Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Waterview Pines Llc during CMS and state inspections, most recent first.
No RN coverage was scheduled for multiple days during the review period, and the facility failed to ensure an RN was on duty for at least 8 hours per day. The corporate administrator confirmed the staffing gaps after reviewing the daily schedules, and the facility had issues with hiring and agency staffing. The deficiency affected all residents in the facility.
A resident with anxiety, major depression, diabetes, and chronic diastolic HF had an alprazolam 0.5 mg PRN order for increased anxiety that had no stop date. Pharmacy consults flagged the missing stop date, but the provider left the order in place, and staff reported the PRN psychotropic should have been renewed every 14 days. The facility policy stated PRN psychotropic meds are limited to 14 days unless the provider documents rationale and duration.
A resident receiving oxygen was repeatedly observed on nasal cannula with the concentrator running, but the chart lacked provider orders for oxygen use or oxygen equipment care, and the care plan did not address breathing or oxygen. Another resident with venous insufficiency and edema had weekly skin checks noting bilateral leg swelling, redness, dry scaly skin, and scabs, but staff signed off on ordered tubi grips even though the resident was observed wearing regular knee-high socks and later staff acknowledged the compression was not actually being worn.
A resident with moderate cognitive impairment and diagnoses including acute respiratory failure and ischemic cardiomyopathy had continuous O2 ordered, but surveyors observed a free-standing portable oxygen cylinder sitting unsecured on the floor in the resident’s room. The resident and family member said it had been there for a long time, and staff later confirmed it was not safe to leave the tank like that. The DON stated oxygen tanks should be transported with a wheeled carrier and secured in appropriate holding devices at all times.
Failure to monitor fluid intake for a resident on dialysis and a 1500 mL fluid restriction. The resident had ESRD, CAD, and anemia, and the care plan included fluid restriction per order. The TAR showed repeated NA, x, and blank entries instead of consistent shift-by-shift intake documentation. The dialysis RN stated the resident’s dry weights were not being reached and low BP made fluid removal difficult, and facility staff said intake documentation should be completed each shift.
A facility failed to use proper PPE for a resident on enhanced barrier precautions and failed to perform proper hand hygiene during a brief change for another resident. Staff entered the room of a resident with wounds and a foley catheter without isolation gowns during high-contact care, and staff caring for another resident with incontinence and severe cognitive impairment moved from dirty to clean tasks without changing gloves or washing hands. The DON and IP confirmed the expected PPE and hand hygiene practices.
A resident with CHF, rectal cancer, and atrial fibrillation had a care plan that did not include chemotherapy, breathing problems, or oxygen use. Provider notes documented oxygen orders and monitoring related to CHF and chemotherapy, but the chart lacked oxygen orders and equipment instructions even though staff observed the resident wearing oxygen via nasal cannula and staff confirmed the resident was using oxygen during daily care and therapy.
Failure to provide and document nail care for a resident dependent in all ADLs. The resident had significant cognitive impairment and Alzheimer’s dementia, with care plans and provider orders directing weekly nail checks and nail care. However, the EMR lacked documentation of nail care or refusals, and family reported long, dirty fingernails and overgrown toenails after the resident had been removed from the podiatry list. Staff gave conflicting accounts about nail care responsibilities and noted the resident resisted nail trimming.
A facility failed to keep the past three years of recertification and complaint survey results available for review. During a review of the survey binder, the 2023 recertification and complaint surveys were missing, and both the administrator and corporate administrator confirmed they should have been included for resident, family, visitor, and staff access.
Rough and disrespectful care during ADL assistance: A resident with colon cancer, pain, edema, malnutrition, and altered mobility reported that an NA moved his legs too fast during care, causing pain and pulling on his drainage tube. He was visibly upset and said he did not want that NA in his room or caring for him. Staff also failed to consistently honor his requests to be left alone when sleeping, and behavior charting was not completed.
A resident with colon cancer, edema, pain, malnutrition, and care-plan needs for safe transfers reported that an NA handled him roughly, moved his legs too fast, and nearly pulled out his drainage tube, causing pain and distress. The physician, RN, and other NA all described the resident as upset and crying and said the event should have been reported immediately, but the concern was not promptly escalated and the NA continued to be assigned to the resident.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with dementia and mobility issues was transferred using a toileting sling instead of the care-planned full body sling, resulting in a fall from the lift and head injury. The staff did not report the incident to the state agency as required by facility policy, despite evidence that the transfer method was inappropriate for the resident's condition.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
The facility failed to maintain adequate staffing levels, resulting in delayed care and unmet needs for residents. Interviews revealed long call light wait times, insufficient personal care, and reliance on undertrained agency staff. Specific incidents included residents left soiled, delayed morning care, and untimely pain medication administration. The facility's staffing assessment was not met, impacting care during emergencies. The resident council expressed ongoing concerns about staffing, with no satisfactory response from administration.
