Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Laverna Manor Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to Initiate CPR for a Full Code Resident: A resident with cardiac and respiratory diagnoses was documented as Full Code and had a TPOPP/POLST requesting CPR if found without a pulse and not breathing. After the resident was found unresponsive, not breathing, and without a pulse, an LPN asked a family member whether CPR should be started and waited several minutes while the family member decided; CPR was not performed and the resident died at the facility. Interviews showed the LPN knew the resident was Full Code but did not initiate CPR, and staff stated CPR should have been started regardless of the family member’s statement.
Food service failed to provide meals at safe, appetizing temperatures and did not consistently follow the posted menu. Surveyors observed hot and cold items served without temperature checks, with breakfast items including a biscuit, omelet, milk, and juice served at improper temperatures and with poor appearance. Residents reported cold, dry, or burnt food, repetitive menus with too many sandwiches, too few salads and fresh fruit, and diabetic residents described meals that were too high in carbs and lacking protein. Staff also served chicken salad on plain white bread when croissants were unavailable and did not document a suitable substitute for missing taco salad items.
A facility failed to maintain professional standards of care when a resident with a PEG tube had no physician order for flushing before and after medications, another resident listed with Hospice lacked a hospice order in the POS, and a third resident received multiple crushed medications without an order to crush them. Staff observed the PEG tube medication administration, confirmed the hospice documentation gap, and acknowledged that crushed-medication instructions should have been in the record.
Expired medications and unlabeled opened medications were found in medication storage areas and carts, including Lorazepam, a Narcan nasal spray, a multivitamin, a TB PPD vial, and an opened insulin pen for a resident with Type 2 DM. Staff also failed to maintain refrigerator temperature logs and the freezer had heavy ice buildup, while interviews confirmed daily temperature checks and dating of opened medications were expected.
Surveyors found multiple food safety failures, including expired and undated food items stored in the refrigerator, staff preparing and handling food without required hairnets or beard nets, and food served without required temperature checks. Breakfast items were moved from the oven to the heating cart and steam line without being temped, and a dietary staff member also failed to wear proper hair restraints while preparing food.
Incomplete Antibiotic Stewardship Monitoring: The facility failed to maintain consistent antibiotic stewardship and infection surveillance tracking. Review showed missing monitoring records for several months, while four residents were receiving antibiotics for UTI and URI. The Infection Control Nurse, DON, and Administrator stated the binder should have been kept up to date, but the Infection Control Nurse reported she had been working frequently as a charge nurse and had not completed the required tracking.
The facility failed to provide required Medicare non-coverage notices for two residents. One resident did not have a NOMNC showing the right to appeal when Medicare Part A services ended, and another resident did not have a signed SNF ABN when Medicare-covered services were discontinued before benefit days were exhausted. The Social Services Director said she was responsible for completing the forms but could not locate the missing documents.
A quarterly MDS for a resident was transmitted well past the required timeframe. The RNC said the prior MDS coordinator had quit, an outside vendor later reported incomplete sections, and she then corrected and sent the assessment. The Administrator stated MDS assessments should be completed and submitted within required timeframes.
Improper catheter care was observed for a resident with an indwelling urinary catheter, dementia, and hospice services. CNAs cleaned the catheter tubing with disposable wipes by wiping toward the insertion site, while multiple staff members, including an RN, Infection Control Nurse, and DON, stated the tubing should be cleaned away from the insertion site.
Staff failed to follow infection control practices during resident care and medication administration. A resident with an indwelling urinary catheter was transferred and checked for brief changes without EBP or gloves, despite staff confirming those precautions were required. In a separate event, an insulin pen was used for a resident with diabetes without cleaning the pen port with alcohol before the needle was attached, and staff confirmed the port should have been wiped first.
Staff failed to properly secure a sling to a mechanical lift during a transfer, resulting in a resident with severe cognitive and physical impairments falling to the floor and sustaining pain to the shoulders and hip. Despite facility policy and equipment guidelines requiring verification of secure sling attachments, staff did not confirm all loops were attached before moving the resident, leading to the incident.
Two residents with cognitive impairment and pain management needs had fentanyl patches go missing, and staff failed to follow protocol by not conducting or documenting investigations into the missing controlled substances. Leadership was either not notified or did not ensure proper follow-up, resulting in unaccounted-for narcotics and a lack of compliance with facility policy.
A resident with multiple complex medical conditions fell from a mechanical lift and complained of pain. Although a physician ordered the resident to be sent to the hospital for x-rays and evaluation, facility administration directed staff to use mobile x-ray services at the facility instead. The physician and medical director both expected the original order to be followed, but the facility did not comply.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident's prescribed Oxycodone was found missing due to inadequate inventory procedures, as staff only counted in-use narcotic sheets and not full, unopened ones. This failure in controlled substance reconciliation and documentation made it impossible to determine when the medication was taken or who was responsible, and the loss was not identified until mid-shift rather than at shift change.
