Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waterview Lodge Llc, Rehabilitation & Healthcare during CMS and state inspections, most recent first.
Infection control practices were not followed in multiple areas. Laundry staff used chemicals that did not match the automated dispensing system and the system had not been serviced or calibrated as expected, while stained linens were observed in clean storage. A nurse did not perform hand hygiene before and after medication administration, and during breakfast service a CNA handled food, dirty dishes, and clean meal trays without washing hands. The Housekeeping Supervisor also used the same mop and bucket in a Contact Precautions room and then in an adjacent room.
Grievance forms were not readily available on Unit Two, Unit Three, or Unit Four, and residents were unable to independently file anonymous grievances. During a group meeting, most residents said they did not know what a grievance form was or where to find one, and they reported they were not offered a form when voicing concerns. The Administrator and SW stated that only Social Workers completed grievance forms and that the forms were not available on the resident units.
MDS assessments not completed in residents’ preferred languages. The facility failed to complete BIMS interviews for one resident on multiple MDSs and for three other residents on singular MDSs using their preferred non-English languages. Records showed diagnoses including dementia, Alzheimer’s disease, anxiety, depression, and schizophrenia, with staff documenting that the residents were rarely or never understood and substituting staff cognitive assessments instead of attempting the BIMS in the residents’ languages. Interviews confirmed no interpreter was offered for one resident, and staff stated they did not attempt the assessments in the residents’ preferred languages.
Failure to Maintain Resident Dignity During Medication Request: A resident with anxiety and Paranoid Schizophrenia, who was cognitively intact, was observed at the nurse’s station while an RN pointed a finger in the resident’s face and yelled that it was not time for medication and that the resident was harassing her. The resident became tearful and said the nurse did not have to speak that way. The DON later stated the interaction was derogatory and violated the facility’s dignity and respect policy.
Advance directive records were not accurately executed for two residents. One resident with dementia and cancer had a MOLST that lacked the legal guardian's valid signature, while another resident with severe cognitive impairment had a MOLST signed by the HCP for DNR/DNI/DNV and no hospital transfer, but the physician orders still listed full code. Staff interviews confirmed the charting mismatch and that the resident wishes were not consistently reflected in the medical record.
A resident with dementia, psychotic disturbance, anxiety, depression, and severe cognitive impairment received PRN quetiapine for agitation without the required physician assessment and documented rationale for continued use. Pharmacy and psych notes stated the PRN antipsychotic should be discontinued or reassessed, but the order remained in place and was administered multiple times without the required review.
Failure to timely report abuse allegations: A cognitively intact resident with DM2, depression, anxiety, and mood disturbance had two separate abuse-related concerns involving a CNA and an RN. The DON did not report the first grievance because the resident later retracted the statement, and a second allegation of verbal abuse was not reported to DPH within the required 2 hours. The IP stated both events were reportable, and the Administrator and IP said they were not aware of the incidents.
Failure to Communicate With Resident in Preferred Language During ADL Care: A resident with dementia, anxiety, and depression had a documented non-English preferred language, unclear speech, and frequent care refusals. Staff observed the resident in disheveled clothing and shoes on the wrong feet, but a CNA and UM reported that when the resident said no, care was stopped and no in-depth discussion was held in the resident’s preferred language to determine why care was being refused. The legal guardian said the resident communicates well in the preferred language, while an AA noted visuals and paired pictures/words were helpful, yet staff had not been using effective language-based communication methods.
Failure to Assist With Facial Hair Removal: A resident with Alzheimer's disease and muscle weakness required assistance with personal hygiene per the care plan and MDS, but surveyors repeatedly observed thick facial hair on the chin. The resident said staff did not offer a razor or assist with removal, and the assigned CNA admitted not offering the service even though facial hair removal should be provided during morning care.
A resident with low back pain, osteoarthritis, and paranoid schizophrenia was ordered Ultram for pain and was cognitively intact, but the opioid tablet was left in a clear medicine cup in the bedside table drawer after the nurse administered it. The resident said the nurse brought the medication earlier and that it was being held until after breakfast; the self-administration assessment did not show the resident was approved to store the medication at bedside, and the UM and DON stated the nurse should have watched the resident take it before leaving the room.
Two residents had pharmacy recommendations from MRRs that were not reviewed or addressed in a timely manner. One resident’s Flonase recommendation to change to PRN was not signed or dated by the physician, and another resident with dementia and PRN quetiapine had no documented AIMS assessment within the required timeframe despite the pharmacist’s recommendation and the care plan’s monitoring focus.
Unsecured medication carts and expired medications in storage cabinets. Staff were observed leaving medication carts unattended and unlocked with medications left on top of the carts or drawers open, including during medication pass and while entering resident rooms. Expired OTC medications, including nasal sprays, Aspirin, and Docusate Sodium, were also found in medication storage cabinets on multiple units. Nurses, UMs, and the DON stated the carts should be locked and the expired medications should not have been in the cabinets.
