Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Catholic Care Center, Inc during CMS and state inspections, most recent first.
Failure to Notify Responsible Party After Medication Error: An agency nurse gave one resident another resident’s nighttime meds after asking the resident if she was the other resident by name and receiving a yes. The resident had multiple diagnoses, moderately impaired cognition, and was on anticoagulant therapy. After the error was discovered, the resident had abnormal VS including low O2 saturation and elevated HR, the PCP was notified, but the record showed no evidence that the responsible party was informed.
Medication error due to failure to verify resident identity. An agency LPN entered a resident’s room, asked if the resident was another resident, and then gave all of the other resident’s nighttime meds, including amiodarone, Eliquis, psych meds, and 5 units of regular insulin. The resident had moderately impaired cognition and required assistance with multiple ADLs. After the error was discovered, the resident had elevated blood sugar and low O2 saturation, and the note did not include family notification.
Failure to Initiate CPR for a Full Code Resident: A resident with a documented full code status, CPR order, and hospice involvement was found unresponsive and not breathing. An LPN assessed the resident, verified the code status in the EMR, and contacted hospice instead of starting CPR. CPR was not initiated until hospice staff arrived about 45 minutes later, and EMS later took over the code.
A resident with a neurogenic bladder had a physician's order for a 20 French suprapubic catheter, but staff inserted a 12 French catheter instead. When staff attempted to correct the error, they were unable to insert the correct size and had to reinsert the smaller catheter. The resident was later seen by a urologist who placed a 16 French catheter. This failure to follow physician orders and facility policy resulted in a deficiency in catheter care.
Staff did not consistently follow Enhanced Barrier Precautions during high-contact care, such as suprapubic catheter care, and failed to disinfect a Hoyer lift between resident uses. These actions were not in accordance with facility policy and placed residents at risk for infection.
The facility failed to maintain a safe environment and implement care-planned fall interventions for residents, leading to deficiencies in care. One resident's bed was placed in a high position against their care plan, increasing fall risk. Another resident's bed was also left high, lacking guidance on bed height. Additionally, two residents did not have required safety measures, such as a Dycem and a fall mat, in place, putting them at risk for falls.
The facility failed to maintain sanitary conditions for residents' medical equipment and did not implement adequate hand hygiene. A CMA used a blood pressure cuff on multiple residents without sanitizing it, and nasal cannulas for three residents were improperly stored. A CPAP mask was also stored incorrectly. Staff interviews revealed inconsistencies in cleaning and storage practices, which did not align with the facility's infection prevention policy, risking infectious disease transmission.
A facility with 147 residents failed to ensure agency CNAs received required resident rights training. Credentialing files for CNAs MM, NN, and OO lacked evidence of this training. Administrative Nurse D assumed the agency provided necessary training, but only covered dementia, infection control, abuse, falls, and change in condition upon staff's first shift. The facility lacked a policy on required training for nurse aides.
A facility failed to maintain the dignity of two residents during meals. One resident, with severe cognitive impairment, was left with a clothing protector on after a meal, while another resident, also with cognitive impairment, was given a drink by a CNA standing over him without interaction. The facility's policy requires residents to be treated with dignity, which was not upheld in these instances.
A facility failed to notify a resident's guardian about the addition of psychotropic medication, Ativan gel, to the resident's treatment plan. The resident, with severely impaired cognition and multiple health conditions, was dependent on staff for daily activities. Despite procedures requiring nurses to inform guardians of medication changes, the guardian was not notified, and the facility lacked evidence of a notification policy.
A resident with end-stage renal disease and a gastrostomy had an inaccurately coded MDS, missing documentation of enteral feeding. The resident's EMR showed a physician's order for enteral feeding, which was not reflected in the MDS, placing the resident at risk for unmet care needs. Staff interviews revealed the dietician's oversight, and the facility lacked a policy for MDS coding.
