Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 The Oaks Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severely impaired cognition and a fall risk related to confusion had a care plan that was not revised after two actual falls. The record showed one fall led to an ER transfer, then the resident returned and fell again shortly after; the chart lacked a fall investigation for the first event, and the existing care plan still only listed an older bed-in-low-position intervention, while therapy services was not documented as a care plan intervention.
Failure to investigate an initial fall and maintain a resident’s bed in a low position led to repeated falls for a resident with metabolic encephalopathy and severely impaired cognition. Staff found the resident on the floor in the morning, but no fall investigation was completed for that event. Later, after the resident returned from the hospital, the resident was found on the floor again within minutes while the bed was elevated and bedrails were raised.
Failure to assess and obtain consent for bed rail use: Surveyors observed a resident with quarter-length bedrails raised on both sides of the bed, but the clinical record contained no bed rail assessment and no informed consent documentation. The DON confirmed the missing records, and the resident had metabolic encephalopathy with a BIMS score of 4, indicating severely impaired cognition.
An LPN did not immediately report an abuse allegation after a resident said a CNA told him not to use his call light again or she would put something on him. The LPN spoke with the CNA, who said she was joking and apologized, and the resident said it was fine, but the allegation was not reported to the DON or Administrator until the next day when another LPN was told. The resident was cognitively intact and had diagnoses including abnormalities of gait and mobility.
A resident was found with long, jagged toenails and reported not receiving assistance with nail care, despite requesting help. This repeated deficiency occurred due to staff overlooking grooming during ADL care and a lack of effective follow-through on the facility's QAPI plan, as confirmed by interviews with the Administrator and DON.
A resident with severe cognitive impairment and physical limitations did not receive needed assistance with grooming and personal hygiene, including facial hair removal and toenail trimming. Despite expressing a desire for help and being unable to perform these tasks independently, staff did not provide the required care, contrary to facility policy and staff responsibilities.
A blind, cognitively intact resident was unable to access or verify the function of the call light system, as it was consistently placed out of reach and not adapted for her vision impairment. Staff interviews and observations confirmed the call light was attached to the wall at the foot of the bed, leaving the resident to yell for assistance. The DON acknowledged the need for more accessible devices for residents with vision loss.
A resident with severely impaired cognition and a stage 3 pressure ulcer did not receive required weekly skin integrity assessments, as documentation was only completed once despite facility policy and a QAPI intervention. The DON and NHA confirmed that the facility failed to consistently perform and document these evaluations for a high-risk individual.
A CNA failed to provide complete perineal care to a resident with severe contractures and cognitive impairment, cleaning only the anal area and omitting care to the vaginal area after a bowel movement. The omission was confirmed by interviews with the CNA, RN, and DON, and was not in accordance with facility policy or professional standards.
Surveyors found a box of moldy oranges with gnats and an unsealed bag of food thickener exposed to air during a kitchen tour. Dietary staff and management confirmed that these items were not properly stored or disposed of, in violation of facility policy, and acknowledged the potential for foodborne illness due to these lapses.
Staff failed to follow hand hygiene protocols during wound and perineal care for a resident with multiple diagnoses and severe cognitive impairment. A nurse did not perform hand hygiene at each step of wound care, and a CNA did not sanitize hands before donning gloves for perineal care. Facility leadership confirmed these actions did not comply with infection prevention policies and placed the resident at risk for infection.
Two residents with cognitive impairments were subjected to physical and verbal abuse by a CNA, with incidents witnessed by other staff who failed to report the abuse immediately due to fear of retaliation. The delay in reporting resulted in the CNA continuing to work with vulnerable residents for several days, contrary to facility policy and placing residents at risk.
Two residents, both with cognitive impairments, experienced physical and verbal abuse by a CNA, which was witnessed by other CNAs who failed to intervene or report the incidents immediately due to fear of retaliation, despite being trained on the facility's abuse policy and reporting requirements.
Staff failed to promptly report and investigate multiple incidents of physical and verbal abuse involving two residents, with delays attributed to fear of retaliation and oversight. Required notifications to the Administrator and State Agency were not made within mandated timeframes, resulting in Immediate Jeopardy and Substandard Quality of Care.
