Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Lewis County Nursing Home District during CMS and state inspections, most recent first.
Food storage, sanitation, and hand hygiene failures were observed throughout the kitchen, activity area, and SCU. The can opener blade and range hood filters had debris and grease buildup, multiple food items were undated, unlabeled, open, expired, or moldy, the ice machine had debris and lacked an appropriate air gap, staff were observed with hair not fully contained and handling RTE foods with bare hands, handwashing was inconsistent after soiled tasks, trash cans were left uncovered, and the SCU fridge/freezer lacked thermometers.
The facility lacked required Legionella water management documentation, including a detailed water flow map and an assigned water management team with meeting records. Staff were observed failing to perform hand hygiene and changing gloves appropriately during resident care, including EBP-related personal care, wound care, peri care, and transfers. An LPN also performed fingerstick glucose checks for three residents with diabetes without hand hygiene before or after glove use.
Failure to Provide Restorative ROM and Mobility Services: The facility did not provide restorative nursing services for residents with limited ROM and mobility needs. A resident with CP and spasticity, a resident with OA and declining endurance, a resident with stroke-related hand contractures, a resident with a hip fracture, and a resident with severe ROM limitations were all identified as needing or benefiting from restorative ROM or mobility support, yet the facility had no restorative program in place. The DOT and DON stated the facility lacked a restorative nurse aide/program due to staffing issues, and records showed no documentation of restorative participation for some residents despite PT recommendations and observed functional decline.
A resident with dementia, osteoporosis, pain, and muscle weakness was supposed to be transferred with 2 staff using a gait belt or a mechanical lift, but staff observed a 1-person transfer and the resident did not bear weight during transfers. Staff later noted the resident was becoming very stiff, and the transfer order was changed to a full-body mechanical lift. The facility also left shower rooms unlocked with Buckeye Neutral Disinfectant stored in unlocked cabinets, and staff said residents could enter the rooms unaccompanied.
Controlled substances were not counted and reconciled each shift as required by policy. Multiple Schedule II, IV, and V medications for several residents were found in a locked medication room cabinet, but there was no documentation of shift counts for those medications. Staff, including an LPN, RN, MDS care plan coordinator, DON, and Administrator, stated that the lock box medications were treated as overflow and were not counted until placed in medication carts.
Failure to destroy discontinued controlled medications: a resident with pain, anxiety, and a sacral pressure ulcer still had hydrocodone, morphine sulfate, and lorazepam stored in the medication cart long after the orders were discontinued. Staff said discontinued meds should be removed promptly and controlled substances destroyed by two nurses using drug buster, but the medications remained in the cart and had not been destroyed.
Staff failed to follow the diet spreadsheet, recipes, and portion controls for residents on pureed and mechanical soft diets during lunch meal service. A dietary staff member served incorrect scoop sizes, omitted buns and required pureed items, and substituted peaches and stewed tomatoes for ordered applesauce, apple slices, and soft-cooked vegetables. The DON stated staff should have followed the spreadsheet and recipes, but the wrong items were prepared and served.
Food and drink were not served at safe, appetizing temperatures, and several menu items were not prepared as ordered for residents on pureed, mechanical soft, and regular diets. Residents reported meals were often cold, overcooked, undercooked, or poorly seasoned, and some said they ate their own food instead of facility meals. During meal observation, hot items were served far below the dietary manager’s stated 165-degree F standard, and grapes on a regular tray were brown and mushy.
Improperly Prepared Pureed and Mechanical Soft Diets: A dietary staff member prepared pureed menu items with the wrong liquid and served them watery, chunky, and not smooth, including pureed hamburger and cauliflower. Residents on a mechanical soft diet were also served large chunks of cauliflower that were not soft or chopped into bite-sized pieces, despite the menu spreadsheet and recipe directions. The DON stated pureed items should be smooth and baby food consistency, and mechanical soft items should be soft and chopped.
Three CNAs did not receive the required 12 hours of annual in-service education. Record review showed one CNA completed 7 hours, another 4 hours, and another 2 hours during the reviewed period. The DON and Administrator stated CNAs were responsible for completing their own training hours and that no one at the facility was tracking in-service hours for regulatory compliance, although recorded education was available by appointment.
