Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Rolling Hills Healthcare Center during CMS and state inspections, most recent first.
A resident with hypotension had a physician order for Midodrine with instructions to hold the dose if systolic BP exceeded a specified parameter. Review of the MAR showed the medication was administered multiple times despite systolic BP readings above the ordered threshold. An RN acknowledged that BP medications should not be given outside ordered parameters, and the facility’s medication administration policy requires medications to be given only as prescribed.
A resident with COPD and emphysema received multiple ordered Yupelri nebulizer treatments, but the clinical record lacked documentation of required pre- and post-treatment respiratory assessments and cleaning of the nebulizer equipment after each use. Facility policy and an RN interview confirmed that respirations, pulse, oxygen saturation, lung sounds, and proper rinsing and drying of the nebulizer were required with each treatment, yet these actions were not documented for the resident’s 16 recorded doses.
The facility did not ensure hot water temperatures in resident rooms and bathrooms were maintained between 100 and 120°F, with some areas having no hot water or temperatures as low as 88°F. Multiple residents and staff reported that hot water was often unavailable or took up to 10 minutes to warm up, particularly in rooms farther from the boilers. The Maintenance Director and Executive Director confirmed these issues during interviews and observations.
A resident with diabetes and moderate cognitive impairment did not have several scheduled doses of Lantus insulin documented as administered in the EMAR, and there was no record of the resident being absent or any explanation for the missing documentation. Nursing staff confirmed that all medication administrations and omissions should be recorded, in accordance with facility policy.
Two residents requiring IV antibiotics for post-surgical infections received their medications late on multiple occasions, with no documentation provided to explain the delays. Staff interviews confirmed that timely administration and proper documentation were expected but not followed in these instances.
Surveyors found expired and improperly labeled food items, lack of internal refrigerator thermometers, and maintenance issues such as dusty and loose vents and a grease-laden drip pan. Staff attempted to use expired milk in food preparation, and some food items were not properly dated or disposed of. Facility policies for food safety and kitchen maintenance were not consistently followed.
A resident with multiple complex medical conditions and severe cognitive impairment refused several critical medications, including blood pressure, cardiac, and blood thinner drugs, due to not wanting them crushed. Additionally, long-acting insulin was held on multiple occasions based on blood glucose readings, but there was no documentation of physician notification or established parameters for holding the insulin. Facility policy and care plans required physician notification and documentation for such events, but these actions were not taken.
A resident with diabetes and sepsis experienced multiple episodes of extremely high blood sugar, but staff did not consistently recheck blood sugar within 30 minutes after insulin administration or promptly notify the physician or NP as ordered. Documentation was incomplete, and required follow-up actions were delayed, contrary to facility policy and physician instructions.
A resident with diabetes and hyperglycemia experienced multiple elevated blood sugar readings above 400 mg/dL, but staff failed to document timely rechecks, physician or NP notification, and verbal orders in the clinical record as required by facility policy. Nursing notes showed attempts to contact providers and instructions to administer insulin, but the necessary follow-up and documentation were missing.
A resident with multiple medical conditions and pressure ulcers did not consistently receive or have documented vital sign monitoring, wound care, or daily wound assessments as ordered. Staff continued to document checks of a low air loss mattress after it was removed at the resident's request, and care plans were not updated to reflect this change. Wound dressings were not dated during care, and no wound care policy was provided by the facility.
An LPN in a facility signed out narcotic medications for seven residents before the scheduled administration times, contrary to facility policy. The residents had various conditions requiring pain management, and the facility's policy mandates that narcotics be signed out at the time of administration.
The facility failed to document the administration of narcotic medications for four residents, despite records indicating the medications were given. Residents with conditions such as a stage 4 pressure ulcer, diabetes, and depression had physician orders for narcotics, but the MAR lacked documentation of administration on several occasions. This discrepancy was confirmed by staff interviews and a review of the facility's medication administration policy.
A facility failed to implement indwelling catheter care orders for a resident with a stage 4 sacral pressure ulcer. The resident's care plan required catheter care every shift, but there was no documentation of this care being provided. A staff member confirmed that catheter care orders should be implemented upon admission, but this was not reflected in the records. The facility's policy required catheter care twice daily, which was not followed.
