Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 St. Joseph Villa Nursing Center during CMS and state inspections, most recent first.
The facility failed to use its QAPI program to identify and address multiple survey deficiencies and did not maintain corrections for repeat issues from prior surveys. Survey findings included failures involving resident notifications, transfer paperwork, PASARR referral, oral hygiene, lab follow-up, neuro checks, weight and fluid monitoring, air mattress function, oxygen settings, PTSD assessment, medication monitoring, dietary qualifications, food temperature, hand hygiene, and grievance posting. Staff interviews showed NA and MA staff did not know what QA/QAPI was or what the committee was working on, and the Administrator stated prior corrections were not sustained.
Multiple residents experienced failures in ordered monitoring and follow-up. A resident with heart failure did not receive ordered daily weights or documented fluid intake tracking despite a fluid restriction. A resident with diabetes and a foot ulcer used an air mattress that repeatedly showed a low-pressure warning without timely action. Another resident with recurrent UTIs had a specialized urine test completed, but the positive results were misdirected to an outdated email and not communicated to the provider until much later. A resident with CHF on diuretics had an order for weekly weights, yet weight records showed repeated multi-week gaps despite visible edema. In addition, after an unwitnessed fall, a resident did not receive the neurological checks required by the facility’s post-fall policy.
Food Trays Delivered to Rooms Were Not Kept at Proper Temperatures. A resident stated meals delivered to the room were cold and not warm enough, and another resident said the food was not hot enough. On observation, the DM measured room tray items below the expected temperatures, including soup, a sandwich, and tater tots below the hot-food standard and peaches above the cold-food standard. The DM confirmed the facility did not have plate warmers or insulated plate covers.
Staff failed to perform hand hygiene between residents while assisting multiple residents with meals. NAs, RNs, and LPNs were observed moving from one resident to another, touching residents, clothing, plates, and silverware without cleaning their hands between contacts. The DON confirmed staff should not go back and forth assisting residents with meals without hand hygiene between residents.
A resident with anxiety disorder, bipolar disorder, and schizophrenia was receiving multiple doses of Seroquel and required total assistance with activities of daily living. Facility policy required that an AIMS score of 2 or higher, suggesting possible TD, be communicated to the physician and discussed with the resident and family. The resident’s AIMS score increased from 0 to 4 after antipsychotic dose increases, but the physician and resident representative were not notified of this change. The DON confirmed that the increase occurred and that required notifications were not made.
A resident with hemiplegia, dysphagia, and dementia, who required staff supervision for oral hygiene, did not receive or was not offered morning oral care as required by facility policy and physician orders. Despite a care plan calling for staff assistance with hygiene and a dental note documenting very poor oral hygiene and the need for daily assisted tooth brushing, staff progress notes showed only two documented refusals over several months. During a surveyed morning care episode, a NA assisted the resident with getting out of bed, dressing, hair care, and eyeglasses but did not provide or offer tooth brushing, later confirming that oral hygiene was omitted even though it should have been part of the morning routine.
A resident with malnutrition, Inclusion Body Myositis, moderate cognitive impairment, total dependence for ADLs, incontinence, recent weight loss, and identified risk for pressure ulcers had a care plan that included use of an air pressure mattress to maintain skin integrity. Surveyors observed multiple times that the air mattress pump was either turned off while the resident was in bed or displaying a persistent low-pressure warning light while in use. A MA confirmed the mattress should have been on when it was not, and the wound nurse acknowledged the low-pressure light but was unsure of its meaning without consulting the manual, demonstrating a failure to ensure the ordered pressure-relieving device was properly functioning for this high-risk resident.
Failure to complete hospital transfer documentation and communication for two residents. One resident with CKD, DM with complications, and OSA was transferred for pneumonia and respiratory failure, and another resident with vascular dementia, CHF, bradycardia, TIA, and cerebral infarction was sent to the ED after a fall. In both cases, the EMR lacked evidence of the required transfer form and hospital communication, and the DON/ADON confirmed the documentation was not completed.
A resident was admitted with depression-related diagnoses and initially did not require a PASRR Level 2 review. After PTSD was later identified and a significant change MDS documented PTSD, depression, and adjustment disorder with depressed mood, the facility did not make a PASRR referral for review. The Administrator confirmed no recommendation had been sent to the PASRR agency after the significant change assessment.
A resident with epilepsy, dementia, schizoaffective disorder, obesity, and other diagnoses had bilateral bed assist rails for self-positioning and transfers, but the facility did not complete required quarterly assessments or preventive maintenance checks. Staff observed the right-side rail was loose and bowed away from the bed on multiple occasions, with a washer and nut left on the bedside table, and interviews confirmed the resident used the rail daily and that the required assessments and maintenance logs were not completed.
