Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Park Place Transitional Care And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to keep beds in safe positions, complete fall investigations, and supervise a resident who was smoking on facility property. A resident with quadriplegia fell from a high bed and sustained a hip fx, another resident had a closed head injury after a fall from bed, and a third resident had a laceration above the eye after a fall that was not fully investigated, including no interview of the roommate. The facility also observed a resident repeatedly leaving unattended to smoke by a dumpster, despite being a non-smoking facility, with no smoking-related orders, care plan interventions, or assessments documented.
Surveyors found that dietary staff preparing and serving food did not wear required beard restraints despite visible facial hair, contrary to facility policy on employee personal hygiene. In addition, review of refrigerator temperature logs showed that two kitchen refrigerators had no recorded twice-daily temperature checks for a two-week period, with notes indicating the logs were lost, in violation of the facility’s policy requiring documented cooler and freezer temperatures to be maintained at or below 41°F.
Unattended medication carts and visible resident information: Staff left a med cart unlocked on the hall and another cart open while entering a resident’s room to give meds. On another hall, a computer monitor with patient info was left unattended and clearly visible, and four medication boxes with resident information were left on the cart without staff present. Staff stated the cart should be locked when unattended and patient health information should not be visible to visitors.
A resident’s MDS incorrectly coded a daily Victoza injection as insulin, with Section N showing 7 injections and 7 days of insulin use. The physician order identified Victoza (liraglutide) for type 2 DM, and staff acknowledged she coded it as insulin based on the diagnosis without verifying the medication class, despite being familiar with the RAI Manual.
A resident with an indwelling catheter was observed sitting in a wheelchair with the catheter tubing coming out from under her pajama pants. Staff stated the catheter was being continued due to incontinence and because the resident wanted it for convenience, but the resident’s care plan did not include catheter care interventions.
Care plan not revised for pneumonia treatment and precautions. A resident with COPD, dysphagia, MS, and a recent pneumonia infection developed emesis, nasal congestion, crackles, and a chest x-ray consistent with early pneumonia, leading to levofloxacin therapy. Staff said they tracked residents on antibiotics and updated care plans for infections, but the resident’s care plan was not revised to add pneumonia-related problems, goals, interventions, or updated transmission-based precautions.
A resident had a 22% weight loss in about a week, but no reweight was completed after the large discrepancy between weights. Another resident reported ongoing low weight, disliked the snacks offered, and was often documented as unavailable for late-night snack offerings; her record also showed a recent weight loss with no dietitian documentation for two months.
A resident’s PEG tube was observed unclamped and disconnected from tubing on one occasion, and later was still unclamped and connected to a kangaroo pump even though enteral nutrition was not running. An LPN stated the pump had been turned off earlier and the tubing should have been flushed, clamped, and unhooked from the resident, and also said clogging was less of a concern because of the larger PEG tubing.
Failure to perform hand hygiene during meal tray service: A new staff member handled meal trays, a resident's wheelchair, and silverware without cleaning his hands between contacts. He placed an uncovered tray on a dining room table, delivered another tray to one resident, and then pushed another resident's wheelchair to the table before handling the resident's silverware. Facility hand hygiene policy required hand hygiene between resident contacts and after handling contaminated objects.
A grievance system was not set up so forms were readily accessible without staff help, and completed grievances were not secured for confidentiality. On multiple units, no visible grievance form holders or signage were present, staff said residents would have to ask for forms or have staff locate them, and completed grievances were kept in an unsecured wall-mounted box outside social services. The grievance official and other staff confirmed the box was not locked and that the facility had no locked drop boxes for grievances.
Survey Results Binder Missing Current Survey Report: A wall-mounted binder near the entrance was supposed to display State Survey Agency survey results, but it did not include the most recent survey report or plan of correction. Staff said they did not know why the documents were missing and noted the same issue had happened the prior year. The facility's Resident Rights document stated residents have the right to examine the most recent survey results and any plan of correction.
A resident admitted with intact sacral skin developed a Stage III pressure ulcer that progressed to Stage IV, with healing not achievable. Despite interventions like an air mattress, repositioning, and wound care, documentation showed inconsistent repositioning, missed dressing changes, and incomplete wound assessments. The care plan lacked specific details about the wound, and pain management was not consistently provided before treatments, contributing to the ulcer's deterioration.
Surveyors found that food items in the kitchen were not properly labeled, dated, or discarded by their use by dates, and some were left uncovered or unlabeled. Additionally, refrigerator and freezer temperatures were not being monitored as required by facility policy. These failures may affect any resident receiving food from these storage areas.
The facility did not maintain a homelike environment by failing to control strong, persistent urine odors in a hallway, as observed over several days. Two residents and their visitors were affected, with one resident's family expressing concern about the overwhelming smell and the negative effects of excessive odor-masking sprays. Residents and families attempted to address the odor themselves, but the malodor remained present.
Contracted staff drew blood from a resident in a dining area without following proper infection control protocols, and facility staff did not provide additional training or enforce guidelines. For residents on droplet and contact precautions, required signage and PPE placement were not maintained, and staff entered rooms without appropriate PPE. In the kitchen, staff failed to change gloves or wash hands between handling soiled items and food, violating facility hygiene policies.
