Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Farmington Village Nrsg during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment, poor safety awareness, and repeated wandering and exit-seeking behavior was inaccurately assessed as not being at risk for elopement. Staff notes documented repeated attempts to go outside, resistance to redirection, and multiple unsupervised exits through the front door, while the care plan lacked elopement interventions. Surveyors also observed unlocked front doors during the day and no active alarm system in use.
Failure to Label Perishable Foods With Use By Dates: Surveyors observed multiple food items in the kitchen, refrigerator, and freezer without use by dates, including cereals, frozen meats, condiment bottles, and frozen nutritional supplements. A container of grits was also labeled with a date that staff said reflected when it was poured into the container rather than a use by date, and the DON and Day Cook agreed the sticker made the product appear expired.
Incomplete antibiotic stewardship and McGeer’s criteria documentation were identified after record review showed multiple residents received antibiotics for conditions such as URI, UTI, cellulitis, COPD exacerbation, and eye or ear treatment without complete or timely criteria documentation. In several cases, the facility could not provide evidence that McGeer’s criteria were used before antibiotics were started, and other forms were incomplete or dated after the antibiotic course had begun or ended.
Inadequate Staff Training Program Documentation: The facility failed to develop, implement, and maintain an effective staff training program and did not determine the amount of time or types of training needed to meet resident needs. The facility’s assessment and monthly in-service records lacked documentation of the subject matter covered, and the Administrator stated there was no agenda, the in-services were done from memory, and the facility could not ensure each staff member received the training.
Incomplete Staff Training Documentation: The facility failed to ensure all staff received mandatory education related to effective communication. The in-service tracking sheets listed topics and attendance, but there was no documentation of the subject matter covered, no agenda used for monthly in-services, and no record of what educational material was presented. The Administrator stated the training was provided from memory and the facility could not ensure each staff member received it.
Incomplete Staff Training Documentation: The facility failed to ensure all staff received and had documented mandatory education on resident rights and facility responsibilities. The in-service tracking sheets listed topics and attendance, but did not document the subject matter covered, and the Administrator stated there was no agenda or documentation of the educational material presented during monthly staff meetings.
Missing Required Staff Training on Abuse, Neglect, Exploitation, and Dementia Care: The facility failed to ensure all staff received mandatory education on abuse, neglect, exploitation, reporting procedures, dementia management, and abuse prevention. The assessment did not include the required in-service/competency training, and the Administrator stated monthly staff meetings were used for training without an agenda or documentation of the material presented, so the facility could not verify that each staff member received the required training.
Failure to Document QAPI Training for Staff. The facility did not ensure all staff received mandatory education on the QAPI program. The in-service calendar did not include specific QAPI training, and monthly staff meeting records listed topics and attendance but did not document the subject matter covered. The Administrator stated there was no agenda for the in-services, that topics were covered from memory, and that the facility could not ensure each staff member received the training.
Missing Documentation for Infection Prevention and Control Training: The facility failed to ensure all staff received mandatory IPC training and education, including the written standards, policies, and procedures for the program. The DON/Administrator said monthly staff meetings were used for in-service education, but the tracking sheets did not document the subject matter covered, there was no agenda for the meetings, and the facility could not ensure each staff member received the training.
CNA Annual In-Service Training Deficiency: The facility failed to ensure CNAs completed the required 12 hours of annual in-service education. The facility assessment did not include specific CNA training topics or how the training would be conducted, and the 2025 tracking sheet showed 42 CNAs did not meet the minimum yearly training requirement. The Staff Educator and Administrator both confirmed the shortfall.
Failure to document Behavioral Health staff training. The facility assessment did not include specific in-service or competency topics for Behavioral Health requirements, and the Administrator stated monthly staff in-services were given from memory without an agenda. The staff education tracking sheets listed topics and attendance, but did not document the subject matter covered or confirm that each staff member received the training.
Unsafe medication storage and an unattended unlocked med cart were observed. A resident without a self-administration order had Albuterol vials left in his room with his nebulizer, and an RN confirmed they should not have been there. In another event, an LPN left the 200 hall med cart unlocked and unattended with crushed meds on top for another resident; the Administrator verified the cart was unsecured and the meds were left out.
Care plans for two residents did not match their signed POLST forms. One resident’s POLST documented DNAR and comfort-focused treatment, but the care plan listed FULL CODE despite a recent change in condition requiring hospice services. Another resident’s POLST documented No CPR and selective treatment, but the care plan contained conflicting FULL CODE and DNR statements. The SSD and care plan coordinator stated code status in the care plan should match the POLST.
