Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Victoria Haven Nursing Facility during CMS and state inspections, most recent first.
Failure to Maintain Required RN Coverage: The facility did not have an RN on duty for at least 8 consecutive hours a day, 7 days a week when no staffing waivers were in place. Record review and interviews showed multiple days with no RN hours, a PBJ staffing trigger for no RN hours, and staff stated they were unaware of the requirement or did not arrange RN coverage when none was scheduled.
The facility failed to complete annual performance evaluations for five CNAs who had been employed for more than 12 months and did not provide regular in-service education based on those reviews. Record review showed no 2025 performance evaluations in the personnel files, and the DON stated he had not completed annual reviews or related in-servicing since working at the facility and that no process was currently in place.
Failure to Implement a Data-Driven QAPI Program: The facility failed to develop, implement, and maintain a QAPI program focused on resident outcomes, quality of care, and quality of life. Although the policy called for monitoring clinical measures, resident/family concerns, and ongoing PIPs, quarterly QAPI agendas showed no PIPs identified. The Administrator could not provide documentation for a claimed missing-clothing PIP, and the DON stated he had not completed any PIPs or clinical audits.
The facility failed to maintain an effective infection prevention and control program during a respiratory illness outbreak. Residents had ongoing cough, congestion, fever, and flu-like symptoms, yet no TBP signs were posted and surveillance did not track symptomatic residents; one resident had been hospitalized and diagnosed with influenza. The facility also failed to follow EBP for a resident with a Foley catheter and PICC line, and a nurse was observed repositioning the resident without gown or gloves. In addition, a nurse picked up a dropped pill with bare hands and administered it, and a shared glucometer was returned to the med cart without cleaning or disinfection.
Failure to administer medications as ordered for two residents. An LPN prepared Juven and Miralax in 5-ounce cups even though the orders required larger specified amounts of fluid. The LPN said she believed the cups were 8-ounce cups, and the DON stated medications must be given per physician orders and the cup size should have been checked.
Failure to Carry Over and Update Wound Treatment Orders: A resident with bilateral lower extremity wounds did not have wound tx carried over into the new eMAR/eTAR after a system change, and the chart lacked the ordered wound care for several weeks. Later, after a Wound NP changed the tx plan to NS cleanse, Xeroform, ABD pad, rolled gauze, and ace wraps, the updated orders were still not entered. The DON and an RN said the orders were missed during the EMR transition and the updated recommendations were not checked.
Pharmacy MRR recommendations were not reviewed or documented timely for two residents. One resident with hyperlipidemia had a pharmacist recommendation about continuing a statin and possibly adding CoQ10, but the chart lacked the pharmacist’s recommendation and the physician response. Another resident with anxiety and depression had repeated MRR recommendations for updated consents for Cymbalta, Trazodone, and Remeron, yet the chart contained outdated or incomplete consents and the DON could not locate additional signed consents.
Medication error rate exceeded 5% during an observed med pass when an LPN made three errors in 28 opportunities. A resident received the wrong dose of Allopurinol and ordered meds including Folic Acid, Vitamin D3, and Pyridoxine were omitted; the cart contained Vitamin D3 1000-unit tablets, and the DON stated meds must be given as ordered and follow the five rights.
Unlabeled Open Insulin and Tubersol Stored Improperly: Surveyors found an open multidose vial of Tubersol in the medication refrigerator and multiple opened insulin vials and pens in a med cart without resident names, dates opened, or expiration dates. The items were stored with other supplies, and staff stated they did not know which residents the insulin belonged to; the DON confirmed opened insulin and multidose vials must be labeled with the resident’s name, date opened, and expiration date.
Improper Diet and Liquid Consistencies Served: A resident with dysphagia and changing liquid orders was served the wrong food and liquid consistencies multiple times, including a whole hot dog and thin liquids despite orders for minced moist and nectar thick. Another resident on a mechanical soft diet was served a whole baked potato instead of the ordered therapeutic alternative, and a third resident ordered nectar thick liquids received Miralax mixed with unthickened water during med pass. Staff interviews confirmed the mismatches between the ordered diets and what was served.
