Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rocky Ridge Manor during CMS and state inspections, most recent first.
A Business Office Manager misappropriated resident funds by accepting cash payments for room, board, and private therapy, issuing receipts, and failing to deposit the full amounts into resident or facility accounts. One resident with significant neurologic impairments had multiple cash payments for rent and a large cash payment for private therapy that were only partially deposited, with thousands of dollars unaccounted for. Another cognitively intact resident with schizoaffective disorder was linked to a cash receipt for shoes that staff and the resident confirmed were never received, while a third resident with hemiplegia had numerous $50 withdrawals documented even as the resident was repeatedly told there was no money available for church tithes, snacks, or shoes. A fourth resident with psychiatric and mobility issues had about $2,000 in withdrawals recorded despite never requesting or using spending money. Staff reported that the manager was secretive about resident funds, frequently obtained witness signatures on ledgers after the fact or on blank forms, and that no one was auditing cash receipts against bank deposits, allowing the misappropriation to go undetected for an extended period.
Facility staff failed to fully investigate a sexual abuse allegation when a cognitively intact resident with schizophrenia, anxiety, and impulse disorder told the DON that a restorative nurse aide had been making the resident suck the aide’s breast and "play" with them. The DON documented the allegation and interviewed the resident and the accused RNA with a CMT present, but did not suspend the RNA, did not interview any other staff or residents, and did not complete or document a full investigation as required by facility policy. Multiple CNAs, RNs, the SSD, and the Administrator stated that such conduct would constitute sexual abuse and that the usual process would be to suspend the accused staff and conduct an investigation, yet the RNA continued working and no complete, timely investigation was documented.
A resident with schizophrenia, anxiety, impulse disorder, and documented behavioral issues, but assessed as cognitively intact, reported to the DON that a restorative nurse aide had been making the resident suck the aide’s breast and play with them. The DON had a CMT present as a witness, called the aide into the office, and the resident quietly repeated the allegation; the aide denied it and described a recent conflict after the resident urinated on the floor and was told to change clothes. Despite facility policy and staff interviews confirming that such an allegation constitutes sexual abuse and must be reported to the Administrator and DHSS within two hours, the DON did not report the allegation, and DHSS records showed no report was made.
A resident with cognitive impairment and psychiatric diagnoses was denied smoke breaks by the Social Services Director after exhibiting disruptive behavior during an outing. Staff interviews revealed confusion about residents' rights, with several staff members confirming that withholding smoke breaks as punishment is not permitted for residents who are their own decision-makers. The facility's actions were not consistent with its policy on resident rights, resulting in a failure to treat the resident with dignity and respect.
A resident with dementia and psychiatric disorders made two separate allegations of abuse, which were not reported to the state agency within the required timeframe. Although staff assessed the resident and found no evidence of injury, there was no documentation or confirmation that the allegations were reported to facility administration or DHSS as mandated. Staff interviews revealed confusion about reporting procedures and timeframes, and both the DON and Administrator acknowledged the incidents were not reported as required.
Staff did not fully investigate or document two abuse allegations made by a resident with dementia and psychiatric disorders. The facility failed to interview other staff or residents, did not suspend the accused staff as required by policy, and did not document protective measures during the investigation. Interviews revealed inconsistent understanding and application of abuse protocols among staff and administration.
A resident with a history of mental health disorders repeatedly engaged in sexually abusive and inappropriate behaviors toward other residents, including physical contact and explicit verbal comments. Despite ongoing incidents reported by staff and residents, the facility failed to update care plans or implement new interventions beyond 15-minute checks, leaving affected residents feeling unsafe and unprotected.
Staff failed to report multiple incidents of sexual abuse by a resident toward peers to the State Survey Agency within the required timeframe. Despite clear documentation of inappropriate sexual behaviors and staff awareness that such incidents constituted abuse, the required notifications were not made, in violation of facility policy and federal regulations.
The facility did not conduct and document annual performance reviews and competency evaluations for CNAs, as required. Two CNAs lacked documentation of yearly reviews despite being employed for over a year. The DON confirmed the absence of documentation, and the QARN noted the lack of a specific policy for annual competencies, which should include essential skills like catheter care and hand washing.
