Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Altercare Of Nobles Pond, Inc during CMS and state inspections, most recent first.
Food sanitation logs were incomplete, and a serving station was observed to be excessively hot during meal service, with staff sweating and condiment packets stored at unsafe temperatures. A resident refrigerator in an employee lounge also contained expired and unlabeled outside foods, and staff confirmed the items were not labeled or within date as required.
A resident with multiple medical conditions, including metabolic encephalopathy and Generalized Anxiety Disorder, was started on BuSpar 10 mg BID following a psychiatric evaluation, but the responsible party was not properly informed of this new psychotropic medication order. Nursing notes lacked documentation of the psychiatrist’s assessment or any notification to the responsible party, even though the MAR showed the resident received two doses. The responsible party later reported learning of the medication only during an in-person visit and expressed concern due to the resident’s prior adverse reactions to psychotropic drugs. Conflicting accounts from two ADONs about when and how the responsible party was notified, combined with the absence of required documentation, demonstrated noncompliance with the facility’s policy on notifying and documenting changes in a resident’s condition or treatment.
A resident with impaired ability to perform ADLs and requiring assistance with toileting reported that her bedpan smelled terrible and was not cleaned by staff after use. During observation, surveyors found two unlabeled, unbagged orange bedpans in the bathroom, one in the toilet bowl and one on the floor between the wall and toilet, both with apparent barrier cream residue. A CNA confirmed the bedpans were stored inappropriately, demonstrating a failure to maintain a clean, comfortable, and homelike environment consistent with the facility’s resident rights policy.
The facility failed to provide appropriate and timely care in several areas. A resident with urinary retention, a Foley catheter, and ongoing hematuria continued to receive an anticoagulant while experiencing large blood clots and low Hgb, with delayed practitioner response and no documented timely family notification, until critically low labs led to hospital transfer. Another resident with a right hip arthroplasty had a hip dressing in place but no wound care orders or care plan interventions. A third resident with a stage 4 pressure ulcer also had an undocumented and untreated skin tear on the posterior inner thigh, despite a dated dressing being present. A fourth resident with obesity, DM, and cardiac monitoring needs had multiple missed daily weights despite a physician order and care plan interventions, with no documentation explaining the omissions.
Two residents did not receive consistent, professionally managed pressure ulcer care. One resident was admitted with a wound noted on assessment, but for weeks the only documented wound was a skin tear, there were no wound-care orders, and facility staff denied any buttock wounds despite a family photo and an outside RN’s documentation of open buttock areas and a stage 1 coccyx ulcer. Another resident with a care-planned stage 4 sacral pressure injury and specific MD orders for Aquacel AG and foam dressings every other day had multiple missed or unrecorded treatments on the TAR, and reported that dressings were not changed consistently and that only two nurses regularly performed the care. The regional RN verified the missing treatment entries, while the ADON, who stated an outside wound center managed the wound, was unaware of the missed treatments, contrary to the facility’s wound care policy requiring adherence to professional standards of practice.
A resident with acute kidney failure, kidney stones, UTI, moderate cognitive impairment, and severe left hip osteoarthritis experienced inadequate pain management when PRN acetaminophen and later PRN oxycodone were not used or escalated in a timely and consistently effective manner. On one occasion, the resident was documented as yelling with pain rated 9/10, initially receiving only Tylenol because narcotics were noted as not due, and although oxycodone was later increased and administered, the resident was again observed yelling in pain that same afternoon. A family member reported the resident screaming in pain on another day, being told that Tylenol would not be available for some time, and that the nurse would not call the NP or physician, instead waiting for the NP’s next visit and only leaving a log-book message. These events occurred despite facility policies requiring prompt physician notification for changes in condition and pain management consistent with professional standards.
A resident with multiple comorbidities, including DM, CKD, morbid obesity, and mobility impairment, had a PRN order for Hydroxyzine Pamoate 25 mg. The consulting pharmacy later recommended discontinuation of this drug, and the physician signed to discontinue it, but nursing staff continued to administer the medication and the order remained active on the MAR for several weeks afterward. This resulted in the resident receiving doses of Hydroxyzine despite the documented decision to stop the medication, contrary to facility policy requiring medications to be administered in accordance with prescriber orders.
A resident without documented psychiatric diagnoses or anxiety symptoms was started on BuSpar and Trazodone following a psychiatric evaluation that relied on the resident’s self-reported sadness, anxiety, and sleep issues, while depression was still being ruled out. Nursing notes did not document the psychiatrist’s assessment or the new psychotropic orders on the day they were made, and there was no clear documentation that the responsible party was notified when BuSpar was initiated. The MAR showed BuSpar was entered and administered twice before being discontinued, and the responsible party later reported not understanding why the medications were started and expressed concern due to the resident’s prior adverse reactions to psychotropics. Interviews with ADONs revealed inconsistent accounts of when and how the responsible party was informed and showed that the rationale for Trazodone was not discussed, contrary to facility policy requiring immediate notification and documentation when there is a change in the resident’s status or treatment.
