Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stratford Pines Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Multiple residents with mobility limitations and incontinence needs experienced prolonged call light response times, often ranging from 30 minutes to over an hour, leading to episodes of remaining wet or soiled and feelings of distress and indignity. One resident with an overactive bladder and moderate cognitive impairment reported having to scream for help and once calling 911 when no one answered her call light. Another cognitively intact resident with documented perineal excoriation and intertrigo, whose care plan required regular toileting and incontinence checks, was observed waiting while staff ignored an active call light, and a CNA told her she could not be assisted to the toilet because it was lunch time before turning off the light and leaving. A third cognitively intact resident with Parkinson’s disease and a fall risk reported repeatedly waiting 30–45 minutes for assistance, sometimes self-transferring to the bathroom without his walker after hearing staff talking in the hall, and was observed having his call light turned off without receiving toileting help while multiple CNAs and nurses passed his room. In a confidential group interview, several residents reported frequent extended waits, staff turning off call lights without meeting needs, and resulting incontinence and emotional distress.
A resident with anxiety disorder, dementia, and depression, and a BIMS score indicating moderate cognitive impairment, was receiving multiple psychotropic medications including an antianxiety, an antidepressant, and an antipsychotic with orders for side-effect monitoring. The MDS triggered CAAs for cognitive loss/dementia, behavioral symptoms, and psychotropic drug use, but the psychosocial well-being and psychosocial care planning areas were not assessed. The care plan contained only a general psychosocial focus on adjustment to placement and did not individualize or address the resident’s specific depression and dementia diagnoses or the use and monitoring of psychoactive medications. In an interview, a social worker reported that residents on psychoactive medications would not necessarily have a care plan for those medications unless they exhibited behaviors.
A resident with lumbar spina bifida and existing pressure ulcers, including a left heel wound that progressed to a stage IV pressure injury, had physician orders and a treatment plan specifying use of heel cushion boots every shift, skin checks, and pressure offloading. An earlier order also required bilateral heel boots to offset pressure and routine skin assessments. However, the comprehensive care plan, though revised, did not include the intervention to ensure the resident consistently wore protective heel cushion boots to relieve pressure on the feet and heels. The DON later stated the resident should have heel boots on when out of bed but was unaware this intervention was missing from the care plan, despite a facility policy emphasizing prompt identification and intervention for skin integrity risks.
A resident with Parkinson's disease, difficulty walking, and weakness was repeatedly observed unshaven and unkempt despite being scheduled for twice-weekly showers with shaving offered on shower days. The resident and family reported he did not wish to grow facial hair and that he was uncomfortable, rubbing his face frequently. On one scheduled shower day, staff told the family the resident had refused a shower, but he was later showered after the family questioned this. On another day, the resident was noted to have new facial hair growth after a shower, and the family ultimately shaved him herself after requesting staff to transfer him to a wheelchair, indicating the facility did not consistently provide shaving as part of routine ADL and grooming care.
A resident admitted for short-term rehab with difficulty walking, weakness, and Parkinson’s disease received PT/OT but was reported by family to spend most of the day sedentary in a recliner, with staff only assisting with ambulation to the bathroom. The care plan showed that a prior restriction limiting ambulation to therapy had been resolved and that staff could assist the resident with a 2WW, but the mobility goal listed only PT/OT and did not include nursing staff or a plan for intermittent mobility outside therapy and toileting. Family requests to walk the resident in the hall were declined by staff, who stated only a nurse could walk the resident, and staff did not offer additional ambulation despite these requests. An OT confirmed there were no care plan restrictions preventing staff from ambulating the resident, while the DON noted that the rehab side, where the resident stayed, did not have the restorative walking programs available on the LTC side.
A resident with Parkinson’s disease and weakness, care planned to transfer using a rocking Broda wheelchair, was observed being pushed by an LPN in the dining area with both feet brushing the floor while not assisting with movement. The LPN reported not knowing where the wheelchair foot pedals were. An RN Clinical Care Coordinator later stated that residents’ feet should not contact the floor during wheelchair transfers unless they are actively assisting, and should instead be elevated or on foot pedals, demonstrating that the observed transfer did not follow safe transfer practices.
A resident admitted with a right hip fracture and a PICC line for IV antibiotics had incomplete PICC assessments and monitoring. Nursing admission and subsequent skin assessments only noted the presence of the PICC in the right upper extremity without documenting insertion site condition, dressing status, catheter length, arm circumference, or signs of infection. The physician progress note did not address the PICC or its site. The DON reported that facility expectations included orders for flushing the PICC and monitoring the site each shift, but the eTAR contained no orders for flushing or site monitoring, and there was no PICC-specific care plan or Kardex instruction to avoid blood pressure measurements in the PICC arm. The resident was later emergently transferred to the hospital, where inflammation around the PICC was noted and the catheter tip culture was positive for Candida albicans.
Two residents’ medical records were not maintained in a clear and complete manner. For one resident with dementia and depression, there was a physician’s order for a bordered foam dressing to the forehead, and nursing staff reported changing the dressing multiple times daily because the resident removed it; however, the EMR contained no documentation of any dressing changes for the entire month, and the order had been entered incorrectly so that PRN dressing changes did not generate as tasks for staff to document. For another resident with multiple chronic conditions, the EMR contained an entry noting that the DPOA agreed with new abdominal x‑ray orders and a new medication from an HCP visit, but there were no progress notes explaining the symptoms prompting the x‑ray, and the HCP’s progress note and visit details were stored in a separate system and not attached to the EMR, leaving the record without clear documentation of the reason for the visit, the diagnostic indication, or the outcomes.
Two residents with dementia and mobility impairments experienced repeated falls and unsafe transfers due to lack of adequate supervision, assistance, and individualized interventions. Staff failed to provide necessary help during critical moments, and care plans were not effectively implemented or updated to address the root causes of falls, resulting in ongoing safety hazards.