A resident with chronic respiratory conditions was found with an oxygen humidifier bottle that had not been changed for over a month, contrary to facility policy. The facility's order summary lacked a schedule for changing the oxygen bubbler, and there was no documentation in the resident's electronic medical record. Both a registered nurse and the DON confirmed the expectation for regular changes, but the facility could not provide the relevant policies.
The facility failed to ensure timely repositioning and coordination of care for a hospice patient, did not follow weight monitoring orders for a resident with CHF, and did not complete dressing changes as ordered for a resident with an amputation. Additionally, the facility failed to ensure the placement of an AFO for a resident and did not deliver medications timely for a resident experiencing significant pain. These deficiencies highlight a pattern of inadequate care coordination and documentation.
A facility failed to provide adequate supervision for a resident with dementia, multiple sclerosis, depression, and dysphagia during dining. The resident, who required assistance with eating, was left alone in the dining room while a dietary staff member cleared tables. The resident remained unsupervised until a nursing assistant arrived to escort her to her room. Interviews with the RN and DON confirmed the need for nursing staff presence during meals for safety, as per facility policy.
The facility failed to dispose of an expired bottle of half and half, which was still accessible to residents. The culinary aide and director confirmed the product should have been discarded five days after opening or by the expiration date. The infection preventionist highlighted the increased risk of bacteria and foodborne illness from using expired dairy products. The facility's policy lacked guidance on monitoring expiration dates.
A resident with cognitive intactness and multiple diagnoses, including anxiety, was not provided adequate personal hygiene care, leading to greasy hair and discomfort. Despite the resident's care plan indicating a need for assistance and proactive care, the facility only scheduled weekly showers, failing to maintain the resident's dignity. Staff acknowledged the oversight, emphasizing the importance of offering hair washing without the resident having to request it.
A resident with cognitive impairment and multiple diagnoses was not assisted in getting dressed and going to the dining room for breakfast due to staffing shortages. The resident's care plan indicated a preference for dining in the main dining room and being ready by 8:00 a.m., but staff were unable to meet these preferences consistently. The facility's policy emphasized person-centered care, yet the resident's rights and dignity were compromised.
A resident's concern about a broken toilet went unaddressed due to a lack of communication and reporting among staff. The cracked toilet bowl was not reported by housekeeping or nursing staff, and no maintenance request was submitted. The regional director of maintenance confirmed the need for replacement, highlighting a failure in the facility's process for reporting and repairing broken equipment.
The facility failed to complete all sections on the MDS for two residents, leading to deficiencies in their assessments. One resident's cognitive and mood assessments were not conducted, while another resident's use of a wanderguard was not documented. These oversights were confirmed by facility staff, highlighting the need for accurate assessments to ensure proper care and billing.
The facility failed to address ADLs for two residents. One resident with a self-care deficit had neglected nail care, while another resident, dependent on staff for transfers, was left in bed undressed and unable to attend meals as preferred. Staff shortages and lack of documentation contributed to these deficiencies.
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies. One resident did not receive documented education or proper heel elevation, while another experienced gaps in weekly skin inspections and delayed notification to the RD about wound care needs. The DON acknowledged the importance of following care plans and conducting regular inspections, but the facility's failure to adhere to protocols resulted in these deficiencies.
A resident with traumatic brain injury and hemiplegia was not provided with a palm protector as outlined in their care plan, leading to a deficiency in care. The resident's left hand was found in a fist, and staff were unable to locate the palm protector. The director of nursing confirmed that the care plan was not followed, which could prevent further contractures.
A facility failed to ensure PRN lorazepam orders were time-limited to 14 days and lacked a documented diagnosis for a resident with severe cognitive impairment. The resident's care plan included psychotropic drug monitoring, but the order for lorazepam was set for six months without a rationale for extending beyond 14 days, contrary to facility policy. After discharge from hospice, a new order with an indication and rationale should have been documented.
A facility failed to secure a resident's hospice medical records. The resident, with dementia and congestive heart failure, had hospice care orders not integrated into the EHR. Hospice staff recorded notes on paper stored in a binder, which went missing. Efforts to locate the chart were unsuccessful, and the facility's record retention policy did not address security.
The facility failed to post daily nurse staffing information over the weekend, impacting all 53 residents and visitors. An observation found the staffing sheet dated from the previous Friday, and the administrator confirmed that the charge nurse was responsible for updating and posting the sheets daily, including weekends.
No RN Coverage for Required Daily Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours a day. Review of staffing schedules from 1/1/25 through 6/30/25 showed no RN coverage on multiple dates, including 1/25/25, 1/26/25, 2/9/25, 3/22/25, 3/23/25, 4/5/25, 4/6/25, 4/19/25, 4/20/25, 5/3/25, 5/4/25, 5/17/25, 5/18/25, 5/26/25, 6/14/25, 6/28/25, and 6/29/25. The deficiency affected all 67 residents in the facility and was identified as past non-compliance due to no RN coverage addressed in the last two quarterly staffing records. During interview, the corporate administrator stated the facility had issues with hiring and getting agency staff to work during the first part of the year, and confirmed that the daily staffing schedules reviewed by the corporate administrator and facility administrator showed no RN coverage on the listed dates. The facility staffing policy was requested but not provided.