Failure to document repeated refusals of care and behavior monitoring. A resident with dementia, depression, and schizophrenia had documented resistance to care, yelling, and cursing, and the care plan called for behavior documentation. Survey observations and staff interviews showed the resident repeatedly refused ADL care, dressing help, and even shoe assistance, while appearing poorly groomed and wearing mismatched clothing. However, the CNA flowsheet and MAR did not record the refusals or required rejection-of-care details, despite staff acknowledging the resident’s frequent refusals.
The facility failed to offer nourishing bedtime snacks to residents when more than 14 hours elapsed between the evening meal and breakfast. Residents reported that snacks were not offered in the evenings, and the Food Service Director confirmed a 15-hour gap between meals without a process to ensure snacks were provided. This resulted in non-compliance with facility policy and USDA guidelines.
The facility failed to offer the updated 2023-2024 COVID-19 vaccine to eligible residents aged 65 and older, despite CDC recommendations and no medical contraindications. The Infection Preventionist was aware of the guidelines but did not offer the vaccine due to other priorities and anticipation of a new vaccine for the next season.
The facility failed to accurately code MDS assessments for several residents, leading to documentation errors. A resident with schizophrenia was not coded for a major injury after a fall, another with a stroke was incorrectly documented as using restraints, a resident with COPD was not coded for their condition and oxygen use, and a hospice patient was not coded for hospice services. These errors highlight deficiencies in assessing and documenting residents' care needs.
A facility failed to ensure proper resident identification during medication administration, leading to significant medication errors for four residents. The policy required two identification methods, such as a photo and verbal confirmation, but observations showed that an LPN administered medications without using any identifiers due to missing photos in the MARs. Interviews revealed reliance on staff for resident identification and a lack of awareness of the policy by the new DON.
A resident's wheelchair was found with a damaged armrest, compromising safety and comfort. Despite staff awareness, the issue was not logged for maintenance, and the resident had to use a sock to cover the damage. The Unit Manager was unaware of the problem until the surveyor's observation.
The facility failed to investigate an incident of physical aggression between two residents, leading to a room change for one of them. Despite the facility's policy requiring immediate investigation, no action was taken. Staff interviews revealed a lack of awareness and follow-up on the incident, resulting in a failure to protect the residents from potential abuse.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their cognitive and physical needs. A resident with Parkinson's Dementia lacked a care plan for cognitive loss, despite severe impairment. Another resident with dementia and anxiety also lacked a cognitive care plan, despite assessments indicating severe impairment. A third resident experienced a fall with injury, but the facility did not update the care plan with new interventions. The MDS Nurse and ADON acknowledged these oversights during the survey.
A resident with paraplegia and neurogenic bladder was found to have an incorrect size suprapubic catheter in place, contrary to the physician's order for a size 18 Fr catheter. The resident, who was cognitively intact, was observed with a size 20 Fr catheter, which was confirmed by the Unit Manager as incorrect, increasing the risk of bladder irritation, infection, and pain.
A resident with COPD was not provided with the correct oxygen flow rate as ordered by the physician. Despite orders to titrate oxygen between 1 to 5 LPM to maintain saturation levels between 90 to 94%, the resident received only 0.5 LPM. The facility staff failed to notify the physician or adjust the oxygen flow rate, and the updated orders were not transcribed correctly into the treatment administration record.
A facility failed to securely store medications according to professional standards, as observed when a surveyor found wound care medications in an unlocked drawer in a resident's room. The resident, who was cognitively intact and had paraplegia and a pressure ulcer, had Santyl ointment improperly stored, contrary to the facility's policy requiring locked storage.
The facility did not ensure all staff wore hair restraints in the kitchen, leading to a potential contamination risk. A staff member was observed without a hair restraint near food preparation areas, despite knowing the requirement. The Food Service Director confirmed the policy that all individuals in the kitchen must wear hair restraints.
The facility failed to implement proper infection control measures for two residents, one with MRSE and another with an indwelling urinary catheter. The Infection Preventionist did not follow CDC guidelines for Contact Precautions for a resident with MRSE, opting instead for Enhanced Barrier Precautions, which did not require gowns and gloves unless performing high-contact care. Additionally, a resident's catheter tubing was observed on the floor, increasing the risk of infection. These deficiencies highlight lapses in infection prevention protocols.
The facility failed to include the resident census in its daily nurse staffing postings, as observed on two consecutive days. The postings, located in the main lobby, contained the facility's name, date, and staffing details for RNs, LPNs, and CNAs, but left the census row blank. The Scheduler responsible for these postings admitted to having access to the required information but had not included the census data.
