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 Complete Care At Corsica Hills Llc during CMS and state inspections, most recent first.
Failure to maintain a clean and homelike environment was observed in multiple resident rooms, a shower room, and the C/D nourishment area. Surveyors noted brown staining on ceilings and around wall-mounted ventilation units, dusty and peeling surfaces, wall damage, unsealed penetrations, a disrepair bathroom door, and crumbs, stains, and trash in the nourishment room. The NHA, Maintenance Regional Director, and Maintenance Supervisor acknowledged the concerns, and the Maintenance Supervisor later confirmed the needed repairs.
Food storage practices failed to meet food safety standards. Surveyors observed multiple kitchen items, including hard boiled eggs, salad, opened liquid eggs, opened dry pasta, Rita's Italian ices, and cups of juice, that were not labeled and dated, as well as an uncovered container of rice. In the A/B Nourishment Room, a green bag, salad dressing, and thickened hydrolyte water were also unlabeled and undated, and the C/D Nourishment Room fridge had sticky residue.
Unsanitary and poorly maintained common areas were observed during survey, including a shower room with hair-covered drains and a loose wall panel, dirty and stained nourishment room floors with trash, an ice machine dripping with black staining around the drain, and a laundry room with dusty vents, a dusty hot water heater, trash in the drain, and missing and stained floor tiles. The NHA and other managers acknowledged the concerns.
Inoperable bathroom exhaust fans were found during survey tours of multiple units after staff and surveyors used toilet paper to check negative pressure at the fan covers. Several resident bathroom ventilation systems were confirmed inoperable across units A through D, and the facility’s ventilation systems were found to be impaired in 4 of 5 units reviewed.
Resident representative not included in consent process. A resident's record showed conflicting documentation about decision-making capacity, with provider assessments indicating the resident lacked capacity while other records stated the resident was responsible for self. Admission and treatment consent, as well as psychotropic med informed consent, were signed on the resident signature line with the RP section left blank, despite documentation that a surrogate was making decisions.
A resident receiving Mirtazapine 7.5 mg nightly had a GDR review by the psych NP, who recommended dose reduction after noting the resident was mostly asleep and unresponsive, with the roommate reporting the resident slept all the time. The recommendation was declined, but the physician note continued the medication for dementia with failure to thrive without documenting why the GDR was not attempted; the DON later stated the medication was being used to increase appetite rather than for behaviors.
A resident’s MDS oral/dental assessment was inaccurately completed and did not code the resident as edentulous, even though the resident stated he/she had no teeth and the care plan identified the resident as edentulous. The DON and NHA confirmed the resident’s edentulous status, and the MDS coordinator acknowledged the assessment should have been coded accordingly.
A resident’s care plan was not reviewed and revised after the resident stopped using hearing aids. The resident had an order for daily hearing aid use and assistance each shift, but was observed without the aids and stated a preference not to use them. The existing care plan still directed staff to offer and place the hearing aids, and the DON confirmed the resident was not utilizing them.
Failure to provide and document ADL hygiene care for two dependent residents. One resident was observed with fingernails longer than preferred, and the care plan required staff to check and trim nails on bath days and as needed, but there was no documentation of nail care and a scheduled ADL entry was missing. A second resident had multiple refused or missed shower/bed bath entries with another scheduled ADL entry missing. The DON could not explain the missed care or absent PCC documentation.
Failure to Monitor Oxygen Saturation Consistently: A resident with an oxygen order for SOB and low SPO2, and a history of pneumonia, had an oxygen concentrator in the room while not receiving O2 during observation. The record showed intermittent SPO2 monitoring, with readings mostly on room air and only one low value, while the facility policy required assessment of oxygen saturation before and during O2 therapy. The DON stated pulse ox should be taken with vitals as ordered or when symptomatic, but the resident’s SPO2 was documented only 6 times during the reviewed period.
