Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aristos Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to implement infection control precautions and maintain infection tracking logs. One resident with a history of CRE and Candida Auris had only EBP signage outside the room instead of contact precautions, and staff and housekeeping relied on that signage while providing care and cleaning. Another resident with a dialysis catheter and wound was on EBP, but staff performed wound care using gloves only and did not wear a gown during high-contact care. The facility also had no infection control logs to track and trend infections.
Failure to monitor antibiotic use and infection trends: The facility did not maintain ATB/infection control logs for several months, and the DON and Regional Director of Clinical Services verified they could not determine which residents were on ATBs, had infections, or whether there were trends or patterns. The facility’s antibiotic stewardship policy addressed antibiotic orders but did not include tracking ATB use or infections for trends, patterns, or MRDO infections.
Homelike Environment Not Maintained: Surveyors observed a trail of bowel movement in a shower room, a soiled brief on a trash can, and cluttered equipment in the area. An environmental tour found missing baseboards, a loose handrail, a stained ceiling, damaged blinds, open holes near a keypad, and other disrepair. Residents reported the shower room was not clean and the water was often cold, and one resident identified additional bathroom disrepair.
Controlled substances were not accurately accounted for or consistently documented for several residents. Narcotic sheets showed mismatched or missing entries compared with MAR documentation, illegible dates and signatures, and missing receipt documentation for controlled meds including oxycodone, tramadol, Lyrica, and morphine. Residents involved had diagnoses such as cancer pain, opioid dependence in remission, stroke, neuropathy, and CHF, and were assessed as cognitively intact.
A resident with impaired cognition, gait issues, and a guardian had an unwitnessed fall during an unassisted transfer. Staff noted facial discoloration/bruising, but the guardian was not notified until about 2 days later. The RDCS confirmed the delayed notification, and the facility policy required representative notification within 24 hours except in medical emergencies.
Missed ADL Care for Showering and Fingernail Trimming A facility failed to provide timely showers and fingernail care for residents who depended on staff for ADLs. One resident with severe cognitive impairment and another with quadriplegia had long gaps in shower documentation, and both had elongated nails with delayed or absent nail care. A third resident with hemiplegia reported that staff did not provide showers per preference and that fingernail trimming was delayed after he requested it; shower records also showed extended gaps and no nail-care documentation on the shower forms.
A resident with cardiac-related diagnoses repeatedly refused Digoxin, but the MAR and record did not show physician notification of the refusals. Two residents with heart failure, CKD, and other complex conditions also had ordered daily weights that were not consistently obtained or documented, and one resident had a 9.9-pound weight increase without documented provider notification.
Delayed nephrostomy orders and care plan: The facility failed to have timely MD orders and a care plan in place for a resident with bladder cancer, CKD, and urinary tract openings requiring nephrostomy care. Although the hospital discharge instructions included daily care, dressing changes, flushing, and an ASAP urology appt, the nephrostomy treatment orders and POC were not started until later, and there was no documented evidence of nephrostomy monitoring or care before then. The DON and RDCS confirmed the delay and could not locate documentation showing the urology appt was scheduled or attempted.
Two residents receiving scheduled HD had no documented exchange of dialysis communication forms between the facility and the outside dialysis center. Both residents had ESRD and other significant diagnoses, and their records showed repeated dialysis visits without evidence that the facility sent the required communication form or received one back after treatment. Staff and dialysis RN interviews confirmed the forms were not being exchanged, and one resident also lacked ordered pre- and post-dialysis assessments.
A physician failed to sign a resident’s admission orders in a timely manner. The resident was admitted after a right knee fracture, right knee replacement, and aftercare following surgery, and the orders were received on admission but were not acknowledged by the MD until weeks later. The DON, VPO, and RDCS confirmed the delay, and the MD stated he usually saw new admissions within 48 hours and had been signing orders manually when at the facility.
A resident with OCD, schizoaffective disorder, and depression had a PRN Hydroxyzine order for anxiety that did not include a stop date. The MAR showed repeated use over several days, and the RDCS confirmed PRN meds were expected to have stop dates. Facility policy limited PRN meds to 14 days unless the MD documented the rationale and duration.
A resident with an indwelling catheter, nephrostomy tubes, and diagnoses including cystitis with hematuria and bladder cancer reported blood-tinged urine in a nephrostomy bag. An NP instructed staff to obtain a urine C&S, but the sample was not collected and no corresponding order appeared in the order recap. Later review showed only one urine test in the reviewed period, and the RN verified the ordered test was not completed.
Room changes were not documented in the medical records for two residents. One resident with dementia and schizophrenia had a room change form uploaded in the EMR, but no corresponding record documentation was found, and another resident with stroke-related deficits and depression had no room change documentation despite the facility list showing a move. The SSD said she was responsible for room changes, including notifying the resident, obtaining a signature, uploading the form, and writing a progress note, but verified the documentation was not completed.
