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 Community Memorial Health Center during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow facility policy and Federal Food Code requirements for checking and maintaining safe temperatures of food and beverages. Microwaved items such as a grilled cheese sandwich, macaroni and cheese, and hot dogs were heated and served to residents without any temperature checks, despite policy requiring all prepared items and reheated ready-to-eat foods to be verified for proper temperatures. Additionally, a dietary aide routinely refilled partially used juice and milk pitchers without discarding leftovers or checking temperatures, and these beverages were found above the required 41°F standard. Staff interviews confirmed that these temperature checks were not performed and that beverage pitchers were only fully cleaned every 72 hours.
Surveyors found that dietary staff did not follow facility policies for personal hygiene and handwashing. A dietary aide with a full beard worked in the kitchen and handled dishes without a beard cover, and another aide wore a hair cap that left loose hair exposed while working around exposed food and serving drinks. The facility’s policy required full hair and beard restraints. Additionally, a cook repeatedly washed hands for only 4–10 seconds with soap and water instead of the policy-required 20 seconds while engaged in meal preparation and related tasks, potentially affecting all residents receiving food.
Surveyors found that the facility did not ensure residents and their POAs were informed of the risks, benefits, side effects, and alternative/non-pharmacological options before initiating or continuing antipsychotic and other psychotropic medications, and did not notify a POA of new skin conditions. Several residents with diagnoses including delusional disorder, anxiety, bipolar disorder, dementia, and major depressive disorder were receiving medications such as Risperidone, Depakote, Risperdal, Xanax, Mirtazapine, Olanzapine, and a compounded topical Ativan/Benadryl/Haldol preparation. Facility policy required education on psychotropic drug use, but medical records and care plan notes lacked specific documentation of risk/benefit and alternative treatment education, and the DON acknowledged that POAs were not informed prior to prescriptions being written and dispensed. In addition, one resident developed multiple new foot and heel wounds, yet the POA reported being unaware of any skin issues, and an LPN confirmed there was no communication to the POA about these wounds or related interventions.
Surveyors found that staff failed to follow infection control policies for hand hygiene and linen handling. A laundry aide delivered clothing to several residents, including one on Enhanced Barrier Precautions, without performing hand sanitization between rooms and placed used hangers back into a shared cart before retrieving more clothing. The same aide was later observed carrying clothing protectors pressed against their uniform instead of away from the body. In a separate observation, an LPN administered medications and applied topical treatments to a resident with multiple chronic conditions, including DM and recurrent infections, without performing hand hygiene between glove changes and after touching potentially contaminated surfaces, despite facility policies requiring hand hygiene before and after glove use and after handling contaminated objects.
The facility did not implement or communicate a method for residents and families to file grievances anonymously, despite a written policy stating grievances may be filed anonymously. Admission materials directed a resident to bring concerns to the administrator, DON, social services, or resident council but did not explain any anonymous option. The SSD, identified as the grievance officer, reported that residents typically notify staff to file grievances and acknowledged not knowing how an anonymous grievance would be submitted beyond possibly sliding a note under the office door. The FA described an open-door grievance approach but did not identify any formal anonymous grievance mechanism, affecting all residents in the facility.
A resident with dementia, Parkinson’s disease, depression, and a history of myocardial infarction had a PRN order for Zyprexa 5 mg every 6 hours for agitation related to dementia that lacked a 14-day limit or specified duration, as required by facility policy. Record review showed no practitioner documentation of review or renewal of this PRN antipsychotic order, and the DON and interim DON confirmed the absence of an end date and physician notes addressing continuation of the medication.
Surveyors found that the facility did not develop baseline care plans within required timeframes and did not provide written summaries of these plans to two residents or their representatives. One resident admitted after a stroke and circulatory surgery had an interim care plan with no documentation of resident or representative participation, and the first care plan meeting occurred after the comprehensive care plan was already completed. Another resident with Parkinson’s disease, visual hallucinations, and a UTI had a baseline care plan initiated more than 48 hours after admission, also without documented participation. For both residents, the first care plan meetings occurred only after comprehensive care plans were developed, and the DON confirmed that the facility discusses baseline care plans verbally but does not complete or offer written summaries for residents or their representatives.
A resident with cervicalgia and osteoarthritis had an order for Diclofenac Sodium 1% gel that lacked a specified dose, despite manufacturer instructions requiring use of dosing cards and defined gram amounts per application. During a medication pass, an LPN applied an unmeasured amount of the gel to the resident’s neck. The IDON confirmed that medication orders must include a dose and that the prescription label for this resident’s Diclofenac gel was missing dose information, even though dosing instructions and a dosing card were present in the medication packaging.