Infection Control Failures in Laundry, Hand Hygiene, Meal Service, and TBP Room Cleaning
Penalty
Summary
The facility failed to implement infection prevention and control practices in its laundry processing system. In the laundry area, two washing machines were observed running with Service Company #1's automated advanced laundry control system, while the facility was using laundry detergent and bleach that were labeled with different names than the system's dispensers. The bleach container stated that the product was to be used with a certified Service Company #2 dispensing system. The Laundry Supervisor stated the facility had not been using Service Company #1's laundry chemicals for over a year or more, that the automated advanced laundry control system was being used with different chemicals than it was set up to use, and that the system had not been serviced in more than a year and needed calibration. The Maintenance Director stated the facility did not have the user manual for the system and did not know the recommended service frequency. The Administrator stated the facility did not have a policy or procedure for routine maintenance and service for the washing machines and automated advanced laundry system, and did not have evidence that the chemicals in use were evaluated for effectiveness with the system. The facility also failed to ensure hand hygiene was performed during medication administration. During observation, Nurse #3 approached the medication cart, removed medications, and poured them into a medication cup without performing hand hygiene before handling the cart or medications. The nurse then administered the medication to the resident. During interview, Nurse #3 stated she should have performed hand hygiene before starting and after completing the medication administration. The DON stated hand hygiene prior to administering medications was important and that Nurse #3 should have washed her hands before beginning the medication pass. Hand hygiene was also not performed during breakfast service on Unit Four. UM #3 and CNA #1 were serving meals in the dining room. CNA #1 took an egg from a resident and peeled it with ungloved hands without performing hand hygiene. CNA #1 then cleared soiled utensils, plates, and cups from two tables, placed the soiled dishware into a meal cart, returned to the steam table without performing hand hygiene, and picked up a clean meal tray with a resident meal. CNA #1 stated she should have washed her hands before peeling the resident's egg and before handling a clean tray after touching dirty dishes. The DON stated staff should wash their hands and wear gloves prior to touching a resident's meal and should wash their hands after removing dirty plates before touching a meal tray. The Housekeeping Supervisor also failed to follow the facility's TBP room cleaning procedure. While cleaning a room posted for Contact Precautions, the Housekeeping Supervisor exited the room, placed the mop into the mop bucket, doffed gown and gloves, and sanitized his hands. He then rolled the same mop and bucket to the doorway of an adjacent resident room and began mopping that room with the same equipment. The Housekeeping Supervisor stated he used the same mop and bucket in both the TBP and non-TBP rooms but should not have because germs were being brought from the TBP room into the adjacent room. The IP stated the residents in the TBP room had bacteria that required TBP and that the Housekeeping Supervisor should have cleaned the TBP room last or changed the mop and mop bucket before moving to the next room.
Grievance Forms Not Accessible on Resident Units
Penalty
Summary
The facility failed to ensure residents had access to grievance forms that would allow them to formulate grievances anonymously on Unit Two, Unit Three, and Unit Four. During tours of all three units, the surveyor did not observe or locate any grievance forms or grievance information readily available for residents or their responsible parties. The facility's policy stated that complaints or grievances would be received and, if not resolved immediately, a Grievance/Complaint form would be completed and processed, and the resident rights notice stated residents had the right to voice grievances without discrimination or reprisal and to prompt efforts to resolve grievances. During a group meeting, eight of eleven residents stated they did not know what a grievance form was or where to find one to file a grievance independently, and they said they were never offered a grievance form when voicing concerns to staff. The Administrator stated the facility did not have a way for residents to file grievances anonymously and that the system was for residents to tell the Social Worker their concern, after which the Social Worker would complete the grievance form on the resident's behalf. SW #1 also stated that only Social Workers completed grievance forms and that the forms were not available for residents or others on the resident units.
MDS assessments not completed in residents’ preferred languages
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of four residents by not completing Brief Interview for Mental Status (BIMS) assessments in the residents’ preferred languages. For Resident #69, the facility did not conduct four consecutive BIMS assessments on three non-comprehensive MDS assessments and one comprehensive MDS assessment using the resident’s preferred non-English language. The record indicated that no facility staff spoke the resident’s preferred language and that an interpreter was not offered for the assessments. The resident’s legal guardian stated he communicated with the resident in the resident’s preferred language and that the resident understood and spoke to him in that language. Resident #69’s records showed diagnoses including dementia, anxiety, depression, and schizophrenia. The resident’s non-comprehensive MDS assessments dated 4/19/25, 7/19/25, and 10/18/25 listed the preferred language as a specific non-English language, stated the resident did not need or want an interpreter, and documented that the resident had unclear speech and rarely or never understood others or made him/herself understood. The BIMS was not conducted, and staff completed an assessment of cognitive skills for daily decision-making instead. The comprehensive MDS assessment dated 1/17/26 contained the same language and communication findings, and again the BIMS was not conducted. The facility’s social worker and MDS nurse stated that the resident was not offered an interpreter and that the BIMS assessments had not been attempted in the resident’s preferred language. The facility also failed to conduct BIMS assessments on singular, non-consecutive MDS assessments for Residents #5, #12, and #57 using their preferred non-English languages. Resident #5 had diagnoses including Alzheimer’s disease and anxiety; Resident #12 had schizophrenia; and Resident #57 had dementia and anxiety. Each resident’s MDS documented a preferred non-English language, stated that no interpreter was needed or wanted, and indicated that the resident’s speech was unclear and that the BIMS could not be conducted because the resident was rarely or never understood. In each case, staff completed an assessment of mental status and cognitive skills for daily decision-making instead of the BIMS. The active care plans for Residents #5, #12, and #57 did not include a focus or interventions for language deficits or preferred language. During interviews, the MDS nurse stated she never selected a yes response for interpreter need because family members were available to interpret, and the social worker stated she did not attempt the MDS assessments in the residents’ preferred languages and that the facility did not have contracted translation services available.
