Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrace At Solarbron The during CMS and state inspections, most recent first.
A facility failed to ensure 6 residents were free from unnecessary medications because PRN antianxiety orders were written as open ended without a specific duration of use or stop date. Residents with anxiety, severe cognitive impairment, PTSD, and other diagnoses had PRN orders for lorazepam, hydroxyzine, Xanax, and clonazepam, and several received doses per the eMAR. The DON stated the facility did not have a policy specific to PRN antianxiety medications and their duration of use.
The facility failed to develop and implement complete care plans for residents receiving anticonvulsant, antidepressant, and antianxiety medications, and failed to carry out fall-prevention interventions already listed on care plans. One resident on gabapentin and duloxetine had no medication-related care plan and no call-don't-fall sign was present; another resident with Parkinson's disease was observed without the ordered BSC nearby; a cognitively impaired resident was not offered toileting as planned and was later found with a saturated brief and on the floor; and two other residents had no care plans for oxcarbazepine or lorazepam use.
Loose, unidentified medications were found in multiple medication carts, including tablets and capsules in several drawers, and staff could not always identify the items. In the Memory Care Unit medication storage room, extra resident insulin pens were found in the refrigerator with the door open and the temperature at 60 degrees, while staff stated the door should remain closed. The facility’s policy required medications to be stored orderly in a secured area and refrigerator temperatures maintained between 36 and 46 degrees.
Code status was not clearly indicated for two residents with advance directive preferences. One resident was listed as full code on the dashboard despite a DNR physician order and care plan instructions for no CPR, while the record lacked a signed DNR advance directive. Another resident had conflicting DNR and full code orders, and staff interviews showed confusion about the resident’s actual code status.
Inaccurate MDS Coding for Anticonvulsant Use: A resident with bipolar disease and severe cognitive impairment received oxcarbazepine, an anticonvulsant, throughout the lookback period, but the quarterly MDS did not code the medication as received. Record review showed the eMAR documented the anticonvulsant on all 7 days, and the MDS Coordinator confirmed it was omitted from the assessment.
A resident with dementia and an active UTI did not receive all ordered Macrobid doses, with the DON confirming missed antibiotic doses and records showing documentation inconsistencies. During observed incontinence care, two CNAs did not perform hand hygiene, changed gloves inconsistently, and handled the resident’s brief and perineal care without proper hand hygiene between tasks.
NJ Tube Placement Not Monitored: A resident with dysphagia and other diagnoses had an NJ tube observed lying flat alongside her with the marker hanging out of the nares and the tubing knotted underneath. Physician orders lacked a placement-check instruction, and the MAR did not show documentation of tube placement or marker measurement. RN and LPN interviews confirmed staff had not been documenting the tube marker as expected, despite the care plan calling for placement checks before feedings and meds.
Failure to provide pain management for a resident with a left femur fracture and facial laceration. The resident had PRN opioid and acetaminophen orders plus a buprenorphine patch, and the care plan directed staff to monitor and treat increased pain. The eMAR showed reported pain scores of 5 and 2, but no documented non-pharmacological interventions or pain meds during extended periods. The resident also had poor intake and increased agitation, refusal of food, and behaviors, and family reported the resident was in immense pain before pain medication was finally given.
The facility failed to monitor side effects of high-risk medications for two residents. One resident with bipolar disorder and severe cognitive impairment had orders for oxcarbazepine, but the record lacked a care plan and monitoring order for anticonvulsant side effects; the DON stated staff monitored indication rather than side effects. Another resident with depression, dysphagia, and chronic respiratory failure received gabapentin and duloxetine, but the record lacked monitoring orders for anticonvulsant and antidepressant side effects, and the Regional Support Nurse said the facility had no policy specific to high-risk medication monitoring.
Failure to Perform Hand Hygiene During Incontinence Care: During observed incontinence care, two CNAs provided care to a resident with a current UTI while wearing gloves, but hand hygiene was not performed during the task. One CNA cleaned the resident’s buttocks, applied cream, changed gloves once, and later applied cream directly to the vulvar area, while the other CNA wiped the perineal area, fastened the brief, and completed care without hand hygiene being performed.
