Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Continental Care And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that during ongoing plumbing repairs, one end of the kitchen had large sheets of bare, stained plywood laid over missing tile, with surrounding floor areas showing debris and stains. Staff reported that holes had been dug under the flooring to fix drainpipes over the prior two weeks, and that plastic sheeting and tenting were used to contain dust and construction materials. Staff also stated they used plywood to avoid a tripping hazard and were waiting for new tile to arrive. These conditions did not comply with the FDA Food Code and the facility’s sanitation policy requiring cleanable, sanitary nonfood-contact surfaces and clean food service areas.
The facility did not provide meals at scheduled times, resulting in multiple residents waiting extended periods for food, with some meals arriving late and cold. Staff and residents reported ongoing delays, particularly in certain wings, and documentation showed inconsistencies between posted mealtimes and actual service. Staffing issues and process problems contributed to the deficiency, affecting both dining room and in-room meal delivery.
Staff routinely left medications with residents to take on their own without documented safety assessments or physician orders, and care plans did not address self-administration or monitoring. Some residents had cognitive or psychiatric conditions and were unsure about their medications, while staff showed inconsistent understanding of required procedures. Facility policy required interdisciplinary assessment and documentation, which was not completed.
A resident's POLST form indicated Do Not Attempt Resuscitation, but the EHR incorrectly listed the resident as Full Code/Full Treatment. Staff confirmed that social services are responsible for reviewing POLST forms and ensuring accuracy, and facility policy requires documentation and communication of resident choices, but this was not followed, resulting in a mismatch between the resident's wishes and the EHR.
Surveyors found that prescribers did not provide adequate, patient-specific documentation when declining pharmacist-recommended gradual dose reductions (GDR) for psychotropic medications in three cases. Instead, responses were vague or lacked clinical justification, and staff were unaware of proper documentation requirements, resulting in insufficient records to support continued use of these medications.
Multiple residents were observed smoking unsupervised in unauthorized areas, including a blind resident with a history of unsafe smoking and falls. Staff were aware of ongoing violations but did not consistently enforce the facility's no-smoking policy or monitor residents as required. Smoking materials were kept by residents, care plans were incomplete or not followed, and required safety equipment was not used, resulting in increased risk of fire and injury.
A resident with significant vision loss due to cataracts was not properly assessed for vision needs, as staff failed to identify or document the impairment during care conferences and on the MDS. The resident was unable to read or see her food, yet the assessment inaccurately reflected no vision concerns.
A resident with documented bowel and bladder incontinence did not have these conditions addressed in their comprehensive care plan, despite assessment data and facility policy requiring care planning for incontinence. Staff acknowledged the omission and indicated the care plan may not have been completed.
A resident with impaired vision was unable to access necessary eye care and surgery due to the facility's failure to schedule and maintain appointments and arrange timely transportation. Multiple appointments were missed or canceled without proper communication, leading to the resident being refused by provider offices. Staff interviews revealed confusion over scheduling responsibilities, and the resident's care plan lacked interventions for vision needs.
The facility did not ensure that POLST forms were accurately completed for two residents, with one form missing the correct first name and another lacking the required patient or decision-maker signature. Staff confirmed that these forms should be reviewed for accuracy and completeness upon admission and that code status information should be consistent between the POLST and the EHR.
The facility failed to provide therapeutic meals according to physician orders for two dialysis residents. Observations and interviews revealed that meals were high in sodium, contrary to the prescribed renal diets. Residents reported excessively salty food, and staff acknowledged that therapeutic diet orders were not consistently followed, with meals often served late.
The facility failed to provide scheduled showers for three residents, resulting in deficiencies in hygiene care. A resident was found in a filthy condition with a matted ponytail, while another reported infrequent shower offers, often late at night. A third resident indicated a need for a shower, with records showing no showers since admission. These findings highlight the facility's failure to adhere to scheduled hygiene care.
The facility failed to maintain adequate CNA staffing levels, resulting in residents experiencing long wait times for call light responses and missed showers. Staff interviews and observations revealed that insufficient staffing led to delays in meeting residents' needs, with staff often working beyond their shifts without breaks. The facility's actual staffing ratios did not meet the recommended levels, contributing to the deficiencies in resident care.
