Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wingfield Skilled Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
Infection control practices were not followed for multiple residents. A resident’s urinal was left on the floor next to drinking water, clean linens were transported uncovered, an LPN did not clean a tablet splitter before and after use, and an LPN performing wound care did not complete hand hygiene as required and lacked paper towels in the bathroom. Staff also did not follow EBP for a resident’s G-tube care and did not follow contact precautions for a resident with MRSA when entering the room.
Care plan not revised after oxygen order discontinued. A resident with COPD, emphysema, and respiratory failure had an oxygen order for 3 L/min via NC, but the order was later discontinued when the resident was stable on room air and said oxygen was not needed. Staff confirmed the order was stopped, yet the care plan still reflected oxygen therapy and was not updated to match the change in treatment.
A resident with an ileostomy was allowed to manage the pouch without a formal assessment of safe self-care, and the care plan lacked goals or interventions for self-care, education, supervision, or monitoring. The resident and spouse reported they took over pouch changes after staff/CNAs were unable to do it properly and leakage occurred; an RN confirmed no assessment was in the record, while the DON and MDS RN acknowledged the resident had not been assessed or educated for safe ostomy self-care and that staff documentation did not match the resident’s actual care.
Failure to identify and report dehydration signs for a resident with hemiplegia, dysphagia, and contractures. The resident was observed with dry, cracked lips and sunken eyes, and an LPN confirmed the findings were consistent with dehydration. The CNAs had not reported the condition to nursing staff, and there was no documentation of the resident’s current condition despite a care plan and MD order for oral care, hydration monitoring, and reporting symptoms of dehydration.
Enteral feeding was not administered per physician order for a resident with a G-tube and diagnoses including hemiplegia, hemiparesis, and dysphagia. An LPN observed the tube feeding running at 60 mL/hr instead of the ordered 65 mL/hr, and the resident was lying in a fetal position with the HOB only about 30 degrees despite an order for 30-45 degrees during feeding. The LPN stated the resident should have been repositioned due to aspiration risk and that the lower rate could result in insufficient nutritional intake; the DON confirmed staff were expected to follow the G-tube orders and the facility policy.
A resident receiving continuous O2 had no O2-in-use sign posted outside the room door, despite facility staff and policy confirming the sign should be in place whenever O2 is used. Another resident with COPD and chronic respiratory failure repeatedly stated, "I can't breathe," while wearing nasal cannula O2 at the nurse's station, but the CNA and support aide present did not acknowledge the complaint; the resident's tank was later found low and needed replacement. Staff stated they were expected to assess O2 saturation and locate a nurse when a resident reports SOB.
Discontinued oxygen order was not removed from a resident’s room. The resident, who had COPD, emphysema, and respiratory failure with hypoxia, had an oxygen order that was later discontinued after the resident was stable on room air. Even so, staff found an oxygen concentrator still set up by the bed, the nasal cannula and tubing on the floor, and oxygen saturation records showed oxygen being administered after the order had been discontinued. An RN initially believed the resident still needed continuous oxygen before confirming the order had been stopped.
Unlocked medication and treatment carts were observed unattended and accessible to unauthorized persons, including a medication cart at the 100 Hall entrance, another medication cart on the second floor, and a treatment cart containing wound care products and resident-specific meds. Nurses confirmed the carts were left unsecured, and the DON stated carts were expected to be locked when not in view. Expired meds, including hydroxyzine HCl and Allegra, were also found in a medication cart, and the DON stated expired meds should be removed from carts and stored pending destruction.
Failure to Enforce Non-Smoking Policy: Staff were observed smoking near the front entrance and behind the kitchen area, and an ashtray with cigarette butts was repeatedly found outside the back door. The Housekeeper stated she smoked several times a day in the same area and used the ashtray for cigarette butts, while the Kitchen Manager confirmed staff were smoking on facility property. The Administrator, Regional MDS RN, and Owner confirmed the campus was non-smoking, and the facility policy prohibited smoking in all indoor and outdoor areas.
Failure to post daily nursing staffing numbers in prominent locations. The daily nursing hours behind the front desk and at both nurses' stations were outdated, and the Administrator and CNA staffing coordinator confirmed the postings had not been updated as required. The facility policy required direct care staffing numbers to be posted on a daily basis in a prominent location.
A resident with reduced mobility and incontinence was left wet overnight due to insufficient brief changes by the night shift staff. Despite the resident's complaints to staff and the social worker, the issue persisted, with the resident often left in wet linens and pads. A CNA confirmed the resident's reports, and the DON acknowledged that such neglect could impact the resident's dignity.
A facility failed to obtain informed consent from a resident before administering a psychotropic medication. The resident, diagnosed with depression, was prescribed Escitalopram Oxalate, but the consent form did not indicate acceptance or refusal. Despite this, the medication was administered, contrary to facility policy requiring consent before initiating psychoactive substances.
A resident with multiple health issues reported inadequate incontinent care overnight, stating they were only changed once, leading to discomfort. Despite informing staff and the Social Worker, no formal grievance was filed. The LSW chose to address the resident's anxiety rather than initiate a grievance, and the Unit Manager and DON were not properly informed. The facility's grievance policy was not followed, as no investigation or communication of findings occurred.