Unsanitary kitchen conditions and improper food handling were observed when the DM found food-like splatters, dust, dirty container lids, and debris on the dish machine in the kitchen. The DM also served a resident a half sandwich using an ungloved hand and handled the food directly before giving it to the resident, despite the facility policy prohibiting bare-hand contact with food.
Failure to Complete Baseline Care Plans After Admission: Four residents admitted with multiple medical conditions, including CKD, DM, COPD, heart disease, major depressive disorder, anxiety, colon cancer, severe protein calorie malnutrition, and need for assistance with personal care, did not have baseline care plans completed after admission. Review of EMR and paper charts showed no baseline care plans, and RN and MDS staff confirmed the plans were not completed within 48 hours as required by facility policy.
Incorrect Portioning of Pureed Carrots: A dietary staff member served pureed carrots using a #16 scoop that provided 2-oz portions, even though the menu called for a 4-oz serving. Observation and staff interview confirmed the error during lunch meal service, and four residents were identified as receiving a pureed diet.
A facility failed to effectively implement its smoking policy for a resident who was an independent smoker. A CNA observed the resident’s cigarettes on her night table and said she could keep them in her possession, while the Administrator stated the policy required independent smokers to keep smoking materials locked up. The DON said the wrong smoking policy had been presented to the State Survey Agency, and two different smoking policies were reviewed with conflicting instructions about whether independent smokers could keep smoking materials in their possession.
A resident with multiple chronic conditions developed new stage III pressure ulcers that were not promptly assessed or accurately documented by facility staff. An LPN identified the wounds and notified hospice, but there was no immediate wound assessment or progress note in the medical record. The facility's records did not reflect the presence of these in-house acquired pressure ulcers, and required documentation by both facility and hospice staff was missing.
PASARR screening was incomplete for a resident with schizophrenia-related diagnoses when the PASARR did not include the resident’s mental health diagnosis. The SSD stated she left out schizophrenia because she believed there was no proof, while the Corporate Nurse confirmed the diagnosis existed prior to admission and should have been included.
Missing Smoking Assessments for Two Residents: The facility failed to complete smoking assessments to determine residents' capabilities and whether supervision was needed. One resident with major depressive disorder, psychoactive substance abuse, throat cancer, and nicotine dependence was identified as an independent smoker in the care plan, but no smoking assessment was found and the DON verified the omission. Another resident with schizophrenia, panic disorder, and psychosis had no smoking assessment in the record, and the Corporate MDS Nurse verified that tobacco use was not indicated on the MDS and that the assessment was not completed.
Pharmacy MRR recommendations were not fully addressed for two residents. For one resident with multiple diagnoses including respiratory failure, pneumonia, obesity, malnutrition, and depression, the consultant pharmacist recommended trial discontinuation or PRN use of several meds and lab checks for vitamin levels, but the chart only showed a brief NP response to continue all meds and no supporting clinical rationale or ordered labs at the time. For another resident with DM, HTN, and dementia, the pharmacist’s acetaminophen clarification to limit total daily dose to 3 grams was agreed to by the physician, but no corresponding order was found in the record.
A resident with depression had active orders for Duloxetine and Bupropion, and the care plan called for monitoring and documenting antidepressant side effects every shift. However, the resident’s record had no documentation of side effect monitoring, and the DON confirmed the absence of such documentation. The facility policy identified antidepressants as psychotropic medications subject to monitoring and review requirements.
A resident with adult failure to thrive, CKD, and DM was enrolled in hospice, but the facility failed to maintain documentation of hospice nurse and aide visits in the resident’s chart or hospice binder. The binder contained only hospice IDG reports and POC documents, while the hospice nurse said staff visited twice weekly and the RN verified no visit documentation was present.
Unsanitary room conditions and unrepaired wall damage were observed for two residents. Dirty linens with feces were found in one resident's closet, and another resident's room had two very large holes in the wall behind the bed that had reportedly been present for about three weeks. The ADON and Administrator verified the observations.
A facility failed to ensure an RN had an active license, allowing her to work 24 shifts with a suspended license. This oversight was discovered after a former employee reported the issue, and it was confirmed that the RN was unaware of her suspension.
