Below 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 Arbor Grove Village during CMS and state inspections, most recent first.
Surveyors found that hot water at multiple resident bathroom sinks was immediately too hot to place hands under without discomfort, with initial temperatures measured as high as 132°F before dropping into the acceptable range after running for several minutes. The Maintenance Director reported he checks water temperatures weekly, allowing water to run until stable, knew the regulatory range to be 100–120°F, and acknowledged ongoing fluctuations despite a recently installed mixing valve. The Administrator stated no residents had been burned, residents were not generally informed to let water run before use, dementia-unit residents had independent access to their bathrooms, and no warning signs were posted, despite a facility policy stating residents have the right to a safe, clean, comfortable, and homelike environment.
Surveyors found that the facility failed to provide and document proper urinary and perineal care, infection control, and resident education for several residents with UTIs, incontinence, and indwelling catheters. A cognitively intact resident with recurrent UTIs and incontinence toileted herself, but the record lacked documentation of education on appropriate toileting procedures. For a resident with severe cognitive impairment and a Foley catheter, CNAs touched multiple room surfaces and personal items with gloved hands and then continued catheter and perineal care without changing gloves. Another cognitively intact, fully incontinent resident with frequent UTIs received incontinence care that did not follow the facility’s perineal care policy, including wiping front to back and back to front with the same wipe and not separating the labia to clean all folds. A resident with vascular dementia and a chronic catheter was repeatedly observed with the drainage bag hanging from a trash can and at times resting on the floor, despite a care plan intervention not to allow the drainage system to touch the floor; the record lacked evidence that the resident was educated on the risks of this practice, even though he had a documented penile tear with purulent, malodorous drainage treated with antibiotics.
Surveyors found that two cognitively intact residents were allowed to take their own morning medications left at the bedside without a nurse present, one with multiple oral medications left in a cup on an over-bed table and another with crushed medications mixed in pudding to be taken after a meal. In both cases, an LPN acknowledged that medications should not be left at the bedside and that residents should be observed until all medications are taken. Record review showed there were no physician orders or interdisciplinary assessments authorizing self-administration of medications, despite facility policy requiring such assessment before residents participate in self-administration.
A resident with dementia, limited ability to communicate, incontinence, and a history of multiple falls had a care plan intervention requiring that the call light be kept within reach due to fall risk. Surveyors repeatedly observed the resident in bed and in a recliner with the call light on the floor or on the bed several feet away, making it inaccessible. Staff interviews confirmed expectations that call lights be placed in residents’ hands or within reach when in bed or chairs, and therapy staff reported the resident fell frequently and was unsteady when first getting up, requiring significant assistance.
Two residents did not have all needs addressed in their care plans. One resident with hearing loss had hearing aids delivered and audiologist instructions for daily use and staff assistance, and the care plan and CNA sheets included interventions to check and place the hearing aids. However, CNAs and an LPN were unaware the resident used hearing aids, had never assisted with them, and related interventions were not accessed or implemented in the electronic system. Another resident, cognitively intact with obstructive uropathy and a long-term urinary catheter, had an inflatable penile pump and ongoing penile pain and prior penile tear, but there was no care plan addressing the penile pump, and nursing leadership reported they did not typically care plan such devices.
Surveyors found that the facility did not revise care plans for two residents after changes in their needs were identified. One resident with documented hearing loss and hearing aids was not using the devices, CNAs were unaware she had them, and there was no documentation of her non-use or refusal, despite prior audiology instructions and a communication care plan that called for checking and supporting hearing aid use. Another resident with dementia who used a manual wheelchair experienced repeated bruising and skin tears on her lower legs linked to contact with wheelchair foot pedals; IDT and wound notes identified root causes and new interventions such as removing foot pedals and using protective bandages, but these interventions were not incorporated into the resident’s care plan.
A resident with ESRD, atrial fibrillation, hypertension, hypokalemia, and depression who went out for dialysis several times a week did not receive multiple prescribed medications on two dialysis treatment days because the resident was documented as not available. EMAR review showed missed doses of amiodarone, carvedilol, Eliquis, potassium chloride, sertraline, and Velphoro during morning administration times. Nursing staff reported that medication timing for residents attending dialysis varied by nurse and was based on EMAR orders, with doses sometimes given before departure or after return. The DON acknowledged that the medications were not given while the resident was at dialysis and that there was no policy specifying how or when to administer medications when residents were out of the building, despite a dialysis care policy requiring services consistent with professional standards of practice.
