Below average — CMS composite of the measures below.
The next survey window likely opens 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 Hillside Manor Nursing Home during CMS and state inspections, most recent first.
A facility failed to provide ordered pressure ulcer care and complete required wound assessments for two residents. One resident with diabetes, PVD, and bilateral BKA developed a Stage III buttock ulcer, but the wound was not documented on facility skin checks, ordered treatments were not recorded on the MAR/TAR, and the DON said the facility was unaware of the wound care order. Another resident with severe cognitive impairment, hemiplegia, and diabetes had an unhealed Stage II buttock ulcer, but the wound order was entered incorrectly, the weekly wound observation tool was not completed, and staff relied on skin observation entries instead of full wound assessments.
Surveyors found multiple food safety and sanitation deficiencies, including an unclean, discolored backsplash with dried splatterings behind a three-compartment sink, uncovered cookie dough stored open to air in a freezer, and improper utensil handling when the DM repeatedly rested chicken-serving tongs against a sanitizing towel between uses during meal service. A live roach was observed on an outlet near the three-compartment sink, despite the DM stating she had not seen live roaches and that pest control visits routinely. Kitchen staff reported that food should be covered in the freezer and that staff are responsible for ongoing and end-of-shift cleaning, while facility policy required food service areas to be kept clean, sanitary, and protected from pests, with the food services manager responsible for scheduling regular cleaning.
DON Not Working Full Time: The facility failed to ensure a RN served as DON on a full-time basis. Staffing records showed the interim DON worked fewer than 40 hours per week across multiple weeks, while the facility assessment called for 1 full-time DON. The DON said she was only there 1-2 days a week and mainly worked on MDS assessments, and the Administrator stated the full-time DON position still needed to be filled.
A CNA was working in the facility without a verified CNA license. Record review found no license for the employee, who had been hired months earlier, and the Administrator said the only document provided was a 105-hour nurse aide training certificate. The report states the license was not verified upon hire, and the employee had worked multiple night shifts alone as a CNA.
Kitchen Manager Lacked Required Food Service Certification: The facility failed to ensure the Kitchen Manager had appropriate food safety or food service management certification. The Kitchen Manager stated she had kitchen experience but no certification, and the DON/Administrator said she was hired to train first with certification planned later. The facility policy provided did not specify the required training for the Kitchen Manager.
Food items were found open to air and not labeled or dated, including cereal, cheese slices, applesauce, clear liquid, deli meat, bacon, meat patties, breadsticks, and cookies. Multiple refrigerators, freezers, and the ice machine also had debris, frost, black or brown substances, and damaged components, and the temperature log was incomplete with prior months discarded.
Improper Dumpster Waste Containment: The facility failed to ensure trash was properly placed inside the dumpster during multiple observations. Bags of trash were seen sitting on top of the dumpster lids, the dumpster was observed overflowing, and trash and empty boxes were on the ground around it. The Administrator stated staff were having issues placing bags inside the dumpster and that staff were expected to put trash in the dumpster.
Failure to designate a qualified Infection Preventionist. The DON was unsure who served in the role, and an RN stated she was the Infection Preventionist but was not yet certified. The Administrator later provided a job description showing the minimum qualifications included completion of a CMS-approved Infection Prevention and Control Training Course.
Resident-Centered Activity Program Not Maintained: The facility failed to provide an ongoing resident-centered activity program for both halls. The posted activity calendar was not followed, residents reported there were not enough activities, and several scheduled activities such as exercise, bingo, Walmart, and movie/popcorn were not observed. The Activity Director stated she was the only staff member who transported residents to appointments and led activities, so activities were often canceled when she was unavailable.
The facility failed to ensure the activities program was directed by a qualified professional because the Activity Director was not certified. The Activity Director stated she was not certified, and the Administrator said the employee had taken over the role from another position, was enrolled in the AD course, but had not yet taken the certification test.
Unlabeled medication cups were found in a med cart, including cups prepared for multiple residents and a narcotic dose that was not under double lock. An QMA was unsure of the specific meds in several cups, yet still entered residents' rooms and administered the medications, including oxycodone to one resident. The DON stated meds should not be set up for multiple residents and left unlabeled, and all narcotics should be kept under double lock in the med cart.
Therapeutic diets were not provided as ordered. Two residents reported the facility did not offer a diabetic menu, and one said blood sugars had been much higher since diabetic meals were not provided. The Kitchen Manager stated all residents were served the same regular meals, with no alternative meal options for diets such as NCS, NAS, low carb, or altered textures/liquids, despite multiple residents having therapeutic diet orders.
Missing Physician Diet Orders: Three residents had no diet order in the current physician's orders despite care plans referencing diets as ordered. The residents had significant diagnoses including dementia with severely impaired cognition, Parkinson's disease, HTN, depression, anxiety, and protein calorie malnutrition. RN stated every resident should have an MD diet order, and the facility diet policy said a therapeutic diet must be prescribed by the attending physician.
Unsafe and Unsanitary Basement and Laundry Room Conditions: The facility failed to maintain a safe and sanitary environment in the basement and laundry room. Dirt and debris were observed on the basement floor near kitchen refrigerators and freezers, and vent covers had a thick layer of dust. In the laundry room, debris was scattered on the floor where clean clothing was kept, dust and debris had accumulated along the walls and ceiling, exposed wires and an uncovered electrical panel were caked with dust, and the carbon monoxide detector and window AC unit were also heavily dust-covered. The DON was unsure who was responsible for cleaning the laundry room, and the Administrator stated there was no specific environmental policy.
A resident with dementia, anxiety, and severe cognitive impairment was started on Risperdal for anxiety and delusional behavior, but the record lacked documentation that the resident and/or representative was informed in advance about the medication’s risks, benefits, black box warning, or alternatives. The DON said consent and notification could not be verified, and the resident stated she did not know why she was taking multiple medications.
Inaccurate code status documentation was found for a resident with anxiety and moderate cognitive impairment. The resident's current MD order listed full code, while the POST form and binder face sheet showed DNR, and the CNA sheet also listed full code. RN and the Administrator gave conflicting information about the resident's code status, showing the resident's advance directive status was not consistently documented.
A resident with HTN and moderate cognitive impairment was discharged without a complete discharge record, including discharge assessments, a medication list, or referral information for a cardiology follow-up that had been anticipated due to uncontrolled BP and epigastric pain. The discharge form only listed the diet and a PCP follow-up, while the DON, RN, and SSD confirmed that medication and specialty follow-up information were not provided.
Inaccurate MDS coding was found for three residents when ordered and administered medications were not properly documented on quarterly assessments. One resident with diabetes had hypoglycemic medications on the MAR but the MDS did not reflect them, while two other residents had Gabapentin and, in one case, buspirone administered during the look-back period but the MDS coded different medication categories instead. The DON confirmed the coding errors during interview.
Failure to document suprapubic catheter output and record catheter care for a resident with dementia, Parkinson’s disease, and a hx of kidney and prostate cancer. The catheter bag and tubing were observed dragging on the floor, the site had yellow drainage with slight redness and crusting, and the record showed no urine amounts documented despite orders to measure output each shift; staff also reported the catheter should be cleaned daily and the bag emptied for output measurement.
The facility failed to verify registry status before allowing a CNA to work in the CNA role. Record review showed no license on file for the CNA, although the Administrator provided proof of 105-hour nurse aide training and later stated the license had not been verified upon hire. The CNA had worked night shifts and had 35 shifts working alone as a CNA, while the CNA job description stated a current Indiana CNA license was required.
Failure to provide person-centered dementia treatment and services for a resident with severe cognitive impairment and dementia with behaviors. The resident repeatedly asked about his wife and wanted to play Connect Four, but the chart lacked an activities care plan for likes, dislikes, and preferences. The wife said she kept him entertained because there was not much for him to do, and the Activity Director noted he liked walking, food, ice cream, Connect Four, and checkers, but her time was limited.
Significant medication error involving a contraindicated drug interaction. A resident with paraplegia, moderate cognitive impairment, and an indwelling urinary catheter received Cipro for a UTI while also receiving scheduled tizanidine. The chart showed an interaction alert warning that Cipro was contraindicated with tizanidine due to hypotension, dizziness, and excessive sedation, but there was no documented physician communication or pharmacy review. After taking medications, the resident was found unresponsive and lethargic, with ER documentation of loss of consciousness and confusion.
Incomplete MAR/TAR Documentation for Medications and Treatments: The facility failed to accurately document medications and treatments for multiple residents with significant cognitive impairment and complex medical conditions. Records showed numerous missing MAR/TAR entries for scheduled meds, including psychotropics, cardiac meds, diabetes meds, and pain meds, as well as missing suprapubic catheter output documentation. An RN stated the meds and treatments were probably given but not documented, and the DON confirmed that all medications and treatments should be recorded each time they are completed.
Failure to Use EBP for Catheter Care: A resident with a suprapubic catheter had drainage and irritation at the site, but no EBP signage was observed. The resident had severe cognitive impairment, prior UTIs, and an indwelling catheter, while the chart lacked an order for EBP with catheter care. Interviews with the RN and DON confirmed catheter care and urine output documentation issues, and that the resident’s wife changed the catheter bag when visiting.