Infection Control Program Failed to Use Ordered Precautions
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program that included enhanced barrier precautions and transmission-based precautions as ordered, and it failed to maintain infection control tracking and trending logs. Review of the infection preventionist records showed the designated infection preventionist changed over time, and review of antibiotic infection summary logs from October 2025 through February 2026 showed there were no infection control logs to track and trend infections, determine whether interventions were appropriate, or timely identify potential outbreaks. For one resident, the medical record showed diagnoses including diabetes, quadriplegia, chronic respiratory failure, and morbid obesity. The record also showed prior discharge orders for droplet precautions due to CRE in sputum and contact isolation due to Candida Auris, and a later physician order for contact precautions secondary to Candida Auris and known history of CRE in sputum. The resident’s care plan included EBP due to a wound to the right great toe, with gown and gloves during high contact resident care, but there was nothing in the care plan regarding respiratory isolation due to CRE or contact isolation due to Candida Auris. When observed, the resident’s door had signage indicating EBP only, not contact isolation. The resident stated staff did not wear PPE when providing care or cleaning the room and said he had tried to tell the facility. For another resident, the medical record showed diagnoses including diabetes with diabetic neuropathy, diabetic foot ulcer, acquired absence of the left leg below the knee, and dependence on renal dialysis. The resident had a dialysis catheter to the right chest and a wound to the right foot, and the care plan required EBP with gown and gloves during high contact resident care. During observation of a dressing change, staff completed hand hygiene and wore gloves but did not wear a gown while performing wound care. The wound nurse practitioner and ADON verified the resident was on EBP and that a gown was not applied. The DON later verified that gown and gloves were to be worn during high contact care. The facility policy stated transmission-based precautions required appropriate notification on the room entrance door and chart, and the EBP policy stated gown and glove use was required during high contact care such as dressing, bathing, device care, and wound care.
Failure to Monitor Antibiotic Use and Infection Trends
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program was in place to monitor antibiotic use, reduce the risk of adverse effects from unnecessary or inappropriate antibiotic use, and track infections. Review of the Infection Control Preventionist records showed that the facility identified the Director of Clinical/RN #410 as the infection preventionist from October 2025 through March 2026, and then the DON from March 2026 through May 5, 2026. However, review of the Antibiotic Infection Summary Logs for October 2025 through February 2026 showed there were no infection control logs completed during that period. During interview, the Regional Director of Clinical Services/RN #404 and the DON verified that no ATB/infection control logs had been completed from October 2025 through February 2026. They stated that when they started in March 2026, the infection control program was not done and was "a mess." They also verified that without the ATB logs, they could not determine which residents were on ATBs, had infections, or whether there were trends or patterns of infections, and they had no evidence that ATB use was documented to show the ATB met criteria for use and was appropriate for the resident. The facility policy on Antibiotic Stewardship, dated December 2016, required antibiotics to be prescribed and administered under the guidance of the stewardship program and included order elements such as drug name, dose, frequency, duration, route, and indication, but it did not address tracking ATB use or infections for trends, patterns, or MRDO infections.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a homelike environment when surveyors observed multiple areas that were not clean, orderly, or in good repair. During an observation, a trail of bowel movement was seen on the floor going into the shower room across from Residents #30 and #31’s room toward the toilet, and a soiled brief was sitting on top of the trash can in that shower room. The shower room was also cluttered with a Hoyer lift and other equipment. A CNA verified the bowel movement appeared fresh and confirmed the shower room was cluttered, though stated it was normally not like that. An environmental tour also identified several maintenance and environmental issues throughout the facility. Surveyors observed missing baseboards near the nursing station and DON office, a loose handrail near Residents #24 and #25’s room with old tattered tape and missing screws, a ceiling stain and slight bulge above Resident #24’s bed where the privacy curtain track was attached, disrepair in the blinds in Residents #22 and #23’s room, and missing baseboards with piles of baseboards stored in the hall near the therapy room. In the vending area near the entrance, two open square-shaped holes were observed under the alarmed keypad. The shower room across from Residents #30 and #31’s room was later observed clean and cleared, but the water temperature tested at 101 degrees Fahrenheit and then 103 degrees Fahrenheit. Resident #31 stated he avoided that shower room because the water was cold and it was always nasty, and Residents #33 and #44 stated it was not clean at all times and that the water was usually cold. Resident #33 also pointed out issues in his bathroom, including a disrepair toilet paper holder, wall areas needing paint, and patched holes near the sink.
Controlled Substance Documentation and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure controlled substances were accurately accounted for, recorded in residents’ medical records, and documented on legible narcotic sheets. This involved five residents reviewed for controlled substances, with discrepancies identified through interview, record review, narcotic sheet review, and facility policy review. The facility census was 53. Resident #28 had diagnoses including bone cancer, right femur fracture, schizoaffective disorder, and need for personal care assistance, and was assessed as having intact cognition. The resident had an order for oxycodone 5 mg, one-half tablet every eight hours as needed for pain. The narcotic sheet showed oxycodone signed out on multiple dates, but the MAR documented administration only on two of those occasions, with no other administration documented in the medical record. Resident #33 had diagnoses including opioid dependence in remission, mood disorder, and depression, and was assessed as having intact cognition. The resident had orders for oxycodone 5 mg and oxycodone 10 mg every four hours as needed for pain, as well as tramadol 50 mg as needed for chronic pain. The narcotic sheet showed multiple oxycodone sign-outs that did not correlate with MAR times, with missing documentation on several evenings, and tramadol was signed out on two occasions without corresponding MAR documentation. Resident #34 had an order for oxycodone 10 mg once daily, but the narcotic sheet contained illegible date and signature entries and no nursing staff signature or date showing receipt of the medication. Resident #40 had orders for Lyrica, with narcotic sheet entries that did not consistently identify the time as A.M. or P.M. and MAR omissions on two occasions. Resident #51 had an order for morphine 30 mg twice daily, but the narcotic sheet contained three doses signed out on one date with one entry lacking a time and another with an illegible date, time, and signature, and there was no nursing staff signature or date showing receipt of the medication.
