Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa Rosa Nursing And Rehabilitation, Llc during CMS and state inspections, most recent first.
Lack of Qualified Full-Time Food and Nutrition Oversight: The facility did not have a qualified full-time person overseeing food and nutrition services. The FSM was on extended medical leave, and the Administrator stated he and a remote dietician were overseeing meal services and kitchen operations even though he was not certified in food service management. The onsite RD and a FSM from a sister facility were each present only once per week for 8 hours.
Facility staff failed to conduct and document routine inspections of resident bed frames, mattresses, and bed rails. Surveyors reviewed maintenance logs and found they reflected various repairs but did not show the required monthly bed inspections. The Administrator stated that routine inspections were not being conducted, and the DON provided a policy that included a 12-point monthly bed inspection checklist.
Unsafe and unsanitary hallway conditions were observed throughout 8 of 8 hallways on both floors, including broken, missing, sagging, and damaged ceiling tiles; missing access panel covers; patched but unfinished drywall; black stains; and dirty or damaged vents, light fixtures, and speaker covers. Air handler units in multiple wings, including the Solarium, had thick dust on intake panels and black substance on louvers and surrounding surfaces. In the 1st floor A wing, a dried black substance was seen on the wall and fire exit door, which the Maintenance Assistant said was old oil and sediment from an HVAC leak after a pipe burst; the DON also observed an air handler unit and said it needed cleaning.
A resident was discharged after rehab goals were met and insurance stopped payment, but the facility did not have a written transfer/discharge notice in the medical record. Staff said the resident received the insurer denial letter and was told discharge would occur if payment was not continued, but the required discharge notice with reason, effective date, location, and appeal rights was not documented in the chart.
Missing Nursing Staff Competency Evaluations: The facility failed to ensure nursing staff had documented competency skill evaluations. Review of staff files showed 5 GNAs had online annual training documented through Relias, but no return demonstration skill competencies were found. The ADON stated she did not conduct annual return demonstration competency training for GNA staff and only addressed skills when care issues were brought to her attention. A Regulation Specialist confirmed there were no documented return demonstration competencies for nursing staff over the past year.
Improper Food Storage and Dishwashing Temperatures: Surveyors found multiple opened, undated, unsealed, and expired food items in the walk-in and reach-in refrigerators, along with opened freezer items that were not resealed. They also observed ice buildup in the freezer and measured dishwashing water temperatures below the facility’s required 110°F minimum while the dishwasher was out of service and dishes were being handwashed.
Failure to Prevent Waterborne Pathogens and Protect Clean Linens: The facility did not have measures in place to prevent Legionella or other opportunistic waterborne pathogens in the water system. The IP confirmed no known cases, while the Maintenance Director stated there was no water treatment, no Legionella testing, no mixing valves, and domestic water was heated to about 120 degrees F before distribution. The facility also left clean linens uncovered in the clean linen area beneath a large ceiling hole exposing pipes, dust, and drywall.
Surveyors identified multiple failures to meet professional standards, including unsecured medication carts and visible resident health information left on unlocked computers, a physician-ordered CBC that was never completed, and inadequate behavior monitoring and documentation for several residents with psychiatric or dementia-related diagnoses who were receiving psychotropic medications. Staff acknowledged that behavior episodes documented on the TAR should be followed by detailed progress notes and, when indicated, SBAR assessments, but such documentation was missing despite repeated behavior entries and ongoing antipsychotic use. In addition, a resident was found wearing a Lidocaine transdermal patch without any physician order or MAR documentation, contrary to facility policy requiring valid orders and recorded application sites for all medications, including patches.
The facility failed to document COVID-19 vaccine education, offer, and refusal for 4 of 5 residents reviewed. Record review showed no 2025 documentation of vaccine administration or refusal for several residents, and the IP stated that while the vaccine is offered annually and education is provided, refusals are not documented when a resident declines after education.
Surveyors identified dignity concerns involving two residents when staff failed to follow expected practices for privacy and communication. In one case, a GNA entered a resident’s closed room without knocking or introducing herself, contrary to the DON’s stated expectation that staff knock, wait for a response, and greet the resident upon entry. In another case, a resident reported feeling anxious, offended, and disrespected because a GNA primarily used hand gestures and pointing instead of verbal communication during care; this concern was echoed by the resident’s POA and documented in a psychiatric note, and the Administrator confirmed that the GNA had used non-verbal communication in this manner.
Surveyors identified a failure to maintain a sanitary and safe environment when large, unrepaired holes were found in the ceilings of the laundry drying area and clean linen folding room, exposing pipes, dust, and drywall near clean clothing and linens. The Maintenance Director reported long-standing building leaks, stated that the ceiling openings were created to access plumbing for repairs, and acknowledged that they remained open due to limited maintenance staffing and delayed full plumbing replacement related to budget and other priorities. The Administrator acknowledged the environmental concerns associated with the ongoing leaks and resulting ceiling damage.
A resident reported to an RN Unit Manager, with a social work staff member present, that a GNA failed to change the resident’s brief after a request for care, but this allegation was not relayed to leadership or reported to OHCQ within the required two-hour window; instead, the Administrator only became aware after receiving a family letter and then filed the report. In a separate issue, the NHA acknowledged that an HVAC heating system serving two solariums had malfunctioned weeks earlier, with only one repair estimate obtained and no timely notification made to OHCQ until the day surveyors arrived and discovered the lack of heat in the usual survey room.
The facility failed to prevent potential abuse or neglect during an active investigation when a GNA accused of neglecting a resident was allowed to return to work before the investigation was completed. Although the Administrator initially suspended the GNA and reported the allegation to the state agency, the GNA was brought back on duty while key RN witness statements were still being collected as part of the ongoing investigation. This resulted in the accused staff member resuming resident care responsibilities prior to the formal completion of the neglect investigation.
The facility failed to provide a written bed-hold notification to a resident or representative at the time of a hospital transfer following a fall, despite having a policy requiring that a bed-hold form be given whenever a resident is transferred out. In addition, the facility did not notify the local ombudsman in a timely manner about the discharges of two residents—one who was sent to the hospital and did not return and another who expired in the facility—with notifications instead occurring later by e-mail.