Incomplete Resident Documentation: The facility failed to keep complete medical records for two residents. One resident reported that scheduled showers were sometimes missed, and the shower record had blank entries on scheduled shower days, with staff later stating they had forgotten to document refusals or a completed shower. For another resident, an LPN documented behavior monitoring related to an antianxiety medication, but the progress notes did not include the required interventions or outcomes, and the DON and Administrator could not provide the missing documentation.
Failure to maintain sanitary conditions was observed in shared shower areas and the laundry room. Surveyors found soiled linen on the floor in a shower room, a brown substance on the shower stall floor next to a stained commode chair, and multiple bags of linen plus unbagged linen stored on the floor in the laundry room. A GNA, Unit Mgr, Housekeeping Mgr, District Housekeeping Mgr, and NHA acknowledged the findings.
The facility failed to prevent and address abuse, leading to Immediate Jeopardy. A resident with cognitive impairment was physically abused by a nurse, and another resident with a fractured arm reported rough handling by a GNA. Investigations were inadequate, and monitoring of a resident with sexual impulse issues was inconsistent, leading to repeated inappropriate interactions.
The facility failed to implement its QAPI plan effectively, particularly in addressing potential deficient practices related to abuse prevention. Although an action plan was created for timely reporting of abuse allegations, there was no evidence of ongoing tracking, trending, or additional training as part of an effective QAPI program. Interviews revealed that while abuse prevention training was provided, there was no focus on sustaining compliance through the QAPI process.
The facility failed to document, investigate, and resolve grievances voiced by residents during Resident Council meetings. Concerns such as aides' attitudes, missing clothing, and issues with laundry were not addressed or discussed in the minutes. Residents reported unresolved issues, and the DON admitted to incomplete staff training. The Activities Director confirmed the lack of follow-up documentation, indicating a systemic issue in handling grievances.
The facility failed to ensure resident safety and conduct thorough investigations following abuse allegations. Incidents included delayed reporting of abuse by a nurse, incomplete documentation of resident interviews, and failure to interview relevant staff and residents. Additionally, a resident was not protected from being alone with the opposite sex, and a GNA with prior conduct issues continued working despite abuse allegations.
A resident reported an allegation of abuse, stating that a GNA caused them pain during care and did not listen to their requests to stop. The incident was also reported by the resident's roommate. The DON confirmed the resident felt their care preferences were ignored. The GNA was placed on administrative leave and later on a do-not-return list.
A facility failed to document and address grievances related to a resident's care, including medication dispensing and personal hygiene issues. Despite multiple discussions with the resident's family, no formal grievance was recorded, and the facility's grievance policy was not implemented until after the complaints. The DON acknowledged the grievance process should have been followed.
The facility failed to report abuse allegations within required timeframes for four residents. Incidents included verbal and physical abuse, and neglect, with delays in reporting to the SSA. In one case, a resident was told to urinate in her brief, and another resident's abuse was observed but not promptly reported. Documentation and procedural lapses were evident, as seen in the case of a resident who recanted an abuse allegation without proper documentation.
A facility failed to update a resident's care plan following two incidents of abuse. The existing care plans only addressed the resident's depression and cognitive decline, with no mention of the abuse incidents. This deficiency was identified during a survey and discussed with the DON and Regional President.
A facility failed to update a resident's care plan with dental recommendations after a consult revealed a fractured tooth requiring extraction, which the resident refused. The care plan did not reflect the resident's ongoing tooth pain or refusal of treatment, leaving staff unaware of these issues. Interviews with staff confirmed the oversight in updating the care plan.
Facility staff failed to provide necessary ADLs for a resident with Alzheimer's dementia, who was dependent on staff for care. Despite being scheduled for showers twice a week, the resident received only one shower in December and none in the first two weeks of February. Mouth care and incontinence care were also frequently marked as not applicable or left blank in documentation. The Memory Support Program Director was unaware of these issues, and the DON acknowledged the documentation errors.