Blood spill remained on the carpet next to the Memory Care Unit nurses station after a resident fall with a head laceration. Family reported seeing blood still on the floor when they entered the building, and surveyors later observed an approximately 12-inch dried blood stain that was still present days later. Staff said blood spills should be cleaned immediately and housekeeping notified, but they were unaware of the stain.
Care plans were not revised when a resident’s coccyx pressure ulcer worsened, when another resident with dementia and behavioral disturbance had repeated physically aggressive episodes with residents and staff, and when a resident with dementia and a left femur fracture had falls. The records showed ongoing wound deterioration, multiple behavior events with hospital transfers, and a fall history, but the care plans did not consistently reflect the changed conditions or new interventions.
A facility failed to maintain accurate and timely resident records for two residents. One resident with paraplegia, malnutrition, and dementia had a coccyx pressure ulcer that was first assessed but not entered into the chart until days later, with later worsening assessments and wound care orders also documented late; the record also lacked documentation of a bedtime snack despite a nutritional assessment noting one. Another resident’s MAR did not match narcotic sign-out records, pharmacy/EDK records, or PRN documentation for an antibiotic, hydrocodone, and Xanax, and the DON acknowledged medication documentation problems in the building.
A resident with multiple chronic conditions and pressure ulcers experienced a decline in wound status, but the facility failed to notify the resident's POA representatives of the worsening coccyx wound and the development of new wounds on the left ankle and heel, despite documentation that the POAs were the primary health contacts. The facility did not have a policy for notifying representatives of changes in condition.
Two residents who were dependent on staff for bathing due to severe medical and cognitive conditions did not consistently receive or have documentation of daily bathing or showers. Care plans indicated the need for total assistance, but records showed missed or undocumented hygiene care, and there was no evidence of resident refusals. Staff confirmed that refusals should be documented, but this was not reflected in the records.
A facility failed to obtain immediate physician orders for a newly admitted resident's colostomy care. The resident, who was cognitively intact and had a colostomy, reported that while nurses provided care, CNAs were generally reluctant. Despite a care plan for ostomy care, no specific physician orders were documented, and an LPN confirmed that such orders should be established soon after admission.
The facility failed to follow infection control practices during wound care for a resident and while using a blood pressure monitor on two residents. During wound care, gloves were not changed or hands sanitized at appropriate times, putting a resident with venous ulcers at risk. Additionally, an LPN did not sanitize a blood pressure monitor between uses on two residents, contrary to facility policy requiring equipment cleaning between uses.
The facility was found to have pervasive odors, including marijuana and sewer gas, in various areas such as the Memory Care Unit and front lobby. Additionally, a resident's room had visible disrepair with dried smears and chipped paint. Despite existing cleaning protocols, these issues persisted, indicating a failure to maintain a clean and homelike environment.
A facility failed to provide a SNF-ABN and NOMNC to a resident who continued to reside in the facility after Medicare services ended. A review showed the necessary forms were not completed, and the Director of Nursing confirmed the absence of a policy for advanced beneficiary notice of non-coverage.
The facility failed to properly label medications on two medication carts. On the West Hall cart, ceftriaxone, lidocaine, and aspirin were unlabeled, while on the East Hall cart, two insulin pens lacked the resident's name. Staff confirmed the labeling errors, and the DON provided a policy outlining proper labeling requirements.
The facility failed to provide consistent bathing care to four residents, as revealed by a survey. Residents reported difficulties in receiving regular showers, and Point of Care documentation showed numerous days without recorded bathing. Grievances filed by families highlighted concerns about the lack of showers, yet inconsistencies persisted in the facility's records, with no refusals documented.
