Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shamrock Nursing Center during CMS and state inspections, most recent first.
A resident who remained in the facility after Medicare Part A skilled services ended was not provided with the required CMS-10055 Advanced Beneficiary Notice (ABN), although they did receive the CMS-10123 Notice of Medicare Non-Coverage (NOMNC). Staff interviews revealed confusion over responsibility for issuing these forms during a transition in the Business Office Manager position, resulting in the ABN not being given as required.
A resident with multiple medical conditions had her code status changed from CPR/Full Code to DNR, as documented by the social worker and on a signed MOST form. However, the care plan was not updated to reflect this change because the MDS Nurse was not informed, and the update was not discussed in the facility's daily meetings as expected.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
Staff failed to follow infection control policies during care of a resident with a chronic wound and feeding tube. One nurse did not change gloves or perform hand hygiene between wound care steps, while another did not wear a gown during high-contact care despite EBP signage and PPE availability. The DON and administrator confirmed that both hand hygiene and use of gown and gloves were required by facility policy.
A medication error rate of 5 percent or greater was found during the survey, showing that the facility did not maintain medication administration errors below the required limit.
The facility did not notify the Medical Director when significant morning medications were missed for a resident due to dialysis treatments, including seizure medication, insulin, and medications for chronic conditions. Additionally, the facility failed to inform the Responsible Person and Medical Director when a cognitively impaired resident attempted to cut off her cast with a knife. These incidents highlight lapses in communication regarding medication administration and significant resident events.
An incident involving a resident with dementia and a history of wandering highlighted deficiencies in maintaining a hazard-free environment and providing adequate supervision. The resident was found attempting to cut off her cast with a knife accessed from an unlocked maintenance room. The room contained potentially harmful tools and materials. Staff members, including the Nursing Assistant and Maintenance Directors, were unaware of the importance of keeping the maintenance room locked. The incident was not promptly reported to the Administrator and DON, emphasizing the immediate jeopardy faced by the resident due to the accessible hazards.
A resident with complex medical conditions, including dependence on renal dialysis, missed multiple doses of morning medications due to being out of the facility for scheduled dialysis treatments. The missed medications included those for depression, epilepsy, type 2 diabetes, hypertensive heart disease, and chronic kidney disease with heart failure. Nursing staff did not administer the medications upon the resident's return, citing the resident's leave of absence. Documentation showed missed doses, but the resident's vital signs remained within normal limits. Interviews revealed gaps in knowledge and communication among nursing staff and the medical doctor regarding medication administration protocols for dialysis residents.
A new cook at the facility prepared fried chicken by cooking it for 15 minutes in a fryer and then transferring it to the oven. The chicken pieces were piled in a 4-inch pan instead of a 2-inch pan, resulting in undercooked chicken. The cook did not check the temperature before serving, leading to undercooked chicken being served to 15 residents, with 5 consuming it. The issue was identified by a nursing assistant who observed the undercooked chicken during lunchtime.
A facility failed to adhere to infection control protocols by using a single resident's insulin pen for another resident, risking bloodborne pathogen transmission. Despite clear guidelines, a nurse administered insulin to one resident using another's pen. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with medical devices and non-chronic wounds, such as indwelling catheters and tracheostomies. Observations revealed a lack of appropriate personal protective equipment outside the rooms of high-risk residents, indicating systemic issues in infection control measures.
The facility failed to refer three residents with serious mental health diagnoses for PASRR level II evaluations. Despite having diagnoses such as PTSD, psychotic disorder with hallucinations, and bipolar disorder, no PASRR level II referrals were documented for these residents. Both the Social Worker and Administrator confirmed that referrals should have been made based on the residents' conditions.
The facility failed to plan group activities outside of the facility, leading to frustration and feelings of being forgotten among residents. Despite requests during Resident Council Meetings, no outings were offered due to the lack of a transportation van. The Activity Director and Administrator acknowledged the issue but had not provided a solution.
