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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valle Vista Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A resident with a chronic scalp lesion had ongoing drainage and foul odor, but the wound was not adequately evaluated or managed despite repeated skin assessments documenting the condition. No wound care orders were in place until maggots were found and removed, and staff did not complete a comprehensive reassessment afterward. The resident was not seen by a provider until several days later, when a surgeon documented fly-laid maggots, drainage, odor, and growth, and a biopsy later showed basal cell carcinoma.
EBP was not identified or initiated for residents with wounds, a skin lesion, or an indwelling Foley catheter, as signage was missing and PPE was not readily accessible at the point of care. In addition, a staff member distributing clean linen entered multiple residents’ rooms and handled clean clothing without performing hand hygiene before entering, after exiting, or before touching clean linen.
Failure to Notify Physician of Wound Change: The facility did not notify the MD of a significant change in condition for a resident with a chronic scalp wound when new drainage developed. The wound was observed with black discoloration, drainage, and a foul odor, and skin assessments documented drainage, but nursing notes showed no documentation that the MD was informed. Staff stated the MD should be notified of wound changes such as drainage, size, shape, or color, though notification was handled case by case.
The facility failed to fully assess and document a resident’s chronic scalp wound. Weekly skin checks noted the lesion at times, but documentation lacked wound size, shape, color, and full drainage details, and no comprehensive skin assessment was documented after maggots were removed. Staff stated wound changes should be reported and documented, but the record did not show complete follow-up assessment of the wound.
Failure to provide physician reassessment after a significant change in condition: a resident with a large, foul-smelling scalp lesion was found to have maggots in the wound. Staff notified the MD, who gave wound care instructions by phone, but did not come to assess the resident or document a reassessment before the resident’s outpatient surgery visit.
Incomplete Documentation of Chronic Scalp Wound: A resident with a chronic scalp lesion/wound had inconsistent and incomplete skin/wound documentation in the EMR. Weekly skin assessments sometimes omitted the lesion entirely, and when it was documented, key details such as size, shape, color, and drainage were missing. The record also lacked documentation of a comprehensive assessment after maggots were found and removed from the wound, and staff acknowledged the chart did not provide a complete picture of the wound status or care provided.
Unsafe food storage and poor dietary hygiene were observed in the kitchen and dining areas. Staff stored multiple foods unlabeled or undated, left opened items improperly handled, and allowed food-contact surfaces and equipment to remain soiled. During meal service, staff wore the same gloves while handling food, utensils, and paperwork, and some staff worked without proper hair nets or beard covers, including a beard cover that did not fully cover a mustache.
The facility failed to keep care plans current for three residents. One resident had ongoing behaviors such as refusing care, refusing meals, refusing the call light, and yelling out, but the care plan did not include those behaviors or related interventions. Another resident’s post-fall care plan did not include grippy strips recommended after the root cause was identified, and it did not reflect walker use observed in the halls. A third resident’s care plan did not include the use of colored lenses after staff documented that the trial helped with vision.
A resident with chronic liver disease had frequent disruptive yelling, refusals of care, refusal to eat, refusal to use the call light, and verbal abuse toward staff. Nursing notes showed staff tried to meet needs, but the behaviors continued, physician notes did not address them, and the resident’s spouse refused a mental health consult without documentation of that refusal being provided to surveyors.
A quadriplegic resident was transferred to another facility without being provided with a wheelchair, despite reliance on it for mobility, and arrived at the receiving facility without one. Additionally, the facility did not document the discharge in the medical record, omitting key information about the transfer and the resident's care.
Surveyors found that a common bathtub had not been cleaned for several months, with visible stains and sediment, and lacked signage indicating it was out of use. Staff confirmed the bathtub was not in use and believed monthly housekeeping audits were occurring, but no documentation of cleaning or audits was provided. Additionally, infection control policies, including water management and Legionella surveillance, had not been reviewed or updated annually as required.
The facility did not maintain complete medical records, as several residents lacked medical provider visit notes in both the EMR and paper charts, and a resident's POLST form was missing a required physician signature. Staff processes for handling provider notes were inconsistent, and the missing POLST signature was not identified during routine reviews.