Failure to Maintain Resident Dignity During Medication Request
Penalty
Summary
The facility failed to provide a dignified experience during a medication request for one resident. Resident #46 was admitted in December 2021 with diagnoses including anxiety and Paranoid Schizophrenia, and the resident’s MDS assessment dated 1/16/26 showed the resident was cognitively intact with a BIMS score of 15 out of 15. The facility policy on Resident Dignity and Respect required residents to be treated with dignity and respect, spoken to in a calm, courteous, and professional tone, and free from mistreatment. On 2/18/26 at 4:13 P.M., a surveyor observed Nurse #1 approach Resident #46 at the nurse’s station with her right index finger pointed in the resident’s face and her voice raised, saying, “stop harassing me, it is not time for your medication, I will tell you when it is time for your medications.” The resident became tearful and cried out that the nurse did not have to speak to him/her like that and that he/she did not deserve that, then walked to the room. The UM said he had not exactly heard the interaction, and the DON later stated the resident reported being yelled at because he/she asked for medication that was not yet due. The DON said the yelling was derogatory, impacted the resident’s right to dignity, and violated the facility policy.
Advance directives and code status records were not accurately aligned
Penalty
Summary
The facility failed to accurately execute advance directives for two residents. For one resident with dementia, type II diabetes mellitus, and liver cell carcinoma, the record showed a permanent legal guardian had been appointed, but the MOLST form was signed by an unknown provider with the words "verbal guardian" in the section requiring the patient or patient's representative signature. The form indicated DNR and DNI, but there was no evidence the MOLST was re-addressed with the guardian after facility admission and before the issue was brought to the facility's attention. For another resident with unspecified dementia, mild without behavioral disturbance, thrombocytopenia, dysphagia, and venous embolism and thrombosis, the record contained a MOLST signed by the healthcare proxy indicating DNR, DNI, DNV, no non-invasive ventilation, and no transfer to hospital. The MDS assessment showed severe cognitive impairment with a BIMS score of 3, the HCP was invoked, and DNR, DNH, DNI, and treatment restrictions were in place. However, the February 2026 physician's orders listed the resident as full code, including resuscitation, intubation, ventilation, hospital transfer, and other life-saving measures. Staff interviews confirmed the inconsistency in the records. One social worker stated the resident's MOLST must have been changed after admission and that the physician's order should have been updated to reflect the resident's current wishes. Another social worker acknowledged entering a progress note stating the resident was full code without reviewing the chart and said the note was inaccurate. A unit manager stated that the resident had full code orders on admission because no MOLST was in the record at that time, but later confirmed after speaking with the healthcare proxy that the MOLST should indicate DNR/DNI/DNV and do not transfer to hospital. The social worker later stated she had copied the MOLST into the record but failed to relay the information to the physician and unit managers.
Unnecessary PRN Antipsychotic Use Not Properly Reviewed
Penalty
Summary
The facility failed to ensure that Resident #42 was free from unnecessary psychotropic medication use when the physician did not evaluate the resident and document the rationale for continued PRN Quetiapine use as recommended by the pharmacist. Resident #42 was admitted in May 2025 with diagnoses including unspecified dementia with mild behavioral disturbance, psychotic disturbance, anxiety disorder, and depression. The resident’s MDS indicated severe cognitive impairment with a BIMS score of 3 and that an antipsychotic medication was being given on a PRN basis. The physician order for Quetiapine Fumarate 50 mg every 8 hours PRN for agitation was initiated on 5/21/25 with no stop date. The MAR showed the PRN Quetiapine was administered five times between October and December 2025 without a physician assessment and documented rationale for continued use. The psychiatric behavioral notes dated 8/8/25 and 9/19/25 both stated that PRN Seroquel should be discontinued because the resident could not be on a PRN antipsychotic without a scheduled dose, and the pharmacist’s regimen reviews on 10/30/25, 11/25/25, and 12/25/25 each stated that PRN antipsychotic orders cannot exceed 14 days and require direct prescriber evaluation for continuation. The physician/prescriber response in December 2025 disagreed with the recommendation and referenced a progress note for medical necessity, and a later response on 1/7/26 requested psychiatric input. Records showed psychiatry reviewed the resident on 1/21/26, and staff interviews confirmed the PRN Seroquel had not been reassessed after the initial psych recommendations. The DON stated she reviewed psych recommendations and coordinated with the physician, the NP said signing the recommendations meant agreeing that the PRN antipsychotic should have a stop date and be discontinued, and the UM said she should have discontinued the PRN Seroquel after physician review but did not.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for one resident. The resident was admitted with diagnoses including Type 2 diabetes mellitus, major depressive disorder, anxiety disorder, and mood disturbance, and was cognitively intact with a BIMS score of 15 out of 15. Facility policy required alleged abuse, mistreatment, neglect, or misappropriation to be reported to the Department of Public Health within 2 hours and investigated internally. A grievance form dated 12/12/25 documented that the resident did not like the way he/she was handled or touched when a CNA was providing care. The DON said she spoke with the resident and the CNA immediately after the incident, but the facility did not report the allegation because the resident later retracted the statement and said he/she wished to forgive the CNA. The DON also stated there was no investigation file related to the allegation. The IP stated that both incidents were reportable and should have been reported to the HCFRS within 2 hours. The facility also failed to report a separate allegation involving Nurse #2 in a timely manner. The resident told the surveyor that Nurse #2 said if he/she did not like it there, he/she could leave, and the resident said the incident had been reported to the UM the day before. The DON acknowledged that the statement should not have been made and could be indicative of verbal abuse, and later said the nurse had used profane language and told the resident to leave if he/she did not like it there. The allegation was not reported to DPH until 24 hours later, and the Administrator and IP stated they were not made aware of the reportable incidents.