Failure to provide required Medicare non-coverage notices to a resident. A resident who had been discharged from Medicare Part A services but still had benefit days remaining and planned to stay in the facility for non-skilled care did not receive the SNFABN or NOMNC. The BOM confirmed there was no record that the required notices were issued.
A resident’s care plan addressed nutrition and ADLs, but it did not include specific interventions for dehydration risk despite an order for 300 mL oral fluids every shift to be provided by an LPN. The resident had a BIMS score of 02, was on a mechanically altered diet, and had received ST services, yet the care plan lacked individualized fluid-management approaches.
Missed Quarterly Care Plan Meetings: The facility failed to ensure quarterly care plan conferences were held for 3 residents. Records and staff interviews showed one resident had a long gap between meetings, another had only two meetings after admission with no other 2025 conferences, and a third resident missed a scheduled meeting after discussing possible discharge home. SSA confirmed the meetings were missed and that the residents fell through the scheduling process.
Failure to date and document wound care for a resident with a Stage IV sacral PU. A resident with a chronic sacral PU had a dressing observed without a date, and the Wound Nurse and DON confirmed dressings should be dated when applied. The resident’s daily wound tx order was also not signed off on multiple occasions in the TAR, despite the ADON stating wound care must be documented and signed off after completion, including wound appearance details.
Medication administration errors exceeded the allowed rate during a med pass observation, with 2 residents affected and a 10.34% error rate. An RN crushed and administered meds to a resident without an order to do so, and an LPN gave only one puff of Advair instead of two, failed to offer a mouth rinse, and applied Balsam Peru Castor oil to the resident’s fingers only instead of fingers and toes as ordered.
Medications and biologicals were found improperly stored and labeled in medication carts and a med room. An RN and an LPN observed multiple resident-specific meds and OTC items open without resident identification or documented open dates, a Glucagon Emergency Kit with its label torn off, and expired sponge swabs in the med room. The DON stated nurses are expected to label opened bottled and OTC meds and monitor expired items.
Incomplete Documentation of Elevated Blood Glucose Notifications: A resident with DM II had multiple FSBS readings above the ordered parameters, but the medical record did not contain progress notes showing provider notification or documentation of how the resident was treated. An LPN stated the process was to notify the Unit Nurse Manager and contact the provider through eMedicall, and the DON confirmed the facility could not provide proof of notification or treatment documentation for the elevated BGL readings.
Nonfunctional Heating in B-Wing Solariums: The facility failed to keep the 1st floor B-wing Solarium and 2nd floor Solarium adequately heated. Surveyors found the usual survey room without heat, portable heaters that repeatedly lost power when the breaker tripped, and a wall unit that did not effectively heat the area. Residents were observed exercising to music in the cold 2nd floor Solarium, while the NHA acknowledged the HVAC malfunction and delay in obtaining required repair estimates.
The facility failed to accommodate resident needs, as observed by surveyors. A resident was found without access to a call light, and another was left suspended in a Hoyer lift sling by a single staff member. The chapel was inaccessible due to storage, preventing services. A resident's call bell went unanswered for 25 minutes, and another was left waiting in a wheelchair for assistance. A resident expressed frustration over delays due to the unavailability of a Hoyer lift. The DON acknowledged these issues.
Surveyors observed multiple deficiencies in the facility, including damaged walls, hazardous power cords, and unclean environments in resident rooms and shower areas. A resident's room had a broken light fixture, and another had insects in the bathroom light. Staff interviews revealed awareness of these issues, but maintenance was limited by staffing constraints.
The facility failed to report abuse allegations and serious injuries within the required timeframe. Multiple residents experienced delayed reporting of abuse incidents, including rough care and mishandling of medical equipment. Additionally, a resident's serious injury was not reported to the State Survey Agency within the mandated 2-hour period, leading to a deficiency in timely reporting.
The facility failed to thoroughly investigate abuse allegations and prevent further potential abuse. Investigations into incidents involving several residents lacked interviews with other residents and formal statements from staff. Additionally, a GNA continued working after an abuse allegation without suspension. Other cases showed incomplete investigation files and missing interviews, indicating a pattern of inadequate response to abuse allegations.
The facility failed to develop and implement person-centered care plans for residents with specific medical needs, including epilepsy, chronic pain, seizures, and skin conditions. A resident with epilepsy did not have a care plan for their seizure disorder or medication monitoring. Another resident's care plan for chronic pain was outdated and did not include opioid use. A resident with a history of seizures lacked a seizure care plan despite experiencing seizures in the facility. Additionally, a resident with a pressure ulcer and fungal rash did not have a care plan addressing these conditions.
A resident was left waiting in a wheelchair for over 40 minutes due to the unavailability of a Hoyer lift, impacting their dignity and ability to participate in activities. The call bell system was also noted to alarm for long periods without response, as confirmed by the DON.
A facility failed to accurately assess a resident's seizure diagnosis during an annual survey. The resident, admitted with a history of seizures and prescribed lamotrigine, did not have seizures listed in the active diagnoses on the admission MDS assessment. The MDS Coordinator acknowledged the omission, attributing it to a potential data entry error.
A facility failed to accurately dispense and record oxycodone for a resident as per the scheduled ordered time. The resident's MAR showed that the medication was documented as given on time only twice between early and late November, with multiple instances of late documentation and two blank sign-offs. Interviews with staff revealed inconsistencies in documentation practices, and the DON acknowledged the discrepancies.
Lack of Qualified Full-Time Food and Nutrition Oversight
Penalty
Summary
The facility failed to have a qualified full-time staff person to oversee food and nutrition services. Review of anonymous complaint #2963054 identified concerns about menus, scheduled meal times, and alternate food items. During interview, the Administrator stated that the Food Service Manager was out on extended medical leave since 1/29/26 and that the facility was using a dietician, who was in the facility once per week. He also stated that he and a remote dietician were overseeing meal services and day-to-day kitchen operations, and he confirmed that he was not certified in food service management. A schedule provided by the facility showed that a Registered Dietician was onsite once per week for 8 hours and a Food Service Manager from a sister facility was onsite once per week for 8 hours. The facility therefore did not have a qualified full-time staff person to oversee food and nutrition services for residents.
