Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency At Chene during CMS and state inspections, most recent first.
A resident sustained an unwitnessed fall with injury, including bleeding from the nose, slight swelling to the eyebrow, and confusion, and was transferred to the ED for further assessment. The facility notified the resident’s friend but did not notify the legal guardian, who was listed in the EHR; staff said the nurse relied on an EHR note stating “Invitation expired,” which was misinterpreted as meaning the guardianship had expired.
The facility failed to maintain an adequate supply of clean linen, including towels, washcloths, bed pads, and sheets. Two residents who needed assistance with hygiene and bathing reported frequent linen shortages, with staff sometimes using paper towels or sheets to clean them. Surveyors found all clean linen closets lacked towels and washcloths, and a CNA and Housekeeping/Laundry Aide confirmed shortages, especially at night. The NHA acknowledged the linen problem and could not verify that ordered linens were actually delivered.
Meals were not consistently served at palatable temperatures for two residents. One resident reported food was always cold and provided photos of burnt, unrecognizable, and cold items, while another described cold meals and an unbalanced dinner. Surveyors observed hot food temperatures were acceptable in the kitchen, but after cart delivery and a delay on the unit, tray temperatures dropped below the Kitchen Manager’s stated standard of above 135 F. The Kitchen Manager said carts were left in hallways for CNA distribution and the facility did not have heated carts.
Failure to Report Allegation of Physical Abuse: A resident with severely impaired cognition and total dependence for care had a red eye and a family member reported the resident said someone hit her. Although the physician documented the concern and noted low clinical suspicion for trauma, the allegation was not immediately reported to the Abuse Coordinator/Administrator. The facility later learned of the allegation after a detective came to the center, despite policy requiring immediate reporting of abuse allegations to the Administrator and DON.
Food Service Sanitation and Equipment Maintenance Deficiencies: Kitchen hand sinks had self-closing faucets that shut off after about 5 seconds instead of providing the required flow time, a rusted chemical storage rack was observed, and an ice cooler in the nutrition room had no ice scoop with cups being used instead. A cooks refrigerator and beverage cooler were out of order for two months due to an electrical issue, a hand sink drain line was dripping, and a reach-in freezer had a tripping breaker and shorted compressor.
Water management program not actively maintained. Surveyors observed multiple hoppers and plumbing fixtures with black particles, dried brown particulate matter, green buildup, and standing discolored water; one hopper also contained a plastic straw and lid. Interviews and record review showed the water management team was not meeting consistently, logs were missing, no one had been performing chlorine and pH tasks after the prior MD left, and the binder lacked water flow diagrams.
Poor Premises Cleanliness and Maintenance: Surveyors observed multiple sanitation and maintenance issues, including an open outdoor waste receptacle with cardboard above the rim, scattered debris, hoppers with black, brown, and green buildup, a missing faucet handle at a hand sink, and shower beds with residue on the mat and underside. In the spa rooms, staff also found a bag of briefs and bed mats on the floor, standing water in a shower stall, and a sink pulling away from the wall with cracked caulk. CNA interviews indicated shower equipment is supposed to be cleaned after use.
Failure to document pneumococcal vaccine offerings and declinations was identified after review of five residents' records. The IP reported that the residents lacked current pneumococcal immunization documentation or signed declination forms, and record review showed one resident with bacterial pneumonia and acute respiratory failure with hypoxia, another with paraplegia and dementia, one with PVD, one with chronic respiratory failure with hypoxia, and one with circulatory and respiratory system symptoms; the DON stated residents or guardians should be educated and offered the vaccine, with refusals documented by signed declination.
Missing COVID-19 Vaccine Education and Documentation: The facility failed to document COVID-19 vaccine education, consent, declination, or contraindication for five reviewed residents. The IP reported no current immunization documentation or signed declination forms for residents with diagnoses including pneumonia, acute respiratory failure with hypoxia, paraplegia, dementia, peripheral vascular disease, and chronic respiratory failure with hypoxia. The DON stated residents and/or guardians should be educated and offered the vaccine, with declination signed if refused, and the facility policy required tracking consents and declinations in the medical record.
A resident was given risperidone for psychotic symptoms, but the record did not show that the resident or representative was informed of the risks, benefits, or alternatives, and no consent was documented. The resident was awake, alert, and communicative, had a BIMS score indicating no cognitive impairment, and stated they were not aware of the medication or its risks and benefits. The SW could not produce consent documentation, and the DON confirmed none was found in the EHR.
Call Light Not Within Resident Reach: A resident with pulmonary HTN, CHF, pneumonia, COPD, and ESRD was observed yelling for help to have a bowel movement while his call light was on the floor out of reach. Staff walked past without acknowledging him, and the CNA later verified feces were in the brief and the call light was not reachable. The resident and family member both reported ongoing problems with the call light not being within reach, and the DON stated the purpose of a call light is for the resident to communicate needs to staff.
Bathroom Odor and Poor Ventilation: Two cognitively intact residents reported a shared bathroom smelled bad, with one describing a sewage-like odor and both saying the smell persisted despite daily housekeeping. Surveyors observed the odor firsthand and noted the vent did not appear to function when tested with toilet paper. The NHA stated the bathroom lacked ventilation, while housekeeping and maintenance staff said they were unaware of the odor or poor ventilation.
PASARR screening requirements were not completed for three residents. One resident with schizophrenia and delusional disorders had no current Level I 3877 or DCH-3878 in the EHR, and the SW said the annual PASARR was submitted only after the State Agency requested it. Two other residents had Level I 3877s showing MI, but no Level II 3878 or determination was in the record; one had diagnoses including dementia and major depression, and the other had Parkinson’s disease and schizoaffective disorder. The SW confirmed one Level II was still pending and the other had not been completed.
A resident with a left-hand contracture and limited mobility was observed without prescribed splints and reported not receiving ROM exercises or splint assistance for an extended period. Therapy had recommended AAROM for both UEs and LEs plus a left resting hand splint, but staff gave inconsistent accounts of the restorative program, and the DON could not provide restorative documentation.
Failure to document physician response to pharmacy MRR: A resident receiving Risperdal for delirium and schizophrenia had a monthly pharmacist review noting an AIMS test recommendation, but the EHR contained no separate irregularity report and no documentation that the attending physician reviewed, accepted, or declined the pharmacist’s recommendations. The DON said the reports were emailed to her and the MD, while the MD stated he responded by email, but no response or rationale was found in the record.
A resident receiving Risperdal for delirium and schizophrenia was found to have no documented baseline AIMS test when the antipsychotic was started, despite a pharmacist recommendation and physician agreement that AIMS monitoring be performed every 6 months. The DON could not provide evidence of baseline AIMS documentation, and the EHR contained no order or proof that the test had been completed as required by facility policy.
A cognitively intact resident with leukemia and pneumonia, assessed as not at risk for elopement and independent with ADLs, left the facility with family members without any LOA order, care plan, or documentation in the EHR. Staff, including an LPN and a CNA, assumed the resident was on an LOA based on informal comments, did not verify a physician order or sign-out information, and did not recognize or report the absence as a potential elopement until the end of the shift. The receptionist did not recall the resident leaving and did not have the resident identified in the elopement book, and existing signage instructing visitors to sign residents out was not effectively followed, resulting in the facility being unaware of the resident’s whereabouts.
The facility did not provide required information and access to the survey team in a timely manner, including the census, resident list, facility matrix, and WIFI access. Delays were attributed to staff unfamiliarity with the EMR system and incomplete access to clinical records, resulting in the survey team not receiving necessary documentation upon entry.
Several residents who required assistance with personal hygiene did not receive adequate care, including help with facial hair removal, showers, and nail care. One resident with multiple health conditions was observed with excessive facial hair and unclean nails, and reported not receiving scheduled showers due to inability to self-perform. Other residents were observed with long, dirty, or jagged fingernails, despite care plans indicating staff should provide this assistance. Documentation of care was incomplete, and relevant policies were not provided upon request.
Surveyors identified failures in medication storage and labeling, including expired and undated medications found on two medication carts, and unsecured medications left unattended on a cart by an LPN. The DON and unit manager confirmed these actions were not in accordance with facility policy. A resident involved was cognitively intact and recovering from knee surgery with multiple chronic conditions.
Staff were observed handling eating utensils without gloves and serving food with long, unrestrained hair, contrary to hygienic standards. Nursing staff participated in meal service without using required hair restraints, while dietary staff complied with these standards. The DON was unaware of the need for nursing staff to use hair restraints during meal service.
Staff did not consistently follow infection control protocols, including enhanced barrier precautions and proper use of PPE, for residents requiring such measures. In one case, a CNA handled soiled linen without a gown due to missing signage, and in another, a resident's PICC line was left uncovered and without a sterile cap. Additionally, a wound care nurse failed to perform hand hygiene between glove changes during wound care for two residents with complex medical needs.
