Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Lawn Nursing Home during CMS and state inspections, most recent first.
A resident with dementia experienced ongoing behavioral symptoms, including aggression, hoarding, and agitation, without staff adequately assessing root causes or implementing individualized, non-pharmacological interventions. Staff relied on redirection and escalated to antipsychotic medications not approved for dementia-related behaviors, without thorough documentation or care plan updates. The resident suffered lethargy, weight loss, and new skin breakdown, while the facility failed to follow its own dementia care policies.
Failure to Monitor and Respond to Significant Weight Loss: A resident with dementia, diabetes, and a regular consistent carbohydrate diet experienced progressive weight loss while staff documented poor intake, repeated meal refusals, and frequent snack requests. Survey observations showed staff did not bring food or fluids to the resident or attempt to wake the resident for meals, and the record contained no documentation that the weight loss was identified, assessed, reported to the MD or RD, or reflected in a care plan revision.
Kitchen surfaces and equipment were not maintained in sanitary condition. Surveyors observed dust, debris, and oil/grease buildup on the steamer oven, upright oven, shelf above the stove top/griddle, range hood fire suppression nozzle cables, and a wall-mounted electrical receptacle box and wire channel. Staff said they had not noticed the buildup, there was no set cleaning schedule for the identified areas, and the DM and ADM were not aware of the condition of these surfaces.
Infection Control, Water Management, and Linen Handling Failures: The facility did not have a complete Legionella water management program, including a functioning water management team, control limits, or cold-water monitoring, and water logs and observations showed multiple hot water temperatures below the facility’s stated range. Staff also failed to follow infection control practices during resident care, including improper glove use and hand hygiene during showering and incontinence care, and a housekeeper mixed soiled and clean linens while handling clothing protectors.
A facility used a night-shift get-up list and early morning shower schedule that conflicted with residents’ care plans and preferences. One resident who preferred to awaken around 7:00 A.M. was awakened, transferred, and showered while still keeping eyes closed, and three other residents who preferred to sleep later were also observed up in recliners before 7:00 A.M. Staff said the list was not optional and had to be completed before day shift, while the DON stated residents should not be woken for staff convenience.
Dust Buildup on Exhaust Ventilation Units: Surveyors observed moderate to heavy, moderate, and light to moderate dust/debris on vent covers for independently motorized exhaust ventilation units in multiple bathrooms, shower rooms, and central bath areas throughout the facility. The Maintenance Director said he was not aware of the buildup, stated maintenance was responsible for monitoring the units at least monthly, and was unsure when each unit was last inspected and cleaned.
Psychotropic Medications Used Without Adequate Assessment or Behavioral Documentation: The facility ordered and increased antipsychotic and other psychotropic meds for residents with dementia without documenting a comprehensive assessment, approved indication, or consistent non-pharmacological interventions. One resident had repeated aggression, wandering, and refusal of care, yet the record lacked rationale for Seroquel and later Haldol, then risperidone caused marked lethargy. Another resident had wandering and exit-seeking with repeated redirection before receiving multiple psychotropics, and a third resident’s Seroquel was increased despite limited documented behaviors and later calm observations. The record also lacked a GDR or contraindication for one resident’s antidepressant.
The facility failed to ensure required CNA education was completed and documented for four CNAs reviewed. Records showed two CNAs had no training documented during the review period, while two others completed only limited hours that did not meet the annual training requirement, including topics such as abuse prevention, dementia care, resident rights, and infection control. The DON and Administrator stated the web-based training system was not being used to ensure staff completed required education and that education records were not being kept well.
A resident with a history of subarachnoid hemorrhage and repeated falls sustained a scalp laceration after a weekend fall, but staff faxed the physician instead of calling the on-call MD and did not follow up when no response was received. The same resident later had emesis, headache, confusion, and was found unresponsive to voice and touch, yet there was no documentation that the physician was notified before the resident was sent to the hospital.
Failure to Report Injuries of Unknown Origin: Staff did not report unexplained bruising and bleeding for one resident who was on warfarin and had severe cognitive impairment, and did not report unexplained bruising for another resident who had severe cognitive impairment and required extensive assistance with care. In both cases, CNAs and LPNs identified the injuries, but administration was not notified as required, and the DON stated she was unaware of the bruising on the second resident.