Failure to Monitor Antibiotic Use and Follow Orders: Two residents had antibiotic orders that were not followed as written. One resident with an indwelling catheter received Macrobid beyond the ordered 7-day course and had Cipro ordered despite culture results showing resistance to one organism; a duplicate nitrofurantoin order was also entered. Another resident with dementia and an indwelling catheter received cephalexin late, missed doses, and then received more doses than ordered, while a Cipro course was short by one dose. The DON stated the orders should have been given as written and that the antibiotic use should have been monitored.
The facility failed to keep the Posted Nurse Staffing form updated and posted each day at the beginning of the shift. Surveyors observed the form dated for prior days on multiple mornings, and the Administrator stated she was responsible for ensuring it was posted with the correct date each day. The facility policy stated the daily staffing schedule should be visible at all times and updated by the DON, ADON, or designee.
A resident with a history of exit-seeking and psychiatric diagnoses eloped by climbing a gazebo and jumping a courtyard wall while unsupervised, despite prior incidents and documented risks. The resident was found by law enforcement after leaving the property, and staff had not updated the care plan or implemented additional interventions following previous escape attempts.
Surveyors identified multiple environmental and sanitation deficiencies, including warped and cracked flooring in a dining room, uncovered transport of clean linens, dust and rust on overhead vents, and a shared shower room with broken tiles, unclean conditions, and a swarm of gnats and flies. A resident reported ongoing maintenance issues, and facility policy requirements for cleanliness and safe linen handling were not met.
A resident with multiple psychiatric diagnoses did not receive several doses of a prescribed antipsychotic medication after a change in their routine medications, due to the facility's inability to obtain the medication from the pharmacy. Staff documented the medication as unavailable on multiple occasions, and interviews confirmed ongoing difficulties in securing the medication, despite facility policy requiring follow-up with the pharmacy and use of emergency drug kits.
The facility did not ensure a safe and comfortable environment, as water temperatures in a resident room and shower room reached 140°F, far above policy limits. Air temperatures in a dining room were recorded as high as 89°F during meals and activities, with residents observed fanning themselves and no fans in use. Multiple areas, including resident rooms and the dining room, had damaged flooring, water leaks, and ceiling damage due to malfunctioning AC units, resulting in wet and uneven floors.
The facility's assessment was found to be incomplete and inaccurate, lacking a staffing plan, specific training topics, transportation details, and communication plans for residents and staff with communication barriers. The Administrator was unaware that the assessment could include detailed facility-specific information and relied on a template updated annually without a specific policy in place.
The facility did not designate a certified Infection Preventionist (IP) for its infection prevention and control program. An LPN, acting as the IP, lacked specialized training and could only dedicate limited time to the role. The facility also lacked a policy or job description for the IP position.
A facility enforced a policy to crush all narcotic medications without resident input or specific physician orders, affecting 10 residents. This decision, made by the Administrator, Medical Director, and DON, was based on concerns about potential misuse of medications. Resident 5, experiencing severe pain, refused her medication due to the unpleasant taste of crushed pills, leading to its discontinuation. The facility lacked a formal narcotic administration policy and did not inform residents of the change beforehand.
The facility failed to ensure accurate MDS assessments for five residents, resulting in discrepancies in documenting medication administration. Residents with various diagnoses were not recorded as taking prescribed antiplatelet, diuretic, or oxygen therapies. The DON was unaware that aspirin is an antiplatelet medication, contributing to the inaccuracies.
The facility failed to develop comprehensive care plans for residents on medications such as antipsychotics, antidepressants, and diuretics. A resident with a history of substance abuse and on antipsychotic medication lacked a care plan. Another resident with COPD and on oxygen also lacked care plans for their medications. The DON acknowledged the absence of care plans and indicated that updates were done quarterly, but care plans were expected for each medication.
The facility failed to provide adequate respiratory care for several residents, including maintaining clean oxygen equipment and ensuring proper documentation of oxygen orders. Residents were observed with dusty filters and undated tubing, and there was confusion about equipment ownership and maintenance responsibilities.
The facility failed to obtain necessary physician orders for medications and oxygen for several residents. A resident with diabetes received insulin without a current order, and three residents lacked current oxygen orders due to a pharmacy change. The facility's pharmacy policy was not followed, leading to these deficiencies.
The facility failed to ensure proper labeling and storage of medications, with several instances of medications lacking open dates and incomplete refrigerator temperature logs. Observations included inhalers, eye drops, and other medications without open dates, and missing temperature records in the medication storage room. The DON confirmed the requirement for open dates on multidose medications and daily temperature logging, but the facility lacked a specific policy for open dates.
The facility failed to meet professional standards in food handling and kitchen sanitation. Staff did not wear proper hairnets or footwear, and food items were unlabeled. The dishwasher was not monitored for safe sanitation, with temperatures below the required minimum and no chemical checks documented. Handwashing protocols were not followed, and scoops were left in containers. The facility's policies on dishwashing, food storage, hairnet use, and thermometer sanitation were not adhered to.
The facility failed to ensure a sanitary environment, with staff not changing gloves between tasks, not sanitizing hands, and not implementing Enhanced Barrier Precautions for residents with wounds and catheters. Clean clothing was transported improperly, and ice was handled inappropriately, indicating a lack of adherence to infection control protocols.
The facility failed to ensure a safe, sanitary, and homelike environment, with issues such as brown substances around toilets, rusted fixtures, chipped doors, and missing tiles in communal restrooms and shower rooms. A couch had peeled fabric, and a courtyard door had a gap. The Maintenance Supervisor, also the Housekeeping Supervisor, was unaware of some issues and indicated a lack of formal policies and documentation for maintenance and cleaning tasks.
The facility failed to maintain an effective pest control program, as evidenced by the presence of insects and rodents in the downstairs dry storage room. Sticky pads were found full of insects and a dead mouse, with a live mouse also observed. The pest control company had visited recently but reported no concerns, despite ongoing issues with mice. The facility's policy required the building to be kept free of pests, but this was not achieved.
A facility failed to assess the clinical appropriateness of self-administration of medications for a resident with COPD and asthma. An Albuterol inhaler was found in the resident's room without an order to keep it at the bedside or a self-administration assessment. The resident was cognitively intact, but the facility did not follow its policy requiring an assessment by an interdisciplinary team.
The facility failed to update comprehensive care plans for three residents. A resident's care plan did not include bed rails as a fall intervention, another resident's care plan listed an outdated antidepressant, and a third resident's care plan was not revised after an antianxiety medication was discontinued. The DON acknowledged these oversights, noting that she was the only staff member able to update care plans in the electronic health record.
A resident at risk for pressure ulcers developed multiple stage two and a stage three pressure injury due to the facility's failure to provide effective care and documentation. Despite the resident's reports of pain and the presence of wounds, staff were unaware of the injuries, and there were inconsistencies in treatment records. The facility did not adhere to its pressure ulcer program policy, leading to inadequate assessments and care plans.
The facility failed to supervise and manage vaping devices among residents, leading to safety hazards. Two residents were found with vapes despite policies requiring storage at the nurse's station. Resident 15, with a history of substance abuse, had vapes on his bedside table, and staff did not address this. Resident 24, with cognitive impairment, was observed holding vapes, and staff failed to intervene. Staff interviews revealed inconsistencies in handling and documenting vaping incidents, and the facility's smoking policy was unclear.
The facility failed to maintain complete and accurate clinical documentation for two residents. One resident's records lacked details about an incident involving THC use and subsequent hospitalization, while another resident had an undated Band-Aid with no documented reason. Staff interviews revealed uncertainty and incomplete records, highlighting deficiencies in documentation practices.
The facility failed to provide adequate staff training for managing residents with substance abuse and PTSD. A resident with a history of substance abuse lacked a care plan for overdose risk, and staff were not trained on Narcan use. Another resident with PTSD had specific needs that were not addressed due to insufficient staff training.
A resident with severe cognitive impairment and documented behaviors eloped from the facility unwitnessed due to insufficient behavioral health care. The resident's care plan was not updated, and the incident was not documented in progress notes. The facility's behavior management program policy was not followed, and the resident's behavioral tracking log was missing.
The facility failed to maintain accurate records for two residents. One resident's elopement incident and behaviors were not documented, and another resident's wound treatment orders were not updated or recorded properly. Staff interviews confirmed the lack of proper documentation.