Two residents' concerns regarding meal preferences, food quality, and ambulation assistance were not addressed in a timely manner. One resident with significant medical needs and weight loss experienced ongoing dissatisfaction with meals and lack of dietary accommodations, while another resident and her family requested ambulation support that was denied without documented justification. In both cases, staff failed to document or communicate the grievances, and residents were not informed about the grievance process.
A resident with cognitive and mobility impairments was found with a shifted specialty mattress, exposing the metal bed frame and creating a gap between the mattress and bed rail that exceeded regulatory limits. The facility's documentation and assessment of bed rail and mattress safety were incomplete, lacking required measurements and ongoing monitoring for entrapment risk.
The facility failed to ensure the fire alarm system was tested and maintained according to NFPA 70 and NFPA 72 standards, and did not have required records of system acceptance, maintenance, and testing readily available.
Two residents in an LTC facility experienced multiple unwitnessed falls due to inadequate supervision and failure to implement effective care plan interventions. Despite having conditions like Alzheimer's, Parkinson's, and orthostatic hypotension, the facility did not conduct necessary post-fall neurological assessments or tailor care plans to address specific fall risk factors. The Director of Nursing acknowledged documentation and supervision deficiencies but did not provide additional information to address the concerns.
The facility's kitchen had several deficiencies, including missing handwashing signage, undated water filters, and improper drainage causing standing water. The kitchen's coving was removed, making surfaces difficult to clean, and a wall required repair due to visible joists. These issues contravene FDA 2017 Food Code requirements for maintaining physical facilities and equipment.
A facility failed to inform the designated medical DPOAs of a resident about the use of psychoactive medications, instead notifying the financial DPOA. The resident, unable to make medical decisions, had designated DPOA R and DPOA S for medical decisions, but the facility lacked their contact information and continued to rely on DPOA Q for medical decisions. The DON confirmed the oversight, acknowledging the absence of documentation involving the correct DPOAs in medical decision-making.
A facility failed to conduct a timely care conference for a resident with a history of stroke, dementia, and depression, resulting in the potential for the resident and/or their responsible party not participating in their person-centered plan of care. Despite the requirement for care conferences every three months, no conferences were scheduled after the initial one, even after the resident was deemed unable to make medical decisions. The Social Services Director cited an upcoming guardianship court date as a reason for the delay.
A facility failed to notify the correct medical DPOA of a resident's treatment preferences, contacting a financial DPOA instead. The resident, unable to make medical decisions due to cognitive impairments, had designated DPOA R and DPOA S for medical decisions, but the facility lacked their contact information. The DON confirmed the oversight and the absence of documentation regarding communication with the appropriate DPOA.
A facility failed to implement a comprehensive care plan for a resident with Multiple Sclerosis and other conditions, lacking personalized and measurable interventions to achieve her goals of weight loss and strength improvement. Despite being cognitively intact, the care plan only included general interventions, and staff interviews revealed insufficient efforts to assist the resident. The resident confirmed that no daily ROM exercises were performed with her.
A resident with a suprapubic catheter experienced issues with the catheter becoming plugged and leaking, which were not promptly addressed by the facility. An LPN changed the gauze at the insertion site without proper assessment, and facility records lacked documentation of the wound or consistent catheter care. Despite communication with a Nurse Practitioner, the electronic medical record did not reflect new assessments or orders for wound care.
A facility failed to provide restorative care and ROM interventions for a resident with quadriplegia and rheumatoid arthritis. The resident was often without prescribed finger flexion gloves, and there was a lack of documentation regarding their use and any PROM services. Despite instructions for the gloves to be worn twice daily, they were not consistently applied, and refusals were not documented or addressed.
A facility failed to provide necessary respiratory care for a resident with COPD who is dependent on supplemental oxygen. The resident reported that staff sometimes did not apply her BiPAP machine at night. Observations confirmed the absence of active orders and documentation for the BiPAP machine in the EMR, despite its necessity being noted in the care plan and progress notes. The DON acknowledged the oversight, noting that orders were not restarted after the resident's hospital return.
A facility failed to ensure proper communication and monitoring for a resident requiring dialysis care. The resident, with diabetes and kidney disease, was dependent on hemodialysis thrice weekly. Despite a care plan requiring communication with the dialysis center and post-dialysis monitoring, these protocols were not followed. LPN C reported no communication paperwork was exchanged, and dialysis forms in the EMR were not reviewed by clinical staff. Additionally, post-dialysis assessments were not conducted as required, with LPN C not obtaining new vital signs upon the resident's return from dialysis.
The facility failed to properly label medications, including a Breo-Elipta discus and a TB PPD vial, in a medication cart and room. The discus was not labeled with the resident's name or room number, and the TB vial lacked an open date. Staff showed inconsistency in understanding labeling requirements, with the DON confirming the need for labeling but unsure of TB vial usage duration.
The facility failed to maintain accurate medical records for three residents, with care conferences not documented in the EMR as required. The Social Services Director admitted to not entering notes for scheduled conferences, leading to discrepancies in the records. This lack of timely and accurate documentation contravenes facility policy and nursing principles.
A facility failed to implement effective infection control interventions and conduct a root cause analysis for a resident with recurrent UTIs. Despite the resident's history of UTIs and positive urinalysis results showing E. coli, the facility did not identify trends or add new interventions to prevent infections. The resident was repeatedly started on antibiotics before culture results were available, leading to changes in medication once results were received. The Infection Preventionist acknowledged the resident's resistance to care but did not provide comments on the origins of E. coli or preventative measures.
A resident with a history of fractures and cognitive issues was admitted to a facility and did not receive prescribed pain medication for over two days. Despite being at risk for falls, the facility failed to implement increased supervision or safety measures. The resident fell, sustaining spinal fractures, and later died from injuries related to the fall.
