Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Inaccurate glucose, BP, and temperature equipment. A resident with DM had facility FSBS readings that did not match later ED findings, including a facility reading of 233 followed by a serum glucose of 1046 and DKA. The ED physician and NP both questioned the glucometer result, and the ED physician said the equipment may not have read correctly. The report also noted a facility BP of 144/69 and temp of 98.8 shortly before EMS found the resident unresponsive with hypotension and a temp of 105.1. The DON said nurses used their own BP cuffs and thermometers and could not say how often they were checked for accuracy or calibration.
A resident with diabetes, recent G-tube placement, and enteral feeding orders had a fingerstick blood sugar of 509 that was not reported to the provider. The RN did not recheck the glucose or call the MD because the resident appeared alert and without symptoms. The next morning the resident was found nonresponsive, EMS noted fever, hypotension, tachycardia, and tachypnea, and the hospital documented DKA/HHS with a serum glucose over 1000.
Failure to Recheck Severe Hyperglycemia After Insulin Administration: A newly admitted resident with DM, a G-tube, and recent insulin changes had a FSBS of 509 after scheduled Humalog was given, but the nurse did not notify the provider or recheck the glucose. The resident had been NPO except for enteral feedings and was later found nonresponsive with fever, tachycardia, hypotension, and a hospital glucose over 1000, with DKA/HHS diagnosed.
A resident with stroke history, trigeminal neuralgia, diabetes, dysphagia, and a G-tube had multiple medication service failures on admission. Metformin and gabapentin were not obtained from the pharmacy or backup supply in time for administration, resulting in held or missed doses, and staff reported not knowing how to access backup medications. The resident was also ordered Tegretol-XR via G-tube without admission clarification for the ER formulation, and the pharmacy later identified the discrepancy and dispensed a liquid form after clarification.
Incomplete documentation of a resident's change in condition led to a medical record deficiency. A resident was found unresponsive with a blood glucose reading too high to register, and an RN reported assessing the resident and calling EMS, but the EMR did not contain the assessment or the events leading to transfer. The only note found documented that the emergency contact was notified of ED transfer, while hospital records showed ICU admission for DKA, HHS, febrile illness, leukocytosis, dehydration, depressed LOC, and acute renal failure. The DON said the care and assessment should have been documented and the required E-Interact form was not found.
Surveyors found that food items in the walk-in cooler, including a container of pudding and a pan of turkey sandwiches, were stored without labels or dates. The Dietary Manager reported that these items were not present before the weekend and must have been prepared and stored during that time, but the exact timing could not be determined due to missing labels and dates. She stated that she and the Assistant Dietary Manager monitor for unlabeled items during the week, but no one is assigned this responsibility on weekends, and that staff who place food in the cooler are responsible for labeling and dating it. The Administrator confirmed that there should be no unlabeled or undated food items in the walk-in cooler.
Surveyors identified that the facility failed to maintain clean and properly maintained privacy curtains, medical equipment, and walls in several rooms occupied by severely cognitively impaired residents. In one room, a privacy curtain remained in use despite multiple dark brown/red stains, even though the assigned housekeeper was responsible for replacing soiled curtains. In another room, an oxygen concentrator had visible white particles on its surface on repeated observations, despite a housekeeping schedule that required weekly cleaning and additional cleaning when dirty. In a third room, blood-like drips were present on a wall where a resident’s scabbed knee rested; the NA reported the wall had not been cleaned for at least two weeks and did not notify housekeeping, and the housekeeper stated she only noticed and cleaned the stains the day before the interview.
A resident with dementia, ESRD on HD, diabetes, and anticoagulant therapy was care-planned as totally dependent for transfers and required a mechanical lift. After returning from HD and repeatedly requesting to go to bed, a NA, unable to access a charged lift, attempted a stand-pivot transfer despite knowing a lift was required. The resident’s legs gave out, resulting in an assisted fall to the floor; the NA then lifted the resident back into a wheelchair and later, with another NA and a medication aide, manually transferred the resident to bed without notifying an RN/LPN or obtaining a nurse assessment. Only after the transfer and onset of right shoulder pain was the unit manager notified, and later that evening a nurse identified a large, painful chest wall swelling that led to hospital evaluation and diagnosis of a large right chest wall hematoma with active bleeding.
