Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 The Haven Of Ridgeview during CMS and state inspections, most recent first.
A resident with impaired mobility, morbid obesity, ESRD, and COPD, who required two-person assistance and a full-body mechanical lift for transfers, was being moved from bed to wheelchair using a bariatric sling and whole-body lift. Two CNAs placed the sling, attached the straps to the lift, raised the resident to obtain a weight, and then began moving the lift toward the wheelchair. While the resident was suspended and the lift was in motion, the bottom right sling strap slipped off the lift hook, causing the resident to slide out of the sling and fall to the floor. The resident was transported to the ER, where records documented a right hip fracture, distal femur fracture, and right tibia fracture resulting from the fall.
A resident with significant physical limitations and dependence on staff for transfers and toileting did not have access to a working call light after being moved to bed. Staff acknowledged the absence and suggested the resident rely on roommates to call for help, despite one roommate's hearing impairment and another's uncertainty. Facility policy required call lights to be accessible, but this was not followed.
A resident who was dependent on staff for mobility and required mechanical lift transfers sustained a skin tear and required emergency care after her leg struck an exposed, sharp bed frame edge that was missing a protective cap. Staff interviews and documentation confirmed the absence of the cap and the presence of sharp edges, which created an accident hazard and led to the injury during a transfer.
A resident with a BIMS of 15 and a smoking screen showing she was cognitively intact and able to understand the smoking policy was not allowed to smoke at the times she chose. She stated she was independent and upset about not being able to go outside by herself to smoke when a scheduled smoking time was missed. The SSD and Regional Director stated all residents were supervised during smoking times even when their smoking assessments indicated independence, and the resident was observed during a supervised smoke break where she was handed her cigarettes and lighter and lit her own cigarette safely.
The facility failed to provide an SNFABN-CMS10055 for a resident when Medicare Part A services ended before the resident exhausted benefit days. The resident had multiple diagnoses, including osteomyelitis, DM2, CKD, and HTN. Staff stated the notice was missed during a transition between business office managers, and the Administrator said the facility did not have a policy for advanced beneficiary notices and followed CMS guidelines.
Failure to substantiate resident-to-resident abuse: a CNA witness statement documented that one resident kicked another resident in the knee, but the allegation was found unsubstantiated because neither resident remembered the event. One resident had severe cognitive impairment and the other had moderate cognitive impairment, with records showing a history of resident-to-resident aggression and a care plan for physical aggression.
Failure to complete quarterly activity assessments and provide activities aligned with a resident’s interests. A resident with dementia and a moderate cognitive deficit had documented preferences for family visits and being outside, while the family reported interest in crafts and paintings. The EHR did not show a later activity assessment, and facility leadership stated the AD position had been vacant and the quarterly assessment was not completed.
Failure to provide restorative nursing services and care planning for a resident with Parkinson's disease and limited mobility. PT documented that the resident had achieved maximum benefit and should be walked to meals and participate in a restorative/functional maintenance program, but the care plan did not include ambulation interventions and charting showed the resident was ambulated three times daily on only one day, with no refusals documented. Staff and the Administrator confirmed the facility did not have an active restorative nursing program, and quarterly restorative assessments were not being completed.
Failure to provide alternate vegetable options at meal service. A cook served lunch trays to three residents without the vegetable portion of the meal, and the trays contained meat, stuffing, and dessert only. The cook stated the residents did not like green beans but did not know what should be served instead. The DNM stated cream corn should have been offered as the alternate vegetable, and the district dietary manager stated residents who do not like the vegetable served that day should be offered the alternate vegetable. The meal cards did not document a dislike of green beans, and facility policy required food dislikes and preferences to be entered into the resident profile and alternate selections of comparable nutrition value to be offered.
A resident with osteoporosis, COPD, atrial fibrillation, impaired mobility, and cognitive intactness did not have a working call light available, and a cow bell was being used instead. The resident stated the call light had been given to a roommate weeks earlier, a CNA confirmed the resident was using the bell instead of a call light, and the DON/Administrator said the call light button was broken and the replacement part had been discontinued.
A resident developed multiple pressure ulcers due to the facility's failure to implement necessary interventions and provide adequate incontinence care. Despite being at high risk for pressure ulcers, the resident was not repositioned or changed frequently enough, as reported by CNAs who noted understaffing issues. The resident's condition worsened, leading to hospitalization, and the family chose to transfer the resident to another facility where their condition improved.
The facility failed to provide adequate staffing, resulting in insufficient care for residents, including a resident with severe cognitive impairment who developed pressure wounds due to infrequent repositioning. CNAs reported frequent understaffing, particularly during night shifts, leading to residents being left in soiled conditions. Another resident reported long wait times for call light responses, with complaints about staffing and care going unaddressed.
A resident with multiple health conditions developed several pressure ulcers, but the facility failed to notify the resident's POA of these changes. The Director of Nurses believed she had informed the POA but did not document the conversation, and the Wound Care Nurse Practitioner relied on nursing staff for communication. The facility's protocol for notifying significant changes was not followed.
The facility failed to provide adequate incontinence care and timely toileting assistance for two residents, leading to deficiencies in their care. One resident, with multiple medical conditions, was often left in bed without being repositioned or changed frequently enough, resulting in pressure wounds. Another resident experienced frequent delays in call light responses for toileting assistance due to staffing shortages. The facility's policies on incontinence care and repositioning were not adhered to, contributing to these deficiencies.
