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 Country Aire Retirement Center during CMS and state inspections, most recent first.
The facility did not have written policies or procedures for visitation rights, resulting in inconsistent and unclear restrictions on visitors for two residents—one with a guardian and severe cognitive impairment, and another who was cognitively intact. Staff were not consistently informed about visitor limitations, and the reasons for restrictions were not clearly communicated or documented, leading to confusion and distress among residents, staff, and family members.
Staff did not follow professional standards during medication administration, including removing medications from original packaging and placing them in unlabeled cups before the medication pass for multiple residents. Additionally, a CMT failed to administer insulin according to policy by not keeping the insulin pen needle in a resident's skin for the required time, potentially resulting in incomplete dosing.
A resident with severe cognitive impairment was started on Rexulti, an antipsychotic medication, without the facility notifying the responsible party, despite facility policy and care plan requirements for such communication. Family members only learned of the medication after observing changes in the resident's condition and questioning staff.
A certified medication technician crushed and administered extended-release glipizide and metoprolol to a resident with diabetes and hypertension, contrary to physician orders and facility policy, resulting in a significant medication error. The CMT was unaware that these medications should not be crushed, and this was confirmed through observation, record review, and staff interviews.
The facility did not maintain adequate licensed nurse staffing, resulting in an LPN working 36 consecutive hours as the only nurse on duty and being unable to fulfill other assigned roles. Residents and staff reported concerns about exhausted staff, missed care tasks, and unaddressed resident needs, while the facility lacked key nursing positions and was unable to secure additional coverage.
The facility did not provide RN coverage for at least eight consecutive hours daily and failed to have a full-time DON, as required by policy. Staffing schedules and staff interviews confirmed gaps in RN coverage and that the DON role was filled only on paper by a corporate RN who was not present onsite full-time.
Facility administration failed to maintain adequate staffing, leadership, and regulatory systems, resulting in shifts without RN coverage, lack of CPR-certified staff, and absence of a DON, ADON, and Infection Preventionist. Residents and families reported ongoing issues with care, food quality, and supplies, while staff described lack of training, excessive workloads, and no administrative support. The facility also failed to pay vendors for essential supplies and services, leading to disruptions in operations and storage of sensitive records inappropriately.
The facility did not respond to repeated Resident Council concerns about care and quality of life, including issues with food temperature, loud televisions, lack of proper incontinence supplies, and missing water for oxygen concentrators. Staff confirmed that concerns were forwarded to administration and department heads, but no actions were taken or documented, and a resident reported ongoing unresolved issues with care and equipment.
Staff did not implement physician-ordered droplet precautions for several residents with respiratory symptoms, and failed to administer medications as ordered for other residents. Despite clear orders and facility policy, precautions were not followed and residents reported missed or incorrect medications, with no documentation of refusals or corrective action taken.
The facility did not ensure that a CPR-certified staff member was scheduled on every shift, leaving multiple night shifts without certified personnel despite having residents with full code status. There was no policy in place for CPR certification requirements, and documentation of staff certifications was incomplete or outdated. Leadership and scheduling staff were aware of the need for CPR-certified coverage but did not maintain compliance.
The facility did not have a functioning antibiotic stewardship program or a designated Infection Preventionist (IP), as required by its own policies. The only full-time RN, who previously served as IP, was unable to continue due to workload, and there was no tracking of infections or antibiotic use. Interviews with corporate and administrative staff confirmed the lack of oversight and documentation for infection control and antibiotic monitoring.
A resident with multiple Stage IV pressure ulcers did not receive consistent weekly wound measurements or skin assessments as required by facility policy. Staff performed wound care but failed to document or measure wounds regularly, and there was no communication of wound status to the physician. The lack of a designated wound nurse and insufficient monitoring by nursing leadership contributed to the deficiency.
The facility failed to maintain RN coverage for at least eight hours a day, seven days a week, and did not have a full-time DON. Staffing schedules showed multiple days without RN presence, with only a corporate RN available by phone. The DON resigned, leaving the facility with one full-time RN and two as-needed RNs, despite efforts to recruit more staff. This compromised the facility's ability to meet resident care needs.
A facility failed to protect two residents from the misappropriation of their narcotic medications by an RN who signed for receiving the medications but did not document their administration or destruction. The medications were not found in the facility, and the RN re-ordered them multiple times without justification. The residents did not report receiving or requesting the medications, and the RN was the only staff member with access during the shifts in question.
