Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Northland Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with multiple sclerosis, bilateral lower extremity impairment, wheelchair dependence, prior falls, and a history of right femur fracture was care planned as dependent for transfers, requiring two staff and a sit‑to‑stand lift. A CNA who had not worked with the resident recently attempted to transfer the resident alone from bed to a shower chair using only a gait belt, relying on the resident’s statement that only one staff member and no lift were needed and without checking the care plan or Kardex or consulting the charge nurse. During the transfer, the shower chair moved, the resident’s legs gave out, and the CNA lowered the resident to the floor, after which the resident developed right knee pain. X‑rays obtained following the incident showed an acute nondisplaced distal right femur fracture, and the resident was evaluated in the emergency room and returned with a knee immobilizer.
Two residents with complex medical needs did not receive breakfast within the facility's scheduled timeframe on consecutive days. One resident, recently admitted with multiple health conditions, missed breakfast entirely until staff were alerted, while another with GERD and anxiety received breakfast late, causing distress. Staff interviews revealed confusion about the cause of the delays, despite policies requiring timely meal service.
Food Storage, Sanitation, and Temp Monitoring Failures: Surveyors found expired and unlabeled leftovers in the refrigerator and pantry, dirty and contaminated storage areas, moldlike growth in the ice machine drain and chest refrigerator, and food stored improperly in the freezer. Staff were observed working without required beard nets, failing to wash hands after break, and handling food with poor hair restraint practices. Multiple cooked items were placed into warmers or served without proper temp checks, and some temps were taken incorrectly or showed food in the danger zone.
Failure to maintain resident dignity occurred when staff entered a resident’s room without knocking or announcing themselves and when an LPN stood over a resident while feeding and assisting with drinks. One resident had urinary incontinence, needed help with dressing, and said staff should knock before entering; another resident had severe cognitive impairment and was dependent on staff for eating assistance.
Meal service and snack access did not reflect resident choice for multiple residents. Residents with intact or impaired cognition, including those with diabetes, renal disease, hemiplegia, and depression, reported late or cold meals, missing drinks and condiments, no routine HS snacks, and staff leaving snacks at the nurses’ station instead of offering them room to room. One resident did not receive requested coffee, another did not get cereal with milk, a resident preferred an earlier breakfast but was served much later, and soup choices were not clearly offered or listed on meal tickets; the alternate dining room also lacked condiment holders.
Two residents did not receive their personal funds and final accounting within the expected 30-day timeframe after discharge. The BOM said one refund was being held due to an unresolved Medicare issue and the other was delayed because of a vendor switch, while the Administrator stated refunds should be provided within 30 days for discharged or deceased residents when required.
Failure to complete required pre-employment background checks: the facility did not verify the NA registry before hire for four sampled employees and did not obtain FCSR letters for two sampled employees. Record review showed several CNA registry checks were completed after employment began or were undated, and two dietary aides had no FCSR documentation in their files. Payroll/HR and the Administrator could not explain why the required paperwork was missing or incomplete.
Failure to follow oxygen orders and maintain tubing affected four residents with significant respiratory conditions, including respiratory failure, COPD, sleep apnea, pulmonary edema, and heart failure. Surveyors observed undated, overdue, or incorrectly labeled oxygen tubing, including tubing labeled for another resident and tubing dated before admission, while physician orders required continuous or scheduled oxygen at specific flow rates and weekly tubing changes. Documentation did not show the tubing had been changed or dated as ordered, and staff interviews confirmed oxygen was adjusted by nursing and tubing should be changed and dated per orders and policy.
Expired medications were found stored in the rehab nurse's medication room, including unopened and opened bottles of mucus relief, Aspirin 325 mg, saline nasal spray, and glucose tablets. An LPN said expired meds should be disposed of but was unsure who was responsible for checking the room, and the DON stated there should not be any expired medication in the room and that nurse managers should check medication rooms at least monthly.
Infection Prevention and Control Program Failures: Staff did not consistently use EBP during high-contact care for residents with wounds, suprapubic catheters, and dialysis access devices, including a CNA providing incontinent care and dressing a resident with an uncovered Stage 3 coccyx ulcer while wearing gloves only. Other residents with catheter or dialysis-related devices also had no barrier precautions observed at their rooms. In addition, a review of new employee records showed multiple staff lacked documented TB skin tests despite the facility policy requiring TB screening upon hire.