Open-Ended PRN Antianxiety Orders Lacked Specific Duration
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications for 6 of 6 residents reviewed for PRN antianxiety medications because the PRN orders did not indicate a specific duration of use and were written as open ended without stop dates. The deficiency involved residents with diagnoses including anxiety disorder, severe cognitive impairment, generalized anxiety disorder, PTSD, and breast cancer, and several of the residents had recent MDS assessments showing antianxiety medication use in the 7-day lookback period. Resident 7 had an open-ended lorazepam order for anxiety and received PRN doses on multiple dates in December 2025, January 2026, and February 2026. Resident G had an open-ended hydroxyzine order for anxiety, but the February 2026 eMAR showed no PRN administration. Resident 2 had an open-ended lorazepam order for anxiety, shortness of breath, and restlessness and received PRN doses on 2/23/26 and 2/24/26. Resident B had an open-ended Xanax order for anxiety and received PRN doses on several occasions in February and March 2026. Resident 81 had an open-ended lorazepam order for anxiety, agitation, and dyspnea, but had not received the medication in February or March 2026 and lacked a care plan related to antianxiety medication use. Resident 6 had an open-ended clonazepam order as needed, and the eMAR showed PRN doses on 2/5/26 and 3/2/26. During interview, the DON stated the facility did not have a policy specific to PRN antianxiety medications and their duration of use and used the federal regulation.
Failure to Develop and Implement Complete Care Plans for Medications and Falls
Penalty
Summary
The facility failed to develop and implement complete care plans with measurable interventions for residents receiving anticonvulsant, antidepressant, and antianxiety medications, and failed to implement fall-prevention interventions that were already listed on care plans. For Resident 9, the record showed diagnoses including depression, dysphagia, and chronic respiratory failure with hypoxia, and the resident was cognitively intact. The resident was receiving gabapentin and duloxetine, but the clinical record lacked a care plan related to those medications. Although the falls care plan included placing a call-don't-fall sign in the room, the sign was not observed in the room during survey observations, and a CNA stated she did not know whether the sign was present. For Resident 30, the record showed Parkinson's disease with dyskinesia, dysphagia following cerebrovascular disease, and depression, and the resident was cognitively intact with a history of falls. The falls care plan directed staff to keep a bedside commode within reach and empty it frequently, but the resident was observed sitting in a recliner with no bedside commode nearby. An RN stated that care plan interventions should be implemented if they were on the care plan and was not aware of the bedside commode intervention. For Resident B, the record showed dementia and severe cognitive impairment, with assistance needs for eating, toileting, transfers, and bathing. The resident had a PRN hydrocodone-acetaminophen order, and the care plan addressed fall risk and toileting assistance, but survey observations showed staff did not offer toileting before meals or after returning from lunch, and the resident was found with a saturated brief and later on the floor with a saturated brief. For Resident 40, the record showed bipolar disorder and an oxcarbazepine order, but there was no care plan for anticonvulsant use. For Resident 81, the record showed malignant neoplasm of the female breast and a PRN lorazepam order for anxiety, agitation, and dyspnea, but there was no care plan related to antianxiety medication use.
Improper Medication Storage in Carts and Refrigerator
Penalty
Summary
The facility failed to ensure medications were stored properly in 3 of 3 medication carts observed and 1 of 2 medication storage rooms observed. During observation of the 300 Hall medication cart, loose medications were found in multiple drawers, including an unidentified tablet, a tablet that appeared to be allopurinol 100 mg, and a capsule that appeared to be carbamazepine 200 mg. An LPN stated it was the responsibility of the nurse on the cart to keep the cart organized and said the night shift nurse typically cleaned the cart. During observation of the Memory Care Unit medication cart, a loose tablet that could not be identified was found in the third drawer. In the Memory Care Unit medication storage room, the refrigerator contained extra resident insulin pens and the refrigerator door was open; a thermometer at the front of the refrigerator showed 60 degrees Fahrenheit. A QMA stated the medication room refrigerator door should remain closed. During observation of the 100 Hall medication cart, an unidentified tablet was found in the eighth drawer and a loose capsule was found in the bottom drawer; an LPN identified the capsule as gabapentin. The facility later provided a policy stating medications are to be stored orderly in a secured area and refrigerator storage should be kept clean and organized with temperatures maintained between 36 and 46 degrees.