Failure to Provide Ordered Pressure Ulcer Care and Complete Wound Assessments
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and failed to prevent new pressure ulcers from developing for 2 residents reviewed. Resident B had diagnoses including bilateral below-knee amputations, type II diabetes, and peripheral vascular disease, and was assessed as at risk for pressure injuries. The resident’s care plan identified impaired skin integrity related to PVD and diabetes, and physician orders included weekly skin assessment and wound center treatments and consults. Resident B developed a Stage III pressure ulcer on the right buttock. Wound center documentation described the ulcer as full thickness with exposed subcutaneous tissue, serosanguineous drainage, slough/fibrin, and measurements that changed over time. The wound center ordered cleansing with Vashe Wound Solution, application of Calmoseptine to peri-wound skin, and offloading with an alternating air mattress. Facility records did not contain documentation of the right buttock wound between the date it was first noted by the wound center and the later wound center visit, and the MAR/TAR contained no treatment order or treatment documentation for the Stage III pressure ulcer through the review date. Facility skin assessments documented the resident as warm, dry, and intact and did not identify the right buttock wound. The DON stated the facility first learned of the wound after the wound center visit, was unaware of the wound care order, and had not completed wound assessments at the facility because the resident was being seen at the wound clinic three times a week. Resident C had diagnoses including type II diabetes, hemiplegia, heart disease, dementia, and overactive bladder, and was assessed as having severe cognitive impairment, dependence for mobility and transfers, and risk for pressure injuries. The resident had an unhealed Stage II pressure ulcer on the left buttock, and physician orders directed cleansing with normal saline, application of Puracol with silver or a similar collagen product, and a daily dressing change. The weekly wound observation tool was created but initially contained no information, and the record showed weekly skin observation entries with wound measurements, but no completed weekly wound observation assessments. The MAR/TAR showed the wound care order was documented daily until it was discontinued, but there was no documentation from the later period showing the Stage II pressure ulcer treatment order had been completed. The DON stated the treatment order had been entered incorrectly into the computer system and was not populating for nursing staff, and that staff were using the weekly skin observation tool instead of the weekly wound observation tool to complete full wound assessments.
Food Storage, Sanitation, and Pest Control Deficiencies in Kitchen
Penalty
Summary
Surveyors identified that the facility failed to store and handle food in accordance with food safety standards during two kitchen observations. During one observation, the backsplash behind the three-compartment sink appeared unclean, discolored, and had several dried splatterings. In a downstairs standing freezer, surveyors found an open bag of individual cookie dough balls exposed to air. Kitchen Staff 4 later stated that food should be covered when stored in the freezer and that staff are responsible for cleaning during their shifts and performing a full kitchen cleaning at the end of each shift. In a separate observation during meal service, the Dietary Manager used a pair of tongs to plate chicken and repeatedly set the tongs down on a tabletop so that the serving end rested against a cleaning towel that had been dipped in sanitizing solution, then used the same tongs to plate the next piece of chicken. Additionally, a live roach was observed on an outlet near the three-compartment sink. The Dietary Manager reported not having seen any live roaches in the kitchen and indicated that pest control visits the facility routinely. The facility’s written sanitization policy required that food service areas be kept clean, sanitary, and protected from rodents, roaches, flies, and other insects, and assigned the food services manager responsibility for scheduling regular cleaning of kitchen and dining areas.
DON Not Working Full Time
Penalty
Summary
The facility failed to ensure a registered nurse was serving as the Director of Nursing (DON) on a full-time basis for 1 of 1 DON reviewed. The DON was listed as interim, and the posted nurse staffing forms from 11/1/25 through 12/7/25 showed the DON worked 36 hours the first week, 36 hours the second week, 34 hours the third week, 31 hours the fourth week, and 39 hours the first week of December. The facility assessment, last revised 11/26/25, indicated staff would include 1 full-time DON. During interview, the DON stated she did not clock in or out, was there 1-2 days a week, and worked mostly on MDS assessments. She said she was retired, did not want the responsibilities of the DON, and was helping on an as-needed basis. The Administrator stated she knew the full-time DON position needed to be filled but the facility was having trouble finding someone. A non-dated DON job description provided by the Administrator described the DON as responsible for overall management of the Nursing Department, ensuring high-quality resident-centered care, supervising staff, ensuring regulatory compliance, and leading quality improvement initiatives.
Unverified CNA Certification
Penalty
Summary
The facility failed to ensure that a staff member working as a Certified Nurse Aide was certified for 1 of 5 CNA licenses reviewed. During record review, no CNA license was found for CNA 24, who was hired on 8/28/24 and whose 120-day period would have ended on 12/26/24. The Administrator provided a certificate showing completion of the 105-hour nurse aide training from the Indiana State Department of Health and stated that was what had been provided to the facility, but she also said she wanted to double check with the employee to see if she was under a different name because she was working as a CNA in the facility. Later, the Administrator stated she was not aware that CNA 24 was not licensed. The report also states the license was not verified upon hire, and that the employee usually worked eight-hour night shifts and had 35 shifts working alone as a CNA since September 2025.
Kitchen Manager Lacked Required Food Service Certification
Penalty
Summary
The facility failed to ensure appropriate certification of the Kitchen Manager for 1 of 1 employee identified as Kitchen Manager. During interview, the Kitchen Manager stated she did not have a certification in kitchen management, had started at the facility about 3 months earlier, and had kitchen experience but no type of certification. The Administrator stated the Kitchen Manager was hired on 9/16/25 and that the plan was to train her in the kitchen first and then obtain certification the first of the year. The Administrator also provided a non-dated Food and Nutrition Services Staff policy, which did not specify the training required of the Kitchen Manager.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety in the kitchen. During observation, multiple food items were found open to air and not labeled or dated, including clear containers of cereal under the food preparation counter, a baggie of cheese slices, pitchers of applesauce and clear liquid, an open package of deli meat, a tray of bacon strips, an open package of meat patties, an open package of breadsticks, and an open bag of cookies. The Kitchen Manager stated she was aware items needed to be labeled and was in the process of trying to get staff to label items. Additional observations showed poor storage conditions and sanitation concerns in several refrigerators, freezers, and storage areas. A refrigerator/freezer drawer was cracked with a large portion missing and exposed jagged edges, debris was observed in freezers and refrigerators, a large freezer in the basement had a thick layer of frost and black substance around the suction part of the lid, and another refrigerator/freezer had dried yellow substance and debris in the bottom. The ice machine had an uncovered scoop sitting on top and a brown substance inside, and two refrigerators in the dry storage room had debris littering the inside. The white refrigerator/freezer had October's temperature log attached and partially filled out, and the Kitchen Manager stated the new December log should have been posted and that previous months were thrown out, with no logs kept of previous months.
Improper Dumpster Waste Containment
Penalty
Summary
The facility failed to ensure waste was properly contained in dumpsters for 2 of 2 random observations. On 12/1/25 at 1:30 P.M., the dumpster in the back parking lot was observed with several trash bags sitting on top of the front lids, and a staff member placed another bag of trash on top of the bags already on the lids. Another staff member then went to the back of the dumpster, lifted the back lids, and placed a trash bag inside the dumpster. Trash was also observed on the ground surrounding the dumpster. On 12/8/25 at 2:02 P.M., the dumpster was observed overflowing with trash, with bags sitting on top of the lids and empty boxes on the ground around the dumpster. On 12/10/25 at 12:10 P.M., the Administrator stated trash pickup days were Tuesday and Friday and that staff were having issues putting bags of trash on top of the dumpster instead of inside it; she also stated there was no policy, but staff were expected to place bags of trash in the dumpster.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate one or more qualified Infection Preventionist(s) responsible for the infection prevention and control program for 7 of 7 days of the survey. During an interview on 12/1/25 at 9:56 A.M., the DON indicated she was unsure who the Infection Preventionist was. During an interview on 12/9/2025 at 12:17 P.M., RN 3 stated that she was the Infection Preventionist, but she was not yet certified. On 12/10/25 at 8:25 A.M., the Administrator provided an Infection Preventionist job description stating that the minimum qualifications included completion of a CMS-approved Infection Prevention and Control Training Course.
Resident-Centered Activity Program Not Maintained
Penalty
Summary
The facility failed to provide an ongoing resident-centered activity program for 2 of 2 halls, Front Hall and Back Hall. The activity calendar was posted, but it was not followed as scheduled. Resident interviews stated there were not enough activities, and one resident said there really was not anything to do and that requests for more activities were met with the response that staff were limited. Another resident stated that if the Activity Director was not available, a couple of residents would sometimes conduct the activity instead. Survey observations showed multiple scheduled activities were not occurring as posted. On 12/4/25, exercise scheduled for 9:00 A.M. was not observed, and later that day a resident was conducting bingo with no staff present. On 12/5/25, the Activity Director was seen leaving with a resident for transportation, and the 9:00 A.M. exercise was not observed. On 12/8/25, Walmart, exercise, and movie and popcorn activities scheduled for 11:00 A.M., 9:00 A.M., and 1:00 P.M. were not observed. The Administrator stated the Activity Director was not there because she was transporting a resident to an appointment. The Activity Director said she was the only staff member who took residents to appointments and did activities in the facility, that activities had to be canceled when she was unavailable, and that she was not aware of how to enter activity care plans for newer residents.