Two residents experienced medication-related deficiencies involving administration practices and drug availability. In one case, an RN administered antacid tablets that had been pre-poured and left on an over-bed table by an LPN in training, rather than the preparing nurse administering and directly observing the dose as required by policy. In another case, a resident with severe cognitive impairment and adult failure to thrive missed multiple scheduled doses of megestrol suspension and sodium chloride because the medications were unavailable, and there was no documentation that the physician was notified of the missed doses despite facility policy requiring immediate action and pharmacy notification when medications are not available.
Surveyors found that two resident snack refrigerators contained staff personal items, therapy equipment, and food items lacking proper labeling, despite posted rules and facility policy requiring clear identification and separation of resident food. Staff confirmed that some items did not belong to any current residents, and labeling requirements were not followed.
A resident at moderate risk for pressure ulcers developed deep tissue injuries on both heels after staff failed to consistently implement care plan interventions such as floating the heels and using soft boots. Despite being care planned for these measures, observations showed the resident's heels were left in contact with the mattress, and staff confirmed that heel-specific interventions were not reliably provided prior to the development of the ulcers.
Two residents did not receive physician-ordered medications as prescribed due to unavailability, with one missing multiple doses of Modafinil for depression and another missing several doses of Xifaxan for NASH. Facility staff did not obtain the medications from emergency supplies or arrange for STAT delivery as required by policy, resulting in missed doses.
A resident with dementia and psychotic disorder did not receive physician-ordered changes to their psychotropic medications, as staff failed to implement a GDR of Risperdal and an increase in sertraline. The resident continued on previous doses, leading to behavioral changes, and the error was only identified after a pharmacy review and staff interviews revealed the orders had not been processed.
A resident with moderate cognitive impairment and multiple diagnoses experienced a fall while transferring from bed to wheelchair, witnessed by a family member. Although the incident was reported to the NP, DON, Administrator, and POA, the required Fall Event documentation, assessment details, and IDT review were missing from the record, resulting in incomplete monitoring and follow-up as per facility policy.
A resident with severe cognitive impairment and multiple diagnoses received blood pressure medication despite physician's orders to hold it if SBP was below 110. The medication was administered on several occasions when the resident's SBP was below the threshold. Interviews confirmed the medication should have been held, but there was no facility policy on following MD orders.
A resident did not receive prescribed medications on multiple occasions due to unavailability and lack of proper documentation. Staff interviews revealed that the facility's policies on medication reordering and documentation were not followed.
The facility failed to label and store medications appropriately in the 100/200 Hall Medication Storage Refrigerator. An open vial of TB serum was found without a label indicating when it was opened, and it was received over a year ago. Facility policy and the TB serum package insert require that it be discarded after 30 days.
Excessive Hot Water Temperatures in Resident Bathroom Sinks
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment related to resident hot water temperatures in resident bathroom sinks, affecting all 75 residents in the building. During multiple observations on the same morning, surveyors found that the hot water at several resident room sinks, including shared bathrooms, was immediately too hot to place hands under without discomfort or redness. Subsequent temperature checks conducted with the Maintenance Director showed hot water temperatures at the point of use as high as 132°F, 127°F, and 123°F when the hot water was first turned on, with later readings at the same sinks dropping into the 110–120°F range after the water had been allowed to run. These findings demonstrated that residents could initially be exposed to excessively hot water at their sinks. In interviews, the Maintenance Director stated he checked water temperatures once a week, allowing the water to run for two to three minutes until it reached a steady temperature, and that he understood the regulatory range to be 100–120°F. He reported that water temperatures fluctuated, that a new mixing valve had recently been installed, and that although the temperature at the mixing valve was appropriate, the water was hotter coming out of the lines and he did not know why. The Administrator reported that no residents had been burned and that she was not aware of residents being instructed to let the water run for a few minutes before placing their hands under it. She also noted that staff assisted residents on the dementia unit with handwashing, but those residents had individual bathrooms accessible to them, and there were no signs in bathrooms advising residents to wait before using the hot water. The facility’s Resident Rights policy stated that residents have the right to a safe, clean, comfortable, and homelike environment, including receiving treatment and supports for daily living safely.
