Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eastview Healthcare & Senior Living during CMS and state inspections, most recent first.
A facility failed to supervise a high-fall-risk resident in the room, and the resident fell from a wheelchair and was later hospitalized with a SAH and T12 compression fracture. The facility also failed to carry out fall-prevention interventions for another high-fall-risk resident, as surveyors found no bed rails or posted signage in the resident’s room despite prior fall-related interventions.
Dishwasher Temperatures and Sanitizer Checks Not Properly Maintained: Staff observed dishwasher wash and rinse temperatures at 118-120 degrees F, with sanitizer readings between 25 and 50 ppm. The DON and Dietary Manager acknowledged that required temperature and sanitizer logs were not consistently completed, and the Administrator stated the dishwasher was not functioning properly and that the facility did not have a specific policy for testing dishwasher temperatures and sanitizer levels.
Unsealed windows with cardboard and loose tape were observed in multiple resident rooms. A resident stated staff knew about the condition and that she could not see out of her window, while another room had foam and white tape that did not fully seal around the AC unit. In a former resident room, the Maintenance Director acknowledged gaps around the cardboard and dead bugs on the window seal, and the Administrator later agreed the windows were not adequately sealed.
A facility failed to protect residents from abuse by other residents. Survey review found multiple incidents where residents with dementia and behavioral diagnoses struck, slapped, or made contact with other residents in common areas or in resident rooms. Staff interviews and records showed aggressive behaviors, wandering into rooms, and incomplete care planning for abuse risk, while the affected residents were assessed and found with little or no visible injury.
A resident with a history of seizures and on anticoagulant therapy experienced repeated refusals of prescribed anticonvulsant medication, which were not reported to medical providers. No new interventions were implemented to address the increased seizure risk, and the resident's bed was not kept in the low position. The resident subsequently had a seizure, fell from bed, and sustained a significant head injury, including a scalp laceration and subdural hematoma. Staff confirmed the lack of seizure precautions and absence of a facility policy addressing such risks.
A resident who was dependent on staff for toileting and frequently incontinent reported waiting up to an hour for call light responses during certain shifts, resulting in being left in urine or feces. Multiple complaints about slow call light response times were documented, and staff confirmed that inadequate CNA staffing contributed to these delays, contrary to facility policy requiring prompt responses.
A resident who was dependent on staff for bathing did not receive scheduled showers as required, with gaps in shower documentation and no records of refusals or alternative arrangements. The DON confirmed incomplete documentation and missed showers, resulting in a deficiency related to activities of daily living care.
A CNA failed to change gloves between cleaning a resident's buttocks and vaginal area during incontinence care, resulting in cross contamination. The resident, who was always incontinent and dependent on staff for hygiene, had a recent UTI with positive cultures for ESBL-producing organisms and was receiving antibiotics. The CNA acknowledged not following proper glove-changing protocol as required by facility policy.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report does not specify further details about the individuals involved or the exact nature of the hazards.
The facility did not have a designated full-time DON for several weeks, as confirmed by staffing schedules and staff interviews. No interim DON was appointed during this period, affecting oversight of nursing services for 50 residents.
The facility did not employ a certified dietary manager to oversee food services. All dietary staff had food safety certifications, but the dietary manager lacked the required certification and was not enrolled in a certification course. The RD, who consults part-time, confirmed the deficiency, which could impact all 50 residents.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, as required by regulations.
Multiple incidents occurred in which a resident made physical contact with several other residents, including entering rooms uninvited and making contact with their hands, wrists, and forearms. Staff and resident interviews, as well as facility investigations, confirmed that these events took place and that the same resident was involved in repeated abusive interactions, indicating a failure to protect residents from physical abuse.
Two residents, one with severe cognitive impairment and another with a history of aggression, were involved in a physical altercation in a common area. Staff, including two LPNs, witnessed one resident holding and punching another while yelling. The facility's abuse policy was not effectively enforced, resulting in a failure to protect residents from physical abuse.
A resident with multiple psychological and physical diagnoses was found with fingerprint-pattern bruises on her inner thighs. The facility did not thoroughly investigate the injury, failing to interview male CNAs who provided care prior to the discovery of the bruises, despite the resident's statement implicating a male and the care plan's requirement for comprehensive investigation. The incident report also incorrectly cited anticoagulant use as a cause, though the resident was not prescribed such medication.
The facility failed to employ a full-time DON and did not provide the required eight consecutive hours of RN coverage on four days within a two-week period. The absence of a DON since September and the lack of RN coverage were confirmed by the Regional Administrator, potentially affecting all 42 residents.