Multiple residents were observed using wheelchairs with torn and ragged armrests, and several facility areas, including the walk-in freezer and nourishment rooms, had broken tiles, open holes, and unsanitary conditions. Kitchen equipment was found to be non-functional or leaking, and documentation regarding these issues was not provided to administration as requested.
A CNA took a photo of a resident's exposed buttocks with a personal cell phone after the resident expressed concerns about cleanliness following incontinence care. The photo was shown to the resident and an RN, leaving the resident feeling embarrassed, ashamed, and unsafe. The incident was not documented in the medical record, and facility policy prohibiting personal device use and resident photography was violated.
A resident with multiple medical conditions was found with their call light out of reach and hazardous items left at the bedside by family, without any care plan interventions or staff education to address these safety concerns. Staff acknowledged the issues but no documentation or care planning was in place to prevent recurrence.
A resident with end stage renal disease and an AV fistula did not have timely or complete physician orders for dialysis, clear fluid restriction parameters, or restrictions on blood pressure measurements on the arm with the fistula. Staff documented blood pressures on the affected arm and were unclear about the status of special instructions versus medical orders in the EMR, resulting in incomplete guidance for care.
A resident with cerebrovascular disease and vascular dementia was repeatedly observed being transported and seated in a wheelchair without footrests, resulting in poor posture and feet dangling. The resident reported that staff did not replace the footrests after removing them, and an Activities Assistant confirmed transporting the resident without footrests, contrary to facility policy and expectations.
Two residents did not receive pressure ulcer care as ordered by their physicians. In both cases, the wound care nurse failed to use the specified dressings and securement methods during wound care, despite clear orders and care plans. The nurse acknowledged not following the orders when questioned, and the facility's policy requires adherence to physician directives.
A resident with a history of stroke and moderate cognitive impairment was found to have long, thick toenails and dry, flaky skin due to a lack of timely foot care. Nursing staff confirmed the condition, and records showed the resident had not received podiatry services for approximately eight months, despite physician orders and facility policy requiring regular assessment and referral for such care.
A resident with hemiplegia and hemiparesis following a stroke did not receive prescribed splint application or ROM exercises, as staff failed to perform or document these interventions. The resident's splints were found unused, and interviews confirmed that CNAs were not completing the restorative program as ordered, with no documentation of care provided in the medical record.
A resident with impaired cognition and multiple medical conditions was left at risk for accidents due to inaccessible call lights, hazardous cleaning products at the bedside, and lack of staff intervention or family education regarding safety. Staff were aware of the issues but did not document or address them appropriately.
A resident with multiple chronic conditions and on hospice care was observed using an oxygen concentrator with a filter visibly covered in lint and dirt. Staff interviews revealed confusion about who was responsible for cleaning and maintaining the oxygen equipment, and the resident's care plan lacked interventions addressing equipment maintenance. Despite a contract with an outside company for oxygen equipment upkeep, the filter was not cleaned or replaced as required.
A medication cart was left unattended with an open EMR screen displaying a resident's PHI in a hallway, making confidential information visible to unauthorized individuals. An LPN confirmed leaving the cart unsecured, which was not in line with facility policy. The resident involved was recovering from knee surgery and was cognitively intact.
A resident with severe cognitive impairment and a history of acute cerebral vascular insufficiency and dysphagia did not receive routine dental services despite a physician order for evaluation and treatment. The care plan lacked documentation of dental concerns, and the MDS was incomplete for oral/dental status. Staff interviews revealed a lack of awareness and follow-through regarding the resident's dental needs, and dental notes were not available at the time of survey exit.
A resident with dysphagia and self-feeding difficulties was not provided with a physician-ordered scoop plate during meals, despite documentation and care plan requirements. Staff served meals on a regular plate and were unaware of the adaptive equipment order, while the necessary requisition for the scoop plate was not submitted, resulting in the resident not receiving the prescribed assistive device.
Two residents receiving hospice care did not have their comprehensive hospice documentation, including assessments and consents, accessible in their records as required. Nursing staff and management were unable to initially locate these documents, which were later found to be held by the administrator. Both residents had complex medical conditions and required significant assistance with daily activities. The DON acknowledged that hospice documentation should have been available to staff but could not account for its absence, resulting in a lack of coordinated hospice care.
A resident with multiple medical conditions and severe cognitive impairment did not receive the Pneumococcal and Influenza vaccines despite having signed consent forms. There was no documentation of vaccine administration in the medical record, and the facility could not provide the influenza vaccination policy when requested.
A resident admitted with acute pancreatitis and found to be cognitively intact did not receive a comprehensive MDS assessment within the required timeframe, with the assessment overdue by more than 120 days. The MDS nurse did not provide information about alerts for late assessments, and the DON indicated that policy should have been followed.
A resident with multiple chronic conditions did not receive any scheduled medications during an evening medication pass, and there was no documentation of administration or vital signs for that shift. Staff interviews confirmed the medications were not given, and the MAR was left blank, contrary to facility policy requiring proper administration and documentation.
A resident with multiple chronic conditions did not receive scheduled medications during an evening shift, and the MAR was left blank with no documentation from nursing staff. Facility staff, including the DON and an LPN, were unable to determine which nurse was assigned to the resident due to incomplete records and limitations in the electronic scheduling system.
A resident with a PEG tube did not receive the prescribed enteral feeding or water flush due to unlabeled and undated feeding and water bags, and an unprogrammed water flush rate. The resident's PEG tube insertion site was improperly cared for, with no dressing or abdominal binder applied. The facility's Enteral Nutrition policy was not followed, leading to this deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound and PEG tube. Staff provided care without wearing required gowns, and there was no signage or PPE supply cart available. The Director of Nursing acknowledged the lapse, despite staff being in-serviced on EBP. The resident's records indicated a physician's order for EBP, but the facility's policy was not followed, risking infection spread.
Two deficiencies were identified in respiratory care practices. The first involved a resident requiring mechanical ventilation who did not have an emergency tracheostomy readily accessible. During an observation, staff were unable to promptly locate a spare tracheostomy, leading to a delay in emergency care. The second deficiency was related to the failure to label and date oxygen tubing for a resident receiving oxygen therapy. The tubing was found to be unlabeled and undated, with the resident unable to recall the last change, posing a potential risk of respiratory infections.
The facility failed to maintain sanitary conditions in the kitchen, with soiled non-food contact surfaces and debris on equipment. Additionally, a meal test tray revealed improper food temperatures, with macaroni and cheese, collard greens, and fried chicken holding below the required 135 degrees F. These deficiencies could potentially affect 143 residents who receive meal services.
The facility failed to maintain the garbage storage area in a sanitary condition, with exterior trash dumpsters observed with open lids and surrounding trash and debris. Staff indicated this was a recurring issue after trash pickup. The facility's waste disposal policy and the 2017 U.S. Public Health Service Food Code were not adhered to.
The facility failed to ensure the 2nd floor wireless nurse call light system was effectively utilized by staff or had consistently functioning centralized monitor screens. A resident's bedside nurse call device was found frayed and taped over, and the nurse's station did not have an audible alarm. Further observations revealed that the computer monitors at various nurse's stations were either not displaying notifications or were turned off, leading to potential delays in response times and unmet resident care needs for 47 residents.
A resident was not dressed in their personal clothing, causing verbal frustration and impaired mental and psychosocial well-being. Despite reporting the issue to social services, no action was taken, and the resident's closet had limited clothing. The facility's policy mandates dressing residents in their desired clothing, but this was not followed.
The facility failed to ensure a call light was within reach for a resident with severe cognitive impairment and multiple medical conditions, and did not provide a wheelchair for another resident with a fractured hip. Both deficiencies resulted in unmet care needs, as confirmed by staff and multiple observations.
The facility failed to update PASARR forms for a resident with bipolar disorder and paranoid personality within the required 30-day period. The resident's MDS assessment indicated cognitive impairment and antipsychotic medication use. Staff interviews revealed that a new PASARR should have been completed 25 days after admission but was only done on the day of the survey. The DON confirmed that the Social Worker is responsible for PASARRs and that they should be reviewed on admission and sent for Level II evaluation if needed.
The facility failed to revise care plans in a timely manner for two residents, leading to deficiencies in their care. One resident's care plan did not address new wounds, and another resident's care plan was not updated after the removal of an indwelling catheter.
Failure to Notify Legal Guardian After Resident Fall With Injury
Penalty
Summary
The facility failed to notify the resident’s legal guardian when the resident sustained an injury after an unwitnessed fall. Record review showed the resident fell in the facility, was found face down on the floor with bleeding from the nose, had slight swelling to the left eyebrow, and was alert but slow to respond and confused. The resident was transferred to the emergency department for further assessment and testing, and the emergency contact listed in the record, a family friend, was informed at 2049 hours before the resident was taken to the hospital by EMS at 2100 hours. Record review showed guardianship papers identifying Family Member H as the resident’s legal guardian, and the papers were uploaded into the EHR. Family Member H stated the facility called the resident’s friend but did not call her when the resident was sent to the hospital after the fall, and she learned about the injury from the friend. Staff interviews indicated the nurse did not contact the legal guardian because the EHR note stated, “Invitation expired,” which the nurse interpreted as meaning the guardianship had expired. The NHA stated that the legal guardian should be notified in the event of a change in condition, and the DON stated the information in the EHR had been entered incorrectly by admissions.
