Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kingdom Care Senior Living during CMS and state inspections, most recent first.
Unsafe Food Storage, Temperature Control, and Dish Drying Practices: Staff failed to keep salad bar foods at safe cold-holding temperatures while residents ate from the salad bar, with items such as tuna salad, potato salad, ranch dressing, and boiled eggs measured above the required range. Staff also left multiple food items undated, unlabeled, uncovered, or past use-by dates in the kitchen and kitchenette, and wet dishes and cups were stacked or stored before air-drying. The cook, DM, and administrator acknowledged gaps in temperature checks, dating, and dish-drying oversight.
Facility staff failed to document a thorough facility-wide assessment that identified staffing needs by unit and shift or included input from direct care staff, residents, resident representatives, or family members. The assessment listed RN, LPN, and CNA workforce profiles, but did not show how each unit would be staffed across day, evening, and night shifts. The Administrator said staffing data should include hours, days, and staff type, but acknowledged no input was included from direct care staff or residents; LPN A, the DON, and RN H also said they did not participate in the assessment review.
Incomplete Person-Centered Care Plans: Facility staff failed to develop and implement comprehensive, person-centered care plans for four residents. Care plans omitted key assessed needs and preferences, including bed rail use for two cognitively intact residents, a resident’s shower preference, and another resident’s stated interests in music, group activities, going outside, and religious activities. The MDS Coordinator and DON stated care plans should reflect residents’ care, needs, and preferences.
Care plans were not reviewed and revised to match assessed resident needs for five sampled residents. Missing items included an indwelling urinary catheter, hospice care, nutritional supplementation and weight loss needs, toileting assistance, and a fall review after a wheelchair fall. MDS, DON, and admin staff stated care plans should reflect resident care needs, preferences, falls, hospice, meds, treatments, and bowel/bladder incontinence.
Unlocked medication and treatment carts were observed unattended at the nurse station and in a dining hallway area, despite the facility policy requiring drugs and biologicals to be kept in locked compartments or under direct observation. RN C said the cart was normally locked but was left unlocked, and the DON and Administrator stated carts should be locked when unattended. In addition, an unlocked cabinet in the kitchenette contained disinfectant and multipurpose cleanser on multiple observations, and the DM said the chemicals should have been locked up.
Facility staff failed to educate and offer the COVID-19 vaccine and document vaccination status for four residents. Their records lacked documentation of education, administration, or refusal for the current vaccination season, and the IP reported the issue may have been related to a recent change in ownership and transition to a new EMR. The Administrator stated all residents were expected to be offered the vaccine per policy, but corporate transition and staff relocation had made compliance challenging.
Facility staff failed to complete required SCSA MDS assessments for two residents who elected hospice services and failed to complete a timely updated MDS for a third resident with changes in toileting, transfers, and bowel continence. The MDS Coordinator said he/she was new to the role and was not aware the SCSA had not been completed, while the DON said the MDS Coordinator was responsible for timely MDS completion and change-of-status assessments.
Staff failed to obtain orders for an indwelling urinary catheter and catheter care for one resident, failed to obtain a hospice order for another resident receiving hospice services, and failed to notify the physician when a resident did not receive tirzepatide as ordered. Records showed missing catheter details and hospice orders, while MARs and nurse notes documented omitted tirzepatide doses, prior authorization issues, and no physician notification or follow-up.
A resident with impaired kidney function and stage four kidney failure had a physician-ordered nephrology consult, but staff did not document timely attempts to schedule the appointment before discharge. Nursing notes showed family contact about the consult and scheduling concerns, while a family member reported the visit still had not been arranged. An LPN said another staff member had been responsible for appointments, and the DON stated appointment setup, transportation needs, and family contact should be documented.
Shower Room Not Kept Clean: A facility failed to maintain the only resident shower room in a clean, comfortable, and homelike condition. Surveyors observed heavy brown discoloration in the spa tub and thick white and off-white buildup on the shower walls, grab bar, caddy, and floor edges. Staff gave conflicting accounts of who was responsible for cleaning, and the DON/maintenance director said the limescale had been known for months but had not been addressed.