The facility failed to submit PASARR level II screenings for two residents who acquired serious mental disorder diagnoses after admission. One resident was diagnosed with delusional disorder, and another with major depressive disorder, yet neither had the necessary PASARR level II submitted. The LSW acknowledged the oversight, which was contrary to the facility's policy requiring such evaluations for new or changed behaviors indicating serious mental disorders.
The facility failed to address a resident's visual impairment in their activities care plan, resulting in a lack of personalized activities and assistance. Another resident with bilateral lower extremity edema did not have a care plan for monitoring and management, despite a physician's order for medication. Additionally, a resident using bed rails for mobility lacked a care plan documenting this need. These deficiencies were confirmed by the DON and other staff, highlighting gaps in comprehensive care planning.
An LPN in a facility failed to adhere to insulin administration protocols by not rechecking a resident's blood sugar levels before administering insulin, despite being trained in proper procedures. The incident involved a resident with type two diabetes, where the LPN checked blood sugar levels, left to attend to another resident, and returned over an hour later to administer insulin without verifying the current blood sugar levels.
A resident dependent on staff for ADLs reported inadequate overnight care, receiving only one brief change and being left in wet bedding. Staff interviews confirmed the resident's claims, revealing a failure to adhere to facility policies requiring regular checks and changes every two hours to maintain hygiene and comfort.
A visually impaired resident in an LTC facility did not receive individualized activities based on their preferences, leading to a deficiency. The resident, diagnosed with vision loss and depression, expressed a desire for audiobooks and music but lacked access and assistance. The Activities Director failed to include these preferences in the care plan or instruct staff on using the audiobook device. The care plan did not specify the assistance needed or responsible staff, contrary to facility policy.
A resident missed eight doses of pregabalin for neuropathy due to the facility's failure to renew the medication order timely. The resident reported a burning sensation in the feet after not receiving the scheduled medication over a weekend. The lapse was attributed to a lack of communication among staff, and no alternative medication was provided.
A resident with a history of cerebral infarction and muscle weakness was using bed rails daily as a physical restraint without documented attempts of alternative interventions or a comprehensive care plan. The facility's policies required less restrictive interventions to be tried and documented before using bed rails, but these steps were not followed, leading to a deficiency.
A resident with multiple health issues reported inadequate incontinent care during the night, stating they were only changed once and left in wet bedding. Despite informing staff and the social worker, no grievance was filed, and the complaints were not documented or investigated. The LSW did not follow up with the Unit Managers or DON, and the facility's grievance policy was not followed.
A resident with type two diabetes mellitus experienced a significant medication error when an LPN failed to administer insulin timely and accurately. The LPN checked the resident's blood sugar levels but did not administer insulin immediately, returning over an hour later without rechecking the levels. This action was against the physician's order, which required insulin administration based on a sliding scale before meals. The facility's policies and the LPN's training emphasized the importance of verifying blood sugar levels and administering insulin according to orders.
A resident with type II diabetes was found with unsecured glucose tablets on their bedside table, despite lacking an order for the medication or permission to keep it at the bedside. The LPN and DON confirmed the medication should not have been there, as it posed a risk of self-medication. Facility policy mandates secure storage of all medications.
A resident with cognitive deficits was kicked by another resident with a history of aggressive behavior, resulting in a bruise. Despite previous incidents of verbal aggression, the facility did not revise the care plan or take adequate measures to prevent the physical altercation, leading to a deficiency in protecting the resident from abuse.
The facility failed to report an allegation of abuse within the required timeframe. A resident reported being kicked by another resident, but the incident was not reported to the State Agency until several hours later, violating the two-hour reporting requirement.
The facility failed to maintain daily kitchen equipment temperature logs and ensure hand hygiene supplies were available, potentially compromising food safety and infection control for all 119 residents.
The facility failed to include essential information in the written Notice of Transfer or Discharge for eight residents discharged in January 2024. The notices lacked the reason for transfer or discharge, the effective date, and/or the location of the transfer or discharge. This deficiency was confirmed by the Discharge Planner and the DON.
Infection Control Practices Not Followed
Penalty
Summary
The facility failed to maintain infection prevention and control practices when Resident #17 had a portable urinal containing dark brown urine placed on the floor at the resident’s feet next to the bed, with the urinal approximately 2 inches from the resident’s gray pitcher of drinking water. A CNA stated the urinal should have been emptied and stored on hooks of the bed or on the side of the trash can, and should not have been kept on the ground next to the resident’s cup of water. The DON stated urinals were to be emptied, cleaned, and returned to the bedside during rounds or when the resident called after use, and that they were not to be kept on the ground because they might not be accessible and created an infection control issue due to bodily fluids. The facility also failed to ensure clean linens were kept covered during transport and delivery. A blue laundry cart outside a room contained folded clean sheets and a blanket and was observed uncovered. The Unit Manager RN confirmed the cart contained clean linens and was left uncovered, and the DON confirmed the laundry was left uncovered and unattended and should have been covered to maintain infection control practices and prevent potential cross contamination. During medication administration for Resident #43, an LPN split a potassium chloride tablet using a tablet splitter and returned the splitter to the drawer without cleaning it before or after use. The LPN later stated staff were supposed to clean the tablet splitter before and after each use, and the DON stated tablet splitters were to be cleaned after each use because it was an infection control concern and could result in cross contamination. For Resident #4, an LPN performing wound care did not perform hand hygiene after removing gloves, before touching the resident, after touching the resident, before exiting the room, or before touching the wound care cart, and the resident’s bathroom lacked paper towels needed to dry hands after washing. The DON stated staff were expected to perform hand hygiene before and after resident care and that paper towels were an essential supply necessary for hand hygiene. The facility further failed to implement Enhanced Barrier Precautions for Resident #13 and Transmission-Based Precautions for Resident #100 as documented. Resident #13 had an order for EBP for G-tube care, but an LPN changed the feeding without wearing a gown and stated neither the LPN nor staff were required to don a gown for that task. For Resident #100, who had MRSA and was on single room contact isolation for the left heel wound, a CNA entered the room without using ABHR and without donning gloves or a gown, despite contact precaution signage at the entrance directing staff to clean hands and wear gloves and gowns before entry. The CNA stated the gown and gloves were only used when assisting the resident to the restroom and kept a gown inside the bathroom to reuse each time assistance was needed.