The facility was found deficient in maintaining kitchen cleanliness and proper food handling practices. Observations showed a buildup of grease on the range hood, debris on the air conditioner and microwave, and improper food storage. The Dietary Manager was unaware of cleaning responsibilities, and food handling practices were inadequate, with staff not washing hands between tasks and improper use of hair restraints. Additionally, the ice machine lacked an air gap, and a light fixture cover was damaged.
The facility failed to maintain the dignity of three residents by not covering their urinary catheter bags, as required by policy. Observations showed that the catheter bags of a cognitively impaired resident, a cognitively intact resident, and another resident requiring substantial assistance were left uncovered in public areas. Staff interviews confirmed the expectation for dignity covers, but the facility lacked sufficient covers for all residents with catheters.
The facility failed to properly manage the resident trust fund account by not maintaining accurate monthly reconciliations. The Business Office Manager only reconciled petty cash, while corporate staff handled bank accounts. Monthly transfers of $1,500 were made to prevent negative balances, but these were not accounted for in reconciliations. The Administrator expected correct reconciliation, but it was not achieved.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting their medical conditions and treatments. A resident's dialysis treatment was omitted, another's intellectual disability was not recorded, and pressure ulcers were inaccurately staged. The MDS coordinator acknowledged these oversights, and the DON expected accurate assessments reflecting current conditions.
The facility exhibited significant deficiencies in infection control practices, including inadequate hand hygiene, improper use of PPE, and poor urinary catheter care. Staff failed to consistently wash hands and use gowns during high-contact activities, and catheter bags were often found touching the floor. Additionally, soiled materials were not handled in a sanitary manner, contributing to the risk of infection.
The facility failed to maintain the three-compartment sink in the kitchen, which had been leaking and lacked hot water for approximately one year. Despite awareness from the maintenance team and the Administrator, the issue remained unresolved, affecting kitchen operations.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for three residents. Despite the facility's policy requiring regular safety checks, there was no documentation of entrapment zone measurements for these residents, who used bed rails or assist bars. Observations confirmed the presence of raised assist bars or bed rails, but necessary safety checks were not documented. Interviews revealed that maintenance staff did not complete or track required measurements, and compatibility with specialty mattresses was not checked.
The facility did not post the required contact information for the state survey agency and elder abuse hotline. Observations showed the information was not visible, and interviews with residents and staff confirmed they were unaware of its location. The Administrator was unaware of the oversight.
The facility failed to provide timely NOMNCs to three residents, not adhering to the required two-day notice period before Medicare coverage ended. Staff interviews revealed a lack of awareness and training on issuing these notices, and the facility could not provide a policy on the matter.
The facility failed to post required nurse staffing information, including licensed and unlicensed staff hours, as mandated by policy. Observations showed missing or incomplete postings, and interviews confirmed the deficiency. Approximately one-third of the staffing sheets over 18 months were blank, lacking necessary details.
Failure to Establish and Communicate Visitation Rights Policy
Penalty
Summary
The facility failed to have written policies and procedures regarding visitation rights, including the management of restrictions placed on two residents' visitors. The Administrator confirmed that there was no policy in place addressing visitation rights, and staff were not provided with clear guidance or communication about the reasons for visitor limitations. The facility's existing Resident Rights policy required informing residents and their representatives of their rights and responsibilities, but did not address the process for restricting visitors or communicating such restrictions to staff. For one resident with severe cognitive impairment and a legal guardian, the guardian provided a list of individuals who were not allowed to visit. This list was included in the resident's care plan and posted at the nurse's station, instructing staff to deny access to those individuals and contact authorities if necessary. However, staff interviews revealed confusion and lack of awareness about the restrictions, with some staff only discovering the list after incidents occurred. The rationale for the restrictions was not discussed with the guardian, and there was no documentation of official reasons or supporting court documents for the exclusions, despite allegations of past financial exploitation and family discord. Another resident, who was cognitively intact and had no guardian, was also affected when a family member was barred from visiting after an incident involving another resident. The family member was told by law enforcement not to return to the facility, which caused distress for the resident who had previously received frequent visits. Staff interviews indicated uncertainty about the authority and process for restricting visitors, and the chain of command was not consistently followed. The lack of a formal policy and clear communication led to inconsistent application of visitor restrictions and confusion among staff and visitors.