Failure to Conduct and Document Routine Bed Inspections
Penalty
Summary
Facility staff failed to conduct regular inspections of resident bed frames, mattresses, and bed rails, and the facility did not maintain records showing that routine bed inspections were completed. Review of anonymous complaint #2963504 led surveyors to request the facility’s bed inspection logs. The Administrator stated that routine inspections were being done but that the facility had not kept very good records. During interview, the DON and Administrator provided maintenance logs dated from 1/2025 through 4/8/2026, which showed various repair concerns for equipment and other areas, but did not reflect routine inspection of the facility’s beds as required. The Administrator stated that maintenance checked bed motors when making repairs and confirmed that maintenance was not conducting routine inspections of the beds. The DON also provided the facility policy and procedure for equipment and utilities management, which included a checklist for a 12-point monthly bed inspection.
Unsafe and Unsanitary Hallway Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in 8 of 8 resident hallways observed on both floors of the building. During a tour of the A, B, C, and D wings, surveyors observed broken, damaged, sagging, and missing ceiling tiles; missing covers over ceiling access panels; damaged or patched plaster/drywall ceilings that had not been painted or sealed; black stains and other discoloration on plaster/drywall and tile ceilings; and dirty, stained, or damaged ceiling fixtures, including vents, light fixtures, and speaker covers. Square ceiling air handler units located at intervals in several hallways, including the Solarium on the 2nd floor B wing, had intake panels covered with thick brown/gray dust-like substance. Black substance ranging from fine speckles to solid lines and patches was observed on the outflow louvers and on surrounding ceilings and fixtures. On the 1st floor A wing, a dried black substance was observed on the wall and fire exit door, extending from above the door for approximately 7 feet toward a resident room, with pea-sized dried drip points on the underside of the door frame and emergency exit light. Staff #9, the Maintenance Assistant, stated the black substance was old oil and sediment that leaked from the HVAC system when a pipe burst in January 2026, and acknowledged the water-damaged ceilings, missing and damaged tiles, unfinished patches, and the need to clean the air handler units. The DON also observed an air handler unit and indicated it would need to be cleaned.
Missing Written Discharge Notice in Resident Record
Penalty
Summary
The facility failed to include a copy of the written notification of transfer or discharge in Resident #4’s medical record. Resident #4 was admitted in early February 2026 following an acute hospitalization and was discharged from the facility in late March 2026. Review of the record did not reveal evidence that the resident was provided a written discharge notice before discharge, including the reason for the discharge, the effective date, the location of discharge, and appeal rights. During interview, the Social Service Assistant stated that Resident #4 had been told the rehabilitation goals had been met and that the insurance company denied further payment after 3/17/28, after which the resident would be discharged or would need to pay to remain at the facility. The resident was given a copy of the insurance denial letter, but the facility had not provided a written discharge notification. The Nursing Home Administrator later stated that a discharge notice had been given based on the insurance denial, but the notice was not found in the medical record during the survey and was not signed by the resident.
Missing Nursing Staff Competency Evaluations
Penalty
Summary
The facility failed to ensure that all nursing staff had competency skill evaluations. Based on review of staff records, 5 Geriatric Nursing Assistants (GNA #2, GNA #3, GNA #6, GNA #7, and GNA #18) were identified as having annual training documented through online Relias training for the mandated 12 hours, but the records did not show return demonstration skill competency evaluations for these staff members. During interview, the ADON stated that she does not conduct annual return demonstration skill competency training with GNA staff and only provides skill competency training when a problem with care is brought to her attention. She said she uses a skill checklist at that time if the skill is not done correctly. When asked about RN or LPN return demonstration competencies, she stated she would look for sign-in sheets for the in-service. A Regulation Specialist confirmed there had been no documented return demonstration skill competencies for all nursing staff over the last year and was unable to find any in-service sign-in sheets for return demonstration skills competency training.
Improper Food Storage and Dishwashing Temperatures
Penalty
Summary
The facility failed to store food in a manner that maintained professional standards of food service safety in the kitchen. During a kitchen tour with the Dietary Manager, surveyors found multiple food items in the walk-in refrigerator that were opened, undated, unsealed, or expired, including a Vital Cuisine Mighty Shake past its use-by date, tuna fish in a plastic container without an opening date or expiration date, two strawberry pies wrapped in plastic without dates, a cup of fruit and a cup of pureed fruit without production or expiration dates, and sliced cheese removed from original packaging and not labeled. In the reach-in refrigerator, an opened package of Block and Barrel Fully Cooked Ham had a facility sticker with a use-by date that had already passed. The Dietary Manager stated that anything opened should be rewrapped and labeled with an expiration date. In the freezer, surveyors observed several opened items that were not resealed, including a box of Ravioli Cheese, a box of Oven Ready Par-fried Alaska [NAME], and [NAME] Dumpling Squares. The Dietary Manager confirmed these items should have been sealed after opening and labeled with an expiration date. Facility policies reviewed by surveyors stated that foods removed from original packaging are to be stored in a closed container or tightly wrapped package and labeled with the common name and date opened, and that refrigerated ready-to-eat TCS foods are to be properly covered, labeled, dated with a use-by date, and refrigerated immediately. Surveyors also observed ice buildup in the freezer, including clumps of ice on the floor, frozen drops of water hanging from the ceiling, and ice cycles hanging from a box lid under the freezer fan. The Dietary Manager attributed the ice issues to a late shipment and staff being in and out of the freezer, while the NHA later stated he thought the buildup may be due to the door being left open often and said maintenance would look at it. In addition, the facility dishwasher had been inoperable since November because of a clogged drainage pipe, so dishes were being handwashed. Water temperatures measured during dishwashing were 91.3 degrees Fahrenheit in the sink, 104 degrees after running fresh hot water, 100.4 degrees during washing, and 108 degrees at the spigot, while the facility's manual cleaning policy required detergent solution of at least 110 degrees Fahrenheit in the first sink.