A resident in a dementia care unit exhibited aggressive behaviors, including physical altercations with another resident and staff, due to the facility's failure to conduct thorough assessments and implement effective interventions. Despite a history of aggression, the resident's care plan was not updated, and behavioral health services were not adequately pursued, leading to ongoing risks for staff and residents.
A facility failed to adhere to professional standards by administering oxycodone and lorazepam concurrently to a resident with COPD, despite warnings of potential side effects. The medications were given together on multiple occasions, although the resident did not have a condition justifying this practice. Staff interviews confirmed awareness of the risks, yet the practice persisted.
The facility failed to maintain sanitary conditions and proper storage in the kitchen, affecting all residents consuming food prepared or stored there. Issues included staff not wearing hairnets, food stored on the floor, a dirty ice machine, expired and undated food items, and a dirty fan pointed towards the dish pit.
The facility failed to complete baseline care plans within the required 48-hour timeframe for 8 out of 25 sampled residents, leading to potential unmet needs. Interviews revealed that the admitting nurse was responsible for initiating these plans, but the facility's policy was not followed.
The facility failed to complete comprehensive, person-centered care plans for four residents requiring oxygen therapy. The care plans lacked necessary details such as the type of oxygen delivery system, when to administer the oxygen, equipment settings, and monitoring of oxygen saturation levels. Staff were also unsure how to access care plans for some residents.
The facility failed to label oxygen tubing and follow physician orders for oxygen administration for two residents. One resident's oxygen tubing was not labeled, and the oxygen concentrator was set incorrectly. Another resident's oxygen concentrator was set higher than the prescribed amount.
The facility failed to serve meals at a palatable temperature for seven residents receiving room trays. Observations and interviews revealed that hot food was often lukewarm or cold by the time it reached the residents' rooms, with inadequate practices for maintaining food temperature during transport.
The facility failed to adhere to infection control practices and proper PPE use during a COVID-19 outbreak involving two residents. Observations showed that the door to the room of two COVID-19 positive residents was left open, and staff did not perform hand hygiene or change PPE when moving between rooms and handling food trays. Despite documented training, staff claimed to have never been educated on proper PPE use.
The facility failed to address the extended duration of antibiotic use for three residents through its Antibiotic Stewardship Program. Despite being aware of the issue, staff reported that prescribing providers refused to discontinue the medications, which did not align with national guidelines or the facility's policy.
The facility failed to update a resident's care plan after the resident, who was severely cognitively impaired, pulled out their PICC line. Despite multiple attempts to contact the facility for more information, no response was received. The care plan was not revised as required by the facility's policy.
The facility failed to follow a dietician's recommendations for a carbohydrate-controlled diet for a resident, resulting in elevated blood sugar levels. The resident was served a meal with higher carbohydrate content than prescribed, and staff confirmed the meal did not meet the dietary order.
The facility failed to ensure accurate MDS assessments for six residents, incorrectly coding bedrails used for mobility as restraints. Staff interviews revealed a lack of understanding regarding the definition of restraints, leading to discrepancies between actual use and documentation.
Unsanitary Kitchen Flooring During Ongoing Plumbing Repairs
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions in the kitchen where food was stored, prepared, and served. During observation, two large four-by-eight-foot sheets of bare plywood were found laid over areas of missing tile on one end of the kitchen floor. The plywood had various black stains and was an uncleanable surface that could not be properly maintained for cleanliness. The surrounding tile floor also had scattered debris and white/gray stains. Staff explained that maintenance had dug holes under the flooring to fix drainpipes and that this construction had been ongoing for approximately two weeks, occurring at night when the kitchen was not in use. Staff reported that plastic sheeting and permanent tenting had been hung around the construction areas to contain dust, sand, and concrete debris. One staff member stated he did not know what else to use to cover the missing tile and wanted to avoid creating a tripping hazard. Another staff member stated the floor would be fixed once new tile arrived, expected in about a week. Review of the FDA 2022 Food Code and the facility’s sanitation policy showed requirements that nonfood-contact surfaces be kept free of dust, dirt, food residue, and other debris, and that all food service areas be kept clean, sanitary, and free from litter and rubbish. The observed conditions in the kitchen did not meet these standards.
