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 Regency, A Villa Center during CMS and state inspections, most recent first.
The facility failed to ensure RN coverage for 8 consecutive hours, 7 days a week. Review of the staffing schedule showed there was an entire day with no RN on duty after the scheduled RN called in sick, and the DON confirmed there was no documentation that the vacancy was filled with another RN. The DON also stated there was no facility policy specific to RN coverage because it was a regulation.
Kitchen sanitation, food storage, and cooling deficiencies were observed when trash cans were found full of trash without liners and with stained, slimy interiors, clean pans were stored wet or with food debris, and sheet pans were stored right side up. In the walk-in cooler, several resident food items were not labeled or dated, a case of peas was left partially open, and staff food and personal items were commingled with resident food. The DD stated there was no evidence cooked food had been properly cooled, and the NHA stated staff were expected to label and date food and keep only resident food in the cooler.
Meals were served at improper temperatures, with a breakfast tray showing scrambled eggs at 95°F, oatmeal at 115°F, milk at 52.8°F, and bacon and raisin bread cool or room temperature. Two residents reported cold eggs and unsatisfactory meal quality, and a resident council meeting found widespread dissatisfaction with food services, including reports that meals were cold, late, or sat in the hall before being passed.
A resident with a surgically repaired femur fracture, anxiety, and left eye blindness was discharged home without a documented discharge care plan or discharge summary, despite social work notes indicating a plan to return home with HHC. Progress notes over more than a month contained no evidence of discharge planning, and the facility’s “My Transition Home-Discharge” form was largely blank, missing the HHC agency phone number, follow-up appointment information, and sections for contact, medications, nursing instructions, dietary needs, and discharge instructions. After discharge, the resident reported that the paperwork lacked contact information for HHC, resulting in a week-long delay in connecting with services and multiple calls back to the facility to obtain correct information, while leadership later acknowledged the incomplete documentation and absence of a formal discharge plan.
The facility failed to complete required discharge summaries and provide essential transition information for two residents. One resident discharged to a family member had a discharge summary form with all summary-of-stay, continuing care, special instructions, and additional information sections left blank despite significant medical conditions. Another resident discharged home after surgery reported difficulty contacting home care because the discharge paperwork lacked phone numbers; this resident’s record contained no discharge summary or recapitulation of stay, and the transition form was missing contact information, medication details, nursing instructions, dietary information, discharge instructions, and follow-up appointment information. The SW and DON confirmed the absence of required discharge documentation, contrary to facility policy.
A resident with ESRD, dementia, psychotic and mood disturbances, anxiety, and schizophrenia exhibited frequent agitation and anger, particularly around hemodialysis treatments, and required significant assistance with daily activities. The dialysis center repeatedly reported the resident’s agitated behaviors and requested that medications be given before treatments, documenting agitation on communication forms and calling the facility multiple times. The facility failed to maintain complete dialysis communication forms in the EMR, did not document telephone communications from the dialysis center, and did not ensure an ordered antianxiety medication was available before a scheduled dialysis session. The resident’s dialysis care plan lacked person-centered goals and interventions to address dialysis-related behavioral needs, and the facility did not consistently follow its own policy requiring written communication and review of pertinent information with the dialysis provider.
Call Light Not Within Reach for Resident Needing Incontinence Care: A resident with severe cognitive impairment, legal blindness, and multiple psychiatric and neurologic diagnoses was found calling out for help while wet and needing incontinence care. The call light was not within reach and was tucked behind personal items on the nightstand, and an LPN acknowledged it should have been placed within reach after the resident was put to bed.
A resident with an indwelling Foley catheter, BPH, and UTI had no catheter care plan despite physician orders for catheter care every shift and drainage bag changes PRN. Staff observed the tubing hanging off the bed, not secured with an anchoring device, and the resident reported urine leaking into the brief and bed overnight. The DON acknowledged the care plan had not been initiated at admission.
A resident with a stage 3 sacral pressure ulcer had the wound left uncovered and directly exposed to a soiled brief after incontinence care. The resident’s ordered daily and PRN wound treatment included cleansing, medi-honey, and a dry dressing, but CNA and LPN staff observed that the dressing had not been replaced after the brief change, and the DON confirmed the night shift nurse should have re-dressed the wound.
Failure to provide appropriate Foley catheter care was identified for a resident with BPH and a UTI history. The resident’s catheter tubing was found hanging off the bed without an anchoring device, the tubing was taut, and the resident reported the Foley had leaked overnight, soaking the brief and bed. A CNA confirmed the bed was soaked, an LPN confirmed the catheter should have been secured, and the record lacked documentation of the leak, urine output monitoring, or the actions taken by staff.
A resident’s call light was not functioning properly, and staff did not respond when it was activated. An LPN and CNA found that the hall indicator would only stay on if the button was held down, and the nurse station indicator was possibly not working. The resident had severe cognitive impairment, legal blindness, epilepsy, and other diagnoses, and the care plan directed staff to assist with transfers and encourage use of the bell for help.
A resident's hydrocodone medication was misappropriated by an LPN, resulting in 28 missing doses. The DON confirmed the loss and acknowledged a lack of documentation for staff education on narcotic reconciliation, as well as no evidence of training for agency nurses or follow-up audits to ensure compliance.
A resident with hemiplegia and a history of stroke eloped from the facility by climbing over a patio fence. Although the family and police were notified and the resident was found safe, the facility did not report the incident to the State Agency as required by policy and law.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with psychiatric and cognitive disorders became agitated and aggressive, leading to administration of Haloperidol and transfer to a hospital on a psychiatric petition. Required transfer documentation, including details of the resident's health status, transfer arrangement, and destination, was not completed or included in the medical record, as confirmed by the DON and facility leadership.
