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 University Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program and adequate sanitation in the kitchen, resulting in ongoing German roach activity despite regular pest control treatments. Pest control records and dietary logs documented repeated roach sightings in food service areas, and a surveyor observed a live roach moving into dry storage. The pest control technician reported persistent infestation due to uncorrected structural issues such as cracks, holes, and open areas around pipes, as well as chronic food debris and grease buildup. The Dietary Manager acknowledged ongoing roach activity, lacked a formal deep‑cleaning schedule, and relied on staff to clean as they worked, while multiple dietary staff reported seeing live roaches regularly. The Maintenance Director and Administrator were aware of needed repairs and cleaning issues in the kitchen but had not ensured completion of repairs or verification of thorough cleaning, contributing to the continued pest problem.
Undated and expired insulin vials and pens were found in multiple med carts. Surveyors observed opened Lantus and Humalog multi-dose insulin items that were either undated or beyond the 28-day discard timeframe, and nurses stated they had not checked the opening dates in their carts at the start of shift. The DON said nurses were responsible for checking cart meds for expiration each shift, and the Administrator expected no expired items to remain in the carts.
Kitchen Food Storage, Sanitation, and Repair Deficiencies: Surveyors found undated frozen chicken and diced chicken, plus exposed bacon stored under a freezer condenser with frozen liquid on the package. They also observed food debris, black buildup, and dirt under the steam table and throughout the kitchen, along with open pipe holes, a water leak, damaged trim and tile, peeling paint, and debris from an air duct vent. The DM, Maintenance Director, and Administrator were aware of multiple issues, and the DM stated full kitchen deep cleaning was not currently performed.
A cognitively intact resident with significant ADL needs and a long-standing preference for Tuesday and Thursday morning showers had his shower schedule moved from first shift to second shift when new ownership and a new DON implemented a building-wide shower schedule to improve structure and workflow. The DON made this change without consulting residents about their preferences. After the change, the resident repeatedly told multiple staff he wanted his original first-shift shower times restored, but staff told him the schedule could not be changed. A nurse and a NA confirmed the resident’s prior first-shift schedule and his ongoing requests, and the family member reported that his requests had gone unaddressed for months. Although the DON acknowledged the concern and delegated a review of the shower schedule to a UM, the UM was not specifically informed of this resident’s request and did not start reevaluating the schedule, resulting in the resident’s expressed choice for shower time not being honored.
A cognitively intact resident reported that both a previous and a current bathroom were in poor condition, including dirty shower tile, wall damage near the toilet and shower, lack of a toilet grab bar, and a broken toilet tank lid. Surveyors observed a large area of blackish-brown substance on the shower floor and wall, damaged sheetrock, a makeshift wood panel attached to the wall, a broken ceramic toilet tank lid, and a bathroom floor with multiple layers of chipped paint. In the prior room, they observed sheetrock damage beside the toilet, a damaged and rusted door frame, and a painted tile floor with extensive chipping. Review of maintenance records showed only one completed work order for a grab bar installation in the current room and none for the prior room, while the Maintenance Director and Administrator acknowledged longstanding awareness of these bathroom conditions and other needed repairs throughout the facility.
A resident with diabetes and a history of basal cell carcinoma developed an itchy scalp lesion that was treated with topical medications per NP orders, but an ordered dermatology consult was never completed. Although the NP documented from the outset that dermatology should evaluate the lesion and later noted the resident’s repeated inquiries about the consult, no appointment was scheduled. A nurse signed off the dermatology order as completed, yet the transportation staff member who later assumed appointment‑scheduling duties was unaware of the need for the visit and could not find a referral. The dermatology clinic reported it had requested additional information from a former appointment scheduler and never received a response, and facility leadership could not verify that the dermatology appointment had ever been arranged.
A resident was admitted with an unstageable sacral pressure ulcer documented in hospital records, but the hospital discharge summary did not include wound care orders. On admission, nursing staff noted an unstageable coccyx wound and care plans referenced treatment "as ordered," yet no wound care orders were present on the TAR and no wound care was documented for several days. Multiple nurses who cared for the resident during this period reported they either did not provide wound care or would only have done so if orders existed. The wound care nurse later assessed the sacral ulcer, found the original hospital dressing still in place, noted the absence of wound care orders, and then entered the first treatment order, with the first documented wound care occurring that same day. Leadership and the NP stated that staff were expected to obtain wound care orders when missing but were unaware that this had not occurred for this resident.
Failure to provide an individualized activity program for a resident with hemiplegia, aphasia, schizoaffective disorder, and cognitive/communication deficits. Although the resident’s MDS and care plan identified preferences such as going outside, reading, music, news, and group activities, observations showed him lying in bed with no meaningful engagement, and staff interviews indicated he had not been attending activities, had limited communication, and had no documented recent 1:1 activity sessions. The AD could not state the frequency, duration, or specific preferences for the resident’s 1:1 activities.
The facility failed to label medications with resident names, discard expired medications, and store medications according to manufacturer instructions. Insulin pens and compounded omeprazole suspensions were found expired, and latanoprost eye drops were improperly stored. The DON confirmed the need for proper labeling, storage, and disposal of medications.
A resident with cognitive impairment and limited mobility was repeatedly found with their call bell out of reach, preventing them from requesting assistance. Despite being alert and able to communicate, the resident's call bell was tied to the bed rail and often on the floor, as confirmed by staff observations and interviews.
The facility inaccurately coded MDS assessments for three residents, leading to discrepancies in their medical records. A resident with schizophrenia was incorrectly coded for PASRR Level I instead of Level II, and another resident was wrongly noted as receiving insulin instead of hypoglycemic medication. Additionally, a resident was inaccurately recorded as receiving antianxiety medication. These errors were acknowledged by the staff involved.
A facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. The resident, admitted with hypoxia, was on continuous oxygen therapy at 2 L/min via nasal cannula. Observations confirmed the absence of signage, and staff interviews revealed that the responsibility for posting signage was with the admitting nurse or Unit Manager, which was missed.
A resident with a history of stroke reported numbness and pain in his left side to nurse aides, but the nursing staff failed to assess the condition or notify the physician. The resident's symptoms worsened, leading to a delayed diagnosis of an ischemic stroke. The lack of timely assessment and communication resulted in the resident being outside the treatment window for Alteplase, a stroke medication.
A facility failed to implement necessary medical interventions for a resident with untreated sleep apnea, leading to severe health decline and hospitalization. Despite physician orders for a CPAP machine and consultations, these were not executed due to transportation issues. Another resident with stroke symptoms was not comprehensively assessed, resulting in delayed treatment and critical care admission. These deficiencies highlight the facility's failure to respond to significant changes in residents' conditions.
The facility failed to conduct annual performance reviews for five nurse aides, as required by regulations. The Director of Nursing and Staff Development Coordinator, both recently hired, were unaware of the facility's process for maintaining nurse aide competency skills training and performance reviews. The Administrator confirmed that due to turnover in the Staff Development Coordinator position, there was no evidence of completed training and education, resulting in a lack of documentation for the required annual performance reviews.
A resident with obstructive sleep apnea did not receive a Pulmonary consultation or a CPAP machine due to transportation issues, despite physician orders. The resident also missed a Neurology consultation for migraines. Facility staff were aware of the transportation difficulties but did not resolve them, leading to missed critical medical appointments.
The facility was cited for deficiencies in food safety and equipment maintenance. A dietary aide handled food without gloves or facial hair covering, and the kitchen was not clean. Food items in the walk-in cooler were not properly labeled, and the dish machine failed to reach the required temperature. Insulated dome lids were stored wet. The dietary supervisor and maintenance director acknowledged these issues.
The facility failed to maintain a clean environment, with growth buildup found in and on an ice machine. Observations revealed blackish-brown spots and pinkish/black matter on the machine, and blackish matter, light beige growths, and yellow material on the floor and molding. The Maintenance Director was unaware of the issue, and the Administrator was uncertain about the deep clean schedule.
A privacy breach occurred when a medication cart laptop was left unattended, displaying resident health information in a public area. Nurse #4 admitted the oversight, and both the DON and Administrator confirmed the need to lock the laptop screen when unattended.
A medication cart in Zone 1 was found unlocked and unattended, with staff and residents passing by. Nurse #3, who was administering evening medications, later locked the cart. The cart contained resident medications, including insulin pens and medicated ointments. The DON confirmed that medication carts should be locked when unattended.
A resident with obstructive sleep apnea did not receive a CPAP machine as documented by a physician. The resident reported never having the machine or seeing a pulmonologist, despite the physician's note indicating CPAP use. The DON confirmed the resident never had the machine, and the facility failed to monitor the physician's documentation.
A resident did not receive their prescribed Liraglutide due to the facility's failure to notify the pharmacy of the missing medication. Despite procedures in place, nursing staff did not contact the pharmacy, leading to missed doses. The physician and administrator highlighted the lack of communication and questioned the pharmacy's delivery system.
A resident with diabetes and kidney failure did not receive prescribed medications due to unavailability. Nurses failed to administer insulin and Liraglutide as ordered, and did not consistently notify the physician about the medication shortages. The DON and physician confirmed that staff should have followed orders and communicated medication issues.
A resident with cerebral palsy and contractures sustained a mildly displaced left medial malleolus fracture during an unsafe transfer using a sit-to-stand lift. The resident's ankle got caught in the wheelchair, leading to significant pain and the need for emergency room evaluation. The facility staff followed protocols for pain management and further evaluation, and the resident's care plan was updated to use a mechanical lift for transfers.
The facility's QAA committee failed to develop and implement an effective plan to prevent accidents, resulting in repeated unsafe transfer incidents. One resident sustained a fracture during a sit-to-stand lift transfer, and another incident involved a mechanical lift tipping, requiring staff intervention to prevent injury.