Insufficient clean linen supply
Penalty
Summary
The facility failed to provide a homelike environment by not ensuring an adequate supply of clean linen for residents, including towels, washcloths, bed pads, and other bath and bed linens. Two residents interviewed reported that the facility was frequently out of linen: one resident stated staff sometimes had to pat them dry with paper towels, that bed pads were unavailable, and that washcloths were not available for cleaning; another resident stated the facility often had no towels or washcloths and that staff sometimes used sheets to clean them up. Both residents had care plans indicating they required assistance with hygiene and bathing-related care, and one resident was documented as cognitively intact. Surveyors observed three clean linen supply rooms and found no washcloths or towels in any of them, with only limited quantities of sheets, blankets, pillows, hospital gowns, and bed mats present. A CNA stated the facility ran out of towels and washcloths, especially at night. The Housekeeping/Laundry Aide stated linen was low because staff hide supplies and also said the laundry service does not return everything sent out. The Nursing Home Administrator acknowledged awareness of the linen shortage and suspected that some soiled linen was being discarded or that contracted laundry was not returning the same amount sent out. The administrator produced invoices for linen orders but could not show that the bath and bed linens were actually delivered, and the facility policy on Laundry Services did not address par levels for resident bed and bath linens.
Meals Served at Unsafe and Unappetizing Temperatures
Penalty
Summary
The facility failed to ensure meals were served at palatable temperatures for two residents, R101 and R104. R104 stated that the food was always cold. R101 provided photographs and descriptions of multiple meals that were burnt, unrecognizable, or cold, including a hamburger with dark, crusted edges, a hot dog with white residue on the casing, an unrecognizable dinner item, and several cold breakfast items such as eggs, sausage, potatoes, grits, and an omelet. R101 also reported receiving an unbalanced dinner consisting of sun chips, juice, and applesauce, and stated that complaints were made to staff or the kitchen. Record review showed the menu items matched the foods shown in R101’s photographs and descriptions. During observation, kitchen staff checked hot food temperatures in the kitchen and recorded temperatures above 158 degrees Fahrenheit. However, when the last tray on the second-floor meal cart was tested after a 10-minute delay in distribution and while the cart door had been left open, the food temperatures were much lower: chicken 103 F, macaroni and cheese 129.8 F, mashed potatoes 120.8 F, and greens 127 F. The Kitchen Manager stated that dietary staff leave carts in unit hallways for CNAs to distribute trays, that the facility does not have heated carts, and that they cannot determine how long it takes for CNAs to deliver food to rooms. The Kitchen Manager also stated that hot food should be above 135 degrees. The NHA stated surprise at the report, and the DON stated that heated meal carts should be considered.
Failure to Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the Abuse Coordinator for one resident who was reviewed for abuse. The resident had severely impaired cognition, could sometimes make herself understood, rarely or never understood others, and was dependent on staff for all activities of daily living and mobility needs. The resident had been admitted and later readmitted to the facility, and was discharged on 5/30/26 with diagnoses that included metabolic encephalopathy. A complaint investigation involved a report that the resident had a black eye and said someone hit her. The facility’s own investigation showed that a detective came to the center on 5/22/26 after an assault allegation had been made to police related to an eye injury. The detective reported that the resident’s daughter alleged the resident had a bruised and bloodshot eye and that the resident answered yes twice when asked if she had been hit by someone. The facility noted that redness or a possible ruptured blood vessel had been seen in the eye, but nursing staff and the attending physician did not suspect trauma based on the clinical presentation, and no bruising, swelling, or other injuries near the eye were observed. Physician A documented on 5/19/26 that the daughter was concerned about a red left eye and reported the resident said someone hit her, but the physician considered the report unreliable because of the resident’s dementia and noted minimal redness with no ecchymosis or swelling and low clinical suspicion for trauma. During interview, Physician A stated he discussed the matter with the Administrator and DON, but the Administrator reported the allegation was not reported to him until after the detective came to the facility and that the physician did not report the allegation when it was made. The facility policy required allegations of physical abuse to be immediately reported to the Administrator and for the Administrator or designee to notify State or Federal agencies within 2 hours for an abuse allegation.
Food Service Sanitation and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area and the maintenance of equipment. During observation, two handwashing sinks in the kitchen area were equipped with self-closing, motion-activated faucets that ran for only about 5 seconds before shutting off, rather than providing water for at least 15 seconds. A rust-colored, rough, worn metal chemical storage rack was also observed in the janitor's closet within the kitchen, and the Culinary Manager acknowledged its condition. In the 300-400 unit nutrition room, an ice cooler was observed on the counter with Styrofoam cups beside it, and there was no ice scoop available; staff were using cups to scoop ice. A plastic bag covering a plate with no date or label was also found in the refrigerator, and the Culinary Manager removed the plate to be discarded. The report also documented equipment and plumbing problems affecting kitchen operations. The cooks refrigerator and beverage cooler were out of order due to an electrical problem, and the Culinary Manager stated the equipment had been down for two months and that maintenance requests were slow because there was no Maintenance Director. The Culinary Manager also stated Housekeeping and Laundry Supervisor E had been helping cover maintenance needs. In addition, water was observed dripping from the drain line of a hand sink when turned on in the second floor kitchenette. Record review showed a heating and cooling contractor had serviced a reach-in freezer by the stove, where the breaker was tripping and the compressor was found shorted out, with a compressor or new unit to be quoted.
Water management program not actively maintained
Penalty
Summary
The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During a tour, surveyors observed multiple hoppers and related plumbing fixtures with visible buildup and contamination, including black particles along the inside edge of a hopper bowl in the soiled utility/laundry room, dried brown particulate matter coating the interior bowl of a hopper in the soiled linen 300-400 hall, green buildup along the inside wall of a hopper in the soiled linen 100-200 hall, and black particulates in the hopper in the soiled utility 500-600 hall. A plastic straw and lid were also observed floating in the water in one hopper bowl. Surveyors also observed a therapy tub in the second floor spa room that the HLS stated was “not really” used. In the 300-400 hall, a shallow pool of brown-colored water was observed in the hopper drain line, and when the hot water faucet was turned on, discolored brown water discharged for a few seconds before running clear. In another area, the hand sink faucet handle was missing, and the HLS stated it was in the facility maintenance system. The HLS acknowledged the green buildup in one hopper and stated they would get someone to clean it. Interviews and record review showed the water management program was not actively functioning as intended. The HLS stated they were only kind of part of the water management team. The Maintenance Director from a neighboring facility stated the previous MD had unorganized documentation and that they were supposed to train people and get a team started. The Interim Nursing Home Administrator stated there had not been a water management team meeting during the prior three and a half months and that logs could not be found for the past few weeks. The facility provided a water management policy, but no water flow diagrams were noted in the binder. The record review also showed chlorine and pH logs in TELS, but staff stated no one had been performing the tasks since the previous MD left.
Poor Premises Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises. On 4/14/2026, surveyors observed three outdoor waste receptacles in an enclosure, with one receptacle left open and cardboard piled above the rim. Scattered debris, including plastic bags, was also observed along the back wall of the enclosure. In the soiled utility laundry room, a hopper had black particles along the inside edge of the bowl, and the hand sink faucet handle was missing. The Housekeeping and Laundry Supervisor stated the hand sink was in the facility maintenance system TELS. Additional observations found multiple areas of buildup and soiling in shower and utility areas. In the first floor spa room, a shower bed had brown buildup in the center crease of the mat, with black residue on the underside of the mat and the plastic shower bed surface. In the 300-400 hall soiled linen room, a hopper had dried brown particulate matter coating the interior bowl, a shallow pool of brown water in the drain line, and an unpleasant odor. In the 100-200 hall soiled linen room, a hopper had green buildup along the inside wall extending onto the water surface. In the second floor spa room, a plastic bag containing opened briefs and disposable bed mats was left on the floor, a puddle of water was present in the shower stall, and the sink in the restroom was pulling away from the wall with cracks in the caulk. In the 500-600 hall soiled utility, a hopper had black particulates in the bowl and a plastic straw and lid floating in the water. Staff interviews indicated shower equipment cleaning was expected after use, with CNA staff stating they clean equipment with sanitation wipes or a solution and that everyone is supposed to clean after use.
Failure to Document Pneumococcal Vaccine Offerings and Declinations
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after interview and record review showed the facility failed to ensure five residents reviewed for immunizations were provided pneumococcal vaccination education and documentation. On 4/16/2026, the Infection Preventionist reported that residents R5, R8, R27, R84, and R85 did not have documentation of a current pneumococcal immunization or a declination form signed by the appropriate guardian. Record review showed R5 was admitted with diagnoses of bacterial pneumonia and acute respiratory failure with hypoxia and had no documentation that the pneumococcal vaccine was declined by the guardian. R8 was admitted with paraplegia and dementia and had no documentation that the pneumococcal vaccine was offered or contraindicated. R27 was admitted with peripheral vascular disease and had no declination form documented. R84 was admitted with chronic respiratory failure with hypoxia and had no declination form signed by the guardian. R85 was admitted with other specified symptoms and signs involving the circulatory and respiratory systems and had no declination form documented. The DON stated residents and/or guardians should be educated and offered the pneumococcal vaccine, and if refused, a declination form should be signed by the appropriate party.
