Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Quail Run Health Care Center during CMS and state inspections, most recent first.
Failure to Maintain Dignity During Meals: A resident with cognitive impairment, dementia, and incontinence was observed eating in a wheelchair next to a urine-soaked bed while without pants or an incontinent brief, and several residents were observed being fed in the dining room by staff who were standing rather than seated at eye level. Staff interviews confirmed that eating next to a soiled bed and standing while assisting residents with meals was undignified.
Delayed Reconciliation of Discharged Resident Funds: The facility failed to reconcile and return resident funds within the required timeframe for six residents with outstanding credit balances after discharge. The BOM said an accounting system change caused delays, and several accounts remained unresolved because TPL forms were not submitted at discharge or corporate approval was still pending. The BOM, Corporate Accountant, and Administrator stated discharged resident accounts are expected to be reconciled within 30 days.
Failure to provide required Medicare coverage and non-coverage notices for two residents. EMR review showed SNFABN/NOMNC-related paperwork was given after Part A coverage had already ended, and both residents were unable to appeal the Medicare A discharge. The SSD said residents should be notified before loss of coverage, and the Administrator was unsure why the SNFABN was not completed before services ended.
Unsafe and unhomelike conditions were observed throughout the facility, including chipped flooring and missing baseboards in resident rooms, a worn toilet seat, and cracked windows in the dining room and a resident room. A resident was not allowed to choose a dining seat, another resident received a PB&J sandwich in a plastic bag without a plate, and the North hall shower room remained out of service because of a broken handle for an extended period. Staff and admin acknowledged the long-standing disrepair and the impact on meal service and shower access.
Incomplete and conflicting care plans for safety, wandering, meal support, and depression: A resident with cognitive impairment, hemiplegia, incontinence, and diabetes had a care plan that listed a call light and Dysem intervention, but observations showed the call light out of reach and Dysem missing. Another resident’s care plan contained conflicting discharge and self-catheterization information without matching MD orders. A third resident with severe cognitive impairment and prior wandering history had no current wandering plan or order for a wander guard despite being observed with one during meals. A fourth resident with depression had no specific psychosocial or activity interventions, and said he or she felt forgotten.
Incomplete perineal care was observed for three dependent residents with incontinence and significant medical and cognitive impairments. Staff reused a disposable wipe while cleaning bowel movement from one resident, and for two other residents staff did not separate and clean all skin folds, did not clean all areas touched by urine, and did not clean the buttocks. Interviews with CNAs, an Activity Director, and the DON confirmed the care provided did not match expected perineal care practices.
Lack of competency training for licensed nurses. The facility had no annual training records for licensed nurses and did not provide a policy for nurse competencies. An LPN reported completing online in-services in several areas, including dementia care, abuse/neglect, infection control, communication, catheter care, peri care, and transfers, but said no competencies were completed. Another LPN gave a similar account, and the RNC stated none of the licensed nurses had completed competencies. The DON said licensed nurses should have been doing competency skills during orientation.
Medication Labeling and Dating Deficiencies: An opened bottle of Lorazepam for a resident was not dated, four house stock Levemir insulin pens were not labeled to show ownership, and an opened bottle of house stock OTC melatonin was also missing an open date. LPNs, CMTs, and the DON stated these items should have been labeled or dated when opened, and the facility did not provide a policy for labeling and dating medications.
Food was served at improper temperatures and meal substitutes were limited. Residents reported cold coffee, lukewarm breakfast items, tough meat, and room trays that arrived barely warm, while others said the only substitute commonly offered was a PB&J sandwich. Surveyors observed multiple batches of French toast held on the steam line without temperature checks, with the final tray showing French toast at 113.5 degrees and sausage at 105.2 degrees; the French toast was soggy and lacked flavor, and PB&J sandwiches were stored in an open container on a counter.
Food service staff failed to follow basic food safety practices, including proper hand hygiene, labeling, expiration monitoring, and temperature checks. Surveyors observed staff changing gloves without washing hands, multiple expired and undated food items in refrigerators and freezers, missing temp log entries and thermometers, and cooked foods such as oatmeal and French toast being moved or served without required temp checks. The DM and Administrator both acknowledged the expected practices for glove changes, food labeling, leftover limits, and food temp monitoring.
A resident with schizophrenia, bipolar disorder, depression, anxiety, obesity, and a history of significant behavioral and psychiatric issues was admitted after a preadmission review deemed the individual appropriate for care, with a care plan noting anger, threats, suicidal thoughts, and need for 2-person assistance. Nursing notes described escalating anxiety, frequent requests for hospice, excessive call light use, attempts to pull staff into bed, and an episode involving chest pain, suicidal/homicidal statements, and object throwing that led to EMS transport to a hospital. After the hospital treated the resident and sought to return the individual, facility social services informed the hospital and the guardian that the resident would not be accepted back, and the Administrator cited behavioral concerns and need for psychiatry as reasons; however, the facility failed to document in the medical record any reason why the resident’s needs could not be met at the time of attempted return, contrary to its own transfer/discharge policy.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving three residents. One resident with cognitive impairment was not assisted during a meal, leading to unsanitary eating conditions. Another resident wore stained clothing and was not offered a change, while their meal was also compromised by flies. A third resident expressed dissatisfaction with being addressed by nicknames, which staff continued to use despite the resident's preferences.
The facility failed to ensure call lights were within reach for two residents with severe cognitive impairment. Observations showed call lights on the floor, inaccessible to the residents, despite staff entering and exiting their rooms. The DON confirmed the expectation for call lights to be within reach at all times.
The facility failed to address and communicate resident council concerns, as meeting minutes showed unresolved issues like laundry problems, cold food, and cleanliness. Ten residents were unaware of the grievance process, and interviews revealed a lack of follow-up on grievances, indicating a breakdown in communication and accountability.