Failure to Provide Dignified, Timely Response to Call Lights and Toileting Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide dignified care and timely assistance with toileting and incontinence needs, resulting in residents experiencing prolonged call light response times and remaining wet or soiled. One resident with weakness, overactive bladder, difficulty walking, and moderate cognitive impairment reported waiting up to 30 minutes for call lights to be answered, which sometimes caused her to soil herself. She stated that soiling herself made her feel terrible and described having to scream to get help. She also reported that on one occasion she called 911 because no one answered her call light, and 911 then contacted the front desk. Another resident, cognitively intact and requiring partial to moderate assistance with toilet transfers, had a care plan directing staff to assist with toileting before and after meals, at HS, with rounds, and PRN, and to check and change incontinence products at those times and when verbal or non-verbal indicators communicated toileting needs. This resident had documented excoriation and intertrigo in the perineal and groin area associated with incontinence and moisture. During an observation, this resident’s call light remained on for an extended period while an LPN and two CNAs were present on the unit but did not respond. The CNAs left the unit, returned with a meal cart, and began passing trays without answering the call light. When a CNA finally entered the room, she told the resident she could not assist her to the toilet because it was lunch time, turned off the call light, and left. The resident’s family member reported that the call light had been on for about 30 minutes, that staff often took up to an hour and a half to respond, and that staff routinely shut off the call light without meeting the resident’s needs. The resident confirmed she was sitting in a soaking wet brief, had a rash in her groin area due to being wet or soiled for extended periods, and reported being told she had to wait for her assigned CNA to return from break. A cognitively intact resident with Parkinson’s disease, weakness, and difficulty walking, who required assistance of one staff and a four-wheeled walker and was at risk for falls, reported frequently waiting 30 to 45 minutes for responses to call lights, leading him to “poop and pee” himself. He stated he was not supposed to get up by himself but sometimes self-transferred to the bathroom without his walker after extended waits, and he described banging on the wall when he heard staff talking and laughing in the hall while his needs were unmet; multiple marks were observed on the wall where he demonstrated striking it. He reported having discussed these concerns with the DON and social worker without resolution and identified this as his biggest complaint. During one observation, his call light was on when a CNA entered with a lunch tray, turned off the light, and left after being told he needed to go to the bathroom, stating she would return. Over the next several minutes, multiple CNAs and nurses were observed walking past his room and responding to other call lights while he remained unattended. Only after the resident reactivated his call light was he assisted to the bathroom, and he later reported that by that time he had been incontinent in his brief. During a confidential group interview, half of the participating residents reported frequently experiencing extended call light response times ranging from 30 minutes to an hour and a half. They stated that staff often shut off call lights before meeting their needs, promising to return but not doing so until the call light was reactivated. One resident reported twice waiting 45 minutes in the last week for assistance to the toilet, resulting in pain, discomfort, and incontinence that made them feel lousy. Another resident reported that staff were not being used efficiently, especially during mealtimes, and that they frequently witnessed a roommate waiting a very long time for call lights to be answered, causing the roommate to cry. These observations and interviews collectively demonstrate repeated failures to respond promptly and appropriately to residents’ toileting and incontinence needs, and to honor their dignity and right to timely assistance and self-determination in care.
Failure to Develop Comprehensive Psychosocial Care Plan for Resident on Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered, comprehensive psychosocial care plan for a resident with anxiety disorder, dementia, and depression. The resident was admitted with these diagnoses and had a BIMS score of 8/15, indicating moderate cognitive impairment. The MDS dated 3/10/2026 showed triggered Care Area Assessments (CAAs) for Cognitive Loss/Dementia, Behavioral Symptoms, and Psychotropic Drug Use. However, the Psychosocial Well-Being Care Area and Psychosocial Care Planning Decision were marked as not assessed/no information, despite the resident’s psychosocial diagnoses and cognitive status. The facility’s policy required use of MDS and CAA results to guide comprehensive care planning. Record review showed that the resident’s physician orders included psychoactive medications: Buspar for anxiety, Sertraline for depression, and Seroquel as an antipsychotic, with orders to monitor for side effects of antidepressant and antipsychotic medications. The resident’s care plan contained only one psychosocial focus related to potential psychosocial distress over lost roles and status, with goals addressing adjustment to placement and maintaining the highest practicable level of communication, memory, judgment, and orientation. Interventions were limited to monitoring for changes and behaviors, allowing expression of feelings, acknowledging mood and behavior, and maintaining a calm environment. The care plan did not recognize or individualize the resident’s specific diagnoses of depression or dementia, nor did it address or incorporate the prescribed psychoactive medications and required monitoring. In an interview, the social worker stated that residents on psychoactive medications would not necessarily have a care plan for those medications and were more likely to have a care plan only if they had behaviors.
Failure to Update Care Plan With Heel Protection Interventions for Pressure Ulcers
Penalty
Summary
The facility failed to revise a resident’s comprehensive care plan to include updated interventions for pressure ulcer prevention and treatment. The resident was admitted with lumbar spina bifida without hydrocephalus and existing pressure ulcers, including a stage 2 pressure ulcer on the left heel and an unstageable pressure ulcer on the left buttock. A subsequent physician progress note documented that these had progressed to stage IV pressure injuries of the left heel and left ischium, with a plan that included cleansing the left heel wound, applying Medihoney and a Mepilex foam bordered dressing, using heel cushion boots every shift, checking the skin daily, continuing position changes at least every two hours, and implementing pressure offloading measures. An order dated several months earlier also directed staff to apply heel cushioned boots to both feet to offset pressure and to remove the boots and check the skin daily to the heels and every shift for the left inner heel wound. Despite these orders and the documented plan of care, the resident’s care plan, which had been initiated and later revised, identified an actual skin impairment to the left heel but did not include the intervention to ensure the resident wore protective heel cushion boots to relieve pressure on the feet and heels. During an interview, the DON stated that the resident should have heel cushion boots in place while out of bed and acknowledged unawareness that this intervention was not included in the care plan. The facility’s policy on skin-at-risk assessment and treatment stated its purpose was to provide prompt identification and intervention for residents at risk of impaired skin integrity and to limit the development of avoidable pressure ulcers, but the care plan was not revised to reflect the ordered heel protection intervention.