Missing COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that five residents reviewed for immunizations were provided COVID-19 vaccination education and had documentation of vaccination status, declination, or contraindication in the medical record. During interview, the Infection Preventionist reported that residents R5, R8, R27, R84, and R85 did not have documentation of a current COVID-19 immunization or a declination form signed by the appropriate guardian. Record review showed that R5, admitted with bacterial pneumonia and acute respiratory failure with hypoxia, had no documentation that the COVID-19 vaccine was declined by the guardian. R8, admitted with paraplegia and dementia, had no documentation that the vaccine was offered or contraindicated. R27, admitted with peripheral vascular disease, had no declination form documented. R84, admitted with chronic respiratory failure with hypoxia, had no declination form signed by the guardian. R85, admitted with other specified symptoms and signs involving the circulatory and respiratory systems, also had no declination form. The DON stated that residents and/or guardians should be educated and offered the COVID-19 vaccine, and if refused, a declination form should be signed by the appropriate party. The facility policy required education using the FDA EUA or VIS fact sheet, signed consent or declination, and tracking of consents and declinations in the immunization section of the medical record.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform one resident, R154, of the risks and benefits of a proposed treatment and failed to obtain consent for the use of an antipsychotic medication before it was administered. R154 was observed awake, alert, and communicative in their room on 4/14/2026. Record review showed R154 was admitted with diagnoses including vascular dementia with other behavioral disturbances, cerebral infarction, age-related physical debility, arthritis, hypertension, and osteoarthritis. The Minimum Data Set with an ARD of 1/31/2026 showed a Brief Interview for Mental Status score of 14/15, indicating no cognitive impairment. A physician order dated 12/24/2025 directed risperidone 0.5 mg by mouth twice daily for delirium and schizophrenia, and the April 2026 MAR showed the medication had been administered since December 2025. A psychiatry note dated 12/24/2025 documented paranoid delusions and the start of risperidone for psychotic symptoms, but there was no documentation in the progress note or electronic health record that R154 or their representative was informed of the medication's risks and benefits or consented to its use. The Social Worker was unable to provide any documentation of education or consent, and R154 stated they were not aware of the medication and had not been educated about its risks and benefits. The DON confirmed that no risk-versus-benefit education or consent was located in the record.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure a call light was within reach of one resident who was observed yelling from the hallway that he had to have a bowel movement. The resident was seen in bed with the bed covers at his knees, attempting to remove his brief, while multiple staff walked in the hallway without acknowledging his request. When asked about the call light, the resident stated he did not know where it was, said he had been calling for someone, and reported that it was too late because he had already soiled himself. The call light was observed on the left side of the bed on the floor, out of reach, and the room had a smell of feces after care was provided. The resident was admitted with diagnoses including pulmonary hypertension, CHF, pneumonia, COPD, and ESRD, and was documented as alert and oriented times three. His care plan identified a functional ability deficit and included an intervention to encourage use of the bell/call light to call for assistance. During interview, the CNA verified there were feces in the brief and that the call light was not in reach. The resident's family member also reported prior problems with the call light being on the floor and stated that the resident can use the call light to make needs known. The DON acknowledged that the purpose of a call light being in reach is for the resident to communicate needs to staff for safety reasons.
Bathroom Odor and Poor Ventilation
Penalty
Summary
The facility failed to ensure the bathroom was free from odors for two residents, R47 and R107, resulting in an unpleasant sewage-like smell in the shared bathroom. On 4/14/26, R107 was observed in a wheelchair at bedside and stated the bathroom smelled bad and had smelled that way for a while, adding that the bathroom was kept closed because of the odor. When the bathroom was entered, an odor was immediately detected, the bathroom appeared cleaned, and a vent in the corner did not appear to be working because a piece of toilet paper thrown toward it immediately fell to the floor. R107 was cognitively intact, required max assistance with most ADLs, and had diagnoses including acute respiratory failure, DM type 2, sleep apnea, vesical fistula, and CHF. R47 was also observed and stated the bathroom stinks, that staff had to spray a lot because it smelled so bad, and that the odor was worse after bowel movements. R47 confirmed the bathroom was cleaned daily by housekeeping. R47 was cognitively intact and required partial assistance with ADLs, with diagnoses including COPD, DM type 2, ischemic stroke, and right-side hemiparesis. The Nursing Home Administrator stated a vent check using toilet paper showed it did not stick to the vent and said the bathroom did not have ventilation, which may have caused the odor. Housekeeping and maintenance staff said they were unaware of the odor or poor ventilation, and the facility policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior.
PASARR Screening and Level II Documentation Not Completed
Penalty
Summary
The facility failed to ensure PASARR screening requirements were completed for three residents reviewed for PASARRs. For one resident with diagnoses of schizophrenia and delusional disorders, the current Level I 3877 form was not in the EHR and there was no DCH-3878 exemption criteria certification form. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 10/15, and the SW stated the annual Level I PASARR-3877 was not submitted until the State Agency requested it, even though it should have been completed earlier. For two other residents, Level II PASARR documentation was not located in the EHR. One resident had a Level I 3877 indicating mental illness and dementia, with diagnoses including adjustment disorder with anxiety and depressed mood, major depressive disorder, delusional disorders, and vascular dementia; the SW stated the 3878 had not yet been signed by a licensed health care provider and the Level II determination had not been received. The other resident had a Level I 3877 indicating mental illness, a prior Level II determination requiring another Level II evaluation by a specified date if the resident remained in the facility, and diagnoses including Parkinson’s disease and schizoaffective disorder, depressive type; the SW stated the Level II evaluation was not completed.
Failure to Provide Ordered Splinting and ROM Care
Penalty
Summary
The facility failed to apply splinting devices and perform range of motion (ROM) exercises as recommended by therapy for one resident with a left-hand contracture and limited mobility. The resident was observed in bed with a left-hand flexion contracture, knees bent, and legs lying together to one side, and stated that he was supposed to have a hand splint, would wear a splint if staff helped him, and was not getting exercise. On another observation, he was again in bed without any splints in place, while two knee splints and one hand/wrist brace were seen on the dresser. He later stated that the splints had not been put on him in a long time, maybe two weeks or more, and that he needed them, especially for his hand. Interviews with staff showed inconsistent restorative care. A CNA stated she did not apply splints or perform ROM exercises, while a restorative aide stated she had been applying the resident’s splints and performing the ROM program but could not produce documentation. The DON also could not provide restorative records and stated she was responsible for the restorative program. The resident’s record showed diagnoses including left-hand contracture, and therapy had recommended a restorative plan with bilateral upper and lower extremity AAROM and a left resting hand splint for 4 hours daily. The care plan did not include the left-hand splint and knee splint intervention until later, and the DON acknowledged there were no records of splint care before the splints were added to the care plan and that the restorative program had been lax since a leadership change.
Failure to Document Physician Response to Pharmacy MRR
Penalty
Summary
The facility failed to obtain and document a review of Medication Regimen Review (MRR) recommendations, and there was no documentation of any physician action in response to the pharmacist’s recommendations for one resident. The resident was admitted with diagnoses including vascular dementia with behavioral disturbances, cerebral infarction, age-related physical debility, arthritis, hypertension, and osteoarthritis. The resident’s MDS assessment showed a Brief Interview for Mental Status score of 14/15, indicating no cognitive impairment. A physician order dated 12/24/2025 showed Risperdal 0.5 mg by mouth twice daily for delirium and schizophrenia, and the MAR showed the medication had been administered since December 2025. A monthly pharmacy MRR document dated 1/20/2026 in the EHR showed the pharmacist checked a note stating to see the report for irregularities and/or recommendations, but there was no separate report in the EHR identifying those irregularities or recommendations. There was also no evidence in the EHR that the attending physician reviewed the MRR or documented any rationale for accepting or declining the pharmacist’s recommendations. The DON stated the reports were emailed to her and the attending physician, and the physician later stated he received the recommendations by email, reviewed them, documented his rationale on the document, and sent them back to the pharmacist, but the EHR contained no evidence of that response or any related medication changes.
