Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arcadia Valley Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Improper Food Storage and Expired Items in Kitchen: Surveyors observed expired hot dog and hamburger buns, expired milk, and multiple unlabeled, undated, or improperly sealed food items in the kitchen freezer and refrigerator, including meat patties, cookie dough, hot dogs, chicken patties, ground turkey, salad, and green Jell-O. Dietary staff confirmed the findings, and the facility policy required food storage areas and stored food items to be kept clean and dry.
Insulin Flex Pens were found improperly stored in a med cart instead of refrigerated until first use, and one used pen was not dated when opened. An RN confirmed the storage and dating expectations. In a separate finding, a resident with COPD and other chronic conditions had an Incruse Ellipta inhaler left on the bedside table without documentation allowing bedside meds or self-administration.
Failure to obtain informed consent for psychotropic medications: A resident with cancer diagnoses, depression, and anxiety had orders for an SSRI and PRN benzodiazepine, but the record lacked documentation that the resident or representative was educated on the risks and benefits needed to provide informed consent. The DON confirmed the missing consent documentation and stated the prior consents should have been completed on admission.
A resident with intact cognition and no behaviors did not receive paper copies of quarterly resident fund statements, even though she preferred them. Review of the account showed no signed quarterly statements for the first three quarters of the year, and the BOM confirmed the missing documentation. Resident Council minutes also noted concern that residents were not receiving statements from their personal accounts.
A resident with MS, COPD, and lymphedema had ordered bilateral pumps for edema management, but the pumps were documented as broken over an extended period. Although staff repeatedly noted the problem and one note stated the MD was informed, the DON confirmed there was no evidence the physician knew the pumps were broken for more than a month.
A resident was discharged from MCR Part A skilled services but remained in the facility, and the facility gave a NOMNC but did not provide the required SNF ABN (CMS Form 10055). Staff were unsure why the notice was missing, and the Administrator said corporate direction was followed even though residents cut from Part A should receive the ABN to address appeal rights and liability for continued skilled services.
Unsafe and poorly maintained resident rooms were identified for two residents. A resident representative and another resident reported damaged walls, peeled paint, scuff marks, unusable drawers, a door that would not close properly, and an overhead light that could not be turned on because it lacked a draw string. Observation confirmed the damaged surfaces, broken drawer fronts, and door and light issues, and the Administrator acknowledged environmental problems across several rooms.
A resident with cerebral infarction, dysphagia, CKD stage 3, anemia, and SVT was transferred to the ED after dislodging a J-tube, but the resident's POA reported not receiving a bed hold notice. Record review found no documentation that a bed hold notice was completed during the resident's hospital stays, and the Administrator confirmed the representative was not given the notice required by facility policy.
A resident with PTSD, anxiety, depression, aphasia, MS, and other diagnoses did not have a documented person-centered care plan for PTSD. The record contained no goals or interventions to address the resident’s mental and psychosocial needs, and the ADON confirmed the care plan was not in place or specific to the resident’s trauma triggers.
Care conferences were not scheduled in conjunction with quarterly MDS assessments for a resident with paranoid schizophrenia, DM2, and COPD. The resident had intact cognition but exhibited hallucinations, delusions, and occasional refusal of care. MDS assessments were completed quarterly, but care conferences were not documented at the same intervals, and the SW confirmed they were not completed quarterly with the MDS schedule.
Two residents did not receive ADL assistance as scheduled, including showers and nail care. One resident with dementia, diabetes, and weakness missed multiple scheduled showers, and staff later confirmed the missed care while her hair appeared greasy. Another resident with multiple serious diagnoses had only limited bath documentation, long fingernails in need of trimming, and stated no one had helped trim them since admission; a CNA confirmed aides were responsible for fingernail care and that the resident needed help with personal hygiene.
Failure to follow bowel protocol and ordered lymphedema treatment: two residents had no documented bowel movement for three days or longer without the required stepwise interventions, and one resident did not receive ordered lymphedema pump therapy because the pumps were documented as broken for an extended period. The DON and Administrator acknowledged the bowel protocol was not followed, and staff documentation was unclear regarding when the pumps stopped working and when they were repaired.
Failure to maintain pressure injury prevention measures affected a resident with dementia, hypertension, severe cognitive impairment, dependence for bed mobility, and a Braden score of 9. The care plan included an air mattress, heel elevation, skin checks, peri-care, and pressure reduction devices, but the resident later developed a coccyx wound/reddened area, and the alternating air mattress was observed and confirmed by an RN to be set at 270 lbs despite the resident weighing 101.1 lbs.
Failure to provide indwelling urinary catheter care was identified for a resident with a Foley catheter. The resident had diagnoses including cerebral infarction, dysphagia, CKD stage 3, anemia, and SVT, and the care plan called for Foley care every shift and PRN. However, the record contained no evidence that catheter care was completed, and the DON confirmed there was no documentation of it.
Failure to provide dental services for a resident with dementia and anemia. The resident had an order for dental care, was identified as at risk for oral/dental problems, and later had decayed or broken teeth documented, including three broken teeth and one chipped tooth. The resident had not seen a dentist since 10/2024 because the facility changed dental providers and she was not re-enrolled, and an MDS was completed without a corresponding oral assessment.
A resident with an indwelling urinary catheter had the collection bag and tubing found on the floor during two observations, once while in bed and again while in a wheelchair. RN and DON both confirmed the bag should be kept below bladder level and off the floor to prevent infection, and the facility’s Foley Catheter Care policy stated the bag and tubing should be kept off the floor at all times.
Mechanical lift failed during a resident transfer when the resident was suspended above the bed and a CNA had to leave to get a replacement battery. The resident, who was dependent on the lift for transfers and had MS, COPD, and muscle weakness, stated the lift often stops working and batteries sometimes have to be changed multiple times before it will operate. CNAs confirmed ongoing reliability problems with the lift during transfers.