Care plan not revised after oxygen order discontinued
Penalty
Summary
The facility failed to revise Resident #70’s care plan when the resident’s oxygen order was discontinued. Resident #70 was admitted and readmitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and emphysema. The resident had a physician’s order for oxygen at 3 liters per minute via nasal cannula continuously every shift for emphysema, but the clinical record lacked documentation of an active oxygen order after it was discontinued. A care plan focus initiated for emphysema and COPD included a goal that the resident would have no signs and symptoms of respiratory difficulty with use of supplemental oxygen through the review date. An alert progress note documented that Resident #70’s oxygen saturation was 95% on room air, that the resident had not used oxygen in the previous 24 hours, and that the oxygen order would be discontinued. The resident verbalized not requiring oxygen therapy. Staff interviews confirmed the oxygen order had been discontinued, and the MDS Coordinator stated the care plan still documented that the resident received oxygen therapy even though the oxygen order was discontinued. The facility policy stated the comprehensive, person-centered care plan would describe services to be furnished to attain or maintain the resident’s highest practicable well-being and would be revised as information and conditions changed.
Failure to Assess and Document Ileostomy Self-Care
Penalty
Summary
The facility failed to ensure a resident with an ileostomy received care consistent with professional standards of practice and the resident’s care plan. Resident #32 was admitted and readmitted with diagnoses including ileostomy status, cognitive communication deficit, and myoclonus. The resident’s hospital discharge summary noted the resident emptied the ostomy but often made a mess. Physician’s orders directed staff to change the ileostomy bag/wafer and cleanse the ileostomy bag/wafer as needed for leaking or accidental removal. The care plan identified the resident’s ileostomy and included interventions to keep the ostomy patent and functional, assess stoma characteristics, change the bag/wafer every other shower day and as needed, cleanse the site daily and as needed, monitor output and stoma condition, and provide ostomy care per facility protocol. The care plan did not include goals or interventions related to ostomy self-care, including assessment, education, supervision, or monitoring of the resident performing independent ostomy care. During interviews, the resident and spouse stated they managed the ileostomy pouch because staff did not know how to properly change it, and the resident reported CNAs had changed the pouch after admission but were not properly trained, which caused leakage of fecal matter. A CNA stated the resident was independent with changing the ileostomy, while an LPN said nurses supervised emptying and changed the bag only as needed, but was unsure whether an assessment existed to determine safe self-care. An RN confirmed there was no assessment of the resident’s ability to perform ileostomy self-care. The DON stated residents would need to be assessed for safety before being permitted to perform self-care and confirmed this resident had not been educated or assessed for safe self-care. The Regional MDS RN stated staff were signing off on ostomy care daily even though the resident had been changing the bag independently, and confirmed the resident lacked a formal assessment and education for ostomy self-care.
Failure to Identify and Report Dehydration Signs
Penalty
Summary
The facility failed to identify, report, and address signs and symptoms of dehydration for Resident #13, who was admitted with hemiplegia and hemiparesis, dysphagia, and contractures. On 02/10/2026 and 02/11/2026, the resident was observed with dry, cracked lips, and on 02/11/2026 the resident was also observed with sunken eyes. An LPN confirmed these findings were consistent with dehydration and stated the CNAs had not reported the resident’s condition to nursing staff, with no documentation of the resident’s current condition. Resident #13’s record showed a Dehydration Risk Evaluation dated 01/09/2026 that documented no signs or symptoms of dehydration, a physician order dated 04/07/2025 for oral and nasal care every shift, and a care plan dated 04/07/2025 identifying the resident as at risk for dehydration and electrolyte imbalance due to stroke-related history of dehydration, weight loss, and poor appetite. The care plan included interventions to observe, document, and report signs of dehydration, assist with fluid intake, monitor vital signs and weights, and notify the physician for symptoms such as dry mucous membranes, poor skin turgor, lethargy, and confusion. The DON stated on 02/12/2026 that signs of dehydration included dry, cracked lips, sunken eyes, and dry, flaking skin, and said CNAs were expected to provide oral care and complete a dehydration risk evaluation when a resident exhibited symptoms.