Two residents were administered psychotropic medications, including antidepressants and antipsychotics, before informed consent was obtained from their representatives. In both cases, medication was started prior to the completion or documentation of consent, contrary to facility policy requiring consent before initiation. Staff interviews confirmed that the required process for obtaining consent was not followed.
Two residents with dementia received PRN antipsychotic medications without the required 14-day limitation or documented provider rationale for continued use. Medication regimen reviews did not address the ongoing use of these medications, and staff were unable to explain the oversight, despite facility policy requiring a 14-day limit for PRN antipsychotics.
A resident with encephalopathy and a conservator was suspected of being financially exploited when staff noticed unpaid bills and possible misuse of funds. Although APS was notified and an investigator assigned, the facility did not report the allegation to the state survey agency or document an internal investigation, contrary to its own policies.
A resident was transferred to the hospital on two occasions without receiving the required written notice explaining the reason for transfer. Staff confirmed that the transfer notices were not completed, and no documentation was found in the medical record or provided upon request, despite facility policy requiring such notification.
A resident with poor vision and limited hand function was not provided with a care plan that addressed her specific activity preferences or physical limitations. She reported spending most of her time in bed without being offered in-room activities or one-on-one visits, and the care plan lacked individualized interventions despite her needs and expressed interests.
A resident with poor vision and limited hand function did not receive group or individual activities to meet her interests or support her well-being. The resident reported no staff visits or in-room activities, and activity participation records showed no documented involvement since admission. The staff member responsible for activities acknowledged documentation issues and lack of time, and no supporting records or assessments were provided.
The facility failed to maintain a sanitary kitchen, affecting all residents consuming food from it. Observations revealed debris and dirt in various areas, and a dark brown substance at the floor's edge. Staff interviews indicated cleaning tasks were not consistently completed due to staff shortages and vacation. The facility's policy required regular cleaning, but checklists showed gaps in completion.
The facility lacked a certified director for food and nutrition services, affecting all residents receiving food. Staff member C, in the role for six months, had no training or oversight due to staff member G's absence. The dietician was only available by phone, and no dietary training documentation existed for staff member C.
The facility was found deficient in maintaining kitchen hygiene and food storage practices. Staff failed to wear required hairnets and beard nets, and several food items were improperly stored without labels or dates. The kitchen was unclean, with dirty equipment and missing laminate on cupboards. Dented cans were improperly stored, and staff admitted to neglecting proper procedures. The dietary manager's supervisor acknowledged a lack of oversight, contributing to these issues.
The facility was found to have expired medications and medical supplies in both the medication and treatment rooms. Items such as test strips, injection solutions, and various catheters were past their expiration dates. Staff acknowledged the oversight, and it was noted that the facility did not have a specific policy for handling expired items.
The facility failed to serve food at safe and appetizing temperatures, affecting three residents. Observations showed food items like eggs and hashbrowns were served below the required 135 degrees Fahrenheit. A resident expressed dissatisfaction with the consistently cold food, and staff acknowledged issues with the steam table and plate warmers. The facility's policy on maintaining hot food temperatures was not followed.
Failure to Monitor and Manage Chronic Scalp Wound With Maggot Infestation
Penalty
Summary
The facility failed to provide necessary care and services to evaluate, monitor, and manage a chronic scalp lesion/wound for one resident despite ongoing changes in the wound condition, including documented drainage. The resident was observed with multiple black lesions on the scalp, including a large central lesion about the size of a tennis ball that was black, partially covered with brown material, and draining yellowish, foul-smelling fluid. The hair around the lesions was discolored and had crusted, dried material present, and the resident stated the lesions had drained off and on and that one lesion had been present for years while the smaller ones were newer. Record review showed weekly skin assessments documented the scalp lesion/wound over many months, with drainage noted on several assessments, but there were no wound care orders for the lesion until after maggots were identified and removed. Facility staff stated the resident was admitted with the lesion and that the staff member aware of it only saw the resident on occasion. After maggots were found and removed from the scalp lesion/wound, staff did not complete a skin assessment, and there was no documentation of a comprehensive assessment of the lesion/wound following removal of the maggots. The resident was evaluated by a general surgeon five days after the maggots were identified and removed, and during that time there was no documentation of a physician or other provider evaluation or a comprehensive reassessment of the lesion/wound. The surgeon’s consultation noted that flies laid maggots on the wound and that it had drainage, odor, and growth, with a history of infection. A biopsy was taken, and later notes showed the biopsy was positive for basal cell carcinoma.