A resident with multiple psychiatric diagnoses exhibited severe behavioral disturbances, leading to a psychiatric petition and hospital transfer. The incident, including staff interventions and the use of emergency medication, was not documented in the EHR as required, despite facility policy mandating such documentation.
A resident with severe cognitive impairment and a history of Parkinson's and Alzheimer's disease experienced a fall and was sent to the hospital for evaluation. Upon return, orders for a Lidocaine 4% topical pain patch and a urinalysis were not transcribed or completed, resulting in the resident not receiving the prescribed pain management or the required laboratory test. Review of records and staff interviews confirmed these omissions.
A resident was not treated with dignity during mealtime assistance as a CNA stood over them while feeding, causing food to drop onto their clothing. The resident was seated in a Broda Chair, and staff had not been trained to feed residents in this type of chair, preventing them from sitting at eye level. The facility's policy requires feeding with attention to safety, comfort, and dignity.
A resident reported that their packages were being opened by staff without consent, leading to feelings of anger and disrespect. Interviews with facility staff confirmed that packages are routinely inventoried before delivery, which contradicts the facility's policy that staff should not open mail without resident permission. The resident, who has intact cognition and several medical conditions, highlighted this breach during a Resident Council meeting.
A resident with a traumatic brain injury was found lying on soiled linens for two consecutive days, despite facility protocols requiring linen changes when soiled and on shower days. The resident expressed dissatisfaction, and staff interviews confirmed the expectation to change linens as needed, highlighting a failure in maintaining a clean and homelike environment.
A resident with intact cognition reported missing clothing items after donating some to the Concierge. The facility failed to document or address the grievance, as the Concierge did not fill out a grievance form or notify the abuse coordinator, contrary to the facility's grievance policy.
An LPN failed to properly position a resident during medication administration, leading to a medication error. The resident, with a history of multiple health conditions, was lying flat in bed, causing pills to spill. The LPN did not identify the spilled medication or contact the physician for further instructions, as confirmed by the DON.
Three residents in the facility did not receive adequate assistance with activities of daily living, resulting in unkempt appearances and unmet hygiene needs. One resident had matted hair and an unshaven beard, with no documentation of scheduled showers being completed. Another resident expressed a desire for shaving assistance, which was not routinely offered. A third resident reported not receiving a shower for two weeks, with inaccurate shower logs failing to reflect the lack of care. The facility's policy for regular showers and accurate documentation was not followed.
A resident's nebulizer mask was improperly stored by hanging on a dresser drawer, contrary to facility policy, which requires storage in a dated plastic bag. The resident, diagnosed with COPD and having intact cognition, was unaware of the proper storage procedure. Both an LPN and the DON acknowledged the correct storage practice, highlighting a failure to follow established respiratory care standards.
Two residents experienced unsafe conditions in the facility. One resident's bathroom lacked warm water and had structural issues, while another resident's call light system had exposed wires. Despite work orders and plans for remodeling, these issues were not promptly addressed, leading to dissatisfaction and potential harm.
The facility failed to provide annual dementia management and abuse prevention training for a CNA, as required by policy. The CNA's training records from the past year lacked documentation of these essential trainings. Both the ADON and DON confirmed the absence of training records and acknowledged the expectation for CNAs to complete yearly training. The facility policy requires a minimum of 12 hours of training per year, including these topics.
The facility failed to provide timely and accurate urinary catheter care for two residents, leading to potential complications. One resident was admitted with a catheter, but care orders were delayed by nine days. Another resident, admitted with a catheter from the ER, reported no initial care and was later hospitalized for a UTI. This highlights a deficiency in catheter management.
A resident was denied the right to discharge AMA from a facility, causing psychological distress. Despite being alert and oriented, the resident was placed in a lockdown dementia unit and deemed incompetent by facility staff without a judicial ruling. The Ombudsman intervened, educating the DON on resident rights, leading to the resident's discharge.
The facility failed to ensure appropriate transfer documentation for a resident transferred to the hospital for hip surgery. The clinical record lacked essential information about the resident's transfer, including their destination, condition, and transportation method, which is necessary for continuity of care.
The facility failed to consistently obtain a resident's blood pressure readings prior to administering antihypertensive medications as ordered, leading to potential risks. The DON acknowledged the oversight, confirming that blood pressure should be taken and documented before medication administration.
The facility failed to complete discharge instructions and recapitulation of stay for a resident, missing critical information such as diagnosis details, lab values, and care plan goals. The DON acknowledged the incomplete documentation, which is essential for continuity of care. The facility's guideline for discharge summary was not followed.
The facility failed to conduct weekly skin observations for two residents and a Braden skin assessment for one resident, leading to potential undetected skin care needs. The DON confirmed the lack of documentation and overdue assessments.
The facility failed to maintain proper sterile hygiene practices, hand hygiene, and glove usage during tracheostomy care for a resident. An LPN did not follow sterile techniques, failed to perform proper hand hygiene when switching gloves, and did not remove dirty gloves throughout the procedure. The resident had medical diagnoses including quadriplegia, anoxic brain damage, and a tracheostomy, and was dependent on assistance for hygiene.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure there was an RN on duty for 8 consecutive hours, 7 days a week. Review of the staffing schedule from 10/1/2025 through 1/14/2026 showed that there was no RN working in the facility for the entire day of 12/28/25. On 1/15/2026 at 2:06 PM, the DON reviewed the staffing schedule and confirmed that no RN was present that day. The DON stated that the RN scheduled to work had called in sick, and there was no documentation showing the facility was able to fill the vacancy with another RN. The DON also reported there was no facility policy specific to RN coverage because it was a regulation.