Failure to Provide Proper Urinary, Perineal, and Catheter Care and Education
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate urinary care, resident education, and infection control practices for multiple residents with UTIs, incontinence, and indwelling urinary catheters. One cognitively intact resident with diabetes, morbid obesity, and frequent bowel and bladder incontinence had a history of recurrent UTIs with positive urine cultures for E. coli and pseudomonas and had been treated with antibiotics on multiple occasions. Staff reported that this resident preferred to toilet independently and required stand-by assistance, and an LPN stated that staff had educated her on wiping from front to back. However, review of the care plan, progress notes, and infection control documentation showed no evidence that the resident had been educated on appropriate toileting procedures. The DON confirmed there was no record of such education, that the resident toileted herself, and that the IDT did not conduct root cause analyses for infections. Another resident with severe cognitive impairment, end stage renal disease, obstructive uropathy, and an indwelling urinary catheter had recently been treated with antibiotics for a UTI. During observed catheter care, two CNAs donned gowns and gloves and brought supplies into the room, but then repeatedly touched environmental surfaces and items such as the bed control device, a disposable water cup, the over-bed table, and the resident’s phone while wearing the same gloves. They then continued to provide perineal and catheter-related care without changing gloves, contrary to infection control practices that require glove changes after contact with inanimate objects before continuing direct care. A third cognitively intact resident, always incontinent of bowel and bladder and requiring substantial assistance for toileting hygiene, reported frequent UTIs and receiving bed baths, usually voiding in her brief rather than using a bedpan. During one observed episode of incontinence care, a CNA wiped the center of the resident’s perineal area from front to back and then back to front with a single wipe without turning it, then used another wipe for the leg creases, and the staff did not separate the resident’s legs to visualize and clean the folds of the labia. This technique did not follow the facility’s perineal care policy, which requires separating the labia, washing the urethral area first, wiping from front to back using a clean area of the washcloth with each stroke, and not reusing the same area of the cloth. In a separate observation with the same resident, another CNA demonstrated correct technique, including separating the labia, wiping front to back with clean portions of the cloth, and changing gloves after touching room surfaces, and later described this as the expected procedure, highlighting that the earlier care did not conform to policy. A fourth cognitively intact resident with vascular dementia, obstructive uropathy, and a long-term indwelling urinary catheter was repeatedly observed sitting in a recliner with the urinary catheter drainage bag hanging from a trash can beside the chair. On one occasion, the bag, partially covered by a dignity cover, was resting on the floor. The DON acknowledged that the bag should not have been hanging on the trash can and moved it, and a QMA stated that staff typically hung the bag where it “needed to be,” while another CNA reported that she always hung the bag on the trash can because that was the resident’s preference. The resident had a history of penile pain, edema, and a tear to the penis associated with the catheter, with purulent, bloody, and malodorous drainage documented in progress notes and treated with antibiotics. During observed catheter care, CNAs noted a tear at the bottom of the penis and a moderate amount of green drainage in the brief, which they stated had been present for a couple of days. The care plan included an intervention not to allow any part of the drainage system to touch the floor, but also documented the resident’s preference to have the catheter bag hanging on the trash can. The clinical record and care plan lacked documentation that the resident had been educated on the risks of hanging the catheter bag on the trash can or that specific interventions addressing this practice were in place prior to the survey. The DON later stated that the facility did not have a policy specifically addressing urinary catheter bags touching objects and confirmed that the resident’s care plan was updated to include the trash-can hanging preference only after she personally observed the bag on the trash can during the survey. The ADON reported that staff had previously called her about a laceration to the resident’s penis and that the resident frequently adjusted his catheter himself, and she stated that staff should be monitoring the resident’s skin during catheter care each shift. The nurse practitioner indicated that a penile tear would likely be due to catheter pulling but was unsure of the exact cause. Overall, the survey findings documented failures to follow the facility’s own perineal care policy, inconsistent adherence to infection control practices during catheter and incontinence care, and lack of documented resident education and care planning related to toileting and catheter management for residents with recurrent UTIs and indwelling catheters.