Failure to Prevent Waterborne Pathogens and Protect Clean Linens
Penalty
Summary
The facility failed to implement measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building’s water systems. During interviews, the Infection Preventionist confirmed there had been no reported cases of Legionella or other opportunistic waterborne pathogens at the facility. The Maintenance Director stated that the facility does not use any water treatment and does not conduct water testing for Legionella or other waterborne pathogens. He also confirmed that the water system does not have mixing valves and that the boiler heats domestic water to approximately 120 degrees Fahrenheit before it is distributed throughout the building for resident use, with water temperatures likely decreasing before reaching resident areas. The Administrator later confirmed that the facility had not had outside testing performed for Legionella or other opportunistic waterborne pathogens and acknowledged the concern that preventive measures were not in place. The facility also failed to ensure proper storage of clean linens. On observation, a large hole in the ceiling was seen in the clean linen room directly above the area where clean clothes were being folded, exposing pipes, dust, and drywall. On a later observation in the Laundry Room clean linen area, two bins of clean linens were left uncovered directly beneath a large hole in the ceiling that exposed pipes, drywall, and dust. When shown photographs of the observation, the Housekeeping Services Manager confirmed understanding of the concern and stated he would address the issue and review expectations with laundry aide staff regarding keeping clean linens covered.
Multiple Failures in Medication Management, Order Implementation, and Behavior Monitoring
Penalty
Summary
The deficiency involves multiple failures to meet professional standards of quality related to medication security, protection of resident health information, implementation of physician orders, behavior monitoring, and medication administration. During early morning rounds on the first floor, a medication cart on B-Wing was observed unlocked and unattended, and an unlocked laptop displaying resident-specific information was left at the doorway of a resident room. During a medication pass with an RN, the medication cart and computer screen were repeatedly left open, unlocked, and unattended in various rooms and in the first-floor lobby, with resident information visible. On a later date, another medication cart on the second floor B-Wing was also observed open and unattended. The RN and an LPN both acknowledged that facility expectations require medication carts and computer screens to remain locked when not in use. Another deficiency involved failure to implement a physician order for a diagnostic test. A physician ordered a Complete Blood Count (CBC) for a resident with pneumonia to monitor the resident’s condition and guide treatment. A subsequent medical record review showed that this laboratory order was not carried out as written. The ADON explained that physicians enter lab orders, nurses transcribe them, and the 11:00 PM–7:00 AM shift is responsible for ensuring completion of lab tests unless the order is STAT. The ADON later confirmed that the CBC for this resident was not completed as ordered and stated that the reason for the failure was unknown. Additional deficiencies were identified in behavior monitoring and documentation for residents with psychiatric or behavioral diagnoses and those receiving psychotropic medications. One resident with depression, anxiety, and insomnia had an order for behavior monitoring every shift, and the TAR showed multiple dates and shifts with documented behavior frequencies, including a high number of behaviors on one date; however, there were no corresponding progress notes describing the types of behaviors or interventions used. Facility staff stated that when behaviors are documented on the TAR, it is the process to write a progress note describing the behaviors and interventions, and to complete an SBAR and notify the provider if behaviors persist or are new. The DON confirmed that progress notes should be written when behaviors escalate and that the TAR only records the number of episodes, not the behavior details, and could not explain the absence of progress notes for the documented behavior episodes. For another resident receiving Duloxetine, Escitalopram, and Olanzapine for depression and anxiety, review of the MAR showed that the medications were administered as ordered, but there was no documentation of behavior monitoring or effectiveness monitoring for the antipsychotic therapy. The ADON stated that effectiveness is to be monitored using behavior monitoring flow sheets and progress notes, but review of the record confirmed that no such documentation existed for this resident despite ongoing psychotropic use. A further resident with vascular dementia with psychotic disturbance, mood disturbance, and anxiety, and known behaviors such as yelling and screaming at others and a preference for personal space, had no documented behavioral assessment, no behavior monitoring tool in place, and no care plan interventions addressing these behaviors in the medical record. A separate deficiency involved improper medication administration when a resident was found with a Lidocaine patch on the mid-back that had been dated the previous day. The wound nurse identified the patch as a Lidocaine patch, but review of the resident’s medication orders and medical record revealed no physician order for a Lidocaine patch and no documentation of its application. The unit manager confirmed that the resident had a Lidocaine patch without a corresponding physician order, and the DON confirmed that the resident should not have had the patch because a physician order is required and administration must be documented on the MAR. The facility’s Nursing Policies and Procedures: Medical Management Program require documentation of medications administered according to state and federal requirements, including correct physician orders and diagnoses for each medication, and specify that for transdermal patches the application site must be documented and sites rotated, which was not done in this case.
Failure to Document COVID-19 Vaccine Education, Offer, and Refusal
Penalty
Summary
The facility failed to educate and offer the COVID-19 immunization to residents, as evidenced by 4 of 5 residents reviewed for vaccination status. Record review showed that Residents #3, #4, #6, and #56 had no documentation of COVID-19 vaccine administration or refusal for 2025, with their last documented COVID-19 vaccines occurring on 04/04/2022, 11/20/2024, 10/08/2022, and 11/13/2021, respectively. During interview, the Infection Preventionist stated that she offers the vaccine to all residents each year and begins offering COVID-19 vaccines in October for the 2025-2026 season, and that education is provided when the vaccine is offered. She also stated that refusals are not documented when a resident declines after receiving education and was unable to explain this practice.