Kitchen sanitation, food storage, and cooling deficiencies
Penalty
Summary
The facility failed to ensure trash cans were clean and properly lined, pans were properly cleaned and allowed to air dry before stacking, food in the walk-in cooler was properly date-labeled, staff food and personal items were kept separate from residents’ food, cooked potentially hazardous food was properly cooled, and food service equipment was maintained in a safe and sanitary operating condition. During a kitchen tour with the Dietary Director, two trash cans full of trash were observed without liners, and both cans had stained, moldy-looking black, slimy patches inside. In the clean pot/pan area, several pans were observed with food debris, wet pans were stacked together, and a stack of sheet pans was stored right side up. The drain lines from the three-compartment sink and the dish machine were not properly air-gapped. In the walk-in cooler, a case of peas was not fully closed, and a multi-shelf metal cart contained cooked seasoned steak fries, a staff member’s personal pot, a disposable cup with remnants of orange-colored liquid, and a pan containing folded towels. Several food items on that cart and on a second metal cart were not labeled or dated, including pureed food, ground meat, a hot dog, and cooked rice. The Dietary Director stated there was no evidence that the cooked food observed in the walk-in cooler had been properly cooled, and said food should be cooled properly to avoid bacterial food growth. The Dietary Director also stated stored food should be dated and labeled, pans should be cleaned and fully dry before being stored face down, garbage cans should be cleaned and lined daily, and the drain lines should be properly air-gapped. The Nursing Home Administrator stated kitchen staff were expected to label and date stored food, only resident food should be stored in kitchen coolers, and trash cans should have liners.
Meals Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure meals were served at palatable temperatures for multiple residents. On 1/14/26 at 8:50 AM, surveyors tested the last tray on a fourth-floor breakfast meal cart with CNA E present and found scrambled eggs at 95°F, oatmeal at 115°F, and an 8 oz. carton of milk at 52.8°F. The raisin bread was room temperature to the touch and the bacon was cool to the touch. During breakfast observations, R4 stated the oatmeal was hot but the eggs were “so, so,” and R185 stated his eggs were cold; when butter was spread on his eggs, it did not melt. At 12:57 PM on 1/15/26, the Dietary Director stated scrambled eggs should be at least 120 degrees, raisin bread was acceptable at room temperature, and bacon should be hot, adding that the facility would have to revisit how bacon was cooked and served. At 10:10 AM on 1/16/26, the NHA stated food temperatures were expected to be within the range they are supposed to be. During an Anonymous Resident Council meeting on 1/14/26, ten cognitively intact residents from the second, third, and fourth floors participated, and seven expressed strong dissatisfaction with food services. Residents stated meals were cold, sometimes arrived late or sat in the hall before being passed, breakfast was the worst, and alternatives such as hamburgers were often dry, cold, and overcooked; they also reported hot dogs were grey and shriveled and said food concerns had been brought to the facility multiple times.
Failure to Complete and Document Effective Discharge Planning and Instructions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and document an effective discharge plan of care for one resident, resulting in delayed initiation of home health care services and potential delay of follow-up appointments. The resident was admitted with multiple diagnoses, including a surgically repaired left femur fracture after a fall at home, anxiety, and left eye blindness, and was discharged home. Although a social work note early in the stay documented that the resident’s discharge plan was to return home, there was no comprehensive discharge care plan or discharge summary in the electronic health record, and progress notes over more than a month did not show evidence of discharge planning. Subsequent social work documentation indicated that the resident received a Notice of Medicare Non-Coverage and that the plan was for discharge home with home health care, and that the resident was discharged home without DME because it was reportedly already available at home. However, the required discharge planning elements outlined in the facility’s own Transfer and Discharge Guideline—such as evaluation of discharge goals, preferences, care needs, and development of a person-centered discharge care plan by the interdisciplinary team—were not reflected in the record. The resident’s needs and discharge plan were not documented as required, and there was no documented discharge summary including post-discharge services, follow-up details, or medication reconciliation. The resident’s “My Transition Home-Discharge” form was significantly incomplete, lacking the home health care agency’s phone number, information on follow-up appointments, and entries in sections for contact information, medication information, nursing instructions, dietary information, and discharge instructions. The resident later reported that it took a week after returning home to reach anyone from home care, and that the paperwork provided at discharge did not include any phone numbers, leading them to call the facility social worker multiple times to obtain the correct contact information. The Director of Social Services and the DON both acknowledged that the transition form was incomplete and that there was no discharge care plan or discharge summary documented for this resident.
Failure to Complete Discharge Summaries and Provide Essential Transition Information
Penalty
Summary
The deficiency involves the facility’s failure to complete required discharge summaries, including a recapitulation of stay and essential discharge information, for two residents. One resident, who was being discharged to stay with her daughter, had a Recapitulation of Stay (Discharge Summary) form dated the day of discharge that was largely blank. Sections 1a–8, which should have contained the summary of stay, continuing care information, and special instructions or precautions, were not completed. The Additional Information section, which should have included contact information, was also blank, leaving the discharge summary incomplete despite the resident’s multiple diagnoses, including cerebral infarction affecting the dominant side and a fractured left humerus. Another resident, discharged home after surgical repair of a fractured left femur and with additional diagnoses including anxiety and left eye blindness, did not have any Recapitulation of Stay (Discharge Summary) form or discharge summary in the EHR. The resident reported that home care had been set up but that it took a week after returning home to reach anyone, and the discharge paperwork provided did not include phone numbers for the home health care agency. The resident’s “My Transition Home-Discharge” form was significantly incomplete, lacking the home health agency phone number, follow-up appointment information, and entries in the sections for contact information, medication information, nursing instructions, dietary information, and discharge instructions. The SW and DON both confirmed, upon review of the record, that there was no discharge summary or recapitulation of stay, despite the facility’s written policy requiring a discharge summary that includes a recapitulation of the resident’s stay and medication reconciliation.