Facility staff failed to maintain and implement a comprehensive, annual facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. The only available assessment lacked required information on staffing for day-to-day and emergency situations. An LPN responsible for scheduling reported staffing based on census rather than resident acuity and was unaware of any staffing direction from the facility assessment. The corporate finance director, temporarily assisting after the prior administrator’s abrupt departure, did not know required update frequency for the assessment. During this period, the facility had no DON, a planned DON hire withdrew before starting, and the Assistant DON (an RN) had only recently returned and was being placed into the DON role, while the facility census was 26 residents.
Facility staff did not maintain a separate accounting of resident personal funds and allowed commingling with operating funds, resulting in multiple residents' funds being held in the facility account without timely refunds. Administrative staff and the DOO confirmed that refunds were not processed within the required timeframe due to corporate-level delays and financial constraints, and there was no written authorization to retain these funds after discharge.
The facility failed to maintain a homelike environment, with multiple resident rooms showing unpainted drywall patches, gouges, and scrapes. Despite policies requiring a safe and clean environment, staff interviews revealed a lack of communication and follow-through in reporting maintenance issues. The maintenance director did not receive work orders for the damages, and the administrator was unaware of unpainted repairs, highlighting a breakdown in the facility's maintenance process.
Facility staff failed to implement Enhanced Barrier Precautions (EBP) for two residents requiring feeding tubes, as staff did not wear gowns during high-contact care activities. Observations showed a lack of EBP signage and PPE stations, and interviews revealed staff were unaware of EBP guidelines. The Director of Nursing and administrator acknowledged the oversight, indicating a gap in infection control practices.
Facility staff failed to update care plans for two residents regarding meal assistance and bed rail usage. One resident struggled to eat due to a hand contracture and required assistance, which was not documented in the care plan. Another resident had swallowing issues requiring nectar thick liquids and supervision, yet the care plan inaccurately documented independence with eating. Staff interviews confirmed the need for care plan updates to reflect the residents' current needs.
Facility staff failed to obtain a physician's order and update the care plan for a resident receiving oxygen therapy. The resident's Physician Orders Sheet lacked an order for oxygen, despite continuous use documented in the care plan. Observations showed varying oxygen levels administered without a corresponding order or care plan update. Interviews with staff revealed inconsistencies in oxygen administration and a lack of awareness regarding correct settings, with the DON acknowledging responsibility for ensuring proper documentation.
The facility failed to post complete nurse staffing information, missing details such as the number of licensed staff and total hours worked for various shifts. Observations over several days showed incomplete postings, and interviews with staff revealed a lack of awareness and responsibility for ensuring the forms were filled out correctly. The DON and administrator were unaware of the deficiencies, despite the facility's policy requiring accurate and timely postings.
Unsafe Food Storage, Temperature Control, and Dish Drying Practices
Penalty
Summary
Food items on the salad bar were not maintained at safe cold holding temperatures during meal service. On 04/13/26, residents ate from the salad bar while the tuna salad measured 44 dF, the potato salad measured 49 dF, and the ranch dressing measured 45 dF. On 04/14/26, residents again ate from the salad bar while the tuna salad measured 48 dF, the boiled eggs measured 55 dF, and the potato salad measured 49 dF. The cook stated he/she sometimes checked salad bar temperatures but did not document them because there was no temperature log, and said unused salad bar items were normally wrapped and served again the following day. The dietary manager stated salad bar items should be 41 dF or below, but staff did not check or log temperatures during meal service and items were prepared on Mondays and discarded on Thursdays. Food storage practices were also not followed. Observations found multiple food items in the kitchen and dining room kitchenette that were undated, unlabeled, or left uncovered, including wrapped French toast, peas, beef patties, chicken patties, hotdogs, prunes, mashed potatoes, dry yeast, cooked green beans, pitchers of yellow liquid, milk, prepared food in to-go containers and bowls, cranberry juice, vegetables, potatoes, cereal removed from original containers, an opened loaf of bread, potato chips past the manufacturer’s use-by date, and a gallon of lime juice dated 7/23/25 with a use-by date of 01/28/26. The dietary manager stated staff were expected to label and date all food items, store them covered or sealed, and discard items past their best-by or use-by dates, but said he/she did not know about the storage issues. Dish handling was also deficient. The facility had no policy related to dish drying or storage, and observations showed wet metal food pans stacked together on a kitchen shelf, wet plastic cups stacked in a cabinet in the dining room kitchenette, and wet red coffee cups stored inverted directly on a cabinet surface without airflow beneath them. The dietary aide stated dishes had been washed that morning and were put away before they were completely dry because he/she was in a hurry, and acknowledged dishes were supposed to air-dry before being stored. The dietary manager and administrator stated staff were responsible for ensuring dishes were dry before being put away, and both said they were not aware of the dish storage issues.
