Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monument Healthcare And Nursing Center during CMS and state inspections, most recent first.
Uncovered garbage receptacle with trash and debris on the ground. The facility failed to keep the outside garbage and refuse receptacle covered and allowed malodorous trash bags, used gloves, an opened pudding cup, paper, cups, bags, metal poles, and fencing supplies to remain on the ground around it. The DM stated the receptacle had been uncovered for about a year, staff sometimes left trash bags on the ground if they could not lift them, and maintenance or the DM would later place them inside during rounds.
Food Storage and Labeling Failures: A cold salad on the tray line was found above the required temperature, cartons of milk were stored without a date label, and multiple refrigerated foods lacked use-by dates or were already expired. In the freezer, dinner rolls were left in an open box and several frozen cases were stored on the floor. Staff interviews showed inconsistent monitoring of cold storage and expired items.
A resident who required pain management did not receive safe and appropriate care to address their pain, resulting in a deficiency related to pain management services.
A resident with COPD, pneumonia, respiratory failure with hypoxia, infective endocarditis, and pleural effusion was sent to the ER after a change in condition, but the record had no documentation that written bed-hold notice was given to the resident or representative at transfer or afterward. The chart also lacked evidence that the Ombudsman received the transfer/discharge notification, despite staff stating bed-hold notices were normally issued and documented.
MDS assessments were coded inaccurately for several residents. One resident with serious mental illness was incorrectly coded for PASRR, tobacco use, and antipsychotic medication use despite records, MAR, care plan, and staff interviews showing otherwise. Other residents were also miscoded for PASRR status, and one resident with longstanding unclear speech was incorrectly coded as having clear speech. The MDS Coordinator, DON, and Administrator acknowledged the errors.
Unqualified Dietary Manager Served as Food Service Director: The facility failed to designate a qualified individual to direct food and nutrition services in the absence of a full-time RD or other clinically qualified nutrition professional. The DM had been hired as a cook, had no food service certification or prior FSD experience, and stated he was not aware of the federal requirements for the role. The ADM knew he was not certified, the RD was only providing limited consultation, and the DON was also unaware of the federal requirements for the dietary director position.
Incomplete MAR and TAR Documentation: The facility failed to keep accurate records for two residents by not documenting a monthly antipsychotic injection for one resident and several scheduled wound care treatments for another resident. Staff and the DON stated the medication and treatments were provided, but the MAR and TAR lacked the required documentation, and the administrator said the incomplete records meant the facility could not prove the care was completed.
Improper PPE Use During Wound Care for a Resident on EBP: Staff failed to use the required PPE during wound care for a resident with a urinary catheter, an open wound, and ESBL history. An LPN and a CMA performed wound care using gloves only, and another LPN assisted without a gown. The facility’s EBP policy required gown and glove use for wound care, and staff acknowledged the proper PPE was not used.
Unqualified Infection Preventionist: The facility failed to consistently have a qualified IP responsible for the infection prevention and control program. Facility records showed one IP served before completing CDC IP training, RN Y served as IP without completing the required training, and another IP also served in the role before completing CDC IP training. The DON and ADM confirmed the facility did not have a qualified IP during the identified timeframe, and the ADM confirmed RN Y never completed the IP training.
Survey results were not posted in a prominent, accessible area and the survey binder was not readily available to residents or visitors. During a Resident Council meeting, most residents said they did not know the location of the binder, and the DON did not know where it was kept. The ADM found the Survey Book on top of the reception desk, where it was not accessible without staff help, and it was missing a complaint survey report. The facility policy required survey reports and related plans of correction to be maintained in a resident-frequented area and available upon request.
A resident with metabolic encephalopathy experienced an unwitnessed fall resulting in a fractured nasal bone and lacerations requiring hospital treatment. While the State Agency was notified within 2 hours of the injury, the facility did not submit the required follow-up investigative report within 5 business days, as confirmed by the DON.
A resident with multiple medical conditions was administered both antipsychotic and opioid medications without adequate monitoring, documentation, or evaluation of necessity. The medications were given frequently, sometimes together, despite warnings about drug interactions, and there was no evidence of non-pharmacological interventions or timely provider review. The resident experienced cognitive and physical decline, and concerns raised by staff and the resident’s representative were not addressed, resulting in a deficiency related to unnecessary drug use.
A resident with mild cognitive impairment and multiple medical conditions was prescribed a PRN antipsychotic for behavioral symptoms without timely notification to their representative. Facility staff confirmed that notification of such medication changes is expected, but there was no documentation or evidence that the representative was informed, leading to a deficiency.
A resident with dementia, Alzheimer's, and depression exhibited ongoing aggressive and agitated behaviors, including altercations with a roommate and staff. Despite documented incidents and staff concerns about room assignments and behavioral triggers, the care plan contained only generic interventions and was not individualized. Staff reported poor communication from management and uncertainty about behavioral interventions, while the administrator confirmed the care plan was not tailored to the resident.
A resident with a chronic surgical wound did not consistently receive daily wound care as ordered by the physician. Documentation showed that dressing changes were missed on multiple days, and both the resident and an LPN confirmed that dressings were sometimes left unchanged for up to three days. The DON verified that the facility's expectation was for daily dressing changes, but this was not consistently followed.
A resident with dementia and a history of aggression was involved in multiple altercations with others, including a physical incident with a roommate and aggression during meals. Staff concerns about room assignments and behavioral triggers were not addressed by management, and recommendations from healthcare providers were not effectively implemented. The lack of a dedicated unit manager and insufficient oversight contributed to the facility's failure to provide adequate supervision and prevent accidents.
A resident with an open shoulder wound did not receive wound care according to the physician's order. The RN failed to apply the No-Sting barrier film and did not establish a clean field during the procedure. The RN confirmed the omission during an interview.
A facility failed to prevent cross-contamination during wound care for a resident with an open shoulder wound. A nurse did not establish a clean field or perform hand hygiene as required by facility policy. Additionally, the nurse did not follow the physician's order to use a no-sting barrier film, and used non-sterile gloves, compromising the sterile environment.
