Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Parkway Health & Rehab Llc during CMS and state inspections, most recent first.
An infection prevention and control deficiency occurred when an LPN performed PEG tube site care for a resident without wearing the gown required by EBP, despite facility policy stating EBPs are used to prevent spread of MDROs. In a separate observation, an LPN placed nasal spray and an inhaler on a bedside table without disinfecting the surface or using a barrier, then returned the items to the med cart without disinfecting them. Facility staff stated both actions were inconsistent with infection control practices.
Failure to maintain EBP during PEG tube care for a resident with a gastrostomy tube. The care plan included maintaining EBP, but an LPN performed the care without donning a gown. The LPN said she forgot the gown, and the IP nurse stated EBP is intended to prevent transmission of bacteria between staff and residents. The DON stated staff are expected to follow care plans as written.
Delayed Response to Fecal Burden and Abdominal Distention: A resident with severe cognitive impairment, CVA, and aphasia developed abdominal distention and bowel concerns, with imaging showing mild fecal loading, then moderate small-bowel distention, and CT findings of a large fecal burden with stercoral proctitis. The resident received intermittent bowel meds, but no routine preventive bowel regimen was documented after the CT findings, and the resident was later hospitalized with rectal fecal impaction and concern for stercoral colitis. The DON and NP acknowledged delayed review of CT results and that earlier treatment could have benefitted the resident.
Dietary staff failed to honor and document meal preferences for two residents with diabetes-related dietary concerns. One cognitively intact resident repeatedly reported receiving high-carbohydrate foods such as rice, potatoes, grits, and muffins despite asking for lower-carb choices, and her tray card was not updated. Another resident with moderate cognitive impairment said she was not offered appropriate alternatives and was served items like grits, biscuits, beans, corn, and rice, with no likes or dislikes listed on her tray card. The DM and Dietitian acknowledged that resident preferences should be reflected and honored, but the meals continued unchanged.
Dietary staff failed to follow proper hand hygiene and thermometer cleaning practices, leading to potential cross-contamination. Staff did not wash hands before checking food temperatures and used a dish cloth instead of disposable wipes to clean the thermometer probe. The Dietary Manager confirmed these practices could spread harmful bacteria.
The facility failed to submit accurate staffing data for Quarter 1 of 2025 due to a transition between payroll systems, leading to discrepancies in reported nursing hours. The PBJ Staffing Data Report flagged the facility for excessively low weekend staffing, although the staffing grid showed no actual issues. The Administrator and HR Director acknowledged the transition as the cause of the inaccuracies.
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet care needs. Residents lacked adequate care plans for ADLs, PTSD triggers, and activity engagement. Observations revealed unshaven and unkempt residents, and interviews confirmed the care plans were vague or not followed. A resident with PTSD lacked a plan for triggers, and another did not have a contracture device as required. Additionally, a resident's activity preferences were not assessed due to the absence of a care plan.
The facility failed to provide adequate ADL care for four residents, resulting in unkempt appearances and unmet grooming needs. Despite expressing a desire for grooming, these needs were not addressed by staff, contrary to the facility's policy. Observations revealed long facial hair and greasy, unwashed hair among the residents, with minimal documentation of personal hygiene care for some. The deficiency highlights a lack of adherence to the facility's quality of life policy.
A resident with a left upper extremity contracture was observed without the required splint on multiple occasions, despite a care plan order for daily application. Staff interviews revealed that the splint was not applied as aides and nurses failed to ensure its use, with one LPN admitting to signing off on its application without verification. The splint's absence was speculated to be due to it being in the laundry, highlighting a lapse in prescribed care delivery.
A facility failed to notify a physician of a resident's change in nutrition and hydration status. The resident, on dialysis, had a fluid restriction order of 1500 ml, but the dialysis RD indicated it should be 1200 ml. The facility RD recommended changes to tube feeding and fluid flushes, but these were not implemented, and the physician was not informed, leading to a delay in care.
A facility failed to ensure a resident's right to be free from physical restraints by using a bed alarm pad and a wheelchair alarm pad that restricted the resident's movements. The alarms caused the resident, who was severely cognitively impaired with a history of repeated falls, to stop moving to avoid triggering the alarm sounds. Staff confirmed the alarms were considered restraints, and the facility did not conduct restraint assessments for the devices.
