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 Crestview Home during CMS and state inspections, most recent first.
The facility failed to ensure the Dietary Manager had the necessary competencies and skills to manage the food and nutrition service. The DM, hired without certification or managerial experience, had not completed the required training. Both the Administrator and Registered Dietitian acknowledged the DM's lack of training, and the facility did not provide a job description for the DM.
The facility failed to maintain a sanitary kitchen environment, with observations of dirt and grime on the hand washing sink, unclean dish room floors, and missing entries in the dishwasher sanitation log. In the dining room, the refrigerator and steam table were covered in debris, and food was improperly stored in the walk-in cooler. The dietary manager and administrator acknowledged these issues, citing a lack of full-time maintenance staff as a contributing factor.
The facility failed to implement a water management plan to prevent Legionella bacteria growth, and a CMT administered eye drops to a resident without wearing gloves, violating infection control guidelines. The Administrator confirmed the absence of a maintenance employee responsible for water system assessments and documentation.
The facility failed to implement an effective antibiotic stewardship program, lacking necessary protocols, monitoring systems, and staff education. Infections were tracked without root cause analysis, and the facility did not have a current Infection Preventionist.
The facility did not hire a qualified Infection Preventionist (IP) to manage its infection prevention and control program. The Administrator acknowledged the absence of an IP and the lack of an IP policy. The DON claimed to have completed the IP course but did not provide certification, and the facility's Infection Control binder lacked evidence of IP training or certification.
The facility failed to provide three CNAs with the required 12 hours of yearly in-service education, including training on abuse, neglect, and dementia care, potentially affecting all 40 residents. Personnel records showed incomplete education documentation, and interviews indicated that the DON and nurse leadership were responsible for training, but the administrator was unaware of the records' location.
The facility failed to ensure lawful Advance Directives for three residents, as the DPOA signed OHDNR forms before residents were declared incapacitated. Two residents had OHDNR forms signed before incapacitation was confirmed by physicians, and one resident lacked a second physician's letter of incapacitation. The facility did not provide the requested policy on Advance Directives, and staff interviews confirmed the requirement for two physician signatures unless otherwise stated.
The facility failed to maintain a safe and homelike environment, with the main dining room being too cold for residents to use comfortably. The facility lacked a maintenance supervisor, leading to disrepair and cleanliness issues, including cracked tiles, dust, debris, and mold-like substances. Staff interviews revealed a lack of organized cleaning and maintenance efforts, with the van driver handling repairs as time allowed.
A facility failed to ensure complete and individualized care plans for residents, leading to unaddressed risks such as elopement, pressure ulcers, and significant weight loss. Residents with severe cognitive impairment, open sores, and weight loss did not have these issues reflected in their care plans. Staff interviews revealed communication challenges and a lack of updates to care plans, contributing to these deficiencies.
The facility failed to provide meaningful activities for residents, impacting their engagement and socialization. Three residents, including one with significant cognitive deficits and another with severe cognitive impairment, were observed without engagement in preferred activities. The facility lacked an activity director and a structured program, relying on volunteers for occasional activities. Residents expressed feelings of loneliness and boredom due to the absence of a consistent activity schedule.
The facility failed to prevent and manage pressure ulcers for multiple residents, resulting in the development and deterioration of wounds. One resident's physician was not notified timely, and another resident developed ulcers due to delayed assistance with toileting. Inconsistent documentation and lack of repositioning contributed to worsening conditions.
The facility failed to provide adequate staffing, resulting in residents not receiving timely repositioning, incontinence care, and assistance during meals. Observations and interviews revealed that residents at risk for pressure ulcers were not properly cared for, leading to open wounds. Staff reported being unable to complete necessary tasks due to insufficient staffing, impacting residents' health and well-being.
The facility failed to ensure an RN was on duty for eight consecutive hours daily, as required. An LPN often served as the sole nurse, with no RN present on multiple occasions from July 2024 to February 2025. Despite recruitment efforts, the facility struggled to fill RN positions, and no waiver was applied for. The Medical Director was unaware of the RN absences, which could impact resident care.
The facility did not ensure yearly performance reviews and education plans for three CNAs employed for over 12 months. Despite completing annual education quizzes, these CNAs lacked competency assessments and training plans. The Administrator was unaware of the last competency assessment date and tracking details, expecting the DON to handle yearly competency education.
The facility failed to prepare meals according to the dietary needs of residents requiring pureed and mechanical soft diets. Observations showed that pureed meals were not smooth and contained chunks, while mechanical soft meals were dry and hard to chew. Staff did not follow the facility's dietary policy, affecting residents' ability to consume meals comfortably.
A facility failed to provide necessary assistance with ADLs for a resident dependent on a mechanical lift and two staff for transfers. The resident, diagnosed with cerebral palsy and incontinent of bowel and bladder, was left in a wheelchair for over six hours without repositioning or perineal care, resulting in a strong urine smell and skin irritation. Interviews with CNAs and an LPN revealed a lack of adherence to the care plan, which required repositioning every two hours.
A resident with anemia experienced a 14-day delay in receiving a physician-ordered blood transfusion due to miscommunication and scheduling issues within the facility. The transfusion was ordered on January 16, 2025, but was not completed until January 30, 2025, partly due to the hospital not having the correct blood type in stock. The facility's process for handling orders and scheduling appointments contributed to the delay, with confusion over responsibilities and a lack of clear communication between staff.
A resident with cerebral palsy and limited ROM in the left hand did not receive necessary care to prevent further ROM loss. The resident, who requires assistance with ADLs, was observed with a hand contracture and expressed a desire for ROM exercises. Facility staff confirmed the absence of an active ROM program and lack of instruction to provide PROM, leading to a deficiency.
A resident with cerebral palsy and dysphagia experienced significant weight loss due to the facility's failure to provide a physician-ordered Magic Cup at lunch. Despite being at risk for weight loss and having a specific diet order, the resident lost 10.5% of body weight over six months. Observations showed the resident was not served the Magic Cup, and staff interviews revealed a lack of communication between nursing and dietary departments.
