Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Ayden Healthcare Of Madeira during CMS and state inspections, most recent first.
Menus were not preplanned or followed for therapeutic and emergency meals. Staff did not have meal spreadsheets for residents on controlled carbohydrate, low sodium, or renal diets, and one staff member said regular diet food and portions were served to residents on therapeutic diets. For puree diets, the portions served were smaller than the menu-directed portions. The facility also had no designated emergency food storage and no sufficient food supply for a 3-day emergency, and staff verified there was no planned emergency menu for 3 to 7 days.
Food storage and preparation practices were not followed in the kitchen and resident refrigerators. Surveyors found expired and undated foods, unlabeled containers, improper thawing and storage, missing thermometers, debris in the freezer, and an ice scoop stored improperly. A staff member also handled biscuits with the same gloves after touching surfaces and utensils, and pureed foods were processed with only a water rinse between items. Dishwasher logs did not document sanitizer levels in the final rinse, and resident refrigerators contained unlabeled food, expired milk, and ice buildup with a water leak.
Uncovered garbage cans were observed in the dish machine and food prep areas of the kitchen. Four cans were nearly full or contained food and garbage while staff were not actively using them, and the DM confirmed the cans should have been covered and that lids were available.
Multiple residents experienced unclean and poorly maintained living environments, including dirty briefs left on the floor, unsightly and damaged curtains, missing furniture parts, broken glass, splattered walls, and debris in air conditioning units. These issues were confirmed by residents, LPNs, and environmental staff, and affected individuals with various medical and cognitive conditions.
The facility failed to provide required supervision for residents who smoke and did not thoroughly investigate or implement new interventions after multiple resident falls. Several residents were observed smoking without staff present, and care plans for smoking safety were incomplete or not followed. Multiple residents with cognitive and physical impairments experienced repeated falls, but there was no evidence of root cause analysis or updated fall prevention strategies, despite facility policy requiring such actions.
Several residents with physician-ordered therapeutic diets, including renal and gluten/lactose-free diets, were served foods and beverages not compliant with their dietary restrictions. Staff, including CNAs, LPNs, and dietary personnel, demonstrated a lack of knowledge about specific diet requirements and failed to follow meal tickets and orders. One resident requiring thickened liquids and no straws due to dysphagia was observed using straws and consuming regular liquids, with staff unaware of the restrictions. Facility policies for verifying diet accuracy were not followed, resulting in residents not receiving prescribed diets.
Two residents with severe cognitive impairment and high care needs were directly affected by unsanitary and unsafe conditions, including a heavily soiled carpet, stained hallway, dirty ceiling vents, a large hole in the wall, and missing baseboards. These deficiencies were confirmed by staff and were not addressed due to lack of proper cleaning equipment, with the potential to impact additional residents in the same unit.
Care plans were not updated after changes in condition for several residents, including repeated falls and significant weight loss. A resident with TBI and severe cognitive deficits had multiple falls without care plan updates, another resident with MS and malnutrition had a downward weight trend not reflected in the nutrition plan, and two residents with severe cognitive impairment had fall plans that were not revised after additional falls. The facility also missed required care conferences for multiple residents, including one with paraplegia and serious mental health diagnoses and another who had no initial conference documented.
The facility failed to follow infection control practices for residents on EBP and during direct care. A resident with a wound and another resident with multiple medical conditions requiring EBP had no sign or PPE cart outside their rooms, and a CNA did not perform hand hygiene before and after incontinence care for a resident with dementia and total toileting dependence. Hand hygiene was also not performed during medication administration for two residents observed.
Failure to Offer and Document Resident Vaccinations: The facility failed to provide or offer pneumococcal, influenza, and COVID vaccines to multiple residents reviewed. Record review showed several residents had no vaccine documentation or no vaccines given, including residents with COPD, DM, psychosis, paraplegia, dementia, and other chronic conditions. The DON confirmed the missing vaccines and stated the facility did not have a specific policy regarding resident COVID vaccines.