A resident who valued choosing her own clothing was not assisted in obtaining enough properly fitting clothes, resulting in her repeatedly wearing the same ill-fitting shirt and becoming distressed. Staff did not retrieve her personal clothing from her previous residence, and the facility's spare clothing did not fit, contrary to policy requiring residents to be dressed according to their preferences.
A resident with ongoing vision difficulties was not provided timely access to an eye doctor, despite repeated requests and documented need. Staff were aware of the resident's complaints and the lack of effective glasses, but no appointment was scheduled and transportation was not arranged, contrary to facility policy.
A resident with a history of neurogenic bladder and paraplegia, who previously managed his condition with intermittent self-catheterization, was admitted with an indwelling catheter. Despite a physician order for cognitive and self-catheterization assessment, the facility did not complete the evaluation or provide necessary supplies, leaving the resident with the indwelling catheter and without the opportunity to regain independence.
A resident with a history of stroke and new dialysis needs exhibited moderate depression and expressed interest in mental health counseling, but was not provided with behavioral health services or referrals. Staff recognized the resident's depressive symptoms, yet there was no documentation of follow-up or specific interventions, despite facility policy requiring person-centered behavioral health care.
A facility failed to identify a resident's elopement risk and did not update the care plan with interventions to prevent elopement. The resident, with severe cognitive impairment, was found wandering outside the facility. Staff members did not recognize this as an elopement, and the care plan was not updated promptly to include necessary interventions.
The facility failed to prevent elopement for two residents, one of whom was found by police hours later, and another who wandered outside unsupervised. The facility did not follow its care plan for hourly monitoring and failed to notify the legal representative or physician as per policy.
The facility failed to identify a severe 16% weight loss in a dialysis resident over two weeks due to discrepancies in weight recordings. The resident's pre-dialysis weights consistently decreased, but the facility's recorded weights were significantly higher, leading to a failure in recognizing the weight loss. Staff interviews and observations revealed issues with the weight monitoring process and malfunctioning scales.
The facility failed to continuously assess and document a resident's worsening penile ulcer. Despite recommendations for wound care and the facility's policy on perineal care, there were no nursing evaluations of the ulcer outside of the initial admission assessment. Staff interviews revealed that the resident's actions compromised wound care, but the facility did not document ongoing assessments or interventions.
A resident missed 15 days of prescribed medications, Flomax and Finasteride, intended to improve urine flow and assist in catheter removal. The error occurred due to incorrect physician orders, causing the resident anxiety about the upcoming catheter removal.
The facility staff failed to use standard precautions while handling soiled laundry, lacking protective gowns and gloves, which could lead to cross-contamination. This practice violated the facility's policy and CDC guidelines, as confirmed by staff interviews and observations.
A resident arrived at a follow-up appointment soiled with urine and dried stool, leading to feelings of embarrassment and humiliation. The resident reported not being toileted or changed all day, and her medical records showed 37 instances of incontinence within a month. Despite this, facility staff denied the resident was soiled prior to the appointment, and a grievance filed by the family member was dismissed as an accident.
A resident with a history of left-sided weakness from a stroke experienced an unwitnessed fall resulting in a fractured hip. The facility failed to conduct a root cause analysis to determine the cause of the fall or implement preventive measures, despite their policy requiring such actions.
The facility failed to complete an accurate MDS assessment for a resident with bowel and bladder incontinence. Despite the resident and medical records indicating incontinence, the MDS assessment inaccurately reported continence, leading to a deficiency in providing appropriate care.
The facility failed to implement a baseline care plan within 48 hours for a new resident who required assistance with dressing, toileting, and bathing. The care plan was not completed until 14 days after admission and lacked essential information. Staff members provided inconsistent information about the resident's condition and care needs, and one staff member was unaware of how to access the care plan.
The facility failed to complete a comprehensive, person-centered care plan for a resident with a knee fracture, resulting in inconsistent care and unmet needs related to ADLs, bowel and bladder status, and physical therapy services.