A facility failed to complete a thorough admission assessment for a resident with dementia, resulting in the resident exiting the facility unsupervised. Additionally, residents in the dementia care unit were observed without activities, and a care plan for a resident with severe cognitive impairment was outdated, leading to a lack of meaningful engagement.
The facility did not post daily nurse staffing information, making it inaccessible to residents and visitors for three consecutive days. The DON was unaware of the requirement and stated they were working on completing the document for posting.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment, as shown by multiple observations of disrepair and unsanitary conditions in resident rooms, a shower room, and the C/D Nourishment Room. Surveyors observed brown staining on a ceiling in one resident room, a dusty wall-mounted ventilation unit, peeling bed board, an indentation in the wall, and peeling paint at the base of a bathroom wall in another room. Brown staining was also seen around wall-mounted ventilation units in two resident rooms. In the C/D Nourishment Room, the refrigerator contained crumbs and brown and red stains, and the floor had trash with black and brown staining on the tiles. During a later tour, surveyors found a bathroom door in disrepair in one resident's room, a large hole in the drywall, and multiple unsealed wall penetrations in another resident's bathroom. The Nursing Home Administrator, Maintenance Regional Director, Maintenance Supervisor, and later the Administrator and Maintenance Supervisor acknowledged the concerns and confirmed the needed repairs.
Food Items Stored Without Labels or Dates
Penalty
Summary
Food storage did not comply with professional standards of food safety in the kitchen and nourishment rooms. During the initial kitchen tour, surveyors observed hard boiled eggs, salad, an opened carton of liquid eggs, opened dry pasta, and multiple Rita's Italian ices that were not labeled and dated, along with an uncovered container of rice. In the A/B Nourishment Room, surveyors observed a green bag, one salad dressing bottle, and two bottles of thickened hydrolyte water that were not labeled and dated, and the C/D Nourishment Room refrigerator had sticky colored residue in it. During a follow-up visit to the kitchen, surveyors observed cups of juice in the walk-in refrigerator that were not labeled and dated, and the District Manager stated they would be used for lunch that day.
Unsanitary and Poorly Maintained Common Areas
Penalty
Summary
The facility failed to provide a functional and sanitary environment in multiple areas observed during the recertification survey. In 1 of 4 shower rooms observed, surveyors found two drains covered in multicolored hair and a metal panel coming off the bathroom wall, which were acknowledged by the Unit Manager #10 and the Maintenance Regional Director. Surveyors also observed a dirty and stained floor with trash in the C/D Nourishment Room, an ice machine dripping with black staining around the drain in the A/B Nourishment Room, and in the laundry room a dusty ceiling vent, a dusty hot water heater, trash in the drain, and missing and stained floor tiles. The NHA, Maintenance Regional Director, Maintenance Supervisor, Housekeeping Manager, and District Housekeeping Manager all acknowledged the observed concerns in the affected areas.
Inoperable Bathroom Exhaust Fans
Penalty
Summary
The facility failed to maintain clean and operational ventilation systems, and surveyors determined that proper airflow was impaired throughout the premises. During the annual survey, this deficiency was identified in 4 of the 5 unit ventilation systems reviewed. The report states that local exhaust ventilation systems are intended to capture and remove contaminants such as heat, steam, condensation, vapor, smoke, odor, and fumes, but the systems were not functioning as intended. On an initial tour of units A and B, surveyors found bathroom exhaust fans in resident rooms to be inoperable. During a later tour with the Maintenance Supervisor and Administrator, toilet paper was placed against exhaust fan covers in residents’ bathrooms to verify negative pressure, and the Maintenance Supervisor confirmed that those systems were inoperable. On a subsequent tour of units C and D, surveyors again used toilet paper to check fan function and found some bathroom exhaust fans inoperable, while others showed positive pressure.