Surveyors observed that two residents with dementia and/or wandering tendencies had multiple prescribed topical medications, including diclofenac gel, Eucerin cream, miconazole powder, and triamcinolone cream, left unsecured in their shared bathroom. Record review showed no Self Administration of Medication (SAM) authorizations for either resident. The DON and IDON confirmed that all practitioner-prescribed medications, including creams and powders, must be locked and never left out, indicating a failure to keep the area free from accident hazards and to provide adequate supervision to prevent accidents.
A resident with obstructive sleep apnea had a provider order for nightly BiPAP use and relied on staff for equipment care, but the facility failed to replace the BiPAP mask and tubing according to its own policy and provider recommendations. Over several observations, the mask and tubing were seen lying on the bed, sometimes lodged between the mattress and side rail, and the mask appeared cloudy with dried white spots. An LPN reported that central supply was responsible for respiratory equipment changes, while central supply staff stated they were unaware the resident used a BiPAP and had not ordered or changed any supplies. The DON confirmed the resident’s respiratory equipment had not been replaced as required.
A resident with chronic kidney disease and actinic keratosis developed a discolored area on the right cheek. Facility staff failed to document weekly skin assessments as required by policy, with a gap of more than one week between entries and missing measurements in later documentation. The DON confirmed these omissions, resulting in noncompliance with facility protocols.
A resident with multiple medical conditions experienced significant weight loss over several months due to the facility's failure to monitor and address the issue. Despite an initial intervention of a daily milkshake, the RD did not evaluate or implement additional interventions until the resident had lost over 12% of their weight in 90 days.
The facility failed to update and implement care plans for several residents, leading to deficiencies in care. A resident with heel wounds and infection control measures lacked documentation in their care plan. Another resident's care plan was missing documentation for daily living activities and pressure ulcer care, and staff did not follow proper infection control procedures. Additionally, two other residents had outdated care plans that did not reflect their current needs or diagnoses. Interviews confirmed these deficiencies.
The facility failed to ensure meals in the SCU were served at the proper temperature, affecting 16 residents. Observations showed inconsistent temperature checks, with some food items below the required 135°F. The DON had to reheat food multiple times, and logs revealed missing temperature documentation on several days. The DM confirmed the issue, emphasizing the need for food to be served at the correct temperature.
Staff at an LTC facility failed to follow infection control protocols, including improper use of gloves and hand hygiene during resident care. Enhanced Barrier Precautions were not consistently implemented for residents with MDROs, leading to inadequate use of PPE during high-contact activities. Documentation and communication issues contributed to staff confusion about PPE requirements.
The facility failed to notify the PCP and RD of significant weight loss in two residents, as required by policy. One resident experienced a 5% and 6% weight loss over consecutive months, while another lost 11% in one month. The lack of communication with healthcare professionals constitutes a deficiency.
The facility failed to accurately complete Level 1 PASARR screenings for two residents prior to admission. One resident's PASARR did not include diagnoses of delusional disorder, anxiety disorder, depression, and PTSD, despite receiving related medications. Another resident's PASARR omitted bipolar disorder and anxiety disorder, even though they were prescribed medications for these conditions. The DON confirmed the facility did not verify the accuracy of these screenings, which should have identified the need for Level 2 evaluations.
A resident under hospice care experienced inadequate bowel management due to the facility's failure to coordinate with the hospice provider. Despite a history of constipation, the resident's care plan did not address this issue, and prescribed laxatives were not consistently administered. Interviews revealed a lack of communication between facility staff and hospice personnel, contributing to the deficiency.
Two residents at high risk for falls experienced multiple incidents without adequate review and update of their care plans. Despite being identified as high risk, interventions were not consistently implemented or documented, and staff were not fully aware of specific fall prevention measures. This led to ongoing fall risks due to insufficient causal factor analysis and care plan revisions.
A facility failed to follow its Antibiotic Stewardship Program for a resident receiving Bactrim DS since June without a clinical rationale or stop date. Despite a recommendation from the Consultant Pharmacist for clarification, the physician continued the medication without proper documentation, and the DON confirmed the ongoing use without adherence to the ASP protocols.
The facility failed to document specific clinical rationales for not attempting Gradual Dose Reductions (GDR) of psychotropic medications for three residents, despite policy requirements. Residents with cognitive impairments and various diagnoses were receiving multiple psychotropic drugs, and the attending physician marked dose reductions as contraindicated without providing patient-specific reasons. The Director of Nursing confirmed the lack of required documentation.
