Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Matthews Memorial Health Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure call lights were accessible and appropriate for several residents, including one with hemiplegia, aphasia, functional quadriplegia, and severe cognitive impairment who could not operate a standard call bell and did not have an adapted device in place. Observations on multiple occasions showed call lights wrapped around bed rails, wedged between the mattress and rail, lying on the floor at the foot of the bed, placed on top of a mini fridge, or hanging on the wall, all out of residents’ reach. Staff, including CNAs, LPNs, the DON, and a corporate RN, acknowledged that call lights were not within reach despite care plans identifying fall risk and specifying that call lights should be kept within reach.
Two residents with existing pressure ulcers and high risk for skin breakdown did not receive ordered pressure-relief interventions and scheduled repositioning. One resident with multiple comorbidities and a Stage 2 heel ulcer had a care plan and posted signage requiring heel protectors, yet surveyors repeatedly observed the resident in bed or in a specialized wheelchair with heels on the mattress and the heel protectors stored on top of a closet; a family member reported never seeing them applied, and nursing staff acknowledged they should have been in use. Another resident with paraplegia, bilateral above-knee amputations, and Stage 4 buttock ulcers was care planned for a q2h turn schedule with wedges, but was repeatedly observed lying on his back with no supportive equipment while the wedges remained unused in a box; the resident stated staff did not turn or offer to turn him, and the assigned CNA and DON later acknowledged that q2h turning should have been provided but was not.
The facility failed to refer two residents with mental illness for PASRR Level II review. One resident was admitted with depression, anxiety, and later Delusional Disorder, and the other was admitted with Major Depression Disorder along with multiple medical diagnoses. PASRR Level I reviews indicated no mental illness for both residents, but staff confirmed neither resident was referred for the required Level II review.
Failure to follow care plans for two residents: one resident with pressure ulcers, moderate cognitive impairment, and a midline IV did not have EBP signage or PPE at the room entrance despite the care plan, and another resident identified as an unsafe smoker was observed smoking with staff present but without the required fire-resistant smoking apron.
Failure to Provide Needed Personal Hygiene Care: Two residents who needed ADL assistance did not receive required personal hygiene services. One resident with intact cognition had long facial hair and jagged fingernails, and staff acknowledged the grooming needs. Another resident with dementia and dependence for personal hygiene had matted hair that staff observed over time; a CNA said the issue had been present for months and had been reported to an LPN, who later confirmed the matted hair.
Failure to perform hand hygiene during pressure ulcer care. A resident with a sacral pressure ulcer and vascular dementia had wound care ordered for daily cleansing, skin prep, calcium alginate, and a dry dressing. During observed wound care, an RN cleaned the wound, reached over a clean field with soiled gloves, and repeatedly continued care without removing gloves or sanitizing hands; the RN confirmed this during interview.
Failure to monitor nutritional intake and weight loss: A resident with severe cognitive impairment, DM II, seizures, and a brain neoplasm had significant unintentional weight loss while receiving a house supplement for weight gain. Meal intake was not consistently documented, supplement intake percentages were not recorded as ordered, and staff confirmed the required intake documentation was not consistently completed.
The facility failed to maintain infection control practices during resident care and laundry handling. A resident with pressure ulcers, a wound-vac, and an IV was on EBP, but a CNA provided incontinent care wearing gloves only and no gown. Staff also failed to perform hand hygiene while feeding two residents, carried soiled linens by hand instead of using the proper barrel, and used the same cart for both soiled and clean resident clothing.
Missing Resident Personal Belongings: The facility failed to protect the personal belongings of two residents, both of whom had intact cognition and required assistance with ADLs. One resident reported a missing blanket and two shirts, and another reported missing pants; both had raised the issue in Resident Council, and the ADM confirmed the complaints had not been addressed despite staff awareness.
The facility did not ensure timely physician notification for an antibiotic order following a consultant's recommendation for a resident with a tooth abscess, resulting in a delay of several days before treatment was initiated. Additionally, another resident with multiple stage 4 pressure ulcers did not receive wound care as ordered on several occasions, with gaps in documentation and responsibility among nursing staff.
