Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Westwood Health And Rehabilitation during CMS and state inspections, most recent first.
A medication aide left after only a few hours, and two nurses stated they did not give medications to residents on two halls for several hours afterward. As a result, multiple residents missed scheduled doses of Parkinson’s meds, antihypertensive therapy, buspirone, depakote, acetaminophen, and glaucoma eye drops that were ordered by the MD.
Insufficient nursing coverage left the D and E halls without staff available to administer scheduled meds for six residents during part of the day shift. Records showed the MA left before mid-afternoon and the Unit Manager did not arrive until later, while other nurses were assigned to different halls.
Surveyors found that medications were not consistently dated upon opening and expired drugs were not removed from storage. An open, undated vial of PPD was found in the medication room refrigerator, and multiple insulin pens and nitroglycerin tablets on two medication carts were either expired, opened and undated, or opened beyond the manufacturer’s 28‑day use period. An undated Novolin R FlexPen and expired ibuprofen tablets were also identified. Nursing staff and the DON reported that the nurse who opens a medication is responsible for dating it and that night shift nurses are expected to check carts and the medication room for expired medications, but staff acknowledged these checks had not been completed as expected.
Surveyors found that dietary staff failed to follow required food labeling, dating, and sealing practices, including a loosely covered and partially exposed container of pimento cheese with an obscured date in a reach-in refrigerator, an unsealed and undated 25‑lb box of rice in dry storage, unlabeled and undated cups of orange juice in a walk‑in cooler reportedly prepared by night shift staff, and an unsealed, undated box of frozen biscuits in the walk‑in freezer. Dietary leadership confirmed that all food items are required to be labeled and dated when prepared, opened, or stored after opening, and that staff were aware of this requirement.
A resident with multiple medical and mental health diagnoses, who was cognitively intact and dependent on staff for several ADLs, experienced a prolonged delay in response to an activated call light while repeatedly yelling for help. Over more than 20 minutes of direct observation, the call light remained on and audible near the nurses’ station, where multiple staff members were present. Staff acknowledged the call light but did not promptly assist, and some did not respond when asked if they answered call lights. The resident reported that such delays in response occurred frequently, sometimes lasting up to an hour, and stated this made him upset and frustrated, demonstrating a failure to honor the resident’s dignity and right to timely assistance.
A cognitively intact resident with property scheduled for auction had a truck bed and other items taken after a nurse discussed purchasing a vehicle and viewed the resident’s belongings off-site. The nurse reported she asked her mechanic only to look at a truck bed, but he picked it up and delivered it to her home, where it remained for about two months before being retrieved. The resident stated he initially told the nurse she could have the truck bed, then told her the next day she could not because it was already promised for auction, yet the nurse obtained it after this revocation. The resident’s friend, who managed the resident’s affairs, discovered the truck bed and other items missing and contacted police, and law enforcement confirmed a report involving a truck bed and miscellaneous property that had been taken and later returned. These events show that the facility failed to prevent misappropriation of a resident’s belongings by staff.
A resident with impaired cognition, recent amputation, and dependence for mobility and toileting developed a sacral pressure ulcer that was not fully assessed or consistently treated. Nursing documentation initially described only healed-appearing tissue on the buttocks, but later a nurse noted new sacral skin breakdown, obtained wound care orders from a Medical Wound Provider, and documented that care was done without describing the wound’s stage, characteristics, or pain. The wound care order to cleanse the sacral area and apply calcium alginate did not populate to the MAR/TAR because it was likely not activated in the EMR, and there was no record of the ordered treatment being provided on three subsequent days. Staff interviews confirmed reliance on EMR activation for orders to appear on the MAR/TAR and uncertainty about whether wound care was actually performed during that period.
MDS assessments were not accurately coded for three residents in relation to falls and medication use. A resident with a history of stroke and muscle weakness had a fall that caused a skin tear, but the MDS coded the event as a fall with no injury. Another resident receiving oral and ophthalmic antibiotics during the lookback period was not coded for antibiotic use on the quarterly MDS. A third resident with bipolar disorder and schizophrenia received an IM antipsychotic injection and an oral anticonvulsant, yet the admission MDS indicated no injections and did not reflect anticonvulsant use. These errors were later acknowledged by the MDS consultant and corporate MDS consultant as oversights when reviewing the MAR and coding the assessments.
A resident admitted with bipolar I disorder with psychotic features and schizophrenia, and discharged from the hospital with instructions for psychiatric follow-up and medication management, did not receive behavioral health services after admission. The admission care plan lacked a behavioral focus despite multiple psychotropic medications and a Level II PASRR. Over several weeks, staff documented repeated episodes of calling out and screaming, and an observation showed the resident yelling for assistance with the call light on for an extended period. The admitting nurse did not recall processing a psychiatry referral, the Social Services Director reported no referral or psych consent and that the resident was not on the psychiatric provider’s active list, and leadership stated they expected residents to receive needed behavioral health care but were unaware this resident had not been referred or seen.
A resident with hypertension and heart failure had a physician order for Metoprolol Tartrate with instructions to hold the dose if systolic blood pressure (SBP) was below 110, but review of the MAR showed the medication was administered on multiple evenings when SBP readings were documented below that threshold. The cognitively intact resident received the medication despite SBP values under the ordered parameter, and the MA who gave several of these doses acknowledged it was an oversight. The Medical Director and DON both stated they expected staff to follow the ordered blood pressure parameters for this medication.
