Average — CMS composite of the measures below.
The next survey window likely opens 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 Medilodge Of Taylor during CMS and state inspections, most recent first.
Failure to Notify Physician of Missed Ordered Medications: A resident with chronic osteomyelitis and type 2 DM did not receive ordered IV antibiotics and insulin as documented on the MAR, and staff confirmed the physician was not notified when the medications were unavailable or missed. Progress notes stated the antibiotics did not arrive from pharmacy, but there was no documentation explaining the missed insulin dose.
Kitchen sanitation, cooling, and dish machine temperature deficiencies: Surveyors observed handwashing sinks with motion-activated faucets that only ran 3 to 5 seconds unless reactivated, a pan of puree chicken cooling at 70F with the cooling log showing it began at 135F, and debris on cooler racks, a slicer blade, utensil bins, and a hand press chopper. Clean pans were stored wet, and the dish machine produced utensil contact temperatures of 147F to 158F across multiple cycles, below the cited 160F requirement.
Failure to implement the facility policy for food brought in by family or visitors. Surveyors observed minimal food storage in the nourishment room refrigerator, and the RD stated the facility does not have a refrigerator for residents and only allows shelf-stable items in resident rooms. The policy states that residents have the right to have food brought in, that labeled and dated prepared items may be refrigerated in the nourishment refrigerator, and that staff will assist residents who cannot access or consume the food on their own.
Dignity during care was not maintained when two CNAs were overheard laughing, talking loudly, and using profanity while providing ADL care to a resident with severe cognitive impairment and dementia, without speaking to the resident. In addition, five cognitively intact residents reported feeling ignored and uncomfortable because aides were on the phone, talking to each other, laughing loudly, and playing inappropriate music in hallways during care, despite prior Resident Council complaints and staff in-service reminders about resident-centered communication.
Food Served at Improper Temperatures: Five of eight cognitively intact residents reported that hot foods were cold, cold foods were warm, and items such as grilled cheese, eggs, sausage, and overcooked foods were hard, cold, or difficult to chew. The RD and DM stated hot food should be 165F or above, but temps were not monitored during meal service, carts were non-insulated, and test trays showed hot items delivered well below acceptable temps, including Shepherd's Pie at 115F, mashed potatoes at 125F, spinach and mushrooms at 123F, and chicken at 110F.
A facility failed to honor resident food preferences and ordered meal items, with residents reporting repeated issues such as wrong milk, missing bananas, hot tea, condiments, juice, and extra food items. Resident council concerns about disliked items on trays remained unresolved, and one resident with no cognitive impairment reported whole milk instead of 2% milk upsetting the stomach, while another resident with dementia and significant weight loss did not receive fortified mashed potatoes, ice cream, coffee, or apple juice listed on the meal ticket.
Unsafe and Unsanitary Environmental Conditions: The facility failed to maintain a safe, sanitary, and comfortable environment in multiple areas, including the Ice room, day space, clean utility room, shower rooms, storage rooms, and a resident room. Surveyors observed black debris, dust, trash, crumbs, paper waste, dried brown smears, wet black staining, and linens, gloves, and towels stored open and exposed to contamination in shower stalls and storage racks.
Hot water in a resident room shower reached 126 F, and the boiler room hot water tanks were observed set at 128 F, sending domestic hot water to resident care areas. The MD stated routine hot water checks did not include personal showers unless concerns were reported, and when he tested the water in a resident room, he said, "It's too hot."
Incomplete controlled substance counts and documentation were found in three medication carts. An LPN on one cart did not sign the shift verification sheet and counted narcotics by prescriptions instead of the required medication cards, causing a mismatch with the log. On two other carts, LPNs acknowledged missing signatures for shift counts, and one LPN also had not signed out medications at the time they were administered. The DON, RN B, and ADON confirmed that both the off-going and on-coming nurses were required to sign during the narcotic count.