Failure to preserve dignity for a resident with a Foley catheter. A resident admitted with urinary retention, sepsis, HTN, and CHF was observed sitting in a wheelchair in a hospital gown with a Foley drainage bag hanging from the back of the chair without a privacy cover. An RRN stated the resident was a new admission and staff should have changed the hospital drainage bag to a facility bag with a privacy cover; another RRN confirmed the bag should have been changed and that a privacy cover was later placed.
Incomplete Fall Investigations for a Resident with Repeated Falls: The facility failed to complete thorough fall investigations for a resident with moderate cognitive impairment and multiple falls. Documentation for several unwitnessed falls did not identify who found the resident, when she was last checked, or include complete witness details, even when nursing notes described the resident being found on the floor, in the bathroom, or under a roommate’s bed. The DON confirmed the investigations lacked enough detail to determine the circumstances of the falls.
A resident with severe calorie malnutrition, colon cancer, and a colostomy had highly variable weights recorded over a short period, including large gains and losses. The RD confirmed that significant weight changes required a re-weight the same day or next day, but reweights were not always timely obtained, and different staff obtaining weights may have contributed to the fluctuations. Facility policy required weekly weights for new admissions and other specified situations.
Medication administration errors exceeded the acceptable rate. Surveyors observed 26 meds given with six errors, including an RN giving Fiber Plus Calcium instead of ordered Calcium Citrate and omitting four ordered supplements because they could not be found in the med cart, and another RN giving aspirin EC instead of chewable aspirin. Two residents were affected, and the facility’s policy required meds to be administered in accordance with prescriber orders.
Surveyors found that food items were stored without required labels or dates, the oven was not kept clean, and a dietary aide handled ready-to-eat food with bare hands, all in violation of facility policies. These deficiencies had the potential to affect nearly all residents receiving food from the kitchen.
Multiple residents did not receive physician-ordered fortified nutritional treats or their preferred food and beverage items during meals, including cases where allergies and dietary orders were not accommodated. Staff and resident interviews, as well as direct observation, confirmed that meal trays were missing required supplements and selected items, and that substitutions were made without honoring resident preferences.
A resident with multiple medical conditions and intact cognition was unable to summon assistance because the call light in their room was not working due to the cord being pulled out of the wall. The resident, who was at risk for falls and required help with transfers, was observed needing assistance and reported the issue. Facility policy required timely response to call lights, but the malfunction prevented the resident from receiving needed support.
A resident with hemiplegia and muscle weakness did not consistently receive a physician-ordered left palm protector as required to prevent skin breakdown and deformity. Observations and staff interviews revealed the device was not always in place during the day, and some CNAs were unaware of the correct timing for its removal. The facility also lacked a policy on palm protector use.
A resident who required tube feeding due to dysphagia and gastrostomy status was given a different enteral formula than what was ordered by the physician, despite the correct formula being available in the facility. Staff did not obtain physician or dietitian approval for the substitution, and facility policy requiring administration of prescribed enteral nutrition was not followed.
A resident with type 1 diabetes and significant physical limitations did not receive consistent staff assistance with carbohydrate counting or insulin pump operation as ordered, resulting in missed or incorrect insulin administration. Staff lacked training on the insulin pump, care plans were not updated to reflect current interventions, and documentation of insulin boluses and carbohydrate counts was incomplete, leading to significant medication errors.
A resident with multiple chronic conditions experienced a fall that was inconsistently documented in the facility's records. Two separate incident reports were created for the same event, both marked as falls with injury, yet both stated there was no injury or pain, despite clinical notes indicating a head abrasion and thigh pain. Staff interviews confirmed discrepancies in the documentation and notification times, and the DON acknowledged the reports did not match.
A resident with multiple medical conditions and a fall risk was unable to summon assistance because the call light in their bathroom was not working due to the cord being pulled out of the wall. The resident attempted to use the call light for help with positioning, but it failed to activate the electronic message board, contrary to facility policy requiring timely response to call lights.
A long-term care facility failed to protect residents from the misappropriation of narcotic medications, affecting several residents. Discrepancies in medication administration records and narcotic count sheets led to missing medications. Incidents included missing oxycodone for a resident post-discharge, premature destruction of another resident's medication, and false documentation of narcotic waste by an LPN. These deficiencies highlight lapses in medication management and documentation procedures.
