Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Pointe during CMS and state inspections, most recent first.
An LPN administered Lorazepam to a severely cognitively impaired resident without a physician's order, using medication from another resident's supply to calm behavioral symptoms. The medication was given for staff convenience, not as a standard treatment, and was not documented in the medical record, in violation of facility policy and residents' rights to be free from chemical restraints.
Staff did not consistently document the administration of a controlled substance for a resident with severe cognitive impairment and anxiety, and failed to complete required shiftly controlled drug counts on the memory care unit. Review of records showed missing staff signatures on multiple dates, and a discrepancy was found between the documented and observed amounts of Lorazepam. Interviews with staff and leadership confirmed that required procedures for narcotic counts and documentation were not followed.
Staff did not develop or implement comprehensive care plans for two residents with documented histories of wandering and aggression. Despite assessments, incident reports, and staff awareness of these behaviors, the care plans lacked necessary documentation and interventions to address them. The Care Plan Coordinator had not updated the plans to reflect these needs, even though staff regularly discussed resident behaviors.
An LPN at a facility misappropriated narcotic medications from three residents without authorization. The residents, who required pain management for various conditions, were affected when the LPN took their medications and failed to document them properly. The issue was discovered after the LPN exhibited suspicious behavior, leading to a positive drug test for oxycodone and subsequent arrest. Missing narcotic log sheets and medication cards were found in the trash, indicating a breach in medication management procedures.
A resident with multiple cancer diagnoses passed away in the facility, but staff failed to notify the family as required by policy. The LPN on duty admitted the oversight, and the family was informed by hospice hours later. Interviews confirmed the expectation to notify the family, doctor, and coroner, but this was not done.
The facility failed to provide adequate nursing staff as per their Facility Assessment, which required one RN or LPN per shift for each unit. From April to July, the facility consistently scheduled only one LPN for both units during night shifts. Interviews with the DON and administrator revealed they were unaware of the requirement for two licensed nurses per unit, per shift.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, as required. The RN staff schedule showed multiple days without an RN on duty, particularly on weekends. The facility is short two RN positions, with the DON and a CNA instructor covering weekday shifts. The administrator is attempting to hire additional RNs to address the shortage.
The facility failed to implement comprehensive water management policies to prevent Legionella growth and did not adhere to infection control procedures during blood glucose monitoring. An LPN placed glucometers on unsanitized surfaces without barriers, contrary to facility policy, risking pathogen transmission. The maintenance director and administrator lacked awareness of CDC Toolkit requirements and infection control protocols.
Facility staff failed to designate a qualified individual with specialized training as the Infection Preventionist for the infection prevention and control program. The ADON was identified as the Infection Preventionist but had not completed the necessary training and certification. The administrator acknowledged the requirement for certification before assuming the role, while the ADON was unaware of their designation and was still undergoing training.
Facility staff failed to update care plans for several residents following significant events, such as falls and pressure ulcers. A resident with quadriplegia and moderate cognitive impairment had a fall that was not documented in the care plan. Another resident with Alzheimer's and diabetes had a fall and a stage III pressure ulcer that were not updated in the care plan. Additionally, a resident with severe cognitive impairment and behavioral issues had an altercation that was not addressed in the care plan. Interviews revealed a lack of awareness and education among staff regarding these incidents.
The facility failed to implement its Grievance Policy for two residents who reported missing personal items. One resident reported a missing Bluetooth earbud set, and another reported a missing cell phone, but neither received updates or replacements. The grievance binder lacked documentation, and staff interviews revealed inconsistencies in the grievance process, including delays and lack of follow-up.
A resident with intact cognition and a history of falls was found with bruises on the forehead and eye area, but the facility failed to investigate and document the injuries as per policy. The CNA and NP observed the bruises but did not ensure proper documentation or notification. The DON was not informed in a timely manner, resulting in an incomplete investigation. The Administrator acknowledged the expectation for reporting and investigating such incidents, highlighting a breakdown in communication and protocol adherence.
Facility staff did not perform required neurological assessments for three residents after unwitnessed falls, as mandated by facility policy. Despite the policy requiring checks every 15 minutes for the first hour, every 30 minutes for the next two hours, and every shift for 72 hours, the medical records for these residents lacked documentation of such assessments. Interviews with an LPN and the DON confirmed the expectation for these checks, which were not completed.