Failure to Maintain Resident Dignity and Respectful Communication
Penalty
Summary
The deficiency involves failure to ensure resident dignity and respect for personal privacy and communication rights for two residents. In the first instance, a GNA entered a resident’s closed room without knocking or introducing herself while surveyors were present. When questioned immediately afterward, the GNA was unable to explain why she had entered without knocking or greeting the resident. The DON later confirmed that facility practice and expectations require all staff to knock, wait for a response or check for visitors, and then greet and introduce themselves and state their purpose every time they enter a resident’s room. In the second instance, a resident reported feeling mistreated and disrespected by a specific GNA who, according to the resident, communicated by pointing and using hand gestures instead of speaking. The resident stated this made him/her feel anxious, offended, and disrespected, and reported the concern to a family member, who then reported it to the facility. The facility’s investigation file documented that the resident’s POA reported the same concerns, and that the GNA acknowledged using both verbal and non-verbal communication, including hand gestures, with the resident. A psychiatric note documented that the resident felt anxious when a particular staff member provided care and that this staff member used hand gestures instead of verbal communication. The Administrator confirmed that the facility substantiated that the GNA used non-verbal communication with the resident, and acknowledged that this caused the resident to feel anxious, offended, and disrespected, constituting a dignity concern.
Unrepaired Ceiling Damage and Exposed Infrastructure in Laundry and Linen Areas
Penalty
Summary
The facility failed to ensure adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and safe environment, particularly in areas used for handling clean laundry and linens. During the annual survey’s Infection Control review, a surveyor observed a large hole in the ceiling of the laundry room in the clean clothes drying area, with exposed pipes, dust, and drywall. A similar large hole was observed in the ceiling of the clean linen folding room, also exposing pipes, dust, and drywall, with a ceiling fan located near the edge of the hole. These conditions were directly observed and photographed by the surveyor. In an interview, the Maintenance Director reported that there have been ongoing leaks in the building since 2014 and that leaks are repaired as they occur, but a full plumbing replacement has been delayed due to budget constraints and other priorities. He stated that the holes in the ceilings were created to access plumbing for repairs and confirmed that they remained open due to limited maintenance staffing, which prevented timely repair of the ceilings with drywall. The Maintenance Director verified that the holes in the laundry/dryer room ceiling were created the previous week for a leak repair and that the holes in the clean linen room ceiling were created in December for a separate leak. The Administrator acknowledged environmental concerns related to the ongoing leaks and resulting ceiling holes during an interview.
Failure to Timely Report Neglect Allegation and HVAC System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe. A resident reported to the RN Unit Manager, with a Social Worker Assistant present, that a GNA had failed to change the resident’s brief after the resident requested assistance, instead covering the resident with a blanket and leaving. This interview occurred on 10/27/2025, and the resident indicated the incident had occurred approximately three weeks earlier, though the exact date was not recalled. The RN Unit Manager acknowledged that the resident reported the aide did not change him and that she spoke with the ADON after the interview. Despite this, the Administrator and ADON later stated they were not aware of the 10/27/2025 interview or the resident’s allegation at that time. The Administrator reported that he first became aware of the concern when he received a letter from the resident’s family member on 10/29/2025. Based on that letter, the Administrator submitted an allegation of abuse/neglect to OHCQ on 10/29/2025 at 1:39 PM. As a result, the allegation communicated by the resident on 10/27/2025 was not reported to OHCQ within two hours of the facility becoming aware of it, and the required initial report was delayed until two days later, after the family’s written complaint. A second deficiency concerns the facility’s failure to timely report a malfunction of the HVAC heating system to OHCQ. On survey entry, staff informed the survey team that the usual survey room (the B-wing solarium) did not have heat, and the team was relocated. Review of a Facility Reported Incident showed the HVAC failure in the B-wing solariums on two floors was not reported to OHCQ until the evening of the same day the survey team arrived. The NHA later stated that the HVAC system had malfunctioned in early November 2025 and that an estimate for repair had been obtained on 11/14/2025, but no additional estimates had been secured and the malfunction had not been reported to OHCQ at the time it occurred. The NHA acknowledged both the delay in obtaining required repair estimates and the delay in reporting the heating system malfunction to the State Agency.
Staff Returned to Work Before Completion of Neglect Investigation
Penalty
Summary
The deficiency involves the facility’s failure to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation into an allegation of neglect was still in progress. An allegation of neglect was reported involving Resident #61 and a Geriatric Nursing Assistant (GNA #5). The Administrator submitted the initial report of the allegation to the Office of Health Care Quality on 10/29/2025 and later submitted the final investigation report on 11/04/2025. Documentation showed that GNA #5 was suspended on 10/29/2025 following the allegation. Record review on 01/07/2026 revealed that the investigation file contained statements from the RN Unit Manager and RN #30, both dated 11/04/2025, indicating that investigative activities were still occurring on that date. During interviews, the Administrator confirmed that the investigation was completed on 11/04/2025 but also confirmed that GNA #5 had been allowed to return to work on 11/01/2025. When questioned, the Administrator stated that by 11/01/2025 he had determined the allegation could not be verified and therefore permitted the employee to resume work. Surveyors identified that because key witness statements were not obtained until 11/04/2025, the investigation was still ongoing when GNA #5 returned to work, meaning the staff member accused of neglect was allowed to resume duties before the investigation was completed.
Failure to Provide Bed-Hold Notice and Timely Ombudsman Discharge Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold notification at the time of a resident’s transfer and failure to notify the local ombudsman of resident discharges. For one resident who fell while self-transferring from a wheelchair to a toilet and was subsequently transferred to the hospital via 911, the medical record contained a transfer summary and documentation that the family, on-call medical provider, and ombudsman were notified of the incident. However, there was no written copy of the facility’s bed-hold notification form in the resident’s medical record for that hospital transfer, despite facility policy requiring that a copy of the bed-hold form be given to every resident or representative at the time of transfer outside the facility. The deficiency also includes the facility’s failure to notify the local ombudsman of resident discharges in a timely manner for two residents. One resident was sent to the hospital and did not return, and another resident expired in the facility. Review of records and e-mails showed that the ombudsman was notified of these discharges and other discharges, hospitalizations, and admissions only later via e-mail, rather than at the time of the events. The Business Office Manager confirmed that the ombudsman had not been notified in a timely manner and stated she had not initially been aware that ombudsman notification was her responsibility.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to Resident #11 after the resident was discharged from Medicare Part A services but still had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. A review of the facility's SNF Beneficiary Protection Notification Review Worksheet showed that the resident's last covered day under Medicare Part A was 07/11/25 and that both the SNF Advance Beneficiary Notice (ABN) and the Notice of Medicare Non-Coverage (NOMNC) were not provided to the resident and/or resident representative as required. During interview, the Business Office Manager confirmed there was no record that the required SNF ABN or NOMNC had been issued for Resident #11.