Failure to Maintain Resident Grooming and Shaving Care
Penalty
Summary
The facility failed to maintain grooming standards for Resident R95 by not ensuring shaving was provided as part of routine care. R95, admitted with Parkinson's disease, difficulty in walking, and weakness, was observed on 3/30/2026 to be unshaven, and his family member reported he was frequently rubbing his face because he was not used to having facial hair. The family member stated she was unsure if the facility would shave him, although a nurse had shaved him once, and reported that he was scheduled for showers on Tuesdays and Saturdays. She also reported that on the previous Saturday she found him unkempt, and staff told her he had refused a shower earlier that day; however, after she questioned this, staff did provide the shower. On 3/31/2026 at 11:39 AM, R95 was observed to have had a shower but with additional facial hair growth compared to the previous day, and he stated he was not trying to grow a beard and wanted his facial hair “mowed.” Later that day, he was observed in his bathroom in a wheelchair while his family member shaved him, after she had requested staff to transfer him from a recliner to the wheelchair so she could perform the shaving. In an interview, the DON stated that residents are offered showers twice weekly and shaving on shower days, that refusals are to be re-approached and documented, and that R95 was offered and received showers on his scheduled days. The DON was informed that on the most recent shower day, staff initially claimed a refusal and that on the current day R95 had not been shaved despite the facility’s practice of offering shaving on shower days, with the family member instead providing the shaving care.
Failure to Provide Adequate Ambulation and ADL Support for Rehab Resident
Penalty
Summary
The facility failed to provide services to prevent decline in activities of daily living (ADLs) for one resident admitted for short-term rehabilitation with diagnoses including difficulty in walking and weakness. The resident’s MDS showed they were receiving PT and OT, and the care plan identified altered functional mobility and ADLs related to Parkinson’s disease with unsteady gait and poor balance. The care plan documented that a prior restriction of “Walking/Ambulation Therapy Only” had been resolved, and current interventions allowed staff-assisted ambulation with a 2-wheeled walker and assistance with toileting before and after meals. However, the goal for altered functional mobility listed only PT/OT as responsible staff, indicating nursing staff were not included in the mobility plan, and the care plan also noted the resident preferred to sleep in a recliner without offering additional intermittent mobility outside therapy and toileting. A family member reported that although therapy was going well, the resident’s progress was slow and the resident spent most of the day sitting in a recliner, with staff only walking the resident to the bathroom and not at other times. The family member stated they had asked several staff if they could walk the resident in the hall and were told no, that only a nurse could walk the resident, and that staff did not offer to ambulate the resident despite the family’s requests for more activity. Observation showed the resident ambulating with an OT using a gait belt and 2-wheeled walker, and the OT confirmed there was nothing in the care plan preventing staff from ambulating the resident if precautions were followed. In an interview, the DON stated the concern had not been conveyed to him and explained that the LTC side had a restorative program with walking by floor staff, while the rehab side, where this resident was located, did not have such a program, contributing to the resident remaining largely sedentary outside of therapy sessions.
Unsafe Wheelchair Transfer with Resident’s Feet Dragging on Floor
Penalty
Summary
The facility failed to ensure safe transfer practices by allowing a resident to be moved in a rocking Broda wheelchair with both feet brushing the floor during transport. The resident, who had been admitted with diagnoses including Parkinson's disease and weakness, had a current ADL care plan intervention indicating transfers with a rocking Broda wheelchair. During an observation in the dining hall, an LPN pushed the resident in this wheelchair while the resident’s feet were in contact with the ground and the resident was not using his feet to assist with movement. When questioned, the LPN stated she was unsure where the wheelchair foot pedals were. In a subsequent interview, the RN Clinical Care Coordinator stated that residents’ feet should not be in contact with the ground during wheelchair transfers unless they are actively assisting with movement, and that feet should be elevated or placed on foot pedals during transfers to prevent injury. This sequence of events, including the resident’s medical condition, the observed transfer with feet dragging on the floor, the lack of use of foot pedals, and staff acknowledgment of appropriate practice, led to the identified deficiency in maintaining a safe environment free from accident hazards and providing adequate supervision to prevent accidents.
Failure to Assess and Manage PICC Line Leading to Infection
Penalty
Summary
The deficiency involves the facility’s failure to follow standards of care for the assessment and management of a peripherally inserted central catheter (PICC) for one resident. The resident was an elderly female admitted with a right hip fracture requiring surgical repair and a PICC line for IV antibiotics for a UTI. On admission, the nursing assessment noted only that a PICC line was present in the right upper arm and did not document the condition of the insertion site or dressing, the catheter length, the arm circumference above the insertion site, or the date the catheter and dressing were placed. Subsequent skin assessments over several days repeatedly documented only the presence of a PICC line in the right upper extremity and did not describe the insertion site condition, signs or symptoms of infection, or dressing integrity. A physician progress note also omitted any mention of the PICC line, its location, its purpose, or the condition of the site. The DON stated that expectations for PICC care included physician orders for flushing before and after medication administration, orders specifying the flush solution, monitoring the insertion site every shift, and checking catheter measurements at admission and with each dressing change. Review of the electronic treatment administration records for February and March showed no physician orders for flushing the PICC line or for monitoring the insertion site every shift for signs and symptoms of infection. The resident’s care plans did not include a specific care plan for PICC use and care during the entire five-day stay, and the Kardex lacked instructions to avoid taking blood pressure in the arm with the PICC. The resident was emergently transferred to the hospital, where records documented a sepsis workup due to hypotension, tachycardia, and confusion, noted concerning inflammation around the PICC line, and showed that the PICC was removed and its tip culture was positive for Candida albicans.