Food sanitation logs incomplete and resident food storage not properly monitored
Penalty
Summary
The facility failed to maintain required sanitation and temperature tracking records in the kitchen. During an initial kitchen tour, the March 2026 sanitizer tracking log, food service cart sanitation record, and dishwasher temperature tracking log were found incomplete with multiple missing dates and missing entries. The dietary staff member present confirmed the forms were not completed as required for each day. During lunch service, the serving station room was observed to be very warm, with staff sweating while working around the warming oven, steamtable, heated plate dispenser cart, coffee maker station, standing refrigerator, and storage rack. The Regional Foodservice Director confirmed the room was very warm and uncomfortable to work in. A test tray completed after the last tray was passed showed food temperatures of 136 degrees F for barbecue pork, 126 degrees F for carrots, 151 degrees F for rice, 125 degrees F for pureed noodles, 41 degrees F for milk, and 88 degrees F for a ranch dressing packet. The Maintenance Director later confirmed the serving station temperature was 97 degrees F, and the Regional Foodservice Director confirmed condiment packets stored there, including honey mustard, thousand island dressing, and mayonnaise, were at temperatures of 90 to 93 degrees F and were not safe storage temperatures. The resident refrigerator in the employee lounge also contained improperly stored outside foods. A bag labeled with one resident's name held multiple items that were expired, including pumpkin loaf, diced peaches, spicy falafel packets, red Jello, and a ham and Swiss sandwich. The refrigerator also contained an unlabeled bottle of Ensure Plus that was expired, along with other unlabeled items that were not expired. The Registered Dietitian confirmed the items were either out of date or not labeled as required, and the Regional Foodservice Director stated dietary staff were responsible for monitoring the resident refrigerator. Facility policy required outside food to be labeled with the resident's name, preparation date if known, and expiration date, and required expired food items to be discarded.
Failure to Notify Responsible Party of New Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s responsible party was fully informed of and understood a change in the resident’s medication regimen. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur underwent an admission psychiatric evaluation by a consulting psychiatrist, who diagnosed Generalized Anxiety Disorder and ordered BuSpar 10 mg orally twice daily. The nursing progress notes for the period surrounding this evaluation contained no documentation of the psychiatrist’s assessment or of any notification to the resident’s responsible party about the new BuSpar order. The MAR showed the BuSpar order was entered and that the resident received two doses. The facility’s policy required immediate notification of the resident and authorized representative, with documentation in the medical record, when there was a change in the resident’s mental, physical, or psychosocial status. The resident’s responsible party reported that the facility started the resident on BuSpar and Trazodone for reasons unknown to her, and that she did not learn about the BuSpar until a nurse mentioned it during a visit. She stated the resident had previously experienced adverse reactions to psychotropic medications and that she did not want him on medications that cross the blood-brain barrier. One ADON stated she believed another ADON had notified the responsible party by phone and that she later met in person with the responsible party to discuss the BuSpar order, acknowledging the resident received two doses before discontinuation. The other ADON, however, stated she did not notify the family by phone, that all communication with the responsible party was in person, and that she discussed the BuSpar order with the responsible party at the next in-person visit and believed the resident did not receive any doses. There was no documentation in the medical record of timely notification to the responsible party about the initiation of BuSpar, contrary to facility policy.
Failure to Maintain Clean and Homelike Environment for Bedpan-Dependent Resident
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean and homelike environment for Resident #58. The resident was admitted on 11/04/25 with diagnoses including need for personal care, difficulty walking, muscle weakness, and repeated falls, and had a care plan dated 01/21/26 indicating an impaired ability to perform or participate in ADLs, with interventions to assist with toileting and provide incontinence care as needed. During an interview and observation on 03/16/26 at 11:40 A.M., the resident reported that her bedpan smelled terrible and that staff did not clean the bedpan after use. At that time, two unlabeled and unbagged orange bedpans were observed in the bathroom, one inside the toilet bowl and one on the floor between the wall and toilet, both appearing to have barrier cream residue on them. At 11:42 A.M., CNA #615 confirmed that the two bedpans were stored inappropriately. Review of the facility’s resident rights policy dated 05/01/25 stated the facility would make every effort to assist each resident in exercising their rights to be treated with respect, kindness, and dignity. This deficiency was cited under Complaint Number 2807084. The deficiency centers on the facility’s failure to ensure that the resident’s bedpan was cleaned after use and that bedpans were properly labeled, bagged, and stored, resulting in a bathroom environment that was not clean, comfortable, or homelike as required by the facility’s own resident rights policy.