The facility failed to invoke the Durable Power of Attorney for a resident with severe cognitive impairments before allowing them to sign an OHDNR form. Additionally, the facility did not document another resident's code status, despite their intact cognitive skills and multiple diagnoses. Staff interviews confirmed that these deficiencies were against facility policy, which mandates proper documentation and respect for residents' treatment preferences.
The facility failed to maintain a sanitary and comfortable environment, with observations of unclean floors, sticky bathroom surfaces, and persistent urine odors in several areas. Maintenance issues included missing call light cords, a difficult-to-open dining room door, and a lack of backflow preventers on shower hoses. Interviews revealed a lack of awareness and communication regarding necessary repairs and cleaning duties, with high staff turnover contributing to the problem.
The facility failed to ensure that ten out of eleven residents knew who the Grievance Official was and how to file a grievance. Despite having a grievance policy, the residents were not informed about their rights or the grievance process, as evidenced by the lack of discussion in resident council meeting minutes. Interviews with staff revealed that the Activity Director and Administrator did not effectively communicate this information to the residents.
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. One resident's care plan only addressed a fall, lacking coverage for obesity, urinary incontinence, and diabetes. Another resident's care plan did not include their code status, and a third resident's care plan failed to address their dialysis needs. The facility also lacked a care plan policy.
The facility failed to update care plans quarterly for two residents, leading to deficiencies in care management. One resident's care plan lacked updates for verbal behaviors, while another resident was not invited to care plan meetings. Staff interviews revealed inconsistencies in inviting residents and maintaining documentation.
The facility failed to obtain a physician's order for a resident's dialysis and did not properly monitor low air loss mattress settings for two residents. One resident lacked a care plan addressing dialysis, while two others had mattresses set incorrectly, with no physician's orders or proper documentation. Staff interviews revealed inconsistencies in monitoring and knowledge of correct settings.
The facility failed to provide adequate perineal care and maintain personal hygiene for several residents, leading to deficiencies in care. Observations revealed improper cleaning practices and inconsistent shower schedules, affecting residents' well-being. A resident was found in a saturated incontinence brief with skin issues, indicating a lack of timely care.
The facility did not ensure that three CNAs completed required competencies upon hire and annually. The Administrator could not find competency records for these CNAs and acknowledged that competencies were not being completed as expected. Additionally, the facility lacked a policy for CNA competencies.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist, affecting three residents. A resident with severe cognitive impairment did not have documented reviews after an attempted dosage reduction. Another resident had no physician response to a pharmacist's recommendation on Haldol use. A third resident's care plan noted risks from psychotropic drugs, but physician notification of recommended dose reductions was lacking.
A LTC facility had a medication error rate of 26.67%, affecting three residents. Errors included improper blood sugar testing, use of expired insulin, incorrect administration of artificial tears, and improper mixing of Metamucil and Miralax. Additionally, Flonase nasal spray was administered incorrectly, with only one spray given instead of two.
The facility failed to maintain a sanitary kitchen environment, with observations of dirt, dust, and broken tiles, and lacked a policy for food storage and sanitation. Improper food handling was noted, with raw chicken left in water without running water and dirty dishes on the clean rack. Staff interviews revealed unmet expectations for cleanliness and repair.
The facility failed to maintain an effective pest control program, leading to a fly infestation affecting all 56 residents. Flies were observed landing on residents and their food in rooms and dining areas. Despite starting a new pest control program, the facility did not provide a pest control policy, and flies were entering through a door gap. The Maintenance Director and Administrator acknowledged the issue and were working with an outside service to address it.
A significant medication error occurred when an LPN administered expired Insulin Lispro to a resident with diabetes mellitus. The insulin was used despite being past its expiration date, as confirmed by the DON. The facility lacked a policy for insulin administration, contributing to the error.
The facility failed to ensure the Dietary Manager had the necessary skills and competencies to manage food and nutrition services. The DM, hired without prior food service training or certification, only had a Food Handler Certificate and lacked managerial experience. Despite working as a dietary aide, the DM had not completed the required dietary manager's course. Interviews with the DM, RD, and Administrator indicated that training was pending, and there was an expectation for the DM to be knowledgeable about kitchen regulations.
Facility staff failed to follow hand hygiene protocols while providing care to a resident with severe cognitive impairment and incontinence. Staff members entered the resident's room, donned gloves, and performed personal care tasks without washing their hands, despite facility policies requiring hand hygiene before and after resident contact and glove changes.
Failure to Maintain Dignity During Meals
Penalty
Summary
The facility failed to treat residents with dignity and respect during dining. Resident #24 had a Quarterly MDS dated 02/12/2026 showing mild cognitive impairment, moderate assistance needs for toileting, hygiene, and lower body dressing, frequent bowel and bladder incontinence, and diagnoses including schizophrenia, Alzheimer's dementia, overactive bladder, and urinary incontinence. The care plan dated 03/17/2026 identified the resident as dependent on nursing staff for assistance with all ADLs. On 03/24/2026 at 08:35 A.M., the resident was observed in a wheelchair in the room without pants, underpants, or an incontinent brief, with the bed and linens saturated with urine. Later that morning, the resident was observed sitting next to the soiled bed with a strong urine odor present, and the resident's eaten meal tray was on the bedside table next to the bed while the resident consumed the meal in that setting. The facility also allowed staff to stand while assisting residents with meals in the dining room. During observation from 12:51 P.M. through 1:15 P.M. on 03/24/2026, RN C, NA B, and NA A were observed standing while feeding Resident #1, Resident #8, Resident #22, and Resident #42. Staff interviews stated that residents should not eat next to a soiled bed and that staff should be seated at eye level when assisting residents with meals. The ADON, Activities Director/CNA, LPN A, LPN B, and the DON all stated that residents should not be fed while staff are standing and that staff should be seated to maintain eye contact and interact with residents.