Failure to Follow Professional Standards in Medication and Insulin Administration
Penalty
Summary
Staff at the facility failed to adhere to professional standards of practice during medication administration for multiple residents. Certified Medication Technicians (CMTs) were observed removing medications from their original packaging and placing them into unlabeled medication cups with only the resident's first name written on the side, prior to the scheduled medication pass. This practice was observed for 13 residents, and the cups were stored in the medication cart drawers until administration. The medications in the cups were not labeled to indicate their contents, and the CMT acknowledged that this was done to expedite the medication pass, despite knowing that medications should not be removed from packaging until the time of administration. The Director of Nursing confirmed that this practice was not in accordance with facility policy and could lead to medication errors. Additionally, staff failed to follow the facility's policy and manufacturer instructions for insulin administration for a resident with diabetes. The CMT administering insulin did not keep the insulin pen needle in the resident's skin for the required 6-10 seconds after pressing the plunger, as specified in both the facility's policy and the medication instructions. Instead, the needle was removed immediately after the dose counter reached zero, potentially resulting in incomplete administration of the prescribed insulin dose. The CMT stated they were unaware of the need to keep the needle in place for the specified duration.
Failure to Notify Representative of New Antipsychotic Medication
Penalty
Summary
The facility failed to notify a resident's representative when a new antipsychotic medication, Rexulti, was initiated. The resident, who had severe cognitive impairment, disorganized thinking, and inattention, was started on Rexulti for anxiety as documented in the physician's orders. Despite the resident's significant cognitive deficits and the presence of a responsible party who had signed the consent to treat form, there was no evidence in the progress notes that the responsible party was informed of the new medication. The facility's own Resident Rights form and care plan required notification and education of the resident or family regarding changes in care and treatment, including new medications. Interviews with family members revealed that they were not notified about the initiation of Rexulti and only became aware of the medication after noticing changes in the resident's behavior, such as increased grogginess and difficulty with speech. The DON stated an expectation that responsible parties should be notified of new medications, while the Administrator expressed uncertainty about the requirement to notify family members in the absence of a legal POA. The facility's failure to notify the resident's representative of the new medication constituted a deficiency in communication and adherence to resident rights.
Crushing and Administering Extended-Release Medications
Penalty
Summary
A certified medication technician (CMT) crushed and administered two extended-release medications, glipizide ER and metoprolol ER, to a resident diagnosed with diabetes and hypertension. The medications were intended to be taken whole, as per physician orders and manufacturer instructions, to ensure gradual release over 24 hours. The CMT was observed removing the tablets from the medication cart, crushing them, mixing them with yogurt, and administering them to the resident. Documentation in the Medication Administration Record confirmed that both medications were given in the morning as prescribed, but in crushed form. During interviews, the CMT stated they were unaware that the medications were extended-release and should not be crushed, acknowledging that crushing such medications would result in the entire dose being absorbed at once rather than over 24 hours. The Director of Nursing and the Administrator both confirmed that extended-release medications should not be crushed, as this practice is inconsistent with facility policy and standard medication administration protocols. The facility's policy and drug information resources also specify that extended-release medications must be swallowed whole and not crushed.
Failure to Maintain Adequate Licensed Nurse Staffing
Penalty
Summary
The facility failed to provide an adequate number of licensed nurses on duty to meet the needs of all residents, as required by policy. The Social Service Director, who was also a Licensed Practical Nurse (LPN), was repeatedly pulled from their primary duties to serve as the only charge nurse on multiple occasions, including working 36 consecutive hours without relief. During this extended shift, the LPN was observed sleeping in a recliner at the nurse's station due to exhaustion. The facility's staffing records confirmed that this LPN was the sole licensed nurse in the building for three consecutive 12-hour shifts. Additionally, the facility lacked an Infection Preventionist, a designated wound nurse, and an Assistant Director of Nursing due to ongoing staffing shortages. Interviews with residents and staff revealed significant concerns about the lack of nursing staff. Multiple residents expressed worry about the safety and adequacy of care, noting that the LPN was visibly exhausted and that other staff, such as a Certified Medication Technician, also worked extended hours to support the LPN. Residents reported issues such as infrequent showers, unchanged bed linens, and improper maintenance of medical equipment like oxygen concentrators. Staff interviews confirmed that the LPN was unable to fulfill their social service duties or follow up on resident concerns due to being consistently assigned to nursing shifts. The only full-time RN was leaving employment, and the facility had been unable to secure additional licensed nurse coverage through staffing agencies. The facility's own assessment indicated a need for more RNs and LPNs than were currently employed, and the census included residents with complex care needs, such as those with contractures, psychiatric diagnoses, pressure ulcers, and specialized treatments. The lack of adequate licensed nursing staff resulted in incomplete wound assessments, missed routine skin checks, and insufficient documentation. Corporate and administrative staff acknowledged the staffing shortages and the inability to cover necessary shifts, confirming that essential care tasks were not being completed as required.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and did not ensure a full-time RN was designated as the Director of Nursing (DON). Review of staffing schedules showed that there was no RN coverage on two specific days, and interviews with staff confirmed that the facility only had one full-time RN, whose last day was shortly after the deficiency was identified. After this RN's departure, only one as-needed (PRN) RN remained, and attempts to secure routine RN coverage through a staffing agency were unsuccessful. Interviews with various staff and corporate personnel revealed that the facility had been listing a corporate RN as the DON on paper, but this individual was rarely present onsite and was not available on a full-time basis. The facility's own policies required a full-time DON and RN coverage for eight hours daily, but these requirements were not met. The administrator and other staff acknowledged the lack of consistent RN presence and the absence of a full-time DON in the building.