Unnecessary Antipsychotic Medication Monitoring Not Completed
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from unnecessary medications. R154 was observed in bed, awake, alert, and communicative. The resident was originally admitted with diagnoses including vascular dementia with other behavioral disturbances, cerebral infarction, age-related physical debility, arthritis, hypertension, and osteoarthritis. The MDS with an ARD of 1/31/2026 showed a BIMS score of 14/15, indicating no cognitive impairment. A physician order dated 12/24/2025 showed Risperdal 0.5 mg by mouth twice daily for delirium and schizophrenia, and the MAR showed the medication had been administered since December 2025. The monthly pharmacy MRR dated 1/20/2026 included a pharmacist recommendation that the resident, who was receiving risperidone, required an AIMS test at baseline and every 6 months while on antipsychotic therapy. The attending physician agreed with the recommendation and added that nursing should perform AIMS every 6 months. However, the electronic health record contained no order for AIMS testing and no evidence that a baseline AIMS test had been completed when the antipsychotic was started. When the DON was asked about baseline AIMS documentation, no information could be provided as to where it was located or why it had not been completed. The facility policy stated that residents receiving antipsychotic medications would have AIMS completed upon admission, at the start of new antipsychotic therapy, and at least every six months.
Failure to Follow LOA Procedures Resulting in Unmonitored Resident Departure
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate supervision and follow its Leave of Absence (LOA) policy for a cognitively intact resident, resulting in the resident leaving the building with family without the facility’s knowledge of their whereabouts. The resident had been admitted with leukemia and pneumonia, had intact cognition per the MDS, and was independent with ADLs including ambulation. An elopement risk assessment completed prior to the incident indicated the resident was not at risk for elopement. However, there was no physician order, no care plan, and no documentation in the electronic health record authorizing or describing an LOA for this resident at the time they left the facility. On the evening in question, the resident was seen on the front door camera properly dressed and walking out of the facility with several family members at approximately 6:00 PM. The receptionist did not recall seeing anything unusual and did not remember seeing the resident leave, despite a sign at the exit instructing visitors to sign residents out when leaving. The facility did not have information on who the resident left with, where they were going, or how long they would be gone, and the resident was not listed in the receptionist’s elopement book. The resident did not return to the facility as expected, and the next morning it was reported in the morning meeting that the resident had not come back from what staff believed was an LOA. Staff interviews revealed that both nursing and CNA staff assumed the resident was on an LOA without verifying orders or documentation. An LPN stated that a CNA had told her the resident went on an LOA with family, but she did not check for an LOA order, did not confirm who the resident was with, and did not report the resident’s absence until the end of her shift. A CNA reported that when she went to pick up the resident’s dinner tray, the resident was not in the room and had earlier been with several visitors; she assumed the resident had gone somewhere with them and did not recognize the situation as a potential elopement, nor did she initiate an elopement response. The facility’s LOA policy required physician orders, care planning, sign-out/sign-in procedures, and implementation of elopement protocol if a resident left without the facility’s knowledge and whereabouts were unknown, but these procedures were not followed in this case.
Failure to Provide Timely Survey Information and Access
Penalty
Summary
The facility failed to provide timely and required information to the survey team upon entry and during the annual recertification survey, affecting all residents. Upon arrival, the survey team leader requested a facility census, resident list, and matrix from an RN, but these were not provided. Subsequent requests for the same information, as well as WIFI access, were made to the DON and NHA, with the full set of documents and access not provided until over an hour after entry. The WIFI access provided did not function throughout the survey, further impeding the process. The entrance conference worksheet, which outlines the required timeframes for document provision, was sent to the NHA, and the entrance conference was conducted, with the NHA confirming familiarity with the electronic file sharing platform. Delays continued as the NHA reported not having full access to the clinical portions of the EMR, and the DON was new and still acclimating to the system. Additional required documents, such as hospice agreements and dialysis contracts, were not provided within the required timeframe and had to be requested again. The DON later acknowledged that any unit manager should have been able to provide a census upon surveyor entry and agreed that the survey team was not provided timely documentation upon entry.
Failure to Provide Adequate Assistance with Personal Hygiene and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in the areas of personal hygiene, for several residents who were unable to perform these tasks independently. One female resident was observed with excessive facial hair and dark matter under her fingernail, and reported not receiving scheduled showers due to pain from arthritis, which she could not manage without help. Documentation of her showers was incomplete or missing, and there was no record of her refusing care or assistance with facial hair removal. Her medical history included rheumatoid arthritis, dysphagia, diabetes with neuropathy, hypertension, acute kidney failure, and spinal stenosis, all of which contributed to her need for assistance with personal hygiene. Three other residents were observed with long, jagged, or dirty fingernails, and in some cases, debris under the nails. Interviews with staff and review of records confirmed that these residents required assistance with personal hygiene due to severe or moderate cognitive impairment, paraplegia, or hemiplegia following a stroke. The facility's care plans and Kardexes indicated that staff were to observe and trim nails on shower days, but observations and interviews revealed that this was not consistently done. There was no documentation in the electronic medical records of refusals of care for these residents. The Director of Nursing confirmed that CNAs were expected to check and provide nail care on shower days and during regular care, but this was not consistently documented or performed. Additionally, when requested, the facility was unable to provide the relevant policies for activities of daily living, shower, and nail care by the time of survey exit.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication management within the facility. During an inspection of two medication carts, expired and undated medications were found, including an expired vial of Humulin R insulin, an opened and undated vial of Lantus insulin, expired Vitamin E pills, and expired Fish Oil pills. When questioned, the registered nurse present was unable to provide an explanation for the presence of expired and undated medications. The Director of Nursing confirmed that staff are expected to follow facility policy, which requires medications to be dated and discarded per manufacturer guidelines. Additionally, a medication cart was found left unattended in a hallway with three prescribed medications unsecured on top of the cart. The LPN responsible admitted to leaving the cart and medications unattended while attending to a resident's vital signs. The unit manager and DON both confirmed that facility policy requires medication carts to be locked and that no medications should be left unattended or on top of the cart. The resident involved was cognitively intact and had a history of osteoarthritis, recent knee replacement, borderline diabetes, lipidemia, and hypertension.
Failure to Follow Hygienic Practices During Meal Service
Penalty
Summary
Surveyors observed that staff failed to follow hygienic practices during meal service, specifically in the handling and serving of food and utensils. Nursing staff were seen wrapping silverware in napkins and placing them on tables after washing their hands, but they touched the eating portions of the utensils without wearing gloves. Additionally, staff with long, loose hair were observed serving and assisting residents with food and beverages without using hair restraints, as required by professional standards and the 2013 Food Code. These practices were noted during multiple meal services in both the first and second-floor dining areas, involving approximately 30 residents at one time. The dietary manager confirmed that all dietary staff wore appropriate hair restraints, but the nursing staff, who also participated in meal service, did not. The Director of Nursing was unaware of the requirement for nursing staff to use hair restraints while assisting with meal service. The lack of proper glove use and hair restraints by nursing staff created the potential for food contamination during the observed meal services.
Failure to Follow Infection Control Protocols and Hand Hygiene Standards
Penalty
Summary
Staff failed to follow enhanced barrier precautions (EBP) and use appropriate personal protective equipment (PPE) for residents requiring infection control measures. In one instance, a certified nursing assistant (CNA) removed soiled linen from a resident on EBP without wearing a gown, as required. The CNA was unaware of the resident's EBP status due to the absence of a precautionary sign on the door. The infection control registered nurse later placed the sign, and interviews revealed that staff were expected to verify EBP status through the electronic medical record (EMR) or Kardex system. The resident involved had significant medical conditions, including end-stage renal disease and bacteremia, and a physician order for EBP was present in the EMR prior to the incident. The facility's EBP policy was requested but not provided at the time of the interview. Another deficiency was observed when a resident with a peripherally inserted central catheter (PICC) line was found in physical therapy with the line uncovered and lacking a sterile cap. The director of nursing (DON) acknowledged that the PICC line should have been covered with a sterile cap after each use, as outlined in the facility's policy for PICC line care. The policy specified that an end cap should be placed on the connector to reduce the risk of vascular-associated infections. The resident had a history of osteoarthritis, contracture, pain, and a surgical wound. Additionally, the facility failed to ensure proper hand hygiene during wound care for two residents. The wound care nurse was observed repeatedly removing gloves and donning new ones without performing hand hygiene between glove changes while providing wound care to residents with surgical wounds and pressure ulcers. The DON confirmed that staff would be re-educated on hand hygiene. The facility's hand hygiene policy emphasized the importance of hand washing to prevent healthcare-associated infections. The residents involved had complex medical histories, including recent surgeries, amputations, and pressure ulcers.
Failure to Maintain Safe and Sanitary Environment Due to Broken Equipment and Unsanitary Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of broken and unsanitary equipment and areas. Several residents were observed using wheelchairs with torn and ragged armrests, and one resident's wheelchair had uneven armrests. In the kitchen area, the walk-in freezer had approximately 5-6 missing floor tiles at the threshold, creating an indentation and a visible gap at the bottom of the freezer door, which led to ice accumulation and safety concerns. Delivery staff required assistance to move goods into the freezer due to the broken tiles. The Dietary Manager stated the threshold had been missing for over a year, and the Maintenance Manager indicated repairs were in process. Additionally, a double-deck steamer was non-functional, and a leaking faucet in the dish room caused water to overflow the sink. The nourishment rooms on both the first and second floors were found to be soiled and littered with paper and debris. The first-floor nourishment room had cracked floor tiles around the sink, creating an uneven surface, while the second-floor nourishment room had a 6x6 inch open hole in the wall, which was covered by a garbage can. The Dietary Manager reported that dietary staff monitored the nourishment rooms three times daily, but cleaning was the responsibility of housekeeping. Requested documentation regarding the broken equipment and safety concerns was not submitted to the Administrator by the time of the survey exit.