Delayed Reconciliation of Discharged Resident Funds
Penalty
Summary
The facility failed to provide personal funds and a final accounting within 30 days after discharge for six residents. Review of the Accounts Receivable Aging Report dated 3/24/26 showed outstanding credit balances for Resident #11, Resident #63, Resident #64, Resident #65, Resident #66, and Resident #67, with discharge dates ranging from 5/27/23 through 1/19/25. The balances included private pay and patient liability account credits, such as $176.38 for Resident #11, $2,697.40 for Resident #63, $923.68 for Resident #64, $885.24 for Resident #65, $26.05 for Resident #66, and $717.08 for Resident #67. During interview, the Business Office Manager stated the facility changed accounting systems in July 2024, which caused reconciliation delays with discharged resident accounts. The BOM also stated that Resident #11 was reviewed and Medicare was informed of the outstanding credit balance through a TPL form dated 3/25/26, while Resident #63 had no TPL form submitted at discharge and the corporate office had been notified of the balance on 12/8/25 without response. The BOM said Resident #64, Resident #65, Resident #66, and Resident #67 each had requests sent to the corporate office for approval or TPL submission, and the BOM, Corporate Accountant, and Administrator all stated that discharged residents' accounts are expected to be reconciled within 30 days.
Failure to Provide Medicare Coverage and Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A services, and failed to provide a Notice of Medicare Non-Coverage (NOMNC, CMS-10123) for two sampled residents, Resident #39 and Resident #62. Review of Resident #62's EMR showed Medicare Part A coverage ended on 01/04/2026, the SNF/ABN form was provided to the resident, and the resident signed the form on 01/05/2026; the record also stated the resident was unable to appeal the Medicare A discharge. Review of Resident #39's EMR showed Medicare Part A coverage ended on 02/16/2026, the SNFABN was provided to the resident/representative, and the form was signed on 02/26/2026; the record also stated the resident or representative was unable to appeal the Medicare A discharge. During interview, the Social Services Designee stated that weekly interdisciplinary team meetings are used to determine which residents will lose covered days soon and that residents should be notified prior to loss of coverage, while the Administrator stated SNFABNs are completed by Social Services and was not sure why it was not completed prior to the end of services/coverage.
Unsafe and Unhomelike Conditions in Resident Rooms, Dining Room, and Shower Area
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment when multiple resident areas were observed in disrepair. Resident #18, who was cognitively intact, used a walker, and had diagnoses including repeated falls, a right artificial hip, and hypertension, was observed with chipped flooring near the bed and bathroom and no baseboards in the room. The resident stated the floor needed to be fixed because he/she had stubbed a toe on the chipped flooring, and said the baseboards had been missing since admission. The Maintenance Supervisor stated a rehab project had started in November 2025 and that all baseboards had been removed from resident rooms and bathrooms, but completion had not been provided by administration. Resident #11, who was cognitively intact and had diagnoses including depression, psychotic disorder, and schizophrenia, was observed with no baseboards around the entire room, including the bathroom, and a toilet seat with the white finish worn away and underlying material exposed. The resident stated the baseboard had been removed about a year earlier when the room was painted and said the toilet seat did not bother him/her. The Administrator in Training stated that if the white finish had worn away and underlying material was exposed, the toilet seat should be replaced, and that baseboards had been missing from some rooms for about a year. The dining room environment also showed disrepair and lack of homelike conditions. A large crack was observed in the glass on the dining room door leading to the patio, and a resident stated the window had been cracked since admission and that he/she would not touch it because of fear it might break. Resident #52, who had no cognitive impairment and diagnoses including arthritis, diabetes, and depression, said he/she wanted curtains open during the day but did not want outsiders looking in; observation showed windows with heavy curtains drawn shut and a window with multiple cracks and clear tape. Resident #29, who was cognitively intact, said he/she had no choice where to sit in the dining room because seats were assigned and he/she could not sit with a friend, which made him/her frustrated and mad. Meal service and shower access also reflected the cited deficiency. Resident #28, who had aphasia, stroke, dementia, anxiety disorder, depression, and seizure disorder, was offered a peanut butter and jelly sandwich and it was delivered in a plastic bag without a plate. Observation also showed no drinks, condiments, place settings, napkins, silverware, decorations, or centerpieces in the dining room at the start of lunch, and dirty dish carts were stored in the dining room near residents eating. On the North hall, the small shower room was observed unable to be used because of a broken shower handle. An LPN stated the small shower had been broken for over a year and that having only one functioning shower room made it difficult to get all residents showered in a timely manner. The Administrator in Training stated the handle had been broken for approximately a year and a half and that other maintenance projects had been placed ahead of fixing it.
