Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Jackson during CMS and state inspections, most recent first.
Food storage and kitchen sanitation were deficient when ready-to-eat items were found without proper dating, expired food remained in storage, and kitchen equipment was dirty. Spices, whipped topping, and an expired angel food cake lacked required dates, a bag of bacon was left open and drying out, the oven had debris buildup, the dish machine low temp log was not checked for all shifts, and the steam table and steamer had visible buildup and oily residue.
The facility failed to maintain effective administration of its IPCP and ASP, with no infection control surveillance documentation in the IPCP binder for multiple months and no functional IPCP or ASP in place during that period. The DON reported there was no ICP/IPCP when she started, and the facility assessment was not reassessed even though the IPCP and ASP were not functioning. The infection prevention and water management policies had not been revised for over a year, and the report stated IPCP data was not presented to QAPI as required.
QAPI did not monitor the IPCP or ASP, and the facility lacked infection prevention and surveillance documentation for multiple months. The DON stated there was no active ICP or IPCP in place when she started, and only one month of IPCP surveillance had been completed. The Administrator said antibiotic use was discussed in morning meetings rather than QAPI meetings, and no IPCP data was brought to monthly QAPI. The QAPI committee did not identify the absence of IPCP/ASP data, infection records, or corrective actions.
Failure to maintain IPCP and follow EBP: The facility had no functional IPCP or IP in place for multiple months, with no infection surveillance documentation or QAPI oversight during that period. A resident with a suprapubic catheter had an active EBP order, but repeated observations found no EBP signage or PPE outside the room, and the resident reported staff used gloves only and did not wear gowns for catheter care. The DON also stated she was not familiar with the Water Management Program, and the water management policy and meeting participation were incomplete.
Failure to Implement Antibiotic Stewardship Program: The facility failed to maintain an ongoing ASP. The Infection Control Antibiotic Stewardship and MDROs policy had not been revised since 4/17/2025, and the DON stated that when she began in February 2026 there was no IPCP or ASP in place. Review of the IPCP binder showed no documentation of antibiotics ordered or resident infections, viruses, or fungal infections for several months, and no ASP was in place during that period.
A facility failed to maintain a clean, homelike environment when surveyors observed dust-covered vents, missing drywall with open holes and exposed pipes, a sticky floor, and a shared bathroom with urine and stool on the toilet and a soiled towel on the floor. The MDS stated the drywall had been damaged after a leak for weeks, had no cleaning schedule or logs, and said housekeeping cleaned only the outside of vents while maintenance was responsible for the inside.
Pharmacy MMRs for several residents noted irregularities or recommendations, but the related reports and provider responses were missing from the chart or not completed. A resident with CVA and DM, a resident with DM and dementia, a resident with HF, and another resident had pharmacy findings documented as "see report" or recommendations without evidence of physician review or action, and the DON stated the reports could not be located or were not addressed.
Failure to Protect Resident from Verbal Abuse: A resident with dementia and depression, and moderately impaired cognition, reported that a housekeeper told him to clean his own bathroom after diarrhea and stool contamination. Interviews with the resident, CNA, housekeeper, and UM showed conflicting accounts, but confirmed that wipes were intended for the resident to clean the area and that the interaction was not consistent with resident dignity, respect, and appropriate staff conduct.
Failure to Thoroughly Investigate Allegation of Drug Diversion: The facility did not thoroughly investigate an allegation that an LPN may have diverted a resident’s PRN Norco. The resident had significant cognitive impairment, and narcotic records showed the same LPN signed out the last 20 documented doses while MAR and narcotic sheet discrepancies were identified. Pain scores were not consistently documented, staff raised concerns about the pattern of administration, and the investigation file lacked key records such as the MARs, narcotic logs, and a police report.
Failure to Provide Written Transfer Notice: A cognitively intact resident was transferred to the hospital for shortness of breath, and the facility gave paperwork to ambulance staff and explained the bed hold policy to the family, but did not provide the resident with a written transfer notice. The DON stated the transfer form in use did not include appeal rights or the State LTC Ombudsman contact information, and acknowledged the facility had a written transfer form that was not given to the resident.
A resident with multiple chronic diagnoses, including rheumatoid arthritis, MS, and functional quadriplegia, had an inaccurate MDS. The MDS showed a BIMS of 13 and documented the resident as receiving an antibiotic, but MAR and order review confirmed there was no antibiotic ordered or administered. The DON reviewed the chart and stated it was an MDS discrepancy.
Medication Administration and Documentation Failure: An LPN failed to timely document nicotine lozenges for a cognitively intact resident who asked for the medication and stated she had not received it. The LPN said she had given the lozenges earlier in the day and again shortly before the observation, but the MAR showed no signed-out doses at those times; the DON later verified both doses were charted at the same later time instead.
Failure to coordinate repair of a resident’s power wheelchair led to prolonged loss of mobility and medically related social services. The resident had been confined to bed and her room for months, reporting frustration, social isolation, increased call light use, and mental and emotional distress. Staff and the guardian were unable to get a clear response from the repair company, and the company had been contacting the resident’s sister instead of the guardian, delaying scheduling of the repair.
Medication administration was not observed by a nurse for a cognitively intact resident with multiple diagnoses, including DM2, obesity, OSA, depression, anxiety, and pain. Several meds were left in a med cup on the over-bed table for the resident to take, and the resident said nurses usually leave meds there and that some pills must be taken at different times. An LPN said the resident had not been evaluated for self-administration, and the DON described standard med administration expectations.
Failure to notify a resident before a room change: A cognitively intact resident with CHF and anxiety reported that a CNA told him he was being moved to another floor, with no choice or explanation given. The record showed the resident asked to speak with nursing management about the room change, but there was no documentation of notice, consent, or follow-up; the DON was unaware of the issue, and the NHA stated the resident’s brother had requested the move.
A resident’s advance directive paperwork was not thoroughly completed. The DNR form was missing dates for the resident signature and one witness signature, and there was no active physician order reflecting DNR status. The DON confirmed the missing dates and the absence of an active code status order.
Failure to timely report suspected crime and abuse allegations: Staff identified a suspected narcotic diversion involving a resident with severe cognitive impairment, but the event was not promptly escalated to the NHA/abuse coordinator or police. In a separate incident, staff reported that a CNA verbally abused and roughly shook another resident’s wheelchair, yet the allegation was widely known on the unit and still not reported to the NHA/DON.
A resident with dementia, schizophrenia, anxiety, malnutrition, and a femur fracture had an initial PASARR on file, but no annual PASARR was completed. The LNHA and DON stated they were reviewing past-due PASARRs, but the resident’s annual review could not be located, and the DON confirmed it was not done.
Failure to provide scheduled showers for a dependent resident. A resident with intact cognition and a recent below-knee amputation reported needing frequent showers to keep the surgical incision clean, but shower logs showed only 2 showers documented despite a twice-weekly schedule. The DON confirmed the limited documentation and noted that refusals should be recorded and the resident reapproached, but no refusals were documented.
Failure to Reassess PRN Anti-Anxiety Medication: A resident with generalized anxiety disorder and depression reported high anxiety, difficulty eating, and being out of his anxiety medication after a PRN Xanax order ended. The MAR showed frequent Xanax use while the order was active, and staff interviews confirmed ongoing anxiety symptoms, but the resident was not reassessed after the 14-day PRN order ended.
Failure to provide dental services for two residents. One resident with only two upper teeth and difficulty chewing had an order for dental services on admission but was never scheduled for a dental appt, despite a care plan noting broken/missing teeth and a dental consult as needed. Another resident was edentulous, reported no dentures at the facility, and stated he had not been seen by a dentist since admission even though active orders called for dental eval and treatment as indicated.
Failure to honor a resident’s food preferences: A cognitively intact resident who practiced Judaism was served meals that included pork on the menu, but staff did not ask what alternative she wanted and relied on informal knowledge rather than documented preferences. The resident was served an unappealing lunch, and dietary staff stated preferences were kept only on tray tickets, not in the medical record, and that a hamburger was served on bread because buns had run out.
The facility failed to update its facility assessment when the ICP and ASP were no longer in place or functioning. The DON stated there was no ICPP/ASP documentation for several months, and review of the IPCP binders showed no infection prevention or surveillance documentation during those periods. The Administrator stated the facility assessment should have been reassessed because the ICP and ASP were not functioning.
The facility failed to ensure the ICP participated in QAPI and reported on the IPCP and ASP. The QAPI plan did not address the IPCP or ASP, and the DON stated there was no ICP or IPCP in place for several months, with no infection surveillance documentation in the IPCP binder for those months. The DON reported only one IPCP-related meeting, and the facility policies stated that infection prevention activities and antibiotic stewardship were part of the QAPI process.
Failure to Document and Resolve Grievance for Broken Eyeglasses: A resident admitted for short-term rehab with cellulitis and a BIMS score indicating cognitive intactness had eyeglasses lost in the laundry and later found damaged. The family repeatedly contacted the AD and NHA about reimbursement for replacement glasses, but the concern was not entered on the grievance log, was not clearly investigated or tracked, and remained unresolved despite multiple emails and staff awareness.
Failure to Investigate Resident Abuse Allegation: A cognitively intact resident recovering from a femur fracture reported that a CNA refused to help her off a bed pan and made a dismissive remark before leaving the room. Other staff heard the exchange, nursing staff and administration were aware of the complaint, and the resident asked to speak with management, but the allegation was not documented or investigated before she left AMA.
Failure to Report Alleged Abuse: A cognitively intact resident admitted for rehab after a femur fracture reported that a CNA refused to help her off a bed pan and made a dismissive remark. Multiple staff knew about the complaint, the care plan was changed to include cares in pairs, but the allegation was not investigated or reported before the resident left AMA.
Failure to thoroughly investigate an injury of unknown source and a verbal abuse allegation. A resident with dementia and severe cognitive impairment reported shoulder pain after being repositioned by staff, later had a proximal fracture identified, and the facility’s investigation had missing statements and inconsistent timelines. Another cognitively intact resident reported that a CNA verbally refused help with a bedpan, multiple staff knew of the complaint, and the concern was not fully investigated before the resident left AMA.
Failure to complete ordered wound care and date dressings. Two residents with pressure-related wounds reported that daily dressing changes were not being done as ordered, and observations showed dressings that were clean, dry, and intact but not dated. The wound NP documented repeated concerns that wound care was not being performed regularly or per order, and nursing administration confirmed there were no audits beyond weekly wound rounds and no ongoing or widespread education after missed wound care was identified.
Improperly Fitted Bed Contributed to Resident Fall: A resident with catatonic schizophrenia and vascular dementia, and moderately impaired cognition, sustained an avoidable fall after rolling out of bed. The incident review and staff interviews showed the bed frame had been reduced and then returned without being properly extended, leaving the mattress hanging over the edge and contributing to the fall.
A resident with a suprapubic catheter and intact cognition reported that ordered catheter flushes were not being done, despite facility documentation showing twice-daily flushes. Urology noted the catheter was not being exchanged regularly, the resident had leaking urine and minimal urine in the bag, and ordered daily irrigation to prevent sediment buildup; the DON stated the expectation was that suprapubic catheter flushing was PRN.
Inaccurate wound care documentation was identified for a resident with DM2, PVD, and osteomyelitis. The resident reported that a foot wound dressing ordered to be changed daily was often changed only every 2 days, while the wound NP documented multiple instances where the dressing had not been changed as ordered or the same dressing remained in place from the prior week. The MAR still showed wound care as completed daily during those periods, and Nursing Administration confirmed weekly rounds were the only audits done and that wound care supplies such as blue foam were sometimes hard for staff to locate.
The facility failed to maintain sanitary food preparation and service while contractors excavated a large hole in the kitchen floor near the steamer and tray line. Unsecured plastic barriers, exposed dirt piles, broken tile, rocks, wastewater, and contractor traffic with dirty boots were present in the food prep area, while garden hoses ran from the kitchen through the dining room and out an open window. Dietary staff continued to prep and serve meals from a steam table and work areas located directly next to the open excavation, with wrapped silverware and disposable items stored near dirt and debris, and a soiled blender left on a dining room table. The CDM, DONs, Maintenance Director, and Administrator all acknowledged that the barrier was not verified as secure and that food preparation was not removed from the contaminated kitchen, resulting in multiple meals being served under these conditions to all residents who ate from the kitchen.