Failure to Maintain Adequate Staffing, Leadership, and Regulatory Systems
Penalty
Summary
Facility administration failed to ensure effective and efficient operations, resulting in multiple regulatory deficiencies. The facility did not have a full-time Director of Nursing (DON), Assistant Director of Nursing (ADON), or an adequate number of licensed nurses to meet resident needs. There was also no Infection Preventionist (IP) or antibiotic stewardship program in place, and the facility was not tracking antibiotic use or infections. Staffing schedules revealed shifts without Registered Nurse (RN) coverage, and several shifts lacked staff with current CPR certification. New nurse assistants reported receiving only onboarding videos with no further training or education, and there was no designated person for staff to approach with questions or concerns. The administrator was seldom present, and staff, including the HR Director and Social Service Director, confirmed ongoing issues with expired or missing CPR certifications and lack of leadership presence. Residents and their families reported ongoing concerns, including insufficient nurse staffing, lack of response to grievances, and persistent issues with food quality, incontinence supplies, and basic care such as showering and linen changes. Resident Council minutes documented repeated complaints about cold food, loud televisions, and inadequate snacks, with no documented staff response. One resident stated that their oxygen concentrator was not properly maintained, and another family member had to purchase incontinence briefs due to facility shortages. Staff interviews corroborated these issues, with reports of exhaustion from working excessive hours due to lack of licensed nurse coverage and no administrative follow-up on resident concerns. The facility also failed to pay vendors for essential supplies and services in a timely manner, resulting in credit holds and inability to reorder necessary items. The maintenance supervisor reported that document shredding services were suspended due to unpaid bills, leading to storage of sensitive records in a shed. The business office manager and corporate staff were unaware of outstanding bills, and the administrator was not informed of these financial issues. The medical director expressed concern about the lack of leadership, absence of required administrative roles, and the facility's inability to meet residents' needs. There was no evidence of infection control tracking or an antibiotic stewardship program, and the facility did not have a designated wound nurse.
Failure to Address Resident Council Grievances and Provide Responses
Penalty
Summary
The facility failed to act promptly on grievances and recommendations made by the Resident Council regarding resident care and quality of life issues. Despite holding monthly Resident Council meetings where residents raised concerns such as loud televisions, inappropriate food options, lack of proper incontinence supplies, absence of water for oxygen concentrators, and dissatisfaction with snacks and meal temperatures, there was no documented response from staff or administration to address these issues. Review of the Administrator's job description indicated a responsibility to review complaints and make written reports of actions taken, but the Administrator was unsure if a written policy on council meetings existed and confirmed only that meetings were held monthly. Interviews with staff and residents revealed ongoing dissatisfaction and a lack of resolution to repeated concerns. A resident reported not having anyone to address their issues, including infrequent showers, unchanged sheets, and an oxygen concentrator without water for humidification, which was confirmed by observation. The Social Service Director/LPN stated that concerns from Resident Council meetings were passed to the previous Administrator and department heads, but no actions were taken. The new Administrator, who had just started, expected policies and regulations to be followed but acknowledged the lack of documented responses to resident concerns.
