Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Future Care Pineview during CMS and state inspections, most recent first.
A resident who had been deemed incapable of making medical decisions had a legal representative who submitted a written request for the resident’s medical record. Facility policy required written requests for PHI and mandated that access be provided within 48 business hours for current patients. The DON initially reported there was no current request on file, while the Director of Medical Records confirmed that a request had been received but that additional facility paperwork from the family was incomplete. The facility did not provide the requested record within the required timeframe, resulting in a failure to provide timely access to the resident’s medical record.
The facility failed to notify a resident’s representative when a resident, previously deemed incapable of making medical decisions, refused a podiatry consult after the podiatrist requested that nursing staff inform the representative, and the subsequent nursing note documenting the refusal did not show any notification. In a separate case, the facility’s own policy required staff to notify the physician and responsible family members of changes in condition and abnormal VS, including a pulse >100 bpm, yet when a resident with chronic respiratory failure, ventilator dependence, and multiple comorbidities developed new-onset tachycardia with a heart rate of 120 bpm, staff documented the abnormal pulse but did not document any notification to the physician or the resident’s representative.
Advance Directive Offer Not Documented: The facility failed to provide evidence that A resident or family representative was offered the opportunity to formulate an Advance Directive for 6 of 9 residents reviewed. During record review, no Advance Directive or documentation of an offer was found for the affected residents, and the Social Services Director stated the offers were verbal but could not be located in the chart or documented in a progress note.
Kitchen sanitation and food handling deficiencies were observed during survey. A staff member was washing dishes while standing water was on the floor, flies and knats were present, and dirty dishes with food particles were left on carts near the dishwasher. The low-temp dishwasher repeatedly showed wash and rinse temps below expected levels, expired Browning and Seasoning Sauce was found in dry storage, and an ice cycle was hanging from a sprinkler in the walk-in freezer.
The facility inaccurately maintained its resident matrix, omitting or miscounting residents on contact/transmission precautions and residents with pressure ulcers. A resident’s continuous tube feeding bag was missing the start time, and staff confirmed the time should have been documented. Three residents’ EMRs were not updated from EBP to contact precautions for a specific MDRO, and one resident with bilateral hand contractures lacked timely splint orders and documentation of restorative ROM and splint application.
Three GNAs did not complete required annual in-service training on time. Record review and a staff interview showed their assigned in-service courses for 2024 and 2025 were incomplete or late, and no additional documentation was provided at survey exit.
A resident with hand contractures and on a Restorative Nursing Program did not have their care plan updated to reflect their contracture status or the use of hand splints, despite staff providing these interventions. Additionally, the care plan was not revised to include the resident's contact precautions for MDRO until after the precautions were already in place and observed by surveyors.
A facility failed to provide a safe environment in residents' rooms when surveyors observed multiple areas of wall damage on the 3rd floor in 3 of 26 rooms. The findings included baseboards coming off the walls and cracked, peeling door protectors; the DON later reviewed the damaged areas with the surveyor and acknowledged the needed repairs.
A resident’s discharge preference was not care planned, despite the sister’s stated plan for community placement and no discharge discussion documented in care plan meetings. Another resident on NPO status had no oral hygiene order, TAR documentation, or care plan interventions. A resident dependent on staff for Hoyer lift transfers was left in bed despite the care plan and the resident’s request to get up, and a resident with an insomnia dx had nightly meds for insomnia but no person-centered care plan.
A resident who was NPO was observed with bad breath, a very dry mouth, and cracked lips, while staff reported oral care was being done during ADLs and at least once per shift. However, the chart had no oral hygiene order, the TAR had no order, and the care plan had no oral hygiene interventions tied to NPO status. The nurse could not locate documentation showing the oral care was completed.
Meals were not palatable, attractive, or appetizing for two residents who were interviewed and observed during meal service. One resident reported the food had no taste and was often undercooked or overcooked, while another said they frequently received the same foods they did not like and relied on alternate meals such as salad or PBJ. During observation, the resident left most of the meal uneaten and said the broccoli was too hard to chew due to limited teeth. A sampled tray also showed tough, chewy pork chop, hard broccoli, and mashed potatoes with no taste.
Failure to Follow Isolation Precautions: An employee was observed speaking with a resident and touching the resident’s linens without wearing an isolation gown, even though contact isolation and enhanced barrier precautions signs were posted on the room door. The resident’s EMR showed the resident, along with another resident, was on contact and enhanced barrier precautions.