The facility failed to consistently provide bagged meals for two residents with diabetes and end-stage renal disease who required dialysis. The residents reported not receiving their meals, which were supposed to include a sandwich, snacks, and a drink, leading to concerns about low blood sugar and hunger during their treatments. Staff interviews confirmed ongoing issues with meal preparation and accessibility.
The facility failed to verify a cook's competencies and certifications before his first day of employment. The cook began working without necessary training due to miscommunication and staff shortages. The Dietary Manager did not verify the cook's ServSafe certification and culinary school training before hiring him.
The facility failed to provide evening snacks to residents when requested, as confirmed through resident and staff interviews. Four residents with serious conditions reported inconsistencies in receiving evening snacks, and observations confirmed that the nourishment room was inadequately stocked. The Unit Manager and Dietary Manager were unaware of the issue until the survey, and nursing staff had informed dietary staff about the problem multiple times. The Administrator expected snacks to always be available, but the facility failed to ensure consistent provision.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in accident hazards and food safety. A cognitively impaired resident accessed a knife from an unlocked maintenance room, and undercooked chicken was served to residents. The facility also failed to properly label and store food items. The Administrator cited staff turnover and lack of accountability as contributing factors.
The facility failed to protect a resident's private health information when an insulin pen labeled with another resident's details was left at the bedside of a cognitively intact resident with diabetes. The incident was reported to the DON, who acknowledged the staff's responsibility to protect health information.
A facility failed to protect a resident from inappropriate physical contact when a Nurse Aide was observed lying in bed with the resident. The resident, who is legally blind and has depression, recalled being awakened but was unsure if the person was in his bed or sitting on it. Another NA confirmed seeing the incident and reported it, but the claim was not immediately investigated, and the incident was not reported to higher management until days later.
A facility failed to follow its abuse policy when a staff member was observed lying in bed with a resident. The incident was not reported immediately, and the staff member continued to work shifts. The delay in reporting and addressing the situation led to a deficiency in the facility's handling of the incident.
A resident with a pressure ulcer and chronic pain syndrome complained of severe pain during wound care, but the nursing staff did not stop the procedure to address the pain. Despite the resident's pain rating of 7 out of 10, the wound care was completed without interruption, leading to a deficiency in pain management.
Failure to Provide Required Medicare Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) to a resident prior to the end of their Medicare Part A skilled services. The resident was admitted and began receiving Medicare Part A services, and a CMS-10123 Notice of Medicare Non-Coverage (NOMNC) was issued to inform the resident that Medicare coverage for skilled services would end. However, the required ABN, which notifies the resident of potential financial liability for services not covered by Medicare, was not provided, even though the resident remained in the facility after skilled coverage ended. Interviews with facility staff revealed confusion regarding responsibility for issuing the required forms during a transition period when a new Business Office Manager (BOM) was being hired. The BOM stated she was responsible for issuing both the NOMNC and ABN but had not started employment at the time the resident's Medicare Part A benefit ended. The former Social Worker and the Administrator provided conflicting accounts of who was responsible for issuing the forms, but both acknowledged that both forms should have been provided when a resident remained in the facility after Medicare Part A coverage ended.
