Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Joseph's Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility failed to report an unexpected, untoward death of a resident to the State Agency within required timeframes, as mandated by its abuse prevention policy and state licensure rules. The resident had multiple serious conditions, including end-stage kidney disease requiring hemodialysis, chronic respiratory failure, heart failure, diabetes, and COPD, with moderately impaired cognition and a care plan addressing dialysis needs and fistula monitoring. Nursing notes documented the resident was found nonresponsive in bed with no pulse or respirations, blood around the body and on the floor, a small open area at the bottom of the left arm fistula, and blood on the fingertips of the right hand, with no trauma or sharp objects present. The DON acknowledged the death was unanticipated and that, although an internal investigation was completed, the facility did not submit the incident or investigation results to the State Agency as required.
Food safety failures were identified with both dishwasher sanitation monitoring and meal holding temperatures. The facility did not consistently document dishwasher wash and rinse temperatures, and multiple logged cycles were outside required ranges. During meal service observation, a hot food item was found at 116.1 degrees, and the Cook and CDM-M confirmed it would have been served at an incorrect temperature.
No Evidence of Active Antibiotic Stewardship Program: The facility failed to show evidence of an active ASP. Although the written policy called for monitoring antibiotic use, assessing infections using McGreer’s criteria, tracking measures, and giving feedback to prescribers, Infection Surveillance records showed no culture information or criteria used to determine whether antibiotics were prescribed in accordance with the ASP. The IP confirmed the facility had not used criteria, tracking, or organism identification to evaluate antibiotic orders or provide prescribers with ASP-related feedback.
A facility failed to resolve repeated grievances about long call light response times and cold food temperatures. Grievance records showed multiple complaints over time, and Resident Council minutes repeatedly documented the same concerns, including delays in call light response and meal service. The Administrator, DON, and RN consultant confirmed the facility knew about the ongoing issues, but documented resolutions and follow-up were not completed, and call light response time reports were not reviewed despite continued complaints.
Food Served at Improper Temperatures: The facility failed to ensure food was served at palatable temperatures. An observation showed a DM grilled hamburgers and hotdogs without checking temperatures, placed them on the steam table, and served them. The DM also microwaved chicken noodle soup and served it without checking the temperature. A meal tray later showed chicken fried chicken, mashed potatoes, and vegetables at temperatures well below palatable levels, and both the Cook and CDM confirmed the food would have been served cold and that temperatures were not checked to verify proper cooking temperatures.
The facility failed to follow infection control practices during resident care and medication administration. Staff did not perform hand hygiene after glove removal, used PPE inconsistently during high-contact care, and handled insulin pens and a blood glucose meter without cleaning the equipment or using a clean barrier. The facility also failed to implement EBP for residents with a dialysis port, an indwelling catheter, and a recently healed pressure ulcer, and staff were unaware of the EBP status for some residents.
Inaccurate MDS coding was identified for two residents. One resident’s PASRR level 2 screen showed MMI, but the MDS stated the resident had not been determined to have a serious mental illness, ID, or related disorder. Another resident’s MDS listed a psychotic disorder, while the care plan listed other mental health diagnoses but no psychotic disorder. RN-B confirmed both MDS assessments were not coded accurately.
PASRR screening and care planning were incomplete for residents with mental health diagnoses. One resident’s PASRR Level 1 did not accurately reflect documented anxiety, depression, psychotic disorder, and hallucinations, while another resident’s care plan did not include the PASRR Level 2 determination despite schizophrenia, prior psychiatric hospitalizations, regular psychiatry follow-up, and a history of medication noncompliance with delusions and hallucinations.
A resident with hip fracture, anemia, depression, and severe cognitive impairment experienced marked weight loss after admission. Although the care plan included a mechanical soft diet, 2Cal, and meal replacement if intake was under 50%, weekly weights were not documented during the first 4 weeks, a re-weigh after a major weight drop was delayed, and meal replacement was not documented when the resident ate poorly. The DON and RN consultant confirmed the IDT had not evaluated the weight loss or the effectiveness of interventions.
Failure to provide routine shaving for multiple residents. Residents with cognitive impairment and ADL assistance needs were repeatedly observed with several days of beard growth while in bed, dining areas, hallways, and wheelchairs. Care plans identified assistance with personal hygiene, but no shaving preference was documented for some residents, and staff interviews showed shaving was often only done when residents were bathed. A resident’s family also reported missing razor equipment and concern that the resident was not being shaved as needed.