PRN Psychotropic Order Lacked Required 14-Day Stop Date
Penalty
Summary
The facility failed to ensure that a psychotropic PRN medication order for one resident was limited to 14 days. The resident had a quarterly MDS indicating cognitive intactness and diagnoses of anxiety disorder, major depression, diabetes, and chronic diastolic heart failure. The resident’s care plan addressed depression, anxiety, and insomnia, and the EMR showed an order for alprazolam 0.5 mg every 24 hours PRN for increased anxiety with an order date of 9/15/25 and no stop date. Pharmacy consult recommendations on 9/17/25 and 10/22/25 noted that the alprazolam PRN order had no stop date and asked the provider to consider discontinuation or adding a stop date per CMS regulation. The provider responded that the resident was stable at the current dose and would be reevaluated at the next appointment, and later requested follow-up with range mental health. During interviews, the clinical manager stated the medication needed a new script every 14 days and that notifications were tracked on a calendar without EMR orders or documentation of the requested provider orders. The DON stated all PRN psychotropic medications needed a stop date every 14 days for provider review and reorder if needed, and the nurse consultant stated the facility policy allowed nursing to stop PRN medication at 14 days to trigger provider reorder. The facility policy stated PRN psychotropic medications are limited to 14 days unless the provider documents rationale and duration in the medical record.
Missing oxygen orders and incomplete edema care documentation
Penalty
Summary
The facility failed to ensure orders were in place for a resident receiving oxygen. R31’s records identified diagnoses including CHF and atrial fibrillation, and the resident was observed multiple times wearing oxygen via nasal cannula connected to an oxygen concentrator set at 1 LPM. R31 stated he wore oxygen daily, and staff confirmed he had been using oxygen during care and therapy. However, the care plan did not contain a focus for breathing or oxygen use, and the provider orders did not include oxygen use or the care and keeping of oxygen equipment. The DON stated continuous and PRN oxygen should have orders in place, and LPN-A confirmed the chart did not contain oxygen orders. The facility also failed to assess and treat lower extremity edema for another resident. R23 had diagnoses including venous insufficiency, acute respiratory failure, and ischemic cardiomyopathy, and the care plan addressed altered skin integrity with weekly skin inspection and tubi grips on in the morning and off at bedtime. The order summary included tubi grips and weekly skin inspection, but no treatments or lotions for the legs. Documentation showed repeated weekly skin inspections noting bilateral lower extremity edema, redness, dry scaly skin, and scabs, while the resident and family member reported ongoing dryness, edema, and scabs and stated family was caring for the legs. Although the TAR showed tubi grips were signed off as completed each day, the resident was repeatedly observed wearing white knee-high socks instead of tubi grips, and staff later acknowledged the resident was not wearing the ordered compression. An LPN stated the sign-offs meant the task had been completed, but then said they guessed the tubi grips had not actually been on. The DON stated tasks should be documented as not done if not completed, and the clinical manager confirmed the resident was not being tracked in wound care because there were no active wound treatments, while also noting the importance of documenting skin changes and ensuring ordered tubi grips were in the room and applied.
Unsecured Portable Oxygen Tank Left on Floor
Penalty
Summary
The facility failed to ensure a resident's portable oxygen tank was safely transported and secured. The resident had an admit MDS indicating moderate cognitive impairment and diagnoses of venous insufficiency, acute respiratory failure, and ischemic cardiomyopathy. The care plan addressed alterations in oxygen/gas exchange with oxygen use as ordered, and the order summary included continuous oxygen at 2 LPM via nasal cannula and instructions to check the portable oxygen/stroller every shift and fill if needed. The treatment record documented that staff checked the portable oxygen/stroller every shift and filled it if needed between 1/1/26 and 1/14/26. During observation, the resident was seated in a recliner with oxygen connected to a large concentrator in the room, and a free-standing portable green oxygen cylinder was sitting upright directly on the floor to the left of the concentrator. The resident and a family member stated the tank had been on the floor like that for a long time. A nursing assistant later confirmed the unsecured tank was not safe, and the RN removed it from the room and secured it in the oxygen storage area. The DON stated oxygen tanks should not be carried or left unsecured in the building and that staff were expected to use a wheeled oxygen tank carrier and keep oxygen tanks secured in appropriate holding devices at all times.