Failure to document influenza vaccination or refusal for a resident with a stroke diagnosis. The IP reported there was no current flu immunization record or guardian-signed refusal, and the EHR also lacked documentation that the vaccine was declined or contraindicated. The DON stated the expectation was to contact the guardian for consent or declination, and the facility policy required resident or representative education and documentation of receipt, refusal, or medical contraindication.
A resident with a diagnosis of psychomotor deficit following cerebral infarction lacked documentation of current COVID-19 immunization, guardian refusal, or contraindication. The IP reported there was no record of vaccine status, and the DON stated the expectation was to contact the guardian for consent or declination. The facility policy required education, offering the vaccine, and documentation of consent or refusal in the medical record.
A resident with impaired cognition and significant care needs experienced a fall that was not promptly reported to the guardian, physician, or DON. The fall was discovered by a CNA, and although no immediate injury was noted, a leg issue was identified the next day. Notification to the guardian and other responsible parties did not occur until after the resident was transferred to the hospital, contrary to facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple chronic conditions and cognitive intactness was left on the toilet for nearly two hours after activating the call light for assistance. Despite the presence of family, staff did not respond promptly due to being occupied with meal service, causing the resident significant distress and discomfort. Facility policy required timely response to call lights, but this was not adhered to, resulting in the resident feeling neglected and anxious.
A resident with a Stage 4 pressure ulcer required enhanced barrier precautions, including PPE, during wound care as per physician orders and facility policy. Despite signage and PPE availability, an LPN was observed performing wound care without the required PPE. Interviews with staff confirmed knowledge of the protocol, but the failure to follow it resulted in a deficiency in infection prevention and control.
The facility failed to date-label food items and ensure a proper air gap for the coffee machine drain. Opened bread and cheese were undated, and the sour cream lacked an expiration date. The coffee machine's drain line did not meet the required air gap standards. The NHA acknowledged the labeling and maintenance issues.
A resident experienced frustration due to the facility's failure to update them on their request to move to another facility. Despite the resident's intact cognition and being their own responsible party, the social worker did not follow up or provide updates after sending a referral to the desired facility. The delay was partly due to the admission person being on vacation, and the social worker acknowledged the oversight in communication.
Two residents in a facility were found with unmet hygiene needs, including matted and greasy hair, due to inadequate grooming and bathing care. Despite being dependent on staff for activities of daily living, their care plans were not followed, and refusals were not consistently documented. Staff interviews revealed inconsistencies in care provision and reporting, leading to emotional distress and loss of dignity for the residents.
A facility failed to provide continuous tracheostomy humidification for a resident, as observed on multiple occasions with an empty humidifier canister. The resident, who was severely cognitively impaired and dependent on all ADLs, had a tracheostomy due to a traumatic brain injury and other conditions. The facility's policy on tracheostomy care was not followed, as confirmed by the DON.
A resident with a left below-the-knee amputation did not receive daily wound care as ordered, despite LPNs documenting that the care was provided. The DON was informed after an investigator found the treatment had not been administered since the initial dressing change.
Failure to Notify Physician of Missed Ordered Medications
Penalty
Summary
The facility failed to ensure the physician was notified when ordered medications were not administered for a resident admitted with chronic osteomyelitis of the left ankle and foot and type 2 diabetes mellitus. The resident was alert and oriented x4 on admission and reported that while at the facility the resident did not receive a dose of insulin or antibiotics that had been prescribed, and then returned to the hospital the next morning so antibiotics could be administered to decrease the risk of continued infection. The MAR documented ordered IV Cubicin (daptomycin) for osteomyelitis with no documentation that it was administered, ordered IV piperacillin-tazobactam with no documentation that the 1800 dose was given and a 0000 dose marked with a nine and nursing initials, and ordered insulin glargine with a nine documented at 9 PM. Progress notes stated the antibiotics did not arrive from pharmacy, but there was no documentation explaining why the insulin was not given. Staff interviews confirmed the three prescribed antibiotics were not delivered from the pharmacy and that the physician was not notified of the missed antibiotic doses or the insulin dose. The facility policy stated that when medications are unavailable, staff should notify the physician upon awareness that the medication is not available and obtain alternative treatment orders and/or monitoring orders.