Ineffective pest control allowed gnats and flies to be seen throughout the facility, including hallways, the dining room, kitchen, and trash areas. Surveyors observed open trash cans, overflowing trash, dirty drains with food debris, and dumpster lids left open with heavy insect activity. Residents with intact cognition, including one with hemiplegia and another with renal failure on HD, reported insects in their rooms and common areas, and a CNA said the gnats were bad in the facility.
Failure to Care Plan Incontinence Needs: A resident with impaired cognition, limited ROM, stroke, kidney disease, and постоян bowel and bladder incontinence had a care plan that addressed ADL deficits and toileting assistance but did not include incontinence or catheter interventions, measurable goals, or time frames. Progress notes showed the resident was not on a toileting program and documentation about catheter use and bladder-control measures was inconsistent, while the resident said the ongoing incontinence was upsetting and staff confirmed the issue was not care planned.
The facility failed to maintain proper food storage and hygiene practices in the kitchen, risking foodborne illness for 96 residents. Observations revealed an unclean ice machine, improperly stored food in the freezer, and unsanitary glove use during meal service. The Dietary Manager and Maintenance Director acknowledged these issues, with the DM noting a focus on other areas and unsuccessful attempts to correct staff during service.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling devices, increasing the risk of MDRO spread. A resident with an enteral feeding tube and another with a suprapubic catheter did not receive care with the required gown and glove use. Staff were not informed about EBP requirements, and the facility had not yet implemented these precautions.
A resident with intact cognition reported verbal abuse by a CNA, including foul language and physical abuse. The incident was documented and given to the former ADON, but there was no evidence of reporting to the SSA or investigation. The DON acknowledged the need for reporting and staff removal, but the facility failed to follow its abuse prevention policy.
A resident with intact cognition reported verbal abuse by a CNA, providing a detailed account to the former ADON. Despite the facility's policy requiring thorough investigation, there was no documentation or evidence of such an investigation. The resident expressed discomfort seeing the CNA, who continued working in the same hall. Interviews revealed a lack of proper documentation and investigation, with the DON acknowledging the need for an investigation to ensure resident safety.
The facility failed to update care plans for two residents, resulting in inaccuracies and lack of coordination with hospice services. One resident's care plan included an outdated diagnosis of dehydration without supporting orders, while another resident's care plan did not reflect hospice services despite being admitted to hospice care. Interviews revealed that the care plans were not updated from previous admissions, and there was no policy for coordinating care with hospice providers.
A facility failed to implement pressure ulcer treatment and prevention measures for a resident with dementia and peripheral vascular disease. A wound treatment order was not correctly entered into the EMR, leading to a lack of scheduled treatment. Additionally, the resident was observed without heel protectors or floated heels, despite having an order for them. Staff were not instructed to apply these measures, contributing to the deficiency.
A resident with severe cognitive impairment was given two doses of psychotropic medications without documented clinical need. Despite Lorazepam being noted as effective, Haloperidol was also administered without justification. Interviews with nursing staff confirmed the lack of documentation and inappropriate administration of a second dose, leading to a deficiency.