Facility Assessment Lacked Unit- and Shift-Specific Staffing Input
Penalty
Summary
Facility staff failed to document a thorough facility-wide assessment to determine the resources needed to care for residents competently during day-to-day operations and emergencies. The assessment did not include specific staffing needs for each resident unit or for each shift, such as day, evening, and night shifts. The facility census was 27.1, and the facility assessment policy dated October 2018 stated that residents, representatives, and family members may be asked to participate in the review of care and services, but the policy did not contain documentation or assessment of staffing needs by unit or shift. Review of the facility assessment dated 04/01/26 showed the workforce profile included RNs, LPNs, and CNAs, but did not document how the facility assessed or would staff each unit or shift. The assessment also did not document involvement from direct care staff, residents, resident representatives, or family members. During interviews, the Administrator said staffing data should include hours, days, and type of staff, but stated he/she did not include input from direct care staff or residents and/or resident representatives and was new to the facility. LPN A, the DON, and RN H each stated they did not participate in or have input into the facility assessment review.
Incomplete Person-Centered Care Plans
Penalty
Summary
Facility staff failed to develop and implement person-centered comprehensive care plans for four of twelve sampled residents. The facility’s Comprehensive Care Plan policy required care plans to be based on a thorough assessment, include measurable objectives and timeframes, describe services to maintain the resident’s highest practicable well-being, include resident-stated goals and outcomes, build on resident strengths, and reflect current recognized standards of practice. Review of the records showed that Resident #1 was assessed as cognitively intact, but the care plan dated 02/04/26 did not include bed rail use even though the resident was observed in bed with both bed rails in the upright position and stated the rails were used for bed mobility. Resident #17 was also assessed as cognitively intact and required partial to moderate assistance with toileting and bathing, yet the care plan dated 02/19/26 did not contain bed rail use despite observation of both bed rails being up while the resident was in bed. Resident #9 was assessed as cognitively intact and needing set up and clean-up assistance for shower/tub hygiene and transfers, but the care plan dated 04/01/26 listed partial to moderate assistance with bathing and did not include shower preferences. During interview, the resident stated a preference to receive a shower once a week on Tuesdays. Resident #23’s significant change assessment showed cognitive impairment and identified preferences for listening to music, participating in group activities, favorite activities, going outside when the weather is nice, and religious activities, but the care plan dated 04/01/26 only noted liking one-on-one activities, enjoying time with a daughter who visited often, and offering participation in all activities, without direction for the resident’s preference to go outside or participate in religious activities. The MDS Coordinator stated care plans should include all aspects of residents’ care based on assessment and preferences, and the DON stated the care plan should reflect residents’ care, needs, and preferences.
Care Plans Not Updated for Assessed Resident Needs
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plan for five of twelve sampled residents. The facility policy stated care plans are to be based on the comprehensive assessment, include measurable objectives and timeframes, reflect current standards of practice, and be revised when a resident’s condition changes or at least quarterly. Review of the records showed that Resident #2’s quarterly MDS dated 03/18/26 identified cognitive intactness, occasional urinary incontinence, and chronic kidney disease, but the 04/01/26 care plan did not address the resident’s indwelling urinary catheter, which was observed on 04/14/26 and described by the resident as being flushed twice daily. An LPN stated the catheter should have been on the care plan. Resident #8’s SCSA MDS dated 03/23/26 showed severe cognitive impairment, stroke, polyneuropathy, and hospice care, with a physician order to admit to hospice on 03/26/26, but the 01/22/26 care plan did not address hospice care. Resident #13’s quarterly MDS showed moderate cognitive impairment and no weight loss or specialized diet, yet dietary notes dated 12/18/25 recommended a daily nutritional shake and the 08/09/25 care plan did not address weight loss or nutritional needs. Resident #19’s quarterly MDS showed cognitive intactness, continence, partial to moderate assistance needs for toilet hygiene and transfers, and renal insufficiency, but the 04/01/26 care plan did not provide direction for toileting needs; the resident stated he/she had occasional bowel incontinence and needed staff help with cleansing. Resident #23’s SCSA MDS showed cognitive impairment, hospice services, no falls since admission/entry or prior assessment, and dementia, but nurse’s notes documented a fall from the wheelchair on 01/03/26 and the census record showed hospice admission on 02/14/26; the 04/01/26 care plan did not include the fall review or hospice election. The MDS Coordinator, DON, and Administrator each stated care plans should reflect residents’ care needs, preferences, falls, hospice, medications, treatments, and bowel and bladder incontinence.