Failure to Provide Timely Medical Response, Wound Management, and Ordered Daily Weights
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medical treatment and timely response to a change in condition for a resident with hematuria and anemia, as well as failures in wound care management and completion of ordered daily weights for other residents. One resident with acute kidney failure, urinary retention, and a Foley catheter had ongoing hematuria and blood clots while receiving Eliquis. Laboratory results showed low red blood cell and hemoglobin levels, and nursing notes documented large blood clots and bloody drainage from the penis on multiple occasions. Although nursing staff paged the nurse practitioner and notified the urologist, there were significant delays in response to the change in condition, and the medical record lacked evidence of timely family notification. The resident continued to receive Eliquis through multiple days of documented bleeding and low hemoglobin until an order was finally obtained to hold the anticoagulant and repeat labs, after which a critically low hemoglobin prompted transfer to the emergency department. Another deficiency involved a resident admitted with a displaced right femur fracture and right hip arthroplasty who had a dressing to the right hip but no corresponding wound care orders or care plan interventions. Observation confirmed the presence of a right hip dressing without any documented wound care orders in the medical record. The DON confirmed that the resident did not have orders or a care plan for wound care and interventions related to the right hip surgical site, despite the presence of a dressing. A further deficiency concerned a resident with a history including surgical aftercare for digestive system surgery, muscle weakness, and malignancies of the liver and colon, who had a documented stage 4 pressure ulcer but also had an additional skin tear on the left posterior inner thigh. The quarterly MDS did not reflect the skin tear, and the physician orders contained no assessments or treatments for this wound. During wound care observation, a dressing dated several days earlier was noted on the left posterior inner thigh, and the DON confirmed that the medical record did not contain documentation of or orders to treat this skin tear, contrary to the facility’s wound care policy requiring verification of physician orders for wound procedures. Additionally, the facility failed to obtain daily weights as ordered for another resident with morbid obesity, type II diabetes mellitus, and cardiac-related monitoring needs. This resident had an order for daily weights and a care plan that included monitoring for edema and obtaining vital signs as ordered. Review of treatment administration records showed multiple missed daily weights in both February and March, with no documentation in the progress notes explaining why the weights were not completed. An LPN confirmed that some of the required daily weights had not been obtained as ordered, despite the facility’s policy that residents’ weights be monitored and recorded in the electronic medical record to evaluate nutritional status within the parameters of their medical condition.
Failure to Provide and Document Consistent Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for existing pressure ulcers and to prevent new ulcers from developing for two residents. One resident was admitted with multiple medical conditions, including peripheral vascular disease and osteonecrosis, and the admission assessment and baseline care plan noted the presence of a wound without documenting its location. From admission through several weeks, nursing progress notes contained no documentation of any wounds other than a skin tear, and there were no physician orders for wound care. Despite this, the resident’s responsible party reported pressure wounds on the buttocks, provided a photograph showing two open reddened areas near the gluteal fold, and stated that the facility was not providing wound care. A urology RN later documented two open skin areas on the left medial buttock and a stage 1 pressure ulcer on the coccyx when the resident presented for a procedure, while facility nursing leadership and staff continued to deny the presence of any buttock wounds beyond the documented skin tear. The second resident had an existing care plan for a sacral pressure injury related to impaired mobility, urinary incontinence, and cancer, with interventions including performing ordered treatments and completing preventive measures. The resident’s MDS indicated cognitive intactness, need for assistance with rolling, frequent urinary incontinence, a colostomy, and one stage 4 pressure ulcer. Physician orders specified cleansing the sacrum with soap and water, patting dry, filling the wound and undermining with Aquacel AG rope, and applying a foam dressing every other day and as needed. However, review of the Treatment Administration Records showed multiple dates in two consecutive months when the ordered sacral wound treatments were not recorded as completed. The resident with the sacral pressure ulcer reported that dressings were not being changed consistently and attributed the development of the wound to not being repositioned, though she was unsure whether it originated in the facility or the hospital. She further stated that only two nurses regularly changed her sacral dressing. The regional RN confirmed the missing treatment entries on the TAR, and the ADON, who indicated that an outside wound center managed the resident’s wound care and had recently changed the treatment frequency, was unaware that treatments were not being completed and suggested agency nursing staff usage as a possible factor. The facility’s own wound care policy required that wound care be provided using professional standards of practice, which was not followed as evidenced by the lack of documented and consistently provided wound care for both residents’ pressure ulcers.