A resident was found unresponsive and without a pulse, but facility staff failed to initiate CPR due to an incorrect code status on an internal report sheet. The resident's medical record indicated she was a full code, but staff mistakenly identified her as DNRCC-A, delaying CPR and EMS notification by over an hour, resulting in the resident's death.
The facility failed to store and prepare food in a sanitary manner, with multiple hygiene violations observed among dietary staff and improper food storage practices, potentially affecting all 42 residents.
The facility failed to provide appropriate liability notices to two residents when they were cut from Medicare Part-A services despite having benefit days remaining. Miscommunication between the therapy department and the facility led to the residents not receiving the required Advance Beneficiary Notice (ABN) forms, leaving them uninformed about their potential financial liability for services not covered by Medicare.
The facility failed to ensure the privacy of a resident whose roommate repeatedly rummaged through her belongings, and also left the resident's medical scripts unsupervised and visible at the nurses' station. Despite being offered room changes, the resident declined, and no additional interventions were implemented to safeguard her privacy.
The facility failed to ensure residents were invited to participate in care planning upon admission and during quarterly reviews. This affected two residents, one of whom was not invited to her care conference despite being cognitively intact, and another who did not have a care plan meeting after a certain date due to a transition in the social services department.
The facility failed to assess and provide activities according to a resident's preferences, who had multiple diagnoses including visual impairment. The activity director was unqualified and did not complete necessary assessments or provide appropriate activities, leading to the resident spending most of her time in bed without access to large print materials.
The facility failed to ensure fall interventions were in place per the resident plan of care, affecting a resident with multiple falls. Observations revealed missing interventions such as bedside mats, bright-colored call light tags, and nonskid socks. The resident's room was also not close to the nurse's station as required.
The facility failed to ensure a resident with significant weight loss received prescribed nutritional interventions. Despite recommendations for super cereal and super mashed potatoes, the resident did not receive these items during observed meals, and the meal ticket did not reflect the prescribed diet. Interviews confirmed the resident had not been receiving the necessary nutrition interventions since they were recommended.
The facility failed to provide medically related social services to monitor behavioral health concerns for a resident with Alzheimer's, depression, and anxiety. Despite documented behaviors such as yelling and refusing care, no social services were provided since 10/07/22, and staff addressed behaviors with food, drink, or medication instead. The DON and Administrator confirmed the lack of consistent social services staffing and the absence of social services interventions in the behavior management plan.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not including parameters for administering Norco and Acetaminophen on an as-needed basis, and by administering Morphine Sulfate for pain instead of dyspnea. The resident, with multiple diagnoses including Parkinson's disease and dementia, received Norco for pain levels between 3 to 5 and Morphine Sulfate for pain despite it being ordered for shortness of breath. Interviews confirmed the inappropriate use of medications.
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69%. An LPN administered Synthroid outside the prescribed time and incorrectly applied Diclofenac gel to a resident, affecting their treatment.
A resident with type two diabetes did not receive their prescribed Humalog insulin due to improper storage and expiration. An LPN confirmed the insulin pen was past its 28-day expiration period, and 15 loose pills were found in the medication cart drawers, violating the facility's medication storage policy.
The facility failed to maintain proper infection control practices while administering eye drops to a resident with macular degeneration and dry eyes. An LPN did not perform hand hygiene after changing gloves or before exiting the resident's room, contrary to the facility's hand washing policy.
The facility failed to ensure that all staff were checked against the Nurse Aide Registry (NAR) for a history of abuse, as required by their policy. Personnel files for a Dietary Cook and an LPN revealed no evidence of these checks, which was confirmed by the Human Resources Manager. This deficiency had the potential to affect all 42 residents at the facility.
The facility failed to ensure the activities director was qualified, potentially affecting all 42 residents. The AD was hired as a Dietary Manager and later assigned as the AD without meeting the required qualifications. Despite informing the facility of her lack of qualifications, the necessary training was not provided until the day before the surveyor's interview. As of the interview date, the AD remained unqualified according to the job description and regulations.
Improper Food Storage and Expired Items in Kitchen
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety. During an observation of the kitchen, surveyors found two packs of nickels hot dog buns expired as of 03/08/26 and two packs of hamburger buns expired as of 03/15/26. In the stand up freezer, there was one open bag of 2 meat patties that was improperly sealed, undated, and unlabeled; one bag containing several portioned pieces of cookie dough that was opened, improperly sealed, unsealed, and unlabeled; one bag containing several hot dogs that was opened and unsealed; one bag containing 5 chicken patties that was undated; and one half-pound package of ground turkey that was opened and improperly sealed with raw turkey outside of the package. In the stand up refrigerator, surveyors found one gallon of whole milk expired as of 03/21/26, an undated and unlabeled bowl of an unknown substance covered with tin foil with MM written on it, one container of undated salad, and one container of 3.5 liter of green Jell-o that was unlabeled and undated. Dietary #240 confirmed the unlabeled, undated, improperly sealed, and expired items in the freezer and refrigerator, as well as the expired buns. The facility policy stated that food storage areas shall be clean at all times and that all packaged food, canned foods, or food items stored shall be kept clean and dry at all times.