Failure to Follow Physician Orders for Droplet Precautions and Medication Administration
Penalty
Summary
The facility failed to follow professional standards of practice by not implementing physician-ordered droplet precautions for four residents who exhibited respiratory symptoms such as cough, congestion, and fever. Despite clear orders from the Medical Director to place symptomatic residents on droplet precautions to prevent the spread of infection, staff did not follow these orders. Observations confirmed the absence of required signage and precautions, and interviews with staff revealed that the previous administrator instructed staff to disregard the droplet precaution orders due to the lack of a definitive diagnosis, even though the orders remained in the residents' charts. Additionally, the facility did not ensure that physician orders for medications were followed for three residents. In several instances, an agency RN was documented as having administered medications, including insulin and other routine morning medications, but residents reported that they either did not receive their medications or were given incorrect medications. These residents, who were cognitively intact and familiar with their medication regimens, reported the discrepancies to facility leadership. There was no documentation of medication refusals, and the agency RN did not provide the correct medications as ordered. Multiple staff interviews corroborated that there were widespread complaints from residents about missed or incorrect medication administration by the agency RN. The facility's own policies required prompt and accurate implementation of physician orders, regular audits, and corrective actions for discrepancies, but these were not followed. The administrator was unable to provide evidence of any education or corrective action taken with the agency RN after the incidents were reported.
Failure to Ensure CPR-Certified Staff Coverage and Maintain Certification Records
Penalty
Summary
The facility failed to ensure that CPR-certified staff were scheduled on all shifts, as required for residents with full code status. A review of staffing records and CPR certification documentation revealed that on multiple night shifts, there was no staff member present with a valid CPR certification. The facility had 13 residents designated as full code, meaning they required full resuscitation efforts in the event of cardiac arrest. Additionally, the facility did not have a policy addressing CPR requirements for staff, nor did it maintain up-to-date documentation of staff CPR certifications. Interviews with facility staff indicated a lack of clarity and oversight regarding CPR certification status. The HR Director reported that many staff had expired certifications or lacked documentation, and that the responsibility for arranging CPR classes had not been fulfilled. The staff member responsible for scheduling was unaware of which employees held current certifications, and both the Administrator and other leadership acknowledged that a CPR-certified staff member should be present on each shift. Despite this, the facility did not ensure compliance, resulting in shifts without appropriately certified personnel.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program (IPCP) that included an antibiotic stewardship program and a system to monitor antibiotic use. Review of the facility's Infection Control Policy and Procedure indicated requirements for evidence-based infection prevention practices, oversight by a designated Infection Preventionist (IP), surveillance of infections, prevention strategies, education, and regular review of antibiotic use. However, interviews and record reviews revealed that the facility did not have a functioning antibiotic stewardship program or a designated IP. The only full-time day shift RN, who previously served as the IP, reported being unable to fulfill IP duties due to workload and overtime, and confirmed that the facility was not tracking infections or antibiotic use. Further interviews with a corporate RN and the facility administrator confirmed the absence of an IP and lack of documentation regarding infection or antibiotic use tracking. The administrator, who had recently started, acknowledged the expectation for a designated IP or for the DON to fulfill that role, and that the facility should follow its infection control policies and CDC guidelines. The facility census at the time was 37, and there was no evidence of an active system to monitor or review antibiotic use as required by policy.
Failure to Provide Consistent Pressure Ulcer Assessment and Documentation
Penalty
Summary
Facility staff failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers and prevent new ulcers from developing for a resident with multiple Stage IV pressure ulcers. The resident was identified as at risk for pressure ulcers, with a Braden Scale score indicating risk, and had a history of multiple pressure ulcers present upon admission, including Stage III, Stage IV, and unstageable ulcers. The care plan included interventions such as frequent repositioning, use of pressure-reducing devices, dietary consults, and wound care treatments, as well as regular wound assessments and documentation. Despite these interventions being outlined in the care plan and facility policy, staff did not consistently perform or document weekly wound measurements or skin assessments as required. Nursing notes and skin assessments over several months showed no evidence of weekly wound measurements or completed skin assessments. During observation, a registered nurse performed wound care but did not measure the wounds, and staff interviews confirmed that wound measurements and assessments were not being completed as per policy. Staff cited short staffing and workload as reasons for not completing required documentation and assessments. Additionally, there was a lack of communication with the physician regarding the status of the wounds, as the physician reported not receiving any wound documentation or weekly reports. The facility did not have a designated wound nurse, and the Director of Nursing or designee was not monitoring wounds as required. The failure to follow facility policy and standard wound care practices resulted in inadequate monitoring and documentation of the resident's pressure ulcers.
