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 Chateau Living Center during CMS and state inspections, most recent first.
Two residents received incorrect dosages of psychotropic medications during observed med passes, resulting in a medication error rate above 5%. One resident with dementia and other conditions was ordered Risperidone 0.25 mg daily, but an LPN administered 0.5 mg instead, despite the eMAR reflecting the reduced dose. Another resident with a history of cerebral infarction and depression was ordered Fluoxetine HCl 50 mg daily (2.5 tablets of 20 mg), but an LPN administered only 40 mg. Multiple staff, including the LPNs, corporate nurse, DON, assistant administrator, and administrator, confirmed that the medications were not given as ordered.
A resident’s right to privacy during perineal care was not maintained when two CNAs provided care without closing the privacy curtain or room door, leaving the resident’s buttocks exposed to a roommate and to another resident who entered the room. Facility policy required that the door and privacy curtain be closed during perineal care, and both a CNA and the DON later confirmed that the door and/or curtain should have been closed.
A resident with urinary incontinence was left in soiled clothing for over 40 minutes after staff were made aware of her need for assistance. Despite the resident's repeated requests and visible distress, both an LPN and a CNA Supervisor failed to provide timely incontinence care, which was only given after a CNA intervened. Facility policy required residents to be changed within 15 to 20 minutes after an incontinence episode, but this standard was not met.
A resident with a history of chronic pain and a previous fall was unable to receive prescribed Hydrocodone-Acetaminophen for pain relief because the medication was not reordered in time and was unavailable when requested. Staff confirmed the medication was out of stock and not administered as ordered.
Unsanitary Tube Feeding Equipment and Room Conditions: The facility failed to keep the tube feeding equipment and surrounding room areas sanitary for two residents receiving enteral feedings. Observations found multiple areas of a reddish/brown substance on each resident’s TF pump, the base of the feeding pole, and the floor near the pole. The Administrator and DON acknowledged the rooms were not maintained in a sanitary manner.
A facility failed to report a resident-to-resident physical abuse incident to the state agency as required by policy. An incident report showed one resident hit one resident and punched another resident in the chest, and the administrator acknowledged he was informed of the abuse but did not make the required report.
Incomplete Investigation of Resident-to-Resident Physical Abuse: A resident-to-resident physical abuse incident was not thoroughly investigated after one resident hit another resident and punched a second resident in the chest. Although facility policy required a thorough abuse investigation with staff statements and interviews of involved cognitively intact residents or roommates, there was no documented evidence of witness statements from nurses or residents, and leadership confirmed the investigation was incomplete.
A resident on strict contact precautions for active C. difficile had multiple infection control failures observed in the room. A CNA used ABHS instead of soap and water, did not maintain proper glove use during care, and handled used linens with ungloved hands. A housekeeper also used ABHS after cleaning and used general disinfectants rather than bleach-based products required for C. difficile room cleaning.
Failure to Maintain Effective Pest Control Program: Brown flying insects were observed in multiple resident rooms, on a resident's blanket and breakfast tray, and in common areas including Dining Room A, Dining Room B, and Hall C. A resident reported insects bothering her in her room, another said one landed on her bread at breakfast, and the pest management contractor stated no reports had been received from the facility while the Administrator was unaware of the issue.
A resident physically abused two other residents by hitting one resident and punching another in the chest. An LPN witnessed the assault, and the administrator acknowledged the incidents. One resident reported being hit several times with a closed fist, while the other resident could not be interviewed due to cognitive status.
A resident with dementia, delusional disorder, MDD, and psychosis had PRN Haldol ordered for agitation, but the chart did not document the behaviors that justified the dose or any non-pharmacological interventions tried first. The record also lacked evidence that the physician re-evaluated the ongoing PRN antipsychotic use, documented the rationale, or specified the duration of the order.
Untrimmed Fingernails Not Maintained for a Resident Needing ADL Assistance: A resident who required substantial/maximal help with personal hygiene had fingernails on both hands extending past the fingertips during repeated observations. The ADON confirmed the nails were long, excessive, and should have been trimmed, and stated they appeared not to have been trimmed in a couple of weeks.
Unsecured chemical in beauty shop room. The facility failed to keep the beauty shop room locked and monitored, and a container of Barbicide was left unsecured on the counter. The Housekeeping Supervisor confirmed the room should be closed and locked when unmonitored and that the chemical should not have been accessible to residents at risk for wandering.
Failure to Change Oxygen Tubing as Ordered: A resident with COPD and respiratory failure had an active order for weekly oxygen tubing changes, but the tubing was repeatedly observed without a date and the resident stated staff did not change it weekly as required. An LPN-level clinical care specialist and the DON confirmed oxygen tubing should be changed per MD orders.
Improper storage of employee beverages in the freezer. Surveyors observed an employee's frozen drink and a Dietary Aide's labeled water bottle stored in the facility freezer. The Dietary Manager and Administrator confirmed the items should not have been stored there, and the Dietary Aide acknowledged placing her water bottle in the freezer.
Failure to Post Required Nurse Staffing Information: Surveyors observed that the facility's posted nurse staffing information did not include the daily census on 3 observed days. The DON stated he did not know what information was required, and the Corporate Nurse confirmed the daily staffing report should be posted every morning and include the current daily census. The Administrator was informed of the findings and offered no further explanation.
A resident with a urinary catheter was observed with her drainage bag visible while using a wheelchair, despite having previously requested a privacy cover. An LPN and the Assistant Director of Nursing both confirmed awareness of the request and the need for a privacy cover, but the resident had not received one, resulting in a failure to maintain the resident's dignity and privacy.
Surveyors found that two medication carts contained insulin pens that were either expired or lacked an opened date, making it impossible to determine if they were safe for use. An LPN confirmed the expired status of one pen, while another LPN acknowledged that an unlabeled pen should have been discarded.
A medication cup with two unidentified pills was found on a resident's bedside table after the resident declined to take her sleeping pills when offered by a nurse. Facility policy prohibits leaving medications unattended with residents, and the ADON confirmed this practice was not followed.