Unnecessary psychotropic medication use and lack of nonpharmacologic interventions were identified for three residents. One resident with dementia, anxiety, and depression received clonazepam, hydroxyzine, fluoxetine, loxapine, and memantine, but the care plan lacked resident-specific interventions despite repeated yelling out and anxiety. A second resident with neurocognitive disorder, Alzheimer’s disease, depression, and anxiety received scheduled and PRN lorazepam plus risperidone, while documentation of behaviors was inconsistent and limited. A third resident with dementia and psychotic disturbance received olanzapine and sertraline even though nursing notes and the care plan did not document behaviors, and the resident was observed pleasant and engaged with others.
Restorative ROM and walking services were not consistently provided as ordered for several residents with restorative nursing plans. Residents with diagnoses including neuropathy, RA, osteoarthritis, COPD, heart failure, and other chronic conditions reported not receiving the ordered exercises or ambulation, while CNAs gave inconsistent accounts and in one case documented passive ROM after mistaking dressing for ROM. The records showed physician orders and care plans for active or passive ROM and walking, but resident statements, staff interviews, and observation showed the ordered restorative care was not reliably carried out.
Improper Catheter Care and Hand Hygiene During Urinary Catheter Care: A resident with a urinary catheter, recurrent UTIs, and multiple chronic conditions had a catheter bag observed on the floor with sediment in the tubing and urine in the bag. A CNA handled the bag without gloves, and another CNA performed catheter care without hand hygiene before donning clean gloves. The resident had reported penile pain and suspected UTI symptoms, but the chart did not document ongoing monitoring or interventions before antibiotic therapy was started.
Failure to offer bedtime snacks to three diabetic residents was identified during record review and resident interviews. The snack policy said snacks are available during and after kitchen hours, but records did not show snacks were offered or consumed, and each resident stated nighttime snacks were not being provided. The residents included one cognitively intact resident with Type 2 DM, CHF, and insulin dependence; one resident with moderate cognitive impairment and multiple serious diagnoses including Type 2 DM and leukemia; and one cognitively intact resident with Type 2 DM, insulin dependence, and a nutrition plan calling for peanut butter and crackers at 7:00 PM. The DON stated snacks were kept in the clean utility closet and residents could request them anytime.
Inaccurate Documentation of ROM Services: Three residents had physician orders for active or passive ROM, but each stated the exercises were not provided and had not been received since admission. Despite this, the Nursing Rehab Time Log documented ROM as completed by CNAs, including entries on the survey date. A CNA said she had not performed the ROM and thought dressing residents counted as ROM, while the Administrator stated documenting care not performed is falsification of documentation.
Several residents were observed waiting in their wheelchairs at the entrance to the dining room or near the nurse's station due to a lack of available seating, with staff and an ombudsman confirming that not all residents who wished to eat in the dining room could be accommodated at once. This resulted in some residents waiting up to an hour before being able to eat, as most preferred dining in the communal area and the facility did not have enough seats for all.
Surveyors found that opened dry food items in the kitchen, such as mixes and fillings, were not labeled with the date they were opened and were not stored in airtight containers. The Dietary Manager confirmed that items were only dated upon receipt and left in their original bags with clips, contrary to facility policy requiring labeling and airtight storage.
Multiple residents were unable to eat in the dining room at their preferred time due to a lack of available seating, resulting in some waiting up to an hour for a spot to open. Staff, including CNAs and an LPN, confirmed that the dining room does not have enough seats for all who wish to eat there, and the DON acknowledged that most residents prefer the dining room, causing recurring delays.
Staff failed to thoroughly cleanse the area around a resident's sacral pressure ulcer, leaving fecal matter at the exterior border of the wound during wound care. Despite facility policy and wound care orders requiring cleansing of the wound and surrounding area, the wound nurse and CNA completed the dressing change and replaced the resident's brief without removing the fecal matter. The wound nurse later acknowledged that the fecal matter should have been cleansed.
A resident with a central line receiving IV Vancomycin for an infection was not placed on Enhanced Barrier Precautions as required by facility policy. Staff provided care without donning a gown, and the resident's care plan did not include EBP, despite ongoing treatment and the presence of an indwelling device. The DON confirmed that EBP was not implemented for this resident.