Kitchen sanitation and food safety lapses: Surveyors observed residents served poached eggs made with shell eggs that were not labeled as pasteurized, despite the menu including an undercooked egg item. They also found multiple refrigerated ready-to-eat foods without open dates, including cheeses, thickened liquids, condiments, and mint jelly with an old best-by date. In addition, the 2nd-floor kitchenette had residue on the microwave and cabinets, a spilled refrigerator drawer, and expired foods in the refrigerator.
A resident with anxiety and depression had a Psych NP recommendation to increase Cymbalta from 60 mg to 90 mg daily, but the Physician was not notified in a timely manner. The Psych NP note was received by the facility and emailed to the DON and DSS, yet the resident continued on the lower dose for 41 days before the MD reviewed and approved the increase. The DON and DSS confirmed the note had been received and stated the MD should have been informed right away.
A resident with failure to thrive and recurrent UTI symptoms had a physician order for a urinalysis and urine C&S, but the specimen was not obtained and no results were found in the record. The DON later learned the lab did not have the urine specimen and stated there was no indication the facility followed up with the lab regarding the ordered test.
Delayed Notification of Abnormal X-Ray Result: A resident with worsening bilateral heel DTIs had heel X-rays ordered after concern for osteomyelitis. The radiology report showed right heel osteomyelitis, but the ordering MD was not informed right away; facility records and staff interviews indicated the result was not reviewed with the physician until several days later, and nursing notes did not document the X-ray or its findings.
Failure to complete hospice referral: A resident with failure to thrive and a lung mass had a physician order for hospice eval and treatment if indicated, but the record showed no completed referral. The DON was unsure whether the referral had been done, the SW was unaware of the order, and the hospice agency reported the family had requested services earlier, with the facility not responding until 42 days later.
Failure to offer and document COVID-19 vaccine education for staff: The facility did not have documentation that a dietary aide was offered or educated about the COVID-19 vaccine. The DON reviewed the personnel file and stated he could not find evidence of the offer or education, believed only the flu vaccine was required, and said there was no process to offer and/or educate staff about the COVID-19 vaccine.
Missing CNA Annual Training Documentation: The facility failed to maintain records showing that CNA #1 completed the required 12 hours of annual training. The DON said there was no system to track or quantify CNA education hours, and the education records reviewed showed multiple in-services, including abuse/neglect, resident rights, infection control, falls prevention, and 4 hours of dementia training, but did not document 12 hours of CNA training since 2024. The Admin Assistant said the CNA received the competency fair packet but did not complete or return the tests.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to utilize the services of an RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place. Record review showed that, during the period from 7/1/25 through 9/30/25, the facility did not provide RN coverage for at least eight hours on 4 of 92 days. The Facility Assessment stated that the facility retained sufficient staffing to maintain a 24-hour licensed nurse schedule with 8 hours of RN coverage seven days a week, and the PBJ Staffing Data Report for Quarter 4: 2025 showed a one-star staffing rating triggered by four or more days within the quarter with no RN hours. Review of the as-worked nursing schedule showed no RN worked eight hours in the facility on 7/6/25, 7/13/25, 8/3/25, and 8/16/25. During interviews, the Administrator and DON stated the facility did not have any nurse staffing waivers in place. The Administrative Assistant, who was responsible for staffing and scheduling, said she was not aware the facility had triggered on the PBJ report for four or more days within the quarter with no RN and stated that if no RN or agency RN was available, she would not schedule one. The Administrator stated he knew the facility needed eight consecutive hours of RN coverage in a 24-hour period seven days a week, but said that on weekends it was not on his radar to get an RN if one was not scheduled.
Failure to Complete Annual CNA Performance Reviews and Related In-Service Training
Penalty
Summary
The facility failed to complete annual performance evaluations for five of five Certified Nursing Assistants (#1, #2, #3, #4, and #5) who had been employed for more than 12 months, and it also failed to provide regular in-service education based on the results of those reviews. Review of the five personnel files showed no indication that a performance evaluation had been completed in 2025. During an interview, the Director of Nursing stated he had been employed at the facility for just over a year and had not completed any annual performance reviews or in-servicing based on performance reviews since working there. He also stated the facility did not currently have a process for annual performance reviews and that he had been looking into doing it but had not gotten around to it.