Improper storage and labeling of insulin pens and bedside inhaler
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles. During observation of the [NAME] Unit medication administration cart, insulin Flex Pens were found in the top drawer that had not yet been used and/or were not dated when first used. Resident #3 had a Semglee (glargine insulin) 100 units/ml Flex Pen that had been filled on 03/04/26 and had been used, but there was no date on the pen to show when it was first removed from refrigeration and put into use. Resident #4 had a Lantus insulin 100 units/ml Flex Pen that had been filled on 01/26/26 and had not yet been used, but it was stored in the medication cart instead of the refrigerator. Resident #18 had a Lantus insulin Flex Pen 100 units/ml that had been filled on 03/11/26, had not been used, and was also stored in the medication cart rather than refrigerated. RN #124 confirmed that insulin Flex Pens should be refrigerated until use and dated when first used. Resident #5, who had diagnoses including COPD, ischemic cardiomyopathy, depression, pulmonary fibrosis, and hypertension, had a quarterly MDS showing a brief interview for mental status score of 15 and required continuous oxygen therapy. The resident’s care plan included inhalers as ordered for altered respiratory function. Although the order was for Incruse Ellipta inhalation aerosol powder, observation showed the inhaler on the bedside table within reach, and the record did not document permission for bedside medication storage or self-administration. RN #124 confirmed the inhaler was located on the resident’s bedside table.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident and/or her representative gave informed consent for the use of psychotropic medications. Resident #44 was admitted with diagnoses including malignant neoplasm of an unspecified part of an unspecified lung, malignant neoplasm of the vulva, basal cell carcinoma of the skin, depression, and anxiety disorder. Her physician’s orders included Diazepam 5 mg by mouth every 12 hours as needed for anxiety, which originated on 03/18/26, and Venlafaxine HCL 75 mg by mouth every morning for depression, which was present on admission. The MAR for March 2026 showed she was receiving Venlafaxine as ordered, and Diazepam had not been administered since the order began. Review of the medical record found no documented evidence that the resident and/or her representative had been educated on the risks and benefits of Venlafaxine or Diazepam in order to provide informed consent for these psychotropic medications. During interview on 03/24/26, the DON confirmed there was no evidence of informed consent for either medication and provided an informed consent form for Venlafaxine and Diazepam that was given to the resident that day. The DON stated the prior consents were not available and should have been completed upon admission.
Resident Fund Statements Not Provided
Penalty
Summary
The facility failed to ensure that residents received copies of their quarterly statements from resident fund accounts. This deficiency involved Resident #37, who was admitted with diagnoses including multiple sclerosis and chronic obstructive pulmonary disease and whose MDS showed intact cognition and no behaviors. Review of Resident Council minutes showed a concern that residents were not receiving statements from their personal accounts. Resident #37 stated during interview that she did not receive a paper copy of her personal statements and that the information was only reviewed verbally, although she preferred a paper copy. Review of the resident fund account showed no evidence of a signed quarterly statement for the first three quarters of 2025, and the BOM confirmed there was no evidence of signed quarterly statements for that period.
Failure to Notify Physician of Broken Lymphedema Pumps
Penalty
Summary
The facility failed to ensure the resident’s physician was notified when the resident’s lymphedema pumps were broken for more than a month. Resident #37 was admitted with diagnoses including multiple sclerosis and COPD, and the care plan identified edema to the lower extremities related to lymphedema. The resident had orders for bilateral lymphedema pumps to be used every morning and at bedtime at a pressure of 40, along with orders to remove the pumps after 60 minutes each time. Record review showed repeated documentation that the resident reported the pumps were broken and awaiting pickup by UPS, with one note on 10/20/25 stating the physician was made aware. Additional notes over the following weeks continued to document that the pumps were broken, including entries by nursing staff, but the DON confirmed there was no evidence the physician knew the pumps were broken for more than a month. The DON also stated she learned of the broken pumps by reviewing shift reports and speaking with the resident, and confirmed the issue was not consistently documented as having been reported to the physician.
Failure to Provide Required Liability Notice After Medicare Part A Ended
Penalty
Summary
The facility failed to ensure a resident received the appropriate liability notices when Medicare Part A services ended and the resident remained in the facility. Review of the Beneficiary Notice list showed Resident #11 had a Medicare Part A discharge date of 10/21/25 and remained in the facility after that discharge. Review of the SNF Beneficiary Protection Notification Review form showed the resident began Medicare Part A skilled services on 09/11/25, had a last covered day of 10/21/25, and the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. The form indicated the resident was given a Notice of Medicare Non-Coverage, CMS Form 10123, but the facility did not provide a SNF Advanced Beneficiary Notice, CMS Form 10055, even though the resident stayed in the facility after being cut from Medicare Part A services. The form also did not include an explanation for why the notice was not provided. During interviews, the Social Service Designee was unsure why the CMS Form 10055 was not given, and the Administrator stated the resident did not receive it because she remained in the facility and did not wish to continue Part B therapy services, which was the direction received from corporate office.
Unsafe and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable environment for two residents, affecting Resident #20 and Resident #4. Resident #20’s representative reported that the room door did not close properly unless slammed, the light above the bed did not work because there was no string to pull it, and the walls showed scuff marks, damaged drywall, and peeled paint. The representative also stated that the drawers did not close all the way and that some drawers had no fronts, making them unusable. Observation of Resident #20’s room confirmed scuff marks on the bathroom door and along the walls, torn paint and drywall above the head of the bed, and an overhead light above the resident’s bed that could not be turned on because it lacked a draw string. The room door could not be shut without aggressive force and made a loud disruptive sound. Resident #4 also reported scuffed and torn wall areas behind the head of the bed that had been waiting a long time for repair, and stated that the drawers did not have fronts and could not be used. Observation confirmed torn and scuffed wall areas above the bed and a drawer on the left side without a front and unable to be used. The Administrator confirmed environmental issues across several resident rooms, including peeled paint, torn drywall, scuff marks, doors unable to be properly closed, and overhead lights unable to be turned on due to missing draw strings.
Failure to Provide Bed Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative received a bed hold notice upon transfer to the hospital. Resident #20 was admitted with diagnoses including cerebral infarction, dysphagia, chronic kidney disease stage 3, anemia, and supraventricular tachycardia. Record review showed the resident was sent to the Emergency Department after pulling out a J-tube, and progress notes documented hospital transfers related to the dislodged J-tube. The resident's power of attorney stated they did not receive a bed hold notice upon transfer/discharge. Review of the resident's record found no documentation that a bed hold notice was completed during the resident's hospital stays. During interview, the Administrator confirmed the resident's representative was not given a bed hold notice upon transfer to the hospital. The facility policy stated that after admission and before a resident is transferred or leaves the facility, the resident and/or sponsor will be provided written information including the state and facility bed hold policy.
