Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Willows Nursing Center during CMS and state inspections, most recent first.
Failure to provide RD services was identified after interviews showed the facility had not had a current RD for a prolonged period. The previous RD said she had not been at the facility since October 2023, the Dietary Manager stated there was no RD and that she did not complete resident BMI, goal weight, or calorie calculations, and the DON confirmed the facility did not currently have an RD. The facility assessment listed RD staffing as part of food and nutrition services, and 22 residents lived in the facility.
Dirty Ceiling Vent in Entrance Foyer: The facility failed to maintain a safe, clean, sanitary environment in the common foyer area. Surveyors observed a ceiling vent in the entrance foyer with a large accumulation of a black substance covering about 90% of the vent on multiple observations. The DON stated the vents in the foyer area should be cleaned. The facility had 22 residents.
Inaccessible Shower Room Call Light: The facility failed to provide an accessible call light in the north hall shower room for residents assigned to that hall. Surveyors observed the call light was present but had no pull string, and a CNA stated north hall residents are typically showered there. The DON said the string had broken off, and the facility policy called for a safe and functional environment.
Mechanical soft diet orders were not followed for 4 residents. A resident who was nonverbal and had right-sided impairment was served a baked potato with skin, a large piece of meatloaf, and carrot slices that were not cut to bite-size, and the resident struggled to chew and could not eat the meatloaf. Dietary staff stated the baked potato should not have had skin and that the meatloaf and potatoes should have been cut into manageable pieces; the soft chopped carrot recipe required bite-size portions.
Infection control practices were not maintained for multiple residents. Staff did not use hand hygiene when changing gloves during catheter care, touched another resident’s cup and straw while feeding without cleaning hands between residents, and carried unbagged soiled linen through the hallway after incontinent care. A resident with urine culture results showing E. coli, ESBL, and Proteus mirabilis had no isolation sign on the door, and a CNA reported the resident was not on contact isolation and that the resident’s laundry was being mixed with other residents’ clothes.
Failure to Provide Dignified Eating Assistance: Two residents were observed receiving meal assistance without proper respect and dignity. A CNA answered a personal cellphone while feeding one resident who was dependent for eating and rarely understood, and the resident was fed mixed pureed foods while making disgruntled faces. Another resident was left with food on the face and chin during the meal while a CNA continued offering bites and drinks, and the DON stated staff should not answer phone calls while providing care and should clean food from a resident's face during feeding.
A cognitively intact resident’s chart contained conflicting end-of-life orders: multiple physician order sheets and a social service assessment listed the resident as DNR, while the POLST stated the resident wanted CPR attempted but did not want intubation or dialysis. The resident said she understood CPR and wanted it performed if her heart stopped. An RN initially identified the resident as DNR from the chart before finding the POLST and acknowledging the resident was supposed to have CPR performed.
Unsafe and Unclean Bathroom Environment: Surveyors observed an east hall bathroom used by a resident with multiple missing floor tiles near the toilet and another area of missing tiles, along with dirt and debris around the toilet pedestal. The DON stated the resident was the only one using that bathroom, and the facility policy calls for housekeeping and maintenance staffing to promote a safe and functional environment.
A resident with Lewy body dementia, severe cognitive impairment, and hand tremors was documented as independent with eating on the MDS and CNA ADL record, despite a malnutrition risk assessment and multiple observations showing he could barely manage utensils or drinks without help. Staff observed food falling off his fork, very limited intake until assisted, and several CNAs and the DON acknowledged he needed eating assistance; the MDS coordinator said she relied on CNA documentation for eating status.
Failure to provide timely eating assistance and scheduled showers. A resident with severe cognitive impairment and marked tremors repeatedly struggled to eat until a CNA sat down and assisted, despite staff expectations to feed him when he could not manage meals. Two residents who required help with bathing also missed multiple scheduled showers, with records showing extended gaps between showers and no nursing note explanation for the missed care.
Failure to supervise a resident at risk for choking during meals. A resident with severe cognitive impairment, GERD, muscle weakness, and a care plan calling for staff supervision with all meals was observed eating without staff present in the dining room. On another meal observation, the resident began coughing and was described by a CNA as having started choking on the last bite fed to her, then continued coughing on and off while eating. The DON stated a staff member should always be present in the dining room during meals, and the dining policy did not address qualified staff supervision during mealtimes.