A resident with a history of falls and dementia, requiring substantial assistance for transfers, was injured during a transfer when a CNA used the resident's arms instead of a Hoyer lift, as prescribed in the care plan. The CNA attempted the transfer without a gait belt, leading to bruising on the resident's arms. The facility's policy on ADLs was not followed, resulting in physical harm to the resident.
The facility failed to provide adequate pressure ulcer prevention and care for two residents, leading to increased risk of ulcer development. One resident, with multiple medical conditions, was not consistently offloaded as required, while another resident, with severe cognitive impairment, lacked a pressure-reducing cushion in their wheelchair. Staff did not adhere to care plans and physician orders, contributing to the deficiency.
A facility failed to ensure a resident's supplemental oxygen was turned on, risking respiratory complications. The resident had a history of respiratory issues and was observed with an inactive oxygen concentrator. Additionally, another resident's CPAP mask was improperly stored, increasing infection risk. Staff interviews revealed procedural inconsistencies, and the facility lacked a policy for respiratory equipment storage.
A facility failed to adequately monitor and document a resident's dialysis access site, specifically the arteriovenous fistula (AVF), which is essential for hemodialysis. Despite the care plan and physician orders requiring daily assessment for thrill, bruit, and signs of infection, the facility only conducted assessments on dialysis days. This lack of daily monitoring and documentation placed the resident at risk for adverse outcomes related to dialysis.
A facility failed to provide trauma-informed care for two residents with PTSD, R75 and R107. R75's care plan lacked individualized interventions to prevent re-traumatization, and staff were unaware of her trauma history. R107's care plan did not address specific triggers, and there was no trauma-informed care assessment conducted. Staff were not informed about residents with PTSD, indicating a lack of communication and training. These deficiencies placed the residents at risk for decreased psychosocial well-being and ineffective treatment.
A resident with Alzheimer's and severe cognitive impairment did not receive adequate dementia-related behavioral services, as her care plan lacked specific strategies to address her aggressive behaviors and potential triggers. Despite interventions like CBD gummies and one-to-one supervision, the facility failed to identify underlying causes for her behaviors, compromising her well-being.
A facility failed to act on a Consultant Pharmacist's recommendations for a resident prescribed Ativan without a stop date. The resident, with diagnoses of anxiety, depression, and dementia, was observed asleep in a wheelchair without food or drinks. The facility's policy required documentation of pharmacist recommendations, but this was not followed, risking adverse effects and unnecessary medication use.
A resident with a history of hypertension and other conditions was administered antihypertensive medications despite having a systolic blood pressure below the physician-ordered threshold. The facility's policy required staff to verify medication orders and parameters, which was not followed, leading to the resident's admission to an acute care facility due to low blood pressure.
The facility failed to ensure that PRN psychotropic medications for two residents had a 14-day stop date or specified duration, risking unnecessary medication administration. One resident with anxiety, depression, and dementia was prescribed Ativan without a stop date, while another with multiple diagnoses was prescribed Lorazepam gel without a stop date. Staff were unsure of the duration for PRN orders, indicating non-compliance with facility policy.
A facility failed to ensure proper collaboration with a hospice provider for a resident, risking inadequate end-of-life care. The resident's care plan lacked directions for staff on hospice collaboration, supplies, and visit schedules. Staff interviews confirmed the absence of necessary hospice information in the care plan, despite facility policy requiring such coordination.
Failure to Notify Responsible Party After Medication Error
Penalty
Summary
The facility failed to notify Resident 1’s responsible party after a medication error in which an agency nurse administered another resident’s nighttime medications to Resident 1. Resident 1 had diagnoses including cerebral infarction, anxiety, asthma, chronic pain, and osteoarthritis, and the admission MDS documented moderately impaired cognition, moderate assistance needs for multiple activities of daily living, and use of anticoagulant and antiplatelet medications during the lookback period. The care plan identified impaired cognitive function, weakness, decreased safety awareness, and risk for adverse medication interactions. On 04/23/26, the nurse entered Resident 1’s room, asked if the resident was the other resident by name, and Resident 1 answered yes; the nurse then administered all of the other resident’s nighttime medications to Resident 1. Resident 1’s heart rate before medication administration was 115 beats per minute, and her blood sugar was over 300 mg/dL. After staff realized the wrong medications had been given, an assessment showed blood pressure 106/46 mm/Hg, heart rate 111 beats per minute, oxygen saturation 85%, respirations 22 breaths per minute, and temperature 97.9 F. The primary care physician was notified, but the medical record lacked evidence that the responsible party was informed, and the administrative nurse confirmed the agency nurse did not notify the responsible party.