A facility failed to implement necessary nutritional and hydration care for a resident on dialysis, leading to fluid overload. Despite recommendations from the RD to adjust tube feeding and fluid restrictions, these were not acted upon, resulting in the resident being consistently over their pre-dialysis target weight. Communication lapses between facility staff and the physician contributed to the deficiency.
A facility failed to provide trauma-informed care to a resident with PTSD, as the care plan did not address specific triggers or interventions. Staff interviews revealed a lack of awareness about the resident's PTSD and triggers, despite the resident being cognitively intact and confirming his PTSD related to Vietnam experiences. The DON acknowledged the care plan's deficiencies, which could lead to re-traumatization.
A resident with moderate cognitive impairment was found with medications left unsecured on their overbed table, contrary to facility policy requiring secure storage. The LPN was unaware of the situation, and the ADON confirmed no self-administration assessment was completed. The resident's medical history includes chronic conditions such as heart and kidney disease.
A resident with a history of urinary tract infections was observed with a catheter bag and tubing on the floor, contrary to facility policy. A CNA cleaned the catheter with only water, not using soap as required. The DON confirmed these actions increased infection risk.
A facility failed to accurately complete section N of the MDS for a resident taking an antiplatelet medication. The MDS was incorrectly coded as the resident receiving an anticoagulant, despite the MAR showing the administration of the antiplatelet medication Plavix. This error was confirmed by the Medicare Nurse, who acknowledged the mistake. The resident involved had a medical diagnosis including Alzheimer's Disease.
A facility failed to update a resident's pressure risk care plan despite a decline in ADL function, leading to the development of a pressure ulcer. The resident, at risk due to incontinence and dementia, was admitted with a care plan that was not revised to address increased risk factors. The DON and MDS Nurse confirmed the care plan should have been updated with new interventions. The resident was later hospitalized with a pressure ulcer on her heel.
A resident with dementia and aphasia experienced a decline in function, requiring increased assistance with daily activities, which heightened the risk for pressure injuries. Despite this, the facility failed to implement specific interventions to prevent pressure ulcers. The resident was later hospitalized with a deep tissue injury on the right heel, which staff had not previously identified or documented. Interviews revealed that the resident's heels were not floated, and no foot pillows or positioning devices were used, contributing to the development of the pressure ulcer.
A resident receiving hospice care for COPD was involved in a misappropriation incident when their morphine sulfate was found altered in color and not properly documented. An LPN was observed tampering with the medication and failed to comply with a drug screen, leading to their termination. The facility's policies on controlled substances were not followed, resulting in a deficiency.
A facility failed to report a narcotic diversion incident involving a resident's morphine prescription to the State Agency. The discrepancy was identified by an LPN and confirmed by the DON, who found the morphine to be a different color than expected. A random drug screen was conducted, and video footage revealed an LPN tampering with the medication. The DON believed the incident was reported, but no documentation was found to confirm this.
A facility failed to document the administration of PRN Morphine Sulfate for a resident with chronic respiratory conditions. Despite being signed out on the narcotic sheet, the medication was not recorded in the MAR, as confirmed by staff interviews. This lapse in documentation could suggest potential diversion or missing narcotics, as noted by the DON.
Infection Control Lapses During EBP and Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was not followed during medication administration and Enhanced Barrier Precautions (EBP) for two residents. Facility policy stated that EBPs are used to prevent the spread of multi-drug-resistant organisms and that the facility had adopted infection prevention and control policies and procedures to help prevent and manage transmission of diseases and infections, but the medication procedure guideline did not include specific infection control instructions. For Resident #9, an LPN was observed performing PEG tube site care without donning a gown before care. The LPN stated she forgot to don a gown, and facility staff later stated that not wearing PPE as specified in policy could lead to transfer of bacteria from one resident to another and cause infection. Resident #9 had diagnoses including Alzheimer's disease with early onset, was unable to complete a BIMS assessment, and had an enteral feeding tube. For Resident #81, during medication administration, an LPN placed fluticasone nasal spray and budesonide inhaler on the bedside table without disinfecting the surface or using a barrier, then returned the medications to the cart without disinfecting the packages. The LPN stated she should have disinfected the bedside table or used a barrier, and facility staff stated the items should have been disinfected before being placed back on the medication cart. Resident #81 was admitted with influenza due to identified novel influenza A virus with pneumonia and had orders for budesonide-formoterol inhalation aerosol and fluticasone nasal spray.
