Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa At Pine Place during CMS and state inspections, most recent first.
A resident with dementia, COPD, and significant ADL dependence was verbally abused by a bus driver during an offsite appointment. Witnesses reported the driver used a loud, condescending tone, made degrading comments about the resident’s mobility, and left the resident in the parking lot briefly before returning to the van.
A resident who was dependent for all care and required assistance with bed mobility fell out of bed while being bathed when a CNA provided one-person assistance and rolled the resident from behind instead of in front. The resident sustained skin tears, pain, and a right femur fracture requiring hospitalization. Surveyors also observed unsafe transfer and positioning issues afterward, including a resident sliding in a wheelchair with a Hoyer sling underneath, a call light out of reach, staff unsure how to use the sling, and an unlocked shower bed during transfer.
A facility failed to follow infection control practices for two residents on EBP, including a phlebotomist who entered a resident’s room without properly reviewing the posted precautions and reused gloves, and a nurse who entered another resident’s room without a gown and later removed gloves in the hallway without hand hygiene before preparing meds for another resident. The laundry area also had several clean carts with debris under the spring lifts, and staff were observed wearing long artificial fingernails with jewels despite the facility policy prohibiting them in patient care areas.
Unclean resident environment and flies observed. Surveyors observed flies in several resident rooms and hallways, and courtyard doors were kept open for residents attending smoking activities. A resident who was in bed with O2 via NC had a portable fan on the bedside table with a heavy buildup of dust, and the resident stated housekeeping swept and mopped but did not dust. The Administrator stated there was no formal log for cleaning personal fans, and staff reported flies might be entering when doors were left open for smoking access.
A driver/CNA was observed carrying residents’ debit/credit cards and cash in the dining room while arranging cigarette purchases for multiple residents. The employee stated they took money or cards from residents who wanted items from the smoke store and kept a sign-off clipboard in the van. The DON/Administrator said staff should not handle resident money and that concerns about misappropriation had previously been addressed, while facility records showed a resident council notice that the facility would no longer purchase personal smoking items.
Standing dietary orders were not honored for multiple residents during meal service. A resident with dx including iron deficiency and dysphagia received a lunch tray that lacked all listed standing-order items, and the DM stated dietary aides were responsible for reading the ticket during tray pass but missed the items. Other residents also had ordered foods and beverages omitted from breakfast and lunch trays, including coffee, oatmeal, yogurt, pink lemonade, chef salad, health shakes, milk, applesauce, and cottage cheese.
Kitchen sanitation and food handling practices were not maintained. A Dietary Manager observed an unsealed box of taquitos, wet metal pans stacked before air drying, and dust and debris on kitchen light and vent covers. In addition, a CNA assisting a resident’s lunch meal handled the resident’s roll with a bare hand, spread butter on it, and returned it to the plate; the IC Preventionist stated staff should not touch resident food with bare hands.
The facility failed to treat several residents with dignity during feeding and while responding to a pain medication request. A CNA was observed standing while feeding residents, alternating bites between two residents, and leaving a table mid-meal to assist others. One resident was left waiting for a meal tray while staff spoke about the delay in front of the resident, and the DON was observed making a comment to the resident during the meal. Another resident complained about not receiving pain medication, but the nurse and a therapy staff member did not acknowledge the concern appropriately.
Resident room privacy was not maintained when a bed positioned against the wall extended into the doorway and prevented the door from closing. CNAs stated the bed could be moved if needed, the UM said the bed did not need to be against the wall, and the DON acknowledged the privacy concern. The resident had dementia, diabetes, and a fracture history, with severely impaired cognition on BIMS.
A resident who required 2-person Hoyer lift transfers hit their head and reported pain when a damaged sling tore during a transfer from bed to wheelchair. Two CNAs did not fully inspect the sling before use, and the sling had been left under the resident by overnight staff. Record review and staff interviews showed the sling was frayed, other slings in circulation also showed wear, and the facility did not have a routine process to inspect all slings before use.
A resident who was always incontinent of bowel and bladder reported that briefs were not being changed regularly and that delays were worse on evenings and weekends. The resident said they had a UTI with ongoing burning and believed it was related to not being changed often enough. Record review showed the care plan called for pericare after each incontinent episode, but task documentation often reflected only a few incontinence care entries per day. The DON stated CNAs should check for incontinence throughout the shift, but also acknowledged documentation was often delayed and staffing and call light response issues affected care on off-shifts.
A resident with intact cognition and no behavior concerns was observed smoking outside, after which a SW searched the resident’s room, found extra cigarettes, and imposed a 3-day smoking suspension. The resident was told the room would be searched and was reminded of the smoking policy and consequences. The facility’s current smoking policy allowed residents deemed safe to smoke in designated areas and did not include room-search authority or punitive measures such as revoking smoking rights.
Inaccessible Overbed Light Pull Cord: A resident who preferred to stay in bed and rarely left the room was observed lying in bed with O2 via nasal cannula, but the pull cord for the overbed light was tied up and too short to reach from the bed. The resident stated they could not turn on the light because a longer cord had never been brought, and later observations showed the cord remained out of reach. The Maintenance Director confirmed the short cord length and said the lights had likely been that way since the rooms were renovated.
Failure to provide evening snacks occurred for a resident with spastic quadriplegic CP, moderate protein-calorie malnutrition, and a weight of 77.4 pounds. The resident was cognitively intact but dependent on staff for eating, stated she was hungry in the evenings and did not receive snacks, and the care plan did not include an evening snack intervention. CNA snack documentation showed no snacks given or eaten, and the DM confirmed the resident was not on the evening snack list.
A resident with multiple comorbidities and total dependence on staff developed a sacral/coccyx wound that was inaccurately assessed and not properly managed. The wound was mischaracterized, not identified in routine assessments, and lacked appropriate interventions in the care plan. The facility failed to recognize the wound's decline or notify the physician, resulting in the resident's hospitalization for a Stage 4 pressure ulcer and sepsis.
The facility failed to maintain sanitary conditions in the kitchen and storage areas, affecting food safety. Raw ground beef was improperly thawed under warm running water, and undated containers of chicken tenders and sliced peaches were found in coolers. Additionally, debris was observed in the dry storage room, and the ice machine area had stagnant water and mold-like substances.