Failure to Complete SCSA for Two Residents The facility did not complete required SCSA MDS assessments for two residents after significant changes in condition affected multiple areas of health status. One resident with anemia, CAD, DM, anxiety, and breast cancer had new Alzheimer’s/dementia diagnoses, a new antipsychotic, worsening behaviors, improved incontinence, healed pressure ulcers, weight loss, and new coccyx wounds. Another resident with severe cognitive impairment and Alzheimer’s had mixed ADL changes, new pain meds, and a new mechanically altered diet, but no SCSA was completed. The MDS coordinator said she compared quarterly assessments to the prior quarter and had not received formal training; the DON said staff should follow the RAI manual.
Failure to assess and document a resident’s acute change in condition and delay in emergency escalation. A resident with a directive to avoid CPR but go to the hospital developed headache, emesis, and elevated BP, then was found unresponsive by an LPN. Staff did not document a thorough nursing assessment or the reason meds were held, and there was confusion about whether a physician order was needed before calling EMS, resulting in a delay before the resident was transferred.
A nurse aide worked at the facility since February and was still not certified after completing training but failing the test twice. The aide was scheduled and worked as a NA despite not passing the state-approved program within the required four months, and the DON stated she did not know the aide could not work past four months without certification.
The facility failed to maintain a functional antibiotic stewardship program and did not have a designated IP or active tracking of infections and antibiotic use. Two residents were involved: one was receiving ongoing Macrobid for chronic UTI prevention without current UTI signs or symptoms, and another had a urine culture showing E. coli followed by antibiotic orders. The ADON, DON, and Administrator stated the facility was not tracking antibiotic usage after the prior IP left.
The facility did not ensure that controlled substance counts for multiple residents were reconciled and documented by two qualified staff at each shift change, as required by policy. Over several days, there was no documentation or nurse signatures verifying narcotic counts for the A-hall medication cart, despite the presence of various Schedule II, IV, and V medications. Interviews with nursing staff and the DON confirmed that the required procedures were not consistently followed or documented.
A resident with paraplegia and moderate cognitive impairment reported a sexual abuse allegation to a CNA, who informed an LPN and RN, but the incident was not escalated to the DON or Administrator as required. Multiple staff members failed to report the allegation to the appropriate authorities, resulting in a delay of four days before the Administrator was informed. The Administrator then failed to notify the state agency within the required two-hour timeframe, violating the facility's abuse reporting policy.
A resident with paraplegia and moderate cognitive impairment reported discomfort and possible inappropriate behavior by a CNA. The facility's investigation into the abuse allegation was incomplete, lacking required documentation such as written statements from involved parties, interviews with the accused CNA and the resident, and a summary of findings, as required by facility policy. Staff interviews revealed confusion about investigation procedures, and key investigative steps were not taken.
A resident with aphasia and hemiplegia was verbally abused by an LPN who raised their voice, repeatedly urged the resident to hurry, and threatened to call the police when the resident attempted to communicate their needs. The incident was witnessed by another resident and confirmed by staff and family interviews, resulting in the resident feeling upset and fearful of the LPN.
The facility did not have a licensed nursing home administrator, as required for effective administration. The previous administrator resigned, and the Human Resources Director, with an expired temporary license, was managing daily operations. The Board of Directors and the Director of Accounting confirmed the absence of a licensed administrator, leading to a deficiency in compliance.
Failure to Provide Individualized Dementia Care and Inadequate Behavioral Management
Penalty
Summary