Failure to Update Care Plan with Resident's DNR Code Status
Penalty
Summary
A deficiency occurred when the facility failed to update a resident's care plan to reflect a change in cardiopulmonary resuscitation (CPR) code status. The resident, who had diagnoses including myasthenia gravis, diabetes mellitus, and hypertension, was cognitively intact at the time of the incident. Her care plan continued to indicate CPR/Full Code status, even after she communicated her wish to change to Do Not Resuscitate (DNR) status. The change was documented in the social work progress note and a Medical Orders for Scope of Treatment (MOST) form was signed to reflect the new DNR status. Despite the code status change being discussed with the social worker and documented in the resident's records, the information was not communicated to the MDS Nurse responsible for updating the care plan. The MDS Nurse was unaware of the change and stated that such updates were typically discussed in clinical or standup meetings, but this particular change was missed. The Director of Nursing and the Administrator both confirmed that code status changes were expected to be discussed in daily meetings, but could not explain why this update was overlooked, resulting in the care plan not being revised in a timely manner.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to adhere to its Handwashing/Hand Hygiene policy during wound care for a resident with a sacral wound. During an observed wound care procedure, a nurse entered the resident's room, donned a gown, sanitized her hands, and put on gloves. She removed the soiled dressing from the resident's sacrum and, without changing gloves or performing hand hygiene, proceeded to clean the wound and apply a new dressing. The nurse only removed her gloves and gown and performed hand hygiene after completing the entire procedure. In an interview, the nurse acknowledged forgetting to sanitize or wash her hands between steps and suggested she could have double-gloved, but this was not in accordance with policy. Additionally, the facility did not implement its Enhanced Barrier Precautions (EBP) policy during high-contact care activities for a resident with a chronic wound and a feeding tube. During an observation, a nurse aide and a nurse entered the resident's room to reposition and dress the resident. While the nurse aide donned both a gown and gloves, the nurse only wore gloves, despite EBP signage and a PPE caddy indicating that both gown and gloves were required for high-contact care activities such as dressing. The nurse later stated she was unaware of the EBP signage and believed a gown was only necessary when directly caring for the wound or feeding tube, not for dressing the resident. Interviews with the Director of Nursing, who also served as the Infection Preventionist, confirmed that staff were educated to follow hand hygiene protocols and EBP requirements, including wearing gowns and gloves during high-contact care for residents with wounds or indwelling devices. The administrator also confirmed that staff should wear both gown and gloves during such activities. The observed failures involved two staff members and were not in accordance with the facility's established infection control policies.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that medication administration errors remained below the acceptable threshold, as required by regulations. The deficiency was based on direct findings from the survey process.
Communication Gaps in Medication Administration and Incident Reporting
Penalty
Summary
The facility failed to notify the Medical Director when significant morning medications were not administered to Resident #20 due to her being out of the facility for dialysis treatments. These medications included seizure medication, insulin, depression medication, and medications for chronic kidney and heart failure. The missed doses of these medications posed serious risks to Resident #20, including potential seizure activity, diabetic coma, and cardiac complications. Despite the facility's policy requiring notification of the physician when medications are not administered, there was no documentation of the MD being informed of the missed medications for Resident #20. In another instance involving Resident #66, the facility also failed to notify the Responsible Person (RP) when the resident, who was severely cognitively impaired with a history of wandering, was observed attempting to cut her cast off with a knife. The Nursing Assistant (NA) who witnessed the incident did not report it to the nursing staff immediately, and there was no documentation of the incident in Resident #66's progress notes. The RP expressed a desire to have been informed of the incident so they could assess Resident #66's well-being and ensure appropriate actions were taken. The Medical Director was also not made aware of this incident, highlighting a lack of communication regarding significant resident events within the facility.
Deficiency in Preventing Access to Hazardous Items and Ensuring Resident Supervision
Penalty
Summary
The report details a deficiency in maintaining a nursing home area free from accident hazards and providing adequate supervision to prevent accidents, specifically focusing on an incident involving Resident #66. Resident #66, admitted with a history of dementia and a left arm fracture, was observed attempting to cut off her cast with a long ridged knife on 2/21/24. The resident, who was severely cognitively impaired and had a history of wandering, was unattended in the hallway outside the maintenance room, which was unlocked and partially open, allowing her access to the knife. Nursing Assistant (NA) #6 discovered Resident #66 with the knife and safely removed it, but failed to lock the maintenance room door after the incident. The report highlights that the maintenance room contained tools and materials that could pose serious harm or injury to residents if accessed. Interviews with staff members, including NA #6, the Regional Maintenance Director, and the previous Maintenance Director, revealed a lack of awareness regarding the incident and the importance of keeping the maintenance room door locked at all times to prevent resident access to hazardous items. The deficiency was further emphasized by the facility's failure to document the incident promptly to the Administrator and the Director of Nursing (DON). The report underscores the immediate jeopardy faced by Resident #66 due to the accessibility of the knife and the unlocked maintenance room. The root cause analysis identified the Maintenance Director's failure to lock the maintenance room door as a key factor contributing to the deficiency.