Oxygen Flowrate Not Set to Ordered Level: A resident with COPD, chronic respiratory failure, CHF, and dependence on supplemental O2 was observed with the O2 concentrator set above the ordered daytime rate on multiple occasions. The resident’s order required 2 L/min during the day and 4 L/min at rest and while sleeping with AVAPS, but staff found the concentrator at 3.5 L/min and later at 4 L/min when it should have been 2 L/min; an LPN confirmed the incorrect setting.
A resident with PTSD and multiple mental health diagnoses had no trauma-informed care assessment completed, despite being cognitively intact and confirming a history of childhood trauma. The facility’s policy called for residents with trauma or PTSD to have care and services addressing the condition and for the resident or representative to help identify triggers and coping interventions.
Failure to identify medication irregularities during DRR affected one resident receiving Seroquel for psychiatric diagnoses and another resident receiving multiple antihypertensives. The pharmacist did not note an increased AIMS score that reached a level consistent with TD, and no provider update was submitted. For the other resident, pharmacy reviews flagged duplicate antihypertensive therapy, but no physician rationale was documented.
The facility failed to ensure a qualified Dietary Manager or qualified nutrition professional was available full-time, part-time, or on a consultant basis. Record review showed the DM was not certified, and the Administrator confirmed the DM had not completed the certification test and that there was no full-time dietician. The facility had a census of 148 residents.
Staff failed to perform hand hygiene between glove changes during perineal care for multiple residents, including one resident with stroke-related deficits and dementia who required substantial toileting assistance. Staff also failed to clean a resident’s nebulizer mask and medication chamber between uses, with the equipment observed resting on a stand with condensation present and no barrier underneath. RN confirmation supported the observations.
An LPN did not wear a gown while providing wound care to a resident with a left heel wound, despite facility policy requiring both gowns and gloves for such procedures. The LPN acknowledged the omission, and the facility's policy specified that PPE must be used during high-contact activities like wound care.
A resident with Alzheimer's and dementia, requiring extensive assistance, was improperly transferred using a Hoyer lift with an incorrect sling, leading to a tibial and fibula fracture. Nursing staff lacked guidance on determining sling size, as the facility's policy did not provide instructions, resulting in a major injury.
Facility staff failed to secure medications properly, with two incidents of unlocked and unattended medication carts on the 100 hall. These lapses were confirmed by interviews with staff, who acknowledged the carts should have been locked. The facility's policy requires all medications to be stored in locked compartments when not in use.
The facility did not adhere to the planned menu for residents on pureed diets, affecting several individuals. Instead of receiving the scheduled pureed hot dog with bun and gravy, they were mistakenly served pureed mashed potatoes with gravy, resulting in a lower intake of protein and calories. This error was confirmed by staff, including the RD.
The facility failed to follow Enhanced Barrier Precautions (EBP) and infection control protocols, as staff did not wear gowns during high-contact care for residents on EBP. Instances included an LPN administering water via a G-tube and NAs providing care without gowns. Additionally, an oxygen nasal cannula was found on the floor, and the Laundry Supervisor mishandled laundry, risking cross-contamination.
A facility breached a resident's privacy by posting dietary instructions on their door, revealing personal health information. The resident, with moderate cognitive impairment and Diabetes Mellitus, had a sign indicating dietary restrictions, which was confirmed by the DON as a privacy violation.
A resident with Peripheral Vascular Disease and Cellulitis did not have compression stockings or Prevalon boots applied as per physician's orders. Observations confirmed the absence of these items, and an LPN noted that the orders were entered incorrectly, leading to the oversight.
A facility failed to evaluate and implement a toileting program for a cognitively intact resident who was frequently incontinent of urine and always incontinent of bowel. Despite the resident's ability to express the need to use the toilet and use a bedpan, the care plan lacked a toileting program, contrary to the facility's policy. Interviews confirmed the absence of such a program, highlighting a deficiency in care planning.
The facility failed to document the indication for antibiotic use for two residents, leading to a deficiency in their antibiotic stewardship program. One resident received Amoxicillin/Augmentin without a documented reason, and another was prescribed doxycycline without a stop date or rationale. This indicates a lapse in the facility's adherence to its antibiotic stewardship policy, which emphasizes appropriate use and documentation of antimicrobials.
The facility failed to offer and document the updated COVID-19 vaccination for 2024-2025 to two residents, despite their vaccination history. The EHR lacked documentation of education or opportunities for these residents to accept or decline the vaccine, as confirmed by the DON. This oversight violated the facility's policy and CDC recommendations.