Failure to Assess and Authorize Residents for Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to assess and obtain physician orders for residents to self-administer medications before leaving medications at the bedside. For one resident, surveyors observed on two occasions that a cup full of morning medications was left on the over-bed table in the resident’s room so she could take them with or after breakfast. The resident stated these were her morning medications and that staff normally left them there for her to take after eating. An LPN later confirmed that the medications should not have been left at the bedside, acknowledged that the resident did not have a physician’s order or an assessment to self-administer medications, and stated that medications should not be left on the bedside table without a nurse present. Record review showed this resident was cognitively intact, with diagnoses including dementia, anemia, hypertension, diabetes, anxiety, and depression, and had multiple ordered morning medications such as alprazolam, aripiprazole, aspirin, diltiazem, metformin, metoprolol, sertraline, and others. For a second resident, surveyors observed a medication cup containing a brown substance with white and pale flecks, identified by the resident as his morning medications mixed with chocolate pudding, sitting on his bedside table next to his breakfast tray. The resident reported he would take them after finishing his meal, and later stated he had finished breakfast and taken the medications. An LPN reported that this resident would not interrupt his meal to take medications, that his medications were crushed in pudding or applesauce and taken after he finished eating, and that medications should not be left at the bedside and residents should be watched until all medications are taken. Record review for this resident showed he was cognitively intact with diagnoses including seizure disorder, high blood pressure, and dementia, and that his clinical record lacked any order or assessment authorizing self-administration of medications. The facility’s policy required an interdisciplinary team assessment of competence using a Self-Administration of Medication Assessment when a resident participates in self-administration, which was not completed for these residents.
Failure to Keep Call Light Within Reach for High-Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep a call light within reach for a resident with dementia and a documented history of multiple falls, despite a care plan intervention directing staff to keep the call light accessible. Surveyors observed on multiple occasions that the resident’s call light was not reachable: while the resident was asleep in bed, both a touch pad and a push-button call light were on the floor under the wall-mounted system; on another day, while the resident sat in a recliner with eyes closed and feet propped on a wheelchair, the push-button call light was lying in the middle of the bed several feet away; and on a later date, while the resident was lying in bed, the call light was on the floor under the edge of the bed, out of reach. A CNA stated that the call light must have fallen. The Infection Preventionist reported that staff were expected to give the call light to residents when laying them down or when they were in chairs to ensure it was within reach. The resident’s clinical record, including a Quarterly MDS, showed that the resident was rarely understood, had dementia, required assistance with hygiene, was incontinent of bowel and bladder, and had experienced two or more falls without injury and two or more falls with minor injuries since the last assessment. The Physical Therapist stated that the resident fell frequently, needed a lot of assistance getting out of bed in the morning, was unsteady when first standing and walking, and that staff typically stood with her when she first got up and walked her to the dining room; later in the day she would ambulate on her own with stand-by assistance. The facility’s IDT Comprehensive Care Plan Policy required development and implementation of resident-specific interventions, including keeping the call light in reach as part of the resident’s fall risk care plan, but observations showed this intervention was not consistently implemented for this resident.
Failure to Implement Hearing Aid Care Plan and Omit Care Plan for Penile Pump
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plan interventions related to hearing aids for one resident. One resident with documented hearing loss reported receiving hearing aids the prior year but not wearing them because she was unsure how to adjust them. During observation, her hearing aids were found in a charging case on a shelf, covered in a thin layer of dust, and she stated CNAs did not ask about them and she did not think staff knew she had them. A Quarterly MDS assessment documented minimal hearing difficulty and indicated she did not wear hearing aids, despite progress notes showing hearing aids were delivered and adjusted, and audiologist instructions that the resident should wear them daily, have them cleaned after each use, and be assisted by staff with insertion and removal and daily charging. The resident’s communication care plan identified hearing loss and included an intervention for staff to check that hearing aids were clean, functioning, and properly placed in both ears. CNA documentation sheets also instructed staff to check the hearing aids and store them appropriately. However, the CNA who routinely cared for the resident stated she had never assisted the resident with hearing aids and was unaware the resident had them. When she opened the computer to review the resident’s record, she did not see hearing-aid-related interventions on her screen and was unaware she could open and review the full care plan with resident-specific interventions. An LPN also stated the resident did not wear hearing aids and believed the resident had only recently had a hearing test, indicating a lack of awareness and implementation of the existing care plan and audiologist orders. The deficiency also includes failure to care plan an implanted penile pump for another resident. This resident was cognitively intact and admitted with a long-term urinary catheter and an inflatable penile pump, and he frequently complained of penile pain. Nursing staff reported that his penis was not flaccid, remained somewhat erect, and that he had a penile tear attributed to long-term catheter use, which had healed but would not grow back. The ADON stated the resident had a penile pump historically, that the resident reported the implant on admission, and that she believed it would have been documented on the admission assessment, but she had never seen it function and did not think there was a policy to care plan a penile pump, only pacemakers and pain pumps. Review of the care plan confirmed there was no care plan addressing the penile pump, despite the resident’s diagnosis of obstructive uropathy and ongoing catheter use.