Medication Administration Gaps for Dialysis Resident
Penalty
Summary
The facility failed to prevent a significant medication error involving Resident #20, a dialysis resident with a complex medical history including dependence on renal dialysis, seizures, type 2 diabetes, depression, chronic kidney, and heart failure. The error occurred when Resident #20 did not receive her morning medications on multiple occasions due to being out of the facility for scheduled dialysis treatments. The missed medications included those prescribed for depression, epilepsy, type 2 diabetes, hypertensive heart disease, and chronic kidney disease with heart failure. Nursing staff, including Nurse #13 and Nurse #15, did not administer the morning medications upon Resident #20's return from dialysis, citing the reason as resident leave of absence. The facility's Medication Administration Record for April 2024 documented the missed doses of significant morning medications for Resident #20, including Escitalopram, Keppra, Ozempic, Carvedilol, and Humalog. Despite the missed doses, Resident #20's progress notes for April 2024 indicated that her blood pressure and blood sugar levels were within normal limits. Resident #20 expressed awareness of the missed medications, stating that they usually occurred on the days she received dialysis treatments. However, she had not reported the issue to the Administrator or Director of Nursing. Interviews with Nurse #13, Nurse #15, and the Medical Doctor revealed gaps in knowledge and communication regarding the administration of medications for dialysis residents. Nurse #13 and Nurse #15 were not aware of the protocol to hold and administer medications upon the resident's return from dialysis. The Medical Doctor emphasized the importance of being informed about any conflicts between dialysis treatments and medication schedules to make necessary adjustments.
Undercooked Fried Chicken Served Due to Inadequate Cooking Procedures
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to ensure that fried chicken was completely cooked before serving to residents. Cook #1, who was new to the facility, prepared the fried chicken by cooking it for 15 minutes in a fryer and then transferring it to the oven. However, due to the chicken pieces being piled on top of each other in a 4-inch pan instead of a 2-inch pan, the chicken was undercooked in the middle and close to the bone. Despite being advised by other staff members, Cook #1 failed to check the temperature of the chicken before serving it to residents. This led to undercooked fried chicken being served to 15 residents, with 5 of them consuming the undercooked chicken. The deficiency was first noticed by Nursing Assistant #6 during lunchtime when she observed undercooked chicken served to Resident #54. Upon further inspection, she found the chicken to be pink, bloody, and undercooked. This prompted the staff to remove all trays from the dining room and halls and provide residents with new trays. The observation continued in the kitchen, where it was confirmed that the fried chicken was undercooked and had to be discarded. Cook #1 admitted to not checking the temperature of the chicken adequately and acknowledged his mistake in the cooking process.
Insulin Pen Misuse and Lack of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that single resident insulin pens were not shared between residents, leading to a serious breach in infection control protocols. Nurse #10 administered insulin to Resident #171 using Resident #172's insulin pen, which posed a significant risk of bloodborne pathogen transmission. Despite clear guidelines from the manufacturer and facility policy stating that insulin pens are for single resident use only, the incident occurred due to a lack of adherence to these protocols. The failure to implement proper procedures for insulin administration and storage resulted in immediate jeopardy being identified on 07/10/23. Additionally, the facility also failed to initiate Enhanced Barrier Precautions (EBP) for residents with medical devices and non-chronic wounds, such as indwelling catheters and tracheostomies, for multiple residents. This lapse in implementing EBP for high-risk residents with medical devices and wounds further compounded the infection control deficiencies within the facility. The observations made during the survey highlighted instances where residents with medical devices did not have appropriate personal protective equipment available outside their rooms, indicating a systemic failure in ensuring proper infection control measures were in place.