The facility failed to follow advance directives for CPR/DNR for three residents, leading to discrepancies in code status documentation. A resident listed as DNR in the code listing report had a signed directive for CPR, while two other residents with DNR orders were inaccurately listed as Full Code in the facility's code book. These inconsistencies resulted in an immediate jeopardy finding, later reduced after corrective actions.
The facility's dishwashing machine failed to reach the required temperatures for effective cleaning, posing a risk of foodborne illness to all residents. Observations showed the wash and rinse cycles were below the necessary minimums, and staff interviews revealed a lack of awareness about temperature requirements and the meaning of a blinking light indicating low detergent levels.
The facility failed to review pre-employment health screens for five staff members, risking the transmission of contagious diseases. Multi-use equipment like a Hoyer lift was not sanitized between uses, and the facility lacked a water management plan to prevent Legionella. The Infection Control Coordinator and Maintenance Director confirmed these deficiencies.
The facility failed to provide a clean and homelike environment, with missing baseboard trim, scuffed floors, and rough handrails in the 200 wing. In the 400 wing, a cracked television, stained carpets, peeling wallpaper, and exposed electrical panels were observed. These deficiencies were confirmed by the Maintenance Director, indicating an unsafe environment.
The facility failed to provide and document baseline care plans for four residents within 48 hours of admission, as required. These residents, with various medical conditions such as Hemiplegia, Encephalopathy, and Chronic Respiratory Failure, did not receive the necessary written summaries of their care plans. The Director of Nursing Trainer confirmed the absence of these documents and the lack of evidence that they were provided to the residents or their representatives.
The facility failed to ensure proper blood glucose testing procedures for several residents with diabetes. Staff did not adhere to the protocol of wiping away the first drop of blood before testing, potentially leading to inaccurate readings. Interviews confirmed a lack of awareness or adherence to this procedure among staff.
A long-term care facility failed to maintain a medication error rate below 5%, with observed errors involving insulin and eye drop administration. Errors included incorrect priming of insulin pens and improper application of eye drops, as confirmed by the DON. These procedural lapses contributed to a 16% medication error rate.
The facility failed to ensure staff competency in blood glucose testing and insulin pen use, as observed in three staff members. Staff did not follow procedures for wiping away the first drop of blood during glucose testing, potentially leading to inaccurate readings. Additionally, insulin pens were not primed correctly, risking incorrect insulin doses. The facility lacked adequate training and competency documentation for the staff involved.
A resident with no cognitive impairment repeatedly requested a bed bath instead of a shower, but the facility staff denied this preference, insisting on showers. The resident's care plan lacked documentation of bathing preferences, and despite the facility's policy to accommodate such preferences, the staff did not adhere to it, leading to multiple refusals by the resident.
A resident with severe cognitive impairment and multiple diagnoses experienced several unwitnessed falls due to the facility's failure to implement prescribed fall prevention measures. Despite recommendations for a scoop mattress, observations revealed the use of a regular flat mattress, and staff interviews indicated a lack of awareness about specific interventions. This led to the resident sustaining injuries requiring emergency treatment.
A facility failed to perform monthly medication reviews for a resident with complex medical needs, including diabetes and major depressive disorder, from September 2023 to February 2024. The resident was on multiple medications, and the absence of these reviews could have led to unaddressed medication irregularities. The Infection Control Coordinator confirmed the oversight in the required monthly reviews.
A facility failed to limit PRN antipsychotic medication to 14 days and did not inform a resident or their representative of the medication's risks and benefits. The resident, with multiple diagnoses including dementia, was receiving antipsychotic medications without a gradual dose reduction or psychiatric evaluation, and the PRN order for Haloperidol lacked a discontinuation date.
Medication aides in an LTC facility failed to follow proper insulin administration procedures, leading to significant medication errors for three residents with diabetes. The aides did not prime insulin pens correctly, as they held the pen with the needle tip downward instead of upward, which is necessary to remove air and ensure the correct dose. The Director of Nursing confirmed the facility's procedure was not followed.
The facility failed to maintain a pest-free environment, affecting all 75 residents. Flying insects were observed in the courtyard, where a resident was sitting. A wasp nest was found in a window frame, with multiple wasps present. A nurse confirmed residents use the courtyard but was unaware of insect issues. The Maintenance Director acknowledged the nest's presence for a week and had not exterminated it, despite monthly exterminator visits.
A facility failed to complete required background checks before allowing a Medication Aide to work with residents, violating their policy on abuse prevention. The employee worked several shifts before the Nebraska Central Registry Check was completed, exposing residents to potential risks.
Uncovered garbage receptacle with trash and debris on the ground
Penalty
Summary
The facility failed to ensure garbage and refuse were stored in a covered receptacle. During a concurrent observation and interview, the garbage and refuse receptacle located outside and behind the facility was observed uncovered and filled with garbage and refuse. Two large malodorous trash bags, garbage and debris including used gloves, an opened pudding cup, paper, paper cups, and bags, along with 18 metal poles and wood fencing supplies, were observed on the ground around the receptacle. The Dietary Manager stated the metal poles had been on the ground for about a month and were part of a fencing project being worked on by maintenance. He confirmed the receptacle had no lid or cover and had been uncovered for the past year. He also stated staff who could not lift trash bags into the receptacle left them on the ground until he or maintenance staff placed them inside during rounds. The Director of Maintenance stated he checked the area once daily in the morning and would put trash bags into the receptacle if found on the ground. The Administrator stated she was not aware repairs were needed to allow the facility to get a trash compactor and expected maintenance to keep the receptacle covered and the area clean.