Failure to Implement a Data-Driven QAPI Program
Penalty
Summary
The facility failed to develop, implement, and maintain a QAPI program that focused on indicators of outcomes of quality of life, quality of care, and services to residents. Review of the facility policy titled Quality Assurance Improvement Plan indicated that the nursing home had a Performance Improvement Program intended to systematically monitor, analyze, and improve performance, including clinical care measures such as falls, medication errors, pressure ulcers, incident reports, and infection reports, as well as resident and family satisfaction, concerns, and council input. The policy also stated that the Steering Committee and Administration were responsible for developing, leading, and closely monitoring the QAPI program, with ongoing committees reporting data and activities to the QAPI Steering Committee. However, review of quarterly QAPI meeting agendas for 10/22/25, 7/22/25, and 4/23/25 showed the same agenda with no Performance Improvement Plans identified. During interview, the Administrator stated that quarterly QAPI meetings reviewed quarterly events, clinical risk indicators, lab reports, and pharmacy recommendations, and said he had completed a QAPI program for missing clothing, but he could not provide documentation of the PIP, including data collection, analysis, time frame, audits, or completion. The Administrator could not provide examples of completed data-driven or ongoing PIPs with measurable goals, data, or audits. The DON stated he had not completed any PIPs and was not currently working on any PIPs for clinical care, infection control, or with other department managers, and he said he did not have any audits he had performed for the clinical nursing staff.
Infection Control Program Failures During Respiratory Outbreak and Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program during a respiratory illness outbreak. Review of the facility’s policies and CDC guidance showed that droplet precautions were to be used for residents with suspected or confirmed influenza, and the infection prevention and control program was to perform surveillance, maintain infection records, and analyze clusters or trends of infection. During the survey, no precaution signs were observed posted outside resident rooms, and the Director of Nurses stated there were no current influenza or COVID-19 cases and no mask requirements. However, multiple residents were observed or documented with respiratory symptoms, including coughing, congestion, fever, and flu-like illness, and one resident had been hospitalized with lethargy, low oxygen levels, fever, and a hospital diagnosis of influenza. The facility also failed to implement and follow Enhanced Barrier Precautions for a resident with a Foley catheter and PICC line receiving IV antibiotics. The resident was admitted with a urinary tract infection, chronic Foley catheter, and IV antibiotics through a PICC line. On one observation, two nurses were in the resident’s room repositioning the resident in bed without wearing gowns or gloves. On a later observation, an EBP sign was posted outside the room, but a nurse was again observed repositioning the resident without gloves or a gown. The DON stated that staff were educated on EBP and were notified through signs placed on resident rooms. The facility further failed to use sanitary practices during medication administration and to clean shared equipment between resident use. While preparing medications for one resident, a nurse dropped a pill onto the narcotic book on top of the medication cart, picked it up with bare hands, placed it in the medication cup, and administered it. The nurse later stated she should have discarded the medication. In a separate observation, the same nurse used a glucometer to check another resident’s blood glucose and returned the glucometer to the medication cart without cleaning or disinfecting it. The DON stated the top of the narcotic book and medication cart were not clean surfaces and that shared equipment needed to be wiped down between uses or when returned to the cart.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide medications in accordance with physician orders for two residents. For Resident #12, the physician ordered Juven, one packet mixed in 8 ounces of fluid twice daily, but during observation on 1/20/26 at 8:53 A.M., Nurse #1 prepared and administered the Juven mixed with water in a 5-ounce cup. For Resident #5, the physician ordered Miralax 17 grams mixed with 6 to 8 ounces of thickened liquids, but during observation on 1/20/26 at 9:53 A.M., Nurse #1 prepared and administered the Miralax mixed with water in a 5-ounce cup. During an interview on 1/20/26 at 4:45 P.M., Nurse #1 stated she thought the cups on the medication cart were 8-ounce cups, but they were actually 5-ounce cups. During an interview on 1/21/26 at 12:44 P.M., the DON stated medications must be administered per physician orders and said Nurse #1 should have checked the size of the cup and how much fluid it could hold.