Violation of Resident Dignity and Privacy Due to Unauthorized Photograph
Penalty
Summary
A certified nurse assistant (CNA) failed to treat a resident with dignity and respect by taking a photograph of the resident's exposed buttocks using a personal cell phone. The incident occurred after the resident expressed concern about not feeling clean following incontinence care. The CNA, in response, took out their phone, asked the resident if they wanted to see a picture, and then took and showed the photo to the resident. The CNA also showed the photo to a registered nurse (RN) present at the time. The resident reported feeling embarrassed, ashamed, nervous, and scared as a result of this action. The resident involved had a history of multiple medical conditions, including hypertension, heart failure, diabetes, morbid obesity, asthma, peripheral vascular disease, epilepsy, obstructive sleep apnea, lymphedema, and anxiety. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The care plan for the resident included interventions to encourage participation in self-care, provide positive reinforcement, and maintain a calm approach due to anxiety. Despite these interventions, the incident was not documented in the resident's medical record, and there was no evidence of psychosocial follow-up or documentation by staff regarding the resident's emotional state after the event. Facility policy explicitly prohibits the use of personal electronic devices, including cell phones, in resident care areas and strictly forbids taking photographs of residents. The CNA admitted to knowing that having a phone on the floor and taking pictures of residents was against policy. The lack of documentation and follow-up in the medical record, as well as the violation of privacy and dignity policies, contributed to the deficiency identified during the survey.
Failure to Develop and Implement Care Plan Interventions for Resident Safety
Penalty
Summary
The facility failed to develop and implement care plan interventions to monitor and prevent accidents for a resident, resulting in a potentially unsafe environment. During observations, the resident's call light was found on the floor and out of reach, and the resident was unaware of its location while expressing feeling unwell and requesting assistance. The bed was positioned at its highest height, further increasing the risk of accident. Staff acknowledged that the call light was out of reach after care had been provided, and it was noted that someone had just left the room without ensuring the call light was accessible. Additionally, hazardous items such as hydrogen peroxide and comet cleaner were found on the resident's bedside table on separate occasions. Staff indicated that the resident's family frequently brought in items and left them without informing staff, and there was no documentation of interventions, education, or care planning to address this ongoing behavior. The care plan did not include any measures to address the family's actions or to prevent unsafe items from being left with the resident, despite the resident's medical history of rheumatoid arthritis, dysphagia, lower back pain, diabetes mellitus with neuropathy, hypertension, acute kidney failure, and spinal stenosis.
Failure to Ensure Timely and Complete Dialysis Orders and Fluid Restriction Parameters
Penalty
Summary
A resident with end stage renal disease and dependency on dialysis was found to lack timely and complete physician orders for dialysis services. Observation revealed the resident had multiple cups of liquid and a large bottle of juice at the bedside, while the electronic medical record (EMR) did not contain a physician order for dialysis or clear directives regarding fluid restrictions. Additionally, there were no orders restricting staff from obtaining blood pressures on the resident's left arm, which contained an arteriovenous (AV) fistula used for dialysis. Documentation showed that blood pressures were recorded on the left arm on several occasions despite the presence of the AV fistula. Interviews with facility staff, including an LPN and the DON, confirmed the absence of a dialysis order in the medical orders section of the EMR and uncertainty about whether special instructions in the EMR qualified as medical orders. The facility's policy required a physician order for hemodialysis and monitoring of fluid restrictions for dialysis residents, but these requirements were not met for this resident. The lack of clear and accessible orders and directives created the potential for missed treatment, compromised vascular access, and inadequate fluid management.
Failure to Use Wheelchair Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure that wheelchair footrests were in place during transportation and to assist with proper seated posture for a resident. On multiple occasions, the resident was observed sitting in a wheelchair without footrests, with her feet dangling and in a slouched position, both while stationary and while being transported by an Activities Assistant. The resident reported that staff often removed the footrests and did not replace them. The Activities Assistant acknowledged transporting the resident without footrests and stated that footrests should be used to prevent injury. Review of the resident's medical record indicated a history of cerebrovascular disease and vascular dementia, with moderate cognitive impairment and a need for dependent assistance with mobility. The Director of Nursing confirmed that footrests should be used during transportation and for positioning to ensure safety. Facility policy also stated that footrests should be down when the wheelchair is moving to prevent injury.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with physician orders and standards of clinical practice for two residents. For one resident with a left above-the-knee amputation and additional wounds on the right foot, the wound care nurse did not follow the physician's order for wound dressing. Specifically, the nurse used an ACE wrap instead of the ordered kerlix to secure the dressing on the right foot. The resident's care plan included interventions to follow facility protocols for impaired skin integrity, but these were not adhered to during observed wound care. For another resident with a history of a gunshot wound, paralysis, and an unstageable sacral pressure ulcer, the wound care nurse also failed to follow the physician's wound care order. The nurse did not secure the sacrococcyx wound with border gauze as ordered, instead applying only Maxorb AG and ABD dressing. Both incidents were observed directly, and the wound care nurse acknowledged not following the physician's orders when questioned. The facility's policy requires treatments to be rendered in accordance with specific physician orders, which was not done in these cases.
Failure to Provide Timely and Adequate Foot Care
Penalty
Summary
A deficiency was identified when a resident with a history of epilepsy, hemiplegia, and hemiparesis following a stroke was found to have long, thick toenails and dry, flaky skin on their feet. The resident, who had moderate cognitive impairment and required dependent assistance for personal hygiene, reported that their nails were not being adequately cared for. Observations by nursing staff confirmed the condition of the resident's feet, and it was noted that the resident had not seen a podiatrist for approximately eight months, despite having a physician's order for podiatry evaluation and treatment as indicated. Review of the resident's care plan indicated that staff were to observe finger and toenails on shower days to determine if trimming was needed, but there was no documentation of care refusals or evidence that this was being consistently done. The facility's policy required referrals to ancillary providers based on individualized needs, but the resident's last podiatry visit was significantly delayed. The deficiency was attributed to the facility's failure to provide timely and adequate foot care, including appropriate podiatry services, for the resident.
Failure to Provide and Document Required Splint Application and ROM Exercises
Penalty
Summary
A deficiency was identified when a resident with a history of epilepsy, hemiplegia, and hemiparesis following a stroke was not provided with the required application of splints and range of motion (ROM) exercises as ordered. Observations showed the resident in bed without the prescribed splints, and the splints were later found stored in a dresser drawer. The resident reported that staff were not applying the splints, stating that they were too busy. Interviews with a CNA and a registered nurse confirmed that splints were not being applied and ROM exercises were not being performed. The registered nurse indicated that CNAs were responsible for these tasks, but there was no restorative nurse or aides assigned to the program at that time. A review of the resident's electronic medical record revealed no documentation of splint application or ROM exercises, nor any record of refusals, for several weeks. The resident's care plan and Kardex included specific instructions for splint use and ROM exercises, but these interventions were not carried out or documented. The facility's policy required daily documentation of restorative care and interventions, but this was not followed for the resident in question.
Failure to Prevent Accident Hazards and Ensure Supervision
Penalty
Summary
A resident was found to be at risk for accidents due to multiple lapses in safety and supervision. On two separate occasions, the resident's call light was not within reach—once entangled in linens and another time on the floor—leaving the resident unable to summon assistance when feeling unwell. Additionally, the resident's bed was observed at its highest position, and the resident was unable to lower it independently. Staff acknowledged that the call light should always be accessible and that the resident required a Geri chair due to issues with the wheelchair armrests and risk of sliding out. Potentially hazardous products, including hydrogen peroxide and Comet household cleaner, were found at the resident's bedside. Staff indicated these items were likely left by the resident's family, who frequently brought in various items without notifying staff. There was no documentation of staff educating the family about safety or addressing the issue, and the unit manager was unaware of the situation. The resident had significant medical conditions, including impaired cognitive function, incontinence, and required assistance with activities of daily living.