Facility staff failed to properly label and store medications, with multiple undated medication bottles found on a medication cart and in a storage room. Additionally, food items were improperly stored in a medication refrigerator. Interviews with staff revealed a lack of adherence to facility policies regarding medication labeling and storage.
The facility failed to provide six residents with access to their trust fund accounts on weekends, as per their policy allowing access only on weekdays. Interviews with residents and staff revealed that residents were unable to obtain funds for weekend activities, and staff were unaware of the requirement for weekend access. All involved residents were cognitively intact, highlighting the impact of the facility's policy on their ability to manage financial affairs.
The facility failed to provide an ongoing program of activities on weekends, affecting three residents. The activity calendar showed limited scheduled activities, and interviews with residents and staff confirmed the absence of regular weekend activities. The Activities Director mentioned occasional assistance, but overall, there was a lack of coordination and communication regarding weekend activities.
Facility staff failed to protect resident privacy by leaving EHRs open and visible, contrary to HIPAA regulations. A CMT left EHRs open while administering medications, and the medication cart was unattended with visible EHRs. Interviews with the ADON and administrator confirmed staff are instructed to lock screens, but the CMT admitted to oversight.
Facility staff failed to follow professional standards in handling controlled substances, with the DON improperly destroying narcotics without a second witness and failing to document the destruction of Hydrocodone. Additionally, staff pre-prepared medications against policy, risking errors.
Facility staff failed to secure medication carts, leaving them unlocked and unattended, contrary to policy. A CMT repeatedly left a cart with keys in the lock, and a treatment cart with insulin pens was also left unsecured. Interviews confirmed the importance of locking carts to prevent unauthorized access, but staff could not explain the oversight.
Unauthorized Administration of Lorazepam as Chemical Restraint
Penalty
Summary
Facility staff failed to prevent the use of a chemical restraint on a resident when an LPN administered 0.25 ml of Lorazepam to a severely cognitively impaired resident without a physician's order or contacting the physician. The LPN took the medication from another resident's supply and gave it to the resident to calm them after they were observed yelling and keeping others awake. The LPN did not document the administration of the medication in the resident's medical record and did not follow facility policy, which requires staff to obtain a physician's order before administering medications for behaviors. The facility's policies state that residents have the right to be free from chemical restraints and that medications should not be administered for staff convenience or to control behavior unless it is a standard treatment for the resident's condition and properly ordered and documented. Interviews with the LPN, DON, and administrator confirmed that staff are not permitted to administer medications for behaviors without a physician's order and that such actions would be considered a chemical restraint.
Failure to Document Controlled Substance Administration and Complete Shiftly Drug Counts
Penalty
Summary
Facility staff failed to provide services that meet professional standards of quality by not properly documenting the administration of a controlled substance for one resident and by failing to complete required shiftly controlled drug counts on the memory care unit. Review of the facility's policy indicated that narcotics must be counted by two staff members at each shift change, with both staff initialing the count sheet and reporting discrepancies immediately. However, multiple dates were identified where the required staff signatures were missing from the controlled substance shift change forms, indicating that the counts were not consistently performed or documented as required. For one resident with severe cognitive impairment and a diagnosis of anxiety, there was a discrepancy between the documented amount of Lorazepam remaining and the amount observed in the bottle. Staff interviews confirmed that narcotic medications are supposed to be counted each shift by two nurses, and both the DON and administrator acknowledged the policy but noted that counts and documentation had not been consistently completed. The DON stated responsibility for ensuring counts but was not aware of the issue due to other responsibilities and lack of notification.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for two residents, as required by facility policy and CMS guidelines. Both residents had documented histories of wandering and physical aggression, but these behaviors were not reflected in their care plans. The care plans lacked documentation and interventions addressing these specific behaviors, despite multiple incidents and staff awareness of the residents' needs. For one resident, assessments indicated moderate cognitive impairment and behavioral symptoms, including physical aggression and wandering. Incident reports documented episodes where the resident entered another resident's room, engaged in verbal and physical aggression, and required staff intervention. Despite these events and staff interviews confirming knowledge of the resident's behaviors, the care plan did not include interventions for wandering or aggression until after the deficiency was identified. The second resident was assessed as severely cognitively impaired with frequent wandering behavior. Observations showed the resident entering another resident's room and lying in their bed, with staff needing to redirect them. Staff interviews confirmed awareness of the resident's wandering, but the care plan did not address this behavior. The Care Plan Coordinator was unaware of the resident's wandering and had not updated the care plan accordingly, despite daily staff meetings to discuss resident behaviors.