Unlocked Medication Carts and Unsecured Cleaning Chemicals
Penalty
Summary
The facility failed to provide an environment free from accident hazards when medication and treatment carts were left unlocked and unattended in areas accessible to residents, staff, and visitors. The facility’s Medication Storage policy required all drugs and biologicals to be stored in locked compartments and kept under direct observation during medication pass or locked in the medication storage area/cart. However, observations showed an unlocked and unattended treatment cart and an unlocked unattended medication cart at the nurse’s station, an unlocked treatment cart with RN C’s back turned to it while residents and staff passed by, and another medication cart left unlocked and unattended by the nurse station. RN C stated he/she normally locks the cart but did not realize the treatment cart was left unlocked, and said residents, staff, or visitors could get into the cart and take things that could hurt them. The facility also failed to secure cleaning chemicals in the kitchenette area of the main dining room. The Environmental Services Safety Procedures policy required equipment and chemicals to be properly stored and not left unattended in areas accessible to residents, and to be stored in a locking closet, cabinet, or storage area when not in use. Observations on multiple days showed an unlocked, unattended cabinet in the kitchenette containing a bottle of disinfectant cleaner and two bottles of multipurpose cleanser. The Dietary Manager stated he/she was responsible for ensuring the cleaning chemicals were secure, said the cleaning sprays should be locked up, and said he/she did not know the cleaning sprays were not locked up.
Failure to Educate, Offer, and Document COVID-19 Vaccination
Penalty
Summary
Facility staff failed to educate and offer the COVID-19 vaccine to eligible residents and to document each resident’s vaccination status as required. Record review showed that the medical records for Residents #8, #13, #15, and #25 did not contain documentation of education, administration, or refusal of the COVID-19 vaccination for the 2025-2026 season. The facility’s policy stated that the facility would educate and offer the COVID-19 vaccine to residents, resident representatives, and staff and maintain documentation of each, and that a copy of the Vaccine Information Statement would be given prior to administration. During interview, the Infection Preventionist stated he/she was new to the position and that the facility had recently undergone a change of ownership. He/She said documentation may not have been uploaded into the computer system after the transition to a new EMR on April 1st and identified responsibility for the immunization program. The Administrator stated he/she expected all residents to be offered COVID-19 vaccination according to policy and said the corporate transition and relocation of staff had made compliance challenging.
Failure to Complete Required SCSA and Updated MDS Assessments
Penalty
Summary
Facility staff failed to complete a significant change in status assessment (SCSA) for two residents who elected hospice services and for one resident who had a change in activities of daily living. The facility policy stated that an SCSA is required within 14 days of identifying a status change that meets RAI manual requirements, including when a resident enrolls in hospice or changes hospice providers and remains in the facility. Review of one resident’s quarterly MDS showed cognitive impairment, hospice services, and dementia, and the census record showed hospice admission on 03/25/26, but the medical record did not contain a completed SCSA. The MDS Coordinator stated he/she was new to the role and was not aware the SCSA had not been completed. A second resident’s SCSA, dated 02/12/26, showed cognitive impairment, hospice services, and dementia, and the census record showed hospice admission on 02/14/26. During interview, the MDS Coordinator said he/she was not aware a SCSA was not completed. For a third resident, the quarterly MDS showed cognitive intactness, supervision/touch assistance for toileting, independent transfers, and occasional bowel incontinence, while a later quarterly MDS showed partial to moderate assistance with toileting and transfers and no incontinence. The resident stated he/she had occasional bowel incontinence, needed help getting cleaned up, and sometimes needed help with transfers. The MDS Coordinator said residents with a change of status should have a new MDS completed within 14 days, and the DON said the MDS Coordinator was responsible for ensuring timely completion of MDS assessments and change-of-status assessments.