A resident with dementia, GERD, and other chronic conditions was underweight and dependent for eating, yet the facility failed to consistently assess, monitor, and document meal and snack intakes. Weight records showed a decline from 103 to 98 pounds, the CNA ADL records had multiple missing intake entries, the quarterly nutrition reviews repeatedly stated weight stable and good intakes, and the RD assessment section was blank. Staff also stated the facility had not had an RD since the end of 2023 and did not calculate BMIs, goal weights, or calorie needs.
The facility failed to prevent cross-contamination during meal service, as CNAs delivered drinks by the rims of glasses after touching various surfaces without hand hygiene. Drinks were also served uncovered, contrary to proper protocols, affecting all 24 residents.
The facility failed to maintain a clean and accessible environment, with observations of dirt, mildew, and blocked access in shower rooms and hall bathrooms. Housekeeping staff acknowledged persistent cleanliness issues, and the DON was unaware of an environmental cleaning policy. These deficiencies potentially affect all 24 residents.
The facility failed to ensure call lights were within reach for several residents, including those with cognitive impairments and histories of falls. Observations revealed call lights were often placed out of reach, compromising residents' ability to request assistance. Staff interviews confirmed the expectation for call lights to be accessible, yet this was not consistently achieved.
A resident with severe cognitive impairment and significant assistance needs was left to eat without immediate help, leading her to use her fingers to eat. Despite the care plan requiring substantial assistance, staff interviews confirmed the resident's meal tray should not have been placed in front of her without someone available to assist, compromising her dignity.
A facility failed to investigate a bruise of unknown origin on a cognitively impaired resident with progressive supranuclear ophthalmoplegia. The resident had a dark purple bruise on the right buttocks, with no pain or discomfort reported. Despite notifying the POA and doctor, no investigation was conducted, contrary to the facility's policy requiring prompt investigation of such injuries.
A resident with multiple health conditions, including diabetes and obesity, was at risk of developing pressure ulcers. Despite a care plan requiring zinc oxide application to the left hip, there was no documentation of treatment in January. Observations showed confusion among staff about treatment responsibilities, leading to inconsistent care and worsening of the resident's condition.
The facility failed to implement effective fall prevention measures for three residents with cognitive impairments, leading to multiple falls and injuries. Care plans were not consistently updated with new interventions, and call lights were often out of reach, contributing to the risk of falls.
A resident with multiple diagnoses, including Parkinsonism and Alzheimer's, experienced significant weight loss, dropping from 178 to 158 pounds. The facility failed to follow its policy for managing weight loss, as there was no referral to a dietician or implementation of nutritional supplements. The dietary manager did not receive weight loss information, and the LPN confirmed the facility's inaction in addressing the resident's weight loss.
A resident with dementia frequently wandered into other residents' rooms, causing distress, without a care plan addressing this behavior. Staff removed the resident multiple times, but the facility lacked behavior tracking for wandering, as confirmed by the DON.
A resident with a history of incontinence and other medical conditions received improper incontinent care from CNAs who failed to follow infection control protocols. The CNAs did not perform hand hygiene before donning gloves, did not change gloves appropriately, and touched the resident's skin and linens with contaminated gloves. The DON observed the incident and instructed the CNAs, but hand hygiene was still not performed as required by the facility's policy.
A resident with a history of multiple health issues was prescribed a Z-pak for bronchitis without proper diagnostic confirmation, such as a culture or x-ray. The facility's documentation was insufficient, with no notes on respiratory symptoms between late December and early January, and the care plan lacked a section for respiratory concerns. The DON admitted to the absence of necessary follow-up documentation after antibiotic administration, leading to a deficiency in antibiotic stewardship.
The facility failed to post current daily nurse staffing data, affecting all 24 residents. On several occasions, the postings were outdated or incorrect, with one instance showing a future date and another showing a past date. A staff member acknowledged the oversight, indicating it was likely missed. The facility's form confirmed 24 residents were present.
The facility failed to store food according to professional standards after their freezer malfunctioned, affecting all 29 residents. The Director of Nurses moved the food to her house, but could not provide evidence of proper temperature maintenance. The facility's policy requires off-site storage in a Public Health Certified area, which was not followed.
Failure to Provide Registered Dietician Services
Penalty
Summary
Employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, including a qualified dietician, was not met because the facility did not provide consulting services of a Registered Dietician. During interview, the previous RD stated she was not familiar with any of the residents and had not physically been at the facility since October 2023. The Dietary Manager stated the facility currently did not have an RD and had not had one since the end of 2023, and that she did not complete BMIs, goal weights, calorie needs, or estimated calories for residents. The DON also stated the facility did not currently have an RD and had not had one for a little while, identifying the previous RD as the last one used. The facility assessment listed food and nutrition services staffing needs as including a Dietary Manager, support staff, and a Registered Dietician, and the facility application documented 22 residents living in the facility.