A resident who was totally dependent for transfers and required a mechanical lift per the care guide returned from dialysis, requested to go to bed due to pain and fatigue, and was assisted by a CNA who found nearby lifts uncharged. Despite knowing a lift was required, the CNA attempted a stand-pivot transfer without a lift, during which the resident’s legs gave out and she was lowered to the floor. Without notifying a nurse, the CNA manually lifted the resident from the floor back into a wheelchair and later, with another CNA and a medication aide, manually lifted the resident from the wheelchair to the bed, again without a lift, while the resident was slumped and at risk of falling. After these transfers, the resident complained of right shoulder pain and was later found to have a large, painful chest wall swelling; hospital evaluation identified a large right chest wall hematoma with active arterial bleeding, and the Medical Director indicated the injury was more likely related to how the resident was transferred than to the assisted fall itself.
A resident was transported to the hospital and admitted for an intestinal obstruction without the responsible party being notified by the facility. The resident, who was moderately cognitively impaired, requested transport to the emergency room. Despite receiving a status update from the hospital, the facility staff failed to inform the responsible party, who only learned of the situation from the hospital social worker.
A resident with a history of falls and recent fall incidents did not have a comprehensive care plan addressing fall risk. The MDS nurse acknowledged the oversight, and both the DON and Administrator were unaware of the missing care plan.
Two residents in the facility did not receive their prescribed Ozempic injections due to the medication being unavailable on multiple occasions. Despite the missing doses, the physician and nursing staff reported no negative outcomes for the residents. The facility's Director of Nursing emphasized the importance of administering medications as prescribed.
A nurse in an LTC facility failed to follow infection control procedures during tracheostomy care for a resident with chronic respiratory failure. The nurse did not perform hand hygiene between glove changes, used contaminated sterile gloves, and utilized a dropped q-tip to clean the tracheostomy site. The resident required complete assistance with daily living activities, including tracheostomy care, and was at risk for ineffective breathing patterns.
A nurse in an LTC facility failed to perform tracheostomy care using proper sterile techniques, as observed during a survey. The nurse did not perform hand hygiene between glove changes and used a dropped q-tip to clean around the tracheostomy stoma. Discrepancies were found in the training provided, as the nurse claimed she was not trained until after the observation, contrary to the facility's statements.
A resident with a history of hemiplegia and back surgery experienced discomfort due to a sagging mattress. Despite a work order and staff awareness, the mattress was not replaced, leading to continued discomfort. Observations confirmed the mattress's poor condition, but the facility failed to take timely action.
Two residents in an LTC facility did not receive their prescribed Ozempic medication due to it being documented as unavailable on multiple occasions. Despite the pharmacy delivering the medication, it was reported as lost, and the facility had to reorder it at their own expense. The facility's investigation revealed discrepancies in medication administration records and packing slips, indicating potential misappropriation or misplacement of the medication.
A resident with impaired vision was mistakenly given ear drops in her eyes by a nurse in orientation, leading to a significant medication error. Despite the resident's concerns about blurry vision, medical evaluations determined the ear drops did not cause vision changes. The facility's investigation involved staff interviews and education on proper medication administration routes.