Food Storage and Labeling Failures
Penalty
Summary
The facility failed to maintain cold foods at 41 degrees Fahrenheit or below during meal service. During observation of the lunch tray line, a large plastic container of Italian salad with dressing was found on the tray line at 44.7 degrees Fahrenheit. The Dietary staff member present stated the salad had been on the tray line for about 10 minutes and had not checked its temperature before service began. He also stated the salad was served at lunch once per month and was stored in a large tub on the tray line without being kept at the proper temperature. The facility also failed to ensure that cartons of milk were labeled with a date of storage, use-by date, or expiration date. During observation of the walk-in refrigerator, 25 eight-ounce cartons of two percent milk were found without any date label from the facility or manufacturer. The Dietary Manager stated the milk vendor delivered milk on Mondays and Thursdays and that he had noticed prior deliveries without a manufacturer expiration date stamp, but he did not contact the vendor to clarify the expiration date for the cartons delivered without a manufacturer date stamp. In addition, multiple food items in the walk-in refrigerator were found without use-by dates, including tomato sauce, butterscotch pudding, cooked roast beef, biscuits, cooked hamburger patties, cooked breaded chicken patties, and uncooked hamburger patties. Expired food items were also present, including cooked apples labeled with a use-by date of 08/08/2025 and cooked turkey patties labeled with use-by dates of 08/10/2025. In the freezer, one case of dinner rolls was stored with the box open, and multiple boxes of frozen food, including pulled pork, chicken breasts, and peas and pearl onions, were stored on the freezer floor. Staff interviews showed that refrigerator monitoring for expired foods was inconsistent and that not all items were checked each time the walk-in was reviewed.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate pain management for a resident who required such services. The report indicates that the facility failed to ensure that a resident in need of pain management received care that met professional standards and addressed their pain appropriately. Specific details about the number of residents sampled or cited, as well as the resident's medical history or condition at the time of the deficiency, are not provided in the report.
Failure to Provide Bed-Hold Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notice of bed-hold policies when a resident was transferred to the hospital and failed to send a copy of the transfer/discharge notification to the Ombudsman for Resident #86. The facility policy titled, Bed-Holds and Returns, required residents and/or representatives to receive written information about bed-hold policies in advance of any transfer and again at the time of transfer or within 24 hours if the transfer was emergency. Resident #86 was admitted on 05/30/2025 with diagnoses including COPD, pneumonia, acute and chronic respiratory failure with hypoxia, acute and subacute infective endocarditis, and pleural effusion. An admission MDS dated 06/04/2025 showed a BIMS score of 15, indicating intact cognition. Progress notes showed that on 06/08/2025 the resident had diminished wheezes and was sent to the emergency room for further evaluation. The medical record contained no documentation that written bed-hold notification was provided to the resident or representative at the time of or after the transfer, and there was no evidence that the Ombudsman received a copy of the transfer/discharge notification. Staff interviews indicated that bed-hold notices were expected to be issued when a resident left the facility, but the Administrator stated there was no documentation for this resident and that the Ombudsman notification had not been done. The SSD stated they did not notify the Ombudsman when a resident was sent to the hospital.
MDS assessments were coded inaccurately for PASRR, smoking, antipsychotic use, and speech clarity
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for five residents reviewed for PASRR requirements, smoking, unnecessary medications, and speech/communication concerns. The report cited the CMS RAI 3.0 User’s Manual for coding A1500 PASRR, B0600 speech clarity, J1300 current tobacco use, and N0450 antipsychotic medication review, and then identified multiple resident assessments that did not match the residents’ records, PASRR determinations, medication administration records, care plans, or staff interviews. For Resident #76, the annual MDS with an ARD of 02/20/2025 indicated no PASRR serious mental illness, no tobacco use, and no antipsychotic medication use. However, the resident’s record included diagnoses of schizophrenia, schizoaffective disorder, anxiety disorder, borderline personality disorder, major depressive disorder, and psychosis. The PASRR Level II determination letter stated the resident had a serious mental illness and recommended psychiatric medication management and activities. The care plan identified the resident as a smoker and as using psychotropic medications, the February 2025 MAR showed olanzapine administration during the assessment period, and the resident stated they smoked two to three times daily. Staff interviews confirmed the MDS should have been coded yes for PASRR, smoking, and antipsychotic use. For Resident #5, the admission MDS with an ARD of 05/28/2025 indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness. The resident’s PASRR Level II determination letter stated the resident had a serious mental illness and recommended psychiatric medication management, supportive counseling, and individual therapy. The care plan also documented that the resident had a PASRR Level II completed and met the state definition for mental illness. For Resident #35, the significant change MDS with an ARD of 08/24/2024 documented No in A1500 even though the resident’s PASRR Level II outcome letter stated the resident was approved for PASRR Level II and the facility should mark yes for A1500. For Resident #2, the annual MDS with an ARD of 06/18/2025 indicated the resident was not currently considered to have a serious mental illness or related condition, despite a Nebraska PASRR Level II Summary of Findings showing the resident met the federal definition of serious mental illness and despite diagnoses including schizophrenia, PTSD, and anxiety. For Resident #37, the quarterly MDS with an ARD of 06/06/2025 coded speech as clear, even though prior MDS assessments had documented unclear speech and the care plan described impaired communication due to unclear speech related to cerebral palsy, severe spasticity, mild intellectual disabilities, and hearing deficits. Staff interviews stated the resident’s speech was difficult to understand and that the clear speech coding was an error. Across these residents, the MDS Coordinator, DON, and Administrator acknowledged the assessments were incorrect and stated the MDS entries did not accurately reflect the residents’ PASRR status, tobacco use, antipsychotic medication use, or speech clarity.
Unqualified Dietary Manager Served as Food Service Director
Penalty
Summary
The facility failed to ensure that, in the absence of a full-time registered dietitian or other clinically qualified nutrition professional, a qualified individual was designated to serve as the director of food and nutrition services. The Dietary Manager (DM) was hired by the facility as a cook on 01/23/2025, and the employment application showed a high school diploma and one and a half years of community college education, but no food service education or prior employment as a food service director. The DM's personnel file and job description for Food Service Director did not show the education and/or experience section completed to establish qualification for the role. During a QAPI meeting, the facility documented that it had a new DM in place and would work with him on dietary items and continue training him, with plans for him to start CDM courses that were expected to take a year. In interview, the DM stated he had not completed a certification course, had no degree in food service, had not previously worked as a dietary or food service director, and was not aware of the federal requirements for the position. The ADM stated she knew the DM was not certified when she became ADM and expected the facility to employ a qualified food service director. The RD provided only eight to twelve hours of onsite and remote consultation per week and was not a full-time RD for the facility. The DON also stated she was not aware of the federal requirements for the dietary director role.