The facility failed to provide enough nursing staff to meet resident hygiene needs and ensure timely call light response. A resident with severe cognitive impairment and another resident needing assistance with personal hygiene were repeatedly observed unshaven over multiple days, while a nurse aide reported too few aides on duty and daily delays in call light response. Resident Council minutes, grievances, and device activity reports documented repeated long call light waits, including waits over an hour, and the DON and Administrator confirmed the facility was aware of the ongoing concerns.
Failure to Administer Consented Pneumococcal Vaccine: A resident with DM, COPD, anemia, and CKD consented to receive the pneumococcal vaccine after receiving education on its risks, benefits, and side effects, but the EMR showed no evidence the vaccine was administered. The IP confirmed the resident had not received the vaccine that was agreed to at admission.
Incomplete discharge summaries and missing Ombudsman notifications: The facility failed to complete required discharge documentation for three residents, including recapitulation of care, final status, med reconciliation, and post-discharge POC. Records also showed no evidence that the State LTC Ombudsman was notified of the residents’ discharges, and RN-B and the SSD confirmed the missing documentation and notifications.
A dietary staff member failed to change gloves and wash hands after handling food, leading to potential cross-contamination. The staff member touched various kitchen items without following proper hygiene protocols, as confirmed by the Dietary Manager.
The facility failed to implement and revise fall prevention measures for three residents with cognitive impairments and high fall risks. One resident lacked required grip strips in their room, another experienced multiple falls without new interventions, and a third had no additional fall measures despite confusion and a fall incident. The DON confirmed these deficiencies.
The facility failed to adhere to hand hygiene protocols and proper use of PPE during care for residents on Enhanced Barrier Precautions, as observed in the care of several residents. Staff did not perform hand hygiene before and after glove use, and gowns were not worn during high-contact care activities. Additionally, the facility did not implement measures to prevent the growth of Legionella in the water system, as confirmed by the Administrator and Maintenance Supervisor.
The facility failed to offer and educate three residents on pneumococcal and influenza vaccines, as required by its policy. The residents' medical records lacked evidence of screening for vaccination status, education on risks and benefits, or offering the vaccines. The DON confirmed the absence of a process and responsible staff for screening immunization status at admission.
The facility failed to offer the COVID-19 vaccine and provide education about its risks and benefits to three residents. The facility's policy required screening and education at admission, but records showed no evidence of these actions. The DON confirmed the absence of a process for screening immunization status and lack of staff responsibility for this task.
The facility failed to notify the PCP about significant lapses in medication and treatment for two residents. One resident did not receive Memantine and CPAP treatment as ordered, and was not assisted with walking as prescribed. Another resident did not receive Prednisone, leading to hospitalization. The DON confirmed the PCP was not informed of these issues.
Two residents in an LTC facility did not receive prescribed medications and treatments due to unavailability and staff oversight. One resident missed Memantine doses and CPAP use, while another did not receive Prednisone, leading to hospitalization. The DON confirmed these deficiencies.
The facility failed to document the duration of antibiotic use for two residents, despite its Antibiotic Stewardship Program requiring such documentation. Both residents, with moderate cognitive impairment and various diagnoses, received continuous antibiotic therapy without specified stop dates. Interviews confirmed that staff had attempted to educate providers on the need for stop dates, but the antibiotics were continued without them.