The facility failed to provide a meaningful activity program for its residents, with a lack of variety and consistency in scheduled activities. Many activities were canceled, and there was insufficient documentation of resident participation and preferences. Residents expressed dissatisfaction with the repetitive nature of activities, and staff interviews revealed a lack of awareness and communication regarding activity preferences.
The facility staff failed to maintain the ice machine and kitchen area in a sanitary condition, with observed buildup on the ice machine and unclean light fixtures, ceiling, and vents. Inconsistencies in cleaning schedules and unclear responsibilities among staff contributed to these deficiencies.
A resident with flaccid hemiplegia and severe cognitive impairment had their call light consistently placed out of reach, contrary to the care plan and facility policy. Staff interviews confirmed the expectation for call lights to be accessible, particularly on the non-affected side, but observations showed this was not adhered to.
A facility failed to complete the required PASARR screening for a resident with mental disorders before admission. The resident's care plan and MDS assessment indicated diagnoses of paranoid schizophrenia and anxiety disorder. The PASARR Level I screening submitted by the hospital was incomplete, and necessary corrections were not made by the facility. Interviews revealed that the MDS Coordinator, who was new and part-time, missed the correction request, and the facility lacked a written PASARR policy.
The facility failed to update care plans for two residents receiving hospice services. One resident with COPD and other conditions was on hospice, but this was not reflected in their care plan or MDS. Another resident with schizophrenia and other diagnoses was also on hospice, as documented in weekly summaries, but their care plan was not updated. Staff interviews confirmed the oversight, and the MDS Coordinator cited time constraints as a factor.
A facility failed to assist a dependent resident with peri-care following an episode of incontinence. The resident, who required substantial assistance for toileting hygiene, was not provided with peri-care by two CNAs after using the toilet. Interviews with staff confirmed that peri-care should be performed with each incontinence episode, but the CNAs did not follow this protocol, nor did they perform hand hygiene between glove changes.
A resident with an indwelling suprapubic catheter did not receive proper catheter care due to a nurse's failure to change gloves and perform hand hygiene during the procedure. The resident, with a history of urinary tract infections, required catheter care every shift. The nurse acknowledged forgetting to change gloves, and facility leadership confirmed the need for proper hand hygiene and glove changes during catheter care.
A hospice resident with severe pain was not provided timely pain management in a LTC facility. Despite frequent complaints and visible distress, staff failed to administer pain relief promptly. The resident's care plan included PRN medications and non-pharmacological interventions, but these were not effectively implemented. Staff interviews revealed communication gaps and a lack of adherence to pain management policies.
A facility failed to provide trauma-informed care for a resident with PTSD. The resident's PTSD diagnosis was not documented in the care plan, and staff were unaware of the resident's history and triggers. Despite the facility's commitment to managing PTSD, the care plan lacked necessary details, leading to inadequate care. Interviews revealed staff were not informed about the resident's psychological background, resulting in a lack of appropriate interventions.
The facility failed to maintain effective infection control during wound care for a resident with a stage 4 pressure ulcer and catheter care for another resident. The RN did not perform hand hygiene after changing gloves and improperly used PPE, such as pulling down the face mask during care. The DON and Administrator confirmed the expectation for proper hand hygiene and mask use.