Failure to Communicate With Resident in Preferred Language During ADL Care
Penalty
Summary
The facility failed to provide treatment and services consistent with Resident #69’s needs related to communication, which increased the resident’s risk for diminished ADL abilities. Resident #69 had diagnoses including dementia, anxiety, and depression, and the record showed the resident’s preferred language was a non-English language. The MDS indicated the resident had unclear speech, was rarely or never understood, rarely or never made him/herself understood, and demonstrated rejection of care four to six days during the observation period. The care plan identified an ADL deficit related to dementia and a communication problem related to a language barrier, with a preference for face-to-face communication and family translation. Survey observations showed Resident #69 wearing mismatched and inappropriate clothing, including hospital gowns, layered clothing, and shoes on the wrong feet, with visible debris on clothing. The resident did not respond when approached by the surveyor and muttered in a language other than English. Staff interviews showed that the resident frequently refused ADL care, but staff did not use the resident’s preferred language or other effective communication methods to explore the reason for the refusals. A CNA stated that when the resident said no, that was it, and that the resident refused care all day. The UM stated that no one had really talked with the resident about why he/she was refusing care because that would require an in-depth conversation in the resident’s preferred language, which had not been done. The resident’s legal guardian stated he/she was appointed because of the ability to speak the resident’s preferred language and communicate with the resident, and said the resident understood and spoke in that language. An Activities Assistant stated the resident’s English was very limited and that visuals were key to communication, and also noted that a visual communication tool using words in the resident’s preferred language paired with pictures had been discussed but not developed until after the surveyor’s inquiry. The MDS nurse stated the resident was the only person at the facility who spoke that language and that no one at the facility seemed able to communicate with the resident. The SLP stated she had never received a referral to assess the resident for cognition or communication.
Failure to Assist With Facial Hair Removal
Penalty
Summary
The facility failed to ensure that activities of daily living were provided as required for one resident, who was admitted with diagnoses including Alzheimer's disease and muscle weakness. The resident's MDS indicated the resident was rarely or never understood and required partial/moderate assistance with personal hygiene. The active care plan and care kardex both directed that the resident required 1-2 staff assistance with personal hygiene. Facility policy stated that ADL care should be provided based on each resident's needs and individual care plan, and that cultural preferences and personal routines should be honored whenever possible. Surveyors observed the resident on multiple occasions with five dime-sized patches of thick, stubbled, gray hair on the chin. During interviews, the resident stated a need for help with facial hair removal and said the CNA had the razors, but also reported that staff had not offered assistance with a razor and that no one had offered, assisted, or provided a razor to remove the facial hair. The assigned CNA stated the resident required assistance to remove facial hair and that facial hair removal should be offered every morning for both men and women, but admitted not offering to assist. A nurse and nursing supervisor also stated that facial hair should be removed during morning care and that the resident's facial hair looked long and should have been removed.
Opioid Medication Left Accessible in Resident Bedside Table
Penalty
Summary
The facility failed to ensure that Resident #46 was free from an accidental hazard related to access to Ultram (Tramadol), an opioid medication. Resident #46 was admitted with diagnoses including low back pain, unspecified osteoarthritis, and paranoid schizophrenia, and the MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The resident had an active order for Ultram 50 mg by mouth three times a day for pain, and the February 2026 MAR showed the medication was administered at 6:00 A.M. on 2/18/26. During an interview later that morning, Resident #46 stated that the nurse had brought the Tramadol earlier and that the tablet was being kept in a clear medicine cup in the top drawer of the bedside table because the resident wanted to wait until after breakfast to take it. The resident then removed the tablet from the bedside drawer in the presence of the surveyor. Review of the self-administration assessment did not indicate that Resident #46 was assessed as capable of storing the Tramadol at the bedside. The UM and DON both stated that the resident should not have been allowed to store the Tramadol in the bedside table and that the nurse should have watched the resident take the medication before leaving the room.
Pharmacy Recommendations Not Reviewed or Addressed Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations from medication regimen reviews were reviewed and addressed in a timely manner for two residents. For one resident admitted with diagnoses including insomnia and acute respiratory failure with hypoxia, the consultant pharmacist recommended that Flonase be changed to PRN to determine whether it was still necessary, but the recommendation was not reviewed, signed, or dated by the physician or prescriber. During interview, the CEO stated she was unable to locate documentation showing that the physician had reviewed the recommendation. For another resident admitted with diagnoses including unspecified dementia, mild, with psychotic disturbance and anxiety disorder, the record showed severe cognitive impairment with a BIMS score of 3 and PRN quetiapine use for agitation. The care plan included monitoring and reporting adverse reactions of psychotropic medications and tardive dyskinesia, and the pharmacist later recommended that an AIMS assessment be completed within 6 months. The clinical record did not show that an AIMS assessment had been completed within the prior 6 months, and the IP stated the assessment was not done and should have been completed for residents receiving antipsychotic medication.