The facility did not maintain current survey results in the publicly accessible survey notebook, leaving only an older recertification survey available for review while multiple subsequent complaint, infection control, and recertification surveys were missing. During tours, surveyors observed that the lobby notebook contained outdated information despite more recent surveys being documented in the iQIES system. The Administrator, who started in mid-2025, reported initial technical issues with printing survey results and admitted that although he had the survey reports in his office and knew they were required to be placed in the notebook, he did not update the binder and could not explain the failure to do so.
The facility failed to accurately post daily nurse staffing information, with 22 days showing discrepancies between the posted sheets and the actual staffing schedules. On multiple occasions, the number of NAs, MAs, RNs, and LPNs listed on the daily posting did not match the staff scheduled or who actually worked specific shifts, including both day and night coverage. One nurse who transitioned from LPN to RN was repeatedly misclassified as an LPN on the postings after his RN licensure became effective. The staff scheduler acknowledged not updating postings when staff were absent or when additional staff came in, and leadership confirmed that the posted staffing did not match the actual worked staffing.
A resident with ESRD receiving thrice-weekly hemodialysis lacked any dialysis communication forms or related documentation in the electronic medical record. Although nurses and the dialysis center reportedly used a notebook-based communication form to record pre- and post-dialysis assessments, vital signs, access site condition, and changes in condition, no completed forms or progress note entries reflecting this communication were found. The Medical Records Manager reported no set process or timeframe for removing completed forms from the notebook and uploading them, and believed the notebook may have left with the family at discharge, while the DON confirmed the facility’s responsibility for ensuring these forms were completed and filed but could not explain their absence.
A male resident with moderate cognitive impairment engaged in sexually inappropriate contact with a severely cognitively impaired female resident on two occasions. The incidents occurred in public areas and were witnessed by staff, who intervened to separate the residents. The male resident did not have a care plan addressing sexually inappropriate behaviors prior to the first incident, and supervision was inconsistently maintained, allowing a second incident to occur.
The facility failed to properly label and store medications, with several insulin pens and vials found opened and undated on medication carts, and PPD testing solution improperly stored outside refrigeration. An expired bottle of Allergy Relief tabs was also found in the medication storage room. Staff interviews revealed expectations for proper labeling and storage were not met.
A facility failed to disinfect a glucometer according to the manufacturer's guidelines. A nurse used the glucometer for a resident's blood glucose check and returned it to the medication cart without proper cleaning. The nurse used alcohol swabs instead of the required Sani wipes, as she was unaware of the correct product. The DON confirmed the need for Sani wipes, and the Administrator expected adherence to the policy.
A resident, admitted with muscle weakness and cognitively intact, was unable to have his hair trimmed to his preferred length due to the absence of a beautician at the facility. Despite expressing his preference to staff, the facility had not coordinated a haircut, as confirmed by interviews with nursing staff and the DON. The administrator was aware of the issue but had not yet resolved it.
Two residents in an LTC facility, both cognitively intact, expressed a desire for haircuts as part of their basic hygiene needs. Despite their requests, no staff was available to provide this service, and there was confusion among staff about who was responsible for haircuts. The Director of Nursing and Administrator were unaware that routine hair trimming was a covered service for Medicaid residents, leading to a deficiency in care.
A resident with cognitive impairment and a history of falls experienced repeated falls due to improper footwear. Despite being aware of the issue, the facility failed to ensure the resident had properly fitting shoes, leading to multiple incidents. The care plan interventions were not effectively enforced or monitored, resulting in continued falls.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. Two residents experienced medication errors: one did not receive an antibiotic for urinary tract infection prophylaxis, and another did not receive prescribed eye drops for dry eye. The Unit Manager, acting as a floor nurse, acknowledged the errors, which were confirmed by interviews with the NP, DON, and Administrator.
The facility failed to provide written notification of the bed hold policy to two residents and their responsible parties upon hospital transfer. Interviews with staff revealed a lack of awareness and absence of a process to ensure the policy was communicated, indicating a systemic issue.
The facility failed to provide written notification to residents and/or their responsible parties regarding hospital transfers. Two residents were transferred without receiving the necessary documentation. The Social Worker and Social Services Director admitted to not sending the required notices, and there was confusion among staff about the process. The Administrator was aware of the requirements but did not know the task was incomplete.
The facility failed to maintain complete and accurate wound care documentation for three residents, leading to a deficiency. A resident with a history of amputation and diabetes had missing documentation for wound care on her forearm and leg. Two other residents, one with a femur fracture and another with a pressure ulcer, also had incomplete records. Interviews with staff revealed that while wound care was reportedly completed, documentation was often forgotten, indicating a systemic issue with record-keeping.
A resident was injured during transport from dialysis when her wheelchair was not properly secured in a contracted van, causing it to tip backward and result in a head injury. The resident, who had a history of diabetes, end-stage renal disease, and was on anticoagulant medication, was taken to the hospital for evaluation. The driver admitted to not securing the wheelchair per protocol, leading to his termination and the facility halting the use of the contracted service.