Failure to Maintain Complete and Accurate EMR Documentation for Wound Care and Provider-Ordered Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to maintain clear, concise, and complete medical records for two residents. For one resident with dementia and depression, there was an active physician’s order starting 3/31/2026 for a bordered foam dressing to be applied to the forehead every 7 days and PRN if the bandage became soiled or loose until healed. On the morning of 3/31/2026, this resident was observed with a dated dressing on the forehead, and later the same morning was observed without a dressing, actively picking at two forehead wounds. A registered nurse stated that staff sometimes replaced this resident’s dressing up to 10 times a day because the resident constantly removed it. However, review of the electronic medical record (EMR) showed no documentation of any dressing changes for the entire month of March, despite the nurse reporting she had already changed the dressing four times that day and had not documented any of these changes. Further review of the EMR by the RN Clinical Care Coordinator revealed that the dressing order had been entered incorrectly, so the PRN dressing change did not generate as a task for nursing staff to complete or document. The coordinator reported that frequent PRN dressing changes were being performed throughout March 2026 but were not documented in the EMR. As a result, the resident’s record did not reflect the type and frequency of wound care actually provided, and there was no clear, contemporaneous record of the nursing interventions related to the forehead wounds. For a second resident with fibromyalgia, dementia, depression, and bipolar disorder, the interdisciplinary documentation dated 3/27/2026 noted a discussion with the resident’s DPOA about new abdominal x‑ray orders and a new medication from a health care provider (HCP) visit on 3/26, with agreement to the plan of care. However, there were no progress notes before or after this entry explaining why the abdominal x‑ray was ordered, what symptoms the resident was experiencing, or the results of the x‑ray. The EMR’s miscellaneous documents section did not contain a recent HCP progress note to account for the x‑ray order or to document the HCP visit. X‑ray results reported on 3/30/2026 indicated no acute obstruction and listed diarrhea as the indication, but no additional information about the resident’s condition at that time was found in the EMR. The DON later accessed an HCP progress note from a separate system, which documented bloating, large hard bowel movements, and diarrhea, as well as an anti‑gas medication and abdominal x‑ray order, but this note had not been attached to or incorporated into the resident’s EMR within the facility, leaving the clinical record incomplete regarding the reason for the visit, tests, and medication changes.
Failure to Provide Adequate Supervision and Fall Prevention for Residents with Dementia
Penalty
Summary
The facility failed to provide adequate supervision, assistance, and meaningful interventions to prevent falls for two residents with dementia and mobility impairments. One resident experienced multiple unwitnessed falls over a period of several months, often while attempting to ambulate or transfer without assistance. Incident reports revealed that interventions were either repeated without modification, not implemented as planned, or not tailored to the root causes of the falls, such as confusion, non-compliance with call light use, and changes in room location. The care plan lacked specific strategies to ensure supervision during waking hours, and staff were not always aware of the resident's routines or needs for observation. Another resident, also with dementia and mobility issues, was observed leaving the dining room unassisted, attempting to access the restroom without staff help, and transferring unsafely from a wheelchair to a chair without locking the brakes. Staff present in the area did not provide assistance or seek help for the resident, and the unsafe transfer was not witnessed by facility staff. The resident's care plan indicated a need for staff assistance with transfers and toileting, but these interventions were not followed during the observed events. Interviews with the DON confirmed that investigations into falls did not consistently identify root causes or result in new or effective interventions. The DON was unable to provide information on how the facility would ensure adequate supervision and assistance for residents with dementia and high fall risk. The lack of meaningful, individualized interventions and failure to provide supervision and assistance directly contributed to repeated falls and unsafe situations for these residents.
Failure to Respond Timely to Resident Grievances and Preferences
Penalty
Summary
The facility failed to respond in a timely manner to resident concerns for two residents regarding food preferences, meal quality, and ambulation assistance. One resident, who had a history of traumatic brain injury, cognitive communication deficit, and cancer with significant weight loss, reported ongoing dissatisfaction with the meals provided, including issues with food type, temperature, and lack of dietary accommodations. The resident and his wife stated they had complained almost daily since admission but were unaware of how to file a formal concern. The dietary manager was not aware of the resident's food preferences, and the required paperwork was found incomplete in the resident's room. Additionally, requests to eat in the dining room and be out of bed for meals were not communicated to the care staff, and no concern forms were completed or provided for these ongoing complaints. Another resident with dementia, depression, and mobility difficulties requested, along with her family, to be walked to the bathroom daily instead of being transported in a wheelchair. Although the care plan indicated she required only one-person assistance with a walker and therapy notes confirmed her ability to ambulate with minimal help, the facility denied the request, citing safety concerns without documented justification. The DON was unable to locate any risk/benefit analysis or documentation supporting the decision to refuse the resident's request, nor were any concern forms found to address the resident's or family's repeated concerns. In both cases, the facility did not provide evidence of a timely or effective response to resident grievances, failed to document or communicate resident preferences and concerns, and did not ensure that residents and their families were informed about the grievance process. These actions resulted in the residents' needs and preferences not being addressed as required by facility policy.