Unsecured handrails were found on the MCU hallway near the nursing station and the route to the outdoor smoking area. An STNA confirmed the handrails were not secured to the wall, and the facility policy required corridors to have firmly secured handrails. The issue affected 20 independently mobile residents on the unit.
A resident with lymphedema did not consistently receive prescribed lymphedema boot therapy as ordered, with multiple shifts lacking application and incomplete documentation in the MAR. The resident, who was cognitively intact and required staff assistance, reported never refusing the treatment, and staff interviews confirmed inconsistent application. The DON acknowledged the MAR was not set up to properly document the required therapy.
A resident did not receive their lunch meal as scheduled, despite requesting food from the alternative menu. Both the resident and the DON confirmed that the meal was not provided, which was not in accordance with the facility's policy requiring three daily meals at regular times.
Failure to provide reasonable handwashing access for three residents with bariatric mobility needs. A resident with morbid obesity and respiratory failure, a resident with lymphedema and GERD, and a resident with diabetes, respiratory failure, morbid obesity, and HTN all used bariatric wheelchairs and had intact cognition, but their room bathroom sinks were not accessible because the doorways were too small and they could not safely walk to the sink. They were given hand sanitizer or had to rely on shower-room access or bed baths, which staff verified did not meet their frequent handwashing needs.
Incomplete Discharge Summary: The facility failed to ensure a discharge summary was completed for a resident with CHF and chronic venous insufficiency who was planned for discharge home. The resident had intact cognition and needed setup or clean-up assistance with multiple ADLs, but the discharge summary was only completed by social services and therapy, not by dietary, activities, or the nursing team. The Administrator confirmed the summary was not completed, despite facility policy assigning responsibility to the nurse caring for the resident at discharge.
Failure to develop and implement a fall care plan for a resident at risk for falls. The resident had multiple diagnoses, severely impaired cognition, and dependence on staff for transfers, toileting, and bathing. After an unwitnessed fall in the resident’s room while walking without a walker and with pants around the ankles, the resident sustained a head injury and was sent to the hospital. The DON verified the fall care plan was not developed until months later, despite the facility policy requiring a comprehensive care plan within 7 days of the MDS assessment.
Failure to provide varied activities to meet resident needs. The activity schedule was repetitive, with the same morning offerings each day, limited evening programming, no activities after 5:00 P.M., and no religious programs. Residents with intact cognition reported boredom, loneliness, and a desire for evening activities and outings, but the facility bus had been out of service for an extended period and no alternative outings were arranged. Activity logs showed the same residents attending most programs, no participation in exercise, and no one-on-one activity documentation provided.
Failure to arrange requested outside vision services for a resident with intact cognition and multiple psychiatric and physical diagnoses. The resident reported inability to see out of one eye and said staff did not help make an eye appt. Facility optometry recommended corrective lenses, but the resident wanted an outside eye exam and the record showed no documented community appt or follow-up.
Weights Not Completed as Ordered for Residents With Significant Weight Loss: The facility failed to complete ordered weights for three residents with nutrition concerns. One resident with paraplegia and multiple psychiatric diagnoses had a significant wt loss trigger, but no reweight or weekly wt documentation was found. Another resident with MS, aphasia, dementia, and protein-calorie malnutrition had repeated significant wt loss triggers and an order for weekly weights, but none were documented. A third resident with CVA, malnutrition, and ESRD was ordered daily weights, yet the record showed weights only on selected dates and no refusals or additional wt documentation.
A resident with a G-tube, dysphagia, DM2, dementia, HTN, and GERD did not receive ordered daily G-tube dressing changes on multiple occasions. During observation, the ADON noted about one quarter inch of crust build-up around the insertion site and confirmed the area should have been cleaned. The resident had moderately impaired cognition and required dependent to max assist with ADLs.