Missed Scheduled Medication Administration
Penalty
Summary
The facility failed to administer scheduled medications as ordered for 6 of 32 residents reviewed on the D and E halls. The missed medications included Parkinson’s disease medications, antihypertensive medication, anxiety and mood-stabilizing medications, pain medication, and glaucoma eye drops. The residents involved had diagnoses that included Parkinson’s disease with dyskinesia, congestive heart failure and hypertension, bipolar disorder, rheumatoid arthritis and polyneuropathy, glaucoma with blindness in one eye, and fibromyalgia with osteoarthritis and polyneuropathy. Resident #4 had active orders for ropinirole three times daily, benztropine in the afternoon, and Sinemet four times daily, but the May 2026 MAR showed those medications were not given at the scheduled afternoon times on 5/16/26. Resident #5 had an active order for hydralazine three times daily with instructions to hold for systolic blood pressure less than 110, but the 2:00 PM dose was not administered. Resident #6 had orders for buspirone three times daily and depakote sprinkles in the afternoon, and the MAR showed both were missed at 2:00 PM. Resident #7 had an order for acetaminophen three times daily for pain, and the 1:00 PM dose was not given. Resident #8 had an order for dorzolamide ophthalmic solution every 8 hours for glaucoma, and the 2:00 PM eye drops were not administered. Resident #9 had an order for acetaminophen three times daily for chronic pain, and the 1:00 PM dose was not given. Staff interviews showed that on 5/16/26, the medication aide assigned to the D and E halls left at 12:45 PM after working only four hours, leaving two nurses in the facility to administer medications. Both nurses stated they did not administer medications to D and E hall residents from 1:00 PM to 5:00 PM. The medication aide stated she told the nurses her time was up and left, and the staffing scheduler, Administrator, interim DON, and Unit Manager #1 described efforts to find a replacement, with Unit Manager #1 arriving at 5:00 PM to cover the cart. The Pharmacy Consultant and Medical Director reviewed the missed medications and stated they did not consider the omitted doses significant, noting that some were given at other times or the next day.
Insufficient Nursing Coverage on D and E Halls
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available on 5/16/26 from 1:00 PM to 5:00 PM to administer medications as ordered to residents on the D and E halls. Based on record review, Pharmacy Consultant, Medical Director, and staff interviews, six of 32 residents reviewed for medication administration—Residents #4, #5, #6, #7, #8, and #9—did not receive scheduled medications as ordered by the physician. The daily assignment sheet showed Nurse #1 was assigned to the A and F halls and Nurse #2 to the B and C halls for the day shift, while Medication Aide #1 and Unit Manager #1 were assigned to the D and E halls. The daily nurse staff report listed a census of 65 residents. Payroll records showed Medication Aide #1 clocked out at 12:54 PM and Unit Manager #1 did not clock in until 5:10 PM, leaving the D and E halls without staff available to administer medications during the cited period.
Failure to Discard Expired Medications and Date Open Multi-Dose Drugs
Penalty
Summary
The deficiency involves failure to ensure medications were properly dated upon opening and expired medications were discarded from medication carts and the medication room. During observation of the medication room refrigerator with the DON and a nurse, surveyors found an open, undated vial of Apilsol Tuberculin PPD solution, despite manufacturer instructions that it be discarded within 30 days of opening. On one medication cart, surveyors identified an expired bottle of nitroglycerin 0.4 mg tablets and multiple insulin pens (Humalog, Insulin Glargine, and Basaglar) that were either opened and undated or opened and dated beyond the manufacturer’s 28‑day use period. On another medication cart, surveyors observed a used, undated Novolin R FlexPen and a bottle of 200 mg ibuprofen tablets past the manufacturer’s expiration date. Nursing staff interviewed stated that the nurse who opened a medication was responsible for dating it and that night shift nurses were responsible for routinely checking medication carts and the medication room for expired medications. Staff also described monitoring of medications as a team effort and acknowledged they had not yet checked their carts on the day of observation, despite the DON’s stated expectation that nurses date medications upon opening and discard expired medications as needed.
Failure to Properly Label, Date, and Seal Food Items in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to properly label, date, and seal food items in accordance with professional standards. During an observation of the reach-in refrigerator, a small metal container of pimento cheese was found loosely covered with plastic wrap, leaving it exposed to air, and the date written on the wrap was obscured. When interviewed, the cook stated the pimento cheese had been made that morning but did not initially respond when asked why it was not sealed; she then re-wrapped and dated it, but it was determined unsafe to serve because the length of time it had been unsealed was unknown. Additional observations showed similar issues in other storage areas. In the dry storage area, a 25‑pound box of white rice was stored in an unsealed bag open to air and was not marked with the date opened, and the dietary staff member present stated she did not know why it was open and undated. In the walk‑in cooler, seven 4‑ounce cups of orange juice were covered with plastic wrap but were unlabeled and undated; the dietary staff member stated night shift staff prepared the orange juice and were responsible for labeling and dating it. In the walk‑in freezer, a box of frozen biscuits was stored in an unsealed bag open to air and was not marked with the date opened, and the dietary staff member again stated she did not know why it was open and undated. The Dietary Manager and District Dietary Manager confirmed that all food items should be labeled and dated when prepared, opened, or stored after opening and that staff were aware of this requirement.