Misappropriation of Resident Funds by Business Office Manager and Lack of Financial Oversight
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their money and belongings by the Business Office Manager (BOM A), in violation of the facility’s own Guidelines for Maintaining the Resident Trust Fund Account. The guidelines required full, complete, and separate accounting of each resident’s personal funds entrusted to the facility. Law enforcement records and facility financial documents showed that BOM A accepted cash payments from residents and responsible parties, issued receipts, and then failed to deposit the funds into the appropriate accounts, or used the funds for personal purposes. A probable cause statement from the county sheriff’s office documented missing cash receipts totaling $4,190.50, with $744 later returned by BOM A, and noted that BOM A admitted to taking multiple smaller cash amounts for personal use, including gas money, and $306 from one receipt. One resident with intracranial injury, epilepsy, quadriplegia, and pain had multiple cash payments for room and board recorded on receipts signed by BOM A that were not deposited into the facility’s petty cash or trust accounts for several months. Three separate cash payments of $248 each for room and board were not deposited when received; instead, a single later cash deposit of $744 was made by BOM A to cover those months. The same resident’s responsible party also paid $4,000 in cash for private therapy through the facility’s contracted therapy company, with a receipt signed by BOM A. Only $1,000 of that amount was deposited into the bank, and the remaining $3,000 could not be accounted for. BOM A later claimed to have placed $3,000 in the facility safe, but the Administrator and current BOM could not locate the money. The resident’s responsible party reported having consistently paid surplus rent in cash during the period when the facility later billed for unpaid surplus, and stated that BOM A had reassured them that the company likely had not yet posted the payments. Another cognitively intact resident with schizoaffective disorder, diabetes, gait unsteadiness, and a history of falls was linked to a cash receipt from a shoe store for two pairs of Skechers shoes totaling $120.33, paid in cash with BOM A’s name printed on the receipt and the resident’s name handwritten at the top. Staff interviews and a search of the resident’s belongings showed the resident did not own Skechers shoes, and the resident stated that only the Administrator had purchased shoes, which were not that brand. Multiple staff, including an RN and CNA, confirmed the resident never had Skechers shoes and that family typically purchased needed items. A third cognitively intact resident with hemiplegia, dysphagia following stroke, and adjustment disorder had a pattern of frequent $50 cash withdrawals documented on facility withdrawal reports over several consecutive months, all signed off during the period when BOM A was employed. After BOM A’s last day of employment, no further withdrawals were recorded. The resident and a family member reported that, on several occasions, when the resident requested money from their own account, BOM A told the resident there was no money available. The resident described being unable to obtain funds for church tithes, vending machine snacks, or replacement tennis shoes, and reported feeling ashamed and therefore not telling others. Staff corroborated that BOM A told the resident and staff there was no money for tobacco, leading staff to purchase tobacco for the resident, while the Administrator later found that $2,445 had been taken from the resident’s account over six to eight months and that the resident actually had a substantial balance. A fourth resident with schizoaffective disorder, bipolar disorder, difficulty walking, and arthritis had numerous $40–$50 cash withdrawals documented over several months, all signed by BOM A. However, the resident stated they never asked for money and did not know whether they had any funds. The Administrator reported that this resident stayed mostly in bed or went only to the dining room, never came to the business office, and never requested money, yet approximately $2,000 in withdrawals were recorded over eight months. Nursing and CNA staff confirmed that this resident did not go out of the facility, did not use vending machines, did not eat sweets, and never had or requested spending money. Multiple staff also reported that BOM A was secretive about resident money processes, often brought cash ledgers to staff at the end of the day for signatures as witnesses without the staff actually observing the resident receive cash or sign, and sometimes had staff sign blank ledgers. The Administrator acknowledged that no one was auditing the cash receipt book or comparing receipts to deposits and withdrawals, and that BOM A’s actions constituted misappropriation of resident property. A regional financial consultant and a police sergeant further confirmed that the Administrator should have been auditing accounts, that witnesses should have observed cash transactions before signing, and that BOM A admitted to stealing resident money, with law enforcement estimating approximately $4,100 stolen from residents and their responsible parties.
Failure to Fully Investigate Resident’s Sexual Abuse Allegation Against Staff
Penalty
Summary
Facility staff failed to complete and document a full investigation of an allegation of sexual abuse made by one cognitively intact resident against a restorative nurse aide (RNA). The resident, who had diagnoses including metabolic encephalopathy, schizophrenia, generalized anxiety disorder, impulse disorder, restlessness, agitation, and a documented history of cussing, yelling, agitation with staff and other residents, lying about staff behavior, and using manipulative tactics, reported to the DON that the RNA had been making the resident "suck his/her boob and play with him/her" and stated this had been occurring "for a while." The resident’s care plan also noted physical and verbal behavioral symptoms directed toward others and other behavioral symptoms. Despite this behavioral history, the allegation itself was clearly documented by the DON in a progress note. The facility’s abuse policy stated that each resident will be free from abuse, that all employees alleged to have committed abuse will be suspended immediately pending investigation, and that the facility will complete an investigation. In this case, the DON interviewed the resident and the accused RNA in the presence of a CMT as a witness. The resident repeated the allegation quietly with head down, and the RNA denied any inappropriate conduct, stating the resident had urinated on the floor, was told to change clothes, became angry, and threatened to get the RNA fired. The DON decided not to send the RNA home and instead instructed the RNA and resident to have no contact. No additional staff or residents were interviewed, and there was no documented, complete, and timely investigation of the allegation as required by policy. Multiple staff interviews confirmed that a staff member asking a resident to suck their breast or play with them would be considered sexual abuse and should be reported and investigated, with the accused staff typically suspended pending investigation. CNAs, RNs, the SSD, and the Administrator all characterized such conduct as sexual abuse and described that the usual process would include suspending the accused staff and conducting an investigation. The SSD reported that the DON told him about the allegation and that the RNA continued to work and was not suspended. The Administrator stated he was not informed that the resident had actually made the sexual abuse allegation, and when the DON’s note was read to him, he agreed it should have been reported as sexual abuse. Review of state records showed the facility did not provide a documented, complete, and timely investigation of the allegation of abuse, and the DON acknowledged not completing a full investigation beyond interviewing only the resident and the RNA.