Failure to Serve Meals at Scheduled Times Resulting in Delayed and Cold Food
Penalty
Summary
The facility failed to provide meals at the regularly scheduled times for five of twenty-five sampled residents, as evidenced by multiple observations and interviews. Residents reported and were observed waiting for extended periods past posted mealtimes, with some meals being delivered up to two hours late. Several residents were found in their rooms or dining areas without food, despite the posted and documented mealtimes indicating when meals should have been served. Staff confirmed that meal delivery was consistently late, particularly for certain wings, and that food was often cold when it finally arrived. Residents expressed dissatisfaction with the timeliness and quality of meal service, with some stating they were forced to order food from outside sources due to hunger or unpalatable, cold meals. Observations showed residents seated with only drinks for prolonged periods, and some residents, such as one who was hungry but had not eaten, had untouched trays delivered late. Staff interviews revealed that dietary staffing fluctuations and process issues contributed to the delays, and that certain wings routinely received meals after others, resulting in predictable lateness for those residents. Documentation provided by the facility showed inconsistencies between posted mealtimes, the mealtime policy, and actual meal delivery times. Staff acknowledged that meal service was not consistent with the documented schedules, and that recent staffing shortages further exacerbated the delays. The deficiency had the potential to affect all residents in the facility, as the late meal service was observed across multiple units and affected both residents in dining rooms and those receiving room trays.
Failure to Assess and Document Resident Safety for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and found safe to self-administer their own medications before allowing them to do so. Observations revealed that staff routinely left cups of medications at residents' bedsides or on meal trays, allowing residents to take their medications independently without direct supervision. In several cases, residents did not immediately take the medications, and some expressed uncertainty about the purpose of the medications or the conditions they were treating. Record reviews for the affected residents showed that there were no documented assessments for the safety of self-administration of medications, nor were there physician orders authorizing self-administration in the electronic health records (EHRs). Care plans for these residents did not reference their ability to self-administer medications or outline any monitoring procedures. For example, one resident with impaired cognitive function and another with a diagnosis of major depressive disorder and delusional disorders were both left to self-administer medications without documented evaluation of their capacity to do so safely. Interviews with staff revealed inconsistent understanding of the facility's procedures regarding self-administration of medications. While one staff member believed that no physician order or assessment was required, another stated that both were necessary, along with a risk/benefit discussion. The facility's own policy required an interdisciplinary team assessment, documentation in the medical record, and care plan updates for residents self-administering medications, none of which were found in the reviewed cases.
Failure to Accurately Reflect Resident Code Status in EHR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in the electronic health record (EHR) in accordance with the resident's completed POLST form. Upon review, the resident's POLST form indicated a preference for Do Not Attempt Resuscitation, while the EHR incorrectly listed the resident as Full Code/Full Treatment. Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of the POLST upon admission, and facility policy requires that any decisions regarding a resident's choices be documented in the medical record and communicated to the care team. However, this process was not followed, resulting in a discrepancy between the resident's documented wishes and the information available to staff in the EHR.
Failure to Document Rationale for Declining Gradual Dose Reductions of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were attempted or that adequate, patient-specific rationales were documented when GDRs were not performed for three residents. For one resident with dementia, the pharmacist recommended a GDR for Seroquel, but the prescriber declined with only a general statement that the patient was stable, without further clinical justification. Another resident was on Sertraline, and the prescriber responded to the pharmacist's GDR recommendation with a vague comment that "things look good," lacking any specific rationale for maintaining the current dose. A third resident was receiving Duloxetine, Trazodone, and Provigil, and the prescriber declined the pharmacist's GDR recommendations for all three medications without documenting patient-specific reasons for not attempting dose reductions. Additionally, a staff member interviewed was unaware of the documentation requirements for supporting or declining GDRs and was behind on addressing pharmacy recommendations due to personal issues. The facility's policy requires that residents on psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated, with clinical rationales documented when GDRs are not attempted. However, the medical records reviewed did not contain adequate documentation to support the continued use of psychotropic medications at the current doses or to explain why GDRs were clinically contraindicated.