Facility staff failed to provide high-quality, compassionate, and individualized care to a resident with dementia, as required by facility policy and best practices for dementia care. The staff did not adequately assess or address the root causes and triggers of the resident's behavioral symptoms, such as hoarding napkins and washcloths, aggression toward staff and peers, and repeated requests for snacks and fluids. Documentation repeatedly lacked evidence of staff attempts to identify antecedents or implement non-pharmacological interventions before resorting to medication changes. Instead, staff primarily used redirection, which was often ineffective, and escalated to antipsychotic medications without clear documentation of failed non-pharmacological strategies or thorough behavioral assessments. The resident, who had diagnoses of Alzheimer's, dementia, and anxiety, experienced a decline in well-being, including lethargy, weight loss, agitation, physical altercations, and new skin breakdown. Despite ongoing behavioral issues, staff did not consistently document or investigate potential triggers such as pain, hunger, thirst, boredom, or environmental factors. There was also a lack of individualized interventions, such as providing the resident with their own supply of napkins or addressing possible discomfort with toileting routines. The care plan was not updated to reflect ongoing behavioral changes or to include new strategies based on observed triggers and outcomes. Additionally, the facility's use of antipsychotic medications, including Seroquel, Haldol, and Risperidone, was not in accordance with approved indications for elderly residents with dementia. Orders for these medications were made without sufficient documentation of behavioral assessments or evidence that non-pharmacological interventions had been exhausted. The facility failed to follow its own dementia care policies, which emphasize person-centered care, regular review of care plans, and prioritization of non-pharmacological interventions. As a result, the resident's dignity, well-being, and independence were not adequately supported, and the unique challenges posed by dementia were not effectively addressed.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration monitoring for a resident with Alzheimer’s disease, dementia, anxiety, and hypertension who was on a regular consistent carbohydrate diet with thin liquids and had a history of being above ideal body weight. The resident’s care plan noted a goal to maintain optimal nutrition and that the resident frequently asked for snacks between meals. The resident’s weight was monitored monthly early in the period, but the record later showed a progressive decline from 183.8 lbs. in June to 162 lbs. in December, including 177.2 lbs. in October and no documented weight for November. Staff documentation showed the resident’s appetite varied, with repeated refusals of meals and frequent requests for snacks and drinks. Nursing notes described the resident refusing meals, sleeping most of shifts, asking repeatedly for snacks and water refills, and at times becoming verbally aggressive or physically aggressive when redirected. During survey observations, the resident was found in a recliner with eyes closed while meal trays were served to other residents, but staff did not attempt to wake the resident or offer a meal tray. On another observation, staff only made a verbal offer of breakfast and did not bring food or fluids to the resident, even though a pitcher of water was beside the resident and the resident did not reach for it. The resident’s record showed no documentation that staff identified the weight loss as significant, completed an assessment for the weight change, notified the physician, dietitian, IDT, or resident representative, or revised the care plan after the decline. The facility’s policy required weight changes to be documented, reported, and faxed to the attending physician, and its weight-loss trigger flowchart called for action at 5% loss in 30 days, 7.5% in 90 days, or 10% in 180 days. Interviews with the LPN, care plan coordinator, DON, dietitian, physician, and the resident’s family representative confirmed that staff were expected to notify the physician and dietitian, investigate the cause of weight loss, and consider interventions, but those notifications and evaluations were not documented for this resident.
Kitchen Surfaces and Equipment Not Kept Clean
Penalty
Summary
Food service equipment and surrounding surfaces were not kept clean under sanitary conditions in accordance with professional standards. The facility’s Guideline & Procedure Manual stated that food preparation equipment must be clean and sanitary, food contact surfaces must be sanitized before use, and specific cleaning rotations were required for the stove top, hood/filters, shelves, ovens, and walls. It also included cleaning instructions for the range and oven surfaces. During kitchen observations, surveyors found a moderate buildup of dust, debris, and oil on the top of the steamer oven, a moderate to heavy buildup of dust, debris, and oil/grease on the top of the upright four-door oven, and a moderate buildup of dust, debris, and oil on the stainless-steel shelf above the four-burner stove top/griddle. Surveyors also observed six range hood fire suppression nozzle cables with a moderate to heavy buildup of dust, debris, and oil/grease, and a wall-mounted metal electrical receptacle box and wire channel with a heavy buildup of dust, debris, and oil/grease. The staff interviewed said they had not noticed the buildup, and there was no set cleaning schedule for the identified areas. The Assistant Dietary Manager stated she was not aware of the buildup and noted some areas were harder to observe without a ladder, while the Dietary Manager said the cooks and Assistant Dietary Supervisor should monitor the areas weekly and that he was not aware of the dust, debris, and oil or grease buildup.