Uncertified Activity Director
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional because the Activity Director was not certified. During employee record review, the Activity Director stated she was not certified at the time of the interview. The Administrator stated that the employee had been hired for another position and took over the Activity Director role on 8/22/25, was currently enrolled in the Activity Director course, but had not yet taken the test to become certified. The Administrator also stated she was aware that certification was required. A current undated Activity Director policy provided by the Administrator listed personnel specifications as a high school graduate with aptitude and some training in arts and crafts, and the ability to plan and organize recreational activities.
Unlabeled Medications and Improper Narcotic Storage in Medication Cart
Penalty
Summary
The facility failed to maintain safe and secure storage of medications for 1 of 1 medication carts observed. During an observation on 12/1/25 at 10:09 A.M., QMA 5 opened the second drawer of the medication cart, which was not under a double lock, and removed an unlabeled medication cup identified as being for Resident 15. QMA 5 stated she was unsure of the specific medications in the cup and then entered Resident 15's room. During the medication pass, she told Resident 15 that 1 of the 11 pills was a pain pill, and later identified that pill as 5 mg oxycodone, a narcotic. Additional observations on 12/4/25 showed more unlabeled medication cups in the cart. QMA 5 opened a medication drawer and found an unlabeled cup containing a yellow substance and a tablet, which she said was for Resident 24 and that the resident liked medications soaked in applesauce. Another drawer contained a clear, unlabeled medication cup that QMA 5 said was for Resident 7, though she was unsure what medications were in it. QMA 5 also removed a clear, unlabeled cup with 10 pills, identified it as being for Resident 30, stated she was unsure what the medications were, added applesauce to the cup, and administered the medications. The DON stated medications should not be set up for multiple residents and left unlabeled, and all narcotics should be under a double lock at all times in the medication cart.
Therapeutic diets were not provided as ordered
Penalty
Summary
The facility failed to ensure that residents received diets that met their daily nutritional and special dietary needs. Based on interview and record review, 12 of 35 residents who ate facility-provided meals were served a regular diet even though their orders included therapeutic diets such as no concentrated sweets, no added salt, low concentrated sweets, low carb, mechanical soft, ground meat, finger foods, and altered liquid consistency. The residents identified in the findings included Resident 4, Resident 9, Resident 11, Resident 13, Resident 20, Resident 3, Resident 29, Resident 8, Resident 30, Resident 22, Anonymous Resident A, and Anonymous Resident B. During the survey, two anonymous residents stated the facility did not provide a diabetic menu. One resident said their blood sugars had been three times higher than they needed to be since a diabetic meal was not provided, and another said residents were expected to know what they could and could not eat from the meals served and avoid contraindicated items themselves. The Kitchen Manager stated that although several residents had therapeutic diet orders, there were no alternative meals or selections for any diets other than regular, and she was unaware of diabetic or renal diet meal options. She said all residents were served the same meals, with alternative choices limited to ramen noodles, soup and crackers, or peanut butter sandwiches. Meal cards and diet orders reviewed showed multiple residents had therapeutic diet orders that were not reflected in the meals being served.
Missing Physician Diet Orders
Penalty
Summary
Therapeutic diets were not documented as ordered by a prescribing practitioner for 3 of 15 residents reviewed for diet orders. Resident 7 had diagnoses including dementia with behaviors, Parkinson's disease, hypertension, and cancer of the kidney and prostate, and the most recent MDS indicated severely impaired cognition. The current physician's orders did not include a diet order, although the nutritional care plan included an intervention to provide and serve diet as ordered. Resident 23 had diagnoses including dementia with behaviors, hypertension, anxiety, and depression, and the most recent MDS indicated severely impaired cognition. The current physician's orders lacked a diet order, while the nutritional care plan included an intervention to provide and serve diet as ordered. Resident 10 had diagnoses including constipation, vitamin D deficiency, insomnia, anxiety disorder, and unspecified protein calorie malnutrition, and the most recent annual MDS indicated severely impaired cognition. The current physician's orders lacked a diet order, although the skin care plan included an intervention to encourage food and fluid intakes within therapeutic diet. RN 3 stated there should be a diet order from the MD for every resident, and the facility's diet policy stated that a therapeutic diet must be prescribed by the attending physician.
Unsafe and Unsanitary Basement and Laundry Room Conditions
Penalty
Summary
The facility failed to ensure a safe and sanitary environment in the basement and laundry room. In the basement, dirt and debris were observed on the floor in the area where the kitchen refrigerators and freezers were stored, and two vent covers in the hallway to the ice machine room had a thick layer of dust between the vent slats on two separate observations. In the laundry room, debris was scattered across the floor where clean clothing was kept, debris had accumulated where the wall and floor met, multiple wires on the ceiling were exposed and caked with dust, the electrical panel box lacked a door and had exposed wires caked with dust, a window air conditioning unit had a thick layer of dust, and a carbon monoxide detector was sitting in the room caked with dust. The DON stated she was unsure who was responsible for cleaning the laundry room, and the Administrator stated there was no specific environmental policy, only a monthly check of the laundry room, basement floors, and vents.
Failure to Document Informed Consent Before Starting Antipsychotic
Penalty
Summary
The facility failed to ensure that a resident was informed in advance by the prescribing practitioner of the risks and benefits of proposed treatment and treatment alternatives before an antipsychotic was started. Resident 23 had diagnoses including dementia without behaviors, anxiety, and hypertension, and the most recent MDS indicated severely impaired cognition, supervision for transfers, and use of an antipsychotic. During an interview, the resident stated she had not been on medications before admission and now was on several medications but did not know why, and she believed her shuffling gait might be from the medications. The clinical record showed Risperdal 0.5 mg twice daily was ordered for unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A progress note stated the resident was very anxious and delusional at times, and the DON reported the behavioral NP gave the order after being informed by the DON. The record lacked documentation that the resident and/or representative was notified or educated about the medication’s risks and benefits, the black box warning, or alternative methods tried and/or contraindicated before the antipsychotic was administered. The DON stated documentation of consent and notification could not be provided and that if it was not documented, it was not done.
Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to ensure accurate representation of advance directive status for 1 of 2 residents reviewed for advance directives. Resident 32 had diagnoses including anxiety and a most recent quarterly MDS dated 9/27/25 that indicated moderate cognitive impairment. The current physician orders listed the resident as full code, dated 5/2/25, but a POST form dated 12/10/24 indicated DNR status. During record review and interview, RN 3 stated that residents' code status was kept in a binder at the nurses station. The binder contained Resident 32's face sheet with DNR written at the top, and RN 3 stated the resident would not be resuscitated in a code situation because of the DNR in the binder. She also stated code status was documented on CNA sheets, but the current CNA sheet for Resident 32 indicated full code. The Administrator later stated she had spoken with Resident 32, who said he wished to be full code, and that all code status information needed to be changed to reflect full code.
Incomplete Discharge Preparation and Missing Follow-Up Information
Penalty
Summary
The facility failed to ensure that a discharged resident was prepared for a safe transfer/discharge and that the discharge met the resident's needs and preferences. Resident 38 was admitted with a diagnosis of hypertension and had an admission MDS indicating moderate cognitive impairment. The clinical record included physician orders for Losartan Potassium-HCTZ 100-12.5 mg daily for hypertension, but the record lacked discharge assessments, progress notes related to discharge, and any referral or other information related to a cardiology appointment. The resident had been seen by the local Health Department before admission, where blood pressure was documented at 222/89 and the provider noted concern for epigastric pain and uncontrolled hypertension, with a likely need for a cardiology consult once insurance was established. At discharge, the written form only listed the current diet and instructed the resident to make a primary care appointment within 30 days. The form did not list the resident's medication or include information directing follow-up with a cardiologist. The Interim DON stated that a discharge summary sheet, follow-up appointments, and a medication sheet should have been provided, while RN 3 said the medication sheet may not have been printed because the resident was only taking one medication. The SSD stated the resident was told to follow up with the PCP only, and a discharge policy was requested but not provided.
Inaccurate MDS Coding for Ordered Medications
Penalty
Summary
The facility failed to ensure accurate MDS assessments for 3 of 12 residents reviewed because medications were not correctly coded on the assessments. Resident 2 had diagnoses including diabetes mellitus, and the quarterly MDS dated 11/28/25 indicated no cognitive impairment and no use of a hypoglycemic medication, even though physician orders showed Jardiance, Humalog, and Tresiba FlexTouch were ordered for diabetes and the MAR showed these medications were administered during the MDS look-back period. The DON later indicated Resident 2's MDS should have been marked with a hypoglycemic medication. Resident 3 had diabetes mellitus and was ordered Gabapentin 400 mg three times daily by mouth, but the quarterly MDS dated 11/5/25 indicated insulin was received and did not document an anticonvulsant. Review of the October and November MAR showed Gabapentin was administered 5 of 7 days during the look-back period, and the DON stated the insulin was coded in error and Gabapentin should have been coded as an anticonvulsant. Resident 8 had diagnoses including paranoid schizophrenia, diabetes mellitus, and bipolar disorder, and the quarterly MDS dated 10/8/25 indicated an antidepressant was received but did not document an anticonvulsant or an antianxiety medication. Current orders showed Gabapentin 300 mg three times daily and buspirone 15 mg three times daily, and the October MAR showed both medications were administered 7 of 7 days during the look-back period; the DON stated the antidepressant was coded in error and that buspirone and Gabapentin should have been coded as antianxiety and anticonvulsant medications.