Failure to Coordinate and Document Dialysis-Related Communication and Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective, documented communication and coordination with an outpatient dialysis center for a resident receiving hemodialysis, resulting in missed communication needed for continuity of care. The resident, who had end stage renal disease, dysphagia, dementia, psychotic disturbance, mood disturbance, anxiety, and schizophrenia, was observed on multiple occasions to be anxious, restless, angry, and agitated, including when preparing to leave for dialysis. The resident required assistance with most daily activities and had severe cognitive impairment and unclear speech. The dialysis care plan dated 6/9/24 did not include person-centered goals or interventions that adequately addressed the resident’s dialysis-related needs, including behavioral issues associated with dialysis treatments. Dialysis communication forms from the dialysis center documented agitation during treatments on specific dates, and the dialysis center reported that the resident frequently arrived very angry and anxious, requiring up to 40 minutes to calm before treatment. Dialysis staff stated they had repeatedly notified the facility, both by phone and in writing, about the resident’s behaviors and the need for medications to be administered prior to dialysis. On one date, an RN reported that an ordered antianxiety medication was not available at the facility before the resident left for dialysis and that a prescription was needed to obtain it, but the RN did not document the telephone communication with the dialysis center. Requested dialysis communication forms for several treatment dates were not present in the electronic medical record and could not be produced when requested by the DON, who acknowledged documentation was an area needing improvement. The facility’s own dialysis guideline required written communication and review of pertinent information between the dialysis provider and the facility, which was not consistently implemented for this resident.
Call Light Not Within Reach for Resident Needing Incontinence Care
Penalty
Summary
The facility failed to ensure a resident’s call light was within reach. On 1/13/2026 at 11:48 a.m., while in the hall on the fifth floor, staff heard a voice saying, “hello, hello, hello.” When the room was entered, R15 was observed facing the wall and stated, “I need help. I’m all wet,” while patting the backside. R15 was asked to reach for the call light but could not because it was not within reach. The call light was observed on the nightstand tucked behind a towel, a stuffed animal, and other personal items. At 11:51 a.m., an LPN approached the room and asked what was needed. R15 stated, “I’m all wet and need to be changed.” When asked whether R15 could use the call light, the LPN looked for it and stated it should have been placed within reach after R15 was put to bed. The record showed R15 was admitted with diagnoses including autistic disorder, epilepsy, schizoaffective disorder, depressive type, atherosclerosis of native arteries of the bilateral legs, and legal blindness, and was severely cognitively impaired with extensive one-person assistance needed for ADLs. The care plan documented that R15 preferred staff assistance to the toilet and required physical assistance with clothing and wiping during toileting and incontinence care, with encouragement to use a bell to call for assistance.
Missing Foley Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with an indwelling urinary catheter. R5 was admitted with diagnoses including benign prostatic hypertrophy and UTI, and the MDS documented intact cognition and that the resident had an indwelling urinary catheter upon admission. The physician ordered foley catheter care every shift and drainage bag changes every two weeks and as needed, but a review of the care plans on 1/13/26 found no catheter care plan in place. During observation, R5 was lying in bed with foley tubing hanging off the bed and draining a small amount of amber urine into a collection bag attached below bladder level. The resident reported leaking urine during the night, stating there was urine in the brief and bed and that the CNA had to change the brief and the whole bed. The resident also said the nurse came in and changed the bag. The catheter was observed not connected to an anchoring device and was pulled taut from the resident's penis through the leg hole of the brief and hanging down from the bed. The DON stated during interview that there was no care plan until that morning and that the oversight was noticed during review of catheter issues. The DON acknowledged that the urinary care plan should have been initiated at the time of admission. The facility's care plan guideline stated that the interdisciplinary team would collect and record data within 24 hours for the admission baseline care plan and that the resident care plan would incorporate risk factors identified in preadmission assessment, hospital records, and admission evaluations, with changes in condition reviewed and updated quarterly.
Uncovered Sacral Pressure Ulcer After Incontinence Care
Penalty
Summary
The facility failed to implement prescribed pressure ulcer care for a resident with a sacral stage 3 pressure ulcer. The resident was admitted with diagnoses including benign prostrate hypertrophy and UTI, had intact cognition on the MDS, and had a documented sacral pressure ulcer that measured 3.8 cm by 0.8 cm by 0.30 cm on 10/3/25 and 3.7 cm by 0.7 cm by 0.3 cm on 1/8/26. The care plan directed evaluation and treatment per physician orders, and the physician ordered Activon medi-honey to the sacrum after cleansing and to cover with a dry dressing every day shift and as needed, with Triad paste to the periwound area. During observation, the resident was incontinent of stool and the sacral pressure ulcer was found uncovered and directly open to a soiled brief. The resident stated the diaper needed to be changed again because it was soiled, and CNA L said the wound should have been covered and told the nurse. LPN M observed the wound and said it needed to be covered and likely had not been replaced after the brief change on night shift. Wound care LPN D later stated the dressing should have been cleaned and dressed after incontinence care on the night shift and that any nurse can and should redo the dressing if it becomes soiled. The DON also stated the night shift nurse should have re-dressed the pressure ulcer after incontinence care, and no progress notes were documented for that shift.