Infection Control, Water Management, and Linen Handling Failures
Penalty
Summary
The facility failed to develop complete infection prevention and control policies and procedures for its water system and did not implement its Legionella monitoring program as written. The facility policy stated that a water management team would oversee the program, identify areas where Legionella could grow and spread, and use CDC and ASHRAE recommendations, but staff interviews showed the maintenance director, ADON, DON, and administrator were not operating a water management team and did not have a water flow map. The policies reviewed did not include control limits, specific monitoring for water temperatures, dead legs, flushing unused areas, scaling, sediment, biofilm, or actions to take when findings were outside established parameters. The facility also had no documentation showing cold-water temperature monitoring, and the maintenance director stated the facility only checked chlorine monthly on hot water lines and did not document rechecks when temperatures were too low. Water temperature records and direct observations showed multiple hot water readings below the facility’s stated range and within ranges associated with Legionella growth. Facility logs documented hot water temperatures as low as 78 to 83 degrees F in several areas, and observations found hot water at 107.2 degrees F in one shower, 91.5 degrees F in a utility room, 103.9 degrees F and 80 degrees F at a shower faucet, 106.2 degrees F at a sink, 104.7 degrees F in a resident room, and 105 degrees F and 82 degrees F in another shower room. The facility’s records did not show cold-water temperature monitoring, and staff interviews confirmed the facility did not monitor cold water temperatures. The facility also failed to ensure proper infection control practices during resident care and linen handling. During shower care for one resident who required substantial to maximal assistance with bathing, dressing, and toileting and was frequently incontinent, two CNAs wore gloves without washing hands, handled soiled linens and clean items with the same gloves, used a washcloth on feces on the floor and then on the resident, rinsed gloves with the shower nozzle, and left the room without hand hygiene. During incontinence care for another resident who was always incontinent of bowel and bladder and at high risk for UTIs, a CNA removed feces-soiled pants and threw them on the floor, left the room without hand hygiene, returned with new gloves but continued care without washing hands, dressed the resident while wearing contaminated gloves, and threw soiled linens on the floor. In the dining area kitchenette, a housekeeper handled soiled clothing protectors with gloves, placed unused protectors back into the clean linen drawer, and mixed items from occupied tables with clean linens without removing gloves or washing hands.
Residents Woken and Showered Before Preferred Times
Penalty
Summary
The facility failed to honor residents’ right to self-determination by using a night-shift get-up list and early morning shower schedule that was not consistent with residents’ care plans or stated preferences. The report states that staff were responsible for getting specific residents up on the 11:00 P.M. to 7:00 A.M. shift, including residents who preferred to awaken after 7:00 A.M. or around 7:00 A.M., and that the schedule was used for facility convenience. The facility policy stated residents have the right to decide when they go to bed, rise in the morning, and eat their meals. For one resident, the care plan documented a preference to awaken around 7:00 A.M. and to receive showers during the day. On observation at 6:30 A.M., two CNAs attempted to wake the resident while he/she remained unresponsive with eyes closed. The resident was then sat up, fitted with a gait belt, stood, transferred to a wheelchair, and taken to the shower room while still keeping eyes closed. During the shower, the resident’s eyes remained closed throughout the entire process, and the resident said, “oh, no,” when stood up. The resident was then dressed, transferred to a recliner in the common area, and remained with eyes closed. Three additional residents were also observed up in the common area before 7:00 A.M. in recliners, dressed, and with eyes closed, including one resident who was making snoring sounds. Their care plans documented preferences to awaken after 7:00 A.M. or around 7:00 A.M. Staff interviews confirmed that the residents were on the night-shift get-up list and that it was not optional, with staff stating they had to get everyone up by the start of day shift so breakfast could be served on time. The DON stated staff should not wake a resident for convenience and that if a resident had a bad night or did not want to wake up, staff were expected to leave the resident in bed until ready to get up.
Dust Buildup on Exhaust Ventilation Units
Penalty
Summary
The facility failed to ensure independently motorized exhaust ventilation units were free from a buildup of dust and debris. During the life safety code tour, surveyors observed moderate to heavy, moderate, and light to moderate dust/debris on vent covers in multiple locations, including the men and women bathrooms at the main entrance, the A-Hall shower room, room A-02, A-03, and A-04 bathrooms, the C-Hall central bath, room C-43, C-44, C-48, C-50, and C-53 bathrooms, room D-64 and D-65 bathrooms, and SCU-101, SCU-103, SCU-107, SCU-109, SCU-111, SCU-113, SCU-114, and SCU-115 bathrooms. During interview, the Maintenance Director stated he was not aware of the dust and debris covering the vent covers on the independently motorized ventilation units. He said it was the maintenance department's responsibility to monitor the units at least monthly, but he was not sure when each ventilation unit was last inspected and cleaned.