A resident with severe malnutrition and quadriplegia fell while attempting to get up from bed, resulting in acute right pubic fractures. The facility failed to immediately inform the resident's representative and consult the physician, with the representative only learning of the fall during a visit. The responsible LPN was suspended for not notifying the representative promptly.
The facility failed to notify physicians of elevated blood sugar levels for two residents with diabetes, despite physician orders requiring such notifications. One resident had CBG levels exceeding 300 on multiple occasions, while another had levels over 400, with no documentation of physician notification. The Corporate RN confirmed the oversight.
Two residents in a LTC facility experienced inadequate pain management. One resident with Multiple Sclerosis did not receive prescribed Oxycodone despite reporting severe pain, while another resident with Type 2 Diabetes reported high pain levels without receiving any medication. Staff failed to administer pain relief or contact a physician, violating care standards.
The facility failed to ensure accurate reconciliation of controlled medications at each shift change. Despite the policy requiring a controlled drug count by both outgoing and incoming nurses, an LPN confirmed she did not reconcile narcotics with the off-going nurse. Another LPN also failed to reconcile medications with the incoming nurse. The DON confirmed the requirement for controlled substances to be counted at the beginning and end of each shift.
The facility failed to provide snacks and timely meals according to residents' needs and preferences. Observations and interviews revealed that snacks were not readily available, and residents had to request them from the nurse's station. Some residents did not receive meals in a timely manner, with one resident not receiving breakfast until late morning after being admitted the previous day. The facility's meal service times exceeded 14 hours from dinner to breakfast, and only residents with a doctor's order received snacks at specific times.
Two residents with cognitive impairments were not provided with necessary shaving services, as required by the facility's policy. One resident, dependent on staff for personal hygiene, was observed with facial hair, and the CNA Task Schedule showed inadequate documentation of care. Another resident, requiring substantial assistance, was also observed with facial hair and expressed that the usual caregiver was unavailable. The ADON confirmed both residents needed assistance with shaving, which they did not receive.
A facility failed to provide necessary treatment and services for a resident with stage 4 pressure ulcers, leading to inadequate wound assessments and care. The resident, who required assistance with mobility, did not receive consistent turning and repositioning as per their care plan. The facility lacked a wound care nurse, resulting in missing wound assessments and unawareness of the current status of the resident's wounds.
A facility failed to provide proper respiratory care for a resident with chronic respiratory failure. The resident's nebulizer mask and oxygen tubing were found uncovered and undated, contrary to professional standards. The DON confirmed that the equipment should be covered and changed every seven days.
A resident fell and sustained a femur fracture after being placed in a shower chair without a safety belt by a CNA. The facility's policy required safety belts on shower chairs, but this was not followed. Multiple CNAs were aware of the missing safety belts but did not report the issue, and the maintenance logs had no records of the problem. The resident required emergency surgery following the fall.
A resident experienced a fall and was not immediately assessed with no injury noted. The facility failed to promptly notify the physician and the resident's representative. Later, the resident was found to have swelling and bruising, and an X-ray revealed an acute fracture. This indicates a failure to follow the facility's policy on immediate notification.
A facility failed to promptly resolve a grievance filed by a resident's RP regarding delayed notification of a fall. The RP was informed of the fall a day later, and the grievance was not resolved within the required timeframe, contrary to the facility's policy.