The facility failed to properly document, investigate, track, and resolve grievances and neglect allegations. A resident who was cognitively intact and dependent for transfers and toileting reported being left without care for 14 hours, but the allegation was not reported to the state and lacked supporting documentation in the record. Another resident with a history of stroke and total dependence for ADLs had repeated unmet care needs, including soiled bedding and missed hygiene, with the family reporting ongoing complaints and no awareness of a formal grievance process. A third resident, cognitively intact and requiring significant assistance for bathing and toileting, reported going weeks without showers despite prior complaints and concern forms, while task records showed extensive gaps in documented care. Staff also reported a night with no CNA coverage on one floor, during which three residents were left in chairs all night and one was found heavily soiled, and stated that grievances and concern forms were submitted to management; however, the NHA later reported no knowledge of these events and no concern forms for the involved residents in the prior month.
The facility failed to ensure timely reporting and investigation of reasonable suspicions of neglect and unmet care needs. A cognitively intact resident with significant physical limitations alleged she received no care for 14 hours and was left soiled, but the NHA did not report this because it was deemed outside a two-hour window, and documentation did not show that the allegation was reported to the state. On a separate weekend, a CNA and an LPN reported that no CNA staff were present on one floor overnight, that several residents were left in chairs all night and into the morning, and that one resident was found heavily soiled and required a shower, yet the NHA stated there were no concern forms or additional abuse allegations for that period. The scheduler further reported chronic inability to staff CNA positions, frequent completion of concern forms about unmet care and staffing, and provision of these forms to management, indicating that multiple care concerns and potential neglect events were not consistently recognized or reported as required under section 1150B.
The facility failed to thoroughly investigate and report multiple allegations of neglect and abuse involving several cognitively intact residents who required extensive assistance with transfers, toileting, and hygiene. One resident alleged being left without care for 14 hours, including being left soiled and experiencing skin breakdown, but the NHA did not report this externally and marked the concern as resolved without supporting investigative documentation. On a separate weekend night, staff reported that no CNA coverage was present on one floor, two residents were left in chairs all night and remained there into the next morning, and another resident was found heavily soiled and in need of a shower after remaining in a chair the entire shift. An LPN confirmed the absence of CNA staff that night and that three residents remained in chairs with the same clothing into the next day, while the NHA denied having concern forms or knowledge of these events, despite the facility’s policy requiring immediate reporting and thorough investigation of all abuse and neglect allegations.
Multiple residents who were dependent on staff for ADLs, including toileting, transfers, hygiene, and showers, did not receive care as planned, with reports of being left in bed or chairs for extended periods, remaining in soiled briefs or clothing, and missing scheduled showers. Cognitively intact residents described being put to bed early because of staffing issues and not being assisted out of bed until mid-afternoon, while another resident’s family found the resident in soiled sheets and nearly falling from bed after repeated unresolved complaints. Task documentation showed numerous missing entries for ADL care and showers, and one severely cognitively impaired resident received only one shower in three weeks and was left on a toilet without access to a call light, having to yell for help. Staff interviews confirmed that an entire night shift on one floor had no CNA coverage, leaving several residents up all night and one heavily soiled, and that chronic CNA shortages forced staff to choose between passing meal trays and providing hands-on care, resulting in unmet ADL needs and undocumented missed care.
The facility failed to provide adequate nursing staff to meet residents’ care needs, leading to multiple instances of unmet basic care. A cognitively intact resident with severe obesity and mobility limitations reported being left in bed from late at night until mid‑afternoon the next day and remaining soiled, while another dependent resident with a history of stroke had repeated gaps in documented hygiene, ADLs, toileting, and missed showers, and was found by family with soiled sheets and positioned unsafely in bed. A third resident reported receiving only one shower in two months, corroborated by task records showing extensive documentation holes. On one night shift, there were no CNAs on a floor, only two nurses, resulting in three dependent residents being left in chairs all night, with one found heavily soiled and others still in the same chairs and clothing the next morning. Staff interviews described chronic schedule shortages, use of non‑nursing staff on schedules, repeated but unaddressed concern forms about staffing, and acknowledgment that numerous residents required two‑person assistance, demonstrating that daily staffing levels were insufficient to meet residents’ assessed needs.
A resident with severe cognitive impairment and multiple serious diagnoses experienced a change in condition noticed by a family member, who questioned his status and asked an LPN whether he should be sent to the hospital. The LPN reportedly stated he was not dying and that the hospital would not do anything but send him back, though the family member requested vital signs be checked and later left when the resident seemed to improve. Hours later, the resident was sent to the hospital, which notified the family member of his arrival; the facility did not contact her about the change in condition or transfer, and she confirmed there were no calls or messages from the facility despite her prior expressed concerns about his care and safety.
A cognitively impaired female resident with a history of stroke, depression, altered mental status, and aphasia, who required assistance with personal care and could not consent, was subjected to sexual abuse by a cognitively intact male resident. The resident’s DPOA had previously observed the two holding hands and explicitly told the NHA that she did not want any physical contact, and the male resident had been counseled that the female resident could not consent. Despite this, a CNA later observed the male resident in his room kissing the female resident’s neck and groping her inner thigh over her pants, and intervened to separate them. Facility records also showed prior incidents of the male resident inappropriately touching other residents and needing redirection, and surveyors identified inconsistencies between staff accounts and the written staffing schedule regarding which CNA was present at the time of the incident.
A resident with severe cognitive impairment, multiple chronic conditions, and dependence in ADLs experienced a decline in condition leading to an emergency hospital transfer. The family had previously reported concerns about a non-functioning call light and inadequate means for the resident to summon help. On the day of transfer, the family member questioned the change in the resident’s condition and whether he should go to the hospital, but later learned from the hospital—not the facility—that he had been transferred. The LPN involved gave inconsistent statements about whether the provider, the resident’s representative, and the hospital received appropriate notifications and transfer/discharge paperwork. Record review showed no documentation that the provider was notified of the change in condition, that the resident or representative received the bed-hold policy or transfer/discharge paperwork, or that the family was informed of the transfer.
The facility failed to develop and implement comprehensive care plans for two residents who left the facility on leave of absence (LOA) or against medical advice (AMA). One resident signed an AMA form stating they were not cleared by a physician to leave unsupervised and that they had participated in care planning, yet no corresponding care plan or IDT discussion addressing AMA/LOA was found. Another cognitively intact resident frequently signed out on LOA, but there was no IDT evaluation of LOA safety and no care plan addressing LOA, safety interventions, or assessments. The DON acknowledged there was no evaluation or IDT documentation for this resident’s LOA ability, despite facility policy requiring a care plan for LOA that addresses medications, education, dietary issues, and other potential concerns.
A resident with intact cognition but documented visual impairment from a prior stroke was allowed to take an LOA without any documented evaluation of LOA safety, despite facility policy requiring such assessments. The resident signed out with another resident, did not use a crosswalk when returning, and was struck by a speeding vehicle, sustaining multiple injuries. The care plan addressed visual impairment but lacked LOA-related safety interventions, the SW reported never having seen or completed an LOA assessment, and EMR review showed no IDT evaluation of LOA ability before or after the incident, which the DON confirmed.
A resident signed consent forms to receive PCV20 and RSV vaccinations, and the EMR listed these immunizations as pending, but no corresponding physician orders were written and no entries appeared on the MAR over several months. Review of records and progress notes showed no documentation that the vaccines were administered or any reason for non-administration, and the DON confirmed in interview that the resident never received the requested vaccinations despite having provided consent.
Surveyors found that the facility repeatedly hired and scheduled CNAs and nurses without completing required hiring steps, background checks, health screenings, or competency validations. Personnel files for multiple CNAs and nurses lacked I‑9s, I‑CHAT and sex offender checks, license or certification verification, TB tests, physicals, and documentation of facility general orientation. CNA‑ and nurse‑specific competencies on core care skills, abuse/neglect, infection control, transfers, ADLs, and other clinical tasks were not completed or not validated by licensed staff, yet these employees were placed on the schedule and worked independently with residents. Leadership and the scheduler confirmed they had no reliable process or checklist to ensure orientation and competencies were finished before staff began unit assignments, and the HRC acknowledged he was unaware of applicable federal regulatory requirements.
A dependent hospice resident with multiple serious diagnoses and intact cognition did not receive regular bed baths or personal care for an extended period. Observations showed the resident in bed with soiled clothing on consecutive days, bare feet pressed against the bed footboard, and an undated or day‑old water glass. The medical record documented total dependence for personal care, while hospice records showed CNA bath visits scheduled twice weekly but with the last bath documented about a month earlier. CNAs reported they believed hospice was responsible for the resident’s showers and that the showers listed on their task sheets referred to hospice visits, and there was no documented coordination of care between the facility and the hospice agency regarding responsibility for ADL care.
A resident who required two-person assistance for bed mobility and mechanical lift transfers, and one-person assistance for bedpan use, fell from bed and sustained a lip laceration and broken tooth while being assisted by a CNA. Facility records showed inconsistent and incomplete functional assessments, and the CNA reported she had not reviewed the Kardex that shift and did not know the resident was a two-person assist. The CNA assisted the resident off the bedpan alone, during which the resident either slid or threw herself from the bed, according to differing accounts. The CNA’s personnel file lacked evidence of completed orientation, background checks, and CNA competency evaluations, and there was no documented assessment of staff competency in performing two-person transfers on the unit.
Surveyors found that the facility did not enforce its COVID-19 infection prevention and control program when a dietary manager was observed working in the kitchen during breakfast service without wearing a mask, despite a facility-wide mandate for staff masking following positive COVID-19 tests among staff. The dietary manager acknowledged not having the mask on at the time of observation. In an interview, the DON explained that after staff reported COVID-19, management required confirmatory testing, conducted serial testing of staff and residents per CDC guidance, and mandated mask use for all working staff, confirming that the observed noncompliance occurred while universal masking was required.
For 14 days within a 30-day period, the facility did not provide the required number of nursing staff, including both aides and nurses, as determined by census and resident acuity. Staffing records and interviews confirmed that shifts were left short-staffed despite attempts to fill vacancies, resulting in insufficient staff to meet resident care needs.
A resident with moderate cognitive impairment experienced two falls resulting in a hip fracture, but the facility failed to conduct a thorough investigation. Incident reports were incomplete, lacking pain assessments, staff statements, and accurate timing. The DON did not obtain statements from direct care staff, and required monitoring and risk analysis were not performed, leading to an incomplete response to the injury.
Food Storage and Kitchen Equipment Sanitation Deficiencies
Penalty
Summary
Food storage and kitchen sanitation practices were found deficient when ready-to-eat items were not properly dated, expired food remained in storage, and kitchen equipment was not effectively cleaned. During an initial walk-through, spices including chicken seasoning and black pepper were observed without open dates or expiration dates, and the Dietary Manager stated they had been received on 05/24/26 and only wrote that date on the containers. Six 16-oz bags of On-Top whipped topping were also observed with no receive dates or expiration dates, and an unopened angel food cake dated 05/01/26 was found expired on 06/01/2026 and not discarded at the time of observation. Additional observations showed a large zip-locked bag of bacon dated 05/24/26 that was wide open and drying out, and the Dietary Manager discarded the items during the observation. The Volcan double oven had debris on the drip sheet/cookie sheet in the bottom of the top oven, and the Dietary Manager stated the kitchen equipment and kitchen overall were only tried to be cleaned weekly without a written cleaning calendar available. The dish machine low temp log was not checked on 06/01/26 for any of the 3 shifts, and on 06/03/26 the large six-section steam table was observed with dirty, stained buildup on the lip and visible dark substance and floating elements in the bottom. The Dietary Manager stated the steam table water was changed daily but had no log or document to show it, and a repairman later cleaned the stand-up steamer after finding an oily mixture in the bottom and instructed the Dietary Manager on how to clean the equipment moving forward.
