Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Loch Haven during CMS and state inspections, most recent first.
Unsafe Food Storage, Hand Hygiene, and Kitchen Sanitation: Staff left food items open, unlabeled, undated, or improperly stored; handled raw and ready-to-eat foods with poor glove and hand hygiene; and worked in areas with heavy grease, debris, and unsanitary equipment. The Dietary Manager also had hair exposed while working around open food, clean dishes were handled with visible debris, sanitizing logs were incomplete, and a dishwasher ate in the dish area near clean dishes.
Meal assistance did not preserve resident dignity for several residents. A CNA stood while feeding residents who were dependent on staff for eating, including a resident with cerebral palsy and quadriplegia, a resident with Alzheimer’s disease, and a resident with MS and dementia. In one case, applesauce was placed out of reach and the CNA fed the resident while standing without further conversation. The DON and Administrator stated staff should sit next to residents when assisting with meals.
Failure to Honor Resident Choice for Morning Routines: Two residents and one additional resident were awakened and gotten up in the early morning despite being observed asleep or appearing asleep, and their care plans did not document a preference for early rising. One resident with severe cognitive impairment and CVA was dressed and moved through the unit while still appearing asleep, another resident with MS and dementia was pushed to breakfast while asleep, and a third resident with severe cognitive impairment, cerebral palsy, quadriplegia, and hospice care was transferred from bed around 5:00 A.M. Staff and family/POA interviews indicated the residents likely preferred later rising, and the DON and administrator stated sleeping residents should not be awakened early.
Delayed MDS Transmission: The facility failed to transmit several MDS assessments within the required timeframe for multiple residents. Records showed a Significant Change, Quarterly, and Annual MDS were completed but not accepted until weeks later. The MDS Coordinator, who was also the DON and the only on-site staff member submitting MDS data, said off-site consultants helped enter the information and that she did not always review it for accuracy before signing.
The facility failed to revise care plans for two residents so they reflected current assessments and needs. One resident with Alzheimer’s dementia had documented hallucinations, delusions, refusal of care, and physical and verbal aggression, but the care plan only addressed limited hygiene assistance and noncompliance. Another resident with MS and dementia had become dependent for mobility and was using a mechanical lift, yet the care plan still referenced a trapeze bar, electric wheelchair independence, and stand-up lift transfers. Staff interviews confirmed the residents’ current conditions did not match the care plans.
Unsecured chemicals and accessible electric range: A cognitively impaired resident with non-Alzheimer's dementia was observed in an area where the shower room door was unlocked and multiple cleaning products, nail polish remover, and disinfectants were left out with warning labels to keep them out of reach. Similar unsecured chemicals were found in an unlocked kitchenette cabinet, an unlocked storage room, and an unlocked drawer in the activity room, where an electric range could still be turned on while residents were present and no staff were nearby.
RN coverage was not maintained for at least 8 consecutive hours each day, and the DON worked as charge nurse when the census was above 60. Records showed multiple days with no RN coverage scheduled or RN shifts under 8 hours, and the DON was documented working charge nurse while the census was 68.
Missing Annual Nurse Aide Performance Reviews: The facility failed to complete annual performance reviews for multiple CNAs and did not provide regular in-service education based on review outcomes. Record review showed no documentation of nurse aide evaluations for several CNAs, and the DON and Administrator stated that these reviews had not been completed for a while and that the facility did not have nurse aide evaluations or annual performance reviews.
Food was not consistently served at safe, appetizing temperatures and required temperature logs were left blank. During meal observations, hot items such as green beans were cool by the time they reached residents, and several cold items including cottage cheese and fruit plates, pudding, dressing, and milk were above ordered temperature ranges. A resident reported coffee was never hot, milk had been sour, and trays were often delayed while staff were interrupted with other tasks.
Bedtime Snacks Not Routinely Offered: Staff failed to offer nourishing bedtime snacks to two residents when the meal schedule left 14 hours between supper and breakfast. Residents reported they did not routinely receive bedtime snacks, and staff said residents had to request snacks rather than being routinely offered them. The Dietary Manager said evening snacks were available in hall refrigerators, but CMTs reported the snack cart was no longer routinely used and residents who did not ask could go without.