Failure to Carry Over and Update Wound Treatment Orders
Penalty
Summary
The facility failed to provide wound care as ordered for a resident who was admitted in February 2025 and later developed wounds to both lower extremities in June 2025. The resident had been receiving wound treatments recommended by a consultant Wound NP, and the November 2025 TAR showed an order for cleansing both lower extremities with normal saline, applying calcium alginate with silver, covering with an ABD pad, rolling with gauze, and securing with ace wraps daily; this was later updated to super absorbent pads. Although the November TAR indicated treatments were provided as ordered, the December 2025 electronic MAR/TAR did not include the bilateral lower extremity wound treatment orders from 12/1/25 through 12/23/25, and the nursing progress notes did not document that wound treatments were provided during that period. The record also showed that the resident saw the consultant Wound NP on 12/3/25, and nursing notes documented refusals of wound treatment and a refusal to see the consultant Wound NP on 12/10/25, followed by another refusal of wound treatment on 12/11/25. Later, after another Wound NP visit on 1/7/26, the treatment to both legs was changed to cleanse with normal saline, apply Xeroform, secure with ABD pad, rolled gauze, and ace wraps, but the treatment orders on 1/16/26 did not include those updated recommendations. During interviews, the DON said the facility had switched from paper documentation to an electronic MAR/TAR system, and Nurse #5 said she was not sure why the wound treatments were not entered or why the updated orders were not checked.
Pharmacy MRR Recommendations Not Reviewed or Documented
Penalty
Summary
The facility failed to ensure that pharmacy recommendations from monthly medication regimen reviews were reviewed and addressed in a timely manner for two residents. One resident, admitted in July 2025 with hyperlipidemia, had a pharmacy MRR recommendation on 9/25/25 regarding whether the resident needed to continue a statin and, if so, whether Coenzyme Q10 should be added. The paper and electronic medical record did not include what the pharmacist recommended or the physician response, and the DON stated on 1/21/26 that he could not locate documentation showing the physician had reviewed the recommendation. A second resident, admitted in July 2023 with anxiety and depression, had pharmacy MRR recommendations on 6/25/25, 7/21/25, and 8/28/25 to obtain consents for Cymbalta, Trazodone, and Remeron. The record showed signed consents dated 7/6/23 for Cymbalta, 11/17/23 for Trazodone, and 7/20/23 for Remeron, while the pharmacy consultant DON Summary Report indicated the consents were incomplete, outdated, due the next month, or not found in the chart. During interviews, the DON stated he only had one recommendation dated 8/25/25 for consents, said all consents in the house were reviewed, and later said he could not find any additional consents for the resident.
Medication Error Rate Exceeded 5% During Observed Pass
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% when two of three nurses observed during a medication pass made three errors out of 28 opportunities, resulting in a 14.29% medication error rate. The errors affected one resident and involved Nurse #1 during a medication pass on 1/20/26 at 8:53 A.M., when the nurse prepared and administered Allopurinol 100 mg but omitted ordered medications for the resident, including Folic Acid 400 mcg, Vitamin D3 5000 units, and Pyridoxine 100 mg. Resident #12 had physician orders dated 1/7/26 for Folic Acid 400 mcg daily at 9:00 A.M., Vitamin D3 5000 units daily at 9:00 A.M., Allopurinol 50 mg daily at 9:00 A.M., and Pyridoxine 100 mg daily at 9:00 A.M. During the medication pass, the surveyor observed a bottle of Vitamin D3 1000-unit tablets in the medication cart. Later, Nurse #1 stated the facility did not have Vitamin D3 5000 units, Folic Acid 400 mcg, and Pyridoxine available, and she acknowledged that she overlooked the Allopurinol order and gave 100 mg instead of the ordered 50 mg. The DON stated the nurse should have given five 1000-unit tablets to equal the ordered Vitamin D3 5000 units and that medications must be administered as ordered by the physician and follow the five rights.