The facility failed to document the administration of medications for three residents, including anti-psychotic and narcotic medications, leading to discrepancies in the MAR and controlled drug records. A QMA confirmed the requirement for proper documentation.
The facility failed to care plan and monitor behaviors for residents with mental disorders. A resident with dementia and schizoaffective disorder sought out another resident without a care plan addressing this behavior. Another resident with dementia and behavioral disturbances also lacked a care plan for similar behavior. Additionally, behavior monitoring logs for a resident with alcohol-induced dementia were incomplete, despite facility policy requiring documentation and management of behaviors.
A facility failed to manage a resident with dementia who exhibited sexually inappropriate behaviors. Despite being on one-on-one supervision, the resident continued to engage in inappropriate actions with female residents. Staff intervened by separating the resident and reporting incidents, but the behaviors persisted. The care plan included interventions like encouraging group interactions and keeping the resident within eyesight of staff, but these measures were insufficient. Interviews with staff confirmed the ongoing issues, highlighting a failure in effectively managing the resident's behaviors.
A facility failed to implement fall prevention measures for a resident with Parkinson's disease and epilepsy. The care plan required non-skid strips on the bed, but they were not in place during an observation with the DON. The DON acknowledged that care plan interventions should be implemented. The facility's fall prevention policy was undated.
The facility failed to ensure call lights were within reach for 10 residents, compromising their ability to communicate needs. Observations showed call lights on the floor or out of reach, with no staff present. Residents affected had various medical conditions, including cognitive impairments and mobility issues, necessitating assistance. Interviews confirmed call lights should be accessible, but this standard was not met, violating the facility's policy on resident-centered care.
The facility failed to address resident concerns during Resident Council meetings over a year, with issues such as nursing shortages, improper meal handling, and laundry problems remaining unresolved. Residents reported verbal abuse, medication errors, and inadequate response times to call lights, with management often brushing aside their grievances.
The facility failed to ensure CNAs were tested for licensure within 120 days of employment, resulting in six CNAs working beyond this period without certification. The oversight was due to a lack of dedicated HR personnel, leading to a lapse in monitoring staff licensure.
The facility failed to ensure meals were served at appropriate temperatures and were palatable, affecting most residents. Observations during meal test trays showed inconsistencies in food temperatures, with some items being bland or requiring additional seasoning. Residents expressed dissatisfaction with food quality, temperature, and presentation, with some reporting weight loss and unappetizing meals. The Dietary Manager noted menu changes for nursing home week, approved by the dietician.
The facility failed to maintain a clean and well-repaired kitchen, with issues such as a malfunctioning dishwasher, flaking ceiling plaster, grease-covered vents, and a significant wall opening behind the garbage disposal. The Dietary Manager acknowledged the kitchen's age and maintenance issues, while the Executive Director presented a roofing quote without a repair date. The facility's policies on maintaining clean food preparation areas and proper dishwashing procedures were not followed.
A resident with multiple health issues, including hemiplegia and dementia, developed a Stage 3 pressure ulcer on the right heel that was not identified until it became an open blister. Despite a care plan for skin integrity, the ulcer was overlooked during routine assessments. The facility's policy for weekly skin evaluations and daily monitoring was not effectively followed, resulting in the deficiency.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s ordered blood pressure parameters for administration of Midodrine for a resident diagnosed with hypotension. The physician’s order dated 2/6/26 directed that the resident receive Midodrine HCl 2.5 mg three times daily at 8:00 a.m., 12:00 p.m., and 4:00 p.m., with instructions to hold the medication if the resident’s systolic blood pressure was above 130. Review of the February 2026 MAR showed that the medication was administered despite systolic blood pressures above the ordered threshold on multiple occasions. Specifically, the MAR indicated that Midodrine was given on 2/07/26 at 4:00 p.m. when the resident’s systolic blood pressure was 132, and on 2/17/26 at 8:00 a.m., 12:00 p.m., and 4:00 p.m. when the systolic blood pressure was 138 at each of those times. During an interview, an RN stated that blood pressure medication should not be administered when a resident’s blood pressure is outside the parameters set by the physician. The facility’s Medication Administration policy, provided by the Regional Director of Clinical Operations, stated that medications are to be administered only as prescribed by the provider and identified the MAR as the legal documentation for medication administration, while emphasizing resident safety and resident-centered care.