QAPI Program Failed to Identify and Sustain Correction of Survey Deficiencies
Penalty
Summary
The facility failed to ensure its QAPI program identified and addressed multiple deficient practices found during the survey and failed to maintain corrections from repeat deficiencies cited on prior surveys. The report states that the facility’s QAA policy was intended to identify and respond to quality deficiencies and develop sustainable outcomes, but the Administrator acknowledged the facility was not sure why the cited areas were not identified before the survey. The Administrator also stated the facility works on items from the previous survey, but once audits show improvement the issue falls off and the correction is not maintained. During the survey, deficiencies were identified involving resident notification for a change in AIMS scale score, transfer and discharge documentation, PASARR referral after a mental disorder diagnosis, oral hygiene, follow-up on lab work and neurological assessments, monitoring of fluid intake and weights, functioning air mattresses, quarterly bed assist device assessments, oxygen flow rate settings, assessment of PTSD triggers, antipsychotic medication monitoring, dietary manager qualifications, food temperature, hand hygiene, and grievance posting. The report also notes repeat deficiencies from the prior standard survey, including accident hazards/supervision/devices, infection prevention and control, quality of care, and unnecessary drugs. Staff interviews showed NA-W and NA-X had no idea what QA was or what the committee was working on, and MA-V knew the term QAPI but did not know what was being worked on or when the committee met.
Multiple Failures to Follow Orders for Monitoring, Equipment, Lab Results, and Post-Fall Assessments
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to practitioner orders and facility policies for several residents. One resident with heart failure was discharged from the hospital with orders for a 2000 ml fluid restriction and daily weights. Record review showed multiple gaps where no daily weights were documented over several multi‑day periods, and the Assistant Director of Nursing confirmed that daily weights were not done as ordered. The resident’s electronic health record also lacked documentation of daily fluid intake monitoring, and interviews with a nursing assistant and an LPN confirmed that the resident’s fluid intake was neither recorded nor tracked to ensure compliance with the 2000 ml restriction. Another resident with diabetes and a documented diabetic foot ulcer had a care plan intervention for use of an air mattress to protect skin and promote healing. Over several days of observation, the air mattress consistently displayed a low‑pressure warning light. The wound nurse acknowledged the low‑pressure light and indicated the need to consult the owner’s manual to determine its meaning. The ADON later confirmed that the mattress was being replaced and provided manufacturer information stating that if the low‑pressure light remained on for longer than 30 minutes, the mattress should be serviced, indicating that the mattress had not been functioning properly for an extended period while in use for this resident. A third resident with a history of recurrent UTIs, ESBL resistance, and prior sepsis had a provider order for a DNA/Microgen urinalysis after completing an antibiotic course. Progress notes documented that a urine specimen was collected and sent, and the physician documented that staff were to monitor closely and await culture and sensitivity results. The MicroGenDX report showed the specimen was collected, received, and reported as positive for a UTI, but the results were not present in the resident’s record and were not communicated to the provider until much later. The DON confirmed that the Microgen UA results had been sent to the ADON’s old email address and were not discovered until they were specifically requested, resulting in a delay in notifying the provider and initiating a new antibiotic. Another resident with chronic diastolic CHF, abnormal weight loss, and diuretic therapy had an order for weekly weights and a care plan intervention to monitor weights and notify the physician of changes. The weight record showed repeated multi‑week gaps where no weights were obtained, despite the resident having documented weight fluctuations and edema requiring additional diuretic therapy. Observations noted significant edema in both legs and feet, and an LPN confirmed that cardiology was following the resident and adjusting medications. The DON confirmed that weekly weights were not being completed as ordered. A further deficiency involved a resident with delusional disorder, epilepsy, and a history of falls, who experienced an unwitnessed fall when staff found the resident on the floor in front of a wheelchair after rolling out of bed. The facility’s post‑fall assessment policy required initiation of neurological assessments for all falls and documentation every shift for 72 hours. Review of the resident’s electronic medical record, including progress notes and scanned documents, revealed that neurological checks were not completed following this unwitnessed fall. The DON confirmed that no neurological checks were found in the resident’s record for this event.
Food Trays Delivered to Rooms Were Not Kept at Proper Temperatures
Penalty
Summary
Food and drink were not maintained at a palatable and safe temperature for residents receiving room trays. During an interview, Resident 15 stated the food was cold and not warm enough and confirmed meals were eaten in the resident's room. On observation of a test tray delivered to hall 900, the Dietary Manager measured temperatures of 108.3 degrees for tomato soup, 107 degrees for a philly steak sandwich, 119 degrees for tater tots, and 43 degrees for peaches. The Dietary Manager stated the soup, sandwich, and tater tots should have been above 135 degrees and the peaches below 41 degrees, and confirmed the facility did not have plate warmers or insulated plate covers. Resident 106 also stated the food was not hot enough and confirmed meals were eaten in the resident's room.