Staff failed to perform hand hygiene between glove changes and during resident care, including care for residents with incontinence, C. diff, and urinary catheters. Staff also did not follow EBP for a resident with a stage four pressure ulcer when repositioning, and respiratory equipment was left uncovered instead of stored per policy. In addition, catheter drainage bags and tubing were observed on the floor for two residents with indwelling catheters.
Failure to Document Staff COVID-19 Vaccine Education and Status: The facility failed to keep written documentation showing staff were educated on the benefits, risks, and potential side effects of the COVID-19 vaccine and failed to maintain staff vaccination status records. Review of new hire files showed no documentation that staff were offered, refused, or educated about the vaccine, and a NA reported not being educated or offered the vaccine. HR stated the files had no COVID-19 vaccine documentation, while the DON and Administrator confirmed the facility relied on verbal communication but had no written records in employee files.
The facility failed to ensure CNAs completed the required 12 hours of annual in-service education, including dementia care training. Record review showed multiple CNAs had only 2.75 to 8.00 in-service hours, with dementia training left blank. The DON said HR was responsible for tracking the training, and the Administrator said prior documentation could not be found after HR staff left, although dementia training had reportedly been offered.
A resident with severe cognitive impairment, vitamin deficiency, and dependence on staff for eating was ordered a pureed diet with double portions at meals, but dietary staff did not serve the meal items and portion sizes listed on the spreadsheet menu. At lunch and dinner, the resident received incomplete or incorrect portions, including missing double portions and a missing pureed bread item, and the Dietary Manager was unaware the ordered portions had not been served.
Failure to track antibiotic use and infection surveillance: A resident had abnormal urine testing with a lab comment to request culture, but there was no documentation that the culture was requested. The resident received ciprofloxacin for UTI and later vancomycin for C. diff, while the RN Consultant said her IP role was only to verify antibiotic orders in the computer. The DON and Administrator stated they did not maintain required infection tracking records, line listings, monthly infection reports, pathogen trend reports, or monthly infection rates, despite reviewing antibiotic lists and cultures with the Medical Director.
The facility failed to provide written transfer/discharge notices and bed hold information when four residents were sent to the hospital. Records showed hospital transfers for residents with responsible parties, and one resident who was his/her own responsible party, but there was no documentation that the resident or representative received the required written notice or bed hold policy; staff and the DON said the charge nurse should provide the notice during emergency transfers.
A resident in a dementia care unit experienced right eye pain and vision issues after an altercation with another resident. Despite multiple reports from staff and family, licensed nurses did not assess the eye or notify a physician promptly. The resident's condition worsened, leading to a dislodged lens requiring medical intervention.
Unsafe Food Storage, Hand Hygiene, and Kitchen Sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations, multiple food items were found open, unlabeled, undated, or not securely sealed, including eggshells mixed in a carton of eggs, open bags of frozen and dry foods, uncovered bulk flour and sugar bins, food items stored on the floor in coolers and freezers, and a dented can of black beans kept with other canned goods. In several kitchenettes and refrigerators, sandwiches and other prepared foods were left unlabeled and undated, and a jar of yeast was stored unrefrigerated despite label instructions to refrigerate or freeze after opening and use within four months. Staff were also observed failing to follow proper hand and glove hygiene. A broken step-pedal trash can at the handwashing sink was noted, and staff were seen handling raw meat, utensils, and ready-to-eat foods with gloved hands without washing hands after changing gloves or after contaminated tasks. One aide picked up a measuring cup from the floor and continued food preparation without washing hands or changing gloves. Another aide touched the handles of equipment, wiped a face with gloved hands, and continued sandwich preparation after removing gloves and washing hands. A different aide left the steam table to get a drink from the cooler, returned without washing hands or changing gloves, and continued serving food. Another aide entered while texting on a phone, did not wash hands before gloving, and handled silverware by the eating surfaces. The kitchen and related food service areas were not maintained in sanitary condition. Observations showed dried debris on the food preparation sink and wall, heavy encrusted buildup on the stove top, grease accumulation on the wall and hood baffle filters, and heavy dried debris on the dishwashing machine and ice dispenser. Sticky residue was also seen in a refrigerator. Hair restraints were not worn properly by the Dietary Manager, with hair exposed on the sides, front, and back of the head while working around open food. Clean dishes and utensils were also handled and stored unsafely, including a plate with dried food debris being used for resident service and pitchers with staining and moisture inside. In addition, the sanitizing bucket log was blank for one month and missing for subsequent months, and a staff member was observed eating in the dishwashing room next to the clean dish area.