Several residents reported that their meals were consistently served cold, and surveyors observed that food trays were transported on top of insulated carts rather than inside them. Temperature checks confirmed that food items were served below acceptable hot food standards, and both staff and surveyors found the food to be cold.
Two residents were left without a working call bell in their bathroom and bathing area for several days, requiring them to wait for staff rounds to receive assistance. Staff were aware of the malfunction but did not notify the administrator, resulting in a prolonged lack of access to the call system.
The facility failed to ensure a clean and odor-free environment, with strong urine odors in two halls and trash on a resident's floor. A resident's room contained debris, and their wedge pillow was damaged. The administrator acknowledged these issues.
A resident with multiple stage 3 pressure injuries did not receive proper wound care when a CNA removed dressings and failed to notify the nurse, leaving wounds exposed. Additionally, a heel protector was incorrectly applied to the right heel instead of the left, as ordered. The resident's medical conditions increased the risk of pressure ulcer development, highlighting the importance of following care protocols.
A resident with peripheral vascular disease did not receive necessary toenail care in a timely manner. Despite the resident's request for toenail care upon admission, observations showed the toenails were long, thick, and curled. Interviews with the ADON and an LPN confirmed the need for trimming, but the resident was not scheduled for a podiatry appointment, and there was no evidence of a prior podiatry consult.
The facility failed to ensure CNAs demonstrated competencies in hand hygiene, EBP, and proper showering, and an LPN demonstrated competency in applying a heel protector. Two residents were affected: one with stage three pressure injuries and an indwelling urinary catheter, where CNAs did not adhere to EBP, and another requiring substantial assistance, where a CNA failed to wash the resident's buttocks and did not perform hand hygiene during incontinence care.
A long-term care facility failed to maintain an effective infection prevention and control program for two residents. One resident, with multiple medical conditions, did not receive proper Enhanced Barrier Precautions (EBP) as CNAs failed to wear gowns, perform hand hygiene, or change gloves during care. Another resident received incontinence care without proper hand hygiene or glove changes. The facility's Administrator and DON confirmed these lapses in infection control protocols.
A resident with moderate cognitive impairment and incontinence issues did not receive adequate personal hygiene care during a bathing session. The CNA failed to wash the resident's buttocks, leaving them uncleaned. The CNA acknowledged the oversight, and the facility administrator confirmed that the resident's buttocks should have been washed.
A resident with a WanderGuard transmitter exited a facility through an unalarmed door, resulting in a head injury. Staff used a secondary reset code to disable door alarms, contrary to policy, compromising resident safety. The deficiency led to Immediate Jeopardy due to the risk of harm to residents at risk for elopement.
A CNA failed to recognize a resident at risk for elopement, despite facility policy requiring staff to be trained on elopement prevention. The CNA, assigned to a room with two at-risk residents, only identified one as at risk. The Director of Nursing confirmed that staff should use binders at nursing stations to identify such residents, but the CNA was unaware of this resource.
A facility failed to ensure privacy for a resident during PEG tube care. An LPN performed the procedure without closing the door, leaving the resident's abdomen exposed and visible from the hallway. The resident had a diagnosis of mild intellectual disability. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that the door should have been closed to maintain privacy.
A facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) during PEG tube care for a resident. Despite a policy requiring gown use for high-contact activities, an LPN was observed performing PEG tube care without a gown. The resident had a gastrostomy and physician orders for EBP, which mandated gown and glove use. Interviews confirmed the lapse in protocol adherence.
The facility failed to ensure a safe environment as water leaked from Shower Room A into the hallway due to an uneven floor. Observations confirmed the presence of water pooling in the hallway, and staff interviews verified the issue. The Administrator was aware of the incident.
The facility failed to complete required Braden skin assessments for a resident upon re-admission and inaccurately documented another resident's pressure ulcer status. Additionally, the facility did not implement necessary pressure ulcer prevention and treatment interventions for a resident, as staff failed to turn the resident every two hours and use heel protectors as per the care plan.
A facility failed to accurately revise a care plan for a resident's skin condition. The resident had a care plan for impaired skin integrity, but it was inaccurately updated to reflect a stage III pressure ulcer later than documented in nursing notes. This discrepancy was confirmed by a corporate nurse.
A facility failed to properly store discontinued and expired medications, as a blister packet of Norco 5-325 mg tablets was found in a medication cart despite being discontinued and expired. Staff, including an LPN, ADON, DON, and the Administrator, confirmed the oversight, acknowledging that the medication should have been removed according to facility policy.
Two residents with moderately impaired cognition were found with medications on their bedside tables without being assessed or care planned for self-administration, as required by the facility's policy. Interviews with staff confirmed the lack of assessment and care planning for these residents.
A resident's wheelchair was found in poor condition, with a blackish-brownish substance on the brake levers, a missing right arm pad, and a torn left arm pad with exposed foam. Facility staff confirmed the issues, and the DON indicated the need for replacement.
A resident admitted for rehabilitation and receiving IV medications through a PICC line reported that the site was not cleaned or bandage changed during their stay. Facility records lacked documentation of PICC site care, and staff interviews confirmed the absence of documentation and inability to recall if care was provided.
A facility failed to accurately complete a Level I PASARR for a resident with Major Depressive Disorder and Bipolar Disorder. The resident's mental illnesses were not documented, and a Level II PASARR referral was not initiated, despite the resident's diagnoses and history of mental health treatment. Interviews revealed staff were unaware of the need for a Level II referral, and the administrator confirmed the oversight.
The facility did not maintain food on the steam table at the required temperature of at least 135°F. During an observation, various foods were held on the steam table for lunch, and the temperature of pureed sweet potatoes was found to be 130°F. Interviews with staff confirmed that the steam table should maintain food at a temperature no lower than 135°F.
