Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Edgemont Healthcare during CMS and state inspections, most recent first.
Two residents with moderate cognitive impairment were observed engaging in sexual activity on multiple occasions without documented assessment of their capacity to consent. The facility's policy did not address procedures for determining capacity to consent to sexual relationships or coordination with the QAPI program, and staff interviews revealed confusion and lack of awareness regarding required assessments.
Incomplete and Unimplemented Person-Centered Care Plans: The facility did not maintain or carry out resident-specific CCPs for multiple residents. One resident at risk for skin breakdown developed a Stage III PU after the care plan lacked turning and repositioning details and did not reflect wound doctor recommendations for offloading; staff also lacked access to the full care plan. Another resident who was incontinent repeatedly asked to be changed while wet, but staff delayed care. A third resident with severe cognitive impairment did not receive the music and social stimulation identified in the CCP.
Failure to provide pressure relief and repositioning for a resident with a Stage III pressure ulcer. A resident with dementia and limited mobility was identified as being at risk for skin breakdown, but the care plan did not include resident-specific turning/repositioning interventions before a facility-acquired pressure ulcer developed on the buttock. The wound later enlarged and was documented as worsened by prolonged sitting, while staff reported they did not have access to the care plan, did not routinely reposition the resident in the wheelchair, and the facility policy gave no guidance on pressure relief or wound prevention.
The facility did not promptly address a prolonged HVAC failure, resulting in resident areas reaching unsafe temperatures and inadequate interim cooling measures. Multiple rooms and common areas were observed in disrepair and unclean, with staff and residents confirming ongoing issues and lack of timely response. The facility lacked documentation, temperature monitoring, and policies for managing such mechanical failures.
Failure to Post Survey Results and Access Information: The facility did not post notice of where the most recent state survey results were located and did not keep the results in a readily accessible place for residents. During a tour, no notice or visible copy of prior survey results was found. The resident council, several residents, and the Ombudsman stated residents were unaware the survey results were available or where to find them, and the ADM acknowledged residents had the right to review prior survey findings.
A facility assessment failed to document how staffing levels were determined for specific shifts, including evenings and weekends, and did not address contingency planning for events such as mild snowstorms that could affect direct care staffing. PBJ data showed one-star staffing and low weekend staffing, and staffing records showed the facility was short of target staffing on multiple days, including weekends when only four SRNAs were present on day shift with a census of 64. A resident reported longer waits for toileting and other care during bad weather, while staff described heavy reliance on agency staff and poor retention; the DON acknowledged the assessment was incomplete and could not be used to determine staffing needs by hall or shift.
Insufficient nursing staffing and inadequate resident care: PBJ data showed one-star staffing and low weekend staffing, and staffing records showed the facility was short of its target on multiple sampled days. Staff and residents reported that with only four to five SRNAs on day shift, aides rushed through care, delayed toileting and brief changes, and often could not reposition dependent residents as needed. A resident with severe cognitive impairment and a stage 3 pressure ulcer was observed sitting in a wheelchair without pressure offloading, while another resident reported waiting hours for toileting assistance and being told staff were too busy.
Undated opened multi-use medications were found on a medication cart, including eye drops, inhalers, cough syrup, lactulose, polyethylene glycol, and nasal spray. The facility policy did not address dating opened multi-use meds, and an LPN, DON, ADM, and Medical Director all discussed the expectation that opened medications be dated to avoid use of expired products.
Infection prevention and control practices were not consistently followed. Staff did not don gowns during direct care for a resident on Enhanced Barrier Precautions, a CNA passed drinks to an entire hallway without hand hygiene, and an RN left resident rooms wearing gloves after glucose checks and handled items at the nurse’s station before removing them. The facility also had outdated infection control guidance, no formal new-hire infection control training process, and a resident’s oxygen tubing was found past the weekly change date.
A facility failed to keep a Hoyer lift scale in working order, and staff observed the scale would not turn on so residents could not be weighed. The lift company found the scale cable had been cut, and multiple staff, including an RN, SRNA, DON, and Dietician, reported the scale had been broken for weeks to months. One resident's weight could not be obtained, and staff stated four residents relied on the lift for weights.