A resident with Parkinson's Disease and dementia, who exhibited aggressive behaviors, did not receive care in accordance with their individualized care plan. During an episode of agitation, staff failed to follow prescribed interventions such as stepping away and returning later, resulting in inappropriate physical handling and a nosebleed. Facility staff and leadership confirmed the care plan was not followed.
Due to a staffing shortage, only one CNA was present during an overnight shift, leaving a resident with an overactive bladder and urinary incontinence without timely care and resulting in the resident remaining soiled all night. Attempts by LPNs to contact the DON and scheduler for assistance were unsuccessful, and no additional staff could be secured.
The facility's assessment failed to specify staffing needs by shift, lacked a recruitment and retention plan, and did not include contingency planning for non-emergency situations. As a result, a resident with an overactive bladder was left in urine overnight when only one CNA was on duty, highlighting insufficient staff coverage and planning.
Daily nurse staffing information was not posted in a visible and accessible location for two consecutive days. Multiple staff, including LPNs and the DON, confirmed the absence of required postings, and no alternative location was identified. This failure limited access to staffing information for residents, families, and the public.
Care Plan Not Updated After Repeated Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan to reflect actual falls and related interventions for one resident with a focus for falls related to confusion. The resident had a care plan that included an intervention for bed in low position dated 4/1/24, but the plan was not updated to include two actual falls that occurred on 3/27/26 or the interventions associated with those events. The resident’s record showed a diagnosis of metabolic encephalopathy and a 5-day MDS with a BIMS score of 4, indicating severely impaired cognition. On 3/27/26, the resident was found on the floor at 7:10 AM and was sent to the emergency room. Later that same day, after returning from the hospital, the resident was again found on the floor at 2:59 PM. The clinical record did not contain a facility fall investigation for the first fall, and the fall investigation completed for the later event described the resident as noted on the floor face down, in between the bed and end table. Staff interviews confirmed the resident had two falls that day, and the RN stated the interventions used after the fall included keeping the bed low and therapy services, although bed in low position had already been listed on the care plan and therapy services was not listed as an intervention.
Failure to Investigate Initial Fall and Maintain Bed in Low Position
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible when it did not investigate an initial fall, did not ensure the resident’s bed was maintained in a low position, and did not consistently implement interventions to prevent recurrence for one resident reviewed for accidents. The resident had been admitted on 3/8/25 and had diagnoses including metabolic encephalopathy; the 5-day MDS showed a BIMS score of 4, indicating severely impaired cognition. On 3/27/26 at 7:10 AM, nursing staff found the resident on the floor and called an ambulance service, but there was no facility fall investigation completed for that fall. Later that same day, after the resident returned from a hospital, nursing documentation and staff interviews described the resident being found on the floor again within minutes, lying face down between the bed and end table. An EMT student stated the resident had been placed in bed with the bedrails raised and the head of the bed elevated before EMS left, and RN #1 confirmed the bed was elevated when she briefly left the room to get vital sign equipment. RN #1 also stated the first fall had not been investigated before her arrival.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure bed rails were assessed for clinical indication, safety, and resident need, and failed to obtain informed consent for bed rail use for one sampled resident. The facility policy on Proper Use of Bed Rails, dated 11/7/25, stated that a person-centered approach must be used when determining bed rail use, that the resident assessment must include evaluation of alternatives attempted before installation or use of a bed rail and how those alternatives failed to meet the resident’s assessed needs, and that the resident’s risk from using bed rails must also be assessed. On 5/6/26, surveyors observed Resident #1 sitting in a wheelchair in her room with quarter-length bedrails raised on both sides of the bed. Review of the resident’s clinical record found no bed rail assessments and no informed consent records for bed rail use. The DON confirmed on 5/7/26 that there was no bedrail assessment or informed consent record related to bedrail use and stated the facility had recent electronic health record system updates and the informed consent may have been misplaced in medical records. Resident #1 was admitted on 3/8/25 and had diagnoses including metabolic encephalopathy; her 5-Day MDS dated 5/5/26 showed a BIMS score of 4, indicating severely impaired cognition.
