Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Living Center during CMS and state inspections, most recent first.
Unsecured controlled medications left in an unattended nurse’s station allowed two residents to access a red pharmacy bag containing alprazolam and lorazepam. One resident directed the other to take the bag, then brought it to his room and ingested multiple tablets, later presenting with lethargy, slurred speech, and repeated vomiting that led to hospital intubation and treatment for aspiration pneumonia. This resident had schizophrenia, severe depression, hallucinations, substance use issues, and intermittent passive suicidal ideation, with a care plan requiring ongoing assessment for suicidal thoughts. Conflicting staff statements showed that an LN signed for the delivery but did not secure the medications, and a CMA only put away non‑controlled medications. Missing narcotics for two other residents were later found hidden in a paper towel dispenser, and surveyor observation showed the nurse’s station could be easily entered while unattended, contrary to facility policies requiring secure medication storage and resident safety and supervision.
Weekend Staffing Shortages: The facility failed to maintain adequate CNA, CMA, and nurse staffing on weekend day and night shifts as identified in its Facility Assessment. Payroll data showed multiple weekend shifts with staff clock-outs that left too few CNAs, CMAs, or nurses on the clinical floor, and staff interviews confirmed weekend call-offs and recurring short staffing, with some resident care tasks such as showers not getting done.
Missing Qualified Dietary Manager: The facility failed to provide a full-time certified dietary manager for residents receiving meals from the kitchen. A dietary staff member said she had recently completed a dietary management course but could not provide proof of completion, certification, or required experience, and admin verified the facility should have a certified dietary manager under its food service staffing policy.
Unsanitary food prep and storage conditions were observed in the kitchen, including dirty equipment and surfaces, a leaking and unusable triple-basin sink, greasy and debris-covered work areas, and soiled utensils and towels. Food storage was also deficient, with moldy bread, rotted produce, open and undated items, insect contamination in bread, and staff food stored with resident food items; Dietary staff confirmed the concerns and discarded the items.
The facility failed to ensure the Medical Director, or designee, attended QAPI meetings at least quarterly. Review of the attendance binder showed no evidence of quarterly attendance within the last year, and an admin staff member stated the signature sheets lacked detailed signatures and reflected only two QAPI meeting attendances during the look-back period. The facility policy stated the QAPI Committee meets monthly and reports to the Governing Body.
The facility failed to ensure the designated IP had the required infection prevention and control training and certification. Administrative Nurse E was listed as the IP and confirmed she held that role, but the facility could not provide certification documentation and she stated she was not currently certified. She also said she shared some IP duties with another nurse, but was unsure whether that nurse was certified.
Unsafe Building Conditions and Ceiling Damage: The facility failed to maintain safe, functional, and comfortable conditions. Observations found cracked and uneven courtyard sidewalks, a missing section of concrete, a large hole in the north hallway ceiling with discolored insulation and water damage, and additional ceiling cracks in both hallways. Staff reported the ceiling had been leaking and that the hole was caused by a frozen fire sprinkler line, while management acknowledged the building needed repair.
Unsafe and Unclean Resident Environment: The facility failed to keep the dining/common area clean and orderly, with spilled food, drinks, and debris left on tables and floors while residents were eating breakfast. Multiple resident rooms also had damaged walls, holes, scratches, missing floor tiles, and other visible wear, and an elevator to the basement had been out of service for over a year, preventing residents from using the basement activity area. Staff and maintenance acknowledged the conditions were not consistent with a homelike environment.
A facility failed to provide a written bed hold policy and failed to give written transfer notifications for several residents sent to the hospital. EMR review showed no evidence of bed hold notices or written notices to the resident or representative, and staff gave inconsistent accounts of how forms were handled and who was responsible for notifying the Ombudsman of transfers.
The facility failed to fully acknowledge and file the Consultant Pharmacist’s monthly MRRs for several residents. The EMR showed irregularities and lab-monitoring recommendations for some residents, including a vitamin level, magnesium level, HbA1c monitoring, and review of multiple psychoactive meds for gradual dose reductions, but the clinical records lacked the actual recommendations and evidence of facility and physician response.
Missing Pneumococcal Vaccine Declinations: The facility failed to document informed declinations or administration for the pneumococcal vaccine for four residents. While the EMR showed influenza vaccines were given to some residents and pneumovax was refused, the record lacked signed declinations from the residents or their representatives, and staff could not provide the missing documentation.