A resident with a history of sexual outbursts and severe cognitive impairment in a memory care unit inappropriately touched another cognitively impaired resident in a common area. The incident occurred while a CMT was preparing medications nearby, and both residents were unsupervised in close proximity despite known behavioral risks. The facility's abuse prevention measures did not prevent the incident, resulting in a failure to protect residents from abuse.
The facility failed to ensure accurate MDS assessments for five residents, affecting care planning. Discrepancies included incorrect coding of tobacco use and anticoagulant medications, contrary to RAI Manual guidelines. The MDS Coordinator followed external advice without verification, leading to misclassification. The administrator expected accurate assessments, revealing a gap between expectations and practice.
The facility failed to provide written transfer notices to two residents transferred to the hospital, as required by policy. Despite having medical conditions necessitating hospital transfers, there was no documentation of written notices in their EMRs. Staff interviews revealed reliance on verbal communication rather than written notices, which was confirmed by the Social Services Director.
The facility failed to provide written bed hold notices to two residents transferred to the hospital, as required by policy. Despite the policy's requirement for written information on bed-hold rights and transfer details, neither resident received such notices. Interviews with staff revealed reliance on verbal notifications, with no written documentation found in the residents' records.
A facility failed to complete and submit a quarterly MDS assessment for a resident, who had not been assessed in over 120 days. The resident's last completed MDS was an annual assessment, and the subsequent quarterly assessment was listed as 'In Progress' but not signed or submitted. The MDS Coordinator admitted the oversight during an interview. The resident has a complex medical history including cerebral infarction and Alzheimer's dementia.
A resident with a history of aggression hit another resident unprovoked, leading to a failure in protecting the resident's right to be free from abuse. Both residents were severely cognitively impaired. The incident was not documented in the nurse's notes, and the LPN forgot to document a skin assessment or progress note. The facility's abuse prevention policy was not effectively implemented, and the incident was substantiated by the Administrator.
A cognitively impaired resident with a known elopement risk was inadequately supervised, leading to multiple attempts to leave the facility unassisted. Despite being placed on one-on-one supervision after an initial elopement, the facility failed to continue this supervision or secure the resident's bedroom window. The resident subsequently exited through a second-story window, resulting in fractures to both heels and the lumbar spine. The facility's policies on accidents, wandering, and supervision were not adequately followed.
The facility did not prepare menus in advance or offer residents the opportunity to choose their meal options, nor were alternatives posted for residents to see. This affected three residents in a facility with a census of 58.
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Observations showed that hot food was not served at an appetizing temperature for several residents, one resident received meat that was too hard to cut, and another was not offered condiments. These issues affected all sampled residents in the facility.
The facility failed to maintain food safety standards by not ensuring proper food temperatures during distribution, reheating, and transport. Food was not consistently checked for safe temperatures, and meal trays were reused for different residents. Additionally, dishwashing temperatures were not regularly documented. The facility census was 58 residents.
The facility failed to provide a dignified dining experience by serving meals on Styrofoam plates with plastic cutlery due to a malfunctioning dishwasher. Three residents, who had no cognitive loss and required assistance with daily activities, expressed dissatisfaction with the disposable dinnerware. The dishwasher had been malfunctioning for over two months, leading to the use of paper products. Staff confirmed the ongoing issue and residents' dislike for the disposable dinnerware, but the Administrator did not consider it a dignity concern.
The facility failed to prepare menus in advance and offer meal choices to residents, affecting their dining experience. Three residents, who were cognitively intact, reported not being able to choose their meals, and observations showed no menus or alternatives posted. Staff interviews revealed issues with meal ticket management and a lack of a standard alternative menu.
The facility failed to serve meals at a safe and appetizing temperature, with residents frequently receiving cold food. Additionally, meals were not always served with appropriate textures or condiments, despite availability. Staff confirmed ongoing complaints about food temperature and taste.
The facility failed to maintain food safety standards, with food temperatures not consistently checked or maintained, improper food coverage during transport, and unsanitary practices such as reusing meal trays without sanitization. Additionally, the facility did not adhere to dishwashing procedures, with incomplete temperature logs and untrained staff.
Failure to Initiate CPR for a Full Code Resident
Penalty
Summary
The facility failed to provide CPR for one of 15 sampled residents, a resident who was documented as Full Code. The resident had diagnoses including paroxysmal atrial fibrillation, intracardiac thrombosis, shortness of breath, congestive heart failure, and ventricular tachycardia. The resident’s records showed a Full Code physician order, a baseline care plan listing Full Code status, and a TPOPP/POLST indicating the resident requested resuscitation/CPR if found without a pulse and not breathing. On the day of the event, the resident had earlier been seen short of breath, with oxygen saturation of 90% on 2 liters nasal cannula, which improved after oxygen was increased to 3 liters. Later, a family member alerted staff that the resident had a seizure. When the LPN arrived, the resident was in a recliner, not breathing, with no pulse or lung sounds. The resident then had agonal breathing. The LPN asked the family member whether CPR should be started and explained the resident was gasping to get oxygen to the brain. After approximately 3 to 4 minutes, the family member told the LPN not to perform CPR because it was not what the resident wanted, and CPR was not initiated. The resident died at the facility. Interviews showed the LPN knew the resident was Full Code but did not start CPR. The LPN stated the resident had told him/her that morning that he/she wanted to be DNR, but the LPN did not have time to call the physician or DON about a change in code status. Other staff stated that when a resident is not breathing or has no pulse, staff should verify code status and begin CPR if the resident is Full Code, regardless of what a family member says. The resident’s DPOA was listed in the record, but the DPOA was not invoked, and the resident’s documented code status remained Full Code.