A resident with spina bifida, diabetes, reduced mobility, obesity, muscle weakness, an indwelling catheter, and a nephrostomy tube had physician orders for daily nephrostomy dressing changes, cleansing with normal saline, and use of Skin Prep with a dry dressing. An RN and later an LPN did not follow the ordered treatment, with one applying only a dry dressing and the other using Vaseline gauze without cleansing the site. The RN, LPN, DON, and physician all confirmed the ordered treatment was not being followed as written.
Pressure ulcer care was not provided as ordered for one resident with a coccyx wound: weekly wound assessments were incomplete or missing, wound worsening was not reported to the MD, and staff cleansed the wound with body wash/periwash instead of NS. Another resident with coccyx and gluteal fold pressure ulcers was left on one side in bed for hours and then sat upright in a Broda chair for over five hours without documented offloading or repositioning.
A resident with dementia and severe cognitive impairment repeatedly became aggressive when redirected from other residents’ rooms or when trying to leave the SCU. Staff used physical holds, including grabbing the resident’s wrists, crossing the arms to the chest, and bear hugging the resident to the floor, while the care plan did not give guidance for therapeutic responses to the behaviors. The DON and Administrator stated staff had dementia training but had not been trained on safely handling aggressive or violent behaviors.
QA committee meetings did not include the required members, including the MD. The facility’s QA policy called for monthly meetings with the MD, attending physicians, NPs, DON, ADON, Medical Records Director, Dietary Manager, and Administrator regularly attending, but attendance records showed the MD attended only one meeting. The Administrator said the meeting schedule was changed to fit the MD’s rounds, the MD was invited, and the facility did not provide her with a report of what was discussed; the NP also did not attend.
Failure to provide required Medicare discharge notices for two residents and complete SNF ABN forms for two residents. One resident with repeated falls and a DPOA, one resident with difficulty walking, muscle weakness, and spinal stenosis, and one resident with a femur fracture were discharged from Medicare Part A skilled services, but the record lacked required NOMNC and/or complete SNF ABN documentation. The BOM stated she completed some forms in the SSD's absence but was not sure which forms were required.
A CNA failed to treat a resident with dignity and respect by administering a Covid test without prior communication, education, or ensuring privacy. This incident involved one resident in a facility with a census of 52.
A resident's iPad was reported missing and presumed stolen, highlighting a failure by the facility to protect the resident's belongings. This issue was identified through interviews and record reviews, involving one resident out of a sample of nine in a facility with a census of 52.
A CNA performed a COVID-19 test on a resident without prior assessment by a licensed nurse and without documented training. The test was conducted without a professional basis for testing, highlighting a failure to follow professional standards of practice.
A facility failed to provide adequate incontinent care for a resident, as identified during a survey involving observation, interviews, and record reviews. This deficiency was noted among nine sampled residents, with the facility's census at 52. The resident required assistance with activities of daily living, particularly in managing incontinence.
The facility did not ensure that a newly hired NA obtained certification within the required four-month period, as identified through observation, interview, and record review. The census was 52, and the review focused on one NA employee file.
The facility did not ensure staff used appropriate PPE during COVID-19 nasal swab testing for a resident. This deficiency was identified through observation, interview, and record review, and remained uncorrected.
Food Storage, Sanitation, and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain the kitchen can opener blade in a clean sanitary condition. During observation, brown crusty and stringy debris was seen on the can opener blade while it was not in use. The Dietary Manager stated that staff should clean the can opener after each use, consistent with the facility policy that the can opener be maintained clean and sanitary. The facility also failed to keep the range hood and filters free of grease and debris. In the kitchen, the baffle filters over both cooking areas had heavy buildup of debris, yellow grease, and visible drips and runs on the outside of the filters. Although the hoods had been professionally cleaned several months earlier, the Dietary Manager was unsure when staff last cleaned the hood and filters and stated they should be cleaned monthly. Food storage and labeling practices were not maintained. In the three-door reach-in refrigerator, multiple items were undated, unlabeled, open to air, or improperly stored, including gravy, ground and puree items, chopped peaches, stewed tomatoes, condiments, sliced grapes, cheese, turkey, bologna, ham, cobbler, orange slices, and a container of yellow liquid. Additional observations found open egg rolls in the freezer, spice containers left open, mold on a loaf of bread, undated cooked carrots and a hamburger patty, expired food items in the activity refrigerator, an undated frozen drink in the activity freezer, an open and unrefrigerated container of apple juice, and an open carton of grape cotton candy mix with a best-by date from years earlier. The Dietary Manager acknowledged several items should have been dated, labeled, refrigerated, or discarded, and stated all food items should be dated. The facility also failed to maintain the ice machine and ensure proper food handling and sanitation practices. The ice machine had debris on the interior and exterior, and its drain sat directly on the floor drain grate without an appropriate air gap. Staff were observed entering the kitchen without washing hands, wearing hair restraints with hair not fully contained, handling ready-to-eat foods with bare hands, turning off faucets with bare hands after washing, and working with food after touching trash cans and other soiled items without washing hands. Trash cans in the dish room and near the preparation counter were left uncovered when not in use. The SCU refrigerator/freezer unit also lacked thermometers, and no temperature log sheets were visible for either section of the unit.