Failure to Maintain IPCP, ASP, QAPI Oversight, and Current Policies
Penalty
Summary
The facility failed to maintain effective administration for its Infection Prevention Control Program (IPCP) and Antibiotic Stewardship Program (ASP), and failed to ensure required oversight through QAPI and policy review. The Infection Prevention Program policy had not been reviewed for revisions since 2/28/2025, and the Infection Prevention Program Overview policy also had not been revised since 2/28/2025. The policies stated that the facility establishes a program to investigate, identify, prevent, report, and control infections and communicable diseases, and that the administrator is ultimately responsible for the infection control program. They also stated that the Infection Prevention Committee meets regularly as part of QAPI and that IPCP reports are reviewed and approved by QAPI. During interview and record review, the DON stated that when she began in February 2026 there was no ICP and no IPCP in place. The IPCP binder showed no infection control surveillance documentation for September, October, November, and December 2025, and the 2026 binder showed no documentation for January, February, or March 2026. The report stated that for those six months there was no functional IPCP or ASP and no ongoing monitoring or QAPI oversight of infections or inappropriate antibiotic use. The facility assessment was last completed on 8/1/2024 and was effective through 7/31/2025, and the Administrator stated the assessment should have been reassessed during the period when the IPCP and ASP were not functioning. The Water Management Program policy had also not been revised since 2/1/2024 and identified a quarterly team that included the Administrator, DON, Maintenance Director, and Infection Preventionist.
QAPI Did Not Monitor IPCP or ASP
Penalty
Summary
The facility failed to maintain an effective QAPI program that monitored the IPCP and ASP for a census of 60 residents. Review of the Corporate QAPI Plan dated 10/24/2018 and revised 1/25/2024 showed the plan described QAPI as a system-focused process, but it did not include the IPCP in the QAPI plan and did not address monthly presentation of infection control data, monitoring for systemic concerns, or corrective actions related to infection control. The Infection Prevention Program Overview policy dated 2/28/2025 stated that the administrator was ultimately responsible for the infection control program and that the Infection Prevention Committee met regularly as part of QAPI, with reports reviewed and approved by the QAPI committee and minutes maintained in QAPI records. Interview and record review showed there was no active ICP or IPCP in place when the DON began in February 2026, and no active ASP documentation for September through December 2025 or January through March 2026. The DON stated that only one IPCP meeting had been attended and that only one month of surveillance and documentation had been completed for April 2026. Review of the IPCP binders confirmed there was no infection prevention or surveillance documentation for September through December 2025 and January through March 2026. The Administrator stated that antibiotics were discussed in morning meetings rather than QAPI meetings, that no IPCP data was brought to monthly QAPI meetings, and that the previous ICP never had data to present. The QAPI committee did not identify the absence of IPCP and ASP data, the lack of infection records and corrective actions, or the facility’s inability to provide antibiotic usage, active infections, interventions, or education for the six-month period.
Failure to Maintain IPCP and Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program (IPCP) and failed to have an Infection Preventionist in place for six months out of the last eight months reviewed. The Director of Nursing stated that when she began working in February 2026, there was no ICP and no IPCP in place. She reported there was no IPCP documentation for September, October, November, and December 2025, and also none for January, February, or March 2026. Review of the IPCP binder confirmed there was no infection control surveillance documentation for those months, and the facility record also showed no ongoing monitoring or QAPI oversight of infections or antibiotic use during that time. Resident 72 was admitted with diagnoses including depression and dementia and had a suprapubic catheter in place. The resident’s record showed an order for Enhanced Barrier Precautions (EBP) placed on 6/2/26. During observations on 6/2/26, 6/3/26, and 6/5/26, no EBP signage was seen on the resident’s door or nearby, and no PPE was observed in close proximity to the room. On 6/5/26, the resident stated that staff used gloves for catheter care but did not wear a gown, only regular clothes. A trash can near the bed contained discarded gloves, but no gowns were noted. During interview, the Unit Manager stated that a resident with a suprapubic catheter should have EBP signage and PPE on the door and verified that the order for EBP was active. The Unit Manager also stated that Infection Preventionist C would normally be responsible for placing the signage and PPE, but none was present. The facility’s EBP policy stated that residents with an indwelling medical device should be on EBP, that signage should be posted, PPE should be readily available, and staff should wear gloves and gowns during high-contact care such as urinary catheter care. The facility’s Water Management Program policy also had not been reviewed since 2/1/2024, and the Water Management Team meeting minutes showed DON B was not in attendance at the 5/5/2026 meeting despite being listed as a team member.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure implementation of an ongoing antibiotic stewardship program for six months. Review of the facility Infection Control Antibiotic Stewardship and MDROs policy showed it had not been revised since 4/17/2025 and stated that the program would encourage appropriate prescribing and reduce adverse effects such as gastrointestinal problems, C. difficile diarrhea, yeast infections, and antibiotic resistance in aging adults. The policy also stated that the medical director and DON would use their influence to help ensure antibiotics were prescribed only when appropriate, and that the infection preventionist would be responsible for promoting and overseeing antibiotic stewardship activities. In an interview on 6/05/2026, the DON stated that when she started in February 2026 there was no infection prevention control program or antibiotic stewardship program in place. Review of the IPCP binder with the DON showed that for September, October, November, and December 2025, and January, February, and March 2026, there was no documentation of any antibiotics ordered and no documentation of resident infections, viruses, or fungal infections, and there was no ASP in place during those months.
Unclean bathrooms, damaged walls, and soiled toilet area
Penalty
Summary
The facility failed to maintain a clean, homelike environment in multiple resident bathrooms and rooms. During observations, surveyors found bathroom vents covered with dust on the inside and outside, drywall cut away or missing from walls and ceilings above and under sinks after a leak, exposed pipes without covers, and a sticky floor in one resident room where the writer’s shoes stuck to the floor. The Maintenance Director stated the drywall had to be fixed after a leak, that it had been that way for a couple of weeks, that a contractor had been lined up but did not show up, and that he did not have the material to fix it. In a shared bathroom between resident rooms, surveyors observed a urinal lying on its side on the back of the toilet with urine spilled on the toilet, stool on the rim inside the toilet and heavily soiled on the back of the toilet riser, and a soiled towel on the bathroom floor with a brown substance consistent with stool. The Maintenance Director stated he had no cleaning schedule, no logs, and no documentation to show what maintenance tasks had been completed, and said he had been there for 3 months and had not been trained. The Housekeeping Manager stated housekeeping cleaned the outside and surrounding area of vents, while maintenance was responsible for cleaning inside the vents.
Pharmacy Medication Review Irregularities Not Reviewed or Documented
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review, including the medical chart, was followed through with physician review and action on identified medication regimen irregularities for four residents. For Resident #1, the clinical record showed pharmacy reviews on 4/23/26 and 5/07/26 that noted irregularities and directed staff to see a report, but no corresponding report with the pharmacist’s recommendations or noted irregularities was found in the record. Resident #5’s monthly medication reviews reflected pharmacy irregularities on 2/05/26 and 4/14/26 with a similar notation to see a report, but those reports were not located, and the 3/7 report did not show whether irregularities were present or absent. For Resident #39, monthly medication reviews dated 11/26/25, January 7, March 7, April 13, and May 5 all noted irregularities or recommendations with a notation to see a report, but none of those reports were found in the clinical record. Resident #59 had pharmacy recommendations on 03/19/2026 and 04/14/2026, but there was no documentation from any provider agreeing or disagreeing with the recommendations, and the 05/07/2026 monthly medication review showed no pharmacy recommendation. During interviews, the DON stated she did not have information on the pharmacy recommendations or provider responses and later reported she was unable to locate the missing pharmacy reports with provider acknowledgments or responses; she also stated the monthly medication review recommendations for 03/19/2026 and 04/14/2026 were not completed and were not addressed by the provider.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect one resident from verbal abuse by staff. The resident had diagnoses including dementia and depression, and the MDS showed moderately impaired cognition. During the incident, the resident reported that a housekeeper told him he needed to clean his own bathroom after he had diarrhea, and that staff were told not to clean the bathroom until he had cleaned up his own stool. The resident stated he was upset by being told this and reported that the Unit Manager was made aware. The investigation included interviews with the resident, the assigned CNA, a second CNA witness, the housekeeper, and the Unit Manager. The resident stated the housekeeper appeared upset about having to clean the toilet and indicated that he should clean it himself. The assigned CNA reported that she handed wipes to the resident, while the housekeeper stated the CNA gave the wipes to the resident and acknowledged the wipes were intended for the resident. The second CNA did not witness the direct interaction but heard the resident yelling and went to the room, which supported that a concern had occurred. The facility determined the interaction was not consistent with expectations for resident dignity, respect, and appropriate staff conduct. The record also showed conflicting statements about the resident’s bowel issues and bathroom cleanliness. Notes documented reports that the resident had frequent bowel movements and diarrhea, while other entries described him as purposefully defecating on the bathroom floor and toilet. The facility policy defined verbal abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation. Based on the interviews and record review, the resident was subjected to a staff interaction in which he was told to clean the bathroom after stool contamination, which formed the basis of the deficiency.
Failure to Thoroughly Investigate Allegation of Drug Diversion
Penalty
Summary
The facility failed to thoroughly investigate an allegation of drug diversion involving one resident’s PRN Norco administration. The resident was admitted with diagnoses including bipolar disorder and anxiety disorder, and the MDS indicated severely impaired cognition. During the period reviewed, the resident was observed self-propelling in a wheelchair and was heard stating he did not know what was going on. The allegation arose after staff questioned why only one nurse was signing out the resident’s Norco over an extended period of time. The facility’s investigation reviewed MARs, narcotic sign-out sheets, resident interviews, and staff interviews, and concluded there was no substantiated evidence of diversion. However, the narcotic records showed that the last 20 documented doses of Norco for the resident were signed out exclusively by the same LPN, and the review identified documentation discrepancies between the MAR and the narcotic sheets. The resident’s pain scores were not consistently recorded before and after administration, and one staff member reported concern that the resident often refused medications and that it seemed unusual the LPN kept documenting that she gave the Norco each night she worked. The investigation file did not include a police report, did not include copies of the MARs reviewed, and did not include copies of the narcotic logs reviewed for the Norco in question. A separate later narcotic incident involving a pill taped back into a narcotic card was also not formally investigated. Interviews with leadership showed uncertainty about the diversion concerns, the timing of reporting, and whether the later incident should have been escalated, while the facility’s written summary still closed the original allegation as unsubstantiated.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for one resident, R75, who was admitted to the facility and had an MDS ARD of 5/8/26 showing a BIMS score of 15 out of 15, indicating the resident was cognitively intact. R75 was transferred to the hospital on 5/17/26 and did not return to the facility. Nursing notes documented that the ambulance was given paperwork including the resident’s admission profile, order summary, and code status, and that the bed hold policy was explained to the family. The eInteract Transfer Form documented the hospital transfer for shortness of breath, but the DON stated that the only transfer form she knew of was the eInteract Transfer Form, which was given to ambulance staff and not to the resident. The DON agreed the form did not include appeal rights or the State Long Term Care Ombudsman contact information, and later stated the facility had a written transfer form it was supposed to use, but it was not given to R75.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to provide an accurate MDS assessment for one resident reviewed for assessment accuracy. The resident was admitted with diagnoses including rheumatoid arthritis, multiple sclerosis, polyneuropathy, osteoarthritis, spinal stenosis of the lumbar region, functional quadriplegia, anxiety, and depression. The most recent MDS with an ARD/target date of 03/26/2026 showed a BIMS score of 13, indicating cognitive intactness, and documented the resident as independent with eating and use of upper extremities, while also indicating dependence for toileting, hygiene, showers/baths, and transfers. Record review further showed the MDS indicated the resident was on an antibiotic, but review of the MAR and orders confirmed the resident was not receiving an antibiotic during that assessment period. The DON reviewed the chart and stated there were no antibiotic orders for the resident, and the DON later stated it must have been an MDS discrepancy.