Failure to Enforce Smoking Safety Policies and Supervision
Penalty
Summary
The facility failed to follow its own smoking safety policies and procedures for residents who smoke, resulting in multiple deficiencies. Several residents, including one who is blind and at high risk for falls and injury, were observed smoking unsupervised in unauthorized areas, such as immediately outside the activity room door and on the sidewalk, rather than in the designated smoking area. Staff interviews confirmed that residents regularly smoked in these locations, especially during inclement weather, and that staff were aware of the violations but did not consistently intervene or enforce the rules. Cigarette butts were observed littering the ground around these unauthorized smoking areas, indicating ongoing noncompliance. Residents who smoked were not consistently assessed or monitored according to facility policy. One resident, who was blind and had a history of unsafe smoking behavior and prior property damage, was allowed to keep smoking materials in his possession and was not required to sign out when leaving to smoke. His care plan indicated he was unsafe to smoke independently, yet he continued to do so without supervision. Another resident, who required a smoking apron for safety, was not documented as a smoker in his care plan and was observed smoking without the required apron. A third resident reported never being assessed for safe smoking practices and was also observed keeping smoking materials in his room and smoking in unauthorized areas. Staff interviews revealed a lack of consistent enforcement of smoking policies, with some staff deferring responsibility to others or citing resident noncompliance and belligerence as barriers to enforcement. The facility's written policy stated that no accommodations for smoking or tobacco products would be made and that such products were not permitted on the premises, yet this policy was not followed in practice. These failures occurred across multiple shifts and days, involving several staff members and placing residents and others at risk of exposure to second-hand smoke, fire, and injury.
Failure to Accurately Assess Resident's Vision Needs
Penalty
Summary
The facility failed to accurately assess the vision needs of a resident, resulting in an incomplete comprehensive assessment. The resident reported significant vision deterioration since October 2024 due to cataracts and demonstrated an inability to read or see her food during observation. Despite these issues, staff did not identify or address any vision concerns for the resident during care conferences, and no vision needs were documented or reported on the Minimum Data Set (MDS). The MDS inaccurately indicated that the resident could see fine detail and did not use corrective lenses. Facility policy requires comprehensive assessment of vision needs through direct observation and communication, which was not followed in this case.
Failure to Include Bowel and Bladder Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan addressing bowel and bladder incontinence for one resident. Review of the resident's Admission MDS indicated that the resident was always incontinent of bowel and bladder, and the Care Area Assessment Summary showed that bladder incontinence had triggered and should have been included in the care plan. The resident's Baseline Care Plan documented frequent incontinence, but the comprehensive care plan did not reflect this condition. During an interview, a staff member acknowledged that bowel and bladder incontinence should be included in the care plan and noted that the resident was relatively new, suggesting the care plan may not have been completed. Facility policy requires the MDS Coordinator and Interdisciplinary Team to review and revise care plans based on resident condition, but this process was not followed for the resident in question.
Failure to Assist Resident with Vision Care Appointments and Transportation
Penalty
Summary
A resident with deteriorating vision experienced significant barriers in accessing necessary vision care services due to the facility's failure to make and maintain timely appointments and arrange appropriate transportation. The resident reported that several appointments had been made and canceled by the facility without her knowledge or notification to the provider offices, resulting in her being late or missing multiple appointments. As a result, some provider offices refused to see her as a patient, and she was unable to receive recommended cataract surgery after being late to a surgeon's appointment. The resident expressed frustration and distress over her inability to participate in activities she enjoyed and her increasing fear of moving around the facility due to her poor eyesight. Interviews with facility staff revealed confusion and lack of communication regarding who was responsible for scheduling and assisting with outside appointments. The new scheduler was unaware of any upcoming vision appointments for the resident, and other staff members either did not know about the resident's vision concerns or denied responsibility for appointment coordination. Review of the resident's care plan showed no documented goals or interventions related to vision appointments, and progress notes contained minimal references to vision care over a six-month period. This lack of coordination and documentation directly contributed to the resident's unmet vision care needs.