Infection Control Program and Hand Hygiene Failures
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program as evidenced by missing documentation for a detailed water flow map and the absence of an assigned water management team with meeting minutes or attendance records. The facility policy required a water management team that included the infection preventionist, administrator, medical director or designee, director of maintenance, and director of environmental services, along with a diagram of the water system and documentation of the program. Facility staff stated the facility did not have a specific water management team, had not held a water management meeting specifically for Legionella, and did not have a water flow map. The facility also failed to ensure staff performed hand hygiene and changed soiled gloves after resident contact during personal care. For a resident with a urostomy, nephrostomy tube, pressure ulcers, and EBP in place, staff were observed providing hygiene and wound care without wearing gowns when required, touching contaminated items and clean items with the same gloves, removing gloves and leaving the room without hand hygiene, and handling wound and nephrostomy dressings without changing gloves or cleaning hands between tasks. For another resident who was mostly incontinent and required peri care, staff were observed touching clean linens and equipment with soiled gloves after providing incontinent care. For a third resident who was dependent for personal hygiene and incontinent of bowel and bladder, staff were observed performing personal care and then touching the mechanical lift, resident linens, and equipment with the same soiled gloves before removing them and leaving the room without hand hygiene. The facility further failed to provide proper infection control during blood glucose testing for three residents with diabetes. An LPN was observed using gloves and an alcohol pad to obtain fingerstick glucose readings from each resident, then removing gloves without washing hands or using hand sanitizer before or after the procedure. The facility policy required clean gloves, finger cleansing, sterile lancet use, glove removal, and handwashing after the procedure. The Infection Preventionist and DON stated staff should perform hand hygiene before glove use, after glove removal, and between glove changes, but the observed practice did not follow those expectations.
Failure to Provide Restorative ROM and Mobility Services
Penalty
Summary
The facility failed to provide restorative services to assist residents with mobility and/or limited range of motion to attain or maintain their highest level of functioning. Review of the facility policy showed that restorative nursing care was to be individualized, resident-centered, and used to help promote optimal safety and independence, including maintaining or strengthening physiological resources. During the survey, the Director of Therapy and the Director of Nursing stated that the facility did not have a restorative nursing program because of staffing issues, although both said residents would benefit from restorative nursing and ROM services. Resident #6 had cerebral palsy, was wheelchair dependent, and had severe spasticity with limited ROM of the arms and upper body. The resident required a mechanical lift for transfers and frequent monitoring of positioning. The resident stated that no therapy had been provided for a long time, that the muscle spasticity in the low back and legs was painful, and that a restorative program might help maintain upper body strength. The Director of Therapy said the resident would benefit from restorative nursing because of the cerebral palsy and spasticity, but also said the resident was not interested when approached about therapy. Resident #28 had osteoarthritis, used a walker and wheelchair, and had been independent with transfers and ambulation in the room, but was observed propelling a wheelchair and stopping several times to rest. The resident stated feeling weaker than on admission, said the resident used to walk farther with a walker, and wanted to work with therapy to get stronger again. Resident #30 had a stroke, severe cognitive impairment, was dependent for positioning and mobility, and was observed lying in bed with both hands and fingers clenched closed. The legal representative reported concern that the resident was not getting therapy and that the hands were getting worse, and said the resident would benefit from ROM even if unable to participate in therapy. The Director of Therapy stated that a resident with bilateral hand contractures would benefit from restorative nursing ROM and adaptive measures, but she had not evaluated the resident. Resident #3 had a hip fracture and had been placed in a restorative ROM program for bilateral lower extremities after skilled PT, with recommendations to continue restorative ROM per tolerance. However, the care plan contained no documentation regarding restorative nursing services, and the medical record showed no documentation of participation in a restorative ROM program. Resident #7 had severe cognitive impairment, functional ROM limitations in both upper and lower extremities, and was dependent for all ADLs and transfers. PT discharge documentation recommended referral to restorative nursing per resident tolerance, yet the resident was observed with a swollen right hand, curled fingers, and a right thumb nail digging into the index finger, and the resident was unable to independently hold the hand open. The DON stated the facility did not have a restorative nurse aide or a current restorative therapy program, and expected nursing staff to offer ROM in bed or during showers.