Missing PTSD Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with PTSD. Resident #2 was admitted with diagnoses including diabetes, asthma, aphasia, multiple sclerosis, von Willebrand disease, insomnia, urinary retention, anxiety, PTSD, and major depressive disorder. The quarterly MDS completed on 02/09/26 identified peripheral vascular disease, urinary tract infections, hyperlipidemia, aphasia, multiple sclerosis, anxiety, depression, and PTSD. Review of the resident's record found no documentation of a care plan related to PTSD, including goals and interventions to meet the resident's mental and psychosocial needs. During interview on 03/25/26 at 3:45 P.M., the Assistant Director of Nursing confirmed the resident did not have a care plan in place related to PTSD, including goals and interventions specific to her trauma and trigger.
Care Conferences Not Scheduled With Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure care conferences were scheduled in conjunction with quarterly MDS assessments for one resident reviewed for care conferences. Resident #1 was admitted with diagnoses including paranoid schizophrenia, type II diabetes, and chronic obstructive pulmonary disease. An MDS assessment noted the resident’s cognition remained intact and that he had hallucinations, delusions, and refused care one to three days during the review period. The MDS listing showed assessments completed on 07/12/25, 10/12/25, 01/12/26, and one scheduled for 04/12/26, but care conferences were documented only on 07/16/25, 10/10/25, and 02/13/26. The Social Worker stated care conferences were completed quarterly and followed the MDS schedule, but later confirmed the resident’s care conferences were not completed quarterly in conjunction with the MDS assessments. The facility policy stated the MDS nurse was responsible for coordinating the routine schedule of the resident’s care conference and the MDS assessment.
Failure to Provide Scheduled ADL Assistance, Including Showers and Nail Care
Penalty
Summary
The facility failed to ensure residents who required assistance with ADLs received nail care and showers as scheduled. The deficiency affected two of four residents reviewed for ADL assistance, based on observations, record review, interviews, and policy review. Resident #33 was admitted with diagnoses including metabolic encephalopathy, type II diabetes, and dementia. Her care plan stated she required assistance with ADLs due to cognitive impairment, dementia, and weakness, and that staff would assist with daily hygiene and showering per facility policy weekly. The shower schedule showed she was to receive showers on Mondays and Thursdays on night shift, but review of shower records showed she did not receive showers as scheduled on 01/01/26, 01/05/26, and 02/12/26. On 03/23/26, she was observed seated in a wheelchair in the dining room and her hair appeared slightly greasy. An LPN later confirmed her hair was a little greasy, and the DON confirmed the missed showers. Resident #44 was admitted with diagnoses including lung cancer, vulvar cancer, basal cell carcinoma, COPD, diabetes, difficulty walking, osteoarthritis, depression, and anxiety disorder. Her initial ADL care plan stated she required assistance with ADLs related to weakness and was to remain clean, dry, odor free, and appropriately dressed. Review of shower/bathing documentation showed only five documented bed baths since admission, with the last on 03/23/26, and the documentation did not specify what personal hygiene care was provided. On observation, her fingernails were long and in need of trimming, and the resident stated she preferred trimmed nails and denied anyone had helped trim them since admission. A CNA stated aides were responsible for fingernail care, confirmed the resident needed assistance with personal hygiene including nail care, and found the resident was not on the current shower schedule.
Failure to Follow Bowel Protocol and Lymphedema Treatment Orders
Penalty
Summary
The facility failed to follow its bowel management protocol for residents who had no documented bowel movement for three consecutive days or longer. For Resident #37, the bowel record showed no bowel movement from 03/01/26 through 03/06/26 and again from 03/08/26 through 03/11/26. The resident had diagnoses including multiple sclerosis and chronic obstructive pulmonary disease, and the record showed she was dependent on staff for toileting hygiene and occasionally incontinent of bowel and bladder. The Administrator confirmed that no intervention was provided after three days of constipation and that the facility bowel management protocol was not followed. The facility policy required bowel sounds assessment and stepwise interventions when a resident had no bowel movement for three days, including milk of magnesia, then a suppository, then an enema if needed. Resident #37 had standing orders for senna and later Miralax, but the record and interview showed the bowel protocol was not initiated during the periods without bowel movement. The Administrator confirmed the resident did not receive any intervention after three days of constipation. The facility also failed to ensure Resident #37 received physician-ordered treatment for lymphedema. The resident had an order for lymphedema pumps to be used for 60 minutes every morning and at bedtime at a pressure of 40 for bilateral lower extremities. The record contained repeated notes over several months stating the pumps were broken or awaiting pickup, and the DON and Administrator acknowledged the documentation was unclear as to when the pumps were broken and fixed. The DON stated she learned of the broken pumps by reviewing shift reports and speaking with the resident, and confirmed she was not sure when the pumps stopped working because no one informed her. For Resident #44, the bowel movement record showed the last documented bowel movement occurred on 03/18/26, with no bowel movements documented for the next six days. The resident had scheduled orders for Miralax every morning and sennosides twice daily, and the MAR showed those medications were given as ordered. However, there was no documented evidence that staff provided additional bowel-promoting medication around the third day without a bowel movement, no evidence that nurses notified the physician about the lack of bowel movement, and no evidence of new orders for MOM, suppositories, or enemas. The DON and Regional Nurse Consultant acknowledged that Resident #44 was not documented as having a bowel movement for six days and that there was no evidence of interventions to promote a bowel movement.