Incomplete Care Plan for Dehydration Risk
Penalty
Summary
A comprehensive care plan was not developed and implemented for Resident #7 to address all identified needs. The record showed a medical order to encourage oral fluid intake of 300 mL every shift, with fluids to be provided by a Licensed Nurse every shift. However, the care plan reviewed on 01/12/2026 included goals related to nutrition and ADLs, with interventions such as monitoring and encouraging meal intake, offering an alternate if intake was less than 75%, providing assistance with meals and snacks as necessary, referring to OT for self-feeding review as needed, and assisting with eating, but it did not include specific interventions or approaches to manage the resident’s risk for dehydration. The resident’s MDS quarterly assessment dated 10/30/25 was triggered for a BIMS score of 02, mechanically altered diet (chopped, bite size), and speech therapy. The record also showed the resident received speech therapy services from 02/14/2025 through 11/14/2025. During the survey review, facility staff failed to develop and implement care plan interventions specific to the resident’s dehydration risk, despite the existing order for scheduled oral fluids and the resident’s assessed needs.
Missed Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that quarterly care plan meetings were provided for 3 of 26 residents reviewed for care plan meetings during the recertification survey. Care plan meetings are used to review and adjust a resident’s plan of care with the interdisciplinary team, including the attending physician, RN responsible for the resident, nursing assistant, dietary services, the resident, and the resident’s representative if applicable. The deficiency was identified through interview and record review for Resident #35, Resident #8, and Resident #1. Resident #35 denied having any recent care plan meetings during interview, and the medical record showed meetings on 8/20/2024, 5/27/2025, 8/29/2025, and 12/02/2025, with no documented meetings from 8/20/2024 through 5/07/2025. Social Services Assistant #8 confirmed that no additional care plan meetings occurred during that period and stated the meetings were missed. Resident #8 was admitted in April 2025 and had care plan meetings only on 5/07/2025 and 1/06/2026, with no other documented meetings in 2025; SSA #8 confirmed the resident missed quarterly meetings. Resident #1 reported the last care plan meeting was about 6 months earlier, and the care conference notes showed quarterly meetings on 07/01/2025, 03/18/2025, 11/27/2024, 10/08/2024, 06/11/2024, 3/19/2024, and 12/20/2023. SSA #8 stated Resident #1 had considered going home in October 2025, so a care plan meeting was not conducted and the resident fell through the scheduling crack.
Failure to Date and Document Wound Care for a Resident With a Stage IV Sacral Pressure Ulcer
Penalty
Summary
Facility staff failed to follow wound care procedures for Resident #22, who had a Stage IV sacral pressure ulcer that had been present since 12/2024 and was receiving ongoing wound care. During an observation with the Wound Nurse, the resident had a dressing over the sacral pressure ulcer that was not dated to show when it had been applied. The Wound Nurse stated that dressings should be dated when wound care is performed and new dressings are placed, and the DON confirmed that wound dressings are expected to be dated upon application. A review of Resident #22’s medical record also showed an order for daily wound treatment to clean the sacral wound with Dakin’s solution, pat dry, apply alginate calcium with silver, and cover with boarder gauze. The TAR showed that the daily wound treatment was not signed off as completed on April 26, 2025, November 23, 2025, December 20, 2025, and January 2, 2026. The ADON stated that wound care treatment requires orders, the orders should be signed off after wound care is completed, and the wound care should be documented with color and size. The facility policy reviewed stated that with each dressing change the clinician should observe and document general appearance, drainage, surrounding skin, wound odor, and all procedures performed and the resident’s response.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors exceeded the required rate of less than five percent during a medication pass observation, with 2 of 10 residents observed affected and 29 medication administration opportunities reviewed resulting in a 10.34% error rate. For Resident #16, RN #17 was observed crushing Tylenol 325 mg, two tablets, and pantoprazole 40 mg, one tablet, and administering them mixed in applesauce. The physician orders and MAR showed both medications were ordered by mouth at 6:00 a.m., with no order to crush them or mix them in applesauce. RN #17 confirmed the medications were crushed because the resident had difficulty swallowing, and also confirmed there was no physician order to crush the medications. For Resident #85, LPN #25 administered Advair HFA 45/21 mcg, which was ordered as two puffs by mouth twice daily with instructions to rinse the mouth after use, but only one puff was given and water for rinsing was not offered as ordered. The MAR was documented as if two puffs had been administered, and LPN #25 confirmed only one puff had been given. In a separate observation, the physician order for Balsam Peru Castor oil directed application to affected fingers and toes daily, but the ointment was applied only to the left and right fingers. The resident stated it was only applied to the fingers, and LPN #25 confirmed it was not applied to the toes as ordered.
Medications and Supplies Found Open, Unlabeled, and Expired
Penalty
Summary
Drugs and biologicals in the facility were not consistently labeled in accordance with accepted professional principles, and several medications were observed stored without resident identification or documented open dates. During a medication cart observation on the 1st floor C and D-Wing with RN #26, opened medications were found without documented open dates or resident identification, including Resident #70's Albuterol and Ellipta inhalers, Resident #10's Albuterol inhaler, Resident #9's Simethicone, and Resident #1's Albuterol inhaler. Additional opened items without identification or open dates included Calcium + D3, Vitamin C 1000 mg, Vitamin D 125 mg, Tylenol 500 mg, and a Glucagon Emergency Kit with the label torn off. In the 1st floor medication room, 10 FA Sponge Swabs were observed on the counter and were expired with an expiration date of 09/2025. On the 2nd floor A and C wing medication carts, RN #26 and LPN #4 observed additional resident medications open without documented open dates, including Latanoprost Ophthalmic for Resident #86 and Lactulose Solution for Resident #72, along with open unlabeled items such as Mucinex 12 hr OTC, Polyethylene Glycol 3350, Milk of Magnesia, and Mupirocin Ointment 2%. During interview, the DON stated nurses are expected to ensure bottled and OTC medications are labeled once opened and that expired medications are monitored and removed from carts.