Loose Stairwell Handrail: A wobbly, unsecured handrail was observed in the stairwell corridor leading to the basement, with a resident sitting at the bottom of the stairway near the secured basement door. An admin staff member later observed the loose railing and noted that the base was out of the hole in the concrete. Facility policy required corridors to have firmly secured handrails on each side.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility failed to document informed consent for psychotropic meds for two residents. One resident had multiple antipsychotic, antidepressant, and antianxiety orders, but the consent forms lacked the resident’s signature. Another resident had orders for antianxiety, antipsychotic, antidepressant, and mood stabilizer meds, but the record contained no consent forms or evidence that the resident or representative was informed of the risks, benefits, and alternatives.
A resident with anxiety, major depressive disorder, moderately impaired cognition, and hospice care had a documented DNR in the care plan and scanned records, but the EMR profile incorrectly listed the resident as Full Code. An RN confirmed the discrepancy and acknowledged that the signed DNR was present in the chart while the code status in the profile remained inaccurate.
Failure to provide fingernail care for a resident who needed staff help with personal hygiene. The resident had DM, moderate cognitive impairment, and required moderate assistance with bathing, dressing, and personal hygiene. Observations showed very long fingernails, chipped nail polish, and brown residue under several nails, while staff stated CNAs should clean the nails and nurses would cut them if needed.
A resident with CVI, osteoarthritis, severe cognitive impairment, and severe immobility was repeatedly observed without a palm guard in her contracted left hand despite care plan instructions and physician orders related to contracture management. Staff moved her from bed to a Broda chair without the device, and interviews showed CNA staff were responsible for restorative tasks while the palm guards were found buried in a nightstand drawer.
A resident with PTSD, bipolar disorder, and schizoaffective disorder was identified as a smoker, but her care plan lacked smoking safety interventions and her last smoking eval in the EMR did not lead to ongoing reassessment. Staff documented smoking incidents in which she could not hold her head up, dropped a cigarette and burned her shirt, and was later found with a vape. Although the posted smoking list indicated she was to wear a smoke apron, she was observed smoking without any safety equipment, and staff interviews showed the apron requirement was not clearly tracked or communicated.
A resident with COPD, sleep apnea, severe cognitive impairment, and hospice care had CPAP orders for bedtime use, daily mask cleaning, and HOB elevation. Surveyors observed the CPAP mask left open to air on a dresser, the machine unplugged, and the HOB flat, and the MAR lacked documentation that the CPAP was applied. An LN said the mask should be stored in a bag when not in use and confirmed the resident had not refused CPAP on her shift; an admin nurse said staff were expected to apply the CPAP and elevate the HOB.
A resident with PTSD, bipolar disorder, and schizoaffective disorder had a care plan identifying loud, crowded areas and roommate changes as triggers, but the facility moved her room without documenting the reason or follow-up on her adjustment. The resident said she was not told why she was moved and reported anxiety because the adjoining resident was loud and repeatedly entered through the bathroom door; staff interviews showed they were unaware of her PTSD-related triggers and the required room-change documentation was not completed.
Failure to assess the safety and necessity of bed rail use for two residents and to document that risks were reviewed and informed consent was obtained. One resident had morbid obesity, schizophrenia, and moderately impaired cognition, while the other had schizophrenia, anxiety, and varying cognitive findings; both had MDSs documenting no bed rails in use, yet observations showed bed rails attached to their beds. The clinical record lacked evidence of a safety assessment or consent, and one resident said he used the rails for turning while the other said the rail had always been there and he did not need it.
Bed rails were not regularly inspected to ensure secure installation for two residents. One resident’s quarter-length rails could be moved side-to-side with minimal effort, and another resident had an eighth-length rail attached to the bed frame. Staff could not provide evidence of routine inspections, and the maintenance staff member could not state when inspections were last done or whether they had ever been completed for these residents.
Improper Disposal of Kitchen Garbage and Refuse: The facility failed to keep outdoor trash receptacles closed and was observed moving a large, uncovered trash can through the parking lot toward the dumpster. Dietary staff stated that outdoor trash lids were to be closed, and the facility policy required outside dumpsters to remain closed and garbage containers to be covered when removed from the kitchen area.
A resident with hypertension and diabetes, who was severely cognitively impaired and dependent on staff for care, received multiple doses of anti-hypertensive and diabetic medications outside of physician-ordered hold parameters for blood pressure, heart rate, and blood glucose. Nursing and administrative staff confirmed that medications should not be given outside these parameters without physician notification and documentation, but no such documentation was found, and the facility lacked a related policy.