Failure to Timely Report Resident’s Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse to the Administrator and to the state licensing agency (DHSS) within the required two-hour timeframe, as required by facility policy. The facility’s abuse policy states that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately, and no later than two hours when abuse or serious bodily injury is alleged. Review of DHSS records showed the facility did not report the allegation in question. Multiple staff interviews confirmed their understanding that an allegation of a staff member asking a resident to suck their breast or play with them constitutes sexual abuse and must be reported to the state within two hours. The resident involved had diagnoses including metabolic encephalopathy (acute), restlessness and agitation, acute pain due to trauma, schizophrenia, generalized anxiety disorder, and impulse disorder. The admission MDS indicated the resident was cognitively intact but had physical and verbal behavioral symptoms directed toward others and other behavioral symptoms occurring one to three days in the lookback period. The resident’s care plan documented a history of cussing, yelling, agitation with staff and other residents, lying about staff behavior or other residents, using manipulative tactics to gain attention or avoid certain actions, hitting objects and threatening to hit staff or others, and taking medications for schizophrenia, anxiety, and impulse disorder. On the date of the incident, the DON documented that the resident came to the DON’s office in the morning and stated that a restorative nurse aide (RNA) was making the resident suck the aide’s breast and play with the aide, and that this had been happening “for a while.” The DON brought in a CMT as a witness and called the RNA into the office, then asked the resident to repeat the accusation; the resident quietly repeated the allegation without looking at anyone. The RNA stated the resident had just left the therapy room after urinating on the floor, became angry when told to change clothes, and had said they would get the RNA fired. The resident denied this statement. The DON did not report the allegation to the state, stating that whether such conduct would be abuse would depend on the circumstances and that, in this case, the resident was upset with the RNA. The Administrator later stated they were not informed that the resident had actually made the specific sexual abuse allegation and, when the note was read to them, agreed it should have been reported as sexual abuse. DHSS records confirmed no report of the allegation was made.
Resident's Rights Violated by Withholding Smoke Breaks as Punishment
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner and allowed to exercise their rights, specifically regarding the withholding of smoke breaks as a form of punishment. The incident involved a resident with multiple diagnoses, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, and PTSD. The resident was noted to have moderate cognitive impairment and a history of verbal and physical aggression, requiring substantial assistance with activities of daily living. On the day in question, the Social Services Director (SSD) accompanied the resident to the social security office, where the resident exhibited disruptive behaviors, including yelling and making threats about the facility. Following these behaviors, the SSD withheld the resident's smoke breaks for the remainder of the day as a consequence. Interviews with staff revealed inconsistent understanding and application of residents' rights regarding the withholding of privileges such as smoke breaks. Several staff members, including CNAs, a CMT, and the DON, stated that it was against residents' rights to withhold smoke breaks as punishment, especially for residents who are their own legal decision-makers and do not have a guardian. Some staff believed that smoke breaks could only be withheld if a guardian had given explicit permission, but this was not the case for the resident involved. The DON and other staff confirmed that the resident was his/her own person and that the action taken by the SSD was not appropriate. The facility's policy on residents' rights emphasizes the right to a dignified existence, self-determination, and freedom from interference or reprisal in exercising those rights. The SSD's decision to withhold smoke breaks as a punitive measure was not in accordance with this policy, and staff interviews confirmed that this action was recognized as a violation of the resident's rights. The incident was attributed to a miscommunication and a lack of clarity among staff regarding the proper procedures for managing resident behaviors and upholding resident rights.