Failure to Report Unexpected Resident Death to State Agency
Penalty
Summary
The facility failed to report an unexpected resident death, considered an adverse event, to the State Agency within required timeframes as outlined in its own abuse prevention policy and state licensure requirements. The facility’s Abuse: Prevention of and Prohibition Against Policy dated 4/25 stated that all allegations of potential abuse, neglect, exploitation, misappropriation, and adverse events were to be reported immediately to the administrator, with notification to law enforcement in the event of a potential crime, and to Adult Protective Services within 2 to 24 hours depending on the case. The policy further required that a written report be submitted to the State Agency within 5 business days of the allegation. Despite these requirements, review of the facility’s 2026 Facility Reported Incidents showed no evidence that the unexpected death of a resident was reported to the State Agency. The resident involved had multiple serious medical conditions, including metabolic encephalopathy, end-stage kidney disease, chronic respiratory failure, anemia, heart failure, diabetes, and COPD, and required hemodialysis. The resident’s cognition was moderately impaired, and the resident did not have a condition or chronic disease documented as likely to result in a life expectancy of less than six months. The care plan noted the need for hemodialysis, occasional refusals of dialysis and medications, and interventions such as daily assessment of the left arm fistula for bruit and thrill, encouragement to attend dialysis, and monitoring for signs of infection. Nursing progress notes documented that the resident was found nonresponsive in bed with no pulse or respirations, with blood around the body and on the floor, a small open area at the bottom of the left arm fistula, and blood on the fingertips of the right hand, with no signs of trauma or sharp objects nearby. During interview, the DON confirmed the death was unanticipated and untoward and that an internal investigation was completed to ensure no neglect was involved, but acknowledged the facility did not report the unexpected death or submit the investigation results to the State Agency within the required timeframe.
Food Safety Failures in Dishwasher Monitoring and Meal Temperatures
Penalty
Summary
The facility failed to ensure food safety by not consistently documenting dishwasher temperatures and by allowing some dishwasher cycles to run outside the required temperature range. The facility policy required high-temperature dishwashers to have wash cycles between 150 degrees and 165 degrees and final rinse cycles of at least 180 degrees, with daily temperature logs completed to verify compliance. Review of the February 2026 dishwasher temperature log showed missing documentation for the breakfast meal on 12 of 28 days, the noon meal on 20 of 28 days, and the evening meal on 21 of 28 days. The log also showed temperatures out of range at the breakfast meal on several days, at the noon meal on one day, and at the evening meal on several days. The CDM-M confirmed that the dishwasher temperatures were not being completed and logged after each meal and that there were water temperatures logged that were not in the correct range. The facility also failed to ensure food was held at safe temperatures during service. The facility policy required hot foods to be held at or above 135 degrees and cold foods at or below 41 degrees. During an observation on 2/26/26 at 1:40 PM, chicken fried chicken was observed at 116.1 degrees. The Cook-L confirmed that the chicken fried chicken would have been delivered to the resident at an incorrect temperature and would have been served cold. The CDM-M also confirmed that the chicken on the meal tray at that time would have been served at temperatures that were not palatable.
No Evidence of Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to have evidence of an active Antibiotic Stewardship Program. Review of the facility policy on Antibiotic Stewardship, revised 1/2022, showed the program was intended to be part of the overall Infection Prevention and Control Program and included monitoring antibiotic use, assessing residents for infections using McGreer’s criteria, tracking measures, reporting data, and providing feedback to physicians on prescribing patterns of cultures ordered and antibiotics prescribed. The facility census was 62 residents, and the deficiency was identified based on record review and interview. Review of the facility Infection Surveillance records from January 2025 through February 2026 found no evidence that the facility identified culture information for infections treated with antibiotics or used any criteria to determine whether antibiotics were being prescribed in accordance with the facility ASP. During an interview on 3/3/26, the Infection Preventionist confirmed the facility had not used criteria, tracking, or determination of offending organisms to evaluate whether ordered antibiotics met the prescribing standards outlined in the ASP, and that information had not been provided to prescribing providers regarding whether the antibiotics ordered met ASP criteria.