Unsafe Resident Transfers and Unsecured Chemicals
Penalty
Summary
The facility failed to ensure staff used the appropriate transfer technique for a resident with unspecified dementia, osteoporosis, pain, and muscle weakness. The resident’s quarterly MDS showed severely impaired cognition and dependence on staff for chair-to-bed transfers. The resident’s care plan and physician orders directed that transfers be done with two staff using a gait belt, or with a mechanical lift, and weight bearing as tolerated. During observation, two CNAs assisted the resident from the bed to a Broda chair using a gait belt, but the resident did not bear weight and the legs were crossed at the ankles. On another observation, one CNA assisted the resident to stand and transfer by him/herself while another staff member was in the room, even though the resident’s care plan required two-person assistance. The resident’s feet drug across the floor during that transfer, and a nursing note later documented that the resident was getting very stiff during transfers and was not bending well. The resident’s transfer status was not followed consistently by staff. One CNA stated the transfer did not go well and the resident might need a mechanical lift, and another CNA stated the resident was a two-person assist with a gait belt and should not be transferred with only one staff. The DON stated staff should not perform a one-person transfer on a resident who was a two-person transfer and that the resident had been reported as declining in transfers with two-person assist and a gait belt. The resident’s physician was notified after the decline in transfers was documented, and the order was changed to a full body mechanical lift. The facility also failed to secure hazardous chemicals. The shower rooms on the 400 and 500 halls were observed unlocked, and a full bottle of Buckeye Neutral Disinfectant was seen in an unlocked cabinet in each room. The disinfectant container was labeled with warnings including danger, corrosive, causes irreversible eye damage and skin burns, and harmful if inhaled, swallowed, or absorbed through the skin. Staff stated the shower rooms were always unlocked and that residents could enter unaccompanied to use the bathroom if they wanted to. A CNA also observed that the cabinet holding the disinfectant was not locked, and the DON stated disinfectants should be stored in a locked cabinet in the shower rooms.
Controlled Substances Not Reconciled in Medication Room Lock Box
Penalty
Summary
The facility failed to ensure that inventories of Schedule II, IV, and V controlled substances were monitored and reconciled every shift, as required by facility policy, for five sampled residents and ten additional residents. During observation of the 300/400/500 Hall medication room, multiple pharmacy medication cards containing controlled substances were found stored in a double-locked metal cabinet, including hydrocodone-acetaminophen, oxycodone, tramadol, lorazepam, and pregabalin for several residents. The medications observed included large remaining quantities, such as multiple cards of hydrocodone-acetaminophen and oxycodone, as well as tramadol, lorazepam, and pregabalin cards kept in the medication room lock box. Review of the facility policy showed that controlled substance inventory was to be counted at the end of each shift by the oncoming and off-going nurses, with discrepancies reported to the DON. However, there was no documentation of shift counts or reconciliations for the narcotic medications in the lock box. Staff interviews confirmed that the medications in the medication room lock box were not being counted or reconciled as part of the shift count process. An LPN stated he/she had not received training on counting the narcotics in the lock box and said staff do not count them there. An RN stated the narcotics in the lock box were considered overflow and were not counted/reconciled, and the MDS Care Plan Coordinator said staff do not count narcotics until they are placed into the medication carts for medication pass. The DON acknowledged awareness of narcotics in the medication room lock box and stated staff had never counted or reconciled them there. The Administrator stated the DON should monitor the medication room, medication carts, and narcotic lock box, and that narcotics in the lock box should be counted at shift change.
