was admitted with diagnoses of posthemorrhagic anemia, malignant neoplasm of the cervix, ovary and uterus, and cerebral vascular infarct. R48's care plan did not indicate self-administration, the record did not include a physician's order for self-administration, and the progress notes did not include an interdisciplinary note approving self-administration. During observation, R48 was seen with medications left in a cup on the bedside table and stated that nurses leave her medications at the bedside and she takes them when she wakes up. The MAR showed gabapentin and ropinirole were documented as administered by the RN during the lunchtime medication pass, and the RN stated that if the resident requests medications be left at bedside, the nurse leaves them there. The DON later stated R48's medications should not have been left at the bedside.
Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The facility failed to prevent physical abuse between residents in the Memory Care Unit, specifically involving two residents with dementia-related diagnoses. One resident, who had a documented history of verbal and physical aggression, was assisting with cleaning after a meal and attempted to remove another resident's lunch tray. The second resident reached out as the tray was being removed, and the first resident responded by striking the second resident in the eye. Staff interviews and record reviews confirmed that the incident occurred in the dining area, and that the aggressive resident had a care plan in place addressing behavioral issues, including interventions to minimize disruptive behaviors. At the time of the incident, staff were present in the unit, and an LPN reported hearing a loud noise and observing the aftermath, with the victim covering his eyes and stating he was hurt. Both residents were assessed following the altercation, and no physical injuries were noted. The facility's policies affirm residents' rights to be free from abuse, and the event was reported to the state agency as required. However, the incident demonstrates a failure to effectively implement interventions and supervision to prevent resident-to-resident physical abuse.
Resident Deprived of Personal Jacket Due to Exit-Seeking Behaviors
Penalty
Summary
The facility failed to protect a resident from abuse by depriving him of his personal jacket, which he relied on for warmth due to his constant feeling of being cold. The resident's jacket was taken by a Certified Nursing Assistant (CNA) because the resident was exhibiting exit-seeking behaviors, and the CNA believed that having the jacket increased these behaviors. The jacket was placed in the shower room and not returned to the resident, despite his repeated requests and complaints of being cold. The resident was observed using a blanket to keep warm in the absence of his jacket, and both the resident and his family reported his ongoing discomfort and distress due to the missing jacket. Multiple staff members, including the Director of Nursing (DON) and other CNAs, were aware that the jacket had been taken and that the resident was left without it for several weeks. The facility's policy prohibits the deprivation of goods or services necessary for residents' well-being, yet no further investigation was conducted by the DON after being notified of the incident. The resident's family and Power of Attorney also raised concerns about the deprivation, but the jacket was never recovered, and the resident continued to experience discomfort as a result.
Failure to Immediately Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the Administrator and the State Agency, as required by facility policy. According to documentation, a family member and a Power of Attorney visiting a resident noticed the resident was without his jacket and was cold. A Certified Nursing Assistant informed them that she had taken the resident's jacket and placed it in the shower room because the resident wanted to leave the facility, and she was not going to return it. The concern was documented on a facility form, but the Director of Nursing did not notify the Administrator until the following day. Additionally, as of the date of the survey, there was no documentation that the allegation of potential abuse had been reported to the state agency, contrary to the facility's policy requiring immediate reporting.
Failure to Investigate Allegation of Potential Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential abuse involving one resident. According to the facility's own Abuse Prevention and Reporting policy, any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property requires an investigation. On 6/15/2025, a resident's family member and Power of Attorney observed that the resident did not have his jacket and was cold, and were informed by a Certified Nursing Assistant that she had taken the jacket because the resident was exhibiting exit-seeking behaviors and intended to keep it from him. This incident was documented on a Concern/Compliment Form, but as of 9/17/2025, there was no documentation of any investigation into the allegation. The facility administrator confirmed that no investigation had been conducted regarding this potential abuse.