Food Service Failed to Provide Palatable Meals and Follow Menus
Penalty
Summary
The facility failed to ensure residents were served food that was palatable, attractive, and at a safe and appetizing temperature, and it also failed to follow the planned menus. Survey observations, interviews, and record review showed that hot and cold foods were not consistently temperature-checked during meal service, and several meals were served in a manner that did not match the menu or appeared unappetizing. This affected 8 of 15 sampled residents, including residents with intact cognition, moderate cognitive impairment, malnutrition, diabetes, anemia, stroke, coronary artery disease, Alzheimer’s disease, anxiety, and depression. During breakfast service, hot items including biscuits, oatmeal, and cheese omelets were cooked and placed in the oven, then removed and transported without temperatures being taken. At the steam line, staff served the food without checking temperatures. The breakfast test tray later showed a biscuit at 88.7 degrees F, a cheese omelet at 134.0 degrees F that visually appeared to be scrambled eggs with a small amount of cheese, milk at 52.2 degrees F, and orange juice at 60.3 degrees F. Residents reported that food was often cold, dry, greasy, or otherwise unappetizing, and one resident said the food was terrible and lacked healthier options such as salads and fruit. Menu planning and menu execution also did not match resident needs or the posted menu. A resident requested bacon at breakfast but was told it was not on the menu and was not offered a substitute. The cycle menu showed repetitive breakfast menus, sandwiches as the main course for half of dinner meals, limited salads, and limited variety in desserts. At lunch, the menu listed chicken salad on a croissant, but no croissants were available, so staff placed chicken salad on plain white bread in a way that obscured the filling and did not improve presentation. A resident with diabetes and renal failure reported being served meals that were too high in carbohydrates, lacking protein, and missing items such as chips, salsa, and dressing for a taco salad. The menu substitution log also showed missing items without a suitable substitute documented. Residents and staff repeatedly described the menu as repetitive, with too many sandwiches, too few salads and fresh fruits, and food that was not appealing or served as planned.
Missing Orders for PEG Tube Flushing, Hospice, and Crushed Medications
Penalty
Summary
The facility failed to ensure services provided or arranged met professional standards of quality when it did not have a physician order for PEG tube flushing for a resident who was not cognitively intact, dependent on nursing staff for all cares, and had diagnoses including stroke, inability to swallow, and tube feedings for nutritional needs. The resident’s March 2026 POS included enteral feeding orders for Two Cal HN at 50 ml/hour for 20 hours and a water flush of 200 ml every four hours, along with an order to check tube placement before formula, medication administration, and flushing, but there was no order specifying flushing before or after medications, the amount of water to use, or how often to flush for medication administration. During observation, an RN administered medication using 10 ml of water before and after the medication and stated there should have been an order for tube flushing with water before and after medications. The facility also failed to ensure a resident had a physician order for Hospice even though the resident’s face sheet listed Hospice as the primary payer and the electronic record contained a hospice order dated 3/11/26. The resident’s POS for March 2026 did not include an order for Hospice, and there was no admission or start date for hospice services located in the electronic medical record. RN A stated the resident was admitted on Hospice but there should still be a physician order for it, and the DON stated there should be a physician order for a resident to be on Hospice. In addition, the facility failed to ensure a resident who required crushed medication had an order for medications to be crushed. The resident’s care plan identified the resident as not cognitively intact, taking medication for depression, and having a communication problem related to dementia, but the order summary and MAR for March 2026 did not include instructions for crushing medications. During observation, a CMT crushed multiple medications, including anastrozole, furosemide, gabapentin, paroxetine, Vitamin D, aspirin, and Echinacea, and placed them in pudding for administration. The CMT, RN A, the Infection Control Nurse, and the DON all stated that an order should have been present for medications to be crushed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to policy in the North medication room and the North nurse’s cart. During observation and interview, staff found expired medications and biologicals that had not been discarded, including an opened bottle of multivitamin that expired in 2/2026 and a Narcan nasal spray with an expiration date of February 2026 that no longer had a pharmacy label or resident name on it. The refrigerator in the memory care unit medication storage room did not have a temperature log, and the small refrigerator in the North medication room also lacked a temperature log. The freezer in the North medication room had a large amount of ice buildup, and staff stated the freezer should be defrosted and refrigerator temperatures should be checked daily. Opened bottles of Lorazepam were not dated when opened for four sampled residents. Resident #67 had an opened vial filled on 1/19/26 with no open date, Resident #5 had an opened vial filled on 10/4/25 with no open date, Resident #1 had an opened vial filled on 2/16/26 with no open date, and Resident #59 had an opened vial in the nurse’s cart with no open date. The manufacturer guidance stated opened liquid Lorazepam was good for 90 days when stored properly, and staff acknowledged the bottles should have been dated when opened. A house stock vial of Tuberculin PPD also had no open date, and staff stated it should have been dated when opened and discarded after 30 days per policy. Resident #56, who had Type 2 diabetes and was dependent on staff for physical, emotional, and intellectual needs, had an order for Degludec insulin 14 units subcutaneously at bedtime. Observation showed the resident’s Degludec insulin pen in the memory care medication cart was opened with no date indicating when it had been opened. Manufacturer guidance reviewed by surveyors stated the insulin pen was only good for 56 days after opening. Staff interviews confirmed insulin pens should be dated when first opened so staff would know when they expire.