Kitchen sanitation, cooling, and dish machine temperature deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area after surveyors observed multiple sanitation and food safety issues in the kitchen. On 12/8/25, the handwashing sinks were observed to have automatic faucets that activated by movement but only ran for 3 to 5 seconds unless reactivated, which did not meet the cited FDA Food Code requirement for a handwashing sink faucet to provide water for at least 15 seconds without reactivation. The report also noted that the facility used a cooling process for food two to three times a week depending on the menu. During observation of the walk-in cooler, a quarter pan of puree chicken was found tightly wrapped in foil and dated 12/8-12/10, with a measured temperature of 70F. The cooling log showed the chicken had started cooling at 8:30 AM at 135F, and the Dietary Manager stated it had started cooling that morning but needed to check the log for the exact time. Surveyors also observed an increased accumulation of spotted black debris on the plastic storage racks inside the walk-in cooler, and the Dietary Manager stated she had only been there a few weeks and had not established a cleaning frequency for the racks. Additional observations found a tabletop slicer covered with a plastic bag, which the Dietary Manager said meant it was clean and sanitary, but debris was observed on the back side of the blade. Clean pots and pans were stored wet with moisture trapped between stacked pans, and the clean utensil bins had crumb debris with no clear cleaning frequency identified. On 12/9/25, a hand press chopper in the clean utensil area was observed with staining and encrusted debris on the wavy blade, and the Dietary Manager stated she did not think anyone used it and would throw it away. The dish machine was also observed in operation with contact temperatures on the surveyor and facility thermometers reading between 147F and 158F across four cycles, below the cited 160F contact temperature requirement, while the rinse gauge ranged between 165F and 190F.
Failure to Implement Policy for Resident Food Brought From Outside Sources
Penalty
Summary
The facility failed to fully implement its policy regarding the use and storage of food brought in by family or other visitors. During observation of the nourishment room's large refrigeration unit on 12/8/25 at 10:52 AM, surveyors found minimal food storage. When asked where residents would store food brought in from outside sources that required refrigeration, the Registered Dietician stated the facility does not have a refrigerator for residents and only has residents keep shelf-stable products in their rooms. Record review of the facility policy, revised 7/1/25, stated that residents have the right to have food brought in by family or other visitors, that the facility may refrigerate labeled and dated prepared items in the nourishment refrigerator, and that staff will assist residents in accessing and consuming food brought in by residents, family, or visitors if the resident is not able to do so on their own.
Dignity During Care Not Maintained
Penalty
Summary
The facility failed to ensure dignity was maintained during care for one cognitively impaired resident and for five cognitively intact residents who reported concerns in an Anonymous Resident Council meeting. While providing ADL care to a resident with cerebral infarction, a-fib, vascular dementia with psychotic disturbance, and adjustment disorder with anxiety, two CNAs were overheard laughing, talking loudly, and using profanity while in the resident’s room, and they did not verbally interact with the resident during care. The resident’s record showed severe cognitive impairment and total two-person assistance needs, and the care plan directed staff to use calm, quiet locations with minimal background noise because of impaired communication and difficulty understanding others. During the Resident Council meeting, five of eight cognitively intact residents said they felt ignored during care because aides were on the phone, talking to each other, laughing loudly, or playing inappropriate music in the halls, especially on afternoon and night shift. The residents reported they had raised the concern in monthly Resident Council meetings, but nothing had changed. The facility’s Resident Council minutes documented an in-service addressing dignity during care and instructing staff not to talk about personal lives in hallways or resident rooms, not to use phones or earbuds on the unit, and to keep conversation resident focused and resident centered. The facility policy also stated staff should not talk to each other while performing a task for the resident as if the resident is not there.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not maintained at a palatable and safe appetizing temperature for residents receiving meals. During an Anonymous Resident Council meeting, five of eight cognitively intact residents stated that hot foods such as soup were cold, cold foods such as ice cream were hot, grilled cheese sandwiches were so cold the bread and cheese were hard, and eggs and sausage were cold to touch and taste. The residents also reported that food was overcooked, often hard, difficult to chew, and that their concerns had been brought to the facility multiple times without improvement. Record review showed the Resident Council monthly meeting minutes for September, October, and November 2025 did not document concerns with food palatability. Interview with the RD and DM found that hot food on the steam table should be 165F or above, but temperatures were not being checked during meal service. Meal carts were observed as non-insulated stainless-steel carts, and no heating or pellet system was used to maintain food temperature after plating. Test tray observations showed hot food temperatures below acceptable levels during lunch service, including Shepherd's Pie at 115F, mashed potatoes at 125F, spinach and mushrooms at 123F, and chicken at 110F after delivery to the hall.