Failure to Provide Appropriate Foley Catheter Care
Penalty
Summary
Appropriate indwelling urinary catheter care was not provided for a resident with an indwelling Foley catheter, a history of benign prostatic hypertrophy, and a urinary tract infection. The resident was admitted with intact cognition and was documented as always incontinent. The physician had ordered Foley catheter care every shift and for the drainage bag to be changed every two weeks and as needed, but the resident did not have a care plan for the Foley catheter until the day of the survey review. On observation, the resident was found lying in bed with the catheter tubing hanging off the bed and the drainage bag below bladder level. The catheter was not secured with an anchoring device, and the tubing was pulled taut from the penis through the leg hole of the brief. The resident reported that the Foley had leaked during the night, causing urine to soak the brief and bed, and the CNA confirmed the bed had been soaked and a complete brief and bed change was needed. During incontinence care, the CNA and an LPN both observed that the catheter was not attached to a device to stabilize it, and the LPN stated an anchoring device should have been in place. The record review and staff interviews showed no documentation supporting the leaking catheter, any assessment of urinary output, or the actions taken overnight. The nurse unit manager confirmed there were no progress notes for the afternoon or night shift and no documentation that the bag had been changed or that urine output had been monitored. The DON acknowledged the catheter had leaked, that the tubing and collection bag were changed, that there was no irrigation or full catheter change, and that there was no documentation of those actions. The DON also stated there had been no Foley catheter care plan until that day and that an anchoring device should have been in place.
Nonfunctioning Call Light for Resident Needing Assistance
Penalty
Summary
A functioning call light was not ensured for one resident’s bedroom, bathroom, and bathing area. On 1/16/26 at 11:58 a.m., an unidentified resident was observed standing at the bedside behind the wheelchair while R15 attempted to scoot to the edge of the bed and get into the wheelchair. The wheelchair wheels were not locked, and the other resident stated that R15 wanted to get up. The call light was activated, but after several minutes no staff responded, and the call light indicator above the bedroom door was not illuminated. When LPN H entered, the resident was redirected out of the room, and LPN H attempted to activate the call light but the hall indicator would not come on. At 12:10 p.m., CNA K arrived to assist R15 into the wheelchair and stated that the call light would come on only if the button was held down; when released, the hall indicator did not stay on. LPN H stated staff were unaware the call light was not working properly, and both LPN H and CNA K said the nurse station indicator was not heard and possibly not working properly. Maintenance Assistant J later stated staff had not reported the problem and that bedroom call lights are checked twice a week, but could not account for the last time R15’s call light was checked. R15’s record showed diagnoses including autistic disorder, epilepsy, schizoaffective disorder, depressive type, atherosclerosis of native arteries of the extremities, bilateral legs, and legal blindness, and the resident was severely cognitively impaired and required extensive one-person assistance with ADLs. The care plan directed staff to assist with transfers and to encourage the resident to use the bell to call for assistance.
Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's property, specifically the loss of 28 doses of hydrocodone, a schedule II narcotic pain medication. The incident involved an LPN who was identified as having taken the medication after a nurse discovered the medication cartridge was empty and the pharmacy would not refill it due to it being too soon. A review of the narcotic count confirmed the missing doses. The resident involved reported receiving all pain medications and had no complaints regarding administration at the time of the interview. The Director of Nursing (DON) confirmed the misappropriation and stated that all nurses had been educated on narcotic reconciliation procedures. However, there was no documentation to support that this education had occurred, nor was there evidence that agency nurses had received any such training. Additionally, the DON acknowledged that there were no audits or follow-up measures in place to ensure compliance with narcotic reconciliation procedures, and no education was provided to agency nurses. The LPN involved refused to participate in an interview regarding the incident.
Failure to Report Resident Elopement as Potential Neglect
Penalty
Summary
The facility failed to report a potential incident of neglect involving one resident who eloped from the facility without staff knowledge. The incident occurred when the resident, who was new to the facility and had a history of elopement from a hospital, climbed over the patio enclosure fence during an activity. The facility notified the resident's family and the police after discovering the resident was missing. The resident was later found unharmed and was with his son. However, the facility did not submit an incident report to the State Agency (SA) as required by their policy and federal and state law. A review of the resident's electronic health record showed the individual had multiple diagnoses, including hemiplegia and a history of stroke, and had not completed the 5-day Minimum Data Set due to the early departure from the facility. The facility's investigation report confirmed that while the family and police were notified, the SA was not informed of the incident. The Nursing Home Administrator acknowledged the failure to report the incident to the SA, stating it was overlooked after the resident was found safe.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Document Resident Transfer Following Psychiatric Emergency
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper transfer documentation for a resident with multiple psychiatric and cognitive diagnoses, including anxiety disorder, mood disorder, unspecified psychosis, and dementia with behavioral disturbance. The resident, who had moderate cognitive impairment and used a wheelchair, became increasingly agitated and aggressive, culminating in a physical altercation with staff and an attempt to leave the unit by force. The situation escalated to the point where the resident was administered Haloperidol and transferred to a local hospital on a psychiatric petition. Despite the severity of the incident and the transfer to the hospital, the facility did not complete or include the required transfer documentation in the resident's medical record. The only documentation available was an incident report, which was marked as privileged and confidential and not part of the medical record, and a progress note regarding the administration of Haloperidol. There were no progress notes or late entries detailing the resident's transfer disposition or destination, and the DON confirmed that a hospital transfer notice had not been completed. The facility's own "Transfer and Discharge Guideline" requires documentation of the resident's health status, the basis for transfer, and the services to be provided by the receiving provider. However, these requirements were not met in this case, as the necessary information regarding the resident's health status, safety, transfer arrangement, and destination was missing from the medical record. The deficiency was confirmed during interviews and record review, with facility leadership unable to provide additional documentation.