Enteral Feeding Not Administered Per Order
Penalty
Summary
The facility failed to ensure enteral nutrition was administered in accordance with physician orders and facility policy for Resident #13, who was admitted with diagnoses including hemiplegia and hemiparesis, dysphagia, and contractures. A physician order dated 04/08/2025 directed Jevity 1.5 continuous feeding at 65 mL per hour, to be turned off at 10:00 AM for four hours and restarted at 2:00 PM. During observation on 02/10/2026 at 8:56 AM, the resident’s tube feeding was running at 60 mL per hour instead of the ordered 65 mL per hour. A physician order dated 04/07/2025 required the head of bed to be elevated 30-45 degrees during feeding and for one hour after gravity or bolus feeding. On 02/10/2026 at 8:58 AM, Resident #13 was observed lying in a fetal position on the flat portion of the mattress near the lower part of the head of the bed, and at 9:00 AM an LPN stated the head of bed was only about 30 degrees and should have been elevated higher. The LPN also stated the resident should have been repositioned due to aspiration risks and confirmed the feeding rate should have been 65 mL per hour, noting that the lower rate could result in insufficient nutritional intake. The DON stated staff were expected to follow physician orders for the G-tube, and the facility policy required checking the enteral nutrition label against the physician order and elevating the head of bed at least 30 degrees during feeding and for at least one hour afterward.
Oxygen Safety Sign Missing and Shortness of Breath Not Timely Assessed
Penalty
Summary
The facility failed to ensure a safety sign was posted on the outside of the room door for a resident receiving continuous oxygen therapy. Resident #50 had diagnoses including chronic pulmonary hypertension and congestive heart failure, and had a physician order for oxygen at 4 liters per minute via nasal cannula continuously. The care plan and MAR documented ongoing oxygen use and weekly tubing changes. During observation, no oxygen sign was posted at the room entrance, while the resident was observed wearing oxygen with a concentrator beside the bed. Facility staff, including an RN and the DON, confirmed the expectation that an "O2 in use" sign should be posted outside the room when oxygen is in use, and the facility policy required posting that sign on the outside of the room entrance door. The facility also failed to timely assess a resident who complained of shortness of breath while receiving oxygen therapy. Resident #113 had diagnoses including chronic respiratory failure with hypoxia, COPD with acute exacerbation, abnormal lung findings, cognitive communication deficit, and anxiety disorder, and had a physician order for continuous oxygen at 3 liters per minute via nasal cannula. The care plan identified oxygen therapy related to ineffective gas exchange and COPD, with an intervention to monitor for signs and symptoms of respiratory distress, including restlessness. While seated at the nurse's station wearing oxygen via nasal cannula, Resident #113 repeatedly stated, "I can't breathe," became tearful, and had an oxygen tank gauge reading refill. A CNA and a support aide were present but did not acknowledge the resident. The CNA later stated she did not respond because she was new and unfamiliar with the resident's care needs, and the support aide also stated she was new and unfamiliar with the resident. Another CNA later checked the tank and stated it was low and needed replacement. Staff interviews showed that when the resident complained of shortness of breath, staff were expected to assess oxygen saturation and locate a nurse, and the DON stated such complaints should be treated as an emergency. The facility policy also required assessment for signs or symptoms of difficulty breathing and oxygen saturation while the resident received oxygen therapy.
Discontinued oxygen order was not removed from resident room
Penalty
Summary
The facility failed to ensure that oxygen therapy was stopped and the oxygen concentrator was removed from Resident #70’s room after the physician’s order for oxygen was discontinued. Resident #70 was admitted and readmitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and emphysema. The record showed an oxygen order for 3 liters per minute via nasal cannula that was discontinued after the resident’s oxygen saturation was documented at 95% on room air and the resident had not used oxygen in the prior 24 hours. Despite the discontinued order, oxygen saturation summaries later documented oxygen being administered via nasal cannula when saturations were 90%, 90%, 90%, and 91%. During an observation, an oxygen concentrator was found next to the resident’s bed set at 3 liters per minute, with the nasal cannula and tubing on the floor. The resident stated oxygen was not needed and did not know why the concentrator was in the room. An RN initially believed the resident still required continuous oxygen, then confirmed the order had actually been discontinued on 01/29/2026. An LPN and the Unit Manager RN stated that when oxygen therapy is discontinued, the concentrator is to be removed from the room, and the DON stated oxygen given after an order is discontinued would be considered unnecessary medication.
Unlocked Medication and Treatment Carts with Expired Medications
Penalty
Summary
The facility failed to ensure medications were secured in locked compartments when two medication carts and one treatment cart were left unlocked and unattended by nursing staff. On 02/09/2026, a medication cart at the entrance to the 100 Hall was observed unlocked and unattended with the top left drawer pulled open. An RN later closed the drawer and stated the cart had been left unlocked and out of sight while blood sugar readings were being taken. The RN acknowledged the cart should have been locked when not within view. The DON later stated all medication carts were expected to be locked at all times when not in view. On 02/10/2026, a medication cart on the second floor was observed unlocked and unattended with no staff in sight. An LPN later confirmed the cart had been left unlocked with the keys in the LPN's pocket while the cart was unattended and out of sight. The DON stated the procedure was for medication cart keys to always be with the nurse and for the cart to be locked when unattended. The facility's training and policy stated medication and treatment carts should always be locked when out of vision and secured during use and non-use. A treatment cart in the 100 hallway was also observed unlocked and unattended, with a nurse opening a drawer without keys and retrieving medication from the cart. RN2 stated the treatment cart could remain unlocked if pushed against the wall, and confirmed it contained resident medications used to treat wounds. The cart contained multiple unsecured wound care products and resident-specific medications. In addition, on 02/12/2026, two expired medications were found in a medication cart on the second floor: hydroxyzine HCl tablets expired 01/30/2026 and Allegra tablets expired 07/2025. An LPN confirmed the medications were expired, and the DON stated expired and discontinued medications were expected to be removed from carts and placed in storage pending destruction.