Incomplete and conflicting care plans for safety, wandering, meal support, and depression
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for multiple residents. For Resident #8, the quarterly MDS dated 02/12/2026 showed moderate cognitive impairment, bowel and bladder incontinence, maximum assist with transfers related to hemiplegia, and diagnoses including heart failure, stroke, and diabetes mellitus. The care plan dated 02/06/2026 included that staff were to ensure the call light was within reach and that Dysem was placed in the wheelchair, but it did not include goals or interventions to prevent skin breakdown related to incontinence or immobility. Observations on 03/24/2026, 03/25/2026, and 03/26/2026 showed the call light out of reach or attached where the resident could not reach it, and Dysem was not in the wheelchair. For Resident #10, the comprehensive MDS showed the resident was cognitively intact and independent with mobility, ambulation, and ADLs, with diagnoses including bipolar disorder, cancer, heart disease, and high blood pressure. The care plan dated 02/26/2026 contained conflicting information, stating the resident was unable to make sound decisions or live independently, while also stating the resident was to be satisfied with current living arrangements and wished to be discharged to the community upon successful completion of treatment. The care plan also stated the resident was performing intermittent self-catheterization twice daily with minimal staff assist, but the physician order set dated 03/24/2026 had no orders for intermittent catheterization by staff or resident. For Resident #37, the quarterly MDS showed severe cognitive impairment, wandering behavior not displayed, and supervision with intermittent assist required for meal intake, with diagnoses including cancer, pneumonia, tremors, and hearing loss. The care plan dated 12/02/2025 stated the resident often wandered and had exit-seeking behaviors, but the current record reviewed had no plan of care for wandering or exit-seeking behavior and no interventions indicating the resident needed assistance with meals in the hallway. Observations on 03/24/2026 and 03/25/2026 showed the resident being assisted with meals at the south nurse's station with a wander guard bracelet in place, while the physician order set dated 03/25/2026 had no order for a wander guard. For Resident #52, the comprehensive MDS showed no cognitive impairment, dependence for mobility and transfers, and diagnoses including arthritis, diabetes, and depression. The care plan dated 03/06/2026 stated the resident was at risk for depression and grieving loss of independence, but it contained no specific interventions, goals, activities, or psychosocial interventions for depression and no documented preferences such as food, activities, rising time, books, or television. The resident stated he or she felt forgotten and said staff provided activity and puzzle books only intermittently.
Incomplete Perineal Care Provided to Dependent Residents
Penalty
Summary
The facility failed to ensure proper perineal care was provided to three residents who were dependent on staff for activities of daily living. The deficiency was identified through observation, interview, and record review and involved residents with conditions including cognitive impairment, incontinence, stroke, schizophrenia, paraplegia, quadriplegia, neurogenic bladder, depression, and mobility deficits. The facility policy on perineal care required cleansing of the perineal and rectal areas in a specific manner, and the policy did not address the use of disposable cleansing wipes. For one cognitively intact resident who required assistance with toileting and dressing and was occasionally incontinent of bowel and urine, staff were observed providing perineal care while the resident’s perineal area appeared red from moisture. A CNA/NA used a disposable cleansing wipe to clean bowel movement off the resident and folded the same wipe to clean more bowel movement off the resident. During interviews, staff stated disposable cleansing wipes should not be folded and reused during perineal care, and the DON confirmed wipes should not be folded and reused when cleaning bowel movement off a resident. For a second resident who was severely cognitively impaired, dependent for toilet use, dressing, personal hygiene, and transfers, and always incontinent of bowel and bladder, staff transferred the resident from a Broda chair to bed and performed peri care. The CNA and Activity Director wiped each side of the groin but did not separate and clean all skin folds, did not clean all areas where urine had touched, and did not clean the buttocks. For a third resident who was dependent for toilet use, personal hygiene, and transfers and frequently incontinent of urine, staff transferred the resident from a motorized wheelchair to bed and performed peri care, but used the same area of a wipe to clean different areas, cleaned the buttocks and groin incompletely, and did not separate and clean all skin folds. Staff interviews and the DON confirmed that all skin folds and all areas touched by urine should have been cleaned and that the same area of a wipe should not be used to clean different areas of the skin.
Lack of Competency Training for Licensed Nurses
Penalty
Summary
The facility failed to ensure nurses and nurse aides had the appropriate competencies to care for residents and maintain the highest practicable physical well-being of the residents because no annual training records were found for licensed nurses. The facility census was 55, and no policy was provided for competencies for licensed nurses. During interviews, an LPN who had worked at the facility for about three weeks said he/she had completed online training in dementia care, abuse/neglect, infection control, communication, catheter care, peri care, and transfers, and remembered an in-service on gait belt training, but had not completed any competencies. Another LPN who had worked at the facility for about four or five months reported completing computer in-services on abuse/neglect, infection control, communication, dementia care, behaviors, transfers, catheter care, and peri care, but also had not completed any competencies. The RNC stated the facility had not had any of the licensed nurses do any competencies, and the DON said the licensed nurses should have been doing competency skills during orientation.
Medication Labeling and Dating Deficiencies
Penalty
Summary
Drugs and biologicals stored in the North medication room were not labeled and dated in accordance with accepted professional principles. During observation and interview on 03/25/26, Resident #16 had an opened bottle of Lorazepam 2 mg/ml that had been filled on 2/13/26, and the box stated it should be discarded 90 days after opening, but the bottle was not dated when opened. In the same medication room, four Levemir insulin pens were found in a clear plastic cup without a pharmacy label to show whether they were house stock or belonged to a resident. LPN A stated the Lorazepam should have been dated when opened and that the insulin pens should have had a pharmacy label on them. An additional observation on 03/26/2026 found the south medication cart contained an opened bottle of OTC 3 mg melatonin without a date showing when the bottle was opened. CMT B, CMT A, LPN B, LPN C, and the DON each stated that house stock OTC medications should have the date written on the bottle indicating the day it was opened. The facility did not provide a policy for labeling and dating medications.