Inaccurate Glucose, Blood Pressure, and Temperature Equipment
Penalty
Summary
The facility failed to ensure a system was in place to check the accuracy of resident care equipment used for blood pressure and temperature readings. The report also identified concern about a glucometer reading that was difficult to reconcile with other known details of a resident’s condition and treatment. The issue affected 1 of 3 sampled residents reviewed for change in condition, with the potential to affect all residents. Resident #2 resided at the facility for four days in April 2026 and had a diagnosis of diabetes mellitus. Facility blood sugar records showed readings of 291, 247, 303, 220, 509, and then 233 over the resident’s stay. According to the MAR, the resident received 5 units of Humalog insulin when the blood sugar was 509 and only one of two scheduled metformin doses on the prior day. EMS was called when the resident was found unresponsive, and the ED record showed a finger stick blood sugar greater than 600 and a serum glucose of 1046, with the resident admitted to the ICU with diabetic ketoacidosis. The ED physician and the NP both stated the facility glucometer result of 233 did not make sense in light of the resident’s condition and the later hospital findings, and the ED physician stated the equipment may not have read correctly. The report also described inconsistent vital sign equipment use and results. A nurse documented a blood pressure of 144/69 and a temperature of 98.8 using a non-contact temporal thermometer shortly before EMS was called, while EMS later found the resident unresponsive, tachypneic, with a blood pressure of 63/35 and 70/48 and a temperature of 105.1. The ED physician stated the facility blood pressure and temperature readings appeared not to be correct. The DON reported nurses supplied their own blood pressure equipment and thermometers, that glucometers were checked nightly with control tests, and that the logs were not kept after discharge, so she could not review Resident #2’s log data. The DON and Administrator both stated they did not know how often the nurses’ personal blood pressure machines and thermometers were checked for accuracy and calibration.
Failure to Notify Provider of Critical Blood Sugar Result
Penalty
Summary
Facility staff failed to notify the physician when a resident’s fingerstick blood sugar reached 509. The resident had a recent hospital discharge diagnosis of diabetes and was admitted to the facility with orders for metformin 1000 mg twice daily via gastrostomy tube, Humalog 5 units three times daily, and all nutrition by enteral feeding. The resident also had a history of prior stroke, trigeminal neuralgia, dysphagia, dysarthria, and had recently undergone gastrostomy tube placement for nutrition. The resident’s MAR showed fingerstick blood sugars of 291, 247, and 303 on the first day after admission, then 220 and 509 on the next day. The 509 result was documented by an RN, but there was no documentation that the physician was contacted. The RN later stated she did not call the physician and did not recheck the blood sugar after giving the scheduled insulin because the resident appeared alert, was talking, and did not show symptoms. She also stated the resident said her mouth was dry, which she attributed to the enteral feeding. The following morning, the resident was found nonresponsive. Staff obtained vital signs, checked the blood sugar, and called 911. EMS documented tachypnea, mottled and pale skin, fever, hypotension, and tachycardia. In the hospital, the resident’s blood sugar was greater than 600 on the first check and serum glucose was 1046. Hospital records documented diabetic ketoacidosis, hyperosmolar hyperglycemic state, febrile illness, leukocytosis, dehydration, depressed level of consciousness, and acute renal failure. The facility NP stated staff should report any blood sugar over 500 and said she had not been notified of the 509 result.
Failure to Recheck Severe Hyperglycemia After Insulin Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for a newly admitted resident with diabetes who had recently changed from an oral diet to enteral feeding. The resident had a history of prior stroke and trigeminal neuralgia, was hospitalized for worsening weakness and dysphagia, and was discharged with a gastrostomy tube for nutrition. On admission to the facility, the resident had orders for metformin 1000 mg twice daily via gastrostomy tube and Humalog 5 units subcutaneously three times daily, with all nutrition to be given by enteral feeding. On the evening when the resident’s finger stick blood sugar was documented as 509, the nurse administered the scheduled insulin but did not notify the physician and did not recheck the blood sugar after insulin administration. The resident was also documented as continuing to request ice chips and sips of water despite being NPO, and the nurse discussed this with the resident and responsible party. There was no documentation of physician notification or reassessment related to the blood sugar of 509. The nurse later stated she did not call the physician or retake the blood sugar because the resident appeared alert, was talking, and had no symptoms, and she believed the resident had received some insulin. During the overnight shift, the resident remained in the facility and received scheduled enteral feedings. The next morning, the resident was found nonresponsive. Staff obtained vital signs, checked the blood sugar, and called EMS. EMS found the resident unresponsive with tachypnea, mottled and pale skin, elevated heart rate, low blood pressure, and a temperature of 105.1. Hospital records showed the resident’s blood sugar was greater than 600 on arrival, with a serum glucose of 1046, and the resident was diagnosed with diabetic ketoacidosis, hyperosmolar hyperglycemic state, febrile illness, leukocytosis, dehydration, depressed level of consciousness, and acute renal failure.