Unsafe Bed Positioning, Incomplete Fall Investigations, and Unsupervised Smoking
Penalty
Summary
The facility failed to keep the environment free of accident hazards and to provide adequate supervision to prevent falls for residents #5, #45, #156, and #160. Resident #160, who was quadriplegic and dependent on staff for care, was observed lying in bed on top of an air mattress with the bed in a high position on multiple occasions. The resident stated that a couple of weeks earlier she fell out of bed after being repositioned too close to the edge while the bed was high in the air, and she sustained a hip fracture and spent three days in the hospital. The incident report and root cause analysis identified the bed being too high or low as a contributing factor, and the interdisciplinary follow-up noted the resident fell out of bed onto the floor, but the record did not document a fall program or other safety interventions, and the bed remained in a high position. Resident #45 was also observed in bed with the bed in a high position, and the resident had bruising on the forehead and eye area from a prior fall. The resident stated he had been taken to the hospital after the fall, and the emergency room note documented a fall with a closed head injury. The fall assessment showed a moderate fall risk score. The interdisciplinary follow-up documented that the resident fell out of bed and listed PT evaluation for side rails as the new intervention, but the record did not document other safety interventions for falls. Staff stated the high bed position was the resident’s preference. Resident #5’s record showed the resident was assisted back to bed and the bed was placed in the lowest position after a fall, but interviews described the bed as often being too high and the resident as being at risk of falling out of bed. Staff stated the resident had not been repositioned to neutral as intended, that the resident naturally shifted to the left side, and that the resident may have had a spasm contributing to the fall. The facility had discussed a fall mat and bed rails, but these were not implemented before the fall, and the investigation did not include staff interviews or a documented attempt to ask the resident what occurred. For resident #156, the fall documentation described the resident found on the floor with a laceration above the left eyebrow, but the facility did not identify a root cause and did not interview the roommate, resident #129, even though the roommate reported hearing the fall and described possible neurologic symptoms two hours earlier. The facility policy required interviewing witnesses, the resident when appropriate, staff members, and reviewing events leading up to the incident, but those elements were not completed as documented. The facility also failed to ensure interventions and safety assessments were in place for resident #86, who was observed repeatedly leaving the facility unattended in an electric wheelchair and smoking by a dumpster on facility property. The resident stated he was a smoker, kept cigarettes and a lighter on him or in his room, did not sign out every time he left, and smoked behind the dumpster because no one could see him there. Staff stated the facility was a non-smoking facility and residents were to sign out when leaving, but the sign-out log showed no recent entries. The resident’s record contained no orders for smoking or smoking cessation, no care plan focus or interventions for smoking, and no smoking-related assessments or evaluations, despite the facility policy stating residents with a history of smoking were to be assessed and that smoking was prohibited on facility grounds.
Failure to Enforce Beard Restraints and Maintain Refrigerator Temperature Logs
Penalty
Summary
The deficiency involves failures in food service safety practices related to staff personal hygiene and monitoring of refrigeration temperatures. Surveyors observed one dietary staff member preparing sandwiches in the kitchen without a beard net despite having visible facial hair, and another dietary staff member serving food onto resident trays from a steam table without a beard net covering his facial hair. The facility’s own policy on Dietary Employee Personal Hygiene requires all dietary staff to wear hair restraints, including beard restraints, to prevent hair from contacting food. During an interview, a dietary staff member confirmed that kitchen staff with beards or mustaches were expected to wear facial coverings while working in the kitchen. The deficiency also includes incomplete monitoring and documentation of refrigerator temperatures. Review of the Daily Freezer/Refrigerator Temperature Logs for March 2026 showed that for refrigerators labeled R1 and R4, there were no recorded twice-daily temperature checks for days 1–15, and each log contained a note stating “Lost these ones” in the section for those days. The facility’s Monitoring of Cooler/Freezer Temperature policy requires that logs for each refrigerator or freezer be posted in a visible location and that temperatures be checked and logged at least twice per day, with refrigerated storage maintained at or below 41°F unless otherwise specified by law. During an interview, the dietary staff member responsible for the logs stated she did not know why the logs for those periods had no temperatures recorded and thought the logs had been misplaced.
Unattended medication carts and visible resident information
Penalty
Summary
The facility failed to follow professional standards of quality by not keeping medication carts locked when unattended. During an observation on the 100 hall, the medication cart was found unlocked with no staff member present. During another observation, a staff member left the medication cart open after preparing medications for a resident and entered the resident’s room to administer them. The staff member stated the cart should always be locked, the keys should be kept in her pockets, and the cart should be locked whenever she was not near it. The facility also failed to protect resident health information from visitors. On the 500 hall, a computer monitor with patient information was left unattended and clearly visible, and four boxes containing patient information were on the medication cart without a staff member present. The boxes were identified as medications for three residents, including fluticasone, diclofenac gel, calcitonin spray, and formoterol spray. Staff stated the information should not be visible to visitors and that medication carts should be locked at all times when unattended, with keys never left on top of the carts. The facility policy titled Medication Storage stated that all drugs and biologicals will be stored in locked compartments.
Incorrect MDS Coding of Non-Insulin Medication as Insulin
Penalty
Summary
The facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) for resident #126. The resident’s MDS with an assessment reference date of 3/23/26 coded Section N, item N300 as 7 injections received in the last 7 days and item N350 as 7 days of insulin injections received. However, the resident’s physician orders dated 1/23/26 showed Victoza Subcutaneous Solution Pen-injector 18 MG/ML (Liraglutide) 0.6 mg subcutaneously once daily for type 2 diabetes mellitus. Victoza is a GLP-1 medication and is not considered insulin. During interview, staff member F stated she completed Section N of the MDS and recognized she coded Victoza as insulin because the diagnosis on the order was diabetes mellitus type II, but did not verify the medication class. Staff member F stated she had training on MDS completion and was familiar with the RAI Manual. The RAI Manual states to review the MAR for the 7-day look-back period and determine if the resident received insulin injections.
Missing Catheter Care Interventions on Care Plan
Penalty
Summary
The facility failed to include catheter care interventions on the care plan for resident #6. During an observation and interview on 4/7/26 at 11:37 a.m., resident #6 was sitting in a wheelchair in her room, and an indwelling catheter tube was coming out from the bottom of her pajama pants. NF3 stated the facility was continuing catheter use for resident #6 due to incontinence and that the resident wanted the catheter for convenience. During an interview on 4/9/26 at 9:25 a.m., staff member D stated that catheter interventions should be on a resident's care plan. Review of resident #6's care plan, dated 3/11/26, showed that catheter care interventions were not included.