Code Status Not Clearly Indicated for Two Residents
Penalty
Summary
The facility failed to ensure code status was clearly indicated for two residents reviewed for advance directives. One resident was cognitively intact and had diagnoses including vomiting, lack of coordination, and abnormalities of gait and mobility. The resident profile dashboard listed the resident as full code, but the current physician orders included a DNR order. The clinical record did not contain a signed Advance Directive document for DNR, even though the care plan stated the resident had requested DNR status and included interventions such as not attempting CPR if no pulse was noted and providing comfort measures as indicated. For the second resident, the record showed diagnoses including Parkinson's disease with dyskinesia, dysphagia following other cerebrovascular disease, and depression. The resident was cognitively intact, and the current physician orders included both a DNR order and a full code order. The care plan indicated the resident wished to have DNR status, and advance directive documents indicated the resident was DNR. During interviews, a CNA stated the resident was listed as full code on assignment forms, and an LPN stated the resident was full code and that there was not supposed to be a DNR order because someone had entered it in the EHR before the resident signed the paperwork.
Inaccurate MDS Coding for Anticonvulsant Use
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for 1 of 5 residents reviewed for unnecessary medications. Resident 40 had diagnoses including bipolar disease and was assessed as having severe cognitive impairment on the most current Quarterly MDS assessment dated 11/17/25. That assessment indicated the resident did not receive an anticonvulsant during the 7-day lookback period of 11/11/25 through 11/17/25. Record review showed physician orders for oxcarbazepine, an anticonvulsant medication, at a total dose of 750 mg twice daily for bipolar disorder, and the November 2025 eMAR showed the resident received oxcarbazepine 750 mg seven out of seven days during the lookback period. During interview, the MDS Coordinator stated the resident received an anticonvulsant medication but it was not coded on the 11/17/25 MDS assessment. The Regional Support Nurse stated the facility did not have a policy specific to MDS coding and used the RAI user manual.
Failure to Provide Proper Incontinence Care and Administer Ordered UTI Antibiotics
Penalty
Summary
The facility failed to provide care to prevent a urinary tract infection and failed to follow physician orders for treatment of an active UTI for one resident with dementia who was severely cognitively impaired and required staff assistance for toileting, transfers, bathing, and eating. The resident had a history of recurring abnormal urinalysis requiring antibiotic treatment, and the care plan directed staff to administer antibiotics as ordered. The physician ordered Macrobid 100 mg twice daily for five days, starting 2/27/26. During observed incontinence care, two CNAs provided care to the resident while wearing gloves, but hand hygiene was not performed during the task. One CNA used a gloved hand to adjust the bed, searched the closet and bedside table for supplies, removed and replaced gloves once, applied cream directly to the resident’s buttocks and vulvar area, and the other CNA wiped the perineal area and fastened the brief and clothing. In addition, the resident did not receive all ordered antibiotic doses: the pharmacy reported the medication was never sent to the facility and the facility used emergency drug kit medication, but records showed missed doses and documentation of doses given without corresponding medication removal. The DON stated the resident missed four of nine antibiotic doses from 2/27/26 to 3/3/26.
NJ Tube Placement Not Monitored
Penalty
Summary
The facility failed to ensure that a resident's nasal jejunal (NJ) feeding tube was monitored for correct placement. The resident had diagnoses including dysphagia following other cerebrovascular disease, gastro-esophageal reflux disease without esophagitis, and borderline personality disorder, and was admitted to the facility on an unspecified date. Current physician orders included Glucerna 1.5 at 50 mL/hr continuous with water flushes of 150 mL every six hours, but the orders lacked an instruction to check tube placement. The February 2026 MAR also lacked documentation showing that NJ tube placement was checked or that the distance of the tube marker was recorded. On 2/26/26 at 8:15 A.M., the resident was observed lying on her right side with the NJ tube lying flat alongside her, with the pink marker hanging out of the left nares about one inch and the nasal endings knotted underneath the distal part of the marker. The care plan for nasogastric tube care included checking placement and patency before each feeding or medication administration and providing enteral feedings and flushes per MD orders. During interviews, RN 9 stated the resident had gone to the hospital two days in a row for NJ tube replacement after sneezing it out the first time and having it clogged the second time, and that an x-ray showed the tube was curled upon itself in the abdomen and had to be reinserted. RN 9 and LPN 3 both stated that staff should have been documenting the marker measurement, but it had not been documented.