A resident and the Resident Council reported a lack of meaningful activities due to staffing shortages after a management change. The facility had only one activities director, leading to limited programs and no weekend activities. The Director of Activities and Administrator acknowledged the issue, with plans to increase staffing.
A resident with dysphagia and Parkinson's disease was observed coughing while consuming thin liquids, despite a physician's order for nectar thick liquids. The facility failed to provide the prescribed diet texture, leading to a deficiency in nutritional care.
A resident with severe cognitive impairment and a recent hospital readmission was not provided with the physician-ordered enteral feeding, and the facility failed to document the feeding accurately or notify the physician of refusals. The resident's legal representative was also not informed of the refusals, despite visiting daily. The facility's policy on feeding tubes was not followed, leading to a deficiency in care.
A resident with end-stage renal failure did not receive consistent post-dialysis assessments, and there was a lack of communication between the dialysis center and the facility. Nursing progress notes lacked documentation of dialysis port site assessments, and recent dialysis communication forms were missing from the resident's records. Interviews revealed confusion among staff about the process for handling dialysis communication forms, contributing to the deficiency.
The facility experienced insufficient staffing on weekends, resulting in extended call light response times and resident dissatisfaction. Three residents reported longer wait times for assistance, particularly during afternoon and midnight shifts. One resident faced difficulties with toileting due to a broken toilet and lack of staff. The facility's staffing report confirmed low weekend staffing, and interviews with staff indicated challenges due to call-offs. The Administrator and DON acknowledged the issues and were working to address them.
The facility failed to implement non-pharmacological interventions and gradual dose reductions (GDR) for residents on psychotropic medications. One resident with Alzheimer's and other disorders was on a regimen of Ativan, Benadryl, and Haldol gel without documented GDR attempts. Another resident with schizoaffective disorder received diazepam without prior non-pharmacological interventions. A third resident with major depressive disorder was given PRN lorazepam frequently without an end date or evidence of target behaviors. The DON acknowledged these concerns.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with pressure ulcers. The resident had multiple open wounds, but there was no signage indicating the need for EBP. A nurse provided wound care without wearing a gown, only using gloves. The resident's medical record showed a Stage 3 pressure injury, but no physician orders for EBP. The infection control nurse and DON confirmed that EBP should have been used, and acknowledged the lack of signage and PPE in the resident's room.
The facility did not effectively implement an antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. The Unit Manager explained the process of ensuring infections meet McGeer's criteria before prescribing antibiotics. However, three residents were on antibiotics without meeting these criteria, and there was no physician documentation justifying the continued use. The Unit Manager could not provide supporting documentation for these cases.
A resident receiving hospice care with a documented high pain level did not receive prescribed pain medication due to a lapse in administration and documentation. The facility's DON confirmed the absence of pain relief on the day of hospice transfer, as the ordered Morphine was unavailable and the previous Norco prescription was discontinued.
A resident with severe cognitive impairment and multiple comorbidities was readmitted to a facility but did not receive critical medications for four days due to a failure in transcribing and following up on admission orders. The facility's process for verifying medication orders was not followed, leading to the oversight.
The facility failed to investigate a resident-to-resident sexual abuse allegation thoroughly. A cognitively intact resident reported inappropriate touching by another resident, but the facility did not interview the victim or obtain hallway footage. The Administrator dismissed the need for a formal interview, relying on conflicting staff reports.
The facility failed to update the care plan for a resident with a history of drug use after an overdose incident. The resident, who was cognitively intact, overdosed on drugs within the facility and was transferred to the hospital, where a urine drug screen confirmed cocaine use. Despite this, the care plan was not updated to include measures to monitor for signs of drug use or to more closely monitor visitors.
A resident with dementia and a history of traumatic brain injury eloped from the facility and was missing for four and a half hours. The facility failed to identify the resident as an elopement risk, did not have staff stationed at the front desk, and lacked clear procedures for responding to door alarms. Staff inconsistencies and inadequate policies contributed to the incident.
A resident with dementia and a history of traumatic brain injury exited the facility without staff knowledge and was missing for four and a half hours. The facility failed to ensure medically-related social services and follow-up, including guardianship and care planning reviews, due to the absence of a full-time social services staff and lack of documentation.
A resident with multiple diagnoses experienced significant weight loss and a decline in health due to the facility's failure to monitor their nutritional needs and weight. Despite being identified as malnourished, the resident did not receive the recommended nutritional supplement, and their weight was not monitored as required. Interviews with staff revealed inconsistencies in the weight monitoring process and lack of follow-up on the resident's nutritional status.
The facility failed to ensure a comprehensive infection control program, resulting in a resident developing a urinary tract infection and being hospitalized. The DON overseeing the program had not completed the necessary training, and the facility's infection control documents lacked essential elements such as calculated infection rates and environmental rounding.
A resident with multiple diagnoses waited nearly three hours for a brief change after activating their call light. Despite the issue being reported to the administration, no timely follow-up was conducted, and the grievance form was only initiated 14 days later. Staff education did not specifically address the incident.
Verbal Abuse Toward Resident During Offsite Appointment
Penalty
Summary
The facility failed to protect a resident from verbal abuse by staff. The resident involved, R802, was admitted with diagnoses including dementia, morbid obesity, and chronic obstructive pulmonary disease. The resident’s MDS showed the resident needed assistance from staff with most activities of daily living, and the BIMS score was 11, indicating moderately impaired cognition. During the survey, the resident was observed lying in bed and could not recall the reported incident when interviewed. The deficiency was based on a facility-reported incident involving a bus driver who accompanied R802 to a dermatology appointment. Witness statements from office staff described the bus driver speaking to the resident in a loud and condescending tone, telling the resident to stop talking, asking whether the resident was able to walk on their own feet, and making comments about the resident’s inability to walk. The office manager reported that the interaction escalated into a verbal altercation, that the resident attempted to object, and that the bus driver left the resident at the parking lot for a few minutes before loading the resident into the van and leaving. The facility investigation concluded the verbal abuse was substantiated.