Dirty Ceiling Vent in Entrance Foyer
Penalty
Summary
The facility failed to maintain a safe, clean, sanitary environment in the common foyer area. During observations on 03/30/26 at 8:50 AM, 03/31/26 at 8:45 AM, and 04/01/26 at 8:30 AM, the ceiling vent in the entrance foyer had a large accumulation of a black substance covering approximately 90% of the vent, with a concentration around the edges and center. On 04/02/26 at 3:10 PM, the DON stated that the vents in the foyer area should be cleaned and that she would get the Maintenance Director to clean it right away. The facility policy states that housekeeping and maintenance staffing are to promote a safe and functional environment, and the facility application dated 3/30/26 documents that 22 residents live in the facility.
Inaccessible Shower Room Call Light
Penalty
Summary
The facility failed to provide an accessible call light for the shower room on the north hall for 10 residents reviewed for accessible call lights in a sample of 22. Surveyors observed that the shower room on the north hall had a call light, but it did not have a string to activate it on 03/30/26 and again on 04/02/26. A CNA stated that there are shower rooms on the north and east halls and that residents on the north hall are typically showered in the north hall shower room. The DON stated that the call light in the shower room works and that the string had broken off. The facility’s Wing Group Assignments identified the affected residents as residing on the north hall, and the facility environmental policy stated that it is the policy of the facility to provide housekeeping and maintenance staffing to promote a safe and functional environment.
Mechanical Soft Diet Food Texture Not Followed
Penalty
Summary
The facility failed to serve food in the appropriate texture for 4 of 10 residents reviewed for dining. The record titled Patient Literal Orders by Category showed that R7, R8, R15, and R22 were ordered a mechanical soft diet. On 03/31/26, these residents were served lunch that included a half baked potato with the skin still on. The facility’s dietary guidance for mechanical soft diets stated that hard crisp fried potatoes and potato skins are excluded, and the food guide stated that peeled, cooked potatoes are allowed while potato skins are not allowed. During observation on 03/31/26, R8 was in bed with a tray in front of her that included half a baked potato and a piece of meatloaf. R8, who was nonverbal and unable to use her right side, attempted to break off pieces of the potato with her fork using her left hand. She placed a chunk of potato over 1.5 inches long into her mouth, struggled to chew it, and removed pieces of potato skin from her mouth. She later broke off a smaller piece and chewed it without difficulty. R8 also attempted to stab a piece of meatloaf approximately 2 inches by 3 inches in size but was unable to get any on her fork and did not eat the meatloaf. On 04/01/26, carrot slices served with lunch to R7, R8, R15, and R22 included slices between 0.5 inches and 1.5 inches in diameter, although the recipe for soft chopped carrots stated carrots should be chopped into bite-size portions prior to serving.
Infection control failures with hand hygiene, isolation, and soiled linen handling
Penalty
Summary
The facility failed to maintain adequate infection control practices, including hand hygiene, identification of appropriate isolation, and proper handling of soiled linens for 6 of 6 residents reviewed for infection control. One resident had a urine culture showing Escherichia coli (E. coli), extended-spectrum beta-lactamase (ESBL), and Proteus mirabilis, and a physician order dated 3/16/2026 documented Augmentin 875/125 mg by mouth twice daily for 10 days related to E. coli, ESBL, and Proteus mirabilis per vagina and urine. On 3/30/2026, there were no signs on the resident’s door indicating any type of isolation, and a CNA reported the resident had not been on contact isolation recently. The CNA stated she had asked the DON why the resident was not on isolation after ESBL was identified and was told standard precautions were sufficient; she also stated the resident’s laundry was being mixed with other residents’ clothes. During observation, two CNAs providing catheter care to one resident removed their gloves multiple times when soiled and donned new gloves without performing hand hygiene. Another CNA feeding one resident took a plastic cup from a second resident and held the second resident’s straw with an ungloved hand to provide drinks, without performing hand hygiene before giving the drink or after giving the drink and before resuming feeding the first resident. In two separate observations, a CNA left residents’ rooms after incontinent care with unbagged soiled linen in hand and walked down the hallway to the shower room to discard the dirty linen in the hamper. The DON stated staff should perform hand hygiene when moving from one resident to another, when touching contaminated surfaces, and when changing gloves during care. The facility’s policies stated soiled linen should be bagged or placed into leak-proof covered carts at the location where it was used, and that a resident with an infectious case shall be placed in the appropriate type of isolation for the specific infection.