A resident was discharged from an LTC facility without notifying the physician or removing a PICC line used for IV antibiotics. The resident, who was cognitively intact and had osteomyelitis, left with the PICC line still in place, and no follow-up care was arranged. Facility staff were unsure if the PICC line was removed, and the Medical Director confirmed no discharge orders were given. The resident was later readmitted to a hospital with the PICC line, highlighting a deficiency in discharge planning.
A resident transferred from hospice to the facility without medications experienced severe pain and anxiety due to the facility's failure to assess and manage their condition. The resident, who had been on round-the-clock Ativan and Morphine, was not administered these medications upon admission, and their pain was not assessed until two days later. The Director of Nurses cited issues with obtaining prescriptions over the weekend. The resident was eventually sent to the ER for pain control.
The facility failed to provide adequate staffing, resulting in significant delays in call light responses for all 49 residents. Multiple residents, including those with conditions like CHF, COPD, and Parkinson's, reported waiting 30 minutes to over an hour for assistance, leading to discomfort and incontinence. The DON confirmed insufficient staffing, particularly during night shifts, despite policy requirements for timely responses.
The facility failed to ensure proper storage temperatures for medications, affecting all 49 residents. Temperature logs for the medication refrigerator were incomplete for September and missing for October. The DON was unaware of the issue, and the midnight nurse was responsible for logging temperatures, which was not done consistently. Medications requiring refrigeration were stored without proper temperature checks, violating FDA guidelines.
The facility failed to provide prescribed diets for residents at nutritional risk, with several residents not receiving double protein portions as ordered. One resident experienced significant weight loss without dietary recommendations being addressed, and another did not have an increase in Med Pass communicated to the physician. These deficiencies highlight a lack of adherence to dietary orders and communication protocols.
A facility failed to ensure proper cooking temperatures for meatloaf served to residents. During a lunch meal, some meatloaf patties were undercooked, with a pink and cool center, as observed in four residents' meals. The cook, V17, did not check the internal temperature of each patty, leading to the oversight. The facility's recipe requires a critical internal temperature of 155°F, which was not consistently met.
The facility failed to provide timely incontinence care for three residents, leading to long waits for call light responses and episodes of incontinence. Residents with conditions such as Congestive Heart Failure, COPD, and Diabetes Type 2 reported waiting up to an hour for assistance, despite being alert and oriented. The facility's policy requires call lights to be answered within a reasonable time, but this was not adhered to, compromising resident dignity.
A facility failed to notify a resident or their representative in writing about a hospital transfer, as required by policy. The resident was admitted to the hospital for observation due to elevated D-Dimer levels and redness in the lower extremities. The Business Office Manager, responsible for sending transfer notices, did not send the notification because she was unaware the resident was out of the facility for over 24 hours. This oversight violated the facility's discharge and transfer policy.
A facility failed to notify a resident or their representative in writing about the bed hold policy during a hospital transfer. The Business Office Manager did not send the required notification, as they were unaware the resident was out for 24 hours. The facility's policy requires written information about bed hold policies to be provided during transfers, but this was not done, and no copy was kept in the resident's medical record.
A resident with severe cognitive impairment and a recent CVA was prescribed Ertapenem for a UTI upon discharge from the ED. The facility failed to administer the medication timely due to the pharmacy being closed over the weekend and issues with reactivating the resident's status with the pharmacy. The medication was not administered until the following day, resulting in a delay in treatment.
A facility failed to ensure a resident was free from unnecessary medications by not implementing gradual dose reductions (GDR) for psychotropic medications. Despite recommendations from the consultant pharmacist to reduce dosages of Doxepin and Clonazepam, there was no documented physician response or evidence of communication to the physician. Observations showed the resident frequently sleeping during the day, and behavior tracking was incomplete, indicating inadequate monitoring and assessment.
A resident with multiple health conditions and a BIMS score indicating cognitive intactness did not receive necessary dental services, including dentures, despite repeated requests. The facility's administrator and business office manager were unaware of the resident's needs, and no appointment was scheduled, highlighting a lapse in communication and service provision.
A nurse failed to clean the glucometer between uses for three residents, contrary to facility policy. The glucometer was placed on a towelette on the med cart without proper disinfection. The DON confirmed the expectation for cleaning after each use, and the nurse admitted to not following the correct procedure. The residents involved had conditions requiring regular glucose monitoring.
The facility failed to provide adequate staffing, particularly during night shifts, affecting the care of 43 residents. The administrator and staff acknowledged the shortage, especially on weekends, with only two CNAs and one nurse available instead of the required five or six. Residents reported significant delays in call light responses, with some waiting up to an hour for assistance. Facility records confirmed multiple instances of understaffed night shifts, impacting residents needing assistance for transfers and daily activities.
Several residents experienced significant delays in receiving assistance due to the facility's failure to respond to call lights in a timely manner. Residents reported waiting times of 20 minutes to over an hour, attributed to staffing shortages, particularly during night shifts and weekends. CNAs confirmed the insufficient staffing levels, which hindered their ability to promptly assist residents, many of whom required two staff members for transfers. The facility's administrator acknowledged the staffing issues and the unsuccessful efforts to recruit additional care staff.
A cognitively intact resident's medications were left at the bedside by an RN, contrary to the facility's policy requiring licensed nurses to observe medication administration. A CNA found the medications and returned them to the resident, who then took them. The resident had not been assessed for self-administration, and the facility's policy mandates that medications be swallowed before the nurse leaves.