Failure to Respond Promptly to Call Light Resulting in Undignified Treatment
Penalty
Summary
The deficiency involves a failure to treat a resident in a dignified manner by not responding promptly to the resident’s call light. The resident, who had diagnoses including type 2 diabetes mellitus, acute arterial ischemic stroke, bipolar I disorder with psychotic features, and schizophrenia, was cognitively intact and required varying levels of staff assistance for activities of daily living, including being dependent for toileting hygiene and bathing. The resident’s admission care plan did not include a focus area for behaviors. During a continuous observation on 02/16/26 from 11:10 AM to 11:31 AM, the resident’s call light remained on while he repeatedly yelled for assistance, stating, “Hey, someone help me, hey come here, I need help.” At approximately 11:16 AM, the surveyor informed the resident they would get assistance, and a nursing assistant in the adjacent room stated she would get to him as soon as possible, but the resident continued to yell out without receiving help. By approximately 11:30 AM, the surveyor went to the nurses’ station where five staff members (a medication aide, a human resource coordinator/NA, a nurse, and two NAs) were present. The staff acknowledged that the call bell was on but did not know how long it had been activated, even though the call light was visible and audible at the beginning of the hall near the nurses’ station. When the surveyor asked if they assisted with answering call lights, the medication aide initially responded that the resident “does that, he yells out for assistance” and did not go to assist him; the nurse and two NAs did not respond to the surveyor’s repeated questions. The human resource coordinator/NA then approached to assist the resident. In an interview, the resident reported he had been yelling for about 30 minutes with no response, stated he tracked the time using his television, and said this delay occurred frequently, sometimes up to an hour or more, regardless of his needs. He stated this made him upset and frustrated. In a separate interview, the DON reported she was unaware of the wait times and staff not answering this resident’s call bell, acknowledged the resident’s mental health conditions could affect his sense of time, and stated her expectation was that all staff answer call lights.
Failure to Protect Resident Property From Misappropriation by Nurse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s property from misappropriation by a staff member. The resident, assessed on a quarterly MDS as cognitively intact without behaviors and with a BIMS score of 12, had personal property including a truck bed and other items that were being handled by a friend and were associated with an auction and probate. An allegation was reported to the State Agency that a nurse had received a truck bed from this resident, and the resident’s contact person notified staff that the nurse was not supposed to receive the truck bed or any other items in her possession. According to the nurse’s interview, she discussed with the resident and the resident’s friend that she needed another vehicle, and the friend told her about a car for sale at auction. She went to look at the car and also discussed a truck bed, then asked her mechanic to look at the truck bed to see if it could be used as a bed for her home. The nurse stated she did not ask the mechanic to pick up the truck bed, but he did so and brought it to her house. She reported that when the resident’s friend wanted the truck bed back, she covered it with a tarp and left it in her yard for about two months until it was picked up. She denied knowledge of a trailer with other items and acknowledged she had been trained not to accept gifts from residents. The resident reported that he had told the nurse she could have the truck bed but did not realize at the time that it was scheduled to go to auction. He stated that the next day he told the nurse she could not have it because it was already promised for auction, but the nurse obtained the truck bed after he revoked permission. The resident’s friend, who handled the resident’s affairs, stated that the nurse had gone alone to the resident’s house to look at buying a car and later had someone pick up the truck bed for her, and that he discovered the truck bed and other miscellaneous items missing from a trailer. Local law enforcement confirmed they were contacted about a 2002 Ford truck bed and other property taken from the resident’s property, and that although the resident had initially told the nurse she could have the items, he later learned from his friend that they could not be given away because they were up for auction. The items were eventually returned and no charges were pressed, but the events demonstrated that the resident’s belongings were not protected from wrongful use or misappropriation by facility staff.
Failure to Assess and Document Sacral Pressure Ulcer and Provide Ordered Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to properly assess and treat a newly identified sacral pressure ulcer for a resident with multiple comorbidities, including a recent left above-knee amputation and history of stroke. On admission, documentation showed a surgical wound with staples to the left thigh, dry and cracked skin on the right foot, discoloration and scarring on the right leg, bruising on the right ankle, and buttocks free of skin breakdown. An admission MDS indicated moderately impaired cognition and dependence on staff for bed mobility, toileting hygiene, and transfers, with no pressure ulcers noted but a surgical wound present. Subsequent skin assessments by a nurse on two dates in December documented only a very thin area of pink and white tissue on the buttocks, consistent with previously healed wounds and no open areas, with staff providing protective skin care after incontinence. On a later date in December, a nurse documented that the resident was noted with a sacral wound, that wound care orders were obtained from the Medical Wound Provider, and that wound care was completed as ordered; however, the note did not include any description of the wound’s stage, characteristics, or presence of pain. A physician order was entered to cleanse the sacral wound with wound cleanser, apply calcium alginate to the wound bed, and cover with a dry dressing daily and as needed, but this order did not appear on the MAR or TAR. Review of the medical record showed no documentation that the ordered sacral wound care was provided on three consecutive days following the initial order. The nurse who obtained the order stated she entered it into the EMR and that it required activation to appear on the MAR or TAR, but she could not recall if she had activated it, could not recall measuring the wound, and only documented the new skin breakdown in a nursing note without detailed description. Interviews and record review confirmed that other nursing staff, including the nurse who later became the wound care nurse, could not recall providing wound care to the resident on the days in question and indicated that, at that time, floor nurses were responsible for wound care and the Medical Wound Provider was responsible for measuring and assessing wounds. The wound care nurse and another nurse explained that if an order was not activated in the EMR, it would not populate to the MAR or TAR, and staff would not know to complete the treatment. Observation of the resident’s buttocks in February showed a small area of pink and white scar tissue on one buttock and a very small, shallow open area with a pink/red wound bed on the other buttock, with wound care then being completed as ordered. The DON, who assumed the role later, stated she was unaware that the sacral wound care orders from late December had not populated to the MAR or TAR and stated she would have expected wound care to be completed as ordered and for the nurse to have documented a description of the wound in the progress note.