Improper One‑Person Transfer Without Lift Leads to Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a resident by not following the resident’s care plan, which required two staff members and use of a sit‑to‑stand lift for transfers. On the date of the incident, a CNA attempted to transfer the resident alone from bed to a shower chair using only a gait belt. The CNA positioned and locked the shower chair next to the bed and began the transfer without verifying the resident’s transfer status in the care plan or Kardex, despite knowing that this information was available and that staff could consult the charge nurse if unsure. During the transfer, the shower chair moved, and the CNA was unable to safely complete the transfer back to the bed. The resident involved had multiple medical conditions and functional limitations documented in the record. Diagnoses included multiple sclerosis, anxiety disorder, a history of falls, and a prior fracture of the right femur. The most recent MDS showed the resident had impairment in both lower extremities, used a wheelchair for mobility, required moderate assistance with ADLs, was dependent on staff for transfers, and had experienced a prior fall with major injury. The comprehensive care plan in effect before the fall specified that the resident required assistance of two staff members and use of a sit‑to‑stand lift for transfers, and also noted that the resident had a history of manipulating staff by telling them he or she could do more than physically able. On the day of the event, the CNA, who had not worked with the resident in some time, believed the resident was a one‑person assist with a gait belt and relied in part on the resident’s statement that he or she could transfer with only one staff member and no lift. The CNA did not review the care plan or Kardex and did not consult the charge nurse before proceeding. During the transfer from bed to shower chair, the resident stood and began to turn toward the shower chair when the resident’s legs gave out, and the CNA lowered the resident to the floor. The resident came to rest on the floor with the right leg underneath the body and requested that the CNA move the leg out in front. The LPN who responded found the resident sitting on the floor with legs extended and initially noted no acute injury, but later the resident reported right knee pain. Subsequent x‑rays revealed an acute nondisplaced distal right femur fracture, and the resident was sent to the emergency room, where the fracture was confirmed and an immobilizing knee brace was applied before the resident returned to the facility. Interviews with facility leadership and the resident’s physician confirmed that the expectation was for staff to follow the comprehensive care plan, Kardex, and therapy recommendations for transfers, and to verify instructions with the charge nurse if a resident’s statements conflicted with the care plan. The CNA acknowledged awareness of these expectations and admitted not checking the care plan or Kardex before attempting the transfer alone. The facility’s fall prevention policy described a fall as an unintentional coming to rest on a lower level and defined serious injury to include fractures, and the resident’s event met these criteria when the transfer attempt resulted in the resident being lowered to the floor and sustaining a nondisplaced distal femur fracture.
Failure to Serve Meals According to Scheduled Mealtimes
Penalty
Summary
The facility failed to serve meals in accordance with its own policy and scheduled mealtimes, resulting in two residents not receiving breakfast within the expected timeframe. According to the facility's posted schedule, breakfast is to be served at 8:30 A.M., and residents should receive their meals within one hour of the start time. However, observations and interviews revealed that one resident, who had multiple medical conditions including acute osteomyelitis, stroke, malnutrition, diabetes, and dementia, did not receive breakfast for two consecutive days after admission. On the second day, the resident expressed feeling hungry and neglected, and staff only became aware of the missed meal after being prompted, eventually delivering breakfast two hours late. Another resident, with diagnoses including a fractured femur, cognitive communication deficit, osteoporosis, GERD, and anxiety disorder, also received breakfast over 1.5 hours late on two consecutive days. This resident's care plan required small, frequent meals due to GERD and anxiety-related nutrition risk. The resident reported increased anxiety and a preference for breakfast at the scheduled time, as late meals caused discomfort and uncertainty. Staff interviews indicated a lack of clarity regarding why these delays occurred, despite established procedures for meal delivery and new admissions.
Food Storage, Sanitation, and Temperature Monitoring Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards of food service safety. During observation, surveyors found expired leftovers in the refrigerator, including egg whites dated 7/16/25 that were opened and resealed but not discarded, heavy whipping cream opened 7/11/25 and resealed but expired, and cherry tomatoes dated 7/17/25 that were expired and not discarded. Other refrigerated items were unlabeled or undated, including leftover food, mushy carrot leftovers, and defrosting meat in a pan with yellow liquid around it. In the pantry, surveyors observed opened browning sauce with no date, opened tomato catsup stored since 4/18/25 with no open date, and bowls of unlabeled or undated dry cereal. The bulk sugar container had food stains and crystallized material on the handle, along with black unknown specs inside the sugar. Kitchen sanitation and storage conditions were also poor. Surveyors observed ice forming and chunks on the floor of the walk-in freezer, condensation puddling in front of the freezer door, grime and dirt under refrigerator racks, unbroken eggs on the floor under the racks, black specs and a moldlike substance inside the chest refrigerator, and caked food debris and stains on dish holders next to the steam line. The ice machine drain in the dining room had buildup of algae and moldlike growth, and multiple drains around the dishwasher and kitchen sinks contained food debris and trash. Horizontal surfaces above the plate holder had food debris and stains, pans in the clean storage rack had an oily film, and the food warmer next to the stove had a broken glass corner missing from the front side. Staff practices observed during meal preparation and service did not follow the facility’s food safety policies. A Dietary Aide with facial hair longer than an eyebrow worked in the dishwashing and kitchen area without a beard net, and another staff member returned from break and put on gloves without first washing hands. A Dietary Aide was observed plating food while wearing gloves and a hair net, but the hair net contacted plates and food items. Another staff member cooked at the stove with a hair net that did not cover the moustache. Surveyors also observed inaccurate temperature monitoring: puree carrots, chicken pot pie, and mashed potatoes were placed into warmers or onto the steam table with no temperatures taken; a thermometer was inserted into carrots for only two seconds and the reading bounced from 180 degrees Fahrenheit to 215 degrees Fahrenheit without stabilizing; and pureed chicken pot pie was later measured at 110 degrees Fahrenheit before being reheated. Test trays delivered to the hall were also measured at 102 degrees Fahrenheit and 106 degrees Fahrenheit. The Dietary Manager had resigned the day before the second kitchen observation, and no person had been appointed to take over at that time.