Failure to Perform and Document Required Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to ensure required respiratory assessments and equipment care were provided and documented for a resident receiving nebulizer treatments. Resident B, who had diagnoses including COPD and emphysema, had a physician’s order dated 2/6/26 for Yupelri 175 mcg, 3 ml once daily via nebulizer at 9:00 a.m. for 20 days. Observation on 2/23/26 showed the resident with a nebulizer machine at the bedside. Review of the February 2026 MAR indicated the resident received 16 doses of Yupelri between 2/6/26 and 2/23/26. The clinical record lacked documentation of pre- and post-treatment respiratory assessments and cleaning of the nebulizer equipment after each administration. Facility policy titled “Nebulizer Treatments,” provided by the Regional Director of Clinical Operations, required collection of respirations, pulse, oxygen saturation, and lung sounds before treatment, repetition of this data collection after treatment, and rinsing the nebulizer with sterile water and allowing it to air dry. In an interview, an RN confirmed that a respiratory assessment should be completed before and after each nebulizer treatment, but such assessments and equipment cleaning were not documented for this resident’s treatments.
Failure to Maintain Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures between 100 and 120 degrees Fahrenheit, as required, throughout resident rooms and bathrooms. Observations revealed that some rooms had hot water temperatures as low as 88.0 and 93.6 degrees Fahrenheit, while at least one room had no hot water at all. Multiple residents reported ongoing issues with the availability and consistency of hot water, with some stating that it took up to 10 minutes for the water to warm up, and others indicating that they often had to use cold water for handwashing due to the delay. The Maintenance Director confirmed these issues during observations and interviews, acknowledging that certain rooms lacked hot water and that a valve replacement was needed in at least one case. Staff interviews corroborated the residents' complaints, with a CNA noting that hot water in resident rooms and the shower room could take 5 to 10 minutes to warm up, especially in rooms farther from the boilers. The Executive Director also confirmed that staff had reported the lack of hot water and that the issue was more pronounced in rooms located farther from the decentralized boilers. The facility's practice of flushing the system each morning did not resolve the problem, and the Maintenance Director had not received formal complaints from residents prior to the survey. The deficiency had the potential to affect all 82 residents in the facility.
Failure to Document Insulin Administration in EMAR
Penalty
Summary
The facility failed to document the administration of Lantus (insulin) for one resident who was moderately cognitively impaired and had diagnoses including diabetes, hypertension, non-Alzheimer's dementia, anxiety, and depression. The resident had a physician's order for Lantus, 30 units, to be administered twice daily. Review of the electronic medication administration record (EMAR) for August and September showed missing documentation for several morning doses, with no indication that the resident was out of the building or that the medication was withheld for a documented reason. Interviews with nursing staff confirmed that all medications should be documented in the EMAR, and if not administered, a progress note should explain the omission. The facility's policy requires that medications be charted when given and that any refusals or omissions be documented. The lack of documentation for the specified dates and times was not explained by any changes in the medication order or resident absence, resulting in a deficiency related to pharmaceutical services and medication administration documentation.
Failure to Administer IV Antibiotics Timely and Document Delays
Penalty
Summary
The facility failed to ensure timely administration of intravenous (IV) antibiotics for two residents who required these medications for post-surgical infections. For one resident with a dehisced surgical wound and infection following a craniotomy, physician orders specified Ceftriaxone Sodium 2 grams IV twice daily and at bedtime for specified durations. The Medication Administration Record (MAR) showed that the resident’s evening doses were administered late on multiple occasions, with some doses given several hours past the scheduled time. There was no documentation in the clinical record explaining the reasons for the late administration or any comments regarding the delays. Similarly, another resident with an infection and inflammatory reaction due to a hip prosthesis had physician orders for Ceftriaxone Sodium Solution 2 grams IV at bedtime. The MAR indicated that several doses were administered late, including one instance where the dose was given several hours after the scheduled time. Again, the clinical record lacked any documentation explaining the late administration. Interviews with the Director of Nursing and a registered nurse confirmed that medications should be given on time and that any late administration should be documented with a reason, but this was not done in these cases.