Food Safety Failures in Kitchen and Dining Service
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety. During kitchen observations, surveyors found multiple expired food items stored in the refrigerator, including tuna casserole, sliced cheese, whipped topping, salad dressing, Miracle Whip, mustard, and a garnish container with sliced tomatoes and pickles. A bowl of sliced strawberries in juice was also observed without a label or date. Facility staff were observed preparing food while not wearing required hair restraints, including a dietary staff member not wearing a beard net over facial hair and not wearing a hairnet under a ballcap, with uncovered hair exposed on both sides of the head. Staff were also observed cleaning, handling leftovers, and washing dishes without hairnets and beard nets. Surveyors also observed failures in food temperature monitoring. Pre-cooked bacon was placed in the oven and later removed without a temperature check. On another observation, breakfast items including biscuits, cheese omelets, and oatmeal were removed from the oven, placed in a heating cart, and then placed on the steam line in the dining room without temperatures being taken before service. Food was observed uncovered and ready to serve on the steam line with no temperatures taken before serving the first meal to residents. The dietary manager stated that temperatures should be taken during cooking, when food is removed from the oven prior to service, and just prior to serving from the steam line, and that opened containers should be dated and leftovers discarded after three days.
Incomplete Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to establish an antibiotic stewardship program that included consistent monitoring of antibiotic use and a system for tracking antibiotic use for residents. Review of the facility’s antibiotic stewardship policy, dated December 2024, showed the program was intended to monitor antibiotic use through core elements including tracking how and why antibiotics are used, the amount used, and adverse outcomes, along with education of staff, residents, and families. However, review of the antibiotic stewardship and infection surveillance book showed no tracking of antibiotic use or infection surveillance for August 2025, September 2025, October 2025, February 2026, and March 2026. Clinical progress notes showed that four residents were receiving antibiotics in March 2026: one resident was started on Cephalexin for UTI, two residents were started on Cefpodoxime for URI, and one resident was started on Trimethoprim for UTI. During interviews, the Infection Control Nurse, Administrator, and DON stated the surveillance and stewardship binder should have been kept up to date and that tracking for February and March 2026 should have been completed. The Infection Control Nurse also stated she had been working frequently as a charge nurse and had not had time to complete the antibiotic stewardship and infection surveillance documentation.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue required Medicare non-coverage notices for two residents. For Resident #70, the record showed a physician’s order for the last covered day for Medicare Part A services on 9/25/25, and progress notes indicated the facility initiated discharge from Medicare Part A services when benefit days were not exhausted on that date. However, the facility could not show that a Notice of Medicare Non-Coverage (CMS 10123-NOMNC), which informs the resident of the right to appeal and how to request an immediate appeal, was issued. For Resident #66, the record showed a physician’s order for the last covered day for Medicare service on 3/6/26, and progress notes indicated the facility initiated discharge from Medicare Part A services when benefit days were not exhausted on that date. The facility could not show that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), which explains that certain services were no longer covered and the associated cost, was signed by the resident. During interview, the Social Services Director said she was responsible for completing these forms and was unable to find the missing documents for both residents.
Late Transmission of MDS Assessment
Penalty
Summary
The facility failed to electronically transmit a quarterly MDS assessment for one resident within the required timeframe. The resident’s quarterly MDS had a care plan completion date of 02/03/26, but the assessment was not transmitted and accepted until 03/12/26, which was 37 days late. The facility’s policy stated that resident assessments are to be submitted in accordance with current federal and state timeframes, and the RAI Manual required all other MDS assessments to be submitted within 14 days of the MDS completion date. During interview, the Regional Nurse Consultant said she had been responsible for the MDS for the past month and a half and acknowledged that the resident’s quarterly MDS was late. She stated the previous MDS coordinator quit around mid-January and that the facility used an outside vendor that only notified them the day before that sections of the MDS were incomplete. She said she corrected the sections and sent the completed MDS. The Administrator stated that MDS assessments should be completed and sent within the required timeframes.