Delayed Guardian Notification After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a resident’s guardian after an unwitnessed fall. Resident #26 was admitted on 06/17/25 and had diagnoses including fusion of spine, intellectual disabilities, abnormalities of gait and mobility, and anxiety. The resident also had a guardian and, per the quarterly MDS, had severely impaired cognitive skills for daily decision making and required partial and/or moderate assistance with transfers. On 12/22/25 at 2:34 P.M., nursing staff were alerted that the resident had an unwitnessed fall in the resident’s room during an unassisted transfer and was found seated on the floor with her legs crossed in front of her wheelchair. The resident stated she was trying to get out of the wheelchair, and her hand was on the floor as if pushing her upper body up. Although the fall was unwitnessed, the resident’s nose appeared discolored with anticipatory bruising, and she denied pain or discomfort at the time. The resident’s guardian was not notified of the fall until 12/24/25 at 12:39 P.M., when the nurse updated the guardian about discoloration around the left eye related to the fall. The note stated there was no edema, the resident was at baseline, and the guardian was appreciative of the update. The certified nurse practitioner was also made aware. During interview on 05/06/26, the Regional Director of Clinical Services verified that the guardian was not notified of the fall until 12/24/25 and stated the expectation was that notification should occur before 48 hours. The facility policy stated that, except in medical emergencies, notifications would be made within 24 hours of a change in the resident’s medical, mental, or psychosocial condition or status.
Missed ADL Care for Showering and Fingernail Trimming
Penalty
Summary
The facility failed to provide timely fingernail care and showers as scheduled and/or per resident preference for residents who were dependent on staff for activities of daily living. The deficiency involved three residents out of five reviewed for ADL care, and the facility identified 31 residents in the census who required assistance with bathing and/or fingernail care. Review of facility policies showed that nail care was to keep nails trimmed and clean, and that residents unable to complete ADLs independently were to receive appropriate assistance with hygiene, including bathing and grooming. Resident #26 had diagnoses including intellectual disability, major depression, fusion of the spine, and seizure disorder. The quarterly MDS showed severe cognitive impairment and need for partial to moderate assistance with toileting hygiene, lower dressing, personal hygiene, transfers, and showers. Her care plan required daily nail checks, routine incontinence care, and weekly showering. The shower schedule indicated she was to receive showers twice weekly, but the available shower sheets documented only a limited number of showers between 03/02/26 and 04/30/26. The Regional Director of Clinical Service/RN verified that there were no shower/bath sheets for multiple extended periods, including 13 days, 19 days, and 5 days, despite the twice-weekly schedule. Resident #24 had diagnoses including cervical spinal cord injury, diabetes, quadriplegia, and chronic respiratory failure. He was cognitively intact but dependent on staff for showers, toileting hygiene, and personal hygiene, and his care plan directed staff to check nail length and trim and clean nails on bath days and as needed. Shower/bath sheets showed intermittent bed baths, and the last documented nail care was on 04/22/26. During observation, his fingernails were approximately one half inch long, and he stated he preferred bed baths twice a week but at times staff did not complete them. He also stated it had been a long time since staff had cut or filed his fingernails, and staff confirmed his nails were long and had not been cut. The Regional Director later verified there were no shower/bath sheets for two extended periods, including 14 days and 15 days. Resident #44 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, diabetes, and major depression. He had intact cognition but required supervision and set-up for personal hygiene and bathing, and his care plan included assistance with showers and personal hygiene. Shower documentation showed only a few baths over the review period, and no documentation that his nails were cut on the shower forms. A grievance form recorded his request for regular fingernail trimming, and the record showed nail care was not provided until nine days after the concern was submitted. During interview and observation, his fingernails were slightly elongated, he stated staff had not assisted with cutting them and that it had been over a month since they were last cut, and he said staff did not assist with showers according to his preference. The Regional Director verified the grievance was late and that shower sheets were missing for multiple extended periods, including 10 days, 34 days, and 8 days.