Improper Mechanical Lift Transfer Leads to Resident Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a whole-body mechanical lift, resulting in the resident falling from the lift to the floor. The resident was admitted with diagnoses including dependence on dialysis, end stage renal disease, morbid obesity, and chronic obstructive pulmonary disease. An MDS dated 11/15/25 documented that the resident required two staff for all transfers and that staff were to use a full-body lift for transfers. The MDS also documented a BIMS score of 15, indicating no cognitive impairment. The resident’s care plan identified impaired physical mobility related to decreased strength, limited weight-bearing tolerance, and dependence on a mechanical lift for transfers. On the day of the incident, two CNAs entered the resident’s room to transfer the resident from bed to wheelchair using a whole-body mechanical lift and a bariatric sling. According to the facility’s serious injury incident report and staff interviews, the CNAs placed the sling under the resident, attached the sling straps to the lift, and raised the resident in the air over the bed to obtain a weight. They then began to move the lift to position the resident over the wheelchair. While the lift was moving with the resident suspended, the bottom right sling strap slipped or slid off the hook on the lift. Staff interviews indicated that one CNA operated the lift while the other prepared and maneuvered the wheelchair. One CNA reported hooking the bottom straps while the other hooked the top straps. During the transfer, as the lift was being moved with the resident elevated, the bottom right strap detached from the lift, causing the resident to slide out of the sling and fall to the floor. The CNAs and the nurse on duty confirmed that the resident fell when the sling strap came off the lift. The resident was subsequently transported by EMS to a local emergency room, where records documented that the resident sustained a right hip fracture, a distal right femur fracture, and a right tibia fracture as a result of falling from the mechanical lift.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a CVA, diabetes, and hypertension, who was dependent on staff for transfers and toileting, was found without access to a working call light after being transferred to bed via mechanical lift. The resident's care plan specifically indicated the need for assistance with activities of daily living and toileting, and included an intervention to encourage the use of a call bell for requesting help. Despite this, the resident did not have a call light within reach, and staff acknowledged the absence, suggesting that the resident could ask roommates to activate their call lights instead. However, one roommate was not sure if they had done so, and another was severely hearing impaired, making this solution unreliable. Further interviews revealed that the resident was unsure how to summon help if needed and would likely have to wait until someone arrived. The facility's policy required that call lights be accessible to residents from their beds or chairs and from each toilet and bathing area, and that defective call lights be reported promptly. The deficiency was identified through observation, interviews with staff, residents, and family members, and review of facility records and policies.
Failure to Maintain Safe Environment During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free of accident hazards for a resident with multiple medical conditions, including lymphedema, cellulitis, type 2 diabetes mellitus, and cerebral palsy. The resident was cognitively intact but dependent on staff for mobility and required mechanical lift transfers. During an evening transfer, two CNAs attempted to reposition the resident in her wheelchair to prepare for a mechanical lift transfer. In the process, the resident's left leg went under her bed and struck the exposed, sharp edge of the bed frame, which was missing a protective black cap. The impact caused a skin tear and bleeding on the resident's left lower leg. Staff interviews confirmed that the bed frame's end was not covered and had sharp edges, which directly contributed to the injury. The wound nurse was called in to assess the injury and, after evaluation, recommended that the resident be sent to the local emergency room for further care. The emergency room physician documented a significant skin tear laceration that required one stitch to control bleeding. Facility documentation, including the incident report and staff statements, indicated that the environment was not adequately prepared to prevent accidents, as required by the facility's mechanical lift policy. The missing bed frame cap and the presence of sharp edges created an accident hazard that was not addressed prior to the incident, resulting in the resident's injury during a routine transfer.
Resident Smoking Times Not Honored
Penalty
Summary
The facility failed to allow a resident to smoke at the times she chose. The resident had an admission date of 11/22/24 and diagnoses including peripheral vascular disease, chronic kidney disease, vitamin D deficiency, a personal history of transient ischemic attack and cerebral infarction, and anxiety disorder. Her MDS documented a BIMS score of 15, indicating she was cognitively intact. Her safe smoking screening dated 5/3/2025 documented that she did not exhibit signs of confusion and that she could make herself understood, understand the smoking policy, understand the times and place to smoke, remain alert while smoking, and communicate the need for help if lit materials fell on her. The resident stated she was independent and could open the door on her own if given the code to go outside, and she was upset about not being able to go outside by herself to smoke, especially when a scheduled smoking time was missed. The SSD stated she completed smoking evaluations and that residents were screened for independent or supervised smoking, but all residents in the facility were supervised at that time. The Regional Director stated all residents were supervised during smoking times even if they were deemed independent on their smoking assessments. The resident was observed self-propelling in her wheelchair in her room and later was observed outside for a supervised smoke break, where she was handed her cigarettes and lighter by the SSD and lit her own cigarette in a safe manner.
Failure to Provide SNFABN for Medicare Part A Non-Coverage
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN-CMS10055) for 1 of 3 residents reviewed for Beneficiary Protection Notification. The resident had an admission record dated 6/18/2025 with diagnoses including osteomyelitis of the vertebra, sacral and sacrococcygeal region, type 2 diabetes mellitus without complications, chronic kidney disease, and essential hypertension. The Skilled Nursing Facility Beneficiary Protection Notification Review form documented that Medicare Part A services ended before the resident exhausted the allotted benefit days, with a last covered day of Part A services of 5/6/25, and that the written notice explaining the resident’s potential liability for a non-covered stay and right to appeal was not provided. A Regional Social Services staff member stated the resident had not been notified because the facility had been between business office managers and it was missed. The Administrator stated the facility did not have a policy for advanced beneficiary notices and followed CMS guidelines.