Failure to Honor Food Preferences and Provide Ordered Meal Items
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer additional or alternative food choices for residents who were identified as needing specific items. During an Anonymous Resident Council meeting, eight cognitively intact residents voiced strong dissatisfaction with food services, stating that disliked items continued to be served, condiments and juice listed on meal tickets were not provided, and requests for extra food items were not honored. Residents also reported that repeated complaints about food had not been resolved, and one resident stated that the dining experience did not feel like home. Resident council minutes documented ongoing concerns across multiple meetings about residents receiving disliked items on their meal trays, with some concerns marked not resolved and no response documented. A Quality Assistance Form noted the issue of residents receiving items on their dislike lists, but the record reviewed did not show that the Kitchen Manager addressed the concern. During interview, the Dietary Manager stated that if items ran out, a similar alternative should be given, and acknowledged that food items should be prioritized for residents needing higher caloric intake. For one resident with no cognition impairments and a regular diet, the meal ticket indicated 2% milk and hot tea, but the resident reported receiving whole milk instead of 2% milk, which upset the resident's stomach, and not receiving bananas or hot tea. The resident and family member stated these preferences had been repeatedly reported without resolution. For another resident with dementia and a documented significant 10% weight loss in the last 6 months, the meal ticket indicated fortified mashed potatoes, ice cream, coffee, and apple juice, but none of those items were on the lunch tray. The resident's family member stated the resident was supposed to receive fortified mashed potatoes and ice cream to help with weight loss, and an LPN stated the kitchen had run out of mashed potatoes and there was no substitute and no ice cream.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the 100, 200, and 300 halls. During observation, the Ice room on the 200 Hall had an increased accumulation of black debris in the cabinet under the sink. The 100 Hall day space had Kleenex and debris stuffed into the side of chair and couch cushions, and the 300 Hall Clean Utility room had an open wire rack of clean linen with debris, dust, and trash on the floor underneath it. Additional observations found the 200 Hall shower room had storage racks in both shower stalls with gloves and towels open and exposed to contamination from residents showering. The Maintenance Director stated that items should be stored in the closet in the shower room. The second shower stall had an odor and numerous dried pieces of brown debris on the floor. On the 100 Hall, the storage room off the day room had dust and debris under the open wire rack storing clean linens, with blankets on the ground behind the rack. The 100 Hall shower room had a shower chair with dried brown smears, a shower bed with smeared dried brown debris, gloves and towels open and exposed on a storage rack between residents, and another shower bed with wet black staining underneath the mattress. A resident room also had dirt, crumbs, and paper trash on the floor in the bed one and bed two area.