Resident Representative Not Included in Consent Process
Penalty
Summary
The facility failed to provide a resident's representative the right to be involved in the informed consent process for Resident #16. During record review, the surveyor found that a MOLST dated 9/10/24 stated the resident's MOLST decisions were made per the legal authority in accordance with the Health Care Decision Act. However, two medical providers completed assessments on 11/11/25 and 11/14/25 and both determined that Resident #16 lacked capacity to make his/her own decisions and decisions related to medical necessity and prognosis. The surveyor also reviewed a social service assessment completed on 11/12/25 that documented the resident was responsible for him/herself. The resident's consent for admission and medical treatment was signed on the resident signature line on 11/10/25, with the Resident Representative section left blank. In addition, the psychotherapeutic medication informed consent dated 11/13/25 was signed in the patient's signature section, and the Representative Party section was also left blank. During interview, the Nursing Home Administrator stated the MOLST had been marked in error and that Resident #16 had a surrogate making decisions, and that the resident's son was in communication with the facility regarding care.
Failure to Document Rationale for Not Attempting GDR of Psychotropic Medication
Penalty
Summary
The facility failed to attempt a recommended gradual dose reduction (GDR) for a psychotropic medication and failed to document a contraindication rationale for why the GDR was not attempted for one resident. Resident #30 was observed resting in bed and did not respond when the surveyor attempted to engage in conversation; the roommate stated the resident did not talk much and rested quietly most of the time. The resident was receiving Mirtazapine 7.5 mg nightly, which is a psychotropic antidepressant medication. A psychiatric nurse practitioner reviewed the resident for a GDR and documented that the resident was seen resting in bed with eyes closed and did not answer questions, and the roommate reported the resident slept all the time. The nurse practitioner recommended reducing Mirtazapine 7.5 mg nightly, but the recommendation was later marked as declined by the NP. The resident’s subsequent physician progress note continued Mirtazapine 7.5 mg nightly for dementia with failure to thrive, but did not include any rationale for not attempting the GDR. The resident’s care plan identified antidepressant use related to depression, and the DON stated the recommendation was declined because the medication was intended to increase appetite rather than treat behaviors; however, that rationale was not documented in the resident’s medical record.
Inaccurate MDS Oral/Dental Assessment
Penalty
Summary
The facility failed to accurately document a Minimum Data Set (MDS) assessment for one resident. During interview, the resident stated that he/she had not had any teeth since admission to the facility. Review of the resident’s most recent comprehensive MDS showed that the oral/dental assessment did not mark the option for no natural teeth or tooth fragments (edentulous) and instead coded the resident as none of the above were present. The resident’s care plan, however, had identified the resident as edentulous and at risk for oral health or dental care problems. The DON and Nursing Home Administrator confirmed the resident was edentulous and were unsure why the MDS did not reflect that status. The MDS coordinator stated the oral/dental assessment was completed by reviewing nursing assessments and confirmed the resident should have been coded edentulous.
Care Plan Not Updated for Resident’s Hearing Aid Use
Penalty
Summary
The facility failed to review and revise Resident #9’s care plan after the resident’s hearing-related situation changed. Resident #9 had an order dated 9/18/25 to continue use of amplification, stating the resident was to wear hearing aids daily and required assistance with insertion and manipulation of the hearing aids every shift. The January 2026 TAR showed documentation on all three shifts from 1/1/26 through 1/7/26 indicating the treatment was completed, yet the resident was observed on 1/6/26 watching television at a loud volume without hearing aids in place. On 1/8/26, the resident was again observed without hearing aids in the dining room and stated that he/she had two hearing aids but preferred not to use them. The care plan reviewed that day had been initiated on 12/18/22 and identified a communication problem related to being hard of hearing, with an intervention to offer hearing aids and put them in place. During an interview on 1/9/26, the DON confirmed that Resident #9 does not utilize his/her hearing aids, and the surveyor noted that the current plan of care did not reflect the resident’s wishes and was not accurate to current treatments.