Failure to Maintain Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for Resident #9 by not maintaining Enhanced Barrier Precautions during care. The resident’s care plan, revised 1/13/26, identified the resident as NPO with a gastrostomy tube and included the intervention to maintain Enhanced Barrier Precautions. During observation on 2/24/26 at 1:20 PM, an LPN performed PEG tube site care without donning a gown before starting the care. During interview, the LPN stated she forgot to apply a gown before performing the PEG tube care and acknowledged the facility uses a green dot indicator on the door name tag to remind staff to wear gowns for care. The Infection Prevention Nurse stated the purpose of Enhanced Barrier Precautions is to prevent transmission of bacteria between staff and residents and that failure to wear required PPE can contribute to the spread of infection. The DON stated she is responsible for ensuring care plans are developed and implemented and that failure to follow the care plan intervention to maintain Enhanced Barrier Precautions could increase the risk of infection transmission. Resident #9 was admitted on 10/8/20 with Alzheimer’s disease with early onset and was unable to complete a BIMS due to cognitive impairment.
Delayed Response to Fecal Burden and Abdominal Distention
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice to address abdominal distention and fecal burden in a timely manner for Resident #56, who had a history of CVA, acute respiratory failure with hypoxia, severe cognitive impairment, and aphasia. Radiology on 11/28/25 showed mild fecal loading, and an abdominal x-ray on 12/22/25 showed moderate gaseous distention of the small bowel. A CT abdomen without pelvis on 12/22/25 showed a large fecal burden with findings suggesting stercoral proctitis. The December 2025 MAR showed Dulcolax suppositories were given on 12/10/25 and 12/24/25, and lactulose was given on 12/25/26, 12/26/26, and 12/27/26, with no documentation of preventive bowel medications after the CT findings on 12/22/25. The resident was hospitalized on 12/27/25, and the hospital course documented rectal fecal impaction with perirectal stranding concerning for stercoral colitis and a large colonic fecal burden. The DON reported the resident had bowel movements on 12/21/25 and 12/22/25, developed abdominal distention, and that CT results were not available to staff until 12/24/25. The DON also stated the resident began facial grimacing and abdominal tenderness on 12/10/25, prompting Dulcolax administration, and later acknowledged that treatment was not initiated until 12/24/25 after the CT findings. The NP stated the resident was not placed on routine preventive bowel medication because he had no prior history of constipation and that earlier treatment could have benefitted the resident, while medical records staff confirmed the CT results were typically available the same day or by the following day but were not retrieved until 12/24/25.
Dietary Preferences Not Reflected on Meal Tickets or Honored
Penalty
Summary
The facility failed to ensure dietary staff supported and respected resident meal preferences for two residents with diabetes-related dietary concerns. A review of the facility policy stated that if a resident expresses a new dislike, the Dietary Manager must update the permanent profile and notify production staff so the change is reflected and food waste is avoided. In both cases, tray cards did not reflect resident likes or dislikes, and the residents reported that their meal preferences were not being honored. Resident #45, admitted with Type 2 DM and essential hypertension, was cognitively intact with a BIMS score of 15. During interview, she stated that she had repeatedly told the Dietary Manager that she did not want starchy, high-carbohydrate foods because they affected her blood sugar, but her concerns were not reflected on her meal ticket. She reported receiving meals that included rice, potatoes, grits, muffins, waffles, pancakes, and biscuits, and said she could not eat the rice on her lunch tray. Observation confirmed her lunch tray contained beans, sausage, and a large amount of white rice. The meal ticket reviewed for her had no likes or dislikes listed. The Dietary Manager acknowledged the meal ticket had not been updated for months and stated it should reflect resident preferences and be honored at every meal. Resident #57, admitted with Type 2 DM and hypertensive heart disease, had a BIMS score of 11 indicating moderate cognitive impairment. She stated that she preferred to eat in her room and felt the kitchen did not offer options that matched her dietary needs or healthier alternatives. She reported being served red beans and rice, grits, butter beans, and corn, and said she ate them even though she believed they were not appropriate for her diagnosis. Observation of her breakfast tray showed grits and a biscuit, and the tray card also had no likes or dislikes recorded. The Dietitian stated resident preferences were important and tray cards should be updated, while the Dietary Manager confirmed no alternative options were displayed on the menu screen and was unaware of that issue. An LPN also confirmed the resident frequently voiced concerns about meals affecting her blood sugar and that the kitchen had been informed multiple times without changes being made.