The facility staff failed to properly store nebulizer masks for two residents, leading to a deficiency in respiratory care. One resident with cerebral palsy and another with COPD were observed with their nebulizer masks not stored in bags when not in use, contrary to facility expectations. This was confirmed by interviews with an LPN and the QA nurse.
A facility failed to document alternatives and assess risks before using Halo side rails for a resident with cognitive deficits. The facility did not obtain informed consent or conduct necessary assessments for entrapment risks. Interviews revealed confusion among staff about responsibilities for assessments and installation, leading to the deficiency.
The facility failed to post daily nurse staffing information, with observations showing outdated postings since February 10, 2025, despite a census of 40. The Interim DON expected the night nurse to update the staffing, but the Administrator was unaware of the lapse. A night shift RN reported not being instructed to fill out the staffing sheet.
Two residents at risk for pressure ulcers were not properly cared for, as staff failed to report skin issues and reposition them as required. One resident with no cognitive deficit had open areas on the thigh that were not reported, while another with severe cognitive impairment had red buttocks but was not repositioned or treated with moisture barrier cream. Staff interviews revealed a lack of adherence to protocols for reporting and repositioning.
The facility failed to maintain a comprehensive water management program to minimize Legionella risk, affecting 43 residents. The Administrator admitted the lack of a general maintenance policy, and the checklist showed incomplete documentation for water system checks. The Maintenance Supervisor lacked Legionella training, and the DON had not discussed it in meetings. The absence of a facility pipe map further complicated monitoring efforts.
The facility failed to store food in a sanitary manner, with over 50 freezer bags of leftovers improperly labeled or unlabeled, contrary to policy. Staff interviews confirmed awareness of labeling requirements, yet practices were inconsistent, affecting all residents receiving nourishment from the kitchen.
The facility failed to maintain essential kitchen equipment, affecting ovens, a freezer, and a steamer. Observations revealed ice buildup in the freezer, a broken oven door, and a non-functional steamer. Staff interviews indicated a lack of awareness and follow-up on these issues, with maintenance not effectively managed.
A resident with severe cognitive impairment and hypertension had their blood pressure medication held on three occasions without notifying the physician, despite facility policy requiring such notification. The resident's blood pressure readings were below the ordered parameters, and staff interviews revealed a breakdown in communication, as the certified medication technician did not report the readings to the nurse. The Medical Director confirmed the primary care physician was unaware and would have adjusted the medication if informed.
The facility failed to maintain a homelike environment for two residents due to missing closet doors. Observations and interviews revealed that the doors had been missing for an extended period, and the Maintenance Supervisor was unaware of the issues. A work order was marked as completed, but the door was not replaced. The Administrator expected the MS to use doors from unoccupied rooms to address such issues.
A facility failed to create a comprehensive care plan for a resident prescribed psychotropic medications, omitting details on target behaviors and side effect monitoring. The resident, with diagnoses including major depressive disorder and Alzheimer's, was cognitively intact and on medications like quetiapine and sertraline. Staff interviews revealed a lack of training and understanding in care plan development, with the DON acknowledging the need for care plans to include medication-related behaviors.
A resident with a history of hypertension experienced a hypertensive crisis, with a blood pressure reading of 189/113 mmHg. Despite facility policy requiring notification of a physician for such condition changes, the nursing staff did not re-evaluate the resident or consult with the physician. The resident's care plan included monitoring for high blood pressure and notifying the physician of abnormalities, but this was not documented in the progress notes. Interviews with staff indicated a breakdown in communication and adherence to protocol.
A facility failed to secure medications for a resident, leaving them at the bedside without proper orders or assessments, and did not thoroughly investigate or implement fall interventions for another resident with severe cognitive impairment. The lack of complete incident reports and follow-up on care-planned interventions contributed to these deficiencies.
A facility failed to monitor and record fluid intake for a resident with a fluid restriction order due to end-stage renal disease and edema. Despite a care plan requiring monitoring, there was no documentation of fluid intake, and staff were unaware of the restriction. Observations showed the resident consumed fluids beyond the restriction, and interviews revealed a lack of communication and documentation. The facility administrator was unaware of the issue.
A facility failed to consistently communicate with a dialysis provider for a resident with end-stage renal disease, as required by their policy. The Dialysis Communication Record, meant to be sent with the resident on each visit, was not regularly used, leading to inconsistent documentation. Interviews revealed that the LPN had only recently started using the report, and the dialysis center often relied on verbal communication instead. This lack of proper communication led to the deficiency identified by surveyors.
The facility failed to ensure that two residents' medication regimens were free of unnecessary antipsychotic medications. For one resident, the facility did not specify target behaviors or monitor for adverse drug reactions, and the care plan lacked relevant interventions. Another resident's care plan identified the use of a psychotropic medication but did not specify the reason for its prescription. Staff interviews revealed a lack of behavior monitoring and documentation, and the Medical Director noted that dementia with agitation or anxiety was not an appropriate indication for antipsychotic use.
A resident with a history of acute upper respiratory infection did not receive a pneumococcal vaccine despite consent being given twice by their responsible party. The facility's vaccination records showed no evidence of administration, and a quarterly assessment confirmed the resident was not up to date. Interviews revealed that the DON was unaware of any unfulfilled vaccination requests, and the Administrator acknowledged the oversight in reviewing consents and administering the vaccine.
Two residents in the facility did not receive showers as scheduled, leading to a deficiency. One resident, with dementia and muscle weakness, was scheduled for showers three times a week but often did not receive them. Another resident, with Alzheimer's, was scheduled for showers twice a week but frequently went without them. Staff interviews revealed issues with documentation and staffing, contributing to the failure to provide showers as planned.