Inaccurate Elopement Assessment and Unsupervised Resident Exits
Penalty
Summary
The facility failed to accurately assess a resident for elopement risk, failed to ensure adequate supervision, and failed to develop and implement interventions to prevent the resident from eloping on multiple occasions. The resident had diagnoses including dementia, depression, bipolar disorder, and falls, with documented moderate cognitive impairment, poor safety awareness, wandering, and repeated exit-seeking behavior. Records and staff statements showed the resident was frequently confused, walked quickly through the facility, required redirection, and repeatedly attempted to go outside or leave through the front door. The resident’s elopement risk assessments were inconsistent with the resident’s documented behavior. Earlier assessments identified the resident as high risk for elopement, but later assessments marked the resident as not at risk and indicated that no interventions were necessary. Staff notes documented that the resident wandered, resisted redirection, attempted to go outside without staff, entered staff-only areas, and was found outside the building on multiple occasions. Staff also stated the resident had previously cut off an electronic wandering device and that the device was later not used. The resident’s care plan did not contain a comprehensive elopement plan or interventions addressing the resident’s exit-seeking behavior. Survey observations and staff interviews showed the front entrance doors were unlocked during the day and no alarm system was activated. Staff stated the front door remained unlocked until evening, that no one was consistently stationed at the door after the prior door-monitoring employee left, and that the facility had not been using the wandering alarm system. Staff further confirmed the resident had exited the building unsupervised multiple times, including being found outside the front door and outside in non-fenced areas. The Immediate Jeopardy began when the resident was inaccurately assessed as zero risk for elopement despite documented elopement-risk behaviors.
Failure to Label Perishable Foods With Use By Dates
Penalty
Summary
The facility failed to place use by dates on perishable foods. During the kitchen tour, surveyors observed seven types of cereal stored in clear airtight containers, two frozen bags of breaded chicken strips, one frozen bag of breaded chicken patties, one bag of frozen hamburger patties in a top load freezer, and sixteen condiment bottles in a standup refrigerator, all without use by dates. Surveyors also observed two trays of individual servings of frozen nutritional supplements in a standup freezer, with use by dates present on only five servings. A clear airtight container under the kitchen counter contained a white granular substance identified by the Day Cook as grits, and the lid had a use by date of 4/14/26. The Day Cook and the Dietary Manager stated that the date reflected when the grits were poured into the container, not the use by date, and agreed that the product appeared expired when viewed by the sticker. The Administrator stated that foods should have a received date and open date, but was unsure about expiration or used by dates without reviewing the facility policy, and stated that the timing would depend on the food item.
Incomplete Antibiotic Stewardship and McGeer’s Criteria Documentation
Penalty
Summary
The facility failed to perform antibiotic stewardship duties and did not fully utilize its adopted McGeer’s criteria for antibiotic use and education. The facility’s policy dated 4/29/2025 stated that antimicrobial stewardship was intended to promote appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration, and that the facility would provide resources to clinicians, nursing staff, residents, and families about resistance and appropriate antibiotic use. The policy also stated the facility would utilize McGeer’s criteria when considering initiation of antibiotics and would work with the hospital and attending physician’s order to validate criteria used for initiation, including culture and hospital criteria. Record review of the Infection Control Log for February and March 2026 showed multiple residents received antibiotics without complete or timely McGeer’s criteria documentation. R9, R12, R33, and R42 had no documentation provided showing McGeer’s criteria were used prior to antibiotic initiation. R14, R70, R19, R57, R64, R88, R15, R26, and R56 had incomplete McGeer’s criteria, and several were dated after antibiotics had already started or after therapy was completed. The log also documented antibiotics for conditions including left eye treatment, upper respiratory infection, COPD exacerbation, urinary tract infection, cellulitis, and eustachian dysfunction, with the facility unable to provide complete criteria documentation for the initiation of several courses.
Inadequate Staff Training Program Documentation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members and did not determine the amount of time and the types of training necessary to meet residents’ needs. The Facility Resident Census Roster and Facility Matrix/802 showed 83 residents in the facility. The Facility assessment stated that staff training and competency included an in-service training calendar with mandated annual training requirements and topics pertinent to the identified population, but it did not include the amount of time or the types of training necessary to meet resident needs. During an interview, the Administrator stated that monthly staff meetings included in-service education and training, and that a monthly staff education tracking sheet listed topics and marked attendance with an X next to staff names. Review of the sheets showed no documentation of the subject matter covered. The Administrator also stated there was no agenda followed for the monthly in-services, that topics were provided according to a required schedule, that the in-services were done from memory, and that the facility did not have documentation of what educational material was presented or assurance that each staff member received the training.
Incomplete Staff Training Documentation
Penalty
Summary
The facility failed to ensure all staff received mandatory training and education related to effective communication. The Facility Resident Census Roster and Facility Matrix/802 showed 83 residents resided in the facility. The facility assessment stated that the in-service training calendar included mandated annual training requirements and topics related to care and services for the identified population, but it did not include the amount of time or the types of training necessary to meet the effective communication training requirement. During interview, the Administrator stated that monthly staff meetings were used to provide in-service education and training, and that a monthly staff education tracking sheet listed topics covered and identified employees who attended if marked with an X. Review of the sheets showed no documentation of the subject matter covered. The Administrator also stated there was no agenda followed for the monthly in-services, that topics were provided according to a schedule, and that the in-services were done from memory. He further stated the facility did not have documentation of what educational material was presented at the monthly staff meeting and could not ensure each staff member received the training.