Meal Assistance Did Not Preserve Resident Dignity
Penalty
Summary
The facility failed to provide care in a manner that enhanced residents’ dignity and ensured full recognition of individuality for one resident and three additional residents during meal assistance. Facility policy stated that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, and staff should not stand over residents while assisting with meals. Resident #26 had severely impaired cognitive skills for daily decision making, diagnoses of cerebral palsy and quadriplegia, and was dependent on staff for eating; the care plan directed staff to assist with all meals, snacks, and drinks. During observation, the resident sat in a reclining wheelchair while a CNA stood beside the resident and fed bites of pureed food. The CNA stated he/she stood while feeding in the dining room to keep an eye on other residents and monitor for choking. Resident #32 had memory problems, Alzheimer’s disease, and was dependent on staff for eating; the care plan directed staff to provide set up, oversight, encouragement, cueing, and assistance during eating and drinking. During observation, the resident sat in a reclining wheelchair at the table while a CNA stood beside the table and fed bites of pureed food. The CNA stated staff should probably sit next to residents when assisting them, but most staff stood because several residents needed assistance and staff did not want food to get cold. Resident #72 had multiple sclerosis and dementia, with severe cognitive impairment and partial to moderate assistance needed for eating; the resident also had a physician order for finger foods to increase self-feeding independence. During observation, the resident sat in a wheelchair with a neck pillow at the dining room table, had food on the plate and applesauce out of reach, and a CNA stood next to the resident, asked if the resident wanted to be pulled up, then fed applesauce while standing and did not speak further during the meal. The DON and Administrator both stated staff should sit next to a resident rather than stand when assisting with eating.
Failure to Honor Resident Choice for Morning Routines
Penalty
Summary
The facility failed to ensure that residents were provided the right to choose schedules, including waking times, and to make choices about significant aspects of their lives. In a review of 18 sampled residents, the deficiency involved two residents and one additional resident whose care plans did not specify a preference for early rising, despite facility policy stating that residents may choose when to sleep, eat, and conduct activities of daily living. Interviews with the DON and administrator indicated that staff should not wake sleeping residents in the early morning and should ask representatives about preferences for cognitively impaired residents. Resident #27 had severe cognitive impairment, required substantial to maximal assistance with toileting and mobility, and had a history of CVA with hemiplegia. Although the care plan addressed a preference for waking time, observations showed the resident asleep in bed at 4:10 A.M., then dressed and in a wheelchair by 5:05 A.M., still appearing asleep at 6:10 A.M., 7:10 A.M., 7:30 A.M., 8:00 A.M., and 8:30 A.M. Staff pushed the resident to the television room and then to the dining room while the resident remained with eyes closed and head down. CNA A stated the resident was a one-person assist and that getting the resident up early helped day shift. The resident's POA said the resident likely would have preferred to stay in bed until closer to breakfast. Resident #72 had diagnoses of MS and dementia, severe cognitive impairment, and dependence for mobility. The care plan did not specify a preference related to early rising. Observations showed the resident asleep in bed at 4:10 A.M., then dressed and in a wheelchair in the television room at 7:10 A.M., and pushed to the dining room at 7:30 A.M. for breakfast while appearing asleep. At 8:30 A.M., staff woke the resident, set up the breakfast tray, and told the resident it was time to eat. The resident's family member stated the resident was not typically an early riser and would prefer staff allow the resident to sleep later unless there was a reason to get up. Resident #26 had severe cognitive impairment, no speech, cerebral palsy, quadriplegia, and hospice care. The care plan said staff would assist with ADLs and meet the resident's needs and wants, but did not specify a preference for early rising. Observations showed the resident awake and fully dressed in bed at 5:14 A.M., transferred by mechanical lift to a wheelchair at 5:27 A.M., awake at the nurses' station at 7:05 A.M., and fed breakfast in the dining room beginning at 8:07 A.M. while later appearing with eyes closed. The resident's representative stated that getting the resident up around 5:00 A.M. was too early.