Failure to Substantiate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse when an alleged resident-to-resident physical abuse incident involving two residents was investigated and found unsubstantiated despite a witness statement documenting that one resident kicked the other in the knee. One resident had a BIMS score of 05 and diagnoses including unspecified glaucoma, osteoarthritis, and unspecified dementia; the other resident had a BIMS score of 09 and diagnoses including bipolar disorder, insomnia, major depressive disorder, and unspecified dementia. The investigation summary stated both residents were separated, assessed, and interviewed, and that neither resident recalled the incident or reported adverse effects. Record review showed the resident who was kicked stated she was kicked in the leg and kicked back, but she could not provide additional information and showed no obvious signs of injury. The administrator stated the allegation was not substantiated because neither resident remembered the event and both had dementia, even though the witness statement from a CNA documented that the resident with a history of physical aggression kicked the other resident. The facility abuse policy required all staff to report any allegation or witnessed abuse immediately to the administrator, and the investigation record identified the incident as resident-to-resident abuse.
Failure to Complete Activity Assessments and Match Activities to Resident Interests
Penalty
Summary
The facility failed to provide activities that met a resident’s interests and failed to complete quarterly activity assessments for one resident reviewed for activities. The resident was admitted with unspecified dementia and had a BIMS score of 10, indicating a moderate cognitive deficit. The care plan identified activity interests and preferences of visiting with family and being outside when the weather was nice, with interventions to encourage and support a new skill, interest, or hobby, give directions as needed, and provide needed supplies and assistance for activities. The resident’s activity initial assessment documented past interests of being outside when weather was nice and visiting with family, and noted that the resident did not wish to participate in group activities, go on outings, or have 1:1 time with staff. The assessment also listed accommodations such as reminders about activities, encouragement to attend, large print, and sitting closer to activities to hear well. The electronic health record did not show an activity assessment after 1/2/2025. The resident’s family member stated the resident liked crafts and paintings and had spoken with staff about getting those activities, but nothing had happened. The Administrator stated the Activities Director had been off work for a family emergency, and Resident Services stated the AD position had been open until 6/20/25 and that quarterly assessments were not completed for the resident.
Failure to Provide Restorative Nursing Services and Care Planning
Penalty
Summary
The facility failed to provide restorative nursing services, including assessments and care planning, for a resident with Parkinson's disease, type 2 diabetes, and atherosclerosis of the bilateral lower extremities. The resident's MDS documented minimal cognitive deficits and the need for supervision or touching assistance with ambulation. PT discharge documentation stated the resident had made substantial functional gains, had met the long-term goal of safely ambulating 50 feet with a walker and supervision or touching assistance, and was to be discharged back to the facility with staff assistance and participation in a restorative nursing program/functional maintenance program to maintain current functional status. Despite those recommendations, the care plan dated 7/31/25 identified a decline in bilateral lower extremity joint mobility but did not include interventions related to ambulation. Point of care response history for July and August 2025 showed the resident was ambulated three times daily on only one day, with no refusals documented during that period. The resident stated staff were supposed to walk her to every meal but were not doing so. Staff interviews confirmed the facility did not employ restorative nurses or restorative CNAs, that the resident was supposed to be walked to dine at each meal, and that refusals were sometimes not documented. The Administrator stated the facility did not currently have a restorative nursing program, and the MDS/Care Plan Coordinator stated restorative nursing services were not yet being added to the care plan. The facility policy required quarterly restorative assessments to identify residents' need for ROM exercise, but the Administrator stated these assessments had not been done.
Failure to Provide Alternate Vegetable Options at Meal Service
Penalty
Summary
The facility failed to ensure that residents received alternative meal options with similar or equivalent nutritive value when the main vegetable selection was not served. During lunch meal service, a cook served herb roasted pork loin, herb stuffing, green beans, and peach crisp from the steam table, but did not serve the vegetable portion to three residents' trays. R42 was observed eating a regular mechanical soft diet with ground herb roasted pork loin with gravy, soft herb stuffing with gravy, and peach crisp, with no vegetables on the tray. R46 was observed receiving a CCHO mechanical soft diet with the same meat, stuffing, and dessert, also without vegetables. R25 was observed eating a regular mechanical soft diet with the same meal items and no vegetables on the tray. The cook stated that R42, R46, and R25 do not like green beans, but did not know what should be served in place of green beans if they did not like them. The Dietary Manager stated that any resident who did not want green beans should have been served the alternative vegetable of cream corn, and the District Dietary Manager stated that any resident who did not like the vegetable being served that day should be offered the alternative vegetable for the day. The meal cards for R42, R46, and R25 did not document a dislike of green beans, and the facility policy stated that food dislikes and preferences must be entered into the resident profile and that residents refusing food or beverage must be offered an alternate selection of comparable nutrition value.