Failure to Maintain Sanitary Oxygen Equipment for Resident
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically an oxygen concentrator and its components, was maintained in a sanitary manner for a resident receiving oxygen therapy. Observations revealed that the oxygen tubing was dated and changed, but the oxygen concentrator's filter was visibly covered with lint and dirt, which was confirmed by the surveyor upon inspection. Interviews with staff, including a hospice aide and a nurse, indicated confusion and lack of clarity regarding responsibility for the maintenance and cleaning of the oxygen equipment. The hospice aide stated she was only responsible for placing the oxygen back on the resident after care, while the nurse deferred responsibility to maintenance. The care plan for the resident did not include interventions related to the maintenance or cleaning of the oxygen equipment or its filter. The resident involved had multiple significant medical diagnoses, including atrial fibrillation, hypertensive heart disease with heart failure, type 2 diabetes mellitus, lymphedema, venous insufficiency, dementia, and acute respiratory failure with hypoxia. The resident was moderately cognitively impaired, frequently incontinent, and required extensive assistance with mobility and transfers. Despite a contract with an outside company to maintain oxygen equipment, the filter on the resident's oxygen concentrator was not cleaned or replaced as required, and there was no documentation or clear delegation of responsibility for this task in the resident's care plan or facility records.
Unsecured Medication Cart Exposes Resident PHI
Penalty
Summary
A medication cart on unit 300 was observed left unattended with the electronic medical record (EMR) screen open, displaying a resident's protected health information (PHI) in a hallway accessible to staff and residents. The cart was not secured, and the EMR was visible to unauthorized individuals. The LPN responsible for the cart confirmed leaving it unsecured with PHI visible, acknowledging this was not in compliance with facility protocol. The unit manager and Director of Nursing both confirmed that staff are expected to lock the cart and secure the EMR screen when not in use, as per facility policy. The resident whose PHI was exposed had been admitted for operative recovery from a total left knee replacement and had a history of borderline diabetes, lipidemia, and hypertension. The resident was cognitively intact at the time of the incident. Facility policies reviewed stated that residents' privacy must be safeguarded and that medication carts should be locked at all times when not in use or not within constant vision.
Failure to Provide Routine Dental Services for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide routine dental services to one resident with severe cognitive impairment and a history of acute cerebral vascular insufficiency and dysphagia. The resident was observed to be edentulous and unable to communicate about his oral health needs. Despite a physician order for a dental evaluation and treatment, there was no documentation in the care plan addressing dental concerns or the absence of teeth. The Minimum Data Set (MDS) for the resident did not have the oral/dental status completed. Interviews with facility staff revealed that the social worker was unaware of the resident's dental needs, even though a physician order was present. The DON acknowledged that the resident should have been seen by a dentist and confirmed that the social work department was responsible for arranging dental appointments. Dental notes for the resident were requested but not provided by the time of survey exit. Facility policy indicated that referrals to ancillary providers should be made based on identified needs, but this process was not followed for the resident in question.
Failure to Provide Prescribed Adaptive Eating Equipment
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, obesity, and self-feeding difficulties was not provided with the prescribed adaptive eating equipment, specifically a scoop plate, as ordered by the physician and indicated on the care plan. The resident was observed being fed by staff using a regular plate instead of the adaptive equipment, despite the tray card and physician order specifying the need for a scoop plate. Staff interviews revealed a lack of awareness regarding the therapy recommendations and the physician's order for the scoop plate. The dietary aide confirmed that the resident previously received meals with a scoop plate, but the new order on the tray card was not matched with the actual provision of the equipment due to the absence of a requisition for purchase. Further review showed that the registered dietitian was unaware of the order and discovered that therapy had not submitted the necessary requisition to obtain the scoop plate. The facility's policy required adaptive equipment to be provided based on comprehensive assessment, but this process was not followed, resulting in the resident not receiving the prescribed adaptive device. The resident's medical record indicated multiple diagnoses, including acute respiratory failure, dysphagia, and muscle weakness, and the MDS assessment showed moderate cognitive impairment and a need for one-person assistance with ADLs.
Failure to Maintain Accessible Hospice Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that relevant hospice documentation was accessible for two residents who were receiving hospice services. For one resident, the nurse was unable to locate the comprehensive assessment, consent for hospice benefits, or the hospice comprehensive plan of care in the designated Hospice Notebook. The unit manager and social worker were also initially unaware of the location of these documents, and it was later revealed that the administrator had them. The documents showed that the resident had been admitted to hospice, but there was a possible lapse in service as indicated by the dates on the comprehensive assessment benefit period. The resident had multiple diagnoses, including atrial fibrillation, heart failure, diabetes, lymphedema, venous insufficiency, dementia, and acute respiratory failure, and required extensive assistance with daily activities. For the second resident, the hospice comprehensive assessment was not included in the electronic health record until a later date, despite the resident being admitted to hospice care earlier. This resident also had significant medical conditions, including acute cystitis, dysphagia, severe malnutrition, pressure ulcer, vascular dementia, aphasia, and major depression, and required maximal assistance for most activities of daily living. The Director of Nursing confirmed that the hospice documentation should have been accessible in the residents' records but was unable to explain why it was missing. The lack of accessible hospice documentation resulted in a lack of coordination of comprehensive services and care for both residents.
Failure to Administer and Document Pneumococcal and Influenza Vaccines
Penalty
Summary
The facility failed to administer both the Pneumococcal and Influenza vaccines to one resident, despite having obtained signed consent for these vaccinations. Documentation provided by the Infection Control RN confirmed that the resident had signed to receive both vaccines, but there was no evidence in either the vaccination book or the electronic medical record that the vaccines were actually administered. The Director of Nursing acknowledged the absence of documentation for vaccine administration, even though the expectation was that residents who sign consent forms would receive the vaccines. The resident involved had multiple significant medical conditions, including a history of stroke, chronic obstructive pulmonary disease, hypertension, generalized anxiety, major depressive disorder, dysphagia, and aphasia. The resident was also noted to be severely cognitively impaired. Facility policy required documentation of vaccine administration, including the injection site, in the medical record, but this was not completed. Additionally, the facility was unable to provide the influenza vaccination policy when requested during the survey.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for one resident who was admitted with a diagnosis of acute pancreatitis and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15. Review of the resident's electronic medical record showed that the MDS assessment was overdue by more than 120 days. During interviews, the MDS nurse did not respond when asked about receiving alerts for late assessments, and the DON stated that the MDS nurse should follow the facility's policy for MDS assessments.
Failure to Administer and Document Scheduled Medications
Penalty
Summary
A deficiency occurred when a resident did not receive any of their scheduled medications during an evening medication pass. The resident, who had diagnoses including hypertension, heart disease, and diabetes, reported not receiving their medications, which included insulin and a blood pressure pill, on the specified evening. Review of the Medication Administration Record (MAR) confirmed that none of the medications scheduled for that time were signed out, and there was no documentation of vital signs or blood sugar checks for that shift. The resident's subsequent vital signs and blood sugar were within normal limits the following morning, but the lack of medication administration and documentation was evident for the evening in question. Interviews with facility staff, including the LPN and DON, revealed that neither could initially determine who was assigned to the resident during the shift, and the MAR remained blank for all scheduled medications. The LPN later identified as assigned to the resident stated they did not recall working that assignment and confirmed that if the MAR was blank, the medications were not given. The facility's policy requires medications to be administered according to physician orders and documented on the MAR, which was not followed in this instance.
Incomplete Medical Records and Unclear Nurse Assignment for Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident reviewed for medication administration. On the evening of February 6th, the resident did not receive any of their scheduled medications, and the Medication Administration Record (MAR) for that shift was left blank with no signatures or documentation from nursing staff. The resident, who had diagnoses including hypertension, heart disease, and diabetes, reported not receiving medications and was unable to identify the nurse assigned to them that evening. The resident's electronic health record also lacked progress notes, vital signs, and blood sugar results for the relevant shift. Upon review, facility staff, including an LPN, nurse manager, and the Director of Nursing (DON), were unable to determine which nurse was assigned to the resident during the shift in question. The facility's electronic scheduling system only indicated which nurses were scheduled and clocked in, but did not specify unit assignments. The nurse identified as possibly assigned to the resident could not recall working with the resident or on that unit and stated that if the MAR was blank, the medications were not administered. The Nursing Home Administrator and DON confirmed there was no accurate way to determine the nurse assignment for that shift due to lack of documentation.
Failure to Provide Appropriate PEG Tube Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a PEG tube, resulting in the resident not receiving the prescribed amount of enteral feeding or water. During an observation, it was noted that the tube feeding bag was unlabeled and undated, with no indication of when it was hung. The water flush bag was also unlabeled and full, indicating that the resident did not receive any water flushes. The infusion pump showed that the tube feeding rate was set at 75 ml/hr, but the water flush rate was not programmed, resulting in a rate of 0 ml/hr. Licensed Practical Nurse (LPN) B acknowledged the error, stating that the water flush was not programmed, and the resident did not receive any water the previous night. Additionally, the resident's PEG tube port had broken, requiring a hospital visit for a new tube insertion. However, LPN B could not provide details on when the tube feeding and water were restarted or how much the resident received. The infusion pump indicated that only 705 ml of tube feeding had been infused, with no start date or time available. The resident's PEG tube insertion site was found open to air with a small amount of reddish drainage, and the required 4 x 4 split gauze was not properly adhered. The abdominal binder, ordered for PEG tube securement, was also not applied. The Director of Nursing (DON) confirmed the resident did not receive the prescribed enteral feeding or water flush and acknowledged the lack of labeling on the feeding and water bags. The facility's Enteral Nutrition policy requires labeling and specific orders for enteral feeding, which were not followed in this case.