Missed Medication Refusals and Incomplete Daily Weights
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for a resident with high blood pressure and COPD who had intact cognition and was at risk for decreased cardiac output. The resident was ordered Digoxin 125 mcg daily, but the MAR showed repeated refusals during May 2026, and the medical record did not include physician notification of the refusals. During observation of medication administration, an LPN asked the resident if he was not going to take his Digoxin, and the resident said no. The resident stated he had not taken the medication because it made his heart rate too low and he felt funny. The LPN stated she knew what the resident would take and refuse and acknowledged she did not notify the physician every time. The facility also failed to ensure ordered daily weights were completed and that ordered notification occurred for two residents. One resident with hypertensive heart disease with heart failure and hemiplegia had a physician order for a weight every morning after voiding, with notification for a 3-pound gain in 24 hours or 5 pounds in 7 days. The TAR showed multiple days marked NA or left blank, and the weight record contained only a few documented weights in April and early May 2026. The Regional Director of Clinical Services verified the daily weights were not obtained on multiple dates and confirmed there was no documentation that the physician was aware the resident refused weights or that the weights were not completed. A second resident with chronic kidney disease, diabetes, HTN, heart failure, and dependence on renal hemodialysis also had an order for daily morning weights with notification parameters. The TAR showed X marks or blanks on nearly all days reviewed, and the weight record showed multiple missed daily weights. The record documented a weight of 217.8 pounds on one day and 227.7 pounds two days later, a 9.9-pound increase, with no documentation that the physician was notified. The RN verified the missed weights, the weight increase, and the absence of physician notification in the medical record.
Delayed Nephrostomy Orders and Care Plan
Penalty
Summary
The facility failed to ensure physician orders were in place and a care plan was developed in a timely manner for nephrostomy care for Resident #46. The resident was admitted with diagnoses including bladder cancer, chronic kidney disease, and artificial openings of the urinary tract. The hospital after-visit summary from the prior hospitalization included nephrostomy tube placement or exchange discharge instructions with dressing changes, daily care, and tube flushing instructions, and also directed the resident to schedule a urology appointment as soon as possible. The admission MDS indicated the resident had intact cognition, had an indwelling catheter for the bladder, and was dependent on staff for toileting hygiene. Review of the physician orders and TARs showed nephrostomy-related treatment orders were not initiated until 03/04/26, with no documented evidence of treatments or monitoring to the left and right nephrostomy tubes from 01/21/26 through 03/03/26. The plan of care was also initiated on 03/04/26 and included alteration in elimination related to the right and left nephrostomy, with interventions for output documentation, emptying the ostomy bag as needed, keeping the nephrostomy tube free from obstructions and kinks, and maintaining drainage below bladder level. The facility could not locate documentation showing whether the urology appointment ordered on admission was scheduled or attempted to be scheduled, and the DON stated the resident went to a urology appointment on 04/15/26. The DON and RDCS verified there were no physician orders for nephrostomy tube care until 03/04/26 and that the care plan was also initiated on that date.
Failure to Exchange Dialysis Communication Forms
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration between the facility and the outside dialysis center for two residents who received hemodialysis services. Resident #4 was admitted with chronic kidney disease, diabetes, hypertension, heart failure, and dependence on renal hemodialysis, and Resident #32 was admitted with malignant neoplasm to the bone, heart failure, anemia, end stage renal disease, and dependence on renal hemodialysis. Both residents had intact cognition and were scheduled for dialysis three times weekly at an outside dialysis center. Review of the medical records showed undated hemodialysis communication forms for Resident #4 from 01/01/26 to 05/06/26 and for Resident #32 from 01/28/26 to 05/06/26, with no forms showing that the facility sent information to dialysis or received information back after scheduled treatments. Resident #4’s care plan included dialysis three times a week and other interventions, but did not address ensuring the communication forms were sent and returned after each dialysis session. Resident #32’s care plan also addressed dialysis-related needs, but likewise did not include ensuring the communication form was exchanged after each scheduled treatment. Resident #4 had physician orders for hemodialysis every Monday, Wednesday, and Friday, pre-dialysis and post-dialysis assessments, and monitoring of the dialysis catheter site for bleeding and infection each shift. Resident #32 had orders for dialysis every Monday, Wednesday, and Friday and monitoring of the right IJ catheter, but no order for pre-dialysis and post-dialysis assessments. Interviews with the residents showed both were unsure whether communication forms were being sent or returned. The LPN stated the facility nurse was supposed to send dialysis communication forms, while the Regional Director of Clinical Service/RN verified the forms were to be sent each dialysis day and returned after treatment, and confirmed there were no forms for either resident during the reviewed periods. Dialysis staff also verified the facility did not send communication forms and the dialysis center did not send any back.
Delayed Physician Signature on Admission Orders
Penalty
Summary
The facility failed to ensure the physician signed off on resident orders in a timely manner for one resident out of three reviewed for timely physician orders. Resident #47 was admitted on 01/30/26 with diagnoses including right knee fracture, right knee replacement, and aftercare following surgery. The medical record showed physician orders were received on the admission date, but Medical Director #408 did not acknowledge the orders until 04/08/26. During interview, MD #408 stated he usually saw new admission residents within 48 hours and had been at the facility at least weekly, but said he had signed orders manually when present and did not currently have electronic access. The DON and VPO stated MD #408 had electronic access and that IT was working to put access on his cell phone; the DON also stated she had been working with MD #408 to get the orders signed in the electronic record. The RDCS confirmed the admission date and that the orders were not acknowledged until 04/08/26, and confirmed the physician orders should have been signed more timely.