Working Call Light Not Available for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available in one resident’s bathroom and bathing area, and the resident did not have a working call light within reach in the room. R27 was admitted with diagnoses including osteoporosis, COPD, atrial fibrillation, contracture of the left lower leg, major depressive disorder, and malignant neoplasm. The resident’s MDS documented a BIMS score of 15, indicating cognitive intactness, and the care plan identified self-care deficit related to impaired mobility and weakness, with an intervention to encourage the resident to use a bell to call for assistance. During observation, R27 was found sitting in bed with a cow bell on the table next to the bed and no call light present. R27 stated the facility had taken his call light and given it to his roommate a couple of weeks earlier, and that he had been given the cow bell and could call the facility from his phone. A CNA confirmed awareness that R27 was using a cow bell instead of a call light and was unsure why he did not have one, guessing it was not working. The Administrator stated the call light button had broken, the needed replacement type had been discontinued, and a technician had been contacted to replace the call system; she also stated the resident had been using his cell phone and a cow bell, and that those interventions had just been added to the care plan that morning.
Failure to Prevent Pressure Ulcers Due to Inadequate Care
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of pressure ulcers for a resident, resulting in the resident developing multiple facility-acquired pressure ulcers and moisture-associated skin damage. The resident, who was at high risk for pressure ulcers due to conditions such as hemiplegia, diabetes, and severe cognitive impairment, was not repositioned or provided with adequate incontinence care as required. The resident's care plan included interventions like repositioning every two hours and monitoring incontinence, but these were not consistently followed. Interviews with staff revealed that the facility was often understaffed, particularly during the night shift, leading to residents not being repositioned or changed frequently enough. Certified Nursing Assistants (CNAs) reported that incontinent residents were often found soaked in urine and feces in the mornings, indicating a lack of proper care during the night. Despite these reports, the Director of Nurses claimed that all residents were being cared for appropriately, contradicting the observations and statements from multiple CNAs. The resident's condition deteriorated, leading to hospitalization for issues including a urinary tract infection and sepsis. The resident's family expressed concerns about the lack of care and decided to transfer the resident to another facility, where the resident's condition improved. The facility's failure to provide adequate care and staffing contributed to the development of the resident's pressure ulcers and overall decline in health.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all 50 residents, as evidenced by multiple accounts of inadequate care and staffing shortages. Resident 1, who has severe cognitive impairment and is at high risk for pressure ulcers, was not repositioned or changed frequently enough, leading to the development of pressure wounds. The resident's Power of Attorney and several CNAs reported that the facility was often understaffed, particularly during the night shift, resulting in residents being left in soiled conditions and not receiving timely care. Interviews with CNAs revealed that the night shift frequently operated with fewer staff than required, leading to inadequate care for incontinent residents. CNAs reported that residents were often found soaked in urine and feces in the mornings, indicating that they were not being changed or repositioned as needed. The Director of Nurses acknowledged the staffing issues, citing difficulties in attracting and retaining CNA staff, and confirmed that the facility did not always meet its staffing requirements. Resident 7, who requires moderate assistance for toileting and transfers, reported long wait times for call lights to be answered, sometimes up to an hour. This resident, along with others, had been complaining about staffing and call light response times for months, with no improvement. The facility's staffing policy and call light guidance were not being adhered to, as evidenced by the documented grievances and resident council meeting minutes highlighting these ongoing issues.
Failure to Notify POA of Resident's Pressure Ulcers
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) of a change in condition, specifically the development of pressure ulcers, for one of the residents reviewed. The resident, who had a history of Hemiplegia, Type 2 Diabetes, Chronic Kidney Disease, Morbid Obesity, Epilepsy, and Aphasia, was admitted and readmitted to the facility with these conditions. The resident developed multiple pressure injuries, including a stage 3 pressure injury on the coccyx and sacrum, and stage 2 and 3 injuries on the ischium. Despite these developments, there was no documentation in the resident's Nurses Notes for November and December indicating that the POA was informed of these pressure ulcers. The POA stated that they were first informed of the pressure ulcers on December 11, when the Director of Nurses called to report the resident's deterioration and hospitalization for a UTI. The Director of Nurses believed she had informed the POA earlier in December but acknowledged that the conversation was not documented. The Wound Care Nurse Practitioner also did not communicate with the POA, relying instead on the facility's nursing staff to do so. The facility's Change of Condition Protocol requires the interdisciplinary team to identify and communicate significant changes in a resident's condition, but this protocol was not followed in this instance.
Inadequate Incontinence Care and Delayed Toileting Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care and timely toileting assistance for two residents, R1 and R7, leading to deficiencies in their care. R1, who has multiple medical conditions including hemiplegia, diabetes, and chronic kidney disease, was found to be at high risk for pressure ulcers. Despite documented care plans requiring regular repositioning and incontinence care, interviews with staff and R1's Power of Attorney revealed that R1 was often left in bed without being repositioned or changed frequently enough. Staff shortages were cited as a reason for the lack of care, resulting in R1 being found in urine-soaked and soiled conditions, which likely contributed to the development of pressure wounds. R7, who has Parkinson's Disease and diabetes, requires moderate assistance for toileting and transfers. Despite being cognitively intact, R7 reported frequent delays in call light responses, often waiting up to an hour for toileting assistance. Staff confirmed that call lights were not answered promptly due to staffing shortages, particularly during evening hours. This delay in response time is contrary to the facility's policy, which states that call lights should be answered within a reasonable time frame. The facility's policies on incontinence care and repositioning were not adhered to, as evidenced by the interviews with multiple CNAs who reported insufficient staffing levels, particularly during the night shift. This resulted in residents not being turned or changed every two hours as required, and incontinence care not being performed adequately. The failure to follow these procedures led to residents being left in soiled conditions, increasing the risk of skin breakdown and pressure ulcers.