Missing catheter, hospice, and medication notification orders
Penalty
Summary
Facility staff failed to obtain orders for an indwelling urinary catheter and catheter care for one resident. The resident’s quarterly MDS dated 03/18/26 showed the resident was cognitively intact, occasionally incontinent of urine, and always continent of bowel. The physician order summary for March 2026 included an order dated 03/18/26 to change the urinary catheter every month on the 19th, but it did not include the catheter size, balloon size, or orders for catheter care. On 04/11/26, the resident was observed sitting in a recliner in the room with a urinary catheter in place, and the resident stated a nurse flushes the catheter twice a day. On 04/15/26, an LPN stated nurses were responsible for changing the resident’s indwelling urinary catheter and said he/she did not know the resident did not have orders for the catheter size, balloon size, or catheter care. Facility staff also failed to obtain an order for hospice for another resident. The facility’s Hospice Program, dated July 2017, did not include direction or guidance for a physician order for hospice services. The resident’s significant change in status assessment showed the resident was cognitively impaired, received hospice services, and had a diagnosis of dementia. The physician order summary for April 2026 did not contain an order for hospice. An LPN stated residents should have a hospice order in the medical record when hospice is elected and said he/she did not know the resident did not have an order. The DON stated nurses should obtain an order from the physician when the resident and/or family elects hospice services and said he/she was not aware there was not an order. Facility staff failed to notify the physician when one resident did not receive medication as ordered. The resident’s quarterly MDS showed the resident was cognitively intact. The physician ordered tirzepatide 2.5 mg/0.5 ml once weekly on Mondays, then the order was discontinued on 03/16/26 and reordered on 03/23/26. Nurse notes documented prior authorization needed, omission, and prior authorization awaiting, and the MAR contained codes or missing entries for several scheduled doses, but the progress notes did not show that staff notified the physician or followed up on prior authorization. The resident’s family member said the medication had not been given after the insurance change and was concerned the resident would not lose the needed weight for hip surgery. The pharmacy stated a denial was sent to the facility for the order and that prior authorization was required. The PCP’s office said it would expect the facility to notify him/her if the medication was unavailable, but was not notified. An LPN stated the facility had an issue obtaining prior authorization and said the physician should be notified when a resident is out of a medication or unable to obtain it.
Failure to Arrange Nephrology Appointment
Penalty
Summary
Facility staff failed to ensure arrangements were made for outside nephrology services for one resident with impaired kidney function. The resident’s annual MDS dated 01/01/26 identified the resident as cognitively intact, always incontinent of bladder, and having a diagnosis of impaired kidney function. The physician ordered a nephrology consult on 02/08/26, and the medical record also showed physician progress notes and an email requesting that staff schedule a nephrology appointment. The facility admission agreement stated that if a resident chose a physician without facility privileges, the resident would travel at their own expense, but it did not provide direction for assistance with transportation or appointment setup. Nursing notes documented that staff left a voicemail for the family about the nephrology consult, spoke with the family about wanting an update on the appointment date and time, and later spoke with the family again when the family said the appointment needed to be scheduled 30 days out because of work requests. The record did not show documentation that staff attempted to schedule the nephrology appointment from the original order until the resident discharged from the facility on 03/30/26. During interview, a family member stated the nephrology appointment had been ordered in February and still had not been set up, and said the resident’s blood work showed stage four kidney failure. An LPN stated another staff member had been responsible for scheduling appointments and was no longer employed, and the DON stated staff would be expected to set up appointments within a day or two of receiving the order and document attempts, appointment dates, transportation needs, and family contact.
Shower Room Not Kept Clean
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment when the only shower room used by all residents was observed with significant buildup of foreign material. During the Life Safety Code tour, the spa tub had a large amount of brown discoloration extending from the faucet to the drain area, all three shower walls, the shower grab bar, and the shower caddy had a thick white substance, and the outer edges of the shower floor had a large buildup of white and off-white substances. The facility policy stated housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment, but it did not include specific guidance for the resident shower room. Staff interviews showed conflicting responsibility for cleaning and maintaining the shower room. A housekeeper said the shower was cleaned daily and identified the thick white substance as limescale buildup that maintenance had a chemical to remove. The housekeeping supervisor said nursing staff were responsible for cleaning the tub and shower after each use, while housekeeping had tried to clean it a few months earlier but could not remove all of the buildup. The maintenance director said nursing staff were responsible to clean the tub and shower daily and housekeeping also deep cleaned it, but he did not know how often; he also said he was responsible for removing the scale buildup and had known about it for about two or three months but had not addressed it. The administrator stated housekeeping was responsible to keep the tub and shower clean and free of limescale buildup and said the shower room should not have been in that condition.