Failure to Ensure Accessible and Appropriate Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs and ensure call lights were accessible and appropriate for residents’ functional abilities. One resident with hemiplegia, aphasia, dysphagia, functional quadriplegia, and severe cognitive impairment was care planned as dependent for mobility and ADLs, with an intervention for the call bell to be within reach due to a history of falls and impaired mobility. Multiple observations on different days showed this resident in bed with the traditional call bell cord wrapped on the right side rail and the button positioned between the mattress and side rail, not within reach. When CNAs placed the call bell in the resident’s left hand and verbally prompted her to use it, she repeatedly shook the device and was unable to press the button to trigger assistance. The DON acknowledged the resident’s paralysis on one side, stated she believed the resident could use a padded/tap-activated call bell, and confirmed that the resident did not have a call bell in place that accommodated her functional needs at that time. Additional deficiencies were identified for four other residents whose call lights were not within reach despite care plans indicating they were at risk for falls with interventions including keeping the call light within reach. One resident, admitted with dementia, depression, psychosis, and other conditions, required assistance with toileting, bathing, dressing, and bed mobility; observations showed this resident asleep in bed with the call light lying on the floor at the foot of the bed on two occasions, not within reach. A CNA confirmed the call light was not within reach and explained that the distance from the wall unit to the head of the bed prevented proper placement without a clamp, and the DON confirmed the call light should have been within reach. Another resident with hemiplegia, aphasia, depression, anxiety, and dependence for transfers and toileting was observed lying in bed with the call light placed on top of a mini fridge at the foot of the bed on two separate observations; the resident stated he could not reach his call light and relied on his roommate to press it for assistance, and an LPN confirmed the call light was not within reach. Further observations showed a resident with diabetes, dementia with mood disturbance, heart failure, CKD, and mobility needs requiring a cane and assistance with ADLs sitting on the side of the bed while the call light was on the opposite side and not within reach. Two LPNs confirmed that this resident’s call light was not within reach and attributed the problem to the bed being too far from the call light. Another resident with seizures, CHF, CKD, generalized muscle weakness, debility, and an above-knee amputation, who required substantial to total assistance for transfers and toileting, was observed lying in bed with the call bell hanging on the wall and not within reach. An LPN confirmed this call bell was not within reach. The DON and a corporate RN later confirmed that each resident should have a call light within reach, but at the time of surveyor observations, these residents did not have accessible or appropriately adapted call systems as required by their assessed needs and care plans.
Failure to Implement Pressure-Relief Devices and Turning Program for Two Residents With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure-relieving interventions and turning/repositioning necessary to promote healing of existing pressure ulcers and prevent further skin breakdown for two of three sampled residents. One resident, admitted with multiple comorbidities including squamous cell carcinoma of the skin, type 2 diabetes with neuropathy, peripheral arterial disease, and identified as at risk for pressure ulcers, had a documented Stage 2 pressure ulcer on the right heel. The resident’s care plan, initiated in late August 2024, included heel protectors as an intervention under a focus on safety devices and special equipment to maintain optimal functioning. Despite posted signage in the room stating the resident was to wear heel protectors, surveyor observations on multiple days and times showed the resident lying on her back in bed or sitting in a specialized wheelchair with her heels resting on the mattress and the heel protectors stored on top of the clothes closet rather than on her heels. Across several observations, the heel protectors remained unused on top of the closet while the resident’s heels were in direct contact with the mattress, and no positioning supports were in place. A family member reported never having seen the heel protectors applied to the resident. The treatment nurse confirmed the resident had a Stage 2 pressure ulcer on the right heel that had previously been a deep tissue injury and stated that pressure reduction was one of the interventions in place to promote wound healing. An LPN later confirmed that the resident’s heel protectors were on top of the closet instead of on the resident’s heels, and acknowledged that they should have been applied as part of the wound-healing interventions. The second resident involved had paraplegia, neuromuscular bladder dysfunction, bilateral above-the-knee amputations, and existing Stage 4 pressure ulcers on both buttocks, with documented wound measurements from a recent skin evaluation. This resident was dependent for bed mobility and transfers and was care planned for the facility’s turn and repositioning program, with a posted turn schedule indicating side-to-side repositioning every two hours. However, repeated observations over two days showed the resident in bed on his back with the head of the bed elevated, without any supportive positioning equipment in use, while two positioning wedges remained unused in a box in the corner of the room. The resident reported that staff did not turn or reposition him every two hours, that he did not refuse turning, and that no one had offered to reposition him that day. A CNA assigned to the resident stated she was familiar with his care needs but believed he was not on a turn schedule, admitted she had not turned or offered to turn him during her shift, and then acknowledged, upon review of the posted schedule, that she should have offered repositioning every two hours but did not. The DON also acknowledged the resident should have been turned or offered turning every two hours and was not.