Failure to Provide Dignified Eating Assistance
Penalty
Summary
The facility failed to provide eating assistance with respect and dignity for 2 of 3 residents reviewed for dignity. R18 had diagnoses including dementia, anemia, major depressive disorder, cataract, gastro-esophageal reflux disease, and age-related osteoporosis, and her MDS documented that she was rarely or never understood and was dependent for eating. During the lunch meal, a CNA answered her personal cellphone while continuing to feed R18 and spoke on the phone for 2 minutes before stating, "I have to get off here, I'm feeding." R18 was also observed being fed a mixture of orange-colored pureed baked beans and dark brown pureed pudding while making disgruntled faces, and on another occasion had pureed food from under her nose to below her chin for several minutes before her mouth was wiped. R12 was observed during the noon meal with a large amount of pureed food under her lower lip, across her chin, and dripping onto her clothing protector while a CNA continued to offer bites of food and drinks. The resident sat with eyes closed during the meal, and the CNA did not wipe the excess food from the resident's face during the observation. The DON stated the facility did not have a policy specific to resident dignity, and also stated staff should not answer phone calls while providing care, including assisting with eating, except in an emergency. The DON further stated staff are expected to clean food off a resident's face during feeding and to avoid mixing foods when assisting with meals.
POLST and DNR Orders Did Not Match Resident Wishes
Penalty
Summary
The facility failed to ensure the resident’s Uniform Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected the resident’s wishes throughout the health record for one cognitively intact resident. R19 was admitted with diagnoses including congestive heart failure and chronic kidney disease stage 4, and the MDS documented a BIMS score of 15 out of 15. The physician order sheets, social service assessment, and other chart entries documented R19 as DNR, while the Advanced Directive/POLST form documented that R19 wanted CPR attempted but did not want to be intubated or receive dialysis in the event of cardiac arrest. During interview, R19 stated she understood CPR and wanted CPR performed if her heart stopped. The RN reviewed the chart and initially identified R19 as DNR based on the physician order sheet, stating she would not perform CPR if cardiac arrest occurred. After locating the Advanced Directive/POLST form in the chart, the RN acknowledged that R19 was supposed to have CPR performed and said someone made a mistake. The facility policy stated that upon admission the DON or designee shall receive residents’ directives concerning end-of-life decisions.
Unsafe and Unclean Bathroom Environment
Penalty
Summary
The facility failed to provide a safe, clean, sanitary environment for one resident who used the east hall bathroom. On 03/30/26 at 10:20 AM, surveyors observed the bathroom floor near the toilet with 10 missing 1 inch by 1 inch tiles in one area and 20 missing 1 inch by 1 inch tiles in another area, along with a buildup of dirt and debris around the pedestal of the toilet. On 04/02/26 at 3:10 PM, the DON stated that the resident was the only resident who used that bathroom. The facility policy titled Facility Environmental Policy states that the facility is to provide housekeeping and maintenance staffing to promote a safe and functional environment.
Failure to Accurately Assess Eating Ability
Penalty
Summary
The facility failed to accurately assess one resident’s eating abilities. The resident had diagnoses including neurocognitive disorder with Lewy Bodies, anxiety disorder, progressive spinal muscle atrophy, and insomnia. The MDS documented a BIMS score of 01 indicating severe cognitive impairment, and Section GG documented the resident’s eating performance as independent. The care plan stated the resident could feed himself and often requested seconds, with interventions to monitor meal intake and attempt second helpings when requested. However, the resident’s malnutrition risk assessment documented that he fed himself slowly, only ate part of meals, and had poor intake of less than 25% of most meals. The assessment was signed by the RN. The CNA ADL daily record for March 2026 documented the resident as independent with eating on most meals, with several meals left blank. During observation, the resident was seen struggling to eat because his hand was shaking so badly that food fell off his fork and he was getting very little into his mouth. When a CNA sat down and assisted him, he ate 100% of his lunch. Additional observations on subsequent days showed the resident repeatedly unable to manage utensils and drinks because of severe tremors, with food falling off his fork and only a few bites eaten until staff assisted him. One CNA stated the resident’s right hand shakes a lot and causes problems eating with silverware, while another said she expected staff to feed him. The DON stated she expected staff to feed the resident, and the Medical Director stated weighted silverware could be beneficial. The MDS coordinator stated she used CNA documentation for eating information, and a CNA stated the resident should have been documented as needing eating assistance rather than independent.