Unlabeled Open Insulin and Tubersol Stored Improperly
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in a safe and secure manner because multidose vials and insulin products were not labeled with a date opened and use-by date in one medication cart and one medication room. Facility policies required opened multidose containers to be dated, and insulin pens to be clearly labeled with the resident’s name or other identifying information. CDC guidance reviewed by the surveyor also stated that insulin pens should be assigned to an individual person and labeled appropriately, and that opened multidose vials should be dated and discarded within the allowed timeframe or per the manufacturer’s instructions. During observation of the medication storage room, the surveyor found one open multidose vial of Tubersol in the refrigerator with a dispense date of 1/23/25, although the manufacturer’s guideline indicated it should be used within 30 days once opened. During observation of the medication cart, the surveyor found one opened multidose vial of Lantus insulin and one opened multidose vial of Humalog insulin uncapped and stored with lancets, glucose test strips, and alcohol wipes, without a resident’s name, date opened, or expiration date. The surveyor also observed two opened Tresiba insulin pens, one opened Aspart insulin pen, two opened Lispro insulin pens, and one additional opened Lispro insulin pen with a dispense date of 10/11/25, all without a resident’s name, date opened, or expiration date. The nurse interviewed stated she did not know which residents the insulin vials and pens belonged to, and the DON stated that once insulin was opened it was only good for 28 to 30 days or per manufacturer’s guideline and should be labeled with a resident’s name, date opened, and expiration date.
Improper Diet and Liquid Consistencies Served
Penalty
Summary
The facility failed to ensure that food and liquids were prepared and served in the form ordered for residents with altered diets. Resident #34, who was admitted with diagnoses including stroke, aphasia, and dysphagia, had physician orders for a minced and moist diet with thin liquids, then a later order for minced and moist with nectar thick liquids after coughing episodes. The record and staff interviews showed that the diet change was not communicated to the kitchen by dietary slip, and the resident was served inconsistent textures and liquids on multiple occasions. On one occasion, Resident #34 was observed with a dinner tray that included a whole hot dog in a bun while the diet slip listed minced moist with thin liquids. Staff stated the resident should have received food chopped into small pieces and not a whole hot dog. On the next morning, the resident was observed at breakfast with thin liquids, including milk, coffee, and cranberry juice, even though the resident had been downgraded to nectar thick liquids the previous day. Later that morning, the resident was heard yelling, a cup of water had been thrown across the room, and the resident stated he/she choked and that it went down the wrong way. Nurse #4 reviewed the orders and acknowledged the resident had nectar thick liquid orders, while the meal ticket and tray still reflected thin liquids. Resident #25, who had dysphagia and was on a mechanical soft diet with aspiration precautions and 1:1 assist at meals, was observed at lunch with a cut-up piece of fish and a whole baked potato with skin on and sour cream in the slit. The facility’s therapeutic menu indicated that residents on mechanical soft diets should receive a baked potato mashed with a fork. Resident #5, who had dementia and severe cognitive impairment and was ordered nectar thick liquids and Miralax mixed with thickened liquids, was observed during medication administration receiving Miralax mixed with water that had not been thickened to nectar consistency. The nurse stated she did not thicken the water and thought the Miralax would act as a thickener, and the DON stated Miralax was not a thickening agent.
