Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Maywood Terrace Living Center during CMS and state inspections, most recent first.
A resident on hospice with multiple serious conditions received a significantly incorrect dose of methadone after family-supplied medications, including an opened methadone bottle, were accepted without pharmacy verification and hospice medication reconciliation was declined. Hospice orders specified methadone 10 mg/mL, 0.5 mL via G-tube every eight hours, but the facility’s POS and MAR were entered as methadone 5 mg/5 mL, 5 mL TID. Several LPNs administered methadone by relying either solely on the MAR or solely on the bottle, without comparing the two, and acknowledged not following the 5 rights of medication administration. One LPN administered 5 mL instead of 0.5 mL based on the incorrect MAR entry, despite noticing a discrepancy with the bottle, and did not alert the DON before giving the dose. The DON later confirmed the order had been entered incorrectly and that the resident had received a total of 25 mg instead of the prescribed 5 mg, constituting a significant medication error.
The facility failed to ensure that multiple residents received and had documented twice‑weekly bathing and individualized ADL care in line with their needs and preferences. Residents with amputations, paraplegia, morbid obesity, muscle weakness, and mobility impairments, all cognitively intact, were dependent on staff for bathing but often did not receive scheduled showers, and staff frequently charted "not applicable" instead of completed care or refusals. One resident lacked an ADL care plan for bathing, another had no documented bathing preferences despite communication difficulties, and several shower review forms were incomplete, missing care details and nurse signatures or even listing the wrong name. Residents reported not getting regular baths, wanting evening showers or showers after pain medication, and feeling unclean, while staff interviews revealed confusion about documentation, missing or delayed MDS and care plans, and reliance on CNAs to complete both paper and EMR records without consistent follow‑through.
A resident with chronic pain and spinal stenosis received Oxycodone 20 mg from the pharmacy, but an RN failed to count the medication with the delivery driver and did not document the full quantity received. Multiple shift-to-shift narcotic counts lacked required dual signatures, and staff interviews revealed inconsistent practices in handling and documenting controlled substances.
The facility failed to maintain cleanliness and sanitation in the kitchen and dry storage areas, as well as proper waste management, which are essential for food safety. Observations included a dislodged refrigerator gasket, food splatters, residue on utensils, and a deeply dented can. The dumpster lid was not properly closed, posing a pest risk. Interviews revealed the absence of a Dietary Manager and new kitchen staff, with persistent issues noted in follow-up inspections.
The facility did not complete a timely Facility Assessment to determine necessary resources for resident care. The assessment was outdated and did not reflect the current resident demographics and needs, including those with complex care requirements such as indwelling catheters, tube feedings, and dementia. The new Administrator had not updated the assessment since starting three months prior.
The facility did not employ a dedicated Infection Preventionist (IP) on at least a part-time basis, as required. The Administrator, who had been in the role for one month, was acting as the IP, dedicating about three and a half hours per week to infection prevention activities. Previously, the former Administrator also served as the IP. The Corporate Nurse acknowledged the impracticality of the Administrator fulfilling the IP role given the requirement for part-time dedication to infection control and antibiotic stewardship activities.
The facility's call light system was found deficient, lacking audible notifications necessary for timely resident assistance. Observations showed lit call lights without audible alerts, and one call light was out of a resident's reach. The Emergency Preparedness plan also lacked alternative communication methods for power outages. Interviews revealed staff were unaware of the system's issues.
A facility failed to ensure nursing staff availability for residents in the dementia SCU, leaving two residents without supervision for 33 minutes. One resident, with vascular dementia and a history of falls, required constant supervision, while another resident, also with dementia, was dependent on staff for all ADLs. Staff interviews confirmed the need for continuous supervision to ensure safety and prevent anxiety.
The facility did not post nurse staffing information in an accessible location for residents and visitors, failing to include necessary details such as the facility name, daily census, and hours worked by RNs, LPNs, and CNAs. Observations confirmed the absence of this information, and interviews revealed a lack of clarity and responsibility among staff regarding the posting process.
The facility failed to properly store, label, and date medications, with observations showing unlocked and unattended medication carts and expired medications. Staff interviews confirmed the expectation for secure storage and regular audits, but practices did not align with policies.
The facility failed to verify, administer, or document influenza and pneumococcal vaccinations for several residents, including those with cognitive impairments. Despite policies requiring vaccination offers and documentation, records showed no evidence of vaccines being offered or administered, nor any refusals documented. Interviews with staff confirmed the lack of documentation in residents' medical records.
The facility failed to offer and document COVID-19 vaccination and education for four residents, including those with cognitive impairments. Interviews with an LPN and the DON confirmed that vaccination status should be documented in medical records, but this was not done for the affected residents.
The facility failed to provide a SNF ABN to two residents discharged from Medicare Part A services, informing them of potential liability for non-covered services. Instead, only a NOMNC was issued, indicating the end of skilled services. Interviews revealed confusion among staff about responsibility for issuing the SNF ABN, despite being informed in advance of therapy service termination.