Failure to Protect Resident Dignity and Privacy: A resident with severe cognitive impairment and Huntington's disease was observed partially undressed in her room with her body exposed because the door was open and the curtain was not pulled, while staff did not immediately protect her visual privacy. Another resident with dementia and an indwelling urinary catheter was observed in common areas with an uncovered catheter collection bag, despite staff stating dignity bags should be used to protect privacy.
Failure to Protect Residents' Personal Property: Two cognitively intact residents reported missing clothing items, including shirts and pants, through grievances. The facility located some items in one resident's room but did not find the missing shirts, and there was no evidence the items were replaced or reimbursed. The other resident's brand-new shirt was never found, and the resident stated the facility did not replace or reimburse her for it.
A resident with diabetes was ordered Lispro sliding scale insulin before meals and Lantus twice daily, but the Annual MDS coded no injections and no insulin during the seven-day look-back period. The MAR showed the resident continued to receive insulin, and the former MDS nurse stated she missed that the resident was still receiving injections after reading an order change that discontinued only breakfast injections. The DON and Administrator stated MDS assessments should be accurate and complete.
A resident with dementia and other diagnoses fell from her wheelchair, reported head, back, and tailbone pain, and was sent to the hospital where she was found to have a sacrum fracture and UTI. Although she had an existing falls care plan, the fall investigation was not completed by an agency nurse, and the DON and Administrator confirmed the care plan was not revised to reflect the new injury and therapy needs.
Failure to provide timely incontinence care for a dependent resident. A cognitively intact resident with spastic hemiplegia and a care plan for toileting hygiene assistance reported that her brief was wet and asked an SRNA to change her, but the aide said she had just changed her and walked away without providing care. The resident asked again, and the aide still did not respond until seeing the surveyor; observation showed the brief was significantly wet. RN, DON, and the Administrator stated staff should change a resident who reports being wet.
Failure to Provide Individualized Activities: A resident with Huntington's disease, Alzheimer's disease, and severe cognitive impairment was found sitting alone in her room with no TV, music, or other stimulation available. Her care plan listed music and TV as favorite activities, but survey observations showed she was not provided ongoing 1:1 or other individualized activities, and the Activities Director stated she only played music once or twice per month.
Failure to provide appropriate catheter care and prevent UTI was identified for a resident with an indwelling urinary catheter, dementia, neuromuscular bladder dysfunction, and a stage 3 pressure ulcer. Staff observed the catheter tubing and bag dragging on the floor under the resident’s wheelchair on multiple occasions, and the bag was also seen lying on the bathroom floor during wound care. The facility policy lacked a catheter care protocol, and the care plan only referenced care per facility policy without specific catheter interventions.
Failure to Maintain Dialysis Communication and Documentation: A resident with ESRD on hemodialysis did not have ongoing communication and collaboration between the facility and the dialysis clinic. The facility did not document post-dialysis VS, weight, or pertinent return information, and staff and the dialysis coordinator confirmed that routine transfer paperwork, medication sheets, and other communication forms were not being exchanged. The resident, an LPN, the DON, and the Administrator all described inconsistent or absent information sharing between the two settings.
Failure to Establish and Implement Protocol for Assessing Capacity to Consent to Sexual Contact
Penalty
Summary
The facility failed to develop and implement policies and procedures establishing a protocol for determining residents' capacity to consent to sexual contact. Specifically, the facility's abuse investigation policy did not address how, when, and by whom determinations of capacity to consent would be made, nor where such documentation would be recorded. Additionally, the policy lacked the required component for coordinating situations of abuse with the Quality Assurance Performance Improvement (QAPI) program. These deficiencies were identified after staff observed two residents engaging in sexual behavior on multiple occasions, with no evidence that the facility had assessed their capacity to consent prior to the survey. One resident was admitted with diagnoses including vascular dementia, delusional disorder, bipolar disorder, Alzheimer's disease, and Lewy Body dementia, and had a BIMS score indicating moderately impaired cognition. This resident was under state guardianship, and there was confusion among staff and guardians regarding whether a capacity to consent assessment had been completed. The psychiatric nurse practitioner had not performed such an assessment prior to the observed incidents, and documentation of any evaluation was absent until after the survey began. The second resident involved also had moderately impaired cognition and multiple physical comorbidities. Nursing notes documented that both residents expressed a desire to engage in sexual activity and claimed to understand the consequences, but there was no documented assessment of their ability to consent. Interviews with staff, including the DON, social services director, and medical director, revealed a lack of awareness and established process for evaluating capacity to consent to sexual relationships. The administrator was unaware that the abuse policy required procedures for such assessments and coordination with the QAPI program.