EBP Not Initiated and Hand Hygiene Not Performed During Linen Distribution
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were identified and initiated for residents with wounds or an indwelling Foley catheter. Review of the facility’s EBP list showed that resident #1 had a wound, resident #2 had a wound and an indwelling Foley catheter, resident #3 had a skin lesion, and resident #7 had a wound requiring EBP. During observations, resident #3 had no EBP signage outside the room and no PPE readily accessible, and there was one PPE caddy for the west hallway serving the Special Care Unit hallway. Additional observations showed resident #1 had no EBP signage outside the room or PPE readily accessible. Resident #2 was observed lying in bed with an indwelling Foley catheter bag located in a basin on the floor and also had a documented wound; there was no EBP signage outside the room or PPE readily accessible. Resident #7 also had no EBP signage outside the room or PPE readily accessible. Later, one PPE caddy was observed in the hallway serving residents #1, #2, and #7, but PPE was not located immediately outside or readily accessible. Staff stated EBP should be used for residents with infections, wounds, or an indwelling Foley catheter, and that residents on EBP should have a shield sign posted on the door frame. The facility also failed to ensure hand hygiene was completed during the distribution of clean linen. During observation, a staff member entered resident #5’s room, placed clean clothing in the closet, and exited without performing hand hygiene before entering or after leaving the room. The staff member then handled clean clothing on the linen cart and repeated the same process for resident #6 and resident #7 without performing hand hygiene before entering or exiting those rooms. The staff member stated she had been educated on proper hand hygiene and was to perform hand hygiene before entering a resident’s room, after leaving a resident’s room, and before touching any clean linen, but acknowledged that she did not perform proper hand hygiene.
Failure to Notify Physician of Wound Change
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for resident #3 related to a chronic scalp lesion/wound, including the new onset of drainage. During an observation on 6/30/26 at 2:50 p.m., resident #3 was noted to have a scalp lesion/wound with black discoloration, drainage, and a foul odor. Weekly skin assessments dated 11/23/25, 11/30/25, and 12/7/25 documented drainage from the scalp lesion/wound. Review of nursing progress notes dated 11/23/25 through 12/9/25 showed no documentation that the physician was notified of the change in condition related to the drainage from the scalp lesion/wound. During interviews, staff stated the physician should be notified of new skin concerns and changes in a wound, including size, shape, color, or drainage, although one staff member said notification was done on a case-by-case basis and earlier changes were not reported because the physician was aware of the lesion on admission. Another staff member stated he did not recall being notified about concerns with the scalp lesion/wound before being notified of a maggot infestation.
Incomplete Assessment and Documentation of Chronic Scalp Wound
Penalty
Summary
The facility failed to ensure comprehensive wound assessment, monitoring, and documentation of a chronic scalp lesion/wound for one sampled resident. Weekly skin assessments for the resident showed periods when the scalp lesion/wound was present, but the documentation did not include complete wound characteristics such as size, shape, color, or drainage details. In some assessments, drainage was noted without describing the lesion/wound itself or the drainage characteristics, including color, consistency, or odor. The record also showed no documentation that a comprehensive skin assessment of the scalp lesion/wound was completed after maggots were identified and removed from the lesion/wound on 6/12/26. During interviews, staff stated that skin assessments were completed weekly, that physicians should be notified of changes in a wound, and that wound documentation should include measurements and descriptive characteristics. Staff also stated the facility did not have a dedicated wound nurse and that nursing staff completed wound care and documentation.
Failure to Provide Physician Reassessment After Maggot-Infested Scalp Wound
Penalty
Summary
The facility failed to ensure physician supervision and ongoing clinical oversight after being notified of a significant change in condition for one resident with a large scalp lesion. During observation, the resident had multiple black-colored lesions on the scalp, including a large central lesion about the size of a tennis ball that was partially covered with brown material and had yellowish, foul-smelling drainage. Staff reported that the resident was admitted with the lesion, that it intermittently drained, and that on 6/12/26 a staff member found maggots in the wound. After the maggot infestation was reported, a staff member assessed the resident and called the physician, who instructed staff to clean the area with soap and water, apply petroleum jelly, and cover the wound. The resident received a shower and the lesion was dressed per orders, but the physician did not come to the facility to assess the resident after notification. The physician later stated he did not evaluate or reassess the resident because an outpatient general surgery appointment was already scheduled. Record review showed no physician progress note documenting reassessment of the resident’s condition between the report of maggots and the outpatient surgical evaluation.