Failure to Refer Residents With Mental Illness for PASRR Level II Review
Penalty
Summary
The facility failed to ensure that individuals with a mental disorder were referred for a PASRR Level II review for two sampled residents. Resident #26 was admitted with diagnoses including Major Depression Disorder and Anxiety Disorder, and a PASRR Level I completed before admission indicated no mental illness; however, the resident was not referred for a PASRR Level II review prior to admission, and after Delusional Disorder was entered on 02/09/2024, the record still did not show a Level II referral. Resident #56 was admitted with diagnoses including Cognitive Communication Deficit, Gastrostomy Status, Cerebral Infarction, Hemiplegia, Major Depression Disorder, and Epilepsy, and a PASRR Level I completed on 03/10/2022 indicated no mental illness; the record showed the resident was not referred for a PASRR Level II review prior to admission. Interviews with S4SSD and S12Admissions confirmed both residents were diagnosed with a mental illness and were not referred for a PASRR Level II review, although they should have been.
Failure to Follow Care Plans for EBP and Smoking Safety
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #57 by not carrying out Enhanced Barrier Precautions that were documented in the care plan. Resident #57 was admitted on 10/02/2024 with diagnoses including un-stageable pressure ulcer of the right heel, pressure-induced deep tissue damage of the left heel, and un-stageable pressure ulcer of the sacral region. The MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the resident required substantial to maximal assistance with toileting hygiene and had unhealed pressure ulcers. The care plan identified the resident as at risk for complications related to the heel wounds and sacral wound and included EBP initiated on 11/18/2025, but observations on 12/01/2025 and 12/02/2025 found no EBP signage or PPE at the bedroom entrance. The resident also had a midline IV in the right upper arm, and staff interviews confirmed the resident was on EBP and should have had signage and PPE on the door, but did not. The facility also failed to follow the smoking care plan for Resident #16. Resident #16 had diagnoses including nicotine dependence, major depressive disorder, and cerebral infarction, and the quarterly MDS showed a BIMS score of 11, indicating moderately intact cognition. The care plan identified the resident as an unsafe smoker and directed staff to offer a smoking apron, while the smoker's assessment stated the resident required 1:1 supervision while smoking, a fire-resistant smoking apron, and that lighters and matches be kept at the nurses station. During observation, Resident #16 was seen smoking in the smokers lounge with staff present but without wearing the required smoker's apron, and the administrator confirmed the apron should have been worn but was not.
Failure to Provide Needed Personal Hygiene Care
Penalty
Summary
The facility failed to ensure residents who were unable to complete activities of daily living received needed personal hygiene care. The report states that the facility did not ensure residents received nail care, shaving, and proper hair care as part of bathing and hygiene services, as required by its policy. The deficiency involved 2 of 4 residents reviewed for ADL care, including one resident with intact cognition who required partial/moderate assistance with personal hygiene and another resident with dementia who was dependent on staff for personal hygiene. Resident #59 was admitted with diagnoses including rhabdomyolysis and major depressive disorder, had a BIMS of 15, and required partial/moderate assistance with personal hygiene. During observation, the resident was noted to have 1/4 inch long facial hair on the chin and 1/4 inch long jagged fingernails, and stated staff did not often offer to cut her nails or facial hair. A later observation showed the same condition, and an LPN confirmed the long facial hair and jagged nails. Resident #76, admitted with diagnoses including Alzheimer’s, dementia, hypothyroidism, and anxiety disorder, required assistance with all ADLs and was dependent on staff for personal hygiene. Observations showed the resident’s hair matted into a ball on the left side of the head, and an LPN confirmed the matted hair and stated it could not be combed through. A CNA stated the hair had been matted since 10/2025 and that she had notified the LPN, while the LPN later stated she was not aware the hair was that matted and that the plan was to work it out or speak with family about a haircut.