Incomplete and Inaccurate POLST Documentation
Penalty
Summary
The facility failed to accurately complete and maintain Physician Orders for Life-Sustaining Treatment (POLST) forms for two residents. For one resident, the POLST form did not contain the resident's correct first name, as it was neither the resident's first name, middle name, nor a name the resident used. For another resident, the required signature of the patient or their decision-maker was missing from the POLST form that was placed in the electronic health record (EHR). Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of POLST forms upon admission, and that the code status on the POLST should match the EHR and be properly signed.
Failure to Provide Therapeutic Meals for Dialysis Residents
Penalty
Summary
The facility failed to provide therapeutic meals that adhered to physician orders for two dialysis residents. Observations and interviews revealed that the meals served to these residents were high in sodium, contrary to their prescribed renal diets. One resident reported that the soup served was excessively salty, and the meal included a roast beef sandwich and a mix of green and kidney beans, which were left untouched. The resident expressed concerns about managing dialysis with a restricted water intake and reported frequent diarrhea. Another resident also noted the saltiness of the food, which included a turkey sandwich with cheese, soup, and saltine crackers. Both residents had physician orders for a renal diet, which requires low sodium intake. Interviews with staff indicated that therapeutic diet orders were not consistently followed, and meals were often served late. The staff member acknowledged that the food trays were similar and did not align with the specific dietary needs of the residents, including those on renal diets. The report references guidelines from the CDC and FDA, highlighting the importance of limiting sodium intake for dialysis patients to prevent complications such as electrolyte imbalances and diarrhea. The failure to provide appropriate meals as per physician orders represents a deficiency in the facility's dietary management for residents requiring therapeutic diets.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers for three of the six sampled residents, leading to deficiencies in hygiene care. Resident #1 was reported to have visited another facility in a filthy condition, with significant body odor and a matted ponytail, raising concerns about potential hair loss. Despite being scheduled for showers twice a week, resident #1 only received four showers in the past 30 days, with one documented refusal. Resident #3 reported that his last shower was on a previous Saturday and expressed dissatisfaction with the timing of shower offers, which were often late at night. His electronic health record (EHR) showed a refusal at 3:00 a.m. on the day of the interview, although he stated he rarely refused showers. Resident #8 indicated a need for a shower and stated she had never refused one. Her EHR showed she was scheduled for showers twice a week, but there was no documentation of a shower since her admission. The record showed a refusal on a day not scheduled for a shower and a 'Not Applicable' status on a scheduled day, indicating a lack of showers since admission. These findings highlight the facility's failure to adhere to scheduled hygiene care, resulting in residents not receiving the necessary showers for maintaining personal hygiene.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing levels, particularly Certified Nursing Assistants (CNAs), as per their own facility assessment recommendations. This deficiency resulted in several residents experiencing prolonged wait times for call light responses, with some waiting over 20 minutes. Residents expressed concerns about the long wait times and insufficient staffing, which affected their ability to receive timely assistance for basic needs such as toileting and showers. Specifically, two residents did not receive showers as scheduled, and multiple residents reported waiting times of up to 40 minutes for call light responses. Interviews with staff members revealed that the facility did not maintain records of call light audits, and staff often worked beyond their shifts without breaks due to high resident acuity and low staffing levels. Staff members expressed that the insufficient staffing made it challenging to meet residents' needs effectively, leading to delays in responding to call lights and completing necessary tasks. Observations confirmed that call lights remained unanswered for extended periods, and staff struggled to manage the workload, often leaving late and without taking breaks. The facility's staffing plan outlined a CNA-to-resident ratio of 1:14, but the actual staffing levels did not meet this standard. On the day of the survey, the facility had a census of 86 residents, with staffing ratios falling short of the recommended levels. The C wing had a ratio of 1:15, while the combined A and B wings had a ratio of 1:37 due to a call-off, significantly exceeding the recommended ratio. This discrepancy between the planned and actual staffing levels contributed to the deficiencies observed in resident care and staff workload.