Inadequate Infection Control Practices for Resident with Wound and PEG Tube
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to Enhanced Barrier Precautions (EBP) for a resident with a wound and PEG tube. During an observation, the resident was found lying in bed with visibly soiled clothing and a soiled gauze dressing in the bed. Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) entered the room to provide incontinence care without wearing gowns, which are required under EBP for residents with wounds and indwelling medical devices. The staff acknowledged the need for gowns but had to leave the room to obtain them, as there was no signage or PPE supply cart available in or near the resident's room. The Director of Nursing (DON) confirmed the lapse in following EBP, noting that the staff had been in-serviced on the precautions but failed to implement them correctly. The resident's electronic health record indicated a physician's order for EBP due to the presence of a PEG tube and wound. The facility's policy mandates the use of EBP for residents with wounds or indwelling medical devices, requiring signage and readily available PPE. However, these measures were not in place, leading to the potential for the spread of infection.
Deficiencies in Respiratory Care: Emergency Tracheostomy and Oxygen Tubing Management
Penalty
Summary
The facility was cited for two deficient practices related to respiratory care. The first deficiency involved the failure to ensure an emergency tracheostomy was readily accessible for a resident (R138) who required mechanical ventilation. During an observation, it was noted that R138 did not have an emergency trach visible in their room, and staff members were unable to locate one promptly. Despite R138's history of respiratory failure and the need for a tracheostomy, there was no spare tracheostomy at the bedside, leading to a delay in accessing emergency care when needed. The second deficiency identified was the failure to label and date oxygen tubing for a resident (R48) receiving oxygen therapy. The observation revealed that R48's oxygen tubing connected to the concentrator was unlabeled and undated, with the resident unable to recall the last time the tubing was changed. Staff members acknowledged the importance of labeling and dating oxygen tubing to track usage and ensure cleanliness, highlighting the potential risk of respiratory infections associated with unclean tubing.
Sanitary Conditions and Food Temperature Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which resulted in an increased potential for cross-contamination of food and foodborne illness. Observations revealed soiled non-food contact surfaces, including ventilation filters above the fryer, the top and sides of the fryer, the sides of the oven next to the fryer, the grates of the flat top grill, and the six-burner oven's stainless steel backsplash. Additionally, the number ten can opener's cutting blade at the cook prep station was observed with visible debris and metal shavings. The flooring throughout all the facility's nourishment rooms was also found to have an accumulation of dust and debris. The Dietary Director acknowledged that these areas were not being cleaned sufficiently and timely, despite the kitchen's cleaning policy stating that these areas should be cleaned three times a day after each meal. No additional cleaning schedule documenting verification of the daily cleaning tasks was provided for review. The facility also failed to maintain proper food temperatures during meal service. A meal test tray revealed that the macaroni and cheese and collard greens were holding at a temperature of 105 degrees F, and the fried chicken at 100 degrees F, which is below the required 135 degrees F for hot holding. The Dietary Director and staff acknowledged the issue and mentioned the need for additional insulated meal carts and a functioning plate warmer to prevent meals from sitting too long before being served. This failure to maintain proper food temperatures could potentially affect 143 residents who receive meal services.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to ensure that the garbage storage area was maintained in a sanitary condition, which increased the potential for the harborage and feeding of pests. During a tour of the facility, the surveyor observed exterior trash dumpsters with lids in the open position and a variety of trash, debris, and used fryer oil surrounding the area. Staff E mentioned that the area often looks like this after trash pickup, and the doors are left open. The facility's waste disposal policy, dated April 2015, stated that outside dumpsters should be maintained in a clean manner, not overflowing, and with lids closed at all times. This was not adhered to, as observed by the surveyor. The 2017 U.S. Public Health Service Food Code also directs that receptacles and waste handling units should be kept covered with tight-fitting lids or doors if kept outside the food establishment, which was not followed in this instance.
Inconsistent Functioning of Nurse Call System
Penalty
Summary
The facility failed to ensure the 2nd floor wireless nurse call light system was effectively utilized by staff or had consistently functioning centralized monitor screens. During an environmental tour, a resident's bedside nurse call device was found frayed and taped over, and upon testing, it was observed that the nurse's station did not have an audible alarm, although the call light was flashing on a computer monitor. A Registered Nurse admitted that the sound was turned off because it was always going off. The Maintenance Director was unaware of the issue and mentioned that the system alarms at each nurse's station on the computer screen and through speakers, but no wireless pagers were used to notify staff of resident needs. Further observations revealed that the computer monitors at the 800, 500, and 600 hall's nurse's stations were either not displaying notifications or were turned off. The Maintenance Director had to reset and reattach cords to the monitors to get them functioning again. Additionally, a Registered Nurse expressed a preference for keeping the monitor off. Bells were available for use on each resident floor as an alternative notification method, but the primary nurse call system was not consistently operational, leading to potential delays in response times and unmet resident care needs for 47 residents.
Failure to Maintain Resident Dignity by Not Providing Personal Clothing
Penalty
Summary
The facility failed to maintain the dignity of a resident (R16) by not dressing them in their personal clothing. On multiple occasions, R16 was observed wearing clothes that did not belong to them, which caused the resident verbal frustration and impaired their mental and psychosocial well-being. R16 reported that their personal clothes had been missing for about two weeks, and despite informing social services, no action was taken. The resident's closet was observed to have limited clothing, and the assigned CNA confirmed that they had to dress R16 in miscellaneous clothes from the laundry that belonged to other residents. R16 was admitted to the facility with diagnoses including dementia, diabetes mellitus type two, malignant neoplasm of the stomach, and major depressive disorder. The resident was cognitively intact with a BIMS score of 14/15 and required extensive assistance with ADLs, including dressing. The facility's policy on Resident Dignity & Personal Privacy mandates that residents should be dressed in their desired clothing, but this was not adhered to in R16's case. The DON confirmed that it should take only one day to wash and return residents' clothes, indicating a failure in the facility's processes.
Failure to Provide Call Light and Wheelchair
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident (R43) and a wheelchair was provided for another resident (R108), resulting in unmet care needs. R43, who has severe cognitive impairment and multiple medical conditions including dysphagia, chronic obstructive pulmonary disease, and hemiplegia, was observed lying in bed without a call light within reach. R43 expressed discomfort and the need for assistance to be repositioned. The facility's policy and R43's care plan both indicated that call lights should be within reach to ensure safety and assistance, but this was not adhered to, as confirmed by the LPN and the Director of Nursing (DON). R108, who was admitted with a fractured hip and no cognitive impairment, reported not having a wheelchair to get up. Multiple observations confirmed the absence of a wheelchair in R108's room. The Therapy Manager and the DON both acknowledged that it is the facility's responsibility to provide necessary mobility aids such as wheelchairs and walkers. Despite this, R108 was left without a wheelchair, which is essential for mobility and emergency situations. These deficiencies highlight the facility's failure to accommodate the needs and preferences of its residents as required by their policies and care plans.
Failure to Update PASARR Forms for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Annual Resident Review (PASARR) forms were reviewed, revised, and sent to the local state agency for evaluation of intellectual or developmental disability needs for one resident. The resident was admitted with diagnoses including bipolar disorder and paranoid personality, but the PASARR Level I screen from the hospital was not updated within the required 30-day period. The resident's Minimum Data Set (MDS) assessment indicated cognitive impairment and the use of antipsychotic medication. Interviews with facility staff revealed that a new PASARR should have been completed 25 days after admission, but it was only completed on the day of the survey. The Director of Nursing confirmed that the Social Worker is responsible for completing PASARRs and that they should be reviewed on admission and sent for Level II evaluation if needed.
Failure to Revise Care Plans in a Timely Manner
Penalty
Summary
The facility failed to revise care plans in a timely manner for two residents, leading to deficiencies in their care. Resident R18, who had bilateral above-the-knee amputations and two open wounds on the bottom back side of the right leg, did not have an updated care plan addressing these wounds. The care plan still included outdated interventions for previous conditions and had not been revised to reflect the current state of the resident's health. The Director of Nursing confirmed that the care plans should have been updated to include the new wounds and that the previous interventions should not have been documented as active. Resident R121, who was admitted with an indwelling catheter, had the catheter removed in March, but the care plan was not updated to reflect this change. The care plan still indicated the presence of the catheter, despite physician orders to discontinue it. The facility's policy on care planning requires that care plans be developed, reviewed, and revised based on comprehensive assessments, but this was not followed in the cases of R18 and R121.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,149 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 Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nursing & Physical Rehab Center Of D | 0.4 mi | ★★★★★ | 16 | 0 |
| Hamilton Nursing Home | 1.3 mi | ★★★★★ | 0 | 0 |
| Qualicare Nursing Home | 1.4 mi | ★★★★★ | 9 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 1.8 mi | ★★★★★ | 5 | 0 |
| Riverview Health & Rehab Center | 1.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Regency At Chene.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.