Failure to Provide Timely and Effective Pain Management for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pain management for a resident with multiple medical issues, including acute kidney failure, kidney stones, urinary tract infection, and primary osteoarthritis of the left hip. The resident had moderate cognitive impairment and reported pain in multiple areas, including his hip, arms, legs, and teeth. Physician orders initially included PRN acetaminophen 325 mg every four hours for pain, which was later discontinued, and then PRN oxycodone 2.5 mg every eight hours for pain. Documentation showed that on one date the resident received acetaminophen for a pain level of six, which was not effective, followed by another dose that was effective. An orthopedic note documented the resident’s left hip pain and the plan for further interventions, including urology and dental evaluations. On another date, the resident’s pain escalated significantly. At approximately midday, the resident was documented as yelling out with pain rated 9/10. At that time, narcotics were noted as “not due,” and Tylenol was administered while the NP was notified. Shortly thereafter, the NP ordered an increase in oxycodone to 5 mg every eight hours PRN, and a dose was administered. The MAR and controlled drug record indicated that the oxycodone dose was effective at a later assessment, with the resident resting; however, an observation later that same afternoon found the resident in bed yelling out that he was in pain. The ADON later stated she did not hear the resident if he hollered out after the oxycodone administration. Family interviews revealed additional concerns about pain management on an earlier date. A family member reported that the resident was screaming in pain and that staff told her Tylenol would not be available for another 40 minutes. The family member stated she had to locate staff to assist the resident and provide pain medication, and that the LPN on duty said the NP would not be in until the next day and would not address the resident’s pain, and that the nurse would not call the physician. The LPN later confirmed she was aware of the family’s concerns, gave Tylenol, did not recall if the resident was hollering in pain, and did not call the NP because the NP preferred to see residents in person for narcotic pain medications, instead leaving a message in the log book for the physician. These actions and inactions occurred despite facility policies requiring notification of the physician and representative upon changes in condition and administration of pain medications in accordance with professional standards of practice.
Failure to Timely Implement Pharmacy and Physician Discontinuation of PRN Hydroxyzine
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely implementation of pharmacy recommendations to discontinue a medication after physician approval. A resident admitted with diagnoses including a displaced right humerus fracture, gait and mobility abnormalities, type II diabetes mellitus, morbid obesity, and chronic kidney disease had a physician order dated 01/27/26 for Hydroxyzine Pamoate 25 mg to be given orally once daily as needed. The five-day admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident was receiving a diuretic, opioid, antiplatelet, and antidepressant. On 02/16/26, the consulting pharmacy recommended discontinuation of Hydroxyzine Pamoate 25 mg, and on 02/20/26 the physician reviewed and agreed with this recommendation, signing to discontinue the medication. Despite the physician’s discontinuation decision, review of the February and March 2026 MARs showed that the Hydroxyzine Pamoate order remained active and the medication continued to be administered. The MAR for February 2026 documented administration of Hydroxyzine Pamoate 25 mg on 02/25/26, and the March 2026 MAR documented administrations on 03/06/26 and 03/11/26. The order itself was not discontinued until 03/16/26. During an interview on 03/17/26, the Regional Nurse confirmed that the pharmacy recommendation to discontinue the medication was made on 02/16/26, the physician signed to discontinue it on 02/20/26, but the medication continued to be given on the above dates and the order remained in place until mid-March. Facility policy on medication administration stated that medications are to be administered in accordance with prescriber orders, which did not occur in this case.
Failure to Ensure Appropriate Indication and Notification for New Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medications by not establishing and documenting appropriate indications for new psychotropic drugs. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur had no documented history of generalized anxiety disorder, depression, or other psychiatric conditions in the medical record. Review of progress notes over several days showed no signs or symptoms of anxiety and no documentation of referral to psychiatric services. During an admission psychiatric evaluation, the consulting psychiatrist documented the resident’s self-reported sadness, depression, poor sleep, anxiety, and restlessness, diagnosed generalized anxiety disorder, ordered BuSpar 10 mg orally twice daily for anxiety, and Trazodone 25 mg orally every evening while depression was still being ruled out and not listed as a confirmed diagnosis. The nursing documentation did not reflect the psychiatrist’s assessment or the new orders for BuSpar and Trazodone on the date they were made, and there was no documentation of notification of the resident’s responsible party regarding the initiation of BuSpar. The MAR showed the BuSpar order was entered the day after the psychiatric evaluation, and the resident received two doses before discontinuation. The responsible party later reported that the medications were started for an unknown reason, stated the resident had prior adverse reactions to psychotropic medications, and did not want medications that cross the blood-brain barrier. Interviews with the ADONs revealed conflicting accounts about whether and when the responsible party was notified of the new orders, with one ADON stating she did not notify the family by phone and that all communication was in person, and acknowledging that nothing was discussed regarding the rationale for Trazodone. The facility’s policy required immediate notification of the resident and authorized representative, consultation with the practitioner, and documentation in the medical record when there is a change in mental, physical, or psychosocial status, which was not consistently followed in this case.
Failure to Preserve Dignity for Resident with Foley Catheter
Penalty
Summary
The facility failed to preserve the dignity of one resident with a Foley catheter. Resident #98 was admitted with diagnoses including urinary retention, severe sepsis with septic shock, high blood pressure, and congestive heart failure. During observation, the resident was sitting in a wheelchair in a hospital gown, and a Foley drainage bag containing urine was hanging from the back of the wheelchair without a privacy cover. The regional registered nurse stated the resident appeared to be a new admission and that the facility had gone through every resident with a Foley catheter to ensure a privacy bag was in place. Another regional registered nurse confirmed the resident was admitted the previous evening, stated staff should have changed the drainage bag from the hospital bag to a facility bag with a privacy cover, and confirmed staff later placed a privacy cover over the drainage bag. The facility's Resident Rights policy stated employees were to treat all residents with kindness, respect, and dignity.