Failure to Use Required Mechanical Lifts for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents who required a full mechanical lift for transfers were consistently transferred using the appropriate equipment, as specified in their care plans and facility policy. Observations, interviews, and record reviews revealed that these residents were either manually transferred by staff or transferred using alternative equipment, such as a sit-to-stand lift, instead of the required full mechanical lift. Staff reported that on at least one occasion, a resident was manually transferred by two CNAs because there were no clean slings available for the mechanical lift, and the resident did not have a sling under her, making the lift unusable at the time of transfer. The care plans and Kardex sheets for the three residents clearly documented the need for a full body mechanical lift for all transfers. Despite this, staff interviews indicated a lack of consistent adherence to these documented requirements. Some CNAs stated they relied on verbal instructions from therapy staff or other CNAs rather than the written care plans or Kardex, leading to confusion and inconsistent transfer practices. Additionally, there was a lack of communication among staff regarding changes in transfer status, with some staff unaware of where to find the correct information in the electronic charting system. The residents involved had significant medical conditions affecting their mobility, including dementia, muscle wasting, orthopedic issues, and hereditary spastic paraplegia. All were dependent on staff for transfers and used wheelchairs for mobility. At the time of the deficiency, observations confirmed that these residents did not have full mechanical lift slings under them, and staff acknowledged using manual or alternative transfer methods contrary to the care plan. The facility's own investigation confirmed that the failure to use the mechanical lift as required was due to a lack of proper equipment setup and communication lapses among staff.
Failure to Accurately Assess and Document Resident Condition Prior to Hospital Transfer
Penalty
Summary
The facility failed to thoroughly assess and accurately document the condition of a resident who was transferred to the emergency room for a rash on the leg, later diagnosed as cellulitis. The facility's policy requires comprehensive assessment and documentation during incidents and significant status changes, including reviewing previous notes, documenting findings, and notifying relevant parties. However, the Change in Condition Evaluation form completed by an LPN on the day of the second transfer lacked updated vital signs, relevant observations, and a summary of the nurse's evaluation and recommendations. The vital signs and notification times recorded were from the previous day, and the most recent blood glucose value was several months old. Additionally, the form did not indicate whether the condition had occurred before, incorrectly marking it as "Unknown" despite the same issue prompting a hospital visit the previous day. There was also no documentation of updated notifications to the primary care clinician or the resident's healthcare power of attorney regarding the second transfer. These omissions were confirmed by the Assistant Director of Nursing, who acknowledged the lack of accurate and current assessment and notification documentation for the resident's second emergency room transfer.
Failure to Implement Fall Prevention Intervention for At-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in its Fall Prevention Program for one resident identified as at risk for falls. The program requires individualized assessment and the use of appropriate interventions, including assistive devices, for residents at risk. Documentation showed that a non-slip material was to be added to the resident's wheelchair as a fall prevention measure. However, during observation, the resident was seen propelling herself in the dining room without the required non-slip material in her wheelchair. This was confirmed by a Licensed Practical Nurse present at the time. Additionally, nurse's notes indicated that the resident had previously been found sitting half-upright near her bed, further indicating a risk for falls.
Failure to Prevent Resident-to-Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect four cognitively impaired residents from abuse, specifically failing to prevent resident-to-resident physical abuse. Two separate incidents occurred involving residents with severe cognitive impairment and documented behavioral issues. In the first incident, one resident with a history of aggressive and combative behavior placed both hands around another resident's neck and forcefully squeezed, requiring staff intervention to separate them. The aggressor had a documented pattern of aggression towards staff and peers, including previous episodes of hitting, scratching, and resisting care. Both residents involved were unable to recall the incident due to their cognitive status. In the second incident, another resident with dementia and a history of behavioral problems struck a peer in the face with a closed fist. The aggressor was observed by staff walking quickly toward the victim, calling her by an incorrect name, and then hitting her. The victim complained of pain and had visible redness on her face. Both residents involved in this incident were also severely cognitively impaired and unable to recall the event during subsequent assessments. Staff interviews and record reviews revealed that both aggressors had known histories of aggression and behavioral disturbances, including prior physical altercations and resistance to care. Despite these known risks, the facility did not implement effective interventions to prevent these incidents. The facility's abuse policy affirms residents' rights to be free from abuse and outlines the responsibility to prevent such occurrences, yet the events described demonstrate a failure to uphold these protections for the residents involved.