Failure to Provide and Document ADL Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for two dependent residents. Resident #66 was observed seated on the side of the bed wearing wrist support braces on both hands, with all 10 fingers appearing clean but the free edge of the fingernails about 0.5 cm in length. The resident stated that shorter nails were preferred. Review of the MDS and care plan showed the resident was dependent for ADL care and that staff were to check nail length and trim and clean nails on bath days and as necessary. Task documentation for December 2025 showed the resident refused a shower or bed bath on 12/9/2025, did not receive a shower or bed bath on 12/12/2025, and documentation for the next scheduled ADL care on 12/26/2025 was missing. There was no documentation that nail care was provided during December 2025. Resident #93 was observed during wound care, and the surveyor could not verify toenail condition because the resident was wearing a medical walking boot. Review of the MDS and care plan showed the resident was dependent for ADL care to maintain good personal hygiene. Task documentation for December 2025 showed the resident refused a shower or bed bath on 12/2/2025, did not receive a shower or bed bath on 12/5/2025, refused again on 12/16/2025, and documentation for the next scheduled shower or bed bath on 12/19/2025 was missing. When questioned about the missed ADL care and the lack of nail care documentation for Resident #66, the DON stated staff were unable to recall the missed ADL cares and could not explain the absence of nail care documentation in PCC.
Failure to Monitor Oxygen Saturation Consistently
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for oxygen administration for one resident who had an oxygen order related to shortness of breath and low oxygen saturation. The resident had a history of pneumonia, and the record showed an oxygen concentrator in the room while the resident was not receiving oxygen during observation. The resident’s orders included oxygen 2 liters per minute via nasal cannula for SPO2 less than 92% every shift for shortness of breath, with a prior order for oxygen 2 liters per minute via nasal cannula every shift for shortness of breath. The facility’s oxygen administration policy stated that oxygen saturation should be assessed before administering oxygen and while the resident is receiving oxygen therapy. Review of the resident’s SPO2 readings showed documented values of 97% on room air, 97% on room air, 94% on room air, 94% on room air, 96% on room air, and 88% on room air. The resident’s care plan, initiated for altered respiratory status related to a left pleural effusion and left lower lobe associated atelectasis, included monitoring for signs and symptoms of respiratory distress and reporting decreased pulse oximetry. During interview, the DON stated that pulse oximetry should be taken with vitals as ordered or if the resident was symptomatic, and the surveyor noted that the resident’s pulse oximetry was documented and monitored only 6 times during the period reviewed.
Incomplete Resident Documentation
Penalty
Summary
The facility failed to maintain complete medical record documentation in accordance with accepted professional standards for 2 residents reviewed. For one resident, the surveyor interviewed the resident, who stated that scheduled showers were sometimes not given. A review of the shower documentation for December 2025 and January 2026 showed blank entries on scheduled shower days. When interviewed, the NHA stated that staff later reported forgetting to document that the resident refused a shower on one date, forgetting to document a refusal on another date, and forgetting to document that a shower was given on a third date. For another resident, the electronic medical record showed that an LPN documented that the resident experienced behavior related to an antianxiety medication on 2 days, but there was no documentation in the progress notes of interventions or outcomes as required by the order. When interviewed, an LPN stated that staff were expected to describe the side effects or symptoms, notify the doctor and family, and document in the progress notes. The DON and Administrator were unable to provide documentation showing that the behavior monitoring entries were addressed in the progress notes and acknowledged the concern.
Failure to Maintain Sanitary Conditions in Shower Rooms and Laundry Area
Penalty
Summary
The facility failed to maintain a sanitary environment in resident shared shower areas and the laundry room. In shower room D, surveyors observed soiled linen on the floor, and a GNA entered the room and picked it up, stating she came in to make sure the shower was clean; she also stated she did not know why the soiled linen was on the floor because staff were expected to place soiled linen in the hamper. Surveyors also observed a brown substance on the floor of a shower stall next to a brown-stained commode chair. In the laundry room, surveyors later observed multiple bags of linen on the floor of the soiled side and unbagged linen on the floor of the clean side. The Housekeeping Manager and District Housekeeping Manager stated the laundry staff had been short-staffed the day before, but the linen should not have been stored on the floor. The NHA acknowledged the concerns in both areas.