Care plan not revised for pneumonia treatment and precautions
Penalty
Summary
The facility failed to review and revise the comprehensive care plan to reflect changes in one resident’s condition. Resident #91 had a comprehensive care plan revised on 1/5/26 that included enhanced barrier precautions for having a catheter and a respiratory problem related to COPD, recent pneumonia infection, history of pulmonary embolism, dysphagia, and multiple sclerosis. However, the care plan was not updated to include a problem, goal, or interventions related to antibiotic treatment for pneumonia that was started on 3/25/26 for 7 days, and it did not include updates to transmission-based precautions for care of the resident during the pneumonia treatment. Provider progress notes showed that on 3/24/26 the resident had two episodes of emesis, nasal congestion, and a chest x-ray was ordered to rule out pneumonia. On 3/25/26, examination revealed mild crackles in the left lower lobe, effusion was being monitored in the context of pneumonia treatment, and lobar pneumonia was diagnosed after the chest x-ray showed a left lower lung infiltrate and/or atelectasis consistent with likely early development of pneumonia. Staff member N stated she kept a list of residents taking antibiotics and would update a resident’s care plan when an infection was identified, and stated enhanced barrier precautions would cover part of the droplet precautions for a resident diagnosed with pneumonia.
Failure to Monitor Significant Weight Loss and Provide Timely Nutrition Follow-Up
Penalty
Summary
Provide enough food and fluids to maintain resident health was deficient for two residents. One resident had an admission weight of 207.8 pounds and then weighed 170 pounds 12 days later, reflecting a 22.2% weight loss in about one week. The care plan was revised to notify the RD and medical provider for weight loss greater than 5 pounds, but the record showed no reweight after the large discrepancy. During interview, staff stated the difference was likely due to an incorrectly obtained weight and explained that the resident had arrived with a wheelchair from the hospital that likely weighed about 50 pounds; the current wheelchair was later weighed at 53.1 pounds. A second resident voiced concern that her clothes were getting too big and that she wanted to gain weight, but she reported the facility did not offer snacks she enjoyed and that the ice cream often arrived melted. Nightly snack documentation showed the resident was marked unavailable on multiple occasions, often late at night when she was asleep. Her weight remained very low, averaging 70 to 80 pounds over the prior year, and a dietitian note documented a 6.25% weight loss in less than one month. The record also showed no dietitian documentation for February or March, despite prior notes indicating the dietitian would revisit if the resident’s weight decreased again.
PEG Tube Left Unclamped and Connected to Pump
Penalty
Summary
Appropriate and safe PEG tube practices were not followed for resident #5. During an observation on 4/7/26 at 9:24 a.m., the resident’s PEG tube was found unclamped and unhooked from any tubing. During a later observation and interview on 4/8/26 at 8:47 a.m., the resident’s PEG tube was again observed unclamped and still connected to the kangaroo pump even though enteral nutrition was not running. Staff member T stated the pump had been turned off at 6:30 a.m. and that the tubing should have been flushed, clamped, and unhooked from the resident. Staff member T also stated they did not worry about clogging as often with this resident because of the larger circumference of the PEG tubing.
Failure to Perform Hand Hygiene During Meal Tray Service
Penalty
Summary
Facility staff failed to follow nationally recognized hand hygiene standards while passing meal trays in the dining room. During an observation on 4/8/26 at 12:05 p.m., staff member K obtained a meal tray from the kitchen and placed it on a dining room table without performing hand hygiene, removed the plate cover, and left the area. Staff member K then returned to the kitchen, obtained another meal tray, and delivered it to resident #85 without performing hand hygiene. Staff member K also walked to resident #92, grasped the wheelchair handles, and pushed the resident to the dining room table where the uncovered meal tray had been placed. Staff member K then handled resident #92's silverware without performing hand hygiene between contact with the wheelchair and the meal tray items. During interview, staff member K stated he was a new employee and had been educated on hand hygiene before his first shift, and stated he should have completed hand hygiene between residents and meal trays. Facility documents titled Hand Hygiene and Hand Hygiene Table stated that staff will perform hand hygiene to prevent the spread of infection and that it is indicated between resident contacts, after handling contaminated objects, and when in doubt.
Grievance forms not readily accessible and completed grievances not secured
Penalty
Summary
The facility failed to ensure a grievance system was in place that allowed grievance forms to be readily accessible without staff assistance and that received grievances were secured to maintain confidentiality. During an observation on 4/7/26, the door to the social services office was closed and a wall-mounted file holder outside the office contained grievance forms along with writing and completed forms showing resident names and information; the completed forms were not secured. On 4/8/26, there was no visible holder or signage for grievance forms on the 400 unit. On 4/9/26, staff member R stated residents would have to ask staff for a grievance form and that grievances were kept in a desk at the nurses' station, with no forms readily available on the unit without staff assistance. On 4/9/26, staff members on the 500 unit also reported that residents could bring grievances to the drop box outside social services or staff could bring grievances down for them if residents could not get there, but no visible holders or signs for grievance forms were present on the unit. During interview, the grievance official stated residents could fill out grievances, staff could assist them, and residents could submit completed grievances in the box on the wall outside the social services office or push them through the bottom of the office door. Staff also stated the wall-mounted box was not locked and that the facility did not have any locked drop boxes for grievances. The facility policy stated grievance information should be readily available throughout the facility and that social services was responsible for maintaining confidentiality of grievance-related information.