A facility failed to transmit a resident's discharge assessment data within the required timeframe, resulting in a deficiency. The assessment was completed and signed by the DON, but an error in the MDS caused a delay in transmission. The MDS Nurse indicated that the error in entering the Unit Certification or Licensure Designation led to the late submission.
A facility failed to ensure a resident's MDS assessment accurately reflected their skin condition. The resident had a stage III pressure ulcer documented in nursing notes, but the MDS inaccurately indicated no unhealed pressure ulcers. This discrepancy was confirmed by a corporate nurse.
Medication Error Rate Exceeded Due to Incorrect Dosages Administered
Penalty
Summary
The facility failed to maintain a medication error rate below 5% when nursing staff administered incorrect dosages of prescribed medications to two residents during observed medication passes. Facility policy on Medication Administration and Storage required staff to check medication directions against the electronic medication administration record (eMAR), ensure medications on the cart were current, and verify that drugs matched the eMAR. For one resident with Alzheimer's disease, vascular dementia, generalized anxiety disorder, and hemiplegia, the physician’s order dated 03/06/2026 specified Risperidone 0.25 mg by mouth once daily. However, review of the March 2026 eMAR showed that from 03/01/2026 through 03/05/2026 the resident received Risperidone 0.5 mg daily, and the 0.5 mg dose was discontinued on 03/05/2026 with a new order for 0.25 mg starting 03/06/2026. On 03/31/2026, observation revealed an LPN administered a 0.5 mg Risperidone tablet instead of the ordered 0.25 mg dose, and the LPN later confirmed she had given the higher dose contrary to the physician’s order. For another resident with diagnoses including unspecified sequelae of cerebral infarction and adjustment disorder with depressed mood, a physician’s order dated 03/03/2026 directed administration of Fluoxetine HCl 50 mg daily, specified as 2.5 tablets of 20 mg each by mouth once a day. During an observed medication pass on 03/31/2026, an LPN administered a single 40 mg Fluoxetine HCl tablet instead of the ordered 50 mg dose. Subsequent interviews with the LPN, the corporate nurse, the DON, the assistant administrator, and the administrator confirmed that 40 mg was given when 50 mg was ordered, and that the Risperidone dose for the first resident was also administered at 0.5 mg instead of the ordered 0.25 mg. These observed and confirmed discrepancies between the medications administered and the physician orders constituted medication errors contributing to a medication error rate greater than 5%.
Failure to Maintain Resident Privacy During Perineal Care
Penalty
Summary
The facility failed to maintain a resident’s privacy during perineal care, contrary to its Perineal Care Policy and Procedure dated 11/17/2015, which required that the resident’s door and privacy curtain be closed during such care. On 02/09/2026 at 12:28 PM, two CNAs (S2CNA and S3CNA) provided perineal care to Resident #1 without closing the privacy curtain, resulting in the resident’s buttocks being exposed to the roommate. During the same episode of care, a random resident walked into the room, and Resident #1’s buttocks remained exposed because the door and privacy curtain were not closed. In a subsequent interview at 2:10 PM, S2CNA acknowledged that she did not close the door or privacy curtain while performing perineal care and stated that she should have done so. In a separate interview at 2:12 PM, the Director of Nursing (S1) indicated that both CNAs should have closed the resident’s door and/or privacy curtain while performing the perineal care.
Delay in Providing Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely assistance with activities of daily living (ADL) for a resident who required help with toileting and hygiene due to urinary incontinence. The resident, who had diagnoses including overactive bladder and unspecified urinary incontinence, was observed crying in her wheelchair in the hallway after experiencing an episode of incontinence. Despite informing staff members, including an LPN and a CNA Supervisor, of her situation and visibly displaying distress, the resident did not receive prompt incontinence care. The LPN stated she would find a CNA to assist, and the CNA Supervisor acknowledged the resident's statement about being wet but did not provide immediate help, instead only showing the resident where her clothes were located. The resident continued to seek assistance, wheeling herself through the hallway and expressing her need for clean clothes and incontinence care. It was not until approximately 42 minutes after the initial observation that a CNA provided the necessary care. Interviews with staff confirmed that facility policy required residents to be changed within 15 to 20 minutes after a known episode of incontinence. The delay in providing care was contrary to this policy, and staff acknowledged the expectation for timely assistance following incontinence episodes.
Failure to Ensure Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's prescribed pain medication, Hydrocodone-Acetaminophen 10-325 mg, was available for administration as ordered by the physician. Review of the medication records showed that the resident had zero tablets available after receiving the last dose on 08/29/2025 at 8:43 PM. The resident reported experiencing pain related to a previous fall and chronic pain during the night and morning following the last available dose, and stated that she requested her pain medication but was informed by nursing staff that it was not available because it had not been reordered. Staff interviews confirmed that the medication was not available when requested, and the LPN on duty was unable to administer the prescribed pain medication due to the lack of supply. The Staff Development/Charge Nurse/Infection Preventionist acknowledged that medications with active orders should be available for administration, and the Director of Nursing indicated that medications should be ordered from the pharmacy before running out. The deficiency was identified for one of three residents reviewed for medication administration.