Failure to Maintain Effective Pest Control and Sanitation in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program in the kitchen, as evidenced by ongoing German roach activity and inadequate sanitation and structural maintenance. Pest control service summaries over several months documented repeated German roach activity in the kitchen, including in the dishwasher electrical box, near the coffee station, and in food warming equipment. The pest control technician repeatedly noted needed repairs such as cracks in walls and floors, broken tiles and baseboards, standing water from poorly functioning drains, and greasy cooking equipment that were providing harborage for roaches and undermining control efforts. Despite weekly and bi‑weekly pest control treatments, the technician reported that an active infestation remained and that he typically observed at least one live roach during each visit. During a kitchen observation with the Dietary Manager, a live roach was seen on the floor in front of the dry storage doorway and then entering the dry storage area. The Dietary Manager acknowledged ongoing live roach activity, particularly under the steam table and in other warm areas. Inspection beneath the steam bar revealed multiple layers of food debris, a dessert cup with food, disposable lids, a fork, dust, and dirt, indicating that the area had not been cleaned. Dietary stand‑up meeting reports and pest control logs documented multiple pest sightings over several weeks, including roaches in the bottom of the gas oven and dish room, and ants and flies around the steam table and gas stove. The Dietary Manager stated there was no formal deep‑cleaning schedule for the kitchen and that she relied on staff to clean as they worked and to perform periodic deep cleaning. Multiple dietary staff members reported seeing live roaches regularly in the kitchen, although they felt the activity had improved somewhat since a change in facility ownership. One cook/aide stated he sees live roaches regularly but ignores them. The pest control technician described persistent sanitation problems, including consistent food crumbs, flour, dough, and other food debris on the floor, and layers of food debris, dust, and dirt behind equipment, under shelves, and beneath the steam bar that appeared not to have been cleaned for a long time. The Maintenance Director confirmed awareness of holes, cracks, damaged trim and molding, open areas around plumbing pipes, a water leak under a sink, peeling paint, and damaged tiles in the kitchen, but acknowledged that these repairs had not yet been completed. The Administrator stated he was aware of repairs, cleaning issues, and pest sightings reported in morning stand‑up meetings, but he did not verify that cleaning was being done and did not make routine rounds in the kitchen, while continuing to review pest service summaries and compare pest control company pricing. Overall, the combination of ongoing roach sightings documented by dietary staff and pest control logs, visible live roaches during surveyor observation, accumulated food debris and lack of a formal deep‑cleaning schedule, and unaddressed structural defects such as cracks, holes, and open areas around pipes led to the facility’s failure to maintain an effective pest control program in the kitchen. The pest control technician’s repeated identification of sanitation and repair issues, along with the Maintenance Director’s and Administrator’s acknowledgment of known but uncorrected problems, further demonstrate the inaction that contributed to the continued presence of roaches in food service areas.
Undated and Expired Insulin Left in Medication Carts
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when opened multi-dose insulin vials and insulin pens were found undated or expired in medication administration carts. Surveyors observed that medication cart #3 contained a Humalog insulin pen opened on 3/1/26 and a Lantus insulin pen opened on 3/12/26, and medication cart #2 contained an opened and undated Lantus insulin vial, an opened and undated Lantus insulin pen, and a Humalog insulin pen opened on 3/14/26. Medication cart #1 contained an opened and undated Lantus insulin vial, a Lantus insulin pen opened on 3/12/26, and a Lantus insulin pen opened on 3/5/26. Manufacturer recommendations reviewed by surveyors stated that both Lantus and Humalog multi-dose vials should be discarded 28 days after opening. During interviews, the nurses responsible for the carts stated that they were responsible for discarding opened, undated, or expired multi-dose medications and that each nurse should date multi-dose medications when opened. The nurses also stated they had not checked the opening dates on the insulin vials or pens in their carts at the beginning of their shifts and confirmed they had not administered the expired medications during those shifts. The DON stated that nurses were responsible for checking medications in their assigned carts for expiration dates and removing expired medications every shift, and the Administrator expected no expired items to be left in the medication carts.
Kitchen Food Storage, Sanitation, and Repair Deficiencies
Penalty
Summary
Food items in the main kitchen were found stored without proper labeling and dating. During the initial tour, surveyors observed one small clear bag containing 8-10 breaded chicken strips with no open date, one medium clear plastic bag about 1/4 full of diced chicken with no open date, and a 15-pound box of sliced bacon stored inside a plastic bag with part of the box missing and the bacon exposed. The bacon box was positioned under the freezer condenser, where frozen icicles were hanging above it and clear frozen liquid was observed on top of the box and on the exposed bacon. The Dietary Manager discarded the items and stated she was responsible for monitoring freezer and cooler items for proper dating and labeling, but she did not explain why the undated items were present. Kitchen sanitation concerns were also observed. Surveyors found food debris under the steam table, black buildup along wall edges and in floor tile grout lines, and dirt and debris throughout the kitchen floor, especially under equipment. During a later tour, the floor under the steam table contained visible layers of food debris, a dessert cup with an unidentified substance, disposable lids, a fork, dust, and dirt. The Dietary Manager stated the area had been cleaned the previous day, but also stated that spot deep cleanings were done and that full kitchen deep cleaning was not currently performed. The kitchen also had multiple maintenance and structural issues. Surveyors observed open areas around plumbing pipes under three sinks, a water leak under the sink on the back wall of the kitchen, damaged trim at doorway entrances and around cooler and freezer areas, peeling paint on the ceiling above racks at the kitchen entrance and in the dish room, damaged wall tile, accumulated debris from an air duct vent, and a leaking water pipe under the sink. The Maintenance Director stated he was aware of the holes, cracks, damaged trim, and leak but had not completed the repairs, and the Administrator stated he was aware of the cleanliness and repair issues and verified the observed conditions.
Failure to Honor Resident’s Established Shower Time Preference
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s established choice of shower time after a change in ownership and scheduling. The resident, who had spastic diplegic cerebral palsy, contractures of the right hand and both knees, chronic kidney disease, and required extensive assistance with ADLs including bathing, had long received showers on Tuesdays and Thursdays during first shift (7:00 AM to 3:00 PM). In January 2026, after new owners assumed control, the DON created a new shower schedule that moved the resident’s showers to second shift (3:00 PM to 11:00 PM) without speaking with residents beforehand or assessing their preferences. The written shower schedule at the nurse’s station reflected this change, listing the resident for showers on Tuesdays and Thursdays on second shift. The resident reported that no one informed him in advance that his shower times would be changed and that he was not asked whether he wanted to alter his long-standing schedule. After learning of the change, he repeatedly told multiple staff members that he did not want showers on second shift and wanted his original first-shift schedule restored, but he was told the schedule could not be changed. He stated that this had been ongoing since January and that he found the situation frustrating, as he believed it was his right to have his preference honored. The resident’s family member corroborated that he had been requesting a return to first-shift showers since the schedule change and that his requests were not acted upon. Nursing staff interviews confirmed that the resident had historically received showers on first shift and that the DON changed his shower times in January as part of a new structured schedule. A nurse and a nursing aide both stated that the resident had been asking to have his showers moved back to first shift and that his preferences had been communicated to administrative staff, with the aide reporting she was told by the DON that the time could not be changed. The DON acknowledged she created the new schedule to improve structure and workflow, did not consult residents before making the changes, and later delegated review of the schedule to a unit manager without specifically directing her to address this resident’s request. The unit manager stated she did not begin reevaluating the shower schedule and was not informed that this resident wanted his shower times changed, despite the DON’s awareness of the concern. This sequence of actions and inactions resulted in the facility not honoring the resident’s expressed choice regarding shower time.