Failure to Document Suprapubic Catheter Output and Perform/Record Catheter Care
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a suprapubic catheter. The resident had diagnoses including dementia with behaviors, Parkinson’s disease, hypertension, and cancer of the kidney and prostate, and his most recent MDS indicated severely impaired cognition, use of a diuretic, an indwelling catheter, and substantial to maximum assistance for toileting. The physician’s orders included documenting suprapubic catheter output every shift and maintaining the catheter per MD orders and facility policy, and the care plan called for monitoring and documenting intake and output and reporting signs and symptoms of UTI. However, the TAR and electronic record from 11/1/25 through 12/5/25 showed the catheter was to be emptied daily for day and night shift, but no urine amounts were documented, and the record lacked documentation that catheter care was performed. During observation, the catheter bag and tubing were seen dragging on the hallway floor while the resident walked to the nurse’s station, and a QMA picked it up and hung it back on the resident’s pant pocket. Later, the catheter site was observed with a small amount of yellow drainage, slight redness/irritation, no odor, and brownish crust around it. The physician’s orders did not include Enhanced Barrier Precautions for catheter care, and staff interviews indicated the wife sometimes changed the catheter bag, nurses were responsible for catheter care, CNAs should drain the bag to measure output, and the catheter site should be cleaned daily. The DON stated the orders were not entered correctly because urine output should have been measured each shift and catheter care should have been documented every time.
CNA License Not Verified Before Working in Role
Penalty
Summary
The facility failed to obtain registry verification before allowing CNA 24 to work in the CNA role, affecting 1 of 5 CNA licenses reviewed. Record review on 12/8/25 showed no license on file for CNA 24, who had been hired on 8/28/24 and whose 120-day period would have ended on 12/26/24. During interviews, the Administrator provided a certificate showing completion of the 105-hour nurse aide training from the Indiana State Department of Health and stated that was what had been provided to the facility, but she wanted to confirm whether the employee may have been under a different name because the employee was working as a CNA in the facility. The Administrator later stated she was not aware CNA 24 was not licensed and that the license was not verified upon hire. She reported the employee typically worked eight-hour night shifts and had worked 35 shifts alone as a CNA since September 2025. A current undated CNA job description provided by the Administrator stated that a CNA must possess a current Indiana CNA license.
Failure to Provide Person-Centered Dementia Activities
Penalty
Summary
The facility failed to ensure person-centered dementia treatment and services were provided for a resident with dementia with behaviors. The resident’s diagnoses included dementia with behaviors, Parkinson’s disease, hypertension, and cancer of the kidney and prostate. The most recent MDS assessment indicated the resident’s cognition was severely impaired. During observations, the resident was seen sitting by the front door asking to play Connect Four and later asking when his wife would be coming, with staff telling him his wife would be here soon or telling him to wait in his room for her. The clinical record did not contain an activities care plan addressing the resident’s likes, dislikes, and preferences. The resident’s wife stated she was present most days and kept him entertained because there was not much for him to do, and that he did not do much with the community because of his dementia. The Activity Director stated the resident liked walking, loved food, had an obsession with ice cream, liked playing Connect Four and checkers, and was family oriented, but also stated that dementia care consisted of one-on-one visits and simple activities because more complex activities could confuse residents. She further stated she was the only one taking residents to appointments, which limited her time.
Significant Medication Error With Contraindicated Drug Interaction
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 1 of 2 residents reviewed for UTI. A resident with paraplegia, polyneuropathy, anxiety, depression, moderate cognitive impairment, and an indwelling urinary catheter was treated for a UTI with Cipro 500 mg twice daily from 11/17/25 through 11/21/25. The resident also had active orders for tizanidine 2 mg three times daily and tizanidine 4 mg three times daily, totaling 6 mg per dose. The record included a drug interaction alert stating Cipro was contraindicated with tizanidine due to the risk of hypotension and dizziness, and the report noted the NIH warned the combination may cause excessive sedation. The resident’s record lacked documented communication with the physician or pharmacy review regarding the new Cipro order and the interaction risk with tizanidine. On 11/21/25, the resident was found unresponsive in his room and did not respond to verbal stimuli, requiring three sternal rubs to awaken him. The nurse documented that the resident was very lethargic, confused, and drowsy after having just taken his medications. ER records from the same day documented a change in mental status related to loss of consciousness, with the resident stating he felt unable to stay awake and was confused. The final ER impression was ureteral stone with hydronephrosis and an acute UTI. The DON stated the interaction should have been addressed and that the facility had concern about the pharmacy, nursing staff, and physician review of the new order.
Incomplete MAR/TAR Documentation for Medications and Treatments
Penalty
Summary
The facility failed to ensure accurate documentation in the MAR/TAR for multiple residents reviewed for unnecessary medications and treatments. The deficiency was based on interview, observation, and record review showing that medications and treatments that were reportedly administered were not documented as given. The report identified missing entries for 3 of 6 residents reviewed: Resident 3, Resident 7, and Resident 23. Resident 3 had diagnoses including diabetes mellitus, hypertension, hyperlipidemia, and stroke, and the most recent quarterly MDS indicated severe cognitive impairment. The resident had numerous physician’s orders, including multiple scheduled medications such as baclofen, oxybutynin, ropinirole, Xarelto, metformin, gabapentin, atorvastatin, lisinopril, Vraylar, benztropine, carvedilol, clonazepam, duloxetine, hydroxyzine, Refresh Optive, and oxycodone-acetaminophen. Review of the October and November MAR showed many missed or undocumented doses across these medications, including repeated omissions for baclofen, oxybutynin, ropinirole, Xarelto, metformin, protein supplement, gabapentin, atorvastatin, baclofen 10 mg, lisinopril, oxybutynin 10 mg, Vraylar, benztropine, carvedilol, clonazepam, duloxetine, hydroxyzine, Refresh Optive, and oxycodone-acetaminophen. Resident 7 had diagnoses including dementia with behaviors, Parkinson’s disease, hypertension, and cancer of the kidney and prostate, and was admitted with a suprapubic catheter. The admission MDS indicated severely impaired cognition and an indwelling catheter. The September through December MAR/TAR contained numerous missing medication entries and missing suprapubic catheter output documentation, including omissions for amlodipine, donepezil, escitalopram, folic acid, furosemide, lactobacillus, thiamine, Augmentin, medroxyprogesterone, oxcarbazepine, benztropine, cephalexin, estradiol patch, potassium chloride, Bactrim DS, buspirone, memantine, and metoprolol, along with repeated missing day-shift catheter output documentation. Resident 23 had diagnoses including dementia without behaviors, anxiety, and hypertension, and the admission MDS indicated severely impaired cognition and antipsychotic use. The October and November MAR showed missing doses of Depakote, risperidone, vitamin D3, donepezil, multivitamin, and lisinopril on multiple dates. On interview, the registered nurse stated the medications and treatments were probably completed but staff probably forgot to document them in the MAR/TAR, and that they should be documented each time they were given. The DON stated staff were absolutely supposed to keep accurate documentation of medications and treatments given and that they should all be documented in the MAR/TAR when completed. The facility’s documentation policy stated that all services provided to the resident shall be documented in the medical record and that documentation should be objective, complete, and accurate.
Failure to Use EBP for Catheter Care
Penalty
Summary
The facility failed to ensure residents with indwelling devices were placed on Enhanced Barrier Precautions (EBP) when indicated. One resident with a suprapubic catheter was observed in his room with a small amount of yellow drainage at the catheter site, slight redness/irritation, no odor, and brownish crust around the site, and there was no EBP signage observed. The resident’s record showed diagnoses including dementia with behaviors, Parkinson’s disease, hypertension, and cancer of the kidney and prostate, and he had been admitted with a suprapubic catheter. His most recent MDS indicated severely impaired cognition, use of a diuretic, an indwelling catheter, and substantial to maximum assistance needed for toileting. The resident’s physician orders included documenting suprapubic catheter output every shift and maintaining the catheter per MD orders/facility policy, but there was no order for EBP to be used with catheter care. The care plan addressed catheter maintenance, intake and output monitoring, and reporting signs and symptoms of UTI. During interview, the RN stated the resident’s wife changed the catheter bag when she visited, that the resident had prior UTIs and was uncircumcised, and that CNAs needed education on retracting the foreskin and cleaning it. The RN also stated catheter care should be done daily and that nurses perform the care while CNAs drain the bag for output measurement; she was unsure when the last catheter-care in-service occurred. The DON stated the orders were not entered correctly in the EHR because urine output should be measured each shift and catheter care should be documented each time it was done.