Unsecured Controlled Medications Allowed Resident Access and Overdose
Penalty
Summary
The deficiency involves the facility’s failure to secure medications and keep them inaccessible to residents. Pharmacy records showed that a delivery including three bags of medications (one white, one blue, and one red) arrived in the evening, with the red bag containing 90 tablets of alprazolam and 90 tablets of lorazepam. Licensed Nurse G signed for the medications, placed the bags on a chair in the nurse’s station, and left them there without securing them in a locked compartment. Video footage later confirmed that the nurse’s station was left unattended with the medication bags still present on the chair. While the nurse’s station was unmanned, two residents were observed outside the area. One resident entered the unsupervised, unsecured nurse’s station, took drinking cups and other items, and then, at the direction of the other resident, took the red bag of medications from the chair and left the nurse’s station. The resident who directed this action later took the red bag back to his room. At an unknown time, he ingested 14 tablets of alprazolam and 18 tablets of lorazepam. Subsequent discovery of pill cards hidden in a paper towel dispenser showed that some of the alprazolam and lorazepam tablets remained, but a portion of each medication was missing, consistent with the amounts the resident reported taking. The resident who ingested the medications had documented diagnoses of schizophrenia, anxiety, suicidal ideation, and major depressive disorder, with a recent MDS indicating intact cognition but severe depression, hallucinations, delusions, and rejection of care. His care plan documented trauma-related distress, hallucinations, substance use that exacerbated suicidal thoughts, and intermittent passive suicidal ideation, with directions for staff to assess for suicidal ideation, intent, and plan each shift, especially at night. In the early morning hours after the ingestion, nursing notes documented that the resident was lethargic, staggering, had slurred speech, and then experienced repeated episodes of dark vomiting, short labored breaths, incoherent speech, and lethargic behavior, leading to transfer to the hospital where he was intubated and later diagnosed with pneumonia and fever secondary to suspected aspiration of fluid into his lungs. The facility’s own policies required that all drugs and biologicals be stored in a safe, secure manner and that resident safety, supervision, and assistance to prevent accidents be a facility-wide priority, but the medications were not secured and the nurse’s station was left unattended, allowing residents access to controlled substances. Further documentation and witness statements highlighted conflicting accounts regarding who was responsible for putting away the delivered medications. LN G stated he had set the medications aside on the overflow medication cart to be put away later and that a Certified Medication Aide later put them away, while the CMA stated she never received a handoff of medications from LN G and only found and stored the white and blue bags, not any controlled substances or a red bag. The facility’s incident report and administrative review confirmed that the controlled substances for two other residents were missing from the medication supply, that the pharmacy delivery forms and controlled substance count sheets could not initially be located, and that the missing narcotics were later found hidden in a paper towel dispenser in a resident’s room. Subsequent observation by the surveyor also showed that the nurse’s station could be accessed by reaching over and unbolting the inside barrel bolt lock, and that a resident was present at the counter while the station was unattended, further demonstrating that medications and staff work areas were not consistently secured from resident access.
Removal Plan
- Re-education on narcotic safekeeping to prevent diversions
- Provision of adequate resident supervision to ensure safety
- Termination of LN G from employment
Weekend Staffing Shortages
Penalty
Summary
The facility failed to provide adequate staffing on weekends to meet resident needs and to maintain the staffing levels identified in its Facility Assessment. The census was 67 residents, and the sample included 17 residents. CMS Payroll-Based Journal data for FY 2025 Quarter 1 through Quarter 4 showed the facility triggered for excessively low weekend staffing. The Facility Assessment dated 01/01/25 stated staffing needs would be identified and adjusted as necessary, including day, evening, night, and weekend staffing, and documented that weekend and holiday staffing patterns would not change. The assessment called for two nurse shifts, four CNA shifts, and two CMA shifts on day shift, and two nurse shifts, two CNA shifts, and two CMA shifts on night shift. Historical payroll data showed multiple weekend shifts with staffing below the facility’s stated levels. On several Saturdays and Sundays, staff clock-outs and gaps left fewer CNAs, CMAs, and nurses on the clinical floor than scheduled, including shifts with only one CNA, zero CMA staff, or zero nurse staff present for portions of the shift. Interviews with a CMA, a CNA, and another CMA on 12/18/25 described that weekend staffing tends to run short, call-offs commonly occur on nights and weekends, and when staffing is low, the care team works together to get tasks done; one CMA stated that resident showers sometimes do not get done. The facility’s Nursing Services policy dated 04/2025 stated the facility would provide adequate staffing on each shift to assure resident safety and meet resident needs.