Misappropriation of Narcotic Medications by LPN
Penalty
Summary
The facility staff failed to prevent the misappropriation of narcotic medications belonging to three residents. This incident involved an LPN who took the medications without authorization. The facility's Abuse Policy defines misappropriation as the wrongful use of a resident's belongings without consent. The issue came to light when the ADON was notified of the LPN's suspicious behavior during a shift. Upon investigation, the ADON and LPN C discovered that three narcotic log sheets and medication cards were missing from the medication cart. The missing items were later found in the trash, and the LPN was arrested after a positive drug test for oxycodone. The residents affected by this incident were cognitively intact and had specific medical conditions requiring pain management. One resident had unspecified pain and was prescribed oxycodone for severe pain. Another resident had arthritis and knee pain, with a prescription for hydrocodone. The third resident had necrosis of an amputation stump and was also prescribed hydrocodone. The narcotic log books for these residents did not contain the necessary log sheets for their medications, indicating a failure in medication management and documentation. Interviews with facility staff revealed that the LPN exhibited odd behaviors, such as not signing out narcotics properly and disappearing for extended periods. The ADON and Human Resources conducted a drug test, which confirmed the LPN's use of oxycodone without a prescription. The police were called, and the LPN was found with narcotic record sheets and medication packages in their vehicle. This incident highlights a significant breach in the facility's procedures for handling controlled substances, leading to the misappropriation of residents' medications.
Failure to Notify Family of Resident's Passing
Penalty
Summary
Facility staff failed to notify the responsible party of a resident's passing, as required by the facility's policy. The resident, who had been admitted to the facility with multiple cancer diagnoses and was receiving hospice services, passed away. The nurse's notes documented the time of death but did not include any record of contacting the next of kin or family. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the expectation was to notify the family, doctor, administrative staff, and coroner when a resident passes. However, the LPN admitted to not contacting the family, stating it had slipped through the cracks, and later asked hospice to make the notification. The resident's next of kin reported not being notified by the facility and only learned of the passing through hospice hours later. This oversight indicates a failure to adhere to the facility's policy on notifying the family or responsible party in the event of a resident's death. The facility's census at the time was 67, and the deficiency was identified through interviews and record reviews conducted by surveyors.
Inadequate Staffing in Accordance with Facility Assessment
Penalty
Summary
The facility failed to provide adequate nursing staff in accordance with their Facility Assessment, which outlined the staffing requirements necessary to meet the needs of their residents. The assessment, dated April 10, 2024, specified that for an average census of 70-80 residents, each unit (West and East) required one Registered Nurse (RN) or Licensed Practical Nurse (LPN) per shift. However, a review of the facility's night shift staff schedules from April 20, 2024, to July 18, 2024, revealed that the facility consistently scheduled only one LPN for both the West and East units, failing to meet the staffing requirements as directed in the facility assessment. Interviews conducted on July 18, 2024, with the Director of Nursing (DON) and the administrator confirmed the staffing deficiencies. The DON acknowledged that while a licensed nurse was always scheduled for each shift, the facility did not always have two licensed nurses as required. The DON was unaware that the facility assessment mandated two licensed nurses at night. Similarly, the administrator was not aware of the requirement for two licensed nurses per unit, per shift, as stated in the facility assessment.
RN Staffing Deficiency
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by their Resident Services Policy. The facility's RN staff schedule for June and July 2024 showed multiple days without an RN on duty, specifically on weekends. Interviews revealed that the facility is currently short two RN positions, with the Director of Nursing (DON) and a Certified Nurse Aide (CNA) instructor, who is also an RN, covering shifts during the week. The administrator acknowledged the staffing shortage and the lack of RN coverage on weekends, indicating efforts to hire additional RNs.