Improper Hand Hygiene and Thermometer Cleaning in Kitchen
Penalty
Summary
The facility failed to ensure proper hand hygiene and food temperature monitoring practices were followed by dietary staff, leading to potential cross-contamination. During a kitchen observation, Dietary Staff #2 was seen gathering kitchen utensils and checking food temperatures without washing his hands. He used a white dish cloth to wipe the thermometer probe between uses, which he admitted could cause cross-contamination. This practice was confirmed to be common among staff, as it was how they were trained. The Dietary Manager confirmed that staff were required to perform hand hygiene before checking food temperatures and should use disposable wipes to clean the thermometer probe. The improper hand hygiene and use of a dish cloth instead of disposable wipes for cleaning the thermometer probe were acknowledged as practices that could result in cross-contamination and the spread of harmful bacteria to food.
Inaccurate Staffing Data Submission Due to Payroll System Transition
Penalty
Summary
The facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one of the four quarters reviewed, specifically Quarter 1 of 2025. The facility's policy requires that direct care staffing and census data be collected quarterly and be both timely and accurate. However, a review of the PBJ Staffing Data Report for Fiscal Year Quarter 1 2025 revealed that the facility was flagged for excessively low weekend staffing. During interviews, the Administrator and the Human Resources Director acknowledged that the facility was transitioning between payroll systems during this period, which may have led to inaccuracies in the reported nursing hours. The facility's staffing grid for the weekends of the quarter did not show any issues with low staffing, indicating that the problem was with the data submission rather than actual staffing levels.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet care needs. Residents #1, #34, #61, and #67 did not have adequate care plans related to Activities of Daily Living (ADL), specifically in terms of personal hygiene and grooming. Observations revealed that these residents were unshaven and had unkempt hair, indicating that their care plans were either not developed to include necessary interventions or were not being followed by the staff. Interviews with the Director of Nursing (DON) and the Medicare Nurse confirmed these deficiencies, highlighting that the care plans were vague and did not accurately reflect the residents' needs. Resident #41, who has a diagnosis of Post-Traumatic Stress Disorder (PTSD), did not have a care plan that addressed his specific triggers or interventions to prevent re-traumatization. The Social Worker and the DON were unaware of the resident's triggers, and the lack of a detailed care plan meant that staff were not informed of necessary precautions. This oversight could potentially lead to situations that exacerbate the resident's PTSD symptoms, as staff were not equipped with the information needed to manage his condition effectively. Additionally, Resident #12's care plan included the use of a contracture device, which was not implemented as observed during multiple visits. The Medicare Nurse confirmed that the staff did not follow the care plan for the splinting device. Furthermore, Resident #68 did not have a developed care plan for activities, which was acknowledged by the Activity Director. The absence of a care plan for activities meant that the resident's functional abilities and preferences were not assessed or addressed, leading to a lack of engagement in meaningful activities.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for four residents who required assistance. Observations and interviews revealed that these residents had unkempt appearances, with long facial hair and greasy, unwashed hair. Despite expressing a desire for grooming, these needs were not addressed by the staff. The facility's policy on quality of life, which includes grooming as per residents' wishes, was not adhered to, leading to this deficiency. Resident #1, who was cognitively intact, had not received a haircut or shave since the previous year, despite expressing a desire for grooming. The resident was not placed on the barber list, and staff failed to inquire about his grooming preferences. Similarly, Resident #61, also cognitively intact, had not been shaved or had a haircut for an extended period, and staff were unaware of his grooming schedule. Both residents expressed dissatisfaction with their current grooming status. Resident #34 and Resident #67 also exhibited signs of neglect in personal hygiene. Resident #34 had greasy hair with visible flakes and facial hair, and could not recall the last time he was groomed. Resident #67, who had severe cognitive impairment, had oily hair and long facial hair, with minimal documentation of personal hygiene care over a two-week period. The Director of Nurses acknowledged the importance of daily personal hygiene, yet the facility failed to provide consistent care, resulting in this deficiency.