Failure to Maintain Pressure Injury Prevention Measures
Penalty
Summary
Failure to ensure interventions to prevent pressure injuries were in place affected Resident #6, who was admitted with diagnoses including dementia and hypertension and was assessed as severely cognitively impaired, dependent on staff for bed mobility, and at very high risk for pressure sores with a Braden Scale score of 9. The care plan identified the resident as at risk for impaired skin integrity/pressure ulcers related to concussion and decreased mobility and included interventions such as an air mattress to bed at all times, heel elevation, skin inspection during routine daily care, peri-care after each episode of incontinence, pillows for positioning, and pressure reduction devices as ordered. Record review showed the resident had a pressure reducing mattress ordered for the bed and later had a wound to the coccyx with a reddened area noted on a skin check assessment. Observation on 03/23/26 at 9:45 A.M. revealed the alternating air mattress was set to 270 pounds, and RN #145 confirmed the same setting during interview at 3:42 P.M. The resident weighed 101.1 pounds on 03/01/26, and an order dated 03/04/26 directed cleansing the coccyx wound with soap and water, applying triad paste, and leaving it open to air.
Failure to Document Foley Catheter Care
Penalty
Summary
Failure to provide indwelling urinary catheter care was identified for one resident with a Foley catheter. The resident was admitted with diagnoses including cerebral infarction, dysphagia, chronic kidney disease stage 3, anemia, and supraventricular tachycardia. The resident’s MDS assessment showed an indwelling urinary catheter, and the care plan dated 03/10/26 identified the resident as at risk for infection or worsening infection due to indwelling medical devices, including a urinary catheter and J-tube. The care plan also documented an alteration in elimination related to the indwelling urinary catheter with an intervention for Foley catheter care every shift and PRN. Review of the record found no evidence that indwelling urinary catheter care was completed, and the DON confirmed there was no documentation of catheter care for the resident. The facility policy titled Foley Catheter Care stated nursing staff would provide indwelling urinary catheter care in the morning, before sleep, and as needed per physician order.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure that Resident #14 received dental services. Resident #14 was admitted with diagnoses including dementia and anemia, had an order allowing dental services, and was identified in the care plan as being at risk for oral/dental health problems related to natural teeth. The resident’s cognition was severely impaired, she refused care four to six days, required set-up help for oral hygiene, and had no obvious or likely cavity or broken natural teeth on the MDS assessment. However, a later oral assessment documented decayed or broken teeth, and the DON stated the resident had three broken teeth and one chipped tooth. Record review and interviews showed the resident had not seen a dentist since 10/2024 because the facility changed dental providers and she was not re-enrolled with the new provider. The resident’s representative stated the resident had admitted with a chipped tooth and was unsure whether the facility had arranged dental services. The DON confirmed that an MDS was completed in 01/23/26 but no corresponding oral assessment was completed, and the facility did not initiate the dental referral until 03/24/26 after the issue was identified.
Urinary Catheter Bag Left on the Floor
Penalty
Summary
The facility failed to ensure a resident’s indwelling urinary catheter collection bag was maintained off the floor. Resident #44 was admitted with diagnoses including malignant neoplasm of the bronchus or lung, malignant neoplasm of the vulva, neuromuscular dysfunction of the bladder, retention of urine, and difficulty walking. She had a physician’s order for an indwelling urinary catheter related to urinary retention, and her care plan included maintaining the catheter bag to gravity drain, keeping it below the level of the bladder, and securing the tubing to prevent accidental dislodgement. The care plan did not include interventions specific to keeping the collection bag off the floor to prevent infection. During observation, the resident was found in bed with the catheter collection bag lying directly on the floor under the bed, with part of the tubing also on the floor. RN #145 confirmed the bag should be kept below the bladder level and secured off the floor to prevent infections, and she repositioned it using the clip on the bag. On a later observation, the resident was in a wheelchair in the therapy room and the catheter collection bag was again in direct contact with the floor, with tubing on the floor underneath the wheelchair. The bag had been secured to the wheelchair frame below the seat, but it still allowed contact with the floor. The DON confirmed the bag and tubing should be kept off the floor and stated the importance was to prevent infection. The facility policy on Foley Catheter Care stated the bag and tubing should be kept off the floor at all times.
Mechanical Lift Failed During Resident Transfer
Penalty
Summary
The facility failed to ensure mechanical, electrical, and patient equipment was in safe operating condition. This affected one resident who was dependent on a mechanical lift for transfers. The resident was admitted with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, and muscle weakness, and the MDS assessment completed on 12/02/25 showed a BIMS score of 15, indicating the resident was cognitively intact. The MDS also showed the resident was dependent on staff for toileting, personal hygiene, bed mobility, and transfers. During observation on 03/26/26, the resident was being transferred from bed to chair with a mechanical lift by two CNAs when the lift stopped working while the resident was suspended above the bed. One CNA left the room to get a replacement battery. The resident stated the lift almost always stops working and staff have to leave to get a new battery at least half of the time, and said it was scary when the lift stopped while they were in the air. The resident also stated that on the prior day staff had to change the batteries four times before the lift would work. Both CNAs confirmed there had been ongoing problems with the reliability of the mechanical lifts, including stopping during transfers and requiring battery changes, sometimes multiple times, while the resident remained in the air.
Failure to Provide CPR Due to Incorrect Code Status
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident as per the resident's advance directives. The resident was found unresponsive and without a pulse, but the facility staff inaccurately identified the resident's code status as Do Not Resuscitate Comfort Care Arrest (DNRCC-A) based on an internal report sheet. This error occurred despite the resident's medical record indicating she was a full code, as per her advance directives upon admission. Consequently, CPR was not initiated, and Emergency Medical Services (EMS) were not called until approximately an hour and fifteen minutes after the resident was found unresponsive. The resident, who had a history of sepsis, urinary tract infection, pressure ulcer, chronic obstructive pulmonary disease (COPD), acute congestive heart failure (CHF), diabetes, atrial fibrillation, hypertension, history of pulmonary embolism, and malignant neoplasm of the endometrium, was admitted to the facility with a full code status. On the night of the incident, the resident was found unresponsive in her bed by a State Tested Nursing Assistant (STNA), who then called for nursing assistance. Two nurses verified the absence of vital signs but relied on an incorrect report sheet that listed the resident as DNRCC-A, leading to a delay in initiating CPR. The error was discovered later when a Licensed Practical Nurse (LPN) reviewed the resident's electronic medical record for next of kin information and found the correct full code status. The Director of Nursing (DON) was notified, and CPR was initiated, but it was too late to prevent the resident's death. The facility's failure to verify the resident's code status in the electronic medical record and reliance on an inaccurate report sheet were critical factors that led to the deficiency.