Deficient Food Storage, Labeling, and Kitchen Maintenance
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and kitchen maintenance practices. During kitchen tours, several refrigerators lacked internal thermometers, and one refrigerator displayed an external temperature of 50°F. Expired food items, such as whole milk and leftover fish, were found in the refrigerators, and some containers lacked proper labeling or use-by dates. Lettuce with brown edges and undated containers were also present. A staff member was seen attempting to use expired milk in food preparation before being stopped. Additionally, prepared drinks and desserts were stored without clear dating, and some items were disposed of only after being identified as expired or undated. The kitchen environment also showed maintenance issues, including dust accumulation on vents, a vent partially detached from the ceiling, and a drip pan under the cooktop with significant food debris and grease buildup. The Dietary Manager acknowledged responsibility for monitoring expiration dates, while the Maintenance Director was responsible for cleaning and repairs. The facility's policies required proper labeling, dating, and preventive maintenance, but these were not consistently followed, as evidenced by the observations and staff interviews.
Failure to Notify Physician of Medication Refusals and Held Insulin
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident refused multiple critical medications and when long-acting insulin was held on several occasions. The resident in question had significant medical conditions, including type 2 diabetes mellitus with chronic kidney disease, a history of cerebral events, atrial fibrillation, congestive heart failure, hemiplegia, and hypertension. The resident also had severe cognitive impairment, as documented in the most recent assessment. On several documented dates, the resident refused to take all morning medications, including blood pressure, cardiac, and blood thinner medications, due to not wanting the medications crushed. There was no documentation that the physician was notified of these refusals. Additionally, the resident's long-acting insulin (Tresiba) was held multiple times due to varying blood glucose levels, but the medical record did not contain documentation of physician notification or clear parameters for when the insulin should be held. The facility's care plans required that medications be administered as ordered and that abnormal findings or refusals be reported to the medical provider, resident, or representative. Interviews with facility leadership confirmed that there should have been parameters for holding medications and that the physician should have been notified of both the medication refusals and the holding of long-acting insulin. The facility's policy also required notification of the physician and resident representative when there was a need to alter treatment, such as discontinuing or holding medications. The lack of documentation and notification in these instances constituted a failure to follow both physician orders and facility policy.
Failure to Provide Timely Diabetes Care and Monitoring
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy, sepsis due to methicillin susceptible staphylococcus aureus, and hyperglycemia did not receive timely treatment and care as ordered. The resident had physician orders for multiple diabetes medications, including Lispro insulin on a sliding scale, Metformin, and Tresiba. The orders specified that staff should notify the physician if the resident's blood sugar was less than 70 or greater than 400 mg/dL, and to recheck blood sugar 30 minutes after administering insulin if levels exceeded 400 mg/dL. Over several days, the resident's blood sugar readings were repeatedly above 400 mg/dL, with values as high as 502 mg/dL. Despite these elevated readings, documentation showed that blood sugar was not rechecked within the required 30-minute window after insulin administration, and there was a lack of timely notification to the physician or nurse practitioner as ordered. Nursing notes indicated that the nurse attempted to contact the physician and left a message, and was instructed by the DON to administer insulin and notify the nurse practitioner. However, the clinical record lacked documentation that the nurse practitioner was notified at the time of the high blood sugar readings, and blood sugar rechecks were delayed, sometimes not occurring until many hours later. Interviews with facility leadership confirmed these documentation gaps and delays in following the physician's orders for monitoring and notification. The facility's policy required timely and accurate documentation of resident information, which was not met in this instance.