Failure to Enforce Non-Smoking Policy
Penalty
Summary
The facility failed to enforce its non-smoking policy and failed to ensure staff refrained from smoking on facility property. On 02/09/2026, two staff members were observed standing outside the front entryway near the handicap parking spaces next to the facility van while smoking, and they extinguished their cigarettes before re-entering the front entrance. Later that morning, an open ash tray with cigarette butts was observed outside the back entrance to the kitchen area. On 02/11/2026, an ashtray with cigarette butts was again observed outside the back door near the kitchen area, and a staff member was seen smoking a cigarette while seated on the curb in the same area. The Housekeeper stated she smoked every day, a few times a day, in the same area behind the kitchen and extinguished cigarette butts in the ashtray, which she believed Maintenance was responsible for emptying. The Kitchen Manager confirmed the ashtray was used by staff for cigarette disposal and acknowledged an employee was smoking on facility property. The Administrator, Regional MDS RN, and Owner all confirmed the campus was non-smoking, and the facility policy stated smoking was prohibited in all indoor and outdoor areas.
Failure to Post Daily Nursing Staffing Numbers
Penalty
Summary
Nursing hours were not posted daily in prominent locations throughout the facility. On 02/09/2026 at 8:02 AM, the daily nursing hours posted behind the front desk reception area was dated 02/06/2026. The Administrator confirmed at 8:09 AM that the front desk posting was still dated 02/06/2026 and should have been changed to the current date. The Administrator stated the CNA, Nursing Aide Staffing Coordinator, was responsible for updating the postings daily. On 02/09/2026 at 8:26 AM, the nursing hours posted at the first-floor nurses' station was dated 02/06/2026, and at 8:29 AM the posting at the second-floor nurses' station was dated 01/31/2026. At 10:30 AM, the CNA, Nursing Aide Staffing Coordinator, confirmed all three postings in the facility had not been updated but should have been. The facility policy titled, Posting Direct Care Daily Staffing Numbers, dated 08/02/2019, stated the facility would post on a daily basis in a prominent location the number of nurses and aides directly responsible for resident care.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by the lack of adequate incontinence care provided to a resident during the night shift. The resident, who was admitted with conditions including rhabdomyolysis, muscle weakness, and reduced mobility, reported being left wet overnight due to insufficient brief changes. The resident expressed that the night shift staff only changed their brief once overnight, leaving them in wet linens and disposable pads, which were not replaced. This situation was corroborated by a CNA who worked with the resident and confirmed that the resident was often left damp and had complained about the lack of care multiple times. The resident communicated their concerns to trusted staff and the social worker, who acknowledged receiving complaints about the lack of overnight care. The Licensed Social Worker confirmed that the resident had reported these issues at least once a week. The Director of Nursing stated that incontinent residents should be changed every two hours or as needed, emphasizing that neglecting this care could impact the resident's dignity. The facility's policies on resident rights and incontinence management highlighted the importance of maintaining dignity and comfort, which were not upheld in this case.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident provided informed consent before administering a psychotropic medication. Resident #80, who was admitted with a diagnosis of unspecified depression, was prescribed Escitalopram Oxalate to be taken orally each morning. However, the Psychoactive Medications Disclosure and Consent form, signed on 12/05/2023, did not indicate whether the resident accepted or declined the medication. Despite this, the medication was administered to the resident. The Director of Nursing confirmed that the consent form should have documented the resident's decision prior to administration. The facility's policy on psychoactive medication use requires that consent be obtained from the resident or guardian before initiating such medications, and the resident rights policy mandates that residents be informed of the risks and benefits of proposed care in advance.
Failure to Address Resident's Grievance on Incontinent Care
Penalty
Summary
The facility failed to ensure a grievance process was initiated and an investigation was conducted regarding a resident's concerns about inadequate incontinent care overnight. Resident #36, who had multiple diagnoses including rhabdomyolysis and pressure ulcers, reported being ignored by night shift staff and only receiving a brief change once overnight, leading to discomfort from wet linens. Despite informing trusted staff and the Social Worker, the resident's complaints were not formally addressed as grievances. The Licensed Social Worker (LSW) acknowledged being informed of the resident's concerns weekly but chose not to file a grievance, believing the resident's anxiety might be influencing their perception of care. The LSW focused on addressing the resident's psychosocial needs rather than initiating a formal grievance process. The LSW did not document the concerns or follow up with the Unit Managers or the Director of Nursing (DON) for an investigation outcome, assuming the complaints were unfounded. The Unit Manager and DON were not adequately informed of the resident's ongoing complaints. The Unit Manager recalled being made aware of the concerns only twice and did not remember the actions taken. The DON was unaware of the complaints and stated that an investigation would have been initiated if informed. The facility's grievance policy required grievances to be investigated and findings communicated to the resident, which was not followed in this case.