The facility failed to ensure required personnel attended QAA committee meetings, potentially affecting all 42 residents. The DON was absent from all meetings in 2024, and the IP was absent from the January meeting, as confirmed by the Regional Administrator.
Staff in a LTC facility failed to use appropriate PPE and follow infection control protocols while caring for COVID-19 positive residents. A CNA did not wear gloves or a gown when obtaining vital signs, and an LPN did not change gloves or perform hand hygiene during medication administration. Another CNA assisted a resident with eating while improperly wearing a surgical mask, contrary to facility policy.
The facility failed to properly assess and manage physical restraints for two residents, leading to deficiencies in care. One resident had a loosely applied seat belt that was not released every two hours, while another had a lap tray used without a documented medical need, causing skin tears. The facility did not adhere to its policy requiring a medical diagnosis for restraint use and regular release for repositioning.
Two residents, both severely cognitively impaired and dependent on staff for personal hygiene, did not receive timely and appropriate incontinence care. One resident was left in a wheelchair with saturated clothing and urine puddles, while another received care that did not follow hygiene protocols, with a saturated brief and no barrier cream applied. The facility's Regional Director confirmed that such care should be provided every two hours to prevent UTIs.
A facility failed to properly store and date nebulizer tubing for a resident with COPD and other medical conditions. The nebulizer tubing was found in a drawer with personal items instead of being stored in a plastic bag as per facility policy. An LPN confirmed the tubing should be changed weekly and stored properly, and the Regional Director of Operations acknowledged the lapse in following the policy.
The facility failed to provide required therapy services for five residents after discontinuing therapy on February 19, 2024. Residents did not receive their prescribed speech, occupational, and physical therapy, leading to a decline in their conditions.
Failure to Supervise a High-Fall-Risk Resident and Implement Bed-Rail Fall Interventions
Penalty
Summary
The facility failed to provide supervision for one resident in the resident’s room to prevent a fall. R2 had diagnoses including unspecified dementia with other behavioral disturbance, cognitive communication deficit, other lack of coordination, and other reduced mobility, and was identified as a high fall risk on multiple fall risk evaluations. R2’s care plan documented that R2 had previously slid out of a wheelchair while unsupervised in the room, with an intervention to place R2 in the common area until staff were available to assist. On 5/25/2026, while staff were getting residents ready for supper, R2 was left in the room in a wheelchair and was later found on the floor in front of the wheelchair with a hematoma to the forehead and signs of pain. Hospital records documented a subarachnoid hemorrhage and an acute-subacute compression fracture of T12. The facility also failed to implement fall prevention interventions for another resident, R3, who was assessed as high risk for falls. R3’s care plan documented a left side rail and a fall intervention related to an unwitnessed fall in the room due to a bed rail not being in proper position, with an intervention to place a sign to ensure the bed rail was up at all times. On 6/16/2026, surveyors observed that there were no bed rails on either side of either bed in R3’s room and no signage posted. R3 stated the resident had been moved to the room from another room and had not had side rails since being in that room. Facility records showed R3 had been moved to the room on 5/18/2026 and was discharged later that day.
Dishwasher Temperatures and Sanitizer Checks Not Properly Maintained
Penalty
Summary
The facility failed to perform adequate sanitation of residents’ eating utensils, cutlery, and dishware. During observation after the lunch meal, a Dietary Aide tested the dishwasher with the manufacturer’s temperature gauge and approved litmus paper and reported the sanitizer reading was between 25 and 50 ppm, with the wash cycle at 118 degrees F and the rinse cycle at 120 degrees F. The next morning, another Dietary Aide was observed washing breakfast dishes and stated the dishwasher wash-cycle temperature was 118 degrees F. The Maintenance Director stated the dishwasher should be at least 120 to 145 degrees F during washing and rinsing, and that staff sometimes had to run the dishwasher three times before using it to reach the needed temperature. The Dietary Manager initially stated staff tested temperatures and sanitizer levels once daily, then acknowledged the results were supposed to be recorded three times a day but had not been logged. The Administrator stated the dishwasher temperatures were low and the machine was not functioning properly. Review of the Dishwasher Temperature/Sanitizer Log showed missing entries for supper on multiple days and no temperature or sanitizer checks for any meals on several consecutive days, and the facility stated it did not have a specific policy for testing dishwasher temperatures and sanitizer levels.