Failure to Notify Physician and Remove PICC Line Before Discharge
Penalty
Summary
The facility failed to notify the physician prior to a resident's discharge, which led to a deficiency in discharge planning. The resident, who was admitted with conditions including osteomyelitis of the left foot and ankle, was discharged without proper physician orders. The resident was cognitively intact and had a PICC line for IV antibiotics, which was supposed to be removed before discharge. However, there was no documentation of discharge orders or the removal of the PICC line in the resident's medical records. The resident left the facility with the PICC line still in place, and there was no follow-up care arranged for its management. The facility's staff, including the Director of Nursing and the Registered Nurse responsible for the resident on the day of discharge, were unsure if the PICC line was removed. The Medical Director confirmed that she did not provide discharge orders and expected the facility to discontinue the PICC line as part of standard care. The facility's policy requires physician orders for discharge, which were not obtained in this case. The resident was later readmitted to a hospital with the PICC line still in place, indicating a lack of proper discharge procedures. The hospital staff noted that the resident was living in unstable conditions and had been using a belt to secure the PICC line. This situation highlights the facility's failure to ensure appropriate discharge planning and communication with the physician, as required by their policy.
Failure to Manage Pain and Anxiety for Resident
Penalty
Summary
The facility failed to assess and manage pain for a resident, resulting in severe pain and anxiety that necessitated a transfer to the emergency room. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder, was transferred from a hospice facility where they were receiving round-the-clock medications for pain and anxiety. Upon admission, the resident's medications, Ativan and Morphine, were not administered as documented in the Medication Administration Record, and their pain was not assessed until two days later. The resident reported experiencing terrible abdominal pain and anxiety shortly after admission, which exacerbated their breathing problems. The Director of Nurses acknowledged that the resident arrived without medications and that there was no way to obtain them over the weekend due to the need for hard copy prescriptions and the pharmacy being closed. Despite contacting the Medical Director, the necessary documentation was not obtained, and the resident's pain was not assessed as per the facility's policy. The resident's family requested a transfer to the emergency room, where the resident received new medication orders for pain and anxiety. The facility's Management of Pain Policy emphasizes the importance of providing necessary comfort and dignity to residents, which was not adhered to in this case.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of its residents, affecting all 49 residents. Multiple residents reported significant delays in response times to call lights, with waits ranging from 30 minutes to over an hour. These delays were particularly problematic for residents requiring assistance with toileting and transfers, leading to discomfort and incontinence episodes. Residents with conditions such as Congestive Heart Failure, Diabetes Type 2, Chronic Obstructive Pulmonary Disease, and Parkinson's Disease were among those affected, all of whom were alert and oriented at the time of the interviews. The Director of Nurses, responsible for scheduling, confirmed that staffing levels were inadequate, particularly during the 6pm to 6am shift, where only one nurse and two CNAs were scheduled, with an additional CNA from 6pm to 10pm. Despite requests for additional staff, corporate denied these requests. The facility's policies stated that call lights should be answered within 15 minutes, but this was not being met. The staffing policy allowed for schedule revisions to meet residents' needs, but this was not effectively implemented, contributing to the deficiency.
Improper Medication Storage Temperatures
Penalty
Summary
The facility failed to ensure that medications were stored at appropriate temperatures, which could potentially affect all 49 residents. During an observation on October 4, 2024, it was found that the temperature logs for the vaccine and medication refrigerator were incomplete for September and entirely missing for October. The Director of Nursing (V2) was unaware of the missing temperature checks and stated that the facility's medication storage policy did not specifically address refrigerator temperature checks. The midnight nurse was identified as responsible for documenting the temperature logs, which had not been done consistently. The medications stored in the refrigerator included promethegan suppositories, an Ozempic pen, a liraglutide insulin pen, a Novolog insulin vial, insulin lispro vials, a Humulin insulin vial, and locked narcotic boxes. According to the FDA, these medications should be stored at temperatures between 36°F and 46°F. The facility's policy, revised in August 2022, requires that drugs and biologicals be stored under proper temperature controls. However, the lack of recorded temperatures indicates a failure to adhere to these guidelines, potentially compromising the safety and efficacy of the medications.
Failure to Provide Prescribed Diets for Residents at Nutritional Risk
Penalty
Summary
The facility failed to provide diets as ordered for residents at nutritional risk for malnutrition. Four residents, each with specific dietary needs due to medical conditions such as diabetes, chronic kidney disease, and anemia, did not receive the prescribed double protein portions during meals. For instance, one resident with a diet order of consistent carbohydrate and double protein received only one slice of meatloaf and pizza instead of the required portions. Another resident, who was noted for significant weight loss and had dietary recommendations for liberalization and an appetite stimulant, did not have these recommendations addressed by the physician, and there was no documentation of follow-up by the staff. Additionally, a resident with a diet order that included Med Pass for malnutrition did not have the recommended increase in Med Pass communicated to the physician. The dietary manager confirmed the discrepancies in meal portions, and the Director of Nursing acknowledged the lack of communication with the physician regarding dietary recommendations. These failures in adhering to dietary orders and communication protocols contributed to the deficiency in providing adequate nutrition to residents at risk for malnutrition.