Failure to Timely Obtain Ordered Urine Sample
Penalty
Summary
The facility failed to follow a physician's order to obtain a urine sample in a timely manner for a resident with a history of paraplegia, depression, ESBL resistance, and urine retention. The resident was on enhanced barrier precautions and required straight catheterization every four hours while awake, with additional catheterization as needed at night. The care plan identified the resident as being at risk for urinary tract infection (UTI) due to their diagnoses and catheterization needs, and noted the presence of a colonized multi-drug resistant organism (ESBL) in the urine. A physician's order for bloodwork and urinalysis (UA) was received after concerns were raised about the resident's behavior and fatigue. Despite the order, the Director of Nursing (DON) completed a laboratory requisition form and provided it to the floor nurse but did not enter a laboratory order into the system, which would have alerted staff to collect the specimen. As a result, staff failed to obtain the urine sample for several days, missing the appropriate collection window. The urine specimen was eventually collected several days after the order was received, and laboratory results showed abnormal findings. The facility's policy required that telephone orders be entered into the resident's chart under the order tab, but this was not done in this instance, leading to the delay.
Failure to Prevent Staff Physical Abuse of Resident
Penalty
Summary
The facility failed to prevent staff physical abuse for a resident, identified as R1, who was at high risk for mistreatment due to a history of previous incidents. R1, who has diagnoses including Dementia, Schizoaffective Disorder, Major Depressive Disorder, Anxiety Disorder, and Generalized Idiopathic Epilepsy, was involved in an incident where a Certified Nursing Assistant (CNA) from an agency allegedly struck R1 on the head. The incident occurred when R1 became combative during assistance, leading to the CNA's reflexive action of hitting R1. This incident was reported by an LPN to the facility administrator, and the CNA was immediately suspended pending investigation. The investigation revealed that the CNA admitted to hitting R1, describing it as a reflexive action after being punched by R1. The facility's social service assistant conducted interviews with staff and residents, confirming the CNA's admission. The incident was reported to the police, and R1 was sent to a local hospital for evaluation. The facility's administrator took immediate action by notifying the staffing agency and ensuring the CNA was placed on a do-not-return list. Despite these actions, the facility's failure to prevent the abuse and protect R1 from harm constitutes a deficiency in their care standards.
Failure to Resolve Resident Grievances Timely
Penalty
Summary
The facility failed to ensure that resident grievances were resolved in a timely manner, as evidenced by repeated unresolved issues documented in the Resident Council Minutes over several months. The facility's policy encourages residents to voice grievances without fear of reprisal and mandates that the Administrator promptly resolve these complaints. However, the Resident Council Minutes from May to October document ongoing issues, such as the need for smoke detectors to be checked and concerns about CNAs using their phones and eating while feeding residents. These grievances were repeatedly brought up in meetings without resolution. The Resident Council President confirmed that grievances are often filed on behalf of the facility but remain unresolved, leading to their recurrence in subsequent meetings. The facility's policy requires the Social Service Director to notify residents and their representatives of the resolution, but this follow-up appears to be lacking. The failure to address these grievances affects all 64 residents residing in the facility, as indicated by the facility's Long Term Care Facility Application for Medicare and Medicaid.
Failure to Schedule Registered Nurse Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours each day, which is a requirement for maintaining the highest practical physical, mental, and psychosocial well-being of each resident. This deficiency was identified through a review of the facility's undated Nurse Staffing Policy and untitled daily assignment sheets for specific dates. The policy mandates that a minimum of 10% of nursing and personal care time should be provided by RNs. However, on the dates of 10/02/24, 10/09/24, and 10/16/24, all nurses working were Licensed Practical Nurses (LPNs), with no RNs scheduled. This was confirmed by the facility's Administrator, who acknowledged the lack of RN coverage on these days. The facility's application for Medicare and Medicaid, dated 10/29/24, indicates that 64 residents currently reside in the facility.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents were informed that signing an arbitration agreement was not a condition of admission and that they had the right to rescind the agreement within 30 days of signing. This deficiency was identified through a review of the arbitration agreements for two residents, dated 05/09/23 and 07/06/23, which lacked language notifying residents of these rights. An interview with a staff member confirmed that the arbitration agreements did not include documentation stating that signing was not a condition of admission or that the agreement could be rescinded within 30 days. This oversight has the potential to affect all 64 residents currently residing in the facility.
Failure in QAA Committee Meetings and Membership
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee had the required number of members and did not meet at least quarterly as mandated. The facility's Quality Assurance Plan, dated August 1, 2017, specifies that the QAA Committee should conduct quarterly meetings at a minimum. However, the Administrator, who has been employed for seven months, admitted that no quarterly QAA meetings had occurred during her tenure. She attributed this to a lack of education and training on conducting the meetings. Additionally, the Medical Director had not attended any meetings, and there was no Infection Preventionist at the facility since January 2024. This oversight has the potential to affect all 64 residents residing in the facility.