Failure to Address Behavioral Health Needs Leads to Aggression
Penalty
Summary
The facility failed to adequately address the behavioral health care needs of a resident, leading to aggressive incidents involving other residents and staff. Resident #2, who resided in the dementia care unit, exhibited aggressive behaviors, including punching another resident, resident #15, and attempting to hit staff members. Despite these incidents, the facility did not conduct a thorough root cause analysis or implement effective interventions to manage the resident's behavior. Interviews with staff revealed that resident #2 had a history of aggression, including an incident where he placed his hands near a staff member's neck, yet these behaviors were not adequately documented or addressed. The facility's records showed that resident #2 had been agitated and noncompliant, with documented aggressive behavior on multiple occasions. However, there were no updates to his individualized care plan or assessments conducted following these incidents. The care plan lacked person-oriented activities specific to resident #2, and there was no evidence of pain, fall, or behavioral health assessments being completed after the aggressive incidents. Staff interviews indicated that while there were discussions about the resident's behavior, no formal documentation or follow-up actions were taken to address the underlying issues. Additionally, the facility attempted to arrange behavioral health services for resident #2 but faced challenges in securing appointments. A referral for psychiatric services was not completed, and there was a lack of documentation regarding follow-ups with nursing staff about the resident's behaviors. The facility's inaction and lack of comprehensive assessments and interventions contributed to the ongoing aggressive behavior of resident #2, posing a risk to both staff and other residents.
Concurrent Administration of Opioid and Benzodiazepine
Penalty
Summary
The facility failed to meet professional standards of practice by administering an opioid medication, oxycodone, in conjunction with a benzodiazepine, lorazepam, to a resident. This practice was observed despite warnings about the potential for serious side effects, such as respiratory depression and oversedation, especially given the resident's condition of COPD. Interviews with staff revealed that the nursing staff were aware of the risks associated with administering these medications together, yet the medications were still given concurrently on multiple occasions by a specific staff member. The resident involved did not have a diagnosis that would justify the concurrent administration of these medications, such as a seizure disorder or end-of-life care. Despite the facility's medication administration guidelines and the presence of warnings in the Medication Administration Record (MAR), the medications were administered together on several dates. The facility's documentation showed that the staff member responsible had completed competencies in medication management, yet the practice continued, indicating a failure to adhere to professional standards and facility protocols.
Sanitary and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions and proper storage in the kitchen, which could affect all residents consuming food prepared or stored there. Observations included staff members not wearing hairnets while in designated areas, food items such as hamburger buns, grape juice, and coffee being stored directly on the floor, and a dirty ice machine with a tan and pink film on its plastic surface. Additionally, expired tortilla shells and undated bread were found, indicating a lack of proper food dating and rotation practices. Further observations revealed that food boxes were also stored on the floor of the freezer, and a dirty fan was pointed towards the dish pit, potentially contaminating clean dishes. Interviews with staff members confirmed these practices, with admissions that bread was not dated, the fan was dirty, and the ice machine was cleaned monthly by the maintenance department. Despite the expectation for staff to wear hairnets past a certain point in the kitchen, multiple instances of non-compliance were noted.
Failure to Complete Baseline Care Plans Timely
Penalty
Summary
The facility failed to complete baseline care plans within the required 48-hour timeframe for 8 out of 25 sampled residents. Specifically, the baseline care plans for residents #44, #50, #53, #54, #58, #59, #61, and #221 were not completed on time. For instance, resident #44's care plan was completed four days after the 48-hour window, while resident #50's care plan was completed 52 days late. Other residents experienced delays ranging from three days to 31 days beyond the required timeframe. Interviews with staff members H and B revealed that the responsibility for initiating the baseline care plans lay with the admitting nurse. Staff member B acknowledged that it was her duty to ensure these plans were completed within the 48-hour period. Despite this, the facility's policy on baseline care plans, which mandates their development within 48 hours of admission, was not adhered to, leading to potential unmet needs for the residents.
