Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mayfair Manor during CMS and state inspections, most recent first.
Failure to resolve and document grievances for missing resident property. A resident reported a missing shirt and said the facility had known about it for months without providing a response or reimbursement. Another resident reported missing clothing items and had not received a resolution, while a third resident’s missing clothing grievance was documented as needing reimbursement but remained unresolved before discharge. Staff described an investigation process, but the grievance log was incomplete and the SSD stated reimbursement depended on a receipt.
A resident with DM2, neuropathy, and a prior stroke had a care plan requiring two staff for transfers and personal care, but an SRNA provided care and completed transfers without another staff member present. During observation, the resident became weak and swayed while being assisted, and staff interviews confirmed the resident required two-person assistance and that care plan interventions were expected to be followed.
Failure to provide required two-person assistance during transfers. A resident with type 2 DM, neuropathy, and a prior stroke was cognitively intact but needed substantial to maximum help with mobility and was care planned for two staff during transfers and personal care. During observation, a SRNA assisted the resident alone, including moving her to the bedside and then transferring her to the toilet without another staff member present, even though staff interviews confirmed she had left-sided weakness and required two-person assistance.
Unlocked Medication Cart Left Unattended: A North Hall medication cart was observed unlocked and unattended while an LPN stepped away from it. The facility policy required medication carts to remain locked when not in use or attended by authorized staff, and the Unit Manager, DON, and Administrator all stated carts were expected to be locked whenever staff were away from them.
Improper Rooming of a Resident on EBP With a Resident on C-diff Contact Precautions: A resident who was not on contact isolation but was on EBP for enteral feedings was roomed with another resident on contact precautions for C-diff. Observation showed mixed signage, no visible EBP signage, and the curtain was not closed between the two residents. Records showed the C-diff resident had a confirmed infection, and staff stated the rooming arrangement was being treated as contact precautions for both residents despite CDC guidance and available room openings.
A resident with Huntington's disease, cerebrovascular disease, and a history of COVID-19 requested the COVID-19 vaccine and signed consent, but the vaccine was never ordered or given. The IP acknowledged the resident asked multiple times and said it should have been ordered immediately; the AD, DON, and Administrator all stated residents who wanted vaccines were expected to receive them in a timely manner.
The facility failed to keep the public binder current with survey, certification, and complaint records from the prior 3 years, including the related POC. Review of the binder showed it did not contain the Recertification Survey results or POC documents for public viewing, and the Administrator stated she was unaware the required records were missing.
A facility failed to properly manage a resident's personal funds, leading to potential exploitation. The resident's funds were mismanaged, with large withdrawals made without proper oversight. Staff interviews revealed a lack of awareness of the facility's role as the resident's representative payee, resulting in improper handling of funds and potential exploitation by family members.
The facility failed to provide sufficient qualified staff to meet resident needs, particularly in the South Hall with 37 residents. Only two CNAs were scheduled for a shift, leading to each CNA being responsible for 17 to 18 residents. The COVID outbreak increased care time, and staff reported feeling rushed, unable to provide timely care, and relying on management to fill in. The facility's staffing assessment aimed for 3.20 hours per resident per day, but actual levels were below this target, resulting in unmet resident needs.
A resident with moderate cognitive impairment was not allowed to choose her shower schedule, contrary to her preference for morning showers. Despite the facility's policy to respect resident choices, she was given showers only once a week in the evening, leading to frustration. Staff shortages and poor communication contributed to the issue, with the Unit Manager and DON acknowledging the problem but failing to ensure resident preferences were consistently accommodated.
A resident with a hearing deficit was not provided with necessary hearing devices or alternative communication aids after his hearing aid malfunctioned. This led to compromised privacy and limited participation in activities, as staff resorted to yelling in his ear. Facility policies on resident rights and activity programs were not followed, and staff were unaware of available communication aids.
A facility failed to maintain an effective infection control program when a CNA improperly used PPE. The CNA exited a droplet/contact isolation room wearing a contaminated face shield and delivered a food tray to another room without changing PPE. Additionally, the CNA donned an N-95 mask over a medical mask and doffed PPE improperly in another resident's room. The facility's policies required proper donning and doffing of PPE to prevent infection spread, but these were not followed.
A resident with moderate cognitive impairment and assessed as at risk for elopement was admitted without a baseline care plan addressing this risk. The resident later exited the facility unsupervised, highlighting a failure in the facility's processes to ensure safety. Interviews revealed that nurses were responsible for care plan revisions, but there was a disconnect between risk assessment and intervention implementation.