Food Served at Improper Temperatures and Limited Meal Alternatives
Penalty
Summary
Facility staff failed to ensure prepared food items were served at a safe and appetizing temperature, failed to monitor the internal temperature of hot foods held on the steam table, failed to offer a variety of meal substitutions, and failed to use preparation and hot storage methods that preserved the palatability of food items. The facility policy required proper hot and cold temperatures during food distribution and service and stated that temperatures of foods held in steam tables were to be monitored throughout meal service, but the policy did not include required serving temperatures to residents. The census was 55. Resident #57, who was cognitively intact and had diagnoses including dementia, depression, and psychotic disorder, reported that coffee was cold, that staff brought three half-filled mugs of lukewarm coffee instead of filling a large insulated cup, that breakfast milk was insufficient for cereal, and that French toast and sausage were lukewarm. Resident #11, who was cognitively intact and had diagnoses including depression, psychotic disorder, and schizophrenia, reported that meat, especially pork, was tough, that the only substitute commonly offered was a peanut butter and jelly sandwich, that there were very few fresh alternatives, and that some food was too hot to eat. Resident #18, who had moderate cognitive impairment and diagnoses including obstructive uropathy, diabetes, and depression, reported that food was cold about half the time and that there were very few alternative options unless a peanut butter and jelly sandwich was desired. Resident #4, who was cognitively intact and had diagnoses including obstructive uropathy and diabetes, reported that meals delivered to the room were barely warm and often had to be reheated before eating. Observation and record review showed that the only alternate food items available for meals were deli meat sandwich, grilled cheese, peanut butter and jelly sandwich, chips, or cottage cheese, and residents were observed being offered peanut butter and jelly sandwiches as the only substitute option. In the kitchen, peanut butter and jelly sandwiches made the prior day were stored in an open plastic container on a counter with a use-by date four days after they were made. During breakfast preparation, multiple batches of French toast were placed on the steam line in a metal container with parchment paper between batches, the oven was not used as a holding area even though it was empty, and no temperatures were taken for the third and fourth batches when completed. At the end of service, the test tray showed French toast at 113.5 degrees and sausage patty at 105.2 degrees, and the French toast was described as soggy, lukewarm, and lacking cinnamon flavor while the sausage was cold to the taste. The DM stated that the French toast was soggy because the oven was not used to keep it hot and free from condensation, that spices should be measured exactly, and that food temperatures should be taken before service and for each batch. The Administrator stated that sausage patties served at 105 degrees were too cold, that temperatures should be taken before service and before the last tray is served, and that alternate food items should be made to order rather than pre-made or served in a plastic bag.
Food Safety Deficiencies in Storage, Hand Hygiene, and Temperature Monitoring
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety. During kitchen observations, surveyors found improper hand hygiene practices, including staff changing gloves without washing hands after handling food and after leaving and returning to the kitchen. The Dietary Manager stated that gloves should be changed whenever staff leave the kitchen or become soiled, and that hands should always be washed between glove changes. The Administrator also stated that kitchen staff should wash their hands between glove changes. Surveyors observed multiple food storage and labeling problems in the kitchen, dry storeroom, vestibule refrigerators, main kitchen refrigerator, and freezer. These included missing temperature log entries for refrigerators and freezers on multiple shifts and dates, a missing refrigerator thermometer, expired tea, expired chicken salad spread, expired sausage, expired chicken pot pie, expired rice pilaf, and expired pimento cheese spread. Other items were improperly labeled or undated, including meat defrosting in pans without labeling, a freezer item of ice cream not labeled or dated, and strawberries with mold and no date. The Dietary Manager stated expired items should be discarded when expired, leftovers are good for three days, and each refrigerator and freezer should have a thermometer and daily temperature checks. Surveyors also observed food preparation and service temperature issues. Oatmeal was transferred to the steam line without a temperature check, and trays were loaded onto hall carts without temperatures being taken at the steam line. French toast was observed in one batch with a temperature check of 190, but other batches were not documented as checked when completed. The Dietary Manager stated food temperatures should be taken right before serving and when foods are completely cooked, including each batch of French toast. The Administrator stated temperatures should be taken before meal service and at the last tray served, and that food should be temperature checked prior to going to the steam line.
Failure to Document Justification for Refusing Resident Readmission After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return from the hospital without a documented reason in the medical record explaining why the resident’s needs could not be met. Facility policy stated that when a resident is sent to an acute care setting, it is considered a transfer with an expected return, and that if the facility does not permit a resident’s return based on inability to meet needs, the facility must notify the resident/representative in writing and document the reason in the record. The policy also required that discharge decisions after an emergency transfer be based on the resident’s status at the time of attempted return, and that nursing notes include documentation of appropriate orientation and preparation prior to transfer or discharge. The resident involved had a PASRR dated several years prior showing manic and depressive episodes, serious functional problems, a history of intense psychiatric treatment, frequent crisis hotline calls with threats of self-harm, difficulty getting along with others, and a need for redirection. The preadmission packet and care plan identified diagnoses of anxiety, diabetes, schizophrenia, bipolar disorder, depression, obesity, and behaviors including becoming angry quickly, making threats, suicidal thoughts without a specific plan, risk for aggression, anxiety, irritability, difficulty getting along with others, and a need for two staff for care due to size and behaviors. The facility’s DON reviewed the preadmission packet and deemed the resident appropriate for admission, and the resident was admitted with the Public Administrator as guardian. Nursing notes documented that after admission the resident was very anxious, repeatedly approached the nurses’ station, requested hospice be called, used the call light frequently for minor issues, attempted to pull staff into bed, and required care in pairs. On the day of transfer, the resident returned from a smoke break, again requested hospice, reported having a mental and physical crisis, complained of chest pain radiating down the left arm, and stated an intention to harm self and everyone around. EMS was called, the resident began throwing things, EMS de-escalated the situation, and the resident was transferred to a hospital. Subsequently, the hospital social worker and the Public Administrator reported that facility social services stated the resident would not be accepted back and delivered a letter declining readmission, while the Administrator stated the facility would not allow return because the resident needed psychiatric evaluation and she felt other residents would not be safe. There was no documented reason in the resident’s medical record at the facility explaining why the resident’s needs could not be met upon attempted return, despite the facility’s decision not to readmit the resident.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving three residents. One resident, who had severe cognitive impairment and required assistance with daily activities, was not properly assisted during a meal. The resident was seated too far from the dining table, resulting in food falling onto the table and their lap. Despite the presence of staff, the resident was left to eat food directly off the table, which was also being landed on by flies, without any assistance or intervention from the staff. Another resident, also with severe cognitive impairment, was observed wearing stained clothing and was not offered a change of clothes by the staff. This resident's meal was also affected by flies, yet the staff did not provide a new plate of food. The resident attempted to address the fly issue themselves by retrieving a fly swatter, but no staff intervention was noted to ensure the resident's meal was sanitary or to address their soiled clothing. A third resident, who had intact cognitive skills, expressed dissatisfaction with being addressed by nicknames such as "honey" or "sweetie," which they found disrespectful. Despite the resident's preference to be called by their given name or formal titles, staff continued to use these nicknames. Interviews with staff revealed a lack of awareness and adherence to the resident's preferences, indicating a failure to respect the resident's right to self-determination and dignity.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach while they were in their rooms. Resident #46, who had severe cognitive impairment and required assistance for mobility and personal care, was observed multiple times with the call light lying on the floor behind the bed, out of reach. Despite the resident's inability to reach the call light, staff members, including a CNA, entered and exited the room without providing the call light to the resident. Similarly, Resident #39, also with severe cognitive impairment and dependent on staff for personal care, was observed with the call light cord draped across the bed frame and the call light resting on the floor. Staff members assisted the resident with care but failed to ensure the call light was accessible. Interviews with staff, including the Director of Nurses, confirmed the expectation that call lights should be within reach at all times, which was not adhered to in these instances.