Failure to Provide Pain Management for Resident With Fracture
Penalty
Summary
The facility failed to ensure an attempt for pain management was provided for a resident with a left femur fracture and a laceration to the left forehead/orbital area. The resident’s record showed diagnoses including urinary tract infection and fracture of the left femur, and the Quarterly MDS indicated the resident was severely cognitively impaired and required assistance with eating, toileting, transfers, and bathing. Physician orders included hydrocodone-acetaminophen as needed for pain, acetaminophen as needed for pain, and a weekly buprenorphine pain patch. The care plan directed staff to monitor for signs and symptoms of increased pain and treat as ordered, with follow-up with the physician as needed. The eMAR showed the resident reported pain of 5 on a 0 to 10 scale on the night shift, but there was no documentation of non-pharmacological pain interventions or pain medication administration from 2/27/26 at 1:20 P.M. to 2/28/26 at 8:00 A.M. The eMAR also showed pain of 5 on day shift and 2 on night shift on 3/1/26, yet there was no pain medication administration from 2/28/26 at 8:27 P.M. to 3/2/26 at 8:23 A.M. A progress note later documented the resident had only eaten three shrimps and a pudding all weekend, and during interview the resident was reported to have increased agitation, refusal of eating, and increased behaviors over the last few days. Family stated the resident was in an immense amount of pain, and pain medication was then provided.
Failure to Monitor Side Effects of High-Risk Medications
Penalty
Summary
The facility failed to ensure monitoring for side effects of high-risk medications for 2 of 5 residents reviewed for unnecessary medications. One resident with bipolar disorder and severe cognitive impairment had orders for oxcarbazepine 750 mg twice daily, but the clinical record lacked a care plan related to anticonvulsant use and lacked an order to monitor for anticonvulsant side effects. During interviews, the DON stated staff would monitor for the indication of a medication but not necessarily the side effects, and later stated staff monitored side effects of psychotropic medications such as olanzapine because those side effects were similar to anticonvulsant side effects. A second resident with depression, dysphagia, and chronic respiratory failure with hypoxia was cognitively intact and received gabapentin and duloxetine during the lookback period. The clinical record lacked orders for monitoring side effects of both the anticonvulsant and antidepressant medications. The Regional Support Nurse stated the facility did not have a policy specific to monitoring high-risk medications and expected staff to monitor for side effects of medications.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed during incontinence care for one resident who had a current urinary tract infection. During an observation of care on 3/2/26 at 1:43 P.M., CNA 7 and CNA 8 entered the resident’s room and both put on gloves before beginning care. CNA 7 raised the bed, flattened it, looked in the closet for a brief, and then, with CNA 8, rolled the resident to her right side and removed a saturated brief. CNA 7 cleaned the resident’s buttocks with wipes and placed a new brief under her. CNA 7 then applied cream with her right hand to the resident’s buttocks, removed her right glove, and put on a new glove. CNA 7 and CNA 8 rolled the resident back onto her back, and CNA 8 wiped the front perineal area from top to bottom. CNA 7 searched through items on the bedside table for a bottle of cream and applied cream directly to the resident’s vulvar area. CNA 8 fastened the brief and pulled up the resident’s pants. CNA 7 removed her gloves and collected the trash, while CNA 8 covered the resident with a blanket, lowered the bed, and removed her gloves. Hand hygiene was not performed during care. The Infection Prevention Nurse stated staff should perform hand hygiene and don gloves before incontinence care, change gloves between dirty and clean tasks, and perform hand hygiene after care. The facility’s Hand Washing/Hand Hygiene policy stated employees must wash their hands for at least twenty (40-60) seconds under specified conditions, including before and after direct resident contact and before and after assisting a resident with personal care.