PRN Medication Order Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure that as-needed (PRN) medications had a designated stop date of usage for one resident reviewed for PRN medications. Resident #30 was admitted with diagnoses of obsessive-compulsive disorder, schizoaffective disorder, and depression, and the care plan identified the resident as being at risk for behavior and mood changes, with interventions including administering medications as ordered and attempting non-pharmacological interventions to improve sleep. The physician order for Hydroxyzine 50 mg every eight hours as needed for anxiety, dated 03/02/26, did not include a stop date. The MAR showed the resident received Hydroxyzine on multiple days in May 2026. During interview, the Regional Director of Clinical Services confirmed that PRN medications were to have stop dates in place. Facility policy stated PRN medications are limited to 14 days unless the physician documents the rationale for extending use and includes the duration of the PRN order.
Failure to Obtain Ordered Urine Culture and Sensitivity
Penalty
Summary
The facility failed to ensure a urine culture and sensitivity was obtained after an NP recommended it for a resident who reported blood-tinged urine in a nephrostomy bag. The resident had been admitted with diagnoses including heart failure, diabetes, acute cystitis with hematuria, acute kidney failure, and malignant neoplasm of the bladder, and nursing documentation noted she denied pain when she reported the blood-tinged urine. The NP was notified and instructed staff to obtain a urine sample for culture and sensitivity, but the record showed no urine culture was collected on that date and no order for the urine sample was present in the physician order recap. Record review showed the resident had impaired cognition, an indwelling catheter, and later care plans addressed alteration in elimination related to bilateral nephrostomy tubes and risk for urinary tract infection complications. Review of laboratory reports showed only one urine test during the reviewed period, collected later and resulting in growth of pseudomonas aeruginosa carbapenem resistant and klebsiella pneumoniae. During interview, the resident stated she had recently seen a urologist who capped the nephrostomy tubes and that she currently only had an ostomy; she denied current blood or pain. The RN verified the urine sample was not collected per the NP's recommendation and stated she was not sure why, and the facility policy stated staff would process test requisitions and arrange for tests.
Room changes not documented in resident medical records
Penalty
Summary
The facility failed to ensure room changes were documented in residents’ medical records, affecting two residents reviewed for room changes. Resident #22 had diagnoses including Alzheimer’s disease with late onset, dementia, muscle weakness, and residual schizophrenia. Although the medical record contained a room change form uploaded in the miscellaneous tab indicating the resident was moving rooms because the roommate needed to be in a room by himself for safety and wellness precautions, the record did not contain documentation of the room change in the resident’s medical record. The form also indicated the guardian was notified and agreed with the move. Resident #23 had diagnoses including hemiplegia and hemiparesis following a stroke affecting the left non-dominant side and major depressive disorder. The medical record contained no documentation of the room change, even though the facility’s list of residents with room changes showed this resident had a room change. The resident stated he was notified at the last minute by the Social Services Director that he was being moved and said he did not receive or sign any room change form. The Social Services Director stated she was responsible for room changes, would speak with the resident, have the resident sign the room change form, upload it to the electronic medical record, and write a progress note, but verified she did not document the room changes for Residents #22 and #23 in their medical records. The facility policy stated documentation of a room change is recorded in the resident’s medical record.
Unsanitary kitchen conditions and improper food handling
Penalty
Summary
The facility failed to maintain a clean kitchen and serve food in a sanitary manner. During observation and interview with the Dietary Manager, the back wall where knives were hung had dried splatters of food-like particles, the large black fan in that area had a moderate amount of dust-like particles, the back wall behind the rack with hanging clean utensils was moderately dusty, and there was a moderate amount of dust-like particles on the side of the reach-in cooler next to it. In the back room of the kitchen, two large clear containers of flour and sugar on the bottom shelf of a dry food rack had blue lids that were dirty with debris and dried stains. The top of the dish machine also had a moderate amount of a tannish colored, wet debris or substance. The Dietary Manager verified all of these findings. The report also documented an unsafe food-handling practice during service to a resident. The Dietary Manager brought a half sandwich to a resident, removed the sandwich with an ungloved hand, put mayonnaise on the bread, then used the mayonnaise packet to spread the mayonnaise around the bread before handing it to the resident. The Dietary Manager stated that she sanitized her hands in the kitchen before walking to the resident's room. The facility identified one resident as receiving nothing by mouth, and the policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices stated that antimicrobial hand gel is not used in place of handwashing in foodservice areas and that contact between food and bare hands is prohibited.
Failure to Complete Baseline Care Plans After Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans for four residents after admission. Review of the medical records for residents admitted with diagnoses including adult failure to thrive, chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, heart disease, major joint replacement or spinal surgery, obstructive sleep apnea, hypertensive heart disease with heart failure, major depressive disorder, anxiety disorder, colon cancer, muscle weakness, severe protein calorie malnutrition, and need for assistance with personal care showed that no baseline care plan had been completed after admission for each of the four residents reviewed. Electronic medical records and paper charts for these residents did not contain baseline care plans, and interviews on 09/24/25 at 10:12 A.M. with RN #569 and the Corporate MDS Nurse confirmed that the baseline care plans had not been completed within 48 hours of admission. The facility policy titled Care Plans-Baseline, dated March 2022, stated that a baseline plan of care would be developed within 48 hours of admission to ensure the resident's immediate health and safety needs were met.