Unsanitary Tube Feeding Equipment and Room Conditions
Penalty
Summary
The facility failed to ensure resident equipment and rooms were maintained in a sanitary manner for 2 sampled residents receiving tube feedings. Resident #57 was admitted with diagnoses including encounter for attention to gastrostomy, dysphagia, and cognitive communication deficit. The resident’s MDS indicated the resident was non-interviewable, dependent for all ADLs, had a feeding tube, and received enteral feeding. On observations on 07/21/2025 and 07/22/2025, multiple areas of a reddish/brown substance were seen on Resident #57’s tube feeding pump, on the base of the tube feeding pole, and on the floor near the tube feeding pole. Resident #148 was admitted with diagnoses including encounter for attention to gastrostomy and dysphagia following cerebral infarction. The resident’s quarterly MDS indicated the resident was non-interviewable and received enteral feedings through a tube. On observations on 07/21/2025 and 07/22/2025, multiple areas of a reddish/brown substance were seen on Resident #148’s tube feeding pump, on the base of the tube feeding pole, and on the floor near the tube feeding pole. In interviews, the Administrator and the DON both indicated these room conditions were not maintained in a sanitary manner.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that an incident of resident-to-resident physical abuse was reported to the state agency for one resident identified in the investigation. The facility policy titled, Abuse-Prevention and Prohibition, stated that the administrator shall immediately initiate a report to the state agency after forming suspicion that an allegation involves abuse of any type. An incident report documented that one resident hit another resident and punched a third resident in the chest. Review of the facility’s list of incidents reported to the state agency for the prior six months showed no documented evidence that this physical abuse incident was reported, and the facility provided no documented evidence that it had been reported. In interview, the administrator stated he was informed that the resident hit one resident and punched another resident, and he acknowledged that he did not report the resident-to-resident physical abuse to the state agency as required.
Incomplete Investigation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure a resident-to-resident physical abuse incident involving Resident #110 was thoroughly investigated. The incident report dated 07/02/2025 stated that Resident #110 hit Resident #62 and punched Resident #180 in the chest. During an interview on 07/23/2025, Resident #62 stated that Resident #110 entered her room and hit her legs several times with a closed fist and also punched her roommate, Resident #180. The facility’s policy required a thorough abuse investigation, including interviews with employees and signed statements, as well as interviews with cognitively intact residents involved or the roommate if a resident was cognitively impaired. However, there was no documented evidence, and the provider could not present documented evidence, that witness statements from nurses or cognitive residents were obtained for the incident. In interviews, the Corporate Administrator and Corporate Nurse stated the facility did not have witness statements for the resident-to-resident physical abuse incident, and the Corporate Nurse confirmed the incident was not thoroughly investigated.
Infection Control Failures During C. difficile Isolation Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient for a resident on physician-ordered contact precautions for active C. difficile infection. Resident #75 had an order for strict isolation related to C. difficile, but observations showed no signage on the room door indicating staff should use soap and water for hand hygiene, and the posted contact isolation sign showed alcohol-based hand sanitizer being used. Facility policies stated that alcohol rub is not effective against C. difficile and that handwashing with soap and water was required before exiting the room. During care, a CNA entered the resident’s room to provide catheter care and incontinence care. After cleaning the catheter tubing, the CNA changed gloves and used ABHS instead of washing with soap and water. The CNA then continued care, including removing a urine- and feces-soiled brief, cleaning the resident’s buttock area, and placing a clean brief, without washing hands with soap and water between glove changes. The CNA later confirmed she did not use soap and water in between glove changes and should have. A housekeeper assigned to clean the room also confirmed she used ABHS after cleaning and did not wash with soap and water before leaving the room. The facility’s isolation policy stated that for C. difficile, gown and gloves are to be used for all interactions involving the resident or potentially contaminated areas, and gloves are to be used at all times. However, observations showed the CNA removed soiled gloves, used ABHS, and then handled the resident’s used linens with ungloved hands. A wound care nurse also entered the room for a sacral wound dressing change, and the CNA again handled the resident’s used linens with ungloved hands. For environmental cleaning, the housekeeper used Micro-kill Q3 general disinfectant and multisurface peroxide in the room, even though the facility policy required bleach wipes or a 1:10 bleach solution for isolation rooms and the EPA list did not identify those general disinfectants as effective against C. difficile spores.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control management program for resident rooms, halls, and dining rooms. During observations, brown flying insects were seen in multiple resident rooms, including Resident #148's room, Resident #24's room, Resident #95's room, Resident #67's blanket while she was in bed, Resident #72's blanket while she was in bed, and on Resident #16's breakfast tray in her room. Resident #24 stated that the flying insects in her room bothered her. Brown flying insects were also observed in common areas, including Dining Room A, Dining Room B, and Hall C. One insect landed on the surveyor's arm in Dining Room A, and additional insects were later seen in Dining Room A on another observation. Resident #139 stated that a brown flying insect landed on her bread at breakfast. The contracted pest management company's administrator stated they had not received any reports from the facility regarding brown flying insects, and the Administrator stated he was not aware of the insects in the affected areas.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident. Review of the abuse policy showed physical abuse includes hitting, slapping, and punching, and that each resident has the right to be free from abuse. An incident report and the administrator’s documentation showed that Resident #110 hit Resident #62 and punched Resident #180 in the chest. Resident #62 stated that Resident #110 entered her room and hit her legs several times with a closed fist, and also punched her roommate, Resident #180. An LPN reported witnessing Resident #110 hit Resident #62 and then punch Resident #180 in the upper chest when staff attempted to remove Resident #110 from Resident #180’s bed. The administrator acknowledged that Resident #110 hit both residents.
PRN antipsychotic use lacked documented indication and physician review
Penalty
Summary
The facility failed to ensure adequate documentation for the use of PRN Haldol for a resident with unspecified dementia, delusional disorder, major depressive disorder, and psychosis. The resident had an order for Haldol 1 mg by mouth every 24 hours as needed for agitation, and the eMAR showed the medication was administered once. However, the record did not include documented evidence of the behaviors that prompted the dose, and the evening and night shift documentation for that day showed the resident was monitored for agitation with no behaviors present. Nurses notes stated the Haldol was given and was effective, but there was no documented evidence of the indication for the PRN dose or of any non-pharmacological interventions attempted before administration. The facility also failed to show that the physician re-evaluated the continued PRN use of Haldol and documented the rationale and duration for the order. A pharmaceutical consultant recommended limiting PRN antipsychotic use to 14 days and providing a diagnosis code for Haldol, but there was no documented evidence that the physician evaluated whether the resident still required the medication, the benefit it provided, or whether the resident’s expressions or indications of distress improved with the PRN medication. The corporate nurse stated the facility did not have documented evidence of a physician evaluation after the order was initiated or of the duration of the order.