Unsafe bed mobility and transfer care led to resident fall and injury
Penalty
Summary
The facility failed to prevent an avoidable fall out of bed for a resident who was dependent on staff for all care and had been care planned for 1-2-person assistance with bed mobility. During bed bathing care, a CNA provided one-person assistance and rolled the resident onto their side while positioned behind them rather than in front of them. The resident continued to roll forward and fell out of bed onto the floor, sustaining skin tears, pain in multiple areas, and a right femur fracture that required hospitalization. The resident’s record showed diagnoses including stroke, anxiety, depression, end stage renal disease, and atrial fibrillation, and the resident was receiving Eliquis at the time of the fall. The investigation file stated the resident was dependent for transfers and bed mobility and used a Hoyer lift for transfers. The DON acknowledged the CNA should have been in front of the resident during care and stated the resident’s care plan should have clearly designated whether one-person or two-person assistance was required, since a CNA did not have the clinical expertise to make that decision. The resident’s care plan contained inconsistent entries regarding whether 1-2-person assistance or 2-person assistance was required. Surveyors also observed ongoing problems with the resident’s handling and positioning after the fall. The resident was seen sliding forward in a wheelchair with a full body Hoyer sling underneath them, grimacing in pain, and stating they wanted to lie down. Their call light was out of reach, and staff who responded were unsure how to use the full body sling and left the room while the resident remained sliding in the chair. Later, a CNA was observed transferring the resident to a shower bed with two brakes unlocked. The DON and RN confirmed the call light should have been within reach and that the transfer and positioning concerns were inappropriate. The resident’s hospice and therapy notes described high pain with movement and transfers, and the orthopedic note stated the resident was at high risk for displacement and skin compromise from the femur fracture.
Infection Control Failures with EBP, Hand Hygiene, Laundry, and Staff Fingernails
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to Enhanced Barrier Precautions (EBP) and hand hygiene for two residents, and also failed to maintain appropriate infection control practices in the laundry area and with staff fingernails. Resident 58 had diagnoses including acute gastric ulcer with perforation, pleural effusion, generalized acute peritonitis, ESBL resistance, fistula of intestine, candidal stomatitis, urinary tract infection, herpesviral gingivostomatitis, pharyngotonsillitis, acute peptic ulcer with perforation, and peritoneal abscess. The resident had a physician order to maintain EBP for high-contact care related to a PICC line and history of MDRO. A phlebotomist was observed at the resident’s room with gloves on, entering the room without first reading the posted precaution signage, then exiting and re-entering the room using the same gloves, touching the door handle and retrieving a tourniquet without changing gloves, using hand sanitizer, or donning a gown. The phlebotomist stated they did not read the sign and went by what nurses showed them rather than what was posted. Resident 65 had a sign on the room door indicating EBP with gown and gloves required for resident care activities. A nurse entered the room carrying wrapped gauze without donning a gown, then later exited with a glove on one hand and carried gauze and the removed glove into the hallway. The nurse removed the remaining glove in the hallway and discarded it in a housekeeping trash cart without being observed performing hand hygiene. The nurse then placed the gauze back on the treatment cart and proceeded to the medication cart without hand hygiene before preparing medications for another resident. The nurse stated they had changed the dressing to the resident’s tracheostomy opening. The resident’s chart showed an order for EBP related to a feeding tube and an order to cover the trach opening with a dressing. In the laundry area, the laundry supervisor reported that the facility had recently switched products and that several days of laundry were done without bleach after the bleach level in the supply bottle stopped moving and the vendor later fixed the problem. Observation of clean laundry basket trunks found copious lint, garbage debris, food debris, peanut shells, examination gloves, and lancets under the spring lifts in three of four carts. In addition, a CNA was observed with artificial fingernails approximately 1 inch long and encrusted with small to large jewels while working with residents. The infection preventionist stated the nails were an infection control issue because they could not be completely cleaned and could rip gloves, and the DON acknowledged concern when informed. The facility policy stated artificial nails are not permitted on staff working in patient care areas.
Unclean resident environment and flies observed
Penalty
Summary
The facility failed to maintain a clean, comfortable, homelike environment for multiple residents, including R60. During the recertification survey, flies were observed in several resident rooms and throughout the hallways. Observations of residents attending smoking activities showed the courtyard doors were kept open to allow residents to exit the facility. The facility’s policy stated that housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. On 8/19/25, R60 was observed lying in bed with oxygen in place via nasal cannula. A small black portable fan on the resident’s table had a large buildup of dust hanging from the front and back protective covering and fan blades. When asked about the room environment, R60 stated they had allergies and that the fan was not cleaned, and reported housekeeping swept and mopped the floors but did not dust. Additional observations on 8/19/25 and 8/20/25 showed the fan remained heavily dust-covered. The Administrator stated there was no formal log for cleaning personal fans and that staff should clean a dirty fan if they saw one. Staff reported there was a monthly pest control log with no fly concerns identified, and stated flies might be getting in when residents went outside to smoke and the doors were left open.
Staff Handled Resident Money and Cards to Buy Smoking Items
Penalty
Summary
The facility failed to prevent staff from handling residents’ money and cards to purchase smoking materials for 18 residents reviewed for abuse, exploitation, and misappropriation of property. During observation in the main dining room, a driver/CNA entered with a gray plastic bag, placed a debit/credit card next to one resident, moved among several residents during lunch, pulled out a large wad of folded cash, and showed another resident a carton of cigarettes. When interviewed, the driver/CNA stated they went to the smoke store for residents and explained that when residents go out to smoke, they take cash or cards from whoever wants items purchased, using a clipboard with sign-offs kept in the van. The Administrator stated staff should absolutely not handle resident money and reported that this had previously been stopped because of concerns about misappropriation, but the driver/CNA’s log showed multiple residents from mid-July through the survey date, with some residents identified by the facility not included in the log. Facility records also showed a resident council notice that the facility would no longer purchase personal smoking items and a disciplinary notice stating staff cannot take resident money or debit cards to purchase cigarettes.