Incomplete MAR and TAR Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not documenting medications and treatments that were reportedly provided. Facility policy required that all services provided, objective observations, medications administered, and treatments or services performed be documented in the resident medical record. Surveyors found that the MAR for one resident lacked documentation showing that Invega Sustenna 234 mg IM monthly was administered in February 2025, even though the resident had diagnoses including schizophrenia, schizoaffective disorder, anxiety disorder, borderline personality disorder, major depressive disorder, and psychosis, and had a BIMS score of 15 indicating intact cognition. Record review showed a Medical Director Report noted the monthly Invega injection was not charted as administered on the MAR. During interviews, the resident stated they received a shot every month and did not recall missing it. Nursing staff and the DON stated that medications administered should be documented on the MAR, and if a medication was held or not given, a progress note and provider notification were expected. The DON stated the resident received the medication, but the nurse did not document the administration, and the administrator stated the shot should have been documented on the MAR. For the second resident, the TAR for wound care to a stage 3 pressure ulcer of the low back/sacrum lacked documentation for multiple scheduled treatments. The resident had diagnoses including neuromuscular dysfunction of the bladder, urinary retention, and ESBL resistance, and the MDS indicated severe cognitive impairment with memory problems and a stage 3 pressure ulcer present on admission. The TAR did not show wound care completed on one daily treatment date and on two scheduled Tuesday/Friday treatments. The LPN who provided care stated the treatments were done but not documented, and the administrator stated incomplete TAR sections meant the facility could not prove the medication or treatment was completed and that the medical record was incomplete.
Improper PPE Use During Wound Care for Resident on EBP
Penalty
Summary
The facility failed to ensure staff used the proper PPE during wound care for a resident on Enhanced Barrier Precautions (EBP). Resident #48 was admitted with diagnoses including neuromuscular dysfunction of the bladder, retention of urine, and ESBL resistance. The resident’s quarterly MDS indicated severe impairment in cognitive skills for daily decision-making and short- and long-term memory problems, and the resident had a Stage 3 pressure ulcer that was present on admission and received wound treatment. The care plan and active physician’s order identified EBP for the resident’s urinary catheter and open wound to the lower back/sacrum. During an observation of wound care, an LPN and a CMA entered the resident’s room, put on gloves, and performed wound care without gowns. Another LPN entered to replace the CMA and assist with the wound care and also did not put on a gown before assisting. The facility’s EBP policy stated that gowns and gloves are to be applied before performing high-contact resident care activities, including wound care. In interviews, the IP stated staff should wear gloves, gown, and mask for care, and the involved staff stated they should have worn the proper PPE during wound care. The Administrator stated staff should know if a resident required EBP because of the signage on the door and should follow the EBP policy when providing care.
Unqualified Infection Preventionist
Penalty
Summary
The facility failed to consistently employ a qualified infection preventionist responsible for the infection prevention and control program. The facility policy titled, Infection Preventionist, stated the infection preventionist is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role. An undated facility document showed that IP P served as the infection preventionist from 08/01/2024 through 12/06/2024, RN Y served from 12/16/2024 through 02/09/2025, and IP O served from 02/10/2025 to present. The record showed IP P completed the CDC Nursing Home Infection Preventionist Training Course on 10/04/2024, meaning IP P served in the role without the necessary training from 08/01/2024 through 10/03/2024. IP O completed the CDC training on 06/17/2025, meaning IP O served in the role without the necessary training from 02/10/2025 through 06/16/2025. During interviews, IP O stated they had been in the IP position since 02/2025 and there had not been another qualified IP on staff. The DON stated the facility was required to have a qualified IP and that the last qualified IP was IP P until IP O completed the CDC training in June 2025. The ADM stated the facility did not have a qualified IP from when IP P left until IP O completed the CDC training, and confirmed RN Y never completed the IP training.
Survey Results Not Posted or Readily Accessible
Penalty
Summary
The facility failed to post notice of the availability of the most recent survey results in a prominent and accessible area for the public, failed to post the most recent survey results in a location readily accessible to residents and visitors, and failed to maintain reports for surveys, certifications, and complaint investigations from the preceding three years for review upon request. The deficiency was identified during observation, interview, facility document review, and policy review, and was cited as affecting 10 of 10 residents interviewed during a Resident Council meeting, with potential to affect all residents in the facility. A facility policy titled, Survey Results, Examination of, stated that copies of all survey reports and approved plans of correction were to be kept on file in the administrative office, and that a copy of the most recent standard survey and related reports was to be maintained in a 3-ring binder in an area frequented by residents, such as the main lobby or resident activity room. The policy also stated that previous survey reports and approved plans of correction were to be available upon request to the public, residents or their legal representatives, the designated ombudsman representative, and staff members. During observations of the lobby, the 100-Hall nurse's station, the 200-Hall, and the 400-Hall unit, no posting was seen regarding the availability of survey results. During the Resident Council meeting, one resident stated there was a book behind the reception desk but staff had to provide it, while the other nine residents stated they were not aware of any binder or its location. The DON did not know where the survey results were kept, and the ADM retrieved a binder titled Survey Book from the top of the reception desk, where it was not accessible to a resident in a wheelchair or to a resident or visitor standing at the desk. The binder did not include survey results for a complaint survey completed on 02/12/2024, and the ADM stated the binder was not accessible without staff assistance and that the notice about survey results had been removed about a week earlier.
Failure to Submit Timely Investigative Report After Resident Injury
Penalty
Summary
The facility failed to submit a required investigative report to the State Agency within 5 working days following a significant injury sustained by a resident. According to the facility's policy, any incident resulting in serious bodily injury must be followed by a detailed investigative report submitted to the state within the specified timeframe. In this case, a resident with a diagnosis of metabolic encephalopathy was admitted to the facility and subsequently experienced an unwitnessed fall, resulting in a fractured nasal bone and lacerations requiring stitches. The incident was documented, and the resident was transported to the hospital for treatment. Although the facility notified the State Agency within 2 hours of becoming aware of the resident's significant injury, there was no evidence that a follow-up investigative report was submitted within 5 business days as required. The Director of Nursing confirmed that the follow-up report was not sent, despite the policy and regulatory requirements. This omission constituted a failure to comply with state regulations regarding timely reporting of incidents involving serious injury.