Failure to Perform Hand Hygiene Between Residents During Meal Assistance
Penalty
Summary
Facility staff failed to perform hand hygiene between residents while assisting multiple residents with eating, contrary to the facility’s Feeding a Resident policy, which stated staff should wash hands before and after assisting residents with meals. During observations, staff were seen moving back and forth between residents and touching residents, clothing, plates, and silverware without cleaning their hands between resident contacts. This occurred with several staff members, including NAs, RNs, and LPNs, while assisting residents in the dining area and during meal service. Observed examples included an NA assisting two residents at the same time, an NA and another NA assisting additional residents with meals without hand hygiene between residents, an RN and an LPN doing the same, and an LPN setting up food for one resident and then feeding another without hand hygiene after resident contact. The DON confirmed during interview that staff should not go back and forth assisting residents with meals without performing hand hygiene between residents. The report also stated that 27 residents in the main dining area were assisted with dining.
Failure to Notify Physician and Representative of Significant AIMS Score Increase
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and resident representative of a significant change in the resident’s Abnormal Involuntary Movements Scale (AIMS) score. Facility policy dated 02-2021 stated that an AIMS score of 2 or higher is evidence of Tardive Dyskinesia (TD), and that if a resident’s score suggests TD, the results should be discussed with the physician, resident, and family, and the need for continued antipsychotic therapy should be considered. Record review showed that the resident, who had anxiety disorder, bipolar disorder, and schizophrenia, was rarely able to make self understood and required total assistance with activities of daily living. The resident was receiving Seroquel 25 mg daily, and additional doses of Seroquel 100 mg at bedtime and 25 mg at noon were later added. An AIMS assessment conducted on 09-17-2025 showed a score of 0, but a subsequent AIMS assessment on 11-04-2025 showed an increased score of 4. Despite this documented increase, which met the facility’s policy threshold for possible TD and required discussion with the physician and family, there was no evidence that the physician or the resident’s representative were informed of the change in the AIMS score. In an interview on 01-08-2026, the DON confirmed that the resident had an increase in the AIMS score and that the facility did not update the resident’s representative or the physician of this increase and acknowledged that they should have done so.
Failure to Provide Required Morning Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide or offer required oral hygiene during the morning routine for one resident who was dependent on staff assistance. Facility policy on oral hygiene, last reviewed in May 2021, required oral care every morning and at bedtime. The resident, admitted in late December 2024, had diagnoses including hemiplegia and hemiparesis following a stroke affecting the right dominant side, dysphagia, and dementia, and was assessed on the MDS as rarely or never understood, rejecting care on one to three days during the assessment period, and requiring supervision to complete oral hygiene. The resident’s comprehensive care plan included an intervention for assistance of one staff member for dressing and hygiene, and a nursing order dated July 2025 directed staff to assist with tooth brushing every morning and night, with refusals to be documented in progress notes. Progress notes from October 2025 through early January 2026 documented refusals of oral care only on two dates in October. A dental visit note from late October 2025 described the resident’s oral hygiene as very poor, with heavy plaque and food debris and moderate tartar accumulation, and stated that the resident’s special needs rendered them incapable of maintaining adequate oral health without daily assistance, encouraging staff to assist with tooth brushing. On a morning in early January 2025, observation showed the resident in their bedroom with food debris in their mouth. A subsequent continuous observation of the resident’s morning care showed a nursing assistant assisting the resident out of bed, dressing them, styling their hair, and cleaning and donning their eyeglasses, but not offering or providing assistance with tooth brushing. In an interview immediately afterward, the nursing assistant confirmed that oral hygiene was not performed or offered and acknowledged it should have been part of the resident’s morning care.
Failure to Ensure Proper Functioning of Ordered Air Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper functioning of an ordered air pressure mattress for a resident assessed as at risk for pressure ulcer development. The resident’s MDS documented diagnoses of malnutrition and Inclusion Body Myositis, moderate cognitive impairment (BIMS score 10), total dependence for all ADLs including bed mobility, and constant bowel and bladder incontinence, with recent weight loss and a current weight of 93 pounds. The care plan identified the resident as at risk for pressure ulcers related to weakness and reduced mobility, with a goal for skin to remain intact, and included use of an air pressure mattress as a specific intervention. Surveyor observations over multiple days showed repeated problems with the air mattress not being powered on and/or not functioning properly. On one occasion, the resident was observed in bed with the air mattress pump not on; on several other occasions, the pump was on but the low-pressure light was illuminated, and on multiple subsequent observations the air mattress was again off while the resident was in bed. A medication aide confirmed that the air mattress was not on and should have been. The wound nurse confirmed the low-pressure light was on and stated they would need to refer to the owner’s manual to determine its meaning. The ADON confirmed the mattress was being replaced and provided manufacturer information indicating that if the low-pressure light remained on for longer than 30 minutes, the mattress should be serviced.