Medication error due to failure to verify resident identity
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when a licensed nurse prepared and administered the wrong medications and five units of regular insulin to the resident. The resident had diagnoses including cerebral infarction, anxiety, asthma, chronic pain, and osteoarthritis, and the admission MDS documented moderately impaired cognition, moderate assistance needs for multiple activities of daily living, and use of anticoagulant and antiplatelet medications. The care plan identified impaired cognitive function, weakness, decreased safety awareness, and risk for adverse medication interactions. The progress note documented that the nurse entered the resident’s room, asked if the resident was the other resident, and the resident answered yes. The nurse then administered all of the other resident’s nighttime medications to the resident. The resident’s heart rate before medication administration was 115 beats per minute, and the blood sugar was checked and found to be over 300 mg/dL. After staff discovered the error, an assessment showed blood pressure 106/46 mm/Hg, heart rate 111 beats per minute, oxygen saturation 85%, respirations 22 breaths per minute, and temperature 97.9 F. The primary care physician was notified, and a nurse practitioner later documented that the resident had received amiodarone, Eliquis, and psych meds overnight and had been placed on oxygen for hypoxia. The note did not include family notification of the medication error. Administrative staff stated the nurse was an agency nurse and should have followed the facility’s medication administration policy and the five rights, including verifying the resident’s identity with the MAR photo before giving medications.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide CPR to a resident who had a documented full code status and a physician’s order for full resuscitative measures. The resident had diagnoses including malignant neoplasm of the bronchus or lungs, acute respiratory failure, and heart failure, and his care plan documented that he requested CPR and was full code. His physician progress notes also documented that he remained full code and that hospice staff were to discuss DNR recommendations with him. On the morning of the event, a CNA found the resident unresponsive and not breathing and immediately notified the licensed nurse. The nurse assessed the resident, then went to the nurse station to verify the code status in the EMR and told the CNA that the resident’s hospice providers would take care of the rest. The nurse then called the hospice provider. CPR was not initiated by facility staff at that time, and hospice staff did not arrive until about 45 minutes after the resident was found unresponsive, at which point CPR was started. EMS later arrived and took over the resuscitation attempt, and the resident was pronounced dead. The facility’s investigation documented that the nurse failed to initiate CPR even after verifying that the medical record showed the resident was full code. The nurse stated she used her nursing assessment and moral judgment not to initiate a code and administer CPR. Survey observations and staff interviews also showed that staff knew code status was available in the EMR and that CPR should begin immediately when a resident had no pulse or was not breathing. The facility determined this failure placed the resident and all full code residents in Immediate Jeopardy.
Failure to Use Correct Catheter Size During Suprapubic Catheter Care
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with a diagnosis of neuromuscular dysfunction of the bladder, who had a physician's order for a 20 French suprapubic catheter. The resident's care plan directed staff to change the catheter monthly and as needed. However, staff inserted a 12 French catheter instead of the ordered 20 French size. When an attempt was made to replace the incorrect catheter with the correct size, the nurse was unable to insert the 20 French catheter after several attempts and ultimately reinserted the 12 French catheter. The incident was documented in the resident's progress notes, and the resident was later seen by a urologist who placed a 16 French catheter. The facility's policy required staff to use the proper catheter size as ordered and to report any complications. Interviews with administrative nurses confirmed the expectation that staff use the correct catheter size. The error in catheter size selection and the subsequent difficulty in correcting it constituted a failure to follow physician orders and facility policy, resulting in a deficiency in catheter care for the resident.