Failure to Timely Report Allegations of Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency, as required by both facility policy and federal regulations. Specifically, two separate allegations of abuse made by a resident were not reported to the Department of Health and Senior Services (DHSS) in a timely manner. In both instances, the Social Services Director (SSD) and other staff became aware of the allegations but did not document or ensure notification to facility administration or DHSS as required. The resident involved had a complex medical history, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, PTSD, and physical limitations requiring substantial assistance with activities of daily living. The resident reported to the SSD that two staff members were abusing them and claimed to have bruising, but no bruising was found upon assessment by the SSD and the charge nurse. On another occasion, the resident made further allegations of abuse in a public setting, but again, there was no documentation of notification to administration or DHSS. Interviews with facility staff revealed inconsistent understanding of the reporting requirements, with some staff unsure of the exact timeframes or whether all allegations, regardless of perceived validity, should be reported to the state. The Director of Nursing and Administrator confirmed that the two incidents were not reported to the state, and there was a lack of clear documentation and follow-through on the required reporting process for abuse allegations.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
Facility staff failed to complete and document a full investigation into two separate allegations of abuse made by a resident against staff members. According to the facility's Abuse Prohibition Protocol, all alleged violations involving abuse must be reported, investigated, and documented, with accused staff suspended pending investigation. However, in both incidents, the facility did not conduct or document a comprehensive investigation, including interviews with other staff or residents, nor did they suspend the accused staff as required by policy. The resident involved had a complex medical history, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, PTSD, and physical limitations requiring extensive assistance with activities of daily living. The resident reported being abused by staff and claimed to have bruising, but assessments by the Social Services Director (SSD) and charge nurse found no bruising. Despite these allegations, there was no evidence in the records of a thorough investigation or documentation of steps taken to protect the resident during the process. Interviews with facility staff, including CNAs, CMTs, the DON, and the Administrator, revealed inconsistent knowledge and application of the abuse investigation protocol. Some staff were unaware of the allegations or the required suspension of accused staff, and the Administrator admitted to not completing or being aware of investigations for the reported incidents. The lack of a documented, comprehensive investigation and failure to follow facility policy led to the deficiency.
Failure to Protect Residents from Sexual Abuse Due to Lack of Updated Interventions
Penalty
Summary
Facility staff failed to protect residents from sexual abuse by not updating care plans or implementing new interventions after repeated incidents of sexually inappropriate and abusive behaviors by one resident toward multiple other residents. The resident in question, who had a history of schizoaffective disorder, bipolar disorder, and anxiety, was cognitively intact and had exhibited sexually inappropriate behaviors since admission, including exposing themselves, making explicit verbal comments, and physically grabbing other residents' genitals. Despite these ongoing behaviors, staff only implemented 15-minute checks and did not document or initiate additional interventions or care plan updates in response to new or repeated incidents. Multiple incidents were documented in which the resident engaged in sexual abuse or made sexually explicit comments to at least three other residents, some of whom were cognitively impaired and unable to consent. Staff and other residents reported that these behaviors occurred frequently, both in public areas and in residents' rooms, and that the affected residents felt uncomfortable, upset, and unsafe. Staff interviews confirmed that the behaviors were well known, had been reported to nursing leadership, and were considered abuse, but no new strategies or individualized interventions were added to the care plans to prevent recurrence. The facility's own policy required thorough investigation, prevention of further abuse during investigations, and appropriate corrective action, but documentation showed that after each incident, staff primarily redirected the resident or educated them about inappropriate behavior without further care planning. The lack of new interventions or care plan updates persisted even after repeated and escalating incidents, including physical sexual abuse of residents who could not consent. The facility did not document any new measures to ensure the safety of the affected residents beyond the initial 15-minute checks.