Standing Dietary Orders Not Honored
Penalty
Summary
The facility failed to ensure food preferences and standing dietary orders were honored for four residents reviewed for dining and nutrition. On 08/20/2025 at approximately 1:20 p.m., R1’s lunch tray was observed with a meal preference ticket listing standing orders for 1/2 cup applesauce, 1/2 cup mashed potatoes and gravy, and yogurt, but none of those items were present on the tray. When the Dietary Manager was questioned, the manager stated that dietary aides are responsible for reading the ticket during tray pass and placing the standard order items on the tray, and that the aide missed R1’s items. Record review showed R1 was admitted with diagnoses including iron deficiency and dysphagia, and the MDS indicated the resident needed assistance from facility staff with most ADLs. Additional observations showed R24 had multiple standing orders not provided with meals, including coffee, oatmeal with brown sugar, fruited yogurt, pink lemonade, and a chef salad that was listed as always available on the posted menu. On 08/19/2025, R20, R43, and R70 also had standing orders omitted from lunch trays, including a health shake, milk, applesauce, cottage cheese, and other ordered items that were not present at the time of service.
Kitchen Sanitation and Bare-Hand Food Contact
Penalty
Summary
Sanitary conditions were not maintained in the main kitchen during observation and food service. On 8/20/2025 at approximately 8:37 a.m., a tour with the Dietary Manager found a box of taquitos that was not secured/unsealed, with individual taquitos falling out when the box was moved. The same tour found stacks of metal pans on a storage rack that were not air dried and had water droplets throughout the stack; when the pans were raised, water poured onto the floor. Kitchen light covers were observed with dust and staining, and ventilation covers had dust and debris spreading onto the ceiling tiles. During food service for R70, on 8/19/25 at 12:37 PM, a CNA was observed assisting with the resident’s lunch meal and removed the resident’s dinner roll from the plate with a bare hand, spread butter on it, and placed it back on the plate. On 8/21/25 at approximately 1:30 PM, the Infection Control Preventionist stated staff should not be touching resident food with bare hands. A facility policy titled Dining Service, revised 1/2025, stated staff will be educated on hygienic practices including no bare hand to food contact.
Failure to Maintain Resident Dignity During Feeding and Medication Requests
Penalty
Summary
The facility failed to ensure treatment in a dignified manner for five residents reviewed for dignity. During one-to-one feeding assistance, CNA M was observed standing at the bedside while feeding R24 rather than being seated. CNA M was also observed standing at the dining table while providing one-to-one feeding assistance to R20 and R70, alternating bites between the two residents. During the meal, CNA M repeatedly left the table to assist other residents and then returned to continue feeding R20. CNA M was later observed again standing at R24’s bedside while attempting to provide feeding assistance. R70 was observed seated at a dining table without a meal tray while other residents at the table had already been served and were being assisted with their meals. Staff were overheard asking one another about getting a tray for R70, and CNA M told R70 that their tray was being brought right away while repeatedly calling the resident “sweet pea.” The DON was observed telling R70, “At least you got your coffee right there,” while the resident continued watching others eat. CNA M also stated out loud that everyone else had their meals and later told R70 that the ground meat was “some beef” while saying they did not want to lie about it. The DON stated R70 usually ate later and the tray usually went to the resident’s room, and also acknowledged staff should be wearing name badges. R76 was overheard near the nursing station saying, “Isn’t anyone going to help me?” and stated they had requested pain medication but were told they had to wait while the nurse sat at the nursing station. R76 later complained in the hallway to Nurse E and Therapy Staff Q about not receiving pain medication. Nurse E did not acknowledge the complaint, and Staff Q told R76 they would be taken care of and to stop swearing. During interviews, Nurse E said they could have acknowledged R76’s complaints, Staff Q said they could have inquired with the nurse, and the DON stated staff could have addressed R76’s needs in a more appropriate way.
Resident room door could not be closed due to bed placement
Penalty
Summary
The facility failed to protect resident privacy for one resident reviewed for privacy. On 8/19/25, the resident was observed lying in bed with a concave mattress, positioned on the left side directly against the wall to the hallway, with the bed extending approximately 6 inches past the doorframe. When the door to the room was attempted to be closed, it hit the footboard and could not close. The resident did not answer questions during the observation, and the clinical record showed the resident was admitted on 6/27/25 with diagnoses including dementia, diabetes, and fracture of the left wrist and hand. A BIMS dated 8/6/25 showed severely impaired cognition. During interviews, CNA F stated the bed had been brought by Hospice and was longer than the facility's beds, and that if the door needed to be closed, staff would move the bed. CNA G said she guessed she would move the bed. The Unit Manager stated the bed did not need to be against the wall because of the concave mattress and that staff kept moving it back against the wall even though it was too long for that location. The DON stated the bed should not block the door from being closed and acknowledged the privacy concern when informed that the resident's door could not be closed. The facility policy titled Resident Rights stated that personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.
Damaged Hoyer Sling Used During Resident Transfer
Penalty
Summary
The facility failed to protect a resident from neglect when a Hoyer lift sling tore during a transfer, causing the resident to hit their head and report pain. The resident required 2-person assistance with a Hoyer lift for transfers, was cognitively intact, and had diagnoses including metabolic encephalopathy, anxiety, depression, and osteoporosis. After the incident, the resident declined emergent CT imaging and agreed to an x-ray, which showed no acute abnormalities or fractures. A pain assessment documented moderate pain rated 3 out of 10 after the transfer. The incident occurred when two CNAs were transferring the resident from bed to wheelchair using a Hoyer lift. One CNA reported the sling had been left under the resident by overnight staff, and both aides stated they did not fully inspect the sling before use. During the transfer, the sling loop tore or broke, and the resident struck the back of the head on the bed baseboard or metal part of the lift. Nursing documentation and staff interviews confirmed the sling was frayed and damaged, and the damaged sling was discarded rather than retained for review. Record review showed the resident's care plan did not identify the sling type or size to be used. The facility's sling inspection process was not routine; laundry staff reported only dirty slings were inspected, and several slings in circulation were found with faded tags and signs of wear. The manufacturer's instructions required slings to be inspected before each use and removed from service if torn, frayed, faded, or otherwise unsafe. Staff interviews and record review showed the damaged sling had been used despite visible wear, and the facility acknowledged the transfer occurred with a damaged sling and that there was no regular inspection process in place for all slings.