The facility failed to complete quarterly assessments for two residents and a significant change MDS for a resident admitted to hospice. The MDS coordinator position was vacant, and staff were unaware of the assessment requirements, leading to incomplete documentation.
A resident with muscle wasting and vascular dementia experienced multiple falls that were inaccurately documented on the MDS. Despite having a hematoma from a fall, the MDS did not reflect this as a non-major injury. The facility's policy requires accurate MDS documentation, but the position of MDS Coordinator was vacant, leading to this deficiency.
A facility failed to follow physician's orders for wound care on a resident with a surgical wound from a right above the knee amputation. The Treatment Administration Record (TAR) showed multiple instances of missing documentation for the required daily treatment. Interviews with the ADON and DON indicated that the charge nurse was responsible for documenting wound care, and if not documented, it was assumed not completed.
A resident with legal blindness and a right leg amputation reported an unwitnessed fall, but the facility failed to conduct a thorough investigation or update the care plan. Despite the resident's report of hitting their head and experiencing a headache, no neurological assessments were documented. Interviews with staff revealed that the facility's protocol for unwitnessed falls was not followed, resulting in a deficiency.
A facility failed to ensure proper catheter care and hand hygiene for a resident with an indwelling catheter. The CNA did not sanitize the catheter port or perform hand hygiene during a tubing change, and the facility lacked complete physician's orders for catheter size. The DON confirmed the need for proper hand hygiene and catheter size orders.
A resident with PTSD was not provided with trauma-informed care due to the facility's failure to include PTSD in the care plan and lack of staff awareness of the resident's condition. The resident's care plan did not address PTSD triggers or interventions, and staff interviews revealed a lack of knowledge about the resident's diagnosis and care needs. The facility's administration acknowledged the oversight, noting the absence of a responsible MDS Coordinator.
A facility failed to address medication irregularities identified by a pharmacy consultant for a resident. The resident's medication orders lacked a diagnosis or indication for use, which was not resolved by the facility staff or the pharmacy consultant. Interviews with staff revealed confusion about responsibilities for ensuring medication orders included necessary documentation.
The facility failed to ensure that physicians reviewed and acted on pharmacy recommendations for Gradual Dose Reduction (GDR) of psychotropic medications for two residents. One resident, severely cognitively impaired, was on multiple psychotropic medications without a GDR attempt, despite pharmacist recommendations. Another resident was taking antidepressants without a documented diagnosis or indication for use. Interviews revealed a lack of clarity on responsibility for addressing pharmacy recommendations and ensuring medication orders included a diagnosis or indication for use.
A resident with hemiplegia and chronic kidney disease was admitted with scabs and edema, but the facility failed to document these conditions or notify the physician. Weekly skin assessments were not conducted, and an anticoagulant medication error occurred due to poor communication. These deficiencies led to severe medical interventions, including amputations.
A resident with partial paralysis and other risk factors developed a coccyx wound after returning from the hospital. The facility failed to conduct weekly assessments and documentation of the wound, as required by policy. An LPN did not follow hand hygiene protocols during wound treatment, which included not washing hands between glove changes and before applying Santyl. The DON acknowledged previous lapses in wound care documentation, leading to staff changes.
A resident with a urinary catheter did not receive proper catheter care, as a CNA failed to follow hand hygiene protocols and did not retract the foreskin or cleanse the catheter adequately. An LPN observed these deficiencies and discussed them with the CNA, while the DON confirmed the expectations for proper care.
A resident receiving hospice care was found with side rails on their bed without a proper assessment, physician's order, or informed consent. The side rails were installed by a hospice company, and facility staff were unaware of the change. The facility lacked a side rail policy, and licensed nurses failed to report the presence of side rails to the administrator.