Delayed MDS Transmission
Penalty
Summary
The facility failed to electronically transmit MDS assessments to the State within the required timeframe for one resident in the sampled group and five additional residents. Review of the MDS records showed that a Significant Change MDS for one resident, Quarterly MDSs for four residents, and an Annual MDS for one resident were completed in June and May 2025, but were not accepted until August 1, 2025 or August 11, 2025. The report also states the facility did not provide a policy for MDS assessment and transmission when requested. During interviews on 08/11/2025, the MDS Coordinator said she was also the DON and the only staff member on-site who submitted MDS information. She stated she tried to submit MDS information weekly and could usually do so, that off-site consultants helped enter MDS information, and that she did not always review consultant-submitted MDS information for accuracy before signing. The administrator stated the facility should follow the RAI manual regarding completion and submission of MDS assessments.
Care Plans Not Updated to Match Resident Conditions
Penalty
Summary
The facility failed to review and revise care plans for two residents to reflect their specific conditions and needs. The cited deficiency involved failure to keep care plans aligned with comprehensive assessments and resident status changes, despite facility policy stating that care plan goals and objectives are derived from the resident’s assessment and are reviewed and/or revised when there is a significant change in condition and at least quarterly. For one resident with Alzheimer’s dementia, cognitive impairment, hallucinations/delusions, verbal behaviors toward others, rejection of care, and supervision needs for hygiene and toileting, progress notes documented repeated refusal of showers, physical and verbal aggression toward staff, wandering, agitation, and combative behavior. Observation showed the resident sitting agitated in the room with a security camera sign posted on the door. However, the care plan only addressed limited grooming/personal hygiene and noncompliance with staff assistance, and did not reflect hallucinations, delusions, verbal and physical behaviors, or the use of a security camera/device in the room. For the other resident with MS and dementia, the record showed severe cognitive impairment and dependence for mobility on the significant change MDS, while the care plan still referenced a trapeze bar, electric wheelchair independence, and stand-up lift transfers. Observation showed a mechanical lift and sling at the bedside and no trapeze bar or frame attached to the bed. Staff interviews confirmed the resident had required a mechanical lift for some time and had not used a trapeze bar for about a year, while the DON stated the resident needed a mechanical device for transfers and had not used a sit-to-stand for some time, yet the care plan had not been updated to match the resident’s current transfer status.
Unsecured Chemicals and Accessible Electric Range
Penalty
Summary
The facility failed to ensure chemicals were secured in locked storage areas and accessible only to staff. Resident #62, whose admission MDS dated 06/17/25 showed cognitive impairment and a diagnosis of non-Alzheimer's dementia, was observed on the 400 hall while the shower room door was unlocked and accessible to residents and no staff were present. In that area, two bottles of Lysol disinfectant cleaner, two bottles of window cleaner, a bottle of non-acetone nail polish remover, and a bottle of HDQ disinfectant cleaner were left out in the shower room on the floor, shelf, and counter, with labels warning to keep them out of reach of children and pets and describing hazards such as eye injury, flammability, and danger if ingested. Additional observations showed unsecured hazardous items in multiple areas of the facility. In the special care unit kitchenette, an unlocked lower cabinet contained bleach, carpet and upholstery shampoo, all-purpose cleaner, and peroxide disinfectant while residents were nearby in the day room and at the kitchen table. In the north activity room, an unlocked drawer contained fertilizer spikes and the electric range was able to be turned on even though a sign stated the stove must be turned off at the breaker box after each use; three residents were in the room and no staff were present. A storage room near the beauty shop and therapy department was also unlocked with three bottles of toilet bowl cleaner inside and no staff in or near the room. The Maintenance Director, DON, and Administrator each stated chemicals should be locked and inaccessible to residents, and the Activities Director stated the stove breaker should be turned off after each use but was unaware it had not been turned off and was unaware the fertilizer spikes were unlocked.