Delayed Incontinence Care and Inconsistent Documentation
Penalty
Summary
The facility failed to provide timely incontinence care for one resident who was always incontinent of bowel and bladder and required substantial to maximal assistance with toileting hygiene and lower body dressing. The resident, who had intact cognition and diagnoses including COPD with acute exacerbation, mild intermittent asthma, fibromyalgia, and recurrent major depressive disorder, reported that briefs were not being changed regularly and stated they had a UTI and continued burning that they believed was related to not being changed frequently enough. The resident said they were trying to get changed every three to four hours but often had to wait a long time, with the last change reported as 5:00 AM, and said the delays were worse on weekends and evenings. Record review showed the care plan directed staff to provide briefs for dignity and pericare after each incontinent episode, but the task documentation for the prior 30 days showed incontinence care was often documented only two or three times in a 24-hour period, with some days showing four entries and other days fewer. The documented times showed care occurring at varying intervals across days and shifts. During interview, the DON stated CNAs should be checking for incontinence throughout the shift, but also acknowledged that documentation was often not done in real time, that call light response and staffing were issues on off-shifts such as nights and weekends, and that at times there might only be one CNA, with acuity making care difficult even when two CNAs were assigned per hallway.
Resident dignity compromised by unauthorized room search and smoking suspension
Penalty
Summary
The facility failed to treat one resident with dignity and respect when staff searched the resident’s personal possessions without giving the resident the opportunity to decline and then imposed a 3-day smoking suspension. The resident, who was admitted in 7/2022 and had diagnoses including alcoholic hepatic failure, alcoholic cirrhosis with ascites, gout, protein-calorie malnutrition, anxiety disorder, major depressive disorder, and traumatic subdural hemorrhage, had intact cognition and no behavior concerns on the annual MDS assessment. The resident reported being able to smoke independently, and the record showed the resident had been re-evaluated for smoking competency in April 2025. On 4/22/25, a Social Worker observed the resident smoking outside even though the cigarette had not been given by activity staff. The Social Worker requested a room search, searched the room, and found additional cigarettes. The resident was told the room would be searched and was reminded of the smoking policy and the consequences for violating it. The Social Worker documented this as a second violation and stated the resident understood the consequence of a 3-day suspension and would resume smoking on 4/25/25. The facility’s current smoking policy allowed residents deemed safe to smoke to do so in designated areas and stated that smoking materials for residents requiring supervision would be maintained by nursing staff, but it did not include documentation authorizing room searches or punitive measures such as revoking smoking rights. The Administrator acknowledged the facility had used an outdated smoking policy and that the resident was disciplined based on the former policy.
Inaccessible Overbed Light Pull Cord
Penalty
Summary
The facility failed to ensure that the pull cord for the overbed light was accessible to a resident who preferred to stay in bed and rarely left the room. On observation, the resident was lying in bed with oxygen via nasal cannula, and the overbed light above the bed had a pull string tied up and hanging down about one foot, making it unreachable from the bed. When asked about the room environment, the resident stated they could not reach the light to turn it on because a longer cord had never been brought. Additional observations on two later dates showed the cord remained tied up and still not within reach. The Maintenance Director observed the room and confirmed the short length of the overbed light, stating those lights had likely been that way since the rooms were renovated.
Failure to Provide Evening Snacks for a Resident with Low Body Weight
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for a resident with low body weight and a history of moderate protein-calorie malnutrition. R54 was admitted with diagnoses including spastic quadriplegic cerebral palsy, moderate protein-calorie malnutrition, and anxiety disorder. The resident was cognitively intact per the MDS and dependent on staff for eating. On observation, R54 appeared very thin with bilateral arm and hand contractures and stated she did not get evening snacks, did not always like the food served, and was hungry in the evenings. She also stated that when snacks were available, she needed assistance to eat and it was hard to get someone to help at snack time. Record review showed R54's most recent weight was 77.4 pounds, and the nutritional care plan revised 2/17/25 did not include an intervention for evening snacks. A 30-day look-back of CNA snack documentation showed no snacks documented as given or eaten. During observation, R54 required staff assistance to open items and eat breakfast. The DM stated evening snacks were prepared for residents on a list, and R54 was not on that list. The RD stated R54 had never asked for evening snacks and acknowledged the concern when asked why snacks were not included in the resident's nutritional interventions. The DON also stated R54 had never asked for evening snacks, but thought it would be a good idea because the resident only weighed 77.4 pounds.
Failure to Accurately Assess and Manage Pressure Ulcer Leading to Hospitalization
Penalty
Summary
The facility failed to accurately assess and manage a sacral/coccyx wound for a resident with dementia, gastrostomy, dysphagia, and total dependence on staff for activities of daily living. The initial wound assessment documented a new open area on the coccyx, but the wound was incorrectly described as moisture-associated skin damage (MASD) rather than a pressure injury, despite clinical findings consistent with a Stage 3 pressure wound. There was no documentation of the facility identifying the wound in weekly skin assessments, nor were adequate and appropriate interventions implemented in the care plan to prevent wound development. Over the following days, the facility did not identify the worsening of the wound or notify the physician of the resident's declining condition. The resident developed abnormal vital signs, altered mental status, and was eventually transferred to the hospital, where the wound was debrided and identified as a Stage 4 pressure ulcer with associated sepsis. The facility's records did not show timely recognition of the wound's deterioration or appropriate communication with the physician prior to the resident's hospitalization.
Sanitation Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all residents consuming food from the kitchen. During an observation, two 10-pound packages of raw ground beef were found thawing under running water in a two-compartment sink. The ground beef was partially submerged in water, with the temperature of the running water measured at 92 degrees Fahrenheit, contrary to the FDA Food Code requirement of 70 degrees Fahrenheit or below. The Dietary Manager confirmed that the water should have been cold. Additionally, undated containers of chicken tenders and sliced peaches were found in the walk-in and reach-in coolers, respectively, violating the FDA Food Code requirement for date marking ready-to-eat, potentially hazardous food. Further observations revealed unsanitary conditions in the dry storage room and the nourishment room. The flooring underneath the racks in the dry storage room had a buildup of debris, including flour, chocolate chips, cups, and snack packages. In the nourishment room, the ice machine's drainage bin contained stagnant, standing water, and the flooring underneath was wet with a black mold-like substance. There was also an accumulation of trash on the floor underneath the ice machine, violating the FDA Food Code requirement for cleaning physical facilities as often as necessary to keep them clean.