Failure to Maintain Resident Bathrooms in Safe, Clean, and Homelike Condition
Penalty
Summary
The facility failed to maintain resident bathrooms in safe, clean, and homelike condition for a cognitively intact resident whose rooms on one hall had longstanding disrepair and cleanliness issues. The resident reported that his previous and current bathrooms were in poor condition, describing dirty shower tile, lack of a grab bar near the toilet, wall damage by the toilet and shower, and a broken toilet tank lid in his current room, as well as visible sheetrock patching and large spots on the painted tile floor in his prior room. He stated he had not used the shower and did not know how long the bathroom had been in this condition, and recalled reporting these issues in the past but could not remember to whom. Review of work orders from the beginning of the year through mid-April showed only one completed work order related to his current room, which was for installation of a grab bar in the bathroom, and no work orders for his prior room; no earlier work orders were available. Surveyor observations confirmed extensive physical damage and unclean conditions in both bathrooms used by the resident. In the current room, the shower had a blackish-brown substance covering a large area of the shower floor and up the left wall, the wall between the toilet and shower had sheetrock damage at the base, a piece of wood had been screwed to the wall on the right side of the toilet, and the ceramic toilet tank lid was broken with a missing corner. In the prior room, there was sheetrock damage extending up the wall beside the toilet, a damaged door frame with missing paint and visible rust, and a bathroom floor consisting of painted tile with multiple areas of chipping paint exposing different colors beneath. The Maintenance Director acknowledged awareness of the poor condition of both bathrooms, attributing some of the deterioration to water damage and stating that many rooms and bathrooms were already in this condition when the current company assumed operations, and that repairs were being prioritized based on severity. The Administrator also acknowledged awareness that several rooms throughout the facility needed repair.
Failure to Schedule Ordered Dermatology Follow-Up for Resident With Skin Cancer History
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dermatology follow‑up appointment was scheduled as ordered for a resident with a history of basal cell carcinoma. The resident was admitted with diabetes and a history of basal cell carcinoma of the head, neck, and skin. In early December, a NP documented a sore on the top of the resident’s head and indicated that a dermatology appointment was to be made by nursing. On January 27, the NP again evaluated the wound, described it as nickel‑sized and caused by scratching, and ordered topical treatment, which records show was administered as ordered. On January 30, a physician order was entered for a dermatology consult as needed for possible basal cell carcinoma on the top of the head, noting the resident’s history of basal cell carcinoma. This order was signed off as completed by a nurse, but there is no documentation that an appointment was actually scheduled. Subsequent NP progress notes in February and March continued to reference the need for a dermatology appointment, including a plan to schedule dermatology to evaluate and treat the wound and documentation that the resident was inquiring about the dermatology consultation for possible basal or squamous cell carcinoma. The wound was described as healed but with ongoing redness, inflammation, irritation, and intermittent itching around the scabbed area. During an interview and observation in April, the resident had a scabbed area on the scalp and reported a history of skin cancer and being told months earlier that a dermatology visit was needed, but he was unsure if an appointment had been made and felt it had been forgotten. The resident transportation staff member, who had assumed responsibility for scheduling appointments after the prior appointment scheduler left, stated she was unaware of the need for a dermatology appointment and could not locate a referral. She later learned from the dermatology clinic that a referral had been received and that the clinic had requested additional information from the former scheduler but never received a response. The NP, unit manager, DON, and administrator each described that referrals or orders should be printed and given to the appointment scheduler, but none could confirm that a dermatology appointment had been scheduled for this resident, resulting in the ordered consult not being carried out.