Failure to Document Blood Sugar Rechecks and Physician Notification for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that sufficient information related to a resident's blood sugar was rechecked and that physician notification and verbal orders were properly documented in the clinical record. The resident in question had diagnoses including type 2 diabetes mellitus, sepsis, and hyperglycemia, and was on a sliding scale insulin regimen with specific instructions to notify the physician and recheck blood sugar if levels exceeded 400 mg/dL. On multiple occasions, the resident's blood sugar readings were above 400 mg/dL, but the clinical record lacked documentation of a timely recheck, confirmation that the physician or nurse practitioner was notified, or that verbal orders were received and recorded as required. Nursing notes indicated attempts to contact the physician and nurse practitioner, as well as instructions from the DON to administer insulin and recheck the blood sugar. However, there was no documentation in the medical record confirming that the nurse practitioner was notified, that a recheck was performed, or that a verbal order was received and documented. Interviews with staff confirmed these documentation gaps, and the facility's policy required real-time charting and documentation of resident status and changes, which was not followed in this instance.
Failure to Complete and Document Pressure Ulcer Interventions and Assessments
Penalty
Summary
The facility failed to ensure that interventions and treatments for pressure ulcers were completed for a resident with significant medical conditions, including type 2 diabetes mellitus, morbid obesity, osteomyelitis, and chronic embolism. The resident had a stage 4 pressure ulcer to the sacrum and a pressure injury to the right hip, with care plans and physician orders specifying interventions such as vital sign monitoring, use of a low air loss mattress, regular wound assessments, and specific wound care treatments. However, the record lacked documentation that vital signs were consistently obtained as ordered, with the last recorded blood pressure noted several months prior, despite vital sign monitoring being a care plan intervention for both skin impairment and osteomyelitis. There were multiple instances where wound care and daily wound assessments were not documented for both the sacrum and right thigh wounds on specified dates. Additionally, the care plan intervention for a low air loss mattress remained active in the resident's record and was documented as checked by staff every shift, even after the mattress had been removed at the resident's request. This discrepancy indicated that staff continued to document compliance with an intervention that was no longer in place, and the care plan was not updated to reflect the change. Furthermore, wound care and dressing changes were not consistently documented as completed according to physician orders. Observations also revealed that wound dressings were not dated during wound care procedures, and there was no wound care policy provided by the facility. Interviews with staff confirmed that the resident refused the low air loss mattress due to discomfort, but the care plan and electronic records were not updated accordingly. The lack of documentation and failure to follow through with ordered interventions and assessments contributed to the deficiency in providing appropriate pressure ulcer care and prevention.
Narcotic Medications Signed Out Prematurely
Penalty
Summary
The facility failed to ensure that narcotic medications were not signed out prior to administration times for seven residents. During an observation, it was noted that an LPN had signed out narcotic medications for the 1:00 p.m. and 2:00 p.m. administration times but had not yet administered them. The LPN acknowledged awareness that medications should not be signed out ahead of time. This practice was contrary to the facility's policy, which requires that narcotics be signed out at the time of administration. The residents involved had various medical conditions requiring pain management, including major depressive disorder, amputations, pressure ulcers, diabetes with neuropathy, rheumatoid arthritis, malignant neoplasms, and peripheral vascular disease. Physician orders for these residents specified the administration of medications such as Hydrocodone-Acetaminophen and Oxycodone HCl at specific intervals for pain management. The facility's policy documents, including the Chain of Custody for Controlled Substances and Medication Administration, were reviewed and indicated that narcotics should be signed out when given, highlighting a deviation from established procedures.
Failure to Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure that medication administration records (MAR) accurately reflected the administration of narcotic medications for four residents. Resident M, diagnosed with a stage 4 sacral pressure ulcer, had a physician's order for Oxycodone to be administered every four hours as needed for pain. However, the MAR lacked documentation of the medication administration on several dates, despite records indicating the medication was given. Similarly, Resident N, with diagnoses including diabetes and arthritis, had a physician's order for Oxycodone every eight hours as needed, but the MAR did not document the administration of the medication on specific dates. Resident O, diagnosed with depression, was prescribed Morphine Sulfate every four hours as needed for pain or shortness of air, yet the MAR did not reflect the administration of the medication on certain dates. Resident V, with conditions including a left femur fracture and diabetes, was ordered Norco every six hours as needed for pain, but the MAR also lacked documentation of the medication administration on multiple occasions. The facility's policy requires that medications be charted when given, but this was not adhered to, as confirmed by staff interviews and the review of the facility's medication administration policy.