Kitchen sanitation and food safety lapses
Penalty
Summary
The facility failed to ensure the main kitchen used pasteurized eggs for poached eggs served to residents. On 1/15/26, surveyors observed residents eating poached eggs for breakfast, and the Fall/Winter 4-week cycle menu showed poached eggs were served on Fridays in Week 3. During observation and interview, the Food Service Director said she was using pasteurized eggs, but an open case of eggs in the refrigerator was not labeled as pasteurized. She stated she had opened the case that morning and had used those eggs for the poached eggs. Review of food delivery orders for November 2025, December 2025, and January 2026 showed raw shell eggs were ordered on multiple occasions, and the Food Service Director later said the poached eggs were the only undercooked eggs on the menu and should have been made with pasteurized eggs. The facility also failed to ensure refrigerated ready-to-eat foods were labeled with the date of opening. Surveyors observed two white plastic containers in the refrigerator with worn labels indicating fruit salad. One container held grated parmesan cheese in a plastic bag with a scoop resting in the food, and the Food Service Director said she did not know when it had been opened because it was not labeled. The second container held mozzarella cheese that was stuck together from being pushed down into the bucket. The Food Service Director said both cheeses should have been dated when opened. Surveyors also observed opened lemon and cranberry thickened liquids with manufacturer directions stating they may be kept up to seven days after opening, but the Food Service Director was not sure when they were opened because they were not labeled. Additional opened items without dates included relish, mayonnaise, Caesar salad dressing, Dijon mustard, and mint jelly; the mint jelly had changed color at the top and a best-by date of 11/22/24 was found under a sticker. The second-floor kitchenette was observed to be unclean and contained expired foods. Surveyors noted food residue on the microwave handle, small pieces of orange substance in the microwave, visible residue around cabinet handles, and a brown spilled substance in the bottom drawer of the refrigerator. The refrigerator contained homemade marmalade dated as expiring June 2025 and two yogurts with a use-by date of 1/13/26. During interview, the Food Service Director said the microwave and cabinets should be cleaned by housekeeping staff and that dietary staff should check the refrigerator daily for expired foods. Housekeeper #1 said she was not responsible for wiping down the cabinets, microwave, or refrigerator, while the Maintenance Director said housekeeping staff should be cleaning the second-floor kitchenette, including the cabinets, microwave, and refrigerator.
Delayed notification of Psych NP medication recommendation
Penalty
Summary
The facility failed to ensure staff notified the Physician in a timely manner of a consulting Psych NP’s recommendation to increase Cymbalta from 60 mg daily to 90 mg daily for Resident #27, who was admitted with diagnoses of anxiety and depression. The Psych NP’s progress note on 10/20/25 documented the resident as sad and depressed and stated, “Consider increasing to 90 mg daily,” with the note also indicating the Psych NP was in a consultative role and the recommendation was given to the facility prescriber. An email from the Psych NP to the DON and Director of SS showed the note was sent to the facility the same day. Nursing documentation did not show the Physician was notified until 12/1/25, when a note stated new Psych recommendations were reviewed with MD #1 and the MD agreed to increase Duloxetine from 60 mg to 90 mg daily and monitor moods. The MAR showed the resident continued receiving Duloxetine 60 mg daily from 10/20/25 through 11/30/25, and began receiving 90 mg daily on 12/2/25, reflecting a 41-day delay in implementing the recommendation. During interviews, the DON and Director of SS confirmed the Psych NP note had been received in the building on 10/20/25 and stated the Physician should have been notified right away; the Physician said he should be made aware of Psych NP recommendations timely.
Failure to Obtain Ordered Urinalysis and Urine Culture
Penalty
Summary
The facility failed to ensure laboratory services were provided for one resident when a urinalysis with culture and sensitivity ordered by the physician was not obtained. Resident #2, who was admitted in July 2025 with a diagnosis of failure to thrive, was seen by the physician for recurrent urinary tract infection symptoms and dysuria. On 11/11/25, the physician ordered a urinalysis and a urine culture and sensitivity, and a nursing progress note on 11/12/25 documented that the resident had been seen the previous evening with an order to collect urine and send it for culture and sensitivity. Review of the paper and electronic medical record on 1/15/26 did not show urinalysis results from November 2025. During an interview on 1/20/26, the DON stated he contacted the lab and learned they did not have the urine specimen from November 2025, and he found a lab slip indicating the specimen required recollection and a new order if results were still needed. He also stated he was not sure whether the lab had notified him that the specimen was not collected and that there was no indication the facility had followed up with the lab regarding the urinalysis.