Failure to Immediately Report Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse prevention policy when an LPN did not immediately notify the Administrator or designee of an abuse allegation involving one resident. The facility policy stated that all allegations of abuse, neglect, exploitation, or mistreatment are to be reported immediately to the Administrator, and that the licensed nurse is to notify the Administrator or designee when suspicion of abuse occurs. The resident involved was admitted with diagnoses including abnormalities of gait and mobility, and a later MDS assessment showed a BIMS score of 13, indicating the resident was cognitively intact. On 8/5/25, the resident reported to an LPN that a CNA had told him not to touch his call bell again or she would put something on him. The LPN spoke with the CNA in the resident’s room, and the CNA said she was joking and apologized. The resident responded that it was fine and that he was done with it. The LPN did not report the allegation to the DON or Administrator at that time because she believed the resident was fine after the apology. The allegation was not brought to the DON until the next day, when the resident repeated the concern to another LPN, who then immediately notified the DON. During interviews, the LPN acknowledged she knew she should have safeguarded the resident and immediately notified the Administrator or DON, and the DON confirmed she was not informed until the following day.
Repeated Deficiency in Resident Nail Care Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) plan, as evidenced by a repeated deficiency related to resident grooming. Specifically, the facility was cited for not ensuring that a resident's nails were clipped, an issue that was previously identified in a prior annual recertification survey. During the most recent survey, a resident was observed with long and jagged toenails and expressed that she had not received assistance with nail care, despite requesting help. This observation was supported by staff and resident interviews, as well as a review of facility policies and prior statements of deficiencies. Interviews with facility leadership revealed a lack of clarity regarding the reasons for non-adherence to the previous plan of correction for Activities of Daily Living (ADL) care. The Administrator was unable to specify why the plan was not being followed, while the DON suggested that staff may be overlooking nail care during routine grooming. The facility's policy on QAPI, which outlines the establishment of performance indicators and systematic actions to improve performance, was reviewed but not effectively implemented to prevent recurrence of the deficiency.
Failure to Provide Necessary ADL Assistance for Grooming and Hygiene
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and physical limitations did not receive necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene. Observations revealed the resident had long, visible facial hair on her chin and upper lip, as well as long, jagged toenails. The resident expressed a desire for assistance with hair removal and toenail trimming, stating that staff had not provided this help and that she was unable to perform these tasks herself due to her health challenges. Interviews with staff confirmed that grooming tasks, including facial hair removal, are the responsibility of CNAs during daily ADL care, and toenail trimming is assigned to LPNs. Staff members were not aware of the resident refusing care, and both the DON and LPN confirmed that these services should have been provided. The facility's policy requires staff to encourage resident participation in ADLs and provide assistance as necessary, but this was not followed for the resident in question.
Failure to Individualize Call Light System for Blind Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a blind resident by not individualizing the call light system to ensure accessibility. The resident, who is legally blind and cognitively intact, reported being unable to see or reach the call light in her private room. She stated that even when the call light was within reach, she could not determine if it was functioning, leading her to feel uncertain and vulnerable when needing assistance. Multiple interviews with staff, including a CNA and an LPN, confirmed that the call light was attached to the wall at the foot of the bed and was not accessible to the resident. Staff acknowledged that the call light was not placed within the resident's reach during the night and that this was a consistent issue. Observations conducted by surveyors corroborated the resident's statements, as the call light was repeatedly found out of reach. The Director of Nursing also recognized the need for a more accessible device for residents with vision impairments. The facility's policy on resident rights was reviewed, which mandates that residents are not deprived of their rights, but the policy was not followed in this case. The resident's medical record confirmed her legal blindness and anxiety disorder, further emphasizing the necessity for individualized accommodations that were not provided.