Missing Qualified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for the 67 residents who received meals from the kitchen. During observation, Dietary Staff BB was seen cleaning up the kitchen after meal service. When interviewed, Dietary Staff BB stated she had recently completed a certified dietary management course and planned to schedule her test, but she was unable to provide proof of course completion. Administrative Staff A later verified that the facility should have a certified dietary manager and was unable to provide proof of Dietary Staff BB's completion of the dietary management course, certification, or evidence that she had the required experience for the position. The facility's Food Service Staffing policy stated that if the dietician is not full-time, the facility would employ a nutritional professional to serve as the dietary manager and that the person must meet specified qualifications, including certification, education, experience, or state standards.
Unsanitary food prep and storage conditions
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions to prevent the potential for food-borne bacteria. During observation of the kitchen and food storage areas, multiple sanitation and storage concerns were identified, including a visibly dirty heat table shelf with caked-on grease, empty boxes stored in and around the trash can near the handwashing sink, and the handwashing sink made inaccessible by boxes and a wire rack. Additional findings included dirty and rusted areas under the dishwasher, a leaking triple-basin sink with warm water on the floor, dried and caked-on residue in the sink, a greasy cook station, a dirty exhaust hood, greasy microwave surfaces, debris and stains on coffee filters, soiled towels under the dishwasher, and old discolored water in the steam table. Several pieces of equipment and utensils were also observed in poor condition, including blackened muffin tins, a dented colander, a pan with bent corners and black residue, and a frayed oven mitt with exposed stuffing. Food storage practices were also deficient. Observations revealed rotted sweet potatoes on the floor, moldy buns, an unopened loaf of bread with gnat-like insects inside the wrapper, an open and ripped package of tortillas, an open box of cookies left unsealed and undated, an open container of oats that was undated, and multiple opened or undated refrigerated items including lettuce, sliced turkey, and Italian salad dressing. In dry storage, the floor was unclean with food particles, dust, and dirt, and staff food items were stored with resident food items. Dietary staff confirmed the concerns, stated that items should be dated when opened, and identified that some items belonged to staff and should not have been stored with resident food items. The facility’s policies required food to be stored in a clean, sanitary manner, kept free of insects, and labeled and dated.
QAPI Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure the Medical Director, or designee, attended QAPI meetings at least quarterly. Review of the QAPI attendance binder showed the facility could not provide evidence of quarterly attendance by the Medical Director or designee within the last year. During interview, Administrative Staff A stated the quarterly attendance signature sheets lacked detailed signatures and indicated the Medical Director attended QAPI meetings only twice during the 12-month look-back period. Administrative Staff A also stated he expected the Medical Director to attend quarterly. The facility policy, Providence QAPI Plan 2025, dated 01/01/24, stated the QAPI Committee reports to the Governing Body and meets monthly, or at additional times when deemed necessary, and that the Administrator may delegate the necessary authority to a QAPI Coordinator.
Unqualified Infection Preventionist Designated
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist (IP), who was responsible for the Infection Prevention and Control Program, had completed the required specialized training in infection prevention and control and possessed the required certification. The Department Heads form completed by the facility on 12/15/25 identified Administrative Nurse E as the designated IP. When documentation was requested, the facility could not provide evidence of certification for the designated IP. On 12/18/25 at 07:57 AM, Administrative Nurse E confirmed that she was the designated IP but stated she was not currently certified. She also stated that she shared some of the IP duties with Administrative Nurse D, but she was not sure whether Administrative Nurse D was certified. The facility's Infection Prevention and Control Program F 880 policy, revised 01/2024, stated that the IP would report monthly to the QAPI committee.