Incomplete and Unimplemented Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents whose medical, nursing, and psychosocial needs were identified in assessment. Facility policy stated care plans were to be comprehensive, person-centered, and consistent with resident rights, but the records and observations showed resident-specific interventions were not consistently included or carried out. For one resident with a history of no pressure ulcers on admission and later identified as at risk for skin breakdown, the care plan listed only a general intervention for staff to assist with repositioning according to facility protocol. The facility could not produce the referenced protocol, and the care plan did not include resident-specific turning and repositioning interventions before the resident developed a facility-acquired Stage III pressure ulcer on the right buttock. The wound was later documented as worsening due to prolonged sitting, and the wound doctor recommended close monitoring and offloading. The care plan did not reflect those recommendations, and observations showed the resident seated in a wheelchair for an extended period without staff encouraging or assisting with pressure offloading. Staff interviews also indicated they did not have access to resident-specific care plans and relied on memory, report, or task lists that did not show repositioning needs. For another resident who was dependent on staff for toileting hygiene, the care plan stated staff should assist as needed, but observation showed the resident repeatedly asking to be changed while her brief was wet. Staff told the resident she had just been changed, walked away without providing incontinence care, and later said they would check again later. The resident remained wet during the observed care, and the staff member acknowledged that residents should be changed when they ask. For a third resident with Huntington’s disease, Alzheimer’s disease, dysphagia, and severe cognitive impairment, the care plan identified favorite activities such as listening to music and watching TV, but observations showed the resident awake in her room without music, television, or social interaction on multiple occasions. The Activities Director stated the resident liked Elvis and gospel music but did not have anything in the room to play music and that music was only played once or twice per month.
Failure to Provide Pressure Relief and Repositioning for Resident With Stage III Pressure Ulcer
Penalty
Summary
The facility failed to provide treatment and services to prevent development of pressure ulcers for one resident who required staff assistance with turning and repositioning. The resident was admitted in 2019, had diagnoses including unspecified dementia and neuromuscular dysfunction of the bladder, and was assessed as needing moderate to maximal assistance with mobility. Although the resident was identified as being at risk for pressure ulcer development and had pressure-relieving devices for the bed and wheelchair, the care plan did not include resident-specific interventions for turning and repositioning before the resident developed a facility-acquired Stage III pressure ulcer on the right buttock in January 2025. When the wound was first evaluated, the wound doctor documented a Stage III pressure ulcer measuring 1.5 cm by 1.5 cm by 0.1 cm, removed dead tissue, and ordered barrier cream. The physician estimated the wound would heal in 27 days with proper intervention. However, later wound documentation showed the ulcer had enlarged to 3.1 cm by 5.5 cm by 0.2 cm and had been present for greater than 57 days. The care plan did not add the facility-acquired pressure ulcer until June 2025, and even then it still did not include resident-specific repositioning interventions. Subsequent wound documentation noted the ulcer had worsened due to prolonged sitting and listed close monitoring and offloading as recommended approaches. The resident remained without a turning or repositioning schedule on the MDS, and staff interviews showed aides did not have access to resident care plans and relied on word of mouth, task lists, or their own judgment. Observation showed the resident sitting in a wheelchair for 2.5 hours without repositioning or staff assistance for pressure offloading. The facility policy provided no guidance on turning, repositioning, pressure relief, or wound prevention and treatment, and the Administrator stated the facility did not recall conducting a root cause analysis on the facility-acquired pressure ulcer.