Failure to Apply Splint for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a splint was applied for a resident with contractures, as observed during a survey. The resident, who had a left upper extremity contracture, was observed on multiple occasions without the required contracture device in place. The facility's policy mandates that residents with limited range of motion receive treatment to prevent further decline, yet the resident's Medication Administration Record indicated an order for a resting hand splint to be applied daily, which was not followed. Interviews with staff revealed a lack of adherence to the care plan. The Assistant Director of Nursing confirmed the absence of the splint and acknowledged that aides were responsible for its application, while nurses were to ensure compliance. A Licensed Practical Nurse admitted to not verifying the splint's application despite signing off on the Medication Administration Record. A Certified Nurse Aide also confirmed the splint was missing and speculated it might be in the laundry, indicating a lapse in ensuring the resident's prescribed care was delivered.
Failure to Notify Physician of Resident's Fluid Restriction Change
Penalty
Summary
The facility failed to promptly notify the physician of a change in a resident's nutrition and hydration status. The resident, who was on dialysis, had a fluid restriction order of 1500 ml, but the dialysis dietician indicated that the restriction should be 1200 ml. The facility's registered dietician (RD) recommended changes to the resident's tube feeding and fluid flushes to accommodate the correct fluid restriction and suggested consulting the physician for clarification. However, these recommendations were not implemented, and the physician was not promptly informed of the necessary changes. The Director of Nursing (DON) confirmed that the RD's recommendations were misplaced and not communicated to the physician, resulting in a delay in care. The resident had been admitted with diagnoses including hypertensive heart disease, chronic kidney disease, and end-stage renal disease. Despite the dialysis RD faxing the correct fluid restriction order to the facility, the physician was not made aware of the new recommendations, as the DON assumed the nurse practitioner would review them during a later visit.
Failure to Ensure Resident's Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints, as evidenced by the use of a bed alarm pad and a wheelchair alarm pad that restricted the resident's movements. The alarms caused the resident to stop moving to avoid triggering the alarm sounds, demonstrating a restrictive effect. The facility's policy defines physical restraints as any device that restricts freedom of movement, which the alarms effectively did for the resident. The resident, who was severely cognitively impaired with a history of repeated falls, expressed dislike for the alarm and reported stopping movement to silence it. Interviews with staff, including a CNA and the Medicare Nurse, confirmed that the alarms were considered restraints due to the resident's behavior of stopping movement in response to the alarm. The Director of Nursing was unaware of the resident's distress and the unauthorized use of a bed alarm pad, as there was no physician order for it. The Assistant Director of Nursing expressed concerns about the use of restraints, noting potential negative impacts on residents. The facility failed to conduct restraint assessments for the alarm devices, leading to the deficiency.
Failure to Implement Nutritional and Hydration Care for Dialysis Resident
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care for a resident receiving enteral feedings and dialysis. The Registered Dietician (RD) identified issues with fluid overload and recommended changes to the resident's tube feeding and fluid restrictions. However, these recommendations were not implemented, as evidenced by the Medication Administration Record (MAR) not reflecting the RD's suggestions. The facility's Director of Nursing (DON) confirmed that the recommendations were misplaced and not acted upon, which could have contributed to the resident's continued fluid overload. The resident, who was admitted with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, was on a fluid restriction of 1500 ml, contrary to the dialysis RD's recommendation of 1200 ml. The facility's RD communicated with the dialysis RD about the resident's weight gain issues and fluid overload during dialysis treatments. Despite the dialysis RD faxing a physician order for a 1200 ml fluid restriction, the facility continued with the 1500 ml restriction, leading to the resident being consistently over their pre-dialysis target weight. Interviews with facility staff revealed a lack of communication and follow-through on the RD's recommendations. The DON admitted that the physician was not informed of the new RD recommendations promptly, as the nurse practitioner was expected to review them during a later visit. This delay in communication and implementation of necessary dietary adjustments resulted in the resident's fluid volume status being inadequately managed, as indicated by the resident's fluctuating weights and excessive fluid retention before dialysis sessions.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with Post Traumatic Stress Disorder (PTSD), which could minimize triggers and prevent re-traumatization. The resident, who was readmitted with diagnoses including PTSD and Bipolar Disorder, had a care plan that did not address specific triggers or interventions related to his PTSD. Interviews revealed that the Certified Nurse Assistant (CNA) was unaware of the resident's PTSD, and the Social Worker had not discussed the resident's PTSD or triggers with him. The Director of Nurses (DON) acknowledged that the care plan did not address the resident's triggers, which included being awakened at night by staff, and confirmed that staff were not informed about these triggers or interventions. The resident, identified as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, confirmed his PTSD was related to his experiences in Vietnam and subsequent treatment. Despite this, the facility's policy on Trauma Informed Care was not effectively implemented, as evidenced by the lack of a developed care plan for triggers and the staff's lack of awareness regarding the resident's condition and specific needs. This oversight could lead to re-traumatization, as the staff were not equipped with the necessary information to provide appropriate care.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as evidenced by the observation of medications left in a resident's room. Specifically, a bottle of Tums Ultra Strength 1000 mg and Equate Nasal Spray 3 fl. oz were found on the overbed table of a resident. The facility's policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, which was not adhered to in this instance. The resident, who has moderate cognitive impairment, expressed a need for the medications due to indigestion and was resistant to having them removed. The Licensed Practical Nurse (LPN) assigned to the resident was unaware of the medications being left in the room, as she typically administers all medications and observes the resident taking them. The Assistant Director of Nurses (ADON) confirmed that the resident had not been evaluated for self-administration of medications, and no self-administration form was completed. The ADON acknowledged that the medications should not have been left at the bedside, as this could lead to the resident taking too much or others accessing them. The resident's medical history includes hypertensive heart and chronic kidney disease, heart failure, and gastro-esophageal reflux disease.