Deficiencies in Water Management and Infection Control Procedures
Penalty
Summary
The facility staff failed to develop and implement comprehensive policies and procedures for the inspection, testing, and maintenance of the facility's water systems, which are crucial to inhibiting the growth of waterborne pathogens such as Legionella. The absence of a detailed water management program, including a water system flow diagram and specific control measures, was noted. The maintenance director admitted to performing only basic checks and cleaning procedures, lacking a thorough understanding of the CDC Toolkit requirements. This oversight potentially exposes residents to the risk of Legionnaire's Disease, a serious type of pneumonia caused by Legionella bacteria. Additionally, the facility staff did not adhere to appropriate infection control procedures during blood glucose monitoring for three residents. An LPN was observed placing glucometers on unsanitized surfaces without using a barrier, both before and after testing residents' blood sugar levels. This practice was contrary to the facility's policy, which mandates placing glucometers on clean surfaces to prevent the transmission of infectious agents. The Director of Nursing and the administrator were unaware of these lapses in protocol, which could lead to the spread of bloodborne pathogens or bacteria. Interviews with the LPN and the Director of Nursing revealed a lack of awareness and adherence to infection control expectations. The LPN acknowledged the importance of using a barrier but failed to do so due to the unavailability of one at the time. The Director of Nursing expressed that placing glucometers on unsanitized surfaces poses a risk for infection transmission, highlighting a gap in staff training and compliance with infection prevention protocols.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
Facility staff failed to designate a qualified individual with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist for the facility's infection prevention and control program. The facility, with a census of 70, did not provide a policy for specialized training for the Infection Preventionist. During an interview, the administrator stated that the Assistant Director of Nursing (ADON) was designated as the facility's Infection Preventionist. However, the ADON had only started the required training classes the previous month and was not yet certified. The administrator acknowledged that the training and certification needed to be completed before the ADON could officially assume the role of Infection Preventionist. In a subsequent interview, the ADON expressed unawareness of being the designated Infection Preventionist, as they were still enrolled in the Centers for Disease Control and Prevention Infection Preventionist training and had not completed the certification. The ADON mentioned being only halfway through the training modules and was aware that certification was required before assuming the title of Infection Preventionist.
Failure to Update Care Plans After Significant Events
Penalty
Summary
The facility staff failed to review and revise care plans for several residents following significant events, such as falls and the development of pressure ulcers. For Resident #13, the care plan was not updated to reflect a fall that occurred on 06/11/24, despite the resident having moderate cognitive impairment and a diagnosis of quadriplegia. Similarly, Resident #21's care plan did not include documentation of a fall on 06/26/24, which resulted in a major injury, even though the resident was assessed as cognitively intact. Resident #36 also experienced a fall on 04/24/24, but the care plan lacked any updated interventions. Resident #44's care plan was missing documentation for a fall on 07/04/24 and a stage III pressure ulcer, despite the resident having multiple diagnoses, including Alzheimer's disease and diabetes mellitus. Resident #52, who has severe cognitive impairment, suffered a fall on 07/06/24, but the care plan was not updated to include this incident. Additionally, Resident #5's care plan did not document a stage IV pressure ulcer, even though the resident was assessed with severe cognitive impairment and diabetes mellitus. The facility also failed to address and update care plans regarding behaviors for Resident #4, who has severe cognitive impairment and a history of behavioral symptoms. Despite a documented altercation on 06/22/24, the care plan did not include strategies for managing the resident's behaviors. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and education regarding these incidents, and the Director of Nursing acknowledged the responsibility of the Care Plan Coordinator to update care plans with necessary interventions.
Failure to Implement Grievance Policy for Missing Items
Penalty
Summary
The facility failed to implement its Grievance Policy for two residents who reported missing personal items. Resident #7, assessed as cognitively intact, reported a missing Bluetooth earbud set to the administrator but did not receive any update or replacement. The administrator was unaware of the missing item. Similarly, Resident #25, also assessed as cognitively intact, reported a missing cell phone to both the administrator and the business office manager but did not receive any update or replacement. The business office manager acknowledged the report but had not discussed further actions with the administrator. The facility's grievance binder contained only two grievance forms from 2024, indicating a lack of documentation for past grievances. Interviews with the business office manager, director of nursing, and administrator revealed inconsistencies in the grievance process, including delays in filling out grievance forms and a lack of follow-up on reported grievances. The facility did not maintain evidence of grievance resolutions for the required three-year period, as stipulated in their policy.