Untrimmed Fingernails Not Maintained for a Resident Needing ADL Assistance
Penalty
Summary
The facility failed to ensure a resident's fingernails were maintained for Resident #174, who required substantial/maximal assistance with personal hygiene per the MDS with an ARD of 5/21/2025 and had a care plan dated 10/11/2024 indicating staff assistance with ADL care. During observations on 7/21/2025 and 7/22/2025, the fingernails on both hands extended past the tips of the fingers, and the right 3rd and 5th fingernails were approximately one-fourth of an inch past the fingertips. During an interview on 7/22/2025, the ADON stated a resident's fingernails were to be trimmed as needed by CNAs during showers and by activities personnel during scheduled rounding. A later observation with the ADON present showed the fingernails on both hands still extended past the fingertips, with the right 3rd and 5th fingernails approximately one-fourth inch past the fingertips and the right 5th fingernail jagged. The ADON confirmed the fingernails were long, excessive, and should have been trimmed prior to the observation, and stated the nails appeared not to have been trimmed in a couple of weeks.
Unsecured Chemical in Beauty Shop Room
Penalty
Summary
The facility failed to ensure chemicals in the beauty shop room were secured and not accessible to wandering residents. Review of the Wandering Residents List showed 11 residents identified by the facility as at risk for wandering. During observation, the beauty shop room was found unlocked, open, and unmonitored, and a container of blue solution labeled Barbicide was observed on the counter unsecured. The Barbicide Safety Data Sheet provided by the facility stated the chemical was irritating to skin and eyes, harmful if swallowed, and that poison control should be called immediately if ingested; it also stated safety glasses and goggles should be worn when handling the chemical. The Housekeeping Supervisor confirmed the beauty room should be closed and locked when unmonitored and acknowledged the Barbicide was unsecured on the counter and should not have been accessible to residents.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide evidence that a resident's oxygen tubing was changed weekly as ordered for Resident #74, who had diagnoses of chronic obstructive pulmonary disease with acute exacerbation and acute chronic respiratory failure with hypoxia and was cognitively intact with a BIMS score of 15. The resident had an active physician order dated 08/13/2024 to change the oxygen tubing every week and as needed. During observations on 07/22/2025 at 10:14 AM and 8:50 AM, and again on 07/23/2025 at 8:34 AM, the resident's oxygen tubing was observed to be not dated. In an interview on 07/23/2025 at 8:35 AM, Resident #74 stated facility staff did not change her oxygen tubing weekly as required. A Clinical Care Specialist and the DON both stated that oxygen tubing should be changed as required per physician orders.
Improper Storage of Employee Beverages in Freezer
Penalty
Summary
Food was not stored in a sanitary manner. On 07/21/2025 at 8:45 AM, surveyors observed an employee's frozen drink stored in the facility freezer. The Dietary Manager stated at 8:46 AM that the employee's frozen drink should not have been stored there, and the Administrator later confirmed at 1:20 PM that the employee should not have stored her frozen drink in the freezer. On 07/22/2025 at 12:21 PM, surveyors observed a bottle of clear liquid labeled with a Dietary Aide's name and date stored in the freezer. The Dietary Aide confirmed she had placed her water bottle in the freezer and stated she should not have done so, and the Dietary Manager also confirmed that the water should not have been stored in the freezer.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information at the beginning of each shift daily for 3 of 3 days observed. On 07/21/2025, surveyors observed the posted nurse staffing information did not include the facility's daily census. The same omission was observed again on 07/22/2025 and on 07/23/2025, with the posted staffing information still lacking the daily census. During an interview on 07/22/2025, the DON stated he did not know what information was required on the posted nurse staffing information. On 07/23/2025, the Corporate Nurse confirmed the daily staffing report form should be posted every morning and include the facility's current daily census, and the Administrator was informed of the findings and offered no further explanation.
Failure to Provide Privacy Cover for Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter was observed ambulating in her wheelchair with her catheter drainage bag attached under the seat, and the contents of the bag, including yellow urine, were visible. The resident called out to an LPN and requested a privacy cover for her catheter drainage bag, stating that she had made the same request the previous week but had not received one. The LPN acknowledged the prior request and confirmed that the resident should have a privacy cover. The Assistant Director of Nursing also confirmed that the resident should have a privacy cover for her catheter drainage bag. These observations and interviews demonstrate that the facility failed to provide the requested privacy cover, compromising the resident's dignity and right to privacy.
Expired and Unlabeled Insulin Pens Found on Medication Carts
Penalty
Summary
The facility failed to ensure that expired medications were not available for resident use on two medication carts. During observation, an insulin pen prescribed for one resident was found in a medication cart with an opened date that indicated it was expired, as it had been opened more than 28 days prior. The LPN present confirmed that the insulin pen was expired and still available for use. Additionally, another insulin pen for a different resident was found in a separate medication cart without any label indicating the date it was opened. The LPN interviewed stated that without the opened date, it was not possible to determine if the medication was expired, and acknowledged that the pen should have been discarded. These findings were based on direct observation, staff interviews, and review of relevant medication storage guidelines.
Medications Left Unattended at Bedside
Penalty
Summary
A deficiency was identified when a medication cup containing two unidentified white, round pills was observed on a resident's bedside table. The resident stated that these were her sleeping pills, which had been given to her by a nurse the previous night, but she chose not to take them and left them on the table. Facility policy specifies that nurses should not leave residents with medications in a medication cup. The Assistant Director of Nursing confirmed that medications should not have been left unattended at the resident's bedside.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified that the facility failed to serve food at an acceptable temperature to residents. Multiple residents reported that their food was consistently cold when served, both in their rooms and in common areas. Observations confirmed that food trays were placed on top of insulated tray carts rather than inside them during transport, which compromised the ability of the carts to maintain food temperature. On two separate occasions, surveyors collected trays that had been transported in this manner and found the food to be lukewarm or at room temperature. Temperature checks conducted by the dietary technician and surveyor revealed that food items such as pork, lima beans, and cabbage were served at temperatures ranging from 78 to 91 degrees Fahrenheit, which is below the standard for hot food service. Both the surveyor and the dietary technician confirmed through sampling that the food was cold. Interviews with staff and residents consistently indicated awareness of the issue, with staff acknowledging that the food temperatures were not acceptable.