Failure to Resolve Repeated Grievances for Call Light Delays and Cold Food
Penalty
Summary
The facility failed to address repeated grievances and failed to ensure sustainable resolutions for ongoing concerns related to long call light response times and cold food temperatures. Review of the grievance records from 1/16/25 to 12/1/25 showed 13 grievances about call light response times and 8 grievances about cold food temperatures, with no evidence that corrective actions or sustained resolutions were implemented to prevent the concerns from recurring. The facility policy required grievances to be tracked through conclusion, documented with a resolution, and followed up with the resident, but the record review and interviews showed these steps were not completed for the repeated concerns. Resident Council meeting minutes from 2/5/25 through 2/6/26 repeatedly documented the same complaints, including long call light response times in the mornings, evenings, and early mornings, as well as ongoing concerns about cold food temperatures and delays in meal delivery. During the 3/3/26 Resident Council meeting with Residents 23, 32, 36, 42, and 51, residents stated they had filed grievances about these issues and were told staff would look into them, but no further interventions were identified. In interview, the Administrator, DON, and RN consultant confirmed the facility was aware of the ongoing concerns, that grievances were supposed to have documented resolutions and follow-up, and that the staff failed to ensure resolution and document follow-up; they also stated the facility could print call light response time reports but had not reviewed them despite continued complaints.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure food was served at palatable temperatures. Review of the facility policy showed hot foods were to be held at or above 135 degrees and cold foods at or below 41 degrees, and food temperatures were to be checked periodically during portioning, transporting, and serving. The facility’s food temperature log also listed required cooking temperatures for poultry, seafood, eggs, beef, and pork, along with a holding temperature of 135 degrees. During observation, the Dietary Manager grilled 4 hamburger patties and 3 hotdogs, but the temperatures were not checked when they were removed from the grill. The hotdogs and hamburgers were then placed in a metal container on the steam table, and one hamburger and one hot dog were served for the noon meal. The Dietary Manager also heated cold chicken noodle soup in the microwave and served it directly after removal without checking the temperature. Later, a meal tray was observed with chicken fried chicken at 116.1 degrees, mashed potatoes at 112.0 degrees, and brussel sprouts/squash at 109.0 degrees. The Cook confirmed the tray would have been delivered with food served at incorrect temperatures and that the food would have been served cold. The Certified Dietary Manager confirmed the chicken, potatoes, and vegetables on the tray were not at palatable temperatures and that the soup, hamburgers, and hot dogs were not checked to ensure they met minimum cooking temperatures.
Infection Control, Hand Hygiene, and EBP Failures
Penalty
Summary
The facility failed to perform hand hygiene at appropriate intervals during care and medication provision, failed to ensure proper use of PPE for several residents, and failed to implement Enhanced Barrier Precautions (EBP) for a resident who met criteria for EBP. The facility policies reviewed described infection control, standard and transmission-based precautions, handwashing, and the use of gowns and gloves for high-contact care activities, including care for residents with wounds, indwelling devices, or MDROs. The Infection Preventionist confirmed that hand hygiene was required each time gloves were removed and that gowns and gloves were to be used for high-contact care for residents on EBP. During care for a resident with ESBL and self-care deficits, staff donned gowns and gloves, but after removing gloves they did not perform hand hygiene before gathering supplies, assisting with dressing, applying socks, or transferring the resident. The same resident was also provided oral care setup and transfer assistance without gloves after glove removal and without hand hygiene between tasks. In another observation, a medication aide provided oral medications, assisted a resident with a transfer, left the room without hand hygiene, and then prepared medications for another resident at the medication cart. A nurse also placed insulin pens and a blood glucose meter on a roommate’s over-bed table without cleaning the surface or using a clean barrier, then performed blood glucose testing and insulin administration and returned the items to the cart without cleaning them or performing hand hygiene. The facility also failed to use PPE correctly for residents identified for EBP. One resident with a dialysis port was documented as requiring EBP, but staff were unaware of the status, there was no EBP sign or PPE on the door, and toileting care and skin treatments were completed without PPE. Another resident with an indwelling catheter was transferred from bed to wheelchair without gown or gloves, despite confirmation from the DON and CNA that gowns and gloves were required for that high-contact care. A resident with a recently healed stage 3 pressure ulcer had no evidence of EBP in the care plan, and staff reported no knowledge that EBP had ever been in place for that resident.
Inaccurate MDS Coding for PASRR and Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for two residents. Review of the Resident Assessment Instrument showed that PASRR review is used to identify individuals admitted to nursing facilities who have or are suspected to have Major Mental Illness (MMI), Intellectual Disability (ID), or Related Disorders (RD), and that Section I is intended to code diseases directly related to a resident’s current functional status, cognitive status, mood and behavior status, medical treatments, nursing monitoring, or risk of death. For one resident, the PASRR level 2 screen identified a Major Mental Illness, but the resident’s MDS indicated the resident had not been determined by the state PASRR level 2 process to have a serious mental illness, intellectual disability, or related disorder. For another resident, the MDS listed Depression, Anxiety Disorder, and a Psychotic disorder, while the care plan listed Major Depressive Disorder, Anxiety Disorder, Hallucinations, and Mood (affective) Disorder, but no Psychotic Disorder. During interview, RN-B confirmed the MDS for both residents was not coded accurately to reflect the resident’s PASRR status and diagnoses directly related to the resident’s current status.