Failure to Provide Timely Eating Assistance and Scheduled Showers
Penalty
Summary
The facility failed to provide timely assistance with eating for a resident with severe cognitive impairment and significant hand tremors. R2 was admitted with diagnoses including neurocognitive disorder with Lewy Bodies, anxiety disorder, progressive spinal muscle atrophy, and insomnia, and his MDS documented a BIMS of 1. Although the MDS listed him as independent with eating and needing partial/moderate assistance with showering, the care plan addressed meal intake but did not address showering or bathing. Observation and staff statements showed R2 repeatedly struggled to feed himself because of severe tremors, with food falling off his fork and very little being eaten until a CNA sat down and assisted him; on multiple occasions, once assisted, he ate most or all of his meal. The DON stated staff were expected to feed R2 and that if a resident had not been able to eat for 30 minutes or less, staff should assist with eating. The facility also failed to ensure R2 received showers according to the posted schedule. Records showed R2 was scheduled for showers on multiple weeks but missed scheduled showers, including a period after admission when he did not receive a shower for 16 days, and another period when he was not showered for 12 days. Nursing notes did not address why the scheduled showers were missed. The DON stated she expected residents to be bathed according to the shower schedule and said two weeks without a bath was too long. The facility similarly failed to provide scheduled showers for R7, who had severe cognitive impairment and required partial/moderate assistance with showering per the MDS. Shower records showed R7 missed scheduled showers on multiple occasions and went 13 days without being showered during one period and 12 days during another. Nursing notes did not explain why the showers were missed, and the DON stated she had not been informed of any refusal or request to change the shower schedule.
Failure to Supervise a Resident at Risk for Choking During Meals
Penalty
Summary
The facility failed to supervise a resident at risk for choking during meals. The resident was admitted with diagnoses including muscle wasting and atrophy, GERD, muscle weakness, and need for assistance with personal care. The MDS documented severe cognitive impairment and partial to moderate assistance needed with eating. The care plan identified a choking hazard and directed staff supervision with all meals, along with monitoring for signs or symptoms of aspiration or dysphagia such as choking, fever, and coughing. During observation, the resident was seen feeding herself lunch while no staff were present in the dining room to supervise residents who were still eating. On another observation, the resident was being assisted with eating by a CNA when she began coughing while eating. Another CNA also checked on her, and the feeding CNA gave her a drink of fluid after the resident nodded that she was alright. The CNA stated the resident had started choking on the last bite fed to her, and the resident continued to cough on and off for several more minutes while continuing to eat. The DON stated there should always be a staff member in the dining room any time residents are eating, and a CNA stated the resident is assisted with feeding because she will stop eating and staff encourage her to eat more. The facility’s dining policy did not address supervision by qualified staff during mealtimes for resident safety.
Failure to Monitor and Document Intake for an Underweight Resident
Penalty
Summary
The facility failed to assess, monitor, and document meal intakes for a resident who was underweight and at risk for weight loss. The resident’s record showed diagnoses including Alzheimer’s disease, dementia, depression, GERD, hypothyroidism, hypertension, and resistant infections. The resident’s MDS documented dependence for eating, and the care plan identified a potential for excessive weight loss related to short attention span, difficulty staying focused to eat, being fed by staff, and sometimes being too sleepy to stay awake to eat. The care plan also noted a potential for excessive vomiting related to GERD and included orders for supplements, fortified foods, super cereal at breakfast, and health shakes with meals and at scheduled times. The resident’s weight records showed 103 pounds in January 2026, 102 pounds in February 2026, and 98 pounds on March 16, 2026. At 65 inches tall, the resident’s BMI was documented as 17.0 at 102 pounds and 16.3 at 98 pounds, which is underweight. The CNA ADL Daily Records for February and March 2026 contained multiple missing entries for breakfast, snacks, lunch, supper, and bedtime snack, and several entries used percentages such as 100%, 125%, 75%, 50+, or were left blank. The quarterly nutritional re-evaluations were signed by the Dietary Manager and repeatedly documented the resident as weight stable with good intakes, while the RD assessment section was blank. During observation on 04/01/26, a CNA was seen assisting the resident with lunch, stopped feeding when the resident began waving her arms, then resumed and the resident calmed down and finished all of her food. The CNA later stated the resident usually finishes all of her lunch and is a pretty good eater. Another CNA stated staff are supposed to document the amount residents eat every day and their eating ability, and that 125% means the resident ate all of the food and usually the supplement. The Dietary Manager stated the facility had not had an RD since the end of 2023 and did not do BMIs, goal weights, calorie needs, or estimated calories given. The Medical Director stated the resident was thin and probably underweight, but he did not recall an in-depth conversation about the resident’s weight and said an RD consult would be nice.