Failure to Maintain Safe, Comfortable Environment and Timely HVAC Repairs
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for all residents by not promptly addressing significant issues with its cooling system and by neglecting necessary repairs and cleaning in resident rooms and common areas. The air conditioning (AC) system was reported as malfunctioning for an extended period, with temperatures in resident areas reaching as high as 90 degrees Fahrenheit and the kitchen reaching 110 degrees Fahrenheit. Despite complaints from residents, staff, and the Ombudsman, the facility did not initiate a work order for HVAC repairs until a week after the problem was first identified. During this period, the facility did not provide adequate interim cooling measures, such as portable AC units or sufficient fans, and failed to document or monitor indoor temperatures. Staff interviews revealed that residents were not consistently provided with extra fluids or ice, and some residents reported not receiving fans that had previously been supplied during hot weather. In addition to the HVAC issues, multiple resident rooms, a common gathering area, and the main dining hall were observed to be in disrepair and in need of cleaning. Observations included large water stains, peeling paint, cracked ceilings, brownish-yellow discoloration, exposed drywall, missing baseboards, and significant dust and debris accumulation. Residents and staff confirmed that these conditions had been present for months, and complaints had been made to administration without resolution. The Director of Maintenance acknowledged a backlog of repairs and stated he lacked autonomy to address the issues, while the Administrator and DON confirmed awareness of the facility's deteriorating condition but could not provide a specific timeline for repairs. Documentation and interviews further revealed that the facility lacked policies and procedures for responding to mechanical failures of the HVAC system or for monitoring temperatures during such events. The Director of Maintenance did not keep written logs of facility temperatures, and the Administrator was unable to provide evidence supporting claims that temperatures remained within a safe range. The absence of a structured response and documentation process contributed to prolonged exposure of residents and staff to unsafe and uncomfortable conditions.
Failure to Post Survey Results and Access Information
Penalty
Summary
The facility failed to post notice of the availability of the most recent state survey results and failed to post those results in a place that was readily accessible to residents. Review of the facility policy titled Resident Rights, revised 04/12/2024, stated residents have the right to receive all forms of communication while residing within the facility and that the facility would assist residents in exercising those rights. During a tour on 07/22/2025 at 10:00 AM, there was no notice indicating the location of the most recent survey results and no visible physical copy of the prior survey results. During interviews on 07/22/2025, the resident council, R1, R9, R37, and R64 stated they were unaware that survey results were available to view or where they were located in the facility. The Ombudsman stated the survey results were not in a proper place and that residents had previously asked about them. The Administrator stated residents had the right to review previous survey results and that it was the facility's responsibility to ensure residents were educated on the survey findings and had access to where the findings were kept.
Incomplete Facility Assessment for Staffing and Contingency Planning
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine the resources needed to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. Review of the 2025 facility assessment showed it did not include information on how staffing levels were determined for specific shifts, including evenings and weekends, and it did not include contingency planning for events that did not require activation of the emergency plan, such as a mild snowstorm that could affect resident care because of limited direct care staffing. Review of the PBJ for FY Q2 01/2025 through 03/2025 showed the facility triggered for one-star staffing and excessively low weekend staffing. Staffing agency invoices and the facility's Calculated Time by Calendar Day document for 02/01/2025 through 02/10/2025 showed the facility was short of the Administrator's stated target staffing on 5 of 10 sampled days, and on 02/01/2025 and 02/02/2025, a Saturday and Sunday, only four SRNAs were present on day shift when the census was 64. During interviews, a resident stated staffing was worse during bad weather and residents had to wait longer for toileting and other assistance and might not get a shower. Staff also reported heavy reliance on agency staff and poor retention, and the Administrator acknowledged the assessment was incomplete, could not be used to determine staffing needs by hall or shift, and did not include information to inform a contingency plan for weather-related call-ins or a recent staff satisfaction survey.