Failure to Monitor and Maintain Safe Food and Beverage Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and the Federal Food Code regarding monitoring and maintaining safe temperatures for food items prepared and served by the dietary department. Surveyors reviewed the 2022 Federal Food Code, which requires microwave-cooked items to be heated to at least 165°F, and a facility policy stating that all items prepared in the dietary department must have temperatures checked, and that ready-to-eat foods requiring heating before consumption should be heated to at least 135°F. During meal service observations, a dietary aide removed a cellophane-covered grilled cheese sandwich from a mobile hot cart, uncovered it, and had it served to a resident without checking its temperature. In separate observations, the dietary manager microwaved a single-serving macaroni and cheese, and a dietary aide microwaved hot dogs covered in cellophane; both items were plated and served to residents without any temperature checks. In interviews, the cook and the dietary manager confirmed that temperatures were not checked on these items, despite the facility policy requiring such checks. The deficiency also includes improper handling and temperature control of beverages served to residents. A dietary aide was observed serving drinks from a wheeled cart in the dining area and later returning the cart with partially used pitchers of various juices and milk to the meal service area. The aide placed a pitcher containing remaining apple juice under a juice dispenser and added more juice to it without discarding the leftover contents, and stated that pitchers are only cleansed and changed every 72 hours, with fluids simply refilled between meals. The aide also stated that temperatures of the drinks are not checked prior to refilling. When the aide did check temperatures during the observation, apple juice, grape juice, orange juice, milk, and tomato juice were all measured above the stated standard of 41°F for cold items. The aide and the dietary manager both confirmed that the fluids were not maintained at the recommended temperature or lower, as required.
Improper Hair Restraints and Inadequate Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in dietary staff hygiene practices related to hair restraints and handwashing. Facility policy on Dietary Employee Personal Hygiene required all dietary staff to wear hair restraints, including hair nets, hats, and beard restraints, to prevent hair from contacting food. During multiple observations, one dietary aide was seen rinsing dishes and placing them in the automatic dish machine, and later putting away clean dish items in the main kitchen, while wearing a hair cap but no beard covering despite having a full beard. Another dietary aide was observed in the main kitchen and later serving drinks in the main dining area with a blue hair cap that covered only the top quarter of their head, leaving loose hair exposed while moving around areas where exposed food items were present. In an interview, the Dietary Manager confirmed that the beard covering and proper hair covering should have been used in these situations. The facility’s Hand Hygiene policy, dated 12/15/2025, required staff to rub their hands together vigorously with soap and water for approximately 20 seconds. During a series of observations, the cook repeatedly performed hand hygiene using soap and water but rubbed their hands for significantly less than the required 20 seconds, with durations ranging from 4 to 10 seconds before rinsing. In a subsequent interview, the cook acknowledged not rubbing their hands with soap for the required 20 seconds, and the Dietary Manager confirmed that the cook did not follow the approved hand hygiene method. These observed practices occurred during meal preparation and food service activities and had the potential to affect all residents receiving food from the kitchen, with a facility census of 59.
Failure to Inform POAs of Psychotropic Medication Risks and New Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their POAs were informed of the risks, benefits, side effects, and alternative treatment options before initiating or continuing antipsychotic and other psychotropic medications, and failure to notify a POA of new skin conditions. For one resident admitted with delusional disorder, restlessness, agitation, and anxiety disorder, the record showed existing orders for Risperidone and Depakote. The facility’s policy on psychotropic medication use required that residents and/or representatives be educated on risks, benefits, and non-pharmacological alternatives. Care plan meeting notes for this resident over multiple dates only indicated that psychoactive medications were prescribed and that family/resident were educated, but contained no details of risks, benefits, side effects, or alternative options. Progress notes over several months also lacked documentation of such education, and the resident’s POA confirmed that no education on these topics had been provided. Another resident admitted with anxiety disorder and bipolar disorder had orders for Risperdal and Xanax. Review of this resident’s medical record revealed no documentation that the resident or responsible party had been educated on the risks, benefits, or alternative/non-pharmacological interventions for these medications. A third resident admitted with major depressive disorder had an order for Mirtazapine, but the medical record similarly contained no documentation that the resident or responsible party received education on the risks, benefits, or alternative treatments for this antidepressant. In interviews, the DON stated that medications are reviewed with residents or responsible parties during care plan meetings, but acknowledged there was no documentation of risk/benefit or alternative treatment education for these medications. For another resident with multiple dementia-related diagnoses, major depressive disorder in remission, and bipolar disorder, the admission record showed a POA for healthcare and orders for Olanzapine at two different dosages. Nursing notes for the period surrounding the initiation of a new Olanzapine order did not document that the POA was informed of the new antipsychotic prescription, its side effects or risks, or any alternative treatment options. The DON confirmed that the POA was not notified of the new treatment’s risks, benefits, side effects, or alternatives prior to prescription and dispensing, and that notification occurred only later during care plan meetings. A further resident with a history of mental and behavioral disorders, dementia, and major depressive disorder in remission had a POA for healthcare and orders for a compounded topical preparation containing Ativan, Benadryl, and Haldol applied to the neck and wrists on a scheduled basis. The DON stated that the POA was not notified of the side effects, risks, benefits, or alternative options for this treatment prior to it being prescribed and dispensed, and that notification occurred during care plan meetings. Care plan notes indicated the POA attended and participated in plan development and was notified of psychoactive medications and educated at those meetings. Separately, this same resident developed multiple new skin issues on both feet and the right heel, documented in progress notes and wound history beginning on a specific date. The resident’s POA reported being unaware of any current skin issues, and an LPN confirmed there was no communication with the POA regarding the foot wounds or related interventions, demonstrating a failure to notify the POA of a change in skin condition.