Removal Plan
- Licensed Practical Nurse (LPN) #150 was reviewing Resident #44's electronic medical record to obtain next of kin information and funeral home preference when she discovered Resident #44's code status was a full code. The DON was notified, and a directive was given to initiate CPR and to call 911. CPR was initiated and EMS were called.
- Resident #44 was transported out of facility via EMS.
- One Registered Nurse (RN), two LPNs, two State tested Nursing Assistants (STNAs) on site were re-educated by the DON on timely delivery of services and care, change of condition, and notification, and where to find code status orders (in Point Click Care (PCC)). RN #100 (the staff member identified to be responsible for the error in not initiating CPR timely) was suspended pending investigation.
- All staff re-education was initiated related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification by the DON, ADON, and Regional Quality Assurance Registered Nurse via in person or telephone. Staff trained included five RNs, nine LPNs, 19 STNAs, three housekeeping staff, three dietary staff, and one activity personnel.
- The Social Service Designee attempted to contact Resident #44's family without success. A voicemail was left. The Social Services Designee and preceptor began an audit of all 43 resident's advance directives' orders and advance directives on file in chart. Each was verified and cross-referenced for accuracy. Any identified findings were corrected upon discovery.
- The Human Resource Director verified CPR certification of RN #100 and LPN #150 and began audits of all licensed nurses (five RNs and nine LPNs) CPR certifications. Any identified findings were addressed immediately.
- All current report sheets were removed from the facility and replaced with new report sheets that did not include the resident's code status by Regional Director of Quality Assurance RN.
- The facility Medical Director was notified by the DON of the incident involving Resident #44 and the delay in CPR initiation and current process of correction.
- All staff on shift interviews were completed with RN #100, LPN #150, STNA #175, and STNA #200, who were all of the staff on duty when Resident #44 was found unresponsive and without an obtainable pulse. Re-education was provided related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification by the Regional Director of Quality Assurance RN.
- All licensed nurses not CPR certified (two RNs and three LPNs) were removed from direct patient care by the Administrator and not utilized in the role as a licensed nurse until their CPR certification was current.
- All staff re-education (which included five RNs, nine LPNs, 19 STNAs, three housekeeping staff, three dietary staff, and one activity personnel) was completed by the DON, ADON, and Regional QA nurse related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification.
- The advance directives/code status for all 43 facility residents was verified and cross-referenced, orders in PCC verified, and audit completed by Social Services Designee.
- A crash cart (cart with emergency supplies/equipment) audit was completed by the DON to ensure all required supplies were present on the cart and the cart was replenished.
- All licensed nurses (five RNs and nine LPNs) CPR certifications were current and valid. An Ad hoc Quality Assurance (QA) meeting was held. The facility implemented a plan for all licensed nursing staff CPR certifications to be verified upon hire, annually, and evaluated during annual performance evaluations.
Sanitary Food Storage and Preparation Deficiency
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner, potentially affecting all 42 residents. During an initial kitchen tour, two bags of salad with a best-by date of the previous day were found in the refrigerator. Continuous observations of the lunch tray line revealed multiple hygiene violations: a dietary aide rubbed her nose and forehead with her wrist without changing gloves or washing hands, and another aide wiped her hand on her pants before applying a new glove without hand hygiene. Additionally, a dietary cook licked her fingers to separate meal tickets, which were then placed on resident trays. Seven trays were sent out with bowls of grapes left open to air. The freezer temperature was also found to be at 14 degrees Fahrenheit, which was confirmed by the dietary cook. The facility's policies on hand hygiene and food storage were not followed, as confirmed by the dietary manager.
Failure to Provide Required Liability Notices
Penalty
Summary
The facility failed to provide appropriate liability notices to two residents when they were cut from Medicare Part-A services despite having benefit days remaining. Resident #40, admitted with diagnoses including acute bronchitis, muscle weakness, and altered mental status, was discharged from Medicare Part A on 02/18/24 without receiving an Advance Beneficiary Notice (ABN) form CMS-10055. Similarly, Resident #41, admitted with multiple sclerosis, cellulitis, and other conditions, was discharged from Medicare Part A on 04/20/24 without receiving the required ABN form. Both residents remained in the facility without being informed of their potential financial liability for services not covered by Medicare. The deficiency was attributed to a miscommunication between the therapy department and the facility regarding responsibility for completing the ABN forms. The Administrator, who was also the Business Office Manager, acknowledged the issue and indicated that a quality assurance/performance improvement (QAPI) plan was developed after the survey team entered the facility. However, the QAPI plan lacked comprehensive interventions, such as initial audits and staff education, to ensure compliance with the requirement to issue ABN forms. The facility's policy stated that the ABN should be provided two days prior to the termination of services, but this was not adhered to in the cases of Residents #40 and #41.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure the privacy of Resident #38, who was admitted with diagnoses including hyperkalemia, gastrointestinal hemorrhage, acute kidney failure, and type II diabetes. Despite having intact cognition and no behaviors, Resident #38 experienced repeated invasions of privacy by her roommate, who rummaged through her belongings and even attempted to touch her food. Staff interviews confirmed that the roommate's behavior was a known issue, and although Resident #38 was offered room changes multiple times, she declined. The Director of Nursing (DON) acknowledged that no additional interventions were implemented to safeguard Resident #38's privacy apart from offering room changes. Additionally, the facility failed to maintain the confidentiality of Resident #38's medical records. Observations revealed that scripts for controlled substances prescribed to Resident #38 were left unsupervised and face-up on the nurses' station, making her personal information visible. The Medication Aide confirmed that the scripts should not have been left out, and the DON stated that new scripts are usually placed face down on a clip until the pharmacy picks them up. The facility did not provide a policy related to privacy when requested.