Improper Catheter Care During Urinary Catheter Maintenance
Penalty
Summary
The facility failed to ensure appropriate catheter care was provided for one resident with an indwelling urinary catheter. The resident was not cognitively intact, was dependent on staff for activities of daily living, resided on the memory care unit, received hospice care, and was incontinent of bowel. The resident also had diagnoses of non-Alzheimer's dementia, anxiety, and depression. The resident's record showed an order for cephalexin for a urinary tract infection, and the facility's urinary catheter care policy directed staff to cleanse and rinse the catheter from the insertion site outward using a clean washcloth with warm water and soap. During observation, two CNAs performed catheter care and used disposable cleansing wipes to clean the catheter tubing while wiping toward the catheter insertion site. Interviews with the CNAs, a CMT, an RN, the Infection Control Nurse, and the DON all confirmed that catheter tubing should be cleaned by wiping away from the catheter insertion site. The facility policy did not address the use of disposable wipes during catheter care, and the observed care did not follow the direction described by staff during interviews.
Infection Control Failures During Resident Care and Insulin Pen Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when staff did not use enhanced barrier precautions during direct care for a resident with an indwelling urinary catheter. Resident #29 had non-Alzheimer's dementia, anxiety, depression, was not cognitively intact, was dependent on staff for activities of daily living, resided on the memory care unit, received hospice care, and was incontinent of bowel with an indwelling urinary catheter. During observation, CNA E and CMT D transferred the resident from a wheelchair to the bed without wearing a gown and gloves, and CNA E touched the resident's brief to check whether it needed to be changed without gloves or a gown. Staff interviews confirmed that EBP should have been used during this care and that gloves should have been worn when checking the brief. The facility also failed to follow proper insulin pen handling during medication administration for Resident #69. The resident's March 2026 orders included Basaglar KwikPen 50 units daily for diabetes mellitus. During observation, CMT A sanitized hands, applied gloves, attached the needle to the insulin pen, primed it, and administered the insulin, but did not clean the tip of the insulin pen with alcohol before attaching the needle. Staff interviews later confirmed that the port of the insulin pen should have been cleaned with an alcohol wipe before the needle was attached, and the facility did not provide a policy for insulin pen use.
Failure to Secure Sling During Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
Facility staff failed to ensure a safe transfer of a resident with significant cognitive and physical impairments by not properly securing the sling to the mechanical lift during a transfer from bed to shower chair. The resident, who had a history of stroke, Alzheimer's disease, hemiparesis, and was assessed as requiring extensive assistance with all activities of daily living, was being transferred by two CNAs using a mechanical lift and mesh sling. According to interviews and documentation, one of the lower sling loops became detached from the lift during the maneuver, causing the resident to fall from the lift to the floor, resulting in pain to the resident's shoulders and left hip. The facility's policy on safe lifting and movement of residents required staff to use appropriate techniques and devices, ensure slings were properly attached, and verify secure connections before moving residents. The user manual for the mechanical lift also specified that all sling attachments must be checked before lifting and moving a patient. Despite these requirements, staff did not confirm that all sling loops were securely attached before proceeding with the transfer. Both CNAs involved in the transfer stated that they each attached loops on one side of the sling, but during the transfer, a loop on the left lower side came off, leading to the resident's fall. Following the incident, the resident was assessed by nursing staff and reported significant pain. The primary care physician was notified and initially ordered the resident to be sent to the hospital for evaluation, but administration directed that mobile x-rays be performed at the facility instead. The resident was subsequently treated for pain. Interviews with staff, including the DON and administrator, confirmed the expectation that staff ensure slings are securely attached before transfers, but this was not done in this case, directly leading to the resident's fall and injury.
Failure to Investigate and Account for Missing Fentanyl Patches
Penalty
Summary
The facility failed to ensure that two residents were free from misappropriation of their controlled pain medication, specifically fentanyl patches, when staff did not follow established protocols for investigating and accounting for missing patches. For one resident with significant cognitive loss and total dependence on staff for activities of daily living, a fentanyl patch was found missing during a scheduled change. The nurse and CNA searched the resident's environment but did not locate the patch, and although the Director of Nursing (DON) was notified via a communication application, no formal investigation or documentation was completed, and the nurse was not questioned further about the incident. A second resident, who had mild cognitive loss and required moderate assistance with daily activities, also experienced a missing fentanyl patch. The resident reported being in severe pain when the patch was discovered missing at the time of a scheduled change. The nurse applied a new patch, but no investigation was initiated, and the resident was not questioned about the missing patch. The DON was unaware of this incident and did not conduct or document an investigation. Interviews with facility leadership, including the DON, Medical Director, President of Clinical Operations, and Administrator, revealed that they expected missing narcotics to be reported, investigated, and documented. However, in both cases, there was a lack of follow-through on these expectations, and the missing patches were not accounted for or formally investigated, contrary to facility policy and standard practice for controlled substances.