Pharmacy Services and Medication Order Clarification Deficiencies
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for a newly admitted resident with a history of stroke, trigeminal neuralgia, diabetes, dysphagia, and a gastrostomy tube for nutrition. On admission, the resident had orders for metformin 1000 mg via G-tube twice daily with meals, but the medication was not obtained from the pharmacy or the facility’s backup supply for administration on the day of admission. Documentation showed the resident missed the admission dose and later doses were also held or not given as scheduled. Staff interviews revealed the nurse did not realize metformin was available in the backup supply, and the DON stated the medication could have been obtained from the emergency supply or backup pharmacy. The resident also had an admission order for gabapentin 100 mg three times daily via gastrostomy tube for trigeminal neuralgia. The first gabapentin delivery from the pharmacy was not documented until the day after admission, and the MAR showed doses were held or not given before the medication was available. The nurse who documented the held doses reported she did not know the medication was in the facility’s backup supply and how to obtain it. The DON confirmed there was no documentation that gabapentin had been removed from the backup supply for the resident. In addition, the resident was admitted with an order for Tegretol-XR 200 mg twice daily via gastrostomy tube. Tegretol-XR is an extended-release medication, and the record showed no clarification on admission regarding how to administer an extended-release tablet through a G-tube. The pharmacy later identified a discrepancy between the hospital discharge orders and the facility admission orders, requested clarification, and then dispensed a liquid form after clarification was obtained. The record showed the extended-release medication had been entered for G-tube administration before that clarification was documented.
Incomplete Documentation of Resident Change in Condition
Penalty
Summary
The facility failed to ensure the medical record was complete regarding a change in condition for 1 of 3 residents reviewed for medical record accuracy. A resident was found unresponsive on the morning of 4/26/26, and a blood sugar check registered too high to read on the facility glucometer. Nurse #1 reported that she assessed the resident and called EMS, but the resident's electronic medical record did not contain the assessment or the events of that morning, and the nurse did not know why the information was not saved. The only nursing narrative note located was entered on 4/26/26 at 9:26 AM and documented that the resident's emergency contact was informed of transfer to the ED, but it did not include an assessment or the reason for transfer. Hospital records showed the resident was admitted to the ICU with diabetic ketoacidosis, elevated beta-hydroxybutyrate, hyperosmolar hyperglycemic state, febrile illness, leukocytosis, dehydration, depressed level of consciousness, and acute renal failure. The DON stated the resident's care and assessment should have been documented, could not find the missing documentation, and could not find the required E-Interact form for the change in condition.
Unlabeled and Undated Food Items Stored in Walk-In Cooler
Penalty
Summary
Surveyors observed that the facility failed to label or date food items stored in the walk-in cooler, contrary to professional standards and facility expectations. During a kitchen tour, an unlabeled and undated rectangular metal container covered with plastic wrap was found to contain approximately 10 ounces of pudding, and an additional unlabeled and undated metal sheet pan covered with aluminum foil was found to contain about 20 turkey sandwiches. The Dietary Manager stated that when she left at 4:00 PM on the preceding Friday, neither the pudding nor the sandwiches were present in the cooler and that they must have been prepared and placed there over the weekend, but she could not determine exactly when due to the lack of labels and dates. She reported that she and the Assistant Dietary Manager monitored the walk-in cooler for unlabeled or undated food items during the week, but no one was designated to perform this monitoring on weekends, and that whoever placed food in the cooler was responsible for labeling and dating it. The Administrator confirmed in an interview that there should be no unlabeled or undated food items in the walk-in cooler. No specific residents or their medical conditions were mentioned in the report, and the deficiency was described as having the potential to affect food served to residents.