A resident with moderate cognitive impairment and a known elopement risk exited the facility unsupervised, leading to an elopement incident. The resident, who was confused and had packed her belongings, was seen walking in the parking lot by a CNA. Staff interviews revealed that the resident may have exited by tailgating, and the facility lacked a care plan to address her elopement risk.
The facility failed to maintain a clean and homelike environment for its 77 residents due to a persistent gnat infestation. Observations revealed gnats in various areas, including resident rooms and dining areas, causing discomfort during meals. Despite having a pest control contract, the facility did not adequately address sanitation issues in the kitchen, contributing to the problem. Staff interviews confirmed awareness of the issue, with the Director of Maintenance acknowledging the pest control efforts but noting the gnats were not controlled.
The facility failed to maintain accurate recordkeeping of controlled drugs, affecting all residents. Staff did not adhere to policies for signing inventory sheets and narcotic count sheets. A resident did not receive required pharmaceutical services, as an LPN signed out narcotic pills as administered but did not give them. Interviews revealed a lack of adherence to policies, highlighting deficiencies in narcotic management.
The facility failed to maintain a sanitary kitchen, affecting all 77 residents. Observations revealed dirty areas under counters, sinks, and prep areas, with food stains and gnats present. Despite having a cleaning schedule, staff interviews indicated it was not effectively followed, partly due to staffing issues. The Registered Dietitian and Director of Maintenance confirmed the kitchen was usually clean, but the survey revealed otherwise, posing a risk of foodborne illnesses.
The facility failed to implement proper infection prevention and control practices, including inadequate signage for isolation rooms, improper use of PPE by staff, and failure to perform hand hygiene. A resident suspected of having COVID-19 was not properly isolated, and staff, including the ADON and CNA, did not adhere to protocols for PPE and equipment cleaning. The BOM also entered an isolation room without PPE, highlighting widespread non-compliance with infection control measures.
A resident's personal funds were mismanaged at an LTC facility, leading to exploitation. The facility failed to maintain adequate accounting documentation, resulting in money being given to family and friends without the resident's consent. An audit revealed inadequate controls and missing receipts. The former social worker was implicated in the misappropriation, and the resident's son was under investigation for exploitation.
The facility failed to document grievances for missing items reported by two residents with severe cognitive impairment. One resident's belongings, including clothes and a cane, were not found or replaced after discharge, and another resident's blankets and a fast charge block were reported missing by his sister, with no resolution provided. The facility's grievance log did not reflect these issues, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal.
A resident's belongings, including a box of clothes and a pink cane, were misplaced after discharge from the facility. Despite assurances from a former Social Worker that the items would be kept safe, they were not found when the resident returned. The facility's policy on misappropriation of property was not followed, and the resident was not reimbursed for the missing items.
Failure to Resolve and Document Grievances for Missing Resident Property
Penalty
Summary
The facility failed to provide resolutions and/or precise documentation for grievances related to missing clothing items for 3 of 13 sampled residents, including R30, R95, and R119. The facility’s grievance policy stated grievances should be resolved promptly, with best customer service practice to resolve a grievance within three business days when applicable, and the written resolution should include the date received, a summary of the grievance, investigative steps, findings, corrective action, and the date the decision was issued. The facility also had policies addressing resident missing property and resident rights, which stated the facility would take reasonable steps to protect personal items and residents had the right to be treated with respect and dignity. During a Resident Council meeting, R30 stated she had been missing a green North Face shirt since 09/11/2025 and reported the facility had been aware of the missing shirt since that time, but she had not received a response or reimbursement by the time of the meeting. During the same meeting, R95 stated he was missing several pairs of pants and several shirts, reported the issue to multiple staff members in early February 2026, and had not received a response, reimbursement, or return of the items. The Laundry Account Manager stated he was aware of R95’s missing items, had begun an investigation, and would inform the Administrator or Social Services Director if the items were not found. Review of the grievance logs showed R119 reported missing two pairs of flannel pants, and the Laundry Account Manager documented the items were not found in the laundry and that the resident needed reimbursement. However, the resident was discharged before the grievance was resolved. Additional review showed R95’s grievance was not listed on the log for the last six months. The SSD stated reimbursement required a receipt and that if no receipt was provided, no reimbursement could be given. The Social Services Assistant stated the department was responsible for tracking logs and giving agreeable resolutions, and the Administrator stated Social Services was responsible for documentation and resolutions for grievances and expected grievances to be documented and resolved within five business days.