PASRR Screening and Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure Resident 2’s PASRR Level 1 screening was completed accurately and failed to care plan Resident 25’s PASRR results related to major mental illness. The facility policy for Resident Assessment and Preadmission Screening for MI/DD stated residents were to be properly screened using the State PASRR process and that residents with MI or DD were not to be admitted without proper referral for specialized services and care planning. The sample size was 3 and the facility census was 62. Resident 2 was admitted with diagnoses including Anxiety, Depression, and a Psychotic Disorder. The PASRR Level 1 completed before admission stated the resident had no signs of serious mental illness, intellectual disability, or related disorder and indicated no known or suspected mental health diagnosis. However, the resident’s care plan later included Major Depressive Disorder, Generalized Anxiety Disorder, Unspecified Mood Disorder, hallucinations, depression, anxiety, psychotropic medication use, and monitoring for hallucinations, delusions, self-isolation, and adverse effects of psychotropic medication. RN-B confirmed the PASRR Level 1 screen did not accurately contain the mental health diagnosis present to determine whether a Level 2 screening was needed. Resident 8 was admitted with diagnoses including Anxiety, Depression, and Schizophrenia, and the PASRR showed signs of serious mental illness with a Level 2 evaluation completed that found the resident had a serious mental illness and was appropriate for nursing facility services. The resident also had a history of three psychiatric hospitalizations, regular psychiatry visits, and medication noncompliance resulting in delusions and hallucinations, but the care plan did not include evidence of the PASRR Level 2 determination or the history of psychiatric hospitalization.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide enough food and fluids to maintain a resident’s health, resulting in significant weight loss for one resident with hip fracture, anemia, depression, and severe cognitive impairment. The resident was dependent for eating and other activities of daily living and was identified as nutritionally at risk. The care plan included a mechanical soft diet, 2Cal supplement, meal replacement if intake was less than 50%, dining room meals if agreeable, and weights as ordered. The resident’s weight declined from 194 lbs on admission to 173 lbs within 22 days, then to 159.2 lbs by day 48, reflecting a 34.8 lb loss or 17.9% from admission. Facility policy required weekly weights for the first four weeks after admission and evaluation of significant weight changes by the IDT, but there was no documentation that weekly weights were obtained during that period. The RD noted weight loss and requested a re-weigh after an 11.3% loss, but the re-weigh was not documented until several days later. The RD later recommended 2Cal twice daily and then increased it to three times daily as weight loss continued. Meal intake records showed the resident refused multiple meals and ate only 25% of some meals, but there was no evidence the resident was offered a meal replacement when intake was less than 50% on several occasions. The resident was also receiving furosemide, spironolactone, and Mounjaro, all of which were documented in the record. The DON stated the resident was not being reviewed by the weight loss committee, and the IDT had not evaluated the resident’s weight loss to determine a cause or assess the effectiveness of current interventions. The RN consultant confirmed that no re-weigh was documented after the initial weight warning until several days later and that no interventions were put into place to prevent further weight loss during the early part of the stay.
Failure to Provide Routine Shaving for Multiple Residents
Penalty
Summary
The facility failed to provide routine hygiene, specifically shaving, for Residents 3, 10, and 14. The facility policy stated that residents unable to perform ADLs would receive the necessary services to maintain grooming, and the residents’ needs were to be outlined in the plan of care. Review of Resident 3 showed severe cognitive impairment, dependence for hygiene-related care, and frequent bladder incontinence, with the care plan identifying a need for staff assistance with personal and oral hygiene. No documented resident preference for shaving frequency was found. Observations of Resident 3 from 2/26/26 through 3/3/26 showed the resident repeatedly unshaven, including facial and upper neck hair growth noted in bed, during morning care, and while seated in a wheelchair in the room and public areas. The resident remained unshaven over multiple observations, with facial hair becoming longer over time, and on one later observation the face was shaved but the upper neck remained unshaven. Resident 10’s MDS showed the resident received set-up and/or supervision with personal hygiene, and the care plan identified a need for assistance with personal and oral hygiene, but no shaving preference was documented. Resident 10 was observed repeatedly unshaven while in the dining room, hallway, recliner, and wheelchair, with facial and neck hair described as very long. The resident’s daughter reported concern about insufficient nursing staff to get things done timely and stated the resident’s electric razor cord had been missing through multiple room changes, with a replacement cord ordered by family; she questioned why the facility had not found another way to ensure shaving. Staff interviews indicated NA-I had not been informed that men needed to be shaved daily or according to the care plan and said residents were only shaved when bathed. For Resident 14, the MDS and care plan showed cognitive impairment and need for staff assistance with personal care, including personal hygiene, and observations repeatedly found several days of beard growth while the resident was in bed and in the dining room. Resident 14 stated the resident had not been shaved for several days and preferred shaving at least every 2 days, and RN-B confirmed the resident was not getting shaved per that preference.