Insufficient Nursing Staffing and Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet resident needs, and it did not have enough nursing staff to assure resident safety and the highest practicable physical, mental, and psychosocial well-being of residents based on assessments and care plans. Review of PBJ data for Fiscal Year Quarter 2, 01/2025 through 03/2025 showed the facility triggered for one-star staffing and excessively low weekend staffing. Review of staffing agency invoices and calculated daily staffing records for 02/01/2025 through 02/10/2025 showed the facility was short of the Administrator’s stated target staffing on five of the 10 sampled days. On 02/01/2025 and 02/02/2025, a Saturday and Sunday, only four SRNAs were present on day shift, and the census on 02/01/2025 was 64. Resident 4 was admitted on 05/18/2019 and had diagnoses including unspecified dementia, neuromuscular dysfunction of the bladder, and a stage 3 pressure ulcer of the right buttock. The resident’s quarterly MDS with an ARD of 07/08/2025 showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and the facility assessed the resident as having a stage 3 pressure ulcer that was not present on admission or re-entry. Continuous observation on 07/23/2025 from 8:56 AM to 11:28 AM showed the resident seated in a wheelchair with no staff encouraging position changes for pressure offloading. The roommate stated staff got the resident up in the morning and left her in the chair until evening except for an occasional nap, and SRNA4 stated it was not feasible to encourage repositioning as often as needed because the facility was frequently short staffed. SRNA5 stated staffing was typically barely enough to do the absolute minimum, such as incontinence care and feeding dependent residents, and that there was not enough time to reposition the resident as often as needed because of other tasks. Additional observations and interviews showed delays and refusals in providing basic care. A resident stated she asked SRNA5 to change her brief because it was wet, but the aide said she had just changed her and did not provide care at that time; the resident asked again later and was still not changed immediately, and the brief was observed to be significantly wet. Another resident stated she asked for help to get to the bathroom around 1:00 PM but staff did not assist her until almost 3:00 PM, causing her to use her brief, and she reported staff told her they were too busy. SRNA4 stated there were days when six SRNAs were scheduled but only four showed up, and the facility then tried to post agency shifts but sometimes still worked short; she stated residents were more likely to receive bed baths instead of showers because that could be done more quickly. RN3 stated it was not unusual to work with only four SRNAs on day shift and that this left too little time to care for residents, especially dependent diners and incontinent residents. The DON stated the facility’s staffing goal was six to seven SRNAs, two nurses, and one medication aide on day shift, and five SRNAs, two nurses, and a medication aide on night shift, but the facility had not had a night shift medication aide since the last one quit. The Administrator stated she expected six to seven SRNAs on day shift and four aides on night shift, acknowledged she had not estimated how much time it took an SRNA to care for a dependent resident, could not state how many dependent residents were in each aide’s assignment, and said it was unlikely SRNAs could meet resident needs as care planned if only four or five SRNAs were on day shift.
Undated Opened Multi-Use Medications on Medication Cart
Penalty
Summary
The facility failed to properly label drugs and biologicals in accordance with currently accepted professional principles. During observation of the medication cart from the 100/200 Hallway labeled RN, surveyors found seven bottles of eye drops, two inhalers, two bottles of cough syrup, two bottles of lactulose, two bottles of polyethylene glycol, and two bottles of nasal spray that had been opened without dates documenting when they were opened. The facility policy titled, Storage of Drugs and Biologicals, stated that drugs and biologicals were to be properly stored in the containers in which they were received, but it did not address dating opened multi-use medications upon opening. During interview, an LPN stated that if a multi-use vial of medication was not dated when opened, it could be outdated and no longer effective. The DON stated that all opened multi-use medications should have a date written on the bottle when opened and that an undated medication could be expired and could result in an infection. The ADM stated she was unsure whether it was the facility's practice or policy to date multi-use containers when opened, and the Medical Director stated it was his expectation that staff date multi-use medications when opened to prevent use of expired medications and ensure efficacy.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility’s Infection Control Plan stated its purpose was to provide a safe, sanitary, and comfortable environment for all residents and staff, and the Handwashing policy stated that all personnel were to follow the established handwashing procedure to prevent the spread of infections and disease, including washing hands after handling items potentially contaminated with blood, body fluids, excretions, or secretions. During wound care for a resident with Enhanced Barrier Signage on the door, RN1 and SRNA3 entered the room to position the resident in bed, but neither donned a gown. RN1 also did not don a gown while performing wound care. RN1 stated the signage was for residents with pressure ulcers, wounds, catheters, and similar conditions, and that a gown and gloves should be worn during direct resident care, including wound care. SRNA3 stated that direct resident care required gown and glove use and that she questioned RN1 about not donning a gown and gloves when pulling the resident up in bed. The DON stated Enhanced Barrier Precautions required staff to don a gown and gloves for direct resident care such as wound care or catheter care, and the Administrator stated her expectation was that staff donned a gown when performing any direct care for a resident with Enhanced Barrier Precautions, including pulling a resident up in bed or positioning them for wound care. The facility also failed to follow its hand hygiene expectations during meal service and resident care activities. SRNA1 passed drinks to the entire 100/300 hallway without performing hand hygiene and stated it was the facility’s practice to perform hand hygiene after passing three residents’ beverages. RN2 completed glucose checks on two residents, left the rooms wearing gloves, opened the nurse’s station door, wrote the glucometer readings on paper, then removed her gloves and washed her hands. The facility’s respiratory equipment cleaning schedule required oxygen tubing and nasal cannulas to be changed weekly, but a resident’s oxygen tubing was observed dated 07/04/2025. RN2 stated she changed oxygen tubing every Thursday and that it had not been changed because she had been off for the last two Thursdays. The DON stated new staff did not get infection control training and were trained on the floor by following another staff member, and the Administrator stated the hand hygiene and infection disease policy was old and needed to be updated.