Incomplete Documentation of Elevated Blood Glucose Notifications
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with a diagnosis of Diabetes Mellitus II. The resident had an order for finger stick blood sugar checks before breakfast and dinner, with instructions to notify the MD/NP if the blood glucose level was less than 70 mg/dL or greater than 200 mg/dL. Review of the Treatment Administration Record showed multiple blood glucose readings outside the ordered parameters, including 300, 215, 236, 210, 326, 207, and 221 mg/dL. Although an LPN stated that the facility process was to notify the Unit Nurse Manager, contact the medical provider through eMedicall, and document the provider response in the resident’s medical record as a progress note, no progress notes were found for the listed dates showing notification of the provider or how the resident was treated. The DON confirmed the facility could not provide proof that the provider was notified when the resident’s blood glucose readings were outside the ordered parameters and could not provide documentation of treatment for the seven occasions when the readings were elevated.
Nonfunctional Heating in B-Wing Solariums
Penalty
Summary
The facility failed to ensure environmental equipment was functional in the 1st floor B-wing Solarium and the 2nd floor Solarium. On the day of survey entry, the survey team was told to wait because the usual survey room in the 1st floor B-wing Solarium did not have heat, and the team was moved to another room. Later, the team was placed in the 1st floor B-wing Solarium, where portable heaters were being used, but the room remained very cold on multiple days and the breaker frequently tripped, cutting power to the heaters. The wall heating unit was attempted but was ineffective in heating the area where it was located. The survey team also observed residents exercising to music in the 2nd floor Solarium while the room felt very cold and had no portable heaters. The DON confirmed that residents exercised to music in that room, and the NHA stated that the HVAC heating system had malfunctioned in early November 2025. The NHA reported contacting the fire marshal and Life Safety Code Coordinator about portable heaters and said Corporate required three estimates for repair. Documentation reviewed showed one estimate dated 11/14/2025 for repair of the heating system for the 1st and 2nd floor B-wing Solariums, but no evidence of the second estimate the NHA had described. The NHA acknowledged the delay in obtaining the required estimates and stated he was not aware residents were exercising in the 2nd floor Solarium without heat.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents, as observed by surveyors. One resident was found without access to a call light, which was out of reach behind the bed. This resident, a new admission, was noted to have demonstrated appropriate use of the call bell previously. Another resident was left suspended in a Hoyer lift sling by a single staff member, who was waiting for additional assistance, contrary to the requirement for two staff members during such transfers. The Director of Nursing (DON) acknowledged these issues and confirmed that the call light should have been within reach and that the resident should not have been left unattended in the sling. The surveyors also noted that the facility's chapel was inaccessible to residents due to storage of beds and other items, preventing scheduled chapel services. Additionally, a resident's call bell was observed blinking for 25 minutes without response, and another resident was left in a wheelchair in the hallway waiting for assistance to be transferred to bed. The DON was informed of these issues and acknowledged the delay in responding to call bells, attributing it to a staff callout. Another resident expressed frustration over delays in assistance due to the unavailability of a Hoyer lift, which was necessary for their transfers. This resident was found waiting for over 40 minutes for assistance back to bed, with their call bell alarming. The resident reported frequent delays in receiving care and being unable to participate in activities due to these issues. The DON and administrative support eventually assisted the resident, and the surveyor noted the resident's dependency on a wheelchair and mechanical lift for mobility.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as observed by surveyors. In Resident #40's room, there was extensive paint damage on the walls, a Geri-chair with tattered armrests, and a mattress air flow device with a power cord that posed a tripping hazard. Resident #67's room had stained bed linens, a plastic urinal on the floor, and meal trays with leftover food and debris. Additionally, the shower and bathing environments in the facility had several issues, including broken tiles, rust-like substances, and soiled drapes. Further observations revealed that Resident #24's room had a television mounted with a power cord suspended in mid-air, creating a potential hazard. Resident #85's bathroom had a ceiling light fixture filled with insects, and Resident #542's room had a broken light fixture and non-functioning sink lights. The surveyors also noted a mold-like substance around the fire alarm in the hallway ceiling, indicating previous leaks that had not been addressed. Interviews with facility staff, including the Maintenance Director and Housekeeping Director, confirmed awareness of these issues. The Maintenance Director acknowledged the hazards and stated that maintenance requests were logged at the front desk or nurses' station. However, there was a reliance on nursing staff to report issues, and with only two maintenance staff members, prioritization was necessary. The Housekeeping Director confirmed that cleaning was done daily, but some areas, like light fixtures, were the responsibility of maintenance.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility staff failed to timely report allegations of abuse to the State Agency, the Office of Health Care Quality (OHCQ), within the required timeframe of 2 hours after the abuse allegation was made. This deficiency was evident in multiple cases involving residents. For instance, in the case of one resident, the Assistant Director of Nursing (ADoN) documented the incident time, but the self-report was sent 2 hours and 37 minutes later than required. In another case, the Director of Nursing (DoN) documented an incident but failed to report it for more than 19 hours. In another instance, a resident accused a Geriatric Nursing Assistant (GNA) of hitting them with a pillow, but the facility did not report the allegation to the OHCQ until several days later, following a grievance form submission. Additionally, a resident reported rough care and mishandling of their enteral feeding tube, but the facility did not report the allegation until surveyors brought it to the attention of the DoN. The ADON admitted to not reporting the allegation due to the resident's history of complaints. Furthermore, a resident sustained a serious injury, a fracture of the left femur, which was not reported to the State Survey Agency within the required 2-hour timeframe. The facility received the radiology report indicating the fracture, and the resident was transferred to the hospital for surgical intervention. However, the facility reported the injury to the State Survey Agency the following day, exceeding the reporting timeframe. The DoN mistakenly believed they had 24 hours to report the incident.