Significant Methadone Dosing Error Due to Incorrect Order Entry and Failure to Follow 5 Rights
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when methadone was ordered, entered, verified, and administered incorrectly. The resident, who was non-verbal, on hospice care, and had multiple serious diagnoses including epilepsy, PURA syndrome, pneumonitis, sepsis, dysphagia, and gastrostomy status, was admitted with hospice orders for Methadone 10 mg/mL concentrate, 0.5 mL (5 mg) via G-tube every eight hours as needed for pain. Hospice documentation showed this order and indicated the methadone had been last filled shortly before admission. However, the facility’s Physician’s Order Sheet and MAR were entered as Methadone HCL oral solution 5 mg/5 mL, with instructions to give 5 mL three times a day for pain, which did not match the hospice order or the concentration on the bottle brought from home. The resident’s medications were supplied by family from home, including an opened bottle of methadone, contrary to the facility’s policy that discouraged use of medications brought in from outside and required verification of contents and labeling by the DON, attending physician, and consultant pharmacist. The DON stated the medications from home were supplied by a family member who was also an LPN at the facility, and that the facility pharmacy did not verify these medications. The hospice Medical Director and facility pharmacist both indicated that hospice medications were normally verified by hospice pharmacy and that opened bottles from home would not typically be accepted by a facility because contents could not be verified. Hospice RN A reported that when they attempted to perform medication reconciliation at the facility, staff declined, stating the medications had already been verified and entered into the computer system. Multiple nurses failed to follow the facility’s policies and the five rights of medication administration by not comparing the MAR orders to the methadone bottle label. LPN A, on the first day working with the resident, administered 5 mL of methadone instead of the intended 0.5 mL, relying solely on the MAR entry and not checking the bottle against the order, despite noticing a discrepancy between the computer screen and the bottle. LPN B reported administering methadone doses by following the directions on the bottle but did not compare them to the computer order and also signed off a dose that another nurse actually gave. LPN C stated they administered the dose on the bottle without looking at the MAR and acknowledged not following the five rights. The DON confirmed that the methadone order had been entered incorrectly into the MAR as 5 mL instead of 0.5 mL and that the error was only discovered when LPN A requested assistance documenting a spilled dose in the narcotic tracking system, revealing that the resident had received a total of 25 mg instead of the prescribed 5 mg. On the day of the significant medication error, LPN A prepared and administered the methadone dose via the resident’s feeding tube according to the incorrect MAR order of 5 mL three times a day. After spilling the initial dose, LPN A obtained and administered a replacement dose and later approached the DON to help document the waste in the electronic narcotic tracking system. During this process, they discovered that the system indicated a 0.5 mL dose, not the 5.0 mL that had been given. The DON reported that the nurse had not performed required safety checks, had not alerted the DON before administration despite noticing a discrepancy, and that the resident had been sleeping with respirations of 14–16 per minute when assessed later that day. The hospice Medical Director confirmed that the correct dose was 0.5 mL of a 10 mg/mL solution and that 5.0 mL equaled 50 mg, far exceeding the intended dose. These combined failures in order transcription, medication reconciliation, pharmacy verification, and adherence to medication administration policies led to the resident receiving a significantly higher dose of methadone than prescribed. The facility’s own policies required that medications be administered in accordance with prescriber orders, that staff verify the five rights of medication administration by checking the label three times against the MAR, and that medications brought in from outside be discouraged and, if used, verified by the DON, attending physician, and consultant pharmacist. Despite these policies, the methadone order from hospice (0.5 mL of a 10 mg/mL concentrate) was not accurately transcribed into the facility’s electronic system, the opened bottle from home was accepted without verification by the facility pharmacy, and multiple nurses administered methadone without reconciling the MAR with the bottle label. Hospice RN A stated that if they had been allowed to complete medication reconciliation, they would have caught the discrepancy between the order and the bottle. The combination of incorrect order entry, failure to reconcile hospice and facility records, acceptance of unverified home medications, and repeated failure by nursing staff to follow the five rights directly led to the significant medication error for this resident.
Failure to Provide and Document Scheduled Bathing and ADL Care per Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to assess, care plan, provide, and document bathing and other activities of daily living (ADLs) in accordance with resident needs, preferences, and facility policy. The facility’s ADL policy required that residents who could not perform ADLs independently receive appropriate support with personal hygiene, including bathing, in accordance with the care plan, and that refusals be explained to the resident/representative, alternative interventions offered, and refusals documented. The facility also had a Skin Monitoring: Comprehensive CNA Shower Review form that required CNAs to visually assess skin during showers, document the type of personal care provided, obtain charge nurse and DON signatures, and document refusals with resident signatures or staff witnesses after multiple attempts. Surveyors found that these processes were not followed for multiple residents. One resident with bilateral lower extremity amputations and a history of stroke required staff assistance for showering and had scheduled bath days twice weekly. The care plan identified a self-care performance deficit and need for assistance with showering, but the shower review form for one date only contained a CNA signature without documentation of the type of personal care provided or a charge nurse signature. The facility could not provide additional documentation that showers were provided twice weekly over a one‑month period, and electronic records only showed that the resident required assistance, not that showers were completed. This resident, who was cognitively intact and able to make needs known, reported needing assistance for all personal care and not receiving baths/showers twice a week, and could not recall the last shower. Another resident with paraplegia, neuromuscular bladder dysfunction, and a suprapubic catheter had an admission care plan that noted a lack of patience for assistance but did not include an ADL care plan specifying the type of assistance needed for baths/showers or the resident’s bathing and personal care preferences. The admission MDS showed the resident was cognitively intact but had difficulty communicating needs, and the admission MDS and care areas had not been completed or submitted by the time of the survey. Shower review forms for this resident on two dates contained the wrong first name, only a CNA signature, no description of personal care provided, and no charge nurse signature. Documentation showed only two showers out of eight scheduled opportunities, with no additional records of showers or refusals over several weeks. The resident reported concerns about not receiving assistance with care and bathing, needing help with transfers, and having difficulty with speech and expressing needs. Additional residents with muscle weakness, morbid obesity, mobility impairments, and dependence on staff for bathing also did not receive scheduled baths twice weekly, and their care plans lacked complete ADL/bathing interventions. One cognitively intact resident with upper and lower extremity impairments required substantial/maximal assistance for bathing but had no ADL care plan for cares. Paper bath sheets and EMR entries showed multiple missed baths over several weeks, with staff documenting “not applicable” instead of completed baths or refusals. This resident was observed with body odor, greasy uncombed hair, and reported not getting showers as scheduled and wanting evening showers, which staff did not provide due to staffing issues. Two other cognitively intact residents, both with morbid obesity and mobility limitations, were dependent or substantially dependent on staff for bathing and had care plans indicating ADL self‑care deficits and total dependence for showers. Bath sheets and EMR documentation showed that each missed multiple baths out of scheduled opportunities, again with “not applicable” recorded instead of completed baths or refusals. These residents reported not getting baths regularly, attributing this to insufficient staff and the lack of a bath aide, and one resident stated a preference for bathing after pain medication due to stiffness and soreness, while another preferred evening or night showers and expressed dissatisfaction with messy, uncombed hair. Staff interviews confirmed that residents were supposed to receive two showers per week on assigned bath days, that preferences should be reflected in care plans or other tools, and that CNAs were responsible for documenting showers and refusals in both shower sheets and the EMR. The administrator, DON, LPN, CNA staff, and MDS coordinator acknowledged missing documentation, confusion between “not applicable” and refusal, incomplete ADL care planning, and delays in completing MDS and care plans, all contributing to the failure to ensure scheduled, documented bathing and individualized ADL care for the affected residents.