Failure to Document Weekly Skin Integrity Assessments for High-Risk Resident
Penalty
Summary
The facility failed to ensure ongoing assessment and documentation of skin integrity for a resident at high risk for skin breakdown. According to facility policy, a licensed nurse is required to complete and document a total body skin evaluation weekly for each resident. However, for one resident with a history of contractures and a stage 3 pressure ulcer, the Weekly Skin Integrity Review was only documented once, with no further weekly assessments recorded as required. This lapse occurred even after a QAPI intervention was initiated, and the lack of documentation persisted. Interviews with the DON confirmed that the facility was aware of the missed reviews but did not effectively implement the QAPI plan, resulting in continued failure to document weekly skin checks for the high-risk resident. The NHA also acknowledged that the facility did not follow through with its internal corrective strategies. The resident in question had severely impaired cognition and required ongoing wound care for a stage 3 pressure ulcer, as indicated by physician orders and clinical records.
Incomplete Perineal Care Provided to Resident with Contractures
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to provide complete perineal care to a resident with a history of muscle contractures and severely impaired cognition. During an observed wound care session, the CNA cleaned only the anal area after a bowel movement, neglecting to clean the front vaginal area as required by facility policy and professional standards. The CNA did not perform hand hygiene upon re-entering the room before donning gloves and did not follow the protocol of cleaning from front to back to avoid contamination. Interviews with the CNA, the Registered Nurse (RN) assisting with wound care, and the Director of Nursing (DON) confirmed that the perineal care was incomplete and not performed according to policy. The staff acknowledged that the resident, who was contracted and difficult to clean, did not receive care to the vaginal area, which was required. The facility's policy and staff statements indicated that the omission placed the resident at risk for complications.
Improper Food Storage and Disposal in Dietary Services
Penalty
Summary
During a kitchen tour, surveyors observed a ten-pound box of Sunkist oranges under a prep table that was three-fourths full and contained three oranges with black and white mold. Gnats were seen flying out of the box when it was opened. Additionally, an unsealed bag of food thickener with a hole in it was found exposed to the air. Both items were not properly stored or disposed of according to the facility's food preparation policy, which requires staff to avoid contamination by harmful agents. Interviews with dietary staff and management confirmed that the oranges had been received earlier in the month and should have been discarded, and that the thickener should have been sealed and dated. The Dietary Manager acknowledged responsibility for checking behind the cook, and the cook admitted to not paying attention to proper storage procedures. The Director of Food Services and the Nursing Home Administrator both confirmed that these lapses could lead to foodborne illness and that staff are expected to maintain proper food storage and dating compliance.
Failure to Follow Hand Hygiene Protocols During Wound and Perineal Care
Penalty
Summary
The facility failed to provide perineal and wound care in a manner that prevents the spread of infection for two of five observed care events involving a resident with multiple diagnoses, including contracture of muscle and essential hypertension, and severely impaired cognition. During wound care, the registered nurse did not perform hand hygiene after initiating the procedure, and the certified nursing assistant did not sanitize hands before applying clean gloves after returning to the room to assist with perineal care. Both staff members acknowledged their lapses in hand hygiene, with the CNA admitting to forgetting to wash hands and the RN confirming failure to perform hand hygiene at each step of the wound care process, including after cleansing, drying, applying collagen, and dressing the wound. Interviews with the infection preventionist and the director of nursing confirmed that both staff members did not follow facility policies regarding hand hygiene and glove changes during wound and perineal care. The facility's policies require hand hygiene before and after care, as well as glove changes and hand sanitization at each phase of wound care. The staff's failure to adhere to these protocols placed the resident at risk for wound and urinary tract infections, as confirmed by the facility's leadership during interviews.
Failure to Protect Residents from Abuse Due to Delayed Reporting and Inaction
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by two separate incidents involving a certified nurse aide (CNA). In one incident, a CNA was witnessed physically abusing a resident with Parkinson's Disease and Dementia, who had moderately impaired cognition. The CNA grabbed the resident's nose and twisted it, causing bleeding, and made a derogatory comment. In another incident, the same CNA verbally threatened a different resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene, by stating she would beat the resident if she soiled the bed again. Both incidents were witnessed by other CNAs. Despite these events, the staff members who witnessed the abuse did not immediately report the incidents to the nurse, DON, or Administrator. The witnesses cited fear of retaliation and concerns about job security as reasons for not reporting. As a result, the Administrator was not informed of the allegations until ten days after the initial incident, leaving the residents and others vulnerable during that period. Interviews with additional staff revealed that the CNA in question was known to speak to residents in an aggressive or angry manner, but this behavior was dismissed by some staff as part of her personality and not reported to management. The facility's own policy required immediate reporting and action in cases of abuse, but this was not followed. The delay in reporting and lack of immediate protective action allowed the CNA to continue working with vulnerable residents, placing them at risk for further harm. The deficiency was identified through interviews, record reviews, and the facility's internal investigation, which substantiated the abuse allegations based on staff witness statements.