Medication Administration and Documentation Failure
Penalty
Summary
The facility failed to administer medications timely and document accurately for one resident, R32, out of 15 residents reviewed. R32 was admitted to the facility with diagnoses including osteoarthritis of the right knee, acute embolism and thrombosis of the right knee, obesity, type 2 diabetes mellitus, obstructive sleep apnea, pain in the left hip, major depression, and anxiety. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and the resident was independent with oral care and eating but dependent for toileting, hygiene, showers/baths, and transfers. During an observation, R32 asked an LPN for nicotine lozenges and stated she had not received them, while the LPN stated she had already given them. A review of the MAR showed no medications signed out for that day at the time of the observation. When questioned, the LPN stated she had given the lozenges that morning and about 15 minutes earlier, but also stated she did not always sign medications out if she was busy. The DON later reviewed the record and verified that the LPN signed out both nicotine lozenges at 4:46 PM, not at the times the LPN reported. The MAR did not document the lozenges as given at the times the LPN stated.
Failure to Coordinate Repair of Resident’s Power Wheelchair
Penalty
Summary
The facility failed to provide medically related social services for a resident who had been without her powered wheelchair since last fall. During interview, the resident stated she did not have her power wheelchair back yet and reported being stuck in bed all day because her chair was not fixed. She said she had been without the wheelchair for months and described being confined to her room with only her TV and cell phone, stating that nobody had updated her on the repair status and that the situation had affected her mentally and emotionally. Record review and interviews showed the facility had not successfully coordinated the repair of the wheelchair. The guardian reported she had not heard back from the repair company and had only contacted customer service through the company website. Staff stated the resident had not had the power wheelchair since last fall, that she was being kept in bed much of the time, and that she had increased call light use, frustration, boredom, social isolation, and more issues with compromised skin integrity on her back side. The DON stated she was unsure what was wrong with the wheelchair and indicated there was confusion about payment for the repair. The repair company later reported it had been in contact with the resident’s sister, who knew nothing about the wheelchair and could not schedule a repair visit.
Medication Administration Not Observed by Nurse
Penalty
Summary
The facility failed to ensure medication administration was observed by a nurse for one resident. The resident had diagnoses including osteoarthritis in the right knee, acute embolism and thrombosis of the right knee, obesity, diabetes mellitus type 2, obstructive sleep apnea, pain in the left hip, major depression, and anxiety. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and the resident was independent with oral care and eating but dependent for toileting, hygiene, showering/bathing, and transfers. During an observation, several of the resident's medications were seen in a med cup left on the over-bed table, and no nurse was present in the room to observe the resident taking them. The resident stated that nurses usually leave medications on the bedside table for the resident to take and that some pills had to be taken on a full stomach while others needed to be taken afterward. An LPN stated the resident was particular about how the medications were taken and would not take them all at once, and also stated the resident had not been evaluated for self-administration of medication. The DON stated the expectation for medication administration included hand hygiene, right resident, right medication, right route, right time, right dose, and documenting administration.
Failure to Notify Resident Before Room Change
Penalty
Summary
The facility failed to notify one resident of a room change and did not document that the resident was given any notice, choice, or explanation before the move. The resident was a [AGE]-year-old male admitted with diagnoses including congestive heart failure and anxiety, and his MDS showed a BIMS score of 12 out of 15, indicating he was cognitively intact. During observation and interview, the resident stated that a CNA told him it was time to go and that he was being moved to the third floor, and he reported that he had no choice and was never given any explanation for the room change. The clinical record included a physician progress note stating that the resident requested to speak to nursing management because he had a change in room over the past few days and wanted to discuss it with them, but there was no documentation of follow-up from nursing management. During interview, the DON stated she had no information about the room change and was not aware the resident wanted to speak with nursing management, and said the facility practice should be to do notifications and a consent, though maybe not actual signed consents. The NHA later stated the resident’s brother was in the facility and requested a room change, and when asked whether room changes were routinely made based on family requests without consulting the resident, the NHA offered no response.
Incomplete DNR Documentation
Penalty
Summary
Advanced directives were not thoroughly completed for one resident. R72 was observed lying in bed with a urinary catheter bag hanging from the side of the bed. The resident was admitted with diagnoses including depression and dementia, and the MDS assessment dated [DATE] showed a BIMS score of 13/15, indicating intact cognition. Review of the resident’s DNR order showed that the resident signature was not dated and one witness signature was also missing a date. Review of the physician orders showed there was no active DNR order. During interview, the DON stated that advanced directives are reviewed on admission and that the DON and Administrator are responsible for ensuring they are completed thoroughly with the required signatures and dates. The DON confirmed the missing dates on the resident and witness signatures and confirmed there was no active physician order reflecting the resident’s DNR status.
Failure to Timely Report Suspected Crime and Abuse Allegations
Penalty
Summary
The facility failed to develop and/or implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident, and failed to report allegations of abuse to the NHA/Abuse coordinator for another resident. The report describes two separate events involving staff concerns that were known to facility personnel but were not timely escalated through the required reporting chain. For one resident admitted with bipolar disorder and anxiety disorder and assessed as severely cognitively impaired, staff identified a suspected drug diversion involving Norco. A nurse reported that during narcotic counts a pill in a Norco 7.5 mg card had been taped into place and appeared different from the other tablets, later identified by imprint as a Norco 5 mg tablet. Interviews showed the incident was known to the UM, who took a photo and statement, but the suspected diversion was not immediately investigated, the suspected perpetrator was not removed from the schedule, and the NHA and DON were not initially aware of the event. The NHA stated the police had been notified of an earlier incident but not this most recent one. For another resident with Alzheimer’s disease, aphasia, and schizophrenia, staff reported an allegation that a CNA verbally abused the resident and roughly shook the resident’s wheelchair. Multiple staff members stated the allegation was well known on the unit and had been reported to ADON C, with one CNA identified as the witness. However, when interviewed, the NHA and DON reported they were not aware of any abuse allegation involving the resident, and the ADON was unavailable due to suspension. The report also notes the resident was observed with an unkempt appearance, including long dirty fingernails, greasy hair, and being unshaven.
Missed Annual PASARR Review
Penalty
Summary
The facility failed to complete a yearly PASARR assessment for one resident. The resident was admitted with diagnoses including displaced mid-cervical fracture of the right femur, malnutrition, vascular dementia, adjustment disorder, schizophrenia, and anxiety, and the most recent MDS showed a BIMS score of 8, indicating moderate cognitive impairment. The record showed an initial PASARR dated 03/26/25, but no annual PASARR dated for 2026 was found. During interviews, the LNHA stated the facility had made a list of every PASARR in the building and was working with Community Mental Health to get past-due PASARRs up to date, and the DON stated residents were divided between herself and the ADON to address past-due and current reviews. When asked about this resident’s annual PASARR, the LNHA could not locate it, and the DON later stated that a PASARR for the resident was not done.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide assistance with routine showers for a dependent resident who was unable to perform activities of daily living independently. R28 was admitted with diagnoses including generalized anxiety disorder, depression, and acquired absence of the right leg below the knee, and the MDS assessment showed intact cognition with a Brief Interview for Mental Status score of 14/15. During observation, R28 was sitting in a manual wheelchair with a breakfast tray in front of him and reported that his right below-knee stump had been surgically removed on April 14th. He stated that he should be receiving at least 3 showers per week to keep his surgical incision clean and without infection, but that this was not happening. Review of the shower task log showed that R28 was scheduled for showers twice weekly, yet only 2 showers were documented over the 16-day period reviewed, despite an expectation of at least 5 showers based on the admission date and schedule. The DON confirmed that only 2 showers had been documented since admission and stated that refusals should be documented and the resident reapproached later, but no refusals were documented.
Failure to Reassess PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to review an anti-anxiety medication to meet the needs of a resident with generalized anxiety disorder and depression. The resident was admitted with diagnoses including generalized anxiety disorder, depression, and acquired absence of the right leg below knee, and the MDS assessment showed intact cognition. During observation, the resident stated that he preferred to be spoken to very slowly because of his anxiety and reported that his anxiety was high enough that he would not be able to eat breakfast. On another observation, he reported that he had been out of his anxiety medication for a couple of days and that his anxiety was "through the roof." Review of the physician orders showed no active anti-anxiety medication order, and the PRN Xanax order had ended after a 14-day period. The MAR showed the resident received Xanax frequently while the order was active, including doses on most days in May and all active days in June. The resident was seen by the facility NP, who documented that he reported feeling anxious, had concerns about staff, and was provided therapeutic communication and coping mechanisms. Staff interviews confirmed the resident was known to become easily upset, needed to be spoken to slowly, and continued to report anxiety, but it was documented that he was not reassessed after the 14-day PRN order ended.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for two residents who had documented dental needs and orders for dental evaluation and treatment. One resident was admitted with multiple diagnoses including osteoarthritis, thrombosis, obesity, diabetes mellitus type 2, obstructive sleep apnea, pain, major depression, and anxiety, and had a BIMS score of 15. The resident reported having only two teeth on the top, difficulty chewing food, and stated that no one had talked to her about seeing a dentist. Record review showed an order for dental services as part of ancillary services on admission, but the resident was never scheduled for an appointment. The care plan identified broken/missing natural teeth and included a dental consult as needed. The second resident was observed to be edentulous and reported having no dentures at the facility, though he had a pair at his prior residence. He stated he had not been seen by a dentist since being in the facility and would use dentures if he had a pair that fit properly. The resident’s record showed active physician orders for dental evaluation and treatment as indicated, and staff documentation identified him as edentulous, but there was no mention of dentures. The DON stated dental needs were assessed on admission and as needs arose, and that she would expect staff to ask about dentures for residents without teeth, but she was unsure why the resident had not been seen by dental services since admission.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident’s religious food preferences. Resident 36 was admitted with diagnoses including osteoarthritis of the right knee, acute embolism and thrombosis of the right knee, obesity, type 2 diabetes mellitus, obstructive sleep apnea, left hip pain, major depression, and anxiety, and the resident practiced the Jewish religion. The most recent MDS showed the resident had a BIMS score of 15 and was independent with oral care and eating. During an interview, the resident stated that pork was on the menu for lunch and dinner and that no one came to ask what alternative she would like. At lunch, the resident was served sweet potatoes, brussel sprouts, and an overcooked, dried-out hamburger patty on two pieces of bread, and she expressed frustration when seeing the meal. Dietary staff stated they knew which residents could not eat pork and would make something from the alternate or all-time menu, but they did not ask residents what they wanted and the alternative menu was not posted with the regular menu. The Dietary Manager stated residents’ likes and dislikes were not documented in the medical record and were only written on tray tickets. Dietary staff also stated they just knew what residents liked and that the resident who could not eat pork was served a potato and seasoned chicken breast when pork was served twice in one day. The Dietary Manager later stated the hamburger was served on bread because buns had run out.
Facility Assessment Not Updated After ICP and ASP Lapsed
Penalty
Summary
The facility failed to perform a facility assessment when there was a change in the Infection Control Program (ICP) and the Antibiotic Stewardship Program (ASP). Review of the facility assessment showed it was last completed on 8/1/2024 and covered through 7/31/2025. During an interview, the DON stated that when she began working in February 2026, there was no Infection Control Preventionist, no infection prevention control program in place, and no active ASP in place. The DON stated there was no IPCP or ASP documentation for September, October, November, and December 2025, and also for January, February, and March 2026. Review of the IPCP binder for 2025 showed no documentation of infection prevention control or surveillance for September through December 2025, and review of the 2026 binder showed no infection control prevention or surveillance documentation for January through March 2026. The Administrator stated the facility assessment should have been performed sometime from September 2025 to the present because there was no IPCP or ASP in place and functioning during those six months, and said she did not know why the assessment was not reassessed or updated.
QAPI Oversight Missing for IPCP and Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure the Infection Control Preventionist (ICP) attended and reported to the QAPI committee on the Infection Prevention Control Program (IPCP), including the Antibiotic Stewardship Program (ASP). The Corporate QAPI Plan dated 10/24/2018 did not include any reference to the facility’s IPCP or ASP. The State Operations Manual guidance cited in the report stated that the ICP must be a member of the quality assessment and assurance committee and report on a regular basis at the same frequency as QAPI meetings. During interview, the DON stated that when she began in February 2026 there was no ICP and no IPCP in place. She reported there was no IPCP documentation for September, October, November, and December 2025, and none for January, February, or March 2026. The DON stated that an IDT meeting in April 2026 was the only IPCP meeting she attended, and that she had only completed one month of surveillance and documentation for the IPCP, for April 2026. Review of the IPCP binder confirmed no infection control surveillance documentation for the listed months in 2025 and 2026. The facility’s Infection Prevention Program Overview policy stated that the Infection Prevention Committee meets regularly as part of QAPI and that IPCP reports are reviewed and approved by QAPI, and the Infection Control Antibiotic Stewardship and MDRO policy stated that tracking and trending infection surveillance and infections is a key component of the facility’s QAPI process.