Broken Hoyer Lift Scale Prevented Accurate Resident Weights
Penalty
Summary
The facility failed to maintain the mechanical lift scale in safe operating condition. Review of the lift company service invoice dated 07/02/2025 showed the Field Service Technician found the cable to the scale on the lift had been cut and quoted a price to replace the scale. On 07/24/2025, observation showed SRNA4 demonstrating the scale function on the lift, but the scale did not turn on so residents could not be weighed. SRNA4 stated the battery was fully charged and that the malfunction had been present for a long time, and that residents who required the lift for weights had not been weighed accurately during that time. The facility had four residents who used a Hoyer lift for weights, and staff documented that a weight could not be obtained for R53 because the lift was not working. RN3 stated the lift scale had been broken for months and that she and SRNA4 had told the Administrator multiple times, but the Administrator denied it was broken and refused to address it at first. The Dietician stated she knew the Hoyer lift scale had not been functioning for at least three weeks and that she needed accurate and consistent weights to monitor residents' nutritional status. The DON stated the scale had not been working for approximately one month, and the Administrator stated she knew the scale was not working and had a technician assess it, but she could not provide a timeline for ordering a new lift or explain why it had not already been ordered.
Failure to Protect Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat residents with dignity and protect their visual privacy for 2 of 21 sampled residents. One resident with Huntington's disease, Alzheimer's disease, restless leg syndrome, dysphagia, and a BIMS score of 0 was observed in her room wearing a hospital gown with her arms wrapped in the bottom of the gown, exposing her bare legs up to the top of her thighs. She repeatedly raised her arms above her head, exposing her bare breasts, while her door was open and the curtain was not pulled, leaving her nude body visible from the hallway. A SRNA walked by, looked at the resident, and did not close the door or pull the curtain until after the observation. Another resident with unspecified dementia, neuromuscular dysfunction of the bladder, a stage three pressure ulcer of the right buttock, and a BIMS score of 0 was observed self-propelling her wheelchair through common areas with no dignity bag covering her catheter collection bag. Her care plan identified the need for an indwelling urinary catheter and catheter care, but did not include interventions related to use of a dignity bag or other measures to protect her dignity while using the catheter. Staff interviews stated that catheter bags should be covered to protect dignity and privacy, and that the resident's bag sometimes slid off, but at the time of observation it was uncovered.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to protect residents from misappropriation of property for 2 of 2 residents reviewed for personal property when it did not reimburse them for missing clothing items that were reported through grievances. The facility's Notice of Resident Rights and Responsibilities stated residents had the right to keep and use personal belongings and to have their property protected from theft. R24, who was cognitively intact with a BIMS score of 15 and stated that caring for personal belongings was very important, reported missing a coral t-shirt, a yellow t-shirt, a sweatshirt, and two pairs of jogging pants. The facility later found the sweatshirt and pants in the resident's room, but did not locate the t-shirts and marked the grievance resolved while continuing to look for them. There was no documented evidence that the shirts were found, replaced, or reimbursed, and R24 stated the facility had lost clothing in the laundry and had not reimbursed her. R10, who was also cognitively intact with a BIMS score of 15 and had indicated that caring for personal belongings was very important, reported a missing brand-new beige shirt on two separate grievance reports. The facility was unable to locate the shirt on either occasion and marked the grievance unresolved, stating it would continue to look for it. R10 stated the shirt went missing in the laundry and that the facility had not replaced or reimbursed her for the item. The Administrator stated the facility's process was to complete a grievance and try to locate missing items, and that items were only replaced if the facility was at fault; she later stated that if an item was not found within an unspecified amount of time, the facility would replace it or reimburse the resident.