Failure to Address and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and communicate the concerns and recommendations of the resident council, as evidenced by the lack of follow-up on issues raised during council meetings. The resident council meeting minutes from August, October, and November indicated recurring issues such as laundry problems, call light response times, trash accumulation, missing clothes, cold food, and cleanliness concerns. However, the meeting forms did not document how these issues were resolved, who was responsible for addressing them, or whether the resolutions were satisfactory to the residents. This lack of documentation and follow-up suggests a failure in the facility's grievance process. Additionally, during a group interview, ten out of eleven residents reported being unaware of the grievance official and the process for filing grievances. They also expressed that they did not receive follow-up from the staff regarding their concerns. Interviews with the Activity Director and the Administrator revealed that while resident concerns were discussed in meetings, there was an expectation that grievances should be followed up on, which was not happening. This indicates a breakdown in communication and accountability within the facility's grievance handling process.
Failure to Properly Invoke DPOA and Document Code Status
Penalty
Summary
The facility failed to ensure that staff properly invoked the Durable Power of Attorney (DPOA) for a resident before allowing them to sign an Outside of Hospital Do Not Resuscitate (OHDNR) form. This affected one resident who had severe cognitive impairments, including dementia and traumatic brain injury, and was dependent on staff for daily activities. Despite these impairments, the resident was allowed to sign the OHDNR form without the activation of the DPOA, which should have been done given the resident's incapacity to make informed decisions. Additionally, the facility did not obtain advance directives for another resident's code status, which is crucial for determining whether the resident wished to have cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest. This resident had intact cognitive skills and multiple diagnoses, including cancer and congestive heart failure, but their care plan, physician order sheet, and face sheet did not address their code status. Interviews with staff, including the MDS/Care Plan Coordinator and the Director of Nursing, confirmed that the resident's code status should have been documented and care planned. The report highlights a lack of adherence to the facility's policy on advance directives, which mandates that residents' treatment preferences be documented and respected. Interviews with various staff members, including the Social Services Designee and the Administrator, revealed a lack of clarity and action regarding the residents' decision-making capacities and the necessary steps to ensure their rights and preferences were upheld. This oversight resulted in a failure to properly document and respect the residents' advance directives and code status preferences.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as evidenced by multiple observations of unclean and poorly maintained areas. Observations revealed dirt and debris on floors, sticky bathroom floors, and brown debris in toilet bowls in several rooms. Additionally, the shower room on the South Hall had broken floor tiles, a cracked light cover, and broken window blinds. The facility also had issues with call light cords being missing or too short in several bathrooms, and a dining room door that was difficult for residents to open. Furthermore, the South Hall and several rooms consistently smelled of urine over multiple days. Interviews with the Maintenance Supervisor and Housekeeping Supervisor highlighted a lack of awareness and communication regarding necessary repairs and cleaning duties. The Maintenance Supervisor was unaware of the need for backflow preventers on shower hoses and did not have work orders for missing call light cords. The Housekeeping Supervisor acknowledged high staff turnover and the need to get back on track with cleaning duties. The Administrator expressed expectations for a clean and odor-free facility in good repair, but these standards were not met, as evidenced by the observations and interviews.
Residents Unaware of Grievance Process
Penalty
Summary
The facility failed to ensure that ten out of eleven sampled residents who participated in a group meeting were aware of who the Grievance Official was and how to file a grievance. The facility's grievance policy, which was undated, outlined that residents have the right to voice grievances without fear of discrimination or reprisal and that the facility must make prompt efforts to resolve these grievances. However, during a group meeting, it was found that the majority of the residents did not know the identity of the Grievance Official or the process for filing a grievance. This lack of awareness was also reflected in the resident council meeting minutes, which did not indicate whether resident rights or grievance procedures were reviewed or discussed. Interviews conducted with facility staff revealed gaps in communication and education regarding the grievance process. The Activity Director, who had been in the position since September, was responsible for setting up resident council meetings but did not ensure that residents were informed about their rights or the grievance process. The Administrator acknowledged that residents should be aware of the Grievance Official and the procedure for filing grievances. Additionally, the Regional Quality Assurance Nurse mentioned addressing grievances with residents back in April, but this information did not seem to have been effectively communicated or retained by the residents.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #25, who had minimal cognitive deficit and required assistance for hygiene and transfers, only had a care plan addressing a fall, lacking a comprehensive plan for other needs such as obesity, urinary incontinence, and diabetes. Resident #18, with intact cognitive skills and multiple diagnoses including cancer and COPD, did not have their code status addressed in the care plan, physician order sheet, or face sheet, which was acknowledged as necessary by the MDS/Care Plan Coordinator and the Director of Nursing. Resident #49, who had severely impaired cognitive skills and required dialysis, did not have this critical aspect of their care included in their care plan. The MDS/Care Plan Coordinator and the Director of Nursing both confirmed that the care plan should have addressed the resident's dialysis needs. The facility also lacked a care plan policy, which contributed to these deficiencies, as evidenced by the absence of comprehensive care plans for the sampled residents.