RN Coverage and DON Charge Nurse Staffing Deficiency
Penalty
Summary
The facility failed to ensure that an RN was on duty for at least eight consecutive hours each day and failed to ensure the DON worked as charge nurse only when the facility had a census of 60 or less. The facility census was 72, and the Facility Assessment dated 07/09/25 listed staffing that included one RN/DON full time on days, one ADON full time on days, and an RN or LPN for two day-shift positions and one night-shift position. However, review of the licensed nurse schedules and timecards showed multiple dates in January through July 2025 with no RN coverage scheduled or with RN coverage that did not reach eight hours, including dates when RN R, the DON, or an RN consultant worked less than eight hours. The records also showed the DON worked as charge nurse when the census was 68 on 01/11/25 and 01/12/25. On 01/11/25, the DON was scheduled for 7:00 P.M. to 7:00 A.M. and the daily schedule showed she worked 6:49 P.M. to 7:31 A.M. as charge nurse. On 01/12/25, she was scheduled for 11:00 P.M. to 7:00 A.M., and the daily schedule showed she worked 10:54 P.M. to 9:09 A.M. as charge nurse. During interviews on 08/11/25, the DON stated HR was responsible for the licensed nurse schedule and that she covered when there were call-ins, while the Administrator stated HR was responsible for ensuring RN coverage eight hours a day and that the DON covered as charge nurse in emergency situations only.
Missing Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to complete a performance review of each nurse aide at least once every 12 months and failed to provide regular in-service education based on the outcome of those reviews. The facility census was 72, and no policy for annual performance reviews was provided. Review of the current staff list dated 08/05/25 showed CNA I with a hire date of 04/15/09, CNA J with a hire date of 07/03/23, CNA H with a hire date of 07/04/07, CNA B with a hire date of 10/20/22, and CNA L with a hire date of 02/10/11. Record review showed no documentation of nurse aide evaluations or annual performance reviews for CNA B, CNA H, CNA I, CNA J, or CNA L. During interview, the DON stated that nurse aide evaluations and annual performance reviews had not been completed for a while and that when there were complaints about staff performance or skills, the RN Consultant provided additional training to that staff member. The Administrator stated the facility did not have nurse aide evaluations or annual performance reviews.
Food served and documented at improper temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature and failed to document required food temperatures during meal service. The facility policy required hot and cold foods to be served within specified temperature ranges and for the cook to take and record temperatures before each meal service, but the food temperature logs for breakfast, lunch, and dinner on 8/1/25, 8/2/25, and 8/3/25 were blank. Diet orders printed 8/4/25 showed 57 residents on regular diets, nine on mechanical soft diets, five on pureed diets, and two on finger foods diets. During observation of dinner meal service, Dietary Aide Y plated food in the kitchen, covered the plates, and placed them on carts for transport to resident halls; when a test tray was checked after residents were served, regular green beans were 116.6 degrees F and tasted cool, despite kitchen logs showing the green beans were 190 degrees F when placed into the steam table and 187 degrees F before serving. During lunch meal service, the kitchen logs showed a chicken salad cold plate at 39 degrees F, but no temperatures were recorded for the regular and pureed cottage cheese and fruit plates; when tested after service, the regular cottage cheese and fruit plate was 56.1 degrees F and tasted warm, the chicken salad cold plate was 46.4 degrees F and tasted lukewarm, and the pureed cottage cheese and fruit plate was 45.7 degrees F and tasted lukewarm. On another lunch meal, no temperatures were recorded in the preparation or holding logs, and a test tray showed ranch dressing at 73 degrees F, tiramisu pudding cup at 51.4 degrees F, and milk at 47.8 degrees F. Resident #50 stated coffee was never hot, milk had been clabbered and sour, milk cartons sat out for over 45 minutes, and staff were often interrupted while delivering trays so food was often cold when served.