Failure to Prevent Unnecessary Drug Use and Monitor Medication Interactions
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, as evidenced by the administration of multiple psychotropic and opioid medications without adequate monitoring or documented justification. The resident, who had a history of vertebral fracture, scoliosis, osteoarthritis, and depression, was prescribed risperidone (an antipsychotic) on an as-needed basis for behaviors, as well as multiple opioid medications for pain management. There was no documented stop date or duration for the risperidone, and the order included instructions to follow up with the primary health care provider, but there was no evidence of such follow-up or of regular evaluation of the continued need for the medication. The resident’s medical records showed frequent administration of both antipsychotic and opioid medications, sometimes concurrently, despite a black box warning regarding the risks of combining these drug classes. Documentation was lacking regarding the specific behaviors that prompted the use of the antipsychotic, and there was no evidence of non-pharmacological interventions for pain. Progress notes indicated a decline in the resident’s cognition and physical abilities, with concerns raised by both staff and the resident’s representative. Despite these concerns and requests for medication review, there was no documented evidence that the need for continued use of the antipsychotic or the potential drug interactions were addressed by providers. Interviews with staff and the resident’s representative confirmed that the resident experienced periods of significant cognitive and physical decline, which improved after changes to the medication regimen. The representative was not informed about the initiation of the antipsychotic and expressed concern about the resident’s decline. Staff acknowledged missed opportunities to evaluate for over-medication and potential drug interactions. The facility’s failure to monitor and evaluate the resident’s medication regimen, document the rationale for continued use, and communicate with the resident’s representative contributed to the deficiency.
Failure to Notify Resident Representative of New Antipsychotic Medication
Penalty
Summary
The facility failed to notify a resident and their representative of a newly prescribed medication, specifically an antipsychotic, as required by policy and regulation. Record review showed that a resident with multiple diagnoses, including vertebral fracture, scoliosis, osteoarthritis, and depression, was admitted from a hospital and had mild cognitive impairment. The resident exhibited behavioral symptoms that disrupted care and required significant assistance with daily activities. On a specific date, the resident began yelling out in pain despite receiving pain medication and other interventions. The on-call provider was notified and prescribed Risperidone 0.25 mg every 12 hours as needed for behaviors, with instructions to follow up with the primary care provider. The medication was administered, and the resident's behavior calmed after about 30 minutes. However, there was no documented evidence that the resident or their representative was notified of the new antipsychotic medication. Interviews with the resident's representative confirmed they were not informed of the medication change until much later and would not have agreed to its use if notified. Facility staff, including an LPN and a unit manager, confirmed that the expectation is to notify representatives of such changes and acknowledged that this notification did not occur or was not documented.
Failure to Individualize Care Plan for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to implement resident-specific interventions to address or minimize the behaviors of a resident with dementia, Alzheimer's disease, and depression. The resident had a history of moderate to severe cognitive impairment and minimal symptoms of depression, as documented in their assessments. Despite a care plan noting the potential for physical aggression related to dementia, the interventions listed were generic and not tailored to the resident's specific triggers or behaviors. Multiple incident and behavior notes documented ongoing aggressive and agitated behaviors, including verbal and physical altercations with a roommate and other residents, as well as aggression toward staff. Staff interviews revealed that concerns about placing two residents with histories of aggression in the same room were raised with the Social Services Director, but these concerns were dismissed, and staff felt their input was not sought or valued. Staff also reported a lack of communication from management regarding behavioral interventions and were unsure where to find documentation of such interventions for the resident. The Nursing Home Administrator confirmed a lack of awareness regarding staff concerns and acknowledged that the care plan was not individualized for the resident. Oversight of the unit was fragmented, with no dedicated unit manager, contributing to the lack of individualized care planning and communication among staff. The deficiency was identified through observation, record review, and staff interviews, highlighting the facility's failure to develop and implement a comprehensive, resident-specific care plan as required.
Failure to Perform Wound Care as Ordered
Penalty
Summary
The facility failed to perform wound care as ordered for one resident with a chronic surgical wound to the right shoulder. The resident's care plan and physician orders specified daily dressing changes, including cleansing with normal saline, application of a no sting barrier film, and covering with a silicon border dressing. However, documentation in the Treatment Administration Record (TAR) for March showed that dressing changes were completed only 20 out of 31 days. Interviews with the resident and an LPN confirmed that dressing changes were sometimes missed for up to three days, and dressings were occasionally found undated or dated from previous days. The resident involved had no cognitive impairment and required partial to moderate assistance with activities of daily living. The resident reported that the wound dressing was not always changed daily as ordered. The DON confirmed the discrepancy in the TAR and acknowledged that the facility expectation was for dressing changes to be completed as ordered, with missed treatments to be passed on to the next shift. The failure to follow the wound care orders as prescribed led to the identified deficiency.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision and Response to Behavioral Risks
Penalty
Summary
The facility failed to protect residents from accident hazards and did not provide adequate supervision to prevent accidents involving a resident with a history of adverse behaviors. The resident in question had diagnoses including dementia, Alzheimer's disease, and depression, and was assessed as having moderate to severe cognitive impairment. Despite a care plan identifying the potential for physical aggression and interventions such as analyzing triggers and seeking psychiatric consultation, the resident was involved in multiple incidents of aggression toward others, including a physical altercation with a roommate and striking another resident during lunch. Staff interviews revealed that concerns were raised about placing two residents with histories of aggression in the same room, but these concerns were not addressed by facility management. Staff reported that their input regarding behavioral triggers and interventions was not solicited by the management team, and that the Social Services Director communicated that corporate priorities were focused on bed occupancy rather than resident safety. The memory support unit where the incidents occurred lacked a dedicated unit manager, and oversight was split between other managers, leading to staff feeling unsupported and overlooked. Documentation showed repeated behavioral incidents, including verbal and physical aggression, and recommendations from healthcare providers to change the resident's room assignment to reduce irritability. Despite these documented behaviors and provider recommendations, the facility did not implement effective interventions or adjust supervision to prevent further incidents, resulting in continued altercations and a failure to ensure a safe environment for all residents.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to perform wound care according to the provider's order for a resident with an open wound on their right shoulder. The resident was admitted with this condition, and the physician's order specified a detailed wound care regimen, including cleansing with normal saline or wound cleanser, applying a No-Sting barrier film, and covering with a silicone border dressing. This care was to be performed daily on the day shift and as needed for drainage or dislodgement. During an observation, a registered nurse (RN) did not follow the prescribed wound care procedure. The RN prepared the wound dressing without establishing a clean field and omitted the application of the No-Sting barrier film as ordered. Additionally, the RN had to retrieve forgotten supplies during the procedure, which interrupted the process. An interview with the RN confirmed the omission of the No-Sting barrier film, indicating a failure to adhere to the physician's order for wound care.