Failure to Maintain Clean Curtains, Equipment, and Walls in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and comfortable environment in multiple resident rooms. In one room on the 300 hall, a severely cognitively impaired resident’s privacy curtain closest to the window was observed on two separate dates with multiple dark brown/red stains. The assigned housekeeper, who was responsible for replacing soiled or stained privacy curtains, acknowledged that the curtain needed to be changed but could not explain why it had not been replaced earlier in the week. The Housekeeping Manager stated that housekeepers were responsible for changing curtains when soiled or stained and agreed that the curtain should have been changed as soon as the markings were noticed. In another room on the 200 hall, a severely cognitively impaired resident’s oxygen concentrator was observed on two separate dates with visible white particles all over the top surface. The housekeeper assigned to that room confirmed that it was her responsibility to wipe down oxygen concentrators in resident rooms and acknowledged that she had not noticed that the concentrator needed to be cleaned prior to the surveyor’s observation. The Housekeeping Manager reported that oxygen concentrators and other medical equipment in resident rooms were supposed to be cleaned weekly and additionally whenever dirty, dusty, or soiled, and that this concentrator should have been cleaned during the scheduled cleaning. In a third room on the 200 hall, a severely cognitively impaired resident was observed lying in bed with his left knee bent and resting on the wall, where dark red marks in a dripping pattern were present. A nurse aide identified the drippings as blood and showed the resident’s knee with three scabbed areas, stating that the wall had not been cleaned since she started working at the facility two weeks earlier. She did not notify housekeeping about the blood stains and could not provide a reason, stating she “just did not think about it.” The housekeeper later reported that she only noticed and cleaned the dark red marks on the wall the day before the interview, and the Housekeeping Manager stated that daily room cleaning was expected to include wiping down vertical and horizontal surfaces, including walls, and that the stains should have been noticed and cleaned during routine cleaning.
Failure to Follow Fall Protocol and Transfer Requirements After Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow fall protocol and the resident’s care plan by not notifying a nurse immediately after an assisted fall and by moving the resident before a licensed nurse assessment. The resident involved had dementia, ESRD on hemodialysis, diabetes, portal vein thrombosis treated with Eliquis, and an aneurysm of the upper extremity artery. Her MDS and care plan specified that she was totally dependent for transfers and required a one-person mechanical lift with a medium sling for all transfers. On the day of the incident, the resident returned from dialysis, ate lunch, and repeatedly requested to be put to bed due to feeling tired and hurting, which staff reported was usual after dialysis. Around mid-afternoon, NA #1 went to transfer the resident to bed. NA #1 knew from the Resident Care Guide that a mechanical lift was required but found that the two lifts on her section were not charged and unavailable. Despite this and the resident’s insistence on going to bed, NA #1 attempted a stand-pivot transfer from the wheelchair to the bed without a lift. During this attempt, the resident’s legs gave out, she panicked, and NA #1 lowered her to the floor. NA #1 then independently lifted the resident from the floor back into the wheelchair, where the resident appeared slumped, and adjusted her upright. NA #1 did not notify a nurse at the time of the assisted fall and did not obtain a nurse assessment before moving the resident from the floor to the wheelchair. Shortly thereafter, NA #1 called NA #2 and the Medication Aide to help transfer the resident from the wheelchair to the bed but did not inform them that an assisted fall had occurred. All three staff lifted the resident from the wheelchair to the bed using manual assistance. The Medication Aide later stated she did not call a nurse because she had not witnessed a fall and only saw the resident slumped in the wheelchair. After the transfer to bed, the resident complained of right shoulder pain and requested pain medication, which was administered. The Unit Manager was then notified and, upon arrival, found the resident already in bed, reporting 10/10 right shoulder pain. The Unit Manager and DON later confirmed that facility protocol required that residents not be moved after a fall until a licensed nurse assessed them, and that NA #1, NA #2, and the Medication Aide should not have transferred the resident before that assessment. Later that evening, another nurse noted a large, painful swelling on the resident’s right upper chest, and the resident was sent to the ED, where imaging showed a large right chest wall hematoma with active bleeding.