Unsealed windows with cardboard and loose tape
Penalty
Summary
The facility failed to provide and maintain a safe, functional, and sanitary environment for three residents reviewed for unsealed windows and environmental conditions. On 6/16/26, R5’s window was observed with a window air conditioning unit on the left side of the opening and a piece of cardboard loosely taped on the right side with white tape. There were openings around the cardboard where the tape was not sealed, outside light was visible through the gaps, and dead gnats, other bugs, and dirt were present on the window sill. R5 used her grabber to poke the cardboard, and it moved easily and the tape came apart. R5 stated staff were aware of the condition of her window and said she did not like it because she could not see out of it. Also on 6/16/26, R6’s window was observed with foam on both sides of the air conditioner unit secured loosely with white tape, with the tape not sealed all the way around and outside light visible through the cracks. On 6/17/26, R2’s previous room was observed with the Maintenance Director, who acknowledged gaps where tape was not sealed around the cardboard on each side of the window air conditioning unit and dead bugs on the window seal, with outside light visible through the cracks. He stated the facility uses white tape around the air conditioning units because the board voted not to use metal tape on the new windows and said the units are temporary and removed in the winter. On 6/18/26, the Administrator stated it was not acceptable to have cardboard taped around the window air conditioning units and agreed the windows were not adequately sealed.
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to ensure residents were free from abuse by other residents for three residents reviewed for abuse. The report describes multiple incidents in which residents with dementia and behavioral diagnoses were involved in physical contact with other residents, including striking, slapping, and entering other residents’ rooms. The facility policy stated residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property by anyone, including other residents. One incident involved a resident with diagnoses including dementia with anxiety, schizoaffective disorder, bipolar disorder, and repeated falls. The resident was observed in the lounge/dining area when another resident approached and hit the resident on the left forearm. Staff separated the residents and assessed for injury, and no redness, bruising, or swelling was noted. The resident later had no recollection of the incident. The other resident involved had diagnoses including metabolic encephalopathy, paranoid schizophrenia, and a urinary tract infection, and had documented aggressive behaviors toward staff, including attempting to punch a CNA, threatening to get a knife, and chasing staff. The resident was also documented as chasing staff and then going after the other resident and hitting the resident before staff could intervene. A second incident involved a resident with unspecified dementia who reported that another resident came into the room and hit the resident in the left upper arm. The resident stated there was no injury and that the resident reported it to the nurse. The progress note documented the other resident made contact with the arm, the residents were separated, and the arm was assessed with slight redness and no bruising or open areas. The other resident had documented behaviors of going into other residents’ rooms, being physically and verbally abusive, throwing objects, and hitting staff. The resident was later sent to the hospital after continued disruptive behavior and was documented as wandering into other residents’ rooms and using their bathrooms. A third incident involved a resident with unspecified dementia and severe psychotic disturbance who was involved in contact with another resident near the resident’s doorway. One account documented that the resident slapped the other resident on the side of the head, while another account stated the resident made contact with the other resident’s face by the ear. The other resident denied injury, and no redness or bruising was noted. The resident’s care plan did not document interventions for the risk of being abused. Staff interviews described the resident as territorial, anxious, and blocking the other resident’s doorway, and the facility documented that the resident had made contact with the other resident. These events were identified during survey review as failures to protect residents from abuse by other residents.
Failure to Implement Seizure and Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to implement appropriate interventions to prevent a fall for a resident with a history of seizures and on anticoagulant therapy. The resident had multiple diagnoses, including epileptic seizures, peripheral vascular disease, chronic kidney disease, muscle weakness, difficulty walking, osteoarthritis, major depression, and a history of subarachnoid hemorrhage with residual hemiplegia and hemiparesis. The resident was prescribed Eliquis and Keppra, but there were repeated refusals of the seizure medication Keppra over several days. There was no documentation that these refusals were reported to the physician or nurse practitioner, nor were new interventions initiated to address the increased seizure risk. On the day of the incident, the resident was found on the floor next to the bed after experiencing a seizure, with significant bleeding from a head wound. The bed was not in the low position, and no fall mats or side rails were in use. Staff interviews confirmed that the bed was not kept in the low position prior to the fall, and that refusals of seizure medication were not routinely reported to medical providers. The facility also lacked a specific policy for seizure precautions. As a result of the fall, the resident sustained a six-centimeter scalp laceration requiring evacuation of a hematoma and sutures, as well as a subdural hematoma.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure timely response to call lights for a resident who was dependent on staff for toileting and was frequently incontinent of urine and always incontinent of bowel. The resident reported waiting up to an hour for call light responses during second and third shifts, resulting in being left in urine or feces. The resident also stated that call light response times were a recurring topic in resident council meetings. A grievance report documented complaints from unidentified residents about slow call light responses on third shift, specifically regarding the need to be changed. Staff interviews confirmed that the number of CNAs on duty was insufficient to meet residents' toileting needs in a timely manner, affecting call light response times. The facility's policy required call lights to be answered as soon as possible, but no later than five minutes, with urgent requests addressed immediately.