Failure to Follow Care Plan for Two-Person Assistance
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for one resident who was admitted with diagnoses including type 2 diabetes with neuropathy and stroke. The resident's quarterly MDS showed a BIMS score of 14 out of 15, indicating cognitive intactness, and the assessment also showed the resident required substantial to maximum assistance with mobility tasks. The comprehensive care plan documented that the resident required two staff members for transfers, and the resident was also listed as a two-person assist at all times because of previous false allegations made against staff. During observation, the resident called for help to have her brief changed, and an SRNA provided care without assistance from another staff member. The resident then asked for help to the bathroom, and the SRNA assisted her to a sitting position on the bedside while retrieving her wheelchair. The resident was observed sitting at the bedside with her feet on the floor, then becoming weak and swaying while calling out for help. After she steadied herself, the SRNA transferred her from the wheelchair to the toilet without another staff member present. Interviews with staff confirmed the resident had left-sided weakness and required two people for assistance, that the care plan guided staff in meeting resident needs, and that the expectation was for staff to follow the care plan interventions for transfers and personal care.
Failure to Provide Required Two-Person Assistance During Transfers
Penalty
Summary
The facility failed to ensure a resident was adequately assisted during transfers and personal care to prevent accidents. The resident had diagnoses including type 2 diabetes with neuropathy and stroke, was cognitively intact with a BIMS score of 14 out of 15, and was assessed to require substantial to maximum assistance with mobility tasks. The comprehensive care plan stated the resident required two staff members when transferring and listed the resident as a two-person assist at all times because of prior false allegations against staff and the need for substantial to maximum assistance with mobility tasks. Facility documentation also identified the resident as a fall risk and noted education on fall prevention and safety management. During observation, a SRNA provided care to the resident without another staff member present. The resident asked for help to the bathroom, and the SRNA assisted her to a sitting position on the bedside while retrieving her wheelchair from the other side of the bed. The resident was observed sitting at the bedside with her feet on the floor, then became weak, started to sway, and called out for help before being transferred from the wheelchair to the toilet without any other staff present. In interviews, the SRNAs stated the resident had left-sided weakness and required two people for assistance, and one SRNA later stated he normally changed the resident's brief and pulled her up in bed by himself even though the resident needed two staff when she transferred. The DON stated the resident was care planned for false accusations and therefore always required two staff members for personal care, and the Administrator stated staff were expected to follow each resident's functional mobility plan of care.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and to limit access to authorized personnel for 1 of 6 medication/treatment carts, the North Hall medication cart. The facility policy titled, Medication Storage, dated 01/2025, stated that only licensed nurses, pharmacy staff, or other lawfully authorized medication administrators were allowed access to medication carts, and that medication rooms, cabinets, and supplies should remain locked when not in use or attended by authorized staff. On 02/10/2026 at 3:11 PM, the North Hall medication cart for Rooms 101-105 was observed unlocked and unattended. An LPN stated she had walked away from the cart for a minute and did not usually leave it unlocked, describing it as a one-off event, and stated the cart should always be locked when not attended. The North Hall Unit Manager stated medication carts were supposed to be locked anytime staff stepped away from them. The DON stated she was made aware of the cart being left unlocked and that it was her expectation that medication carts always be locked if unattended. The Administrator also stated it was her expectation that the medication carts were locked so no one could get into the cart.
Improper Rooming of a Resident on EBP With a Resident on C-diff Contact Precautions
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 for 1 of 18 residents sampled for infection control. On observation, a resident who was not on contact isolation for C-diff was roomed with another resident who was on contact isolation for C-diff. The room had contact precaution signage outside, but there was no indication of which resident it applied to, no enhanced barrier precaution signage was visible for the resident on EBP, the curtain between the two residents was not pulled closed, and both residents could be viewed from the doorway. The resident not on contact isolation had diagnoses including seizures, aphasia, dysphagia, stroke, and a gastrostomy tube, and was care planned and ordered for Enhanced Barrier Precautions related to enteral feedings. The other resident had diagnoses including dementia, dysphagia, stroke, and a gastrostomy tube, was severely cognitively impaired, and was care planned and ordered for Contact Precautions related to C-diff. The resident on contact precautions had C-diff detected on a diagnostic order review. Facility records showed there were multiple room openings during the relevant period, including discharges, hospital leaves, and admissions, yet the two residents remained roomed together. Facility documents listed the room as having both residents on their respective precautions with stocked isolation supplies and correct signage. During interviews, staff stated both residents were being treated as contact in the room, that residents with C-diff should be in a private room or cohorted with another resident with the same infection, and that the facility followed CDC guidelines. The IP stated the facility had a bed open up in which to move the resident, but the resident was not moved at that time.