Failure to Use Required Mechanical Lift and Report Assisted Fall Leads to Hematoma After Manual Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistive devices were used during transfers, as required by the resident’s care plan and Resident Care Guide. The resident had dementia, ESRD on hemodialysis, diabetes, was cognitively intact, and was totally dependent on staff for transfers. Her care plan and Resident Care Guide, implemented and revised prior to the incident, specified that she required a one-person assist with a mechanical lift for all transfers, with a medium sling. She was also receiving Eliquis, an anticoagulant that increases the risk of bruising and bleeding, and had an as-needed order for oxycodone for pain. On the day of the incident, the resident returned from dialysis around midday, ate lunch, and requested to be put to bed because she was tired and hurting, which staff reported was usual for her after dialysis. Nursing Assistant (NA) #1, who was passing meal trays, told the resident she would assist after meal service. When NA #1 later attempted to retrieve a mechanical lift, she found that the two lifts in her assigned section did not have any charge. NA #1 informed the resident she would have to wait longer because the lifts were not available, but the resident was adamant about being transferred to bed immediately. Around 2:45 PM, despite knowing from the Resident Care Guide that the resident required a mechanical lift for all transfers, NA #1 decided to accommodate the request and attempted a stand-pivot transfer from the wheelchair to the bed without using a lift. During this attempted manual transfer, the resident’s legs gave out, she began to panic, and she put her full weight on NA #1, who then lowered her to the floor. NA #1 did not notify a nurse at that time and, instead of leaving the resident on the floor for assessment, manually lifted her from the floor back into the wheelchair by placing her arms under the resident’s arms and her knees against the resident’s knees. The resident appeared slumped in the wheelchair, and NA #1 pulled her more upright. NA #1 then called for help without disclosing the assisted fall. NA #2 and the Medication Aide responded; seeing the resident slumped and appearing at risk of falling from the wheelchair, they, together with NA #1, manually lifted the resident from the wheelchair to the bed without a mechanical lift, with two staff at the upper body and one at the legs. After being placed in bed, the resident complained of right shoulder pain and requested pain medication. Later that evening, a large, painful swelling was observed on the right upper chest, and hospital evaluation documented a large, tense right chest wall hematoma with active bleeding, ultimately diagnosed as an arterial hemorrhage requiring interventional radiology embolization and subsequent surgical hematoma evacuation. The Medical Director stated that the hematoma more likely resulted from how the resident was transferred, including pressure applied under the armpits, rather than from the fall itself.
Failure to Notify Responsible Party of Resident's Hospitalization
Penalty
Summary
The facility failed to notify the responsible party (RP) of a significant change in a resident's condition, which included transport and admission to the hospital. The resident, who was initially cognitively intact upon admission, was later assessed as moderately cognitively impaired with a diagnosis of delirium. On the night of the incident, the resident requested to be transported to the emergency room and was subsequently admitted to the hospital for an intestinal obstruction. Despite this significant change, the RP was not informed by the facility and only learned of the situation from the hospital social worker two days later. Interviews with facility staff revealed a breakdown in communication and responsibility. Nurse #1, who was responsible for the resident's discharge to the hospital, did not notify the RP, and Nurse #2, who later received a status update from the hospital, also did not inform the RP, assuming it was Nurse #1's responsibility. The facility's Director of Nursing and Administrator acknowledged the oversight, indicating that the hall nurse should have notified the RP of the resident's transport and hospital admission.
Failure to Develop Comprehensive Fall Risk Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing fall risk for a resident who was admitted with a history of falling, unspecified fracture of the lower end of the left radius, and unspecified dementia. A review of the resident's Minimum Data Set (MDS) indicated a fall in the previous 30 days, yet the comprehensive care plan lacked a section on fall risk. During an interview, the MDS nurse acknowledged the absence of a falls risk care plan, attributing it to an oversight. The Director of Nursing (DON) confirmed that the MDS nurse was responsible for developing comprehensive care plans and was unaware of the missing falls risk care plan. The Administrator also stated she was not aware of the deficiency.