Failure to Perform Hand Hygiene During Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident #10 received the necessary treatment and services to prevent and promote healing of a pressure ulcer by failing to perform hand hygiene during wound care. Resident #10 was admitted on 11/9/2023 with diagnoses including a sacral pressure ulcer and vascular dementia. Physician orders directed cleansing of a stage 4 sacral wound with wound cleanser, patting dry, applying skin prep to the periwound area, placing calcium alginate, and covering with a dry dressing daily until resolved. During observation of wound care on 12/03/2025 at 2:25 p.m., the nurse cleaned the sacral wound with wet gauze, discarded the gauze, reached over a clean field with soiled gloves, removed gauze from a cup, and cleansed the wound. This action was repeated four more times without removing gloves or sanitizing hands. When interviewed immediately afterward, the nurse confirmed she did not remove gloves or sanitize hands after cleaning the wound and reaching into the clean field for new gauze.
Failure to Monitor Nutritional Intake and Weight Loss
Penalty
Summary
The facility failed to implement, monitor, and modify interventions for Resident #86 to maintain acceptable nutritional status. The resident was admitted with diagnoses including seizures, DM II, and a benign brain neoplasm, and the quarterly MDS showed a BIMS score of 00 with severe cognitive impairment and substantial/maximal assistance needed for eating. The resident had orders for a house supplement 4 oz. with med pass four times daily for weight gain, and the care plan addressed unplanned weight loss related to poor food intake with interventions to observe food intake, give supplements as ordered, and alert the nurse/dietician if the resident was not consuming on a routine basis. Record review showed significant weight loss over time, including weights of 186.6 pounds, 169.2 pounds, 167.4 pounds, and 157.5 pounds, along with RD assessments documenting significant weight loss and a Weight Evaluation Form noting significant and unintentional weight loss. The nutrition task record showed meal intake was not documented on multiple days, and the MARs did not document the percentage consumed for the house supplement as ordered. Staff interviews confirmed CNAs were responsible for documenting meal intake, nurses were responsible for documenting supplement intake, and the RD confirmed the intake documentation was not consistently completed for the resident.
Infection Control Failures During Resident Care and Laundry Handling
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. One resident with a BIMS score of 8, indicating moderate cognitive impairment, had diagnoses including unstageable pressure ulcers of the right heel and sacral region, deep tissue damage of the left heel, and a wound-vac and midline IV for antibiotic treatment. The resident’s care plan identified Enhanced Barrier Precautions (EBP) as in place, but a CNA entered the resident’s room to provide incontinent care and turning while wearing gloves only and without a disposable gown. The CNA stated she was unsure how to know if a resident was on EBP, and the CNA supervisor confirmed the resident was on EBP and that the gown should have been worn. The facility also failed to maintain infection prevention practices during resident care and linen handling. A CNA was observed feeding two residents without using hand sanitizer or performing hand hygiene between direct contacts, and the CNA supervisor confirmed this did not occur. Another CNA was observed carrying soiled bedding in her hands and placing it into a yellow barrel inside a room, and staff confirmed soiled linens should have been transported in a yellow barrel. In the laundry area, a cart used to collect soiled resident clothing from rooms was also used to transport washed clothing to the dryer area and then to move dried clothing, and both laundry staff and corporate staff confirmed soiled and clean clothing should not have been transported in the same cart.
Missing Resident Personal Belongings
Penalty
Summary
The facility failed to provide a safe and homelike environment by not ensuring systems were in place to protect residents’ personal belongings, resulting in missing clothing items for two residents. Resident #34 was admitted with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia, Hypertension, Acute Kidney Failure, Metabolic Encephalopathy, and Gastro-Esophageal Reflux Disease, and her admission MDS showed a BIMS score of 15, indicating intact cognition. Resident #55 was admitted with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Hyperlipidemia, Major Depressive Disorder, and Anxiety, and her quarterly MDS showed a BIMS score of 14, also indicating intact cognition. Resident #34 reported that a blanket and two shirts had been missing since September 2025, and Resident #55 reported that two pairs of pants had been missing since October 2025. Both residents stated they had raised their concerns during Resident Council meetings and that the items had not been replaced. Resident Council minutes documented that both residents reported missing personal items during the months of September and October 2025. The Activity Director stated she informed supervisors of the appropriate departments after each Resident Council meeting, and the Administrator confirmed that staff were expected to notify her when items were missing and could not be located after searching. The Administrator also confirmed that the complaints about missing clothing items had not been addressed despite staff awareness.