Failure to Destroy Discontinued Controlled Medications
Penalty
Summary
The facility failed to destroy two Schedule II controlled substances and one Schedule IV controlled substance for a resident with diagnoses including unspecified pain, other unspecified anxiety, and a sacral pressure ulcer. Review of the resident’s records showed no current orders for hydrocodone, morphine sulfate, or lorazepam, while discontinued orders showed lorazepam stopped on 04/09/25, morphine sulfate stopped on 03/11/25, and hydrocodone stopped on 03/10/25. Despite those discontinuations, observation of the medication cart lock box on 09/25/25 showed hydrocodone 5/325 mg with 13 tablets remaining, an unopened bottle of morphine sulfate oral suspension with 30 ml remaining, and an unopened bottle of lorazepam oral suspension with 30 ml remaining. Facility staff stated that discontinued medications should be removed from the medication cart and, if controlled substances, destroyed by two nurses using drug buster and documented on a medication destruction log. The LPN said it was the responsibility of the nurse who took the discontinue order to remove the medication from the cart and was unsure why the medications had not been destroyed. The DON stated discontinued medications should be removed from the cart as soon as possible and narcotics disposed of by two nurses using drug buster as soon as possible after the discontinue order, but the medications remained in the active medication cart for months after discontinuation.
Incorrect Diet Preparation and Portioning During Meal Service
Penalty
Summary
The facility failed to ensure staff prepared all food items and served the correct portion sizes for residents with physician orders for pureed and mechanical soft diets. During the lunch meal service, Dietary Staff V served residents on a pureed diet a #16 scoop of pureed hamburger instead of the #6 scoop listed on the diet spreadsheet, did not puree the bun with the hamburger, did not prepare or serve pureed bread, did not prepare or serve pureed soft cooked vegetables, and served pureed peaches instead of applesauce. Four residents had physician orders for a pureed diet, and the diet spreadsheet specified pureed hamburger or cheeseburger on bun, pureed breaded cauliflower, pureed soft cooked vegetables, and applesauce. The same meal service showed residents with mechanical soft diet orders were also not served as directed. Nine residents had physician orders for a mechanical soft diet, but Dietary Staff V served a #12 scoop of ground hamburger instead of the #8 scoop or 4-ounce serving listed on the spreadsheet and did not serve it with a bun. Staff also failed to prepare and serve the soft chopped cooked vegetable specified by the recipe and served cold stewed tomatoes instead, and served chopped peaches instead of chopped apple slices. The Dietary Manager stated staff should follow the spreadsheet menu, meal tickets, and recipe books, but she overlooked that apples and applesauce were on the menu, told staff to prepare peaches, was not aware the bun was not blended with the pureed hamburger or served with the mechanical soft meat, and overlooked that a second soft-cooked vegetable should have been prepared.
Food Served at Improper Temperatures and Not Prepared as Ordered
Penalty
Summary
Food and drink were not prepared and served at a safe and appetizing temperature, and food items were not prepared according to the recipe for residents on physician-ordered pureed, mechanical soft, and regular diets. The facility policy stated food would be served at acceptable temperatures, but residents reported that meals were often overcooked, undercooked, cold, or otherwise not good. Several residents said the food did not taste good, was not seasoned well, or that they often refused facility meals and ate their own food instead. One resident said warm food was not served warm and cold food was not served cold, even when meals were served in the dining room. At lunch, the sample test tray showed hot menu items served below the dietary manager’s stated standard of 165 degrees F. Pureed hamburger was 116.4 degrees F and pureed cauliflower was 111.7 degrees F for residents on a pureed diet. For residents on a mechanical soft diet, the hamburger was 116.2 degrees F and the cauliflower was 106.3 degrees F. For residents on a regular diet, the hamburger was 114.6 degrees F, the fried breaded cauliflower was 100.9 degrees F, and the fresh grapes were discolored brown and mushy. The dietary manager stated hot food should be 165 degrees F and said staff cut up the grapes just prior to the meal, but she was unsure why they turned brown.