Failure to Document and Resolve Grievance for Broken Eyeglasses
Penalty
Summary
The facility failed to ensure that a grievance was documented, investigated, tracked, and resolved for one resident who had been admitted for short-term rehab with diagnoses including cellulitis and who scored 12 out of 15 on the BIMS. The resident’s family member reported that the resident’s eyeglasses went through the laundry and were broken in December 2025, and that the facility said the family would be reimbursed, but reimbursement had not been received by late May 2026. Review of the grievance log for November 2025 through May 2026 did not show any concern related to the broken or missing eyeglasses. Email correspondence showed the family member contacted the Admissions Director about the missing eyeglasses, then later reported that the glasses were found in the laundry but were damaged, with one lens missing and the frames partially melted. The family member repeatedly requested reimbursement and sent an estimate and later a receipt for replacement glasses, but the emails were either forwarded internally or went unanswered. During interviews, the Admissions Director stated she forwarded the emails to the Nursing Home Administrator, and the Nursing Home Administrator stated she was aware of the broken glasses, believed a check had been written, and initially said a grievance form had been filed, but later could not locate any grievance or concern form involving the resident.
Failure to Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure after an allegation involving a resident who was cognitively intact with a BIMS of 15 and required extensive assistance with ADLs following a right femur fracture and surgical aftercare. The resident reported that a CNA responded to her request for help getting off a bed pan by saying, "Oh hell no You are on rehab, you can do this yourself," and then left the room. Another CNA stated she heard the exchange from the hallway and later assisted the resident off the bed pan. The resident also stated she reported the incident to nursing staff and nursing administration, but her concerns were not resolved before she left the facility against medical advice. Multiple staff members acknowledged awareness of the resident's complaint and the interaction with the CNA, but no one documented or investigated the allegation as abuse. A CNA stated she was told not to go back into the resident's room by an LPN, and nursing administration later placed the resident on "cares in pairs." The resident told staff she wanted to speak with management about her concerns, and staff members stated they knew there was an issue, but they were unsure who was supposed to follow up. Record review showed no nursing progress note explaining the behaviors or the reason for adding cares in pairs to the care plan. The DON and nursing administration stated they attempted to speak with the resident as she was leaving, but the resident and her family left before the discussion was completed. The DON also stated she had received a verbal report that the resident complained of not getting water and not having her needs met, but there was no documentation in the chart from the business office manager. When asked why the allegation was not investigated or reported despite staff awareness and the care plan changes, the DON and RN P stated they did not know.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged abuse involving a resident who was admitted for short-term rehab after a displaced comminuted fracture of the right femur, with diagnoses including epilepsy and diabetes mellitus type 2. The resident was cognitively intact with a BIMS of 15 and required extensive assistance with ADLs, including maximum assist to dependent personal care and use of a wheelchair. During the stay, the resident reported that a CNA responded to a call light for help getting off a bed pan by saying, "Oh hell no, you are on rehab, you can do this yourself," and then left the room. Another CNA heard the exchange and later assisted the resident off the bed pan. The resident stated she told an RN and nursing administration about the incident and wanted to file a complaint, but the concern was not promptly addressed. Multiple staff members acknowledged awareness of the resident's complaint and the interaction with the CNA, including the CNA involved, another CNA who overheard it, an RN, an LPN, the DON, and nursing administration. The care plan was revised to include "cares in pairs," and staff discussed the resident's concerns, but there was no nursing progress note documenting behaviors or the reason for the change in the care plan. The resident left the facility against medical advice after voicing concerns and waiting for someone to speak with her, but no one had investigated or reported the allegation before she left. The DON later stated she had written a risk management note and had received a verbal report that the resident complained of not getting water and her needs not being met, but there was no documentation in the record of a progress note or investigation related to the allegation. The surveyor reported the abuse allegation to the LNHA and DON at the end of the interview process.
Failure to Thoroughly Investigate Injury of Unknown Source and Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source involving a resident with chronic obstructive pulmonary disease, dementia, depression, and severe cognitive impairment who later expired. The resident required two staff for bed mobility and repositioning. An incident report stated that a CNA heard a popping sound while repositioning the resident and later reported the resident had shoulder pain. The resident was assessed, given Tylenol, and an x-ray later identified a proximal fracture. Hospital records reflected the resident reported that someone recently jerked her by the right arm and that the pain had been present since. The investigation was incomplete because the facility did not obtain a written statement from an LPN who was reportedly involved, and the timeline of events was inconsistent. One CNA statement indicated the resident complained of shoulder pain at about 8:00 p.m., while another staff member later reported the CNA who heard the pop was working on a different floor until midnight and had no contact with the resident until later. The facility’s abuse coordinator stated she did not substantiate abuse and believed the fracture was pathological, but she was unaware that the original report of shoulder pain occurred earlier than the time she believed the care event happened. The record also reflected that staff routinely changed and transferred residents requiring two-person assistance by themselves. The facility also failed to thoroughly investigate an allegation of verbal abuse involving another resident who was cognitively intact and required extensive assistance with ADLs. The resident reported that a CNA responded to a request for help getting off a bedpan by saying, "Oh hell no, you are on rehab, you can do this yourself." Another CNA stated she overheard the exchange and then assisted the resident. Multiple staff members, including nursing staff and administration, were aware that the resident had an issue with the CNA and that the resident wanted to speak with management, but the concern was not fully addressed before the resident left the facility against medical advice. The record showed no nursing progress note explaining the behavior issue or the reason for placing the resident on cares in pairs, despite staff acknowledging that the intervention had been added because of the resident’s complaint.
Failure to Complete Ordered Wound Care and Date Dressings
Penalty
Summary
The facility failed to complete wound care as ordered for two residents with pressure-related wounds. Resident #10 was admitted with chronic kidney disease and had multiple pressure wounds to the right hip, left hip, and coccyx. During observation, the resident stated that a wound on his buttocks was supposed to be changed daily but had not been changed for 2 to 3 days. When the dressings were later observed with an LPN, all three dressings were clean, dry, and intact, but none were dated, and the LPN stated she had changed them that day and normally dates dressings but could not find a marker. Resident #13 was admitted with diagnoses including type 2 diabetes, peripheral vascular disease, and acute osteomyelitis of the right ankle and foot. The resident stated that his left foot dressing was ordered to be changed every day but was instead being changed about every 2 days. When the dressing was observed with an RN, it was clean, dry, and intact, but no date was present. The RN stated she had completed the dressing change that same day and that she typically dates each dressing. The wound NP documented repeated concerns that wound care was not being completed regularly or according to orders for both residents. For Resident #10, the wound NP noted that dressing orders needed adherence and that wound care must be done regularly. For Resident #13, the wound NP documented that dressings had not been changed for extended periods, including one note stating the dressing had not been changed in one week, and repeatedly wrote that dressings must be changed regularly. During interview, the wound NP stated that there were times when wound care had not been performed or not performed as ordered, and nursing administration confirmed that no audits beyond weekly wound rounds were completed and that no ongoing or widespread education had been done after being notified of missed wound care.
Improperly Fitted Bed Contributed to Resident Fall
Penalty
Summary
The facility failed to prevent an avoidable fall for one resident who had diagnoses including catatonic schizophrenia and vascular dementia and who scored 8/15 on the Brief Interview for Mental Status, indicating moderately impaired cognition. The resident was observed in bed after the event reporting soreness and pain in the right hip, and did not recall the details of the fall. The clinical record showed the resident had been involved in a prior fall in which she was found lying on her right side and complained of pain to the head and right arm, requiring ambulance transfer to the ER for evaluation. The incident review documented that the resident rolled out of bed because the mattress was hanging over the edge after the bed was not extended to the proper size. Staff interviews described that the bed frame had been reduced to fit out of the room and then returned without being properly expanded, leaving the mattress too wide for the frame. The RN, CNA, and NHA each described the bed as improperly fitted at the time of the fall, and the facility policy stated that hazards and resident risk factors are to be identified and interventions implemented to minimize falls and fall-related injury.
Failure to Provide Ordered Suprapubic Catheter Care
Penalty
Summary
The facility failed to perform catheter care consistent with professional standards for one resident with a suprapubic catheter. The resident was observed sitting in a wheelchair and confirmed having a suprapubic catheter, stating it had recently become clogged and that orders were in place to keep it open by flushing it regularly, but the flushing had not been done. The resident’s record showed a history of chronic kidney disease and intact cognition, with a BIMS score of 14/15. A urology office note documented that the resident lived in a nursing facility, had a catheter previously ordered to be changed every 4 weeks, and reported that it was not being exchanged regularly. The note also stated the resident and aide confirmed he was not receiving catheter flushes, with leaking urine from the urethra and minimal concentrated urine in the bag. Urology assessed that daily irrigation was needed to prevent sediment buildup and ordered daily irrigation of the suprapubic tube with 50 mL normal saline and as needed for clogging. The facility’s MAR showed documentation of twice-daily 60 mL flushes for April and May, but the resident reported they were not being done, and the DON stated the expectation was that a suprapubic catheter should be flushed as needed.
Inaccurate Wound Care Documentation and Missed Dressing Changes
Penalty
Summary
The facility failed to accurately document wound care for one resident with diagnoses including type 2 diabetes, peripheral vascular disease, and acute osteomyelitis of the right ankle and foot. The resident reported having a current wound to the left foot and stated the dressing was ordered to be changed every day but was instead being changed about every 2 days. The resident’s MDS assessment indicated moderately impaired cognition. Record review showed repeated inconsistencies between the wound nurse practitioner’s observations and the facility’s documentation of wound care. The wound NP documented that on multiple occasions the dressing had not been changed as ordered, including notes stating the dressing had not been changed in a week, had not been changed since the prior week, or that no blue foam was present on initial assessment. Despite these observations, the MAR documented wound care as completed daily during periods when the wound NP documented it had not been performed as ordered, including daily documentation for a once-daily order and documentation of care on dates when the wound NP noted the dressing had not been changed. During interviews, the wound NP stated he rounds in the facility weekly with Nursing Administration and had observed times when wound care had not been performed or not performed per order, including occasions when the same dressing was still in place from the prior week. Nursing Administration confirmed that weekly rounds were the only audits completed and that no ongoing or widespread education had been done after being notified that wound care had not been completed for an entire week. Nursing Administration also stated the expectation was for dressings to be dated with date, time, and initials, and acknowledged concerns about wound care supplies, including blue foam, being difficult for staff to locate on the treatment cart.
Unsanitary Food Preparation During Kitchen Plumbing Excavation
Penalty
Summary
The deficiency involves the facility’s failure to prepare and serve food under sanitary conditions while major plumbing repairs and floor excavation were occurring in the kitchen. After an underground water line break affecting the kitchen and laundry, contractors began digging a large hole in the kitchen floor near the steamer and tray line. Temporary plastic barrier walls were placed, but they were unsecured and had open areas. Surveyors observed garden hoses running from the kitchen across the dining room floor and out an open window, with hoses duct-taped to the floor. The kitchen floors were heavily soiled with boot prints, and contractors walked through the food prep area, tracking dirt. Large piles of dirt, broken tile, concrete, rocks, and wastewater were present near the tray line, stovetop, and three-compartment sink. Despite these conditions, the facility continued to prep and serve meals from the kitchen. Dietary staff were observed serving food from a steam table located directly next to the unsecured plastic barrier and large open holes in the floor with exposed dirt and debris. Prepped and wrapped silverware was stored on the steam table within about two feet of the large hole and dirt piles. Cardboard boxes of disposable meal service items were placed directly on the kitchen floor near the tray line. A soiled blender was observed on a dining room table next to personal drinks and a soiled towel. The Certified Dietary Manager (CDM) stated that after the first hole was dug following breakfast, all subsequent meals continued to be prepped and served in the kitchen next to the excavation area, and that food had been taken back and forth from refrigerators located beyond the barrier and past the large hole. Multiple staff interviews confirmed that the barrier was not effectively monitored or verified as secure. The Maintenance Director acknowledged that he did not verify that the plastic barrier wall was secured or check it frequently, and that a wet saw was used to cut through floor tiles, which created dust. The DON stated that if the barrier was broken open there was a risk of pathogens contaminating the food and that, because the barrier was not sealed, food should not have been prepared in the kitchen. The previous DON reported she knew digging was occurring in the kitchen but did not enter the kitchen initially, assumed there was a barrier, and believed food preparation had been moved out of the kitchen without confirming this. The Administrator stated she saw the barrier closed but did not order food preparation to be removed from the kitchen and did not assign anyone to monitor the barrier. From the time the hole was dug until surveyor intervention, 10 meals were served out of the kitchen under these unsanitary conditions, affecting all residents who ate meals prepared there.