Failure to Ensure Timely Physician Notification and Wound Care as Ordered
Penalty
Summary
The facility failed to provide services in accordance with professional standards of practice for two residents. For one resident with a history of gastro-esophageal reflux disease, hypertension, delusional disorder, and cellulitis, there was a delay in obtaining an antibiotic for a tooth abscess. After returning from a medical appointment with a recommendation for an antibiotic, the nurse contacted the resident's physician and left a message but did not follow up the next day. The oncoming nurse was not made aware of the situation, and the issue was not documented in the 24-hour report as required. The physician was not contacted again until several days later when the resident complained of pain and swelling, at which point an antibiotic was finally ordered. Another resident with quadriplegia, pain, hypertension, urinary tract infection, and multiple stage 4 pressure ulcers did not receive wound care as ordered on several documented dates. The treatment nurse, who worked weekdays, stated that floor nurses were responsible for treatments in her absence, and the RN supervisor was responsible on weekends. However, there was no documentation that wound care was provided on specific dates, and this was confirmed by the DON. The lack of timely follow-up and communication among staff led to missed treatments and a delay in physician notification for necessary care.
Failure to Notify Resident's Representative After Fall
Penalty
Summary
The facility failed to immediately inform a resident's representative and consult the resident's physician following an accident involving the resident that resulted in injury and had the potential for requiring physician intervention. The incident involved a resident who was found on the floor after attempting to get up from bed, reporting no pain or head injury at the time. Despite the resident's fall, the facility did not notify the resident's representative immediately, and the representative only learned of the incident during a visit later that day. The resident, who had a history of severe protein-calorie malnutrition and functional quadriplegia, was admitted to the facility with previous pelvis fractures. After the fall, the resident's family requested an x-ray, which revealed acute right pubic fractures. The facility's failure to notify the resident's representative promptly was acknowledged by the Director of Nursing and Corporate Nurse, and the responsible LPN was suspended following the event.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two residents. Resident #27, who was admitted with Type 2 Diabetes Mellitus with Neuropathy and long-term use of insulin, had physician orders for insulin administration and capillary blood glucose (CBG) monitoring. The orders specified that the physician should be notified if CBG levels were less than 60 or greater than 300. However, the resident's CBG levels exceeded 300 on multiple occasions in September 2024, and there was no documentation that the physician was notified of these elevated levels. Similarly, Resident #64, who was admitted with Type 2 Diabetes Mellitus and other conditions, had physician orders for insulin administration and CBG monitoring. The orders required notification of the physician if CBG levels were greater than 400. Despite this, the resident's CBG levels exceeded 400 on several occasions in August and September 2024, and there was no documentation that the physician was informed. Interviews with the Corporate RN confirmed the lack of documentation and acknowledged that the physician should have been notified in both cases.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident #4, who has a history of Multiple Sclerosis and Chronic Pain Syndrome, reported severe pain and did not receive her prescribed pain medication, Oxycodone, as needed. Despite calling for the nurse multiple times during the night, Resident #4 did not receive any pain relief, as confirmed by the CNA and the LPN on duty, who admitted to not attending to the resident throughout her shift. Resident #64, diagnosed with Type 2 Diabetes Mellitus and other conditions, consistently reported high pain levels without receiving any pain medication. The resident's MAR documented pain levels ranging from 6 to 7, yet no pain relief was administered. The LPN responsible for Resident #64 acknowledged the resident's pain but failed to contact the physician to address the lack of pain medication orders. The facility's policy on pain management emphasizes the importance of treating pain and revising care plans as necessary. However, both residents experienced unrelieved pain due to the staff's failure to administer medication or seek medical advice, resulting in a breach of professional standards and the residents' care plans.