Improperly Prepared Pureed and Mechanical Soft Diets
Penalty
Summary
Food was not prepared in the proper form to meet residents’ ordered diets. Four residents had physician-ordered pureed diets, and the lunch meal spreadsheet for 9/22/25 indicated they were to receive pureed hamburger or cheeseburger on bun and pureed breaded cauliflower. The recipe for pureed breaded cauliflower directed staff to place the prepared breaded vegetables in a food processor with chicken broth and blend until smooth, and the recipe for pureed hamburger or cheeseburger on bun directed staff to place the prepared sandwiches and beef broth in a food processor and blend until smooth. During observation and interview, Dietary Staff V placed an unmeasured amount of cooked cauliflower and water, rather than chicken broth, into the food processor and pureed it. The mixture was very thin and watery with visible chunks of cauliflower, and the staff member stated the pureed mixture should be thin and smooth. Later observation during lunch service showed watery and chunky pureed cauliflower being served, and the pureed hamburger was also observed to be chunky and not smooth. Nine residents had physician-ordered mechanical soft diets, and the lunch spreadsheet indicated they were to receive soft chopped cauliflower. The recipe required cauliflower to be cooked until fork tender, drained, and chopped into bite-sized pieces, but Dietary Staff V served large chunks of cauliflower that were not soft and not chopped into bite-sized pieces. The Dietary Manager stated pureed items should be smooth and baby food consistency, and mechanical soft items should be soft and chopped.
Incomplete CNA Annual In-Service Training
Penalty
Summary
The facility failed to ensure three CNAs in a review of three received the required 12 hours of annual in-service education. The facility assessment stated that staff training and competencies included monthly in-services on topics of need and mandatory training as needed, and the 2025 mandatory in-service list included topics such as abuse/neglect/misappropriation of belongings, resident rights/customer service, infection control, disaster preparedness, and fire drills. However, review of the employee in-service histories showed CNA H attended seven in-service hours, CNA L attended four in-service hours, and CNA S attended two in-service hours during the reviewed period. The reviewed CNAs were hired on 01/28/24, 02/13/24, and 01/28/24. During interview, the DON and Administrator stated that CNAs are offered at least 12 hours of in-service education annually and that CNAs are responsible for ensuring their required hours are completed because annual raises are based on completion. They also stated that no one at the facility was tracking in-service hours for regulatory compliance, and that recorded in-service education was available for staff to view by appointment.
Failure to Follow Nephrostomy Dressing Orders
Penalty
Summary
The facility failed to ensure staff followed professional standards of practice when treatment orders were not followed for a resident with spina bifida, diabetes, reduced mobility, obesity, muscle weakness, an indwelling catheter, and a nephrostomy tube. The resident’s physician ordered the nephrostomy dressing site to be changed daily, cleansed with normal saline, and covered with Skin Prep around the tube, followed by drain sponge and border gauze. The resident’s care plan also identified the urostomy and nephrostomy tube and directed staff to notify the nurse immediately if either became dislodged. During observation, an RN removed the resident’s nephrostomy dressing and applied a dry dressing secured with tape without applying Skin Prep. On a later observation, an LPN removed the dressing, did not cleanse the nephrostomy site, and applied Vaseline gauze around the site and under the tubing, then covered it with gauze and tape. The LPN stated he/she was not aware of the order to cleanse with normal saline or apply Skin Prep and had been using Vaseline gauze for several weeks. The RN stated he/she was not aware of the order to cleanse with normal saline and apply Skin Prep, and the DON stated staff should follow treatment orders as written. The physician stated she expected staff to follow the orders and that the nephrostomy site should be cleansed with normal saline and covered with a dry dressing as ordered.