Inaccurate MDS Coding for Falls and Medication Use
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for multiple residents in the areas of accidents and medications. One resident with a history of stroke and muscle weakness experienced a fall that caused a skin tear to his right arm. In the subsequent quarterly MDS, his cognition was coded as severely impaired and the fall section was coded as one fall with no injury since the previous assessment, despite documentation in the medical record that the fall resulted in a minor injury. The MDS Consultant who completed the assessment later confirmed that the fall should have been coded as one fall with a minor injury and described the incorrect coding as an oversight. Two additional residents had inaccuracies in the medication sections of their MDS assessments. One resident with neuromuscular bladder dysfunction and age-related cataracts received Macrobid orally once daily and Moxifloxacin eye drops every two hours during the lookback period, but the quarterly MDS did not code any antibiotic use, which the MDS Consultant later acknowledged should have been coded. Another resident with bipolar I disorder with psychotic features and schizophrenia had active orders and documented administration for an intramuscular antipsychotic injection and an oral anticonvulsant medication during the admission MDS lookback period. However, the admission MDS was coded as receiving zero injections and did not reflect anticonvulsant use. The Corporate MDS Consultant confirmed she did not accurately code the injections or the anticonvulsant, stating she overlooked the intramuscular aspect of the antipsychotic and the presence of the anticonvulsant when reviewing the MAR.
Failure to Provide Behavioral Health Services for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to provide behavioral health care services to a resident with diagnosed serious mental illness and ongoing behavioral symptoms. The resident was discharged from the hospital with diagnoses including bipolar I disorder, current manic with psychotic features, and schizophrenia, and the hospital discharge summary documented a need for follow-up psychiatric appointments and medication management. On admission, the resident’s care plan dated 01/23/26 did not include a focus area for behaviors despite these diagnoses and the presence of multiple psychotropic medications, including olanzapine, lamotrigine, and fluphenazine decanoate. The admission MDS indicated intact cognition, no behaviors coded during the lookback period, and a Level II PASRR, and the resident was coded as receiving antipsychotic medications. Behavioral documentation on the MAR from 01/23/26 through 02/13/26 showed repeated episodes of calling out and screaming/calling out on multiple days, yet the medical record from 01/23/26 through 02/16/26 contained no evidence that psychiatric or other behavioral health services were provided. During observation on 02/16/26, the resident’s call light remained on while he yelled for assistance for over 20 minutes, and a med aide acknowledged that he frequently yelled out but did not know how long he had been yelling on that occasion. The admitting nurse stated she did not recall seeing a psychiatry referral, explained that her process was to place such referrals in the social worker’s box, and did not know why the resident had not been seen by psychiatry despite his behaviors. The Social Services Director confirmed she had not received a referral or completed a psych consent for this resident and that the resident was not on the psychiatric provider’s active list. The Medical Director and DON both stated they expected residents to receive necessary behavioral health care services and were unaware that this resident had not been referred to or seen by psychiatric providers.
Failure to Follow Hold Parameters for Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to hold a blood pressure medication when the resident’s systolic blood pressure (SBP) was below a specified parameter. A resident admitted with hypertension and heart failure had a physician’s order for Metoprolol Tartrate 25 mg, to administer 12.5 mg by mouth every 12 hours, with instructions to hold the dose if SBP was less than 110. Review of the January 2026 MAR showed that the resident received Metoprolol Tartrate for multiple 9:00 PM doses when the SBP was documented below 110, including SBP readings of 109, 109, 99, and 106. The resident’s quarterly MDS indicated the resident was cognitively intact. During an interview, the medication aide who administered several of the doses confirmed that Metoprolol Tartrate was given despite SBP readings below the ordered parameter and stated this was an oversight. Attempts to contact the nurse who administered one of the doses were unsuccessful. The Medical Director stated that, although she did not feel the resident would have suffered serious harm from receiving the medication outside the parameter, she expected nursing staff to follow the blood pressure parameters as written. The DON also stated she expected staff to follow physician orders, including hold parameters for blood pressure medications, and reported she had recently assumed the role and was unaware that the medication had been administered outside the prescribed parameters.