Inadequate Activity Programming Due to Staffing Shortages
Penalty
Summary
The facility failed to provide consistent, meaningful, and person-centered activities for residents, as evidenced by the experiences of one resident and feedback from the Resident Council. One resident, who had intact cognition and a history of anxiety disorder, bipolar disorder, and depression, reported a lack of engaging activities since a change in management led to a reduction in activity staff. The resident expressed dissatisfaction with the limited activities available, such as bingo, and noted the absence of one-on-one activity visits from staff. The Resident Council, consisting of seven residents, corroborated these concerns, with five residents reporting a significant reduction in activities and staff following management changes. They noted that the facility currently had only one activities director, who struggled to manage the program alone. The residents highlighted the lack of activities on weekends and the reliance on volunteers and nursing staff to assist with activities, which was insufficient to meet their needs. Interviews with the Director of Activities and the Administrator confirmed the staffing challenges and the limited scope of the activities program. The Director of Activities acknowledged being the sole staff member since April 2024 and described efforts to manage group activities and one-on-one visits with limited resources. The Administrator recognized the issue and mentioned recent approval for a part-time staff member, with plans to increase staffing further. The facility's policy emphasized the importance of providing activities that support residents' physical, mental, and psychosocial well-being, which was not being adequately met.
Failure to Provide Prescribed Thickened Liquids
Penalty
Summary
The facility failed to provide liquids according to the prescribed therapeutic diet texture for a resident, leading to a deficiency in nutritional care. On the morning of September 9, 2024, a resident was observed in their room attempting to eat breakfast while seated in a wheelchair. During this time, the resident was seen coughing while consuming cereal and drinking juice, both of which appeared to be thin liquids. A review of the resident's meal ticket indicated that they were supposed to receive nectar thick liquids, but this was not provided. Nurse C was informed of the situation and upon assessment, confirmed that the liquids were not thickened as required. Nurse C then added thickener to the liquids. The resident's medical record revealed a history of dysphagia, mild-protein-calorie malnutrition, and Parkinson's disease, with a physician's order specifying a diet of soft and bite-sized texture with mildly thick/nectar consistency liquids. The care plan also highlighted the resident's potential for nutritional and hydration problems due to their medical history and mechanically altered diet. Despite these documented needs, the facility did not adhere to the prescribed dietary requirements, resulting in the resident receiving inappropriate liquid consistency during their meal.
Failure to Administer and Document Enteral Feeding
Penalty
Summary
The facility failed to provide the total amount of physician-ordered enteral feeding to a resident, document the feeding accurately, and ensure timely follow-up with the physician. The resident, who had severe cognitive impairment and was represented by a legal guardian, was observed with an unopened bottle of enteral feeding dated three days prior. The charge nurse reported that the resident had been refusing tube feeding for several days, despite needing it to meet nutritional needs due to inadequate food intake. The resident had recently returned from the hospital with a new diagnosis of a pelvic mass and was experiencing abdominal discomfort. The resident's electronic medical record showed an order for enteral feeding once a day, but there was no documentation of the resident receiving the feeding on multiple days. Additionally, there was no evidence that the medical provider was notified of the resident's refusals or an episode of vomiting. The legal representative was also not informed of the refusals, despite visiting the facility daily. The unit manager acknowledged that the staff should have notified the physician and dietitian and that the legal representative should have been informed. Interviews with the registered dietitian and the director of nursing revealed that the facility's process for handling feeding refusals was not followed. The dietitian was only notified after the issue was brought to the facility's attention, and the director of nursing confirmed that the situation should not have occurred. The facility's policy on feeding tubes emphasized the importance of following physician orders and notifying the physician of any complications, which was not adhered to in this case.
Failure to Ensure Consistent Dialysis Care and Communication
Penalty
Summary
The facility failed to consistently assess a resident after dialysis and maintain accessible communication and collaboration between the dialysis center and the facility. The resident, who had end-stage renal failure and severe cognitive impairment, was receiving dialysis four times a week. However, the nursing progress notes from August to September did not consistently document the assessment and monitoring of the dialysis port site or post-dialysis nursing assessments. Additionally, there was a lack of recent dialysis communication forms in the resident's clinical record, indicating a breakdown in communication between the facility and the dialysis center. Interviews with facility staff revealed confusion and lack of awareness regarding the process for handling dialysis communication forms. The Unit Manager admitted to being new to the facility and unaware of the proper procedure, while the Dialysis Manager explained that forms were supposed to be reviewed and followed up by facility staff. The Director of Nursing confirmed that the forms were not uploaded to the resident's electronic medical record as expected. The facility's policy required comprehensive care plans and coordination between the facility and the dialysis provider, but these were not effectively implemented, leading to the deficiency.
Insufficient Weekend Staffing Leads to Resident Dissatisfaction
Penalty
Summary
The facility failed to provide sufficient staffing on weekends, leading to inadequate care and services for residents. During a confidential Resident Council interview, three residents reported extended wait times for assistance after activating their call lights, particularly during afternoon and midnight shifts on weekends. One resident experienced a broken toilet over a weekend and struggled to receive help with toileting due to insufficient staff. Additionally, two residents noted that staff were often required to perform multiple roles, further exacerbating the issue. The facility's staffing report from April to June 2024 confirmed low weekend staffing levels. Interviews with the Unit Manager and a CNA revealed that staffing challenges were primarily due to staff call-offs, particularly on afternoon and midnight shifts. The facility Administrator acknowledged the staffing issues and attributed them to call-ins, while the Director of Nursing noted that staffing was improving but still faced challenges due to attendance issues. Both the Administrator and DON were aware of the concerns raised by residents and were working on addressing the staffing problems.