Psychotropic Medications Used Without Adequate Assessment or Behavioral Documentation
Penalty
Summary
The facility failed to complete a comprehensive assessment, including review of the clinical rationale and approved indication, before using psychotropic medications for residents with dementia, and it also failed to consistently identify and document non-pharmacological interventions used to address behaviors. For three residents with dementia, antipsychotic medications were ordered and adjusted for behaviors without documentation showing why the medications were clinically indicated for the specific resident conditions described in the record. The report also states that one resident did not have a gradual dose reduction (GDR) for an antidepressant medication and there was no documentation that a GDR was clinically contraindicated. For one resident with Alzheimer’s disease, dementia, and anxiety, Seroquel was ordered for anxiety disorder even though the record showed no documentation supporting the rationale for the new order and no diagnosis of schizophrenia, bipolar disorder, or manic disorder. The resident’s care plan listed behaviors such as smacking staff and peers, refusing care, and taking napkins, and nursing notes documented repeated aggression, refusal of care, and fixation on collecting napkins and washcloths. The resident later received Haldol IM for dementia-related aggression, and the physician later changed Seroquel to risperidone after staff reported increased behaviors. The record also showed the resident became very sleepy and lethargic after risperidone was started, requiring wheelchair transport and later two staff for transfers. For another resident with dementia and metabolic encephalopathy, trazodone and olanzapine were ordered for dementia, and the care plan addressed psychotropic drug use and wandering/elopement risk. Nursing notes documented wandering into other residents’ rooms, exit seeking, repeated redirection, attempts to leave through exits, and inappropriate physical contact with staff. The resident later received Seroquel and Ambien for continued exit seeking and disruptive behavior, then Haldol IM after escalating behavior, and the medication regimen was later changed to risperidone for dementia with other behavioral disturbances. For a third resident with severe cognitive impairment, anxiety, and depression, Seroquel was increased despite no documented behaviors on several dates around the increase, and the physician note stated nursing staff reported agitation and that the resident had been falling asleep a lot. The resident’s chart later showed limited behavioral documentation, including attention-seeking, yelling for help, and nighttime restlessness, while observations showed the resident calm, asleep, or quietly sitting without agitation.
Incomplete CNA Training Records and Required Education Not Met
Penalty
Summary
The facility failed to ensure staff training needs identified in its facility assessment were met for four certified nurse assistants (CNAs) out of five reviewed who had been employed for more than one year. The facility assessment dated 11/20/25 required education on resident rights, abuse/neglect/exploitation, infection control, and changes in condition on hire, annually, and as needed, and also stated that staff shall complete education to maintain their certifications/licenses. Review of employee files and training records showed CNA HH had no documented training during the review period, CNA JJ had no documented training during the review period, CNA II completed only 4 hours of training including abuse/neglect/exploitation, dementia care, transmission-based precautions, workplace emergencies, privacy/security, and resident rights, and CNA F completed 2 hours and 45 minutes of training including dementia care, resident rights, transmission-based precautions, privacy/security, and employee wellness/stress management. During interview, the DON stated the facility used a web-based training system to record employee training, but most staff had not completed the required trainings. She said she had not yet had the opportunity to evaluate each employee's training records and that the facility was still deciding how to ensure education, competencies, and evaluations were completed. The Administrator stated the facility did not keep good education records and, based on the web-based education system, they did not ensure employees completed required training.
Failure to Notify Physician After Fall Injury and Change in Condition
Penalty
Summary
The facility failed to follow its physician-notification policy for a resident who fell on a Saturday and sustained a small laceration to the right front scalp. Staff documented that the resident was found on the floor by a chair in the room, the area was cleaned, pressure was applied, and the bleeding stopped. Instead of calling the on-call physician as required for a weekend fall with injury, RN L sent a fax to the physician’s office, and the fax noted the resident was found on the floor in front of the chair with no attachment included. The physician did not respond until six days later with a note to monitor, and there was no documentation that staff followed up by phone over the weekend when no response was received. The resident involved had diagnoses including subarachnoid hemorrhage and repeated falls. During interview, RN L stated the resident’s vital signs were normal, the resident was alert and oriented, and neurological assessments were within normal limits, so a fax was sent because there were no significant injuries noted. The ADON stated that if a resident fell on a weekend and had any injury, staff should notify the on-call physician by phone, not by fax, and that staff should have called after the scalp laceration. The facility also failed to timely notify the physician when the same resident had a change in condition. On 12/01/25, staff reported emesis, a stabbing headache, some confusion, and Tylenol administration. LPN K found the resident in bed at 7:40 A.M. and reported the resident did not respond to voice or touch stimuli, though the resident twitched a foot with sternal rub. LPN K asked the MDS Coordinator to check the resident, later told the ADON the resident did not seem right and needed hospital evaluation, and the resident was ultimately sent to the hospital at 11:23 A.M. The record contained no documentation that the physician was notified when the resident was initially found unresponsive or during the subsequent assessments before transfer. The DON and Administrator stated they expected staff to call the physician immediately for an unresponsive resident and to use the on-call schedule after hours or on weekends.