Failure to Submit PASARR Level II for Residents with New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to ensure that residents with an acquired serious mental disorder diagnosis after admission were submitted for a pre-admission screening and resident review (PASARR) level II screening. This deficiency was identified for two residents. Resident #80 was admitted with a PASARR level I and later diagnosed with delusional disorder. Despite meeting the requirements for a PASARR level II submission, the Licensed Social Worker (LSW) did not submit the necessary documentation for review, even after taking responsibility for submissions. Similarly, Resident #57 was admitted with a PASARR level I and later diagnosed with major depressive disorder. The LSW confirmed that a PASARR level II was not submitted, despite the resident meeting the criteria for submission. The facility's policy on Behavioral Assessment, Intervention, and Monitoring required that new or changed behaviors indicating a serious mental disorder be referred for a PASARR level II evaluation, which was not adhered to in these cases.
Deficiencies in Care Planning for Activities, Edema, and Bed Rails
Penalty
Summary
The facility failed to ensure that the activities care plan for a resident with visual impairment addressed the need for staff support and assistance with personalized activities. The resident expressed a desire to participate in group activities when accessible and had specific interests in mystery and history audiobooks and oldies music. However, the activities care plan did not include these individualized activities, and the resident reported difficulty using an audiobook device due to visual impairment and a lack of assistance from staff. The Activities Director acknowledged the omission and confirmed that the care plan did not reflect the resident's preferences or the need for staff assistance. Another deficiency was identified in the care planning for a resident with bilateral lower extremity edema. Despite a physician's order for medication to manage the edema, the resident's clinical record lacked a care plan for monitoring and managing the condition. The Director of Nursing confirmed the absence of a care plan, acknowledging the risk of fluid retention and the potential for worsening symptoms due to inadequate monitoring. Additionally, the facility did not develop a care plan for the use of bed rails for a resident with mobility issues. The resident used bed rails daily for mobility, but the comprehensive care plan did not document this need. Both the Director of Nursing and the Regional MDS Registered Nurse confirmed the lack of a care plan for bed rails, which was necessary for coordinating proper care. The facility's policy on comprehensive person-centered care plans emphasized the importance of including all necessary care elements to maintain residents' well-being.
Failure to Follow Insulin Administration Protocol
Penalty
Summary
The facility failed to ensure that an LPN adhered to the State Board of Nursing Nurse Practice Act regarding safe medication administration. Specifically, the LPN did not check a resident's blood sugar levels before administering insulin, as required by the physician's sliding scale order. This oversight involved a resident with type two diabetes mellitus, who was admitted to the facility with a diagnosis that necessitated careful monitoring and management of blood sugar levels. On the day of the incident, the LPN checked the resident's blood sugar levels at 12:51 PM but did not administer insulin immediately. Instead, the LPN walked away to attend to another resident and returned over an hour later to administer insulin without rechecking the blood sugar levels. The resident's daughter confirmed that the insulin was administered after the resident had already eaten lunch, and the LPN did not verify the blood sugar levels again before giving the insulin. The facility's policies and the LPN's training emphasized the importance of checking blood sugar levels immediately before insulin administration. The Director of Nursing confirmed that the LPN was trained in proper insulin administration protocols, which included verifying blood sugar levels and following the physician's sliding scale order. Despite this training, the LPN failed to follow the correct procedure, resulting in a medication error as defined by the facility's policy on adverse consequences and medication errors.
Inadequate Overnight Care for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for Activities of Daily Living (ADLs), received adequate brief changes overnight. This deficiency was identified for one resident, who was admitted with conditions including rhabdomyolysis, muscle weakness, and a pressure ulcer. The resident reported being ignored by the night shift staff, receiving only one brief change overnight, and being left in wet bedding, which was not changed, leading to discomfort. Interviews with staff confirmed the resident's claims. A Certified Nursing Assistant (CNA) acknowledged that the resident was incontinent and required maximum assistance for all ADLs, including the use of a Hoyer lift for transfers. The CNA believed the resident's reports of inadequate care and informed the Unit Manager nurses of the resident's concerns. Another CNA corroborated that incontinent residents should be checked and changed every two hours, but the resident reported being changed only once overnight. The facility's policies on Activities of Daily Living and Urinary Continence and Incontinence emphasized the need for regular checks and changes to maintain dignity, comfort, and skin protection. Despite these policies, the resident's care plan and Minimum Data Set (MDS) assessment indicated a need for substantial assistance, which was not adequately provided. The Director of Nursing confirmed the expectation for two-hour checks and changes, highlighting a gap between policy and practice.