Removal Plan
- Quality Assurance (QAPI) Committee met to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees included the Executive Director, Minimum Data Service nurse, Medical Records, Regional Director of Clinical Services, Assistant Director of Nursing, Medical Director, Social Services, Staff Development/Infection Preventionist nurse, Activities Director, Human Resources, Housekeeping, Dietary Manager, Therapy director, Unit Managers, and the Admission Coordinator. No changes were made to the policy and procedure. The areas discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse were identified.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2. No residents voiced complaints of abuse.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse.
- The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements and 100% has been completed.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Implement Abuse Policy and Immediate Reporting
Penalty
Summary
The facility failed to implement its abuse policy, resulting in two incidents of abuse involving two residents. In the first incident, a resident with Parkinson's Disease and Dementia, who had a moderately impaired cognitive status, was physically abused by a CNA during care. The CNA responded to the resident's combative behavior by grabbing and twisting the resident's nose, causing it to bleed, and made a derogatory comment. This act was witnessed by another CNA, who did not immediately report the incident or intervene effectively, despite being aware of the facility's abuse policy and having received training on the obligation to report abuse. In the second incident, another resident with severe cognitive impairment and dependent on staff for toileting hygiene was verbally abused by the same CNA. The CNA threatened the resident with physical harm if the resident soiled the bed again. This was overheard by a different CNA, who confronted the abusive CNA but also failed to report the incident at the time. Both witnessing CNAs later admitted they did not report the abuse immediately due to fear of retaliation from other staff members, even though they were aware of the reporting requirements outlined in the facility's policy. The facility's policy required all employees to report any witnessed or known abuse within two hours to the Administrator and other officials as per state law. However, the incidents were not reported until anonymous letters were received by the Administrator, leading to a delayed response. The failure of staff to intervene and promptly report the abuse placed the affected residents and others at risk for further abuse and constituted a violation of residents' rights to be free from abuse.
Removal Plan
- Quality Assurance (QAPI) Committee reviewed, developed, and implemented the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee reviewed the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse to the state agency, attorney general and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse.
- The Staff Development nurse started education with licensed nurses, CNAs and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report suspected abuse within the required two-hour timeframe and did not submit a completed investigation for an allegation of abuse within five working days, as required by regulation. Two residents experienced abuse by a CNA, with one incident involving physical abuse resulting in a nosebleed and verbal abuse, and another incident involving verbal threats. Both incidents were witnessed by other CNAs, but neither was reported immediately due to fear of retaliation from staff. The abuse was only reported ten days after the initial incident, when anonymous letters were left for the Administrator. The facility's policy required any employee who witnesses or has knowledge of abuse, neglect, exploitation, or mistreatment to report the information within two hours to the Administrator and other officials in accordance with state law. Despite this, the CNAs who witnessed the abuse did not report it promptly, leaving residents at risk for continued abuse. The Administrator became aware of the incidents only after receiving anonymous letters, at which point the accused CNA was suspended and subsequently terminated. Additionally, the facility failed to submit a final investigation report to the State Agency within five working days for a separate allegation of verbal abuse involving another resident. The Administrator and DON acknowledged that the final report was not sent due to the DON's illness and oversight, despite being aware of the requirement. This failure to report and investigate in a timely manner was determined to be Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- Quality Assurance (QAPI) Committee met to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees included the Executive Director, MDS nurse, Medical Records, Regional Director of Clinical Services, Assistant Director of Nursing, Medical Director, Social Services, Staff Development/Infection Preventionist nurse, Activities Director, Human Resources, Housekeeping, Dietary Manager, Therapy director, Unit Managers, and the Admission Coordinator. No changes were made to the policy and procedure. The areas discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse were identified.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2. No residents voiced complaints of abuse.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse within 2 hours to the state agency, attorney general, and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse.