Failure to Follow Physician's Order for Hospital Evaluation After Resident Fall
Penalty
Summary
The facility failed to follow a physician's order for a resident who experienced a fall from a mechanical lift. After the fall, the resident was found on the floor, covered with a blanket, and was assessed by an LPN. The resident, who had a history of cerebral infarction, Alzheimer's disease, hemiplegia, and other significant medical conditions, complained of pain in the shoulders and left hip. The physician was notified and gave a direct order to send the resident to the hospital for x-rays and evaluation. Despite the physician's order, facility administration instructed staff not to send the resident to the hospital, but instead to use mobile x-ray services at the facility. The LPN communicated this change to the physician, who reluctantly agreed to the use of mobile x-rays only if they could be performed within the hour, but expressed disagreement with the decision, stating that hospital x-rays are superior and that residents who fall from such a height should always be sent to the hospital for evaluation. The medical director and DON both stated that physician orders are expected to be followed, and the administrator indicated a preference for using contracted mobile x-ray services. The deficiency occurred because the facility did not adhere to the physician's explicit order to send the resident to the hospital following a significant fall, instead substituting mobile x-rays at the facility. This action was taken despite the physician's and medical director's expectations that such orders be followed, and without documented justification for not following the original order.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a significant quantity of the resident's prescribed narcotic medication, Oxycodone 5mg tablets, was found missing. The resident, who had diagnoses including depression, dementia, heart disease, and low back pain, was prescribed Oxycodone to be taken every eight hours. The missing medication was discovered after it had been received and verified by staff, but the loss was not identified until the middle of a shift rather than at shift change, as required by policy. The facility's investigation did not clearly state the reason for initiation, did not identify an alleged perpetrator, and failed to address inventory procedures or pinpoint when the medication went missing. Interviews with staff and review of facility policies revealed that, at the time of the incident, the process for counting controlled substances was inadequate. Staff only counted in-use sheets of narcotics and did not include full, unopened sheets in their shift-end counts, making it impossible to determine when the medication was taken or who was responsible. The count sheets and medications were accessible to all staff with access to controlled drugs, and the lack of comprehensive inventory controls prevented the facility from identifying the responsible party or the exact timing of the loss. The police investigation also noted the absence of proper inventory controls over the controlled medication.
Failure to Prevent Resident-to-Resident Sexual Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident, both with severe cognitive impairments, was able to physically touch the first resident inappropriately in a common area. The incident occurred when one resident, diagnosed with Alzheimer's disease, dementia with agitation, and delusional disorder, was walking through the memory care unit and was approached by another resident with Alzheimer's disease, a history of traumatic subdural hemorrhage, and mild cognitive impairment. The second resident, who had a documented history of behavior problems related to sexual outbursts and grabbing staff, reached out and ran a hand up the inside of the first resident's thighs, grabbing the genital area as the first resident walked by. At the time of the incident, the first resident had severely impaired cognition, displayed wandering behavior, and was sometimes understood in communication. The second resident also had severely impaired cognition and was noted to have behavior problems, including sexual outbursts, with care plan interventions instructing staff to redirect and distract the resident when inappropriate behaviors occurred. The incident was witnessed by a Certified Medication Technician (CMT) who was preparing medications in the common area and observed the inappropriate contact as it happened. Both residents were in the common area of the memory care unit, unsupervised in close proximity, despite the known behavioral risks associated with the second resident. The facility's abuse prevention policy required protection of residents from abuse by anyone, including other residents, but the measures in place at the time did not prevent the incident from occurring. The event was reported to the charge nurse, and both residents were assessed with no injuries noted.
Inaccurate MDS Assessments Affect Resident Care Planning
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five residents, which could potentially affect their care planning and provision. The Director of Nursing confirmed the use of the Resident Assessment Instrument (RAI) Manual, and the facility policy required comprehensive assessments to be conducted according to the RAI Manual's criteria and timeframes. However, discrepancies were found in the coding of tobacco use and anticoagulant medication, which were not aligned with the RAI Manual guidelines. For one resident, the MDS did not reflect their tobacco use, despite observations and documentation indicating they were a regular smoker. The MDS Coordinator acknowledged this might have been an oversight. For other residents, the MDS inaccurately coded the use of anticoagulant medications, listing antiplatelet medications like aspirin and Plavix as anticoagulants, contrary to the RAI Manual's instructions. The MDS Coordinator mentioned receiving guidance from an external auditing company, which led to the incorrect coding. The inaccuracies in the MDS assessments were identified through interviews, record reviews, and observations. The MDS Coordinator admitted to following external advice without verifying it against the RAI Manual, resulting in the misclassification of medications. The facility's administrator expected the MDS to accurately reflect residents' conditions, highlighting a gap between expectations and practice.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to two residents, R29 and R61, who were transferred to the hospital. This deficiency was identified during a review of records, interviews, and policy examination. The facility's policy requires that residents and their representatives receive written notice detailing the reason for transfer, the location, and information on how to appeal the transfer. However, this procedure was not followed for the two residents in question. Resident R29, who had medical diagnoses including chronic obstructive pulmonary disease, cerebral infarction, and hemiplegia, was transferred to the hospital in April. Despite the transfer, there was no documentation in the electronic medical record (EMR) indicating that a written notice of transfer was provided. Similarly, Resident R61, with diagnoses such as cystitis, dementia, and uterine cancer, was transferred to the hospital in July. Again, there was no evidence in the EMR of a written notice being given. Interviews with facility staff revealed that the process for emergent transfers involved verbal communication with the family and the Director of Nursing, but not the provision of written notices. The Social Services Director confirmed that the required documentation was not completed for these residents. This lack of adherence to policy potentially left residents and their representatives without crucial information regarding their transfers and their rights to appeal.