Failure to Obtain and Implement Timely Wound Care Orders for Existing Sacral Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to assess and obtain timely treatment orders for a resident admitted with an existing sacral pressure ulcer. Hospital records from 12/31/25 to 1/23/26 documented a hospital-acquired unstageable pressure injury to the sacrum, and the resident was admitted on 1/23/26 with diagnoses including end stage renal disease on hemodialysis and a sacral pressure ulcer. The hospital discharge summary did not include wound care orders for the sacral wound. On admission, Nurse #13 documented an unstageable skin impairment to the coccyx in the admission assessment and nursing progress note, but provided no further description of the wound, and there is no evidence that wound care orders were obtained at that time. From 1/23/26 through 1/26/26, multiple nurses cared for the resident without providing documented wound care to the sacral pressure ulcer. The care plan initiated on 1/23/26 identified skin impairment and included an intervention for treatment as ordered, but there were no wound care orders on the Treatment Administration Record during this period. Nurse #7, who cared for the resident on 1/24/26, could not recall providing wound care and stated she would only have done so if an order was present. Nurse #3, who cared for the resident on 1/26/26, stated she did not provide wound care that day. Attempts to contact other involved nurses, including Nurse #8 and Nurse #13, were unsuccessful, and there is no documentation that any nurse contacted the NP or on-call provider to obtain wound care orders during these days. The wound care nurse, Nurse #5, completed an admission skin assessment on 1/27/26, documenting a sacral pressure ulcer measuring 2 cm by 2 cm and noting that the bandage in place was from the hospital. She recalled that there were no wound care orders on the resident’s Treatment Administration Record at that time and could not recall if she reported this to anyone. On that same date, 1/27/26, Nurse #5 entered the first wound care order for cleansing the sacral ulcer with 1/4 strength Dakin’s solution, applying calcium alginate, and covering with super absorbent foam, and the first documented treatment occurred that day. The NP and nursing leadership, including the unit manager and DON, stated their expectation that admitting nurses and the wound care nurse would ensure wound care orders were obtained when not present on hospital discharge paperwork, but they were unaware that this resident had no wound care orders from 1/23/26 to 1/26/26.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of Resident #13. The resident was readmitted with diagnoses including hemiplegia, hemiparesis following a cerebral infarction, speech and language deficits, aphasia, schizoaffective disorder, and a cognitive/communication deficit. The annual and quarterly MDS assessments showed the resident had adequate hearing, unclear but understandable speech, was cognitively intact, and required moderate assistance to dependence for ADLs. The assessments also identified activity preferences that were very important to the resident, including going outside in good weather and participating in favorite activities, with other interests such as books, newspapers, magazines, music, news, and group activities. The care plan revised on 3/17/26 directed staff to converse with the resident during care, assist with community activities, match activities to his abilities and interests, invite him to scheduled activities, and provide materials for independent activities such as painting. However, observations on 4/13/26, 4/15/26, and 4/16/26 showed the resident lying in bed with the television on but not watching it, with no music playing and no observed activity materials in the room. On one observation, the roommate was watching TV while the resident lay in bed with his back to the television. Attempts to interview the resident were unsuccessful because he did not speak, covered his face, or closed his eyes, and he did not respond when approached with a communication board. Staff interviews showed the resident frequently stayed in bed, avoided communication, and had not gone for activities for some time. A NA stated the resident responded best to a communication board, liked reading the newspaper, and required encouragement to get out of bed or attend activities, but the NA had not observed activity staff performing one-to-one activities with him. A nurse stated she did not know whether staff encouraged activity participation or whether he received one-to-one sessions. The Activity Director stated she conducted one-to-one activities such as conversations, but could not state the duration or frequency of sessions for this resident, could not identify his specific preferences, and produced documentation only from April 2025. The NP stated the resident would benefit from leaving his room or from one-to-one activities even if he showed limited interest, and the DON stated staff should encourage him to get out of bed, use the communication board, and honor his activity choices.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label medications with the minimum required information, including the resident's name, on one of the medication carts observed. During an observation, an in-use prefilled pen of Insulin Glargine-yfgn was found on the medication cart without a resident's name, and the expiration date indicated it had expired 11 days prior. Additionally, an in-use prefilled pen of Insulin Lispro for a resident was found with an expiration date that had passed 17 days before the observation. There was no indication of when these insulin pens were dispensed or put into use. The facility also failed to discard expired medications on two medication carts and in the medication storeroom. In the medication storeroom, an opened vial of Novolin R insulin was stored without a date indicating when it was opened, and it had been dispensed 111 days prior. Two bottles of compounded omeprazole suspension were found with expiration dates that had passed 37 and 2 days before the observation, respectively. These expired medications were confirmed by the nursing staff during the observation. Furthermore, medications were not stored according to the manufacturer's instructions on one of the medication carts. An unopened bottle of latanoprost eye drops, which should be refrigerated, was found stored on the medication cart. The Director of Nursing confirmed that medications needed to be labeled correctly, stored as instructed, and expired medications should be discarded or returned to the pharmacy. The facility's unit managers were expected to perform weekly checks to ensure compliance with these requirements.
Resident's Call Bell Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to request staff assistance. The resident, who was moderately cognitively impaired and dependent on staff for all activities of daily living, was observed multiple times with the call bell out of reach. The resident had impairments in both upper and lower extremities, requiring substantial to maximum assistance for movement. Despite being alert and able to communicate needs, the resident was unable to reach the call bell, which was tied to the bed rail and often found on the floor. Observations and interviews with staff, including a nurse and the Director of Nursing (DON), confirmed that the call bell was not within the resident's reach on several occasions. The DON acknowledged the issue and repositioned the call bell within reach during an observation. Staff interviews revealed that the resident was alert, oriented, and able to use the call bell, but the staff had not noticed it was out of reach. The resident required total assistance for care and could not reposition independently, highlighting the importance of having the call bell accessible.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #23, who was diagnosed with major depressive disorder and schizophrenia, was inaccurately coded as having a PASRR Level I status instead of Level II, despite her care plan correctly reflecting the Level II status. Additionally, her MDS assessment incorrectly indicated that she received an insulin injection, while her records showed she was on hypoglycemic medications like Ozempic and glipizide, with no insulin administered during the specified period. Resident #52, diagnosed with schizoaffective disorder, was incorrectly coded as having received an antianxiety medication during the 7-day lookback period on her MDS assessment. However, her medical records and interviews with staff confirmed that she did not receive any antianxiety medication during that time. This discrepancy was acknowledged by the MDS nurse responsible for the assessment. Resident #4, with a diagnosis of type 2 diabetes mellitus, was inaccurately coded as receiving insulin on her MDS assessment. In reality, she was receiving Ozempic for weight management, not insulin. The MDS Coordinator misinterpreted the drug classification, leading to the error. Interviews with the resident and nursing staff confirmed that she was not on insulin, highlighting a misunderstanding of the medication classification system used by the facility.