Failure to Revise Care Plans for Hearing Aid Use and Skin Protection
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans in response to changes in residents’ needs, specifically related to hearing aid use and skin protection measures. For one resident with documented hearing loss and hearing aids, surveyors found that the resident reported not wearing her hearing aids because she was unsure how to adjust them, and that CNAs did not ask about or assist with the devices. The hearing aids were observed in a dust-covered charging case near the resident’s bed. A CNA who routinely cared for the resident stated she did not know the resident had hearing aids and did not document refusals or problems, instead verbally informing the nurse. An LPN stated she believed the resident did not wear hearing aids and that she would document non-use and notify social services if a resident was not wearing them, but the record lacked documentation that the resident was not using her hearing aids. Record review for this resident showed a quarterly MDS indicating minimal hearing difficulty and no hearing aid use, despite prior progress notes documenting delivery of hearing aids, audiology follow-up, and specific instructions that staff were to insert and remove the hearing aids daily, ensure cleaning and charging, and assist the resident with use. An audiologist note indicated the hearing aids were functioning well, fit properly, and were paired to the resident’s cell phone, and that nurses were to manage insertion and removal. The resident’s communication care plan included interventions to check that hearing aids were clean, functioning, and properly placed, and to explore reasons for refusal if the resident did not want to wear them. However, the care plan was not revised to reflect the resident’s ongoing non-use or refusal of the hearing aids, nor were the interventions updated to address the identified issues with adjustment and use. For a second resident with dementia who used a manual wheelchair and could self-propel short distances, the facility also failed to update the care plan to include new preventive interventions for recurrent lower leg injuries. The resident’s record documented bruising on the left lower leg aligned with the wheelchair pedal, with staff education to ensure proper positioning. Subsequent IDT notes identified bruising and skin tears on the backs of both legs, with root causes linked to the resident moving her feet off the foot pedals and hitting her legs on the wheelchair pedals. New interventions were documented in IDT and wound review notes, including removing the wheelchair foot pedals when not in use and applying support bandages or stockings to protect the legs. Despite these identified causes and interventions, the resident’s care plans in place at the time of the injuries did not reflect updates to include removal of the foot pedals or other preventive measures related to the wheelchair and leg protection.
Missed Medication Doses for Dialysis Patient Due to Lack of Coordination
Penalty
Summary
The deficiency involves the facility’s failure to ensure ongoing communication and coordination with the dialysis center regarding medication administration for a resident who received regular dialysis treatments. The resident, who was severely cognitively impaired, had diagnoses including end stage renal disease, hypertension, hypokalemia, atrial fibrillation, and depression, and received dialysis on Monday, Wednesday, and Friday. Review of the April 2026 EMAR showed that multiple prescribed medications were not administered on two dialysis days because the resident was marked as “not available.” These missed medications included amiodarone for atrial fibrillation, carvedilol for hypertension, Eliquis (apixaban) for atrial fibrillation, potassium chloride for hypokalemia, sertraline for depression, and Velphoro (sucroferric oxyhydroxide) for end stage renal disease. Interviews with nursing staff indicated that for residents who left the facility for dialysis, staff managed medications based on physician orders in the EMAR, and that the timing of administration (before leaving or upon return from dialysis) depended on the nurse on duty. One LPN stated the resident could receive medications either before departure or after return, while another LPN stated they simply followed the EMAR orders. The DON confirmed that the resident did not receive amiodarone on the two identified dialysis days because the resident was out of the facility and that there was no facility policy specifying when medications should be given when residents were out of the building. The facility’s Dialysis Care policy stated that residents requiring dialysis should receive services consistent with professional standards of practice, but did not address the specific issue of medication administration timing on dialysis days.