Failure to Provide Scheduled Showers and Maintain Documentation
Penalty
Summary
The facility failed to provide scheduled showers for a resident who was dependent on staff for bathing due to above knee amputations and was cognitively intact. According to the facility's policy, showers are to be provided twice weekly, refusals are to be documented, and supervisors notified if a resident refuses. The resident reported not receiving showers for two weeks and expressed confusion about changes to the shower schedule. The resident's care plan specified the need for assistance with activities of daily living, including scheduled showers twice weekly. Review of the facility's shower documentation for November and December revealed gaps, with showers only documented on a few dates and no consistent twice-weekly pattern. The DON confirmed that the available documentation was incomplete and acknowledged the gaps. There was no documentation of refusals or alternative arrangements during the periods when showers were missed, despite facility policy requiring such records. The lack of consistent documentation and missed showers led to the deficiency.
Failure to Prevent Cross Contamination During Incontinence Care
Penalty
Summary
During incontinence care for one resident, a Certified Nursing Assistant (CNA) failed to follow proper infection control procedures as outlined in the facility's Perineal Care policy. The CNA, after cleaning the resident's vaginal area in a front to back motion, turned the resident to cleanse the buttocks but did not change gloves before applying a clean brief and subsequently cleaning the vaginal area again. This sequence of actions resulted in the use of contaminated gloves to clean the resident's vaginal area after having cleaned the buttocks, which is contrary to the facility's policy requiring glove changes when moving from soiled to clean areas. The resident involved had moderate cognitive impairment, was always incontinent of bowel and bladder, and was dependent on staff for toileting hygiene. Medical records indicated the resident had a recent history of urinary tract infection (UTI) with urine cultures showing significant growth of Klebsiella Oxytoca ESBL and Escherichia Coli, and was receiving antibiotic treatment. The CNA confirmed during interview that gloves should have been changed between cleaning the buttocks and the vaginal area, acknowledging the lapse in infection control practice.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions by staff or details about the residents involved are not provided in the report. No further information about the circumstances or individuals affected is included.
Failure to Maintain Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate and maintain a full-time Director of Nursing (DON) as required. Review of staffing schedules over a one-month period confirmed that no licensed nurse was assigned as DON, and no interim appointment was made during this time. Interviews with staff, including an LPN, the Administrator, and a Corporate Nurse, confirmed that the facility had been without a DON for several weeks, with no interim DON in place. The facility census indicated that 50 residents were present during this period.
Lack of Certified Dietary Manager in Food Services
Penalty
Summary
The facility failed to employ a certified dietary manager to oversee food services, as required. Review of dietary staff certifications showed that while all dietary staff had food safety certifications, none held a Dietary Manager Certification. The current dietary manager confirmed she is not certified in dietary management, and the administrator and regional nurse verified that she is not enrolled in any certification courses. The registered dietician, who consults for the facility and is present approximately 16 hours per month, also confirmed that the dietary manager is not certified. This deficiency has the potential to affect all 50 residents currently residing in the facility, as documented in the facility census.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the meals did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from resident-to-resident physical abuse, as evidenced by multiple documented incidents involving one resident making physical contact with several other residents. According to the facility's own investigations, one resident was involved in repeated incidents where they entered other residents' rooms, went through their belongings, and made physical contact with their hands, wrists, and forearms. These incidents were reported by both staff and residents, and the facility's investigations confirmed that the events occurred as described. Staff interviews and record reviews further confirmed that the same resident was known to have been involved in multiple abusive incidents affecting at least three other residents. The incidents occurred in various settings, including during one-to-one care and while other residents were engaged in activities such as playing cards. The facility's abuse prevention program states that residents have the right to be free from all forms of abuse, but the repeated nature of these incidents demonstrates a failure to uphold this standard for the affected residents.