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to report multiple allegations of resident-to-resident sexual abuse to the State Survey Agency (DHSS) within the required two-hour timeframe. Despite having a policy that mandates immediate reporting of abuse, neglect, or exploitation, staff did not notify DHSS after several incidents involving a resident with a history of sexually inappropriate behavior. Documentation showed that the resident, who was cognitively intact and had diagnoses including schizoaffective disorder, anxiety, bipolar disorder, and alcohol abuse, engaged in repeated inappropriate sexual conduct toward other residents, such as grabbing genitals, making explicit verbal comments, and being found partially unclothed in another resident's room. Progress notes detailed at least five separate incidents where the resident either physically or verbally acted in a sexually inappropriate manner toward peers. In each case, staff documented the events, redirected the resident, notified the physician and family when appropriate, and sometimes sent the resident for evaluation. However, there was no documentation that any of these incidents were reported to DHSS as required by facility policy and federal regulations. Review of DHSS records confirmed that the facility did not self-report these allegations on the dates the incidents occurred. Interviews with staff, including CNAs, CMTs, nurses, the Social Services Director, and the Administrator, revealed a general understanding that such behaviors constituted abuse and should be reported to DHSS within two hours. Staff consistently stated that it was the responsibility of the charge nurse, DON, or Administrator to make the report. Despite this awareness, the required notifications were not made, resulting in a failure to comply with mandated reporting protocols for abuse allegations.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct and document annual performance reviews and competency evaluations for certified nurse aides (CNAs) as required. Specifically, two CNAs, who had been employed for over a year, did not have documentation of a yearly performance review. The Director of Nursing (DON) confirmed that while monthly in-services were conducted, there was no documentation of annual performance reviews. Additionally, the corporate Quality Assurance Registered Nurse (QARN) acknowledged the absence of a specific written policy for completing CNA annual competencies, which should include skills such as catheter care, transfers, peri-care, hand washing, and glove use. The Administrator also confirmed that the facility should be completing and documenting these competencies annually.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities tailored to the interests and abilities of its residents. The activity schedule lacked variety and consistency, with many activities being canceled or not conducted as planned. The facility's activity calendar often did not include specific times for activities, and there was a lack of documentation regarding resident participation and preferences. This deficiency affected nine residents out of a sample of 20, with a facility census of 39. Observations and interviews revealed that residents were often left without engaging activities, leading to boredom and dissatisfaction. For instance, one resident expressed frustration with the repetitive nature of activities like Bingo and Scrabble, desiring more variety. Another resident was not informed about ongoing activities and expressed a desire for playing cards, which were available but not offered. The facility's activity director acknowledged the lack of direction and support, noting that activities were often canceled due to insufficient staff. The facility's documentation practices were inadequate, with many residents' activity preferences and participation not recorded. Care plans often did not reflect residents' interests or provide guidance on encouraging participation. Staff interviews indicated a lack of awareness and communication regarding residents' activity preferences, and there was no consistent method for informing residents about scheduled activities. The facility's failure to maintain a comprehensive and engaging activity program compromised the psychosocial well-being of its residents.
Sanitation and Maintenance Deficiencies in Kitchen Area
Penalty
Summary
The facility staff failed to maintain the ice machine in a sanitary condition, as evidenced by observations of white and brown buildup on the machine's exterior. The facility's policy required weekly cleaning of the ice machine's exterior, but the last documented cleaning was on 08/31/24. Interviews with dietary aides and the dietary manager revealed inconsistencies in the cleaning schedule and responsibilities, with some staff unaware of the requirement to clean the machine daily. The dietary manager acknowledged the oversight and stated that the cleaning of the ice machine was not included in the kitchen's cleaning schedule. Additionally, the facility staff failed to maintain cleanliness in the kitchen area, as observed with brown spots on the fluorescent light and ceiling, and fuzzy lint on the ceiling vent. Interviews with dietary aides, the maintenance director, and the dietary manager indicated a lack of clarity regarding responsibilities for cleaning the lights, ceiling, and vents. The maintenance director admitted to only cleaning the lights when changing bulbs and did not clean the ceiling or vents. The administrator expected maintenance to handle these tasks but was unsure of the specific responsibilities, leading to the observed deficiencies.