Failure to Prevent and Address Abuse in LTC Facility
Penalty
Summary
The facility staff failed to recognize and prevent abuse towards multiple residents, leading to an Immediate Jeopardy situation. For instance, a resident with moderately impaired cognition and behavioral disturbances was physically abused by a registered nurse who slapped the resident on the head multiple times after the resident became combative. The incident was not reported immediately, allowing the nurse continued access to vulnerable residents. Additionally, the psychiatric consult for the resident did not address the abuse, and the nurse involved had not completed required annual training. Another resident, who required non-weight-bearing care for a fractured arm, reported being handled roughly by a GNA, causing fear and distress. The facility's investigation into the incident was inadequate, as it failed to interview all relevant staff and residents, and the allegation of abuse was deemed inconclusive. The resident was found lying on their injured side, contrary to care instructions, and expressed fear of the GNA involved. Further deficiencies included a failure to report and address allegations of abuse in a timely manner, as seen in the case of a resident who was allegedly slapped by a GNA. The incident was not reported immediately, and the GNA continued to work in the facility. Additionally, a resident with a history of sexual impulse control issues was not adequately monitored, leading to repeated inappropriate interactions with other residents. The facility's interventions were delayed and inconsistently implemented, contributing to ongoing risks for residents.
Failure to Implement Effective QAPI for Abuse Prevention
Penalty
Summary
The facility failed to implement its Quality Assessment and Performance Improvement (QAPI) plan effectively, particularly in addressing potential deficient practices related to abuse prevention. The facility's policy, dated 2020, aimed to continuously evaluate systems to ensure quality care and life. However, the facility did not gather, analyze, or re-evaluate data related to adverse events concerning abuse, which could potentially affect all 105 residents. Although an action plan was created in September 2022 for timely reporting of abuse allegations, there was no evidence of ongoing tracking, trending, or additional training as part of an effective QAPI program. Interviews with the Regional Clinical Consultant (RCC) and the Director of Nursing (DON) revealed that while abuse prevention training was provided, there was no focus on sustaining compliance through the QAPI process. The RCC admitted that there was no data collection, monitoring, or evaluation to demonstrate sustained compliance with abuse prevention. The DON confirmed that QAPI meetings were held monthly, but no additional information was available regarding the tracking, trending, or monitoring of abuse prevention efforts with an action plan developed as a result.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced by residents during Resident Council meetings were documented, investigated, resolved, and followed up on. The Resident Council Minutes from multiple meetings did not indicate the names of residents who attended, nor did they show that concerns raised, such as aides having attitudes, missing clothing, and issues with laundry, were addressed or discussed. Additionally, concerns about being put to bed with clothes on, showers not being given, and call lights not being answered timely were not documented as resolved. This lack of documentation and follow-up was consistent across several meetings, indicating a systemic issue in handling grievances. During a resident group meeting, residents expressed that they had reported concerns about laundry and staff not introducing themselves, but had not received any follow-up. The DON acknowledged that training had been conducted for aides on certain issues but admitted that not all staff had been educated. The Activities Director stated that there was no follow-up documentation on whether concerns were addressed or resolved, and the Administrator received a copy of the Resident Council Minutes without any follow-up documentation. This failure to document and resolve grievances had the potential to leave resident concerns unaddressed throughout the facility.