Medication Administration and Availability Deficiencies
Penalty
Summary
The deficiency involves failures in medication administration and medication availability for two residents. For one resident, a nurse in training prepared medications and took them to the resident’s room prior to a treatment being performed by an RN. The RN instructed the nurse in training to wait to administer the medications until after the treatment, but after completing the treatment, the RN personally gave the resident two pink tablets that had been left in a medication cup on the over-bed table. The RN later identified the tablets as antacids and stated that usually the nurse who prepared the medication would be the one to administer it. The facility’s medication administration policy required staff to observe the resident taking medications. For another resident with severe cognitive impairment and diagnoses including metabolic encephalopathy and adult failure to thrive, the EMAR showed multiple missed doses of prescribed medications due to unavailability. Megestrol suspension 400 mg twice daily for adult failure to thrive was not administered for three scheduled doses over two days, and sodium chloride 1,000 mg three times daily was not administered for three scheduled doses over two days. The clinical record did not contain documentation that the physician was notified about the unavailability of these medications. Facility policy on medication shortages/unavailable medications required staff, upon discovering an inadequate supply at the time of administration, to immediately initiate action to obtain the medication from the pharmacy and to notify the pharmacy immediately.
Improper Storage and Labeling of Food in Resident Snack Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to properly maintain resident snack refrigerators in two out of three locations. In the 100/200 Hall Resident Snack Refrigerator, staff personal items such as an LPN's lunch bag and a therapy department ice pack were stored alongside resident food items. Additionally, food items such as cartons of vanilla ice cream were found without proper labeling, including missing resident names, dates, or room numbers. The refrigerator had posted rules explicitly prohibiting staff food and requiring labeling of all open items, but these were not followed. The Physical Therapist confirmed the ice pack belonged to the Therapy Department and was unsure how it ended up in the resident refrigerator. In the 400 Hall Resident Snack Refrigerator, two bottles of soda were found labeled with initials and dates, but staff confirmed that no residents with those initials resided on that hall. The facility's policy required that food brought in by family or visitors be clearly labeled with the resident's name, the date brought in, and a discard date, and that staff monitor for food needing disposal. These requirements were not met, as evidenced by the incomplete labeling and presence of non-resident items in the refrigerators.
Failure to Implement and Maintain Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident who was admitted without pressure ulcers and identified as being at moderate risk for pressure sores developed deep tissue injuries (DTIs) on both heels during their stay. Despite being care planned for heel protection interventions such as floating the heels with pillows and the use of soft boots, multiple observations revealed that the resident's heels were consistently left in direct contact with the bed mattress, without the prescribed protective devices in place. The resident reported discomfort and confirmed that staff did not consistently implement the interventions intended to relieve pressure from his heels. Staff interviews and record reviews confirmed that prior to the development of the DTIs, only standard pressure ulcer prevention measures were in place, such as a pressure-reducing mattress, cushion, regular repositioning, and incontinence care. No additional heel-specific interventions were implemented until after the DTIs were identified. Documentation and staff statements indicated that the care plan interventions for heel protection were not reliably followed, leading to the development of pressure ulcers that were not present on admission.
Failure to Provide Timely Access to Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were available and administered as ordered for two residents. For one resident with severe cognitive impairment and diagnoses including heart failure, diabetes, and depression, Modafinil was not available and therefore not administered on multiple dates following admission, despite a physician's order. The process for medication ordering involved the admitting nurse transcribing orders into the computer system, which were then sent to the pharmacy, with an expectation that medications would arrive within 24 hours. However, the medication was not available for several days, and alternative sources such as a local pharmacy or family-provided medications were not utilized in a timely manner. Another resident, who was cognitively intact and had diagnoses including hepatic encephalopathy and NASH, did not receive Xifaxan as ordered for several days due to the medication not being available. The medication was eventually obtained from the resident's previous assisted living facility, but not before multiple doses were missed. The facility's policy required staff to obtain medications from emergency supplies or arrange for STAT delivery if delays occurred, but these steps were not effectively implemented, resulting in missed doses for both residents.