Inaccessible Call Light for Resident with Hemiplegia
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring the call light was accessible. The resident, who had been admitted with a diagnosis of stroke resulting in flaccid hemiplegia affecting the left side of the body, required maximum assistance with activities of daily living and was severely cognitively impaired. Despite the care plan specifying that the call light should be within reach at all times, observations on multiple occasions showed the call light was clipped to the head of the bed on the resident's left side, making it inaccessible. Interviews with staff, including CNAs, an RN, the DON, and the Administrator, confirmed that call lights should be placed within reach of residents, particularly on the non-affected side for those with impairments. However, the call light for this resident was consistently placed out of reach, contrary to the facility's policy and the care plan. This oversight was identified through observations and staff interviews, highlighting a deficiency in accommodating the resident's needs.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident prior to or upon admission. The resident, who was admitted with a history of mental disorders including paranoid schizophrenia and anxiety disorder, did not have a completed PASARR Level I screening. The resident's care plan indicated the need for monitoring due to these conditions, and the Minimum Data Set (MDS) assessment confirmed the presence of these diagnoses. However, the PASARR Level I screening submitted by the hospital was incomplete and required corrections, which were not addressed by the facility. Interviews with facility staff revealed that the MDS Coordinator, who was relatively new and worked part-time, missed the email requesting further corrections to the PASARR submission. The Director of Nursing (DON), who had experience in MDS completion, was assisting the MDS Coordinator. Additionally, the facility lacked a written policy on PASARRs, and staff were instructed to follow regulations without specific guidance. The Corporate Quality Assurance Registered Nurse and the Administrator acknowledged that the PASARR should have been completed before admission, and the responsibility for corrections lay with the MDS Coordinator and DON.
Failure to Update Care Plans for Hospice Services
Penalty
Summary
The facility failed to ensure that the care plans for two residents receiving hospice services were accurate and up-to-date. Resident #39, who was admitted with diagnoses including COPD, stroke, depression, anxiety, and PTSD, was on hospice services as indicated by a physician order and a hospice book. However, the resident's care plan did not reflect the hospice services, and the admission MDS did not document the hospice care. Interviews with staff, including CNAs and an RN, confirmed that the resident was receiving hospice services, but it was not included in the care plan. Similarly, Resident #2, diagnosed with schizophrenia, urinary tract infection, dysphagia, and falls, was also receiving hospice services as documented in the patient's specific letter of agreement and weekly summaries. Despite this, the resident's care plan, revised in June, did not include hospice services. Interviews with RNs, the MDS Coordinator, the DON, and the Administrator confirmed the resident's hospice status and acknowledged that hospice should be included in the care plan. The MDS Coordinator noted that care plans should be updated quarterly or as needed, but due to time constraints, this was not adequately done.
Failure to Perform Peri-Care for Incontinent Resident
Penalty
Summary
The facility failed to assist a dependent resident with activities of daily living, specifically in maintaining good grooming and hygiene, following an episode of incontinence. The incident involved a resident with severe cognitive impairment, frequent bladder incontinence, and occasional bowel incontinence, who required substantial assistance for toileting hygiene. During an observation, two CNAs assisted the resident to the toilet after noticing the back of the resident's pants were wet. However, they failed to perform peri-care after the resident used the toilet, instead placing a new brief and clean pants on the resident without cleaning the peri-area. Interviews with facility staff, including CNAs and the Director of Nursing, revealed that the standard procedure for peri-care was not followed. Staff members acknowledged that peri-care should be performed whenever a resident is changed or after using the bathroom, regardless of output. The CNAs involved did not perform hand hygiene between glove changes, which is against the facility's protocol. The Director of Nursing and the corporate QA RN confirmed that staff should always perform peri-care with incontinence and/or toileting, and should change gloves and sanitize hands during care.
Failure in Catheter Care and Infection Control
Penalty
Summary
The facility failed to adhere to acceptable standards of care during the management of a resident's indwelling suprapubic catheter. The resident, who was admitted with multiple diagnoses including bipolar disorder, generalized anxiety disorder, and a history of urinary tract infections, had an indwelling catheter due to benign prostatic hyperplasia and urinary retention. The care plan required catheter care every shift to prevent complications. However, during an observation, a registered nurse (RN) did not change gloves or perform hand hygiene after cleaning the catheter insertion site, which is a breach of infection control protocols. The RN was observed entering the resident's room with gloves, gown, and mask, and proceeded to perform catheter care without changing gloves or sanitizing hands after cleaning the catheter site. This included handling the catheter tubing and replacing the drain sponge without proper hand hygiene. The RN later acknowledged forgetting to change gloves during the procedure. Interviews with the facility's administrator and corporate QA RN confirmed that staff should wash or sanitize hands before donning gloves and change gloves after cleaning a catheter to prevent contamination.