Incomplete Staff Training Documentation
Penalty
Summary
The facility failed to ensure all staff received mandatory training and education related to resident rights and the facility’s responsibilities to care for residents. Review of the Facility Resident Census Roster and Facility Matrix/802 showed 83 residents in the facility. The facility assessment documented staff training and competency and noted that the in-service training calendar indicates mandated annual training requirements and topics pertinent to the provision of care and services to the identified population, but it did not include the amount of time and types of training necessary to meet the rights of residents and responsibilities of the facility to care for residents training requirement. During interview, the Administrator stated that monthly staff meetings were used to provide in-service education and training, that the monthly staff education tracking sheet listed topics and attendance if marked with an X, but that the sheets did not document the subject matter covered. The Administrator also stated there was no agenda followed for the monthly in-services, that topics were provided according to a schedule and delivered from memory, and that the facility did not have documentation of what educational material was presented at the monthly staff meeting or assurance that each staff member received the training.
Missing Required Staff Training on Abuse, Neglect, Exploitation, and Dementia Care
Penalty
Summary
The facility failed to ensure all staff received mandatory training and education on abuse, neglect, and exploitation, including activities that constitute abuse, neglect, and exploitation, procedures for reporting incidents, dementia management, and abuse prevention. The report states that this deficiency had the potential to affect all 83 residents residing in the facility. Review of the Facility Resident Census Roster and Facility Matrix/802 dated 4/21/26 showed that 83 residents lived in the facility. The Facility assessment dated [DATE] documented staff training and competency and noted that the in-service training calendar indicates the mandated annual training requirements and topics pertinent to the identified population, but it did not include the in-service/competency training needed for abuse, neglect, and exploitation, reporting procedures, dementia management, and abuse prevention. On 4/24/26 at 2:00 PM, the Administrator stated that monthly staff meetings were used for in-service education and training, but the monthly staff education tracking sheets only listed topics and attendance marks, with no documentation of the subject matter covered. The Administrator also stated there was no agenda followed for each monthly meeting, that in-services were given from memory, and that the facility did not have documentation of what educational material was presented or assurance that each staff member received the training.
Failure to Document QAPI Training for Staff
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program was not ensured for all staff. Review of the Facility Resident Census Roster and Facility Matrix/802 showed 83 residents lived in the facility. The facility assessment documented staff training and competency and noted that the in-service training calendar included mandated annual training requirements and topics related to care and services for the identified population, but it did not include specific in-service or competency training to meet the elements and goals of the QAPI program. During interview, the Administrator stated that monthly staff meetings were used to provide in-service education and training, and that a monthly staff education tracking sheet listed topics covered and staff attendance. However, review of those sheets showed no documentation of the subject matter covered. The Administrator also stated there was no agenda followed for the monthly in-services, that topics were provided from a schedule he had to follow, and that he gave the in-services from memory. He further stated the facility did not have documentation of what educational material was presented at the monthly staff meeting and could not ensure each staff member received the training.
Missing Documentation for Infection Prevention and Control Training
Penalty
Summary
The facility failed to ensure all staff received mandatory training and education for the Infection Prevention and Control program, including the written standards, policies, and procedures for that program. The facility assessment dated [DATE] documented staff training and competency and noted that the in-service training calendar indicates the mandated annual training requirements and topics pertinent to care and services for the identified population, but it did not include specific in-service or competency training topics to meet the Infection Prevention and Control program requirements. The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, showed that 83 residents resided in the facility. During an interview on 4/24/26 at 2:00 PM, the Administrator stated that monthly staff meetings were used to provide in-service education and training, and that the monthly staff education tracking sheet listed topics covered and marked employees who attended with an X. Review of those sheets showed no documentation of the subject matter covered. The Administrator stated he did not have an agenda for the monthly meetings, provided in-services according to a schedule of topics to cover each month, and gave the in-services from memory. He also stated the facility did not have documentation of what educational material was presented at the monthly staff meeting and could not ensure each staff member received the training.