- The Staff Development nurse started education with licensed nurses, CNAs, and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements and 100% was completed.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.
Failure to Implement Comprehensive Care Plan Interventions for Resident with Behavioral Needs
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident with diagnoses including Parkinson's Disease and dementia, who exhibited behaviors such as occasional physical and verbal aggression. The resident's care plan, revised to address these behaviors, included specific interventions such as intervening before agitation escalates, guiding the resident away from distress, engaging calmly in conversation, and, if aggression occurred, staff were to walk away and return later. Despite these documented interventions, staff did not follow the care plan during an incident where the resident became agitated and physically aggressive during incontinence care. During the incident, a CNA held the resident's hands and attempted to reassure her, but the resident pulled away and grabbed another CNA by the hair. In response, the second CNA grabbed the resident's nose and twisted it, causing a nosebleed, and made an inappropriate comment. Interviews with staff and facility leadership confirmed that the care plan was not followed, as staff did not step away and allow the resident time to calm down before reattempting care, contrary to the established interventions for managing the resident's behaviors.
Insufficient Staffing Leads to Resident Left Soiled Overnight
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in a resident being left soiled throughout the night. On the overnight shift in question, only one CNA was present in the facility, despite the staffing grid indicating that more were needed. Three CNAs failed to call in for their shift, and attempts by the LPN on duty to contact the DON and the scheduler for assistance were unsuccessful. The LPN was given a list of potential replacements, but none were available, and no further support was provided by facility leadership. As a result of the staffing shortage, a resident with a diagnosis of overactive bladder and documented as always incontinent of urine was unable to receive timely incontinence care. The resident reported being left in urine for the entire night, causing discomfort. The resident was cognitively intact and able to clearly describe the incident, stating that the lack of staff directly led to her needs not being met.
Facility Assessment Lacks Required Staffing Details and Contingency Planning
Penalty
Summary
The facility failed to include all required elements in its Facility Assessment, specifically omitting detailed staffing needs by shift, a plan for recruitment and retention of staff, and contingency planning for situations that do not require activation of the emergency operations plan. The Facility Assessment only identified total staffing numbers needed over a 24-hour period and did not specify requirements for each eight-hour shift or account for changes in the resident population. During an interview, the Administrator acknowledged a lack of awareness regarding the federal requirement to address staffing by shift and confirmed the assessment's deficiencies. Additionally, a resident interview revealed that on one overnight shift, only one CNA was present, resulting in the resident being left in urine throughout the night due to insufficient staff coverage. The resident, who has an overactive bladder and is always incontinent of urine, expressed discomfort and noted the absence of contingency plans for staffing shortages. Review of facility records confirmed the resident's medical condition and the staffing grid for the shift in question, substantiating the reported deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a visible and accessible location for two out of three survey days. Observations on multiple occasions revealed that the required staffing postings were not present in the designated area near the copier room in a glass case, nor was an alternative posting location identified. Interviews with LPNs and the Director of Nursing confirmed that the staffing information was not posted as required, and a review of facility records showed that postings were missing for the specified days. The Administrator acknowledged that the postings were not present for the previous two days and attributed the lapse to an oversight, despite internal tracking of staffing. The absence of posted staffing information limited residents, family members, and the public from accessing required information and impeded transparency regarding facility staffing levels, as confirmed by staff interviews and record review.
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 29 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 Meridian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trend Health & Rehab Of Meridian Llc | 0.4 mi | ★★★★★ | 2 | 0 |
| Diversicare Of Meridian | 0.8 mi | ★★★★★ | 3 | 0 |
| Arabella Health & Wellness Of Meridian | 2.4 mi | ★★★★★ | 1 | 0 |
| Bedford Care Center Of Marion | 2.5 mi | ★★★★★ | 9 | 0 |
| Poplar Springs Nursing Ctr, Llc | 2.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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