Inadequate Competency of Dietary Manager
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to effectively manage the food and nutrition service. The DM, hired on October 4, 2023, lacked certification in food service management or as a dietary manager. Despite being in the role for six months, the DM had no prior managerial experience and had not completed the required dietary manager's course. The facility did not provide a job description for the DM, and both the Administrator and the Registered Dietitian acknowledged that the DM had not completed the necessary training. The facility census was 40 at the time of the survey.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by multiple observations of unclean conditions and improper food storage. The hand washing sink in the kitchen was found dirty, with dirt and grime in the basin and debris on the handles. A white bucket of dirty water was observed under the sink, and the dish room floor was covered in dirt and debris. Additionally, a black substance was noted on the outside of the dishwasher and under it on the floor, and the paint was peeling off the ceiling in the dish room. The dishwasher sanitation and temperature log showed missing entries for checking the sanitizer level on several dates, and the dietary aide did not check the sanitizer before or after using the dishwasher. In the dining room serving area, the refrigerator was covered in dirt and debris, with a brown sticky substance on the handle and inside. Glass cups and bowls were stored face up with dirt and debris in them, and the steam table was covered in food debris and grime. The floor next to the steam table had missing tiles, and the trash can next to the hand washing sink had no lid. In the walk-in cooler, undated food items were found, including hamburger patties and hotdogs, and a box of health shakes was stored on the floor. The cooler floor was sticky and covered with food debris, and black spots were observed on the ceiling outside the cooler. The facility's dietary manager and administrator acknowledged the unsanitary conditions and improper food storage practices. The dietary manager stated that the kitchen should be clean and sanitary, with food stored appropriately and dated. However, the facility lacked a full-time maintenance person, which contributed to the lack of repairs and cleanliness. The registered dietitian also expected the kitchen to be clean and in good repair, with the dishwasher sanitizer checked and recorded three times a day. Despite these expectations, the facility failed to adhere to its policies and maintain a sanitary environment in the kitchen and dining areas.
Inadequate Water Management and Infection Control Practices
Penalty
Summary
The facility failed to develop and implement a water management policy and procedures to mitigate the risk of Legionella bacteria growth and spread, which could potentially affect all residents. During an interview, the Administrator acknowledged the absence of a maintenance employee for over a month, who would typically be responsible for assessing the building's water systems and documenting water testing and monitoring. The Administrator was unable to locate the facility's water management plan, indicating a lack of preparedness in managing water safety. Additionally, the facility did not adhere to infection control guidelines when a Certified Medication Technician (CMT) administered eye drops to a resident without wearing gloves. The resident, who had a diagnosis of dementia, anxiety, hypertension, and dry eye, required artificial tears as per physician orders. The CMT admitted to not wearing gloves during the procedure, which was confirmed by the Quality Assurance Nurse and the Administrator as a breach of expected infection control practices.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking an antibiotic stewardship program. This program is essential for optimizing the treatment of infections and minimizing adverse events related to antibiotic use. The facility did not provide an Antibiotic Stewardship policy or documentation, which should have included protocols for appropriate antibiotic prescription, procedures to reduce the risk of antibiotic-resistant organisms, and a system to monitor antibiotic use. Additionally, there was no designated staff accountable for overseeing antibiotic stewardship, nor was there access to pharmacists or other experts in antibiotic stewardship. The facility also lacked regular reporting on antibiotic use and resistance, and there was no evidence of staff and resident education on antibiotic stewardship. The review of the Infection Control binder revealed that in January and February 2025, the facility tracked infections, including urinary tract infections, respiratory infections, and others, on a color-coded map. However, there was no evidence of root cause analysis for these infections or infection control education provided to staff. During an interview, the Administrator admitted to not having a current Infection Preventionist, further highlighting the facility's deficiencies in managing infection control and antibiotic stewardship.
Failure to Hire Qualified Infection Preventionist
Penalty
Summary
The facility failed to hire a qualified Infection Preventionist (IP) to oversee the infection prevention and control program, as required. The facility, with a census of 40, did not have an IP policy in place, nor did it provide evidence of IP training or certification in its Infection Control binder. During an interview, the Administrator acknowledged that the Director of Nursing (DON) claimed to have completed the IP course but had not provided certification to confirm this. The Administrator also admitted that the facility did not currently have an IP and was aware of the requirement to have one.
Deficiency in CNA Training and Documentation
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) out of seven sampled staff received the required minimum of 12 hours of documented yearly in-service education, which should have included training on abuse, neglect, and dementia care. This deficiency had the potential to affect all 40 residents in the facility. Personnel records showed that CNAs hired in 2000, 2001, and 2022 had only completed an annual education quiz in 2024, with no other education or in-service records available. Additionally, a nurse aide hired in 2024 had no education or in-service records at all. Interviews revealed that training, documentation, and tracking were the responsibility of the Director of Nursing (DON) and nurse leadership, but the administrator was unaware of the location of tracking and attendance records.
Improper Execution of Advance Directives by DPOA
Penalty
Summary
The facility failed to ensure that Advance Directives for three residents were lawful, as the Designated Power of Attorney (DPOA) signed out-of-hospital Do Not Resuscitate (OHDNR) forms before the residents were declared incapacitated. For Resident #3, the DPOA signed the OHDNR on 01/15/22, prior to the resident being deemed incapacitated on 11/16/22 by one physician and later on 05/08/24 by two physicians. Similarly, for Resident #19, the DPOA signed the OHDNR on 01/07/19 before the resident was declared incapacitated on 01/24/19 by two physicians. In both cases, the DPOA documents did not specify whether one or two physicians were needed to determine incapacity. For Resident #32, the facility failed to obtain two physician letters of incapacitation before the DPOA made decisions on behalf of the resident. The resident was declared to have lost decisional capacity on 04/06/23, but only one letter of incapacity dated 01/31/23 was signed by a physician, with no second letter provided. The facility did not provide the requested policy on Advance Directives, and interviews with the Quality Assessment Nurse and the Administrator confirmed that two physician signatures are required for incapacity letters unless otherwise stated, and that a DNR form should not be signed by the DPOA unless the resident has been declared incapacitated.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several observations and interviews. The main dining room was found to be uncomfortably cold, with thermostat readings of 60-61 degrees Fahrenheit, and residents reported that it had been too cold to eat there for weeks. The facility lacked a maintenance supervisor for over a month, and the transportation driver was assisting with maintenance tasks as time allowed. The administrator acknowledged the issue but did not know when the heating would be fixed. Additionally, the facility's physical environment was in disrepair, with cracked and missing floor tiles, dead bugs, dust, and debris in light fixtures, and damaged PTAC units. Fire doors and sheetrock in various halls were chipped and gouged, and handrails had missing or loose end caps, creating sharp edges. The facility also had issues with cleanliness, as evidenced by dust and debris in vents, cobwebs, and mold-like substances in the shower room. Interviews with staff revealed that there was no specific assignment for high dusting, and deep cleaning of common areas was not organized. The facility had no maintenance personnel, and the van driver was responsible for completing work orders as time allowed. The administrator and quality assurance nurse confirmed the lack of maintenance staff and the reliance on the van driver for repairs, indicating a significant gap in the facility's ability to maintain a safe and clean environment.