Incorrect Portioning of Pureed Carrots
Penalty
Summary
The facility failed to ensure the correct servings for pureed vegetables were provided to residents receiving a pureed diet. On lunch service for the pureed diet, the menu listed a four-ounce serving of pureed carrots, but dietary staff served the carrots using a blue-handled #16 scoop that provided two-ounce servings, giving one scoop on each plate. Observation during meal service showed the pureed carrots being served with this scoop, and interview with the dietary staff member confirmed the #16 scoop was used and that it provided two-ounce servings rather than the required four-ounce serving. Review of the diet type report showed four residents in the facility received a pureed diet.
Smoking Policy Not Followed for Independent Smoker
Penalty
Summary
The facility failed to effectively implement its smoking policy for one resident who was identified as an independent smoker. During observation, the resident had cigarettes on her night table, and a CNA stated that the resident was allowed to keep them in her possession because she was an independent smoker. The Administrator later stated that the smoking policy required independent smokers to keep their smoking materials locked up. The DON then stated that the wrong smoking policy had been presented to the State Survey Agency and provided a second policy, noting that corporate legal staff was working on a new policy. Review of the first policy dated 10/28/21 showed that independent smokers were required to keep smoking materials in red lock boxes stored in a lobby cabinet, while the second policy dated 2001 stated that residents would be evaluated upon admission and independent smokers were permitted to keep smoking materials in their possession.
Failure to Timely Assess and Document New Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely assessment and accurate documentation of new wounds for a resident with multiple comorbidities, including chronic kidney disease, diabetes mellitus, and contractures. The resident was admitted with no skin breakdown noted on the last weekly skin evaluation, but there was a gap in weekly skin assessments from early to late in the month. During this period, shower sheets indicated intact skin until one entry noted skin was not intact, but did not specify the location or provide further documentation. An internal incident report, not included in the resident's medical record, documented that an agency LPN identified open wounds on both lower ankles, describing them as stage II or III pressure ulcers. The LPN notified hospice and applied dressings, but there was no corresponding wound assessment or progress note in the medical record for that date. Subsequent review revealed that a physician's order for wound care was issued, but there was still no documentation explaining the new order or a hospice nurse progress note for the relevant dates. The first wound evaluation in the medical record occurred two days after the initial discovery, confirming new stage III pressure ulcers acquired in-house. The facility's records, including the Matrix for Providers, failed to list these pressure ulcers, and interviews with staff confirmed confusion about whether the wounds were in-house or community acquired. Additionally, hospice staff visits and assessments were not documented in the resident's medical record or hospice binder, and the facility's wound care policy requiring documentation of changes and assessment data was not followed.
PASARR Screening Did Not Include Mental Health Diagnosis
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was incomplete for one resident when the facility failed to ensure the resident’s mental health diagnosis was included in the PASARR. Resident #46 was admitted with diagnoses including schizophrenia disorder, panic disorder, and psychosis not due to a substance or known physiological condition. Review of the PASARR assessment showed it did not address the resident’s diagnosis of schizoaffective disorder. During interview, the Social Service Designee stated she completed the PASARR but did not include a schizophrenia diagnosis because she believed there was no proof of schizophrenia, and she was waiting for psychiatric documentation before completing a significant change assessment. Corporate Nurse #569 later stated the resident had a diagnosis of schizophrenia prior to admission and that this was the reason for antipsychotic medication, and that the PASARR should have included the schizophrenia diagnosis.
Missing Smoking Assessments for Two Residents
Penalty
Summary
The facility failed to ensure there were smoking assessments of residents' capabilities and deficits to determine whether supervision was required. Resident #15 was admitted with diagnoses including major depressive disorder, psychoactive substance abuse, throat cancer, and nicotine dependence. The admission MDS showed intact cognition and tobacco use, and the care plan identified the resident as at risk for injury related to smoking with interventions stating the resident was an independent smoker. However, there was no smoking assessment in the medical record from admission through the survey review, and the DON verified that Resident #15 was a smoker and that no smoking assessment had been completed. Resident #46 was admitted with diagnoses including schizophrenia disorder, panic disorder, and psychosis not due to a substance or known physiological condition. The admission MDS showed the resident was cognitively intact and required moderate assistance with activities of daily living, but did not indicate tobacco use. There was no smoking assessment in the medical record from admission through the survey review, and the Corporate MDS Nurse verified that the MDS did not indicate tobacco use and that a smoking assessment was not completed. The facility policy titled Smoking Policy-Residents stated that residents will be evaluated upon admission.