Failure to Monitor Fluid Intake for Resident on Dialysis
Penalty
Summary
The facility failed to monitor fluid intake for a resident on hemodialysis and a 1500 mL per 24-hour fluid restriction. The resident’s admission MDS indicated the resident was cognitively intact. Diagnoses included anemia, coronary artery disease, and end stage renal disease. The care plan identified risk of complications related to dialysis and included a fluid restriction per order, with a potential alteration in nutrition related to end stage renal disease on a 1500 mL fluid restriction. The OSR showed a provider order for 1500 mL per 24 hours, with 600 mL from nursing and 900 mL from dietary. Review of the TAR from 12/10/25 to 1/14/25 showed the fluid restriction required documentation on every shift, but intake entries were inconsistent. The TAR contained 27 NA entries in December and 15 in January for nursing and dietary intakes, 2 x entries in December and 6 in January, and blank spots 3 times in December and once in January. During interviews, the dialysis center RN stated the resident’s dry weights were not getting reached and low blood pressures made it difficult to remove all fluid, noting excess fluid intake could be one reason. Facility staff stated aides gathered fluid intakes and nurses documented them, and the DON stated all staff should document accurate fluid intakes each shift when a resident is on a fluid restriction. The facility policy indicated fluid intakes would be measured every shift.
Failure to Use PPE and Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to perform appropriate hand hygiene during a brief change and failed to use appropriate PPE for a resident on enhanced barrier precautions. The report identified two residents affected: one resident with wounds and a foley catheter who was cognitively intact, dependent on staff for ADLs, and frequently incontinent of bowel, and another resident with severe cognitive impairment and incontinence of bowel and bladder who required maximal assistance to dependent care for toileting, hygiene, and other cares. For the resident on enhanced barrier precautions, nursing assistants entered the room and completed high-contact care activities, including transfer assistance, brief change, and emptying the foley catheter, while not wearing isolation gowns. The resident’s care plan and active orders identified enhanced barrier precautions for wounds and foley catheter, with instructions to don and doff PPE during high-contact cares. During the observation, the DON entered the room wearing gown and gloves and later verified that the nursing assistants should have been wearing isolation gowns when completing personal cares related to the resident’s foley catheter and wounds. For the second resident, a nursing assistant performed clothing change, brief change, peri care, and transfer activities while moving from dirty to clean tasks without changing gloves or washing hands. The observation showed the nursing assistant touching clean clothing, the brief, peri area, and linens with the same gloves and at times with ungloved hands before later putting on new gloves for transfer. The nursing assistant acknowledged not changing gloves during cares and removing a glove to complete a brief change with an ungloved hand. The infection preventionist/DON stated gloves needed to be changed and hands washed anytime staff moved from dirty to clean during peri care, and the facility handwashing policy addressed handwashing after changing incontinent products or cleaning up after toileting.
Care Plan Did Not Address Oxygen Use and Chemotherapy Needs
Penalty
Summary
The facility failed to review and revise the care plan for a resident with CHF, rectal cancer, and atrial fibrillation to include chemotherapy, breathing problems, and oxygen use. The resident’s quarterly MDS identified those diagnoses, and the care plan dated 12/11/25 did not contain a focus statement for coordination and care of chemotherapy treatments, breathing problems, or oxygen use. Provider progress notes documented new CHF-related orders on 10/29/25, including oxygen use during the day at 2 LPM via nasal cannula while on chemotherapy, oxygen at 1 LPM during the night, and monitoring of oxygen saturation, but the provider orders dated 1/12/26 did not contain orders for oxygen use or for the care and keeping of oxygen equipment. Observations and interviews showed the resident wearing oxygen via nasal cannula on multiple occasions, with the oxygen concentrator set at 1 LPM during one observation and running during another. The Weights and Vitals Summary identified the resident was wearing oxygen via nasal cannula on dates when oxygen saturation levels were recorded from 10/29/25 through 1/15/26. Staff interviews confirmed the resident had been wearing oxygen during therapy and daily, and the DON stated continuous and PRN oxygen should have orders. LPN-A confirmed the medical record did not contain orders for oxygen.
Failure to Provide and Document Nail Care
Penalty
Summary
The facility failed to ensure a resident who was dependent in all ADLs received nail care. The resident had significant cognitive impairment and a diagnosis of late-onset Alzheimer's dementia. Her care plan identified a need for assistance with all ADL tasks, including trimming fingernails and toenails as needed on shower days, and her provider orders directed staff to check fingernails and toenails weekly and provide nail care every Wednesday, with documentation of any behaviors or refusals. However, the electronic medical record did not contain a progress note related to bathing, nail care, or refusals of nail care on the scheduled date, even though a weekly skin inspection documented that the resident had a bath or shower and her finger and toenails were trimmed. During observation and interview, the resident's family member stated there were issues with her nails not being taken care of and that she had been removed from the podiatry list without his knowledge. He reported her great toenails had about one inch of overhang and that her fingernails were at least one-quarter inch long with brown matter under some nails and staining on others. Staff interviews showed differing expectations about who should provide nail care, with one NA stating nurses handled diabetics and another LPN stating the toenails were too thick to cut but fingernails could be done. The clinical nurse manager stated the resident screamed when staff tried to trim her nails and said she would expect documentation if the resident refused, while the DON stated resident nails should be trim and clean and that a nursing note would be expected if the resident refused care.