Inadequate Investigation and Response to Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate alleged violations of abuse and prevent further potential abuse while investigations were in process. In the case of Resident #91, the facility did not conduct interviews with other residents who were under the care of the alleged perpetrator, GNA Staff #39, to verify if there were additional concerns. Similarly, for Resident #108, the investigation lacked interviews with other residents cared for by GNA Staff #38, and no formal written statements were obtained from staff, only summaries. The facility also failed to suspend GNA Staff #38 pending the outcome of the investigation into the alleged abuse of Resident #108. Despite the allegation being reported, Staff #38 continued to work shifts, and there was no documentation of suspension or termination related to the abuse allegation. The investigation was deemed incomplete as it did not include statements from other residents or staff who interacted with the alleged perpetrator. Additional deficiencies were noted in other investigations, such as the case of Resident #2, where the facility failed to provide a complete investigation file for a reported incident of missing funds. In another instance, the investigation into an injury of unknown origin for Resident #19 did not include interviews with the resident or their family, nor with other residents. Similarly, the investigation of an alleged abuse involving Resident #93 lacked interviews with the resident and other residents cared for by the alleged perpetrator, GNA #9. These deficiencies highlight a pattern of incomplete investigations and inadequate measures to prevent further potential abuse.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for several residents, leading to deficiencies in addressing their specific medical needs. Resident #60, who was admitted with a diagnosis of epilepsy and was taking anticonvulsant medication, did not have a care plan addressing their seizure disorder or the use and monitoring of the medication. This oversight was confirmed by the MDS Coordinator, who acknowledged that the resident should have been care planned for epilepsy due to their medication regimen. Resident #65, admitted with chronic pain syndrome and prescribed opioids for pain relief, had a care plan for pain that was outdated and did not include the use and monitoring of the narcotic analgesics. The care plan had not been revised since November 2023, despite changes in the resident's medication orders. The Director of Nursing was informed of the concern regarding the development and implementation of care plans for residents. Resident #96, who had a history of seizures resulting from a stroke and was actively being treated with lamotrigine, did not have a seizure care plan in place. This was despite the resident experiencing seizures while in the facility, which required medical intervention and hospitalization. Additionally, Resident #64, who had a pressure ulcer and a fungal rash, did not have a care plan addressing these conditions, even though they were documented and treated. The Director of Nursing was unable to provide a care plan that included these issues when requested by surveyors.
Failure to Maintain Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to maintain and enhance the dignity of its residents, as evidenced by the situation involving Resident #81. During an annual survey, it was observed that the resident was left sitting in a wheelchair with a Hoyer pad underneath for over 40 minutes, waiting for assistance to be transferred back to bed. The resident's call bell was alarming, indicating a need for help, but the response was delayed. The resident expressed dissatisfaction, stating that finding a Hoyer lift is a recurring issue, leading to prolonged waiting times for assistance. This situation prevented the resident from participating in activities and receiving timely morning care. The Director of Nursing (DON) and Administrative Support were eventually observed assisting the resident back to bed. The surveyor informed the DON of the resident's concerns, including the persistent issue of call bells alarming for extended periods without response. The DON confirmed the problem, highlighting a systemic issue with the facility's response to residents' needs and the availability of necessary equipment like the Hoyer lift.
Failure to Accurately Assess Resident's Seizure Diagnosis
Penalty
Summary
The facility failed to accurately assess a resident, identified as Resident #96, during an annual and complaint survey. The resident was admitted to the facility in late February 2023 with a medical history that included difficulty walking, muscle weakness, seizures, and a cerebral infarction (stroke). The hospital admission history from January 31, 2023, noted seizures resulting from an anterior cerebral artery stroke, and the resident was prescribed lamotrigine to prevent seizures. However, during the review of the resident's admission Minimum Data Set (MDS) assessment completed on February 22, 2023, seizures were not listed among the active diagnoses. The surveyor interviewed the MDS Coordinator, who explained that conditions and diagnoses are coded by reviewing the admitting diagnosis, discharge summary, and medications ordered. Despite the presence of a seizure diagnosis in the hospital discharge paperwork and a corresponding medication order, seizures were not coded on the resident's admission MDS assessment. The MDS Coordinator acknowledged the omission and suggested it could have been a data entry error, although the condition was included in the discharge assessment.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to accurately dispense and record medications as per the scheduled ordered time for a resident who was prescribed oxycodone for pain management. The resident was admitted in early November 2022 and had an order for oxycodone 5 mg every 6 hours as needed for pain. On November 7, 2022, the Medical Director evaluated the resident and ordered routine oxycodone to be given at 7 AM along with the as-needed dose. However, the Medication Administration Record (MAR) review revealed that from November 8 to November 30, 2022, the scheduled oxycodone was documented as given on time only twice. There were multiple instances of late documentation, and on two occasions, the sign-off for the scheduled oxycodone was blank. Interviews with staff revealed inconsistencies in the documentation practices. An LPN stated that she charts the administration shortly after giving the medications in the MAR. The Director of Nursing (DON) acknowledged the discrepancies in the MAR documentation and noted that the delayed documentation was done by multiple staff members. The DON also mentioned that she was not in her current role at the time of the incidents and could not comment on the documentation practices during that period.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Mitchellville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Capital Region | 3 mi | ★★★★★ | 31 | 0 |
| Doctors Community Rehabilitation And Patient Care | 3.4 mi | ★★★★★ | 16 | 0 |
| Largo Nursing And Rehabiliation Center | 4.1 mi | ★★★★★ | 37 | 0 |
| Larkin Chase Center | 4.4 mi | ★★★★★ | 9 | 2 |
| Deanwood Rehabilitation And Wellness Center | 6.4 mi | ★★★★★ | 13 | 1 |
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