Inadequate Pain Management for Hospice Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident on hospice care, identified as Resident #39, who frequently experienced severe pain. The resident, who had a history of chronic obstructive pulmonary disease, stroke, depression, anxiety, and PTSD, was not on a scheduled pain regimen despite frequent complaints of pain affecting sleep and daily activities. The resident's care plan included goals for adequate pain control and instructions for staff to offer PRN pain medications and non-pharmacological interventions, but these were not effectively implemented. On a specific day, the resident was observed in significant distress, repeatedly calling out for pain relief over an extended period without receiving timely assistance. Despite vocal complaints and visible signs of pain, such as moaning and rubbing legs together, staff failed to respond promptly. A CNA eventually entered the room but was unsure about the resident's pain medication schedule and left to consult a nurse, further delaying pain relief. Interviews with staff revealed a lack of communication and understanding of responsibilities regarding pain management. The CNA did not report the resident's pain to the nurse, and the nurse was unaware of the resident's complaints until much later. The facility's policy required pain assessments and documentation, but these were not consistently followed, leading to inadequate pain management for the resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's PTSD diagnosis was not documented in the medication record or care plan, and staff were not informed of the resident's history, triggers, or necessary interventions. This oversight occurred despite the facility's assessment indicating that they accept residents with PTSD and are committed to managing such conditions through person-centered care. The resident, who had a history of traumatic experiences including childhood abuse and a recent house fire, exhibited aggressive behaviors upon returning from an outing. The staff administered medication and eventually sent the resident for evaluation due to continued aggression. However, the care plan was not updated to reflect the PTSD diagnosis or to include specific triggers and interventions, leaving staff unaware of the resident's psychological background and care needs. Interviews with facility staff, including CNAs, LPNs, the MDS Coordinator, the Director of Nursing, and the Administrator, revealed a lack of awareness regarding the resident's PTSD diagnosis and history. The staff did not receive adequate information about the resident's emotional triggers, which were known to the resident's sibling. The facility's failure to incorporate this critical information into the care plan and communicate it to the staff resulted in inadequate care for the resident.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and inappropriate use of personal protective equipment (PPE) during wound care for Resident #32. The registered nurse (RN) involved did not perform hand hygiene after changing gloves multiple times during the wound care process. Additionally, the RN pulled down their face mask, exposing their nose, and fanned their face with a gloved hand, which is against the facility's infection control policy. The Director of Nursing (DON) and the Administrator confirmed that the staff is expected to follow proper hand hygiene protocols and maintain mask coverage during care. Resident #32, who was admitted with diagnoses including a stage 4 pressure ulcer, heart failure, hypertension, and depression, required extensive assistance for personal care and was always incontinent of bowel and bladder. The resident's care plan mandated the use of enhanced barrier precautions (EBP) during care. However, during an observation, the RN failed to adhere to these precautions, compromising the infection control measures intended to protect the resident. Similarly, the facility failed to ensure proper hand hygiene during the care of Resident #20, who had a history of urinary tract infections and an indwelling suprapubic catheter. The RN did not change gloves or perform hand hygiene after cleaning the catheter insertion site and before handling clean items. This oversight was acknowledged by the RN and confirmed by the Administrator and the corporate Quality Assurance RN, who stated that staff should sanitize their hands before donning gloves and after cleaning a catheter.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 8 citations issued within 25 miles in the last 12 months — 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 Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hartville Care Center | 9.7 mi | ★★★★★ | 0 | 0 |
| Autumn Oaks Caring Center | 13.6 mi | ★★★★★ | 1 | 0 |
| Heart Of The Ozarks Healthcare Center | 15.1 mi | ★★★★★ | 0 | 0 |
| Glenwood Healthcare | 15.7 mi | ★★★★★ | 0 | 0 |
| Kabul Nursing Homes Inc | 22.1 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.