Failure to Complete Hospital Transfer Documentation and Communication
Penalty
Summary
The facility failed to communicate with the hospital and failed to provide transfer documentation during hospital transfers for 2 residents. Facility policy required the nurse to complete an INTERACT Nursing Home to Hospital Transfer Form, contact the emergency department nurse to give report including the resident’s COVID-19 status, and document the basis for transfer, conversations with the physician or nurse practitioner, family, and hospital nurse, along with other transfer details in the electronic record. Resident 154 was admitted with stage four chronic kidney disease, type 2 diabetes mellitus with complications, and obstructive sleep apnea. On 10/15/2025, the resident was discharged to the hospital for pneumonia and respiratory failure, and the POA was notified, but the electronic record lacked evidence that a transfer form or communication with the hospital was completed at the time of transfer. Resident 6 had vascular dementia, hypertension, congestive heart failure, bradycardia, transient cerebral ischemic attack, and cerebral infarction, with a BIMS score of 3 indicating severe cognitive impairment. On 12/13/2025, after a fall, the resident was sent to the Emergency Department for evaluation, but the electronic record lacked evidence that a transfer form was completed at the time of transfer.
Failure to Complete PASRR Referral After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure a new PASRR referral was completed after a mental health diagnosis was identified for one resident. The facility policy stated that residents with newly evident or possible serious mental disorder, intellectual disability, or related condition must be referred for a level 2 resident review upon a significant change in status assessment, and that the state mental health or intellectual disability authority must be notified promptly after a significant change in condition for resident review. Resident 10 was admitted with diagnoses including adjustment disorder with depressed mood and depression, and the admission PASRR Level 1 screen did not require a Level 2 evaluation at that time. Later record review showed PTSD was added to the resident’s diagnoses, and subsequent MDS assessments documented PTSD along with cognitive impairment, rejected care, and need for maximal assistance with ADLs. The significant change MDS also listed PTSD, adjustment disorder with depressed mood, and depression, but the resident was not currently considered to have a serious mental illness or intellectual disability. During interview, the Administrator confirmed no recommendation had been made to the PASRR agency for review of the resident’s mental health condition after the significant change MDS was completed, and confirmed this should have been done after PTSD was identified.
Incomplete Bed Assist Device Assessments and Maintenance
Penalty
Summary
The facility failed to complete quarterly bed assist device assessments and regular preventive maintenance checks for a resident who had bilateral assist rails for self-positioning in bed and transfers. The resident had diagnoses including epilepsy, unspecified dementia, schizoaffective disorder, morbid obesity, panic disorder, major depression, obstructive sleep apnea, and sepsis. The resident’s MDS showed the resident was cognitively aware and required varying levels of assistance with personal care, transfers, and bathing, while remaining independent with bed positioning and sit-to-stand activities. The resident’s care plan identified the assist rail as a risk area and noted the resident had assist rails on both sides of the bed. The physician order for bilateral assist rails was dated 12/04/2025, but the only documented bed assist device evaluation in the record was dated 06/13/2025. The facility’s policy required the evaluation to be completed upon assessed need and reviewed quarterly, annually, and with significant change, and required environmental staff to inspect the device for safety before use with preventive maintenance done bi-monthly and as needed. Observations showed the right-side quarter-length bed rail was very loose and bowed or sticking away from the bed on multiple occasions, with a washer and nut left on the bedside table. The resident stated the washer and nut were not known to the resident and that the resident did not know there was a problem with the bed rail. Staff interviews confirmed the resident used the bed rail for getting in and out of bed and into the wheelchair, that the rail was loose, and that quarterly assessments should have been completed but were not. The DON also confirmed there were no preventive maintenance logs completed for the resident’s bed assist devices.
Oxygen Flowrate Not Set to Ordered Level
Penalty
Summary
The facility failed to set one resident’s oxygen flowrate to the prescribed settings. Resident 47 had diagnoses of dependence on supplemental oxygen, COPD, chronic respiratory failure, and chronic diastolic CHF, and the resident’s MDS indicated a BIMS score of 15, showing the resident was cognitively aware. The care plan identified a risk for respiratory complications related to oxygen therapy and included interventions to administer oxygen continuously to keep saturations greater than 90%. The resident’s order history showed oxygen by nasal cannula at 2 L/min during the day and 4 L/min at rest and while sleeping with AVAPS. However, on observation the resident was found sitting in a wheelchair with oxygen on and the concentrator set at 3.5 L/min on two occasions, and later the concentrator was observed set at 4 L/min when it should have been 2 L/min during the day. An LPN confirmed the concentrator was set at 4 L/min and should have been set at 2 L/min.