Failure to Provide Requested COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure a resident who requested the COVID-19 vaccine was ordered and provided the vaccine. The resident, who was admitted with diagnoses including Huntington's disease, cerebrovascular disease, and a personal history of COVID-19, had a BIMS score of 15 out of 15 on the annual MDS, indicating she was cognitively intact. Her record showed she signed consent for the COVID vaccine, and her vaccination status was marked as not up-to-date, but the vaccine was not ordered or administered despite her request. Record review and interviews showed the resident asked the Infection Preventionist multiple times for the COVID-19 vaccine and was told it would be ordered and given, but it was not. The IP stated the vaccine should have been ordered immediately and acknowledged the resident requested it more than once. The Activities Director stated the resident first requested the vaccine in October 2025 and had not yet received it, while the DON and Administrator stated residents who wanted vaccines were expected to receive them in a timely manner and that residents had the right to receive vaccines at any time.
Missing Survey and Plan of Correction Records in Public Binder
Penalty
Summary
The facility failed to ensure that survey results, certification results, and complaint results from the preceding three years, along with any related plan of correction, were available for any individual to view upon request. During review of the facility’s binder on 02/11/2026 at 3:13 PM, the binder that was supposed to contain these records did not include the Recertification Survey results from 11/26/2024 or the Plan of Correction documents for that survey for public viewing. In an interview on 02/12/2025 at 3:30 PM, the Administrator stated she was unaware that any survey, certification, complaint, or related Plan of Correction documents were missing from the binder and stated that the binder was required by the state to be current and up to date for anyone who wanted to view it.
Failure to Safeguard Resident's Funds Leads to Exploitation Concerns
Penalty
Summary
The facility failed to have an effective system in place to ensure residents were free from exploitation, specifically in the management of a resident's personal funds. The facility, acting as the representative payee for a resident, did not properly manage and account for the resident's personal funds. This was evidenced by large amounts of withdrawals from the resident's account without a proper check and balancing system over a period of time. The facility's policy on Resident Trust Fund was not adequately followed, leading to the mismanagement of the resident's funds. The resident involved was admitted to the facility with diagnoses including anxiety disorder, altered mental status, and transient cerebral ischemic attack. Despite being assessed as cognitively intact, the resident's funds were not managed according to Social Security guidelines. The Social Security Administration discovered during an audit that the resident's money was not spent appropriately, leading to concerns of potential exploitation by family, staff, and friends. The facility's failure to safeguard the resident's funds allowed for the possibility of exploitation, as evidenced by the resident's family receiving large sums of money and gift cards. Interviews with various staff members revealed a lack of awareness and understanding of the facility's role as the resident's representative payee. The former Social Service Director and Business Office Manager were unaware of the facility's responsibilities, leading to improper handling of the resident's funds. The facility's policies were not adequately communicated or enforced, resulting in the misappropriation of the resident's money. The facility's failure to implement proper controls and oversight allowed for the resident's funds to be mismanaged, leading to the identification of Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- Resident #17 account was audited by the Signature Compliance Department and credited by the facility for $18,594.15.
- The Resident Trust Fund policy was reviewed and revised to include requirements for disbursement logs for petty cash box, remaining funds deposited back into a resident trust account after shopping, direct debit, and representative payee.
- Resident 17 was interviewed by the Administrator and expressed understanding of the personal needs allowance increase.
- Business Services Consultant audited Resident 17's trust account to ensure no concerns related to withdrawals, deposits, closed accounts, representative payee accounts, authorization agreements, trust fund petty cash box, and recordkeeping practices.
- The facility is the representative payee for no other residents. Business Services Consultant audited all resident trust accounts.
- All current residents with a BIMS score of 8 or above were interviewed by the Social Services Director to inquire about concerns with their trust account.
- The Resident Trust Fund policy was reviewed and revised, and staff were educated on the policy with a posttest required to score 100%.
- The Signature Care Consultant educated the Interim Administrator, Social Service Director, Unit Managers, Staff Development Coordinator, Activities Director, Minimum Data Set Coordinator, Business Office Manager, and Interim Director of Nursing on the Abuse, Neglect, and Misappropriation of property policy.