CNA Annual In-Service Training Deficiency
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants (CNAs) were provided and completed a minimum of 12 hours of in-service training per year. Review of the Facility Resident Census Roster and Facility Matrix/802 showed 83 residents resided in the facility. The facility assessment stated that the in-service training calendar included mandated annual training requirements and topics pertinent to the identified population, but it did not include specific in-service or competency training topics or how the required 12 hours of CNA training would be conducted. Review of the 2025 Certified Nurse Aide In-service Tracking Sheet showed 42 CNAs did not meet the 12-hour training requirement. The Staff Educator confirmed that CNAs should receive at least 12 hours of continuing education yearly and stated the tracking sheet documented that 42 CNAs had not completed the minimum yearly training. The Administrator also reviewed the tracking sheet and agreed that 42 CNAs had not completed the required 12 hours of minimum yearly training.
Failure to Document Behavioral Health Staff Training
Penalty
Summary
Behavioral health training was not provided in a manner consistent with the facility assessment and mandatory training requirements. The facility assessment documented staff training and competency and stated that the in-service training calendar indicates mandated annual training requirements and topics pertinent to the identified population, but it did not include specific in-service or competency training topics to meet Behavioral Health training requirements. Review of the facility resident census roster and matrix showed 83 residents in the facility. During interview, the Administrator stated that monthly staff meetings were used for in-service education and training, but the monthly staff education tracking sheets only listed topics and attendance marks, with no documentation of the subject matter covered. The Administrator further stated there was no agenda followed for the monthly in-services, that topics were covered from memory according to a schedule, and that the facility did not have documentation of what educational material was presented or assurance that each staff member received the training.
Unsafe Medication Storage and Unattended Unlocked Medication Cart
Penalty
Summary
The facility failed to safely store medications for two residents and failed to keep a medication cart locked when it was not attended. R28, who was admitted with diagnoses including chronic diastolic heart failure, COPD, and unspecified dementia, had an order for Albuterol Sulfate nebulizer solution four times daily but did not have an order to self-administer medications. During observation, R28 was found in his room with a nebulizer machine on the nightstand and a plastic cup containing five 3 mL vials of Albuterol Sulfate left in the room. R28 stated that nurses leave the vials there so they can be used when needed, and an RN later verified that the vials should not have been left in the room. The Administrator and DON stated that medications should not be left in a resident’s room unless there is a physician order for self-administration. The facility also left the 200 hall medication cart unlocked and unattended with a medication cup on top containing crushed medication for R71. R71 had diagnoses including Parkinsonism, osteoarthritis, colon cancer, hypertension, and supraventricular tachycardia, and had physician orders for acetaminophen, calcium carbonate with vitamin D3, Mucinex ER, multivitamin, furosemide, and metoprolol ER. The cart was observed in the hallway across from a resident room, unlocked and unattended, while the medication cup remained on top of the cart. The Administrator confirmed the cart was unlocked and unattended and locked it after being notified. The LPN stated she had been pulled away unexpectedly and identified the medications in the cup as belonging to R71.
Care Plans Did Not Match Signed POLST Forms
Penalty
Summary
The facility failed to ensure resident care plans were updated to accurately reflect current code status and advance directive wishes consistent with signed POLST forms for two residents reviewed for advance directives. The facility’s guideline stated that changes to resident choices for advance directives would be documented in the plan of care, related documents would be updated as necessary, physician orders would reflect new choices, and all items would be communicated to staff providing care. For one resident, the signed POLST documented DNAR and comfort-focused treatment, but the care plan stated the resident did not want to die and had a POLST form signed FULL CODE. The Social Services Director stated there had been a recent change in code status due to a change in condition requiring hospice services, and the care plan was not updated at the time of the change. For another resident, the signed POLST documented No CPR and selective treatment, but the care plan stated the resident was FULL CODE and also included conflicting DNR and full code statements. The Social Services Director and Care Plan Coordinator both stated the care plan code status should match the signed POLST form.