Failure to Implement Physician-Ordered Medication Changes
Penalty
Summary
The facility failed to follow physician's orders regarding a Gradual Dose Reduction (GDR) of psychotropic medication for a resident with diagnoses including dementia, psychotic disorder, and depression. The psychiatric nurse practitioner ordered a decrease in Risperdal and an increase in sertraline, but these changes were not implemented in the resident's medication administration. The resident continued to receive the previous doses, and there was no documentation that the new orders were processed. Nursing progress notes indicated the resident experienced no psychosocial distress initially, but later exhibited hallucinations and increased confusion. The medication orders were eventually updated after a delay, following a pharmacy consultation that identified the discrepancy. Interviews with facility staff revealed that the failure to update the medication orders was due to a lack of policy regarding the implementation of physician orders, relying instead on standard nursing practice. The assistant director of nursing and the regional director of clinical services confirmed that the medication changes were not made as ordered, and that staff were unaware the GDR had not actually been implemented when they observed changes in the resident's behavior.
Failure to Document and Monitor Resident After Fall
Penalty
Summary
The facility failed to completely and accurately document the assessment and monitoring of a resident after a fall. A resident, who was moderately cognitively impaired and had diagnoses including hypertension, overactive bladder, and weakness, experienced a fall while attempting to transfer from her bed to her wheelchair. The fall was witnessed by a family member, who notified staff. Nursing progress notes indicated that the fall was reported to the NP, DON, Administrator, and POA, but the resident's record lacked further documentation related to the assessment, monitoring, and follow-up of the fall event. Interviews with facility staff revealed that standard protocol required a Fall Event to be documented in the computer system, including specifics about the fall, immediate interventions, and an IDT review to determine root cause and update the care plan as necessary. The Physical Therapist, who reviews daily fall reports generated from documented Fall Events, was unaware of the incident due to the absence of such documentation. The facility's Fall Management Policy also required immediate assessment, initiation of a Fall Event, IDT review, and care plan updates, none of which were fully documented for this incident.
Failure to Follow Blood Pressure Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician's orders related to hold parameters for a resident's blood pressure medication. Resident 34, who was severely cognitively impaired and diagnosed with Parkinson's disease, dementia, and hypertension, had an order for losartan to be held if his systolic blood pressure (SBP) was less than 110. However, the resident received the medication on multiple occasions when his SBP was below the specified threshold: 101 on 03/14/24, 104 on 03/30/24, 100 on 04/08/24, and 108 on 04/17/24. Interviews with an LPN and the DON confirmed that the medication should have been held according to the physician's orders, but there was no facility policy on following MD orders, only standard nursing practice.
Failure to Ensure Medication Availability and Documentation
Penalty
Summary
The facility failed to ensure medications were available and properly documented for a resident. The resident, who was cognitively intact and had diagnoses including seizure disorder, depression, hypertension, and spinal stenosis, did not receive his prescribed phenytoin and cyclobenzaprine on multiple occasions. Specifically, phenytoin was unavailable on several dates in April and May 2024, and there was no documentation of physician notification when the medication was not administered. Additionally, cyclobenzaprine was not documented as administered on three separate occasions in April and May 2024. During interviews, staff indicated that the phenytoin was not available in the required form in the emergency drug kit and that the physician should have been notified each time the medication was not administered. The facility's policies on receiving pharmacy products and documenting medication administration were not followed, as evidenced by the lack of documentation and the unavailability of medications. The Director of Nursing provided the relevant policies, which emphasized the need for proper reordering and documentation of medications.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to label and store medications appropriately in the 100/200 Hall Medication Storage Refrigerator. During an observation, an open vial of Tuberculin (TB) serum was found without a label indicating when it was opened. The RN indicated that the TB serum was received from the pharmacy over a year ago and should have been discarded after 30 days of being opened. The facility's policy requires that TB serum be labeled with the date it was opened and discarded after 30 days. The Director of Nursing confirmed that the TB serum package insert also indicated that vials in use for more than 30 days should be discarded.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 165 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Creek At Greensburg | 1.1 mi | ★★★★★ | 10 | 0 |
| Aspen Place Health Campus | 1.2 mi | ★★★★★ | 0 | 0 |
| Willows Of Greensburg | 1.4 mi | ★★★★★ | 15 | 0 |
| Morning Breeze Retirement Community And Healthcare | 1.5 mi | ★★★★★ | 0 | 0 |
| Waldron Rehabilitation And Healthcare Center | 13.4 mi | ★★★★★ | 7 | 0 |
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