Infection Control Failures in Hand Hygiene and Linen Handling
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control program related to hand hygiene and linen handling. The facility’s hand hygiene policy, dated 12/15/25, required staff to perform hand hygiene between resident contacts, after handling contaminated objects, and before and after handling clean or soiled linens. During observation on the 100 hall, Laundry Aide-G (LA-G) delivered clothing to multiple residents’ rooms, including a resident on Enhanced Barrier Precautions (EBP), without performing hand sanitization between rooms. After exiting each room, LA-G placed used hangers back into the laundry cart and then retrieved additional clothing from the same cart for the next resident without using the alcohol-based hand rub that was available on the cart, contrary to facility policy and LA-G’s own acknowledgment of the requirement. Additional observations showed that the facility did not ensure laundry was transported in a sanitary manner. The infection prevention and control policy for linens required that laundry staff handle, store, process, and transport linens to prevent the spread of infection. However, LA-G was observed carrying a stack of clothing protectors cradled against their shirt while moving from the laundry area through the dining room and into another hallway. In an interview, the DON confirmed that clothing and linens were expected to be carried away from the uniform to prevent potential cross-contamination, indicating that this method of transport did not comply with facility policy. Surveyors also found failures in hand hygiene practices during medication administration and topical treatment for a resident. Resident 17’s record showed multiple diagnoses, including hypothyroidism, diabetes mellitus, basal cell carcinoma of the skin, candidiasis, urinary tract infections, and excoriation (skin-picking) disorder. During a medication pass, LPN-E did not perform hand hygiene between glove changes and applied topical medications to Resident 17 without changing gloves or performing hand hygiene after touching the wheelchair, medication cart, and tablet used for charting. Facility hand hygiene policy stated that glove use does not replace hand hygiene and required hand hygiene before donning gloves, immediately after removing gloves, after handling contaminated objects, and when moving from a contaminated body site to a clean body site. The Infection Preventionist confirmed that staff were expected to perform hand hygiene after removing dirty gloves and before donning clean gloves, which did not occur in this instance.
Failure to Provide and Communicate Anonymous Grievance Process
Penalty
Summary
The facility failed to ensure residents and family members had a method to file grievances anonymously and were provided information on how to do so, as required by its own policy and licensure regulations. Record review of the undated facility policy titled "Resident and Family Grievances" showed that information on how to file a grievance or complaint would be available and that a grievance may be filed anonymously. However, review of the undated Admission Agreement showed that while residents were encouraged to voice grievances and suggestions to the administrator, DON, social service director, or resident council, it did not include any information on how to file a grievance anonymously. During interviews, the SSD, who serves as the facility’s grievance officer, stated that residents or families wishing to file a grievance would notify a staff member, who would assist them with the process, and acknowledged uncertainty about how a resident could file a grievance anonymously other than sliding it under the SSD’s office door. The SSD confirmed that although the policy states a grievance may be filed anonymously, residents and families are only educated on the grievance process during admission paperwork and are not given education or instruction on how to file grievances anonymously. The FA reported that the facility has an open-door policy for grievances and that residents and families are encouraged to notify staff with grievances, but did not identify any established anonymous grievance mechanism. This deficiency had the potential to affect all 59 residents in the facility.
Failure to Limit and Review PRN Antipsychotic Medication Order
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to limit a PRN antipsychotic medication order to 14 days and to ensure practitioner evaluation for renewal. The facility’s policy on psychotropic medication, dated 10/12/2025, stated that PRN psychotropic orders must be used only for a diagnosed specific condition documented in the clinical record and for a limited duration of 14 days, and that if the practitioner believed it appropriate to extend the PRN order beyond 14 days, the duration must be specified. Record review showed that this policy applied to psychotropic medications, including antipsychotics. Record review for one resident revealed an admission date of 1/29/26 and diagnoses including dementia in other diseases classified elsewhere with behavioral disturbance, non-ST-elevation myocardial infarction, Parkinson’s disease with dyskinesia and fluctuations, and unspecified depression. The resident had a PRN order for Zyprexa 5 mg by mouth every 6 hours as needed for agitation/outbursts related to dementia, with an order date of 2/6/26. The order did not include an end date. During an interview, the DON and Interim DON confirmed that there was no end date on this PRN antipsychotic order and that there were no physician notes documenting a review of the PRN antipsychotic medication, contrary to the facility’s policy and regulatory requirements.