Failure to Post Oxygen Signage for Resident on Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. This deficiency was identified for a resident who was admitted with a diagnosis of hypoxia and had a physician's order for oxygen supplementation at 2 liters per minute via nasal cannula. Observations on multiple occasions revealed that the resident was receiving continuous oxygen therapy, but there was no signage outside the room to indicate this. The absence of signage was noted during observations on different days and times. Interviews with facility staff, including a nurse and the Director of Nursing (DON), confirmed that the responsibility for placing oxygen signage on a resident's door fell to the admitting nurse or the Unit Manager. The DON acknowledged that the signage was missed by the nurses, indicating a lapse in the facility's protocol for ensuring safety measures were in place for residents receiving oxygen therapy.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician and responsible party of changes in condition for a resident with a history of stroke and intact cognition. On the evening of 10/21/24, the resident reported pain and numbness in his left arm and leg to a nurse aide, who informed the nurse. However, the nurse did not assess the resident or notify the physician. The resident continued to experience symptoms, including an inability to feel his left side, which he reported to another nurse aide on the next shift. Again, the nurse was informed but did not conduct an assessment or notify the physician. The situation escalated when the resident was found by a unit manager on the morning of 10/22/24 with slurred speech and paralysis on his left side. The nurse practitioner assessed the resident and arranged for his transfer to the emergency department, where he was diagnosed with an ischemic stroke. The delay in assessment and notification resulted in the resident being outside the window for administering Alteplase, a medication used to treat ischemic strokes. Interviews with staff revealed a lack of communication and failure to follow protocol in assessing and reporting the resident's change in condition. The nursing staff did not document any progress notes regarding the resident's condition on 10/21/24 or 10/22/24 until after the unit manager's assessment. This deficiency in communication and documentation contributed to the delay in the resident receiving timely medical intervention.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance.
- An audit to determine if any residents had reported any new change in condition that was not reported to the healthcare provider by a licensed nurse of residents with a brief interview for mental status (BIMS) score of 13 or higher was completed by the Administrator.
- An audit was completed by the Director of Nursing of progress notes to ensure that anyone reporting a change of condition had provider notification.
- The Director of Nursing questioned all of the licensed nurses regarding knowledge of any residents having had a change in condition that deviated from their baseline and did not have healthcare provider notification.
- The Director of Nursing or Staff Development Coordinator interviewed all nursing assistants regarding knowledge of any residents having change of conditions that were not reported to the healthcare provider.
- The Director of Nursing initiated education to all licensed nurses to complete a clinical assessment of a minimum vital signs and pertinent body systems once notified of a change in condition.
- Education included any changes reported by nursing assistants.
- Any licensed nurse that has not been educated will be taken off the schedule until the education has been received.
- All new hires will be educated by the Director of Nursing during orientation.
- The Regional Director of Clinical Services educated the Administrator, The Director of Nursing, Staff Development Coordinator, and The Human Resource Director on the orientation process for nursing staff.
- The Director of Nursing/Staff Development Coordinator re-educated all nursing assistants on change in condition of residents to include recognizing signs and symptoms of a stroke.
- Any nursing assistant that has not received the education will be taken off the schedule until the education has been received.
Failure to Implement Medical Orders and Assess Changes in Condition
Penalty
Summary
The facility failed to comprehensively assess and implement necessary medical interventions for a resident with untreated obstructive sleep apnea, leading to a significant decline in the resident's health. Despite physician orders for a CPAP machine, a pulmonology consultation, a neurology consultation, and an x-ray, these were not executed due to transportation issues and lack of follow-through. The resident experienced periodic abdominal pain, changes in mental status, and migraines over six months, with elevated CO2 levels noted in lab results. On one occasion, the resident was excessively sleepy, difficult to rouse, and had no oral intake, leading to an emergency medical intervention where the resident was found to be hypoxic and in a comatose state. Another resident with a history of stroke reported numbness and pain in the left arm and leg, which was not comprehensively assessed by the nursing staff. The resident's condition worsened overnight, and by the next morning, the resident exhibited symptoms of a stroke, including slurred speech and vision changes. The resident was eventually transferred to the emergency department, diagnosed with a cerebral vascular accident, and admitted to the critical care stroke unit. The delay in assessment and intervention resulted in the resident being outside the window for effective stroke treatment. These deficiencies highlight the facility's failure to identify and respond to significant changes in residents' conditions, leading to immediate jeopardy situations. The lack of comprehensive assessments and timely medical interventions for both residents resulted in severe health outcomes, including hospitalization and critical care admissions.
Removal Plan
- The facility failed to comprehensively assess a resident who had untreated obstructive sleep apnea to determine the root cause of periodic abdominal pain, change in mental status, and migraines in conjunction with elevated CO2 levels on labs.
- The facility also failed to implement physician's orders for a CPAP, pulmonology consultation, neurology consultation, x-rays and ultrasound.
- The nurse practitioner performed a comprehensive assessment and recommended that she be transferred to hospital.
- Resident was comprehensively assessed by the nurse practitioner who recommended she go to the hospital.
- Resident was diagnosed in the hospital with altered mental status, acute respiratory failure, acute kidney injury, transaminitis, and migraines.
- Resident was placed on a BIPAP and admitted to an intensive care unit.
- She received IV Lasix and supplemental oxygen.
- An Ultrasound was done due to transaminitis which demonstrated steatosis.
- Resident received an order for Fioricet for migraines.
- Resident's pulmonary and neurology consultations were discontinued upon discharge to hospital.