Nonfunctional Call Bell System Leaves Residents Without Means to Request Assistance
Penalty
Summary
A deficiency was identified when it was observed that the call bell system in the bathroom and bathing area for two residents was not functional. The call light above their room door remained illuminated, indicating a malfunction. Staff interviews confirmed that the call bell had been broken since a specific date and that the issue persisted over the weekend. Both residents reported that they were unable to use the call bell to request assistance and had to wait for staff to enter their room during routine rounds. Further interviews revealed that staff were aware of the malfunction but did not notify the facility administrator. The administrator confirmed that he was not informed about the broken call bell and could not provide evidence to dispute the deficiency. The lack of a working call system left the residents without a means to call for help in their bathroom and bathing areas for several days.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several observations. On March 11, 2025, strong unpleasant odors of urine were detected throughout Hall A, and a combination of trash and urine odors were present in Hall B. Additionally, a resident's room was found to have debris, including a container, napkins, mints, two plastic bags, and chipped paint on the floor near the bed. Furthermore, the resident's wedge pillow, used for repositioning, was damaged with pieces of foam missing. In an interview conducted on March 13, 2025, the facility's administrator acknowledged the presence of trash on the resident's floor and confirmed that such conditions were unacceptable.
Failure in Wound Care and Heel Protector Application
Penalty
Summary
The facility failed to ensure proper wound care and prevention of pressure ulcers for a resident with multiple stage 3 pressure injuries. A Certified Nursing Assistant (CNA) removed the resident's wound dressings during incontinence care but did not notify the nurse, leaving the wounds exposed. The resident's electronic medical record indicated orders for specific wound care, including cleansing and dressing changes every hour as needed for soilage and dislodgement. However, the CNA's failure to communicate the removal of dressings resulted in the resident's wounds being left uncovered and exposed to potential contamination. Additionally, the facility did not ensure the correct application of a heel protector as ordered by the physician. The resident was observed without a heel protector on the left heel, as required, and instead had it incorrectly placed on the right heel. This oversight was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the error. The resident's medical history included conditions such as morbid obesity, muscle weakness, and reduced mobility, which increased the risk of pressure ulcer development, making adherence to care protocols critical.
Failure to Provide Toenail Care for Resident with Peripheral Vascular Disease
Penalty
Summary
The facility failed to ensure that a resident diagnosed with peripheral vascular disease received appropriate foot care, specifically toenail trimming. The resident was admitted with a condition that required careful management of blood flow to the limbs. An observation revealed that the resident's left great toe toenail was unusually long, thick, and curled backward. The resident had requested toenail care upon admission, but interviews with the Assistant Director of Nursing (ADON) and an LPN confirmed that the resident's toenails were long and thick and needed trimming. The ADON admitted that the resident was not scheduled for a podiatry appointment or consult. There was no documented evidence that the resident had seen a podiatrist prior to the survey entrance date.
Deficiencies in CNA and LPN Competencies
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) demonstrated competencies in hand hygiene, use of Enhanced Barrier Precautions (EBP), and proper showering techniques, as well as a Licensed Practical Nurse (LPN) demonstrating competency in applying a heel protector. This deficiency was observed in two residents. For Resident #1, who had multiple medical conditions including stage three pressure injuries and an indwelling urinary catheter, CNAs did not adhere to EBP by failing to wear gowns and perform hand hygiene before and after providing incontinence care. Additionally, the LPN incorrectly applied a heel protector to the wrong heel, contrary to the physician's orders. For Resident #2, who required substantial assistance with activities of daily living due to moderately impaired cognition, a CNA failed to wash the resident's buttocks during a shower. Furthermore, another CNA did not perform hand hygiene before and after providing incontinence care, and did not change gloves after removing a soiled brief. These actions were contrary to the facility's protocols and the expectations for maintaining hygiene and infection control.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents, leading to deficiencies in care. Resident #1, who had multiple medical conditions including stage three pressure injuries and an indwelling urinary catheter, required Enhanced Barrier Precautions (EBP) to prevent the spread of Multi Drug Resistant Organisms (MDRO). However, observations revealed that Certified Nursing Assistants (CNAs) did not adhere to these precautions. They failed to wear gowns, perform hand hygiene, or change gloves while providing incontinence care, and they improperly handled Resident #1's BIPAP/CPAP mask, which was left uncovered in an open drawer. Resident #2, who had moderate cognitive impairment and was incontinent of bladder and bowel, also received inadequate care. A CNA was observed performing incontinence care without performing hand hygiene before or after the procedure, and without changing gloves. This lack of adherence to infection control protocols was confirmed by the CNA during an interview. Interviews with the facility's Administrator and Director of Nursing (DON) confirmed that the CNAs did not follow the facility's policies and procedures for infection control. The Administrator and DON acknowledged that staff should have performed hand hygiene and worn gowns when required, particularly for residents on EBP. The improper storage of medical equipment and failure to follow hygiene protocols contributed to the facility's deficiency in maintaining an effective infection prevention and control program.