Failure to Assess and Maintain Bed Rail and Mattress Safety
Penalty
Summary
The facility failed to ensure proper assessment and maintenance of bed rails and mattresses for one resident reviewed for accident hazards. The resident in question had a history of traumatic brain injury, cognitive communication deficit, difficulty walking, and general weakness. Upon observation, the resident was found sitting at the edge of his bed with the mattress shifted, exposing six inches of the metal bed frame. The mattress, which was a specialty air mattress, was easily compressed and slid with minimal effort, creating a gap of five inches between the mattress and the bed rail while the resident was in a sitting position. The resident had visible bruises and a dressing on his leg, and he was unable to recall the cause of his injuries due to short-term memory loss. No staff were present in the room during the observation. Interviews with facility staff revealed that the maintenance director kept bed safety assessment forms in his office, but the form for this resident allowed for a maximum gap of 2 3/8 inches, while the observed gap exceeded this measurement. The mattress was also found to be easily compressed, further increasing the gap beyond regulatory limits. The assessment for bed system entrapment zones was only completed on one day and did not specify whether the resident was in bed at the time of measurement. Additionally, the assessment did not include the required documentation of the maximum acceptable gap for the resident, as mandated by state guidelines. Review of the resident's medical record showed only one restraint/enabler assessment, which was completed after the surveyor identified the bed safety concerns. This assessment noted the use of bilateral assist rails but did not address measurements or entrapment risks. No other relevant assessments, measurements, or physician orders were found in the record to evaluate the resident's risk of bed rail entrapment, indicating a lack of ongoing monitoring and documentation as required by state regulations.
Noncompliance with Fire Alarm System Testing and Maintenance Standards
Penalty
Summary
A deficiency was identified regarding the testing and maintenance of the fire alarm system. The fire alarm system was not tested and maintained in accordance with an approved program that complies with NFPA 70 (National Electric Code) and NFPA 72 (National Fire Alarm and Signaling Code). Additionally, records of system acceptance, maintenance, and testing were not readily available as required by the cited standards. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Failure to Implement Fall Prevention and Supervision
Penalty
Summary
The facility failed to follow policies and procedures for falls, implement meaningful care plan interventions, and conduct post-fall neurological assessments for two residents, R65 and R66, who were reviewed for accidents and supervision. R65, who was admitted with Alzheimer's and Parkinson's diseases, experienced multiple falls, many of which were unwitnessed. The facility's documentation revealed a lack of immediate action to prevent future falls and inadequate supervision, as evidenced by R65 being found unsupervised and without necessary safety equipment, such as a Dycem mat in his chair. Additionally, there was no documentation of neurological checks following suspected falls, despite the facility's policy requiring such assessments. R66, who was cognitively intact but had limited range of motion and a history of falls, also experienced numerous unwitnessed falls. The facility's records showed that R66's care plan did not adequately address his specific needs, such as orthostatic hypotension and metabolic encephalopathy, which were contributing factors to his falls. Despite repeated incidents, the care plan interventions were often repetitive and not tailored to address the root causes of the falls. Furthermore, R66 was observed alone in his room multiple times, contrary to the care plan's directive for constant supervision in common areas. Interviews with the Director of Nursing (DON) revealed that the facility's investigations into the falls were not thoroughly documented, and there was a lack of consistent implementation of care plan interventions. The DON acknowledged the deficiencies in documentation and supervision but did not provide additional information or documentation to address the concerns raised during the survey. The facility's failure to adhere to its policies and procedures for fall management and supervision resulted in repeated falls and injuries for both residents, highlighting significant deficiencies in the quality of care provided.
Deficiencies in Kitchen Maintenance and Equipment Labeling
Penalty
Summary
The facility failed to maintain its physical facilities and equipment in proper condition, as observed during a kitchen tour. Key issues included the absence of a handwashing reminder sign at the handwashing area, which is required by the FDA 2017 Food Code to notify food employees to wash their hands. Additionally, two water filters supplying water to the ice and water machines were found undated and unlabeled, with the Dietary Manager unaware of when they were last changed or their lifespan. This lack of information and documentation is contrary to the FDA 2017 Food Code requirements for scheduling inspection and service for water system devices. Further observations revealed two drain lines discharging water directly onto the floor beneath the ice machine, causing standing water and a white substance on the floor and wall. The kitchen's coving was removed from floor/wall junctures, making the area no longer smooth, non-absorbent, and easily cleanable, as required by the FDA 2017 Food Code. Additionally, the wall behind the steamer unit needed repair due to visible wall joists and missing board and coving, which contravenes the FDA 2017 Food Code's requirement for physical facilities to be maintained in good repair and designed to be smooth and easily cleanable.
Failure to Inform Medical DPOA of Psychoactive Medication Use
Penalty
Summary
The facility failed to properly inform the designated medical decision-makers for a resident, identified as R71, about the risks, benefits, and alternatives of psychoactive medications prescribed for dementia care. R71, who was cognitively intact according to a recent assessment, had been determined unable to make medical decisions by their attending physician. The resident had designated DPOA R and DPOA S as medical decision-makers, but the facility instead informed DPOA Q, who was only authorized for financial decisions, about the medications. This resulted in the responsible medical parties being uninformed about the resident's treatments. The facility's records did not include contact information for the designated medical DPOAs, and there was no documentation of any attempts to contact them regarding R71's medical care. Despite being informed by DPOA Q that DPOA S was unable to make decisions due to terminal cancer and that DPOA R was the primary medical decision-maker, the facility continued to rely on DPOA Q for medical decisions. The Director of Nursing confirmed that DPOA Q had been notified for medical decisions, acknowledging the lack of documentation involving DPOA R and DPOA S in care conferences or medical decision-making processes.