Failure to Complete PASRR Level II Referrals for Residents with Serious Mental Health Diagnoses
Penalty
Summary
The facility failed to refer three residents with serious mental health diagnoses for Preadmission Screening and Resident Review (PASRR) level II evaluations. Resident #4 was admitted with diagnoses of PTSD and a mental disorder, but no PASRR level II referral was documented. The Social Worker (SW) and Administrator both confirmed that a PASRR level II referral should have been completed based on the resident's diagnoses. Similarly, Resident #19 was admitted with a diagnosis of psychotic disorder with hallucinations, but no PASRR level II referral was documented. The SW and Administrator again confirmed that a referral should have been made based on the resident's mental health condition. Resident #54 was admitted with adjustment disorder with mixed anxiety and depressed mood, and later received diagnoses of depression disorder and bipolar disorder. Despite these serious mental health conditions, no PASRR level II referral was documented. The SW and Administrator both acknowledged that a PASRR level II referral should have been completed upon admission and when the new diagnoses were made. The failure to complete these referrals indicates a lapse in the facility's adherence to PASRR requirements for residents with serious mental health diagnoses.
Lack of Group Outings for Residents
Penalty
Summary
The facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility. This deficiency affected five residents who reported feeling frustrated, awful, forgotten about, hemmed in, angry, and mad due to the lack of outings. The residents had voiced their desire to go on outings during Resident Council Meetings, but no action was taken to address their requests. The facility's activity calendars from January to April 2024 showed no scheduled activities outside of the facility, and the residents had not been offered any outings since their admission. Resident #203, the Resident Council President, expressed frustration over not being able to go on group outings and reported that other residents felt the same. Despite reporting this to the Administrator, no outings were offered. Resident #102 felt hemmed in and desired to go shopping or out to eat, but had not been out of the facility since admission. Resident #114 also wanted to go out but had not been offered any outings since admission. Resident #216 felt angry and mad about being stuck in the facility and suggested that local sports teams might donate tickets or food for outings. Resident #46, who is legally blind, felt awful and forgotten due to the lack of outings and desired to participate in activities outside the facility. The Activity Director, who had been in her position for five months, stated that the Administrator had told her to wait for outings until they got a van. The facility did not have a transportation van and used a contracted transportation company only for medical appointments. The Director of Nursing confirmed the lack of a van and stated that the facility used a contracted transportation company for medical appointments only. The Administrator acknowledged the residents' desire for outings but could not provide a timeline for obtaining a van and had not come up with an alternative solution to meet this need.
Failure to Provide Bagged Meals for Dialysis Residents
Penalty
Summary
The facility failed to provide breakfast, a bagged meal, or snack for two residents who required dialysis services. Both residents, who were cognitively intact and diagnosed with type 2 diabetes and end-stage renal disease, reported not receiving their bagged meals consistently when leaving for dialysis treatments early in the morning. These meals were supposed to include a sandwich, snacks, and a drink to ensure they had some nutrition during their treatments, which lasted from 5:30 AM to 10:30 AM. The residents expressed concerns about having to wait until lunch to eat and the potential risk of low blood sugar during their treatments. Interviews with the Dietary Manager, Nutritional Manager, Nursing Assistant, and Unit Manager revealed that there were ongoing issues with the preparation and availability of the bagged meals. The Dietary Manager, who had been employed for about a month, acknowledged the problem and stated that dietary staff were responsible for preparing and labeling the bagged meals the night before. However, there were instances where the meals were not prepared or were missing items, and nursing staff could not access the kitchen to prepare the meals themselves. The Nutritional Manager and Nursing Assistant confirmed these issues and noted that there had been some recent improvements after staff education. The Administrator confirmed awareness of the problem and had personally delivered the bagged meals to the dialysis facility on several occasions. The Administrator expected the bagged meals to be prepared and labeled the night before to ensure they were accessible to residents leaving early for dialysis. Despite recent staff education, the deficiency persisted, affecting the residents' ability to have adequate nutrition during their dialysis treatments.