Failure to Document Psychiatric Incident and Hospital Transfer in EHR
Penalty
Summary
The facility failed to include critical documentation in the electronic health record (EHR) for a resident who experienced a significant behavioral incident that resulted in a psychiatric petition and transfer to a hospital. The resident, who had diagnoses including anxiety disorder, mood disorder, unspecified psychosis, and dementia with behavioral disturbance, became increasingly agitated and aggressive, culminating in physical altercations with staff and other residents. Despite staff interventions, including administration of PRN medications and attempts at redirection, the resident's behavior escalated to the point of property damage and threats of violence. An incident report was created by the DON detailing the resident's actions, staff responses, and the subsequent decision to transfer the resident to a hospital under a psychiatric petition. This report included information about the administration of Haloperidol and the use of emergency services. However, this incident report was marked as "Privileged and Confidential - Not part of the Medical Record," and the corresponding clinical documentation was not entered into the resident's EHR. Upon review, the DON acknowledged that the incident and the rationale for the psychiatric petition should have been documented in the resident's clinical record, as it reflected significant changes in the resident's condition and the facility's inability to provide appropriate care at that time. The facility's own policy required documentation of all services, changes in condition, and incidents in the medical record, but this was not followed in this case. No additional documentation was provided by facility leadership when requested.
Failure to Implement Physician Orders Following Resident Fall
Penalty
Summary
The facility failed to implement physician orders for a resident with multiple diagnoses, including Parkinson's disease and Alzheimer's disease, who experienced a fall resulting in a visible injury to the face. After the fall, the resident was assessed, denied pain, and was sent to the hospital for further evaluation, including a CT scan, blood work, and a urinalysis as ordered by the nurse practitioner. Upon return from the hospital, new orders included a Lidocaine 4% topical pain patch every 12 hours for 5 days. However, the order for the Lidocaine patch was not transcribed into the resident's records, and the medication was not administered. Additionally, there was no documentation or evidence that the urinalysis was completed, either at the hospital or upon return to the facility. Review of the resident's electronic health record and medication administration record confirmed the absence of the Lidocaine patch order and administration, as well as the missing urinalysis results. Staff interviews revealed a lack of clarity regarding the process for reviewing and transcribing hospital discharge orders, and the nurse practitioner confirmed not being contacted upon the resident's return. The failure to implement these physician orders resulted in the resident not receiving prescribed pain management and not having a urinalysis completed as directed.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R163, during mealtime assistance. Observations revealed that a certified nurse aide (CNA K) was feeding R163 while the resident was seated in a Broda Chair, which is a type of chair designed for comfort and flexibility. During the feeding process, CNA K was observed standing over the resident, causing portions of the pureed food to drop onto the resident's clothing. This was noted to occur because the CNA was unable to sit at eye level with the resident due to the height difference between the Broda Chair and the available dining room chairs. Interviews with CNA K and the Unit Manager (UM H) revealed that staff had not received specific training on how to assist residents seated in Broda Chairs. CNA K mentioned that the previous chair used by the resident allowed staff to sit comfortably at eye level, which was not possible with the current setup. The Director of Nursing acknowledged that staff should be seated at eye level with residents during feeding. The facility's policy on Assistance with Meals emphasized the importance of feeding residents with attention to safety, comfort, and dignity, specifically stating that staff should not stand over residents while assisting them with meals.
Breach of Resident Privacy Due to Unauthorized Package Opening
Penalty
Summary
The facility failed to maintain and respect the personal privacy of a resident, identified as R142, by opening their packages without consent. This breach of privacy was highlighted during a Resident Council meeting where R142 expressed concerns about their packages being opened by staff. R142, who has an intact cognitive status with a BIMS score of 14 out of 15, reported feeling anger and disrespect due to this invasion of privacy. The resident's medical history includes conditions such as hypertension, low back pain, and chronic embolism, and they are independent in several activities of daily living. Interviews with facility staff, including the receptionist and the facility concierge, revealed that all packages are inventoried before being delivered to residents. The facility administrator confirmed that packages are checked for contraband, either before the resident receives them or in their presence. However, the facility's policy on resident rights clearly states that staff should never open a resident's mail unless permitted by the resident. This discrepancy between policy and practice led to the identified deficiency in maintaining resident privacy.
Failure to Change Soiled Linens for Resident
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident, identified as R131, by not changing soiled linens. On two consecutive days, observations revealed that R131 was lying on a bed with soiled sheets marked by a urine ring, which was wet in the center and dried around the edges. The resident, who has a diagnosis of traumatic brain injury and requires assistance with activities of daily living (ADLs), reported dissatisfaction with the living conditions, stating that the staff should change the sheets after their shower. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that linens should be changed when soiled and on shower days. A Certified Nursing Assistant (CNA) also acknowledged that residents should be checked frequently during each shift and that soiled bed linens should be changed as needed. Despite these protocols, the resident's linens were not changed, resulting in the resident sleeping on soiled and damp sheets, which contributed to their dissatisfaction with the living conditions.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to record, track, and respond to a grievance reported by a resident, identified as R15, who had intact cognition with a BIMS score of 15/15. R15, who was admitted with chronic kidney disease and type two diabetes, reported a missing item concern during a resident council meeting. R15 stated that after giving a bag of unwanted clothes to the Concierge for donation, additional clothing items were found missing from their closet. Despite informing the Concierge about the missing clothes, no grievance form was filled out, nor was the abuse coordinator notified. The facility's grievance policy requires that all grievances be promptly resolved, with the Administrator responsible for overseeing the process. However, the Concierge admitted to not following the procedure by failing to document the grievance or inform the abuse coordinator. The Nursing Home Administrator confirmed that the proper grievance process was not followed, as there were no grievance forms available for R15, indicating a lapse in the facility's grievance handling procedures.