Survey Results Binder Missing Current Survey Report
Penalty
Summary
The facility failed to ensure that current, readily available State Survey Agency survey results were maintained in a publicly accessible area near the entrance and reception desk. During observation, a wall-mounted file holder labeled Survey Results contained a binder with State Survey Agency survey reports, but the binder did not include the 2025 recertification survey report. Staff member N stated she would check why last year's survey results were not in the binder. During interview, staff member A stated she did not know why the survey results binder did not include last year's survey results and was not sure why the 2025 survey report and plan of correction had been removed. Staff member A also stated she usually checked the binder closer to annual survey time, about two weeks before the survey, and that the same thing happened the prior year. Review of the facility's Resident Rights document showed that residents have the right to examine the results of the most recent survey and any plan of correction in effect.
Failure to Prevent and Manage Pressure Ulcer Progression
Penalty
Summary
A resident who was admitted with intact skin on the sacrum developed a Stage III pressure ulcer that progressed to a Stage IV, with healing ultimately not achievable. The resident was dependent on staff for all care needs and had a history of medical co-morbidities, increasing the risk for pressure ulcers. Although interventions such as an air mattress, repositioning, use of a wedge, and a cushion in the wheelchair were implemented, documentation showed that repositioning every two hours was not consistently performed or recorded. The care plan specified limited time in a wheelchair and frequent repositioning, but these interventions were not reliably documented or executed. Wound care documentation was inconsistent, with measurements and identification of undermining and tunneling not reliably recorded. Dressing changes ordered by the physician were missed on multiple occasions, as evidenced by gaps in the treatment administration records. The wound was identified as infected at one point, and the resident received several courses of antibiotics for wound infection and cellulitis. However, the care plan did not specify the location or severity of the wound, and interventions for pain management prior to wound treatments were not consistently documented, despite the resident refusing some treatments due to pain. Staff interviews indicated that the resident occasionally refused repositioning, but staff generally believed the resident did not frequently refuse care. There was a lack of consistent documentation regarding refusals and pain management interventions. The combination of missed repositioning, incomplete wound care documentation, missed dressing changes, and insufficient pain management contributed to the failure to prevent the development and worsening of the pressure ulcer.
Failure to Properly Store, Label, Date, and Monitor Food Items and Temperatures
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, dating, and discarding of food items. Specifically, in the backroom cooler, several food items were found either past their use by date, not labeled, not dated, or not properly covered. Examples included tortillas with an expired use by date, a potato-like item wrapped in foil without a label or date, beef and mushrooms in pans or bags without labels or dates, uncovered and unlabeled hotdogs, ground beef, deli ham, sausages with only a date, and chicken with two different dates. Staff confirmed that the use by date should be seven days after opening, and facility policy requires proper labeling, dating, and timely use or disposal of refrigerated foods. Additionally, the refrigerator next to the juice dispenser lacked a temperature log, and there was no evidence of temperature monitoring for that unit. Staff confirmed that all refrigerator units should have their temperatures monitored. Facility policy also mandates daily and routine monitoring of food temperatures and refrigeration equipment to ensure safe storage. These failures may affect any resident consuming food from these storage areas.
Failure to Control Persistent Urine Odors in Resident Hallway
Penalty
Summary
The facility failed to maintain a homelike environment and adequately control persistent urine odors in the 400B hallway, affecting two of 39 sampled residents and their visitors. Multiple observations over several days documented a strong, unpleasant urine smell throughout the hallway. Interviews revealed that one resident, who previously maintained a clean home before a dementia diagnosis, would not have tolerated such conditions, and her family expressed concern about the overwhelming odor upon her relocation to the hallway. The family also noted that excessive use of odor-masking spray caused the resident to cough, and they attempted to mitigate the smell with personal air fresheners and a fan. Another resident also commented on the persistent malodor in the area.
Infection Control Failures in Blood Draws, Precautions, and Kitchen Hygiene
Penalty
Summary
Contracted staff failed to follow safe and effective blood-draw practices by attempting to draw a resident's blood in the main dining room while the resident was eating breakfast and another resident was present at the table. The contracted staff stated they had been told by a facility staff member that they could draw blood in the dining room if the resident consented, and they confirmed they had not received any additional training on the facility's infection control expectations. Facility staff interviews revealed that contracted staff were expected to follow the facility's guidelines and not perform blood draws in common areas, but no additional training or clear communication of these expectations had been provided to the contracted staff. The facility did not implement appropriate transmission-based precautions (TBP) for residents on droplet and contact precautions. For a resident on droplet precautions due to parainfluenza virus pneumonia, there was no signage on the outside of the door, and personal protective equipment (PPE) was stored inside the room rather than outside, contrary to facility policy. Staff interviews confirmed that signage and PPE placement did not meet policy requirements, and documentation showed the resident was on droplet precautions at the time of the observation. For another resident on contact precautions due to a methicillin-susceptible Staphylococcus aureus (MSSA) infection, PPE was inconsistently placed, and staff were observed entering the room without donning PPE, despite policy requiring PPE to be donned before room entry. In the kitchen, staff failed to follow proper hand hygiene and glove use protocols. One staff member was observed sweeping the floor with gloved hands and then handling food items without changing gloves. Another staff member handled both soiled items and ready-to-eat food with the same pair of gloves, without changing gloves or washing hands between tasks. Facility policy required gloves to be changed between tasks and for staff to adhere to hygienic practices to prevent food contamination, but these procedures were not followed during the observations.