Incomplete Fall Investigations for a Resident with Repeated Falls
Penalty
Summary
The facility failed to ensure complete and thorough fall investigations were completed for one resident with multiple falls. The resident had an admission date of 12/06/25 and diagnoses that included displaced fracture of the upper right humerus, abnormalities of gait and mobility, history of contusion of lung, type II diabetes mellitus, morbid obesity, and stage III chronic kidney disease. The resident’s MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment, and she required substantial staff assistance with ADLs. Review of the resident’s fall investigations showed repeated gaps in the documentation and fact gathering for falls that occurred in the facility. For the unwitnessed fall on 12/07/25, the resident was found face down on the floor next to the bed with bruising to the right posterior upper arm and was sent to the ER, but the investigation did not identify who found her, when she was last checked, or include complete witness information. The nursing note stated two unidentified CNAs found her and that the resident said her foot got caught in the bed sheet, but this was not supported by the investigation materials. Similar omissions were present in the 12/27/25 fall investigation, which did not identify who found the resident or when she was last seen before the fall, despite a nursing note stating a roommate observed the resident fall coming out of the bathroom. The same pattern continued in the 02/06/26 and 03/02/26 fall investigations. The 02/06/26 investigation lacked a specific last-seen time and relied on limited witness statements, while the nursing note documented that a CNA notified the nurse after the resident was found sitting on the bathroom floor and the resident reported slipping while walking with her walker. The 03/02/26 investigation also did not show when the resident was last seen before the fall, even though multiple witness statements described the resident on the floor with her head under her roommate’s bed and a bump on her head. During interview, the DON confirmed the fall investigations did not provide evidence of when the resident was last checked prior to the falls and did not contain enough detail to complete a thorough investigation. The facility policy stated fall investigations should include witness statements from residents, roommates, visitors, and staff on the unit and that an IDT root cause analysis would be conducted.
Failure to Obtain Timely Reweights for Significant Weight Fluctuations
Penalty
Summary
The facility failed to ensure weights and reweights were obtained as required to verify accuracy for one resident. Resident #24 was admitted with diagnoses including infection following a procedure, colostomy, secondary malignant neoplasm of the liver and intrahepatic bile duct, unspecified severe calorie malnutrition, and malignant neoplasm of the colon. The quarterly MDS indicated a BIMS score of 15, set-up assistance for eating, and a therapeutic diet with desired weight gain. The resident’s recorded weights fluctuated markedly over time, including gains and losses ranging from 4.1 pounds to 22.2 pounds within short intervals. During interview, the RD confirmed that significant weight changes such as 5% in one month, 7.5% in three months, or 10% in six months require a re-weight, which is supposed to be completed the same day or the next day. The RD stated Resident #24’s weights had fluctuated and re-weights were not always timely obtained, and that different people obtained the weights, which may have contributed to the fluctuation. The facility policy stated weights are to be monitored to evaluate nutritional status and that weekly weights are to be obtained for at least four weeks for new admissions, readmissions, pressure injuries, and significant unplanned weight loss.
Medication administration errors exceeded the acceptable rate
Penalty
Summary
The facility failed to ensure a medication error rate of 5% or less. During observation, record review, interview, and policy review, surveyors found that 26 medications were administered with six errors, resulting in a medication error rate of 23.08%. This affected two residents, Residents #27 and #37, out of three residents observed for medication administration, with the facility census listed as 61. For Resident #37, the medical record showed diagnoses including muscle weakness, need for assistance with personal care, and chronic obstructive pulmonary disease. During medication administration observation, RN #531 gave one Fiber Plus Calcium tablet instead of the ordered Calcium Citrate and did not administer Preservision Areds, Coenzyme Q10, Miralax, or Glucosamine-Chondroit-Vitamin C-minerals because the nurse could not find them in the medication cart. For Resident #27, the record showed diagnoses including atherosclerotic heart disease, hyperlipidemia, and major depressive disorder. During observation, RN #514 administered aspirin 81 mg enteric coated when the order was for aspirin 81 mg chewable. RN Regional #629 and RN #513 confirmed the wrong form of aspirin was given. The facility’s Medication Administration policy stated medications were to be administered in accordance with prescriber orders.