Failure to Conduct Timely Care Conference for Resident
Penalty
Summary
The facility failed to conduct a timely care conference for a resident, identified as R43, which resulted in the potential for the resident and/or their responsible party not having an opportunity to participate in their person-centered plan of care. R43, a resident with a history of cerebral infarction, dementia, and depression, was admitted to the facility and had an initial care conference on 8/12/24. However, no subsequent care conferences were scheduled or attempted, despite the requirement for such conferences to occur at least every three months. This lapse occurred even after R43 was determined to be unable to make medical treatment decisions on 8/16/24. The Social Services Director confirmed that no care conferences had been held since the initial one, citing an upcoming court date for guardianship as a reason for the delay. The facility had petitioned the court for the appointment of a guardian, as the current patient advocate was not participating in care conferences. Despite this, the facility did not attempt to schedule any care conferences for R43, leaving a gap of over five and a half months without a care conference, and potentially extending to six months by the time the next conference would be scheduled.
Failure to Notify Medical DPOA of Resident's Treatment Preferences
Penalty
Summary
The facility failed to notify the responsible party of a resident's preferred treatment options, which is a violation of the resident's rights. The resident, who was admitted with diagnoses including Alzheimer's Disease, dementia with behaviors, depression, and anxiety, was determined by physicians to be unable to make medical decisions. Despite having a Durable Power of Attorney (DPOA) for medical decisions, the facility did not have contact information for the designated DPOA individuals, DPOA R and DPOA S, and instead contacted DPOA Q, who was only authorized for financial decisions. The facility's records did not document any attempts to notify the correct medical DPOA about the resident's treatment preferences, which included hospitalization for treatments beyond the nursing home's capabilities but excluding resuscitation. The Director of Nursing confirmed that DPOA Q was contacted for medical decisions, despite not being the designated medical DPOA, and acknowledged the lack of documentation regarding communication with the appropriate DPOA. This oversight was compounded by the fact that DPOA S was terminally ill and unable to make decisions, and DPOA R's contact information was missing from the records.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive and personalized care plan for a resident, identified as R15, who was admitted with multiple health conditions including Multiple Sclerosis, a history of stroke, hemiplegia, and anxiety. Despite being cognitively intact, as indicated by a BIMS score of 15, the care plan for R15 lacked individualized and measurable interventions to help the resident achieve her goals of losing weight and becoming stronger. The care plan only included general interventions such as arranging care conferences and reviewing MDS Section Q with referrals as needed, without specific actions to promote the resident's physical well-being. Interviews with facility staff, including the Director of Nursing, Social Services Directors, and the Clinical Care Coordinator, revealed a lack of personalized efforts to assist R15 in achieving her goals. Although staff encouraged R15 to get out of bed and perform range of motion (ROM) exercises, documentation showed that these efforts were not comprehensive or consistently implemented. The resident often refused the ROM exercises, and there was no further documentation to demonstrate a concerted effort to maintain or improve her mobility. The deficiency was further highlighted when R15 herself stated that staff were not performing any daily ROM exercises with her.
Deficiency in Catheter and Wound Care for Resident
Penalty
Summary
The facility failed to provide appropriate assessments and care for a resident with a suprapubic catheter, leading to a deficiency in addressing skin conditions. The resident, who is cognitively intact, expressed concerns about her catheter becoming plugged and leaking, which was not promptly addressed. During an observation, an LPN changed the gauze at the catheter insertion site without measuring or assessing the wound, which was approximately the size of a marble. The facility's records, including the Minimum Data Set and Treatment Administration Record, did not document the wound at the catheter insertion site or indicate that catheter care was consistently performed as ordered. Further review revealed that the resident's care plan included interventions for skin impairment and catheter care, but there were no specific orders for wound care at the catheter insertion site. An LPN reported noticing increased drainage at the site and communicated with a Nurse Practitioner, who ordered the use of an antimicrobial foam. However, the electronic medical record did not reflect any new skin assessments or orders for wound care, indicating a lack of documentation and follow-up on the resident's condition.
Failure to Provide Restorative Care and ROM Interventions
Penalty
Summary
The facility failed to provide appropriate restorative care and range of motion (ROM) interventions for a resident with quadriplegia, weakness, and rheumatoid arthritis. The resident, identified as R10, was observed on multiple occasions without the prescribed finger flexion gloves, which are part of her restorative nursing program to prevent decline in hand function. Despite the occupational therapist's instructions for the gloves to be worn for 30 minutes in the morning and evening, the resident reported that staff did not apply them consistently. The gloves were found across the room, indicating they were not in use as required. Further investigation revealed a lack of documentation in the resident's electronic medical record (EMR) regarding the application of the gloves and any passive range of motion (PROM) services. The licensed practical nurse (LPN) confirmed the absence of documentation and noted that the resident sometimes refused the gloves, although there was no record of refusals or follow-up actions in the progress notes. The care plan included the use of finger flexion gloves but did not address active or passive ROM, and there were numerous instances of unrecorded or refused tasks related to the restorative program.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident received necessary respiratory care, specifically oxygen therapy, as required. The resident, who has chronic obstructive pulmonary disease (COPD) and is dependent on supplemental oxygen, reported that staff sometimes did not apply her BiPAP machine at night. During an observation, the BiPAP machine was seen on the nightstand next to her bed, but there were no active orders for its use in the electronic medical record (EMR). Additionally, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2025 lacked documentation of the BiPAP machine being applied. The resident's care plan indicated the need for respiratory equipment, including the use of BiPAP at bedtime, initiated in May 2023. An interdisciplinary progress note from November 2024 also highlighted the resident's occasional shortness of breath while lying flat, requiring BiPAP use. The Director of Nursing confirmed the absence of active orders and documentation for the BiPAP therapy, noting that orders were not restarted after the resident's return from the hospital.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper communication and monitoring for a resident requiring dialysis care. The resident, who was admitted with diagnoses including diabetes and kidney disease, was dependent on hemodialysis three times a week. Despite having a care plan in place that required communication with the dialysis center and post-dialysis monitoring, the facility did not adhere to these protocols. Licensed Practical Nurse (LPN) C, who routinely cared for the resident post-dialysis, reported that there was no communication paperwork exchanged between the facility and the dialysis clinic. Furthermore, the dialysis communication forms uploaded into the electronic medical record (EMR) were not reviewed by clinical staff, as confirmed by the Director of Nursing (DON) and Medical Records Manager (MRM) B. Additionally, the facility did not conduct the necessary post-dialysis assessments as outlined in the resident's care plan. LPN C admitted to not obtaining new vital signs upon the resident's return from dialysis and instead filled in the morning vital signs on the Post Dialysis Assessment Care Plan. The DON confirmed that weight, vital signs, and assessments should be conducted after dialysis, and the dialysis communication forms should be reviewed each time the resident returned from treatment. The facility's policy on dialysis communication, effective since December 2021, emphasized the importance of ongoing assessment and collaboration with the dialysis facility, which was not followed in this case.