Failure to Update Care Plans Quarterly
Penalty
Summary
The facility failed to review and update care plans quarterly for two residents, leading to deficiencies in their care management. Resident #36's care plan was not updated since May 2024, and it did not address verbal behaviors identified in the most recent MDS assessment. This resident had a mild cognitive deficit, Alzheimer's disease, urinary incontinence, and required assistance with daily activities. The lack of updates in the care plan indicates a failure to incorporate current assessments into the resident's care strategy. Resident #43's care plan conference summary from May 2024 was the only documentation available, and it did not indicate whether the resident was invited or attended the meeting. The resident, who had intact cognitive skills, upper extremity impairment, and was frequently incontinent, reported not being invited to any care plan meetings. Interviews with facility staff revealed inconsistencies in inviting residents and responsible parties to care plan meetings and maintaining documentation of these meetings. The Director of Nursing confirmed that care plans should be updated quarterly and as needed, but this was not adhered to in these cases.
Deficiencies in Dialysis Orders and Mattress Settings
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality care, as evidenced by the lack of a physician's order for a resident to attend dialysis. This deficiency affected one resident who had severe cognitive impairment and multiple diagnoses, including stroke, COPD, and diabetes mellitus. The resident's care plan did not address the need for dialysis, and there was no physician's order documented in the resident's records. Interviews with facility staff, including the MDS/Care Plan Coordinator, LPN, and DON, confirmed that the care plan should have included dialysis and that a physician's order was necessary. Additionally, the facility did not properly monitor the settings of low air loss mattresses for two residents. One resident, with moderately impaired cognitive skills and a history of pressure ulcers, had a mattress set incorrectly at 300 pounds, despite weighing significantly less. The resident's care plan did not include a physician's order for the mattress or its settings. Observations showed that the mattress settings were not adjusted according to the resident's weight, and staff interviews revealed a lack of documentation and knowledge regarding the correct settings. The second resident, with severe cognitive impairment and multiple diagnoses, also had a low air loss mattress set incorrectly at 230 pounds, despite weighing more. Similar to the first case, there was no physician's order for the mattress or its settings in the resident's care plan. Interviews with nursing staff indicated that while they were responsible for monitoring the mattress settings, there was no consistent documentation or understanding of the correct settings. The Regional QA nurse confirmed that a physician's order should guide the mattress settings based on the manufacturer's guidelines.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide adequate perineal care and maintain personal hygiene for several residents, leading to deficiencies in care. Observations revealed that staff did not clean all areas of the skin where urine or feces had touched, and they used the same area of a wipe to clean different areas, which is against proper hygiene practices. For instance, Resident #21, who was always incontinent of bowel and bladder and dependent on staff for personal hygiene, did not receive complete perineal care. Staff members were observed not separating and cleaning all areas of the skin, and they did not wash their hands between glove changes. Additionally, the facility did not ensure that residents received showers or bed baths as per their preferences and care plans. Resident #43, who required assistance due to hemiplegia, reported not receiving showers on scheduled days, which affected their sense of cleanliness and well-being. The facility lacked a dedicated shower aide, and the shower schedule was inconsistently followed, leading to some residents not receiving their showers as planned. This inconsistency was further exacerbated by a change in the facility's computer program, which disrupted the documentation of shower schedules. Resident #25, who required assistance for hygiene and was bound to a wheelchair, was found in a saturated incontinence brief with a strong odor of urine, indicating a lack of timely care. The resident's skin was dark red and had an open slit, suggesting prolonged exposure to moisture and inadequate care. Staff interviews confirmed that the resident had not been checked or cleaned since early morning, despite the expectation of providing incontinent care every two to three hours. The facility's failure to address these care needs highlights significant deficiencies in maintaining residents' personal hygiene and dignity.
Failure to Complete CNA Competencies
Penalty
Summary
The facility failed to ensure that three certified nurse aides (CNAs) completed required competencies upon hire and annually. The staff roster indicated that CNA E was hired on February 21, 2024, CNA D on August 21, 2023, and CNA C on April 15, 2024. During an interview, the Administrator admitted that she could not locate the competency records for these CNAs and acknowledged that competencies were not being completed as expected. The facility did not have a policy in place for CNA competencies, contributing to this oversight.