Unnecessary Psychotropic Medication Use and Lack of Nonpharmacologic Interventions
Penalty
Summary
The facility failed to ensure psychotropic medications had proper indications for use and failed to use nonpharmacologic interventions other than psychotropic medication for three residents reviewed for unnecessary medications. The facility’s psychotropic medication policy stated that residents should not receive psychotropic drugs unless therapy is necessary to treat a specific diagnosed condition, and that chemical restraints are not to be used for staff convenience. The policy also listed specific acceptable indications for antipsychotic use and stated that antipsychotics should not be used when the only indication is behaviors such as wandering, restlessness, crying out, insomnia, being uncooperative, anxiety, or unspecified agitation. One resident had diagnoses including unspecified dementia, generalized anxiety disorder, major depressive disorder, and mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Her orders included clonazepam, hydroxyzine, fluoxetine, loxapine succinate for neurocognitive disorder with behavioral disturbance, and memantine. Behavior monitoring documented yelling out and anxiety on multiple dates in January and February 2026, but the care plan did not document resident-specific interventions for anxiety or dementia. The resident stated she was a nervous person, liked to attend activities, and felt her anxiety was related to being lonesome at times; survey observation found her pleasant with staff and other residents and attending activities. A second resident had diagnoses including mild neurocognitive disorder due to known physiological condition with behavioral disturbance, Alzheimer’s disease, depression, and anxiety. Orders included scheduled lorazepam twice daily, PRN lorazepam renewed every 14 days since April 2025, and risperidone daily. The MAR showed PRN lorazepam was given six times in one month, with some doses documented for pain and others for behavior issues. The MDS documented no behaviors, while point-of-care documentation showed tearful, anxious, sad, and apathetic behaviors three times and only one nursing note addressed behaviors with repeated reassurance. Staff gave differing descriptions of the resident’s behaviors, with some stating she worried and asked about family, while others said she cried, was restless, or was inconsolable; one nurse stated the behaviors were not harmful and the resident enjoyed activity programs and being around people. A third resident had diagnoses including vascular dementia, unspecified dementia with psychotic disturbance, and mild neurocognitive disorder with behavioral disturbance. Her current orders included olanzapine and sertraline, but nursing notes and the plan of care did not document behaviors from January 2026 to present. The resident was observed pleasant, interacting with others, and making a gesture indicating she knew she took medications, while the DON stated she had a history of hallucinations and being convinced she saw things others did not, but that these hallucinations were not harmful to her or others.
Restorative ROM and walking services not provided as ordered
Penalty
Summary
The facility failed to ensure residents who depended on staff assistance for restorative care received range of motion and walking services as ordered. The deficiency involved residents R6, R8, R16, R18, and R43, whose records showed physician orders and care plans for restorative nursing services, including active or passive range of motion and, for one resident, a walking program. The facility’s restorative nursing policy stated residents would be assessed for restorative needs and placed in programs intended to maintain or improve self-care and independence, and the ROM policy stated passive ROM required support of the resident’s body part being exercised. For R6, the record showed diagnoses including polyneuropathy, diabetes, lymphoma, leukemia, anemia, atherosclerotic heart disease, and muscle wasting, with moderate cognitive impairment. The physician ordered active ROM two sets of 15 repetitions three times daily, and the care plan directed active ROM to both lower extremities with staff assistance and verbal cues. Although the nursing rehabilitation time log documented ROM by CNAs two to three times daily, R6 stated staff had not conducted ROM since admission and that he had gotten weaker. A CNA stated she was unaware that R6 needed active ROM. For R8, who was cognitively intact and had diagnoses including rheumatoid arthritis, diabetes, thrombosis of the upper extremity, major depressive disorder, and lumbar disk degeneration, the physician ordered active ROM two sets of 15 repetitions three times daily and the care plan required the same. The rehabilitation time log documented ROM two to four times daily by CNAs, but R8 stated staff had not conducted ROM exercises. For R16, who had diagnoses including osteoarthritis, atrial fibrillation, hypertension, hyperlipidemia, anxiety, depression, and COPD, the physician ordered ambulation 100 feet three times per day and the care plan identified a restorative walking program. R16 stated staff were not helping with walking as promised and reported being walked only once in a week; multiple CNAs gave inconsistent accounts of how often they ambulated R16, and one CNA reported never ambulating her. For R18, who was cognitively intact and had diagnoses including fibromyalgia, heart failure, atherosclerotic heart disease, hypothyroidism, osteoporosis, and hypertension, the physician ordered active ROM to both upper extremities three times per day and the care plan required it. R18 stated staff only occasionally performed ROM, while a CNA said she did not perform ROM on R18 despite documentation showing she had recorded ROM six times in April 2026. For R43, who was cognitively intact and had diagnoses including osteoarthritis of the right knee, diabetes, atherosclerosis, ventricular tachycardia, chronic systolic heart failure, ischemic cardiomyopathy, and generalized anxiety disorder, the physician ordered passive ROM to both lower extremities three times daily and the care plan reflected that order. R43 stated he was not getting therapy, was not getting stronger, and that staff never exercised or walked him. A family member stated he was having difficulty with loss of physical activity and wanted basic exercises and standing. During observation, a CNA instructed R43 in exercises that were not on the posted care plan, and the CNA stated she had not conducted ROM during her shift and had documented passive ROM because she thought dressing him counted as passive ROM.