Failure to Complete Trauma-Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to assess and identify situational stressors and triggers related to PTSD for one resident. The cited policy stated that residents admitted with a diagnosis or history of trauma or PTSD were to receive care and services to address the problem, and that the resident and/or resident representative were to be active participants in identifying triggers for behaviors and developing coping interventions. A record review showed the resident had diagnoses of PTSD, schizoaffective disorder, major depressive disorder, anxiety disorder, and bipolar disorder, and the MDS documented a BIMS score of 15, indicating the resident was cognitively intact. Review of the resident’s electronic medical record, including progress notes and observations, showed that a trauma informed care assessment was not completed. During interview, the resident confirmed a history of childhood trauma. The Social Service Director later confirmed that a trauma informed care assessment had not been completed for the resident.
Failure to Identify Medication Irregularities and Document Rationale for Duplicate Therapy
Penalty
Summary
The facility failed to identify and address drug irregularities during monthly pharmacist drug regimen review for a resident receiving antipsychotic therapy. Resident 7 had diagnoses of anxiety disorder, bipolar disorder, and schizophrenia, was rarely able to make self understood, and required total assistance with eating, dressing, hygiene, toileting, bathing, bed mobility, and transfers. The resident was receiving Seroquel 25 mg daily, with additional doses added on 10/02/2025 and 10/09/2025, resulting in Seroquel 25 mg in the morning and at noon and 100 mg at bedtime. The resident’s AIMS score was 0 on 09/17/2025, then increased to 4 on 11/04/2025. The consultant pharmacist stated the increase in AIMS score was not noted on the November 2025 DRR or the December 2025 DRR, and therefore a recommendation to update the physician was not submitted. The DON confirmed the resident had an increase in the AIMS score and the facility did not act on the results. The facility policy stated that an AIMS score of 2 or higher is evidence of TD and should be discussed with the physician. The facility also failed to ensure the physician documented a rationale for multiple antihypertensive medications for Resident 6. Resident 6 had diagnoses including dementia, hypertension, CHF, bradycardia, transient cerebral ischemic attack, and cerebral infarction, and had a BIMS score of 3 indicating severe cognitive impairment. The resident received amlodipine, doxazosin, hydralazine, and lisinopril, and pharmacy medication regimen reviews identified duplicate therapy concerns on multiple occasions. The reviews requested provider rationale for the combination, but no rationale was documented, and the ADON confirmed that a rationale for duplicate therapy was not present.
Unqualified Dietary Management Coverage
Penalty
Summary
The facility failed to ensure there was a qualified Dietary Manager or qualified nutrition professional available full-time, part-time, or on a consultant basis. Record review of employee files showed the Dietary Manager was not certified, and the Administrator confirmed in interview that the DM had not completed the test to become certified and that the facility did not have a full-time dietician. The facility had a census of 148 residents.
Hand Hygiene and Nebulizer Cleaning Deficiencies
Penalty
Summary
The facility failed to perform hand hygiene between glove changes during perineal care for Resident 1, Resident 17, and Resident 47. During observation of perineal care, staff removed gloves and then put on new gloves without washing hands in between. For Resident 47, NA-D placed a clean brief under the resident, took trash into the bathroom in a bag, removed gloves, and then performed hand hygiene. NA-D later confirmed that hand hygiene had not been performed when changing gloves and should have been. Resident 17 was admitted on 12/30/2024 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, and dementia. The annual MDS dated 01/05/2026 showed Resident 17 was rarely or never understood, rejected care on one to three days during the assessment period, and required substantial assistance with toileting hygiene. The care plan included an intervention to cleanse the peri-area after each incontinent episode. During continuous observation, NA-M performed hand hygiene, donned a gown and gloves, removed the resident's brief and cleaned the resident, then doffed gloves and donned new gloves without hand hygiene before applying a clean brief. NA-M again removed gloves and later donned new gloves without hand hygiene while assisting the resident with dressing and positioning. The facility also failed to clean nebulizer equipment between uses for Resident 160. Resident 160 had diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia and hypercapnia, dependence on supplemental oxygen, and centrilobular emphysema. The physician ordered albuterol sulfate solution for nebulization as needed. Observations on 01/05/2026 and 01/06/2026 showed the resident's nebulizer mask and medication chamber laying on top of a stand with no barrier underneath and condensation in the medication chamber. RN-H confirmed the nebulizer medication chamber and mask were not cleaned and were not on a barrier and should have been.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a left heel wound. The resident had a practitioner order for wound treatment, and the facility's EBP policy required the use of gowns and gloves for residents with wounds, regardless of known infection or colonization status. During an observed wound care procedure, an LPN performed hand hygiene and donned gloves but did not wear a gown at any point while providing care, including when removing soiled dressings and cleaning the wound. The LPN confirmed during an interview that a gown should have been worn during the procedure. The facility's EBP policy, revised in March 2024, specifically states that PPE, including gowns and gloves, must be worn during high-contact resident activities such as wound care. The failure to don a gown during the wound care procedure constituted noncompliance with the facility's infection prevention and control program.