Medication Labeling Deficiency in Facility
Penalty
Summary
The facility failed to ensure proper labeling of medications in one of the medication carts and one of the medication rooms inspected. During an observation, a Breo-Elipta discus belonging to a resident was found in a box labeled with the resident's name, but the discus itself was not labeled with any identifying information. The LPN stated that nurses usually do not label the discus with the resident's name because it comes in a labeled box, but they do label it with the resident's room number in case it gets separated. However, in this instance, the discus was not labeled with either the resident's name or room number. Additionally, an open vial of Tuberculosis Purified Protein Derivative (TB PPD) was found in a medication room without an open date labeled on the vial itself, although the box had an open date. The RN confirmed that without the box, the open date would be unknown. There was inconsistency among staff regarding the labeling requirements for TB vials, with one LPN stating they should be labeled with an open date and another stating they are good for 30 days in the refrigerator. The Director of Nursing confirmed that individual vials, inhalers, and discus should be labeled with the resident's name when boxes are opened, and TB vials should be labeled with an open date, but was unsure of the exact duration for which a TB vial remains usable after opening.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation. For one resident, the Social Services Director (SSD) failed to document a care conference in the electronic medical record (EMR) on the correct date. The SSD initially claimed the conference occurred on a date when the resident was hospitalized, and later could not confirm the actual date from handwritten notes. This discrepancy highlights a lack of timely and accurate documentation, as the facility's policy requires entries to be made as soon as possible after an event. Another resident's care conference was not documented in the EMR, despite being scheduled and reportedly conducted. The SSD admitted to not entering the notes into the system. Similarly, for a third resident, a care conference was conducted but not documented in the EMR, with the SSD acknowledging the oversight. These failures in documentation contravene the facility's policy and the American Nursing Association's principles, which emphasize the importance of timely, accurate, and complete documentation to ensure informed decisions and high-quality care.
Failure to Implement Effective Infection Control for Recurrent UTIs
Penalty
Summary
The facility failed to implement appropriate infection control interventions and conduct a root cause analysis for a resident with recurrent urinary tract infections (UTIs). The resident, who has Alzheimer's disease, dementia with behavioral disturbances, and a history of UTIs, was admitted to the facility and experienced multiple UTIs over several months. Despite the frequent occurrence of UTIs, the facility did not identify any trends or implement new interventions to prevent these infections. The Infection Preventionist/Registered Nurse (RN) reported that the facility commonly sees UTIs and skin infections but did not provide specifics on infection control audits or interventions for the resident's UTIs. The resident's care plan included bowel and bladder planning and assistance with toileting, but no new interventions were added despite the recurrent E. coli infections. The facility's policy on antimicrobial stewardship emphasizes the importance of obtaining cultures before administering antibiotics, but the resident was repeatedly started on antibiotics before culture results were available, leading to changes in medication once results were received. The resident's urinalysis history showed positive results for UTIs on multiple occasions, with E. coli being the main bacterial growth. The facility's failure to implement effective infection control measures and conduct a thorough root cause analysis contributed to the resident's ongoing UTIs. The Infection Preventionist acknowledged the resident's resistance to care and fluctuating behaviors but did not provide comments on the origins of E. coli or potential preventative measures.
Failure to Provide Increased Supervision Leads to Resident's Fall and Death
Penalty
Summary
The facility failed to provide increased supervision for a resident who was at risk for falls, resulting in a fall with neck fractures and subsequent death. The resident, a male with a history of a broken femur, multiple pelvic fractures, highly impaired vision, hearing difficulties, and chronic kidney disease, was admitted to the facility after a hospital stay. The hospital discharge summary noted issues with altered mental status, possibly related to dementia and hospital delirium, and the resident was prescribed medications that could cause sedation and confusion. Upon admission, the resident was assessed as alert and oriented but had sundowning syndrome. Despite being at risk for falls due to his medical condition and debility, the resident did not receive his prescribed pain medication, Norco, for over two days after admission. The resident exhibited signs of pain and confusion, which were not adequately addressed by the facility staff. A nurse practitioner noted the resident's symptoms and ordered an increased dose of Norco, but was unaware that the medication had not been administered as prescribed. The facility's interdisciplinary team noted a change in the resident's cognitive status, but there was no evidence of increased supervision or safety measures being implemented. The resident eventually fell, sustaining multiple spinal fractures, and was found in a state of septic shock, possibly due to pneumonia and a urinary tract infection. The resident was admitted to the hospital's trauma service and later died from injuries related to the fall. The death certificate indicated that the fall in the facility directly caused the resident's death.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 133 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Midland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brittany Manor | 1.1 mi | ★★★★★ | 4 | 0 |
| Medilodge Of Midland | 6.1 mi | ★★★★★ | 3 | 0 |
| Carriage House Nursing And Rehabilitation | 10.6 mi | ★★★★★ | 1 | 0 |
| Huron Woods Nursing Center | 11.4 mi | ★★★★★ | 15 | 0 |
| Caretel Inns Of Tri-cities | 11.5 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.