Improper Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper catheter care and infection control practices for a resident, identified as Resident #37, who was observed with a catheter bag and tubing resting on the floor. This observation was made during a visit where the resident's representative mentioned the resident's history of frequent urinary tract infections and the need for a catheter due to bladder retention issues. The facility's policy requires that catheter tubing and drainage bags be kept off the floor to prevent infection, but this was not adhered to in the case of Resident #37. Additionally, during an observation of catheter care, a CNA was seen cleaning the urinary meatus and catheter tubing with only water, without using soap or cleansing products as required by the facility's policy and the resident's active care order. The CNA acknowledged the oversight, stating a concern about skin irritation as the reason for not using soap. The Director of Nursing confirmed that the catheter bag should not have been on the floor and that soap and water should have been used, acknowledging that these lapses increase the risk of infection for the resident.
Inaccurate MDS Coding for Antiplatelet Medication
Penalty
Summary
The facility failed to accurately complete section N of the Minimum Data Set (MDS) for a resident taking an antiplatelet medication. Specifically, the MDS for a resident was incorrectly coded as receiving an anticoagulant medication during the 7-day look-back period, despite the Medication Administration Record (MAR) indicating that the resident did not receive an anticoagulant but was instead administered the antiplatelet medication Plavix. This discrepancy was confirmed during an interview with the Medicare Nurse, who acknowledged the error and stated that the antiplatelet box should have been marked. The resident, who was admitted with a medical diagnosis including Alzheimer's Disease, was affected by this coding error.
Failure to Revise Pressure Risk Care Plan
Penalty
Summary
The facility failed to revise a pressure risk care plan for a resident who developed a pressure ulcer. The resident, who was at risk for pressure ulcers due to incontinence and dementia, was admitted to the facility with a care plan that was not updated despite a decline in her activities of daily living (ADL) function. This decline, which included reduced mobility and self-feeding, increased her risk for pressure injuries. The care plan, initially set on 12/11/24 and revised on 1/27/25, did not reflect any changes or interventions to address the increased risk prior to the development of a deep tissue injury (DTI) on her right heel, identified on 1/19/25. The Director of Nursing confirmed that the care plan should have been revised to include new interventions for pressure prevention following the resident's decline in function. The MDS Nurse also acknowledged that the resident's care plan was not updated to reflect her increased risk for pressure injuries. The resident was sent to the hospital on 1/19/25, where she was assessed with a pressure ulcer on her right heel, which was black, draining, and had deep purple discoloration. The facility's failure to update the care plan and implement necessary interventions contributed to the development of the pressure ulcer.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide necessary services to prevent new pressure ulcers from developing for a resident. The resident, who was admitted with diagnoses including unspecified dementia and aphasia, experienced a decline in function approximately two weeks before being sent to the hospital. During this period, the resident required increased assistance with activities of daily living, such as feeding, toileting, and transfers, indicating a higher risk for pressure injuries. Despite this decline, no specific interventions were documented or implemented to mitigate the risk of pressure ulcer development. The resident was eventually sent to the hospital, where a deep tissue injury with epithelial separation was identified on the right heel. The wound was described as having a partial thickness pink wound bed with deep purple discoloration, scant drainage, and devitalized tissue. Interviews with staff and the resident's representative revealed that the resident's heels were not floated, and no foot pillows or positioning devices were used prior to the discovery of the wound. The only item placed on the resident's feet were socks, and there were no active orders related to skin or pressure relief prevention. Interviews with various staff members, including the Director of Nursing, Licensed Practical Nurses, and Certified Nurse Assistants, confirmed the lack of awareness and documentation regarding the resident's declining condition and the presence of the wound. The staff acknowledged that the resident's increased need for assistance should have prompted the implementation of resident-specific interventions to prevent pressure injuries. The failure to do so likely contributed to the development of the pressure ulcer on the resident's heel.