Failure to Account for and Document Controlled Substance Delivery and Shift Counts
Penalty
Summary
The facility failed to properly account for the delivery and documentation of a controlled substance, specifically 120 tablets of Oxycodone 20 mg, for a resident with chronic pain syndrome and spinal stenosis. The medication was delivered from the pharmacy and signed for by an RN, but the RN did not count the medication with the delivery driver or confirm the correct quantity before signing the receipt. The facility's controlled substance receipt/record showed a discrepancy, with only 60 tablets documented as received, despite the pharmacy delivering 120 tablets. Additionally, the RN did not perform a full narcotic count with the oncoming nurse during shift change, and there were multiple instances where required dual signatures for shift-to-shift controlled drug counts were missing over several days. The resident involved was cognitively intact and reported not missing any pain medication doses, with staff providing alternative pain management if needed. Interviews with staff revealed inconsistent practices regarding the receipt, counting, and documentation of controlled substances, as well as a lack of adherence to the facility's expected procedures for shift-to-shift narcotic counts. The facility was unable to provide a policy and procedure for controlled substances prior to the survey exit.
Deficiencies in Kitchen Sanitation and Waste Management
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen and dry storage areas, as well as proper waste management, which are essential for food safety. During the survey, it was observed that the reach-in refrigerator had a dislodged gasket, and various food splatters were present on the stove and grill. A meat knife was found with residue, and a scoop was improperly stored in a sugar bin. Ladles had food residue, and a cutting board was excessively scored, posing a risk of contamination. Additionally, a deeply dented can of creamed corn was found in the dry storage room, and the floor was littered with trash and debris. The dumpster lid was not properly closed, which could attract pests. Interviews revealed that the facility did not have a Dietary Manager at the time of the initial inspection, and all kitchen employees were new, as the previous staff had quit. The new Dietary Manager, hired after the initial inspection, stated that the day-cook and dishwasher were responsible for cleaning, and damaged items should be reported and replaced. Despite these statements, follow-up inspections showed persistent issues, including the improperly closed dumpster lid. The facility's census was 44 residents, with a licensed capacity for 86, indicating that these deficiencies had the potential to affect a significant number of individuals.
Failure to Update Facility Assessment
Penalty
Summary
The facility failed to complete a timely Facility Assessment to determine the necessary resources to meet the needs of its residents. The assessment, which should be conducted annually and updated with any changes in facility status, was not completed by the new Administrator who had been in position for approximately three months. The facility's policy, dated 8/8/17, mandates an annual review of the facility-wide assessment, including evaluations of the resident population and the resources required for their care. However, the assessment dated 10/26/22 did not reflect the current resident demographics and needs as observed during the survey conducted from 7/9/24 to 7/16/24. The facility's resident census and condition report showed a variety of complex care needs among the 44 residents, including those with indwelling catheters, tube feedings, pressure ulcers, dementia, infections, significant weight loss, and falls. Additionally, the facility had a specialized memory care unit and residents receiving hospice care and oxygen. Despite these diverse needs, the facility assessment was outdated, failing to account for the current resident population and the necessary staff competencies, physical plant requirements, and technology resources needed to provide adequate care.
Failure to Employ a Dedicated Infection Preventionist
Penalty
Summary
The facility failed to employ a dedicated Infection Preventionist (IP) on at least a part-time basis, as required by their own policy. The facility's census was 44 residents at the time of the survey. The Administrator, who had been in the position for one month, was acting as the IP and dedicated approximately three and a half hours per week to infection prevention activities. Prior to this, the previous Administrator, who had been at the facility for about a year, also served as the IP. The facility's Corporate Nurse acknowledged that it was impractical for the Administrator to fulfill the IP role given the requirement for part-time dedication to infection control and antibiotic stewardship activities.