Failure to Develop Timely Baseline Care Plans and Provide Written Summaries to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure baseline care plans were developed within required timeframes and that written summaries of these plans were reviewed with and provided to residents or their representatives. Facility policy required an interim/baseline care plan to be developed and implemented within 24 hours of admission, using information from the admission assessment, hospital transfer documents, physician orders, and discussions with the resident and/or representative, with initial goals reflecting the resident’s stated goals and objectives. The policy also required that a comprehensive care plan be developed within 7 days after completion of the comprehensive MDS assessment, with participation from the resident and/or representative to the extent practicable. Despite these policies, records showed that baseline care plans were either not timely or did not document resident/representative participation or receipt of a written summary. For one resident admitted from the hospital with diagnoses including stroke, difficulty swallowing after stroke, and circulatory system surgery, the interim (baseline) care plan contained no documentation that the resident or resident representative participated in or reviewed the baseline care plan. The comprehensive admission MDS assessment was completed, and the comprehensive care plan was developed with a focus on the resident’s need for long-term care due to decreased mobility and weakness requiring assistance with transfers, toileting, and ADLs. However, the first care plan meeting with the resident/representative occurred two days after completion of the comprehensive care plan, which did not allow participation in the development of either the baseline or comprehensive care plan. The medical record contained no documentation that a written summary of the baseline care plan was provided to the resident or representative. For another resident admitted with Parkinson’s disease, visual hallucinations, and a urinary tract infection, progress notes documented that the resident arrived able to walk with a walker, with a bent neck posture and shakiness due to Parkinson’s. The interim (baseline) care plan for this resident was not developed until more than 48 hours after admission, exceeding the 24-hour requirement. This baseline care plan also lacked documentation of resident or representative participation or review. The comprehensive admission MDS assessment and comprehensive care plan were completed, but the first care plan meeting occurred after the comprehensive care plan was already developed, again preventing participation in the development of the baseline and comprehensive care plans. The medical record contained no documentation that a written summary of the baseline care plan was provided. In an interview, the DON confirmed that baseline care plans are discussed verbally on admission, that the facility does not complete written summaries, and that no written summaries were offered or signed for these residents.
Failure to Include and Use Measured Dose for Topical Diclofenac Gel
Penalty
Summary
The facility failed to ensure that a prescribed topical medication included dosing information and was administered in a measured amount for one resident. The resident was admitted with diagnoses of cervicalgia and unspecified osteoarthritis. An order dated 2/25/2026 for Diclofenac Sodium 1% external gel directed staff to apply the gel to the resident’s neck and back every day and on the night shift for primary osteoarthritis, but the order did not specify the dose. Review of the manufacturer’s instructions for Diclofenac sodium topical gel showed that the medication is to be measured using dosing cards, with application within the oblong area of the card up to the 2‑gram or 4‑gram line, and a total daily dose not to exceed 32 grams. During observation of a medication pass, an LPN applied an unmeasured amount of Diclofenac gel to the resident’s neck rather than using a measured dose. The Interim DON confirmed that medication orders are required to include the resident’s name, medication dose, time of administration, route of administration, and prescriber name, and that orders missing information should be corrected after notifying nursing and pharmacy. Review of the prescription label for the resident’s Diclofenac sodium topical gel with the Interim DON confirmed that the label lacked dose information, even though the manufacturer’s instructions and dosing card were available in the medication box.
Unsecured Topical Medications Left in Bathroom of Residents With Dementia
Penalty
Summary
Surveyors found that two roommates with dementia and/or wandering tendencies, residing on a secure unit, had multiple prescribed topical medications left unsecured in their shared bathroom. During an environmental observation, diclofenac sodium 1% gel, Eucerin cream, miconazole nitrate powder, and triamcinolone cream were observed in the bathroom designated for these two residents’ use. These medications had active prescriber orders with various start dates and were not stored in a locked medication cart or locked nurse office as required. Record review showed that neither resident had a Self Administration of Medication (SAM) authorization on file for any of the observed medications. In interviews, the DON and IDON confirmed that all medications, including creams, powders, and other topicals prescribed by a practitioner, are required to be locked and are not to be left out under any circumstance. The presence of these unsecured medications in the residents’ bathroom, combined with the absence of SAM documentation, constituted a failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.