Medication Administration Errors for Ozempic
Penalty
Summary
The facility failed to ensure that two residents received their prescribed Ozempic subcutaneous injections as ordered, resulting in medication errors. Resident #116, who was admitted with a diagnosis of diabetes mellitus, had orders for Ozempic to be administered weekly. However, the Medication Administration Record (MAR) indicated that the medication was not available on multiple occasions, specifically on 4/30/24, 5/7/24, and 5/14/24. Interviews with the nursing staff revealed that they did not recall the incidents but mentioned standard procedures for handling unavailable medications, such as contacting the physician and pharmacy. The pharmacist confirmed that the Ozempic pen dispensed for Resident #116 was reported lost by the facility, and a replacement was provided on 5/15/24. Similarly, Resident #163, also diagnosed with diabetes mellitus, had orders for Ozempic to be administered weekly. The MAR showed that the medication was unavailable on 4/24/24, 5/1/24, 5/8/24, and 5/15/24. Interviews with the nursing staff involved indicated a lack of recollection of the specific incidents but outlined the usual protocol for addressing unavailable medications. The pharmacist reported that the Ozempic pen dispensed for Resident #163 was also reported lost, and a replacement was provided on 5/16/24. The physician involved was aware of the missing Ozempic pens and noted that while the medication was not critical for daily blood sugar control, it was important for stabilizing hemoglobin A1C over time. Despite the medication errors, the physician and nursing staff reported no negative outcomes for the residents due to the lack of Ozempic. The Director of Nursing emphasized that medications should be administered as prescribed, highlighting the facility's expectation for adherence to medication orders.
Infection Control Breach in Tracheostomy Care
Penalty
Summary
The facility failed to adhere to professional standards of practice and infection prevention measures during the provision of respiratory care to a resident with a tracheostomy. The incident involved a nurse who did not perform hand hygiene between the removal of soiled gloves and the application of sterile gloves. Additionally, the nurse touched the outside of the tracheostomy packaging with sterile gloves and did not change them, and used a sterile q-tip that had been dropped onto the resident's nightgown to clean the tracheostomy site. The nurse also contaminated the new sterile inner cannula by touching it with gloves that had contacted the outside of the tracheostomy tray. The resident involved was admitted with acute and chronic respiratory failure with hypoxia, a history of neoplasm of the nasal cavity and mid ear, and a chronic tracheostomy. The resident was cognitively intact and required complete assistance with all activities of daily living, including tracheostomy care. The care plan indicated a risk for ineffective breathing patterns related to the tracheostomy. Interviews with the nurse, the Staff Development Coordinator, the Director of Nursing, the Administrator, the infection preventionist, and the Nurse Practitioner revealed a lack of adherence to infection control procedures. The nurse acknowledged the errors and the importance of maintaining sterile technique to prevent respiratory infections. The facility staff emphasized the necessity of hand hygiene and proper glove use to prevent contamination during tracheostomy care.
Nurse Competency Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to ensure that a nurse was competent in providing tracheostomy care for a resident. During an observation, Nurse #4, who was an agency nurse, performed tracheostomy care without adhering to proper sterile techniques. She donned sterile gloves without performing hand hygiene after removing soiled gloves, touched the outside of the tracheostomy care tray with sterile gloves, and used a q-tip that had been dropped on the resident's clothing to clean around the tracheostomy stoma. Additionally, she opened the inner cannula package with sterile gloves, which compromised the sterility of the procedure. Interviews revealed discrepancies in the training provided to Nurse #4. The Staff Development Coordinator (SDC) claimed to have completed hands-on tracheostomy training with all nurses, including Nurse #4, before they worked with the resident. However, Nurse #4 stated that she did not receive this training until after the observation. The Director of Nursing and the Administrator also stated that new nurses, including agency nurses, were trained on tracheostomy care before working with the resident, but this was contradicted by Nurse #4's account.