Survey Binder Missing 2023 Recertification and Complaint Surveys
Penalty
Summary
The facility failed to ensure that the past three years of recertification and complaint survey results were available for resident, family, visitor, and staff review. During review of the survey binder, all required recertification surveys and complaint investigation surveys were present except for the 2023 recertification and complaint surveys. The administrator stated that three years of recertification and complaint surveys should be available for residents, family, and visitors to view, and also stated she had recently checked the binder and believed all needed surveys were included. The corporate administrator later reviewed the binder and confirmed that all 2023 surveys were missing. A facility policy about the survey binder was requested but not provided.
Rough and disrespectful care during ADL assistance
Penalty
Summary
The facility failed to promote dignity and respect for a resident who required assistance with ADLs and who reported rough and disrespectful care by staff. The resident was admitted from an acute care hospital with colon cancer, edema, pain, malnutrition, altered mobility, and altered mood and psychosocial well-being. His care plan directed staff to monitor for emotional distress, reapproach him when he refused cares with a soft tone, give him time and options, and provide emotional support and comfort measures as needed. On the day of the incident, the resident refused cares and medications at times and asked staff to let him sleep and return later. He also reported pain and was receiving PRN hydromorphone for low back pain and cancer. During care provided by two NAs, the resident stated that one NA was rough with him, moved his legs too fast, and almost ripped out his drainage tube. He became visibly upset and cried, stating that his tube hurt. The other NA stated that when the resident’s legs were swung onto the bed, the drainage tube must have been underneath and pulled, and she described the handling as not gentle. The resident later stated he did not want that NA in his room or caring for him anymore and said staff would not listen to him when he wanted to sleep or when he expressed his wishes. The DON and RN later acknowledged that they were aware the resident had requested that the NA not care for him, but the NA was still assigned to him and continued to work on the unit. The MD stated he observed the resident teary eyed and visibly upset during the care episode and believed the situation should have been followed up as rough handling. Facility records and interviews also showed that behavior charting was not completed for the resident on the date of the event.
Failure to Investigate Rough Handling Allegation and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation that a staff member handled a resident roughly and caused pain, and failed to protect the resident during the investigation. The resident was admitted from an acute care hospital and had care plan interventions for vulnerability to abuse, altered mobility related to colon cancer, edema, pain, and malnutrition, and altered mood and psychosocial well-being related to adjustment to the facility and current health condition. He was also directed to be assisted with movement in bed and in and out of bed with one-person assist using a front wheeled walker/wheelchair, and staff were to reapproach him when he refused care with a soft tone and give him time and options. During observation and interview, the resident stated that a staff NA had been rough with him while assisting him, moved his legs too fast, and almost ripped out his drainage tube. He said he did not want that NA in his room or caring for him anymore and reported that staff would not listen to him when he wanted to sleep or delay care. The resident was observed lying in a dark room, fully dressed and covered with a blanket, and he stated he wanted to get back to sleep and would let staff know when he wanted his bed changed. Multiple staff members and the physician described the event as one that required immediate reporting and follow-up. The physician stated he saw the resident crying in pain during care, heard the resident say the NA pulled on his catheter drain, and told staff it should be reported. The assisting NA stated the resident screamed and cried when his legs were quickly swung onto the bed and that the resident said his drainage tube hurt. The other NA and RN both stated they were informed the resident had been manhandled or rough handled and was upset and in pain, and both acknowledged the incident should have been reported to the DON right away. The floor manager later stated she emailed the DON after the fact and did not think it needed to be reported at the time, and the DON stated she was not aware of the concern until later and that the NA remained assigned to care for the resident after the incident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report Suspected Neglect After Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency after a resident experienced a fall from a mechanical lift. The resident, who had diagnoses including dementia with behavioral disturbance, back pain, chronic pain, and spinal stenosis, was care planned to be transferred using a ceiling lift with a toileting sling for toileting and a full body split leg sling for all other transfers. On the date of the incident, staff transferred the resident from the wheelchair to the bed using a toileting sling, contrary to the care plan, and the resident fell out of the sling and hit her head. The nursing assistant involved stated the resident, who was confused and tired, placed her arms inside the sling during the transfer, despite being instructed to keep them outside. The ceiling lift representative confirmed that the toileting sling required the resident to keep their arms outside and that the sling may not have been appropriate for someone with cognitive or physical limitations. Despite the incident, the administrator and DON did not report the event to the state agency, stating that the care plan had been followed, even though documentation and interviews indicated otherwise. Facility policy required all suspected abuse or neglect, defined as failure to provide necessary goods and services to avoid harm, to be reported to the state agency within two hours of suspicion. The failure to report the incident as required constituted a deficiency in timely reporting of suspected neglect.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Inadequate Staffing Leads to Delayed Care and Resident Neglect
Penalty
Summary
The facility failed to ensure adequate staffing levels, resulting in delayed and insufficient care for residents. Multiple interviews with staff, residents, and family members highlighted significant concerns about the lack of staff, particularly during weekends and night shifts. Residents experienced long wait times for call lights, leading to incidents of incontinence and unmet personal care needs. Family members reported having to assist with care themselves due to the lack of available staff. The use of agency staff without proper training further exacerbated the issue, as regular staff had to spend time guiding them, detracting from their own duties. Specific incidents included a resident being left soiled for extended periods, another resident not receiving morning care until the afternoon, and a resident not receiving timely pain medication. The facility's staffing assessment indicated a need for a certain nurse-to-resident and NA-to-resident ratio, but actual staffing levels fell short, with hours of care per resident per day ranging from 1.6 to 2.2, below the required 2.8 to 3.2. The facility's administration acknowledged the staffing issues but believed their ratios supported the care being provided, despite evidence to the contrary. The deficiency was further highlighted by the facility's inability to manage care during emergencies or unexpected events, such as a resident's death, which impacted the care of other residents. The facility's policy on Activities of Daily Living emphasized person-centered care, but the lack of staff prevented the fulfillment of residents' preferences and needs. The resident council and ombudsman also expressed concerns about staffing, indicating that the issue was a recurring topic in their meetings, with no satisfactory response from the administration.