Failure to Maintain and Implement Comprehensive Facility-Wide Assessment for Staffing
Penalty
Summary
Facility staff failed to conduct and document a comprehensive, annual facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment Report dated July 2024 showed it did not contain required information on staffing for routine operations and emergency situations. The July 2024 assessment was identified as the only facility assessment available. The corporate director of finance, who was temporarily assisting at the facility after the abrupt departure of the previous administrator, stated not knowing how often the assessment needed to be updated or why the previous administrator had not maintained it. Interviews further showed that staffing practices were not guided by the facility assessment. An LPN responsible for the nursing staff schedule reported scheduling staff based on census rather than resident acuity and stated not knowing what the facility assessment directed for staffing. The corporate director of finance confirmed that the LPN handled the staffing schedule. Additionally, the facility had been without a DON since mid-December, and a planned DON hire had declined the position before starting. The corporate administrator reported that the Assistant DON, an RN, had only recently returned to work and would be placed in the DON role until a new DON was hired. The facility census at the time of the survey was 26 residents.
Failure to Maintain Separate Accounting and Timely Refunds of Resident Funds
Penalty
Summary
Facility staff failed to prevent the commingling of personal funds belonging to nine residents with the facility's operating funds. Record review showed that the facility's admission assessment policy requires a system that ensures separate accounting of resident funds, prohibits commingling with facility or other individuals' funds, and mandates timely refunds within 30 days of discharge. Despite these requirements, the Accounts Receivable (AR) Aging report revealed that significant amounts of resident funds were held in the facility's operating account, totaling $22,759.25 for the nine residents. There was no written permission to hold these funds after discharge. Interviews with the administrator and Director of Operations (DOO) confirmed that the process for issuing refunds and updating the AR Aging report is managed at the corporate level, and the facility administrator cannot issue refunds directly. Both the administrator and DOO acknowledged awareness of outstanding credits owed to residents, with refunds not being issued within the required 30-day timeframe. The DOO stated that financial constraints sometimes delayed approval for refunds, and that refund checks and updates to the AR Aging report were not consistently communicated to the facility. The facility did not have written authorization to retain resident funds after discharge.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, and comfortable home-like environment for its residents, as evidenced by multiple observations of damaged and unmaintained areas within resident rooms. The facility's policy on Quality of Life-Homelike Environment, dated May 2017, mandates that residents are provided with a safe, clean, comfortable, and homelike environment. However, observations revealed numerous instances of unpainted drywall patches, gouges, and scrapes in the paint across various resident rooms. These deficiencies were noted in several rooms, with issues such as peeled paint, unpainted patched areas, and damaged drywall being prevalent. The facility's Maintenance Service policy, dated December 2009, outlines the responsibility of the maintenance department to maintain the building in a safe and operable manner. Despite this, the maintenance director reported not receiving any work orders for the observed damages during the week of the survey. Interviews with staff, including a CNA and an RN, indicated a lack of communication and follow-through in reporting maintenance issues. The CNA mentioned being too busy to notice cosmetic issues, while the RN expressed uncertainty about whether damage had already been reported, leading to inaction. The maintenance director stated that repairs require a work order before entering resident rooms and acknowledged the absence of a set schedule for painting patched drywall. The administrator confirmed that staff should notify maintenance of any damage, with aides reporting to nurses and nurses emailing maintenance. Despite having paper requests available at the nurses' station, the administrator had not noticed unpainted drywall repairs. This lack of effective communication and follow-up resulted in the failure to maintain a homelike environment as required by facility policies.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of infection-causing contaminants during care for two residents. The facility's EBP guidelines, which are designed to reduce the transmission of Multidrug-Resistant Organisms (MDROs), require the use of gowns and gloves during high-contact resident care activities. However, observations revealed that staff did not adhere to these guidelines, as evidenced by the lack of EBP signage and Personal Protective Equipment (PPE) stations outside the residents' rooms, and staff not wearing gowns during care activities. Resident #9, who had a severe cognitive impairment and required a feeding tube, was observed receiving care without the necessary EBP measures in place. Staff members, including a Licensed Practical Nurse (LPN), Certified Nurse Aide (CNA), and Registered Nurse (RN), were seen providing care such as tube feeding, medication administration, and personal hygiene without wearing gowns. Similarly, Resident #28, who also required a feeding tube, was observed receiving care without EBP signage or PPE stations, and staff did not wear gowns during care activities. Interviews with staff, including CNAs, RNs, and the Director of Nursing (DON), revealed a lack of awareness and training regarding EBP. Staff members admitted to not knowing what EBP was or that it should be used for residents with feeding tubes and catheters. The DON and the facility administrator acknowledged the failure to implement EBP and the absence of necessary equipment and signage, indicating a significant gap in infection control practices at the facility.