- All facility staff were educated on the Abuse, Neglect, and Misappropriation of property policy with a posttest required to score 100%.
- The Business Office Manager conducts a monthly audit of all residents for whom the facility is the representative payee to ensure all monies dispersed are for resident care needs.
- The Social Services Director, Business Office Manager, or Assistant Business Office Manager will conduct interviews of 5 random residents or resident representatives weekly for 4 weeks, then monthly for 2 months.
- The Regional Business Services Consultant will audit 2 resident trust accounts weekly for 4 weeks, then monthly for 2 months.
- An Ad Hoc Quality Assurance meeting was held with the Medical Director, the Facility Administrator, the Director of Nursing, and the Signature Care Consultant regarding the plan of correction.
- The Facility Administrator held a Quality Assurance meeting weekly for 4 weeks to review audits and discuss any concerns related to those audits regarding resident #17 exploitation.
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient qualified staff was available at all times to meet the needs of residents, particularly in the South Hall, which had a census of 37 residents. Observations and interviews revealed that only two CNAs were scheduled for the 7:00 AM to 7:00 PM shift on the South Hall, leading to each CNA being responsible for 17 to 18 residents. This staffing shortage was exacerbated by the presence of a COVID outbreak, which increased the time required for donning and doffing PPE. The facility's policy indicated an average of 27 nurse aides per day, but the staffing schedule showed only 12 to 14 nurse aides were scheduled for the 24-hour periods in question. Interviews with staff highlighted the challenges faced due to inadequate staffing. CNAs reported feeling rushed and unable to provide timely care, such as showers and incontinence care, which could lead to residents experiencing longer wait times and potential skin issues. The Director of Therapy and other staff members had to assist with resident care due to the shortage of CNAs. Additionally, the facility's management attempted to mitigate the staffing issues by having salaried staff and management fill in, but this was not always sufficient to meet the residents' needs. The facility's staffing assessment, based on resident acuity and other factors, aimed for 3.20 hours per resident per day, but the actual staffing levels were below this target. The facility's President of Operations acknowledged the staffing challenges and the need for adjustments during higher acuity situations. Despite these efforts, the staffing deficiencies led to unmet resident needs, such as delayed meal services and inadequate personal care, highlighting the facility's struggle to maintain adequate staffing levels during the COVID outbreak and other operational challenges.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's right to make choices about significant aspects of their life, specifically regarding the scheduling of showers. The resident, who was admitted with diagnoses including surgical aftercare, muscle weakness, and difficulty walking, expressed a preference for morning showers, which was not accommodated. The facility's policy stated that residents should be able to choose when they receive showers, but the resident reported that staff often told her they did not have time to provide a shower in the morning, leading to frustration and a feeling of lack of control over her personal care. Observations and interviews revealed that the resident was consistently given showers on Tuesdays, with partial bed baths on Fridays, contrary to her preference for morning showers. The resident expressed dissatisfaction with the bed baths, stating they did not make her feel as clean as showers. On multiple occasions, the resident was observed with dirty and unkempt hair, and she reported not having received a shower for two weeks. Staff interviews confirmed that due to staffing shortages, it was challenging to provide showers as scheduled, and there was a lack of communication regarding which residents had received showers. The Unit Manager and Director of Nursing acknowledged the issue, with the Unit Manager stating that the shower schedule was set prior to their tenure and that residents generally adapted to the twice-weekly schedule. The Director of Nursing emphasized the importance of allowing residents to choose their shower times, but admitted that the current system did not consistently accommodate resident preferences. The facility's administrator also highlighted the importance of resident-centered care but was unsure if the facility consistently asked residents about their shower preferences upon admission.
Failure to Provide Necessary Hearing Devices and Communication Aids
Penalty
Summary
The facility failed to provide a resident, identified as R46, with necessary hearing devices, which adversely affected his ability to communicate and participate in activities. R46, who was admitted with diagnoses including hemiplegia, hemiparesis following a stroke, and a cognitive communication deficit, experienced a malfunction of his hearing aid after it was washed with his bed linens. Despite the hearing aid being repaired by an outside audiologist, it continued to produce static, impairing R46's ability to hear human voices. The facility did not provide alternative communication devices to R46 when his hearing aid was not functioning properly. This lack of provision led to staff resorting to yelling in his ear, compromising his privacy and confidentiality as his care needs and personal information were exposed to others. The facility's policies on resident rights and activity programs were not adhered to, as R46 was not provided with appropriate adaptations to engage in activities or maintain his privacy. Interviews with staff revealed a lack of awareness and action regarding R46's communication needs. The Activity Director acknowledged the need for a communication board, which had not been provided, and the Social Services Director confirmed the hearing aid issue but noted the family's preference for using their audiology service. The Director of Nursing and other staff members were unaware of the availability of communication aids like communication boards and amplifiers, which were not utilized for R46 until much later.