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents after bruising and, in one case, bleeding were identified by staff. The facility policy defined injuries of unknown origin as unexplained injuries that are suspicious because of their extent, location, number, or recurrence, and required staff to immediately report suspected abuse to the Administrator or designee, with reporting to the Missouri Department of Health and Senior Services no later than two hours after the allegation was received. For one resident, who had severe cognitive impairment, was dependent for toileting and personal hygiene, and was receiving warfarin for anticoagulant therapy with a care plan noting a risk for bleeding and instructions to avoid bumping and handle gently, a CNA notified an LPN of bruises on the right wrist, right bottom, and under the right armpit. The LPN also found dried blood on the corner of the resident’s mouth, blood specks on the bed, and small scratches that were bleeding on the sheets. The LPN completed a skin assessment, but the facility record showed no evidence that the bruising and bleeding were reported as an injury of unknown origin when discovered. During interview, the LPN stated the bruises and bleeding were not reported to administration because he/she did not think they were caused by abuse and was unsure what caused them. For a second resident, who had severe cognitive impairment and required varying levels of assistance with transfers, bathing, dressing, toileting, and personal hygiene, staff observed a large purple bruise on the back of the left upper arm and a large bruise behind the right leg with a knot in the center during a shower transfer. The CNA stated the bruise had not been seen before and that the resident had not fallen, yet the bruising was not reported to the DON or Administrator at the time it was identified. The next day, nursing documentation described bruising to the right calf and left upper arm with unknown etiology, and staff interviews showed the LPNs did not notify administration because they did not think the bruises were caused by abuse or because the event occurred on another shift. The DON stated no one told her about the bruising found on the resident.
Failure to Complete Significant Change in Status Assessments for Two Residents
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) within 14 days after determining, or when it should have determined, that two residents had significant changes in condition affecting more than one area of health status. The deficiency involved Resident #14 and Resident #9, both of whom had changes documented in their MDS assessments and clinical records that met the criteria for interdisciplinary review and/or care plan revision under the RAI User’s Manual. Resident #14’s records showed an annual MDS dated 05/22/25 with diagnoses including anemia, coronary artery disease, diabetes mellitus, anxiety, and malignant neoplasm of the breast, along with no behaviors, always incontinent of bowel and bladder, and one Stage 2 pressure ulcer not present on admission. A later quarterly MDS showed new diagnoses of Alzheimer’s and dementia, a new antipsychotic medication, worsening physical behavioral symptoms directed toward others, improved incontinence, and a healed pressure ulcer. The resident’s weight record also showed progressive weight loss, including 2% in one month and 11.86% over six months, and nursing notes documented two new coccyx wounds on 12/04/25. The facility did not complete a SCSA for the new diagnosis, medication change, improved incontinence, healed pressure ulcer, worsening behaviors, weight loss, and new pressure ulcers. Resident #9’s annual MDS dated 01/07/25 showed severe cognitive impairment, Alzheimer’s disease, no behaviors or rejection of care, use of a walker, varying levels of assistance with mobility and ADLs, two falls, and antianxiety medication. A later quarterly MDS showed improvement in walking and some transfer areas, improvement in anxiety medication use, and worsening assistance needed for showering/bathing. Another quarterly MDS showed further declines in walking, sit-to-stand, chair/bed-to-chair transfer, toilet transfer, and eating, along with new scheduled pain medications and a new mechanically altered diet. The facility did not complete a SCSA for these combined improvements and declines. During interview, the MDS coordinator stated she used quarterly-to-quarterly comparisons, had not been trained formally, and had never heard of comparing the resident to the last comprehensive assessment; the DON stated she expected staff to follow the RAI manual.
Failure to Assess and Promptly Escalate an Unresponsive Resident
Penalty
Summary
The facility failed to conduct and document a thorough nursing assessment when a resident was found with a change in condition and was unresponsive. The resident had a healthcare directive indicating no CPR but a desire to go to the hospital, and the admission MDS showed moderately impaired cognition. Earlier in the morning, the resident complained of a headache and had emesis, received Tylenol, and was assisted to the bathroom. A blood pressure reading later that morning was 183/95, but there was no nursing progress note documenting an assessment of the resident’s condition, the headache, the emesis, or the Tylenol administration. At approximately 7:40 A.M., an LPN went to assess the resident and found the resident in bed and not responding to verbal or touch stimuli, though the resident twitched a foot with sternal rub. The LPN reported the concern to other staff, including the MDS Coordinator and later the ADON, and stated the resident did not appear right and needed to go to the hospital. The LPN also stated the resident’s medications were not given during the morning medication pass due to the resident’s condition, but there was no progress note documenting the resident’s status or the reason medications were not administered. The resident remained unresponsive for several hours before EMS was contacted and the resident was transferred to the hospital. Additional documentation showed the DON later found the resident unresponsive with fixed and dilated pupils, flushed face, incontinence of urine, elevated blood pressure, and an elevated pulse. Interviews with staff showed confusion about whether a physician’s order was needed before sending the resident to the hospital, and the LPN stated he/she had been told residents could not be sent without a physician’s order. The facility policy stated that residents with emergent situations who are full code should have 911 called immediately, and staff interviews confirmed the resident should have been sent out when found unresponsive.