Unsafe Building Conditions and Ceiling Damage
Penalty
Summary
The facility failed to maintain the building in good condition and provide a safe and hazard free environment for residents, visitors, and staff. During observation, the sidewalk in the courtyard connecting the north and south sides of the facility was cracked and uneven in several areas, and the sidewalk connecting the east and west sides had a large missing piece of concrete and was uneven. In the north hallway, a large hole was observed in the ceiling with surrounding tiles discolored brown, and pink insulation hanging from the opening with some areas discolored black. In the clean laundry room area, a barrel was placed in the doorway, and the ceiling above it showed an unintended black substance, brown dried discolored areas consistent with water damage, and one damaged tile. During a walkthrough with Maintenance U, additional ceiling damage was identified in both the north hallway and south hallway, including large cracks between specified resident rooms. CNA S reported the large hole in the north hallway ceiling had been present since the day before the observation. Laundry Staff V stated the ceiling dripped water when the shower room in the north hallway was used, which was why the barrel had been placed in the doorway. Administrative Staff A stated the facility environment as a whole needed repair and that the facility was aware and planned for improvements. Maintenance U reported the hole in the ceiling developed from a frozen fire sprinkler line and that attic access holes in the ceiling were open throughout the building to allow heat to escape into the attic to prevent sprinkler lines from freezing. He also stated the facility had obtained a bid for repairs but did not provide proof that repair attempts had been initiated.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, sanitary, and homelike environment in the common and dining area and in multiple resident rooms. During early morning observations, the combined dining and common area floor was dirty and had spilled popcorn, empty soda cans, food containers, and spilled liquids. No staff were present in the area during the first walkthrough. Later observations showed that the tables had been rearranged but not cleaned, food debris remained on the floor, and residents were served breakfast at tables that still had food debris and spilled liquids. A walkthrough with maintenance staff identified numerous environmental concerns throughout the building. These included plastic covering the windows in two resident rooms because of leaky windows, gouges, scratches, writing, holes, and other marks on walls and drywall in multiple resident rooms, missing floor tiles at a bathroom transition, drag marks with exposed sub-floor material in one room, and holes in several closet doors. One resident identified a hole in the closet wall that was being hidden with clothing. The north hall tub room also had a repaired wall area that had not been repainted. The elevator in the south hallway from the first floor to the basement was out of order and had been out of service for over a year. Staff stated that residents previously used the basement activity area, but it was no longer accessible because of the broken elevator. Activity staff confirmed residents had used the basement for billiards, TV, and other activities, but had not been able to participate since the elevator became inoperable. Facility staff and maintenance staff acknowledged the conditions were not consistent with a home-like environment, and the facility policy required a safe, clean, comfortable, and homelike setting with cleanliness and order.
Missing Bed Hold Notices and Transfer Notifications
Penalty
Summary
The facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for hospital transfers involving R1, R33, R52, and R70. The record review showed that R1 was transferred to the hospital on 7/14/25, 8/17/25, and 9/14/25, R33 was transferred on 7/03/25, R52 was transferred on [DATE] and 11/20/25, and R70 was transferred on [DATE]. For each of these residents, the EMR lacked evidence that the facility provided a bed hold notice or written notification of the transfer to the resident and/or representative, and the facility was unable to produce the documentation when requested. During interviews, staff described different processes for completing bed hold forms and transfer notifications, including placing forms in an administrative mailbox, routing them through medical records, social services, or administrative staff, and scanning them into the EMR. LN J stated the bed hold form should be in the transfer packet and signed by the resident or obtained by phone consent from the representative. CNA S, Administrative Staff B, SSD X, and Administrative Nurse E each described their roles in the process, and SSD X stated she was unaware until 12/17/25 that she was responsible for notifying the Ombudsman of transfers. The facility policy titled Bed Hold dated 06/25 stated staff shall inform residents upon admission and prior to transfer for hospitalization, unless for an emergency, or therapeutic leave, of the bed hold policy, including any charges and the time limit established by the State Medicaid Plan for reserving the resident's bedspace.
Failure to Document and Respond to Monthly Pharmacy Reviews
Penalty
Summary
The facility failed to ensure a licensed pharmacist’s monthly medication regimen review (MRR) was fully acknowledged and filed in the clinical record for multiple residents, including R1, R7, R9, R13, and R30. The EMR showed that the Consultant Pharmacist completed MRRs and noted irregularities for these residents, but the clinical records lacked the actual recommendations made and lacked evidence that the facility and physician acknowledged and responded to the reports. For R1 and R7, the pharmacist also requested lab monitoring, including a vitamin level for R1 and a magnesium level for R7, but the corresponding results were not found in the record until later dates provided by the facility. For R13, the pharmacist documented diabetes mellitus and recommended monitoring hemoglobin A1c every 6 months, and later requested review of multiple psychoactive medications for gradual dose reductions, but the record lacked physician responses to those recommendations.
Missing Pneumococcal Vaccine Declinations
Penalty
Summary
The facility failed to ensure that residents were offered the pneumococcal vaccine or that informed declinations were obtained and documented for R13, R5, R6, and R34. The census was 67 residents, with a sample of 17 residents and five reviewed for vaccinations. Record review showed that R13 had a signed declination for the influenza vaccine documented in the EMR on 10/03/25, but the EMR lacked evidence of pneumovax administration and lacked an informed declination signed by the resident or representative. For R5, R6, and R34, the EMR documented that each resident received the influenza vaccine on 10/08/25 and refused the pneumovax, but the EMR lacked evidence of an informed declination signed by the resident or his/her representative. On 12/18/25 at 10:25 AM, Consultant GG confirmed the facility was unable to provide the informed declinations for the pneumovax vaccines for these residents. The facility policy stated that residents or legal representatives would be provided information and education regarding the benefits and potential side effects of vaccinations, that such education would be documented in the medical record, and that refusals would be documented in the resident's medical record.