Unsecured medication carts and expired medications in storage cabinets
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal requirements on Unit Four and Unit Three, and failed to ensure that expired over-the-counter medications were removed from medication storage rooms on Unit Two, Unit Three, and Unit Four. The facility policy stated that all drugs and biologicals were to be stored in locked compartments and that medication rooms were to be routinely inspected for discontinued, outdated, defective, or deteriorated medications. During medication pass observations on Unit Four, Nurse #2 poured Tylenol tablets into a medication cup and walked away from the medication cart to the nursing station while the bottle of Tylenol remained on top of the cart. A resident approached the cart while Nurse #2 was away, and the bottle remained unsecured until Nurse #2 returned it to the cart drawer. Nurse #2 was also observed leaving blister packs of Haloperidol, Omeprazole, Aspirin, and Vitamin D3 on top of the medication cart and leaving the second drawer open while entering a resident room. Nurse #2 stated that medications should not be left on top of the cart and that they should remain locked to prevent unauthorized access. On Unit Three, Nurse #3 was observed walking away from the medication cart into the nurse's station with her back to the cart, leaving it unattended in the hallway with residents and staff nearby. Nurse #3 later walked away from the cart with the cart unlocked and the keys left on top of it while going to a resident room. On the same day, expired medications were found in medication storage cabinets on Unit Two, Unit Three, and Unit Four, including expired nasal sprays, multiple expired bottles of Aspirin, expired Docusate Sodium, and additional expired nasal sprays. Staff members stated that these medications should not have been in the cabinets because they were expired, and the DON stated that the expired medications should not have been in the building or stocked in the cabinets.
Failure to Document Repeated Refusals of Care and Behavior Monitoring
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident related to refusals of care and behavior monitoring. The resident was admitted with diagnoses including dementia, depression, and schizophrenia. The resident’s behavior note documented resistance to care, anger when staff approached for hygiene and care, screaming at staff, no effect from verbal redirection, and occasional response to reapproach. The active care plan identified an ADL performance deficit, impaired cognitive function, and a behavioral problem involving yelling, screaming, and cursing, with a directive to monitor behavior episodes and document behavior and potential causes. The resident’s MDS assessment showed the resident required partial/moderate assistance with bathing, supervision/touching assistance with dressing, and had four to six days of rejection of care during the seven-day observation period. Survey observations and staff interviews showed the resident was wearing soiled and mismatched clothing, with shoes on the wrong feet, and remained dressed the same way later in the day. A CNA stated the resident’s hygiene was not good and that the resident said no whenever approached for ADL care, and that the resident refused care all day. The surveyor also observed a CNA offering dressing assistance and a sandwich, both of which the resident refused, and observed the UM attempt to fix the resident’s shoes, which the resident also refused. Despite these refusals, the February CNA flowsheet did not record bathing performance for nine shifts, upper body dressing for three shifts, or lower body dressing for seven shifts, and did not document any refusal of care for bathing or dressing during the month. The February MAR also showed rejection of care monitoring was recorded as zero for frequency, interventions, outcome, and whether rejection occurred for the 2/19 day shift, even though staff and the UM acknowledged multiple refusals that day. The UM stated the resident’s cognition had worsened and that refusals of care were becoming more frequent, and confirmed the MAR did not include the required documentation of the resident’s rejection of care.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to offer each resident a nourishing snack at bedtime when more than 14 hours elapsed between the substantial evening meal and breakfast the following day. Specifically, the facility did not provide items from the basic food groups at bedtime when 15 hours elapsed daily between the scheduled evening meal and breakfast. The USDA guidelines indicate that there are five basic food groups, and the facility's policy requires that at least three meals or their equivalent are served daily, with not more than a 14-hour span between the evening meal and breakfast. However, the facility's meal service times showed that the evening meal was served at 5:00 P.M. to 5:10 P.M., and breakfast was served at 8:00 A.M. to 8:10 A.M., resulting in a 15-hour gap. During a Resident Council Meeting, residents reported that snacks were not offered in the evenings for the past year, although they could request a snack from the nurses' station. The Food Service Director confirmed that 15 hours elapsed between the evening meal and breakfast and that there was no process to ensure each resident was offered a nourishing snack at bedtime. This lack of a structured process to offer snacks resulted in the facility's failure to comply with its policy and the USDA guidelines, leading to the deficiency.