Incomplete and Inaccurate Care Plans in LTC Facility
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. For Resident #28, the care plan did not include interventions for the use of an alarm, elopement risk, or pressure ulcers, despite the resident having a history of falling, severe cognitive impairment, and an open area on the buttock. The resident was observed with an alarm pad under the bed, and staff acknowledged the elopement risk, yet these were not reflected in the care plan. Resident #92's care plan was incomplete as it did not address pressure ulcers or skin concerns, even though the resident had open sores on the buttocks. The resident reported having sores, and a CNA confirmed the presence of an open area for at least a week. However, the LPN was unaware of the open area, indicating a lack of communication and updates to the care plan. Similarly, Resident #11 had a care plan that did not include the current pressure ulcer, despite documentation of skin breakdown and a high risk for developing wounds. Residents #15 and #36 experienced significant weight loss, which was not addressed in their care plans. Resident #15 had a history of weight loss and was on a pureed diet with honey-thick liquids, yet the care plan did not reflect the significant weight loss. Resident #36 also experienced weight loss, but the care plan did not address this issue. Interviews with staff revealed that communication challenges and a lack of updates to care plans contributed to these deficiencies, with the MDS Coordinator and Quality Assurance Nurse acknowledging the need for better communication and education for charge nurses on care planning.
Facility Fails to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities to meet the needs of three residents, as observed through a lack of structured activity programs and absence of an assigned activity director. The facility did not have a system to inform residents of available activities, including their location and time, which potentially impacted all residents. The facility's Resident Right policy emphasized the right to participate in activities, but no activity calendar was provided, and there was no policy regarding activities. Resident #6, with significant cognitive deficits and dependence on staff for activities of daily living, showed no activity attendance in January and February. Observations revealed the resident was often found in the hallway or room without engagement in preferred activities like music or group interactions. Similarly, Resident #28, with severe cognitive impairment and a need for moderate assistance, was observed in the hallway without engagement, despite interests in crafts, music, and socialization. Resident #92, with no cognitive loss, expressed feelings of loneliness and boredom, as there were no activities provided to meet their preferences for reading, music, and social interaction. Interviews with staff and the administrator revealed that the previous activity director was reassigned, and no one was currently responsible for the activity program. Volunteers occasionally provided activities like bingo and exercise, but there was no consistent schedule or staff involvement. The administrator acknowledged the lack of an activity director and expected staff to assist with activities, but no structured plan was in place to address the residents' needs for socialization and engagement.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate care and services to prevent the development and deterioration of pressure ulcers for several residents. For one resident, the facility did not notify the physician in a timely manner about the pressure ulcer, nor did they obtain treatment promptly. This resident developed pressure ulcers on the buttocks, which were not consistently assessed or documented by the nursing staff. The facility's failure to adhere to pressure ulcer precautions resulted in the resident's condition worsening, with observations noting the resident sitting in a wheelchair for extended periods without repositioning or incontinence care. Another resident, who was admitted without any wounds, developed pressure ulcers due to inadequate response to call lights and delayed assistance with toileting needs. The resident reported pain and burning from the sores, which were not present upon admission. The facility staff failed to notify the physician about these open wounds, and the resident was observed without a pressure-relieving cushion, further exacerbating the condition. Additionally, the facility did not consistently document wound assessments or notify the physician about the deterioration of pressure ulcers for another resident. This resident's wound was observed to have worsened, with eschar development, yet there was no documentation of physician notification or wound assessments. The facility's staff also failed to reposition and provide perineal care for a resident with a chronic wound, leaving the resident in a wheelchair for extended periods without care, contributing to the development of an open area on the resident's thigh.
Inadequate Staffing Leads to Care Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in several deficiencies. Observations and interviews revealed that residents at risk for pressure ulcers were not repositioned or provided with incontinence care in a timely manner. For instance, one resident with severe cognitive impairment and at risk for pressure ulcers did not receive scheduled baths and was observed with open wounds due to inadequate care. Another resident, who was cognitively intact, reported waiting over 30 minutes for assistance, leading to incontinence and subsequent skin issues. The facility's staffing levels were insufficient to meet the needs of residents during meal times and daily care routines. Observations showed that only one staff member was available to assist multiple residents requiring nutritional assistance during meals. Interviews with staff indicated that they were unable to complete all necessary tasks, such as turning and repositioning residents every two hours, due to the lack of adequate staffing. This resulted in residents not receiving the care they needed, leading to the development of wounds and other care deficiencies. The facility did not have a policy on staffing, and the administrator was unaware of the extent of the issues, including the presence of multiple wounds and the failure to provide two baths weekly for residents. Staff interviews consistently highlighted the challenges faced due to insufficient staffing, which impacted their ability to provide necessary care and maintain the residents' health and well-being.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews, revealing that on multiple occasions, there was no RN present in the facility. Instead, a Licensed Practical Nurse (LPN) was serving as the Charge Nurse and was the only nurse on duty. The facility's daily staffing sheets confirmed the absence of an RN on several specific dates from July 2024 to February 2025. Additionally, the facility did not provide a policy on staffing, and there were no staffing sheets available for October 2024. Interviews with facility staff, including the Quality Assurance Nurse and the Administrator, highlighted awareness of the staffing issue. The Administrator acknowledged the absence of an RN on multiple days and mentioned efforts to recruit a Director of Nursing (DON) and charge nurses, including offering bonuses and increased wages, but these efforts did not yield applications. The Medical Director was unaware of the RN absences and noted that not having an RN could be detrimental to resident care in certain situations. Despite the ongoing staffing challenges, the facility had not applied for a waiver to address the deficiency.