- Upon return to the facility, Resident did not have any new orders for pulmonology consultation or follow up as she currently has BIPAP in place.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for five nurse aides, as required by healthcare regulations. The employee files for these nurse aides did not contain the necessary performance review documents for the years 2023 and 2024. The Director of Nursing, who was hired in May 2024, was unaware of the facility's process for maintaining nurse aide competency skills training and performance reviews. She could not provide evidence of any training done prior to her employment. Similarly, the Staff Development Coordinator, hired in August 2024, was also unaware of the facility's process and had not started reviewing employee training files or conducting annual performance evaluations. The Administrator confirmed that nurse aides' skills assessments and competencies should be completed at hire and annually, along with a performance review. However, due to turnover in the Staff Development Coordinator position, there was no evidence that the required training and education were completed and documented. The facility was unable to provide documentation indicating that the nurse aides' annual performance reviews were completed, highlighting a lapse in maintaining proper records and ensuring compliance with mandatory requirements.
Failure to Provide Necessary Medical Consultations and Equipment
Penalty
Summary
The facility failed to ensure that a resident with obstructive sleep apnea received a necessary Pulmonary consultation and a CPAP machine, as ordered by the physician. The initial order for a Pulmonary consultation and CPAP machine was made in April 2024, and a subsequent order was made in May 2024. However, the resident never attended the consultation or received the CPAP machine due to transportation issues. The resident was also ordered to attend a Neurology consultation in August 2024 for constant migraines, but this appointment was also missed due to the same transportation difficulties. The resident, who was admitted with multiple diagnoses including tachycardia, asthma, morbid obesity, and obstructive sleep apnea, did not have a CPAP machine upon admission. The resident's medical record showed no evidence of receiving the CPAP machine or attending the required consultations. Interviews with the physicians, transport staff, and the resident confirmed the lack of follow-through on these medical orders. The transport staff indicated that the resident's size required non-emergency stretcher transport, which was difficult to arrange due to the transport company's availability. The facility's staff, including the Unit Manager, Nurse Practitioner, and Director of Nursing, were aware of the transportation issues but did not resolve them, resulting in the resident missing critical medical appointments. The resident reported experiencing excessive sleepiness, memory issues, headaches, and abdominal pain over the past six months, which were not addressed due to the missed consultations. The facility's administrator acknowledged the transportation issues but did not provide comments on the lack of follow-through with the resident's appointments.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility was found to have several deficiencies in its food service operations. Observations revealed that a dietary aide was handling food without wearing gloves or a facial hair covering, despite having facial hair. The dietary supervisor confirmed that facial hair coverings and gloves should be used during food preparation. Additionally, the kitchen environment was not maintained in a clean state, with the 3-compartment sink heavily soiled and containing food debris, a greasy substance, and a deceased insect. The maintenance director acknowledged the need for repairs in the dishwashing area, where decaying wooden material was observed. Further issues were identified in the walk-in cooler, where food items such as unshelled hard-cooked eggs and an opened jar of grape jelly were found without proper labeling or dating. The dietary supervisor admitted responsibility for checking the cooler daily but failed to notice these items. The dish machine used for cleaning dishware was also problematic, as it was not reaching the required minimum temperature of 120 degrees Fahrenheit during wash and rinse cycles. The dietary aide operating the machine did not consistently check the temperature, and the dietary supervisor had to contact the vendor for a service call. Lastly, the facility failed to ensure that insulated dome lids and bases were dry before being stored. A dietary aide admitted to rushing and not allowing the items to dry properly. The dietary supervisor and administrator both acknowledged that items should be properly dried before storage. These deficiencies highlight lapses in food safety practices and equipment maintenance within the facility.
Unsanitary Conditions in Ice Machine
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by the presence of growth buildup in and on one of the two ice machines observed. During an inspection, blackish-brown spots were found on the external facing of the ice machine, and pinkish/black colored matter was observed on the internal ceiling and metal lip of the machine. Additionally, the floor and corner molding behind the ice machine exhibited blackish matter, light beige puffy growths, and yellow matted stringy material. The Maintenance Director was unaware of the ice machine's condition and stated that the machines were cleaned quarterly. He had not received any concerns from staff regarding mold in the ice machine. The Administrator mentioned that ice machines were checked weekly by staff and maintenance, but was uncertain about the deep clean schedule for the machines.
Privacy Breach of Resident Health Information
Penalty
Summary
The facility failed to maintain the privacy of a resident's medical records when a medication cart laptop was left unattended with resident health information exposed. This incident occurred with one of the four medication carts, specifically the Zone 1 medication cart. During an observation, the laptop was found displaying personal health information, including names, medications, and diagnoses, in an area accessible and visible to the public. Staff and residents were observed passing by the medication cart during this time. Nurse #4, responsible for the medication cart, acknowledged in an interview that she should have closed or locked the laptop screen to prevent exposure of resident information. The Director of Nursing (DON) and the Administrator both confirmed in their interviews that the laptop screen should have been locked before leaving the medication cart unattended.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to secure resident medications in an unattended medication cart, specifically the Zone 1 medication cart. On the specified date and time, the medication cart was observed to be unlocked and unattended, with the locking mechanism in the unlocked position. During this period, staff and residents were seen passing by the unsecured cart. Nurse #3 was later observed approaching the cart from a resident's room and subsequently locking it. In an interview, Nurse #3 acknowledged that the cart should have been locked when not attended. The cart contained various resident medications, including insulin pens, medicated ointments, and eye drops. The Director of Nursing confirmed that medication carts should be locked when not attended by staff.