Bedtime Snacks Not Routinely Offered
Penalty
Summary
The facility failed to ensure staff offered a nourishing bedtime snack to two residents when meals were served more than 14 hours apart. The posted meal schedule showed breakfast from 7:30 A.M. to 8:30 A.M., lunch from 11:30 A.M. to 12:30 P.M., and supper from 4:30 P.M. to 5:30 P.M., leaving 14 hours between supper and breakfast. During the resident council meeting, some residents said they did not receive routine snacks at bedtime, and Resident #11 said he/she did not routinely receive a bedtime snack but would take one if offered. Resident #25 said staff did not offer a bedtime snack, and Resident #50 said he/she did not routinely receive one but would take one if staff offered it. Resident #6 said staff did not offer a bedtime snack and that he/she would like one routinely because sometimes he/she got hungry. The Dietary Manager said the kitchen routinely provided evening snacks such as peanut butter and jelly sandwiches, ham and cheese sandwiches, ice cream, yogurt, fresh fruit, and leftover fruit cups, and that snacks were kept in clean utility room refrigerators on the halls and SCU. The Dietary Manager also stated residents would have to go to the nurses’ station to request a snack, or nursing staff could bring one to the room if asked. CMT C said the facility used to have a snack cart between 7:00 P.M. and 8:00 P.M., but it had not been offered routinely for some time, and residents had to request a bedtime snack; if a resident did not know to ask or was unable to ask, they would go without. CMT E said he/she was not familiar with staff offering bedtime snacks routinely in the evening hours. The DON and administrator both stated bedtime snacks should be offered to all residents and should be immediately available for staff to obtain and pass.
Hand Hygiene, EBP, and Equipment Storage Failures
Penalty
Summary
The facility failed to ensure staff performed hand hygiene in accordance with acceptable standards of practice for three residents. For one resident with C. diff, a urinary catheter, bowel incontinence, and severe cognitive impairment, a CNA provided peri care, removed gloves and gown, then returned to the room, donned clean PPE, and continued care. During that care, the CNA handled clean linens and the resident’s catheter drainage bag and tubing with the same gloves used to clean feces from the resident, touched multiple surfaces in the room, and emptied the urinary drainage bag without changing gloves or performing hand hygiene between dirty and clean tasks. For two other residents, staff were observed entering rooms, donning gloves, and providing care without hand hygiene before glove use, after glove removal, or between tasks. The facility also failed to follow Enhanced Barrier Precautions for a resident with a stage four pressure ulcer and wound infection. The resident had COPD, hemiplegia/hemiparesis, and a wound on the buttock, and EBP signage was posted at the door. During repositioning, two staff entered the room wearing gloves but no gowns, and they rolled and adjusted the resident using the draw sheet while their uniforms contacted the resident’s clothing and bedding. The resident’s nebulizer face mask was also observed uncovered on the nightstand rather than stored as required by facility policy. The facility further failed to keep urinary catheter drainage bags and tubing off the floor for two residents with indwelling catheters. One resident with C. diff and a urinary catheter was observed with the drainage bag on the floor beside the bed and dark yellow urine with sediment in the bag and tubing. Another resident with a suprapubic catheter had the drainage bag covered with a privacy bag, but the top of the drainage bag and catheter tubing were lying on the floor, despite a sign above the bed stating the catheter bag should not be on the floor at night. The facility also failed to store BiPAP masks and tubing in accordance with policy for three residents, with the equipment observed uncovered on nightstands or wrapped around bed rails rather than stored in a bag.