Failure to Maintain Resident Dignity During Room Entry and Mealtime Assistance
Penalty
Summary
The facility failed to ensure residents were treated in a manner that maintained dignity when staff entered a resident’s room without knocking or announcing themselves. Resident #57 had an ADL self-care performance deficit, urinary incontinence, wore incontinent briefs for dignity, could change briefs with minimal assistance, and required one staff member for dressing. The resident’s MDS showed moderately impaired cognitive skills, independence with toilet use, dressing, and transfers, occasional urinary incontinence, and diagnoses of high blood pressure, anxiety, and depression. During observation, Housekeeping Staff A opened the resident’s closed door and entered without knocking or announcing himself/herself, an unknown CNA entered without knocking while looking for a mechanical lift, and an unknown housekeeper entered the room without knocking and cleaned the bathroom before leaving. The resident stated a preference for staff to knock and announce themselves before entering. The facility also failed to maintain dignity when staff assisted a resident with eating while standing over the resident. Resident #29’s quarterly MDS showed severe cognitive impairment, dependence on staff for eating assistance, and diagnoses of stroke, cancer, anemia, diabetes, and multiple sclerosis. During observation, LPN A stood over the resident for four minutes while feeding the resident with a spoon and helping the resident drink from a cup. When interviewed, LPN A stated that staff assisting residents with meals should ideally sit between no more than two residents and should be sitting, not standing, when helping residents eat.
Meal Choices, Snacks, and Dining Preferences Not Honored
Penalty
Summary
The facility failed to promote resident choice and self-determination in meal service and snack availability for multiple residents. The report states that four residents were not provided satisfactory meals or evening snacks, two residents did not have their menu choices honored, one resident was not served meals according to preference, one resident was not offered menu items prepared for the meal, and the alternate dining room did not have condiments available. The facility policy on resident rights stated that each resident has the right to a dignified existence and self-determination, but no policy was provided regarding snacks or resident meals. Several residents and family members described repeated problems with food quality, meal timing, and snack access. One resident with intact cognition, dependent mobility, and diagnoses including hip fracture and depression reported meals that were unappetizing, missing items such as milk, utensils, or straws, and being upset about repeated grilled cheese lunches, late breakfast, and no snack the prior night. The resident and spouse also stated that snacks were not routinely brought around and that condiments were not normally provided. Another resident with renal failure on hemodialysis, diabetes, and high blood pressure reported that trays were often late and cold, that snacks were never offered, and that the facility did not consistently bring water or ice as expected. Additional residents reported similar concerns. A resident with hemiplegia, diabetes, and high blood pressure said food was bland, cold, and late, snacks were left at the nurses’ station instead of being passed room to room, and meal times had been changed without notice. A resident with osteoarthritis and depression said snacks were not passed around and that the resident depended on staff to offer them while confined to bed. In the dining areas, staff and residents reported that condiments were not consistently passed with trays, and the alternate dining room had no condiment holders while the main dining room did. The report also documented that one resident who preferred coffee with breakfast and lunch did not receive it despite telling staff, another resident who routinely ordered cereal with milk did not receive it, one resident preferred breakfast at 8:00 A.M. but ate at about 10:30 A.M., and one resident was not told what soup was available and the menu ticket did not list soup as a choice.