Lack of Yearly Performance Review and Training Plans for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received a yearly performance review and individually based education plans for three nurse aides who had been employed for more than 12 months. The facility, which had a census of 40, did not provide a policy for education and nurse assistant training. Personnel records showed that Certified Nurse Aides (CNAs) D, E, and F had completed their annual education quizzes but lacked competency assessments and training plans. During interviews, the Quality Assurance Registered Nurse indicated that trainings and tracking were managed by nurse leadership, while the Administrator was unaware of the date of the last competency assessment and where the tracking was kept. The Administrator expected the Director of Nursing (DON) to complete yearly competency education but was not informed about the tracking details.
Failure to Prepare Meals According to Dietary Needs
Penalty
Summary
The facility failed to ensure that food was prepared in a manner that met the dietary needs of individual residents, specifically those requiring pureed and mechanical soft diets. Observations revealed that the pureed meals served to two residents were not of the appropriate consistency, containing thick and chunky textures instead of the required smooth, pudding-like consistency. Additionally, the mechanical soft diet provided to another resident included meat that was dry, tough, and difficult to chew, contrary to the dietary requirements for easy-to-chew, ground meat. These deficiencies were observed during meal preparation and service, affecting the residents' ability to consume their meals comfortably and safely. The facility's policy on diet types, which outlines the requirements for mechanical soft and pureed diets, was not adhered to during meal preparation. Staff members, including the dietary manager and registered dietitian, acknowledged that the food did not meet the expected standards for consistency and palatability. The dietary staff failed to use recipes or guidelines to ensure the correct preparation of meals, resulting in meals that were either too dry, hard, or watery, and lacking in flavor. This oversight in meal preparation and adherence to dietary orders directly impacted the residents' dining experience and nutritional intake.
Failure to Provide Timely ADL Assistance and Repositioning
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident who was dependent on a mechanical lift and two staff for transfers. The resident, who had no cognitive deficit and was diagnosed with cerebral palsy, dysphagia, and weakness, required assistance with all ADLs and was incontinent of bowel and bladder. Despite the care plan indicating the need for repositioning every two hours and timely perineal care, the resident was left in a wheelchair from 7:30 A.M. to 1:52 P.M. without being repositioned or changed, resulting in a strong urine smell and skin irritation. Interviews with facility staff, including CNAs and an LPN, revealed that the resident was not repositioned or provided with perineal care as required. The CNAs admitted to not performing rounds every two hours as trained, and the LPN acknowledged that the staff did not change the resident as expected. The Quality Assurance nurse and the Administrator confirmed that the resident should have been repositioned and provided with perineal care every two hours, highlighting a failure in adhering to the care plan and facility expectations.
Delayed Blood Transfusion for Anemic Resident
Penalty
Summary
The facility failed to provide timely care for a resident who required a blood transfusion due to anemia. The physician ordered a blood transfusion on January 16, 2025, but the transfusion was not completed until January 30, 2025, resulting in a 14-day delay. The resident, who had moderate cognitive impairment and was dependent on a wheelchair, experienced fatigue, which concerned the physician. The delay was partly due to the hospital not having the correct blood type in stock when the resident was initially taken for the transfusion on January 27, 2025. The facility's process for handling physician orders and scheduling appointments contributed to the delay. The Business Office Manager (BOM) was responsible for scheduling appointments and arranging transportation, but there was confusion about who was responsible for scheduling the transfusion appointment. The BOM believed the family was handling the appointment, but the family did not agree to this. Additionally, when the BOM was unavailable, the Human Resources staff was supposed to cover these duties, but there was a lack of clear communication and documentation. Interviews with facility staff revealed that there was a breakdown in communication between the administration and nursing staff. The Director of Nursing and the Administrator expected physician orders to be carried out promptly, but the process for receiving and acting on orders was not effectively managed. The physician expected the transfusion to occur within 5-7 days, but the facility's failure to coordinate and communicate effectively led to the significant delay in care.
Failure to Provide ROM Care for Resident with Contracture
Penalty
Summary
The facility staff failed to provide appropriate care for a resident with limited range of motion (ROM) in the left hand, resulting in a deficiency. The resident, who has cerebral palsy and requires assistance with activities of daily living (ADLs), was observed with a contracture in the left hand, with fingers curled in and unable to straighten. The resident expressed that they did not receive any assistance or devices to prevent further ROM loss and desired ROM exercises to maintain hand function. Interviews with facility staff revealed that there was no active ROM program in place, and the Certified Nurse Aide (CNA) and Licensed Practical Nurse (LPN) confirmed that they were not instructed to provide passive range of motion (PROM) exercises to the resident. The facility's administrator acknowledged the absence of a current ROM program and stated that CNAs should be performing PROM and stretching exercises during care, which was not being done for the resident.
Failure to Provide Nutritional Supplement Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to prevent significant weight loss for a resident when it did not provide the physician-ordered Magic Cup, a nutritional supplement, at lunch. The resident, who had a BIMS score indicating no cognitive deficit, was diagnosed with cerebral palsy and dysphagia, requiring a pureed diet with honey thick liquids. Despite being at risk for weight loss and having a physician order for a Magic Cup with lunch, the resident experienced a weight loss of 26.2 pounds, or 10.5% of body weight, over six months. Observations on multiple days showed the resident was not served the Magic Cup at lunch, consuming only 50-75% of meals. Interviews with facility staff, including the Dietary Manager, LPN, QA Nurse, and Administrator, revealed a lack of communication between nursing and dietary departments. The staff was unaware that the resident was not receiving the Magic Cup and of the significant weight loss. The facility did not have a significant weight loss policy, and the resident's weight loss was discussed in monthly risk meetings, but the ordered nutritional supplement was not consistently provided.