Hot Water Temperature Exceeded Safe Limits
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F in resident care areas. On 12/8/25 at 1:33 PM, hot water in a resident room shower reached 126 F when tested with a rapid read thermometer, while the hand sink measured 118 F and had a point of use mixing valve installed. Later that day, other resident room sinks and showers were observed to be under the maximum 120 F. During interview, the Maintenance Director stated that hot water temperatures are maintained between 105 F and 120 F and that a sample of rooms is checked every morning so all fixtures are checked monthly, but personal showers are not part of the routine hot water checks unless concerns are reported. On 12/9/25, the boiler room hot water tanks were observed set at 128 F, sending domestic hot water directly to resident care areas, and the Maintenance Director could not hold his hand under the hot water in a resident room and stated, "It's too hot."
Incomplete controlled substance counts and documentation
Penalty
Summary
The facility failed to follow standards of practice for accurate reconciliation of controlled medications in three of eight medication carts. On 12/09/2025, inspection of Medication Cart A on the 200-hall with an LPN found the Controlled Substance Verification Log incomplete, with no licensed nurse signatures documenting reconciliation for the prior 24 hours, including the day shift to night shift count on 12/8/25 and the night shift to day shift count on 12/9/25. The LPN stated the count had been done with the night shift nurse but the sheet had not been signed, and could not explain why the night shift nurse did not sign. The actual number of controlled substance medication cards in the cart did not match the number recorded on the log, and the LPN stated the count was based on the number of prescriptions rather than the number of medication cards, even though the log specifically required the number of cards. A complete controlled substance count with the unit manager and RN B showed no discrepancies. RN B stated there had been questions about whether narcotics should be counted by medication cards or prescriptions. On the same day, inspection of Medication Cart B on the 200-hall with an LPN found the Controlled Substance Verification Log incomplete, with no signatures documenting reconciliation from night shift to day shift; the LPN acknowledged the omission. During further review, the LPN stated that a couple of medications had been administered but not signed out yet, and acknowledged that controlled substances should be signed out at the time of administration. Inspection of Medication Cart B on the 100-hall with another LPN also found the log incomplete with no signatures for the shift count. During interview, the DON, RN B, and ADON confirmed that facility policy and standard practice required both the off-going and on-coming nurses to sign when the narcotic count was conducted, and the DON stated nurses are supposed to sign the sheet at the time they count and sign out medications at the time they are given.
Failure to Document Influenza Vaccination or Refusal
Penalty
Summary
The facility failed to ensure that one resident, admitted with a diagnosis of psychomotor deficit following cerebral infarction (stroke), had documentation of a current influenza immunization, a signed refusal by the guardian, or documentation that the vaccine was contraindicated. During interview, the Infection Preventionist reported that the resident did not have documentation of a current influenza immunization or a refusal signed by the guardian. Record review of the resident’s EHR showed no documentation indicating that the influenza vaccine was declined by the guardian or that it was contraindicated. The DON stated that the expectation was for the guardian to be contacted to obtain consent or a declination regarding immunizations. The facility policy stated that residents and/or their representatives are to be provided education regarding the benefits and potential side effects of immunization, and that the medical record must document that the resident received or did not receive the immunization due to medical contraindication or refusal.
Missing COVID-19 Vaccine Education and Documentation for a Resident
Penalty
Summary
The facility failed to ensure that one resident, R45, was provided COVID-19 vaccination education and that the resident’s vaccination status was properly documented. During interview, the Infection Preventionist reported that R45 did not have documentation of a current COVID-19 immunization or a refusal signed by the guardian. Review of R45’s EHR showed the resident was admitted with a diagnosis of psychomotor deficit following cerebral infarction (stroke), and there was no documentation indicating that the COVID-19 vaccine had been declined by the guardian or that it was contraindicated. The Director of Nursing stated that the expectation was for the guardian to be contacted to obtain consent or a declination regarding immunizations. Review of the facility’s COVID-19 Vaccination policy stated that residents or their representatives are to be educated and offered the COVID-19 vaccine, that consent is to be signed prior to administration, and that the resident medical record is to include documentation of education regarding the risks, benefits, and potential side effects of the vaccine. The record reviewed did not contain documentation of this education, consent, or refusal for R45.