Deficiency in Personal Hygiene Care for a Resident
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident with moderate cognitive impairment and incontinence issues. The resident, who required substantial assistance with bathing and personal hygiene, was observed during a bathing session where the Certified Nursing Assistant (CNA) did not wash the resident's buttocks. The CNA transferred the resident to a shower chair, rinsed the front of the resident's body, and encouraged the resident to wash his own genital area. However, the CNA did not ensure that the resident's buttocks were washed, leaving them dry and uncleaned. During an interview, the CNA acknowledged that the resident's buttocks had not been washed. The facility administrator also confirmed that the resident's buttocks should have been washed during the bathing process. This oversight in personal hygiene care was identified during a survey, highlighting a deficiency in the facility's provision of activities of daily living (ADL) care for the resident.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, leading to an Immediate Jeopardy situation. A resident, who was ordered a WanderGuard transmitter due to being at risk for elopement, managed to exit the facility through an unalarmed door. The resident was found 0.4 miles away with a head injury, which resulted in a right temporal bone fracture and a right subdural hematoma. This incident highlighted the facility's failure to maintain effective elopement prevention measures. Further investigation revealed that staff members were using a secondary reset code to disable door alarms, allowing residents with WanderGuard transmitters to exit the facility without triggering an alert. This practice was contrary to the facility's policy, which required that door alarms remain active unless under direct supervision. Interviews with staff confirmed that multiple employees were using this code, which bypassed the WanderGuard system's security features, compromising resident safety. The facility's policy required staff to be trained on preventing and responding to elopement, including understanding risk factors and interventions. However, the use of the secondary reset code by unauthorized staff members indicated a lack of adherence to these protocols. The deficiency had the potential to cause more than minimal harm to residents identified as being at risk for elopement, as evidenced by the incident involving the resident who sustained serious injuries after eloping.
CNA Lacks Competency in Elopement Risk Procedure
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S7CNA, was competent in the procedure for managing residents at risk for elopement. The facility's policy, effective since July 31, 2019, mandates that all staff be trained on preventing elopement, including understanding risk factors and interventions. However, during an interview, S7CNA denied receiving training on residents at risk for elopement since December 23, 2024, despite having signed an in-service acknowledgment on December 26, 2024. S7CNA was unaware that Resident #R4, in her assigned room, was at risk for elopement, although the facility's Elopement Binder, located at the nursing station, listed both Resident #R4 and Resident #R7 as requiring WanderGuard transmitters due to their elopement risk. The Director of Nursing (DON), identified as S2DON, confirmed that nursing staff should be knowledgeable about which residents are at risk for elopement and that the facility's process involves checking binders at the nursing stations for this information. S2DON acknowledged that S7CNA should have been aware of the elopement binder as a resource. The deficiency was identified during a review of the facility's CNA staffing schedule and census, which showed that S7CNA was assigned to the room where both at-risk residents resided, yet she failed to recognize Resident #R4 as an elopement risk.
Failure to Ensure Privacy During PEG Tube Care
Penalty
Summary
The facility failed to ensure privacy for a resident during Percutaneous Endoscopic Gastrostomy (PEG) tube feeding care. The facility's policy required staff to pull a privacy screen and drape the resident during such care. However, an LPN entered the resident's room and performed PEG tube care without closing the door, leaving the resident's abdomen exposed and visible from the hallway. This incident involved a resident with a diagnosis of mild intellectual disability. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that the door should have been closed to maintain the resident's privacy.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
The facility failed to ensure that staff adhered to the Enhanced Barrier Precautions (EBP) policy during the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The facility's policy, dated April 1, 2024, required staff to wear a gown when performing high-contact activities, such as feeding device care, for residents with indwelling medical devices. Despite this policy, an LPN was observed performing PEG tube care for a resident without wearing a gown, which included air bolus placement check, residual check, and free water flush. The resident involved had a diagnosis of age-related cognitive decline, moderate protein-calorie malnutrition, and a gastrostomy. The resident's physician orders from August 2024 specified the use of EBP, requiring staff to wear a gown and gloves during high-contact care activities. Interviews with the LPN, the Assistant Director of Nursing, and the Administrator confirmed that a gown should have been worn during the PEG tube care for the resident on EBP, indicating a lapse in following the established infection prevention and control protocols.
Water Leakage from Shower Room A into Hallway
Penalty
Summary
The facility failed to maintain a safe and clean environment as evidenced by water leaking from Shower Room A into the hallway. Observations on August 27, 2024, at various times revealed a pool of water present in the hallway outside Shower Room A's doorway. Interviews with staff, including the Staff Developer, Maintenance personnel, and the Assistant Director of Nursing, confirmed the presence of water in the hallway and identified the cause as an uneven floor in Shower Room A. The uneven floor allowed water to pool in low areas and drain into the hallway. The Administrator acknowledged awareness of the incident.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adhere to its policy of completing a Braden skin risk assessment upon re-admission for a resident who had multiple hospital stays. Despite the policy requiring assessments upon re-admission, the assessments were not completed on two separate occasions. This oversight was confirmed by both the Assistant Director of Nursing and the Corporate Nurse, who acknowledged that the assessments should have been conducted. Additionally, the facility did not accurately document the status of a resident's pressure ulcer. The resident had a stage III pressure ulcer to the sacral area, but the wound was inconsistently documented as an irritation/excoriation in the Wound Assessment Reports. This inconsistency in documentation was acknowledged by the Corporate Nurse, who confirmed that the wound should have been documented as a new pressure ulcer when its status changed. Furthermore, the facility failed to implement pressure ulcer prevention and treatment interventions for another resident. Despite the care plan indicating the need to turn the resident every two hours and use heel protectors, observations revealed that these interventions were not consistently carried out. Staff interviews confirmed the lack of adherence to the care plan, with staff unaware of the need for heel protectors and failing to turn the resident as required.
Inaccurate Care Plan Revision for Pressure Ulcer
Penalty
Summary
The facility failed to accurately revise a care plan addressing a resident's skin condition. Resident #62 had a care plan developed for impaired skin integrity due to irritation/excoriation in the sacral area on 06/16/2024. However, the care plan was inaccurately revised on 07/15/2024 to indicate a stage III pressure ulcer, despite nursing notes from 07/02/2024 already documenting the presence of a stage III pressure ulcer with slough in the same area. This discrepancy was confirmed by S2Corporate Nurse, who acknowledged that the care plan did not accurately reflect the resident's skin condition.