Infection Control Deficiency Due to Improper PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Certified Nurse Aide 11 (CNA11). Observations revealed that CNA11 exited a droplet/contact isolation room while still wearing a contaminated face shield and subsequently delivered a food tray to another room without changing the PPE. This action was contrary to the facility's policy, which required the removal and disposal of PPE, including face shields, before exiting an isolation room. The residents involved, R2 and R65, were under COVID Isolation Droplet/Contact Precautions due to their diagnoses, which included chronic obstructive pulmonary disease, diabetes, heart disease, anemia, high blood pressure, and depression. Further observations showed that CNA11 improperly donned and doffed PPE when entering and exiting another resident's room, R30, which was also under droplet/contact isolation precautions. CNA11 donned an N-95 mask over a medical mask, which was not part of the training provided by the facility, and doffed the PPE in the doorway with the door open, contrary to the facility's infection control policy. R30 had been diagnosed with cerebral infarction, congestive heart failure, and diabetes, and was also under COVID Isolation Droplet/Contact Precautions. Interviews with CNA11, the Infection Preventionist/Staff Development Coordinator (SDC), the Director of Nursing (DON), the Medical Director, and the Administrator revealed that the staff had been trained on proper PPE procedures, but CNA11 did not follow these protocols. The Infection Preventionist/SDC confirmed that the training did not include double masking and emphasized the importance of removing face shields before exiting isolation rooms. The DON and Medical Director reiterated the expectation for staff to adhere to infection control policies to prevent the spread of infections, and the Administrator confirmed that PPE supplies were adequate.
Failure to Implement Elopement Risk Interventions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident identified as being at risk for elopement. The resident, who was admitted with diagnoses including urinary tract infection, adult failure to thrive, and anxiety disorder, was assessed to be at risk for elopement upon admission. However, the baseline care plan dated the same day did not include any interventions to address this risk. This oversight led to the resident exiting the facility unsupervised on a later date. On the day of the incident, a Certified Nurse Aide observed the resident walking unsupervised in the facility's front parking lot. The resident was moderately cognitively impaired, as indicated by a Brief Interview for Mental Status score of 12 out of 15. Despite this, the facility's initial care plan did not reflect the necessary interventions to prevent elopement, which was a critical oversight given the resident's condition and risk factors. Interviews with facility staff revealed that the responsibility for creating and revising care plans lay with the nurses on the floor, including Licensed Practical Nurses and Registered Nurses. However, there was a disconnect between the assessment of the resident's risk and the implementation of appropriate interventions in the care plan. The Director of Nursing acknowledged that the baseline care plan should have included measures to address the elopement risk, highlighting a failure in the facility's processes to ensure resident safety.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety and supervision of a resident, leading to an elopement incident. The resident, who had been admitted with diagnoses including urinary tract infection, adult failure to thrive, and anxiety disorder, was assessed to be at risk for elopement upon admission. Despite this assessment, the facility did not develop a care plan to address the resident's elopement risk. On the day of the incident, the resident was observed by a CNA walking in the facility's parking lot unsupervised, after having exited the building without staff knowledge. Interviews with staff revealed that the resident was moderately cognitively impaired and had exhibited confusion and wandering behaviors. The resident's daughter confirmed that the resident had been diagnosed with dementia and was admitted to the facility to be with her spouse, who was hospitalized and later passed away on the day of the elopement. The resident was seen by a nurse with her belongings packed, stating she was going to be picked up by the sheriff, indicating a state of confusion. The facility's staff, including the Business Office Manager and the Director of Maintenance, were unable to determine how the resident exited the building. It was suggested that the resident may have followed someone out, a practice known as tailgating. The facility's surveillance cameras were not available for review as they had been updated after the incident. The staff responsible for monitoring the front door did not recognize the resident as such, which contributed to the failure to prevent the elopement.