Failure to Provide Resident Fund Refunds After Discharge
Penalty
Summary
The facility failed to provide personal funds and a final accounting within 30 days after discharge for two residents. Review of the interim aging report showed that one resident discharged with a credit balance of $2,641.41 in the Resident Liability account and another resident discharged with a credit balance of $1,360.00 in the Private Pay account. During interview, the BOM said the first resident's refund was being held because of money owed to Medicare, but no documentation or correspondence was available to show the issue had been addressed. The BOM also said the second resident's refund had not yet processed because the facility was switching vendors and the refund had been delayed. The BOM stated the normal expected process time for refunds to discharged or deceased resident accounts was 30 days, and the Administrator stated refunds should be provided within 30 days for deceased and discharged residents when required.
Failure to Complete Required Pre-Employment Background Checks
Penalty
Summary
The facility failed to verify required background checks before hiring newly employed personnel. Based on interview and record review, the Nurse Assistant registry was not checked prior to employment for four of 10 sampled employees hired since October 2024, and the Family Care Safety Registry was not checked prior to employment for two of 10 sampled employees hired since October 2024. The facility census was 95, and the abuse policy stated that all employees must have criminal and state/federal required background checks completed prior to the start of employment. Personnel record review showed CNA C was hired on 03/17/25 with the NA registry check completed on 04/03/25, CNA D was hired on 02/17/25 with an undated NA registry check, CNA E was hired on 03/10/25 with the NA registry check completed on 04/23/25, Dietary Server A was hired on 06/30/25 with the NA registry check completed on 07/03/25, and CNA F was hired on 12/09/24 with the NA registry check completed on 04/14/25. Dietary Aide A and Dietary Aide B, both hired in October 2024, had no FCSR letters in their personnel records. During interview, Payroll/HR stated he/she was not sure what had gone wrong with the process, and the Administrator stated there was no explanation for why the paperwork could not be produced to show the background reports were completed.
Failure to Follow Oxygen Orders and Maintain Tubing
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice by not following physician orders for oxygen maintenance and oxygen flow rate for four sampled residents. The report cited residents with respiratory failure, COPD, acute respiratory failure, sleep apnea, pulmonary edema, heart failure, and other significant medical histories, and described repeated observations of oxygen tubing that was undated, overdue for change, labeled for another resident, or dated before the resident’s admission. Facility policies required verification of an oxygen order, checking tubing for kinks, starting oxygen at the ordered flow rate, and changing tubing on the ordered schedule. For one resident with a history of stroke, kidney disease, heart rhythm problems, and a pacemaker, surveyors observed oxygen tubing that was eight to ten days overdue for change, and the current orders showed no oxygen order and no oxygen care plan. The resident stated he/she was not aware the tubing was to be changed. For another resident with acute respiratory failure and sleep apnea, the physician ordered oxygen with nebulizer at 4 liters continuous or PRN, along with weekly changes of the nebulizer, tubing, and concentrator filter, but surveyors observed oxygen at 4 liters with undated tubing on multiple occasions and found no documentation that the tubing had been dated or changed. For a third resident with acute respiratory failure, COPD, pulmonary edema, and heart failure, the physician ordered oxygen at 3 liters at rest and 4 liters with activity, with weekly tubing changes, but surveyors observed tubing labeled with another resident’s name and dated before admission on multiple days. For a fourth resident with respiratory failure and COPD, the physician ordered oxygen at 4 liters continuously and weekly tubing and filter care, but surveyors observed no date on the tubing on multiple occasions and found no documentation that the tubing had been changed. Staff interviews confirmed that nurses adjusted oxygen flow and that tubing should be changed and dated per orders and policy.
Expired Medications Found in Medication Room
Penalty
Summary
The facility failed to ensure expired medications and biologicals were discarded from the rehabilitation nurse's medication room. During an observation and interview on 7/23/25 at 12:12 P.M., surveyors found multiple expired items stored in the room, including one unopened bottle of mucus relief expired 5/25, one opened bottle of mucus relief expired 9/24, three unopened bottles of Aspirin 325 mg expired 9/24, one unopened bottle of saline nasal spray expired 1/25, one opened bottle of mucus relief expired 4/25, two unopened bottles of mucus relief expired 5/25, two unopened bottles of mucus relief expired 4/25, and two unopened bottles of glucose tablets expired 11/24. The facility's undated Medication Administration policy stated expired or discontinued medications should not be stored and should be disposed of according to proper procedures. During the same observation, an LPN stated staff should not use expired medications and that they should be disposed of, but he/she was not sure who was responsible for checking the medication room for expired medications. On 7/24/25 at 11:19 A.M., the DON stated there should not be any expired medication in the medication room and that nurse managers should check the medication rooms for expired medications at least monthly. The sample size was 19 residents, and the facility census was 95.