Improper Catheter Care and Hand Hygiene During Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper urinary catheter care for a resident with a urinary catheter and a history of UTIs, cerebral palsy, diabetes, prostate cancer, neurogenic bladder, chronic kidney disease, and contracture. The resident was cognitively intact and had a physician order for daily Cephalexin for recurrent UTIs. The care plan addressed catheter care and monitoring for UTI signs, but it did not include the resident’s long-term antibiotic use or recurrent UTIs. The record also showed that when the resident reported penile pain and suspected another UTI, the urine was cloudy and pink-tinged, urology was notified, and later a new order for Ciprofloxacin was received; however, the chart did not document ongoing monitoring or interventions between the onset of symptoms and the start of antibiotic therapy. Surveyors observed the resident’s urinary catheter collection bag sitting on the floor with sediment in the tubing and amber urine in the bag. A CNA confirmed the bag should not be on the floor and then picked it up without gloves and placed a towel underneath. During catheter care, a CNA applied clean gloves and a gown without performing hand hygiene first and then proceeded with the care; she acknowledged she forgot to perform hand hygiene. The infection preventionist confirmed that catheter bags should be kept off the floor and hand hygiene should be performed before applying gloves to help prevent catheter-associated UTIs.
Failure to Offer Bedtime Snacks to Diabetic Residents
Penalty
Summary
The facility failed to offer bedtime snacks to three of three diabetic residents reviewed for bedtime snacks. The Snack Protocol policy states snacks are available to all residents during and after kitchen operation hours, and dietary is to provide appropriate snacks based on diet order. However, the record review did not show snacks were provided, offered, or consumed for the residents reviewed, and interviews with each resident indicated nighttime snacks were not being offered or received. R4 was cognitively intact, had diagnoses including Type 2 DM, A-fib, CHF, polyarthritis, and muscle wasting and atrophy, and was identified in the care plan as insulin dependent and at risk for hypo/hyperglycemic episodes. R6 had moderate cognitive impairment, diagnoses including Type 2 DM, lymphoma, leukemia, anemia, atherosclerotic heart disease, polyneuropathy, and muscle wasting, and was documented as at risk for malnutrition; dietary notes said to continue offering snacks and to keep snacks in the room, yet the snack record did not document snacks being provided. R43 was cognitively intact, had diagnoses including Type 2 DM, atherosclerosis, ventricular tachycardia, chronic systolic HF, ischemic cardiomyopathy, osteoarthritis, and generalized anxiety disorder, and the care plan identified insulin dependence and risk for hypo/hyperglycemic episodes; the nutrition at risk report specified peanut butter and crackers at 7:00 PM daily, but the resident stated snacks were not offered or received nightly. The DON stated snacks are kept in the clean utility closet and residents can have snacks anytime they request them, and agreed nighttime snacks should be offered, especially to residents with diabetes and those taking insulin.
Inaccurate Documentation of ROM Services
Penalty
Summary
The facility failed to maintain accurate medical records for three residents reviewed for restorative range of motion services. R6, who was admitted with diagnoses including polyneuropathy, type 2 diabetes mellitus, small cell B-cell lymphoma, chronic lymphocytic leukemia, anemia, atherosclerosis heart disease, and muscle wasting, had an MDS documenting moderate cognitive impairment and a physician order for active ROM two sets of 15 repetitions three times daily. On interview, R6 stated ROM exercises were not provided and had not been received since admission, yet the Nursing Rehab Time Log documented active ROM two to four times daily by CNAs, including an entry showing a CNA performed active ROM on the morning of the survey date. R8, who was cognitively intact and had diagnoses including rheumatoid arthritis, type 2 diabetes mellitus, thrombosis of the upper extremity, major depressive disorder, and intervertebral disk degeneration, also had a physician order for active ROM two sets of 15 repetitions three times daily. R8 stated ROM exercises were not provided and had not been received since admission, but the Nursing Rehab Time Log documented active ROM two to four times daily by CNAs, including an entry for the morning of the survey date. R43, who was cognitively intact and had diagnoses including osteoarthritis of the right knee, type 2 diabetes mellitus, atherosclerosis, ventricular tachycardia, chronic systolic heart failure, ischemic cardiomyopathy, and generalized anxiety disorder, had an order for passive ROM to both lower extremities with staff assistance and verbal cues three times daily. R43 stated ROM exercises were not provided and had not been received since admission, while the Nursing Rehab Time Log documented passive ROM two to four times daily by CNAs, including an entry for the morning of the survey date. A CNA stated she had not conducted ROM exercises with R6, R8, or R43 during her shift and explained she thought dressing the residents was considered ROM exercises, while the Administrator stated staff should not document cares that were not performed and that doing so was falsification of documentation.