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility staff failed to transfer a resident, identified as Resident 9, in a manner that would prevent injury. Resident 9, who was admitted to the facility, had both short-term and long-term memory problems and was diagnosed with Alzheimer's and dementia with behavioral disturbances. The resident was dependent on staff for eating, bed mobility, transfers, and toileting, requiring extensive to total assistance with activities of daily living. The Comprehensive Care Plan indicated that two staff members were needed to transfer the resident using a full body sling, but it did not specify the size of the sling required. During a transfer from the bed to a wheelchair using a Hoyer lift, Nursing Assistants Q and R used a divided leg Hoyer sling instead of a full body sling. As a result, Resident 9 began to slide out of the sling, causing the nursing assistants to intervene to prevent further sliding. Despite their efforts, Resident 9 experienced extreme pain during the transfer and was later diagnosed with a tibial fracture and an anterior displaced fibula fracture after being sent to the emergency room. Interviews with the nursing staff, including NA Q, NA R, LPN N, and the MDS Coordinator, revealed a lack of knowledge regarding the appropriate sling size for the Hoyer lift. The facility's Nursing Policy and Procedure Manual did not provide instructions on determining the correct sling size, contributing to the improper transfer and subsequent injury of Resident 9. The Director of Nursing confirmed the incident resulted in a major injury for the resident.
Medication Security Lapses in Facility
Penalty
Summary
The facility staff failed to secure medications properly, as observed on two separate occasions. On the first occasion, a medication cart was found unlocked and unattended on the 100 hall at 7:10 AM. This was confirmed by interviews with a Registered Nurse (RN) and a Medication Assistant (MA), who acknowledged that the cart should not have been left unlocked and out of sight. This oversight had the potential to affect 10 residents identified as self-mobile who resided on the 100 hall. On a second occasion, another medication cart was left unlocked and unsupervised by a Medication Assistant (MA) between 6:12 and 6:18 AM. Additionally, a card of Acetaminophen was left unsecured on top of the cart. The MA confirmed during an interview that the medication card should not have been left on top of the cart and that the cart should have been locked and secured. The facility's medication storage policy, dated August 2018, mandates that all medications and biologicals be stored in locked compartments when not in use or left unattended.
Failure to Follow Pureed Meal Menu
Penalty
Summary
The facility failed to follow the menu to meet the nutritional needs of residents requiring pureed meals, affecting 7 out of 13 residents identified as needing such meals. On a specific day, the menu planned for lunch included a pureed hot dog with bun and gravy, among other items. However, during lunch service, residents on pureed diets were mistakenly served pureed mashed potatoes with gravy instead of the planned pureed hot dog and bun. This error was confirmed by staff interviews, including one with the Registered Dietician, who noted that the residents received less protein and calories than intended due to the menu not being followed.
Failure to Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for several residents, leading to potential cross-contamination risks. Observations revealed that staff members did not wear gowns during high-contact care activities for residents on EBP. For instance, a Licensed Practical Nurse (LPN) administered water via a G-tube to a resident without donning a gown, despite the resident being on EBP due to a gastrointestinal tube. Similarly, a Nursing Assistant (NA) emptied a foley catheter bag for another resident without wearing a gown, even though the resident was on EBP due to an indwelling medical device. Further deficiencies were noted with other residents on EBP. A Nursing Assistant provided care to a resident with a Multi-Drug Resistant Organism (MDRO) without wearing a gown, despite the resident being on EBP for having a gastrostomy tube. Another instance involved two Nursing Assistants transferring a resident to a commode without gowns, even though the resident was on EBP due to a gastrostomy tube. Additionally, a Licensed Practical Nurse administered medications through a gastrostomy tube to a resident on EBP without wearing a gown. The facility also failed to maintain proper infection control practices in other areas. An oxygen nasal cannula for a resident was repeatedly observed on the floor, contrary to the facility's policy requiring it to be stored in a plastic bag when not in use. Furthermore, the Laundry Supervisor was observed delivering laundry with clothing and linens touching their body and dragging on the floor, which is against the facility's protocols for preventing cross-contamination.
Privacy Violation of Resident's Medical Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical information. Specifically, information regarding a resident's dietary restrictions was posted on the outside of their door, visible to anyone passing by. The resident, identified as having a moderate cognitive impairment with a BIMS score of 9 and a diagnosis of Diabetes Mellitus, had a sign on their door indicating dietary instructions, such as avoiding snacks full of sugar and allowing Glucerna and half a sandwich. This action was confirmed by the Director of Nursing to be a violation of privacy, as it disclosed personal health information publicly.