Expired and Discontinued Medication Found in Use
Penalty
Summary
The facility failed to ensure that discontinued and expired medications were properly stored and not available for resident use. During an observation of medication carts, it was found that a blister packet of Norco 5-325 mg tablets, which had been discontinued for a resident, was still present in Med Cart a. The medication had expired on 06/06/2024, yet five tablets remained available for use. This was in violation of the facility's policy on the disposal and destruction of medications, which requires that discontinued controlled medications be removed from the medication cart and stored securely until destroyed. Interviews with facility staff, including an LPN, the Assistant Director of Nursing, the Director of Nursing, and the Administrator, confirmed the presence of the expired and discontinued Norco tablets in Med Cart a. Each staff member acknowledged that the medication should not have been available for use and should have been removed following the discontinuation order. The oversight was identified as a failure to adhere to the facility's established procedures for handling discontinued and expired medications.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for self-administration of medications, as required by their policy. Resident #122, with a Brief Interview for Mental Status score indicating moderately impaired cognition, was observed with a bottle of Nystatin Topical Powder on the bedside table. There was no documented evidence that Resident #122 was assessed or care planned for self-administration of medication. Interviews with the LPN, ADON, and DON confirmed that Resident #122 was not assessed for self-administration and should not have had medications at the bedside. Similarly, Resident #189, also with a moderately impaired cognition score, was observed with multiple bottles of Nystatin Topical Powder and a tube of Ammonium Lactate 12% lotion on the bedside table. The facility did not have documented evidence of an assessment or care plan for Resident #189 to self-administer medication. Interviews with the LPN, ADON, and DON confirmed that Resident #189 was not assessed for self-administration and should not have had medications at the bedside.
Deficiency in Wheelchair Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain a resident's wheelchair in good repair and sanitary condition, impacting one of the three residents reviewed for environmental conditions. Observations over three consecutive days revealed that the resident's wheelchair had a blackish-brownish substance covering both brake levers, a missing right arm pad, and a torn left arm pad with exposed foam. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the poor condition of the wheelchair, with the Director indicating that the wheelchair should be replaced.
Failure to Document and Provide PICC Site Care
Penalty
Summary
The facility failed to provide proper site care for a peripherally inserted central catheter (PICC) for a resident receiving intravenous medications. The resident, admitted for rehabilitation following knee surgery, reported that the PICC site was not cleaned or the bandage changed during their stay from early April to early May 2024. Record reviews revealed no documented evidence of PICC site care during this period. Interviews with the Director of Nursing and treatment nurses confirmed the absence of documentation and inability to recall if the care was performed. The administrator also acknowledged the lack of documentation for the PICC site care during the resident's stay.
Failure to Complete Accurate PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with Major Depressive Disorder and Bipolar Disorder. The resident, who was admitted with these diagnoses, was taking antidepressants daily and had a history of mental health treatment. Despite these indicators, the Level I PASARR documentation did not reflect the resident's mental illnesses, and it was neither signed nor dated by a physician. Furthermore, the facility did not initiate a referral for a Level II PASARR evaluation, which is required for residents with such diagnoses. Interviews with facility staff revealed a lack of awareness and follow-through regarding the PASARR process. The social services staff member admitted uncertainty about whether a Level II PASARR was completed and acknowledged that a referral should have been made based on the resident's mental health diagnoses and assessments. The facility administrator confirmed the inaccuracies in the Level I PASARR and the omission of a necessary Level II referral, highlighting a significant oversight in the facility's compliance with PASARR requirements.
Failure to Maintain Proper Food Temperature
Penalty
Summary
The facility failed to maintain food on the steam table at the required temperature of at least 135 degrees Fahrenheit, as per the Centers for Medicare and Medicaid Services guidelines. During an observation, it was noted that various foods, including hamburger, rice, mashed potatoes, and pureed meat, were being held on the steam table for lunch. The temperature of the pureed sweet potatoes was checked by a cook and found to be 130 degrees Fahrenheit, which is below the required temperature. Interviews with the cook and the dietary supervisor confirmed that the steam table should maintain food at a temperature no lower than 135 degrees Fahrenheit. The administrator also acknowledged that the food temperature should be at least 135 degrees Fahrenheit.
Late Transmission of Resident Assessment Data
Penalty
Summary
The facility failed to transmit a resident's assessment data within the required timeframe, resulting in a deficiency. Specifically, the discharge assessment for Resident #105 was completed on February 21, 2024, but was not transmitted by the required date of March 6, 2024, as mandated by the Centers for Medicare and Medicaid Services (CMS). The assessment was signed by the Director of Nursing on February 23, 2024. However, a review conducted on July 23, 2024, revealed that the assessment had not been transmitted within the 14-day window. The facility's Final Validation Report on July 24, 2024, confirmed that the Minimum Data Set (MDS) for Resident #105 was accepted with an error message indicating late submission. During an interview on July 24, 2024, the MDS Nurse explained that an error in entering the Unit Certification or Licensure Designation in Section A0410 of the MDS caused the delay in transmission. This error led to the discharge MDS being submitted late, beyond the required deadline.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's skin condition. Specifically, Resident #62 had a stage III pressure ulcer with slough to the sacral area as documented in the wound assessment nursing notes dated 07/02/2024. However, the MDS with an Assessment Reference Date (ARD) of 07/07/2024 inaccurately indicated that Resident #62 had no unhealed pressure ulcers. This discrepancy was confirmed during an interview with the S2Corporate Nurse, who acknowledged that the MDS did not accurately reflect the resident's skin condition at the time of the assessment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 138 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kenner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waldon Health Care Center | 2 mi | ★★★★★ | 6 | 0 |
| Metairie Health Care Center | 2.8 mi | ★★★★★ | 12 | 0 |
| East Jefferson General Hospital - Snf | 4.6 mi | ★★★★★ | 3 | 0 |
| Colonial Oaks Living Center | 4.7 mi | ★★★★★ | 6 | 0 |
| St Anthony Community Care Center | 4.9 mi | ★★★★★ | 9 | 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.