Failure in Monthly Drug Regimen Review and Physician Notification
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a comprehensive monthly drug regimen review for each resident, which included assessing for unnecessary medications, psychoactive medication management, and drug irregularities. This deficiency affected three residents, who did not receive appropriate medication reviews or physician notifications regarding the pharmacist's recommendations. For instance, Resident #4's records showed an attempted gradual dosage reduction for Trazodone and Zoloft, but no further drug regimen reviews were documented. The resident had severe cognitive impairment and was dependent on staff for daily activities, receiving multiple psychotropic medications for conditions such as depression and dementia. Similarly, Resident #51's records indicated that the pharmacist recommended a 14-day limit on Haldol prescriptions, but there was no documented response from the physician. This resident was at risk for side effects from antidepressant and antipsychotic use. Resident #1's care plan highlighted the risk of side effects from psychotropic drugs, yet there was no evidence that the physician was notified of the pharmacist's recommendations for gradual dose reductions of several medications. The Regional Quality Assurance Nurse confirmed that drug regimen reviews should be completed monthly and that the previous Director of Nursing did not consistently fulfill this requirement.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 26.67% with eight errors out of 30 opportunities. This affected three residents, including one who had their blood sugar checked improperly and was administered expired insulin. The Licensed Practical Nurse (LPN) involved did not allow the alcohol to dry completely before pricking the resident's finger and used insulin that was past its expiration date. Another resident received incorrect administration of artificial tears and a mixture of Metamucil and Miralax. The Certified Medication Technician (CMT) touched the resident's eyelid and eyelashes with the eye dropper and did not apply lacrimal pressure for the recommended duration. Additionally, the CMT mixed Metamucil and Miralax in the same cup with insufficient water, contrary to the instructions on the labels. A third resident was administered Flonase nasal spray incorrectly. The CMT did not shake the bottle, have the resident blow their nose, or close one nostril before administering the spray. Only one spray was given instead of the prescribed two. The CMT also improperly administered artificial tears by touching the resident's eyelid and eyelashes with the dropper and not applying lacrimal pressure for the recommended time.
Unsanitary Kitchen Conditions and Improper Food Handling
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, which had the potential to affect all residents. Observations revealed several unsanitary conditions, including a light switch covered in dirt, a vent above the hand washing sink covered in dust and debris, and food particles on the back-splash behind the stove. Additionally, the light in the dish-room was cracked, multiple tiles on the kitchen and dish room floors were broken, and there was a black substance on the wall behind the three-compartment sink. The facility did not have a policy addressing food storage, kitchen cleaning, and sanitation. Further observations and interviews highlighted improper food handling practices. Raw chicken quarters were found sitting in water in the middle compartment of the three-compartment sink without running water, a method instructed by the Dietary Manager. The chicken had been in the sink for an hour. Additionally, a pan from the clean dish rack was found with food debris, indicating it was not properly cleaned. Interviews with the Registered Dietitian and Maintenance Supervisor revealed expectations for cleanliness and repair were not met, and there was a lack of awareness regarding the necessary repairs and cleaning schedules.
Facility Fails to Control Fly Infestation Affecting Residents
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies within the premises, potentially affecting all 56 residents. Observations on multiple occasions revealed flies landing on residents and their belongings, particularly in their rooms and the dining area. During meal times, flies were seen landing on residents' food, and residents were observed swatting at the flies with their hands. Despite the presence of flies, residents consumed the food that the flies had landed on, indicating a lack of effective pest control measures. Interviews with the Maintenance Director and the Administrator highlighted that the facility had recently initiated a new pest control program. However, the Maintenance Director acknowledged that flies were entering the facility through a door gap by the gazebo exit door. Both the Maintenance Director and the Administrator agreed that residents should not have flies in their rooms or dining areas, nor should flies land on their food. The facility was in the process of working with an outside pest control service to develop a fly control program, but at the time of the survey, the facility did not provide a pest control policy when requested.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in a significant medication error involving the use of expired insulin. Specifically, a Licensed Practical Nurse (LPN) administered four units of expired Insulin Lispro to Resident #48, who had a physician's order for insulin administration based on a sliding scale for diabetes mellitus. The insulin vial used was opened and expired, yet it was still administered to the resident. During an interview, the Director of Nursing (DON) confirmed that staff should check insulin vials for expiration dates and should not use them if expired. The facility did not provide a policy for the administration of insulin, contributing to this oversight.
Inadequate Competency of Dietary Manager
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to effectively manage the food and nutrition services. The DM was hired on March 1, 2024, as a Food Service Manager but lacked prior food service training and did not hold any certification in food service management or as a dietary manager. The DM only possessed a Food Handler Certificate obtained on November 5, 2024, from Always Safe Food Company. Despite having worked as a dietary aide, the DM had no managerial experience and had not completed the required dietary manager's course. Interviews with the DM, Registered Dietitian (RD), and the Administrator revealed that the facility was in the process of initiating the DM's training, but it had not yet been completed. The RD and Administrator both expressed expectations that the DM should have completed the necessary training to manage the kitchen and be knowledgeable about all relevant regulations.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility staff failed to adhere to hand hygiene protocols during the care of a resident with severe cognitive impairment and multiple diagnoses, including stroke, heart disease, and schizophrenia. The resident was dependent on staff for personal hygiene and was incontinent of bowel and bladder. During an observation, two staff members, NA A and CNA D, entered the resident's room without performing hand hygiene. They proceeded to put on gloves without washing their hands and engaged in personal care tasks, including washing the resident's face and performing perineal care, without adhering to proper hand hygiene practices. NA A removed gloves and left the resident's room without performing hand hygiene, then returned with clean linens, again failing to wash hands before resuming care. Interviews with RN A and the Director of Nursing revealed that staff were expected to perform hand hygiene upon entering and exiting resident rooms, before and between glove changes, and when hands were visibly soiled. The failure to follow these protocols was observed during the care of the resident, indicating a deficiency in the facility's infection prevention and control program.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 68 citations issued within 25 miles in the last 12 months — including the 1 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 Cameron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cameron Nursing Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Sunset Home | 10.4 mi | ★★★★★ | 1 | 0 |
| Hill Crest Manor | 13.9 mi | ★★★★★ | 16 | 0 |
| Nick's Health Care Center | 15.6 mi | ★★★★★ | 13 | 1 |
| Oakridge Of Plattsburg | 16.5 mi | ★★★★★ | 16 | 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.