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care for a resident with an open wound on their right shoulder. The facility's policy required staff to establish a clean field using a disposable cloth on the resident's overbed table and to perform hand hygiene at specific points during the procedure. However, during an observation, a registered nurse (RN) did not follow these protocols. The RN placed the wound dressing directly on the overbed table without establishing a clean field and did not perform hand hygiene after placing supplies on the table, after removing the soiled dressing, or after completing the wound care. Additionally, the RN did not adhere to the physician's order for the wound care procedure. The order specified the use of a no-sting barrier film, which the RN failed to apply. The RN also used non-sterile gloves obtained from the resident's bathroom and did not maintain a sterile environment throughout the procedure. These actions and inactions led to a deficiency in the facility's infection prevention and control program, as they increased the risk of cross-contamination during wound care.
Failure to Follow Advance Directives for CPR/DNR
Penalty
Summary
The facility failed to adhere to the advance directives for cardiopulmonary resuscitation (CPR) or do not resuscitate (DNR) orders for three residents, leading to a deficiency. Resident 40 was listed as a DNR in the facility's code listing report, but their medical record and a signed advance directive indicated a preference for CPR and full treatment. This discrepancy was confirmed through interviews with the Unit Manager and the resident, who verified their choice for CPR. Resident 32's records showed a preference for DNR, as indicated in their resuscitation orders and care plan. However, the facility's code book inaccurately listed them as a Full Code, contradicting their documented wishes. Similarly, Resident 46 had a DNR order signed by their physician, but the facility's code book also incorrectly listed them as a Full Code, not reflecting their choice for no CPR. These discrepancies in code status documentation and the failure to follow residents' advance directives were identified during a survey, resulting in an immediate jeopardy finding. The facility's failure to ensure accurate and consistent documentation of residents' code statuses in their records and emergency crash carts led to the deficiency being cited at the immediate jeopardy level, which was later lowered after corrective actions were verified.
Removal Plan
- All residents' signed code status forms will be audited to ensure physician orders match resident preferences.
- Code status spreadsheet will be updated to reflect accurate and current code statuses for each resident.
- Social Services will contact residents without current code status preferences and discuss resident or representative wishes related to code status.
- The Admissions Department will verify and obtain code statuses prior to admission with responsible party.
- Current code status forms will be placed in the code status binder and placed inside crash cart.
- Director of Nursing (DON) will start in-services regarding: Code status policy, Code status spreadsheet, Code status form: DNR/Full Code/Do Not Hospitalize (DNH), Identifying a resident's code status, Education will be provided to all staff currently on duty and prior to any staff coming off duty.
- Resident profile and code status icon on PCC will be audited and updated with current resident wishes related to code status by Unit Managers or designee weekly or upon admission or re-admit.
- Social Services will audit code status book weekly to ensure code statuses for residents are accurate.
- Admissions Department will audit code status forms received and obtained from hospital records weekly for new residents.
- New admissions will be reviewed during clinical meetings to discuss and determine resident code statuses.
- Auditing results will be submitted to Quality Assurance and Performance Improvement (QAPI) and addressed as appropriate.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility staff failed to ensure that the dishwashing machine reached the required temperatures necessary to prevent potential foodborne illness, affecting all residents who consumed food from the kitchen. Observations revealed that the dishwasher's wash cycle temperature was 145 degrees Fahrenheit, and the rinse cycle was 163 degrees Fahrenheit, both below the required minimums of 160 and 180 degrees Fahrenheit, respectively. Interviews with dietary aides and maintenance personnel indicated a lack of knowledge regarding the dishwasher's temperature requirements and the significance of a blinking light on the dishwashing monitor, which signaled low detergent levels. The facility had a census of 75 residents at the time of the observation.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to ensure that pre-employment health history screens were reviewed to prevent the potential transmission of contagious diseases for five staff members. The records for Medication Aide-E, Maintenance Worker-H, Nurse Aide-F, Transportation Driver, and Medication Aide-G all showed that their Employee Health Screening forms were not reviewed or signed by a Registered Nurse, as required. The Human Resources department confirmed that these forms were placed in employee files without being reviewed by nursing staff to assess for potential communicable diseases. Additionally, the facility did not ensure that multi-use equipment, such as a Hoyer lift, was sanitized between uses. Observations revealed that Medication Assistants did not sanitize the Hoyer lift after using it with different residents. The Infection Control Coordinator stated that cleaning multi-use equipment should be done between uses by the nursing department. Furthermore, the facility lacked a water management plan to prevent waterborne illnesses, such as Legionella. The Maintenance Director confirmed that there were no measures or monitoring processes in place to prevent the growth of Legionella, and there was no documentation or communication regarding a water management plan.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment, as evidenced by several deficiencies observed during a survey. In the 200 wing, the baseboard trim was missing, exposing unfinished and flaking drywall, and there was a visible buildup of gray-black substance in the cracks where the trim was absent. The tile floor was scuffed and stained, with yellow-brown buildup along the edges. Additionally, the wooden handrail was rough and porous due to the varnish wearing off, changing its color from light tan to white-gray. In the 400 wing, the commons sitting area had a television with a splintering crack, rendering part of the screen non-functional. The floor trim was missing, exposing soiled underlayment. The hallway carpet had multiple large stains, and the wallpaper was peeling. An electrical panel had crumbling spackling and warped wallpaper, while the dining room ceiling had reddish-brown stains and a loose electrical outlet. The window was obstructed by a white-gray film and old tape. These issues were confirmed by the facility's Maintenance Director, indicating an unsafe and un-homelike environment.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to ensure that a written summary of the baseline care plan was reviewed with the resident or their representative and that a copy was provided to them within 48 hours of admission. This deficiency was identified for four residents during the review. The baseline care plan is crucial as it includes instructions needed to provide effective, person-centered care for residents until a comprehensive care plan is developed. For Resident 22, who was admitted with diagnoses including Hemiplegia following a stroke, Pneumonia, and Parkinson's Disease, there was no baseline care plan identified in the medical record. Additionally, there was no documentation that the resident or their representative received a written summary of the baseline care plan. The Director of Nursing Trainer (DONT) confirmed the absence of these documents and the lack of evidence that the required information was provided to the resident or their representative. Similar deficiencies were found for Residents 127, 23, and 13, each with their own set of medical conditions. Resident 127, admitted with Encephalopathy, Severe Malnutrition, and Acute Kidney Failure, also lacked a baseline care plan and documentation of its provision to the resident or representative. Resident 23, with Chronic Respiratory Failure and Severe Obesity, and Resident 13, with Malnutrition and Transient Ischemic Attacks, similarly had no baseline care plans or documentation of their provision. In each case, the DONT confirmed the absence of these critical documents and the failure to provide them to the residents or their representatives.