Delayed Notification of Abnormal X-Ray Result
Penalty
Summary
The facility failed to timely notify the ordering practitioner of an abnormal X-ray for one resident with bilateral heel deep tissue pressure injuries. Resident #1 was admitted in October 2025 with deep tissue pressure injuries to both heels and was later seen by the contracted wound nurse practitioner on 12/26/25 after a recent hospitalization. The wound note stated the heels had worsened and there was concern for osteomyelitis, with a recommendation for X-rays of both heels, and an order was entered on 12/29/25. The X-ray results, dated 12/29/25 at 8:35 A.M., showed osteomyelitis of the right heel, and the report included a handwritten note that the results were reviewed with the physician on 1/6/26. Nursing progress notes from 12/29/25 through 1/6/26 did not mention the X-ray or its results. The contracted radiology service stated the images were taken on 12/29/25 at 7:30 A.M., the results were ready at 8:35 A.M., and were faxed to the facility at 8:37 A.M.; the DON later stated the physician was not aware of the results until 1/6/26. The Medical Director said he expected to be contacted right away with the X-ray results.
Failure to Complete Hospice Referral
Penalty
Summary
The facility failed to ensure that Resident #2 was referred to hospice services for an evaluation after a physician wrote an order on 12/10/25 for hospice evaluation and treatment if indicated based on the resident’s diagnoses of failure to thrive and a lung mass. The resident had been admitted in July 2025 with those diagnoses. Review of the paper and electronic medical record on 1/15/26 did not show any information that the hospice referral had been completed. During interviews, the DON said he did not know whether a hospice referral had been completed in December 2025, and the Social Worker said she had been out of the facility in December and was not aware of the nursing note or order. The Social Worker later learned that the resident’s family had called the hospice agency on 12/7/25 to request services, that the hospice agency contacted the facility on 12/10/25 for a physician order, and that the facility did not respond to the hospice agency until 42 days after the request.
Failure to Offer and Document COVID-19 Vaccine Education for Staff
Penalty
Summary
The facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per CDC recommendations for one of one employee records reviewed for immunizations. CDC guidance reviewed in the report stated that most adults ages 18 years and older, including people who live and work in LTC settings, should receive 1 dose of an updated COVID-19 vaccine, and people ages 65 years and older should receive 2 doses 6 months apart. Review of the facility assessment indicated that flu, COVID, and RSV vaccinations were offered for all residents and staff, including contracted staff if needed, and that staff were in-serviced and educated annually at a minimum on infection prevention and spread. However, Dietary Aide #1's personnel file, with a hire date of 9/26/25, did not contain documentation that he was offered and/or educated about the COVID-19 vaccine. During interview, the DON reviewed the file and stated he could not find evidence that Dietary Aide #1 had been offered or educated about the COVID-19 vaccine. He stated he believed only the influenza vaccine was required to be offered and educated to staff, was unaware that staff must be educated and offered the COVID-19 vaccine with documentation of acceptance, declination, or education, and said there was no process to offer and/or educate facility staff about the COVID-19 vaccine.
Missing CNA Annual Training Documentation
Penalty
Summary
The facility failed to maintain records showing that certified nurse aides completed at least 12 hours of mandatory annual training for continuing competency for CNA #1, out of five employee training records reviewed. The Facility Assessment stated that all employees complete training and competencies upon hire and annually thereafter, and that nurse aides are provided 12 hours of annual in-house training, including a minimum of 12 hours per year. However, the Director of Nursing said there was no system to track or quantify the number of education hours provided to CNAs in a year. Review of the Employee In-service Education Attendance Record showed multiple in-service topics, including abuse/neglect/mistreatment, resident rights, infection control, workplace violence, falls prevention, fire safety, back safety ergonomics, HIPAA, working with the elderly, and 4 hours of dementia training. Despite this, CNA #1's education records did not show that 12 hours of CNA training education had been completed and documented since 2024. The Administrative Assistant said CNA #1 had been given the competency fair education packet, but had not completed the tests or returned the packet, and she was unable to provide any additional education for CNA #1.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Norwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norwood Healthcare | 0.6 mi | ★★★★★ | 21 | 2 |
| Charlwell House Health And Rehabilitation | 0.8 mi | ★★★★★ | 0 | 0 |
| Ellis Nursing Home (the) | 1.5 mi | ★★★★★ | 2 | 0 |
| Premier Healthcare At Harrington House | 2.1 mi | ★★★★★ | 0 | 0 |
| Foremost At Sharon Llc | 3.6 mi | ★★★★★ | 4 | 0 |
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