Failure to Maintain RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and did not ensure a full-time Director of Nursing (DON) was designated. The facility's assessment indicated the need for a DON and two full-time RNs, but staffing schedules revealed significant gaps in RN coverage. On multiple occasions in December 2024 and January 2025, there was no RN coverage in the facility, with a corporate RN only available by phone. The facility's policies required adequate staffing to meet resident needs, but these were not adhered to, resulting in insufficient RN presence. Interviews with the Administrator in Training (AIT) and the Administrator highlighted the challenges faced by the facility in maintaining adequate RN staffing. The DON had resigned on December 29, 2024, leaving the facility with only one full-time RN and two RNs working as needed. Despite efforts to recruit through staffing agencies and corporate support, the facility struggled to fill the RN and DON positions. The lack of a full-time DON and consistent RN coverage compromised the facility's ability to meet the nursing care needs of its residents, as outlined in their policies and the Centers for Medicare and Medicaid Services guidelines.
Misappropriation of Narcotic Medications by RN
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their narcotic medications by a Registered Nurse (RN) who was also the Former Assistant Director of Nursing (ADON). The RN signed for receiving narcotic medications from the pharmacy for two residents but did not document their administration or destruction. The medications were not found in the facility after being received by the RN, indicating a misappropriation of property. Resident #1, who had a diagnosis of complete traumatic amputation at the level between the knee and ankle, was prescribed oxycodone-acetaminophen for pain management. Despite receiving multiple deliveries of this medication, there was no documentation of its administration, and the resident reported not requesting or receiving pain medication. The RN re-ordered the medication multiple times without justification, and the medication was not logged into the narcotic count/lock box. Resident #2 had an order for hydrocodone-acetaminophen for hand pain but similarly showed no documentation of administration. The RN discontinued the order in the computer system and signed for a delivery of the medication, which was not logged into the narcotic count/lock box. The facility's investigation revealed that the RN was the only staff member with access to the medications during the shifts in question, and the narcotics were ordered and received by the RN without being accounted for in the facility.
Deficiencies in Kitchen Cleanliness and Food Handling Practices
Penalty
Summary
The facility failed to maintain cleanliness and proper food handling practices in the kitchen, leading to multiple deficiencies. Observations revealed a significant buildup of grease and debris on the range hood and filters, which had not been cleaned as per the facility's policy. The Dietary Manager was unaware that the responsibility for cleaning the hood filters fell on the dietary staff, and the Maintenance Supervisor was unsure of the last cleaning date. Additionally, the air conditioner and microwave in the kitchen were found with a heavy buildup of debris, and the microwave showed signs of rust and damage. Food storage practices were also found to be inadequate. Several food items in the refrigerator and freezer were uncovered, unlabeled, or not dated, contrary to the facility's policy. This included ice cream, burritos, hamburger patties, and various other food items. The Dietary Manager reheated and served chicken noodle soup that was improperly dated, and several spice containers were left open and unsealed. The water dispenser and its filter were not maintained properly, with a buildup of debris observed on the dispensing spout. The facility also failed to ensure safe food handling practices. The Dietary Manager was observed handling food with gloves without washing hands between tasks, and staff did not wear hair restraints properly, leaving hair exposed while handling food. Furthermore, the ice machine lacked an appropriate air gap to prevent back siphonage, and a light fixture cover in the kitchen was damaged, posing potential contamination risks. Interviews with the Dietary Manager and Maintenance Supervisor revealed a lack of awareness and adherence to the facility's policies regarding these issues.
Failure to Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure the dignity and respect of three residents by not covering their urinary catheter bags, as required by the facility's policy. The policy, dated August 2009, mandates that each resident should be cared for in a manner that promotes dignity and prohibits demeaning practices. Specifically, the policy requires staff to assist residents in keeping urinary catheter bags covered. However, observations revealed that the urinary catheter bags of Residents #40, #293, and #35 were consistently left uncovered in public areas, compromising their dignity. Resident #40, who was cognitively impaired and dependent on assistance for toileting, was observed multiple times in the common area and dining room with an uncovered urinary catheter bag. Despite the care plan indicating the need for a dignity cover, the bag remained exposed on several occasions, including during meals and in the presence of other residents. Similarly, Resident #293, who was cognitively intact and independent for toileting, was observed with an uncovered catheter bag while dining and moving around the facility. The lack of a dignity cover was noted during interactions with staff and other residents. Resident #35, who was cognitively impaired and required substantial assistance for toileting, also had an uncovered urinary catheter bag during meals and while being transferred by staff. Interviews with facility staff, including CNAs and the Infection Preventionist/RN, confirmed that catheter bags should always have dignity covers. The Director of Nursing acknowledged the issue and admitted that the facility did not have enough dignity covers for all residents with urinary catheters.