Failure to Update Care Plans for Meal Assistance and Bed Rail Usage
Penalty
Summary
The facility staff failed to update the care plans for meal assistance and bed rail usage for two residents. Resident #3's care plan did not include documentation regarding the resident's need for meal assistance and the use of side rails, despite observations showing the resident struggled to eat due to a partial contracture of the right hand and required assistance. The resident's care plan inaccurately documented independence with meals after setup assistance, and there was no mention of the resident's use of bed rails for positioning with staff assistance. Resident #24's care plan also lacked necessary interventions for choking concerns, despite the resident being assessed as having difficulty swallowing and requiring nectar thick liquids with supervised assistance during meals. Observations showed the resident coughed and choked while eating and drinking, yet the care plan documented the resident as independent with eating. Staff interviews confirmed the resident's need for supervision during meals due to swallowing issues, which was not reflected in the care plan. Interviews with facility staff, including a CNA, RN, and the DON, revealed a lack of awareness and adherence to the care plans, with staff acknowledging the need for updates to reflect the residents' current needs. The MDS coordinator, responsible for care plan development, was on leave, and the DON had been updating care plans but failed to include critical information for these residents. The administrator also confirmed the necessity for care plans to address the residents' swallowing issues and meal assistance needs.
Failure to Obtain Physician's Order and Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility staff failed to obtain a physician's order and update the care plan for a resident receiving oxygen therapy. The facility's policy requires staff to verify a physician's order for oxygen administration and review the care plan for any special needs. However, the resident's Physician Orders Sheet did not contain an order for oxygen, despite the resident using oxygen continuously as documented in the care plan. Observations showed varying oxygen levels administered to the resident, ranging from three to five liters per minute, without a corresponding physician's order or care plan update. Interviews with facility staff, including a CNA, RN, and the DON, revealed inconsistencies in the oxygen administration and a lack of awareness regarding the correct oxygen settings. The CNA mentioned that the oxygen use should be on the care plan, and the RN confirmed that there should be an order for oxygen. The DON acknowledged the responsibility for ensuring oxygen is listed on the physician's orders and care plan, especially in the absence of the Assistant Director of Nursing. The administrator admitted to confusion and changes in the resident's oxygen use upon admission, highlighting a lapse in communication and documentation.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care, per shift, and on a daily basis. The facility's policy, dated August 2022, mandates that staffing data be posted within two hours of the beginning of each shift in a prominent location. However, observations over several days revealed that the postings were incomplete, missing details such as the number of licensed staff and total hours worked for various shifts. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and the administrator, highlighted a lack of awareness and responsibility regarding the completion of the staffing forms. The LPN responsible for putting out the forms each night was unaware that they were not being filled out correctly. The DON and the administrator both acknowledged that the forms should be completed during shift reports and monitored for accuracy, but neither was aware of the ongoing deficiencies. The administrator indicated that the DON should ensure the forms are completed accurately during floor rounds.
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 144 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fulton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fulton Nursing & Rehab | 0.5 mi | ★★★★★ | 4 | 0 |
| Fulton Manor Care Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Riverview Nursing Center | 12.3 mi | ★★★★★ | 0 | 0 |
| Lenoir Health Care Center | 18.9 mi | ★★★★★ | 0 | 0 |
| Neighborhoods Rehabilitation And Skilled Nursing B | 19.3 mi | ★★★★★ | 14 | 0 |
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