Undercooked Meatloaf Served to Residents
Penalty
Summary
The facility failed to ensure proper cooking temperatures were reached when preparing meals for four residents. During a lunch meal observation, the cook, identified as V17, was preparing meatloaf and initially recorded a temperature of 128 degrees Fahrenheit, which was below the required 160 degrees Fahrenheit. Despite placing the meatloaf back in the oven, some patties were served to residents with a pink and cool center, indicating they were undercooked. Residents R18, R20, R23, and R27 received these undercooked meatloaf patties, with R18 and R20 specifically noting the cool, pink center. The cook, V17, later explained that the meatloaf was prepared as single-serving patties rather than a loaf, and while a patty from each tray was checked for internal temperature, not every patty was individually checked. This oversight likely resulted in some patties being undercooked. The facility's recipe for meatloaf specifies a critical control point of reaching an internal temperature of 155 degrees Fahrenheit for 17 seconds, which was not consistently achieved for all patties served.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to promote resident dignity by not providing timely incontinence care for three residents. Resident 1, who has diagnoses including Congestive Heart Failure and Diabetes Type 2, reported that staff are slow to respond to call lights, often waiting 30 minutes to an hour. This resident requires partial assistance for toileting and transfers and is alert and oriented. Resident 198, with Chronic Obstructive Pulmonary Disease and Anxiety Disorder, also reported long waits for call light responses, sometimes up to an hour, causing discomfort while holding urine or feces. This resident is dependent on staff for toileting and transfers and is also alert and oriented. Resident 21, diagnosed with COPD and Diabetes Type 2, is totally dependent on staff for toileting and transfers and experiences occasional urinary incontinence. This resident reported having four incontinence episodes in one day while waiting for call light responses. The Director of Nurses stated that call lights should be answered within 15 minutes, but the facility's policy indicates that call lights should be responded to within a reasonable amount of time. The facility's failure to adhere to these guidelines resulted in a deficiency in promoting resident dignity and timely incontinence care.
Failure to Notify Resident of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident or their representative regarding a hospital transfer. This deficiency was identified for one resident, who was admitted to the facility in January 2023. On August 2, 2024, the resident was transported to a hospital for observation due to elevated D-Dimer levels and redness in the lower extremities. The resident returned to the facility the following day, transported by their daughter. However, the Business Office Manager, responsible for sending out transfer notices, did not send the required notification because she was unaware that the resident had been out of the facility for over 24 hours. The facility's policy, revised in August 2022, mandates that written information regarding bed hold policies and transfer notifications be provided to residents and their representatives when a resident is transferred to a hospital. The Business Office Manager admitted to not keeping copies of the bed hold or transfer notifications, which contributed to the oversight. This failure to notify the resident or their representative in writing of the hospital transfer constitutes a deficiency in the facility's adherence to its discharge and transfer policy.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident or their representative in writing about the bed hold policy during a transfer to a hospital. This deficiency was identified for one resident out of four reviewed for hospitalization in a sample of 34. The resident was initially admitted to the facility on January 12, 2023, and was transported to a hospital for observation on August 2, 2024, due to D-Dimer elevation and redness in the lower extremities. The resident returned to the facility the following day, transported by their daughter. The Business Office Manager, responsible for sending out bed hold and transfer notices, admitted to not being aware that the resident was out of the building for 24 hours and consequently missed sending the required notifications. The facility's policy mandates providing written information about the bed hold policy to the resident and their representative during transfers. However, the Business Office Manager did not keep a copy of the notification, which is against the facility's policy that requires a copy to be placed in the resident's medical record until readmission.
Delayed Medication Administration Due to Pharmacy Closure
Penalty
Summary
The facility failed to acquire medications timely from the pharmacy for a resident who was admitted with diagnoses including Hemiplegia, Hemiparesis, and Aphasia following a Cerebral Vascular Accident. The resident's cognition was documented as severely impaired. Upon discharge from the Emergency Department, the resident was prescribed Ertapenem for a Urinary Tract Infection, to be administered every 24 hours starting the following day. However, the medication was not available at the facility upon the resident's return. The Director of Nurses stated that the resident did not receive the Ertapenem because the pharmacy that provides IV medications was closed over the weekend. The facility contacted the pharmacy, which initially did not recognize the resident as active and required reactivation by sending a facesheet and order. Despite these actions, the medication was not administered until the following day, resulting in a delay in treatment for the resident.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, as evidenced by the lack of implementation of gradual dose reductions (GDR) and non-pharmacological interventions for psychotropic medications. The resident, who was admitted with diagnoses including unspecified dementia, anxiety disorder, bipolar disorder, major depressive disorder, and insomnia, was prescribed multiple psychotropic medications, including Clonazepam, Doxepin, Olanzapine, and Venlafaxine. Despite the facility's care plan indicating the need for GDR and monitoring for adverse effects, there was no documented evidence of attempts to reduce the dosages of these medications. Observations of the resident showed that they were frequently sleeping in their recliner during the day, which could indicate over-sedation or other side effects of the medications. The facility's consultant pharmacist had recommended GDR for Doxepin and Clonazepam to reduce fall risk, as these medications are on the Beers List for potentially inappropriate medications for older adults. However, there was no response from the physician to these recommendations, and the facility could not provide documentation that the recommendations were communicated to the physician. The facility's policy requires the consulting pharmacist to review residents' charts monthly and notify the Director of Nursing (DON) of any recommendations, which should then be communicated to the physician. However, the Director of Nursing admitted that some physicians do not respond to these requests, and there was no documentation of the facility sending the recommendations for the resident to the physician. Additionally, behavior tracking for the resident was incomplete, with several shifts not documented, further indicating a lack of proper monitoring and assessment of the resident's condition and medication effects.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, identified as R31, who was admitted with diagnoses including Diabetes Mellitus, Hypertension, Polycystic Kidney Disease, and Gout. Despite being cognitively intact, as indicated by a BIMS score of 12, R31's care plan did not address any dental concerns. The resident reported not having dentures since admission and expressed difficulty eating and potential weight loss due to this issue. R31 stated that he had communicated his need for dental services to the facility's administrator, business office manager, and previous social worker, but no action was taken. The administrator, identified as V1, claimed to be unaware of R31's request for a dentist appointment and mentioned plans to arrange for a dentist to visit the facility. The business office manager, V3, also confirmed having no record of R31's request and was in the process of finalizing a contract with a dentist to provide monthly services. Despite these discussions, no attempt had been made to schedule a dental appointment for R31, and the previous social worker, V8, who might have been informed, was no longer employed at the facility.