Failure to Include Residents in Care Planning
Penalty
Summary
The facility failed to ensure residents were invited to participate in care planning upon admission and during quarterly reviews. This deficiency affected two residents, Resident #15 and Resident #22. Resident #22, who was admitted with diagnoses including metabolic encephalopathy, type II diabetes, and congestive heart failure, was not invited to participate in her care conference despite being cognitively intact and having no behaviors. Interviews with the resident and staff confirmed that Resident #22 was not aware of the care conference or the facility's social worker. The facility's policy stated that the interdisciplinary care team and the resident should meet and review the care plan upon admission, which was not followed in this case. Resident #15, admitted with multiple diagnoses including chronic obstructive pulmonary disease, cerebral infarction, and mild cognitive impairment, also experienced a lapse in care planning. The last documented care conference for Resident #15 was held with only the resident and an LPN present, and there was no evidence of a care plan meeting after that date. The Director of Nursing confirmed that a care plan meeting should have occurred in April 2024 but did not due to a transition period in the facility's social services department. The facility's policy required quarterly care plan meetings with the interdisciplinary team and the resident, which was not adhered to in this instance.
Failure to Provide Activities According to Resident Preferences
Penalty
Summary
The facility failed to ensure that Resident #247 was assessed and provided activities according to her preferences. Resident #247, who had multiple diagnoses including malignant neoplasm of bone, type two diabetes, diabetic retinopathy with macular edema, visual loss, anxiety, depression, spinal stenosis, arthritis, sleep disorder, and heart disease, was admitted and readmitted to the facility. The activity participation review for the resident was incomplete, and there was no evidence of a new assessment upon her readmission. The resident's activity participation was minimal, and her visual plan of care did not include provisions for large print materials, which she needed due to her vision impairment. Observations revealed that the resident spent most of her time in bed without access to large print reading materials, and interviews confirmed that the activity director was not qualified and had not completed the necessary assessments or provided appropriate activities for the resident's needs. The facility's policies required activity assessments to be completed on admission, readmission, and annually, with quarterly progress notes. However, these assessments were not properly conducted for Resident #247. The activity director admitted to not completing the resident's activity assessment and not documenting activity refusals. Additionally, the director of nursing confirmed that the resident's activity assessment was not comprehensive, and the activity plan of care was not individualized. The facility's failure to adhere to its policies and provide appropriate activities for Resident #247 led to the deficiency identified in the report.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure fall interventions were in place per the resident plan of care, affecting one resident. Resident #10, who was admitted with diagnoses including muscle weakness, dementia, macular degeneration, difficulty walking, lack of coordination, and a fracture of the right humerus, experienced multiple falls on 07/17/23, 09/01/23, 01/20/24, and 04/25/24. The falls on 07/17/23 and 09/01/23 were not captured in the Minimum Data Set (MDS) assessment dated 10/03/23. The resident's fall plan of care included interventions such as a low bed with a mat on the floor, placement in a room closer to the nurse's station, nonskid socks, and a bright-colored tape on the call light. However, these interventions were not consistently implemented or maintained as observed on multiple dates in May 2024. Observations revealed that Resident #10 did not have mats at the bedside, the call light did not have a bright-colored tag, the resident was not wearing nonskid socks, and the resident's room was not close to the nurse's station. Interviews with the State tested Nurse's Aide (STNA) and Licensed Practical Nurse (LPN) confirmed these observations and noted that the resident refused to wear nonskid socks. The Director of Nursing (DON) confirmed that the falls on 07/17/23 and 09/01/23 were not captured in the MDS assessment. The facility's policy on Fall Management stated that the care plan should be updated routinely and with significant changes in the resident's condition, which was not adhered to in this case.
Failure to Provide Prescribed Nutritional Interventions
Penalty
Summary
The facility failed to ensure a resident with a history of significant weight loss received the prescribed nutritional interventions. Resident #35, who had diagnoses including morbid obesity, moderate protein-calorie malnutrition, and dysphagia, was supposed to receive a consistent carbohydrate diet with super cereal and super mashed potatoes daily. However, observations during lunch and dinner on 05/15/24 revealed that the resident did not receive the super mashed potatoes as recommended by the dietitian. Additionally, the resident's meal ticket did not reflect the prescribed super cereal or super mashed potatoes, indicating a failure in communication and implementation of the dietary orders. Interviews with the Director of Nursing and the Dietary Manager confirmed that the resident had not been receiving the prescribed nutritional interventions since they were recommended on 04/10/24. The facility's policy on Immediate Temporary Interventions for Unintended Significant Weight Loss was not followed, as the resident did not receive the necessary nutrition interventions to prevent further weight loss. This deficiency was identified through record reviews, observations, and staff interviews, highlighting a lapse in ensuring the resident's nutritional needs were met as ordered by the dietitian.