Failure to Provide Resident with Properly Fitting and Sufficient Clothing
Penalty
Summary
A resident who was cognitively intact and valued choosing her own clothing was not provided with adequate or properly fitting clothes during her stay. Despite having personal clothing available at her previous assisted living facility, staff did not make efforts to retrieve these items or ensure she had enough suitable clothing. Observations over several days showed the resident repeatedly wearing the same ill-fitting shirt, and her closet was found to be empty except for a few items, none of which fit appropriately. The resident expressed distress about her lack of appropriate clothing, becoming tearful when discussing the issue. Interviews with staff revealed that while spare clothing was available in a linen closet, it was often used for residents admitted from hospitals, and there was an expectation that social services would contact families for additional clothing when needed. However, no staff had requested the resident's clothing from her previous residence, and the clothing provided by the facility did not fit. Facility policy required residents to be groomed and dressed according to their preferences, but this was not followed in the resident's case, impacting her dignity and emotional well-being.
Failure to Arrange Timely Vision Services for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received proper treatment, services, and assistive devices to maintain optimal visual abilities. The resident repeatedly reported difficulty seeing, even with the glasses provided, and expressed frustration over not being able to see the eye doctor despite multiple requests. Observations confirmed the resident's ongoing struggle to watch television and read, and interviews with staff revealed that no eye appointment had been scheduled, even though the need was documented in progress notes and communicated among staff. The resident's only available glasses were simple readers brought in by a family member, and his magnifying glass was broken and awaiting replacement by his sister. Documentation showed that a referral for an eye exam was made by the provider, and staff were aware of the resident's visual difficulties, but there was no evidence that an appointment was scheduled or transportation arranged. The facility's policy required staff to refer identified needs for vision services to social services, who were then responsible for making appointments and arranging transportation. Despite these requirements and ongoing monitoring, the resident did not receive timely access to necessary vision services.
Failure to Assess and Support Self-Catheterization for Resident with Indwelling Catheter
Penalty
Summary
A deficiency occurred when the facility failed to address the discontinuation of an indwelling urinary catheter for a resident who was admitted with the device. The resident, who is paraplegic and has a history of neurogenic bladder, previously managed his condition through intermittent self-catheterization and expressed a desire to return to this method for greater independence. Upon admission, the resident communicated his preference and history to staff, and a physician order was placed to assess his cognitive and physical ability to resume self-catheterization. However, no such assessment was completed, and the resident continued to have an indwelling catheter in place. Multiple staff interviews revealed a lack of awareness regarding the referral and physician order for the necessary cognitive and self-catheterization assessment. Documentation confirmed that no therapy evaluation or cognitive assessment was performed, and the order was not present on the facility's communication board. Staff also indicated that there was confusion about how to order self-catheterization supplies, and no supplies were procured for the resident. The facility's own policies require timely assessment for catheter removal and appropriate services to restore continence or independence, but these were not followed in this case. The resident did not receive the ordered evaluation to determine his ability to self-catheterize, nor was he provided with the supplies or services needed to restore his previous level of independence. The failure to complete the assessment and provide appropriate care was confirmed through record review, staff interviews, and observation, demonstrating noncompliance with facility policy and professional standards of practice.
Failure to Provide Behavioral Health Services for Resident with Depression
Penalty
Summary
A deficiency was identified when the facility failed to provide necessary behavioral health services to a resident who exhibited signs of depression following a significant life-changing event. The resident, a former school teacher who suffered a stroke resulting in right-sided weakness and the need for dialysis, expressed feelings of sadness, loss of independence, and uncertainty about recovery. During interviews and observations, the resident was noted to be tearful, reported not being approached about mental health services, and expressed interest in counseling, stating that it could help him mentally. Staff interviews confirmed awareness of the resident's depressive symptoms, with one staff member acknowledging that the resident seemed depressed and would likely benefit from mental health counseling. Despite this, there was no documentation of any follow-up or referral for behavioral health services, and the resident's participation in activities was minimal. The staff member who completed the PHQ-9 assessment upon admission recalled discussing mental health therapy with the resident but admitted there was no documentation of this conversation. Review of the resident's records showed a PHQ-9 score indicating moderate depression at admission, with no subsequent assessments completed before the survey. The care plan identified mood problems and included general interventions such as encouraging meaningful activities and monitoring mood, but there were no specific interventions or referrals for behavioral health services documented. The facility's policy requires person-centered behavioral health care, but the lack of documented interventions or referrals for the resident's depressive symptoms constituted a failure to provide necessary behavioral health services.