Failure to Implement GDR and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to implement non-pharmacological interventions and gradual dose reductions (GDR) for residents receiving psychotropic medications, as observed in three cases. One resident, diagnosed with Alzheimer's disease, major depressive disorder, anxiety disorder, and psychotic disorder with delusions, was on a regimen of Ativan, Benadryl, and Haldol gel for agitation, anxiety, and psychosis. Despite a behavioral consultant's note indicating no recent behavioral changes and a contraindication for GDR, there was no documentation of previous GDR attempts or other medication options since 2016. The facility's social worker confirmed the absence of documented GDR attempts and was unable to provide further explanation or documentation. Another resident with schizoaffective disorder, bipolar disorder, and anxiety disorder was prescribed diazepam as needed (PRN) for anxiety. The electronic medication administration record (EMAR) showed multiple administrations of diazepam without documented non-pharmacological interventions prior to its use. The Director of Nursing (DON) acknowledged that nursing staff should document attempted interventions in the progress notes before administering the medication. A third resident, with major depressive disorder and anxiety disorder, was receiving PRN lorazepam for agitation/anxiety without an end date on the order. The resident's medication administration record (MAR) indicated frequent administration of lorazepam without evidence of target behaviors or non-pharmacological interventions. The social worker confirmed the lack of documentation for target behavior monitoring and non-pharmacological interventions, and the DON acknowledged the concern regarding the absence of an end date and monitoring by floor staff.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were applied for a resident with pressure ulcers. On a specific date, a concern was submitted to the State Agency indicating that facility staff were not following infection control procedures. During an observation, a resident was found in their room without any signage indicating the need for EBP, despite having multiple open wounds on their heel and leg. A nurse was observed providing wound treatment to the resident without wearing a gown, only using gloves. The nurse confirmed that they did not use a gown and stated there was no indication on the resident's door that EBP was required. The resident's medical record revealed they had been admitted with diagnoses including Bipolar and Schizoaffective disorder, and had a BIMS score indicating moderately impaired cognition. A wound evaluation showed a Stage 3 pressure injury that was not healed. There were no physician orders for EBP in the medical record. During an interview, the infection control nurse and the Director of Nursing confirmed that staff should have been using EBP, including gowns, when providing direct care to the resident. They acknowledged the absence of signage and a PPE bin in the resident's room, which should have been present to inform staff of the necessary precautions.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to effectively implement an antibiotic stewardship program, resulting in the inappropriate use of antibiotics for three residents. During an interview, the Unit Manager (UM) explained the process of ensuring infections meet McGeer's criteria before antibiotics are prescribed. If criteria are not met, the provider is contacted to discontinue the medication, and a progress note should be written to justify continued use. However, a review revealed that three residents were on antibiotics without meeting McGeer's criteria, and there was no documentation from physicians justifying the continued use of these medications. The UM was unable to provide supporting documentation, such as physician notes, labs, or symptoms, for the continued antibiotic use in these cases.
Failure to Administer Pain Medication to Hospice Resident
Penalty
Summary
The facility failed to administer pain medication to a resident who required such services, as identified during a survey. The resident, who was receiving hospice care and had a terminal illness, was documented to have a pain level of seven out of ten. Despite having physician orders for pain management, including Norco and Morphine, the resident did not receive any pain medication on the day in question. The Norco prescription had been discontinued, and the Morphine ordered by hospice was not yet available, leaving the resident without pain relief. The Director of Nursing (DON) confirmed that there was no documentation of pain medication administration on the day the resident transferred to hospice care. Although two Norco pills were removed from the container, there was no record of them being given to the resident. The DON acknowledged that the nurse should have contacted the physician for an alternative pain relief order while waiting for the Morphine delivery. The lack of documentation and failure to administer pain medication as ordered resulted in the deficiency noted in the survey.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
The facility failed to accurately transcribe and follow up on admission orders for a resident, resulting in the resident missing four days of critical medications. The resident, who had severe cognitive impairment and multiple comorbidities, was readmitted to the facility after a hospital stay. Upon readmission, the facility did not order the medications listed in the hospital discharge summary, which included blood thinners, diabetic medications, blood pressure medications, and others. The resident's electronic medical record and medication administration record did not reflect the necessary medications, and the resident did not receive these medications until four days after readmission. Additionally, the facility staff failed to check the resident's blood sugar levels until several days after readmission, resulting in a high blood sugar level that was not addressed in a timely manner. The facility's process for verifying and reconciling medication orders was not followed, leading to the oversight. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, revealed that the medication error was identified after the fact, and there was a lack of clarity on how the error occurred. The facility's process was supposed to involve verification of orders by the admitting nurse, unit managers, pharmacy, and attending physician, but this process was not effectively implemented in this case.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to complete a full investigation following an allegation of resident-to-resident sexual abuse involving two residents. Resident R701 reported that Resident R706 entered their room on two occasions, with the second incident involving inappropriate sexual touching. Despite R701's report, the facility did not conduct a thorough investigation, including failing to interview R701 about the incident. The facility's Administrator and Director of Nursing (DON) relied solely on staff reports that contradicted R701's account, without obtaining any hallway camera footage or conducting a comprehensive review of the incident. R701, who is cognitively intact with a BIMS score of 15/15, reported feeling unsafe and having issues with other residents and staff. The resident's clinical record did not contain any notes or follow-up regarding the alleged incident. R706, who is severely cognitively impaired and primarily speaks Spanish, was not appropriately interviewed due to language barriers. The facility's documentation included only brief and conflicting staff statements, with no formal interviews conducted with R701. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and interviews with all involved persons, including the alleged victim. However, the Administrator dismissed the need for an official interview with R701, citing the resident's history of making up stories and dissatisfaction with the living situation. This failure to adhere to the facility's policy and conduct a thorough investigation led to the deficiency cited in the report.
Failure to Update Care Plan for Resident with History of Drug Use
Penalty
Summary
The facility failed to develop a comprehensive care plan to address a resident's history of drug use. The resident, who had a history of drug use, was observed to have overdosed on drugs within the facility. On the day of the incident, the resident had left the facility on a leave of absence and returned later in the day. A few hours after returning, the resident became unresponsive, prompting the Director of Nursing (DON) to administer Narcan, suspecting an overdose. The resident was then transferred to the hospital, where a urine drug screen confirmed the presence of cocaine. Despite this incident, the resident's care plan was not updated to include measures to monitor for signs of drug use or to more closely monitor visitors, which the DON acknowledged should have been done to ensure the resident's safety. The resident's clinical records indicated that he was cognitively intact and had a history of drug use. The DON confirmed that the care plan had not been updated following the overdose incident, and there was no documentation of any measures taken to prevent future occurrences. The failure to update the care plan and implement appropriate monitoring measures constituted a deficiency in the facility's care planning process, as it did not adequately address the resident's needs and potential risks associated with his history of drug use.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as R704, who exited the facility without staff knowledge and was missing for four and a half hours. The resident, who had a history of dementia with behavioral disturbances and a traumatic brain injury, was not identified as an elopement risk prior to the incident. On the day of the incident, R704 was observed on video surveillance exiting the facility through the front door and was later found approximately 0.5 miles away by facility staff. The resident was wearing a wanderguard bracelet, which was applied after the elopement incident. The facility's response to the elopement was inadequate. Staff did not notice R704's absence until several hours later, and there was no immediate response to the door alarm that was triggered when the resident exited. The facility had no staff stationed at the front desk on the day of the incident, and the door alarm system was managed by the nursing station, which failed to follow through with a visual check of the area outside the door. Interviews with staff revealed inconsistencies in their accounts of the events and a lack of clear procedures for responding to door alarms. The facility's policies and procedures for handling elopements and door alarms were found to be insufficient. The maintenance director confirmed that there was no documentation available for when the alarm was silenced, and the facility's elopement policy did not provide specific guidelines for staff response to door alarms. The administrator admitted that staff were verbally informed of the procedures, but there was no written policy in place. This lack of clear procedures and staff training contributed to the failure to prevent the resident's elopement and ensure their safety.