Improper oxygen administration was identified for a resident with COPD and impaired cognition. The resident was observed in bed with a nasal cannula in place, but the tubing was not connected to the running concentrator. An LPN confirmed the resident was supposed to be receiving oxygen, while the RDCO verified there was no active MD order for oxygen. The facility policy required oxygen to be given under MD order and for all concentrator and tubing connections to be secure.
Medication administration errors exceeded the allowed rate after surveyors observed two residents with missed or incorrect meds. An LPN substituted loratadine for ordered cetirizine for one resident and did not give spironolactone because it was on order, while another resident missed multiple doses of Depakote and a dose of sertraline when the LPN reported the meds were not available. The facility policy required meds to be given as prescribed using the five rights.
A resident with osteomyelitis, type 2 DM with foot ulcer, and bipolar disorder missed multiple ordered doses of IV daptomycin. The MAR showed the antibiotic was not administered on several days, and the DON confirmed the doses should have been given as prescribed. Facility policy stated medications are administered as prescribed.
A resident receiving IV vancomycin for MRSA bacteremia did not have ordered vancomycin trough labs completed. The nurse checked with the lab and learned the resident was not in the system and no draw had been done; the chart contained no documented trough result during the stay, and the DON verified the lab was not completed as ordered.
A resident with DM, diabetic neuropathy, and unsteadiness of feet had a scheduled surgical dental visit that could not be completed because of elevated BP. The dental office was to reschedule, but there was no documented follow-up by nursing or evidence of attempts to arrange the oral surgery appointment. The resident had very few lower teeth, many broken or decayed, wanted extractions for denture fitting, and reported pain when eating; the DON confirmed the follow-up appointment had not been made.
Lack of Visual Privacy in Shared Resident Room: Two residents with severely impaired cognition shared a room that had no privacy curtain, and an STNA verified the absence during observation. One resident had dementia, encephalopathy, AKI, DM2, and hyperlipidemia, while the other had Alzheimer's disease, cerebrovascular disease, anxiety, and severe malnutrition; both required significant staff assistance with ADLs.
A staff member was observed handling dirty dishes and then immediately unloading clean dishes from the dish machine without performing hand hygiene in between tasks. The staff member confirmed this lapse during an interview, and facility policy requires handwashing after handling dirty dishes. This failure had the potential to affect all residents receiving food from the kitchen.
A resident did not receive prescribed Adderall on multiple occasions due to unavailability, despite staff signing off on its administration. The DON was unaware of the missed doses until questioned by a surveyor, indicating a failure to adhere to the facility's medication administration policy.
A resident with ADHD did not receive prescribed Adderall on multiple occasions, despite the MAR indicating administration. Interviews confirmed the medication was unavailable, yet staff documented it as given. The facility's policy requires accurate recording of medication administration.
The facility failed to include activities in the care plans for three residents, despite their interests and cognitive abilities. Interviews confirmed that the responsibility for updating activity care plans was not met. The facility's policy requires comprehensive care plans within seven days of assessment, involving the care planning team, including the activity director.
The facility did not ensure eight consecutive hours of RN coverage on multiple days during the first quarter of 2024, as revealed by the PBJ report and staffing schedules. This deficiency, confirmed by the Administrator, potentially impacted all 92 residents.
The facility failed to provide perineal care for an incontinent resident, as documented only twice during night shifts over a 30-day period. The resident reported being left wet and cold until morning, and the DON confirmed the lack of documentation and stated the resident should be checked and changed every two hours.