Blood Spill Left Uncleaned in Memory Care Unit
Penalty
Summary
The facility failed to provide a sanitary environment in the Memory Care Unit when a blood spill remained on the carpet next to the nurses station after a resident’s fall that resulted in a head laceration. Family members reported that when they entered the building, blood from the resident’s fall was still on the floor and were visibly upset. Survey observations found an approximately 12-inch stain that appeared to be dried blood next to the nurses station on 2/26/26, and the stain was still present on 3/2/26. During interview, Housekeeper 11 stated that blood spills should be cleaned immediately and housekeeping notified to disinfect the area, but staff were unaware of the blood stain in the Memory Care Unit. The facility policy titled Cleaning of Spills or Splashes of Blood or Body Fluids stated that blood spills must be cleaned and the area decontaminated as soon as practicable.
Care Plans Not Revised After Wound Deterioration, Aggressive Behaviors, and Falls
Penalty
Summary
The facility failed to ensure care plans were revised when residents’ conditions changed for wounds, behaviors, and falls. For a resident with paraplegia, unspecified protein-calorie malnutrition, and dementia, the record showed a coccyx pressure ulcer that was present on admission and later worsened on repeated wound assessments. Although the care plan addressed risk for skin breakdown and later identified the coccyx wound, the record did not show that the care plan was revised after the wound deteriorated. For a resident with dementia and behavioral disturbance, the record documented multiple physically aggressive incidents involving other residents and staff, including altercations, blocking a CNA, smacking a QMA, and repeated episodes requiring staff intervention and hospital transfers. The resident’s behavior care plan listed interventions, but the record lacked documentation that the plan was updated after several of the incidents, including episodes on 7/25/25, 8/29/25, 10/9/25, 1/2/26, 1/3/26, 2/6/26, and 2/9/26. The record also showed that after return from a psychiatric hospital, the care plan was not revised to reflect new medications and adjustments. For a resident with dementia and a left femur fracture, the record showed multiple falls over a short period, including a fall on 1/31/26 and additional falls on 2/1/26 and 2/25/26. The care plan included fall-risk interventions, and an IDT note documented review of multiple falls and later updates to toileting and positioning interventions. However, the record lacked a review following the 1/31/26 fall, and the care plan did not include an intervention related to that fall. Facility interviews confirmed that behavior care plans were not always updated after each aggressive episode and that the resident’s care plan should have been updated after the ongoing behaviors.
Inaccurate and Late Documentation of Wound Care, Bedtime Snack, and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and timely documentation in resident medical records for a resident with a coccyx pressure ulcer and for a resident receiving PRN medications and an antibiotic. For the resident with the wound, the record showed paraplegia, protein-calorie malnutrition, and dementia, and included a nutritional assessment indicating a bedtime snack. However, the record contained no physician order for a bedtime snack and no documentation that a bedtime snack was ever provided. The resident’s coccyx wound was first assessed on 8/4/25, but that assessment was not entered into the record until 8/8/25, and the resident did not receive a wound treatment order until the wound was added to the record. Weekly wound assessments showing worsening of the wound on 8/11/25 and 8/18/25 were not entered until 8/25/25, and updated wound care orders were not entered until those assessments were added. The wound documentation also showed that the resident’s coccyx wound progressed from an unstageable deep tissue injury to unstageable slough/eschar with declining healing status, but the facility did not have timely record entries reflecting those changes. During interview, an LPN stated that a new wound should trigger a wound event and initial assessment in the resident record, and that wound management assessments should then be completed routinely. The DON stated the nutritional assessment did not include a new recommendation for a bedtime snack, but rather indicated the resident was already receiving one, and also stated the initial wound assessment had been entered into the wound management assessment without a wound event being created. For the second resident, the record showed diagnoses including urinary tract infection, left femur fracture, and anxiety, with orders for Macrobid, hydrocodone-acetaminophen, and Xanax. The pharmacy technician stated the pharmacy’s systems had not aligned and the antibiotic was never sent to the facility, so the facility used medication from the EDK. The electronic MAR documented antibiotic administration on dates when no antibiotic was removed from the EDK, and controlled drug records showed hydrocodone and Xanax were signed out of the locked narcotic box on multiple dates and times when the electronic MAR did not document pain or anxiety assessment or medication administration. The DON acknowledged documentation of medication administration was an issue in the building, and the Regional Nurse Coordinator stated staff were expected to document timely and accurately.