Failure to Offer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to five residents in accordance with national standards of practice, as recommended by the CDC Advisory Committee on Immunization Practices (ACIP). The residents, all aged 65 years or older, were eligible for an additional dose of the updated 2023-2024 COVID-19 vaccine. Despite the absence of medical contraindications and the fact that none of these residents had received the recommended additional dose, the facility did not offer the vaccine to them. This oversight was identified during a review of the residents' clinical records, which showed that their most recent COVID-19 vaccinations were administered several months prior, and no updated doses were offered after the recommended four-month interval. During an interview, the facility's Infection Preventionist (IP) acknowledged awareness of the CDC's recommendation for an additional COVID-19 vaccine dose for older adults. However, the IP admitted that the updated vaccine was not offered to any eligible residents because she was occupied with other tasks and anticipated a new vaccine for the upcoming 2024-2025 season. This inaction resulted in the facility's failure to adhere to the CDC guidelines and ensure that eligible residents received the recommended COVID-19 vaccine updates.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their care needs. Resident #74, who was admitted with paranoid schizophrenia, experienced a fall resulting in a bloody mouth and a fractured finger. The MDS Nurse incorrectly coded this fall as a minor injury, not recognizing the fracture as a major injury. Resident #9, with a history of cerebral vascular accident and vascular dementia, was incorrectly documented as using bedrail restraints daily, despite a consent indicating the use of side rails for bed mobility, not as restraints. Resident #49, diagnosed with schizophrenia and chronic obstructive pulmonary disease (COPD), was not accurately coded for COPD and oxygen use in the MDS assessment, an oversight acknowledged by the MDS Nurse. Lastly, Resident #71, admitted for hospice care with end-stage dementia, was not coded for hospice services in the MDS assessments, despite admission orders indicating the need for such care. These inaccuracies in MDS coding reflect a failure to properly assess and document the residents' conditions and care requirements.
Failure to Use Proper Resident Identification During Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice to ensure that significant medication errors did not occur for four residents. Specifically, the facility did not have an appropriate process in place for identifying residents during the medication pass procedure. The facility's policy required the use of two identification methods before administering medication, such as a photo and verbal confirmation of the last name. However, during observations, it was noted that Nurse #2 administered medications to four residents without using any resident identifiers, as the photos were missing from the Medication Administration Records (MARs). Interviews with Nurse #2, the Unit Manager, and the Director of Nursing revealed that the facility staff relied on other staff members to identify residents during medication administration. The Unit Manager confirmed that there were no photos in the MARs for residents on the second-floor unit, which was against the facility's policy. The Director of Nursing, who was new to the role, was unaware of the requirement for two identifiers during medication administration. This lack of adherence to the facility's policy and the absence of proper resident identification methods led to the deficiency.
Failure to Maintain Resident's Wheelchair in Safe Condition
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for Resident #23, who was observed using a wheelchair with a damaged left armrest. The leather on the front portion of the armrest was torn, and the padding was missing, compromising the resident's comfort and safety. The resident, who has diagnoses including depression, anxiety, and osteoarthritis, had tied a sock around the armrest to compensate for the damage, indicating awareness of the issue and a lack of timely intervention by the facility staff. Despite the resident's report that staff were aware of the issue, the maintenance log for October 2024 showed no record of a repair request for the wheelchair. A Certified Nursing Assistant (CNA) confirmed awareness of the damage and stated that a nurse was informed, but the specific nurse was not identified, and the issue was not logged for maintenance. The Unit Manager was unaware of the problem until the surveyor's observation and acknowledged that unit staff should have notified maintenance promptly.
Failure to Investigate Resident-to-Resident Aggression
Penalty
Summary
The facility failed to investigate an incident of physical aggression between two residents, identified as Resident #49 and Resident #54, which was a violation of their policy on resident abuse. Resident #49, who has schizophrenia and COPD, was reported to have been physically aggressive towards Resident #54, who has bipolar disorder. This incident led to Resident #54 being moved to a different room. Despite the facility's policy requiring immediate investigation of such incidents, no investigation was conducted. Interviews with staff revealed a lack of awareness and follow-up on the incident. The Unit Manager was informed of the room change due to aggression, but the Social Worker was not aware of the details and did not investigate further. The Administrator acknowledged knowing about the room change but was unaware of the aggression and admitted that the incident should have been investigated. This lack of action and communication among staff members resulted in a failure to protect the residents from potential abuse and neglect.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their cognitive and physical needs. Resident #72, diagnosed with Parkinson's Dementia, did not have a care plan addressing cognitive loss and dementia, despite the Minimum Data Set (MDS) assessments indicating severe cognitive impairment. The MDS Nurse acknowledged the absence of a care plan, which should have been in place following the triggering of the Care Area Assessment (CAA) for cognitive loss. Resident #64, admitted with dementia and anxiety, also lacked a comprehensive care plan for cognitive loss. The MDS assessments highlighted the resident's severe cognitive impairment and inability to make decisions. Despite the CAA triggering a need for a cognitive loss care plan, the facility did not provide evidence of such a plan being developed or implemented. The MDS Nurse confirmed the absence of a care plan during the survey. Resident #74, with a history of paranoid schizophrenia, experienced a fall resulting in injury. The facility's care plan for falls did not include new interventions following the incident. The Assistant Director of Nurses (ADON) was responsible for updating care plans after serious events but failed to provide evidence of revisions addressing the fall. This oversight left the resident without an updated care plan to prevent future falls.