Failure to Investigate and Document Bruises of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate and document bruises of unknown origin for a resident, as directed by the facility's policy. The facility's Abuse Policy and Procedures/Investigation Protocols require a comprehensive investigation for injuries of unknown source, including documentation, notification of responsible parties, and a series of assessments and interviews. However, the resident's medical record did not contain documentation of the bruises or an investigation into the injury. The resident, who has intact cognition, is dependent on staff for certain activities and has a history of falls, was observed with bruises on the forehead and lateral right eye area. Interviews revealed that the CNA noticed the bruises during a shower but did not document them, assuming the nurse was already aware. The NP also observed the bruises but did not communicate with staff, assuming they were already informed. The DON was not notified in a timely manner and admitted to not knowing how to proceed with the investigation. The Administrator confirmed the expectation for such incidents to be reported and investigated, but acknowledged the delay in notification and investigation. This lack of communication and failure to follow protocol led to the deficiency.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
Facility staff failed to adhere to professional standards of practice by not completing neurological assessments for three residents following unwitnessed falls. The facility's policy mandates that after an incident involving a head injury or an unwitnessed fall, a nurse must perform neurological assessments and document the results on a flow sheet. These assessments should include checks every 15 minutes for the first hour, every 30 minutes for the next two hours, and every shift until 72 hours have passed. However, the medical records for three residents, who experienced unwitnessed falls, did not contain the required neurological checks as per the facility's policy. Resident #7, assessed as cognitively intact, had an unwitnessed fall with no injury documented, but lacked the necessary neurological checks. Resident #21, also cognitively intact, experienced an unwitnessed fall with a major injury, yet their medical record did not include the required assessments. Resident #36, with moderate cognitive impairment and dependent on assistance for mobility, had an unwitnessed fall with no injury, but similarly, their record was missing the neurological checks. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the expectation for neurological checks following unwitnessed falls, which were not completed in these cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Facility staff failed to store and label medications in a safe and effective manner, as observed during a survey. The survey revealed that multiple opened multi-dose medication bottles, such as vegetable laxative, diphenhydramine, ibuprofen, calcium, and milk of magnesia, were undated on the west wing medication cart. Additionally, the [NAME] wing medication storage room contained undated bottles of dietary supplements and Vitamin D3. This lack of proper labeling contravenes the facility's policy, which mandates that staff record the open date on multi-dose medication containers. Furthermore, the survey found that the medication refrigerator in the [NAME] wing medication storage room contained various food items, including a cinnamon roll, sandwiches, pizza, butter, soda, chipotle ranch, lime juice, leftovers, and coffee. This is contrary to the facility's policy, which requires medications to be stored separately from food. Interviews with staff, including a certified medication technician (CMT), a licensed practical nurse (LPN), the Director of Nursing (DON), and the administrator, revealed a lack of awareness and adherence to the facility's policies regarding medication labeling and storage. The DON acknowledged the issue of food being stored with medications and mentioned ongoing efforts to find a solution.
Residents Denied Weekend Access to Trust Funds
Penalty
Summary
The facility failed to ensure that six residents had appropriate access to their trust fund accounts during weekends. The facility's policy allowed residents to access their funds only from Monday to Friday, between 9:00 A.M. and 4:00 P.M., excluding holidays. This policy required residents to request funds on Fridays if they needed money for the weekend. Interviews with the residents revealed that they were unable to access their funds on weekends, which affected their ability to engage in activities such as dining out or shopping with family. All six residents involved were assessed as cognitively intact, indicating they were aware of their financial needs and the limitations imposed by the facility's policy. Interviews with facility staff, including an LPN, the Business Office, the DON, and the administrator, confirmed that there was no staff available on weekends to provide residents with access to their funds. The staff members were unaware that residents were required to have access to their money on weekends. This lack of awareness and the facility's restrictive policy led to the deficiency, as residents were unable to manage their financial affairs as needed during weekends.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the residents' interests on weekends for three residents out of a census of 70. The facility's policy requires an ongoing program to support residents in their choice of activities, including both group and individual activities. However, the activity calendar for June 2024 showed a lack of scheduled activities on weekends, with only occasional bingo and church services. Interviews with residents revealed dissatisfaction with the lack of weekend activities, as they expressed a desire for more engagement during these times. Interviews with facility staff, including a CNA, LPN, Activities Director, DON, and Administrator, confirmed the absence of scheduled activities on weekends. The Activities Director mentioned that an assistant helps with activities one weekend a month, but otherwise, weekend activities are left to the receptionist or CNAs if they have time. The DON and other staff were unaware of any scheduled weekend activities, indicating a lack of coordination and communication regarding the activity program. This deficiency highlights the facility's failure to adhere to its policy and meet the residents' needs for weekend activities.