Failure to Document Staff COVID-19 Vaccine Education and Vaccination Status
Penalty
Summary
The facility failed to provide all staff with written documentation of education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine and failed to maintain documentation related to staff COVID-19 vaccination status. The facility census was 72, and its COVID-19 Staff Vaccination policy required that staff be provided education before the vaccine was offered, that a vaccine administration record be filed in the employee health file, and that the infection preventionist maintain a tracking worksheet of staff vaccination status. Review of the facility's list of new employees from 11/2/23 through 8/5/25 showed 158 new hires, and employee files contained no documentation showing staff were educated on the benefits, risks, and potential side effects of the COVID-19 vaccine or that they were offered or refused the vaccine. A NA stated he/she had worked at the facility for two months, had not been educated about the COVID-19 vaccine, and had not been offered the vaccine. HR staff stated there was no COVID-19 vaccine documentation in the new staff files and was not aware it was still required. The DON stated HR was responsible for educating new hires and offering the COVID-19 vaccinations, and the Administrator stated the facility verbally informed staff about the latest COVID-19 vaccines but had no documentation of staff education or staff vaccination status in the employee files.
Missing CNA Annual In-Service and Dementia Training
Penalty
Summary
The facility failed to provide required in-service training for nurse aides that included dementia management training as part of the minimum 12 hours of annual training. The facility assessment listed dementia care and managing challenging behaviors as new hire training for nursing staff and included those topics in annual education, but a review of staff in-service education hours for the period from 07/01/24 through 06/30/25 showed that CNA I had 6.50 hours with dementia training blank, CNA/CMT C had 8.00 hours with dementia training blank, CNA K had 5.25 hours with dementia training blank, and CNA J had 2.75 hours with dementia training blank. During interview, the DON said HR was responsible for ensuring CNAs completed the required 12 in-service hours per year and that she would expect this to be done, but there had been an issue getting the hours completed. The Administrator said HR tracked CNA in-service education, the previous HR staff left at the end of 2024, and documentation of prior in-service hours could not be found. She also stated the facility offered dementia training in January 2025 but could not find documentation of that training, and she would expect CNAs to receive 12 hours of annual in-service education including dementia training.
Failure to Follow Pureed Diet Orders and Menu Portions
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the physician’s orders and the diet spreadsheet menu for a resident with severe cognitive impairment, vitamin deficiency, dependence on staff for eating, and a mechanically altered pureed diet. The resident’s care plan directed staff to provide a regular pureed diet, feed the resident, and monitor and record food intake. The physician’s orders dated 03/27/25 specified a pureed texture with double portions at meals every day. During lunch service, Dietary Aide S served the resident pureed chicken salad, cottage cheese/fruit plate, and zucchini, but did not provide double portions of all menu items as listed on the spreadsheet menu. During dinner service, Dietary Aide Y served pureed beef and noodles and green beans, but did not provide the ordered double portions and did not serve the pureed breaded dinner roll. Later that evening, CNA L fed the resident in the dining room, and the resident’s plate still did not contain double portions; the resident ate 100% of the meal. The Dietary Manager stated staff were expected to follow the spreadsheet menu and residents’ diet orders and was unaware the resident had not received double portions during the lunch and dinner meal services.