Failure to Replace Damaged Mattress
Penalty
Summary
The facility failed to replace a damaged bed mattress for a resident, leading to discomfort and potential exacerbation of existing medical conditions. The resident, who was cognitively intact and had a history of right-sided hemiplegia, neuropathy, and back surgery, reported feeling like he was lying in a hole due to the sagging mattress. Despite a work order being placed by a medication aide, the mattress was not replaced with a new one, and the resident continued to experience discomfort. Interviews with staff revealed a breakdown in communication and follow-through regarding the replacement of the mattress. The maintenance assistant referred the work order to the central supply manager, who claimed to replace old mattresses if they were in poor condition. However, the central supply manager did not recall replacing the mattress for the resident, and the maintenance director confirmed that the work order was marked as completed without a new mattress being provided. Observations confirmed the poor condition of the mattress, with visible sagging and wear. The resident's family member and a nurse also noted the mattress's poor condition, and the nurse stated that it should be replaced. Despite these observations and complaints, the facility did not take timely action to address the resident's concerns, resulting in the resident sleeping on an uncomfortable and potentially harmful mattress for an extended period.
Misappropriation of Diabetes Medication in LTC Facility
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their medication, specifically Ozempic, which is used to manage diabetes mellitus. Resident #116 was prescribed Ozempic to be administered once a week, but the medication was documented as unavailable on multiple occasions, including 4/23/24, 4/30/24, 5/7/24, and 5/14/24. Despite the pharmacy delivering the medication, it was reported as lost, and the facility had to reorder it at their own expense. Interviews with nursing staff revealed a lack of recollection regarding the incidents, and the facility's initial response did not identify the issue as misappropriation. Similarly, Resident #163 experienced a similar issue with their Ozempic medication. The medication was documented as unavailable on 4/24/24, 5/1/24, 5/8/24, and 5/15/24, despite being delivered by the pharmacy. The facility's investigation revealed discrepancies in the medication administration records and packing slips, indicating that the medication was not administered as prescribed. The facility was unable to determine the location of the missing medication, leading to the conclusion that it was either misplaced or misappropriated. The facility's failure to ensure the availability and administration of prescribed medications resulted in a deficiency related to the misappropriation of resident property. The investigation highlighted issues with the facility's medication management processes, including inadequate tracking and documentation of medication availability and administration. The facility's inability to substantiate the misappropriation of the medication further underscores the need for improved oversight and accountability in medication handling and administration.
Medication Error: Ear Drops Administered in Eyes
Penalty
Summary
The facility failed to ensure that ear drop medication was administered via the correct route, resulting in a significant medication error for a resident. The resident, who was cognitively intact but had impaired vision, was mistakenly given ear drops in her eyes by a nurse who was still in her orientation period. The nurse, while orienting with another nurse, brought both eye and ear drops into the resident's room and handed the ear drops to the resident, who then administered them into her eyes. Despite attempts to stop the resident, the medication had already been administered incorrectly. The incident was reported to the Director of Nursing (DON) and the resident's physician, who instructed that the resident's eyes be flushed with saline. The resident expressed concern about the incident, reporting blurry vision afterward, although two separate eye examinations concluded that the ear drops did not cause any vision changes. The resident was dissatisfied with the explanations provided by the medical professionals and believed the blurry vision was a result of the medication error. Interviews with the involved staff revealed discrepancies in their accounts of the incident. The nurse who administered the medication denied the error, while another nurse observed the administration but could not confirm which drops were used. The facility's consultant pharmacist and the resident's physician both indicated that the ear drops could cause mild irritation but not lasting vision damage. The facility's investigation did not identify a trend of incorrect ear drop administration, and education was provided to the involved nurse regarding proper medication administration routes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 71 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Goldsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Goldsboro Rehabilitation And Healthcare Center | 0.7 mi | ★★★★★ | 3 | 1 |
| O'berry Neuro-medical Treatment Center | 4.2 mi | ★★★★★ | 2 | 0 |
| Mount Olive Center | 15.2 mi | ★★★★★ | 14 | 1 |
| Greendale Forest Nursing And Rehabilitation Center | 17.2 mi | ★★★★★ | 5 | 0 |
| Nc State Veterans Home-kinston | 20.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.