Improper Medication Administration and Positioning
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, identified as R5, during a morning medication round. An LPN was observed administering medication to R5 while the resident was lying flat in bed, which is against the proper procedure for medication administration. This improper positioning led to the resident dropping the pills, with some falling behind the bed. The LPN retrieved three pills and disposed of them without identifying them, and then attempted to administer additional medication without confirming what had been ingested. The LPN did not contact the physician for further instructions after the incident. R5, who has a medical history including hemiplegia, diabetes, hypertension, and other conditions, was at risk due to the improper administration. The resident's care plan indicated a need for assistance with activities of daily living due to limited mobility and other impairments. The Director of Nursing confirmed that the resident should have been positioned upright to prevent choking and ensure proper medication ingestion, and acknowledged that the nurse should have contacted the physician after the medication error.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, resulting in unkempt appearances and unmet hygiene needs. Resident R107 was observed with matted hair, a long unshaven beard with food particles, and untrimmed nails. Despite being scheduled for showers and grooming, there was no documentation of these tasks being completed. Staff members acknowledged the lack of care, citing issues such as absence of personnel to braid hair and failure to document care provided. Resident R5 was found with unkempt hair and facial hair, expressing a desire for assistance with shaving. The resident's care plan indicated a need for supervision or assistance with personal hygiene, but staff only provided shaving assistance upon request. The Director of Nursing confirmed that residents should be offered shaving services, indicating a lapse in routine care provision. Resident R110 reported not receiving a shower or bed bath for two weeks, despite being scheduled for showers twice weekly. The shower log inaccurately reflected completed showers, and the Assistant Director of Nursing confirmed the resident had not been bathed since a specific date. The facility's policy required regular showers and accurate documentation, which was not adhered to, leading to unmet hygiene needs for the resident.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to adhere to standards of practice for respiratory care for a resident, resulting in improper storage of a nebulizer mask and potential cross-contamination. Observations on multiple occasions revealed that the resident's nebulizer mask was hanging on a dresser drawer next to the bed, without a storage bag. The resident, who was admitted with chronic obstructive respiratory disease (COPD) and had intact cognition, was unaware of a storage bag for the nebulizer mask. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the nebulizer mask should be stored in a bag and dated, as per facility policy. The facility's policy requires that nebulizer equipment be rinsed, disinfected, air-dried, and stored in a plastic bag with the resident's name and date.
Facility Fails to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to provide a safe and functional environment for two residents, resulting in dissatisfaction and increased risk for harm. One resident reported that their bathroom did not have warm or hot water, with the hand sink only running cold water at 54 degrees Fahrenheit. The bathroom also had a loose cold-water faucet that continuously ran, cracked ceiling walls with broken plaster, peeling paint, and a loose cove base around the bathtub. Despite the Maintenance Director indicating that the unit was scheduled for remodeling, no work order had been placed to address the immediate issues with the water temperature and the leaking faucet. Another resident pointed out exposed wires protruding from the call light system on the wall, with a long white wire and an outlet cover dangling from it. The resident expressed concerns that their call light was sometimes not answered, potentially due to the hanging wires. The Unit Manager confirmed that a work order had been placed the previous week, but the issue persisted. The Maintenance Director attributed the problem to the resident pulling the wires out of the wall, while the Administrator believed the work order should have resolved the issue. The facility's preventative maintenance policy emphasizes the importance of maintaining equipment in good repair, but the issues with the call light system and bathroom remained unaddressed.
Deficiency in Annual Training for CNA
Penalty
Summary
The facility failed to ensure that annual dementia management and abuse prevention training was conducted for one Certified Nurse Assistant (CNA), identified as CNA G, out of five CNAs reviewed for in-service training. CNA G was hired on June 2, 2009, and a review of the facility-provided transcript from June 2, 2023, through June 2, 2024, revealed a lack of documentation for the required training. The Assistant Director of Nursing (ADON) confirmed the absence of records for the necessary training, which was due on June 2, 2024. The Director of Nursing (DON) also acknowledged that CNAs are expected to complete yearly training, including abuse and dementia management. The facility's policy mandates that training topics for all staff must include dementia management and resident abuse prevention, with a minimum of 12 hours per year.
Deficiency in Urinary Catheter Care for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments and implementation of indwelling urinary catheter care for two residents, resulting in the potential for the development of urinary tract infections and complications. Resident R901 was observed with a urinary catheter drainage bag, and despite being admitted with an indwelling urinary catheter, the orders for catheter care were not implemented until nine days after admission. This delay in care could have contributed to the resident's existing diagnoses, which included Parkinson's Disease, urinary tract infection, and other serious health conditions. Resident R902 also experienced a lack of timely catheter care upon admission. Although the resident was admitted with a urinary catheter placed in the emergency room, there was no documentation of catheter care orders until several weeks later. The resident reported not receiving catheter care initially and had to be hospitalized shortly after admission, where they were treated for a urinary tract infection. The facility's failure to document and implement catheter care orders upon admission for both residents highlights a significant deficiency in the management of urinary catheter care.
Facility Failed to Honor Resident's Right to Discharge AMA
Penalty
Summary
The facility failed to honor a resident's right to discharge against medical advice (AMA), resulting in psychological distress and depression for the resident. The resident, identified as R210, had requested to leave the facility for two days but was denied discharge until the Ombudsman intervened. The facility's Director of Nursing (DON) initially refused the discharge, citing an upcoming court guardianship hearing. The Ombudsman educated the DON on the resident's rights, leading to the resident's discharge on the same day. R210 was admitted to the facility with diagnoses including encephalitis, inhalant abuse, cognitive communication deficit, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. Upon admission, R210 had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Despite this, the resident was alert and oriented, as noted by a Psychiatric Mental Health Nurse Practitioner (NP) and a Licensed Practical Nurse (LPN). The facility's records indicated that the resident was deemed incompetent by the facility's psychiatric evaluation, but there was no documented evidence of a judicial ruling on incompetence. The facility's policy on resident rights states that residents have the right to exercise their rights without fear of interference. However, the facility's actions contradicted this policy, as they did not allow R210 to leave AMA despite the lack of a court ruling on incompetence. The facility's staff, including the DON and social workers, informed the resident that she could not leave due to being deemed incompetent, which was not legally substantiated. This led to the Ombudsman's intervention to uphold the resident's rights.