Incomplete Documentation of Chronic Scalp Wound
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a chronic scalp lesion/wound. Weekly skin assessments from 6/2/25-6/29/25 and 11/2/25-11/16/25 contained no documentation of the resident’s scalp lesion/wound, while assessments from 7/6/25-9/28/25 and 12/14/25-6/14/26 documented the presence of the lesion/wound but did not include complete details such as size, shape, color, or drainage characteristics. The resident’s electronic medical record also showed no documentation that a comprehensive assessment of the chronic scalp lesion/wound was completed after maggots were identified and removed from the lesion/wound on 6/12/26. During interviews, staff stated that weekly skin assessments were completed, that nursing staff were expected to document skin and wound assessments, and that documentation should include at minimum a description of the skin concern, wound description or measurements, shape, color, drainage, and odor. Staff acknowledged the record did not contain all information needed to provide a complete picture of the resident’s wound status and related care provided.
Unsafe Food Storage and Poor Dietary Hygiene
Penalty
Summary
Food storage, labeling, preparation, and sanitation practices in the kitchen and dining areas were not followed as observed by surveyors. In the kitchen, maroon cereal bowls were stored upright in a bus tub, several metal bowls were stored upright on wire shelves, and multiple food items were left unlabeled or undated, including a tub of dried beans identified by staff as pinto beans, cornmeal, rice, and several meat products in the cooler. Opened items such as strawberry jam, soy sauce, vanilla, vegetable oil, butter/oil substitute, and vinegar were also observed without proper dating, and some were not securely closed. The walk-in freezer had large mounds of ice on the shelves and floor, and several food-contact and equipment surfaces, including the microwave interior, stand mixer underside, hot chocolate machine nozzles, and juice dispenser nozzles, were soiled with dried food residue. Employee hygiene and food handling practices were also observed to be deficient. Staff entered and worked in the kitchen without required hair nets or beard covers, including staff with facial hair whose beard cover did not fully cover the mustache. During meal service in the dining room, one staff member wore the same gloves throughout service, touched bun bags, soup bowls, a pen, and food items, and placed thumbs and fingers inside bowls while dishing soup. Another staff member washed dishes while wearing gloves, handled dirty and clean items with the same gloves, and did not remove the gloves or sanitize hands between tasks. Staff also handled clean dishes and cutting boards while still wearing dirty gloves. The report also noted that staff were new and had not completed all education, and one staff member stated the company would have a dietary manager from another facility come in to train the dietary manager and staff. These observations showed repeated failures in food labeling, storage, sanitation, and glove and hair restraint use across kitchen and dining room operations, affecting all residents receiving food services from the facility.
Care Plans Not Updated to Reflect Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised to reflect individual resident-centered care needs for residents #4, #18, and #61. For resident #61, the record showed frequent behaviors throughout the stay, including refusing care, refusing to eat, refusing to use the call light, and yelling out for help for extended periods of time. Nursing notes documented staff attempts to meet the resident’s needs, but the behaviors continued, and the care plan from 6/2/25 to 10/19/25 did not identify disruptive behaviors as focus areas or include interventions to address them. Resident #61’s Significant Change MDS with an ARD of 9/8/25 triggered care planning for behaviors and cognitive loss. The assessment documented a BIMS score of 11/15, indicating moderate cognitive impairment, and described confusion, disorientation, forgetfulness, yelling for staff, not using the call light at times, and refusing cares and meals. Staff stated the resident was admitted for strengthening PT with a goal to return home, that behavioral health services were not discussed, and that the resident was not always compliant with lactulose for chronic liver disease. The care plan did not reflect the resident’s disruptive behaviors or revisions when interventions were not effective. For resident #18, the interdisciplinary team identified after a fall that the feet and floor were wet in front of the toilet and recommended grippy strips in that area, but the care plan did not include that intervention. The care plan also stated the resident was often able to ambulate independently and did not show that he used a walker, even though he was observed using a walker during multiple hallway observations. For resident #4, staff documented that filtered or colored lenses were trialed and that the resident said the glasses worked and made a difference in one eye, but the current care plan only reflected a referral for a vision evaluation and did not include the use of colored lenses as a new intervention.