Failure to Implement Indwelling Catheter Care Orders
Penalty
Summary
The facility failed to implement indwelling catheter care orders for a resident with a stage 4 sacral pressure ulcer. The resident was observed with an indwelling catheter in place, but the clinical record lacked documentation of any catheter care being provided. The care plan, dated earlier in the month, indicated that catheter care should be provided every shift. However, there was no evidence that this care was documented or performed. During an interview, a staff member indicated that catheter care orders should be implemented upon admission, but this was not reflected in the resident's records. The facility's policy stated that catheter care should be performed twice daily for residents with indwelling catheters, but this was not adhered to in the case of the resident in question.
Medication Administration Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for three residents, leading to deficiencies in maintaining accurate medical records. Resident G, diagnosed with dementia with behavioral disturbance, had multiple instances where the administration of Divalproex Sodium was not documented in the medication administration record (MAR) for both November and December 2024. The medication was not signed out as given on several scheduled administration times, indicating a lapse in documentation practices. Similarly, Resident C, who was prescribed Hydrocodone-Acetaminophen for pain, had a missing entry in the October 2024 MAR despite the controlled drug record indicating administration. Resident E, with diagnoses of pain and anxiety, also had discrepancies in the documentation of Lorazepam and Morphine Sulfate administration in both the controlled drug record and the MAR. These documentation failures were confirmed during an interview with a Qualified Medication Aide, who acknowledged that the MAR and controlled drug record should be signed off to confirm medication administration.
Failure to Care Plan and Monitor Resident Behaviors
Penalty
Summary
The facility failed to ensure that behaviors were care planned and monitored for several residents with mental disorders or psychosocial adjustment difficulties. Resident B, diagnosed with dementia with agitation and schizoaffective disorder, was observed to actively seek out another resident, Resident C, but lacked a care plan addressing this behavior. Similarly, Resident D, with dementia and behavioral disturbances, also sought out Resident C without a corresponding care plan. The Director of Nursing noted inappropriate interactions between Residents B and D in Resident C's room, which were not addressed in their care plans. Resident G, diagnosed with alcohol-induced persisting dementia and dementia with behavioral disturbance, had a care plan indicating behavior problems such as inappropriate bowel movements and verbal aggression. However, the behavior tracking logs for November and December 2024 lacked documentation of behavior monitoring on several days. A Qualified Medication Aide confirmed that all behaviors should be documented, but this was not consistently done. The facility's policy required a resident-centered behavior management care plan and documentation of behavior assessments, which were not adequately implemented for these residents.