Infection Prevention and Control Program Failures
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when staff did not use proper Enhanced Barrier Precautions (EBP) during resident care and when new employees were allowed to work without documented TB skin testing. The facility policy stated that the infection prevention and control program included standard and transmission-based precautions, PPE use, TB screening of staff, and systems for surveillance and control of infections. The EBP policy stated that gown and glove use was required during high-contact resident care activities for residents with wounds or indwelling medical devices, including suprapubic catheters and dialysis access devices. Resident #10 had dementia, weakness, and a Stage 3 pressure ulcer to the coccyx, with the quarterly MDS showing severe cognitive impairment, dependence for toileting, dressing, and transfers, and incontinence of urine and bowel. During observation, a CNA provided incontinent care and dressed the resident while the coccyx wound was open and uncovered, but the CNA did not wear a gown or mask. The CNA later stated a gown and mask should have been worn, and the DON stated staff should wear a gown and gloves when a resident has a wound and is on EBP. Resident #2 had cognitive impairment, non-traumatic brain injury, coronary artery disease, obstructive uropathy, viral hepatitis, and Alzheimer’s disease, and the care plan identified a suprapubic catheter and EBP status. During observation, a CNA wiped and cleaned the resident’s face, inserted dentures, and adjusted clothing while wearing gloves only and no isolation gown, despite the room being marked for EBP. Resident #8 and Resident #108 also had dialysis-related access devices and were identified in care plans as requiring EBP, yet observations showed no barrier precautions or equipment at the room entrances or inside the rooms, and the residents stated staff had not worn gowns in their rooms. Resident #28 had a suprapubic catheter and a care plan calling for catheter care and infection monitoring, but no barrier precautions or equipment were observed at the room entrance or inside the room. The facility also failed to ensure TB screening was completed for new employees before they worked. A review of 10 randomly selected employees hired since October 2024 showed seven had no documentation that a TB skin test had ever been completed. The facility policy required all healthcare workers to be tested for TB upon hire and yearly thereafter, with new employees not allowed to work until TST or chest x-ray results were known. The HR manager stated the first TB test was given during pre-employment screening and the DON handled the paperwork for the second test, while the Administrator acknowledged the facility was not in compliance and that all new employees should be screened with a TB skin test.
Ineffective pest control with gnats and flies throughout the facility
Penalty
Summary
The facility failed to maintain an effective pest control program when numerous flying insects, described as gnats and flies, were observed throughout the building, including the 100 Hall, 160 Hall, dining room, kitchen, and outside trash disposal area. Survey observations noted frequent flying gnats in the hallway, many gnats and flying insects at the drink station, an open trash can at the drink station, an overflowing trash can at the handwashing station, multiple dirty drains with food debris and trash, and dumpster lids left open with a heavy concentration of flies and gnats nearby. Record review of pest service showed vendor findings on 6/10/25 and 7/11/25 of fly activity around dumpsters, food residue on equipment, food filth on walls and drains under the dish machine, and an interior door left open. Residents reported the insects were present in their rooms and common areas. One resident with intact cognition, hemiplegia, diabetes, and high blood pressure said the gnats were terrible in the dining room and throughout the facility, tried to get into food, and could not be bat away because of limited use of one hand. Another resident with intact cognition, renal failure requiring hemodialysis, diabetes, and high blood pressure said gnats and spiders were seen sometimes and that the facility was too old for that. A third resident with intact cognition, osteoarthritis, depression, and substantial assistance needs for mobility and transfers reported seeing gnats in the hallway and a spider in the bathroom and said it made the resident feel scared and not want to be bit. A CNA also stated the gnats were bad in the facility, and the Maintenance Supervisor and Administrator acknowledged pest control was being handled through an outside vendor and attributed the increase to seasonal weather.