Deficient Call Light System in Facility
Penalty
Summary
The facility was found to have a deficient call light system that failed to provide audible notifications, which is crucial for meeting residents' needs promptly. During inspections, it was observed that several resident rooms had their hallway ceiling call lights lit, but there was no audible notification at the nursing station or in the rooms themselves. Additionally, in one instance, a call light button was not within reach for a resident while lying in bed, further compromising the ability to call for assistance. These observations indicate a systemic issue with the call light system's functionality, affecting the facility's ability to respond to residents' needs effectively. The facility's Emergency Preparedness plan lacked a policy or procedural plan for an alternate method for residents to contact staff during a power outage, which could exacerbate the issue of inoperable call lights. Interviews with the Director of Maintenance and the Administrator revealed a lack of awareness regarding the malfunctioning audible notification system. The Director of Maintenance was unaware of the issue, and the Administrator believed the system was functioning at times, indicating a communication gap and oversight in monitoring the system's performance.
Nursing Staff Unavailability in Dementia Care Unit
Penalty
Summary
The facility failed to ensure that nursing staff were available at all times for residents in the dementia Special Care Unit (SCU). On July 9, 2024, it was observed that two residents, who were in their respective beds on the SCU, were left without nursing staff for 33 minutes. During this time, only non-nursing staff such as laundry and housekeeping personnel were present on the unit. This lack of supervision occurred despite the facility's staffing sheets indicating that a Licensed Practical Nurse (LPN) and two Certified Nurse Assistants (CNAs) were scheduled to be on the SCU. Resident #4, who was admitted with diagnoses including vascular dementia with agitation and behavioral disturbance, was severely cognitively impaired and required maximal assistance for activities of daily living. The resident had a history of falls and was at high risk for further falls due to unsteady gait and cognitive impairment. Interviews with staff revealed that the resident often attempted to get out of bed without assistance and required constant supervision to prevent falls and ensure safety. Resident #21, also diagnosed with dementia with behavioral disturbance, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident had safety awareness problems and required total care, including assistance with feeding and ensuring beverages were within reach. Staff interviews confirmed that the resident needed frequent checks and should not be left alone due to the risk of anxiety and emotional distress. The Director of Nursing acknowledged that it was unsafe for residents to be left without nursing staff on the unit.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in a location that was easily accessible to residents and visitors on both the Long Term Care and Rehabilitation units. The required information, including the facility name, daily census, and actual hours worked per shift for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs), was not posted in a prominent location. Observations on multiple occasions confirmed that the staffing information was not visible to residents and visitors, which is a requirement for transparency and compliance. Interviews with the facility's Administrator and Director of Nursing (DON) revealed a lack of clarity and responsibility regarding the posting of staffing information. The Administrator acknowledged being responsible for posting staffing but admitted to not having a staffing coordinator and was in the process of hiring one. The Administrator also mentioned that the schedule was posted by the time clock, which was not accessible to residents and visitors. The DON, who had recently started at the facility, was unaware of who was responsible for posting the staffing information and did not verify its completion. Both the Administrator and DON expressed expectations that the staffing information should be posted daily and be accessible to all residents and visitors, indicating a gap between expectations and actual practice.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of medications in the medication room and on two of the three medication carts. Observations revealed that the North medication cart was left unlocked and unattended on multiple occasions, with staff members walking by without securing it. Additionally, the North treatment cart was found unlocked and unattended, containing three undated cups of unknown medication. In the medication room, the refrigerator lock box for controlled substances was unlocked, and an opened vial of tuberculin PPD lacked an open date. Furthermore, six bottles of over-the-counter calcium tablets were found to be expired. Interviews with facility staff, including a CNA, ADON, LPN, and DON, confirmed that medication carts and refrigerator lock boxes should be locked when unattended, and that nursing staff are responsible for ensuring medications are not expired. The ADON and DON acknowledged their responsibility for auditing medication carts and rooms, with the DON stating that audits should occur monthly. Despite these expectations, the facility's practices did not align with their policies, leading to the observed deficiencies.
Failure to Ensure Vaccination Status and Documentation
Penalty
Summary
The facility failed to ensure that residents' influenza and pneumococcal vaccination statuses were verified, administered, or refused, and that the risks and benefits of these vaccinations were communicated to residents or their representatives. This deficiency was identified for four residents out of a sample of twelve, with a total facility census of 44 residents. The facility's policies required that influenza vaccines be offered annually between October 1st and March 31st, and pneumococcal vaccines be assessed and offered within thirty days of admission. However, the records for Residents #22, #25, #40, and #42 showed no documentation of being offered or receiving these vaccines, nor any record of refusal. Resident #22, who was severely cognitively impaired, had not received or been offered the influenza vaccine during the 2023-2024 season. Resident #25, also severely cognitively impaired, had an outdated pneumococcal vaccination status and had not been offered the vaccine. Resident #40, with severe cognitive impairment, had neither received nor been offered both the influenza and pneumococcal vaccines. Resident #42, moderately cognitively impaired, had an outdated pneumococcal vaccination status and had not been offered the vaccine. Interviews with facility staff, including an LPN and the DON, confirmed that vaccination information should be documented in the residents' medical records, but this was not done for the affected residents.