Menus Not Preplanned or Followed for Therapeutic and Emergency Meals
Penalty
Summary
The facility failed to ensure menus were preplanned and followed for daily meals and emergency meals for all 86 residents receiving meals from the kitchen. During breakfast observations on 12/08/25 and 12/10/25, and a lunch observation on 12/11/25, there were no meal spreadsheets used during tray line service for residents on therapeutic diets. The facility’s diet listing showed six residents on controlled carbohydrate restrictions, three on low sodium restrictions, and two on renal restrictions, but staff stated there was no spreadsheet of planned meals for those diets. One staff member said he did not know the specific food items to avoid or the portions to serve for the physician-ordered therapeutic diets, and another staff member stated he served regular diet food and portions to residents with therapeutic diets. For puree diets, breakfast observation on 12/10/25 showed puree portions of hot cereal, scrambled eggs with cheese, and sausage with biscuit that were smaller than the menu-directed portions. The facility’s puree diet menu listed larger portions than what was served, and staff verified the portions served did not match the menu. In addition, the facility had no designated storage of emergency foods and did not have sufficient food quantity in storage for a three-day emergency. Staff also verified there was no planned emergency menu for three to seven days, despite facility policy stating menu extensions should list foods and amounts for regular or therapeutic diets and that sufficient inventory should be maintained for emergency menu needs.
Food Storage and Preparation Deficiencies
Penalty
Summary
Food was not prepared and stored in accordance with professional standards in the kitchen and resident refrigerators. During the initial kitchen tour, the dietary employee handwashing sink had no soap in the dispenser and the hand drying towels were not in a hands-free dispenser. In the walk-in refrigerator, surveyors found an undated open container with orange liquid labeled water, packaged coleslaw with an expired best-used-by date, an expired opened container of boiled eggs, and an uncut watermelon that was blacked throughout the exterior. There were also opened thawing pie shells with no open date, undated thawing pork loin, chicken pieces, and hamburger, while the walk-in freezer had no thermometer and food debris on the floor. The refrigerator also lacked an internal thermometer and contained expired open cheese, cottage cheese, sliced cheese, and three open containers of relish with no open date or use-by date. In the dry storage area, surveyors found two bags of breadcrumbs past the use-by date and the automatic-closing door propped open with a can of food. The ice machine scoop was stored directly on top of the machine with the scoop side up, and there was no drainage pan. The Dietary Manager verified the mislabeled orange liquid should have had an open date, the coleslaw, boiled eggs, and watermelon should have been discarded, the thawing meat should have been dated when removed from the freezer, the freezer should have had an internal thermometer, and the freezer floor needed cleaning. The Dietary Manager also verified opened containers needed open dates and expiration dates, and stated the new ice machine had no scoop holder to allow water drainage. Surveyors also observed food handling and sanitation issues during meal preparation. A staff member placed biscuits on resident meal plates with gloved hands, touched countertop surfaces, drawers, and utensils, and then picked up another biscuit with the same gloves without changing them. The staff member and Dietary Manager verified gloves were not changed between tasks and should have been changed or a utensil used. Later, the same staff member pureed macaroni and cheese, stewed tomatoes, and cauliflower in a blender bowl, rinsing the bowl only with water between foods. The staff member stated the bowl should have been washed and sanitized through the dishwasher or three-compartment sink process. Review of dishwasher logs showed no documentation of sanitizer levels in the final rinse for October through mid-December, and the Dietary Manager verified the low-temperature dishwasher required chemical sanitizer in the rinse cycle. Resident refrigerator checks on multiple units found unlabeled and undated food containers, milk dated the prior day, yogurt with no name, and ice buildup with a water leak in one refrigerator compartment. Staff verified resident foods should be labeled with the resident name and that the milk was expired. The facility policy required opened foods to be labeled and dated, sanitizer parts per million to be recorded on a sanitation log, and the ice machine scoop to be stored in a closed and clean container.
Uncovered Garbage Cans in Kitchen Areas
Penalty
Summary
The facility failed to ensure garbage cans were covered when not in use in the kitchen. During the initial kitchen tour with the Dietary Manager, four garbage cans in the dish machine area and food preparation area were observed uncovered, nearly full of food and garbage, and not actively being used by staff. A later observation with the Dietary Manager again found four garbage cans in the same areas uncovered, containing food and garbage, with staff not actively using them. The Dietary Manager verified the cans should be covered and stated lids were available. Review of the facility's Food Safety and Sanitation policy showed the facility would follow state and federal regulations to assure a safe and sanitary food department.