Cross-Contamination of Drinking Glasses During Meal Service
Penalty
Summary
The facility failed to prevent cross-contamination of drinking glasses during meal service, affecting all 24 residents. On multiple occasions, a Certified Nurse Aide (CNA) delivered drinks to residents by holding the rims of the glasses, which is where residents drink from. This occurred after the CNA had touched various surfaces, including the kitchen door, drink cart handle, her jeans, and wheelchair handles, without performing any hand hygiene. Additionally, drinks were delivered uncovered from a cart, further increasing the risk of contamination. The Dietary Manager and a dietary staff member acknowledged that drinks should not be handled by the rims and should be covered when transported. Despite this understanding, the drinks were not covered, and the improper handling continued over several days. The lack of adherence to proper food handling protocols was observed and confirmed through interviews with staff, highlighting a systemic issue in the facility's meal service procedures.
Facility Fails to Maintain Clean and Accessible Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and clean environment for its residents, as evidenced by multiple observations of unclean and obstructed areas. In the shower rooms on the 200 and 400 halls, there was a significant accumulation of dirt, mildew, and a black substance along the edges between the floor and walls, as well as missing tiles. Toilets in these areas had visible dirt and black rings, and access to handwashing sinks was blocked by large linen barrels and trash cans. Additionally, a resident's handwashing sink was found to drain extremely slowly, taking nearly nine minutes to empty, which the resident had previously reported to the facility. Housekeeping staff acknowledged the persistent issues with cleanliness, stating that the shower rooms always appear dirty despite cleaning efforts, and that there is no housekeeping staff available in the evenings. The Director of Nursing was unaware of the existence of an environmental cleaning policy, indicating a lack of structured procedures for maintaining cleanliness. These deficiencies have the potential to affect all 24 residents living in the facility, as the shower rooms and hall bathrooms are shared by multiple residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for six out of seven residents reviewed for call lights. This deficiency was observed through multiple instances where residents with varying degrees of cognitive and physical impairments were unable to access their call lights. For example, Resident 19, who has severe cognitive impairment and a history of falls, was found with call lights out of reach on multiple occasions, leading her to express concerns about having to crawl to the bathroom without assistance. Similarly, Resident 5, with moderate cognitive impairment and a history of falls, was observed with call lights under the bed covers and wrapped around a wall light, both out of reach. Resident 21, who has severe cognitive impairment and a history of falls, was also found with call lights on the floor behind a recliner, not accessible to him. These observations indicate a pattern of neglect in ensuring that residents have access to call lights, which are crucial for their safety and ability to request assistance. Additional residents, including Resident 24, who has Parkinsonism and Alzheimer's disease, and Resident 11, with Parkinson's disease, were also found without call lights within reach. Resident 1, who is cognitively intact but has physical limitations, was observed with a call light five feet away on the floor, leading her to express that reaching it would be challenging. Interviews with staff, including the Director of Nursing and Certified Nurse Assistants, confirmed that call lights should be within reach of all residents, yet this standard was not consistently met, as evidenced by the observations and resident statements.
Failure to Assist Resident with Eating Compromises Dignity
Penalty
Summary
The facility failed to promote dignity for a resident with severe cognitive impairment and significant assistance needs during meal times. The resident, diagnosed with unspecified dementia and other conditions, was observed attempting to eat with her fingers after her meal tray was placed in front of her without immediate assistance. Despite the care plan indicating that the resident requires substantial to maximal assistance with eating, the tray was left unattended, leading the resident to use her hands to eat, which compromised her dignity. Staff interviews confirmed that the resident should not have been left to eat without assistance, as she is dependent on staff for eating. The Director of Nursing and a Certified Nurse Assistant both acknowledged that the resident's food should not have been placed in front of her without someone available to assist, highlighting a lapse in following the care plan and ensuring the resident's dignity during meals.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to investigate a bruise of unknown origin for a resident diagnosed with progressive supranuclear ophthalmoplegia, who was severely cognitively impaired with a BIMS score of 2. The resident's nurse's note documented a dark purple bruise on the right buttocks, measuring 5.5 cm by 4.5 cm, with no open areas or edema, and the resident denied any pain or discomfort. Despite notifying the power of attorney and the doctor, no new orders were given. The Director of Nursing acknowledged the lack of further information or investigation into the injury, despite it being mentioned in a meeting. The facility's policy mandates that all injuries of unknown source be promptly and thoroughly investigated, which was not adhered to in this case.