Facility Fails to Maintain a Clean and Homelike Environment Due to Gnat Infestation
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its 77 residents, as evidenced by the presence of gnats throughout the building. Observations during the survey period revealed gnats in various locations, including resident rooms, conference rooms, hallways, the kitchen, and dining areas. Interviews with residents and staff confirmed that gnats had been an ongoing issue, with residents expressing discomfort and annoyance, particularly during meals. The facility had a contract with a pest control company since 2015 for monthly and as-needed services. However, the pest control company's invoices from January to June 2024 highlighted persistent sanitation issues in the kitchen, which contributed to the pest problem. These issues included unclean floors, trash cans, and structural concerns like loose tiles and worn grout lines, which provided breeding grounds for gnats. Despite the pest control company's recommendations for cleaning and maintenance, the facility did not adequately address these concerns, leading to the continued presence of gnats. Interviews with staff, including CNAs, LPNs, and the Director of Maintenance, indicated awareness of the gnat problem and its link to residents keeping food in their rooms. The Director of Maintenance acknowledged the pest control company's efforts but noted that the gnats were not controlled. The CEO was aware of the issue but relied on the Director of Maintenance to manage the pest control contract. The Regional Nurse Consultant emphasized the importance of maintaining a clean and homelike environment for residents, aligning with the facility's policy on resident rights.
Deficiencies in Controlled Drug Recordkeeping and Administration
Penalty
Summary
The facility failed to maintain accurate recordkeeping of controlled drugs across all medication carts, affecting all 77 residents. The staff did not adhere to the facility's policy for signing inventory sheets for controlled narcotics, signing narcotic count sheets at the change of shift, and signing narcotic sheets prior to the end of the shift. Specifically, two residents did not have their narcotic medications signed out as administered, despite being subtracted from the count. Additionally, a resident did not receive pharmaceutical services as required. An LPN signed out three narcotic pills as administered but did not actually give the medication to the resident. The LPN also signed out a dose of a narcotic analgesic that was administered by another LPN. This discrepancy was discovered during a narcotic count, which revealed missing tablets that were not administered to the resident. Interviews with various staff members, including KMAs, LPNs, the CEO, and the DON, revealed a lack of adherence to the facility's policies regarding narcotic counts and documentation. The staff acknowledged the importance of following these policies for the safety of residents and staff, as well as to protect their professional licenses. The CEO confirmed that the facility had been informed of a nurse under investigation for drug diversion, which further highlighted the deficiencies in narcotic management and documentation.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a safe and sanitary manner, affecting all 77 current residents. Observations revealed that areas under counters, sinks, and prep areas were dirty with debris and buildup. The kitchen wash area had food stains on the walls, floor, and around the sink, with debris on the floor and gnats flying near the dirty sink area. The contracted company's policies required routine cleaning and sanitation, but the facility did not adhere to these standards, as evidenced by the unclean conditions observed during the survey. Interviews with staff, including the Dietary Aide, Dietary Manager (DM), and Regional Dietary Manager (RDM), indicated that there was a cleaning schedule in place, but it was not effectively followed. The DM acknowledged the unclean condition of the kitchen during the survey and attributed it to being short-staffed at the time. The Regional Dietary Manager also noted that staffing issues contributed to routine tasks being delayed, and the kitchen was not clean at the time of the surveyor's observations. The Registered Dietitian (RD) and the Director of Maintenance (DOM) confirmed that the kitchen was normally kept clean, but the presence of gnats and the unclean conditions observed during the survey indicated otherwise. The RD's last visit did not reveal any major issues, and the CEO was not aware of the kitchen's condition, as the last three reports from the contracted company did not show concerns related to cleanliness. The facility's failure to maintain a clean and sanitary kitchen environment posed a risk of foodborne illnesses and infection control issues for the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, as evidenced by several observations and interviews. In one instance, a resident suspected of having COVID-19 was placed in Contact/Droplet Isolation, but there was no signage on the door to indicate this status. Staff interviews revealed confusion and inconsistency regarding the resident's COVID-19 status and the implementation of appropriate precautions. The Infection Prevention/Staff Development Coordinator and the Director of Nursing were aware of the situation but did not ensure that proper signage and precautions were consistently in place. The Assistant Director of Nursing (ADON) was observed administering eye and nose drops to a resident without wearing gloves or performing hand hygiene. Additionally, the ADON entered a room with Enhanced Barrier Precautions without donning PPE and improperly cleaned shared medical equipment. The ADON admitted to not following the facility's policy and was unaware of the need for PPE during certain resident care activities. The Infection Prevention/Staff Development Coordinator confirmed that staff were educated on the need for PPE and proper cleaning protocols. Other staff members, including a Certified Nurse Aide (CNA) and the Business Office Manager (BOM), were also observed failing to adhere to infection control protocols. The CNA did not perform hand hygiene after removing gloves and improperly handled biohazardous waste. The BOM entered a Contact/Droplet isolation room without PPE. Interviews with various staff members, including the Interim Director of Nursing and the Medical Director, highlighted a general expectation for adherence to infection control practices, yet these expectations were not consistently met, leading to potential risks for healthcare-associated infections.