Failure to Follow Enhanced Barrier Precautions and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by policy and regulatory standards. Specifically, a licensed nurse provided suprapubic catheter care to a resident using gloves but did not don a gown, as required under Enhanced Barrier Precautions (EBP) for high-contact care activities involving indwelling medical devices. Additionally, another licensed nurse assisted a certified nurse aide in transferring a resident using a Hoyer lift and subsequently placed the lift in a hallway cubby without disinfecting it between resident uses, contrary to facility policy and CDC recommendations. Interviews with administrative nursing staff confirmed that staff were expected to follow EBP protocols and clean equipment such as Hoyer lifts between each resident use. The facility's own policies, dated October 2024 and 2018, outlined the need for EBP during high-contact care and for cleaning and disinfecting resident-care equipment according to CDC and OSHA standards. These lapses in following established infection control procedures were observed during routine care activities and placed residents at risk for infection.
Failure to Maintain Safe Environment and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to deficiencies in care. One resident, with severe cognitive impairment and a history of falls, was found to have her bed intentionally placed in a high position by staff, contrary to her care plan which required the bed to be in a low position to prevent falls. This action was taken to prevent the resident from getting back into bed without assistance, but it increased her risk of falling due to her impulsive behavior and cognitive deficits. Another resident, who was dependent on staff for transfers and had moderately impaired cognition, was also found with their bed in a high position. The care plan did not provide guidance on bed height, but staff interviews confirmed that the bed should not be left in a high position due to the resident's fall risk. This oversight placed the resident at risk for fall-related injuries. Additionally, the facility failed to implement care-planned fall interventions for two other residents. One resident, who required a Dycem in their wheelchair to prevent falls, was observed multiple times without it in place. Another resident, who was at risk for falls, did not have a fall mat beside their bed as required by their care plan. These failures to follow care plans and ensure safety measures were in place put the residents at risk for preventable falls and injuries.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain sanitary conditions for several residents' medical equipment and did not implement adequate hand hygiene practices. Specifically, a Certified Medication Aide (CMA) used a blood pressure cuff on multiple residents without sanitizing it between uses and did not perform hand hygiene before handling the equipment. Additionally, nasal cannulas for three residents were not stored in a sanitary manner when not in use, with instances of them being placed on the floor, over wheelchairs, or hanging over bed rails without proper containment. A CPAP mask for another resident was improperly stored directly on the CPAP machine or bedside table, contrary to the facility's infection prevention and control policy. Interviews with staff revealed inconsistencies in the cleaning and storage practices for CPAP masks and nasal cannulas. While some staff members stated that CPAP masks should be cleaned with soap and water and hung to dry, others mentioned using disinfectant wipes and storing them in plastic bags. The facility's infection prevention and control policy, dated 2019, emphasized the importance of maintaining a safe and sanitary environment to prevent the transmission of communicable diseases. However, the observed practices did not align with these guidelines, placing residents at risk for infectious diseases.