Failure to Implement Respiratory Care Orders
Penalty
Summary
The facility failed to implement orders for respiratory care for a resident with multiple chronic respiratory conditions. The resident was observed lying in bed with oxygen administered via nasal cannula at 2 liters per minute, with the oxygen being humidified. The humidifier bottle was dated over a month prior, indicating it had not been changed as expected. The resident's medical history included centrilobular emphysema, chronic obstructive pulmonary disease, pulmonary fibrosis, atherosclerosis of the aorta, morbid obesity with alveolar hypoventilation, and chronic respiratory failure with hypoxia. The facility's order summary for the resident included instructions to fill the concentrator bubbler every evening shift, but did not specify a schedule for changing it. A review of the resident's electronic medical record revealed no documentation of the oxygen bubbler being changed. A registered nurse confirmed the lack of documentation and stated that the oxygen bubbler should be changed monthly according to policy for infection control purposes. The director of nursing also confirmed the expectation for regular changes of oxygen bubblers per policy, but the facility was unable to provide the relevant respiratory care policies upon request.
Deficiencies in Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure timely repositioning and coordination of care for a hospice patient, identified as R8, who experienced a change in condition. R8, who had moderately intact cognition and diagnoses of dementia and congestive heart failure, was dependent on staff for various activities of daily living. Despite orders for repositioning every three hours and communication with hospice for changes in condition, R8 was not repositioned for over four hours, and hospice was not notified of her unresponsiveness and lack of intake. Observations revealed that staff were unaware of the last repositioning time, and there was a lack of coordination in administering medications appropriately. The facility also failed to follow provider orders for weight monitoring for a resident, identified as R26, with congestive heart failure and chronic kidney disease. The resident's care plan did not address weight monitoring, and there were multiple lapses in weekly weight checks, which could lead to fluid overload. The Director of Nursing acknowledged these lapses and the associated risks. Additionally, the facility did not complete dressing changes as ordered for a resident, identified as R40, with an above-the-knee amputation and surgical wounds. The dressing change was not documented, and the resident reported that the dressing had not been changed as scheduled. The facility also failed to ensure the placement of an ankle-foot orthosis for a resident, identified as R32, and did not deliver medications timely for a resident, identified as R1, who experienced significant pain due to delayed medication administration. These deficiencies highlight a pattern of inadequate care coordination and documentation within the facility.
Lack of Supervision During Dining for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during dining, leading to a deficiency. The resident, who was diagnosed with dementia, multiple sclerosis, depression, and dysphagia, was identified as severely cognitively impaired and required partial to moderate assistance with eating. On the evening of November 18, 2024, the resident was observed alone in the dining room, eating and drinking without supervision from nursing staff or trained feeding staff. A dietary staff member was present but was engaged in clearing tables rather than supervising the resident. The resident remained unsupervised until a nursing assistant arrived to escort her to her room. Interviews with the RN and DON confirmed that nursing staff should be present in the dining room during meals to ensure safety, particularly in the event of choking. The facility's policy, dated August 26, 2020, stated that a nursing assistant or other designated, trained personnel should be assigned to the dining room at all meals to assist residents with food preparation and feeding.
Expired Dairy Product Not Disposed of in Facility
Penalty
Summary
The facility failed to dispose of an expired bottle of half and half dairy product, which was still available for residents to use. An opened bottle of half and half was found in the refrigerator of the dining hall dinette room with a handwritten open date and a manufacturer's expiration date. The culinary aide confirmed the dates and acknowledged that the dairy product should have been discarded five days after opening or by the manufacturer's expiration date. The culinary director reiterated that dairy products should be disposed of after five days of being opened or by the expiration date. The infection preventionist noted that using dairy products past their expiration date increases the risk of bacteria and foodborne illness. The facility's policy on food receiving and storage, last revised in 2017, did not include information on monitoring foods and liquids for expiration dates.