Failure to Prevent Worsening of Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards to prevent the worsening of pressure ulcers for a resident identified as R4. R4 was admitted with diagnoses including Type 2 diabetes mellitus, morbid obesity, and venous insufficiency, and was at risk of developing pressure ulcers. Despite having a care plan that included the application of zinc oxide to the left hip three times a day and as needed, there was no documentation of this treatment being administered throughout January. Observations revealed that the treatment was not consistently performed by the nursing staff, and there was confusion among staff regarding who was responsible for applying the treatment. On January 14, 2025, a registered nurse (V12) was observed not performing the treatment, mistakenly believing that CNAs were responsible for it. The Director of Nursing (V2) clarified that the nursing staff should apply all treatments. When the treatment was eventually performed, the left hip area was observed to have open and scabbed areas, indicating a lack of consistent care. The Director of Nursing acknowledged the lack of documentation and expressed uncertainty about the specific treatment being administered, highlighting a failure in communication and adherence to the prescribed care plan.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement effective and appropriate interventions to prevent falls for three residents, R5, R19, and R21, who were reviewed for falls. R5, who has moderate cognitive impairment and a history of falls, experienced multiple falls resulting in injuries such as bruises and hematomas. Despite these incidents, the care plan was not consistently updated with new interventions. Observations revealed that R5's call light was often out of reach, and the alarm pad was not used correctly, contributing to the risk of falls. R21, with severe cognitive impairment, also experienced several falls, some resulting in injuries. The care plan for R21 included interventions such as visual checks and reminders to use the call light, but these were not effectively implemented. Observations showed that R21's call light was frequently out of reach, and there was a lack of documentation regarding physician notification after falls, indicating inadequate follow-up and intervention. R19, who has severe cognitive impairment and a history of falls, experienced falls resulting in injuries such as lacerations and hematomas. The care plan included interventions like visual checks and ensuring the call light was within reach, but these were not consistently followed. Observations indicated that R19's call light was often inaccessible, and there was a lack of timely assistance, contributing to the risk of falls. The facility's failure to update care plans and implement effective interventions for these residents highlights deficiencies in fall prevention and supervision.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to adhere to its policy for managing weight loss in a resident, identified as R24, who was part of a sample of 23 residents. R24, who has diagnoses including Parkinsonism, anemia, Alzheimer's disease, and cerebral infarction, was noted to have a potential for excessive weight loss due to cognitive issues and being a picky eater. Despite documented interventions in R24's care plan, such as monitoring meal intake and offering food substitutes, the facility did not implement these measures effectively. R24 experienced significant weight loss, dropping from 178 pounds to 158 pounds over a few months, which exceeded the facility's threshold for notifying a physician and dietician. However, there was no evidence of a referral to a registered dietician or the provision of nutritional supplements to address the weight loss. The facility's documentation was inconsistent, with different weights recorded on various forms, and the correct weights were not communicated to the dietary manager. The dietary manager, V15, stated that she did not receive information about residents' weight loss or calculate weight loss, relying on nursing staff to provide this information. V16, an LPN, confirmed that the facility did not follow through with R24's weight loss management, including failing to notify the registered dietician or implement supplements. The facility's policy required notifying the physician and dietary supervisor of significant weight changes, but this was not done, contributing to the deficiency in care for R24.