Failure to Protect Resident Privacy
Penalty
Summary
The facility staff failed to maintain the confidentiality of personal medical information for three residents, as observed during a survey. The facility's policy on Resident Confidentiality and HIPAA mandates that protected health information should only be discussed with those directly responsible for a resident's care and treatment. However, observations revealed that a Certified Medication Technician (CMT) left residents' Electronic Health Records (EHR) open and visible to others, compromising their privacy. Specifically, the CMT left the EHR open while administering medications to three residents, and the medication cart was left unattended with the EHR visible at the nurse's station. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the administrator, confirmed that staff are instructed to lock or close screens when not at the medication cart to protect resident information. The CMT admitted to having a habit of leaving EHR records open, acknowledging it as an oversight. The ADON and administrator expressed awareness of the importance of following HIPAA regulations but were unsure why the EHRs were not being locked as required.
Improper Handling and Documentation of Controlled Substances
Penalty
Summary
The facility staff failed to adhere to professional standards regarding the handling and destruction of controlled substances. Specifically, the Director of Nursing (DON) was involved in the improper destruction of narcotics for Resident #4, where 30 Oxycodone tablets were documented as wasted without a second witness signature, as required by the facility's policy. The Assistant Director of Nursing (ADON) discovered the discrepancy and reported it to the administrator after confirming with a Registered Nurse (RN) that they did not participate in the destruction, contrary to the DON's claim. Additionally, the Certified Medication Technician (CMT) involved was pressured by the DON to sign off on the destruction, despite not being a nurse, and feared job loss for questioning the DON's actions. For Resident #5, the facility failed to maintain proper documentation for the destruction of a card of Hydrocodone. The DON signed out the medication, but no destruction sheet was found in the records. A family member of another resident reported that the Hydrocodone was removed from the narcotic box after they expressed a preference for it to be used only as a last resort. The DON claimed to have wasted the narcotics but could not recall who witnessed the destruction, and no documentation was available to verify the claim. Additionally, the facility staff did not follow proper procedures for medication administration. An observation revealed that medication cups with various pills were pre-prepared and labeled with handwritten last names, without listing the medication names. A CMT admitted to removing all medications needed for a 12-hour shift from the ISTAT at once to save time and due to a belief that opening the ISTAT incurred costs. The ADON and administrator confirmed that pre-popping medications was against policy due to the risk of errors, and staff were expected to administer medications immediately after gathering them.
Medication Storage Deficiency Due to Unlocked Carts
Penalty
Summary
Facility staff failed to ensure the secure storage of medications, leading to a deficiency in maintaining a safe environment for residents. The facility's policy, revised in December 2012, mandates that medication carts must be kept closed and locked when not in the direct sight of the medication nurse or aide. However, observations on multiple occasions revealed that a Certified Medication Technician (CMT) left the medication cart unlocked and unattended in the hallway, with keys left in the lock. This occurred at various times throughout the day, indicating a repeated oversight in following the facility's medication storage policy. Further observations showed a treatment cart left unlocked and unattended, containing 15 insulin pens, which were accessible to unauthorized individuals. Interviews with the Assistant Director of Nursing (ADON) and the CMT confirmed that the carts should be locked to prevent access by other staff, residents, or visitors. The CMT admitted to accidentally leaving the cart unlocked, acknowledging the importance of securing the cart for resident safety. The facility administrator also confirmed the requirement for carts to be locked when not attended, but could not explain why this protocol was not being followed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 39 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 Rolla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Phelps Health | 0.6 mi | ★★★★★ | 0 | 0 |
| Silverstone Place | 0.9 mi | ★★★★★ | 1 | 0 |
| Rolla Presbyterian Manor | 1.5 mi | ★★★★★ | 0 | 0 |
| Aurora Health And Rehabilitation | 1.9 mi | ★★★★★ | 10 | 0 |
| St James Living Center | 9.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cedar Pointe.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.