Deficiency in Resident Rights Training for Agency CNAs
Penalty
Summary
The facility, with a census of 147 residents, failed to ensure that direct care staff received the required training on resident rights. This deficiency was identified through a review of the credentialing files for agency CNAs MM, NN, and OO, which lacked evidence of completed resident rights training. Administrative Nurse D, responsible for reviewing nursing staff information from the agency staffing company, assumed that the agency ensured the nurse aides had the necessary training. However, upon the staff's first shift, only training on dementia, infection control, abuse, falls, and change in condition was provided, omitting resident rights. The facility did not have a policy regarding the required training for nurse aides, which contributed to the oversight.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to uphold the dignity and respect of Resident 75 by not removing her clothing protector after a meal. Resident 75, who has severe cognitive impairment due to conditions such as anxiety, depression, and dementia, was observed in the dining room with a clothing protector still attached, even though she was not eating or drinking. Staff members, including a CNA and a licensed nurse, acknowledged that leaving a clothing protector on a resident after a meal is a dignity concern, and the facility's policy emphasizes treating residents with dignity and respect. Another incident involved Resident 13, who has severe cognitive impairment and multiple health conditions, including schizoaffective disorder, epilepsy, and cerebral palsy. During a meal, a CNA was observed standing over Resident 13 while giving him a drink, without engaging in any interaction. This action was contrary to the facility's policy, which requires staff to be at eye level and engage with residents during assistance. Both a licensed nurse and the CNA involved confirmed that staff should sit next to residents and engage with them during meals. The facility's Quality of Life-Dignity policy, revised in 2020, mandates that residents be treated in a manner that promotes their well-being and self-esteem. The failure to adhere to this policy in the cases of Residents 75 and 13 resulted in a deficiency report, highlighting the risk of negative psychosocial outcomes and decreased dignity for the residents involved.
Failure to Notify Guardian of Medication Changes
Penalty
Summary
The facility failed to notify the guardian of Resident 13 about changes related to the addition of psychotropic medications, specifically Ativan gel, to the resident's treatment plan. The resident, who has a history of schizoaffective disorder, epilepsy, depression, diabetes mellitus, hypertension, intellectual disabilities, anxiety, cerebral palsy, sleep apnea, adult failure to thrive, and edema, was documented to have severely impaired cognition and was dependent on staff for activities of daily living. The resident's care plan included monitoring for side effects and effectiveness of the antianxiety medication every shift, but there was no evidence in the clinical record that the guardian was informed of the new medication order. Interviews with the nursing staff revealed that it was the nurses' responsibility to inform guardians and resident representatives of any medication changes and to document this communication in the electronic medical record. However, the guardian of Resident 13 stated that she had not been informed about the addition of any medication or changes to the medication regimen. The facility's administrative nurse confirmed that the charge nurse should notify the resident's guardian of any changes, and unit nurse managers were responsible for running daily reports of new orders and following up with guardians. Despite these procedures, the facility did not provide evidence of a policy for notification of changes, leading to the deficiency in communication with the resident's guardian.
Inaccurate MDS Coding for Resident with Enteral Feeding
Penalty
Summary
The facility failed to ensure that a significant change Minimum Data Set (MDS) for a resident with end-stage renal disease and a gastrostomy was accurately coded. The resident's MDS section K0520, which pertains to Nutritional Approaches, lacked documentation of the feeding tube and the percentage of calories and amount of fluids provided through it. This oversight was identified during a review of the resident's Electronic Medical Record (EMR), which showed a physician's order for enteral feeding that was not reflected in the MDS. The resident was on a physician-prescribed weight gain regimen and was at risk for dehydration, as noted in the Nutritional Care Area Assessment (CAA). The deficiency was further highlighted when the resident, who was able to eat regular meals but required enteral feeding due to weight loss and dialysis therapy, was observed in the dining room. Interviews with facility staff revealed that the dietician did not mark the MDS for enteral feeding, and the administrative nurse acknowledged the need for a modification to the MDS. The facility did not provide a policy regarding the MDS when requested, indicating a lapse in ensuring accurate coding as required by the Resident Assessment Instrument (RAI) Manual.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to ensure appropriate and safe assistance with activities of daily living (ADL) for a resident, identified as R93, during a transfer, which resulted in bruises on both of the resident's arms. R93 had a medical history that included repeated falls, hypertension, blindness in one eye, and dementia, and was on hospice services. The resident required substantial to maximal assistance for bed-to-chair transfers and had a care plan that directed the use of a Hoyer lift for such transfers. However, during an incident, a Certified Nurse Aide (CNA) transferred R93 using the resident's upper arms instead of the prescribed method, leading to bruising. The incident occurred when the CNA attempted to transfer R93 to a wheelchair that was not properly prepared, as it was full of bed pads. Despite the resident's refusal to use a gait belt, the CNA proceeded with the transfer, resulting in the resident becoming stiff and uncooperative. The CNA, along with another aide, attempted to complete the transfer by holding the resident's arms, which led to the bruising. The resident expressed concern about the transfer process and reported that the CNA seemed frustrated during the incident. The facility's policy on ADLs emphasizes providing care to maintain or improve residents' abilities, but in this case, the staff did not adhere to the care plan or the policy. The CNA involved was unaware of the proper procedure to follow when a resident refuses a gait belt, which should have included stopping the transfer and notifying a charge nurse. This lack of adherence to the care plan and policy resulted in the resident experiencing physical harm and distress.