Pressure Ulcer Care and Repositioning Failures
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with spina bifida, diabetes, reduced mobility, obesity, and muscle weakness. The resident had a sacral/coccyx pressure ulcer with physician orders to cleanse the wound with Normal Saline, apply Maxorb AG, and cover with a dry dressing. Weekly wound assessments were expected, but several assessments lacked required documentation such as wound depth, characteristics, and complete measurements. One weekly assessment documented no wound characteristics, another was not completed, and later assessments continued to omit depth and wound description even as the wound measurements changed over time. The resident’s wound measurements showed periods of worsening, including increases in length and width, but the record did not show that the physician was notified of those changes as required by facility policy. Staff also documented that the resident refused weekly wound measurements on one occasion, and the record did not show that staff attempted to obtain the measurements later. During observation, staff did not follow the ordered cleansing method: one RN washed the open wound with shampoo/body wash on a washcloth instead of Normal Saline, and later an LPN cleansed the wound with periwash and a washcloth that had stool on it rather than using Normal Saline. Staff interviews confirmed that the wound should have been cleansed with Normal Saline and that the physician should have been notified when the wound was not healing or was worsening. The facility also failed to turn and reposition another resident who had pressure ulcers and was dependent for turning, repositioning, and transfers. That resident had a coccyx pressure ulcer and a right gluteal fold wound, and the care plan did not document an individualized repositioning schedule. Observations showed the resident remained on one side in bed for hours without repositioning, and later sat upright in a Broda chair for more than five hours without offloading pressure. Staff stated the resident should be repositioned every two hours, but the observations and the paper log reviewed did not show repositioning being provided or documented as expected.
Failure to safely respond to a resident with dementia and aggressive behaviors
Penalty
Summary
The facility failed to ensure staff demonstrated appropriate skills to respond to a resident with dementia who displayed aggressive behaviors. Resident #17 had diagnoses of mild cognitive impairment and dementia, was alert to name only, and was usually able to make needs known, but at times perceived situations differently and needed staff help to maneuver through them. The resident’s care plan described dementia, delirium at times, confusion, and irritability, but it did not provide direction for staff on how to effectively and therapeutically respond when the resident became behaviorally escalated. On 07/14/25, the resident was in another resident’s room, became agitated, and was kicking, hitting, calling names, and trying to stab staff with a pen hidden in a napkin. NA J blocked the resident by grabbing the resident’s wrist and holding it against the resident’s chest while wrapping arms around the resident and sitting the resident on the floor. The DON documented the incident and later explained to the resident that staff had held the wrist to prevent the resident from stabbing staff or self. The resident later had a purple/black bruise on the right hand below the fourth and fifth knuckles. Additional incidents showed the resident continued to become aggressive when redirected from other residents’ rooms or when trying to leave the special care unit. On 07/25/25, the resident and a CNA fell in the hallway while the CNA attempted to redirect the resident out of another resident’s room. On 08/18/25, staff reported the resident struck an employee in the face, and the employee went to hold onto the resident to prevent another hit; the resident sat on the floor. During interviews, NA J stated no one had trained him/her on how to safely handle residents with aggressive or violent behaviors and described using wrist holds and bear hugs to control the resident. The DON and Administrator acknowledged staff had dementia training but had not received training on safely taking down or handling aggressive residents, and they were unsure whether the physical holds used were appropriate.
QA Committee Meetings Lacked Required Members
Penalty
Summary
The facility failed to ensure that Quality Assurance (QA) committee meetings included the required members, including the Medical Director. The facility census was 45. During interview, the Administrator stated the facility did not have a policy for Medical Director responsibilities. The Medical Director Agreement, signed by the Medical Director, stated that the Medical Director would serve on facility committees, including QA, and assist the Administrator in implementing committee recommendations and plans of action. The facility’s QA Committee policy stated that monthly QA meetings would be held and that the Medical Director, attending physicians, Nurse Practitioners, DON, ADON, Medical Records Director, Dietary Manager, and Administrator would regularly attend. Review of QA meeting attendance sheets from January 2025 through September 2025 showed the Medical Director attended only one QA meeting. During interview, the Medical Director stated she made rounds in the facility on the second and fourth Tuesdays of each month, was available for QA meetings when she made rounds, had not been attending QA meetings, and was only available on those days. The Administrator stated the QA committee changed the meeting date and time to accommodate the Medical Director’s schedule, that the Medical Director was invited to the meetings, and that the facility did not provide her with a report of what was discussed at the QA meetings. The Administrator also stated the Nurse Practitioner working alongside the Medical Director did not attend the QA meetings.