Failure to Replace and Maintain BiPAP Equipment per Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to replace and maintain respiratory equipment for a resident using a BiPAP machine. Facility policy dated 02/25/2026 required routine replacement of BiPAP components to prevent infection, specifying that the face mask and tubing be replaced every three months and the headgear, non-disposable filters, and humidifier every six months. A diagnostics and consultants document for the resident also specified replacement intervals for the water chamber, tubing, and face mask. The resident, admitted with obstructive sleep apnea and with a provider order for nightly BiPAP use, reported using the BiPAP every night and relying on staff for care and maintenance of the equipment. The resident stated that the mask in use was the same one received at the initial equipment appointment and, to their knowledge, had never been changed. During multiple observations over three days, surveyors saw the resident’s BiPAP mask and tubing lying on the bed, with the mask lodged between the mattress and a quarter side rail on two occasions, and noted the mask appeared cloudy with dried white spots. In interviews, an LPN stated that central supply was responsible for managing and changing residents’ respiratory equipment and determining replacement frequency. The central supply staff member reported being unaware that the resident used a BiPAP and confirmed they had not ordered or changed any respiratory supplies for this resident. The DON confirmed that the resident’s respiratory equipment had not been changed according to facility policy or the provider’s recommendations documented on the diagnostics and consultants form.
Failure to Complete and Document Weekly Skin Assessments per Policy
Penalty
Summary
The facility failed to complete skin assessments per its own policy and standards of practice for one resident with a notable wound and high risk for skin breakdown. The facility policy required weekly skin assessments for residents with wounds or high Braden scores, and documentation of any alterations in skin integrity using a standardized method. For the resident in question, who had chronic kidney disease and actinic keratosis and was cognitively intact, a discolored area was observed on the right cheek. The area was initially documented with measurements, but subsequent documentation was missing for a period exceeding one week, and later entries lacked required measurements. Interviews with staff confirmed that the resident had been self-administering a steroid cream and staff were applying urea cream, both of which were discontinued after the discoloration developed. The Director of Nursing acknowledged that there was a gap in documentation from the initial assessment to the next entry, which was longer than the weekly interval required by policy, and that some later assessments did not include measurements. These actions and omissions resulted in the facility not following its own protocols for skin assessment and documentation.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address ongoing weight loss for a resident, identified as Resident 19, who was admitted with a history of weight loss and several medical conditions, including major depressive disorder, Parkinson's disease, non-Alzheimer's dementia, and chronic obstructive pulmonary disease. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for assistance with eating and drinking. Despite an initial order for a daily milkshake to provide additional calories, the resident experienced significant weight loss over several months, with a 5% loss in one month and a 6% loss in another. The facility's Weight Monitoring policy required the Registered Dietician (RD) and physician to be notified of weight loss and to assist with interventions. However, the RD did not evaluate the resident's weight loss or develop additional interventions after the initial assessment. It was not until several months later, after the resident had lost a total of 12.2% of their weight over 90 days, that a new intervention was implemented. This delay in response and lack of ongoing monitoring and intervention contributed to the deficiency identified by the surveyors.
Deficiencies in Care Plan Implementation and Revision
Penalty
Summary
The facility failed to implement and revise care plans for several residents, leading to deficiencies in their care. Resident 29, who was cognitively intact and had multiple diagnoses including dementia and Parkinson's Disease, was at risk for pressure ulcers and had ongoing heel wounds. However, the care plan did not document these pressure sores or the Enhanced Barrier Precautions (EBP) in place for infection control. Observations confirmed the presence of heel sores with black eschar, and interviews with staff verified that these issues were not reflected in the care plan. Resident 59, who was dependent on staff for various activities of daily living and had a stage 3 pressure ulcer, also had an incomplete care plan. The care plan lacked documentation for activities of daily living, indwelling catheter care, falls, pressure ulcer care, hospice care, pain management, and constipation. During care observations, staff failed to follow proper infection control procedures, such as changing gloves after providing peri and catheter care, which was not addressed in the care plan. Resident 54's care plan had not been reviewed or revised since June, despite the resident's dependence on staff for several activities of daily living and the use of antipsychotic and antianxiety medications. Similarly, Resident 1's care plan was outdated and did not include interventions for impaired cognition or activities, nor did it address the resident's MRSA diagnosis. The care plan had not been updated since August, even though a quarterly MDS assessment was completed in October. Interviews with the MDS Nurse confirmed these deficiencies in care plan updates and implementations.