Failure to Identify and Address Elopement Risk
Penalty
Summary
The facility failed to identify a resident's risk of elopement and did not update the care plan with necessary interventions to prevent such incidents. The resident, who had a severe cognitive impairment as indicated by a BIMs score of 3, was found wandering outside the facility. Despite this incident, staff members did not recognize it as an elopement. Staff member A observed the resident near the doors but did not consider the resident's actions as an elopement. Staff members B and D were unaware of the resident's tendency to sit near the doors or go outside alone, while staff member C, who was familiar with the resident's habits, was informed of the wandering incident after it occurred. The care plan for the resident was not updated in a timely manner following the elopement incident. It was only on a later date that interventions were added to the care plan to prevent further elopements. This delay in updating the care plan highlights a lapse in the facility's response to the resident's elopement risk, as the necessary interventions were not promptly implemented to ensure the resident's safety.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to identify and manage the elopement risk for two residents, leading to incidents where both residents left the facility unsupervised. One resident, identified as having a high elopement risk, was able to leave the facility and was found by the police several hours later, a significant distance away. The facility did not adhere to its care plan, which required hourly monitoring and checking the functionality of the resident's wander guard bracelet. The incident report indicated a lapse in monitoring, as the resident was last seen at 3:00 a.m. and was not found in their room at 4:15 a.m., with the elopement being reported to authorities at 5:00 a.m. Another resident, who had severe cognitive impairment, was found wandering outside the facility. The nursing notes did not document the notification of the resident's legal representative or attending physician, nor was the resident reassessed upon return, as required by the facility's elopement policy. Staff interviews revealed inconsistencies in awareness and monitoring of the resident's behavior, with some staff unaware of the resident's tendency to sit near exit doors. The resident's care plan was not updated with interventions to prevent further elopement until after the incident.
Failure to Identify Severe Weight Loss in Dialysis Resident
Penalty
Summary
The facility failed to identify a significant discrepancy in weight recordings for a dialysis resident, leading to a severe 16% weight loss over two weeks. The resident's Dialysis Communication Records showed a consistent downward trend in weight, with no body or fluid weight gain between treatments. Despite this, the facility's weekly weight summary showed conflicting weights, which were used in the IDT weight meeting and failed to identify the resident's weight loss. The resident's pre-dialysis weights consistently decreased, but the facility's recorded weights were significantly higher than those recorded at dialysis, leading to a failure in recognizing the severe weight loss. Interviews with staff revealed that the weight monitoring process relied on the electronic health record dashboard and nursing concerns. Staff member M noticed the weight loss only after observing muscle and fat loss in the resident. Additionally, an observation of the weighing process showed that the mechanical lift scale was not functioning correctly, as it displayed an incorrect weight. Staff member A mentioned that maintenance had a schedule for calibrating the scales, but this did not prevent the discrepancy in the resident's weight recordings.
Failure to Continuously Assess and Document Worsening Penile Ulcer
Penalty
Summary
The facility failed to continuously assess and document the condition of a resident's penile ulcer, which was progressively worsening. The resident was admitted with skin concerns to the groin, including moisture and excoriation to the head of the penis. Despite the hospital discharge summary recommending wound care and noting the progression to a penile ulcer, the facility's records showed no nursing evaluations of the ulcer outside of the initial admission assessment. The facility's policy on perineal care required noting and reporting any skin changes, but this was not followed, as there was no documentation on the resident's penile ulcer or its worsening status in the nursing progress notes from the time of admission to the date of the surveyor's request for records. The care plan initiated later also failed to address the worsening condition adequately. Interviews with staff revealed that the resident's wound care was being compromised by the resident's actions, such as wiping off the applied wound care and touching himself, which made the wound care difficult. Despite these challenges, the facility did not document ongoing assessments or interventions to address the worsening ulcer, leading to a deficiency in providing appropriate treatment and care according to orders, resident’s preferences, and goals.
Medication Error Omission for Resident
Penalty
Summary
The facility failed to ensure a resident was free from a medication error omission, resulting in the resident missing 15 days of two prescribed medications, Flomax and Finasteride. These medications were intended to improve urine flow and assist in the resident's catheter removal. The resident had a urinary catheter placed due to urinary retention while in the hospital, and the plan was to continue these medications before a follow-up with urology. However, the resident's Medication Administration Record (MAR) showed that Finasteride was not administered, and Flomax was discontinued. The resident expressed anxiety about the upcoming catheter removal, and a staff member confirmed that the physician orders were not correctly followed, leading to the medication error.
Failure to Use Standard Precautions in Laundry Handling
Penalty
Summary
The facility staff failed to use standard precautions while handling soiled laundry, which could lead to cross-contamination. During an observation, it was noted that there were no protective gowns or gloves available for staff in the dirty linen area of the laundry room. A staff member confirmed that they did not use any personal protective equipment (PPE) while handling soiled laundry, simply throwing it into the washing machine without any covers or gloves. This practice was in direct violation of the facility's policy on handling soiled linen, which mandates the use of gloves and other protective equipment as necessary. Additionally, the facility's policy explicitly states that all used linen should be treated as potentially contaminated and should not come into contact with uniforms or the floor. The lack of adherence to these guidelines was further highlighted when another staff member inquired about the need to educate laundry staff on the proper use of PPE. The facility's failure to provide and enforce the use of appropriate PPE for laundry staff was also inconsistent with best practices outlined by the Centers for Disease Control and Prevention (CDC), which recommend the use of tear-resistant gloves, gowns, aprons, and face protection when handling soiled linens.