Failure to Notify Resident's POA of Wound Decline
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) representatives of a worsening pressure ulcer and the development of new wounds. The resident in question had multiple diagnoses, including paraplegia, dementia, and chronic conditions that increased the risk for skin breakdown. The care plans and clinical records indicated the resident was at high risk for pressure ulcers and had several wounds, including to the coccyx, left ankle, and left heel, with documented decline in wound status over time. Wound notes showed that the resident's husband was present and informed during some wound assessments, and the physician and spouse were notified of changes. However, there was no documentation that the resident's POA representatives, who were listed as the primary contacts for health and financial matters, were notified of the decline in the coccyx wound or the development of wounds on the left ankle and heel. The clinical record confirmed the absence of such notifications, despite the POAs being the designated representatives. During interviews, the Administrator acknowledged that the POA was not notified of the wound decline and that the facility did not have a policy regarding notification of a resident's representative about changes in condition. The lack of notification to the appropriate representatives constituted the deficiency identified in the report.
Failure to Provide and Document Daily Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically bathing and showers, were provided and properly documented for residents who were unable to perform these tasks independently. For one resident with multiple complex medical conditions, including paraplegia, dementia, and a history of pressure ulcers, the clinical record and care plan indicated a need for total assistance with bathing. However, a review of the point of care documentation for July and August showed inconsistent entries for bathing, with several days lacking documentation of any bathing or shower, and no records indicating resident refusal. Similarly, another resident with severe cognitive impairment and total dependence for bathing had a care plan specifying preferred shower days. Documentation for July, August, and September revealed irregular entries for partial or complete bed baths and showers, with gaps in daily bathing records and no documentation of refusals. Staff interviews confirmed that refusals should be documented and reported, but no such documentation was found. The facility's policy required appropriate support and assistance with hygiene for residents unable to perform ADLs, but this was not consistently provided or recorded.
Lack of Immediate Physician Orders for Colostomy Care
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident D, had immediate physician orders for the care of a colostomy. Upon admission, Resident D, who had a colostomy and was cognitively intact, indicated that while nurses attended to his colostomy, CNAs were generally reluctant to provide care. A review of Resident D's clinical records and care plans revealed that although there was a care plan in place for ostomy care, there were no specific physician orders documented for the care of the colostomy in January and February. An LPN confirmed that orders for colostomy care should be established shortly after a resident's admission, typically requiring changes every 2 to 3 days. However, no policy was provided regarding the procedure for obtaining admitting physician orders.
Infection Control Lapses in Wound Care and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for Resident 33 and while using medical equipment on Residents 13 and 16. During a wound care procedure, RN 2 and LPN 10 did not change gloves after cleaning a bedside table and before handling clean dressing supplies. Additionally, gloves were not changed or hands sanitized at appropriate times during the dressing change process. Resident 33, who was cognitively intact and had venous ulcers on both legs, was at risk due to these lapses in infection control. The facility's policy required hand hygiene with alcohol-based gel before and after handling dressings and after removing gloves, which was not followed. In another instance, LPN 9 failed to sanitize a blood pressure monitor between uses on different residents. The monitor was used on Resident 13 and then placed in a bag without being cleaned. It was later used on Resident 16 without prior sanitization. The facility's policy, aligned with CDC and OSHA standards, required that resident-care equipment be cleaned and disinfected between uses, which was not adhered to in this case.