Failure to Safeguard Resident's Personal Funds
Penalty
Summary
The facility failed to protect a resident, identified as R15, from exploitation of personal funds. The facility did not maintain adequate accounting documentation to ensure R15 was safeguarded from misappropriation of funds. An audit by Kentucky Protection and Advocacy revealed that the facility had inadequate controls for safeguarding residents' funds, was missing receipts for large and unusual purchases, and did not retain records for the required two years. The facility was required to submit a plan of correction to address these deficiencies. R15, who was admitted to the facility with diagnoses including stroke, anemia, and anxiety disorder, had a BIMS score indicating intact cognition. Despite this, R15's funds were mismanaged, with money being given to family and friends with and without her consent. The former social worker (SW) was implicated in the misappropriation of R15's funds, as R15 reported that the SW had stolen her money. R15 had given the SW money to purchase items such as clothes, jewelry, and lotion, but these items were not in her possession. Additionally, R15's son was under investigation for exploitation, having opened a credit card in R15's name without her authorization. Interviews with various staff members, including the Social Service Director (SSD), Business Office Manager (BOM), and CEO, revealed that the facility had policies in place to prevent such exploitation, but these were not effectively implemented. The SSD stated she did not handle personal funds, and the BOM confirmed that residents were not allowed to give checks or cash for deposit or to request purchases outside the facility. The CEO emphasized the importance of a check and balance system to ensure residents' funds were managed correctly. Despite these policies, the facility's failure to maintain proper documentation and oversight led to the exploitation of R15's personal funds.
Failure to Document and Resolve Grievances for Missing Items
Penalty
Summary
The facility failed to document grievances related to missing items for two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident 21, who had severe cognitive impairment, reported missing items, including a box of clothes and a pink cane, after being discharged. Despite an investigation being initiated, the items were not found or replaced, and the grievance was not documented in the facility's grievance log. Interviews revealed that the items were last seen in the therapy gym and later moved to the Social Worker's office, but they were not located thereafter. Resident 28, also with severe cognitive impairment, had two blankets and a fast charge block reported missing by his sister. She reported the missing items to the Social Worker and the CEO, but received no feedback or resolution. The CEO stated that proof of purchase was required to replace items, contrary to the Regional Nurse Consultant's expectation that grievances should be documented and items replaced without proof of purchase. The facility's failure to document these grievances and resolve them promptly led to the deficiency.
Failure to Safeguard Resident's Belongings After Discharge
Penalty
Summary
The facility failed to protect a resident's belongings after discharge, leading to the misappropriation of property. Resident 21, who was cognitively intact with a BIMS score of 14 out of 15, left a box of clothes and a pink cane at the facility upon discharge. The former Social Worker assured the resident that the items would be kept in her office for safekeeping. However, when the resident returned to retrieve her belongings, they were missing, and the facility did not reimburse her. The facility's policy defines misappropriation of property as the wrongful use of a resident's belongings without consent, which was not adhered to in this case. Interviews and record reviews revealed that the items were initially left in the resident's room and later moved to the therapy gym. A housekeeper recalled seeing the items during a deep clean, but they were no longer there afterward. The Regional Nurse Consultant and other staff members confirmed the resident's account of the missing items. Despite the facility's policy and the expectation of an investigation to locate the missing items, the resident was not compensated, and the items were not found. The Chief Executive Officer stated that proof of purchase was required for reimbursement, contrary to the Regional Nurse Consultant's statement that it was not necessary.
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What surveyors actually found near you
We read the 61 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sayre Christian Village Nursing Home | 1.8 mi | ★★★★★ | 0 | 0 |
| Bluegrass Care & Rehabilitation Center | 1.8 mi | ★★★★★ | 0 | 0 |
| The Willows At Fritz Farm | 2.4 mi | ★★★★★ | 3 | 0 |
| Hartland Park Health & Rehabilitation | 2.4 mi | ★★★★★ | 4 | 0 |
| Lexington Country Place | 3.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.