Failure to Care Plan Incontinence Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident with incontinence needs. The resident's quarterly MDS dated 7/22/25 showed impaired cognition, limited range of motion on one side of the upper and lower extremity, dependence on staff for toileting hygiene and showering, use of a wheelchair, and that the resident was always incontinent of bowel and bladder, with diagnoses including stroke and kidney disease. The facility's care plan, revised 5/5/25, addressed ADL performance deficits and two-person assistance for toileting, but it did not include staff interventions related to incontinence or catheter usage. Progress notes from May through July 2025 documented that the resident was incontinent of bladder and bowel, was not on a toileting program, and at times used pads, briefs, or a urinary catheter, with inconsistencies in the documentation regarding catheter use and bladder-control interventions. During interview, the resident stated he/she had been incontinent since arriving at the facility and wanted help with a solution because soiling was upsetting and made him/her feel very dirty. Staff interviews confirmed the resident was not on a toileting program, that incontinence had not improved, and that incontinence should have been care planned with goals and measurable measures, but those elements were not present in the resident's care plan.
Food Storage and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper food storage and hygiene practices in the kitchen, which could potentially lead to the spread of foodborne illness among all 96 residents. During an inspection, it was observed that the ice machine had a brownish-yellowish-greenish substance on the inside of the lid, indicating inadequate cleaning. The Dietary Manager (DM) acknowledged that the maintenance department was responsible for cleaning the ice machine and claimed it had been cleaned recently. Additionally, in the stand-alone freezer, bags containing chicken nuggets, hash brown patties, and hamburger patties were found open and unsealed, which the DM confirmed should not have been the case. The DM, who was new to the position, admitted to focusing on other areas and had not noticed these issues. During lunch service, further unsanitary practices were observed. A breadstick that fell onto the steam table was placed back into the pan for serving. Dietary cook (DC) 2 was seen using the same gloves to handle various kitchen equipment and food items, including ready-to-eat foods, without changing them, which could lead to contamination. A meal tray card that fell into a pan of breadsticks was removed by DC1 using gloved hands, and the breadsticks were still served. The DM attempted to correct these unsanitary practices during the service but was unsuccessful. The Maintenance Director (MD) stated that the ice machine was cleaned monthly, but he did not notice the substance on the lid, focusing instead on the ice compartment.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling devices, which are at increased risk for multidrug-resistant organism (MDRO) acquisition. This deficiency was observed in three residents, including one who was admitted with an enteral feeding tube and another with a suprapubic catheter. The facility's policy required gown and glove use during high-contact care activities for such residents, but this was not followed. In one instance, a Hospice Registered Nurse provided care to a resident with an enteral feeding tube without wearing a gown, despite the facility's policy. The nurse was not informed about the EBP requirements and stated that the facility had not communicated the need for such precautions. Similarly, the Assistant Director of Nursing and a Licensed Practical Nurse also failed to wear gowns while administering medications and tube feeding to the same resident. Another resident with a suprapubic catheter did not have EBP signage or PPE supplies available at the room entrance. Staff members confirmed that they only wore gloves during catheter care and were not aware of the EBP requirements. The Director of Nursing acknowledged that the facility had not yet implemented EBP, although preparations were underway. This lack of implementation created the potential for the spread of MDROs throughout the facility.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Survey Agency (SSA). The incident involved a resident with intact cognition who reported being verbally abused by a Certified Nursing Assistant (CNA). The resident had previously undergone a procedure affecting her memory but recalled the CNA using foul language and being physically abusive. The resident had documented the incident and submitted it to the former Assistant Director of Nursing (ADON), who then passed it to the former Administrator. However, there was no evidence that the allegation was reported to the SSA or that an investigation was conducted. Interviews with staff revealed that the former ADON was aware of the resident's complaint but did not ensure it was reported to the state. The CNA involved was informed by a charge nurse not to provide care to the resident but was not interviewed or asked to provide a statement regarding the allegations. The Director of Nursing (DON) acknowledged that the allegations should have been reported to ensure resident safety and that the staff involved should have been removed from the care area pending investigation. The lack of documentation and follow-up on the allegations highlights the facility's failure to adhere to its abuse prevention and reporting policy.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident, identified as R37, who had intact cognition and was admitted with diagnoses including depression and anxiety. R37 reported being verbally abused by a Certified Nursing Assistant (CNA7) and provided a detailed written account of the incident to the former Assistant Director of Nursing (FADON), who then passed it to the former Administrator. Despite this, there was no documentation or evidence of a thorough investigation into the allegations, as required by the facility's abuse prevention policy. R37 expressed discomfort seeing CNA7, who was still working in the same hall, as it brought back unpleasant memories. Interviews with the FADON and CNA7 revealed that the allegations were not properly documented or investigated. The FADON acknowledged receiving a report from R37 about CNA7's rudeness but did not recall specific details or document the incident. CNA7 confirmed being informed by a charge nurse not to provide care to R37 but was never interviewed or asked to provide a statement regarding the allegations. The Director of Nursing (DON) confirmed that the allegations should have been investigated to ensure resident safety, highlighting a failure in the facility's response to the reported abuse.