Failure to Provide Timely Access to Resident Medical Record
Penalty
Summary
The facility failed to provide a resident’s legal representative with timely access to the resident’s medical record after a written request. A complaint was received by the Office of Health Care Quality alleging that the facility did not provide a copy of the medical record when requested. Review of the resident’s clinical record showed the resident had been admitted on an earlier date and was deemed incapable of making all medical decisions by two physicians, with the resident’s mother identified by the DON as the legal representative. The facility’s Access to PHI policy requires that all requests for access or inspection be submitted in writing (or documented in writing by staff if made orally) and that the facility act on all requests within 48 business hours for current patients. During interviews, the DON initially stated that the resident’s representative could request and obtain copies of the medical record but must follow the facility’s process, and reported that there was no current medical record request on file for this resident. However, the Director of Medical Records later confirmed that the facility had, in fact, received a medical record request for this resident on a specific date, but that the family had not completed and returned additional facility paperwork. Despite the existing written request and the facility’s policy requiring action within 48 business hours, the record was not provided to the representative, leading to the cited deficiency.
Failure to Notify Physician and Representatives of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative in a timely manner after a significant change and failure to immediately notify a physician and representative when a resident developed tachycardia. One resident had been admitted with a determination by two physicians that the resident was incapable of making all medical decisions. A podiatry consult dated 08/28/2025 documented that the resident refused to be seen by the facility podiatrist, who informed the nursing unit manager and requested that nursing staff call the resident’s representative about the refusal. A nursing progress note later completed by the unit manager on 10/31/2025 documented that the resident refused care on 08/28/2025 by telling staff to stop and leave them alone, but there was no indication that the resident’s representative was notified at the time of the refusal. The corporate DON confirmed that the representative was not notified when the refusal occurred. The second deficiency involved another resident with chronic respiratory failure, a gastrostomy tube, ventilator dependence, seizure disorder, and multiple sclerosis, who was totally dependent on staff for all care. The facility’s policy on physician notification of a change in condition required nursing staff to report changes in condition to the physician and responsible family members and to notify the physician of abnormal vital signs, including a resting pulse rate greater than 100 beats per minute. A respiratory therapist’s note on 12/25/2025 documented that this resident’s heart rate was 120 beats per minute, irregular, and a new onset, and that the attending RN on day shift was notified of the tachycardia. The MAR showed that an LPN administered Metoprolol at 9:00 a.m. the same day and documented a blood pressure of 140/78 with a pulse of 120 beats per minute, but there was no documentation that the physician or the resident’s representative was notified of the abnormal heart rate, and the LPN could not recall being informed of or documenting the elevated pulse.
Advance Directive Offer Not Documented
Penalty
Summary
The facility failed to provide residents or family representatives with an opportunity to formulate an Advance Directive for 6 of 9 residents reviewed during the recertification survey: Residents #5, #6, #18, #37, #50, and #56. During medical record reviews on 07/31/25, the surveyor was unable to locate an Advance Directive or any evidence that an Advance Directive had been offered to each of these residents or their family representatives. On 08/05/25, the Social Services Director stated that residents or family representatives are offered the opportunity to formulate an Advance Directive at admission and that refusals are documented in a progress note. The Social Services Director later stated that, for Residents #5, #6, #18, #37, #50, and #56, the residents or family representatives were verbally offered the opportunity to formulate an Advance Directive, but Social Services could not locate evidence that the offer had been made and did not document that the residents or their family representatives were offered the opportunity.
Kitchen Sanitation, Dishwashing, and Food Storage Deficiencies
Penalty
Summary
The kitchen failed to maintain sanitary conditions during survey observations. During the initial tour, a staff member was washing dishes in the 3-compartment sink while a large puddle of water was on the floor nearby, and a fly was observed in the area along with several knats flying around. On a follow-up visit, another large puddle of standing water was observed near the entrance doorway inside the kitchen, and the Dietary Manager and Administrator were made aware of the observation at that time. The dishwashing and food storage areas also showed additional concerns. Dirty dishes with food particles and debris were observed on two silver carts near the dishwasher, and the Dietary Manager stated they had been there from the previous evening and would be washed that morning. The low-temp dishwasher was run multiple times, with wash temperatures observed at 115 degrees F and rinse temperatures at 130 degrees F, then 120 degrees F on repeated cycles, before a later observation showed wash at 138 degrees and rinse at 128 degrees F. In dry storage, a full gallon jug of Browning and Seasoning Sauce had a best buy date of April 11, 2025, and in the walk-in freezer there was a long ice cycle hanging from the sprinkler.