Failure to Provide Dignity and Respect to Resident
Penalty
Summary
The facility failed to provide dignity and respect to a resident, leading to feelings of embarrassment and humiliation. During a follow-up appointment at a local physician's office, the resident arrived soiled with urine and dried stool. The resident's incontinent brief was saturated and had leaked onto her clothing and wheelchair. The resident reported not being toileted or changed all day, which was corroborated by the nurse who assisted her at the appointment. The resident and her family member both expressed feelings of embarrassment and humiliation due to the incident. Upon returning to the facility, the resident's room had a strong urine smell, and she confirmed occasional bowel and bladder incontinence, requiring assistance with toileting. The resident had been living independently before her admission and had recently started to regain some independence. Despite this, the facility staff denied that the resident was soiled prior to her appointment. A grievance was filed by the family member, but the facility's investigation concluded that the resident was continent and the incident was an accident. However, the resident's medical records showed 37 instances of incontinence within a month, contradicting the staff's claims.
Failure to Conduct Root Cause Analysis for Resident Fall
Penalty
Summary
The facility failed to complete a thorough investigation, including a root cause analysis, for a fall with injury involving a resident. The resident, who had a history of left-sided weakness from a stroke, experienced an unwitnessed fall in his room, resulting in a fractured hip. Despite the resident being sent to the emergency room and undergoing surgery, staff members were unable to determine the cause of the fall or articulate any root cause analysis during interviews. The facility's policy mandates conducting root cause analysis to prevent recurrences and improve resident care, but this was not followed in this case. The incident report submitted to the State Survey Agency indicated that an investigation was started, but the findings did not include a root cause analysis. Staff interviews revealed that the resident might have fallen while attempting to walk to the bathroom, but no formal analysis was conducted to confirm this or to implement preventive measures. The facility's failure to conduct a root cause analysis and implement corrective actions as per their policy represents a significant deficiency in their management of resident care and safety.
Inaccurate MDS Assessment for Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to complete an accurate MDS assessment for a resident in the area of bowel and bladder incontinence. During an observation and interview, the resident reported issues with bowel and bladder incontinence, which had worsened after knee surgery. Despite this, the resident's MDS assessment indicated that the resident was always continent of bowel and bladder. Interviews with staff members revealed inconsistencies in their knowledge of the resident's continence status, with some staff members stating the resident was continent and others being unfamiliar with the resident's condition. A review of the resident's electronic medical record showed 37 instances of incontinence over a one-month period, contradicting the MDS assessment. The case manager responsible for MDS assessments stated that the facility did not have a specific MDS policy and relied on the guidelines set forth in the RAI manual. The case manager also mentioned that another MDS nurse had completed the resident's MDS assessment while she was out of town. The facility's policy on incontinence indicated that residents who are incontinent should receive appropriate treatment and services to prevent infections and restore continence. However, the inaccurate MDS assessment failed to reflect the resident's actual condition, leading to a deficiency in providing appropriate care and services.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for a new resident, which is a requirement according to their policy. The resident, who had a knee brace and was non-weight bearing on her left leg upon admission, required assistance with dressing, toileting, and bathing. However, the baseline care plan was not completed and locked until 14 days after admission, and it did not address the resident's transfer status, weight-bearing status, or activities of daily living. During interviews, staff members provided inconsistent information about the resident's condition and care needs. One staff member stated the resident was continent of bowel and bladder, while another mentioned the resident had problems with incontinence. Additionally, a staff member who did not usually work on the unit was unaware of how to access the resident's care plan and relied on verbal reports for information. This lack of a timely and comprehensive care plan had the potential to affect the quality of care for all new admissions in the facility.
Incomplete Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to complete a comprehensive, person-centered care plan for a resident who had a knee fracture and was admitted to the facility non-weight bearing. The resident required assistance with activities of daily living (ADLs) such as dressing, toileting, and bathing. Despite the resident's progress in becoming more independent and being able to bear weight with a knee brace, the care plan did not include focus, goals, or interventions related to ADLs, bowel and bladder status, transfer status, weight-bearing status, or physical therapy services. This omission was observed during interviews and record reviews, where staff members provided inconsistent information about the resident's needs and care plan details. During observations and interviews, it was noted that the resident's room had a strong urine smell, and the resident reported occasional bowel and bladder incontinence. Staff members had varying levels of knowledge about the resident's condition and care needs, with some unable to access or verbalize the care plan. The facility's document on comprehensive care plans indicated that care plans should include measurable objectives and timeframes to meet the resident's needs, but this was not reflected in the resident's electronic care plan dated February 2024.
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 7 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 Great Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benefis Senior Services - Eastview | 0.5 mi | ★★★★★ | 6 | 0 |
| Benefis Senior Services - Grandview | 0.5 mi | ★★★★★ | 1 | 0 |
| Benefis Senior Services - Westview | 2.3 mi | ★★★★★ | 0 | 0 |
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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.