Deficiency in Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to complete comprehensive, person-centered care plans for four residents who required oxygen therapy. Resident #37, who used a nasal cannula at two liters, had a care plan that did not specify whether the oxygen was to be intermittent or continuous, if there was oxygen saturation monitoring, or the type of oxygen equipment used. Resident #58, who used a BI-PAP machine at night and required two to three liters of oxygen, had a care plan that lacked person-centered interventions and did not specify the details of oxygen use. Resident #61, who needed two liters of oxygen at all times, had no focus, goals, or interventions addressing the use of oxygen in her care plan. Additionally, staff were unsure how to access the care plan for Resident #61. Resident #5's care plan also failed to specify the amount of oxygen to be administered or when it should be applied. The facility's policies on comprehensive care plans and oxygen administration were not followed, as the care plans did not include necessary details such as the type of oxygen delivery system, when to administer the oxygen, equipment settings, and monitoring of oxygen saturation levels. These omissions were identified through observations, interviews, and record reviews conducted by the surveyors, highlighting a significant deficiency in the facility's ability to provide adequate respiratory care for residents requiring oxygen therapy.
Failure to Label Oxygen Tubing and Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to label oxygen tubing when it was changed for two residents and did not follow physician orders for prescribed oxygen amounts for two residents. For resident #5, the physician's orders required the oxygen tubing and storage bag to be changed every Sunday and as needed, with the date labeled. However, during an observation, it was noted that there were no labels on the oxygen tubing or equipment for this resident. Similarly, resident #3's oxygen tubing was not labeled with the date, and the oxygen concentrator was set to one and a half liters per minute (lpm) instead of the prescribed two lpm. Additionally, the resident's care plan and physician orders were inconsistent regarding the oxygen amount, with the care plan indicating four lpm and the physician order indicating two lpm. Observations showed the oxygen concentrator set at one and a half lpm on multiple occasions, and the resident was not observed using the oxygen properly during the survey period. For resident #13, the oxygen concentrator was observed to be set at three lpm, while the physician's order specified two lpm. The facility's policy on oxygen administration states that oxygen should be administered under the orders of a physician. These discrepancies indicate a failure to adhere to physician orders and facility policies regarding oxygen administration and equipment labeling, potentially compromising the residents' respiratory care.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to serve meals at a palatable temperature for seven residents who received room trays. Multiple residents reported that their hot food was often lukewarm or cold by the time it reached their rooms. Observations confirmed that the food was transferred from the steam table to a thermal insulated food cart without insulated bases for the plates or lids for the bowls. Temperature measurements of the food served to residents showed that the hot food was not maintained at appropriate temperatures, with some items being significantly below the recommended serving temperatures. For example, one resident's white bean soup was measured at 100.5 degrees Fahrenheit, and another resident's tomato soup was measured at 88.5 degrees Fahrenheit. Staff interviews revealed that there were known complaints about the food temperature, and staff members acknowledged that the food was not always warm by the time it reached the residents' rooms. One staff member mentioned that the facility occasionally conducted test trays but was unsure if the food remained warm by the time it was served at the end of the hallway. The facility's current practices for maintaining food temperature during transport were inadequate, leading to the deficiency in serving meals at a palatable temperature for the residents receiving room trays.
Infection Control and PPE Use Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to infection control practices and proper PPE use during a COVID-19 outbreak involving two residents. Observations revealed that the door to the room of two COVID-19 positive residents was left open to the hallway, despite one resident frequently coughing. Staff admitted that the door was left open because the resident did not like it closed, although there were no safety risks necessitating this. Additionally, staff were observed not performing hand hygiene or changing PPE when moving between rooms and handling food trays, despite having attended training sessions on these protocols. Interviews with staff indicated a lack of consistent adherence to infection control practices, with one staff member expressing frustration over the daily struggle to enforce proper hand hygiene and PPE use. The facility's policies on hand hygiene and transmission-based precautions were not followed, as evidenced by staff member L's actions of wearing full PPE in the hallway and not performing hand hygiene between tasks. Despite having documented training on these procedures, staff member L claimed to have never been educated on proper PPE use. The facility also failed to provide a requested COVID-19 policy and procedure document during the survey.