Failure to Monitor Antibiotic Use and Follow Antibiotic Orders
Penalty
Summary
The facility failed to ensure an antibiotic stewardship program was used to monitor appropriate antibiotic use for 2 residents reviewed for antibiotic use. One resident with paraplegia, polyneuropathy, anxiety, depression, moderate cognitive impairment, and an indwelling urinary catheter had physician orders for Cipro and Macrobid/nitrofurantoin after a urinalysis indicated a UTI and culture and sensitivity showed morganella morganii resistant to Cipro and Macrobid, and pseudomonas aeruginosa sensitive to Cipro. The resident’s MAR showed Macrobid ordered for 7 days was still being administered on day 12, and the DON stated the Cipro should have been questioned because it was resistant to one of the organisms and that the duplicate nitrofurantoin order likely resulted from the generic name being entered as a separate order. A second resident with dementia with behaviors, cancer of the kidney and prostate, hypertension, severe cognitive impairment, and an indwelling catheter had orders for cephalexin for cellulitis of the right great toe and Cipro for UTI. Review of the MAR showed cephalexin was not started as ordered, doses were missed and then continued beyond the ordered course, resulting in 34 doses given when 21 were ordered, while the Cipro course was short by one dose. The DON stated the cephalexin should have started as ordered and that the resident should have received the antibiotics as ordered, but the orders were entered incorrectly and no one paid attention.
Posted Nurse Staffing Form Not Updated Daily
Penalty
Summary
The facility failed to ensure the Posted Nurse Staffing form was posted and updated daily at the beginning of each shift for 3 of 6 days reviewed. Surveyors observed the form on 12/4/25 at 10:01 A.M. dated 12/3/25, on 12/5/25 at 9:09 A.M. dated 12/4/25, and on 12/8/25 at 9:06 A.M. dated 12/5/25. During an interview on 12/10/25 at 12:00 A.M., the Administrator stated she was responsible for posting the form with the correct date each day first thing in the morning and that it should be up to date. On 12/9/25 at 4:02 P.M., the Administrator provided a staffing policy stating the daily staffing schedule is to be posted at the back hall, visible at all times, and updated by the DON, ADON, or designee.
Failure to Prevent Elopement of Resident with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for a resident with a known history of exit-seeking and elopement behaviors. The resident, who had diagnoses including anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia, was assessed as having moderately impaired cognitive skills and required supervision for mobility and transfers. Despite a care plan identifying the resident as at risk for elopement and documenting previous incidents of exit-seeking, interventions such as personal safety alarms or devices were not implemented. The resident had previously exhibited exit-seeking behaviors, including climbing over a courtyard wall when frightened by EMTs and moving furniture to facilitate escape attempts. On the evening of the incident, the resident climbed a gazebo in the facility's walled courtyard, jumped over the 66-inch wall, and left the property. The event occurred while the nurse was occupied assisting EMS with another resident, leaving the at-risk resident unsupervised. The resident was located approximately 0.6 miles from the facility, hiding behind an air conditioning unit near a busy intersection, and attempted to flee from law enforcement before being apprehended. The facility's records and staff interviews confirmed that the resident had previously used the same method to attempt elopement and that staff were aware of the resident's behaviors and triggers, such as being frightened by EMS presence. The facility's policy required that residents identified as at risk for wandering or elopement have care plans with appropriate interventions to maintain safety. However, the resident's care plan and supervision were not updated in response to repeated exit-seeking behaviors and prior incidents. Staff interviews indicated that elopement risk assessments and care plan updates were not consistently performed when the resident exhibited increased exit-seeking behavior, contributing to the failure to prevent the elopement event.
Removal Plan
- Completed audits of clinical records for residents at risk for exit-seeking behavior or elopement.
- Removed the Gazebo from the courtyard.
- Removed a tree in the courtyard.
- Secured patio furniture.
- Equipped all exit doors with Wander-guard key pad.
- Provided in-service training to staff on the elopement exit seeking policy.
- Monitoring changes in residents' behavior.
Environmental and Sanitation Deficiencies in Resident Areas
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's environment, including a lack of maintenance and cleanliness in key resident areas. In the North Unit dining room, the flooring was found to be uneven, warped, and cracked, with a towel placed under an in-wall air conditioning unit. Clean linens were transported through the South Unit in an open laundry basket, exposing them to potential contamination. Overhead air vents in both the North Unit hall and the shared shower room were noted to have a significant build-up of dust, and one vent appeared rusted. The shared shower room in the middle hall, used by residents from both the North and South Units, had three broken floor tiles near the base of the commode, which itself appeared unclean. A small swarm of gnats and flies was observed around the commode, indicating unsanitary conditions. During an interview, a resident reported that the shower room required maintenance and that the maintenance staff could not keep up with the facility's needs. Facility policy requires the environment to be safe, functional, sanitary, and comfortable, and for clean linens to be transported in a manner that prevents contamination, but these standards were not met in the areas observed.
Failure to Provide Ordered Routine Medication Due to Pharmacy Service Issues
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident who required routine physician-prescribed medication. Following a change in the resident's medication regimen, the facility did not obtain the ordered medication, Geodon 40 mg, resulting in multiple missed doses over several days. Documentation in the Medication Administration Record and nurse's progress notes repeatedly indicated that the medication was unavailable or not in stock on specific dates. The resident's diagnoses included anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia, and the resident was noted to have moderately impaired cognitive skills and was rarely to never understood. Interviews with staff revealed ongoing difficulties in obtaining the medication from the pharmacy, attributed in part to the resident's payor source. Nursing staff reported that when a routine medication was unavailable, they were expected to check the emergency drug kit, document missed doses, and notify the physician. Despite these procedures, the resident did not receive the prescribed medication as ordered, and the facility's policy required contacting the pharmacy and using after-hours emergency numbers if necessary. The deficiency was identified through record review and staff interviews, confirming that the facility did not ensure the resident received all ordered medications.
Failure to Maintain Safe, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in several areas, as evidenced by observations and interviews. In one resident room and one shower room, water temperatures were found to be excessively high, reaching 140 degrees Fahrenheit, which exceeds the facility's policy limit of 120 degrees Fahrenheit. The Maintenance Director confirmed that these temperatures were too high and indicated that adjustments would be made. Additionally, a resident reported a lack of hot water in their restroom and shower room, further highlighting inconsistencies in water temperature regulation. In the North Unit dining room, air temperatures were consistently recorded as excessively high, with the thermostat indicating temperatures between 85 and 89 degrees Fahrenheit during meal times and activities. Residents were observed fanning themselves, and staff confirmed that the dining room became uncomfortably hot during a recent heat wave. No fans were in use to mitigate the heat, and the air conditioning unit was not functioning adequately. The Maintenance Director reported that the AC unit had frozen and required servicing, and an external HVAC company was scheduled to address the issue. Multiple areas of the facility were found to be in disrepair. In one resident room, a ceiling tile was damaged and stained due to a leaking AC unit, with an air vent and duct hanging from the ceiling. The same room had a hole and soft spot in the floor, and the closet floor was patched with plywood. Another resident room had broken flooring near the doorway. The North Unit dining room had a leaking AC unit, resulting in a wet, uneven, and soft floor, with water seeping through cracks. These conditions were confirmed by the Maintenance Director, who attributed the damage to previous incidents and ongoing maintenance issues.
Incomplete Facility Assessment Lacks Critical Details
Penalty
Summary
The facility failed to ensure a complete and accurate facility assessment that was based on the resident population and the identification of resources needed to provide necessary care and services. During the survey, it was found that the facility assessment form, revised on January 17, 2024, listed facility personnel but lacked a staffing plan to ensure sufficient staff were available to meet resident needs. The form also omitted training topics and competencies specific to the facility, transportation information including the use of a facility van, Enhanced Barrier Precautions, resident equipment, use of oxygen therapy, pharmacy information, and the facility's plan for communication with residents and staff who have communication barriers. The Administrator indicated that she was unaware that the facility assessment could include specific detailed information about the facility. She mentioned that a template was used to fill out the current facility assessment, which was updated annually, and that there was no facility policy in place, but regulation guidelines were followed to complete the assessment.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The current IP, an LPN, indicated that she did not have any specialized training or certification for the role and was only able to dedicate approximately 3-4 hours per week to the infection control program. Additionally, the facility's Administrator, through the Activity Director, confirmed that there was no policy or job description for the Infection Preventionist, and the role was simply assigned to someone without formal designation or training.