Insufficient Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the hygiene needs of residents and to ensure timely call light response. The deficiency was identified during observation, interview, and record review at a facility census of 62 residents. The report states that the facility did not have enough staff to meet the needs of residents and did not have timely responses to call lights. Resident 3 had severe cognitive impairment, and staff completed all hygiene needs, dressing, transferring, and substantial assistance with bed mobility. The resident was frequently incontinent of bladder and required staff assistance for personal and oral hygiene. Observations over several days showed the resident lying in bed or sitting in a wheelchair while unshaven, with several days of beard growth and later substantially longer facial hair. On one observation, the face was shaved but the upper neck remained unshaven. No documented resident preference for shaving frequency was found in the care plan. Resident 10 required set-up and/or supervision with personal hygiene and needed assistance for personal and oral hygiene. Observations over several days showed the resident repeatedly unshaven, with facial and neck hair described as very long at one point. The resident’s daughter reported concern about the lack of nursing staff to get things done timely and stated that the resident’s electric razor cord had gone missing through multiple room changes, with family unsure why the facility did not find an alternate way to ensure shaving was completed. Staff interviews and facility records showed ongoing concerns about staffing and call light response times. A nurse aide reported that there were often too few nurse aides to get residents up in time for breakfast and that after 2:00 PM there were often only 3 nurse aides for nearly 70 residents, with long call light responses happening daily. Resident Council minutes documented repeated complaints about long call light response times in the mornings, evenings, and early mornings across multiple meetings. The facility also had 13 grievances involving call light response times, and the device activity report showed numerous call lights exceeding 15 minutes on multiple days, including waits of more than 1 hour on some occasions. During interview, the Administrator, DON, and RN consultant confirmed the facility was aware of the ongoing concerns, that grievances were supposed to have documented resolutions and follow-up, and that the facility had failed to review response times despite continued complaints.
Failure to Administer Consented Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide Resident 8 with the pneumococcal vaccine that the resident had consented to receive at admission. The facility’s immunization policy stated that influenza, pneumococcal, and COVID-19 immunizations were offered and administered to eligible residents after education on risks and potential side effects and after obtaining consent. The admission packet also included a Resident Consent for Influenza, Pneumococcal and COVID-19 Form for residents and/or responsible parties to complete at admission. Resident 8’s consent form dated 10/9/25 showed the resident received education about the pneumococcal vaccine, reviewed the risks, benefits, and potential side effects, understood there were different types of pneumococcal vaccines that could be reviewed with the physician, and wished to receive the vaccine according to CDC recommendations. Resident 8’s care plan, revised 1/6/26, listed diagnoses of diabetes, COPD, anemia, and chronic kidney disease, and noted the resident was to be monitored for signs and symptoms of respiratory insufficiency. Review of the electronic medical record showed no evidence that the pneumococcal vaccine was administered, and the Infection Preventionist confirmed on 3/2/26 at 3:00 PM that Resident 8 had not received the vaccine that had been consented to.