Failure to Address Wandering Behavior in Dementia Resident
Penalty
Summary
The facility failed to provide necessary person-centered care and services for a resident diagnosed with dementia, specifically in addressing wandering behavior. The resident, identified as R14, was admitted with diagnoses including dementia without behavioral disturbance and altered mental status. The Minimum Data Set for R14 indicated that no brief interview of mental status was performed due to the resident being rarely or never understood. Despite these conditions, R14's current care plan did not address the issue of wandering into other residents' rooms. Multiple incidents were observed where R14 entered other residents' rooms, causing distress to those residents. On several occasions, residents were heard calling for help to have R14 removed from their rooms. Staff members, including a Certified Nurse Aide and Housekeeping personnel, were involved in removing R14 from these rooms. The Director of Nursing confirmed that there was no behavior tracking for R14's wandering, and the care plan provided to the surveyor was the entirety of R14's care plan, which lacked any problem areas related to wandering.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques during the provision of incontinent care for a resident, identified as R4, who was observed to be totally incontinent of bowel and bladder. R4's medical history includes Type 2 diabetes mellitus, morbid obesity, venous insufficiency, muscle weakness, and a need for assistance with personal care. During an observation, a CNA, identified as V10, did not perform hand hygiene before donning gloves and proceeded to clean R4's buttocks and rectum area, which had a moderate amount of stool. After removing the soiled gloves, V10 failed to perform hand hygiene before putting on a new pair of gloves and continued to clean R4's groin area. Additionally, V10 did not remove gloves when touching R4's skin and clothing, and along with other CNAs, touched R4's bed linens with contaminated gloves. The Director of Nursing (DON), identified as V2, was present during the incident and instructed the CNAs to remove their gloves when touching linens. However, the CNAs did not perform hand hygiene after removing their gloves. Interviews with the DON and other CNAs confirmed that the staff should have changed gloves and performed hand hygiene after cleaning stool and before continuing care. The facility's handwashing policy, which aligns with CDC guidelines, emphasizes the importance of handwashing before and after situations likely to cause microbial contamination, including contact with body fluids, even when gloves are worn.
Deficiency in Antibiotic Stewardship for Resident with Bronchitis
Penalty
Summary
The facility failed to adhere to standards of practice for antibiotic use for a resident diagnosed with bronchitis. The resident, who had a history of anxiety disorder, cerebral infarction, chronic kidney disease, gastroesophageal reflux disease, and adult failure to thrive, was prescribed a Z-pak antibiotic on January 8, 2025, without a documented culture or x-ray to confirm the diagnosis. The resident's nurse's notes did not document any symptoms of respiratory distress or infection between December 23, 2024, and January 8, 2025, when the antibiotic was ordered. The care plan also lacked a section addressing respiratory problems or concerns. The Director of Nursing acknowledged that the resident had symptoms of clear phlegm as early as November 10, 2024, but no further documentation was made until the antibiotic was prescribed. The resident was observed coughing and spitting clear phlegm into tissues, but no diagnostic tests were conducted to justify the antibiotic use. The facility's infection control log noted the infection as nosocomial, yet there was no follow-up documentation for 72 hours after the antibiotic administration, as required. This lack of documentation and diagnostic confirmation led to the deficiency in antibiotic stewardship practices.
Failure to Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data for both licensed and unlicensed staff responsible for resident care, which has the potential to affect all 24 residents residing at the facility. On multiple occasions, the staff postings were either outdated or incorrect. On January 13, 2024, the staff posting displayed a future date of February 26, 2024, with a census of 32 residents. On January 14, 2025, the posting was updated to reflect the correct date and a census of 24 residents. However, on January 15 and 16, 2025, the postings still showed the date as January 14, 2025. During an interview on January 15, 2025, a staff member acknowledged that the daily staff posting was not current and suggested it was likely missed that day. The Long-Term Care Facility Application for Medicare and Medicaid form 671, dated January 14, 2025, confirmed there were 24 residents living in the facility.
Improper Off-Site Food Storage Due to Freezer Malfunction
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which has the potential to affect all 29 residents currently residing at the facility. The deficiency was identified when the facility's freezer malfunctioned, and the Director of Nurses (V2) moved all the food off-premises to a dedicated freezer at her house. However, V2 was unable to provide reproducible evidence that the temperature of the freezer/food was maintained per current standards of practice. The Cook (V4) and Dietary Aid/Cook (V5) confirmed that the freezer had been non-functional for about two weeks, and V2 was responsible for transporting the food daily from her house to the facility. The Dietary Manager (V6) and Maintenance Director (V3) corroborated the situation, stating that the freezer had been repaired temporarily but failed again. They mentioned that a part had been ordered to fix the freezer, expected to arrive soon. The facility's Food Storage policy from 2009 requires that freezers maintain a temperature that ensures products remain frozen, and an addendum added to the policy on 7/8/24 specifies that food stored off-site must be transferred to a Public Health Certified area. This policy was not followed, as the food was stored at V2's house, which does not meet the specified requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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 Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Doctors Nursing & Rehab Center | 0.9 mi | ★★★★★ | 29 | 1 |
| Odin Health And Rehab Center | 6 mi | ★★★★★ | 2 | 1 |
| Centralia Manor | 12.9 mi | ★★★★★ | 19 | 1 |
| Fireside House Of Centralia | 12.9 mi | ★★★★★ | 0 | 0 |
| Axiom Healthcare Of Mount Vernon | 22.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.