Failure to Document COVID-19 Vaccination Offer and Education
Penalty
Summary
The facility failed to ensure that four residents were offered the COVID-19 vaccination, provided with education regarding the benefits and risks of the vaccine, and had signed consent or refusal documented. This deficiency was identified for four out of twelve sampled residents, with a facility census of 44 residents. The residents involved included those who were severely or moderately cognitively impaired, as well as those who were cognitively intact. The medical records of these residents did not contain any documentation indicating that they were offered the vaccine, received education about it, or had consented to or refused the vaccination. Interviews with facility staff, including an LPN and the DON, confirmed that each resident should have documentation in their medical record regarding their COVID-19 vaccination status, including whether they were offered the vaccine and if they consented or refused. The LPN stated that this information should be found under the vaccine tab in the medical records, while the DON emphasized the importance of offering the vaccine and providing information about its benefits and risks to residents or their decision-makers. Despite these procedures, the records for the four residents in question lacked the necessary documentation, indicating a failure in the facility's adherence to its vaccination policy.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents who were discharged from Medicare Part A services. The SNF ABN is a required document that informs residents or their legal representatives about potential liability for services not covered by Medicare. In this case, the facility provided a Notice of Medicare Provider Non-Coverage (NOMNC) to the residents, indicating the end of skilled services, but did not issue the SNF ABN, which is necessary to inform them of their financial responsibilities for non-covered services. Interviews with facility staff revealed a lack of clarity and responsibility regarding the issuance of the SNF ABN. The Social Services Director, who had been at the facility for just over a month, was not aware of whether the previous Social Services Director or the Bookkeeper had issued the required notices to the residents. The Regional Nurse and the Director of Nursing confirmed that the Bookkeeper was responsible for ensuring residents received the SNF ABN when therapy services were expected to end. Despite being informed three days in advance of the end of therapy services, the residents did not receive the SNF ABN as required.
Failure to Complete Required MDS Assessments
Penalty
Summary
The facility failed to complete required quarterly assessments for two residents and a significant change Minimum Data Set (MDS) for one resident. Resident #5 did not have any MDS assessments completed after a quarterly MDS on January 9, 2024. The facility's administrator acknowledged that the MDS coordinator had left the position and that no one was monitoring the completion of MDS assessments. The Director of Nursing (DON) was unaware of any incomplete MDS assessments and had only been in the position for a week. Resident #7 was admitted to hospice services on June 21, 2023, but there was no documentation of a significant change MDS being completed after this admission. The resident's records showed multiple entries indicating hospice care, yet the quarterly MDS dated after the hospice admission did not reflect this status. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the DON, revealed a lack of awareness regarding the responsibility and frequency of MDS updates, as well as the absence of a current MDS coordinator.
Inaccurate Documentation of Resident Falls on MDS
Penalty
Summary
The facility failed to ensure that resident falls were accurately reflected on the Minimum Data Set (MDS) for one resident. The resident, who was admitted with diagnoses including muscle wasting and vascular dementia, experienced multiple falls that were not accurately documented in the MDS. On one occasion, the resident was found on the floor with a hematoma on the forehead after a fall, which was not recorded as a non-major injury in the MDS. Subsequent falls were also not accurately documented, with the MDS indicating only one fall since the prior assessment and zero non-injury or non-major injury falls. The deficiency was identified during an interview with the Director of Nursing and the Regional Nurse Manager, who acknowledged that the MDS Coordinator position was vacant and that the MDS information should be accurate at the time of submission. The facility's policy requires that the MDS reflect information consistent with progress notes, care plans, and resident observations, which was not adhered to in this case. The lack of accurate documentation of falls in the MDS represents a failure to comply with federally mandated assessment requirements.
Failure to Document and Administer Wound Care as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders for wound care on a surgical wound for a resident with severe cognitive impairment and a right above the knee amputation. The resident's care plan indicated a healing surgical wound, and the physician's orders required daily treatment of the right distal stump with wound cleanser or normal saline, application of skin prep, and leaving it open to air. However, the Treatment Administration Record (TAR) for June and July 2024 showed multiple instances where there was no documentation of the treatment being completed, specifically 12 out of 30 opportunities in June and 15 out of 15 opportunities in July. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the charge nurse was responsible for documenting wound care on the TAR. Both the ADON and DON stated that if the wound care was not documented, they would assume it was not completed. The DON also mentioned that if the resident refused wound care, the charge nurse should document the refusal on the TAR. The lack of documentation and adherence to the physician's orders led to the deficiency identified by the surveyors.