Failure to Provide Behavioral Health Services and Document Refusal
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident who repeatedly displayed disruptive yelling, refusals of care, refusal to eat, refusal to use the call light, and verbal abuse toward staff. The resident’s electronic health record from 6/2/25 to 10/19/25 showed these behaviors occurred frequently and continued without change, while nursing notes showed staff attempted to meet the resident’s needs without a corresponding decrease in the behaviors. The resident’s physician progress notes dated 6/4/25, 8/4/25, and 10/10/25 did not address the disruptive behaviors documented by nursing staff. During interviews, staff stated the resident had been admitted for strengthening PT with a goal of returning home with her spouse, that the spouse wanted many medications discontinued, and that the spouse refused to allow a mental health consultation. Staff also stated the resident was not always compliant with lactulose, which was used to decrease ammonia levels related to the resident’s chronic liver disease. When documentation related to the refusal of behavioral health services was requested, none was provided before the end of the survey.
Failure to Provide Wheelchair and Proper Discharge Documentation
Penalty
Summary
A quadriplegic resident, who required a wheelchair for primary mobility due to spastic quadriplegic cerebral palsy, was discharged and transferred to an Adult Services Residential Program facility in Pennsylvania without being provided with a wheelchair. Interviews with staff revealed that although there was discussion about sending a manual wheelchair with the resident, there was no documentation confirming that a wheelchair was actually sent. The receiving facility reported that the resident arrived without any wheelchair, manual or electric, which was his main mode of locomotion. Additionally, the facility failed to document the transfer and discharge of the resident in the medical record. There was no discharge progress note on the day of discharge, and essential information such as a summary of the resident's stay, education on medications and treatments, a list of belongings, details of who picked up the resident, and the reason for discharge were missing. All discharge documentation was handled through email and TEAMS meetings rather than being properly recorded in the medical record as per facility policy.
Inadequate Infection Control Program and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program, as evidenced by improper cleaning and maintenance of resident-care equipment and lack of annual review of infection control policies. During an observation, a common bathtub in the North hallway was found with long streaks of dark, rust-colored stains and dried brown sediment around the drain. The bathtub lacked signage or a cover to indicate it was out of use. A staff member reported that the bathtub had not been cleaned in five or six months and confirmed it was not being used by residents, with only the toilet and sink in use in that bathroom. The staff member also believed that housekeeping audits were being conducted monthly by another staff member. Review of facility policies revealed that the cleaning and disinfection policy for resident-care equipment was last updated in April 2025, and both the Water Management Program Policy and Legionella Surveillance Policy had not been reviewed or revised since April 2020. The facility assessment indicated that routine maintenance and cleaning schedules existed for most equipment, with non-routine maintenance conducted as needed. However, when documentation was requested for cleaning or deep cleaning of the North hallway tub and for housekeeping audits from June 2024 to the present, no records were provided by the end of the survey.
Incomplete Medical Records and Missing POLST Signature
Penalty
Summary
The facility failed to maintain complete and accessible medical records for several residents, specifically lacking medical provider visit notes in both the electronic medical record (EMR) and paper charts. For four residents, there were no medical provider visit notes available in the EMR or in the paper charts at the nurse's desk, despite the residents having been admitted months prior. The process for handling provider notes involved receiving them via facsimile, review by the charge nurse, and subsequent scanning into the EMR, with the original faxed copy placed in the paper chart. However, the most recent notes had not been scanned, and in some cases, no notes were found in either record system. Staff confirmed that a nurse was present during provider visits but did not document the visit in the EMR, and the facility was in the process of changing to direct provider entry into the EMR. Additionally, the facility failed to ensure that a resident's Provider Orders for Life-Sustaining Treatment (POLST) form was properly completed, as one resident's POLST lacked a required physician signature. The unsigned POLST had been carried over from a previous facility and was not identified as incomplete during the admission or care planning process. Facility policy required that advance directives be copied and placed on the chart upon admission and reviewed periodically, but this process did not identify the missing signature.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications for two residents. For one resident, citalopram hydrobromide was ordered and administered before the resident's spouse signed the informed consent form, with the first dose given two days before consent was obtained. The same resident was later started on sertraline HCl, which was also administered before the spouse signed the consent form, with the first dose given two days prior to consent. Another resident received citalopram hydrobromide without any documented consent found in the electronic health record. This resident was also given haloperidol, with the consent form signed by the guardian two days after the medication order was received. Staff interviews revealed that the staff member responsible for obtaining consents could not explain why the consents were not completed prior to starting the medications. The facility's policy requires that residents or their representatives be informed of the risks and benefits of psychotropic medications before initiation, but this was not followed in these cases.