Deficiency in Resident Trust Fund Account Management
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile each month. The facility managed funds for 25 residents, and the census was 43. A request for a facility policy regarding the reconciliation of the resident funds account was made, but none was provided. Record reviews showed no reconciliation for the full resident trust account, and the Corporate Accountant's attempted reconciliation for specific accounts showed no reconciliations for the period from June 2023 through June 2024. Interviews revealed that the Business Office Manager (BOM) only reconciled the petty cash accounts, while corporate staff reconciled the bank accounts. The BOM and Corporate Accountant confirmed that only petty cash was reconciled, and the facility management company staff indicated that $1,500 was transferred monthly to the resident trust account to prevent negative balances. However, the reconciliation did not account for these transfers, and there was no documentation to verify the source of the petty cash funds. The Administrator expected the resident funds account to be reconciled correctly, but this was not the case.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete comprehensive assessments for three residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #25's quarterly Minimum Data Set (MDS) did not document the resident's ongoing dialysis treatment, despite the resident's care plan and physician orders indicating regular dialysis sessions. The MDS coordinator admitted to an oversight in failing to include this critical information. Similarly, Resident #2's MDS lacked documentation of a severe intellectual disability, a condition confirmed in the resident's physician progress notes. The MDS coordinator was unaware of this diagnosis, resulting in an inaccurate assessment. Resident #18's MDS inaccurately documented the presence of three stage III pressure ulcers upon readmission, while the nursing admission screening indicated the presence of stage II pressure ulcers. The MDS coordinator acknowledged the error after reviewing the resident's medical records, which showed no evidence of the ulcers worsening. The Director of Nursing (DON) expected the MDS to be accurate and reflective of current resident conditions, but the inaccuracies in these assessments indicate a failure to meet these expectations.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control procedures, particularly in hand hygiene and the use of personal protective equipment (PPE). Observations revealed that staff did not consistently wash their hands before and after resident contact, nor did they use gowns when required for Enhanced Barrier Precautions (EBP). For instance, the Assistant Director of Nursing (ADON) and other staff members were observed performing wound care and other high-contact activities without wearing gowns, despite the presence of wounds and indwelling medical devices that necessitated such precautions. Additionally, signage indicating EBP was often missing from resident rooms, and PPE was not readily available, further contributing to the lapses in infection control. The facility also failed to maintain proper urinary catheter care, as drainage bags were frequently observed touching the floor, which poses a risk for contamination and infection. This was noted for several residents, including those with urinary catheters for retention or other medical conditions. Despite facility policies requiring that catheter bags be kept off the floor, observations showed that bags were often found dragging on the ground or resting directly on the floor, both in resident rooms and common areas. Furthermore, the handling of soiled materials and the execution of perineal care were not conducted in a sanitary manner. Staff were seen placing soiled washcloths on surfaces without barriers and failing to perform hand hygiene after removing gloves or handling contaminated items. These actions were contrary to the facility's policies and expectations for infection prevention, as stated by the Director of Nursing and the Infection Preventionist. The lack of adherence to these protocols highlights significant deficiencies in the facility's infection control practices.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in good working order, specifically the three-compartment sink used for sanitizer solution. Observations revealed that the drain pipe for the third sink well was leaking, causing water to overflow from a plastic tub onto the floor. The Dietary Manager confirmed that the pipes under the sink leaked due to broken seals and that the sink lacked hot water. Despite being aware of these issues, the maintenance team and the Administrator had not resolved the problem, which had persisted for approximately one year. Interviews with the Maintenance Supervisor and the Administrator indicated that the sink had not functioned properly for at least six months, and previous repair attempts were unsuccessful. The facility was in the process of finding a custom-built replacement due to size constraints in the kitchen. The kitchen staff had stopped using the sink for washing large items or dishware when the dish machine was broken, highlighting the ongoing impact of the deficiency on kitchen operations.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment risks for three residents. The facility's policy, dated December 2007, required maintenance staff to inspect all beds and related equipment as part of a regular bed safety program. However, there was no documentation of entrapment zone measurements for Residents #24, #25, and #40, despite their use of bed rails or assist bars. Observations confirmed that these residents had assist bars or bed rails in the raised position, but the necessary safety checks were not documented. Resident #40, who was cognitively intact but had upper and lower extremity impairments, was observed with assist bars on both sides of the bed. The resident's Bed Rail Assessment indicated a need for these bars to promote independence, yet there was no documentation of entrapment zone measurements. Similarly, Resident #24, who required substantial assistance with bed mobility, had mobility bars as per physician orders, but again, no entrapment zone measurements were documented. Resident #25, also non-ambulatory and requiring assistance, had quarter bed rails, but the necessary safety checks were not recorded. Interviews with facility staff revealed gaps in the implementation of the bed safety policy. The Maintenance Supervisor admitted to installing bed rails without completing or tracking the required measurements and did not check compatibility with specialty mattresses. The DON stated that maintenance staff were responsible for measuring entrapment zones and ensuring compatibility, but these tasks were not completed as expected. The Administrator acknowledged that maintenance and nursing staff should collaborate to ensure these measurements are completed and tracked, as per facility policy.