Failure to Apply Compression Stockings and Prevalon Boots as Ordered
Penalty
Summary
The facility failed to ensure that a resident's compression stockings and Prevalon boots were applied according to the physician's orders. The resident, who had diagnoses of Peripheral Vascular Disease, Cellulitis of the right lower leg, and Unspecified Dementia, was dependent on staff for all activities of daily living and was at risk for developing pressure ulcers. Despite these conditions, the resident's Medication Administration Record and Treatment Administration Record from June to August 2024 did not show that compression stockings or Prevalon boots were applied until late August. Observations on multiple occasions revealed that the resident was not wearing compression stockings or Prevalon boots as prescribed. A Licensed Practical Nurse confirmed that the orders were entered incorrectly into the system, which resulted in the oversight. The nurse also confirmed that the resident would not have refused to wear the compression stockings or Prevalon boots, indicating that the failure was due to administrative error rather than resident non-compliance.
Failure to Implement Toileting Program for Cognitively Intact Resident
Penalty
Summary
The facility failed to evaluate and implement a toileting program for a resident who was frequently incontinent of urine and always incontinent of bowel. The resident, identified as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13, expressed awareness of the need to use the toilet and the ability to use a bedpan if provided. Despite this, the resident's care plan did not include an evaluation or implementation of a toileting program, which is a requirement based on the facility's policy and procedure for urinary incontinence. Interviews conducted with the resident and the MDS Coordinator confirmed the absence of a toileting program for the resident. The facility's policy, dated June 2021, outlines the need for assessing urinary continence status upon admission, quarterly, and with any significant change of condition. It also requires developing an incontinence plan of care, particularly for cognitively intact residents who can participate in their care. However, these procedures were not followed for the resident in question, leading to the deficiency noted in the report.
Deficiency in Antibiotic Stewardship for Two Residents
Penalty
Summary
The facility failed to provide an indication for antibiotic use for two residents, leading to a deficiency in their antibiotic stewardship program. For Resident 28, a physician order for Amoxicillin/Augmentin was issued without a documented reason for its administration. The medication was administered for 20 doses over a period of ten days, yet there was no indication in the resident's records, including practitioner orders, progress notes, or laboratory work, to justify the use of the antibiotic. An interview with the Infection Preventionist Coordinator confirmed that the antibiotic use did not meet the criteria set by McGeer's tool for determining the necessity of antibiotic use. Similarly, Resident 144 was prescribed doxycycline without a specified stop date, and there was no documented rationale for the continued use of the antibiotic. The facility's policy requires that when a resident is admitted on an antibiotic, staff must verify the reason for its use and obtain a stop date or rationale from the physician. This was not adhered to in the case of Resident 144, indicating a lapse in the facility's antibiotic stewardship practices. The facility's Infection Control Policy and Procedure Manual outlines the importance of a quality antibiotic stewardship program, emphasizing the need for appropriate use of antimicrobials and minimizing antibiotic overuse and resistance. The policy includes procedures for the interdisciplinary antibiotic stewardship team to ensure antibiotics are used appropriately, with proper follow-up on cultures and sensitivities. However, the failure to document the indication for antibiotic use for both residents highlights a significant deficiency in adhering to these established protocols.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to prevent potential COVID-19 infection by not offering, providing education, or documenting the opportunity for two residents, Resident 15 and Resident 25, to accept or decline the updated COVID-19 vaccination for 2024-2025. The facility's policy, dated May 2021, mandates that all residents should be educated about the COVID-19 vaccine, including its risks and benefits, and be given the opportunity to be vaccinated. However, the Electronic Health Records (EHR) for both residents did not show any documentation of education, the vaccine being offered, or any opportunity for the residents to decline or accept the updated vaccination. Resident 15 had a history of receiving COVID-19 vaccines on three occasions in 2021, while Resident 25 had a history of receiving vaccines on five occasions between 2020 and 2022. Despite these histories, there was no documentation in the EHR for the 2024-2025 vaccination. An interview with the Director of Nursing confirmed that these residents were not offered the updated COVID-19 vaccination, nor were they provided with the necessary education. This oversight is a direct violation of the facility's policy and the CDC's recommendations for COVID-19 vaccination.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 381 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Omaha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Douglas County Health Center | 2.4 mi | ★★★★★ | 2 | 0 |
| The Cypress At Midtown | 2.5 mi | ★★★★★ | 11 | 0 |
| Ambassador Health Of Omaha | 3.1 mi | ★★★★★ | 0 | 0 |
| Omaha Nursing And Rehabilitation Center | 3.7 mi | ★★★★★ | 3 | 0 |
| Emerald Nursing & Rehab Omaha | 3.7 mi | ★★★★★ | 31 | 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.