Failure to Maintain and Post Current Survey Results in Public Notebook
Penalty
Summary
The facility failed to make the most recent survey results readily available to residents and visitors by not updating the survey results notebook in the front lobby with multiple completed surveys. On two separate days of the survey, the notebook on a low table in the lobby was observed to contain only the results from a recertification survey completed on 8/16/23, despite the iQIES database showing that the most recent survey was a complaint investigation completed on 11/7/25. Review of records identified that several intervening surveys were missing from the notebook, including a complaint investigation survey dated 1/30/24, a focused infection control survey dated 4/8/24, complaint investigation surveys dated 8/22/24, 12/30/24, 1/15/25, 7/15/25, and 11/7/25, and a recertification survey dated 11/21/24. In an interview, the Administrator reported he began employment at the facility at the end of July 2025 and acknowledged awareness of the regulation requiring that the most recent survey results from any survey be placed in the notebook. He stated that technical issues initially prevented him from printing the survey results when he started, and that while he had the survey results in his office, he had not placed them in the public binder. The Administrator acknowledged that he should have placed the survey results in the notebook once he was able to print them but could not explain why this had not been done.
Inaccurate Daily Posting of Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post accurate daily nurse staffing information when compared to the actual staffing schedules and staff who worked. A review of daily postings and nursing schedules from early January through mid-February showed that on 22 of 46 days, the posted numbers and types of nursing staff did not match the schedule. Examples included discrepancies in the number of nurse aides (NAs), medication aides (MAs), registered nurses (RNs), and licensed practical nurses (LPNs) listed as working specific shifts versus what was reflected on the daily posted nurse staffing sheets. Specific instances of inaccuracy included days when fewer or more NAs were posted than were scheduled for the 7:00 AM–3:00 PM and 11:00 PM–7:00 AM shifts, and days when the number of MAs posted did not match the schedule. On multiple dates, the postings showed different numbers of NAs on day and night shifts than the staffing schedule indicated. There were also days when the postings showed an MA working when none were scheduled, or showed no MA working when one or more were scheduled. Similar inconsistencies occurred with LPN coverage, where the posted sheets sometimes reflected more or fewer LPNs than were actually scheduled for 12-hour shifts. The report also documents repeated misclassification of one nurse’s licensure status on the posted staffing sheets. This nurse was hired as an LPN and later became an RN effective mid-January, but the staff scheduler continued to count him as an LPN and not as an RN on multiple dates after his RN licensure became effective. Interviews with the staff scheduler confirmed that she did not update the daily posted nurse staffing sheets when staff failed to report for work or when additional staff came in to cover, and that she had not adjusted the postings to reflect the nurse’s change from LPN to RN. The administrator and DON acknowledged that the staffing schedules and daily postings did not match the actual staff who worked on given shifts.
Failure to Maintain Dialysis Communication Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain evidence of ongoing communication with a dialysis treatment center in the medical record for a resident with end stage renal disease (ESRD) who was dependent on hemodialysis three times per week. The resident’s significant change MDS assessment showed the resident was cognitively intact, but dialysis was not coded on the assessment in error. Review of the electronic medical record revealed no completed dialysis communication forms, and the facility was unable to locate any such forms for this resident. Progress notes contained no documentation of communication between facility staff and the dialysis center, and there was no documentation that pre-dialysis or post-dialysis assessments were completed and communicated. Nursing staff interviews confirmed that a dialysis communication form and notebook system was in place, with nurses completing pre-dialysis information such as vital signs, weight, access site condition, and changes in condition, and dialysis nurses documenting post-dialysis assessments. However, the Medical Records Manager reported there was no scheduled timeframe for removing completed forms from the notebook and uploading them into the electronic medical record, and she was unable to locate any forms for this resident, suggesting they may have remained in the notebook and possibly left with the family at discharge. The DON stated the facility was responsible for ensuring completion of the forms and placement in the medical record after review, but could not explain why the forms were not present for this resident.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to protect a severely cognitively impaired female resident from sexual abuse by another resident. On two separate occasions, a male resident with moderate cognitive impairment was observed engaging in sexually inappropriate contact with the female resident, who was unable to consent due to her severe cognitive impairment. In the first incident, the male resident lifted the female resident’s breasts out of her shirt and fondled them in a public area of the facility. In the second incident, the same male resident took the female resident’s hand and rubbed it over his pants in his crotch area. Both incidents were witnessed by staff, who intervened to separate the residents. The male resident had a history of dementia, cognitive communication deficit, and other medical conditions, but there was no care plan in place addressing sexually inappropriate behaviors prior to the first incident. The female resident had Alzheimer’s dementia, was severely impaired in daily decision making, and required total assistance with most activities of daily living. She was dependent on staff for mobility and transfers and was unable to provide a reliable account of the incidents due to her cognitive status. Staff interviews confirmed that the male resident had previously made inappropriate sexual comments to staff but had not been known to touch other residents inappropriately before these events. Despite the initial implementation of one-to-one supervision for the male resident following the first incident, supervision was not consistently maintained, as evidenced by observations of the resident without a sitter at the nurses’ station and in the hallway. Staff were unclear about the requirements for one-to-one supervision, and the male resident was able to approach and have further inappropriate contact with the same female resident. The lack of a care plan addressing the male resident’s behaviors and inconsistent supervision contributed to the recurrence of resident-to-resident sexual abuse.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, as observed during a survey. On two medication carts, several insulin pens, including Lispro, Lantus, and Basaglar, were found opened and undated, with some not labeled with resident names. Additionally, a vial of Lantus insulin and an Insulin Aspart pen were also opened and undated. The manufacturer's instructions require insulin to be discarded 28 days after opening, which was not adhered to. Furthermore, two vials of tuberculin purified protein derivative (PPD) testing solution were found opened, undated, and improperly stored outside of refrigeration, contrary to the manufacturer's guidelines. In the medication storage room, an unopened bottle of Allergy Relief tabs was found with an expiration date of September 2024, indicating it was expired and should have been discarded. Interviews with the staff, including a pharmacist, the Director of Nursing (DON), and the Administrator, revealed that there was an expectation for nurses to date all medications upon opening and to store them correctly. The pharmacist, who visits monthly, had previously identified expired or undated medications but relied on the nursing staff to dispose of them. The unit managers were responsible for auditing the medication carts for expired medications, but this process was evidently insufficient to prevent the deficiencies observed.