Removal Plan
- Facility plans to use prepared food from a US food vendor for upcoming meals as a back-up plan.
- Facility is using disposable paper products immediately as a back-up plan.
- Facility discarded all lunch that was ordered for residents and stopped lunch trays enroute to the units; lunch was catered in for the residents.
- Dietician and Medical Director were notified of the Immediate Jeopardy.
- The kitchen immediately closed for services.
- The dining room next to the kitchen is being set up as the temporary kitchen until pipe work and construction are completed.
- The juice machine, coffee maker, steamer, steam table, tray line, prep area, 3-compartment area, and handwashing station are being utilized in the temporary kitchen.
- All residents who eat meals were immediately assessed for food borne illness.
- All residents at risk for food borne illness.
- A temporary refrigeration truck is providing both freezer and refrigeration.
- An electrician inspected for the correct plug for the steamer, rewired to accommodate the steamer in the temporary kitchen, and cleared it for use.
- The steam table was disinfected after removal from the construction zone.
- A handwashing station was delivered and set up in the temporary kitchen.
Failure to Document, Investigate, and Resolve Resident Grievances and Neglect Allegations
Penalty
Summary
The deficiency involves the facility’s failure to promptly document, investigate, track, and resolve resident grievances, including allegations of neglect, as required by its grievance policy. The Nursing Home Administrator (NHA) reported that a resident had recently alleged receiving no care for 14 hours, but this allegation was not reported because it was determined it did not occur within a two-hour window. A concern form dated 2/16/26 documented that this resident reported being left 14 hours without staff checking on her, not enough staff, and being told she had to go to bed. The form indicated that management spoke with staff who claimed they had gotten the resident up multiple times and changed her when needed, and it was marked as investigation complete with staff education, but there was no evidence that the allegation of neglect was reported to the State and no supporting documentation in the medical record to show the neglect did not occur. The report further describes multiple residents with care concerns that were not effectively captured or addressed through the grievance process. One resident with a history of stroke, moderate cognitive impairment, and dependence on staff for all ADLs had multiple undocumented care tasks, including hygiene, ADLs, toileting, and missed showers over nearly a month. This resident’s daughter reported that every time she visited, she found care problems such as soiled sheets and the resident leaning in bed almost falling out, and that she repeatedly voiced concerns to staff without any change and was not aware of a concern form process. Another resident, cognitively intact and requiring significant assistance for toileting and bathing, reported not receiving a shower for two weeks and only one shower in the past two months, despite having reported several complaints and having a concern form completed without follow-up or improvement. The NHA later verified there were no care concern forms for these residents in the past 30 days. Additional deficiencies in grievance handling are linked to staffing-related neglect concerns for several other residents. A CNA reported that on a specific weekend night there were no CNA staff on one floor, only two nurses, and that three residents were left up in chairs all night, with one resident heavily soiled with urine and stool and requiring a shower after being left in a chair for the entire 12-hour night shift. The CNA stated a grievance form was completed and given to the NHA, and that potential allegations of neglect were reported to nursing staff. An LPN confirmed that no CNA worked that night, that three residents were left in chairs and remained in the same clothing when day shift arrived, and that management was informed because resident care needs were not met. Despite this, the NHA reported having no knowledge of the three residents who remained up all shift and no concern forms for the involved residents in the past 30 days. A former scheduler reported being unable to fill CNA staffing on multiple occasions, being instructed to add non-CNA staff to the schedule, and stated that concern forms related to unmet care needs and staffing were completed at least twice weekly and provided to the NHA and DON, but these were not reflected in the grievance tracking or resolution process.
Failure to Report and Investigate Allegations of Neglect and Unmet Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to implement policies and procedures to ensure timely reporting of reasonable suspicions of a crime, including abuse and neglect, as required by section 1150B of the Act. The Nursing Home Administrator (NHA) reported that a cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety alleged she had received no care for 14 hours. The NHA stated this allegation was not reported because it was determined the event did not occur within the prior two hours. A concern form documented that the resident reported being left 14 hours without staff checking on her, not enough staff, and being told she had to go to bed, but there was no evidence that this allegation of neglect was reported to the State. The form was signed by the NHA, and staff witness statements lacked dates and times. Review of the resident’s electronic medical record for the date in question showed no evidence to support that the allegation of neglect did not occur. During an interview, the same resident, who was calm and able to answer questions, reported that staff often tried to put her to bed earlier than she wanted due to staffing issues and that one night she was transferred to bed late at night and not gotten up until after mid-afternoon the next day because two staff were needed for a mechanical lift. She reported being unhappy about the long period she remained soiled and mentioned recent skin breakdown with no follow-up. Additional residents with intact decision-making abilities and significant physical care needs, including multiple sclerosis with functional quadriplegia, dementia with repeat falls, and Alzheimer’s disease with dependence for transfers and toileting, were also involved in care concerns related to staffing and potential neglect. A CNA reported that on a weekend night there were no CNA staff on one floor for the entire night shift, and that two residents were left up in chairs all night, with one remaining in the chair into the following morning, and another resident found heavily soiled with urine and stool and requiring a shower after being left in a chair for the entire 12-hour shift. The CNA stated that potential allegations of abuse related to these care concerns were reported to nursing staff. An LPN confirmed that no CNA staff worked that night on the floor, that three residents were left up in chairs and remained in the same clothing when she returned for the day shift, and that management was informed because resident care needs were not met. The NHA reported having no knowledge of these three residents remaining up all night and stated there were no concern forms or additional allegations of abuse over that weekend, while the scheduler reported frequently being unable to fill CNA shifts, documenting care concerns and staffing issues on concern forms, and providing them to the NHA and DON. The report reflects that these multiple allegations and observations of potential neglect and unmet care needs were not consistently recognized, documented, or reported as required.
Failure to Investigate and Report Multiple Allegations of Neglect and Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report multiple allegations of neglect and abuse, as required by its abuse prohibition policy. One cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety alleged that she received no care for 14 hours, including being left in bed soiled and experiencing skin breakdown. This concern was documented on a care concern form indicating she was left 14 hours without staff checking on her, that there was not enough staff, and that she was told she had to go to bed. The Nursing Home Administrator acknowledged that this allegation was not reported externally because it was determined the event did not occur as alleged, and the concern form showed the facility marked the investigation as complete without evidence that the allegation of neglect was reported to the state or that a thorough investigation with supporting documentation was conducted. Additional allegations of neglect involved three other cognitively intact or partially impaired residents who required extensive assistance with transfers, toileting, and hygiene. A CNA reported that on a weekend night there were no CNA staff on the second floor for the entire 12‑hour night shift, and that two nurses were present, one of whom was called in as CNA coverage but continued to function as a nurse passing medications. According to this CNA, two residents were left up in chairs all night and remained in the chairs when day shift arrived, and another resident was found heavily soiled with urine and stool and required a shower after being left in a chair the entire shift. An LPN corroborated that no CNA staff worked that night on the second floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs, and that these three residents were still in the same chairs and clothing at the start of the next day shift. Despite these reports, the NHA stated there were no concern forms for these residents in the past 30 days and denied knowledge of three residents remaining up all night on the referenced night shift. The scheduler reported chronic difficulty filling CNA positions, being instructed to add non‑CNA staff such as transportation and medical records staff to the schedule, and having repeatedly completed concern forms related to unmet care needs and staffing issues and provided them to the NHA and DON. The facility’s own abuse prohibition policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be immediately reported, thoroughly investigated, and documented by the Administrator, and reported to appropriate state agencies and others. The documented failure to initiate and complete thorough investigations, to document them adequately, and to report allegations as required constitutes the cited deficiency.
Failure to Provide Planned ADL Care and Showers Due to Staffing Shortages and Missed Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) care, including toileting, hygiene, transfers, and showers, as outlined in residents’ care plans and reflected in their MDS assessments. Multiple residents who were dependent on staff for ADLs reported not receiving timely or adequate care, and task documentation showed numerous missing entries for required care. One cognitively intact resident with severe morbid obesity, muscle wasting, and depression reported being put to bed early due to staffing issues and described an incident where she was transferred to bed late at night and not gotten out of bed until after mid-afternoon the next day, remaining in a soiled brief and reporting skin breakdown with no follow-up. A concern form documented her allegation of being left 14 hours without staff checking on her and being told she had to go to bed, but the facility’s internal form only reflected staff statements that she had been gotten up and changed, with no supporting evidence in the medical record and no documentation that the allegation of neglect was reported to the state. Another resident with a history of stroke, right-sided weakness, and depression, who was dependent on staff for transfers, bed mobility, hygiene, dressing, showering, and toileting, had multiple undocumented ADL and hygiene tasks and missed showers on task reports over several weeks. During observation, this resident was found in bed with a family member expressing upset that the sheets were soiled and the resident was leaning in bed almost falling out. The family member stated that every visit resulted in complaints to staff about care concerns, including staffing, call light response times, and lack of dignity and respect, and that she was not aware of any formal concern form process. Another cognitively intact resident requiring moderate to maximum assistance for toileting and bathing reported not having received a shower for two weeks and only one shower in the prior two months, despite multiple complaints and completion of a concern form, with task reports showing multiple undocumented ADL and toileting tasks and several missed showers. Additional residents with significant physical impairments and dementia, who required two-person assistance for transfers and toileting and staff assistance for showering and personal hygiene, were not provided ADL care as planned during a night shift when no CNA staff were present on one floor. A CNA reported that on that night, one resident was not laid down the entire night, another remained in a chair all night and into the next morning, and a third was found heavily soiled with urine and stool and required a shower after being left in a chair for the entire 12-hour shift. An LPN confirmed that no CNAs worked that night on the affected floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs who remained in the same clothing until morning, and that management was informed because resident care needs were not met and there was a potential allegation of neglect. The scheduler reported chronic inability to fill CNA positions on multiple shifts, being instructed to add non-CNA staff to the schedule, and submitting concern forms about unmet care needs and staffing at least twice weekly. Another resident with severe cognitive impairment, pneumonitis, severe protein-calorie malnutrition, non-pressure ulcers, dementia, and peripheral vascular disease required substantial assistance with showering and personal care and was dependent on staff for toileting and perineal hygiene. Family members reported that during a three-week stay, this resident received only one shower, wore a pull-up that he manipulated to urinate into a urinal, and was given a bedpan despite his inability to use it and his stated need for a commode. They described an incident where he was placed on a toilet with the call light behind him and out of reach, leaving him to yell repeatedly for help until someone responded. Task sheets showed that scheduled showers on multiple dates were not provided, with no reasons documented, one refusal documented without evidence of additional attempts, and no documentation that CNAs notified a nurse when showers were not completed. The DON stated that her expectation was that CNAs would re-approach residents and notify the nurse if showers could not be given, but the record contained no such documentation, further demonstrating the failure to provide and document ADL care as required. Across these residents, interviews with CNAs and nursing staff indicated that staffing shortages forced staff to choose between passing meal trays and providing hands-on care, and that routine two-hour checks and changes could not be completed for all residents. The NHA reported no knowledge of the three residents left up all night and stated there were no concern forms for several of the affected residents in the prior 30 days, despite staff and scheduler reports that concerns and potential neglect had been reported. These observations, interviews, and record reviews collectively show that seven residents did not receive ADL care per their care plans and MDS-identified needs, including missed showers, prolonged periods without toileting or repositioning, remaining in soiled conditions, and lack of timely assistance with transfers and toileting, in the context of documented and reported staffing shortages and incomplete documentation of care.