Failure to Investigate and Document Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's fall, which was unwitnessed and reported by the resident after the fact. The resident, who was legally blind and had a right lower leg amputation, reported falling out of bed while reaching for a meal tray. Despite the resident's report of hitting their head and experiencing a headache, the facility did not document any neurological assessments or initiate a fall investigation. The resident's care plan, which identified them as at risk for falls due to their medical conditions, was not updated with new interventions following the reported fall. The facility's policy required a detailed investigation and documentation of any accidents or incidents, including unwitnessed falls, but this was not adhered to in this case. The resident was sent to the hospital after complaining of a headache, but no further actions were documented by the facility. Interviews with staff, including a CNA and the ADON, revealed that the facility's protocol for unwitnessed falls, which includes neurological checks and a root cause analysis, was not followed. The DON, who had recently started at the facility, confirmed that a complete investigation should have been conducted, including assessments for injuries and updates to the care plan. However, these steps were not taken, resulting in a deficiency in the facility's handling of the resident's fall.
Deficiency in Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper sanitization and hand hygiene during catheter care for a resident with an indwelling catheter. The resident, who was severely cognitively impaired and had a history of urinary tract infection, was observed with sediment and discoloration in the catheter tubing. During a catheter tubing and drainage bag change, a CNA did not cleanse the end of the catheter with an alcohol pad, removed gloves without sanitizing hands, and attached new tubing without proper hand hygiene. The CNA acknowledged the lapse in hand hygiene and the failure to cleanse the catheter drainage port, noting that alcohol wipes were available but not used. Additionally, the facility did not have complete physician's orders for the size of the catheter for the resident. The Director of Nursing confirmed that all residents with indwelling catheters should have a physician order indicating the catheter size and that staff should perform hand hygiene before starting care, with all glove changes, and after finishing care. The deficiency was identified during a survey, highlighting the facility's failure to adhere to its own policies on catheter care and hand hygiene.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who had experienced a traumatic car accident in 2022, was noted to have chronic symptoms of PTSD. Despite this, the resident's care plan did not address PTSD, nor did it include any information about the resident's triggers or interventions. The resident was on medication for anxiety and depression, but there was no specific mention of PTSD in the physician's orders. Interviews with staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis and associated care needs. The resident expressed uncertainty about their PTSD diagnosis and mentioned feeling anxious around loud sounds and large crowds. Staff members, including a Certified Nurses Aide (CNA) and the Assistant Director of Nursing (ADON), were unaware of the resident's PTSD diagnosis, triggers, or interventions. The ADON and other staff members indicated that the care plan should have included this information, but it was not present. The facility's administration acknowledged the oversight, noting that the MDS Coordinator, who was responsible for care plan development, had recently left the position. The Director of Nursing (DON) and the Administrator both stated that the care plan should have accurately reflected the resident's condition, including PTSD triggers and interventions. The lack of a comprehensive care plan and staff awareness resulted in a failure to provide trauma-informed care for the resident with PTSD.
Failure to Address Medication Irregularities
Penalty
Summary
The facility failed to address medication irregularities identified by the pharmacy consultant during the monthly Drug Regimen Review (DRR) for one resident out of a sample of 12. The consultant pharmacist's review, which is supposed to be conducted monthly, identified medication orders for Resident #29 that lacked a diagnosis or indication for use. Despite the identification of these irregularities, the facility did not follow through with the necessary actions to resolve them, as required by their policy. Resident #29, who was cognitively intact, was using multiple medications, including anticoagulants, diuretics, antiplatelets, hypoglycemics, and others. The resident's care plan indicated a diagnosis of Type II Diabetes Mellitus. However, the July 2024 Physician's Order Sheet (POS) for the resident listed several medications, such as Lantus, Amlodipine, Aspirin, Plavix, and others, without any documented diagnosis or indication for use. This lack of documentation was not addressed by the facility staff or the pharmacy consultant, as expected by the facility's policy. Interviews with facility staff, including a Certified Medication Technician (CMT), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed a lack of clarity and follow-through regarding the responsibility for ensuring medication orders included a diagnosis or indication for use. The staff believed that the pharmacy consultant was responsible for checking the diagnosis on the POS, and there was an expectation that either the facility nurse or the pharmacy consultant would identify and clarify any medication orders lacking this information. However, this did not occur, leading to the deficiency identified in the report.
Failure to Review and Act on Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the resident's physician reviewed the pharmacist's recommendations for a Gradual Dose Reduction (GDR) of psychotropic medications for two residents. Resident #7, who was severely cognitively impaired and on multiple psychotropic medications, did not have a GDR attempted despite recommendations from the pharmacist. The physician's visit notes repeatedly showed that medications were reviewed and continued without addressing the pharmacy's recommendations for GDR. The facility could not locate any physician responses to these recommendations, indicating a lack of follow-through on the pharmacist's identified irregularities. Additionally, the facility did not address the pharmacy consultant's identification of medication orders without a diagnosis or indication for use for Resident #26. This resident, diagnosed with major depressive disorder, was taking antidepressants without a documented diagnosis or indication for use in the physician's order sheet. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed a lack of clarity on who was responsible for addressing pharmacy recommendations and ensuring that all medication orders included a diagnosis or indication for use. The report highlights a systemic issue within the facility regarding the management and review of psychotropic medication orders. The failure to act on pharmacy recommendations and ensure proper documentation of medication indications suggests a breakdown in communication and oversight among the facility's staff and healthcare providers. This deficiency was observed in the context of a facility with a census of 44 residents, where the Medication Regimen Review (MRR) policy was not effectively implemented.