Inaccurate matrix, missing tube feeding documentation, outdated infection control status, and incomplete restorative splint records
Penalty
Summary
The facility failed to accurately reflect resident information on its facility matrix across three submissions reviewed by the survey team. During the entrance conference, the DON provided a copy of the matrix, but later review showed it did not accurately reflect the number of residents on transmission-based precautions and/or contact precautions, or the number of residents with pressure ulcers acquired prior to admission and/or after admission. When the concern was raised, the DON later provided additional copies of the matrix, and during discussion with the DON, unit manager, MDS coordinators, and regional staff, it was determined that MDS information had been unintentionally deleted each time the matrix was updated. The facility also failed to document the start time on the continuous tube feeding bag for one resident receiving tube feeding. During observation, the resident’s tube feeding bag had the resident’s name, date, and rate, but the time it was hung was missing. The resident’s nurse and the unit manager both confirmed that the time should have been documented on the bag. The next day, the DON again observed the same issue and was unable to locate the time the tube feeding had been started. The facility failed to update infection control status in the electronic medical record for three residents whose room doors displayed contact precaution signage. Review of the records showed active orders for enhanced barrier precautions for each resident, while staff told the surveyor the residents were on contact precautions due to the same MDRO. The surveyor and facility staff confirmed the records should have been updated to reflect contact precautions for the specific MDRO. In addition, the facility failed to initiate and document restorative splinting and range-of-motion services for one resident with bilateral hand contractures. The resident was observed with contractures in both hands, the record did not show documentation of the contractures or resident-specific equipment, and the restorative binder did not include hand ROM or interventions for the contractures. Therapy notes showed a splint and brace program and ROM program had been established for restorative nursing, but the resident’s record did not contain an order for bilateral resting hand splints until a late entry was made, and documentation of ROM exercises and splint application by restorative staff was not found.
Delayed Annual In-Service Training for GNAs
Penalty
Summary
The facility failed to ensure Geriatric Nursing Assistants completed required annual in-service training in a timely manner. During record review of 4 GNA employee files, 3 files for GNA #16, #31, and #34 did not show timely completion of annual in-service training courses due every 12 months for 2024 and 2025. During interview, the Regional Clinical Nurse provided a Student Assignment Completion Report covering 1/1/2024 through 8/6/2025, which showed that these 3 GNAs had incomplete required in-service training for 2024 and 2025. The surveyor noted the trainings were past due or completed late, and no further documentation was provided at exit regarding completion for these GNAs.
Failure to Timely Update Care Plan for Contractures and Infection Control
Penalty
Summary
The facility failed to ensure that a person-centered care plan was reviewed and revised in a timely manner for a resident with specific clinical needs. The resident, who had contractures in both hands and was participating in the Restorative Nursing Program, was observed with hand contractures and the use of bilateral hand splints. However, the care plan did not initially include any problem, goal, or intervention addressing the contractures or the use of splints, despite staff providing these interventions. The care plan was only revised to include these details after the surveyor's observation, rather than at the time the needs were identified by staff. Additionally, the same resident was placed on contact precautions due to the presence of a multidrug-resistant organism (MDRO) as indicated by a rectal screen. Although a sign was posted on the resident's door and staff were aware of the contact precautions, the care plan did not reflect the resident's infection control status or appropriate interventions until after the surveyor's review. The care plan was not updated to address the resident's MDRO status and required precautions until well after the laboratory results were available and the precautions were implemented.
Unsafe Room Conditions Observed on 3rd Floor
Penalty
Summary
The facility failed to provide a safe environment in residents' rooms, as identified during observation and staff interviews. During the initial observation of the 3rd floor, multiple areas of identifiable wall damage were found in three of 26 rooms observed, including baseboards coming off the walls and door protectors that were cracked and peeling off the doors. When the DON later accompanied the surveyor to review the damaged areas, she observed the needed repairs and stated she would notify maintenance, while also taking pictures of the areas reviewed and sending them to her team.