Insufficient Dining Room Seating Limits Resident Access to Meals
Penalty
Summary
The facility failed to provide sufficient seating in the dining room to accommodate all residents who chose to eat there, resulting in several residents having to wait for extended periods before being able to eat. On multiple occasions, groups of residents were observed sitting in their wheelchairs at the entrance to the dining room or near the nurse's station, waiting for a seat to become available. Staff members, including certified nursing assistants and an LPN/staff educator, confirmed that there were not enough seats for all residents who wished to eat in the dining room at the same time, leading to some residents having to wait until others finished their meals. Residents reported that if they did not arrive early enough, they would have to wait up to an hour before being able to eat, and expressed frustration with the situation. The ombudsman also noted that the lack of dining room seating was a significant concern, as it frequently resulted in residents waiting for a spot to open up. The facility had 83 residents at the time, and the issue was acknowledged by the Director of Nursing, who stated that most residents preferred to eat in the dining room, further exacerbating the seating shortage.
Failure to Date and Properly Store Opened Dry Food Items
Penalty
Summary
During a kitchen tour, surveyors observed multiple opened dry food items, including cake mix, cornbread mix, waffle mix, buttermilk biscuits, pudding and pie filling, graham cracker crumbs, strawberry and lime gelatin mixes, and batter mix, that were not labeled with the date they were opened. The Dietary Manager confirmed that the facility only dates items upon receipt and does not date them when opened. Additionally, none of the opened dry food items were stored in airtight containers; instead, they were left in their original bags with clips to keep them closed. These practices were not in accordance with the facility's policy, which requires opened products to be labeled, dated with the use by date, and tightly covered, and for dry goods to be stored in plastic containers with tight-fitting lids.
Insufficient Dining Room Seating Limits Resident Access to Meals
Penalty
Summary
The facility failed to provide sufficient seating in the dining room to accommodate all residents who chose to eat there, resulting in multiple residents having to wait for extended periods before being able to eat. Observations showed several residents in wheelchairs waiting at the entrance to the dining room while others were already seated and eating. Staff interviews confirmed that residents often have to wait for a seat to become available, as there are not enough seats for everyone who wishes to eat in the dining room at the same time. This situation was corroborated by both staff and the facility ombudsman, who noted that the lack of seating is a recurring issue. Residents reported that if they did not arrive early enough, they would have to wait up to an hour before being able to eat, and some were observed waiting near the nurse's station or in their rooms due to the lack of available seating. The Director of Nursing acknowledged that while some residents choose to eat in their rooms, most prefer the dining room, leading to insufficient seating capacity during meal times. The deficiency directly affected multiple residents who were unable to eat at their preferred time and location due to the facility's failure to reasonably accommodate their needs and preferences.
Failure to Cleanse Fecal Matter from Pressure Ulcer During Wound Care
Penalty
Summary
During wound care for a resident with a sacral pressure ulcer, staff failed to thoroughly cleanse the area around the wound, leaving fecal matter at the exterior border. The facility's policy and the resident's wound care orders required cleansing the wound and surrounding area with a specified solution and patting it dry with gauze. Observation showed that the wound nurse and CNA performed wound care without removing a round ball of light brown fecal matter present in the upper gluteal cleft at the exterior border of the wound. After completing the dressing change, the staff replaced the resident's adult brief and covered her without addressing the fecal matter. The wound nurse later confirmed that the fecal matter should have been cleansed from the wound area.
Failure to Implement Enhanced Barrier Precautions for Resident with Central Line
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a central line who was receiving intravenous Vancomycin for an infection related to an internal joint prosthesis. According to the facility's own EBP policy, residents with indwelling medical devices such as central lines are required to be placed on EBP, which includes the use of gowns and gloves by staff during high-contact care activities. However, during direct observation, a registered nurse provided care to the resident by flushing the central line and administering medication while only wearing gloves and not donning a gown. The nurse also confirmed that the resident was not on EBP at the time of care. Further review revealed that the resident's care plan did not include any documentation or plan for EBP, despite ongoing treatment for infection via a central line. Interviews with the Director of Nursing confirmed that all residents with central lines should be on EBP and that this particular resident was never placed on such precautions. The lack of signage and absence of an EBP care plan contributed to the failure to implement the required infection prevention measures for the resident.
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What surveyors actually found near you
We read the 166 citations issued within 25 miles in the last 12 months — including the 6 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Loft Rehab & Nursing Of Canton | 6.9 mi | ★★★★★ | 1 | 0 |
| Renaissance Care Center | 8.9 mi | ★★★★★ | 1 | 0 |
| Sunset Rehabilitation And Health Care | 9.5 mi | ★★★★★ | 8 | 0 |
| Graham Hospital | 9.6 mi | ★★★★★ | 9 | 0 |
| Clayberg, The | 17 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.