Inadequate Response to Abuse Allegations and Investigation Failures
Penalty
Summary
The facility failed to ensure the safety of residents following allegations of abuse and did not conduct thorough investigations into these allegations. In one instance, a Registered Nurse was reported to have cursed and hit a resident, but the incident was not reported to the Director of Nursing until over an hour later, allowing the nurse continued access to vulnerable residents. Another case involved a resident who reported rough treatment by a staff member, but the investigation was incomplete, lacking proper documentation and failing to identify who conducted the interview. Further deficiencies were noted in the investigation of a resident's representative's report of neglect, where the facility did not interview other staff who might have had knowledge of the care provided. In another case, a resident was found in distress, and the investigation was deemed inconclusive due to a lack of interviews with other staff and residents who might have had relevant information. Additionally, a resident was not protected from being alone with residents of the opposite sex despite previous orders, and the facility failed to document interventions to prevent such occurrences. The facility also did not complete a thorough investigation into an allegation of physical abuse involving a GNA and a resident, as no additional interviews with other residents or staff were conducted. The GNA involved had previous write-ups for unprofessional conduct but continued to work at the facility until termination for unrelated reasons. These incidents highlight significant lapses in the facility's response to abuse allegations and the protection of residents.
Failure to Honor Resident's Right to Dignified Care
Penalty
Summary
The facility staff failed to honor a resident's right to a dignified existence by not listening to the resident during care. Resident #911 reported an allegation of abuse, stating that a GNA turned them, causing pain, and continued despite their request to stop. The incident was reported by the resident on 1/14/23, and the roommate also reported mistreatment by the same GNA. The Director of Nursing confirmed that Resident #911 felt the GNA was not listening to their care preferences. The GNA was placed on administrative leave and subsequently on a do-not-return list after the investigation.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were afforded the right to file a grievance and receive a response regarding the action taken by the facility. This deficiency was identified during a recertification and complaint survey for one of the three residents reviewed. The issue was highlighted by a complaint concerning care concerns for a resident, which included improper medication dispensing, inconsistent staffing in the memory care unit, and inadequate personal hygiene care. Despite the complainant having communicated these concerns to the Memory Support Program Director (MSPD), Director of Nursing (DON), and the Administrator, no grievance was formally documented or addressed. The facility's failure to document and address grievances was further evidenced by the absence of any grievance records for the resident in question, despite multiple discussions with the resident's family about care concerns. The MSPD admitted to not completing a grievance form if she believed the issue could be addressed immediately, and the DON acknowledged that the grievance process should have been followed. Additionally, the facility's Resident and Family Grievances policy was not implemented until after the complaints were made, indicating a lack of proper grievance handling procedures at the time of the incident.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft within the required timeframes to the state survey agency (SSA). This deficiency was identified during a recertification and complaint survey, affecting four residents. The facility's policy mandates that any alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. However, in the case of Resident #77, the allegation of verbal and physical abuse by a Geriatric Nurse Aide (GNA) was not reported to the Director of Nursing (DON) until the following morning, resulting in a delay in notifying the SSA. Resident #303 reported being told by staff to urinate in her brief, which she found uncomfortable and distressing. This incident was reported to a GNA, who then informed a Registered Nurse (RN). However, the incident was not reported to the Administrator or the DON until after noon, missing the two-hour reporting window. Similarly, Resident #921 was observed being abused by a Registered Nurse (RN), but the report to the DON was delayed, and the SSA was not notified within the required timeframe. In the case of Resident #928, an allegation of rough treatment and verbal abuse was made, but there was no evidence that this was reported to the SSA. The interview with the resident was conducted without proper documentation, and the resident later recanted the allegation. The DON was unable to confirm when the interview took place, indicating a lack of proper procedure and documentation in handling the incident. These failures highlight the facility's inability to adhere to its own policies and regulatory requirements for timely reporting of abuse allegations.