Failure to Address Extended Antibiotic Use
Penalty
Summary
The facility failed to address the extended duration of antibiotic use through its Antibiotic Stewardship Program for three residents. Resident #37 had been taking Methenamine Hippurate for 154 days and Macrobid for 20 days without a specified duration or stop date. Resident #26 had been taking Macrobid for 866 days, also without a specified duration or stop date. Despite being aware of the extended use, staff members reported that the prescribing providers refused to discontinue the medications, which did not align with national guidelines or the facility's policy on antibiotic stewardship. The facility's policy required prescribers to provide complete antibiotic orders, including the duration of treatment, which was not followed in these cases. Resident #4 was prescribed Cefadroxil for osteomyelitis and received the medication for four months. The Medication Regimen Review for this resident did not include any recommendations for changes within the specified timeframe. Although research suggests a longer treatment duration for osteomyelitis, the facility's failure to address the extended use of antibiotics for this resident was noted. The facility's policy on antibiotic stewardship was not adhered to, as the orders lacked the required elements such as start and stop dates or the number of days of therapy.
Failure to Update Care Plan for PICC Line
Penalty
Summary
The facility failed to revise and update a resident's care plan to address a PICC line. During an observation and interview, the resident was found sitting in a wheelchair and was unable to answer questions appropriately. The resident's 5-day MDS indicated severe cognitive impairment. Despite multiple attempts to contact the facility for more information, no response was received. The resident's care plan included goals and interventions for IV medication administration via a PICC line, but the care plan was not updated after the resident pulled out the PICC line, as noted in the nursing notes. The facility's policy on care plan revisions upon status change was not followed, leading to the deficiency.
Failure to Follow Carbohydrate-Controlled Diet
Penalty
Summary
The facility failed to ensure that the food served to a resident followed the dietician's recommendations for a carbohydrate-controlled diet. During an observation, the resident was served a ham sandwich with two slices of bread, potato chips, white bean soup with three packages of saltine crackers, and a fruit cup. The resident reported that his blood sugar had been significantly higher since his admission to the facility and attributed this to the increased carbohydrates in his meals. The dietary order for the resident specified a Regular-Carbohydrate Controlled diet, which was not followed. Staff confirmed that the carbohydrate-controlled meal should have included only one slice of bread and two ounces of meat. The resident's blood sugar readings on the day of the observation were elevated, with an average of 228 mg/dL over a ten-day period.
Inaccurate MDS Assessments for Bedrail Use
Penalty
Summary
The facility failed to ensure that resident MDS assessments contained accurate information for six residents. Observations and interviews revealed that several residents had metal bars attached to their beds, which they used for mobility and repositioning. However, these bars were incorrectly coded as restraints in the residents' MDS assessments. For instance, one resident stated that the bars helped her position herself in bed and did not restrict her movement, yet her MDS assessment indicated daily use of restraints. Similar discrepancies were found in the assessments of other residents, where bedrails used for mobility were inaccurately documented as restraints. Staff interviews further highlighted a lack of understanding regarding what constitutes a restraint, with one staff member admitting to being unsure about the definition of restraints and mistakenly coding mobility bars as such. Additionally, the review of physician orders showed no orders for bedrails for some residents, despite their MDS assessments indicating the use of restraints. This inconsistency between the residents' actual use of bedrails and their documentation in the MDS assessments points to a significant issue in the accuracy of resident assessments. The facility's failure to correctly document the use of bedrails and restraints in the MDS assessments could lead to inappropriate care planning and interventions for the residents involved.
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 43 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 Butte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Copper Ridge Health And Rehabilitation Center | 0.1 mi | ★★★★★ | 17 | 0 |
| Crest Nursing Home | 0.2 mi | ★★★★★ | 9 | 0 |
| Southwest Montana Veterans Home | 3.3 mi | ★★★★★ | 0 | 0 |
| Community Nursing Home Of Anaconda | 24 mi | ★★★★★ | 17 | 0 |
| Ivy At Deer Lodge | 29.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Continental Care And Rehabilitation.
100% money-back within 48 hours.
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.