Failure to Provide Written Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, R29 and R61, who were transferred to the hospital, as required by their policy. The policy mandates that residents or their representatives receive written information about bed-hold rights and limitations, payment policies, and transfer details prior to any transfer or therapeutic leave. However, during interviews and record reviews, it was found that neither resident received such a notice. R29, who was hospitalized for kidney stones, confirmed she did not receive a written notice, and her electronic medical record showed no evidence of one being provided. Similarly, R61, who was transferred to the hospital after being found outside, also had no documentation of receiving a written bed hold notice in her records. Interviews with facility staff, including the Administrator, RN1, and the Social Services Director, revealed a lack of adherence to the policy. RN1 described the process of transferring residents, which included verbal notifications to families but not the provision of written notices. The Social Services Director acknowledged that the nursing staff was responsible for providing the bed hold notice, but it was not done in these cases. The absence of written documentation for both residents indicates a systemic issue in the facility's process for handling emergent transfers and ensuring compliance with their own policies.
Failure to Complete and Submit Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed and submitted for processing for a resident, identified as R14, who had not received an assessment in over 120 days. This deficiency was identified during a review of records, interviews, and the Resident Assessment Instrument (RAI) manual. The facility's policy, revised in March 2022, mandates that comprehensive assessments be conducted according to the criteria and timeframes established in the RAI User Manual. The October 2023 RAI Manual specifies that quarterly non-comprehensive assessments are due within 92 days after the Assessment Reference Date (ARD) of the most recent assessment. R14's electronic medical record (EMR) showed that the last completed and accepted MDS was an annual assessment with an ARD of 05/16/24. A quarterly MDS with an ARD of 08/15/24 was listed as 'In Progress' but had not been signed and submitted as of 10/08/24. During a telephone interview, the MDS Coordinator acknowledged that the quarterly assessment for R14 was missed, despite being on the list for completion in August. The resident's medical history includes cerebral infarction, hemiplegia, dysphagia, esophageal obstruction, heart failure, Alzheimer's dementia, depression, hypothyroidism, atrial fibrillation, chronic respiratory failure, anxiety disorder, and pain.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a resident with a history of aggression hit another resident unprovoked. Resident 42, who was severely cognitively impaired, was hit on the shoulder by Resident 23, who also had severe cognitive impairment and a history of physical aggression related to dementia. The incident occurred when Resident 23 entered Resident 42's room and hit her with a closed fist. This incident was not documented in the nurse's notes, and there was no immediate documentation of a skin assessment or progress note by the LPN who was informed of the incident. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of documentation and follow-up after the incident. The LPN admitted to forgetting to document the incident due to being overwhelmed, and the Director of Nursing was not present at the time. The Administrator confirmed the incident was substantiated and that Resident 23 was placed on 1:1 supervision until discharged for a psychiatric evaluation. The failure to document and address the incident promptly had the potential to affect all residents in the secured unit.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident with a known elopement risk. The resident, who had been admitted with dementia and a history of exit-seeking behavior, was involved in multiple incidents where they attempted to leave the facility unassisted. On one occasion, the resident became combative when staff tried to redirect them back inside from an outside activity and managed to reach the parking lot. The resident also threw objects out of a dining room window and later eloped through the same window, which was six feet above the ground. Despite being placed on one-on-one supervision after the first elopement, the facility did not continue this supervision or secure the resident's bedroom window. Consequently, the resident removed the window screen and exited through a second-story window, approximately 13 feet above a paved sidewalk, resulting in fractures to both heels and the lumbar spine. The facility's policies on accidents, wandering, and supervision were not adequately followed, as the resident's high risk for elopement was not effectively managed. Interviews with staff revealed that the resident had been exit-seeking since admission, and family members had previously struggled to keep the resident inside at home. Staff observed the resident's attempts to open windows and doors, and although medication was administered to manage agitation, the resident's behavior persisted. The facility's failure to maintain one-on-one supervision and secure all potential exit points contributed to the resident's injuries.
Failure to Prepare and Post Menus in Advance
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and developed to meet resident choices. Specifically, menus were not posted in advance, residents were not offered the opportunity to choose their menu options, and alternatives were not visibly posted for residents. This deficiency affected three out of five sampled residents, with the facility having a census of 58.
Deficiencies in Food Service Quality
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature for four residents. Additionally, one resident was served meat that was too hard to be cut, and another resident was not offered condiments. These deficiencies were noted for all five sampled residents in a facility with a census of 58.
Deficiencies in Food Service Safety and Temperature Control
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, resulting in multiple deficiencies related to food storage, preparation, and service. Staff did not maintain food temperatures during distribution from the kitchen to the steam table and from the service point to resident delivery, allowing food to remain in the danger zone. Additionally, the facility did not check the temperature of reheated food on the steam table or food warmed in the microwave to ensure it was at a safe temperature. There was also a failure to cover all foods during transport to the special care unit. Furthermore, the facility reused meal trays for meal service delivery to other residents in the dining room, compromising safe food preparation. Lastly, the facility did not consistently check and document dishwashing temperatures on the temperature log daily. The facility census was 58 residents.