Failure to Assess and Document Skin Conditions and Medication Errors
Penalty
Summary
The facility failed to adequately assess and document a resident's skin condition upon admission, leading to a series of oversights in care. The resident, who had a history of hemiplegia and chronic kidney disease, was admitted with scabs on the right foot, lower legs, and weeping edema in the left lower leg. However, these conditions were not documented in the nurse's progress notes or the daily skilled nurse's notes. Furthermore, there was no physician's order for treatment of these conditions, and weekly skin assessments were not properly conducted or documented, resulting in a lack of appropriate care and notification to the resident's physician. The facility also failed to follow the emergency room physician's instructions regarding the resident's anticoagulant medication. The resident was supposed to have two doses of Eliquis held due to hematuria, but this was not documented in the physician's orders or the medication administration record. Consequently, the resident received a dose of Eliquis that should have been withheld. This oversight was attributed to a lack of communication and review of hospital paperwork by the nursing staff upon the resident's return from the emergency room. Additionally, the facility's policies and procedures for skin assessments and medication administration were not followed. The previous Director of Nursing had instructed staff to discontinue highlighting weekly skin assessments, leading to a lapse in these assessments being completed. The facility also failed to notify the resident's physician of changes in the resident's condition, such as the development of necrotic toes and the need for emergency medical evaluation. These deficiencies in care and communication contributed to the resident's deteriorating condition, ultimately resulting in severe medical interventions, including amputations.
Deficiency in Pressure Ulcer Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident, leading to a deficiency in care. The resident, who had a history of partial paralysis and other risk factors, was admitted without any skin breakdown. However, upon returning from a hospital visit, the resident was noted to have wounds on the coccyx area. The facility's policy required weekly assessments and documentation of pressure ulcers, but there was no further licensed nurse assessment of the resident's sacral wound after the initial observation. Additionally, the facility did not adhere to its hand hygiene policy during wound treatment. An LPN was observed removing a dressing and cleansing a slough-covered pressure ulcer without washing or sanitizing hands between glove changes and before applying Santyl to the wound. The LPN admitted to possibly not following hand hygiene protocols during the treatment, which was against the facility's policy that required hand hygiene before and after treatments, and between different wound care tasks. The facility's DON acknowledged that the wound nurse had not been performing their duties, including weekly documentation of resident wounds, leading to the termination of the wound nurse's employment. The new ADON was tasked with ensuring that weekly wound documentation was completed. Despite these administrative changes, the deficiency in pressure ulcer care and hand hygiene practices was evident during the surveyor's observation.
Improper Catheter Care and Hand Hygiene Deficiency
Penalty
Summary
The facility failed to provide correct catheter care for a resident, leading to a deficiency. The resident, who had mild cognitive impairment and occasional urinary and bowel incontinence, was at high risk for pressure ulcers and had a urinary catheter placed for wound healing. During an observation, a CNA did not wash or sanitize their hands before applying barrier cream and cleansing the resident's penis. The CNA also failed to retract the foreskin before cleansing the head of the penis and did not cleanse the catheter the required four inches from the insertion site. Interviews with the CNA, an LPN, and the Director of Nursing confirmed the improper catheter care. The CNA admitted to not following proper hand hygiene and catheter care procedures, such as retracting the foreskin and cleansing the catheter adequately. The LPN, who was present during the care, noticed these deficiencies and discussed them with the CNA. The Director of Nursing stated expectations for proper hand hygiene and catheter care, which were not met during the observed incident.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that side rails were not used unless a resident's assessment indicated they were safe. This deficiency was observed in the case of a resident who was admitted to the facility and was receiving hospice care. The resident had limited mobility and required assistance with activities of daily living. Despite this, side rails were installed on the resident's bed without an assessment, physician's order, or informed consent. The side rails were added when the hospice company switched out the resident's bed, and the facility staff, including the CNA and LPN, were unaware of the change until it was observed during a survey. The facility did not have a side rail policy available upon request, and the licensed nurses, who were in the resident's room daily, failed to report the presence of side rails to the facility administrator. The administrator and the DON acknowledged that the side rails were not part of the facility's standard practice and should not have been installed without proper assessment and consent. The deficiency was identified when the resident was found with side rails that extended from the head to halfway to the foot of the bed, despite the resident's inability to use them for positioning or turning.
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 791 citations issued within 25 miles in the last 12 months — including the 19 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 Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Rehab And Healthcare Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Independence Manor Care Center | 1.4 mi | ★★★★★ | 17 | 0 |
| Carmel Hills Wellness & Rehabilitation | 2.9 mi | ★★★★★ | 1 | 0 |
| Parkview Healthcare | 3.6 mi | ★★★★★ | 6 | 1 |
| Abode Health And Wellness Center | 4.5 mi | ★★★★★ | 6 | 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.