Failure to Ensure Appropriate Transfer Documentation
Penalty
Summary
The facility failed to ensure appropriate transfer documentation for a resident who was transferred to the hospital for hip surgery and did not return. The resident, who had diagnoses including congestive heart failure, opioid dependence, atrial fibrillation, and depressive disorder, was documented to have intact cognition. The Director of Nursing (DON) confirmed that there should have been a discharge progress note indicating where the resident went, how they were transported, and the resident's condition upon transfer. However, the clinical record lacked this essential information, which is necessary for continuity of care for the facility, the resident's doctor, and the responsible party. A review of the facility's Transfer and Discharge Guideline revealed that the facility must document the transfer or discharge in the resident's medical record and communicate appropriate information to the receiving health care institution or provider. The documentation should include the basis for the transfer. Despite this guideline, the resident's clinical record did not indicate where the resident was sent, their disposition upon leaving, or how they were transported. During the exit conference, the Nursing Home Administrator and DON confirmed that there was no additional documentation or information to provide.
Failure to Monitor Blood Pressure Before Administering Antihypertensive Medications
Penalty
Summary
The facility failed to consistently obtain a resident's blood pressure readings prior to the administration of anti-hypertensive medications as ordered. This deficiency was identified for one resident who had diagnoses including chronic obstructive pulmonary disease, hypertension, hypertensive heart disease without heart failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. The resident was prescribed Nifedipine, Carvedilol, and Hydralazine, all of which required blood pressure monitoring before administration. However, the facility did not consistently document the required blood pressure readings, with significant gaps noted in the months of September and October 2023. During an interview and record review, the Director of Nursing (DON) acknowledged that the resident's blood pressure was not obtained according to the physician's orders. The DON confirmed that blood pressure should be taken and documented prior to administering antihypertensive medications to ensure the resident's blood pressure is not too low, which could lead to adverse effects. The deficiency was confirmed during an exit conference where the Nursing Home Administrator and DON did not provide any additional documentation or information to counter the findings.
Incomplete Discharge Instructions and Recapitulation of Stay
Penalty
Summary
The facility failed to adequately complete discharge instructions and recapitulation of stay in a timely manner for a resident, resulting in the potential for lack of communication to care providers assuming the resident's care. The resident, who had diagnoses including hypertensive urgency and cervical disc disorder with myelopathy, was discharged home from the facility. During an interview and review of the resident's clinical record with the Director of Nursing (DON), it was found that the Recapitulation of Stay document was incomplete, missing critical information such as diagnosis details, lab values, diagnostic tests, consultations, care plan goals, and practitioner contact information. The DON acknowledged that the recapitulation of stay was not adequately completed and emphasized its importance for continuity of care. The completion of this document was supposed to be a collaborative effort between nursing and social work. The facility's guideline for discharge summary and recapitulation of resident stay, dated 11/28/17, stated that a completed discharge plan and recapitulation of stay should be provided to facilitate continuity of care after discharge. However, this was not adhered to in this case. During the exit conference, the Nursing Home Administrator and DON confirmed that there was no additional documentation or information to provide before the end of the survey.
Failure to Conduct Weekly Skin Observations and Braden Assessments
Penalty
Summary
The facility failed to consistently conduct weekly skin observations for two residents and a Braden skin assessment for one resident, resulting in the potential for skin care needs to go undetected. Resident 606, who had multiple medical diagnoses including a cutaneous abscess and moderate protein-calorie malnutrition, did not receive any weekly skin observations from 10/29/23 until their discharge on 12/20/23. The Director of Nursing (DON) confirmed the lack of documentation for these assessments, which were expected to be conducted weekly according to facility guidelines. Resident 610, who was at high risk for developing pressure ulcers, also did not receive consistent weekly skin evaluations. Although the March 2024 Medication Administration Record indicated that weekly skin checks were completed, there were no detailed evaluations available in the electronic health record. Additionally, the quarterly Braden Scale assessment for pressure ulcer risk was overdue. The DON confirmed these deficiencies and acknowledged that the purpose of weekly skin evaluations is to ensure no new issues with skin integrity arise.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to perform proper sterile hygiene practices, hand hygiene, and glove usage during tracheostomy care for a resident (R624). During an observation, an LPN was seen providing tracheostomy care without following sterile techniques. The LPN sanitized his hands upon entering the room and donned PPE, including gloves and a face shield. However, the LPN did not maintain sterile technique when donning gloves, as the right-hand sterile glove fell on the bedside table before being worn. The LPN also failed to perform proper hand hygiene when switching gloves and did not remove gloves when they were considered dirty throughout the procedure. This was acknowledged by the LPN during an interview, where he admitted to not following proper sterile techniques and hand hygiene practices during the procedure. The DON confirmed that tracheostomy care should be a sterile procedure and that the nursing staff should maintain sterile technique. The resident involved, R624, had medical diagnoses including quadriplegia, anoxic brain damage, and a tracheostomy. The resident was admitted to the facility on 3/1/24 and was dependent on assistance for oral and personal hygiene. The facility's policies on tracheostomy care and hand hygiene were reviewed, revealing that hand hygiene should be followed, and gloves are not a substitute for hand hygiene. The failure to adhere to these policies during the tracheostomy care procedure resulted in the potential for tracheostomy infection and airway impairment for the resident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 944 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Taylor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Taylor | 0.3 mi | ★★★★★ | 15 | 0 |
| The Lodge At Taylor | 0.6 mi | ★★★★★ | 16 | 0 |
| Optalis Health And Rehabilitation Of Allen Park | 3.1 mi | ★★★★★ | 1 | 0 |
| The Orchards At Southgate | 4 mi | ★★★★★ | 8 | 0 |
| Rivergate Terrace | 4.3 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.