Inadequate Management of Resident's Inappropriate Behaviors
Penalty
Summary
The facility failed to implement effective interventions for a resident diagnosed with dementia and exhibiting sexually inappropriate behaviors. Resident C, who has a history of sexually acting out, was placed on one-on-one supervision due to these behaviors. Despite this measure, the resident continued to engage in inappropriate actions, such as attempting to touch and kiss female residents. Staff members frequently intervened by separating Resident C from others and reporting incidents, but the behaviors persisted. The care plan for Resident C included interventions like encouraging interactions in group settings and keeping the resident within eyesight of staff, but these measures were insufficient in preventing the inappropriate behaviors. Interviews with staff members revealed that Resident C was known to be overly affectionate, often rubbing the backs of female residents and attempting to kiss them. The Memory Care Unit Manager and Social Services staff acknowledged the resident's behaviors, noting that they were not consistent but still problematic. Despite the ongoing one-on-one supervision, Resident C continued to seek out female company and engage in inappropriate actions, indicating a failure in the facility's approach to managing the resident's behaviors effectively. The facility's policy emphasized resident-centered care and safety, but the interventions in place did not adequately protect the rights and safety of other residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place for a resident identified as being at risk for falls. The clinical record for the resident, who had diagnoses including Parkinson's disease and epilepsy, indicated a care plan dated March 4, 2022, which required the application of non-skid strips to the left side of the bed to mitigate fall risks. However, during an observation conducted with the Director of Nursing (DON), it was noted that the non-skid strips were not in place as per the care plan. The DON confirmed that interventions listed in a resident's care plan should be implemented. Additionally, the facility's policy on Fall Prevention and Management, which emphasizes resident-centered care and fall risk management, was provided but did not have a date.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for 10 residents, leading to a deficiency in meeting the needs and preferences of each resident. Observations revealed that call lights were often found on the floor, under beds, or otherwise out of reach, with no staff present in the rooms. This was noted for residents with various medical conditions, including cognitive impairments, mobility issues, and other health concerns that necessitate assistance with personal care. Resident 20, for example, had a call light on the floor beneath the bed, despite having conditions such as COPD, dementia, and difficulty walking, which require frequent assistance. Similarly, Resident 77's call light was found on the floor and under pillows, out of reach, while the resident was severely cognitively impaired and needed a wheelchair for mobility. These observations were consistent across multiple residents, including those with severe cognitive impairments, functional limitations, and other significant health issues. Interviews with CNAs confirmed that call lights should always be within reach of residents, yet this standard was not met. The facility's policy on resident rights emphasizes the importance of providing resident-centered care and ensuring safety, including having a method for residents to communicate their needs. However, the repeated observations of inaccessible call lights indicate a failure to adhere to this policy, compromising the ability of residents to communicate their needs effectively.
Facility Fails to Address Resident Concerns
Penalty
Summary
The facility failed to ensure that the administration was taking resident concerns seriously or being visible to the residents during Resident Council meetings. Over a period spanning from March 2023 to May 2024, residents repeatedly voiced concerns that were not resolved or acted upon. These concerns included issues with administration's responsiveness, nursing staff shortages, improper handling of meals, and laundry problems. Residents reported that their concerns were often met with excuses, and there was a lack of visible action from the administration to address these issues. Specific grievances included nursing staff walking past rooms without assisting residents, meals not being served according to dietary needs, and laundry not returning clothes to the correct residents. Additionally, residents complained about the lack of cleanliness in their living areas, with housekeeping failing to mop floors or clean restrooms. The documentation from these meetings often lacked responses from the responsible department heads, indicating a systemic issue in addressing and resolving resident grievances. The report also highlighted instances of verbal abuse by staff, medication errors, and inadequate response times to call lights. Residents expressed dissatisfaction with the management's handling of their concerns, feeling that their issues were brushed aside without resolution. The facility's policies on resident grievances and council meetings were not effectively implemented, as evidenced by the ongoing unresolved issues and lack of corrective actions documented in response to the residents' complaints.