NA Worked Beyond Training Deadline Without Certification
Penalty
Summary
The facility failed to ensure that one nurse aide completed a state-approved training program within four months of hire. NA D’s employee file showed a hire date of 02/18/25, and payroll records showed the employee worked 205 hours as a nurse aide from 11/12/25 to 12/15/25. The facility schedule for 12/11/25 showed NA D assigned to work 11:00 P.M. to 7:30 A.M. as a nurse aide. During interviews, NA D stated he/she had worked at the facility as a nurse aide since February 2025 and had completed a training program but had not passed the test. The Administrator stated NA D had taken the training course but failed the test twice and was scheduled to test again. The DON stated NA D was not certified, had worked as a nurse aide since February 2025, and had passed the class but failed the test; the DON also said she did not know NA D could not work past four months if not certified.
Lack of Functional Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program that included a functional antibiotic stewardship program monitoring antibiotic use for two residents. The facility did not have a designated Infection Preventionist or an active antibiotic stewardship program with tracking of infections or antibiotic use since November 2025. The facility policy on antibiotic stewardship stated that nursing staff would not request antibiotics from attending physicians, cultures should be obtained when possible before antibiotics, culture results should be reviewed to determine whether the antibiotic was sensitive, and a monthly list of residents with infections and antibiotic use would be sent to the medical director. Resident #2 had an undated physician order for Macrobid 100 mg by mouth three times per week for chronic UTI, with no stop date, and the MAR showed the resident received the medication on Monday, Wednesday, and Friday during multiple months. An LPN stated the resident was taking Macrobid for prevention of UTI and did not have current signs or symptoms of UTI and had not had any recent UTIs. Resident #32 had a urine culture and sensitivity showing E. coli, after which Macrobid 600 mg twice daily and Rocephin 1 gram IM for three days were ordered. During interviews, the ADON, DON, and Administrator stated the facility did not have a designated IP, the prior IP had left abruptly, and the facility was not tracking antibiotic usage at that time.
Failure to Reconcile and Document Controlled Substance Counts per Policy
Penalty
Summary
The facility failed to ensure that inventories of Schedule II, IV, and V controlled substance medications were reconciled by at least two qualified staff members each shift, as required by facility policy. Multiple days were identified where there was no documentation of shift-to-shift narcotic medication counts, no nurse signatures on narcotic count sheets, and no total card counts for the A-hall medication cart. This lack of documentation occurred across all three daily shifts on several dates, and included the absence of required log sheets for certain periods. The facility's policy required two staff members to count and sign off on all controlled substances at the start and end of each shift, but this was not consistently done. Review of individual resident narcotic count sheets confirmed that various controlled substances, including Ativan, morphine sulfate, hydrocodone/acetaminophen, Roxanol, Lyrica, tramadol, and oxycodone, were stored in the narcotic lock box for ten residents. Despite the presence of these medications, the required documentation and reconciliation procedures were not followed. Observations and record reviews showed that for several days, there were no signatures or documentation to verify that the counts were completed as per policy. Interviews with nursing staff and the Director of Nursing revealed a lack of adherence to the established procedures for narcotic counts. Staff acknowledged that two nurses were supposed to count and sign for the narcotics at each shift change, but this was not consistently practiced. The Director of Nursing and the Administrator both stated that they expected staff to complete and document the narcotic counts at every shift change, but were unaware of the missing documentation until it was brought to their attention during the survey.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to follow its policy regarding the timely reporting of an allegation of sexual abuse involving a resident with paraplegia and moderate cognitive impairment. The resident reported to a CNA that a staff member had engaged in sexually inappropriate behavior, including stroking the resident's hair and handling women's underwear in a suggestive manner. The CNA reported the allegation to an LPN, who then informed an RN, but the information was not escalated to the Director of Nursing (DON) or the Administrator as required by facility policy. Despite multiple staff members being made aware of the allegation, including the CNA, LPN, and RN, none of them reported the incident to the DON or Administrator until four days after the initial report. The RN, who was the nursing supervisor at the time, did not believe the allegation and failed to notify the appropriate authorities or follow the established reporting protocol. The DON and Assistant DON were also not informed in a timely manner, and the Administrator only became aware of the situation after several days had passed. When the Administrator was finally informed, she did not notify the state agency within the required two-hour window, instead reporting the incident several hours later. The facility's policy clearly states that allegations of abuse must be reported to the state agency immediately, but no later than two hours after the allegation is made. The failure to promptly report the allegation and initiate an investigation as required by policy and regulation constitutes a deficiency in the facility's abuse reporting procedures.