Misappropriation of Morphine Sulfate in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a bottle of Morphine Sulfate was found altered in color composition and not properly accounted for on the medication administration record. The incident involved a resident who was receiving hospice care for Chronic Obstructive Pulmonary Disease (COPD) and was prescribed Morphine Sulfate for pain and wheezing. The morphine, which was supposed to be light blue, was discovered to be clear by an LPN during administration, prompting an investigation. The Director of Nursing (DON) confirmed that a narcotic diversion investigation had been conducted after the discovery. Video surveillance revealed that an LPN was observed manipulating the morphine vial in a suspicious manner, including withdrawing liquid from the vial and entering a bathroom with it. This LPN failed to comply with a random drug screen requested by the facility, further substantiating the allegation of diversion. The morphine vial in question was compared to a new vial, confirming a notable difference in color, which supported the suspicion of tampering. The facility's policies on abuse prevention and controlled substances were reviewed, indicating a failure to comply with regulations related to handling and documentation of controlled substances. The investigation revealed that the LPN had signed out multiple doses of morphine for the resident, despite the altered state of the medication. The facility terminated the LPN following the investigation, citing failure to comply with the narcotic investigation as the reason for termination.
Failure to Report Narcotic Diversion Incident
Penalty
Summary
The facility failed to report an allegation of narcotic diversion involving a resident to the State Agency, as required by their policy. The incident involved a discrepancy in the color of liquid morphine prescribed to a resident, which was initially identified by an LPN and confirmed by the Director of Nursing (DON). The morphine, which should have been a clear blue color, appeared clear when drawn into a syringe. Upon further investigation, it was found that the morphine bottle delivered earlier in the month was a lighter color than a newly delivered bottle. The DON initiated a random drug screen for all nurses with access to the medication, which all complied with except for one LPN who was later observed on video footage tampering with the morphine bottle. The resident involved had been admitted to the facility with diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. Despite the DON's belief that the incident had been reported to the State Agency, there was no documentation to confirm this, and the DON acknowledged the failure to report. This oversight in reporting the narcotic diversion incident represents a deficiency in the facility's adherence to its policy on reporting and investigating suspected misappropriation of property.
Failure to Document PRN Pain Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of PRN pain medication for a resident, leading to a deficiency in maintaining proper medical records. The facility's policy on controlled substances and charting documentation requires that all administered medications be documented in the resident's medical record. However, a review of the Medication Administration Record (MAR) for a resident revealed that doses of Morphine Sulfate administered on specific dates were not documented, despite being signed out on the narcotic-controlled drug form. Interviews with staff confirmed the administration of the medication but acknowledged the failure to document it in the MAR, which is essential for proving administration, informing other staff, and ensuring compliance with physician's orders. The resident involved was admitted to the facility with diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. The lack of documentation for the administered narcotic medication could lead to concerns about potential diversion or missing narcotics, as noted by the Director of Nursing. The deficiency highlights a lapse in following the facility's policy and professional standards for documenting controlled substances, which is crucial for maintaining accurate medical records and ensuring the safety and well-being of residents.
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 92 citations issued within 25 miles in the last 12 months — including the 3 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 Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Co Nh | 4.8 mi | ★★★★★ | 4 | 0 |
| The Nichols Center | 6.7 mi | ★★★★★ | 5 | 0 |
| The Madison Health And Rehab | 8.2 mi | ★★★★★ | 4 | 0 |
| Highland Home | 12 mi | ★★★★★ | 1 | 1 |
| Community Place | 14.9 mi | ★★★★★ | 1 | 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.