Failure to Disinfect Glucometer as per Guidelines
Penalty
Summary
The facility failed to properly disinfect a glucometer used for checking a resident's blood glucose level, as per the manufacturer's guidelines. The glucometer was individually assigned to a resident and stored in the medication cart. According to the facility's policy, the glucometer should be cleaned and disinfected with disinfecting wipes, specifically Sani cloth wipes, and allowed to remain wet for a full 2 minutes before air drying. However, during an observation, a nurse used the glucometer to check the resident's blood glucose level and then placed it back into the medication cart without cleaning it as required. Upon interview, the nurse acknowledged that the facility's policy was to clean the meters both before and after use, but she used alcohol swabs instead of the required Sani wipes, as she was unaware of the specific product to be used. The Director of Nursing confirmed that the glucometers should be disinfected with Sani wipes, and the Administrator expected the facility policy to be followed. The absence of disinfecting wipes on the cart contributed to the failure to adhere to the proper cleaning protocol.
Failure to Provide Haircut Services to Resident
Penalty
Summary
The facility failed to honor a resident's request for a haircut, which was a preference known to the staff. The resident, who was cognitively intact and admitted with a diagnosis of muscle weakness, expressed frustration over not having his hair trimmed since admission. Despite reporting his preference to multiple staff members, the resident was informed that there was no beautician available at the facility to provide haircuts. Interviews with staff, including a nurse and a nurse aide, confirmed that there had been no beautician available for several months, and staff were not trained or licensed to cut hair. The Director of Nursing acknowledged awareness of complaints regarding the lack of haircuts but was not specifically aware of this resident's preference. The facility administrator also confirmed the absence of a beautician and was in the process of hiring one, but had not addressed the immediate needs of the residents who preferred haircuts.
Failure to Provide Routine Hair Trimming for Medicaid Residents
Penalty
Summary
The facility failed to provide routine hair trimming as part of basic hygiene services for residents whose payor source was Medicaid. This deficiency was identified for two residents who were cognitively intact and expressed a desire for haircuts. Both residents had hair that was longer than they preferred, touching their collars and around their ears. Despite their requests, there was no staff available to provide haircuts, and the residents were unsure of whom to approach for this service. Interviews with various staff members, including the Social Services Director, Nurse, Nurse Aide, Unit Manager, Director of Nursing, and Administrator, revealed a lack of awareness and responsibility regarding the provision of haircuts for residents. The Social Services Director and other staff members were unaware of any concerns regarding the residents' requests for haircuts. The Director of Nursing and the Administrator were also unaware that routine hair trimming was a covered service for Medicaid residents. The staff interviews highlighted a lack of clarity and communication about who was responsible for providing haircuts, with some staff suggesting that residents could have a beautician or family member come in to cut their hair. This lack of coordination and understanding among the staff led to the failure to meet the residents' basic hygiene needs as required by Medicaid coverage.
Failure to Prevent Falls Due to Improper Footwear
Penalty
Summary
The facility failed to implement effective interventions to prevent further falls for a resident with a history of falls and cognitive impairment. The resident, who was admitted with diagnoses including unsteadiness on feet, orthostatic hypotension, osteoporosis, and dementia, experienced multiple falls. Despite being identified as at risk for falls due to cognitive loss, weakness, and poor safety awareness, the interventions in place were insufficient. The resident's care plan included ensuring appropriate footwear and encouraging the resident to call for assistance, but these measures were not effectively enforced or monitored. The resident experienced falls on multiple occasions, with incident reports indicating that improper footwear was a contributing factor. Observations revealed that the resident's shoes were too big, affecting her balance and leading to falls. Despite the facility's awareness of the issue, there was a lack of follow-up to ensure the resident received properly fitting shoes. Interviews with staff, including the DON, highlighted a failure to implement and monitor interventions effectively, resulting in repeated falls due to the same issue of ill-fitting footwear.