Deficient Food Storage, Sanitation, and Handling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and service practices. During a kitchen tour, open bags of cake mix and instant mashed potatoes were found in the dry goods storage room without labels or dates indicating when they were opened. In the walk-in freezer, frozen french toast sticks and an opened bag of biscuits were also found without labels or dates. Additionally, the oven in the preparation area had visible food residue and splatter, indicating it was not maintained in a clean and sanitary condition. During lunch meal service, a dietary aide was seen handling a deli sandwich with bare hands, removing it from a sandwich bag and placing it on a plate for a resident, contrary to facility policy requiring glove use for food handling. Facility policies reviewed by surveyors specified that all open food items must be labeled with the opened date, expiration date, and food item name, and that gloves must be worn when handling food. These deficiencies had the potential to affect 68 out of 69 residents who received food from the kitchen, with one resident not affected due to being NPO (nothing by mouth).
Failure to Provide Physician-Ordered Supplements and Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide meals that accommodated resident allergies, physician-ordered supplements, and stated preferences for multiple residents. For one resident with COPD, failure to thrive, and dementia on hospice, the physician ordered a regular diet with a four-ounce fortified nutritional treat at lunch. However, observation revealed that the fortified treat was not included on the lunch tray, and this omission was confirmed by both a CNA and review of the meal ticket. Another resident with systemic lupus and recent significant weight loss had a physician order for a regular diet with no bananas or seafood due to allergies and a daily fortified nutritional treat at lunch. Observation and interviews confirmed that the fortified treat was missing from the lunch tray, despite being indicated on the meal ticket. Additional deficiencies were observed regarding resident meal preferences. One resident with anorexia and moderate cognitive impairment was supposed to receive apple juice according to the meal ticket but was instead given cranberry juice and, on another occasion, lemonade. These errors were verified by both staff and the resident, who expressed dissatisfaction with the incorrect beverage. Another resident with chronic respiratory failure and muscle wasting selected specific breakfast items, including a hash brown patty and cranberry juice, but did not receive the hash brown and was given orange juice instead. Staff confirmed the kitchen had run out of hash browns. A further resident with COPD and moderate cognitive impairment also did not receive a selected hash brown patty for breakfast, as the kitchen had run out. Across these cases, the facility did not consistently provide food and beverages according to physician orders, resident allergies, and stated preferences, as evidenced by direct observation, record review, and staff interviews. These failures affected five of six residents reviewed for food and drink, out of a facility census of 69.
Failure to Ensure Functioning Call Light for Resident Needing Assistance
Penalty
Summary
A deficiency was identified when a resident with diagnoses including pancytopenia, diabetes mellitus, and atherosclerotic heart disease, and who exhibited intact cognition, was observed needing assistance and reported that the call light was not working. The resident's care plan indicated a risk for falls and included an intervention to encourage the use of the call light for transfer and ambulation assistance. During observation and interview, it was confirmed that the call light did not activate the electronic message board, and further inspection revealed the call light cord was pulled out of the wall, rendering it nonfunctional. The facility's policy required timely response to call lights to meet residents' needs.
Failure to Implement Physician-Ordered Palm Protector for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's left palm protector was implemented as ordered to prevent skin breakdown and deformity. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, and vascular dementia, had a physician's order for a left palm protector to be applied in the morning and removed at bedtime, with skin integrity checks twice daily. Documentation in the medical record indicated the palm protector was applied as ordered, and the care plan included this intervention. However, during observation, the resident was found with a contracted left hand and no palm protector in place, and the resident confirmed that the device was supposed to be worn during the day. A CNA also confirmed the palm protector was not in place as ordered and applied it at that time. Further interviews revealed that staff were not consistently aware of the timing for removal of the palm protector, with one CNA stating she was unaware it was to be removed at bedtime. Additionally, the facility did not have a policy regarding the use of palm protectors.
Failure to Administer Prescribed Enteral Feeding Formula
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, aphasia, and gastrostomy status, who was dependent on staff for activities of daily living and received the majority of their nutrition and hydration via tube feeding, was not provided the prescribed enteral feeding formula. The physician's order specified continuous administration of Isosource 1.5 at 55 ml per hour, but instead, Vital 1.5 formula was administered. This substitution was observed during a survey, and the medication administration record indicated the feeding was signed as administered according to the order, despite the actual formula being different. Interviews with nursing and dietary staff confirmed that no physician order or dietitian consultation had been made to authorize the substitution of the enteral formula. The supply room was found to have the prescribed Isosource 1.5 formula available at the time of the incident, and the medical records coordinator was unable to explain why the incorrect formula was used. Facility policy required that enteral nutrition be administered as prescribed, in accordance with professional standards, which was not followed in this instance.