Failure in Pressure Ulcer Prevention and Care for Two Residents
Penalty
Summary
The facility failed to ensure proper pressure ulcer prevention and care for two residents, R22 and R13, which increased their risk for pressure ulcer development and delayed healing. R22, who had multiple medical conditions including diabetes mellitus, hemiparesis following a stroke, and a deep tissue injury on the right lateral foot, was observed on multiple occasions with his heels resting directly on the mattress, contrary to physician orders to keep his heels offloaded. Despite having boots and a pillow available for offloading, R22 was not consistently provided with these interventions, and there was no documentation of refusal from R22. Staff members, including CNAs and nurses, were not adequately informed or did not follow through with the care plan requirements for offloading R22's heels. R13, who had severe cognitive impairment and multiple diagnoses including schizoaffective disorder, epilepsy, and cerebral palsy, was observed sitting in his wheelchair without a pressure-reducing cushion on several occasions. The care plan for R13 required the use of a pressure-reducing device in his wheelchair to prevent pressure ulcers. However, staff, including therapy and nursing personnel, failed to ensure that R13 had the necessary cushion in place. The therapy director acknowledged that therapy staff should have noticed the absence of the cushion, and the responsibility was shared between therapy and nursing staff. The facility's policy on pressure ulcers and skin breakdown required nursing staff and practitioners to assess and document risk factors for pressure ulcers and to implement medical interventions as ordered. However, the facility did not adhere to these policies, as evidenced by the lack of proper offloading for R22 and the absence of a pressure-reducing cushion for R13. This oversight in following care plans and physician orders contributed to the increased risk of pressure ulcer development for both residents.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure that a resident's physician-ordered supplemental oxygen supply was turned on, which placed the resident at risk of respiratory complications and possible infection. The resident, who had a history of respiratory failure, dysphagia, aspiration pneumonia, dementia, and COPD with hypoxia, was observed sitting in a wheelchair with a nasal cannula connected to an oxygen concentrator that was not turned on. Despite the resident's care plan directing staff to maintain oxygen saturation above 90%, the concentrator was found off, and staff were notified of this oversight. Additionally, the facility did not store another resident's CPAP mask in a sanitary manner, increasing the risk of respiratory infection and complications. The resident, who had a history of cerebrovascular accident and sleep apnea, was observed with her CPAP mask and tubing placed directly on the CPAP machine on the bedside table. The care plan required the CPAP mask to be cleaned with soap and water and hung to dry, but staff were found to be using disinfectant wipes and storing the mask in a plastic bag instead. Interviews with staff revealed inconsistencies in the procedures followed for both residents. Certified Nurse Aides and Licensed Nurses acknowledged the need for continuous oxygen for the first resident and proper cleaning and storage of the CPAP mask for the second resident. However, the facility lacked a policy related to the storage of respiratory equipment, contributing to the deficiencies observed.