Facility's Blanket Policy on Crushing Narcotics Violates Resident Rights
Penalty
Summary
The facility failed to uphold residents' rights to participate in the development and implementation of their person-centered care plans by enforcing a blanket policy to crush all narcotic medications without resident input or obtaining specific physician orders. This policy affected 10 out of 32 residents reviewed for narcotic use. The decision to crush narcotics was made by the facility's Administrator, Medical Director, and Director of Nursing (DON) due to concerns about residents potentially hoarding or trading pills. However, this decision was implemented without consulting the residents or considering individual needs, leading to some residents, like Resident 5, refusing their medication due to the unpleasant taste of crushed pills. Resident 5, who suffered from severe pain, had her narcotic medication discontinued because she refused to take it in crushed form. Despite her complaints and the absence of any suspicion of her hoarding or selling narcotics, the facility continued with the policy. The facility did not have a formal narcotic administration policy, and the residents were not informed of the change prior to its implementation. The facility's actions were based on unverified concerns about residents' misuse of medications, and the policy was enforced without proper documentation or physician orders for each affected resident.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in the documentation of medication administration. Resident 16, who had diagnoses including COPD, anemia, and atrial fibrillation, was not recorded as taking antiplatelet medication or using oxygen, despite physician orders for aspirin and oxygen therapy. Similarly, Resident 28, with diagnoses of cerebral infarction, anemia, and heart failure, was not documented as using antiplatelet or diuretic medications, although physician orders indicated daily aspirin and furosemide. Resident 25, diagnosed with schizophrenia, renal insufficiency, and thyroid disorder, was not marked as taking antiplatelet medication, despite an order for daily aspirin. Resident 7, with diabetes mellitus, depression, and cancer, was also not recorded as taking antiplatelet medication, although there was an order for daily aspirin. The Director of Nursing was unaware that aspirin is an antiplatelet medication, indicating a lack of knowledge that contributed to the inaccurate MDS assessments.
Failure to Implement Comprehensive Care Plans for Residents on Medications
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents who were on various medications, including antipsychotics, antidepressants, antianxiety, diuretics, and oxygen. The deficiency was identified through observation, interviews, and record reviews. For instance, Resident 15, who had a history of substance abuse and was taking antipsychotic medication, did not have a care plan addressing these issues. The Director of Nursing (DON) acknowledged that care plans should have been in place but indicated that she was the only staff member capable of entering care plans into the electronic health record. Resident 16, who had diagnoses including COPD, anemia, and atrial fibrillation, was on medications such as antiplatelets, anticoagulants, and diuretics, and required oxygen. However, the clinical record lacked care plans for these medications and oxygen use. Similarly, Resident 28, with diagnoses of cerebral infarction, anemia, and heart failure, was taking antidepressants, antiplatelets, and diuretics, but did not have corresponding care plans. The DON confirmed that care plans should have been implemented for these medications and treatments. Other residents, such as Resident 7, Resident 25, and Resident 6, also lacked appropriate care plans for their prescribed medications, including antidepressants, antiplatelets, antipsychotics, and diuretics. The DON indicated that care plans were updated quarterly and with the MDS, but acknowledged the expectation for care plans to be in place for each specific medication administered to residents. The facility's care planning policy, dated May 2013, required comprehensive care plans for each resident, which were not adhered to in these cases.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for several residents. Resident 6's oxygen tank was observed with debris, and the filter was caked with dust. Despite having a care plan that included oxygen as an intervention, Resident 6's clinical record lacked a current order for oxygen. The resident was using oxygen at night due to a sleep study, but there was no documentation or order in the clinical record to support this. Resident 5 was observed using an oxygen concentrator without a filter, and the tubing was undated. The resident's clinical records indicated diagnoses of COPD, emphysema, and asthma, but lacked orders to change the oxygen tubing and clean the filter. The care plan did not include interventions for changing the tubing or cleaning the filter. There was confusion about the ownership and maintenance of the oxygen concentrator, with conflicting information from the DON, the resident, and the Administrator. Resident 23 was observed with undated oxygen tubing and a dust-covered filter on the oxygen concentrator. The resident's clinical records indicated a diagnosis of COPD with acute exacerbation, but lacked orders to change the tubing and clean the filter. Similarly, Resident 14 was observed with a dust-covered filter on the oxygen concentrator and lacked a current physician order for oxygen. The facility's respiratory therapy policy required changing the oxygen cannula and tubing every seven days and washing the filters weekly, but these actions were not documented or consistently performed.
Deficiency in Obtaining Physician Orders for Medications and Oxygen
Penalty
Summary
The facility failed to ensure that all physician's orders were obtained from the pharmacy for certain residents, leading to deficiencies in medication administration and respiratory care. Specifically, Resident 2, who has a severe cognitive impairment and diabetes mellitus, did not have a current physician order for Tresiba Flextouch insulin, despite receiving it daily as indicated in the August blood sugar log. This oversight was confirmed by RN 5 and the Director of Nursing (DON), who provided evidence of the insulin administration without a corresponding physician order. Additionally, the facility did not have current physician orders for oxygen for Residents 14, 5, and 23. Resident 14, who has a mild cognitive impairment and uses oxygen, was observed with oxygen administered via nasal cannula, but lacked a current order for it. The DON explained that a change in pharmacy at the beginning of August resulted in the failure to transfer oxygen orders from the previous pharmacy to the current one. The facility's pharmacy policy requires maintaining a medication profile for each resident, but this was not adhered to, contributing to the deficiency.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to maintain safe and secure storage of medications, as observed in two medication carts and one medication storage room. During the review of the Back Hall Medication Cart, several medications were found without open dates, including an Albuterol Sulfate inhaler, Breyna inhaler, and allergy relief nasal spray. Additionally, a ferrous sulfate pill was found in a medication cup without identification, and a Trelegy Ellipta inhaler was observed with an open date of 5/21/24. Another Trelegy Ellipta inhaler had a tag to discard after six weeks but lacked an open date. Furthermore, Neo/Poly/HC otic drops, which should have been discarded after 8/22/24, were still present in the drawer. In the Back Hall Medication Storage Room, the medication refrigerator temperature log was incomplete, with missing entries for several days in August 2024. The Front Hall Medication Cart also had medications without open dates, such as Polymyxin B TMP eye drops and artificial tears. A Ventolin inhaler was found with an open date of 6/30/23 and an expiration date of 6/30/24. The Director of Nursing confirmed that multidose medications should have open dates, and the medication refrigerator temperature should be logged daily. The facility's Medication Storage Policy, dated 5/2013, requires daily monitoring of refrigerator temperatures, but there was no specific policy for open dates on multidose medications, although it was their practice to do so.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, distribution, and service, as observed in the kitchen. Staff members did not wear hairnets that adequately covered all their hair, and inappropriate footwear was noted. Additionally, food items were not properly labeled, and the dishwasher was not monitored daily for safe sanitation. Observations revealed that the dishwasher's temperature was below the required minimum, and there was no documentation of chemical checks. Staff members also did not wash their hands for the appropriate length of time, and scoops were left in containers, which is against the facility's policies. During the inspection, it was noted that the kitchen lacked soap in the handwashing sink, and the Dietary Manager and Kitchen Staff 1 did not wear hairnets that fully covered their hair. The freezer and refrigerator contained opened and unlabeled food items, and there was stagnant water in the freezer room. The dishwasher was not properly checked for chemical levels, and the staff was unaware of the correct procedures for ensuring sanitation. Interviews with the Dietary Manager and Maintenance Supervisor revealed a lack of training and knowledge regarding the dishwasher's operation and chemical monitoring. Further observations showed that the ice scoop was left uncovered on a dusty machine, and staff members did not follow proper handwashing protocols. The Dietary Manager used a washcloth to clean a thermometer probe, which was not in line with the facility's policy. The facility's policies on dishwashing machine use, food receiving and storage, hairnet use, and thermometer sanitation were not followed, leading to the deficiencies noted during the survey.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment, leading to the potential transmission of infections. Observations revealed that staff did not change gloves between dirty and clean tasks, nor did they sanitize their hands between glove changes. In one instance, a resident was not completely cleaned during incontinence care, and fecal matter was transferred onto the resident's back and clean sheet. Additionally, staff did not offer residents the opportunity to wash their hands after toileting, which is a basic hygiene practice. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds, urinary catheters, and a stoma. The Director of Nursing was unaware of any residents on EBP, and the Infection Preventionist did not know what EBP was. This lack of knowledge and implementation of EBP could contribute to the spread of infections among vulnerable residents. Furthermore, clean clothing was not handled properly, as staff transported it uncovered and against their uniforms, risking contamination. Ice was also transported inappropriately in a trash bag, which was then used to serve residents. These practices indicate a lack of adherence to infection control protocols, potentially compromising resident safety and health.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in several areas, including a communal restroom and three shower rooms. Observations revealed various issues such as a brown substance around the bottom of toilets, rusted toilet paper holders, chipped doors, and missing tiles in the shower rooms. Additionally, there were gnats on the floor, spiderwebs on the ceiling, and soiled grout. These deficiencies were consistently observed over multiple days, indicating a lack of timely maintenance and cleaning. Further observations included a couch in a common area with peeled fabric and a courtyard door with a three-quarter inch gap, which the Maintenance Supervisor was unaware of and unable to fix immediately. The Maintenance Supervisor, who also served as the Housekeeping Supervisor, indicated there were no formal policies for maintenance or housekeeping, and tasks were not documented. Despite daily walkthroughs and a cleaning schedule, the facility failed to address these issues promptly, leading to the observed deficiencies.