Failure to Limit PRN Antipsychotic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medications, specifically antipsychotics, were limited to a 14-day duration unless a medical provider documented a rationale for continued use. For one resident with vascular dementia and delusional disorders, an order for PRN olanzapine did not specify a 14-day limit, and subsequent medication regimen reviews did not address the need to monitor or discontinue the medication after 14 days. The medication remained active beyond the allowed period without appropriate documentation or evaluation by a provider. Similarly, another resident with severe dementia and behavioral disturbances had a PRN order for quetiapine fumarate that also lacked the required 14-day limitation. The medication regimen review process did not identify or address the ongoing use of the PRN antipsychotic within the required timeframe. Staff interviews revealed a lack of understanding regarding the review process for PRN antipsychotic medications, and facility policy required PRN antipsychotic orders to be limited to 14 days, with a new evaluation needed for continued use.
Failure to Report and Investigate Suspected Financial Exploitation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the possible misappropriation of a resident's property by their conservator. A resident with encephalopathy and an appointed conservator was the subject of concern after staff noted issues with unpaid bills and suspected the conservator might be using the resident's funds for personal use. Staff discussed the issue in an interdisciplinary team (IDT) meeting, and Adult Protective Services (APS) was notified, resulting in the assignment of an APS investigator. However, there was uncertainty among staff about who was responsible for following up on the concern after the IDT meeting. Despite the facility's policy requiring immediate investigation and timely reporting of suspected exploitation to the state survey agency and other authorities, there was no evidence that the allegation was reported through the State Survey Agency reporting portal. Additionally, the facility could not provide documentation of an internal investigation into the exploitation allegation. This failure to report and investigate as required by policy and regulation constituted the deficiency.
Failure to Provide Written Transfer Notice to Resident and Representative
Penalty
Summary
The facility failed to provide written notification to a resident and/or the resident's representative regarding the reason for transfer when the resident was transferred to the hospital on two separate occasions. During interviews, a staff member confirmed that no transfer notice was completed for the resident's hospitalizations, and review of the electronic medical record did not show any documentation of such notices for the specified transfers. Additionally, when requested, the facility was unable to produce any records or documentation of the required transfer notices. The facility's own policy requires that transfer/discharge notices be provided to residents or their representatives in a language and manner they can understand.
Failure to Develop and Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed a resident's activity preferences and physical abilities. Observations showed the resident spent most of her time in bed, with limited engagement in activities. The resident reported poor vision and limited hand function, which prevented her from participating in group activities, and stated that staff had not offered her in-room activities or one-on-one visits. She expressed a desire for staff to visit her in her room, as she was unable to participate in most activities due to her physical limitations. Review of the resident's care plan revealed it did not identify her specific life roles, activities of interest, or provide for one-on-one visits, despite her expressed preferences and needs. The care plan included only general interventions such as encouraging participation in activities and supplying leisure materials as needed, without customization to her abilities or preferences. Staff interviews indicated issues with documentation and care plan customization due to changes in the facility's computer system and staffing limitations. The resident's MDS assessment confirmed she required maximal assistance for mobility and self-care, further highlighting the need for individualized activity planning.