Failure to Clean Glucometer Between Uses
Penalty
Summary
The facility failed to properly clean the glucometer between resident uses, as observed during a survey. A registered nurse, identified as V4, was seen obtaining blood glucose samples from three residents without cleaning the glucometer between uses. After each test, the glucometer was placed on a towelette on the medication cart, and the same towelette was used for multiple residents without proper disinfection. This practice was contrary to the facility's policy, which requires the glucometer to be cleaned with a Sani-Wipe after each use and to remain wrapped for three minutes. The Director of Nursing, V2, confirmed that the expectation was for nurses to clean the glucometer after each use according to the policy. V4 admitted to not cleaning the glucometer correctly during the blood glucose checks. The residents involved had various medical conditions, including diabetes, heart failure, and hypertension, which necessitated regular blood glucose monitoring. The facility's policy and the Sani-Cloth container instructions both emphasized the importance of cleaning and disinfecting reusable equipment after each use to prevent the transmission of bloodborne diseases.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care needs of its 43 residents, particularly during the night shift. The administrator acknowledged the shortage, especially on weekends, where the night shift often operated with only two CNAs and one nurse, instead of the required five or six care staff. This staffing inadequacy was confirmed by interviews with staff and residents, who reported significant delays in responding to call lights, with some residents waiting up to an hour for assistance. The facility's records for June and early July 2024 corroborated these reports, showing multiple instances of understaffed night shifts. Residents requiring assistance for transfers and activities of daily living experienced prolonged wait times, impacting their care and safety. Several residents, who were alert and oriented, expressed concerns about the delays in receiving help, particularly during the night shifts on weekends. The facility's census indicated that 19 residents required a minimum of two staff for safe transfers, yet the staffing levels were insufficient to meet these needs, leading to delays and potential risks for the residents.
Delayed Response to Call Lights Due to Staffing Shortages
Penalty
Summary
The facility failed to respond to call lights in a timely manner for several residents, leading to significant delays in receiving necessary assistance. Residents R2, R5, R6, R8, and R9, all of whom have self-care deficits requiring assistance with activities of daily living, reported waiting times ranging from 20 minutes to over an hour for their call lights to be answered. These delays were attributed to a shortage of staff, particularly during night shifts and weekends, as noted by both residents and staff members. The residents expressed frustration and concern over the prolonged wait times, which affected their ability to receive timely care and assistance. Interviews with Certified Nursing Assistants (CNAs) V5 and V6 confirmed the staffing shortages, stating that typically only two CNAs were available during night shifts, with occasional increases to three. This staffing level was insufficient to meet the needs of residents, many of whom required assistance from two staff members for transfers. The facility's administrator, V1, acknowledged the staffing issues and the unsuccessful efforts to recruit additional care staff. The deficiency in timely response to call lights compromised the residents' right to a dignified existence and self-determination, as they were unable to receive prompt assistance for their needs.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered according to current standards of practice for a resident who was not assessed for self-administration of medication. The incident involved a cognitively intact resident who had a cup of medications left at their bedside, which was discovered by a CNA. The Director of Nursing was informed of the situation and confirmed that the resident had not been screened for self-administration of medication. The Registered Nurse responsible for the resident on that day admitted to leaving the medications at the bedside, assuming the resident would take them, and was later reminded by the Director of Nursing to ensure residents take their medications in her presence. The facility's policy on medication administration requires licensed nurses to observe residents taking their medications and to ensure medications are swallowed before leaving. Despite this policy, the CNA, who is not a licensed nurse, found the medications and returned them to the resident, who then took them. The facility's administrator confirmed that the expectation is for licensed nurses to observe medication administration and that the resident had not been assessed for self-administration. The resident's medical history includes conditions such as hemiplegia, type 2 diabetes with diabetic neuropathy, hypertension, and hyperlipidemia.
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What surveyors actually found near you
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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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Nursing homes near Oblong
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Robinson Rehab And Nursing | 9.3 mi | ★★★★★ | 21 | 0 |
| Helia Healthcare Of Newton | 13.2 mi | ★★★★★ | 9 | 0 |
| Helia Healthcare Of Olney | 19.6 mi | ★★★★★ | 4 | 0 |
| Richland Nursing & Rehab | 20 mi | ★★★★★ | 9 | 1 |
| The Haven Of Bridgeport | 21.2 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.