Loose Stairwell Handrail
Penalty
Summary
The facility failed to provide a safely secured handrail in the stairwell corridor leading to the basement. During observation, the handrail on the north side of the courtyard stairwell was wobbly and not secured, and Resident 62 was sitting at the bottom of the stairway near the secured basement door. During interview, Administrative Staff A observed the loose handrail, stated he had not been aware of it, and then moved the railing and saw that the base was out of the hole in the concrete. The facility policy in effect required a safe, functional environment and stated that corridors must have firmly secured handrails on each side.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform Resident 1 and Resident 13 and/or their representatives about the risks related to psychotropic medications. Resident 1’s record showed active orders for fluphenazine, mirtazapine, lorazepam, escitalopram oxalate, and quetiapine fumarate. The scanned informed consent documents for psychotropic medication listed the medications and potential risks, but there was no Resident 1 signature showing that he received the information. During interview, Administrative Nurse D stated that Resident 1 made his own decisions and did not have a DPOA or guardian on file, and both Administrative Nurse D and Consultant GG stated that Resident 1 should have signed the forms. Resident 13’s record showed orders for clonazepam, quetiapine fumarate 300 mg, quetiapine fumarate 200 mg, citalopram hydrobromide, and lithium. The scanned documents did not contain consent forms for these medications and there was no evidence of informed consent by the resident and/or representative. Upon request, the facility could not provide evidence of informed consent. Consultant GG stated that signed consents should be completed if a new psychotropic medication is prescribed or if there is a change in dose. The facility policy stated that residents and/or their representatives would be informed of new or changed psychotropic orders, including benefits, risks, and alternatives, prior to initiation or increase, and that staff would obtain consent and document the conversation in the clinical record.
Advance Directive Status Not Accurately Reflected in EMR
Penalty
Summary
The facility failed to accurately identify Resident 30’s advance directive status for a Do Not Resuscitate order. The resident’s EMR diagnosis tab documented anxiety and major depressive disorder, and the Significant Change MDS dated 11/10/25 documented a BIMS score of 9, indicating moderately impaired cognition, along with hospice care. The resident’s care plan dated 09/19/18 documented that she wished to have a DNR, and the EMR MISC tab contained an outside-of-hospital DNR signed by the resident and other required parties. Despite this documentation, the resident’s EMR profile information listed her as Full Code. On 12/16/25 at 2:00 PM, Administrative Nurse D confirmed the profile showed Full Code and also confirmed the signed DNR advance directive was present in the scanned documents. She stated that if there was a change in code status related to an advance directive, it should be reflected in the EMR and relayed to staff during verbal and written reports. The facility policy revised in 11/2023 stated that each resident had the right to formulate advance directives and that information about whether the resident had executed an advance directive would be displayed prominently in the medical record.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to provide assistance with fingernail care for a resident who participated in her hygiene activities but needed staff help. The resident had diagnoses of diabetes mellitus and a need for assistance with personal care. Her annual MDS documented a BIMS score of 11, indicating moderate cognitive impairment, and showed she required moderate assistance with bathing, dressing, and personal hygiene. Her care plan directed staff to provide set-up assistance with prompts for personal hygiene, and the resident reported that she liked her fingernails long. During observations, the resident’s fingernails were very long, the nail polish was chipped on some nails, and brown residue was seen underneath several fingernails. A later observation showed the fingernails remained very long, the nail polish was unchanged, and brown residue was still present. Staff interviews indicated that nurses would cut the resident’s nails and CNAs should ensure the nails were clean, while a nurse stated the resident would refuse nail cutting but her fingernails should still be clean and polished. An administrative nurse stated staff were expected to provide fingernail care to residents who could not complete the task independently. The facility did not provide a policy for ADLs.