Incomplete discharge summaries and missing Ombudsman notifications
Penalty
Summary
The facility failed to complete required Ombudsman notifications and comprehensive discharge summaries for Residents 71, 72, and 74. Facility policy stated that discharge summaries were to include a recapitulation of the resident’s stay, a final summary of status, medication reconciliation, and a post-discharge plan of care, and that written notification was to be provided to the resident, resident representative, and the Office of the State Long-Term Care Ombudsman in advance of transfer or discharge, or as soon as practicable when required. Review of the records showed Resident 71 was discharged to home/community, but the discharge summary and post-discharge plan of care contained no evidence of the resident’s care and services, final status, discharge plan, or medication reconciliation, and there was no evidence the State Ombudsman was notified. Resident 72’s record showed discharge with a return anticipated, but there was no evidence a discharge summary was completed and no evidence the State Ombudsman was notified. Resident 74’s discharge summary and post-discharge plan of care also lacked evidence of a recapitulation of care and services, final status, discharge plan of care, and medication reconciliation, and there was no evidence the State Ombudsman was notified. During interview, RN-B confirmed the facility had no evidence the discharge summaries and post-discharge plan of care were completed for Residents 71, 72, and 74, and the SSD confirmed the State Ombudsman had not been notified of the discharges.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene and glove use during a meal service, leading to a potential for cross-contamination. During the noon meal service, a dietary staff member, identified as DC-P, was observed handling food with gloved hands. After placing a piece of pork loin on a dinner plate and cutting it into small pieces, DC-P did not change gloves or wash hands before touching various kitchen items, including resident cards, dishes, and serving utensils. This action was contrary to the Drug Administration Food Code, which mandates that food employees wash their hands and change gloves to prevent cross-contamination. An interview with the Dietary Manager confirmed that the staff should have removed gloves, washed hands, and donned a new pair of gloves before handling other kitchen items.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adequately review, revise, and implement care plan interventions to prevent falls for three residents, leading to deficiencies in fall management. Resident 16, who had moderate cognitive impairment and was a high fall risk, did not have grip strips present on the floor in front of their recliner as required by their care plan. Despite multiple observations over several days, the grip strips were consistently missing, which was confirmed by the Director of Nursing (DON). Resident 19, also with moderate cognitive impairment and a high fall risk, experienced multiple falls without any new immediate interventions being implemented. The resident's care plan included various fall prevention measures, but after falls on two separate occasions, no additional interventions were put in place to prevent future incidents. The DON confirmed the lack of new interventions following these falls. Resident 7, who had a diagnosis of anemia, non-Alzheimer dementia, seizure disorder, and depression, experienced a fall while sitting on a floor mat next to the bed. The resident was confused and unaware of their limitations. Although an SBAR was completed and a urinalysis was ordered, no other fall interventions were implemented. The DON confirmed the timeline of the urinalysis and culture results, but no treatment was ordered, and no further fall prevention measures were taken.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols, as observed in the care of Residents 17, 11, and 7. For Resident 17, a nurse aide did not perform hand hygiene before and after glove use during multiple care activities, including assisting the resident with dressing and personal hygiene. Similarly, for Resident 11, a nurse aide did not wash hands or use hand sanitizer before and after glove changes while providing toileting and incontinence care. These actions were confirmed by interviews with the Director of Nursing and the staff involved, who acknowledged the lapses in following the facility's hand hygiene policy. The facility also failed to utilize appropriate Personal Protective Equipment (PPE) during the care of Residents 34 and 7, who were on Enhanced Barrier Precautions (EBP). For Resident 7, staff did not wear gowns during high-contact care activities, such as toileting and incontinence care, despite the resident having a stage 4 pressure ulcer and being on EBP. This was confirmed by interviews with the staff involved and the Director of Nursing, who acknowledged that gowns should have been worn. Similarly, for Resident 34, a nurse aide did not wear a gown while assisting with wound care and other high-contact activities, which was confirmed by the staff and the Infection Preventionist. Additionally, the facility failed to develop and implement measures to prevent the growth of potential waterborne illnesses, such as Legionella. The facility did not conduct a risk assessment to identify potential sources and areas of risk for Legionella growth in the water system. This was confirmed by the Administrator and the Maintenance Supervisor, who acknowledged that no measures had been implemented to prevent the growth of Legionella in the facility's water systems.
Failure to Offer and Educate on Vaccinations
Penalty
Summary
The facility failed to ensure that three of five sampled residents were offered the pneumococcal and influenza vaccines and were educated about the associated risks and benefits. The facility's policy, revised on October 24, emphasized the importance of vaccinations for the health and well-being of long-term care residents, with procedures in place for screening residents at admission and annually for influenza. However, the facility did not adhere to these procedures, as evidenced by the lack of documentation in the electronic medical records of Residents 31, 197, and 244. These records showed no evidence of screening for vaccination status, education on the risks and benefits, or offering and administering the vaccines. During an interview, the Director of Nursing confirmed that the facility lacked a process and responsible staff for screening residents' immunization status upon admission. This oversight resulted in Residents 31, 197, and 244 not receiving the necessary education or being offered the influenza and pneumococcal vaccines. The facility's failure to implement its immunization policy and procedures led to this deficiency, impacting the residents' access to essential vaccinations.