Failure to Provide and Document Activities to Meet Resident Needs
Penalty
Summary
A deficiency was identified when a resident, who had poor vision and limited hand function, reported not participating in activities since admission. The resident stated that staff did not offer or provide one-on-one visits or in-room activities, and expressed a desire for staff to visit her, as she spent most of her time in her room. Observation confirmed the resident was alone in her room, awake, with the television off, and no activities being offered. Review of the resident's activity participation record showed no documented participation in any activities since admission. During interviews, the staff member responsible for activities acknowledged issues with documentation and stated that, due to working in two positions and limited time, she had not been documenting resident participation as required. Despite claims that the resident had participated in several activities, no documentation or records were provided to support this, and no activity assessment or evidence of one-on-one visits was available by the end of the survey.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary and clean condition, which had the potential to affect all residents consuming food or services from the kitchen. During an observation, surveyors found white debris resembling crumbs in the corners of the kitchen floor, white, tan, and brown debris resembling crumbs and dirt underneath the shelves, and white and tan debris resembling crumbs and food particles underneath the workspace next to the stove. Additionally, a dark brown substance was observed at the edge of the floor where the mop boards meet the floor. Interviews with staff revealed that the cleaning tasks were assigned to employees on shift, with a checklist that was initially required to be completed weekly but was changed to daily due to non-compliance. Staff member G mentioned that some staff were on vacation, and there was a loss of employees after school started. A review of the facility's policy on dietary sanitization indicated that all kitchen and dining areas should be kept clean, with the food services manager responsible for scheduling regular cleaning. However, a review of the kitchen checklists for the last two months showed gaps where the checklists were not completed.
Lack of Certified Director in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a certified individual to serve as the director of food and nutrition services, which could potentially affect all residents receiving food from the kitchen. Staff member C, who took over the position in November, reported having no orientation or training due to the absence of staff member G, who was involved in a car accident. Despite being in the role for six months, staff member C had not received any corporate training or oversight and was not enrolled in any dietary courses, although he planned to take the ServSafe course. The dietician was available only by phone for substitution changes and did not supervise or oversee staff member C in the kitchen. Additionally, there was no documentation of specific dietary orientation or training for staff member C.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards in the kitchen, as observed during a survey. Staff members were found not wearing required hairnets and beard nets, with one staff member wearing a baseball cap instead. The kitchen had several open food items without labels or dates, including large tubs of rice, brown sugar, flour, and other ingredients. Additionally, the kitchen was found to be unclean, with dirty toasters, drink dispensers, and a chest freezer with food debris and frost buildup. The cupboards above the food prep area were also dirty, with missing laminate chunks. Further observations revealed dented cans in the dry storage room, which should have been discarded according to facility policy. Staff members admitted to not following proper procedures, with one stating that the staff often got in a hurry and neglected to label and date food items. The dietary manager's supervisor acknowledged a lack of oversight in the kitchen, contributing to the ongoing issues. The facility's policies on food labeling and hairnet usage were not being adhered to, as evidenced by the conditions found during the survey.
Expired Medications and Supplies Found in Facility
Penalty
Summary
The facility failed to remove and dispose of expired medications and medical supplies in both the medication room and the treatment room, as observed during a survey. In the medication room, expired items included Coaguchek XS PT test strips, glucose control solution set, sodium chloride injection solution, a red top blood collection tube, and Monoject hypodermic needles. In the treatment room, expired items included various types of catheters. During interviews, staff members acknowledged the oversight, with one staff member admitting to missing the expired items during checks. Additionally, it was revealed that the facility lacked a specific policy addressing the management of expired medications and supplies.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature for three residents. Observations and interviews revealed that the food served was consistently cold. Resident #200 expressed dissatisfaction with the food quality, stating it was always cold. Temperature checks conducted by staff member C on various dates showed that food items such as eggs, hashbrowns, and cream of wheat were served at temperatures significantly below the required 135 degrees Fahrenheit. Additionally, the steam table used to keep food warm was found unplugged and not turned on, contributing to the issue. Further observations indicated that the steam table was not functioning properly, and a new steam table was available but not assembled. Resident #38 also complained about cold food, opting to eat only her salad. Staff members acknowledged the problem, noting that food was served on cold plates with unheated plate warmers, exacerbating the issue. The facility's policy on meal assistance, which mandates that hot foods be held at 135 degrees or above until served, was not adhered to, leading to the deficiency.
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Illustrative
What surveyors actually found near you
We read the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lewistown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montana Mental Health Nursing Home | 0.6 mi | ★★★★★ | 4 | 0 |
| Central Montana Nursing & Rehabilitation Center | 0.8 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 August 2026) and official state health department websites.