Use of Styrofoam Dinnerware Due to Dishwasher Malfunction
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by serving meals on Styrofoam plates with plastic cutlery due to a malfunctioning dishwasher. This issue affected three residents who were observed and interviewed, all of whom expressed dissatisfaction with the use of disposable dinnerware. The residents, who had no cognitive loss and required varying levels of assistance with activities of daily living, preferred to eat on glass dishes. The facility's policy on dignity emphasizes providing a dignified dining experience, which was not upheld in this situation. The dishwasher had been malfunctioning for over two months, leading to the use of paper products for meal service. Staff interviews revealed that the dishwasher was fixed and broke down multiple times, resulting in the continued use of Styrofoam plates. The Dietary Director and CNAs confirmed the ongoing issue with the dishwasher and the residents' dislike for the disposable dinnerware. The Administrator acknowledged the dishwasher's problems but did not consider the use of Styrofoam a dignity concern, despite residents' preferences.
Failure to Provide Menu Choices and Alternatives
Penalty
Summary
The facility failed to ensure that menus were prepared in advance and that residents were given the opportunity to choose their meal options. This deficiency was observed when menus were not posted in advance, and residents were not offered choices or alternatives. This affected three of the five sampled residents, who were cognitively intact and capable of making their own meal choices. The facility's policy, 'The Dining Experience,' aimed to provide a person-centered dining experience, but this was not implemented effectively. Resident #2, who had a history of stroke and dysphagia, reported never being able to choose meals except at breakfast. Resident #3, with renal failure and other health issues, also stated they could not choose their meals. Resident #4, who had impaired vision and depression, mentioned being forgotten at lunch and having to wait for meals to be prepared. Observations showed no menus or alternative options were posted in the dining room, and meal tickets were mishandled, leading to confusion and delays in meal service. Interviews with staff revealed that the facility did not have a standard alternative menu, and meal tickets were often lost, causing residents to miss meals. The Dietary Manager admitted that menus were not posted since new ownership took over, and residents were informed of food choices through a printed ticket system. The Administrator was unaware of the requirement to post menus, indicating a lack of communication and organization in meal service management.
Deficiency in Meal Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at an appetizing temperature for several residents, with meals often arriving cold. For instance, one resident reported receiving their meal an hour late, resulting in cold food. Another resident expressed dissatisfaction with the quality and temperature of the food, noting that it was generally not good and often cold. Additionally, the facility did not provide appropriate food textures and condiments as per residents' preferences and dietary needs. One resident was served a hamburger on bread without the desired condiments like pickles and cheese, despite the facility having these items available. Another resident was served meat that was too hard to cut, indicating a failure to provide food that met the required texture and consistency for safe consumption. The facility's failure to maintain proper food temperatures was further evidenced by a test tray showing food items below safe holding temperatures. Staff interviews confirmed that residents frequently complained about the temperature and taste of the food, with trays often left sitting out before being served. The dietary manager acknowledged the issue with food temperatures and the lack of condiments, while the administrator was aware of complaints but attributed them to age-related loss of taste buds.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, resulting in multiple deficiencies related to food storage, preparation, and service. Observations revealed that food temperatures were not consistently maintained within safe ranges during distribution from the kitchen to the steam table and from the service point to resident delivery. Specifically, several food items, such as pureed carrots, ground chicken, and pureed chicken, were found to be below the required serving temperature of 135 degrees Fahrenheit. Additionally, the facility did not consistently check the temperature of food reheated in the microwave, and there was a lack of documentation for serving temperatures, which were only recorded for cooking temperatures. The facility also failed to ensure proper food coverage during transport, as observed with hall trays where desserts and soups were not covered. This lack of coverage was confirmed by interviews with staff, who indicated that only the main dish was typically covered. Furthermore, the facility did not maintain sanitary conditions during meal service, as evidenced by the reuse of meal trays without proper sanitation, which could lead to cross-contamination. The Dietary Manager acknowledged that reusing trays without sanitization was not sanitary. Additionally, the facility did not adhere to its own policies regarding dishwashing procedures. The dishwasher temperature log was not consistently completed, with records showing it was only filled out once a day instead of the required three times. The Dietary Manager admitted that the staff was new and unaware of the need to record temperatures on the dishwasher sanitation log. These deficiencies highlight significant lapses in maintaining food safety and sanitation standards, as required by local, state, and federal regulations.
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 65 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Abundant Acres Care And Rehab | 3.4 mi | ★★★★★ | 42 | 2 |
| Carriage Square Rehab And Healthcare Center | 9.8 mi | ★★★★★ | 5 | 0 |
| Advanced Care Of St Joseph | 9.9 mi | ★★★★★ | 2 | 0 |
| St Joseph Manor Health & Rehabilitation | 10.6 mi | ★★★★★ | 2 | 0 |
| Living Community Of St Joseph | 11 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.