Incorrect Catheter Size Used for Resident
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for a resident with an indwelling suprapubic catheter. The deficiency involved the incorrect size of the catheter being used for the resident, who was admitted with diagnoses including paraplegia and neurogenic bladder. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15. The physician's orders specified the use of a size 18 Fr 3-way suprapubic urinary catheter, which was to be changed every four weeks. However, during an observation by the surveyor and Unit Manager, it was noted that the resident had a size 20 Fr catheter in place instead of the ordered size 18 Fr. The Unit Manager confirmed that the incorrect size catheter was used, acknowledging that the resident should have had a size 18 Fr catheter as per the physician's order. This oversight placed the resident at increased risk for bladder irritation, infection, and pain.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #49, by not adhering to the physician's orders regarding oxygen administration. The resident, who was admitted with diagnoses including schizophrenia and chronic obstructive pulmonary disease (COPD), required oxygen support to maintain adequate oxygen saturation levels. Despite the physician's orders to titrate oxygen between 1 to 5 liters per minute (LPM) to maintain oxygen saturation levels between 90 to 94%, the resident was observed receiving only 0.5 LPM of oxygen. The facility's policy mandates notifying the physician when there is a change in a resident's condition or when treatment needs to be altered. However, the staff failed to notify the physician or adjust the oxygen flow rate as per the updated orders following the resident's hospitalization and subsequent follow-up with a pulmonologist. The resident's treatment administration record (TAR) for October 2024 showed consistent administration of oxygen at 0.5 LPM, contrary to the physician's orders. During an interview, the Unit Manager acknowledged the oversight, stating that the physician's updated orders were not transcribed correctly into the TAR. This failure to comply with the prescribed oxygen flow rate and to communicate effectively with the physician resulted in the resident not receiving the appropriate level of respiratory care as required by professional standards of practice.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and according to professional standards of practice, specifically for one resident. During an observation, a surveyor noted that wound care medications, including Santyl ointment, were left in an unlocked drawer in the resident's room. This was contrary to the facility's policy, which mandates that all drugs and biologicals be stored in locked compartments. The resident involved was admitted to the facility with diagnoses including paraplegia and a pressure ulcer of the sacrum. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15. During an interview, the Unit Manager acknowledged that the Santyl ointment, a prescription medication, should have been stored in the locked treatment cart rather than in an unlocked drawer in the resident's room.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen where food items were prepared and stored for resident consumption. Specifically, the facility did not ensure that all staff wore hair restraints while in the kitchen and in the vicinity of food preparation areas, which is necessary to prevent contamination and the spread of infections. During an observation, a surveyor noted that Additional Staff #2 was in the kitchen near the stove, speaking with a dietary staff member, without a hair restraint. Several pots containing food were covered with clear plastic wrap on the stove at the time. Additional Staff #2 acknowledged that she entered the kitchen without a hair restraint to ask for assistance, despite knowing the requirement. The Food Service Director confirmed that all individuals entering the kitchen are required to wear hair restraints, and Additional Staff #2 should have complied with this policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, leading to potential risks of infection transmission. Resident #292, who was readmitted to the facility with Methicillin-Resistant Staphylococcus Epidermidis (MRSE), was not placed under Contact Precautions as recommended by the Centers for Disease Control and Prevention (CDC) guidelines. Instead, the Infection Preventionist (IP) opted for Enhanced Barrier Precautions (EBP), which did not require staff to wear gowns and gloves upon entering the resident's room unless performing high-contact care activities. This decision was made despite the facility's policy indicating that Contact Precautions should be implemented for residents with MRSA infections. Observations revealed that staff did not consistently adhere to the precautionary measures. A staff member was seen sitting at the bedside of Resident #292 without wearing a gown or gloves, and another staff member, CNA #1, confirmed that gowns and gloves were only used during high-contact care. The IP admitted to not using the Contact Precautions sign because of personal preference and a belief that the EBP sign was clearer for staff. This deviation from established guidelines and facility policy increased the risk of MRSE transmission within the facility. Additionally, the facility failed to ensure proper catheter care for Resident #287, who had an indwelling urinary catheter. The catheter tubing was observed lying on the floor on multiple occasions, which CNA #2 acknowledged as inappropriate due to the risk of contamination from the dirty floor. The Infection Control Preventionist (ICP) confirmed that catheter tubing should never be on the floor to prevent infection. These lapses in infection control practices highlight significant deficiencies in the facility's adherence to infection prevention protocols.
Failure to Include Resident Census in Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to comply with the requirement to post complete nurse staffing information on a daily basis. On two consecutive days, the surveyor observed that the nurse staffing information posted in the facility's main lobby was missing the resident census data, which is a required component of the posting. The postings included the facility's name, the current date, and the total number and actual hours worked by RNs, LPNs, and CNAs, but the row designated for the resident census was left blank. During an interview, the Scheduler, who is responsible for completing the daily nurse staffing postings, acknowledged that she had access to the necessary information, including the resident census, but admitted that she had never included it in the postings. She indicated that she could start including the resident census information if required.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 931 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ashland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Skilled Nursing Facility | 3.1 mi | ★★★★★ | 0 | 0 |
| Carlyle House | 3.6 mi | ★★★★★ | 2 | 0 |
| Timothy Daniels House | 4 mi | ★★★★★ | 1 | 0 |
| Casa De Ramana Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Whittier Westborough Transitional Care Unit | 4.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.