Failure to Timely Notify Guardian of Resident Fall
Penalty
Summary
The facility failed to promptly notify the guardian of a resident's fall, as required by policy. A resident with a history of right femur fracture, chronic lymphocytic leukemia, and legal blindness, who was dependent for transfers and had moderately impaired cognition, experienced a fall next to the bed. The fall was discovered by a CNA, who notified an LPN, and together they assisted the resident back to bed. No new injuries were observed at the time, and the CNA did not notice anything wrong until the following day, when a leg issue was identified and reported to another LPN. Despite the incident, the guardian was not informed of the fall or the resulting leg injury until the resident was transferred to the hospital two days later. The facility's policy requires immediate notification of the resident's practitioner and family or representative following such incidents, but documentation and interviews confirmed that the guardian, physician, and DON were not notified until well after the event. The late entry in the progress note and interviews with staff and the guardian's office corroborated the delay in communication.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Timely Respond to Call Light Leaves Resident Unattended on Toilet
Penalty
Summary
A resident with multiple medical conditions, including Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Atherosclerotic Heart Disease, Chronic Fatigue, Age-Related Macular Degeneration, and Adjustment Disorder, was left on the toilet for an extended period after activating the call light for assistance. The resident, who was cognitively intact and required partial to moderate assistance with toileting hygiene and supervision or touching assistance with toilet transfer, reported waiting almost two hours for staff to respond to the bathroom call light. During this time, the resident's family attempted to locate staff but was unable to find anyone to help, and the resident expressed significant distress, stating they were begging for help and felt unimportant. The facility's call light system was designed to alert CNAs and, after ten minutes, notify the nurse if unanswered. On the day of the incident, staff were occupied with passing and feeding lunch trays, which delayed their response to the call light. The facility's policy required all staff to respond to activated call lights and ensure resident access to the system, but this was not followed, resulting in the resident being left unattended and experiencing discomfort, disrespect, and anxiety.
Failure to Apply Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were consistently applied during wound care for a resident with a Stage 4 pressure ulcer in the sacral area. The resident had a physician's order and a care plan in place requiring the use of EBP, including the use of personal protective equipment (PPE) during high-contact care activities such as wound care. Observations revealed that a sign and PPE storage were present outside the resident's room, indicating the requirement for PPE use. However, an LPN was observed entering the resident's room and performing wound care without donning the required PPE, despite the presence of red-colored drainage from the wound. Interviews with the LPN, the Assistant Director of Nursing, and the Infection Control Preventionist confirmed that PPE was expected to be worn during wound care and that staff had been in-serviced on these protocols. Record review of the facility's policy also documented the requirement for enhanced barrier precautions to prevent the transmission of multidrug-resistant organisms. The failure to follow these established protocols and physician orders resulted in a deficiency related to infection prevention and control practices.
Improper Food Labeling and Air Gap Deficiency
Penalty
Summary
The facility failed to properly date-label food items in the kitchen and ensure the coffee machine's drain was properly air gapped. During an initial tour of the kitchen, it was observed that several loaves of bread and a bag of hotdog buns were opened and undated on the bread rack. The Registered Dietitian (RD) stated that food items should specify delivery, opened, and discard dates. Additionally, inside the reach-in cooler, an opened five-pound bag of shredded cheese was dated, but the Dietary Manager (DM) and RD could not identify if the date signified delivery, opened, or discard. An opened five-pound tub of sour cream also lacked an expiration date. Furthermore, the drain line from the coffee machine did not have the required minimum one-inch air gap, which is an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain. The Nursing Home Administrator (NHA) acknowledged that kitchen items should be labeled when received, opened, and use-by, and that kitchen staff should have notified maintenance to adjust the coffee machine drainpipe. The facility did not provide any additional documentation or information before the end of the survey.