Failure to Post State Agency and Elder Abuse Hotline Information
Penalty
Summary
The facility failed to ensure that the telephone number and contact information for the state survey agency and the elder abuse hotline were posted in the facility, as required by federal and state laws. Observations conducted over several days revealed that there was no visible posting of this information throughout the facility. Although the elder abuse hotline number was found in the front foyer area, it was not readily visible to those entering the facility, and the state survey agency contact information was not posted at all. Interviews with residents and staff further confirmed the deficiency. During a group resident council interview, residents expressed that they were unaware of where the contact information for the state survey agency or elder abuse hotline was posted. A resident also stated that they had not seen the numbers posted anywhere in the facility, only the Resident's Rights posters in the hallways. The Human Resources staff member corroborated this by stating that she could not find the contact information posted anywhere in the facility. The Administrator acknowledged that social services were responsible for posting the information and admitted that he was unaware it was not posted throughout the facility.
Failure to Timely Issue NOMNCs
Penalty
Summary
The facility failed to provide timely Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) to three residents, as required by regulations. The NOMNC should be delivered at least two calendar days before Medicare coverage services end. However, the facility did not meet this requirement for three residents. Resident #343 received the NOMNC one day before the last skilled day, Resident #34's representative received it on the same day as the last skilled day, and Resident #344's representative received it one day before the last skilled day. This indicates a failure to comply with the required notice period. Interviews with facility staff revealed a lack of awareness and training regarding the issuance of NOMNCs. The Social Services Director (SSD) admitted to being unaware of the two-day notice requirement and stated that they had never been trained in issuing Advance Beneficiary Notices (ABNs) or NOMNCs. The Administrator expected the Business Office Manager or SSD, in collaboration with Therapy, to issue the notices according to regulations, but this expectation was not met. The facility also failed to provide a policy regarding the issuing of NOMNCs when requested.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the facility name, resident census, and total actual hours worked by both licensed and unlicensed nursing staff per shift. Observations on multiple occasions revealed that the required staffing information was not posted in a prominent location as mandated by the facility's policy. On one occasion, the Administrator in Training admitted to removing the postings because a resident was tearing them off the bulletin board. Further observations showed that the posted nurse staffing sheet only contained census information without the necessary details of licensed or unlicensed staffing numbers or hours for each shift. A review of the facility's records over an 18-month period revealed that approximately one-third of the nurse staffing sheets were blank and lacked the required information. Interviews with the Director of Nursing and the Administrator confirmed the deficiency, with both expressing expectations that the staffing sheets should be completed accurately and posted conspicuously as per regulations. The failure to maintain and display accurate staffing information as required by policy and regulations was evident, leading to the deficiency noted in the report.
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 36 citations issued within 25 miles in the last 12 months — including the 2 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 Lewistown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Belle Manor Care Center | 7.2 mi | ★★★★★ | 0 | 0 |
| Lewis County Nursing Home District | 13.8 mi | ★★★★★ | 27 | 0 |
| Knox County Nursing Home District | 19.2 mi | ★★★★★ | 1 | 0 |
| Quincy Healthcare & Sr Living | 22.9 mi | ★★★★★ | 2 | 0 |
| Sunset Home | 23.2 mi | ★★★★★ | 4 | 2 |
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.