Lack of Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an Antibiotic Stewardship Program, which is essential for promoting the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This deficiency potentially affects all 64 residents in the facility. The facility's policy, dated 12/12/18, outlines the purpose of the program, but it was not put into practice. Specific instances include a resident with a physician's order for Doxycycline for skin wounds and another resident with an order for Clindamycin for a left toe infection. Despite these orders, the Regional Director of Operations confirmed that there was no Antibiotic Stewardship Program, no monitoring of infections, no Infection Preventionist, and no Infection/Antibiotic logs or Infection Prevention and Control Program in place.
Lack of Infection Preventionist in Facility
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program, which is crucial for assessing, developing, implementing, monitoring, and managing infection control measures. This deficiency potentially affects all 64 residents in the facility. The facility's policy, dated December 7, 2018, mandates routine surveillance and monitoring to ensure compliance with infection control practices and requires at least a part-time Infection Control Preventionist. However, the facility was unable to provide documentation or logs for infection monitoring and tracking, indicating a lapse in adherence to its own policy. The report highlights specific cases involving two residents receiving antibiotics for infections. One resident was administered Doxycycline for skin wounds, while another received Clindamycin for a left toe infection. Despite these ongoing treatments, the facility lacked an Infection Preventionist since January 2024, as confirmed by the Administrator and the Regional Director of Operations. This absence of a designated IP raises concerns about the facility's ability to effectively manage and control infections, as there is no individual responsible for overseeing these critical functions.
Failure to Administer Influenza Vaccines
Penalty
Summary
The facility failed to provide influenza vaccinations to residents eligible for the vaccine during the flu season, as required by their own policy and state guidelines. The facility's policy, dated 10/10/22, mandates the administration of the influenza vaccine throughout the flu season, from the receipt of the vaccine until March 1. However, the facility did not have any influenza vaccines available in their medication rooms as of 10/31/24, and no vaccines had been administered to residents or staff since the start of the flu season. This failure affected five residents, all of whom had physician orders indicating they could receive the annual flu vaccine with consent unless contraindicated. Each of these residents last received the influenza vaccine on 10/03/23, indicating a lapse in the current flu season's vaccination efforts. The Regional Director of Operations confirmed that the facility had not provided influenza vaccines for residents or staff and that an outside company contracted to administer the vaccines had not done so. The director was unaware of when the vaccines would be administered and stated that the facility had not ordered any influenza vaccines. This lack of action and preparation resulted in the facility's inability to minimize the risk of acquiring, transmitting, and suffering complications from influenza for the residents reviewed.
Failure to Complete PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure a PASARR (Pre-Admission Screening and Resident Review) screening was completed for one of the five residents reviewed for PASARR screenings. The resident, identified as R28, was admitted to the facility with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the basilar artery, generalized anxiety disorder, and major depressive disorder, recurrent, moderate. Upon review, it was found that R28's medical record did not include a completed PASARR screening. The facility's administrator acknowledged that the screening was not done and stated that all residents should have a screening prior to admission. The Business Office Manager also confirmed that the resident was supposed to be screened before admittance and admitted that the facility failed to conduct the screening after the hospital did not perform it prior to the resident's admission.
Failure to Revise Care Plans for Hospice and Pressure Wound
Penalty
Summary
The facility failed to revise care plans for two residents, which was identified during a review of 16 residents for care plan revisions. According to the facility's policy on Comprehensive Care Planning, care plans should be revised when the needs or problems of a resident change. However, the care plan for one resident, who was placed on hospice services per a physician's order, did not include hospice care. Another resident with a stage 2 pressure wound on the coccyx had wound care orders, but the care plan was not updated to reflect this condition. The Regional Director of Operations confirmed that the care plans for these residents were not revised as required.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 51 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Toulon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenues At Royal Oak | 10 mi | ★★★★★ | 17 | 1 |
| Arcadia Care Kewanee | 10.8 mi | ★★★★★ | 13 | 0 |
| Arc At Chillicothe | 22.7 mi | ★★★★★ | 13 | 0 |
| Lacon Rehab And Nursing | 23.5 mi | ★★★★★ | 7 | 1 |
| Manor Court Of Peoria | 24.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.