Failure to Reconcile Controlled Medications at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate reconciliation of controlled medications for each resident. This deficiency occurred because the facility did not conduct a physical inventory of controlled medications at each shift change, as required by their policy. The policy, revised in November 2017, mandates that a controlled drug count be performed at the beginning of each shift by both the outgoing and incoming medication nurses. However, on September 8, 2024, an LPN who reported to work at 7:00 a.m. confirmed that she did not reconcile narcotics with the off-going nurse or any other nurse, despite acknowledging that she should have. Similarly, another LPN who worked the previous shift from 11:00 p.m. to 7:00 a.m. also confirmed that she did not reconcile medications with the incoming nurse. The Director of Nursing (DON) confirmed that all controlled substances should be counted at the beginning and end of each shift by both the on-coming and off-going nurses.
Failure to Provide Snacks and Timely Meals
Penalty
Summary
The facility failed to ensure that snacks were served at times in accordance with residents' needs, preferences, and requests. Observations and interviews revealed that snacks were not available at all times, and residents had to request them from the nurse's station. Residents reported that snacks were labeled with specific names, and those without a label did not receive any. Additionally, the facility did not provide snacks for residents outside of scheduled meal service times, and some residents reported not receiving meals in a timely manner. For instance, one resident did not receive breakfast until 11:30 a.m. after being admitted the previous day and had not eaten since the previous evening. Interviews with the Director of Nursing (DON) and the Dietary Manager revealed that only residents with a doctor's order received snacks at specific times, and bedtime snacks were left at the nurse's station. This practice excluded residents who could not go to the nurse's station to request a snack. The facility's meal service times were also noted to be longer than 14 hours from dinner to breakfast, which contributed to residents not receiving adequate nourishment. The Administrator and Dietary Manager acknowledged these issues, indicating awareness of the deficiencies in meal and snack distribution.
Failure to Provide Necessary Shaving Services for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to perform Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents were not provided with shaving services as required. Resident #2, who has severe cognitive impairment and is dependent on staff for personal hygiene, was observed with facial hair on multiple occasions, indicating a lack of shaving. The CNA Task Schedule for September 2024 showed no documentation of a bath for Resident #2, and personal hygiene was only recorded on two specific dates. Resident #82, who has moderate cognitive impairment and requires substantial assistance for bathing, was also observed with facial hair. The resident expressed that someone usually shaved him, but the person was not available. Both residents were confirmed by the Assistant Director of Nursing (ADON) to need assistance with shaving, which they did not receive. These observations and interviews highlight the facility's failure to adhere to its policy of providing necessary personal hygiene care, including shaving, for residents who are unable to perform these tasks themselves.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice, to promote healing and prevent infection. The resident, who was cognitively intact and required assistance with mobility, had multiple stage 4 pressure ulcers on the sacral region and buttocks. Despite having physician's orders for specific wound care treatments, the facility did not ensure that the resident's wounds were accurately assessed and documented on a weekly basis as required by their policy. The Director of Nursing (DON) confirmed that there were missing wound assessments for the resident's pressure ulcers over a specified period, and acknowledged that the assessments should have been conducted weekly by a nurse. Additionally, the facility failed to implement a consistent turning and repositioning program for the resident, which was part of the care plan to prevent further skin breakdown. During an observation, the resident reported that staff did not turn or reposition him every two hours as required, and that his positioning wedge was not in use. The DON was unaware of the current status of the resident's sacral wound and why treatment orders for a stage 4 pressure ulcer were still in place. The facility had not had a wound care nurse since June 2024, which contributed to the lack of proper wound assessments and care.