Improper Blood Glucose Testing Procedures
Penalty
Summary
The facility failed to ensure that staff performed blood glucose testing in accordance with current professional standards for five residents diagnosed with diabetes. The deficiency was identified through observations, record reviews, and interviews, revealing that staff did not follow the proper procedure for blood glucose testing. Specifically, the staff did not wipe away the first drop of blood and obtain a second drop for testing, as required by the facility's procedure. For Resident 47, the medication aide did not follow the procedure of wiping away the first drop of blood before testing, resulting in a blood sugar reading of 130. This was documented in the Medication Administration Record (MAR) for the resident, who had an order for sliding scale insulin. Similar observations were made for Residents 40, 48, 21, and 1, where the staff failed to wipe away the first drop of blood before applying it to the glucometer test strip, leading to potentially inaccurate blood sugar readings. Interviews with the Director of Nursing and the medication aides confirmed that the staff were either unaware or did not adhere to the procedure of using the second drop of blood for testing. The Director of Nursing acknowledged that not following this procedure could result in inaccurate blood sugar readings, which are critical for residents with diabetes who require precise insulin dosing.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 16%. This was identified through multiple observations of medication administration errors involving insulin pens and eye drops. The errors were primarily due to incorrect procedures followed by medication aides during insulin administration, such as not priming the insulin pen correctly by holding the needle tip upward and failing to apply the needle before priming. Additionally, there was an error in administering eye drops, where the medication was not placed in the lower eyelid as required. One specific incident involved a resident with diabetes who was supposed to receive 6 units of Lispro insulin. The medication aide did not prime the insulin pen correctly and failed to apply the needle before priming, leading to a medication error. Another resident with diabetes was observed receiving 2 units of Lispro insulin, but the medication aide again did not prime the pen correctly by holding the needle tip downward instead of upward. These procedural errors were confirmed by the Director of Nursing, who reiterated the correct steps for insulin administration. In another case, a medication aide incorrectly administered Systane eye drops to a resident by placing the drops on the top of the eyelid instead of pulling down the lower eyelid and placing the drop in the lower eyelid pocket. This resulted in the eye drop not being administered correctly, as confirmed by the Director of Nursing. These errors highlight the facility's failure to adhere to established procedures for medication administration, contributing to the high medication error rate.
Deficiency in Staff Training and Competency for Blood Glucose and Insulin Administration
Penalty
Summary
The facility failed to ensure that staff received adequate training and competency assessments for obtaining resident blood glucose levels and using insulin pens, as observed in three staff members. This deficiency was identified through observations, record reviews, and interviews. The facility's procedure for measuring blood glucose using a handheld glucometer requires staff to wipe away the first drop of blood and use the second drop for testing to ensure accuracy. However, staff members did not follow this procedure, potentially leading to inaccurate blood sugar readings. In one instance, a medication aide did not wipe away the first drop of blood when checking the blood glucose level of a resident with diabetes, resulting in a documented blood sugar reading of 130. The Director of Nursing confirmed that the expectation is for staff to follow the procedure to ensure accurate readings. Additionally, the facility's competency checklist for insulin administration did not include steps for using an insulin pen, and the medication aide did not prime the pen correctly, which could lead to incorrect insulin doses. Another medication aide also failed to follow the correct procedure for blood glucose testing and insulin pen use. The aide did not wipe away the first drop of blood and did not prime the insulin pen correctly. The facility was unable to provide adequate training or competency documentation for the staff involved, and the Director of Nursing was unsure of the timeframe for competency assessments. This lack of proper training and assessment could result in potential harm to residents with diabetes due to inaccurate blood sugar readings and incorrect insulin administration.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident 27, who was cognitively intact with a BIMS score of 15. Despite the resident's request for a bed bath, the facility staff insisted on showers, which the resident consistently refused. The resident's care plan did not document any preferences regarding bathing methods, and the facility's policy required that such preferences be accommodated. Interviews with staff revealed that the resident's request for a bed bath was denied, and the staff believed that bed baths would not adequately clean the residents. Documentation in the Hall Bath Book and the electronic medical record showed multiple instances of the resident refusing scheduled showers, with no evidence of alternative arrangements being made. The facility's policy stated that if a resident refused a bath due to a preference for a different method, such as a bed bath, the preference should be accommodated. However, the facility did not adhere to this policy, resulting in a failure to support the resident's right to self-determination and choice in their care.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adequately investigate and implement interventions to prevent falls for Resident #24, who was admitted with multiple diagnoses including Multiple Sclerosis, generalized muscle weakness, seizure disorder, and dementia. The resident experienced several unwitnessed falls over a period of time, with documented incidents on specific dates. Despite the resident's severe cognitive impairment and dependence on staff for mobility and toileting, the facility did not consistently apply the prescribed interventions to mitigate fall risks. Observations and interviews revealed discrepancies in the implementation of fall prevention measures. Although a scoop mattress was recommended as an intervention, the resident's bed was found to have a regular flat mattress on multiple occasions. Additionally, staff interviews indicated a lack of awareness regarding the specific interventions required for the resident, such as the use of a scoop mattress. This inconsistency in applying fall prevention strategies contributed to the resident sustaining a hematoma and laceration requiring emergency room treatment after a fall.