Improper Storage of Nebulizer Masks for Two Residents
Penalty
Summary
The facility staff failed to properly store nebulizer machine masks for two residents, leading to a deficiency in respiratory care. Resident #15, who has a BIMS score of 15 indicating no cognitive deficit, and diagnoses including cerebral palsy, dysphagia, bronchitis, and weakness, was observed multiple times with their nebulizer mask resting uncovered in the sink bowl. Despite having a physician's order for nebulizer treatments four times daily, the mask was not stored in a plastic bag when not in use, as confirmed by interviews with an LPN and the QA nurse. Similarly, Resident #38, also with a BIMS score of 15 and diagnoses of heart failure and COPD, was observed with their nebulizer mask sitting on a towel instead of being stored in a bag. The resident's physician's orders included nebulizer treatments twice daily and monthly tubing changes. The QA nurse confirmed the expectation that nebulizer masks should be stored in bags when not in use, highlighting the facility's failure to adhere to proper storage protocols for respiratory equipment.
Failure to Document and Assess Bed Rail Use
Penalty
Summary
The facility failed to document the identification and use of possible alternatives before using Halo side rails for a resident, as well as failed to assess the risks versus benefits of their use. Additionally, the facility did not obtain informed consent for the use of these side rails prior to their installation. The resident in question, who has a significant cognitive deficit and requires substantial assistance for daily activities, had Halo rails installed for repositioning without a documented assessment for use, entrapment, or to ensure the rails remained functional and safe. Interviews with facility staff revealed a lack of clarity and responsibility regarding the assessment and installation of bed rails. The LPN was unaware of who completed entrapment assessments and had never conducted an assessment for bed rails. The Quality Assurance Nurse indicated that entrapment zones must be assessed and informed consent obtained, but these steps were not completed. The Administrator acknowledged that maintenance was responsible for installing the rails and measuring entrapment spaces, but no maintenance staff were available to complete these assessments. This lack of documentation and assessment led to the deficiency identified by the surveyors.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required nurse staffing information, including the resident census and actual hours worked by both licensed and unlicensed nursing staff responsible for resident care, on a daily basis. Observations on multiple dates showed that the posted staffing information was outdated, with the last update being on February 10, 2025, despite the facility census being 40. Interviews revealed that the Interim Director of Nursing (DON) expected the night nurse to post the daily staffing numbers, and if not done, the DON should ensure it is updated. The Administrator was unaware of the outdated information and stated that the night charge nurse was responsible for posting the daily staffing, with the DON ensuring its completion. A night shift Registered Nurse reported not being instructed to fill out the staffing sheet and was unaware of who was responsible for posting it.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to prevent compromised skin integrity for two residents, leading to deficiencies in pressure ulcer care and prevention. For the first resident, staff did not alert the charge nurse when open areas were observed on the back of the upper right thigh, and the resident was not repositioned to relieve pressure after care. The resident, who had a BIMS score indicating no cognitive deficit, was at risk for pressure ulcers due to diabetes, obesity, incontinence, and immobility. Observations revealed the resident was left lying on their back after care, despite having dark red buttocks and open areas, which were not reported to the charge nurse. The second resident, with severe cognitive impairment and a BIMS score of 0, was also at risk for pressure ulcers due to immobility and incontinence. During care, the resident was found to have dark red buttocks, but the CNAs did not apply moisture barrier cream or reposition the resident to offload pressure. The CNAs failed to report the redness to the charge nurse, despite being trained to do so. The resident's care plan included the use of a pressure-reducing device and a repositioning program, which were not adequately followed. Interviews with staff, including CNAs and the DON, revealed expectations for reporting red and open areas immediately and repositioning residents every two hours. However, these protocols were not adhered to, resulting in the deficiencies observed. The administrator also confirmed the expectation for staff to report skin issues and use moisture barrier cream when necessary, highlighting a gap between policy and practice in the facility.
Deficiency in Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain a comprehensive water management program to minimize the risk of Legionella in its water supply, potentially affecting all 43 residents. During an interview, the Administrator admitted that the facility lacked a policy for general maintenance. The Monthly Water Management Checklist, dated 05/06/2024, indicated that while some systems and fixtures were inspected, there was no documented evidence of annual cleaning or monthly control measure checks for electric and manual faucets, hot and cold-water storage tanks, or water on closed wings/halls. Additionally, the facility did not have a system to assess the water systems using text and flow diagrams. The Maintenance Supervisor, who had been with the facility for about a month, completed the checklist but had not received training on Legionella. An Independent Environmental Consultant claimed to have trained the Maintenance Supervisor on the checklist and water checks but noted the absence of a facility pipe map, which made it difficult to identify potential standing water areas. The Director of Nursing, also the Infection Preventionist, acknowledged not discussing Legionella in infection control meetings, despite understanding its risks. The Administrator believed the Maintenance Supervisor and the Consultant were responsible for monitoring Legionella, but the report indicates a lack of comprehensive oversight and documentation.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored in a sanitary manner, as observed during a survey. The facility's policy required all leftover food to be labeled, dated, and discarded after three days. However, during an inspection of the kitchen, more than 50 heavily frosted freezer storage bags containing leftover food items were found in the deep freezer. Of these, 42 bags were dated but lacked a description of the contents, and 10 bags had neither a proper date nor a description. This oversight had the potential to affect all 43 residents who received nourishment from the facility kitchen. Interviews with the Dietary Supervisor, Dietary Manager Assistant, and a Dietary Aide revealed that the staff was aware of the labeling and dating requirements, yet the practice was not consistently followed. The Dietary Supervisor acknowledged the issue and stated that the Dietary Manager Assistant was assisting in discarding the items. The Dietary Aide confirmed that leftover food should be labeled with a time, date, and description and discarded if not used within three or four days. A follow-up observation found additional improperly labeled or unlabeled food items in both the walk-in deep freezer and refrigerator. The Administrator confirmed the expectation for proper labeling and dating of leftover food, in line with the facility's three-day storage policy.