Failure to Properly Label and Store Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with a history of hypertensive heart failure, gastrostomy status, and chronic respiratory failure with hypoxia. The resident's care plan indicated a risk for shortness of breath and required oxygen as ordered. During observations, the resident's nebulizer mask and oxygen tubing were found uncovered and undated, lying on the over-bed table and oxygen concentrator, respectively. Interviews confirmed that the oxygen equipment was not properly labeled or stored, and the Director of Nursing acknowledged that the equipment should be covered and changed out every seven days.
Failure to Secure Resident in Shower Chair Leads to Injury
Penalty
Summary
The facility failed to ensure that Resident #3 was safely secured in a shower chair prior to showering, resulting in a fall and subsequent injury. On 04/19/2024, Resident #3, who required substantial assistance with bathing and transfers, was placed in a shower chair without a safety belt by S5 CNA. During the shower, Resident #3 fell from the chair to the floor, sustaining a displaced left intertrochanteric femur fracture, which required surgical intervention. The facility's policy mandated the use of safety belts on shower chairs, but this was not adhered to in this instance. Interviews with multiple CNAs revealed that the shower chairs had been without safety belts for an unspecified period, and the issue had not been reported to maintenance. S5 CNA admitted to using the shower chair without a safety belt on multiple occasions, assuming the issue had already been reported. Other CNAs confirmed the absence of safety belts on the shower chairs and acknowledged that they were aware of the requirement for safety belts but did not log the issue in the maintenance log. The maintenance supervisor confirmed that there were no records in the maintenance logs regarding the missing safety belts on the shower chairs. The administrator acknowledged that the shower chair used for Resident #3 did not have a safety belt and confirmed that all shower chairs should have safety belts attached for resident safety. This deficiency resulted in actual harm to Resident #3, who required emergency medical treatment and surgery following the fall.
Failure to Immediately Notify Physician and Resident's Representative After Fall
Penalty
Summary
The facility failed to immediately consult with the physician and notify the resident's representative when a resident experienced a fall. On 04/05/2024, Resident #1 slid out of bed at approximately 9:12 p.m. and was assessed with no injury noted. The nurse's progress notes documented that the resident was assisted back to bed and instructed to use the call light, but there was no documentation that the resident's physician or representative had been notified of the fall. The incident report indicated that the physician was contacted at 9:15 p.m., but the time of contact for the resident's representative was not documented. Later, on the same day at 9:19 p.m., while assisting Resident #1 to undress, a CNA noted swelling and bruising on the resident's right upper arm, and the resident complained of pain in the right ribcage and back. The physician was notified, and an order for a stat X-ray was given. The resident's representative was also notified at this time. The X-ray results revealed an acute fracture of the right 6th rib. This sequence of events indicates a failure to promptly notify the physician and the resident's representative immediately after the initial fall, as required by the facility's policy.
Failure to Promptly Resolve Grievance Regarding Resident Fall Notification
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance filed by a resident's Responsible Party (RP). The grievance was related to the RP not being notified of a fall that the resident sustained. The facility's policy requires that grievances be resolved promptly and that findings and recommendations be discussed with the complainant within five workdays. However, the RP was not informed of the fall until the day after it occurred, and the grievance was not resolved within the required timeframe. The incident involved a resident who fell on the night of April 5, 2024. The RP was not notified of the fall until the following night, despite the facility's policy requiring immediate notification. The Director of Nursing (DON) registered the grievance electronically on April 8, 2024, but the complaint had not been completed by the time of the survey. Interviews with the involved staff confirmed the delay in notification and the failure to resolve the grievance promptly.
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.
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What surveyors actually found near you
We read the 124 citations issued within 25 miles in the last 12 months — including the 5 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alexandria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Nursing At St. Christina | 2 mi | ★★★★★ | 23 | 0 |
| The Summit | 2.5 mi | ★★★★★ | 10 | 0 |
| Lexington House | 2.8 mi | ★★★★★ | 3 | 0 |
| Hilltop Nursing & Rehabilitation Center | 3.1 mi | ★★★★★ | 16 | 2 |
| Regency House Of Alexandria | 3.5 mi | ★★★★★ | 16 | 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.