Failure to Provide Individualized Activities for Visually Impaired Resident
Penalty
Summary
The facility failed to provide individualized activities for a visually impaired resident, leading to a deficiency in meeting the resident's needs. The resident, who had diagnoses including unqualified vision loss and depression, expressed a desire to participate in group activities when accessible but lacked individual activities they could engage in alone. An activity interview highlighted the resident's preference for mystery and history audiobooks and oldies music, yet the care plan did not reflect these preferences. The resident reported having difficulty using an audiobook device due to their vision impairment and had not received assistance, resulting in the resident ceasing attempts to listen to audiobooks. Additionally, the resident did not have access to music or a radio in their room, leading to feelings of boredom. The Activities Director acknowledged the lack of instruction provided to staff on operating the audiobook player and confirmed that the resident's care plan did not include the individualized activities the resident had communicated as important. The care plan also failed to specify the assistance needed by the resident or the staff responsible for providing it. The facility's policy required individualized activities reflecting residents' interests and preferences, with documentation in the medical record, but this was not adhered to in the case of the resident. The Director of Nursing confirmed that the Activities Director was responsible for personalizing the resident's activities care plan, which should have included the necessary assistance and responsible staff positions.
Failure to Refill Neuropathy Medication Timely
Penalty
Summary
The facility failed to ensure timely refilling of a resident's medication for neuropathy, resulting in the resident missing eight doses. The resident, who was admitted with diagnoses including chronic pain and neuropathy, reported not receiving scheduled pain medication over a weekend. The medication, pregabalin, was prescribed to be taken three times a day to manage pain in the resident's feet. The resident experienced a burning sensation in the feet and was informed by the nursing staff that the medication renewal had been overlooked, and an on-call provider was not available to write a new order. The facility's policy required narcotic medications to be reassessed every 30 days, with renewal orders requested three days before expiration. However, the order for pregabalin expired and was not renewed in time, leading to missed doses. The Director of Nursing confirmed the lapse was due to a lack of communication among staff and acknowledged that alternative medication could have been requested in the interim. The facility's pain management policy emphasized a proactive approach with scheduled medications, which was not adhered to in this instance.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to attempt appropriate alternative interventions and create a comprehensive care plan before installing and using bed rails for a resident. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, and generalized muscle weakness, was using bed rails daily as a physical restraint. The facility's documentation did not show evidence of any alternative interventions being tried before the bed rails were installed, nor was there a comprehensive care plan documenting the use of bed rails. The Director of Nursing and the Regional MDS Registered Nurse confirmed that no prior interventions were attempted before the installation of the bed rails, despite the facility's policy requiring less restrictive interventions to be tried first. The facility's policy also required documentation of unsuccessful less restrictive approaches before considering bed rails. The resident's clinical record and care plan lacked documentation of these necessary steps, leading to a deficiency in the facility's compliance with its own policies and procedures.
Failure to Address Resident's Incontinence Care Complaints
Penalty
Summary
The facility failed to ensure that a social services staff member followed up on complaints from a resident regarding inadequate incontinent care during the night. Resident #36, who was admitted with conditions such as rhabdomyolysis, muscle weakness, and pressure ulcers, reported being ignored by night shift staff and only receiving a brief change once overnight. The resident expressed discomfort due to wet linens and underpads, despite the brief being changed. The resident communicated these concerns to trusted staff and the social worker, who promised to investigate. The Licensed Social Worker (LSW) acknowledged being informed by the resident about the lack of care at least once a week but did not file a grievance, believing the resident's concerns were not genuine. The LSW did not document the complaints or follow up with the Unit Managers or the Director of Nursing (DON) for an investigation outcome. The LSW verbally notified the Unit Manager nurses and the DON but did not receive any feedback or results from them. The Unit Manager and the DON were not adequately informed about the resident's complaints. The Unit Manager only became aware of the issue on the day of the interview and once in October, but could not recall any specific actions taken. The DON confirmed not being notified of the complaints and expected to be informed immediately. The facility's grievance policy allows residents to file grievances orally or in writing, and the Grievance Coordinator is responsible for investigating and reporting findings, which was not adhered to in this case.
Failure to Administer Insulin Timely and Accurately
Penalty
Summary
The facility failed to ensure timely blood sugar testing and insulin administration for a resident with type two diabetes mellitus, leading to a significant medication error. Resident #212, who was admitted with a diagnosis of type two diabetes mellitus without complications, experienced a delay in insulin administration. On the day of the incident, the resident's blood sugar levels were checked at 12:45 PM, but the nurse did not administer insulin immediately and returned over an hour later without rechecking the blood sugar levels before administering four units of insulin. The physician's order required insulin administration based on a sliding scale, with specific units to be administered according to the resident's blood sugar levels before meals. The nurse, however, failed to adhere to this protocol by not administering the insulin promptly after checking the blood sugar levels and not rechecking the levels before administering the insulin later. This oversight was confirmed by the Licensed Practical Nurse (LPN) involved, who admitted to walking away from the resident after checking the blood sugar levels and returning later without rechecking them. The Director of Nursing (DON) confirmed that the proper procedure for insulin administration involves checking blood sugar levels immediately before administering insulin, as per the sliding scale. The facility's policy on insulin administration and adverse consequences of medication errors also emphasized the importance of verifying blood sugar levels and administering insulin according to physician orders. The LPN involved had been trained in these procedures, as documented in their training records and job description, yet failed to follow them, resulting in a significant medication error.