Inadequate Monitoring of Dialysis Access Site
Penalty
Summary
The facility failed to provide adequate monitoring and documentation of a resident's dialysis access site, specifically the arteriovenous fistula (AVF), which is crucial for hemodialysis. The resident, identified as R80, had a diagnosis of end-stage renal disease and required dialysis three times a week. Despite the care plan and physician orders indicating the need for daily assessment of the AVF for thrill and bruit, as well as monitoring for signs of infection, the facility's records showed a lack of daily documentation and assessment. Observations and interviews with staff revealed that assessments were only conducted on dialysis days, contrary to the expected daily checks. The facility's policy required staff to monitor the dialysis access site for signs of infection, bleeding, and the status of the dressing, and to document these assessments in the electronic medical record (EMR). However, the clinical record for R80 lacked evidence of daily assessments, placing the resident at risk for adverse outcomes and physical complications related to dialysis. Interviews with nursing staff and administrative personnel confirmed the deficiency in monitoring and documentation practices, highlighting a failure to adhere to the facility's dialysis policy.
Failure in Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents, R75 and R107, who had histories of trauma and PTSD. R75's electronic medical record documented diagnoses of anxiety, depression, and dementia, with a severely impaired cognition score. Despite the care plan indicating that staff should recognize her specific triggers to avoid re-traumatization, there were no individualized interventions in place. Observations showed R75 unattended in the dining room, and staff members, including a CNA and a licensed nurse, were unaware of her trauma history or potential triggers. R107, diagnosed with PTSD and schizoaffective disorder, also lacked a trauma-informed care assessment. Her care plan included engaging her in simple activities but did not address specific triggers to prevent re-traumatization. Staff, including a CNA and an agency licensed nurse, were not aware of any residents with PTSD, indicating a lack of communication and training regarding trauma-informed care. The facility's policy required assessments for trauma-informed care at admission and during significant changes, but this was not followed for R107. The facility's failure to identify trauma-based triggers and implement individualized interventions for R75 and R107 placed them at risk for decreased psychosocial well-being and ineffective treatment. The facility's trauma-informed care policy emphasized culturally sensitive and person-centered care, yet the lack of adherence to this policy resulted in deficiencies in the care provided to these residents.
Inadequate Dementia Care for Resident
Penalty
Summary
The facility failed to provide adequate dementia-related behavioral services for a resident, identified as R30, which compromised her highest practicable level of well-being. R30 had a medical history of Alzheimer's disease, seizures, epilepsy, and insomnia, and was noted to have severe cognitive impairment with a BIMS score of five. Her care plan indicated she required substantial assistance with activities of daily living and had aggressive behaviors towards others, often refusing care. Despite these needs, the care plan lacked specific strategies to address potential triggers or causes for her behaviors, particularly around meal services, and did not include individualized non-pharmacological interventions to prevent repeated behaviors. R30's behavioral episodes were documented in her EMR, including incidents of verbal and physical aggression towards other residents and staff. These episodes occurred in various settings, such as the dining room and other residents' rooms, and were sometimes managed with CBD gummies and one-to-one supervision. However, the facility's care plan did not adequately identify or address the underlying causes of her behaviors, nor did it provide effective strategies for redirecting her during episodes of confusion and agitation. Interviews with facility staff revealed that while some interventions, such as walks and one-to-one time, were used to manage R30's behaviors, there was a lack of consistent identification of triggers and causative factors. The facility's Behavioral Health Services policy emphasized the need for individualized interventions, but the absence of a specific dementia care policy and the incomplete care plan for R30 highlighted deficiencies in the facility's approach to managing her condition. This oversight placed R30 at risk for decreased quality of life, isolation, and impaired dignity.
Failure to Address Pharmacist Recommendations for Antianxiety Medication
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist's (CP) recommendations were acknowledged and acted upon for a resident identified as R75. The resident's electronic medical record documented diagnoses of anxiety, depression, and dementia, with a severely impaired cognition score. The resident was prescribed Ativan, an antianxiety medication, without a stop date, and the CP's monthly medication review recommended a rationale for continued use and a specific stop date. However, there was no documentation that the physician reviewed or addressed these recommendations. Observations revealed that R75 was found asleep in a high-back wheelchair in the dining room, not positioned at a table, and without food or drinks present. Administrative Nurse D confirmed the absence of a physician's response to the CP's recommendations and described the process of handling medication regimen reviews, which included delivering them to physicians and unit managers. The facility's policy required that CP recommendations be documented and maintained as part of the permanent medical record, but this was not adhered to, placing the resident at risk of adverse side effects and unnecessary medication use.