Failure to Ensure Timely CNA Licensure Testing
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) were tested for their licensure within 120 days of employment, resulting in six CNAs working beyond this period without proper certification. The CNAs in question were identified during a review of employee records, which revealed that they had been employed for more than 120 days without having taken their licensure test. Specifically, CNAs 13, 14, 16, 15, 19, and 17 continued to work past their 120th day of employment without being certified, with some working significantly beyond this timeframe. The Executive Director (ED) acknowledged the oversight, noting that there was no dedicated Human Resources (HR) personnel until April 5, 2024, which contributed to the lapse in monitoring staff licensure. The ED discovered that eight staff members, who were licensed in Kentucky, had not taken their CNA licensure test within the required 120 days in Indiana. Consequently, these staff members were removed from the work schedule until they passed their licensure test. The deficiency was identified as part of a complaint investigation, highlighting a systemic issue in the facility's process for monitoring CNA licensure compliance.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures and were palatable for residents, as observed during three meal test trays. The baked ziti served during the 100 Hall lunch test tray was at 145 degrees Fahrenheit, which was palatable but bland, requiring additional salt for flavor. The Caesar salad was at 65.6 degrees Fahrenheit, which was appetizing. During the 400 Hall lunch test tray, the baked ziti was at 135 degrees Fahrenheit, and the Caesar salad was at 63.5 degrees Fahrenheit. In the 200 Hall lunch test tray, the pepperoni pizza was at 168.8 degrees Fahrenheit and was appetizing, while the baked ziti was at 131.5 degrees Fahrenheit and palatable. The side salad with mushrooms was at 48.7 degrees Fahrenheit and appealing, and the mixed fruit was at 74.7 degrees Fahrenheit, served at room temperature. Interviews with residents revealed dissatisfaction with the food quality and temperature. One resident mentioned the food could be better, often requesting a cheeseburger due to the poor quality. Another resident complained about cold breakfast and bad food quality. A resident expressed that the food was unappealing and that their likes and dislikes were not considered, leading to weight loss. Another resident noted that food was always cold and unappetizing, and staff delayed addressing food issues. A resident showed a picture of a meal where the sloppy joe bun was soggy due to the placement of vegetables on the plate. The Dietary Manager explained that menu changes were made for nursing home week, approved by the dietician, and that the regular menu would resume the following day.
Kitchen Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired kitchen environment, as observed during multiple inspections. On one occasion, the dishwasher was initially not working but was later observed to be functioning with a wash cycle temperature of 145 degrees F and a rinse cycle temperature of 170 degrees F. The kitchen ceiling had flaking plaster around a vent, brown stains, and grease-covered vents. The stove's back panel had brown grease streaks, and the ceiling around another vent was cracked. On another occasion, the dishwasher's wash and rinse temperatures were recorded at 150 degrees F and 187 degrees F, respectively, with a leak previously repaired. Grease was noted on the wall behind the dishwasher, and a significant wall opening was observed behind the garbage disposal, with water dripping from the sink. The Dietary Manager acknowledged the kitchen's age and maintenance issues, including a stuck drip pan and grease behind the dishwasher. The dishwasher's temperature logs showed consistent readings of 160 degrees F for the wash cycle and 180 degrees F for the rinse cycle, despite observed fluctuations. The Executive Director presented a roofing company quote for roof repairs, but the kitchen ceiling was not included, and the repair date was uncertain. The facility's policies required maintaining clean and sanitary food preparation areas and proper dishwashing procedures, which were not adhered to, leading to the observed deficiencies.
Failure to Identify and Manage Pressure Ulcer
Penalty
Summary
The facility failed to identify a pressure ulcer on a resident's right heel before it developed into an open blister. The resident, who had multiple diagnoses including hemiplegia, dementia, and difficulty walking, required substantial assistance with activities of daily living. Despite having a care plan in place that included interventions for impaired skin integrity, such as applying barrier creams and conducting weekly skin checks, the pressure ulcer was not detected until it had progressed to a blister that no longer held fluid. The CNA shower records from late April to early May indicated no new skin issues, suggesting a lack of thorough skin assessments. On May 7, the wound was identified during wound rounds as a pressure ulcer on the right heel, measuring 5.0 cm by 4.0 cm with a depth of 0.1 cm. The wound was classified as a Stage 3 pressure ulcer, indicating full-thickness skin loss. The wound care nurse confirmed that the ulcer began as a blister that had popped, revealing the wound bed. The facility's policy required weekly skin evaluations and daily monitoring of existing wounds, but these measures were not effectively implemented, leading to the oversight of the resident's pressure ulcer development.
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What surveyors actually found near you
We read the 398 citations issued within 25 miles in the last 12 months — including the 10 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 New Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wedgewood Healthcare Center | 1.6 mi | ★★★★★ | 12 | 0 |
| Charlestown Place At New Albany | 1.7 mi | ★★★★★ | 33 | 1 |
| Westminster Village Kentuckiana | 2.2 mi | ★★★★★ | 16 | 0 |
| Green Valley Care Center | 2.3 mi | ★★★★★ | 20 | 0 |
| Autumn Woods Health Campus | 2.4 mi | ★★★★★ | 7 | 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.