Failure to Provide Required Medicare Discharge Notices
Penalty
Summary
The facility failed to provide required Medicare discharge notices to residents or their representatives when Medicare Part A skilled services were ending before benefit days were exhausted. In a review of three discharged-from-service residents, surveyors found that two residents did not receive a CMS Notice of Medicare Non-Coverage (NOMNC), and two residents did not receive a complete Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The facility census was 45, and the reviewed policy stated that residents using Medicare services would be given proper notice before services were discontinued and that the Case Manager or Medical Records clerk would complete ABN forms. Resident #1 had diagnoses including repeated falls and had a DPOA for healthcare. The record showed Medicare Part A skilled services began on 07/25/25, the NOMNC was completed and signed by the resident's representative on 08/20/25, and the last covered day of Part A service was 08/21/25. The resident was discharged from Medicare Part A services on 08/21/25 and remained in the facility. However, the record did not show that an SNF ABN form was issued to identify what skilled services the resident would be discharged from, the reason for termination, or the estimated cost if the resident chose to continue daily skilled care. Resident #38 had diagnoses including difficulty walking, muscle weakness, and spinal stenosis, and was his/her own person. The record showed an SNF ABN form stating skilled benefits would end on 04/25/25, that the resident would need to pay out of pocket for PT and OT because the resident had plateaued in therapy, and that the estimated cost would be $40.00 per session; however, the resident's signature was undated. The record showed the resident was discharged from Medicare Part A services on 04/26/25 and remained in the facility, but there was no documentation that a NOMNC form was provided. Resident #101 had diagnoses including a displaced intertrochanteric fracture of the right femur and had a DPOA for healthcare. The record showed a Medicare Part A skilled services episode start date of 08/05/25 and discharge from Medicare Part A services on 08/30/25, with return home. The record did not show that a NOMNC form or a complete SNF ABN form was provided to the resident or representative.
Failure to Ensure Resident Dignity During Covid Test
Penalty
Summary
The facility failed to ensure that staff treated a resident with dignity and respect during a Covid test administration. A Certified Nurse Assistant (CNA) conducted the test without communicating with the resident beforehand to request permission, provide education on the rationale or preparation for the test, or ensure the resident's privacy during the procedure. This incident involved one resident out of a sample of nine, with the facility census at 52.
Resident's iPad Presumed Stolen
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically when the resident's iPad went missing and was presumed stolen. This incident involved one resident out of a sample of nine, within a facility census of 52. The deficiency was identified through interviews and record reviews, indicating a lapse in safeguarding the resident's belongings.
CNA Conducts Unauthorized COVID-19 Test
Penalty
Summary
The facility failed to adhere to professional standards of practice when a Certified Nurse Assistant (CNA) conducted a COVID-19 test on a resident without proper assessment or authorization. The CNA performed the invasive procedure, which involves inserting a cotton swab into the nasal passages to collect a sample, on a resident who had not been evaluated by a licensed nurse to determine if testing was necessary. Furthermore, there was no documented evidence that the CNA had received appropriate training to perform the test. This incident was identified during a review of nine sampled residents, with the facility having a total census of 52.
Inadequate Incontinent Care for a Resident
Penalty
Summary
The facility failed to provide adequate incontinent care for a resident, as identified during a survey. This deficiency was observed through a combination of observation, interviews, and record reviews. The specific resident involved was one of nine sampled residents, and the facility's census at the time was 52. The report highlights a lapse in the care provided to a resident who required assistance with activities of daily living, specifically in managing incontinence.
Failure to Ensure Timely Certification for Newly Hired NA
Penalty
Summary
The facility failed to ensure that a newly hired nurse assistant, referred to as NA B, obtained their certification within the required four-month time frame. This deficiency was identified through observation, interview, and record review. The facility's census at the time was 52, and the review focused on one nurse assistant employee file, which revealed the lapse in certification compliance.
Inadequate PPE Use During COVID-19 Testing
Penalty
Summary
The facility failed to ensure that staff utilized appropriate personal protective equipment (PPE) during nasal swab testing for COVID-19 on a resident. This deficiency was identified through observation, interview, and record review. The incident involved one resident out of a census of 52, and the deficiency remained uncorrected as noted in a previous Statement of Deficiencies.
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 48 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 Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Aire Retirement Center | 13.8 mi | ★★★★★ | 4 | 0 |
| Quincy Healthcare & Sr Living | 15.3 mi | ★★★★★ | 2 | 0 |
| Sunset Home | 16.7 mi | ★★★★★ | 4 | 2 |
| Blessing Hospital Snu | 16.8 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Home | 17.9 mi | ★★★★★ | 1 | 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.