Failure to Maintain Proper Food Temperatures in SCU
Penalty
Summary
The facility failed to ensure that meals served in the Special Care Unit (SCU) were palatable and served at the proper temperature, potentially affecting all 16 residents in the unit. The facility's policy required food temperatures to be recorded daily to ensure they were served at the proper temperature, with hot food items maintained at 135 degrees Fahrenheit or higher. However, observations revealed that food temperatures were not consistently checked or documented. For instance, during a breakfast meal, the Director of Nursing (DON) had to reheat ground sausage multiple times to reach the required temperature of 165 degrees Fahrenheit, and no further temperature checks were conducted for the rest of the meal. Additionally, a test tray after a noon meal service showed several food items, including cheesy potatoes, ham slice, and diced carrots, were below the required temperature of 135 degrees Fahrenheit. A review of food temperature logs from the SCU indicated that temperature checks were not documented on multiple days for breakfast, noon, and evening meals. An interview with the Dietary Manager (DM) confirmed that SCU staff were not consistently completing temperature checks, and food should not be served below 135 degrees Fahrenheit to ensure palatability.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols, specifically in the use of gloves and hand hygiene during the provision of care to several residents. Observations revealed that staff did not wash hands or use hand sanitizer at appropriate intervals, such as before and after resident contact, and when handling potentially contaminated items. For instance, a Medication Aide assisted a resident with toileting without washing hands or wearing gloves, and continued to provide care without changing gloves or performing hand hygiene. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) as required for residents known to be colonized or infected with multidrug-resistant organisms (MDROs). Staff failed to wear gowns and gloves during high-contact care activities for residents on EBP, such as those with indwelling medical devices or chronic wounds. In one case, a Licensed Practical Nurse did not change gloves after removing a soiled dressing from a resident's suprapubic catheter, and in another instance, staff did not wear the required PPE while repositioning a resident with a foley catheter. The facility's documentation and communication regarding EBP were inconsistent, leading to confusion among staff about when PPE was necessary. For example, a resident with heel wounds was on EBP, but staff were incorrectly informed that PPE was only needed when the wounds were uncovered. This lack of clarity resulted in staff not wearing gowns during high-contact care activities, contrary to the facility's policy. Interviews with staff, including the Director of Nursing, confirmed these deficiencies in following EBP protocols.
Failure to Notify Healthcare Professionals of Significant Weight Loss
Penalty
Summary
The facility staff failed to notify the primary care practitioner (PCP) and the Registered Dietician (RD) of significant weight loss in two residents, which is a requirement according to the facility's policy on Notification of Changes. The policy mandates prompt notification to the resident's physician and representative when there is a change requiring notification, such as significant changes in the resident's physical condition. For Resident 27, the Weights and Vitals Summary Sheet showed a progressive weight loss over several months, with a 5% loss in one month and a 6% loss in another. Despite this ongoing significant weight loss, there was no evidence in the resident's electronic medical record that the RD or PCP were notified. Similarly, for Resident 12, the Weights and Vitals Summary Sheet indicated a substantial weight loss of 17 pounds, or an 11% loss, in one month. An interview with the Dietary Manager confirmed that neither the PCP nor the RD were informed of this significant weight change. This lack of communication and failure to adhere to the facility's policy on notifying relevant healthcare professionals of significant changes in residents' conditions constitutes a deficiency in the care provided by the facility.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Level 1 Preadmission Screening and Resident Review (PASARR) for two residents prior to their admission. Resident 48's PASARR did not include diagnoses of a delusional disorder, anxiety disorder, depression, and PTSD, despite the resident receiving antipsychotic, antianxiety, and antidepressant medications. The Director of Nursing (DON) confirmed that the facility did not verify the accuracy of Resident 48's Level 1 PASARR screen at the time of admission, which should have included these diagnoses to determine if a Level 2 evaluation was necessary. Similarly, Resident 44's PASARR Level 1 screen failed to include diagnoses of bipolar disorder and anxiety disorder, even though the resident was prescribed medications for these conditions. The DON acknowledged that the facility did not check the accuracy of Resident 44's Level 1 PASARR screen at the time of admission, which should have identified the need for a Level 2 screen. Both residents were at risk for adverse reactions to medications, and their care plans reflected the need for monitoring due to their mental health conditions.