Failure to Verify Cook's Competencies and Certifications
Penalty
Summary
The facility failed to verify Cook #1's competencies and certifications for food production and meal service prior to his first day of employment. Dietary Manager (DM) #1 admitted that new employees should be signed off on competencies before working independently, but Cook #1 was assigned to another staff member for training without proper communication. DM #1 did not ensure that DM #2, who was supposed to train Cook #1, was informed of her responsibilities. Consequently, Cook #1 began working without receiving necessary training, including food temperature training, which was scheduled for the second day. DM #1 also failed to verify Cook #1's ServSafe certification and culinary school training before hiring him, relying solely on his word during the interview process. It was only after Cook #1 started working that DM #1 requested copies of his certifications. Cook #1 confirmed that he had not received any training from the facility and had to start preparing food on his own due to staff shortages. A review of Cook #1's competency checklist revealed discrepancies, with competencies marked as completed on dates before he actually started working. The Regional Director of Operations (RDO) for Dietary later provided Cook #1's ServSafe certification and a screenshot of his culinary school acceptance but could not verify his completion of the program. The RDO confirmed that DM #1 was responsible for the hiring process and verifying competencies and certifications for new kitchen staff.
Failure to Provide Consistent Evening Snacks
Penalty
Summary
The facility failed to provide evening snacks to residents when requested, as observed and confirmed through resident and staff interviews. Four residents, all with diagnoses including type 2 diabetes and other serious conditions, reported inconsistencies in receiving evening snacks. They mentioned that staff often informed them that no snacks were available in the nourishment room and that they did not have access to the kitchen to obtain more. Observations confirmed that the nourishment room was inadequately stocked, with only a few items available. The Unit Manager and Dietary Manager were unaware of the issue until it was brought to their attention during the survey. The Dietary Manager acknowledged the problem and took immediate steps to restock the nourishment room and educate dietary staff on their responsibilities. Interviews with nursing staff revealed that they were aware of the residents' complaints about the lack of evening snacks. One Nursing Assistant mentioned that she had informed dietary staff about the issue multiple times. The Administrator stated that she expected snacks to always be available and that dietary staff should stock enough snacks, sandwiches, and drinks for residents. She also indicated that nursing staff should have notified supervisors or herself if there were issues with snack availability. Despite ordering an overabundance of snacks each month, the facility failed to ensure that residents consistently received their evening snacks as requested.
Repeat Deficiencies in Accident Hazards and Food Safety
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeat deficiencies. Specifically, the facility failed to maintain an environment free of accident hazards for a resident who was severely cognitively impaired with a history of wandering. The resident was found attempting to cut her cast off with a knife obtained from an unlocked maintenance room. Additionally, the facility failed to ensure the securement of a resident and her chair during van transport, failed to investigate an injury and complete a root cause analysis, and failed to secure bleach used by a resident, all of which were identified in previous surveys but not adequately addressed or prevented from recurring. The facility also failed to ensure food was prepared and served under sanitary conditions. Undercooked fried chicken was served to residents, with some consuming it, posing a high likelihood of foodborne illness. The facility also failed to label, date, and properly store food items in the walk-in refrigerator, reach-in cooler, and dry storage room. These issues were identified in multiple surveys, indicating a pattern of non-compliance with food safety standards. The Administrator attributed these repeat deficiencies to turnover in department heads and staff, and a lack of systems and accountability in place for staff.
Failure to Protect Resident's Private Health Information
Penalty
Summary
The facility failed to protect Resident #172's private health information when an insulin pen labeled with Resident #172's name, room number, type of insulin, prescription number, and fill date was left at the bedside of Resident #171. Resident #171, who was cognitively intact and had a diagnosis of diabetes mellitus, noticed the label after receiving an insulin shot from Nurse #10. The incident was reported by Resident #171 and her family member to the Director of Nursing (DON). The DON acknowledged that all staff were responsible for ensuring the protection of protected health information and that the prudent action would have been to ensure no protected health information was left visible to another resident.