Failure to Prevent Physical Abuse Between Residents
Penalty
Summary
The facility failed to protect two residents from physical abuse, as required by its abuse prevention policy. One resident with severe cognitive impairment and a history of dementia, agitation, and behavioral disturbance was observed by staff holding another resident by the collar and punching him in the back of the head while yelling. This incident occurred in a common area and was witnessed by two LPNs, one of whom described seeing the altercation upon entering the kitchen, and another who observed the event during breakfast in the dining room. The facility's records confirm that the resident who initiated the altercation had a care plan noting impaired cognitive function, while the other resident involved was cognitively intact but had a documented history of aggressive behavior and threats toward staff. The facility's abuse policy, which strictly prohibits any form of abuse, was not effectively implemented in this case. Documentation and staff interviews confirm that the physical altercation occurred, and the administrator acknowledged awareness of the incident but was unable to provide an explanation for its cause. The failure to prevent this altercation resulted in a violation of the residents' right to be free from physical abuse.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident who was found with multiple bruises in a fingerprint pattern on her inner thighs. The resident, who has diagnoses including psychological disorders, schizophrenia, major depressive disorder, and peripheral vascular disease, was noted to be moderately cognitively intact. The care plan required that any allegations or signs of mistreatment, such as physical marks or injuries, be investigated, including conducting skin checks and interviewing staff assigned to the resident's care. Despite this, the facility's investigation into the bruising did not include interviews with male CNAs who had provided care to the resident in the days prior to the discovery of the bruises, even though the bruises were described as looking like fingerprints and the resident had made a statement to a family member implicating a male individual. Additionally, the facility's incident report incorrectly attributed the bruising to the resident being on an anticoagulant, when a review of the resident's medications showed no such prescription. The administrator acknowledged not realizing that aspirin is not classified as an anticoagulant and stated she did not think there were any male staff on the schedule who could have been involved, despite evidence to the contrary. The investigation did not include interviews with all relevant staff, specifically the male caregivers who were scheduled during the period in question, and failed to fully address the resident's and family member's concerns.
Failure to Employ Full-Time DON and Provide RN Coverage
Penalty
Summary
The facility failed to employ a full-time Director of Nurses (DON) and did not provide the required eight consecutive hours of Registered Nurse (RN) coverage on four specific days within a two-week period. This deficiency was identified through a review of the Facility Nursing Staff Daily Assignment Sheets, which documented the absence of RN coverage for at least eight consecutive hours on November 5, 8, 9, and 10, 2024. Additionally, the facility has been without a DON since September 18, 2024, as confirmed by the Regional Administrator. These failures have the potential to affect all 42 residents residing in the facility, as there was no DON observed working in the facility from November 12 to November 15, 2024.
QAA Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the required personnel attended the Quality Assessment and Assurance (QAA) committee meetings, which has the potential to affect all 42 residents in the facility. Specifically, the January 2024 QAA meeting attendance signature sheet did not document the presence of the Director of Nursing (DON) or the Infection Preventionist (IP). Additionally, the attendance sheets for the April, July, and November 2024 QAA meetings did not document the presence of the DON. This was confirmed by the Regional Administrator, who reviewed the last four quarterly QAA sign-in sheets and noted the absence of the DON at all meetings and the absence of the IP at the January 2024 meeting.
Inadequate PPE Use and Infection Control in LTC Facility
Penalty
Summary
Facility staff failed to adhere to proper infection prevention and control protocols, particularly in the use of Personal Protective Equipment (PPE) while caring for residents with COVID-19. A Certified Nurse Aide (CNA) did not wear gloves or a protective gown when obtaining vital signs for two COVID-19 positive residents, despite clear signage indicating the need for contact and droplet precautions. The CNA's clothing came into contact with surfaces in the residents' room, and the CNA admitted to not following proper hand hygiene or equipment cleaning procedures between residents. Additionally, a Licensed Practical Nurse (LPN) failed to change gloves and perform hand hygiene during the administration of medication to a resident. The LPN used the same gloves to handle a resident's oxygen nasal cannula from the floor and then administered medication without changing gloves or sanitizing hands. Furthermore, another CNA was observed assisting a COVID-19 positive resident with eating while only wearing a surgical mask that did not cover her nose, contrary to the facility's policy requiring an N95 mask, gloves, gown, and eye protection. The CNA was unaware of the proper PPE requirements during a COVID-19 outbreak.