Failure to Apply Palm Guard for Contracture Prevention
Penalty
Summary
The facility failed to provide a palm guard to Resident 44 to help prevent contractures and maintain hand positioning. Resident 44 had diagnoses including acute cerebrovascular insufficiency and osteoarthritis, severe cognitive impairment, impairment to both upper and lower extremities, total dependence for all ADLs, and severe immobility. Her care plan documented pain in her left hand related to contractures and instructed staff to apply a gel support to the left hand for contractures. Physician orders also documented removing the palm guard protectors each shift to check skin integrity. Survey observations showed Resident 44 repeatedly without the palm guard in her left hand while in bed and while seated in her Broda chair, and staff moved her without placing the device. On one observation, her left hand remained contracted and she was unable to stretch it out when asked. Staff interviews indicated CNA staff were responsible for restorative tasks, but one CNA stated she did not realize the palm guard was not applied. A nurse reported checking the skin of the resident’s palm daily and found the palm guards buried under personal items and pictures in the nightstand drawer. The administrative nurse stated staff were expected to apply devices to help prevent contractures as ordered.
Failure to Assess Smoking Safety and Provide Required Smoking Equipment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who was identified in the record as an outdoor smoker. The resident’s EMR documented diagnoses of PTSD, bipolar disorder, and schizoaffective disorder. Her care plan identified her as a smoker, but it did not include interventions for safe smoking practices or smoking equipment needs. The resident’s smoking evaluations in the EMR were dated 01/22/24 and 04/05/24; the latter stated she required no adaptive safety equipment for smoking, and no further smoking evaluations were found in the record. The resident later had multiple smoking-related incidents documented in progress notes. One note stated she was smoking on the patio, could not hold her head up, dropped a cigarette, and burned a hole in her shirt. Another note documented that during a smoking period she kept drooping her head forward, had to be repeatedly told to sit up and hold her head up, and staff assisted her when she said she could not. During that same event, staff found a vape in her possession, confiscated it, and she cried and begged for it back. The resident’s smoking list posted at the nurses’ station indicated she was to wear a smoke apron, but during observations she was outside in the supervised smoking area without any safety equipment. Staff interviews showed the smoking apron process was not clearly communicated or managed. A CNA reported she would not know who was supposed to wear an apron because she had not been told and had no list identifying those residents. An LN confirmed the resident had been a smoker for over a year and that the last smoking safety evaluation was from 04/05/24, and stated that residents who had burned clothing while smoking should wear a smoking apron. The Activity Director stated she typed and posted the smoking list but would not know where to find information about whether a resident required an apron or other smoking safety equipment. The Administrative Nurse confirmed the resident’s most current smoking evaluation was from 04/05/24 and that residents required safe smoking evaluations quarterly and as needed.
CPAP Not Applied, Cleaned, or Stored Properly
Penalty
Summary
The facility failed to apply, clean, and store a resident’s CPAP in accordance with physician orders and standards of practice. The resident had diagnoses of COPD and sleep apnea, severe cognitive impairment, and was receiving hospice care for end-of-life comfort care. The care plan directed staff to apply the CPAP with auto settings of 12 cm to 16 cm water and EPR3 at bedtime and remove it in the morning, and physician orders also directed staff to clean the CPAP mask every day shift and elevate the head of the bed every shift to prevent shortness of breath. Record review and observations showed that the resident’s CPAP was not documented as applied on the MAR, the CPAP mask was observed lying on the dresser attached to the machine and open to air, and the machine was not plugged in during one observation. The resident was also observed in bed with the head of the bed flat despite the order to elevate it. During interview, an LN stated the CPAP should be placed in a storage bag when not in use and verified the resident had not refused the CPAP on her shift. An administrative nurse stated she expected staff to apply the CPAP and ensure the head of bed was elevated, and reported she was not aware the CPAP machine was not working. The facility did not provide a respiratory care policy.
Failure to Provide Trauma-Informed Care During Room Change
Penalty
Summary
The facility failed to implement trauma-informed approaches to prevent identified triggers for a resident with a history of personal trauma. The resident’s EMR documented diagnoses of PTSD, bipolar disorder, and schizoaffective disorder. Her care plan directed staff to monitor for agitation, flashbacks, anxiety, insomnia, and nightmares, and identified overstimulation in the dining room, loud and crowded areas, adjusting to new places, and new roommates as triggers. The resident’s MDS assessments documented intact cognition, and a later quarterly MDS documented severe depression with a PHQ-9 score of 24. The resident was moved to a different room, but the progress notes did not document why the room change occurred or include follow-up notes about how she adjusted to the change. During interview, the resident stated she was not told why she was moved and reported that the resident in the adjoining room was loud and repeatedly came into her room through the bathroom door, which made her anxious. Staff interviews showed that management and Social Service handled room changes, but one nurse had no knowledge of the resident’s concerns, and the SSD stated she did not realize the resident had PTSD or that roommate changes and loud noises could trigger it. The facility’s policy required trauma-informed care for known trauma survivors and required written notice and documentation for room changes, including the reason for the change.