Failure to Provide Adequate Nursing Staff Resulting in Unmet Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff to meet residents’ needs and to ensure that resident care was consistently delivered as required. One cognitively intact resident with severe morbid obesity, cervical disc degeneration, muscle wasting, depression, and anxiety reported being left in bed from approximately 11:00–11:30 p.m. until after 3:00 p.m. the next day because two staff were needed for a mechanical lift transfer and staff were not available. This resident also reported being left soiled for a long period and having recent skin breakdown, and stated that staff tried to put residents to bed early due to staffing issues, particularly on night shift. A concern form documented allegations that the resident was left 14 hours without staff checking on her, that there was not enough staff, and that she was told she had to go to bed, with no supporting documentation in the medical record to refute the allegation. Another resident with a history of stroke affecting the right dominant side and depression, who was dependent on staff for transfers, bed mobility, hygiene, dressing, showering, and toileting, reported concerns about insufficient staffing, delayed call light response, and lack of dignity and respect. Review of this resident’s task reports over nearly a month showed multiple gaps in documentation of hygiene, ADLs, toileting, and several missed showers. During an observation, the resident’s family member found the resident’s sheets soiled and the resident leaning in bed almost falling out, and stated that every visit involved raising care concerns to staff without change, and that she was not aware of the concern form process. A third resident, cognitively intact and requiring moderate to maximum assistance for toileting and bathing, reported not having received a shower for two weeks and only one shower in the past two months, with multiple holes in task documentation for hygiene, ADLs, toileting, and showers, despite having previously reported complaints and concern forms without improvement. Additional residents with multiple sclerosis and functional quadriplegia, dementia with repeat falls, and Alzheimer’s disease with chronic spinal pain, anxiety, and depression, all requiring significant staff assistance for transfers, toileting, and showers, were affected by staffing shortages on a specific weekend night shift. A CNA reported that on one night there were no CNA staff on the second floor night shift, only two nurses, and that one nurse who was called in as CNA coverage instead passed medications as a nurse. According to this CNA, three residents were left up in chairs all night, with two of them remaining in the same chairs and clothing when day shift arrived, and one resident was heavily soiled with urine and stool and required a shower after being left in a chair for the entire 12‑hour shift. An LPN confirmed that no CNA staff worked that night on the second floor, that a CNA had stayed over late to get most residents to bed but left three residents up in chairs, and that those three residents were still up and in the same clothing at 7:00 a.m. the next morning. The scheduler reported being unable to consistently fill CNA and nurse positions on the schedule, being instructed to add non‑nursing staff to the schedule, and completing concern forms about unmet care needs and staffing at least twice weekly, while the NHA reported having no concern forms for several of the affected residents and no knowledge of the three residents who remained up all shift. The DON reported that 12 residents required assistance of two staff with care needs, underscoring the level of dependency among the resident population. Despite this, there were documented instances where no CNA coverage was present on a unit for an entire night shift, and where residents dependent on staff for basic ADLs, toileting, and transfers experienced prolonged periods without appropriate care, remained in chairs overnight, or were found soiled. Multiple staff interviews described chronic difficulty filling schedules, lack of support from management when staffing could not be secured, and repeated but unaddressed concern forms related to staffing and unmet resident care needs. These observations, interviews, and record reviews collectively demonstrate that the facility did not ensure sufficient nursing staff each day to meet the needs of residents and did not consistently provide the level of care required by residents’ conditions and care plans.
Failure to Notify Family and Provider of Resident’s Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family and the on-call provider of a significant change in condition that resulted in the resident being sent to the hospital. The resident had multiple serious diagnoses, including pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure ulcers of the lower extremities, dementia, and peripheral vascular disease. The most recent MDS showed severe cognitive impairment with a BIMS score of 3/15 and dependence on staff for toileting and perineal hygiene. The resident’s wife had previously expressed concerns about his safety and care, including that his call light did not work and that the bell provided as an alternative could not be heard because he was at the end of the hall. A nursing progress note documented the wife’s complaint that it was neglectful that no one could hear when he needed help and that she believed he had received the worst care there. On the day of the change in condition, the resident’s family member noticed he was responding differently and questioned a decline in his condition. She reported that the LPN caring for him told her he was not dying and, when asked if he should go to the hospital, stated that the hospital would not do anything but send him back. The family member requested that staff check his vital signs, and when the resident appeared to perk up somewhat, she left for the day. Later, the hospital contacted her to inform her that the resident had been there for several hours. The family member reported that the facility had not called her about this change in condition and that there were no missed calls or messages on her cell phone or home landline. She was very upset that she was not notified, particularly after having earlier asked the LPN whether he should be sent to the hospital.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired female resident from sexual abuse by another resident. The resident who was abused had a history of cerebral infarct, anxiety, depression, altered mental status, substance use disorder, and aphasia, and required assistance with personal care, including one-person assist for transfers, dressing, hygiene, and bathing, and two-person assist for toileting. Her MDS reflected moderately impaired decision-making, and the Nursing Home Administrator (NHA) confirmed she was not able to consent and that her responsible party did not want her to have contact with the male resident involved. Despite this, the male resident, who was cognitively intact and independent with care needs, was observed engaging in physical contact with her. Prior to the incident that led to the citation, the abused resident’s mother, who was her DPOA, had observed her daughter holding hands with the male resident in his room and reported feeling uncomfortable. She communicated to the NHA that she did not want the male resident touching her daughter for any reason. The facility’s own investigation documented that the male resident had been counseled that the female resident was unable to consent to physical touching and that her mother did not want physical contact between them. The male resident verbalized understanding. There were also prior documented behaviors by the male resident involving inappropriate touching of other residents, including touching another resident’s dorsal hand and arm, requiring redirection and behavioral monitoring. On the date of the incident, a CNA reported rounding on the unit and observing the cognitively impaired female resident in the male resident’s room. The CNA witnessed the male resident standing over her, kissing her neck, with his hand on her inner thigh by the vaginal area over her pants, groping her. The CNA immediately intervened, separated the residents, and removed the female resident from the room while telling the male resident he could not engage in that behavior. The male resident laughed, became angry, raised his voice, and began slamming items in the room. Nursing staff were notified, and documentation reflected that the contact left a red mark on the female resident’s neck. The facility’s investigation concluded that non-consensual physical contact occurred with a resident who lacked capacity to consent, and that the male resident had previously been educated not to touch her, yet still engaged in the behavior, resulting in substantiated sexual abuse. Additional documentation and interviews highlighted inconsistencies in staffing records related to who was present on the unit at the time of the incident. The CNA who reported witnessing and intervening in the abuse was not listed on the facility’s working schedule for that shift, even though both the CNA and an LPN described that CNA as being on the floor and directly involved in responding to the event. The facility schedule showed only two CNAs scheduled for the shift on the second floor, and the NHA initially stated the schedules provided were accurate. This discrepancy in staffing records was identified during the surveyor’s review of the incident and related interviews.
Failure to Provide and Document Bed-Hold and Transfer/Discharge Information During Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required bed-hold policy and transfer/discharge documentation, and to document that these were given, when a resident was transferred to the hospital with a change in condition. The resident had been admitted with diagnoses including pneumonitis due to inhalation of food and vomit, severe protein-calorie malnutrition, non-pressure ulcers of the lower extremities, dementia, and peripheral vascular disease. The most recent MDS showed a BIMS score of 3/15, indicating severe cognitive impairment, and the resident required substantial assistance with ADLs and was dependent for toileting and perineal hygiene. Despite these needs, the record did not contain evidence that the resident or representative received the bed-hold policy or transfer/discharge paperwork at the time of the emergency transfer. Interviews and record review showed multiple communication and documentation gaps surrounding the resident’s change in condition and transfer. The resident’s family member reported concerns about his care, including a non-functioning call light that led the facility to provide a bell that staff could not hear, and she stated she was unsure the resident knew how to use it. A nursing progress note documented the wife’s complaint that the call light did not work and that the bell was not loud enough, her statement that he had received the worst care and that it was neglectful that no one could hear when he needed help, and that the resident was moved to a different room with a working call light. The prior DON acknowledged being informed of concerns about the call light, including that it had been placed in a dresser drawer out of the resident’s reach at some point, and also acknowledged not completing a grievance or concern form. On the day of the hospital transfer, the family member noticed a change in the resident’s responsiveness and questioned whether he should go to the hospital; she reported that an LPN told her he was not dying and that the hospital would not do anything but send him back. Later, the hospital notified her that the resident had been there for several hours, and she stated the facility had not called her about this change in condition. The LPN reported that the resident was initially fine but became unstable around dinner, that she obtained vital signs, placed him on oxygen, and called 911, and that she believed she called the wife and sent transfer/discharge paperwork, but then stated she was unsure and that it had been “kind of crazy” at the end of her shift. Record review confirmed there was no documentation that the provider was notified of the change in condition before transfer, no documentation that the resident or representative received the bed-hold policy or transfer/discharge paperwork, and no documentation that the wife was notified of the transfer. The unit manager and social worker both indicated that such paperwork should be completed and documented, but acknowledged that it was not evident in the record for this resident.
Failure to Care Plan for Residents Leaving on LOA or AMA
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing leave of absence (LOA) and leaving against medical advice (AMA) for two residents. For one resident, the record included a signed "Determination to Leave the Facility Against Medical Advice" form, which stated the resident was not cleared by the physician to leave due to being at high risk for accidents, falls, or other acute illness/conditions when outside the facility unsupervised, potentially resulting in serious negative health outcomes. The form documented that the resident was their own responsible party, not deemed incompetent, and that they had participated in care planning related to the decision to leave unsupervised and agreed to abide by the plan of care, with plans to be reviewed and revised as needed. However, review of the resident’s care plans showed no care plan addressing the decision to leave AMA or go on LOA, and there was no documentation that the resident had actually participated in care planning related to this decision. For the second resident, the face sheet showed admission to the facility and an MDS with a BIMS score of 13/15, indicating intact cognition. LOA sign-out sheets showed this resident frequently left the facility on LOA. Despite this, review of IDT notes revealed no discussion regarding the resident’s LOA or evaluation of safety, and review of the resident’s care plans showed no care plan addressing LOA, safety interventions, or assessments. In an interview, the DON stated she did not find an evaluation of this resident’s ability to go on LOA or any IDT documentation regarding LOA ability, and she stated her expectation was that evaluation and care planning be completed for a resident who goes on LOA. The facility’s policy dated 11/16/2022 required that a corresponding care plan be developed and initiated for LOA, addressing clinical issues such as medication needs during leaves, education on medication administration, dietary issues, and any other potential concerns or problems, which was not done for these residents.
Failure to Evaluate Resident’s Safety for Leave of Absence
Penalty
Summary
Failure to complete and document an evaluation of a resident’s ability to take a leave of absence (LOA) occurred when a cognitively intact resident with known visual impairment was allowed to sign out on LOA without an assessment of safety. The resident had a BIMS score of 13/15, indicating intact cognition, and a care plan identifying impaired visual function related to stroke, but the care plan did not include any interventions addressing LOA safety in light of the visual impairment. Progress notes documented that the resident signed out on LOA with another resident and, upon return, did not use the crosswalk to cross the street and was struck by a speeding vehicle, resulting in a fractured spleen, rib fracture, and scalp laceration. The facility’s LOA policy required that affected residents be evaluated regarding their abilities at admission, quarterly, upon significant change in condition, and after any new developments that might warrant a change in the evaluation. The social worker reported she had heard that staff needed to know if a resident was safe to go out on LOA as their own responsible person and assumed there was an assessment form, but she had never seen or completed such an assessment. Review of the electronic medical record showed only one IDT meeting, which did not address LOA or evaluate the resident’s LOA safety, and the DON confirmed she could not find any LOA ability evaluation for the resident. No IDT meeting or LOA ability evaluation was conducted or documented after the accident.