Failure to Provide Medically-Related Social Services and Follow-Up
Penalty
Summary
The facility failed to ensure that medically-related social services and follow-up were provided to address guardianship, patient advocacy, and care planning reviews for a resident. The resident, who had diagnoses including dementia with behavioral disturbances and a history of traumatic brain injury, exited the facility without staff knowledge and was missing for four and a half hours. Upon return, the resident was given a wanderguard bracelet, but there was no documentation of a care planning review or guardianship status in the resident's records at the time of admission. The facility's Social Services Manager job description required the assessment and evaluation of each resident's psychosocial needs, incorporation of social service goals into the resident's plan of care, and completion of any required guardianship paperwork. However, the facility did not have a full-time social services staff since the previous social worker resigned in February, and the regional corporate social worker was only present once a week. This lack of consistent social services oversight contributed to the failure to identify and document the resident's legal guardianship status. The Administrator acknowledged that the resident's guardianship status should have been reviewed during care planning sessions, which were supposed to occur quarterly. However, there was no documentation of any care planning review for the resident since their admission. The Administrator also noted that the resident's guardianship paperwork was not reviewed upon admission, leading to the resident being incorrectly considered able to leave the facility on their own. This oversight resulted in the resident's elopement and subsequent placement on elopement risk protocols only after the incident occurred.
Failure to Address Nutritional Needs and Monitor Weight
Penalty
Summary
The facility failed to timely identify and address the nutritional needs and monitor the weights of a resident admitted with higher risk, resulting in decreased intake, significant undetected weight loss, and overall decline in status. The resident, who had diagnoses including respiratory failure, pneumonia, congestive heart failure, and COPD, was admitted for a short-term stay. Despite being identified as malnourished with a Mini Nutritional Assessment score of 6, the resident did not receive the recommended nutritional supplement, and their weight was not monitored as required. The resident's weight records showed a significant weight loss of 18.2 lbs over 25 days, with no monitoring of weights in between despite identified risks. The food acceptance record indicated that the resident frequently ate less than 50% of their meals or refused meals altogether. There was no follow-up by the Registered Dietician throughout the resident's stay, and the attending physician or their practitioner did not follow up on the resident's nutritional status or the ordered laboratory tests. Interviews with facility staff, including the Registered Dietician, Nurse Practitioner, and Director of Nursing, revealed inconsistencies and failures in the weight monitoring process and follow-up on the resident's nutritional needs. The facility's weight monitoring policy was not adhered to, and the resident's significant weight loss and malnourishment were not addressed in a timely manner, leading to the resident's overall decline in health status.
Inadequate Infection Control Program Leading to Hospitalization
Penalty
Summary
The facility failed to ensure a comprehensive infection control program that consistently identified infections based on symptoms and justified the use of antibiotics, as well as calculated infection rates, demonstrated ongoing tracking, trending, in-services, education, and environmental rounding. This deficiency resulted in a resident developing a change of condition leading to hospitalization due to a urinary tract infection. The complaint revealed that the resident was transferred to the hospital after a family member identified the change in their condition, and the resident was admitted to the hospital with a urinary tract infection and later readmitted to the facility. During the survey, it was found that the Director of Nursing (DON) was overseeing the infection prevention and control program but had not completed the necessary training or certification. The facility's MDS coordinator, who was a certified infection preventionist, was identified later and began reviewing charts for residents on antibiotics. However, the facility's infection control documents lacked calculated infection rates, trending, and environmental rounding/audits. The facility's infection prevention and control program policy indicated that the designated infection preventionist is responsible for oversight, but the program was not fully implemented as required, leading to the identified deficiency.
Failure to Timely Resolve Resident Grievance
Penalty
Summary
The facility failed to follow up and resolve a grievance in a timely manner for a long-term resident, resulting in feelings of frustration. The resident, who had diagnoses including congestive heart failure, metabolic encephalopathy, and breast cancer, reported waiting for almost three hours for a brief change after activating their call light. The incident occurred during the day shift, and the resident did not receive any follow-up from the facility administration despite the issue being brought to their attention by staff members. Interviews with various staff members, including a CNA, an LPN, and the Director of Nursing (DON), confirmed the resident's account of the incident. The DON stated that the facility's grievance process involves providing a grievance form and assisting residents or family members in filling it out if needed. However, no grievance form was initiated for this incident until 14 days later, after the concern was brought to the attention of the facility administrator and DON. The facility's follow-up included educating the CNA involved, but the education documentation did not specifically address the incident reported by the resident. The grievance form provided by the facility was dated 14 days after the incident, and the staff education focused on general CNA documentation and rounding procedures rather than the specific grievance. This lack of timely and specific follow-up contributed to the resident's frustration and the deficiency noted in the report.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 948 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clarkston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lourdes Rehabilitation And Healthcare Center | 3.1 mi | ★★★★★ | 1 | 0 |
| Wellbridge Of Clarkston | 3.3 mi | ★★★★★ | 2 | 0 |
| Regency At Waterford | 3.3 mi | ★★★★★ | 3 | 0 |
| The Orchards At Canterbury On The Lake | 3.5 mi | ★★★★★ | 5 | 0 |
| The Villa At Silverbell Estates | 4.1 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.