MDS Failed to Reflect Ongoing Insulin Injections
Penalty
Summary
The facility failed to ensure that one resident’s assessment accurately reflected the resident’s status. R30 was admitted with diagnoses including unspecified congenital malformation of limbs, unspecified anemia, and unspecified obesity, and later had type II diabetes mellitus added. R30 was ordered Lispro insulin sliding scale before meals and later Lantus Solstar Pen 60 units twice daily. However, the Annual MDS dated 05/23/2025 coded R30 in Section N0300, Injections, as having no injections during the seven-day look-back period and also coded Section N0350, Insulin, as having no documented injections during that same period. Review of the MAR for 05/2025 showed R30 received Lispro, although the lunch and dinner doses were cancelled as of 05/15/2025, and R30 continued to receive Lantus twice daily. During interviews, the MDS Nurse stated the assessment had been completed by the former MDS Nurse, LPN3, who said she reviewed the last three months of notes and pertinent documentation when completing MDS assessments. When reviewing R30’s MDS, LPN3 stated she read the order change discontinuing breakfast injections and failed to realize R30 was still receiving insulin injections. The DON stated there would not have been a seven-day period in 05/2025 when R30 went without insulin, and the Administrator stated MDS assessments should be complete and accurate.
Care Plan Not Revised After Fall With Injury
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident after a fall that occurred in her room and resulted in injury. The resident was admitted with diagnoses including encephalopathy, unspecified dementia without behavioral disturbance, and unspecified malignant neoplasm of the skin. Her quarterly MDS assessment showed a BIMS score of 13/15, indicating intact cognition, and she was assessed as independent with wheelchair mobility and requiring supervision with transfers. Her care plan had addressed falls since 07/03/2024, but there was no evidence it was revised after the later fall. After the resident was found on the floor, she reported hitting her head hard and having severe pain in her back and tailbone. Her vital signs were stable, her responsible party and MD were contacted, and she was sent to the hospital. ED records showed a sacrum fracture and a UTI. Interviews with the resident, the Director of Rehabilitation, the DON, and the Administrator confirmed that the resident fractured her tailbone, required therapy for two or three months after the fall, and that the fall investigation paperwork was not completed by the agency nurse. Because no fall investigation was located, the care plan was not revised to include additional interventions, including therapy, after the fall.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care and maintain good personal hygiene for a dependent resident who was cognitively intact and assessed as dependent on staff for toileting hygiene. The resident was admitted with diagnoses including spastic hemiplegia of the left dominant side, need for assistance with personal care, and anxiety disorder. Her care plan identified her as dependent with toileting hygiene and included interventions to assist as needed. During observation, the resident was sitting in her wheelchair and appeared upset after stating her brief was wet and that she had asked a State Registered Nurse Aide to change her less than five minutes earlier. The aide told the resident she had just changed her and did not provide care, then said she would check later and walked away. The resident asked again to be changed, but the aide walked past her and did not respond until seeing the surveyor in the hall, at which point she said she would change her. Observation of the incontinence care showed the resident's brief was significantly wet. Interviews with the aide, RN, DON, and Administrator confirmed that staff should change a resident who reports being wet and that it was unacceptable to tell the resident she had just been changed and not provide care.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities based on the comprehensive assessment, care plan, and resident preferences for one resident, R36. R36 was admitted on 05/21/2018 and had diagnoses including Huntington's disease, Alzheimer's disease, restless leg syndrome, and dysphagia. Her Annual MDS dated 01/07/2025 showed staff completed the activity preference assessment because she could not complete the interview, and staff identified that she liked listening to music. Her Quarterly MDS dated 06/27/2025 showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. Her Comprehensive Care Plan dated 01/07/2025 identified her as dependent on staff to meet emotional, intellectual, and social needs and listed favorite activities as listening to music and watching TV. Observations throughout the survey showed R36 sitting alone in her room, awake, with no television, music, or other stimulation available, including on 07/23/2025 at 2:23 PM, 07/24/2025 at 10:41 AM, and 07/25/2025 at 3:34 PM. Surveyors also observed that she was not in the dining room for coffee social on 07/23/2025 at 10:26 AM. The Activities Director stated staff occasionally brought R36 to morning coffee social, but not the day before, and said that meant R36 did not get any activities for that day or almost any day she did not come to coffee social. She also stated she played music for R36 only once or twice per month and that R36 did not have anything in her room staff could use to play music for her. The DON stated she did not get involved in activities, and the Administrator stated her expectation was for the activity department to provide 1:1 activities at least daily to residents whose cognition, mobility, or preferences meant they did not benefit most from group activities.