Pest Control Deficiency in Storage Room
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations made in the downstairs dry storage room. On two separate occasions, a sticky pad intended for catching insects and rodents was found full of insects, with a dead mouse attached to it. Additionally, a live mouse was observed stuck to the sticky pad, and flying insects, both dead and alive, were present in the area. The refrigerator door in the storage room was not properly closed, which may have contributed to the presence of flying insects. The facility's pest control contract indicated that the pest control company was scheduled to visit monthly, with additional visits in January, to monitor for specific pests such as spiders, mice, and German cockroaches. Despite this arrangement, the facility had ongoing issues with mice, which the Administrator was not aware of until notified. The pest control company had visited approximately two weeks prior and reported no concerns. The facility's Pest Control Policy, dated January 2024, stated that the building should be kept free of insects and rodents, with maintenance services assisting as necessary.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to determine the clinical appropriateness of self-administration of medications for a resident. An Albuterol inhaler was found in the room of a resident diagnosed with chronic obstructive pulmonary disease (COPD) and asthma, without an order to keep it at the bedside or a self-administration assessment. The resident was cognitively intact according to the most recent Minimum Data Set (MDS) assessment. The physician's order for the inhaler did not specify that it should be kept at the bedside, and the clinical record lacked a self-administration assessment. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration of medications was safe and clinically appropriate, but this was not done for the resident in question.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised for three residents. For Resident 2, the care plan was not updated to include the use of bed rails as a fall intervention, despite the resident being observed with a bed rail in use and having a severe cognitive impairment requiring extensive assistance. The Director of Nursing (DON) acknowledged that the care plan should have included the bed rail intervention. Resident 16's care plan was outdated, as it still listed Lexapro as the antidepressant medication, even though the resident was currently prescribed venlafaxine. The DON admitted to not updating care plans with specific medication names due to potential changes. Similarly, Resident 15's care plan was not revised to reflect the discontinuation of Klonopin, an antianxiety medication, and the current use of Hydroxyzine, which is not classified as an antianxiety medication. The DON was the only staff member capable of updating care plans in the electronic health record, which contributed to the oversight.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide effective services to prevent the development of pressure injuries for a resident who was admitted without any pressure ulcers but was identified as being at risk. The resident, who had a history of cerebral infarction, anemia, and heart failure, required extensive assistance with mobility and was incontinent of bowel. Despite being at risk, the resident developed multiple stage two pressure injuries and a stage three pressure injury over time. The facility's records showed inconsistencies and omissions in documenting the resident's skin condition and wound treatments. Observations revealed that the resident had been experiencing pain in the buttocks for several weeks, which he had reported to the staff. However, the clinical records lacked specific care plans for the actual pressure ulcers, and there were missing entries for wound treatments in August. The facility's staff, including the DON and LPN, were unaware of the resident's wounds until they were observed during incontinence care. The staff failed to perform hand hygiene before and after providing care, and there was a lack of timely notification and documentation of new wounds. The facility's pressure ulcer program policy required comprehensive assessments and individual care plans for residents at risk, but these were not adequately implemented for the resident. The DON indicated that risk assessments would only be updated with significant health changes, and the resident's record lacked updated care plans for the new wounds. The facility's failure to adhere to its policy and ensure proper wound care and documentation contributed to the development and worsening of the resident's pressure injuries.
Inadequate Supervision and Management of Vaping Devices
Penalty
Summary
The facility failed to ensure adequate supervision and management of vaping devices among residents, leading to potential safety hazards. During observations, two residents were found with vapes in their possession, despite facility policies requiring these devices to be stored at the nurse's station and used only in designated smoking areas. Resident 15, who has a history of substance abuse, was observed with vapes on his bedside table, and staff members, including a Qualified Medication Aide and the Dietary Manager, did not address the presence of these devices. The resident's clinical record lacked a care plan addressing his history of substance abuse and risk of overdose, and there was no documentation of a previous incident where the resident allegedly smoked a THC-containing vape, resulting in a change of condition and hospitalization. Resident 24, who has moderate cognitive impairment and requires extensive assistance, was observed holding vapes on multiple occasions. Despite a behavior care plan indicating the need to remind the resident to return vaping materials to staff, the resident was seen with vapes in his possession, and staff did not intervene. An anonymous resident reported that vaping and smoking occurred in the building, affecting their allergies. A Registered Nurse acknowledged that some residents, including Resident 24, were reluctant to return vapes to staff, and there was confusion among staff about the facility's policy on vapes. Interviews with facility staff, including the Director of Nursing and the Social Services Director, revealed inconsistencies in the handling and documentation of vaping incidents. The facility's smoking policy, dated October 2021, did not require a smoking evaluation for e-cigarette use, and vapes were to be kept at the nurse's station. However, staff were unclear about the policy, and there was a lack of documentation regarding incidents involving vapes. The Administrator admitted to wanting to change the policy but had not done so, contributing to the ongoing issue of residents possessing and using vapes within the facility.
Incomplete Clinical Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate clinical record documentation for two residents. For Resident 15, the clinical record lacked documentation related to an incident where the resident allegedly smoked a vape containing THC, leading to a change in condition and hospitalization. The Administrator and DON were unsure of the exact details and dates, and the clinical record did not reflect the incident accurately. The resident admitted to smoking a vape from a local gas station, which led to unconsciousness and hospitalization. However, the Administrator later clarified that the hospitalization was due to sepsis from a fall, not the THC incident, indicating a lack of accurate documentation. For Resident 23, the facility failed to document the reason for a Band-Aid on the resident's left lower arm. The resident was observed with multiple bruises and an undated Band-Aid, but the clinical records and physician orders did not provide any information about a dressing or skin issue. Interviews with staff, including a QMA and LPN, revealed that they were unaware of the reason for the Band-Aid, and the nursing notes lacked documentation. The DON acknowledged that dressings should be dated, but there was no indication of a wound when the Band-Aid was removed, highlighting incomplete documentation.
Deficiency in Staff Training for Substance Abuse and PTSD
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff, which led to deficiencies in care for residents with specific needs. Resident 15, who had a history of substance abuse, was not provided with a care plan addressing the risk of overdose. Despite being prescribed Norco, a narcotic pain medication, there was no plan in place to manage the resident's substance abuse history. Additionally, staff were not trained on the use of Narcan, a medication used to treat narcotic overdoses, as evidenced by an LPN's uncertainty about its location and administration. Resident 24, diagnosed with PTSD, was also affected by the lack of staff training. The resident expressed that knocking on the door was a trigger, yet there was no indication that staff were trained to accommodate this need. The Director of Nursing confirmed the absence of specific in-services for PTSD, substance abuse, or Narcan administration, relying instead on common nurse knowledge. The facility lacked a policy for required in-services, contributing to the deficiency in addressing the residents' needs.
Failure to Provide Sufficient Behavioral Health Care Leading to Resident Elopement
Penalty
Summary
The facility failed to provide sufficient behavioral health care for a resident with documented behaviors, resulting in the resident eloping from the facility unwitnessed. The resident, who had severe cognitive impairment and used a wheelchair for mobilization, was upset about not being able to obtain cigarettes and exited the facility courtyard through an unlocked gate. The incident was not documented in the resident's progress notes, and the resident's care plan was not updated following the elopement. Additionally, the resident's behavioral tracking log was missing from their record, and the facility's behavior management program policy was not followed. The resident's diagnoses included undifferentiated schizophrenia, acquired absence of the right leg below the knee, partial traumatic amputation of the left midfoot, and nicotine dependence. Despite having a care plan that included interventions for behavior problems, the facility did not provide additional monitoring or services during the behavioral episode. The resident's physician orders included Lorazepam for agitation, but the medication was not administered during the month of the incident. Interviews with staff revealed that the resident had not previously attempted to elope and was not considered exit-seeking prior to the incident.
Failure to Maintain Accurate Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate records for two residents. For Resident B, there was no documentation of an elopement incident, the behaviors leading up to it, or any monitoring following the event. Resident B's diagnoses included undifferentiated schizophrenia, acquired absence of the right leg below the knee, partial traumatic amputation of the left midfoot, and nicotine dependence. Despite an incident where Resident B exited the facility to buy cigarettes, no records reflected this occurrence or the resident's behavior before and after the event. For Resident C, the facility did not update wound treatment orders in the resident's record, nor did they document wound treatment changes as required. Resident C, diagnosed with quadriplegia, overactive bladder, and neurogenic bowel, had specific wound care orders that were not consistently followed or recorded. The treatment administration record showed incomplete documentation, and interviews with staff confirmed that updates from the wound care center were not properly recorded in the resident's records. The DON acknowledged that maintaining accurate records is part of the nurse's job description, but there was no specific policy for documentation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 138 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Village Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 0 | 0 |
| Eastgate Manor Nursing And Rehabilitation | 0.8 mi | ★★★★★ | 0 | 0 |
| Villages At Oak Ridge, The | 1.5 mi | ★★★★★ | 1 | 0 |
| Amber Manor Care Center | 13 mi | ★★★★★ | 4 | 0 |
| Brickyard Healthcare - Petersburg Care Center | 13.4 mi | ★★★★★ | 13 | 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.