Failure to Maintain Resident Dignity Through Adequate Hygiene Care
Penalty
Summary
The facility failed to ensure the dignity of a resident, identified as R52, by not providing adequate personal hygiene care. R52, who was cognitively intact and had diagnoses including diabetes, depression, hemiplegia, and hemiparesis, required moderate assistance for personal hygiene and maximal assistance for showering. The resident's care plan indicated that R52 was shy, had anxiety, and often did not ask for help, leading to incontinence issues. Despite these needs, R52 was only scheduled for a shower once a week, which was insufficient as their hair became greasy quickly, causing discomfort and a feeling of uncleanliness. Interviews and observations revealed that R52's hair appeared greasy on multiple occasions, and the resident expressed a desire for more frequent hair washing. Staff, including a nursing assistant and a registered nurse, acknowledged that residents should not have to request hair washing if it was visibly needed, and it should be offered proactively to maintain dignity. The Director of Nursing also stated that staff should recognize and address such needs without the resident having to ask. The facility's policy on Activities of Daily Living emphasized the importance of person-centered care and maintaining residents' dignity, which was not upheld in this case.
Failure to Honor Resident's Preference for Dining Room Breakfast
Penalty
Summary
The facility failed to honor a resident's preference to be dressed and have breakfast in the dining room, as observed in the case of a resident with significant cognitive impairment and multiple diagnoses, including neurological disorders and dementia. The resident's care plan indicated a preference to dine in the main dining room and to be ready by 8:00 a.m. However, the resident was found shirtless in bed during an interview, expressing frustration about not being able to get dressed and go to the dining room due to insufficient staffing. The resident required maximal assistance for activities of daily living and was dependent on staff for transfers. Interviews with nursing staff revealed that the resident was not consistently assisted in getting up and dressed in the morning due to staffing shortages, particularly because the resident required a two-person transfer. The nursing assistant confirmed that they were unable to meet the resident's preferences on days when only one nursing assistant was scheduled until later in the morning. The director of nursing acknowledged that the resident's preferences should be honored, and the facility's policy emphasized the importance of person-centered care and honoring resident preferences. Despite this, the resident's preferences were not consistently met, leading to a deficiency in resident rights and dignity.
Failure to Report and Repair Broken Toilet
Penalty
Summary
The facility failed to ensure a safe and homelike environment for a resident due to a broken toilet that was not reported or repaired. The resident expressed concern about the cracked toilet bowl, which was observed to be damaged near where the seat attached. Despite the resident's concern, there was no maintenance request submitted to address the issue. Staff members, including LPNs and housekeeping personnel, were unaware of the broken toilet or did not report it. The regional director of maintenance confirmed the need for the toilet bowl to be replaced and noted that no maintenance slip had been filled out. The housekeeping staff assumed the issue had been reported by others, and the housekeeping director was not informed of the problem. The associate administrator and regional director of operations emphasized the importance of reporting and addressing broken equipment to prevent injuries.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete all sections on the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. For one resident, identified as R23, the quarterly MDS did not assess cognitive patterns and mood, despite indications that these assessments should have been conducted. This oversight was confirmed by both a registered nurse and the director of nursing, who acknowledged that these assessments were necessary to ensure the resident received appropriate medication and care planning. Another resident, identified as R14, had an annual MDS that failed to document the use of a wanderguard, a device intended to prevent elopement. The director of nursing verified this omission and emphasized the importance of accurate assessments for billing, payment, and identifying elopement concerns. The facility did not provide a policy on filling out resident assessments, which may have contributed to these deficiencies.