Failure to Provide Medically Related Social Services for Behavioral Health Concerns
Penalty
Summary
The facility failed to provide medically related social services to monitor behavioral health concerns for Resident #10, who was admitted with diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder. The resident exhibited behaviors such as yelling out, crying, and refusing care, which were documented in the care plan. However, the last Social Service History assessment was completed on 09/27/23, and there was no evidence of medically related social services being provided since 10/07/22. Observations on multiple dates revealed the resident frequently yelling for help, with staff either not acknowledging the calls or addressing the behaviors with food, drink, or medication rather than social services interventions. Interviews with staff confirmed the lack of consistent social services staffing and the absence of social services interventions in the behavior management plan for the resident. The Director of Nursing (DON) and the Administrator acknowledged the deficiency, noting that social service assessments should be completed quarterly and that a social worker would be integral to behavior management. The facility's policy on Behavior and Psychoactive Management Program indicated that social service support should be provided as needed, with a social service representative evaluating and documenting changes in behaviors and communicating with the Behavior Committee. However, this protocol was not followed, leading to the deficiency in providing necessary social services to Resident #10.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, the facility did not include parameters for administering narcotic pain medication (Norco) and Acetaminophen on an as-needed (prn) basis, and administered Morphine Sulfate for pain instead of its intended use for dyspnea. This affected a resident with multiple diagnoses, including Parkinson's disease, congestive heart failure, dementia, emphysema, anxiety disorder, schizophrenia, and psychotic disorder with delusions. The resident's medical record showed that Norco was administered for pain levels between 3 to 5 on a 1-10 scale, and Morphine Sulfate was frequently given for pain despite being ordered for shortness of breath, with no documented complaints of dyspnea. Interviews with the resident's Power of Attorney and the Regional Quality Assurance Nurse confirmed the inappropriate use of medications. The Power of Attorney noted that the resident experienced chronic pain due to arthritic pain and compression fractures but did not regularly suffer from shortness of breath. The Regional Quality Assurance Nurse acknowledged the lack of parameters for the Norco order and confirmed that Morphine Sulfate was administered for pain instead of dyspnea, as ordered. The findings indicate a failure to adhere to proper medication administration protocols, leading to the inappropriate use of controlled narcotic medications.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a medication error rate of 7.69%. This deficiency was identified through record review, observation, interview, and policy review. Specifically, Resident #33, who was admitted with diagnoses including hypothyroidism, low back pain, chronic pain, and fractures, was affected. The resident had orders for Synthroid to be administered early in the morning and Diclofenac Sodium gel to be applied to specific areas for pain relief. However, the Licensed Practical Nurse (LPN) administered Synthroid at 8:11 A.M. instead of the prescribed early morning time and applied the Diclofenac gel incorrectly, both in terms of location and omission of certain areas. During the observation, the LPN confirmed the errors, acknowledging that Synthroid was administered outside the prescribed time window and that the Diclofenac gel was not applied to the ankles and feet as ordered. Additionally, the LPN applied the gel to the upper back, which was not included in the physician's order. The facility's policies on medication administration were reviewed, revealing that the physician's specific orders should supersede any routine schedule, and medications should be administered in an organized and safe manner. The failure to adhere to these policies contributed to the observed medication errors.
Improper Medication Storage and Expired Insulin Administration
Penalty
Summary
The facility failed to ensure medications were stored properly and that expired medications were not administered. Specifically, a resident with type two diabetes did not receive their prescribed Humalog insulin from the specified dates. Upon inspection, it was found that the Humalog pen had been opened and was past its 28-day expiration period. Additionally, there were 15 loose pills found in the medication cart drawers, which were not properly stored or identified. An LPN confirmed the Humalog pen should have been discarded two days prior to the survey. The facility's medication storage policy mandates that insulin products should be stored in the refrigerator until opened and that the date of opening should be noted on the label. The policy also requires that medication storage areas be kept clean, well-lit, organized, and free of clutter. These guidelines were not followed, leading to the deficiency.
Infection Control Lapse During Eye Drop Administration
Penalty
Summary
The facility failed to maintain proper infection control practices while administering eye drops to a resident. The resident, who was admitted with diagnoses including macular degeneration and dry eyes, had orders for artificial tear solution to be administered twice daily. During an observation, an LPN administered the eye drops to the resident's left eye, removed her gloves, and applied a new pair of gloves without performing hand hygiene. She then administered the drops to the right eye and left the room without performing hand hygiene after removing the gloves or before exiting the room. The LPN confirmed in an interview that she did not perform hand hygiene as required. The facility's hand washing policy required the use of alcohol hand sanitizer before exiting a resident's room, and the medication administration policy did not specify when to apply or remove gloves or when to perform hand hygiene during the process.
Failure to Check Staff Against Nurse Aide Registry
Penalty
Summary
The facility failed to ensure that all staff were checked against the Nurse Aide Registry (NAR) for a history of abuse, as required by their policy. Specifically, the personnel files for a Dietary Cook and an LPN revealed no evidence that they were checked against the NAR. This deficiency was confirmed by the Human Resources Manager during an interview. The lack of these checks had the potential to affect all 42 residents at the facility. The facility's undated policy titled 'Licensing Requirements' mandates that all required checks, including the Ohio Nurse Aide Registry and Office for Inspector General, be completed on anyone the facility is considering hiring.
Unqualified Activities Director
Penalty
Summary
The facility failed to ensure the activities director was qualified, potentially affecting all 42 residents. The personnel file review revealed that the Activity Director (AD) was hired as a Dietary Manager and later assigned as the AD without meeting the required qualifications. The job description required the AD to be a qualified therapeutic recreation specialist, licensed activities professional, or have relevant experience or training. However, there was no evidence that the AD met these qualifications. Interviews confirmed that the AD was aware of her lack of qualifications and had informed the facility, which promised but failed to provide the necessary training until the day before the surveyor's interview. As of the interview date, the AD remained unqualified according to the job description and regulations.
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 210 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Coolville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockland Ridge Nursing & Rehabilitation Center | 11.4 mi | ★★★★★ | 3 | 0 |
| Belpre Landing Nursing And Rehabilitation | 12.3 mi | ★★★★★ | 7 | 0 |
| Arbors At Pomeroy | 13 mi | ★★★★★ | 1 | 0 |
| Willows Center | 13.1 mi | ★★★★★ | 31 | 0 |
| Parkersburg Center | 13.3 mi | ★★★★★ | 34 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Arcadia Valley Skilled Nursing And Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.