Facility Fails to Maintain Sanitary Environment and Address Odors
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of pervasive odors and physical disrepair. On several occasions, surveyors noted an odor consistent with marijuana in the Memory Care Unit and East Hall Nurses Station. Additionally, the front lobby was reported to smell like sewer gas, which the Director of Nursing attributed to a backed-up trap, especially during rain. Interviews with staff revealed a lack of specific policies for controlling odors, with housekeeping and maintenance expected to address these issues as they arise. However, the presence of these odors suggests that the current measures were insufficient. Further observations revealed physical disrepair in a resident's room, where dried deep red smears, missing paint chips, and scuff marks were noted along the walls. Despite daily inspections and weekly deep cleaning protocols, these issues persisted, indicating a failure to maintain cleanliness and order as outlined in the facility's policy for a homelike environment. The Director of Nursing provided a policy emphasizing the importance of minimizing institutional odors and maintaining cleanliness, yet the observed conditions contradicted these standards.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) and a Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from Medicare services but continued to reside in the skilled nursing facility. On December 6, 2024, a review of the SNF Beneficiary Protection Notification Review Forms revealed that the form was blank regarding whether the resident received the necessary SNF-ABN and NOMNC forms. The review indicated that the resident's Medicare coverage ended on August 3, 2024, but the required documents (CMS 10055 and NOMNC 10123) were not signed by the resident or their representative. On December 10, 2024, the Director of Nursing stated that the facility did not have a policy related to advanced beneficiary notice of non-coverage and relied on instructions from the Center for Medicare and Medicaid Services website.
Medication Labeling Deficiency in Facility
Penalty
Summary
The facility failed to ensure proper labeling of medications on two medication carts, leading to a deficiency. On the West Hall medication cart, a vial of ceftriaxone injection, a vial of lidocaine with an open date, and a bottle of aspirin with an open date were observed without proper labeling. The Qualified Medication Aide (QMA) indicated that the ceftriaxone and lidocaine were removed from the Emergency Drug Kit (EDK) and should have had the resident's name written on them. The aspirin, brought in by a family member, also lacked the resident's name. On the East Hall medication cart, two insulin pens, Lantus Solostar and Humalog Kwikpen, were found with open dates but without the resident's name. The Licensed Practical Nurse (LPN) confirmed that these insulin pens belonged to a resident and should have been labeled accordingly. The Director of Nursing (DON) provided a Medication Labeling policy that outlined the requirements for labeling, which were not adhered to in these instances.
Failure to Provide Consistent Bathing Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, specifically bathing, to four residents, as identified during a survey. Resident L reported difficulties in receiving regular showers, with inconsistencies noted in the Point of Care (POC) documentation for May, June, and July 2024. Despite a grievance filed by the family in June 2024, indicating that showers were not being done, the facility's records showed numerous days where no bathing was documented, and there was only one recorded refusal. Resident N, who resides in a locked dementia unit and is non-interviewable, also experienced lapses in bathing care. The POC history for May, June, and July 2024 revealed several days without recorded bathing, and a grievance from the family in May 2024 highlighted concerns about the lack of showers. Despite the grievance, the documentation continued to show gaps in bathing care, with no refusals noted in the clinical record. Resident Q and Resident P also faced similar issues with bathing care. Resident Q's records showed inconsistencies in the POC documentation, with several days lacking any recorded bathing. A grievance from Resident Q's family in May 2024 addressed concerns about shower schedules, yet the documentation did not reflect consistent care. Resident P, who was discharged in June 2024, had a grievance filed on the day of discharge, indicating a lack of showers for two weeks. The POC history for Resident P also showed numerous days without documented bathing, and no shower sheets were observed for May 2024.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West River Health Campus | 1 mi | ★★★★★ | 10 | 0 |
| Park Terrace Village | 2.5 mi | ★★★★★ | 1 | 0 |
| River Bend Nursing And Rehabilitation | 4.4 mi | ★★★★★ | 23 | 0 |
| Parkview Care Center | 5.7 mi | ★★★★★ | 25 | 0 |
| Brickyard Healthcare - Woodbridge Care Center | 6.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.