Deficiencies in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, affecting two of three ovens, one of two freezers, and one food steamer. During observations, significant issues were noted, including ice buildup in the walk-in freezer, which was confirmed by the Dietary Supervisor and Maintenance Supervisor as a safety hazard. The freezer had been serviced earlier in the year, but the problem persisted, with staff having to replace a drip pan daily to manage the dripping water. Interviews with dietary staff revealed that the ice buildup had not been addressed effectively, and the Maintenance Supervisor was unaware of the extent of the issue. Further observations revealed that Oven 2 had a door hanging from its hinges, rendering it unable to close properly, and was only used to keep food warm. The Maintenance Supervisor was unaware of this issue, and dietary staff confirmed that only one oven was functioning correctly. Additionally, the kitchen steamer was not operational, with the Maintenance Supervisor unaware of its condition, despite it being reported broken a month prior. The Administrator stated that staff were expected to complete work orders for maintenance issues, but it appeared that follow-up and repairs were not adequately managed.
Failure to Notify Physician of Blood Pressure Medication Hold
Penalty
Summary
The facility failed to notify the physician when a resident's blood pressure medication was held on three occasions due to the resident's blood pressure being outside the physician-ordered parameters. The resident, who had a medical history of essential hypertension and severe cognitive impairment, was admitted to the facility in February 2023. The facility's policy required notifying the physician of any condition changes or medication order changes, but this was not followed. The resident's blood pressure readings on three separate days were below the ordered parameters, leading to the withholding of the medication without notifying the physician. Interviews with facility staff, including a registered nurse, the Director of Nursing, and the Medical Director, revealed that the certified medication technician did not report the resident's blood pressure readings to the nurse, as expected. The Medical Director confirmed that the resident's primary care physician was unaware of the blood pressure readings and would have adjusted the medication if informed. The facility's administrator also stated that the charge nurse was responsible for notifying the primary care physician when medication parameters were not met.
Failure to Maintain Homelike Environment Due to Missing Closet Doors
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, as their closet doors were missing. Observations revealed that both residents had missing closet doors, which exposed their clothing. The Maintenance Supervisor (MS) was unaware of these issues, as they had not been reported to him. A work order for one of the residents' rooms was dated over a month prior, indicating that the closet door was barely hanging. The work order was marked as completed, but the door was not replaced, and the MS could not locate the door. Interviews with the residents and staff revealed that the closet doors had been missing for an extended period. One resident stated their door had been gone for about a year, while the other mentioned the door was removed seven months ago. The Administrator explained the process for reporting maintenance issues, which involved staff completing a work order form and leaving it at the nurses' station. The MS, who was the only maintenance person at the time, was expected to address these issues. However, the MS did not follow up on the work orders, and the Administrator expected the MS to use doors from unoccupied rooms to replace broken ones.
Failure to Develop Comprehensive Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed psychotropic medications, including antipsychotic, antidepressant, and antianxiety drugs. The care plan did not address the use of these medications, nor did it include information on target behaviors or monitoring for potential side effects. The resident, who was admitted with diagnoses of major depressive disorder, Alzheimer's disease, and anxiety disorder, was cognitively intact and did not exhibit hallucinations or delusions during the assessment period. Despite having active medication orders for quetiapine, sertraline, and lorazepam, the care plan lacked specific interventions related to these medications. Interviews with facility staff revealed a lack of training and understanding regarding the development and updating of care plans. A Licensed Practical Nurse (LPN) admitted that many nurses were unaware of how to access care plans in the electronic health record, and stated that nurses had not been trained in care planning. The Director of Nursing (DON), who was also the acting MDS Coordinator, acknowledged that care plans should include target behaviors related to prescribed medications but noted that nurses had never been involved in the care planning process. The Administrator confirmed that care plans should reflect the purpose of medications and specific resident behaviors, but indicated that any nurse could update care plans, although this was not being done effectively.
Failure to Address Hypertensive Crisis in Resident
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice and the comprehensive care plan for a resident whose medication regimen was reviewed. On a specific date, the resident's blood pressure met the criteria for a hypertensive crisis as defined by the American Heart Association (AHA), with a reading of 189/113 mmHg. Despite this, the nursing staff did not re-evaluate the resident or consult with the resident's physician, as required by the facility's policy on observing, recording, and reporting condition changes. The policy mandates notifying the physician of any condition changes, which was not adhered to in this instance. The resident, who was admitted to the facility with a medical history of bradycardia and essential hypertension, had a care plan that included monitoring for signs or symptoms of high blood pressure and notifying the physician of any abnormalities. However, the progress notes for the month did not document any reassessment of the resident's elevated blood pressure or notification to the physician. Interviews with staff, including a CNA, LPN, and CMT, revealed that while there was an expectation to report abnormal readings, the process was not followed, and no concerns were raised to the Director of Nursing regarding the resident's condition.
Medication Security and Fall Prevention Failures
Penalty
Summary
The facility failed to secure medications for a resident, identified as Resident #30, who was cognitively intact but had impaired vision. The resident had medications, including ciclopirox gel and clotrimazole-betamethasone lotion, in their room without a physician's order for self-administration or an assessment to determine if they were safe to self-administer. The medications were left at the bedside, and the resident reported using them independently. Staff interviews revealed a lack of awareness and communication regarding the proper storage and administration of these medications, with some staff assuming the medications were allowed at the bedside without verification. Another deficiency involved the facility's failure to thoroughly investigate a fall and implement fall interventions for Resident #28, who had severe cognitive impairment and a history of falls. The resident experienced an unwitnessed fall resulting in a hip fracture, but the event report was incomplete, lacking details such as possible contributing factors and witness statements. Observations showed that a fall mat, which was part of the care plan, was not in place, and staff interviews indicated confusion and inconsistency in implementing fall prevention interventions. The Director of Nursing and Administrator acknowledged the deficiencies, noting that medications should not be left at a resident's bedside without proper orders and assessments, and that fall interventions should be consistently implemented and documented. The lack of complete incident reports and follow-up on care-planned interventions contributed to the facility's failure to prevent accidents and ensure resident safety.