Unsecured Medication Found at Resident's Bedside
Penalty
Summary
The facility failed to ensure that a resident did not have a bottle of over-the-counter medication unsecured on the bedside table. This incident involved a resident who was admitted with diagnoses including type II diabetes mellitus with diabetic neuropathy and long-term use of insulin. During an observation, a bottle of glucose tablets was found on the resident's bedside table, despite the resident not having an order for these tablets or permission to keep medications at the bedside. The Licensed Practical Nurse confirmed that the medication should not have been at the bedside, as it posed a risk of the resident self-medicating without the facility's knowledge. The Director of Nursing also confirmed the presence of the medication and stated that medications were not supposed to be stored in a resident's room without an order and an assessment to determine if the resident could safely self-administer. The facility's policy on the storage of medications required that all drugs and biologicals be stored securely and not left unattended.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from being kicked by another resident. Resident #5, who had cognitive communication deficit and major depressive disorder, reported to the Licensed Social Worker (LSW) that they were kicked in the leg by Resident #6, resulting in a bruise. Resident #6 had a history of unspecified dementia, vascular dementia with agitation, and schizoaffective disorder, and had exhibited verbally aggressive behaviors prior to the incident. Despite these behaviors, the care plan for Resident #6 was not revised to address the ongoing aggression effectively. The Director of Nursing (DON) and the Administrator were aware of the incident and acknowledged that Resident #6 had been verbally aggressive towards staff and other residents before. However, the facility's interventions, such as redirection and offering snacks, were not sufficient to prevent the physical altercation. The facility's policy on abuse prevention and resident-to-resident altercations required staff to monitor and document aggressive behaviors and make necessary changes to care plans, which was not adequately done in this case. The LSW and the Regional Director of Social Services (RDSS) confirmed that abuse includes any willful intent to cause harm, such as unwanted physical acts. The LSW also noted that Resident #5 had asked for assistance in ending their relationship with Resident #6 a week before the incident. Despite this, the facility did not take adequate measures to separate the residents or revise the care plan to prevent further incidents, leading to the deficiency in protecting Resident #5 from abuse.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) within the required timeframe. Resident #5, who has diagnoses including cognitive communication deficit and major depressive disorder, reported to the Licensed Social Worker (LSW) that they were kicked in the leg by another resident. This incident was documented on 01/16/24 at 9:25 AM. However, the initial Facility Reported Incident (FRI) was not submitted to the SA until 6:51 PM on the same day, which is later than the two-hour reporting requirement for allegations of physical abuse. The Administrator confirmed that all types of abuse are required to be reported to the SA within two hours of becoming aware of the allegation. The Administrator was notified of the incident in the afternoon on 01/16/24 but did not submit the report until 6:51 PM. The facility's policies on abuse prevention, resident-to-resident altercations, and abuse investigation and reporting all stipulate that allegations of abuse must be reported immediately but no later than two hours if the alleged violation involves reasonable suspicion of a crime or results in serious bodily injury. The failure to report within the required timeframe constitutes a deficiency in the facility's compliance with federal requirements.
Failure to Maintain Kitchen Equipment Logs and Hand Hygiene Supplies
Penalty
Summary
The facility failed to ensure that kitchen equipment temperature logs were completed daily and that hand hygiene supplies were available for dietary staff. During a tour of the kitchen, it was observed that temperature logs for various kitchen equipment, including refrigerators and dishwashing machines, were not up to date. The Food Services Manager confirmed that the logs were not current and expressed uncertainty about the proper functioning of the kitchen equipment. Facility policies required daily temperature checks and recordings, but these were not adhered to, potentially compromising food safety for all 119 residents. Additionally, the tour revealed that none of the three hand washing sinks in the kitchen had paper towels available. The Assistant Food Services Manager, who was responsible for stocking paper towels, confirmed the absence of paper towels and acknowledged the importance of having them to ensure proper hand hygiene. Facility policy emphasized the necessity of accessible hand hygiene supplies to prevent healthcare-associated infections, but this was not followed, potentially affecting the health and safety of the residents.
Incomplete Transfer or Discharge Notices
Penalty
Summary
The facility failed to include essential information in the written Notice of Transfer or Discharge provided to residents. Specifically, for eight residents discharged in January 2024, the notices lacked the reason for transfer or discharge, the effective date, and/or the location of the transfer or discharge. This deficiency was identified through clinical record review, document review, and interviews with the Discharge Planner and the Director of Nursing (DON). Both confirmed that the notices were incomplete and acknowledged that the required information should have been documented. The affected residents had various medical conditions, including chronic obstructive pulmonary disease, diabetes, respiratory failure, heart failure, cognitive deficits, and other serious health issues. Despite these conditions, the facility did not provide complete transfer or discharge notices, which is a violation of their policy titled 'Bed-Holds and Returns.' This policy mandates that written information explaining the details of the transfer must be given to residents and their representatives prior to a transfer. The deficiency was confirmed by both the Discharge Planner and the DON, who admitted that the nursing staff had failed to include the necessary details in the notices provided to the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sparks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hearthstone Health And Rehabilitation | 3.7 mi | ★★★★★ | 26 | 0 |
| Northern Nevada State Veterans Home | 4.6 mi | ★★★★★ | 13 | 0 |
| Rosewood Rehabilitation Center | 6 mi | ★★★★★ | 30 | 0 |
| Advanced Health Care Of Reno | 7.8 mi | ★★★★★ | 12 | 0 |
| Caremeridian Llc, Dba Neurorestorative | 7.8 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.