Care Plan Inaccuracies and Lack of Hospice Coordination
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to inaccuracies in their medical records and care coordination. For one resident, the care plan inaccurately included a diagnosis of dehydration, which was not current. The resident's care plan included interventions such as monitoring fluid intake and output and conducting lab work, but there were no orders or documentation to support these interventions. Interviews with the Director of Nursing (DON) and other staff revealed that the care plan was not updated from a previous admission, and the process for verifying and updating care plans was not adequately followed. Another resident's care plan failed to address hospice services despite the resident being admitted to hospice care. The care plan mentioned a terminal prognosis related to Alzheimer's disease but did not include goals or interventions for hospice care. The collaborative care plan in the hospice binder outlined the hospice services to be provided, but this information was not incorporated into the resident's care plan. Interviews with staff, including the MDS Coordinator, indicated that the care plan should have been updated to reflect hospice services and coordination of care, but this was not done in a timely manner. The lack of coordination and communication between facility staff and hospice providers was evident, as the care plan did not reflect the necessary hospice services. The facility did not have a policy in place to ensure coordination of care between the facility and hospice providers, leading to gaps in the care plan. The DON acknowledged that the care plan should have included hospice services to ensure proper communication and care delivery by the direct care staff.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to implement pressure ulcer treatment orders and prevention measures for a resident, leading to potential wound deterioration or the development of avoidable pressure ulcers. The resident, who was admitted with diagnoses including dementia, venous insufficiency, muscle weakness, and peripheral vascular disease, was at risk for pressure ulcers. Despite having a care plan that included floating heels and following treatment orders, the facility did not ensure these measures were consistently implemented. A wound was identified on the resident's left outer foot, but the treatment order was not correctly entered into the electronic medical record (EMR) system, resulting in the treatment not being scheduled or documented as performed. The wound was later noted to be healed, but there was no documentation of the treatment being administered. Additionally, the Infection Preventionist/Wound Care Nurse admitted to not completing any assessments of the wound, which was a deviation from the typical protocol. Furthermore, the resident was observed multiple times without heel protectors or floated heels, despite having an order for heel protectors to be used as tolerated. Staff members confirmed that they had not been instructed to apply heel protectors or float the resident's heels, and no heel protectors were found in the resident's room. This lack of adherence to the care plan and treatment orders contributed to the deficiency identified in the facility's care practices.
Failure to Document and Justify PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medications when a resident was administered two separate doses of psychotropic medications without any documented clinical need. The resident, who had severe cognitive impairment and was prescribed antipsychotic medication, was given Lorazepam and Haloperidol on the same day. The Treatment Administration Record indicated that Lorazepam was administered and noted as effective, yet Haloperidol was also given shortly after without any documented behaviors of agitation or restlessness. Interviews with the Registered Nurse and the Director of Nursing revealed that staff should have documented the resident's behaviors and justification for the use of PRN medications in the progress notes. They also stated that if the initial dose was effective, a second dose should not have been administered. The lack of documentation and the unnecessary administration of a second dose of medication were identified as inappropriate actions, leading to the deficiency.
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.
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What surveyors actually found near you
We read the 742 citations issued within 25 miles in the last 12 months — including the 18 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 Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Kansas City, Llc | 2.1 mi | ★★★★★ | 11 | 0 |
| Parkview Healthcare | 3.4 mi | ★★★★★ | 6 | 1 |
| Mccrite Plaza At Briarcliff Skilled Facility | 3.6 mi | ★★★★★ | 3 | 0 |
| Linden Woods Village | 4.4 mi | ★★★★★ | 17 | 0 |
| Pleasant Valley Manor Care Center | 4.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.