Improper Use and Management of Physical Restraints
Penalty
Summary
The facility failed to properly assess and manage the use of physical restraints for two residents, R24 and R28, leading to deficiencies in care. For R24, the facility did not identify a specific medical condition necessitating the use of a self-releasing seat belt, which was applied loosely and inconsistently. Observations showed that R24's seat belt was not released every two hours as required, and the resident was unable to remove it independently, despite being ambulatory and having no musculoskeletal or neurological disorders that would interfere with ambulation. Staff interviews revealed that the seat belt was used to prevent R24 from standing, but it was not effectively monitored or adjusted, posing a potential safety hazard. For R28, the facility used a lap tray as a restraint without documenting a specific medical need. Despite R28's severe cognitive impairment, the resident was observed attempting to remove the tray and stand up from the wheelchair. Staff reported that the lap tray was used to prevent R28 from getting up, but it was not released every two hours as required. Additionally, the tray caused skin tears, leading staff to place pool noodles on it to prevent further injury. The facility's failure to properly assess and document the need for the lap tray, as well as to ensure its safe use, contributed to the deficiency. Overall, the facility did not adhere to its policy on physical restraints, which requires a documented medical diagnosis for their use and mandates that restraints be released every two hours for repositioning and care. The lack of proper assessment, documentation, and monitoring of restraints for R24 and R28 resulted in deficiencies that affected the residents' safety and well-being.
Inadequate Incontinence Care for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for two residents, R22 and R10, who were both severely cognitively impaired and dependent on staff for personal hygiene and toileting. R22 was observed sitting in a wheelchair for extended periods without being offered or assisted with incontinence care, resulting in her pants and mechanical lift sling being saturated with urine, and urine puddles forming on the floor. Staff admitted to not having provided incontinence care to R22 during their shift, despite her evident need. Similarly, R10, who has a history of urinary tract infections, was provided incontinence care that did not adhere to the facility's standards. The CNA failed to follow proper hygiene protocols, such as changing gloves and using hand hygiene, and did not apply barrier cream or dry the resident after cleansing. R10's incontinence brief was found to be thoroughly saturated and had a strong urine smell, indicating a lack of timely care. The Regional Director of Operations confirmed that residents should receive incontinence care every two hours and that improper care could lead to UTIs.
Improper Storage and Dating of Nebulizer Tubing
Penalty
Summary
The facility failed to properly store and date nebulizer tubing for a resident, identified as R5, who was reviewed for oxygen use. The facility's policy requires nebulizer tubing to be stored in a plastic bag and changed weekly. However, observations revealed that R5's nebulizer tubing was not stored according to these guidelines. On one occasion, the nebulizer machine was found on R5's bedside dresser with a plastic bag labeled with a date, but the tubing itself was stored in a drawer with other personal items. This was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that the tubing should be changed weekly and stored in a plastic bag when not in use. R5's medical history includes diagnoses of Dementia, Intellectual Disabilities, Chronic Obstructive Pulmonary Disorder (COPD), Glaucoma, Chronic Systolic Heart Failure, and a dependence on a wheelchair, requiring assistance with personal care. Despite being cognitively intact, as documented in the Minimum Data Set (MDS), the facility did not adhere to the physician's order to change the nebulizer tubing weekly and store it properly. The Regional Director of Operations also confirmed that all respiratory tubing should be stored in a clean plastic bag when not in use, indicating a lapse in following the facility's policy and physician's orders.
Failure to Provide Required Therapy Services
Penalty
Summary
The facility failed to ensure therapy services were provided for five residents who required them. Therapy services were discontinued on February 19, 2024, and a new therapy provider had not yet started by the time of the survey on March 20-21, 2024. As a result, residents R1, R2, R3, R4, and R5 did not receive their prescribed therapy services, which included speech, occupational, and physical therapy. The lack of therapy services was confirmed through interviews with staff and residents, as well as a review of medical records and therapy notes. Resident R3 was admitted with orders for speech, occupational, and physical therapy, but their last therapy sessions were in mid-February. Resident R4 had orders for occupational therapy, with the last session on February 13, 2024. Resident R5, who was working on walking, had their last therapy session on February 16, 2024. Resident R1 had orders for both occupational and physical therapy, but therapy was discontinued in mid-February. Resident R2, who was receiving speech therapy to help with eating, also had their therapy discontinued. Staff and family members noted the residents' progress with therapy and their subsequent decline after therapy services were halted.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 204 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sullivan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sullivan Healthcare & Senior Living | 1.4 mi | ★★★★★ | 15 | 0 |
| Arthur Home, The | 9.8 mi | — | 0 | 0 |
| Palm Garden Of Mattoon | 15.1 mi | ★★★★★ | 37 | 1 |
| Odd Fellow-rebekah Home | 15.5 mi | ★★★★★ | 15 | 0 |
| Mattoon Rehab & Hcc | 15.6 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.