Failure to Maintain Indwelling Catheter Off the Floor
Penalty
Summary
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections was not provided for a resident with an indwelling urinary catheter. The resident had diagnoses including unspecified dementia, neuromuscular dysfunction of the bladder, and a stage three pressure ulcer of the right buttock. The resident’s BIMS score was 0 out of 15, indicating severe cognitive impairment, and the care plan identified the need for an indwelling urinary catheter with interventions to provide catheter care per facility policy, but it did not include specific catheter care interventions. Observations showed the resident’s catheter tubing and catheter bag dragging on the floor under the wheelchair on multiple occasions, and the catheter bag was also observed lying flat on the bathroom floor during wound care. The facility’s policy on indwelling catheter use did not address a protocol for catheter care to prevent infections, including cleaning the catheter and maintaining the collection system. Staff and leadership stated the catheter bag and tubing should be kept off the floor, and the DON and Administrator both stated this was important for infection control, but the Administrator did not know whether the resident had been offered a leg bag.
Failure to Maintain Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care/services for a resident who required hemodialysis by not maintaining ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The resident had diagnoses including atrial fibrillation, kidney and ureter disorder, bipolar disorder, and end stage renal disease, and was dependent on hemodialysis therapy. The facility’s policy required ongoing communication and collaboration with the dialysis facility, including meeting documentation requirements, and the dialysis transfer agreement required the resident to be accompanied by appropriate medical information at the time of transfer, including current treatment, medications, and changes in condition. Record review showed the facility did not obtain or document the resident’s post-dialysis vital signs, weight, or pertinent report information after dialysis visits. The record also showed no communication or daily transfer sheets in either the hard copy chart or EMR for communication and collaboration between the facility and the dialysis clinic. Although the dialysis clinic sent multiple faxes and requests to the facility regarding medications and treatment-related information, the facility did not have documentation showing routine exchange of information with the clinic. The dialysis clinic’s treatment records contained pre-treatment, intra-treatment, and post-treatment vital signs, weights, nursing assessments, and access site assessments for multiple dialysis treatments. Interviews confirmed the lack of routine communication. The resident stated the facility did not send paperwork with her to dialysis and that no paperwork had ever been sent or returned during the admission. An LPN stated the facility did not send communication forms or paperwork with dialysis residents and no paperwork was returned after treatment. The dialysis clinical coordinator stated no paperwork had been sent by the facility, including communication forms, medication sheets, or face sheets, and that the facility had never requested treatment records. The previous DON and current DON stated that only a face sheet or medication list was sent initially or when medications changed, and the Administrator stated she was unfamiliar with the dialysis policy and could not explain how documentation requirements were met.
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What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — 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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Nursing homes near Cynthiana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrison Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 20 | 0 |
| Cedar Ridge Health Campus | 1.8 mi | ★★★★★ | 2 | 0 |
| Bourbon Heights Nursing Home | 12.8 mi | ★★★★★ | 0 | 0 |
| Willowbrook Healthcare | 14.3 mi | — | 0 | 0 |
| Robertson County Health Care Facility | 16.5 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.