Failure to Provide CPAP Machine for Resident with Sleep Apnea
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident regarding the use of a Continuous Positive Airway Pressure (CPAP) machine. The resident, who was admitted with multiple diagnoses including obstructive sleep apnea, was documented in the quarterly Minimum Data Set (MDS) as not having a CPAP machine. However, a physician's note dated June 19, 2024, indicated that the resident was to be initiated on CPAP settings and was stable to continue using the CPAP machine at night. Despite this, the resident reported never having received a CPAP machine or having seen a pulmonologist, which was necessary to obtain the machine. Interviews with the physician and the Director of Nursing (DON) revealed a lack of communication and monitoring of the physician's documentation. The physician was under the impression that the resident had received the CPAP machine, while the DON confirmed that the resident never had a CPAP machine prior to her hospitalization. The facility did not review or monitor the physician's documentation, leading to the oversight that the resident did not receive the necessary equipment for her obstructive sleep apnea.
Failure to Notify Pharmacy of Missing Insulin
Penalty
Summary
The facility failed to notify the pharmacy of missing insulin for a resident, leading to the resident not receiving their prescribed Liraglutide, an anti-diabetic medication, on multiple occasions. The physician's order required the administration of Liraglutide subcutaneously once a day, but the medication was not administered on specific dates in July 2024 due to it being on hold. The Medication Administration Record (MAR) indicated the medication was unavailable, yet there was no documentation of efforts to obtain it from the pharmacy. Interviews with nursing staff revealed a lack of communication with the pharmacy regarding the missing medication. The Director of Nursing (DON) and the consulting pharmacist confirmed that the facility had procedures for notifying the pharmacy when medications were low or unavailable, but these procedures were not followed. The physician expressed concern over not being informed about the medication's unavailability and questioned why the pharmacy did not automatically deliver the medication. The administrator also acknowledged that nursing staff should have contacted the pharmacy to obtain the medication for administration.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to follow physician orders for a resident with type 2 diabetes and kidney failure, leading to significant medication errors. The resident did not receive the prescribed insulin, Tresiba FlexTouch, on a specific date because the medication was not available. Nurse #2, who was responsible for administering the medication, realized the absence of insulin during her shift and notified the Director of Nursing (DON), who then contacted the pharmacy. However, there was no documentation of the insulin being administered on that day. Additionally, the resident did not receive another prescribed medication, Liraglutide, on multiple occasions. The Medication Administration Record (MAR) indicated that the medication was on hold due to unavailability. Several nurses, including agency nurses, were involved in the administration process but failed to ensure the medication was available or to notify the physician about the unavailability. Interviews with the DON and the physician confirmed that staff should have contacted the physician when medications were not available and should have followed the physician's orders as written.
Resident Injury During Unsafe Transfer
Penalty
Summary
The facility failed to safely transfer a resident using a sit-to-stand lift, resulting in the resident sustaining a mildly displaced left medial malleolus fracture and experiencing significant pain. The resident, who had a history of cerebral palsy, contractures, and previous left knee fusion surgery, was dependent on staff for transfers and other activities of daily living. During the transfer, the resident's ankle got caught in the wheelchair, leading to the injury. The incident was reported by the nurse aide to the assigned nurse, who then assessed the resident and administered pain medication as per physician orders. An X-ray confirmed the fracture, and the resident was sent to the emergency room for further evaluation and treatment, including the application of a CAM boot and prescription of pain medication. The resident was discharged back to the facility the same day. The nurse aide involved in the incident was an agency staff member who worked sporadically at the facility. He did not recall the type of mechanical lift used during the transfer and only realized the resident's leg was caught after the transfer was completed. The nurse aide received in-service training on mechanical lift transfers after the incident. The assigned nurse and the physician were both notified of the incident and took appropriate steps to manage the resident's pain and ensure further evaluation. The Director of Nursing confirmed that the resident required staff assistance for transfers and that the incident occurred during a sit-to-stand lift transfer. The resident's care plan was subsequently updated to reflect the use of a mechanical lift for transfers. The facility's Director of Nursing and Administrator were both aware of the incident and confirmed that the facility followed protocols to ensure the resident's safety. The Director of Nursing stated that the nurse aides were retrained on mechanical lift transfers, and the resident's care plan was updated to reflect the change in transfer method. The Administrator reviewed the interventions put in place and confirmed that they were effective, as no further incidents had occurred.
Repeat Issues with Resident Transfers Highlight QAA Failures
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to self-identify the need for the development and implementation of an effective plan to achieve and sustain compliance in the area of supervision to prevent accidents. This was evidenced by a repeat issue with staff failing to transfer residents safely. Specifically, an incident occurred where a resident was transferred using a sit-to-stand lift, resulting in the resident sustaining a mildly displaced left medial malleolus fracture and experiencing significant pain. Another incident involved a mechanical lift tipping to one side, requiring two staff members to lower the resident to the floor without injury. During an interview, the facility's Administrator stated that the QAA committee was scheduled to meet at least quarterly but typically met about once a month. The Administrator acknowledged that after the first incident, the resident was transferred using a mechanical lift instead of a sit-to-stand lift. However, no performance improvement plan was implemented after the initial incident, as there were no other residents using a sit-to-stand lift in the facility. This lack of a comprehensive plan contributed to the recurrence of unsafe transfer practices, highlighting the facility's inability to sustain an effective QAA program.
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Illustrative
What surveyors actually found near you
We read the 66 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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Nursing homes near Durham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth-durham | 0.7 mi | ★★★★★ | 0 | 0 |
| Pettigrew Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Hillcrest Convalescent Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Croasdaile Village | 1.9 mi | ★★★★★ | 8 | 0 |
| The Forest At Duke Inc | 2.7 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.