Failure to Track Antibiotic Use and Infection Surveillance
Penalty
Summary
The facility failed to follow its antibiotic stewardship policy and its infection surveillance policy for one sampled resident. The policy required the facility to record all antibiotics used on a resident-to-resident basis, including dose, duration, and indication, and to alert the attending physician when antibiotics reached 14 days and obtain new orders. The surveillance policy also required the Infection Preventionist or designated infection control personnel to gather and interpret surveillance data, maintain daily infection reports, monthly line listings, monthly unit summaries, monthly or quarterly trend reviews, and calculate monthly infection rates using resident days as the denominator. For the resident, a urinalysis showed blood, turbid urine, positive nitrites, many bacteria, protein, and white cells greater than 100, with a lab comment to call within 48 hours to request a culture of the specimen. The record showed no documentation that staff requested a culture of that specimen. The physician ordered ciprofloxacin 250 mg by mouth twice daily for 7 days for UTI, and the MAR showed the resident received the antibiotic as ordered. Later, the resident had a positive C. diff toxin antigen test, followed by an order for vancomycin 125 mg by mouth four times daily, and the MAR showed the resident received vancomycin as ordered. During interviews, the RN Consultant said her role as IP was only to double check that antibiotic orders were entered correctly into the computer. The DON said she printed a list of residents receiving antibiotics and reviewed it weekly with the Medical Director, kept up with cultures and sensitivities, and reviewed information with the Medical Director weekly, but she did not keep an infection treatment and tracking record, a line listing of infections by resident, a facility-wide monthly infection report, a 12-month pathogen trends report, or monthly infection rates, and she did not compare current infection incidence to previous data to identify trends. The Administrator said she, the DON, and the RN Consultant served as IPs, but she also did not keep an infection treatment and tracking record, a facility-wide 12-month pathogen trends report, or monthly infection rates.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure staff notified residents and/or their representatives in writing of hospital transfers and failed to provide the bed hold policy at the time of transfer for four residents. The facility’s undated Bed Hold Statement and Notice of Emergency Transfers stated that residents or responsible parties are to be informed of the bed hold policy upon admission and again if transferred to an acute care hospital, and that documentation in progress notes stating the resident or representative has been notified would meet the criteria for emergency transfer notification. For Resident #3, the record showed hospitalizations from 05/05/25 through 06/20/25 and again from 06/21/25 through 06/22/25, but there was no documentation that a written transfer notice or bed hold policy was provided. Resident #10 was transferred to the hospital on [DATE], with progress notes showing the physician was called at 8:14 P.M. and the resident admitted to the hospital at 11:26 P.M., but there was no documentation of a written transfer notice to the resident or representative. Resident #74, who was his/her own responsible party, was sent to the hospital by ambulance on 06/19/25 after abnormal labs and confusion, and the record lacked documentation of a written transfer/discharge notice or bed hold notice. Resident #78, who had a responsible party, was transferred to the hospital on 12/10/24 and again on 06/30/25, but the record showed no documentation that a written transfer/discharge notice or bed hold notice was provided for either hospitalization.
Failure to Timely Address Resident's Eye Injury
Penalty
Summary
The facility failed to provide necessary care and services to a resident who complained of right eye pain, redness, watering, and blurry vision following a physical altercation with another resident. Despite multiple reports from staff and family members about the resident's eye condition, licensed staff did not assess the resident's eye in a timely manner. The resident's condition worsened over time, leading to a dislodged lens in the right eye that required medical intervention. The resident, who had a history of dementia, anxiety, and depression, was involved in an altercation with another resident in the Special Care Unit. The altercation resulted in a bruise on the resident's arm, but no immediate attention was given to the resident's eye complaints. Staff members, including Certified Medication Technicians and a Certified Nursing Assistant, reported the resident's eye issues to licensed nurses, but the nurses failed to assess the situation or notify the physician promptly. The resident's family members also noticed the worsening condition of the resident's eye and reported it to the facility staff. However, it was not until a care plan meeting that the resident's physician was informed of the eye issues. The resident was eventually seen by an optometrist and an ophthalmologist, who confirmed the need for surgical intervention to correct the dislodged lens caused by blunt force trauma. The facility's failure to assess and report the resident's eye condition in a timely manner resulted in a significant delay in necessary medical treatment.
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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 64 citations issued within 25 miles in the last 12 months — including the 4 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Macon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Macon Health Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Clarence Care Center | 12.6 mi | ★★★★★ | 7 | 0 |
| La Plata Nursing Home | 19.4 mi | ★★★★★ | 0 | 0 |
| North Village Park | 21 mi | ★★★★★ | 52 | 3 |
| Valley View Health & Rehabilitation | 23 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.