Pharmacy MRR recommendations were not fully addressed
Penalty
Summary
The facility failed to ensure pharmacy medication regimen reviews were adequately addressed and followed through in a timely manner for two residents reviewed for unnecessary medications. For one resident with diagnoses including acute respiratory failure with hypoxia, pneumonia, a chronic left heel and mid-foot ulcer, obesity, mild protein calorie malnutrition, and depression, the consultant pharmacist’s medication regimen review recommended trial discontinuation or PRN use of several medications, including Mucinex, aspirin, vitamin D, multivitamin, vitamin B-12, ipratropium-albuterol, and meloxicam. The response on the review form stated, "Reviewed and all medications require continuation," and was signed by the NP, but the record contained no additional clinical rationale note and no physician order for vitamin D and vitamin B-12 lab values on the next lab draw at the time of review. For another resident with diagnoses including diabetes mellitus, hypertension, and dementia, the consultant pharmacist recommended adding a clarification to the acetaminophen order that total acetaminophen from all sources not exceed 3 grams in 24 hours, and the physician agreed and stated to write the order. However, the resident’s record contained no physician order dated on or after the agreement to include that clarification. The DON verified the facility had not followed the pharmacist’s recommendation after the physician had agreed and provided an order for the acetaminophen clarification.
Lack of Monitoring for Antidepressant Side Effects
Penalty
Summary
The facility failed to ensure that a resident receiving antidepressant medications was monitored for side effects. Resident #45 was admitted with a diagnosis of depression, and the care plan identified the use of antidepressant medication with interventions to administer the medications as ordered and monitor and document side effects and effectiveness every shift. Physician orders for September 2025 included Duloxetine HCl 60 mg daily and Bupropion HCl ER (XL) 300 mg daily for depression. Review of the resident’s medical record found no documentation of monitoring for side effects related to the antidepressant medications. The DON confirmed during interview that there was no documentation in the resident’s record for monitoring antidepressant side effects and stated there would be a physician order for monitoring side effects. The facility policy titled Psychotropic Medication Use identified antidepressants as psychotropic medications subject to prescribing, monitoring, and review requirements.
Missing Hospice Visit Documentation
Penalty
Summary
The facility failed to ensure effective collaboration of care for a hospice resident. Resident #1 was admitted on 02/28/25 with diagnoses including adult failure to thrive, chronic kidney disease, and diabetes mellitus, and later enrolled in hospice services on 08/11/25. Review of the hospice contract dated 06/17/25 stated that documentation would be provided to the facility, including copies of clinical notes after each visit. However, the hospice binder for Resident #1 contained only two hospice interdisciplinary group reports and plan of care documents dated 08/20/25 and 09/03/25, with no documentation of nurse or aide visits from 08/11/25 through 09/23/25. Hospice Nurse #572 stated hospice staff came to the facility twice weekly and that Resident #1’s documentation would be kept in his personal binder at the nurse’s station, including the plan of care, physician’s orders, staff visits, and certificate of need. RN #569 verified there was no documentation in the resident’s medical record or hospice binder related to hospice nurse and aide visits since hospice admission. The facility policy titled Hospice Program stated the facility was responsible for meeting the resident’s personal care and nursing needs in coordination with the hospice representative.
Unsanitary Room Conditions and Unrepaired Wall Damage
Penalty
Summary
The facility failed to maintain a clean and sanitary environment and did not ensure timely wall repairs for two residents. In Resident #42's room, observation on 09/22/25 at 10:31 A.M. found dirty linens with feces on them in the corner of the closet, and the ADON verified the observation at that time. In Resident #45's room, observation on 09/22/25 at 2:45 P.M. revealed two very large holes in the wall behind the resident's bed, with the bed moved away from the wall. Resident #45 stated the holes had been there for about three weeks and that maintenance said they would take care of it when they redo the rooms. The Administrator later verified the holes and stated she was not aware of them before.
Failure to Verify Nursing License Status
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) providing care and services to residents had an active and unencumbered license to practice. The RN, who was hired with a valid nursing license, had her license suspended indefinitely due to a violation of federal or state statutes, regulations, or rules. Despite this suspension, the RN worked a total of 24 shifts as the Assistant Director of Nursing, which included direct resident care and oversight, potentially affecting all 46 residents in the facility. The issue came to light when a former employee informed the facility about the RN's suspended license. Upon verification, the facility confirmed the suspension and found that the RN had worked numerous hours without a valid license. The RN was unaware of the suspension at the time of her employment. This deficiency was identified during a complaint investigation, highlighting a lapse in the facility's process for verifying the licensure status of its nursing staff.
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 1,043 citations issued within 25 miles in the last 12 months — including the 9 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 Cleveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Larchwood Care | 1 mi | ★★★★★ | 16 | 0 |
| Rocky River Gardens Rehab And Nursing Ctr | 1 mi | ★★★★★ | 7 | 0 |
| Westpark Healthcare Campus | 1.4 mi | ★★★★★ | 15 | 0 |
| O'neill Healthcare Fairview Park | 1.8 mi | ★★★★★ | 0 | 0 |
| North Park Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.