Failure to Administer Consented PCV20 and RSV Vaccinations
Penalty
Summary
The facility failed to ensure that ordered immunizations were administered for a resident who had consented to receive them. The resident, identified as Resident #108, had an original admission date noted on the face sheet and a most recent admission date of 2/14/2026. Review of consent forms showed that the resident signed consents on 10/28/2025 and again on 10/28/2026 to receive the Pneumococcal (PCV20) and Respiratory Syncytial Virus (RSV) vaccinations. In the electronic medical record, both RSV and PCV20 immunizations were listed as pending with a confirmation date of 10/28/2025. However, review of the physician orders from October 2025 through 2/26/2026 revealed that no physician orders were ever written for either vaccination. Further review of the Medication Administration Records (MARs) for October, November, and December 2025, and January and February 2026 showed no documentation that the PCV20 or RSV vaccines were administered to the resident. The DON confirmed during interview that, despite the signed consents, the resident never received the vaccinations. The DON also reviewed the resident’s progress notes for October and November 2025 and found no documentation that the vaccinations were given or any notation explaining why they were not administered. The DON stated that the vaccinations should have been administered because the resident requested them and signed consent.
Widespread Failure to Complete Hiring, Orientation, and Competency Validation for CNAs and Nurses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and CNAs possessed and demonstrated required competencies and that hiring, background checks, and orientation processes were completed as required by state and federal regulations. Surveyors’ interviews and personnel file reviews showed that a CNA hired and later terminated within a two‑month period had no completed orientation plan or new hire paperwork in her file, including no background check, certification verification, I‑9, fingerprinting, drug screening, or pre‑hire physical. When asked, the DON initially produced only a freshly printed, blank general orientation form and could not provide completed orientation, competency check‑offs, or required CNA‑specific training documentation for this CNA. The Human Resource Coordinator (HRC) confirmed that this CNA’s new hire process and CNA‑specific trainings were not completed and that she had not been checked off on any required competencies such as abuse/neglect, transfers, ADLs, infection control, residents’ rights, dementia care, change in condition, skin assessments, behavior management, elopement risk, bowel and bladder, hospice, hemodialysis program, bed mobility, body mechanics, gait belts, CNA documentation, cleaning equipment, respiratory care, emergency care, abdominal thrusts, code status, and unit orientation. Further review of personnel files for a sample of 19 CNAs hired over a six‑month period revealed widespread omissions in required hiring and orientation documentation. Multiple CNAs had incomplete or unsigned new hire checklists, no reference checks, no I‑9 forms, no I‑CHAT background checks, no sex offender registry checks, no eligibility letters, no certification verifications, no TB tests, no documentation of active driver’s licenses, and no evidence of completed facility general orientation. CNA‑specific competency evaluations were consistently missing, and there was no verification that orientation was completed before CNAs were scheduled to work on the units. One rehired CNA had only an I‑CHAT background check completed at rehire, with no updated competencies, no certification verification, and no clinical oversight to determine training needs, yet was placed on the schedule. Another CNA completed her own competency skills check‑off and signed it as passed without any nurse or management validation or signature. Interviews with leadership and staff confirmed that unvalidated staff were working independently with residents. The HRC stated he was unaware of federal regulations in the State Operations Manual and was learning CNA education and training requirements during the survey. He described a process in which he conducted a one‑day general orientation and then sent new hires to the DON or ADON for job‑specific orientation and unit shadowing, but there was no documentation that competencies were actually completed before staff were released to work. The DON acknowledged that CNA competencies had not been done prior to her arrival, that she had no log or proof of completed competencies, and that she was aware CNAs were working with residents without required training and competencies but could not remove them from the floor due to staffing needs. A CNA reported she went from shadowing other CNAs directly to being scheduled on the floor without a nurse checking her use of equipment or transfers. The scheduler confirmed she had no checklist to verify completion of orientation or competencies and simply scheduled CNAs once they stated they were done orienting, and she reported receiving no training on competency requirements. Similar deficiencies were identified in the hiring and orientation of licensed nurses. Personnel files for several RNs and LPNs hired in the same six‑month period showed new hire checklists either blank or minimally completed, with missing I‑CHAT background checks, eligibility letters, sex offender registry checks, nursing license verifications, I‑9 forms, TB tests, physicals, and drug screenings. There was no evidence of completed facility general orientation or nursing‑specific competency evaluations, and no verification that orientation was completed before these nurses were scheduled to work on the units. In one case, only the nursing license verification, I‑CHAT background check, and sex offender list verification were present, with no orientation plan or health screening documentation. Overall, the survey findings document that both CNAs and nurses were hired and placed on the schedule without completed regulatory hiring elements, orientation, or validated competencies necessary to safely meet residents’ assessed needs and care plans.
Failure to Provide ADL Care and Coordinate Hospice Services for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide required activities of daily living (ADL) care, including bed baths and personal care, to a dependent hospice resident. The resident was admitted with multiple serious diagnoses, including congestive heart failure, COPD, major depression, chronic pain syndrome, multiple vertebral fractures, and generalized weakness, and the most recent MDS documented that the resident was cognitively intact but dependent on staff for all personal care. During observation, the resident was found asleep in bed with oxygen at 2.5 L/min with no date on the tubing, wearing a white T‑shirt soiled with crumbs and spilled coffee from lunch, and positioned with bare feet pressed against the hard footboard without socks or a cushion. The resident’s water glass on the overbed table was empty and undated at that time. On a subsequent observation and interview, the resident was coughing while trying to eat breakfast, and the water glass was dated from the previous day, indicating it had not been refreshed. The resident reported that hospice aides provided baths when they came in and stated he could no longer perform personal care independently. The resident was still wearing the same soiled T‑shirt from the prior day. Review of the hospice binder showed hospice CNA bath/shower visits scheduled twice weekly, with the last shower/bed bath documented on 12/30/25, indicating no bath for approximately 30 days. CNAs interviewed stated they believed hospice was responsible for the resident’s showers and that the showers listed on their task sheets corresponded to hospice visit days; they also stated they were not told to provide the scheduled showers themselves. The NHA stated that floor CNAs were expected to provide baths or showers in addition to any provided by hospice, and record review showed no documented coordination of care between the facility and the hospice agency regarding who was responsible for personal care.
Failure to follow care plan and ensure competent assistance during bedpan use leading to fall with injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistance were provided during care, resulting in a fall from bed with injury. The resident, identified as R7, experienced an incident in which she fell or rolled out of bed while being assisted with a bedpan, landing on her face, splitting her lip, and breaking a tooth. The incident summary notes that the bed was in a low position and that the resident stated something slipped and she fell. Emergency room evaluation confirmed no fractures but documented the need for sutures to the upper lip and a broken front tooth. Prior to the incident, facility records contained inconsistent and incomplete assessments and directions regarding the resident’s functional status and required level of assistance. The care plan and Kardex documented that the resident required assistance from two staff for bed mobility (turning and repositioning in bed) and for transfers with a hoyer/mechanical lift, and that she required assistance from one staff to use the bedpan. However, the MDS functional status section showed multiple mobility and transfer items as “not assessed” as of the day before the incident, including chair/bed transfers, lying to sitting, sit to lying, toilet transfer, toileting, and transferring. A transfer report also documented that the resident only needed assistance with toileting and transfers and was not dependent on care, which conflicted with the care plan and Kardex indicating two-person assistance for certain tasks. On the night of the incident, the CNA assigned to the resident (CNA K) assisted her with the bedpan without a second staff member present. In an interview typed by the Nursing Home Administrator (NHA), the resident reported that she wanted to get up, that the CNA was helping her off the bedpan, and that she felt herself sliding before she rolled out of bed; she stated the CNA was not being mean and that she believed the CNA had not hooked her up correctly. In a separate typed interview, CNA K stated that the resident wanted to use the bedpan, that she placed the resident on it and checked on her multiple times, and that when she attempted to remove the bedpan, the resident began yelling and then threw herself on the floor. CNA K acknowledged she had not reviewed the Kardex that night and did not know the resident was a two-person assist, and she did not ask anyone for assistance. The facility’s own incident summary later stated that the allegations were substantiated due to the CNA not following the plan of care. Additional record review revealed broader deficiencies related to staff preparation and documentation that contributed to the unsafe situation. The personnel file for CNA K, who had been hired approximately two months before the incident, lacked a completed new hire checklist, reference checks, I-9, background checks, eligibility letter, sex offender registry check, certification verification, pre-hire drug screen and physical, TB test, driver’s license verification, general orientation checklist, CNA-specific competency evaluations, and verification of orientation completion before working on the units. There was also no evidence that CNA K’s competency in performing two-person transfers or other required CNA skills had been assessed. Interviews with staff on first and third shifts indicated they were aware the resident was a two-person assist for care, and nursing staff reported that the resident had been exhibiting behaviors and yelling at staff during care in the evenings. Despite this, there was no documented investigation into the competencies of CNAs providing two-person transfers on the day or unit of the incident, and no hands-on demonstrations or return demonstrations were recorded for staff performing two-person transfers.
Failure to Enforce Staff Mask Use Under COVID-19 Infection Control Protocol
Penalty
Summary
The facility failed to enforce its infection prevention and control program related to COVID-19 by not ensuring mandated mask use for staff. During an observation in the kitchen while breakfast was being served, the surveyor observed the Dietary Manager not wearing a mask, despite a mandate from the Infection Preventionist that all staff wear masks following two other staff members testing positive for COVID-19. When the Dietary Manager noticed the surveyor, the manager smiled, giggled, and stated they were just going to put a mask on. In a subsequent interview, the DON reported that when staff reported they had COVID, the management team requested a second COVID test and, if positive, tested all staff and residents according to CDC guidelines on the first, third, and fifth days. The DON also stated that, in this context, mask-wearing was mandated for all staff working, confirming that the Dietary Manager’s failure to wear a mask occurred while a universal staff masking requirement was in effect.
Failure to Maintain Adequate Nursing Staff Levels
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents for 14 out of 30 days reviewed. Staffing records and interviews revealed that on multiple days, the number of aides and nurses scheduled was below the required levels based on the facility's census and acuity assessments. The Nursing Scheduler explained that staffing is determined by average daily census and adjusted for resident acuity, but when vacancies occurred, efforts to fill shifts with other staff or managers were not always successful. Specific dates were identified where the facility was short by one or more aides or nurses on both day and afternoon shifts. The Nursing Home Administrator confirmed during the review that there were 14 days within the review period where the necessary nursing staff was not present to provide care to residents as required. No information was provided regarding the specific impact on individual residents or their medical conditions at the time of the deficiency.
Failure to Investigate and Document Resident Falls Resulting in Fracture
Penalty
Summary
The facility failed to thoroughly and accurately investigate two falls experienced by a resident with moderate cognitive impairment, resulting in a left hip fracture that required hospitalization and surgery. The resident, who had diagnoses including dementia, schizophrenia, and difficulty walking, experienced two falls on the same day. Documentation of both incidents was incomplete, with missing entries for pain assessment, level of consciousness, mental status, and mobility. The incident reports lacked essential details, such as staff involved, witness statements, and accurate timing, and there was no comprehensive summary or root-cause analysis to determine how the falls led to the fracture. Direct care staff, including CNAs assigned to the resident, were not interviewed or asked to provide statements at the time of the incidents. The DON considered the nurse's incident report as the only required statement and did not obtain additional narratives from other staff. The investigation process was inconsistent, with the DON unable to identify which CNAs were assigned to the resident and no summary of the investigation available. The facility's fall program and incident reporting policies were not followed, as evidenced by the lack of risk analysis, monitoring for pain or neurological changes, and implementation of interventions to prevent further injury. Additionally, the facility did not report the incident as required by its abuse and neglect policy, despite the resident sustaining a serious injury of unknown origin. The documentation was further compromised by altered dates and times on post-fall forms, and the DON admitted that certain documentation was omitted if no abnormal findings were observed. The lack of a thorough investigation and failure to follow established protocols resulted in an incomplete response to a significant injury event.
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What surveyors actually found near you
We read the 93 citations issued within 25 miles in the last 12 months — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jackson County Medical Care Facility | 0.4 mi | ★★★★★ | 13 | 0 |
| Vista Grande Villa | 1.8 mi | ★★★★★ | 18 | 0 |
| Mission Point Health Campus Of Jackson | 2.9 mi | ★★★★★ | 25 | 0 |
| Cascade Senior Care Center | 3 mi | ★★★★★ | 10 | 0 |
| Faith Haven Senior Care Centre | 5.1 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.