Failure to Conduct Monthly Medication Review
Penalty
Summary
The facility failed to ensure a monthly medication review (MRR) was performed for a resident, identified as Resident 37, which is a requirement to minimize or prevent adverse consequences or unnecessary drug administration. The record review revealed that Resident 37, who was admitted with diagnoses including diabetes, hypertension, and major depressive disorder, did not have MRRs completed for several months, specifically from September 2023 to February 2024. This oversight had the potential for significant medication irregularities to go unidentified, as the resident was on multiple medications, including insulin, antipsychotic, antianxiety, antidepressant, and antiplatelet medications. The care plan for Resident 37 indicated the use of diuretic therapy, which could cause dizziness, hypotension, fatigue, and increased risk for falls. The resident's care plan also noted an increase in antipsychotic medication due to increased anxiety. Despite these complexities in the resident's medication regimen, the facility did not conduct the required monthly reviews for several months, as confirmed by the facility's Infection Control Coordinator, who is responsible for following up on MRRs. This lapse in protocol could have led to unaddressed medication issues, as previous MRRs had noted recommendations for medication adjustments.
Failure to Limit PRN Antipsychotic Use and Inform Resident
Penalty
Summary
The facility failed to ensure that as-needed antipsychotic medications were limited to 14 days of use and that residents or their representatives were informed of the risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use. This deficiency affected one resident, who was admitted with multiple diagnoses including Multiple Sclerosis, generalized muscle weakness, seizure disorder, and dementia. The resident was severely cognitively impaired, requiring assistance with daily activities, and was receiving antipsychotic medications without a gradual dose reduction being attempted or documented as clinically contraindicated. The resident's care plan indicated a potential for verbal and physical aggression, wandering, and care rejection, with interventions including medication administration, offering choices, and psychiatric evaluation. However, there was no documentation of behaviors in July 2024, and the resident's as-needed Haloperidol order lacked a 14-day discontinuation date. The Assistant Director of Nursing confirmed the indefinite use of Haloperidol and acknowledged that the resident had not been seen by a psychiatric provider as planned, nor were the resident or their representative informed about the antipsychotic medication's risks and benefits.
Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that staff administered insulin correctly, leading to significant medication errors for three residents with diabetes. The errors were observed during insulin administration by medication aides who did not follow the proper procedure for priming insulin pens. Specifically, the aides did not hold the insulin pen with the needle tip upward while priming, which is necessary to remove air and ensure the correct dose is administered. For Resident 40, the medication aide did not apply the needle before priming the pen and attempted to administer insulin without proper priming, resulting in a failed injection attempt. The aide then replaced the needle but did not prime the new needle before administering the insulin. Similarly, for Resident 48, the medication aide primed the pen with the needle tip downward, contrary to the required procedure, before administering the insulin. Resident 16 also experienced a similar error, where the medication aide primed the pen incorrectly by holding the tip downward. The Director of Nursing confirmed that the facility's procedure requires the needle to be applied before priming and the pen to be held with the needle tip upward during priming. These observations indicate a failure to adhere to the established insulin administration protocol, resulting in significant medication errors for the residents involved.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, which had the potential to affect all 75 residents residing in the facility. During an observation, flying insects were seen gathering in the corner of a window in the courtyard, across from two rooms. A resident was observed sitting in their wheelchair in the gazebo in the courtyard area. A wasp nest, approximately the size of a softball, was present in the upper right-hand corner of the window frame, with multiple wasps visibly crawling on the nest and flying to and from it. In an interview, a registered nurse confirmed that residents frequently use the courtyard to enjoy the flowers and weather but denied awareness of any issues with flying insects. The Maintenance Director confirmed the presence of the active wasp nest, which had been observed about a week prior, and admitted not having had the time to exterminate the wasps. The Maintenance Director also stated that the exterminator visits monthly for pest and insect control and acknowledged that the active wasp nest posed a potential hazard to residents wishing to use the courtyard.
Failure to Complete Background Checks Before Employment
Penalty
Summary
The facility failed to ensure that background checks were completed prior to staff working in the facility, which is a violation of their policy on abuse, neglect, exploitation, and misappropriation prevention. The policy mandates that the facility conduct employee background checks and not employ individuals with findings of abuse, neglect, exploitation, or related offenses. However, a review of the employee file for a Medication Aide (MA-E) revealed that the Nebraska Central Registry Check was completed 13 days after the hire date, during which time the employee had already worked with residents. The facility's hiring process checklist requires a Nebraska state-specific APS/CPS Registry Check to be completed, but this was not done before MA-E began working. The timecard report showed that MA-E attended orientation and worked several shifts before the background check was completed. An interview with the facility's Human Resources confirmed that the Central Registry check was not completed before MA-E started working with residents, exposing the facility to potential risks of abuse and neglect.
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 13 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 Scottsbluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northfield Retirement Communities Care Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Heritage Estates | 4.4 mi | ★★★★★ | 0 | 0 |
| Mitchell Care Center | 8.2 mi | ★★★★★ | 10 | 0 |
| Chimney Rock Villa | 19.3 mi | ★★★★★ | 1 | 0 |
| Goshen Healthcare Community | 30.6 mi | ★★★★★ | 1 | 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.