Failure to Address ADLs for Residents
Penalty
Summary
The facility failed to ensure activities of daily living (ADL) were adequately addressed for two residents. One resident, identified as R4, had a care plan indicating a self-care deficit related to traumatic brain injury and hemiplegia, requiring assistance with dressing, grooming, and bathing. Despite this, weekly skin care assessments documented that R4's fingernails and toenails were not addressed on multiple occasions. Observations revealed that R4's fingernails were approximately 1/2 inch in length with a brown substance underneath, indicating neglect in nail care. The Director of Nursing stated that nail care should be completed by nursing assistants on shower days, or by a licensed nurse if the resident is diabetic, but documentation of this care was not provided. Another resident, R32, required maximal assistance for ADLs and was dependent on staff for transfers. R32 expressed frustration about not being dressed and out of bed in time for breakfast, as was their preference. On multiple occasions, R32 was observed shirtless in bed, stating that staff shortages were the reason for the delay in assistance. Interviews with staff confirmed that R32's preferences should have been honored, but they were not consistently met, resulting in the resident remaining in bed for extended periods without being dressed or able to attend meals in the dining room.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. For one resident, identified as R35, the facility did not document education or refusals related to pressure ulcer relief. R35, who had multiple diagnoses including hemiplegia, dementia, and morbid obesity, was observed multiple times without proper heel elevation or the use of prescribed heel boots, despite care plan interventions requiring these measures. Staff interviews revealed that attempts to encourage heel elevation were not consistently documented, and there was no record of education provided to R35 about the importance of these interventions. Another resident, R39, experienced gaps in weekly skin inspections as ordered, and there was a lack of timely notification to the registered dietician (RD) regarding new and worsening wounds. R39, who had diabetes and chronic kidney disease, was dependent on staff for mobility and had developed pressure ulcers while at the facility. The care plan required weekly skin inspections, but records showed significant gaps in these inspections over several months. Additionally, the RD was not promptly informed of the resident's nutritional needs related to wound care, despite changes in the resident's condition and dietary orders. The Director of Nursing (DON) acknowledged the importance of following care plans and conducting regular skin inspections to monitor and address skin integrity issues. However, the facility's failure to adhere to these protocols resulted in deficiencies in the care provided to residents R35 and R39, as evidenced by the lack of documentation and communication regarding their pressure ulcer care and nutritional needs.
Failure to Use Palm Protector for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure the use of a palm protector for a resident with limited range of motion, leading to a deficiency in care. The resident, who had a history of traumatic brain dysfunction, hemiplegia, and traumatic brain injury, was severely cognitively impaired and dependent on staff for activities of daily living. The care plan specified the use of a foam built-up palm protector to reduce contraction in the resident's left hand, which was to be worn overnight and removed in the morning. During observations and interviews, it was noted that the resident's left hand was in a fist and the palm protector was not in use. Staff, including a nursing assistant and an LPN, were unable to locate the palm protector in the resident's room, and the nursing assistant admitted not having seen it for a long time. An occupational therapist confirmed the absence of the palm protector and noted debris on the resident's hand, indicating a lack of proper care. The director of nursing acknowledged that the care plan was not followed, which could prevent further contractures.
Failure to Time-Limit PRN Lorazepam Orders
Penalty
Summary
The facility failed to ensure that PRN orders for lorazepam, a psychotropic medication, were time-limited to 14 days and accompanied by a documented associated diagnosis for a resident with severe cognitive impairment. The resident's care plan included psychotropic drug monitoring and interventions for cognitive and mood alterations, but the order summary for lorazepam lacked a medical diagnosis. The order was set for a duration of six months without a documented rationale for extending the PRN use beyond 14 days, contrary to the facility's policy. The resident was previously on hospice care, during which lorazepam was used for comfort and symptom management. However, after discharge from hospice, the hospice order should have been discontinued, and a new order with an indication and rationale for PRN lorazepam use should have been documented. The facility's policy required that PRN psychotropic medications be prescribed for the shortest period necessary and that any extension beyond 14 days be justified by the healthcare practitioner, which was not done in this case.
Failure to Secure Hospice Medical Records
Penalty
Summary
The facility failed to ensure the security of medical records for a resident receiving hospice care. The resident, who had moderately intact cognition and diagnoses of dementia and congestive heart failure, was dependent on staff for daily activities. The resident's care plan included hospice care through Essentia East Range Hospice, with specific orders to maintain communication with hospice staff. However, the hospice care plan was not integrated into the resident's electronic health record (EHR). During the survey, it was discovered that the facility could not locate the resident's hospice chart. Hospice staff recorded their notes on paper, which were stored in a binder at the nurse's station, rather than in the EHR. Despite efforts by the corporate nurse consultant and the director of nursing to locate the hospice chart, it remained missing. The facility's document on the retention of medical records did not address the security of these records, contributing to the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required nurse staffing information was posted daily over the weekend, which had the potential to impact all 53 residents and visitors who may wish to review this information. During an observation on a Sunday, the posted staffing sheet was found to be dated from the previous Friday, indicating that the staffing information had not been updated for the weekend. For the remainder of the survey period, the daily staffing information sheets were updated and posted each day. In an interview, the administrator acknowledged that staffing hours should be updated and posted daily, including on weekends. The responsibility for updating and posting the staffing sheets on Saturdays and Sundays was assigned to the charge nurse, who failed to post a new staffing sheet each day over the past weekend.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 40 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 Virginia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Essentia Health Virginia Care Cent | 1 mi | ★★★★★ | 4 | 0 |
| The Waterview Woods Llc | 3.5 mi | ★★★★★ | 18 | 0 |
| Cornerstone Villa | 10.7 mi | ★★★★★ | 4 | 0 |
| Heritage Manor | 15 mi | ★★★★★ | 0 | 0 |
| Essentia Health Northern Pines Medical Center | 15.1 mi | ★★★★★ | 5 | 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.