Failure to Protect Resident from Inappropriate Physical Contact
Penalty
Summary
The facility failed to protect a resident's right to be free from inappropriate physical contact by a staff member. On 4/1/24, a Nurse Aide (NA) was observed lying in bed with a resident, which was reported by another NA. The resident, who is legally blind and has a diagnosis of depression, was cognitively intact and recalled being awakened by a voice but was unsure if the person was in his bed or sitting on it. The resident later identified the person as NA #1 and mentioned that he might have inadvertently touched her thigh. NA #1 denied ever lying in the bed or touching the resident, stating she sat in a chair at the foot of the bed throughout her shift. However, NA #3 confirmed seeing NA #1 lying in bed with the resident and reported it to the nurse on duty, who did not immediately investigate the claim. The incident was not reported to the Director of Nursing (DON) until 4/10/24, despite multiple staff members being aware of the situation. The DON and the Administrator were both surprised by the delay in reporting, as staff usually communicated other incidents promptly. The facility's policy on abuse, neglect, and exploitation was not followed, leading to a failure in protecting the resident from inappropriate physical contact. Interviews with the involved staff and the resident provided conflicting accounts of the event. While the resident was not bothered by the presence of NA #1 in his bed, the facility's policy clearly prohibits such actions. The lack of immediate and thorough investigation by the nursing staff and the delay in reporting the incident to higher management contributed to the deficiency in ensuring the resident's safety and well-being.
Failure to Report and Address Inappropriate Staff-Resident Interaction
Penalty
Summary
The facility failed to follow its policy on reporting and protection, resulting in a deficiency. Nurse Aide (NA) #1 was observed by another staff member, NA #3, lying in bed with Resident #46. Despite this observation, NA #1 continued to work shifts on multiple days following the incident. The facility's policy mandates immediate reporting of such incidents to the Administrator and other required agencies, but this was not done in a timely manner. NA #3 reported the incident to Nurse #13, who did not escalate the report to higher authorities, assuming it was a joke or that supervisors were already aware. Other staff members also overheard discussions about the incident but did not take appropriate action to report it immediately to the Director of Nursing (DON) or the Administrator. The incident was only formally reported on 4/10/24, several days after it occurred, leading to a delay in the suspension of NA #1 and the initiation of an investigation. Resident #46, who is legally blind and dependent on renal dialysis, was cognitively intact and did not express distress over the incident. However, the failure to report and address the situation promptly represents a significant lapse in the facility's duty to protect its residents from potential abuse and exploitation. The DON and Administrator were unaware of the incident until 4/10/24, highlighting a breakdown in communication and adherence to the facility's abuse policy. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed, resulting in a deficiency in the facility's handling of the situation.
Failure to Address Resident Pain During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during wound care. Resident #1, who had a diagnosis of a pressure ulcer on the right hip and chronic pain syndrome, complained of pain rated at a 7 on a scale of 1-10 during wound care. Despite the resident's complaints, Nurse #9 continued with the wound care procedure without stopping to address the pain. The resident had received Acetaminophen-Codeine earlier in the day and was not due for another dose until later. Nurse #9 acknowledged the resident's pain but did not take immediate action to alleviate it, stating that she would get pain medication after completing the wound care. The resident continued to express pain throughout the procedure, but the wound care was completed without interruption. Interviews with the nursing staff and the Director of Nursing confirmed that the resident's pain should have been addressed immediately by stopping the wound care and conducting a full pain assessment. The Administrator also stated that wound care should have been halted to manage the resident's pain. The facility's failure to stop the wound care and address the resident's pain resulted in a deficiency in providing safe and appropriate pain management for the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 243 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Asbury Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Peak Resources - Charlotte | 1.6 mi | ★★★★★ | 0 | 0 |
| Wilora Lake Healthcare | 2.7 mi | ★★★★★ | 4 | 0 |
| Pelican Health At Charlotte | 2.8 mi | ★★★★★ | 19 | 2 |
| Crown Haven Health And Rehabilitation | 2.8 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 July 2026) and official state health department websites.