Failure to Offer COVID-19 Vaccine and Education
Penalty
Summary
The facility failed to provide evidence that three residents were offered the COVID-19 vaccine or educated about its risks and benefits. The facility's policy required residents to be screened at admission to determine their vaccination status and eligibility, and to receive education about the vaccine before it was offered. However, the records for Residents 31, 197, and 244 showed no evidence of such screening, education, or vaccine offering. This deficiency was identified through a review of the residents' electronic medical records. During an interview, the Director of Nursing confirmed that the facility did not have a process in place for screening residents' immunization status at admission, and no staff were responsible for this task. Additionally, there was no evidence that the residents or their responsible parties received education about the COVID-19 vaccine or were offered the vaccine. This lack of process and documentation led to the deficiency noted in the report.
Failure to Notify PCP of Medication and Treatment Lapses
Penalty
Summary
The facility failed to notify the Primary Care Physician (PCP) regarding significant lapses in medication and treatment administration for two residents. Resident 17 did not receive the prescribed medication Memantine for 13 days and was not provided with a CPAP machine for 15 days, as ordered. Additionally, Resident 17 was not assisted with walking as prescribed on multiple occasions. There was no evidence that the PCP was informed about these failures, which were confirmed by the Director of Nursing (DON). Resident 22 did not receive the prescribed Prednisone for several days due to unavailability, which was not communicated to the PCP. This resident experienced shortness of breath and was eventually hospitalized with a diagnosis of pneumonia. The DON confirmed that the PCP was not notified about the unavailability of the medication and the resident's subsequent condition.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to adhere to practitioner's orders for two residents, leading to significant deficiencies in care. Resident 17, who was admitted with multiple diagnoses including Alzheimer's disease and obstructive sleep apnea, did not receive prescribed Memantine medication for 13 out of 28 days due to unavailability. Additionally, the resident's CPAP machine, ordered for nightly use, was not provided for 15 out of 28 days. Furthermore, the resident was not assisted with walking as ordered, missing numerous scheduled ambulation times. The Director of Nursing confirmed these lapses, noting the absence of a policy related to following physician orders. Resident 22, with diagnoses including heart failure and respiratory failure, was prescribed Prednisone for respiratory issues but did not receive the medication for 8 out of 14 days due to pharmacy unavailability. This resident experienced worsening respiratory symptoms, including shortness of breath and diminished lung sounds, and was eventually hospitalized with pneumonia. The Director of Nursing acknowledged the medication was not available and confirmed the resident's subsequent hospitalization.
Failure to Document Antibiotic Duration for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 16 and 19, had a documented duration of use for their long-term antibiotic therapy. The facility's Antibiotic Stewardship Program (ASP) policy requires that antibiotic orders include the indication, dose, and duration, and that the pharmacy consultant reviews and reports antibiotic usage monthly. However, the records for both residents showed continuous antibiotic administration without specified stop dates. Resident 16, who has moderate cognitive impairment and diagnoses including Parkinson's Disease and dementia, was receiving Bactrim DS for a urinary tract infection from April through December 2024. Similarly, Resident 19, with moderate cognitive impairment and a history of bladder infections, was receiving Keflex from June through December 2024. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the facility staff had reached out to the providers for education regarding the need for stop dates, but the antibiotics were continued without them. This oversight indicates a failure to adhere to the facility's ASP policy, which aims to optimize antibiotic use and reduce adverse events. The lack of documented stop dates for the antibiotics prescribed to Residents 16 and 19 represents a deficiency in the facility's medication management practices.
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What surveyors actually found near you
We read the 40 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Norfolk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Of Bel Air | 0.7 mi | ★★★★★ | 0 | 0 |
| Community Pride Care Center | 9.1 mi | ★★★★★ | 7 | 0 |
| Stanton Health Center | 12.1 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of Pierce | 12.1 mi | ★★★★★ | 2 | 0 |
| Arbor Care Centers-countryside Llc | 13.8 mi | ★★★★★ | 16 | 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.