Failure to Update Care Plan After Abuse Incidents
Penalty
Summary
The facility failed to review and update the care plan for a resident following two incidents of abuse. The electronic health record for the resident did not show any updated care plans addressing these incidents, which occurred four days apart. The existing care plans only addressed the resident's depression and cognitive decline, without any mention of the abuse incidents. This deficiency was identified during a complaint and recertification survey and was discussed with the Director of Nursing and the Regional President at the exit meeting.
Failure to Update Care Plan with Dental Recommendations
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R73, to include recommendations from a dental consult. The dental consult on 05/11/24 recommended the extraction of tooth #20 due to a fracture and food impaction, which the resident refused. Despite this, the care plan was not updated to reflect the fractured tooth, the recommendation for extraction, or the resident's refusal, leaving staff unaware of the resident's ongoing tooth pain and the dentist's recommendations. Interviews revealed that the Medical Records Director and Unit Manager were responsible for ensuring follow-up from dental appointments was documented and communicated. However, the Unit Manager admitted that the care plan should have been updated to include the dentist's recommendations and the resident's refusal. The Resource Nurse confirmed that the care plan was not revised in a timely manner to address the resident's dental issues, which were significant to the resident's care and comfort.
Failure to Provide Scheduled ADLs for a Resident
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADLs) for a resident who was dependent on them for care. The resident, who had Alzheimer's dementia with anxiety and was severely cognitively impaired, was documented as being dependent on staff for most ADLs according to the Minimum Data Set (MDS). Despite being scheduled for showers twice a week, the resident only received one shower in December and none in the first two weeks of February. Additionally, the resident's mouth care and incontinence care were frequently marked as not applicable (N/A) or left blank in the geriatric nursing assistant (GNA) documentation. The Memory Support Program Director was unaware of the documentation issues, despite frequent communication with the resident's family about care concerns. The Director of Nursing and other regional staff were informed of the deficiencies, and the DON acknowledged that the GNAs should not have documented N/A for those care categories. The failure to provide scheduled showers, mouth care, and incontinence care as documented indicates a significant lapse in the facility's care for the resident.
Deficiencies in Dementia Care and Resident Safety
Penalty
Summary
The facility failed to complete a thorough admission nursing assessment for a resident with a known history of dementia, leading to an incident where the resident was able to exit the facility unsupervised. The resident, who had been admitted following hospitalization for changes in vital signs and dementia-related behaviors, was not properly assessed for elopement risk upon admission. This oversight resulted in the resident exiting the facility through a side door, only to be noticed and brought back by a geriatric nursing assistant. The elopement assessment section of the nursing admission assessment was incomplete, failing to identify the resident's medical conditions that could lead to confusion or exit-seeking behaviors. Additionally, the facility did not ensure that residents in the dementia care unit had access to activities that would help them achieve their highest practicable physical, mental, and psychosocial well-being. Observations revealed that residents were left without activities on multiple occasions. A specific resident with severe cognitive impairment had a care plan that was not updated to reflect their current needs and abilities, resulting in a lack of meaningful engagement. The Memory Support Program Manager acknowledged the lack of activities but did not provide a rationale for the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the regulatory requirement to post daily nurse staffing information, which was not available to residents or visitors during the first three days of the survey. Observations on three consecutive days revealed that the nurse staffing information was not posted or accessible at 8:35 AM each day. During an interview, the Director of Nursing (DON) admitted that the facility did not have the nurse staffing information posted and was unaware of the requirement to do so. The DON mentioned that they were in the process of completing the document for posting.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 190 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Centreville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Brooke Ct Skilled Care Ctr At Heron Point | 11.6 mi | ★★★★★ | 5 | 0 |
| Resorts At Chester River Manor Corp | 12 mi | ★★★★★ | 19 | 0 |
| Chestertown Nursing And Rehab | 12 mi | ★★★★★ | 9 | 0 |
| Caroline Nursing And Rehab | 17.4 mi | ★★★★★ | 5 | 0 |
| Denton Nursing And Rehab | 17.5 mi | ★★★★★ | 36 | 0 |
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