Missing and Unfollowed Care Plans for Discharge, Oral Hygiene, Transfers, and Insomnia
Penalty
Summary
A comprehensive care plan was not developed for Resident #14 to address discharge planning and the resident’s preference for future discharge to the community. The resident was observed in bed with a trach and was non-verbal, but could communicate by shaking her head yes or no, sign language, and writing on a white board. The resident’s sister stated that she wanted the resident to live with her in an apartment and serve as the primary caregiver, and also stated that discharge to the community had not been discussed during care plan meetings. Review of the electronic medical record and interviews with nursing and social services staff showed no discharge planning care plan in place and no discussion of discharge planning during the June care plan meeting or during July or August 2025. A comprehensive care plan was also not developed or implemented for Resident #34’s oral hygiene needs while the resident was on NPO status. Record review showed no order for oral hygiene care, no documentation on the TAR for oral hygiene care, and no care plan interventions addressing oral hygiene care related to long-term NPO status. When asked to locate the order and documentation, the nurse was unable to do so and stated she would speak with the doctor about adding the order back on. Resident #3’s care plan was not followed regarding transfers out of bed. The resident stated that it had been about two weeks since getting up to the chair after a fall during a Hoyer lift transfer, and the resident said lying in bed for long periods caused discomfort. The resident was observed in bed during subsequent observations. The fall investigation showed that during a Hoyer lift transfer with two GNAs, the resident tried to get out of the lift pad and was assisted to the floor. The care plan included an approach to ensure the resident was calm before using the Hoyer lift, and the DON later confirmed that staff were to follow the care plan and use the Hoyer lift to transfer the resident out of bed. Resident #72 also did not have a person-centered care plan for insomnia despite an active diagnosis of insomnia and MAR documentation showing nightly administration of mirtazapine and melatonin for insomnia and appetite stimulation. The DON confirmed that the resident was not care planned for insomnia.
Failure to Provide Ordered Oral Hygiene Care for an NPO Resident
Penalty
Summary
The facility failed to provide oral hygiene care to a resident who was NPO. During observation, the resident was noted to have bad-smelling breath, a very dry mouth, and cracked lips. On a later observation, the resident was alert and smiling, but the lips remained dry and cracked. Staff interviews showed that a GNA stated oral care was provided during morning ADLs and again in the afternoon, while a nurse stated oral hygiene was provided at least once per shift. Record review did not show an order for oral hygiene care in the resident’s chart, and the TAR also did not contain any oral hygiene order. The care plan did not include interventions for oral hygiene related to the resident’s NPO status. When asked to show the order and documentation for oral hygiene care, the nurse was unable to locate either and stated she was going to speak with the doctor about adding the order back on.
Meals Not Palatable or Properly Prepared
Penalty
Summary
Food and drink were not prepared in a palatable, attractive, or appetizing manner for residents who were interviewed and observed during meal service. One resident stated the food “just isn’t that good” and reported not eating most meals, while another resident said the food was terrible, had no taste, and was either undercooked or overcooked. The second resident also reported that they often received the same foods they did not like and usually chose an alternate lunch such as a salad or peanut butter and jelly sandwich. During a lunch observation, the second resident was seen not eating the meal provided and had already eaten only the salad and some broccoli. The resident stated the broccoli was too hard to eat, especially because they did not have many teeth. Another resident later complained that lunch included country-fried steak that was tough and slightly burnt, mashed potatoes without gravy, and broccoli that was hard and not cooked enough. A sampled lunch tray also contained a smothered pork chop in gravy, mashed potatoes without gravy, and broccoli; the pork chop was tough, hard to cut, and very chewy, while the broccoli was not cooked thoroughly, hard when chewing, and had no taste, and the mashed potatoes had no taste.
Failure to Follow Isolation Precautions
Penalty
Summary
The facility failed to ensure infection control and prevention policies and procedures were carried out by its employees for one resident reviewed for infection control. During a tour of the 2nd floor clinical unit, Resident #86 was observed lying in bed with the room door open while an employee was speaking with the resident. Two isolation signs were posted on the room door for contact isolation and enhanced barrier precautions. Staff #26, a physical therapy assistant, was observed speaking with Resident #86 without wearing an isolation gown and was also observed touching the resident’s linens during the interaction. A review of the electronic medical record showed that both Resident #8 and Resident #86 were on contact and enhanced barrier precautions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hidden Waters Rehabilitation And Wellness Center | 0.2 mi | ★★★★★ | 30 | 0 |
| Autumn Lake Healthcare At Bradford Oaks | 1.2 mi | ★★★★★ | 8 | 0 |
| Forestville Rehabilitation And Wellness Center | 5.8 mi | ★★★★★ | 44 | 0 |
| Ft Washington Rehabilitation And Wellness Center | 6.1 mi | ★★★★★ | 35 | 0 |
| Serenity Rehabilitation And Health Center Llc | 7.1 mi | ★★★★★ | 2 | 0 |
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