Failure to Assess and Document Bed Rail Use for Two Residents
Penalty
Summary
The facility failed to assess the safety and necessity of bed rail use for two residents, R1 and R29, and failed to document that the risks and benefits of bed rail use were reviewed and informed consent was obtained before the rails were installed. R1 had diagnoses including morbid obesity and schizophrenia, with MDS assessments documenting moderately impaired cognition, wheelchair use, dependence for transfers, and no bed rails in use. Despite this, the clinical record lacked evidence of a safety assessment or informed consent, while observations showed quarter-length bed rails attached to both sides of R1's bed on multiple occasions, and R1 stated he used the rails for turning and repositioning in bed. R29 had diagnoses including schizophrenia and generalized anxiety disorder, with one MDS documenting intact cognition and another documenting modified independence with locomotion, mobility, and transfers; both assessments documented that bed rails were not used. The clinical record also lacked evidence of a safety assessment or informed consent before bed rails were installed. Observations showed an eighth-length bed rail attached to one side of R29's bed on multiple occasions, and R29 stated the rail had always been attached to the bed, that he could turn over and get out of bed independently without it, and he was unable to explain why it was there. Staff interviews indicated bed rail need was assessed by nursing or physical therapy, and maintenance confirmed the rails were present on both residents' beds.
Bed rails not regularly inspected for secure installation
Penalty
Summary
The facility failed to inspect bed rails to ensure they were correctly and securely installed on the beds for two residents, R1 and R29. The facility provided an Assessment history Nursing: Side Rail Evaluation-V5 dated 12/01/24 through 12/22/25, but it did not list any assessments for either resident prior to the survey event, and the facility was unable to provide evidence of regular maintenance inspections for their bed rails upon request. During observation, R1 had a quarter-length bed rail attached to both sides of the bed and was able to move the bed rail side-to-side with minimal effort. R29 was observed resting in bed with an eighth-length bed rail attached to one side of the bed frame. During interviews, LN I stated the bed rails were placed on the beds by PT personnel, while Maintenance U stated he was responsible for periodic inspections to ensure the bed rails were securely fastened to the bed frames, but he could not say how often inspections were done, when they were last completed, or whether they had ever been done for R1 or R29. Administrative Nurse E identified eight residents in the facility with bed rails and stated maintenance personnel should conduct periodic inspections to ensure the bed rails were safe for residents to use. The facility policy stated staff would install bed rails using the manufacturer's instructions and specifications, then inspect them regularly for safety.
Improper Disposal of Kitchen Garbage and Refuse
Penalty
Summary
The facility failed to maintain and dispose of kitchen garbage and refuse properly. During a kitchen tour, the outside garbage receptacle was observed with one lid open, and on a later observation two lids on the trash receptacle were left open. Two female staff members were also observed rolling a large, uncovered trash can through the parking lot toward the garbage receptacle in the corner of the lot. During interview, Dietary Staff BB stated that all lids to outdoor trash receptacles were to be closed. The facility policy, Food-Related Garbage and Rubbish Disposal F814, last approved 10/2025, states that outside dumpsters provided by garbage pickup services will be kept closed and that garbage containers are covered when removed from the kitchen area to the dumpster.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to follow physician-ordered parameters for medication administration for a resident with diagnoses of hypertension and diabetes mellitus. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, had specific medication orders that included hold parameters for blood pressure, heart rate, and blood glucose levels. Despite these orders, the Medication Administration Records (MAR) for June and July 2025 showed that anti-hypertensive and diabetic medications, including amlodipine, propranolol, hydralazine, glimepiride, and insulin, were administered on multiple occasions when the resident's vital signs or blood glucose levels were outside the prescribed parameters. Interviews with licensed nursing staff and administrative staff confirmed that medications should not be given outside of ordered parameters and that any deviation should be communicated to the physician, with documentation of the physician's instructions. However, there was no evidence provided of such communication or documentation when medications were administered outside the parameters. Additionally, the facility did not provide a policy related to following physician-ordered parameters for medication administration.
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What surveyors actually found near you
We read the 137 citations issued within 25 miles in the last 12 months — including the 3 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy On 10th Avenue | 0.4 mi | ★★★★★ | 22 | 0 |
| Countryside Health Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Brighton Place North | 2.3 mi | ★★★★★ | 13 | 0 |
| Brewster Health Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Heritage Grove Estates | 3.7 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.