Medication Administration Errors Result in 6.9% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.9% error rate during a medication administration observation. This was evidenced by two medication errors out of 29 opportunities involving two residents. Resident #16, who was admitted with a diagnosis of retention of urine, had an active physician's order for Macrobid capsules for urinary tract infection prophylaxis. During the medication administration, the Unit Manager, acting as a floor nurse, prepared 11 out of 12 medications for Resident #16, omitting the Macrobid capsule. The error was identified when the Unit Manager was asked to recount the medications, and she acknowledged the oversight and administered the antibiotic subsequently. Similarly, Resident #5, admitted with a diagnosis of dry eye, had an active order for Artificial Tears to be administered twice daily. The Unit Manager prepared 10 out of 11 medications for Resident #5, leaving the Artificial Tears on top of the medication cart and failing to administer them before taking the resident to the cafeteria. The Unit Manager later admitted to forgetting to administer the eye drops. Interviews with the Nurse Practitioner, Director of Nursing, and Administrator confirmed the expectation that all medications should be administered as ordered, within the specified time frame.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents and their responsible parties upon transfer to a hospital, affecting two residents reviewed for hospitalization. Resident #37, who was cognitively impaired, was admitted to the facility and later transferred to the hospital without receiving the required bed hold policy notice. Interviews with the social worker and unit manager confirmed that the policy was not sent with the discharge paperwork. The administrator was unaware of this oversight and acknowledged the absence of a process to inform residents or their representatives about the bed hold policy. Similarly, Resident #30, who was cognitively intact, was transferred to the hospital on two occasions without receiving the bed hold policy notice. Interviews with the Social Services Director and a nurse revealed a lack of awareness regarding the requirement to send the bed hold policy during hospital transfers. The administrator confirmed the absence of a process to ensure residents and their responsible parties were informed of the bed hold policy, indicating a systemic issue within the facility.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their responsible parties regarding the reason for hospital transfers, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital without receiving the necessary documentation. Resident #37, who was cognitively impaired, was transferred to the hospital without a written notice of discharge or transfer. The Social Worker admitted to not sending the required notice and was unsure of the process for issuing such notices. The Unit Manager, who was the nurse assigned to Resident #37 at the time of transfer, confirmed that the discharge paperwork sent with the resident did not include the notice of transfer/discharge. Similarly, Resident #30 was transferred to the hospital on two occasions without the facility providing written notification to the responsible party. The Social Services Director acknowledged not sending a written reason for the hospital transfer and was unaware of this requirement. Interviews with the nursing staff revealed uncertainty about who was responsible for sending the hospital transfer notice. The Administrator confirmed awareness of the notification requirements but was unaware that the Social Services Director had not completed this task.
Incomplete Wound Care Documentation for Three Residents
Penalty
Summary
The facility failed to maintain complete and accurate documentation for wound care for three residents, leading to a deficiency in safeguarding resident-identifiable information and maintaining medical records. Resident #30, who had a history of surgical aftercare for a right below-the-knee amputation and diabetes type 2, had multiple instances where wound care documentation was missing. Despite physician orders for daily wound care on her left forearm and right leg, the Treatment Administration Record (TAR) showed no documentation of completion or refusal on several dates in June 2024. Interviews with the Unit Manager and the Director of Nursing (DON) revealed that while they claimed to have completed the wound care, they forgot to document it. Resident #55, admitted with a right femur fracture, end-stage renal disease, and congestive heart failure, also had incomplete wound care documentation. Physician orders required daily wound care for pressure wounds on the coccyx and left hip. However, the May 2024 TAR lacked documentation of completion or refusal on multiple dates. Interviews with several nurses indicated that while they ensured wound care was completed, they often forgot to document it. The DON reviewed the TAR and acknowledged the expectation for complete and accurate documentation. Resident #56, with diabetes type 2 and a stage 3 pressure ulcer to the sacral region, had similar issues with documentation. The June 2024 TAR showed missing documentation for sacral wound care on numerous dates. The Unit Manager, responsible for wound care, stated that she completed the care but forgot to sign off on it. The DON and the Administrator both expressed expectations for complete and accurate documentation, highlighting a systemic issue with documentation practices in the facility.
Failure to Secure Wheelchair Leads to Resident Injury During Transport
Penalty
Summary
The facility failed to provide safe transportation for a resident when she was being transported by a contracted van transport company from dialysis back to the facility. The resident's wheelchair was not secured to the floor securement system per the manufacturer's instructions. As a result, when the driver accelerated the vehicle, the resident's wheelchair tipped backward, causing her to hit the right back side of her head. Emergency Medical Services (EMS) were called, and the resident was taken to the hospital for evaluation. The resident involved in the incident had a medical history that included diabetes mellitus, end-stage renal disease with hemodialysis, and bilateral below-knee amputations. She was cognitively intact and required extensive assistance with activities of daily living, using a wheelchair for mobility. The resident was on anticoagulant medication, which increased the risk of serious adverse outcomes from head injuries. After the incident, she was diagnosed with a right parietooccipital hematoma but had no acute traumatic pathology on the CT scan. Interviews and records revealed that the driver did not secure the wheelchair according to the manufacturer's instructions, which required four separate floor-mounted restraints. The driver admitted to having issues with the latching mechanism and thought it was secured well. The facility was notified of the incident by the transportation company, and an internal investigation confirmed the driver's failure to follow protocol, leading to his termination. The facility subsequently stopped using the contracted transportation service.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 186 citations issued within 25 miles in the last 12 months — including the 5 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 Archdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Graybrier Nursing And Retirement Center | 2.5 mi | ★★★★★ | 6 | 0 |
| Meridian Center | 4.5 mi | ★★★★★ | 9 | 2 |
| Westchester Manor At Providence Place | 4.7 mi | ★★★★★ | 3 | 0 |
| The Shannon Gray Rehabilitation & Recovery Center | 5 mi | ★★★★★ | 1 | 0 |
| Maryfield Nursing Home | 5 mi | ★★★★★ | 1 | 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.