Failure to Follow Antihypertensive Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering antihypertensive medications to a resident, identified as R303, which led to the administration of unnecessary medications. R303 had a medical history that included acute respiratory failure, atherosclerotic heart disease, atrial fibrillation, hypertension, and chronic kidney disease. The resident's care plan required monitoring and reporting changes related to his antihypertensive medications to his medical provider. Despite this, on November 9, 2024, the resident's systolic blood pressure was recorded at 99 mmHg, below the threshold of 110 mmHg, yet the medications amlodipine, lisinopril, and terazosin were administered contrary to the physician's orders. The facility's medication administration policy required staff to verify medication orders and parameters before administration, which was not followed in this instance. Interviews with staff revealed that the Medication Administration Report (MAR) should have flagged the low blood pressure to prevent medication administration, and staff were expected to check vital signs before giving antihypertensive medications. The failure to adhere to these protocols resulted in the resident being admitted to an acute care facility due to low blood pressure, highlighting a significant lapse in medication management and monitoring within the facility.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications for two residents, R75 and R13, had a 14-day stop date or a specified duration with supporting physician documentation. This oversight placed the residents at risk for unnecessary medication administration and potential adverse side effects. The facility's policy, revised in 2016, required that antipsychotic medications be prescribed at the lowest possible dosage for the shortest period and be subject to gradual dose reduction and re-review. Resident 75's electronic medical record documented diagnoses of anxiety, depression, and dementia, with a severely impaired cognition score. The resident was prescribed Ativan as needed for anxiety or restlessness, but the order lacked a stop date or a physician-documented rationale for the extended PRN use. Observations noted the resident asleep in a wheelchair without proper positioning or access to food and drinks, indicating potential overmedication. Resident 13's medical record included diagnoses of schizoaffective disorder, epilepsy, depression, and other conditions, with a severely impaired cognition score. The resident was prescribed Lorazepam gel for agitation or anxiety, but the order also lacked a stop date. The facility's staff, including licensed nurses and administrative nurses, were unsure of the duration for which PRN antianxiety medication orders could be active, indicating a lack of adherence to the facility's policy and procedures for psychotropic medication use.
Failure to Collaborate with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration of care between a resident's hospice provider and the facility, which placed the resident at risk of inadequate end-of-life care. The resident, who had a history of repeated falls, hypertension, blindness in one eye, and dementia, was on hospice services. The resident's care plan, however, lacked specific directions for staff on how to collaborate with hospice, what supplies the hospice service provided, or when hospice staff would make visits. This lack of information was confirmed through interviews with facility staff, who indicated that while hospice books were available, the care plan did not contain the necessary hospice information. The facility's policy required coordination with hospice representatives to ensure the resident's needs were met 24 hours a day, and that care plans included the most recent hospice plan of care. Despite this, the care plan for the resident did not reflect the hospice services provided or how to contact them, as confirmed by the administrative nurse. This oversight in the care plan documentation and lack of collaboration with hospice services led to the deficiency identified by the surveyors.
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 383 citations issued within 25 miles in the last 12 months — including the 8 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 Bel Aire
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Larksfield Place | 2.2 mi | ★★★★★ | 0 | 0 |
| Great Plains Post Acute | 3 mi | ★★★★★ | 17 | 0 |
| Legacy At College Hill | 3.2 mi | ★★★★★ | 17 | 1 |
| Center At Waterfront Llc | 4.4 mi | ★★★★★ | 19 | 0 |
| Regent Park Rehabilitation And Healthcare | 4.7 mi | ★★★★★ | 21 | 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.