Failure to Thoroughly Investigate Abuse Allegation per Facility Policy
Penalty
Summary
The facility failed to provide evidence that allegations of abuse were thoroughly investigated according to its own policy for one resident out of a sample of eight. The resident in question had paraplegia and moderate cognitive impairment, but was able to make himself/herself understood and had no history of hallucinations, delusions, or behavioral issues. The resident reported discomfort with a CNA, describing incidents where the CNA stroked the resident's hair and was seen handling women's underwear in a manner that made the resident uncomfortable. When the allegation was reported, the administrator initiated some steps, such as contacting the police and the resident's next of kin, and collecting statements from several staff members. However, the investigation did not include a written, signed statement from the resident or the accused CNA, nor documentation of the resident's refusal to provide a statement. The accused CNA was not contacted by the facility regarding the allegation. Additionally, there was no documentation of interviews conducted or attempted with the resident or other residents, and no summary of the investigation or corrective actions taken was included in the records. Interviews with staff revealed confusion and lack of clarity regarding the investigation process. Several staff members, including the DON and nursing staff, indicated they had not initiated or participated in an investigation into the abuse allegation. The DON, who was responsible for Human Resources duties, did not recall being informed of the allegation in a timely manner and did not conduct interviews with the resident or other residents. The administrator did not review available camera footage related to the incident. The facility's documentation did not meet the requirements outlined in its own abuse investigation policy.
Verbal Abuse of Resident by LPN During Assistance
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, aphasia, and hemiplegia was subjected to verbal abuse by an LPN. The resident, who had difficulty communicating due to aphasia but was cognitively intact and able to understand others, attempted to express specific needs while trying to wheel themselves to the bathroom. The LPN became agitated, repeatedly raised their voice, and told the resident to "come on" while the resident tried to communicate and requested more time. When the resident attempted to touch the LPN's hand to gain attention, the LPN jerked away and threatened to call the police, causing the resident to feel upset and scared. Multiple interviews corroborated the incident. Another resident reported hearing the LPN yelling and threatening to have the resident arrested, and noted that the affected resident was visibly depressed afterward. Staff interviews revealed that the LPN expressed frustration about the resident's behavior and stated an unwillingness to continue caring for the resident. The resident's family member was contacted by the resident, who was upset and crying about the incident, and subsequently requested that the LPN not be assigned to the resident. The facility's policy requires all residents to be free from abuse, including verbal abuse, and mandates staff training on abuse prevention and reporting. The DON and administrator both acknowledged that the LPN's actions constituted abuse and violated expectations for treating residents with dignity and respect. The administrator was not aware of the incident until informed by the surveyor, and the event was confirmed through interviews with the resident, family, staff, and other residents.
Absence of Licensed Administrator in Facility
Penalty
Summary
The facility failed to ensure that a licensed nursing home administrator was employed, which is a requirement for effective and efficient administration. The facility had a census of 62 residents, with 23 requiring extensive assistance for activities of daily living. The facility's assessment outlined the need for various services, including ADL assistance, restorative nursing, and specialized care, and specified that an administrator was part of the required administrative staff. However, the facility did not have a licensed administrator at the time of the survey. Interviews revealed that the previous administrator had resigned, and the Human Resources Director, who held a temporary emergency license that had expired, was managing the daily operations. The Director of Accounting confirmed the absence of a licensed administrator, and the Board of Directors' President indicated that the Human Resources Director and the Board were handling the facility's operations. This lack of a licensed administrator constitutes a deficiency in the facility's compliance with regulatory requirements.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 76 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.
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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 Palmyra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luther Manor Retirement & Nursing Center | 1.9 mi | ★★★★★ | 36 | 0 |
| Beloved Health And Rehabilitation Center | 8.1 mi | ★★★★★ | 0 | 0 |
| Beth Haven Nursing Home | 9.1 mi | ★★★★★ | 0 | 0 |
| Sunset Home | 11.5 mi | ★★★★★ | 4 | 2 |
| Good Samaritan Home | 11.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.