Failure to Coordinate Bowel Management with Hospice Care
Penalty
Summary
The facility failed to ensure that a resident's bowel and bladder management plan was coordinated with the hospice care provider. The resident, who was under hospice care, had a history of constipation, as noted in the Minimum Data Set. Despite having a care plan in place, the facility did not address constipation in the resident's care plan. The facility's policy required specific interventions if a resident had no bowel movement for a certain number of days, but these interventions were not consistently followed. The resident experienced extended periods without bowel movements, and the facility's documentation showed gaps in the administration of prescribed laxatives. Interviews with facility staff and hospice personnel revealed a lack of communication and coordination regarding the resident's constipation management. The Director of Nursing confirmed that the resident's bowel medications were administered on an as-needed basis rather than routinely, and the resident's limited activity and poor intake were noted. The hospice nurse was not informed of any constipation concerns, and a registered nurse confirmed the absence of a constipation care plan for the resident. This lack of coordination and adherence to the facility's bowel management policy contributed to the deficiency identified by the surveyors.
Inadequate Fall Prevention and Care Plan Updates
Penalty
Summary
The facility failed to ensure that falls experienced by Residents 14 and 16 were adequately reviewed for causal factors, and that fall prevention interventions were based on these factors and revised as necessary. Resident 16, who had cancer and required partial assistance with daily activities, was identified as being at high risk for falls. Despite multiple incidents of falls, the facility did not consistently update the resident's care plan with new interventions based on the causal factors of each fall. For instance, after several falls, interventions such as using a gait belt during transfers and ensuring proper footwear were not consistently implemented or documented as new interventions. Resident 14, who was severely cognitively impaired and required assistance with various activities, also experienced multiple falls. The facility's response to these incidents was inadequate, as the care plan was not updated with new interventions based on the causal factors of the falls. For example, after a fall where the resident was found without gripper socks, the intervention to use gripper socks was not clearly documented as a new measure. Additionally, the use of a TABS monitor was not consistently included in the care plan following incidents where the resident removed the alarm and attempted to walk unassisted. Interviews with staff, including the Director of Nursing, confirmed that while falls were reviewed, the facility did not always identify causal factors or implement prevention measures related to those causes. Furthermore, staff were not consistently aware of specific fall prevention interventions for the residents, indicating a lack of communication and training regarding fall prevention strategies. This oversight contributed to the ongoing risk of falls for Residents 14 and 16, as their care plans were not adequately updated to reflect necessary interventions.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure antibiotics were administered in accordance with its Antibiotic Stewardship Program (ASP) for a resident. The ASP is designed to optimize infection treatment and reduce adverse events from antibiotic use. The program involves the Infection Preventionist, Director of Nursing, Medical Director, Consultant Pharmacist, and Attending Physicians in developing and implementing protocols for antibiotic use, including assessment, laboratory testing, and criteria for treatment. However, the facility did not adhere to these protocols for a resident who had been receiving the antibiotic Bactrim DS since June 2023 without a documented clinical rationale or supporting evidence for its continued use. The resident's Minimum Data Set (MDS) indicated antibiotic use in the preceding week, and a recommendation letter from the Consultant Pharmacist to the physician requested clarification of the Bactrim DS order. Despite this, the physician continued the medication without providing a clinical rationale or a stop date, contrary to the facility's ASP. The Director of Nursing confirmed the ongoing use of the antibiotic without a stop date or predetermined course duration, highlighting a failure to comply with the facility's ASP requirements.
Failure to Document Clinical Rationale for Psychotropic Medication Use
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) of psychotropic medications for three residents or to have a documented clinical rationale for continued use. The facility's policy on the use of psychotropic medications, implemented on October 6, 2023, requires that residents who use these drugs receive gradual dose reductions unless clinically contraindicated. However, the facility did not adhere to this policy, as evidenced by the lack of specific clinical reasons documented for not reducing the doses of psychotropic medications for Residents 24, 26, and 29. Resident 24, who had severe cognitive impairment and diagnoses of depressive disorder and anxiety, was receiving multiple psychotropic medications, including antipsychotics and antidepressants. Despite the requirement for a GDR, the attending physician marked the dose reduction as contraindicated without providing a patient-specific reason. Similarly, Resident 29, who was cognitively intact but dependent on assistance for daily activities and had diagnoses of dementia, Parkinson's Disease, anxiety, and depression, also did not have specific reasons documented for the contraindication of GDR for their medications. Resident 26, who had moderate cognitive impairment and a range of diagnoses including Parkinson's disease, cancer, and bipolar disorder, was also due for a GDR of several psychotropic medications. The physician denied the GDR due to the resident's behaviors but failed to document a specific clinical rationale. Interviews with the Director of Nursing confirmed that the required documentation for contraindications was missing for these residents, indicating a failure to comply with the facility's policy and regulatory requirements.
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 17 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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 Burwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Care Centers - Ord, Llc | 16.1 mi | ★★★★★ | 17 | 0 |
| Rose Lane Home | 35.9 mi | — | 0 | 0 |
| Brookestone View | 36.9 mi | ★★★★★ | 8 | 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 July 2026) and official state health department websites.