Failure to Monitor and Record Fluid Intake for Resident with Fluid Restriction
Penalty
Summary
The facility failed to monitor and record fluid intake for a resident with a physician's order for a fluid restriction. The resident, who had a history of end-stage renal disease and edema, was admitted to the facility and had a care plan that required staff to monitor and record food and fluid intake. Despite this, there was no documented evidence that the facility monitored and recorded the resident's fluid intake, which was crucial given the resident's medical condition and fluid restriction order. Observations revealed that the resident consumed fluids beyond the prescribed restriction, with no system in place to track the intake. Interviews with staff, including a CNA and an LPN, indicated a lack of awareness and understanding of the resident's fluid restriction. The CNA was unaware of the fluid restriction, and the LPN admitted that the facility had not kept track of the resident's fluid intake and was unsure of the daily fluid allowance. The LPN also noted the absence of a process for tracking fluid intake and was unclear about who was responsible for monitoring the resident's fluid consumption. Further interviews with an RN and the Dialysis Facility Administrator highlighted the lack of communication and documentation regarding the resident's fluid intake. The RN confirmed that fluid intake was not documented, making it impossible to know the resident's consumption over a 24-hour period. The Dialysis Facility Administrator noted that the resident's laboratory results were poor and that the facility had not provided any fluid intake records. The facility administrator was unaware of the lack of documentation and expected fluid intake to be recorded and shared between shifts.
Failure to Communicate with Dialysis Provider
Penalty
Summary
The facility failed to ensure proper communication with a dialysis provider for a resident with end-stage renal disease, who required dialysis services. The facility's policy mandated that a Dialysis Communication Record be sent with the resident on each dialysis visit, detailing care concerns, medications given, and a facility contact person. The dialysis unit was expected to complete the lower portion of the report with information such as the resident's weight before and after dialysis, any labs completed, medications given, follow-up information, and any new physician orders. However, it was found that this communication protocol was not consistently followed for the resident in question. Interviews revealed that the Licensed Practical Nurse (LPN) responsible for the resident had not been sending the communication report to the dialysis center until the day of the survey. The Director of Nursing (DON) confirmed that communication was expected to be documented and sent, but this was not happening regularly. The Dialysis Facility Administrator (DFA) noted that the dialysis center rarely received the communication forms and was surprised to receive one recently. Instead, the dialysis center often relied on verbal communication with the facility. This lack of consistent documentation and communication between the facility and the dialysis provider led to the deficiency identified by the surveyors.
Failure to Monitor and Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that the medication regimen for two residents was free of unnecessary medications. For Resident #34, the facility did not specify the target behaviors for which the antipsychotic medication quetiapine was prescribed, nor did it monitor for potential adverse drug reactions. The resident's care plan did not address the use of the antipsychotic medication or include interventions related to target behaviors. Despite an order for behavior monitoring, there was no documentation of behavior tracking or monitoring for adverse drug reactions. Resident #41 was also affected by the facility's failure to specify target behaviors for the use of antipsychotic medication. The resident's care plan identified the use of a psychotropic medication but did not specify which one or the reason for its prescription. The medication flowsheets lacked documentation of target behaviors, behavior tracking, or monitoring for adverse drug reactions. Observations and interviews with staff indicated that the resident exhibited wandering behavior but no aggressive or threatening behaviors. Interviews with facility staff, including nurses and the Director of Nursing, revealed a lack of behavior monitoring and documentation. The Medical Director stated that dementia with agitation or anxiety was not an appropriate indication for antipsychotic medication use and emphasized the importance of monitoring and documenting resident behaviors. The facility's failure to document and monitor behaviors led to the continued use of antipsychotic medications without clear justification.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal vaccine to a resident who was reviewed for vaccinations. The resident, who had a medical history including an acute upper respiratory infection, was admitted to the facility in 2019 and readmitted in 2022. Consent for the pneumococcal vaccine was given by the resident's responsible party on two occasions, in September 2022 and September 2023. However, the resident's vaccination record showed no evidence of the vaccine being administered, and a quarterly Minimum Data Set assessment indicated the resident was not up to date on their pneumococcal vaccine. Interviews revealed that the Director of Nursing stated vaccinations were offered upon admission and should be administered if accepted, unless contraindicated by a physician. The Director was unaware of any residents who had requested but not received the vaccine. The Administrator confirmed that while consent was present, the vaccine had not been administered to the resident. The Administrator admitted to failing to review the consents and provide the vaccinations, and noted that the former Director of Nursing, responsible for coordinating the vaccination program, did not follow through with the vaccinations during their tenure.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide showers as scheduled or preferred for two residents, leading to a deficiency in the care provided. Resident #37, who has a medical history including dementia and muscle weakness, was scheduled for showers three times a week but often did not receive them. Despite a care plan that included strategies for when the resident declined care, documentation showed that Resident #37 received significantly fewer showers than scheduled. Interviews with family members and staff revealed inconsistencies in shower documentation and a lack of follow-up when showers were missed. Resident #34, with a history of Alzheimer's disease and other conditions, was also affected by the facility's failure to adhere to the shower schedule. This resident was scheduled for showers twice a week but often went without them for extended periods. The care plan did not address the resident's daily bathing needs, and there was no documentation of refusals or additional shower offers. Interviews with staff indicated that showers were not consistently provided due to staffing issues and workload. The deficiency was further highlighted by the lack of proper documentation and communication among staff. Several CNAs and other staff members reported that showers were not given as scheduled due to insufficient staffing and workload pressures. The facility's system for tracking showers was inadequate, with discrepancies between scheduled showers and those documented. The failure to provide showers as scheduled and the lack of proper documentation and follow-up contributed to the deficiency identified by the surveyors.
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 citations issued around you in the last 12 months — including the 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 Bethany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Daviess County Nursing And Rehabilitation | 23.7 mi | ★★★★★ | 0 | 0 |
| Sunnyview Nursing Home & Apartments | 25 mi | ★★★★★ | 10 | 1 |
| Eastview Manor Care Center | 25.1 mi | ★★★★★ | 7 | 0 |
| Lamoni Specialty Care | 25.5 mi | ★★★★★ | 3 | 0 |
| Worth County Convalescent Center | 25.6 mi | ★★★★★ | 9 | 0 |
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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.