Failure to Ensure Proper Insulin Pump Management and Carbohydrate Counting
Penalty
Summary
The facility failed to ensure that a resident with type 1 diabetes mellitus, spastic quadriplegic cerebral palsy, and a recent right humerus fracture received proper assistance with insulin pump management and carbohydrate counting as ordered by the physician. The resident was dependent on staff for all activities of daily living, including eating, and was unable to independently calculate or enter carbohydrate counts into the insulin pump due to physical limitations. Despite physician orders specifying that staff should assist with carbohydrate counts and insulin pump operation, there was no evidence in the medical administration records that this assistance was consistently provided across multiple meals and days. Staff interviews revealed a lack of knowledge and training regarding the resident's insulin pump and carbohydrate counting. Several nurses and LPNs admitted they were unfamiliar with the insulin pump's operation, did not know they were responsible for providing carbohydrate counts, or relied on the resident to guide them through the process. Documentation showed that staff did not consistently record carbohydrate counts or verify that insulin boluses were administered as ordered. Additionally, there was a transcription error regarding insulin dosage, and the nurse involved was unaware of the correct dose to administer, further contributing to medication errors. The resident's care plan did not reflect current physician orders related to carbohydrate counting and insulin pump management. The facility did not provide staff education on the use, care, or maintenance of the insulin pump, nor did it assess the resident for self-administration of medication. The lack of updated care plans, staff training, and proper documentation led to significant medication errors, including missed or incorrect insulin administration and inadequate monitoring of blood glucose levels.
Inaccurate Documentation of Fall and Investigation
Penalty
Summary
The facility failed to accurately document the details of a fall and the subsequent fall investigation for one resident. The medical record review revealed inconsistencies in the documentation of the fall event, including conflicting dates and times of the incident, discrepancies in the reporting of injuries, and inconsistent notification times for the nurse practitioner and resident representative. Two separate fall investigation reports were completed for the same incident, both indicating the fall was classified as 'with injury,' yet both reports stated there was no injury and no pain. Additionally, the progress note from the nurse practitioner described a small abrasion on the back of the resident's head and right thigh pain, which was not reflected in the fall investigation reports. The care plan identified the resident as being at risk for falls due to multiple medical conditions and medications, but the documentation of the actual fall event and related assessments was not consistent or accurate. The resident involved had multiple diagnoses, including osteoarthritis, atrial fibrillation, diabetes, COPD, bipolar disorder, hypertension, and impaired mobility. The resident self-reported the fall, stating she hit her head and hurt her arm, but the incident reports did not document these injuries. Interviews with facility staff confirmed the existence of two incident reports for the same event and acknowledged that the information in the reports did not match. The Director of Nursing confirmed that the fall was classified as a fall with injury, despite the incident reports indicating otherwise, and explained that the duplication occurred because the first report was accidentally closed before completion.
Non-Functioning Call Light in Resident Bathroom
Penalty
Summary
A deficiency was identified when a resident, admitted with pancytopenia, diabetes mellitus, and atherosclerotic heart disease, was found to have a non-functioning call light in their room. The resident, who was assessed as having intact cognition and was at risk for falls, reported using the call light to request assistance for positioning prior to lunch, but the device did not work. Observation confirmed that the call light failed to activate the electronic message board, and further inspection with the Administrator revealed the call light cord was pulled out of the wall, rendering it inoperable. The facility's policy required timely response to call lights to meet resident needs, but this was not met in this instance.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to protect several residents from the misappropriation of narcotic medications, affecting five residents who were prescribed such medications. The incidents involved discrepancies in medication administration records (MAR) and narcotic count sheets, leading to missing medications. For instance, Resident #70's oxycodone was reported missing after discharge, prompting a facility-wide search and drug testing of nurses, which returned negative results. Similarly, Resident #22's narcotic medication was found to be destroyed prematurely, with the facility unable to verify the receipt of medications due to missing records. Resident #21 experienced issues with medication administration documentation, where an LPN failed to record the administration of narcotic medication in the MAR, leading to a policy violation write-up. Resident #64's records showed discrepancies between the MAR and the narcotic sheets, with more administrations recorded on the narcotic sheets than in the MAR. This was discovered during routine medication audits, indicating a lack of proper documentation and accountability. Resident #71's case involved an LPN who falsely documented the wasting of narcotic medication, claiming a witness who later denied involvement. This led to the termination of the LPN and further investigation by the facility. The facility's policies on medication administration and narcotic handling were not adequately followed, resulting in these deficiencies. The incidents highlight lapses in the facility's procedures for narcotic medication management and documentation.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose Lane Nursing And Rehabilitation | 2.3 mi | ★★★★★ | 15 | 0 |
| Gardens Of Belden Village | 2.8 mi | ★★★★★ | 27 | 0 |
| Laurels Of Massillon, The | 2.8 mi | ★★★★★ | 1 | 0 |
| The Pavilion At Canal Fulton For Nursing And Rehab | 3.3 mi | ★★★★★ | 0 | 0 |
| Amherst Meadows Skilled Nursing And Rehab | 3.9 mi | ★★★★★ | 1 | 0 |
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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.