Failure to Update Resident on Move Request
Penalty
Summary
The facility failed to ensure timely communication with a resident regarding their preference to move to another facility, resulting in the resident experiencing frustration. The resident, who was cognitively intact and their own responsible party, expressed a desire to move to another facility. The social worker was notified of this request and sent a referral to the admissions department of the desired facility. However, due to the admission person being on vacation, there was a delay in receiving a response, and the social worker did not follow up or update the resident on the status of their request. The social worker acknowledged the oversight in not following up with the facility or updating the resident about the status of their move request. The Assistant Director of Nursing also noted that the social worker should have contacted the facility to confirm receipt of the referral and informed the resident of the status. The lack of documentation and follow-up led to the resident not being updated on their request to move, causing frustration.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate nail care, facial hair grooming, and hair washing for two residents, resulting in unmet hygiene needs, loss of dignity, and emotional distress. Resident R18 was observed with matted, greasy hair full of dandruff and overgrown facial hair. Despite being dependent on staff for grooming and bathing due to moderate cognitive impairment, R18's care plan was not followed, and no refusals were documented. Interviews with staff revealed inconsistencies in care provision, with some staff indicating that R18 often refused care, while others noted cooperation with familiar staff. Resident R81 was also observed with disheveled, greasy hair and thick dandruff. Despite being dependent on staff for all activities of daily living, R81's care plan was not adequately implemented. The resident's medical records indicated a refusal to bathe on one occasion, but no other refusals or notifications were documented. Interviews with staff revealed a lack of familiarity with R81 and inconsistent reporting of care refusals. The facility's policy on activities of daily living emphasizes the importance of maintaining residents' grooming and personal hygiene. However, the observations and interviews indicate a failure to adhere to this policy, resulting in unmet hygiene needs for both residents. The Director of Nursing acknowledged the expectation for bathing and grooming on shower days, but the care was not consistently provided, leading to the identified deficiencies.
Failure to Ensure Continuous Tracheostomy Humidification
Penalty
Summary
The facility failed to provide continuous tracheostomy humidification for a resident, resulting in a deficiency in respiratory care. Observations on multiple occasions revealed that the humidifier canister, which is essential for generating humidification, was completely empty. This was noted on two consecutive days, indicating a lack of proper maintenance and monitoring of the resident's respiratory equipment. The resident involved had a history of severe cognitive impairment and was dependent on all activities of daily living. The resident's medical history included a traumatic subdural hemorrhage, traumatic brain injury, lung injury, and fractures, necessitating a tracheostomy. The facility's policy on tracheostomy care, which requires consistent care in line with professional standards and the resident's care plan, was not adhered to, as confirmed by the Director of Nursing during an interview.
Failure to Maintain Accurate Wound Care Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required wound care following a left below-the-knee amputation. The resident, who had intact cognition and required assistance with activities of daily living, was admitted with a pertinent diagnosis of acquired absence of the left leg below the knee. Physician orders specified that the surgical incision should be cleansed and a dry dressing applied daily. However, the Treatment Administration Record (TAR) indicated that the dressing was only applied on the first day, and subsequent entries falsely documented that the dressing changes were administered on the following days. Interviews with the Licensed Practical Nurses (LPNs) involved revealed that they signed off on the TAR indicating that the wound care was completed, despite not administering the treatment. The Director of Nursing (DON) was made aware of the issue after a State Agency investigator observed that the treatment had not been administered since the initial dressing change. The DON acknowledged that documenting treatments as completed when they were not is against the standard of practice.
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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 Taylor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lodge At Taylor | 0.3 mi | ★★★★★ | 16 | 0 |
| Regency, A Villa Center | 0.3 mi | ★★★★★ | 16 | 0 |
| Optalis Health And Rehabilitation Of Allen Park | 3 mi | ★★★★★ | 1 | 0 |
| The Orchards At Southgate | 3.7 mi | ★★★★★ | 8 | 0 |
| Rivergate Terrace | 4 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.