Failure to Maintain Clean, Comfortable, and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for multiple residents, as evidenced by direct observations, record reviews, and interviews. Several rooms were found with significant cleanliness and maintenance issues. For example, one resident had a dirty brief left on the floor for over an hour, which was confirmed by both the resident and an LPN. Other rooms had window curtains that were improperly hung, faded, wrinkled, and with hems detached, as well as missing drawer fronts, broken glass picture frames with shards of glass, loose wallpaper, and unpainted plastered areas. These conditions were verified by both residents and the Environmental Director, who acknowledged the need for repairs or replacements. Additional observations included rooms with air conditioning units containing fabric softener sheets and food debris, walls with brownish/red splatters and exposed drywall, and areas of black substance on the floor. Residents reported that these unsightly and unclean conditions had been present since they moved into their rooms, and some had attempted to clean the areas themselves without success. Maintenance staff confirmed the presence of these issues, including the splattered walls, exposed drywall, and debris in the air conditioning units. In another instance, a resident's window shade was found to have brown splatter that had not been cleaned for over four years, as confirmed by both the resident and an LPN. The report documents that these deficiencies affected residents with various medical conditions, including chronic obstructive pulmonary disease, diabetes, morbid obesity, and cognitive impairments. The findings were substantiated through interviews with residents, nursing staff, and maintenance personnel, all of whom confirmed the ongoing nature of the environmental deficiencies.
Failure to Supervise Smoking and Investigate/Reassess Falls
Penalty
Summary
The facility failed to ensure adequate supervision for residents who smoke, as well as to thoroughly investigate falls and implement appropriate interventions to prevent future incidents. Three residents with a history of smoking were observed or documented as smoking without required staff supervision, contrary to their care plans and facility policy. One resident was found outside smoking alone and unable to re-enter the building, while two others were observed smoking in the designated area without staff present, and one was not wearing the required protective apron. Staff interviews confirmed that residents were allowed to smoke unsupervised, and documentation revealed missing or incomplete care plans for smoking safety. Additionally, the facility did not conduct thorough investigations or implement new interventions following multiple falls experienced by five residents. Medical record reviews and fall investigation reports showed repeated falls for these residents, with no evidence of root cause analysis or updated fall prevention strategies. In several cases, residents with cognitive impairments or physical limitations experienced multiple unwitnessed or witnessed falls, yet their care plans and interventions remained unchanged. Interviews with the DON confirmed the lack of documentation and absence of new interventions after these incidents. Facility policies required staff to identify and implement interventions based on residents' risks and causes of falls, and to re-evaluate and adjust interventions if falls continued. Despite these policies, the records reviewed indicated that staff did not consistently follow these procedures, resulting in repeated falls without documented efforts to address underlying causes or prevent recurrence. The deficiency was identified through medical record review, staff and resident interviews, observation, and policy review.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to ensure that therapeutic diets were provided as ordered by physicians for four residents reviewed. Residents with specific dietary needs, such as those on renal diets or requiring gluten and lactose-free diets, were observed receiving foods and beverages that were not in accordance with their prescribed diets. For example, residents with renal diet orders received foods such as milk, cheese, sausage, ham, and vegetable soup, all of which were listed as restricted items for renal diets according to the facility's own therapeutic diet definition sheet. Additionally, residents reported receiving high-sodium snacks and orange juice, which were also restricted. Staff interviews revealed a lack of knowledge regarding the specific dietary restrictions for residents on therapeutic diets. Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPNs), and dietary staff were unable to identify which foods were restricted for residents on renal diets or gluten and lactose-free diets. Meal tickets and dietary orders were not consistently followed, and staff confirmed that residents were regularly served foods that were not compliant with their dietary restrictions. One resident with gluten and lactose sensitivity reported abdominal pain after consuming a supplement containing milk protein and stated that she routinely received inappropriate foods, leading her to rely on food brought in by her family. Another resident with an order for a mechanically altered diet and thickened liquids due to dysphagia was observed using straws and consuming unthickened liquids, contrary to physician orders. Staff were unaware of the order prohibiting straws and had not been thickening the resident's liquids. Documentation showed that the resident had been non-compliant with the diet order, but staff had not consistently documented refusals or set up care conferences as required by facility policy. Facility policies required meals to be checked against therapeutic diet spreadsheets and meal tickets, but these procedures were not followed, resulting in residents not receiving diets as ordered.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment, as evidenced by multiple observations and staff interviews. In the 500 hall, the carpet was heavily soiled at the entrances to several rooms, with a three-foot-long stain at the start of the hallway and three ceiling vents covered in brown debris. The Environmental Director confirmed the lack of a carpet cleaning machine and was unaware of when the carpets were last shampooed, indicating that only a vacuum was available for cleaning. These conditions were directly observed and verified by staff. In a room shared by two residents with severe cognitive impairment and significant care needs, there was a baseball-sized hole in the wall near the bathroom door and missing baseboards along several walls. These environmental deficiencies were confirmed by a State Tested Nursing Assistant during the survey. The facility's own policy required a safe, clean, and comfortable environment, but these standards were not met, affecting the two residents directly and potentially impacting others in the same hall.
Care plans not updated after changes in condition and care conferences overdue
Penalty
Summary
The facility failed to develop and update care plans after changes in condition for Residents #02, #10, #25, and #60. Resident #02 was admitted with traumatic brain injury, psychosis, Barrett's esophagus, and dysphagia, had severe cognitive deficits, and required total dependence for ADLs. The record showed multiple falls on 06/23/25, 06/24/25, 07/05/25, 07/29/25, and three separate falls on 08/07/25, but the care plan dated 06/14/25 and canceled on 08/25/25 was not updated after those falls. The DON verified that the care plan had not been updated after the falls and stated that staff should update care plans after a resident falls. Resident #10 had diagnoses including multiple sclerosis, aphasia, pulmonary embolism, depression, dementia, and protein-calorie malnutrition. The resident’s documented weights showed a downward trend over several months, and nutrition progress notes dated 07/04/25, 08/06/25, and 08/22/25 indicated the resident triggered for significant weight loss. A nutrition assessment noted a gradual downward trend, but the nutrition care plan dated 11/03/25 did not document that the resident had experienced recent weight loss. The quarterly MDS showed moderately impaired cognition, and the RDCO verified that the nutrition care plan did not address the recent weight loss. Resident #25 had diagnoses including a healing left femur neck fracture, Parkinson’s disease with dyskinesia, Alzheimer’s disease, unspecified protein-calorie malnutrition, and CHF, and the five-day MDS showed severely impaired cognition. The fall care plan initiated on 08/22/25 identified the resident as at risk for falls, but it was not updated after falls on 09/19/25, 10/09/25, and 10/19/25. Resident #60 had diagnoses including Alzheimer’s disease with late onset, unspecified protein-calorie malnutrition, generalized anxiety disorder, hypertension, and a right femur fracture in routine healing. The record showed falls on 03/21/25, 04/11/25, 08/29/25, and 11/04/25, and the care plan was revised on 08/26/25, but the DON verified it had not been updated following the falls. The facility policy stated staff would identify interventions based on current data and implement a resident-centered fall prevention plan for each resident at risk or with a history of falls. The facility also failed to ensure care conferences were completed for Residents #04, #09, #10, #11, #13, and #39. Resident #04 had diagnoses including paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse, and the last care conference documented was on 12/06/24. Resident #09 had diagnoses including cellulitis, type 2 diabetes mellitus, and bilateral knee osteoarthritis, had intact cognition with a BIMS score of 15, and had no initial care conference documented. Resident #10, #11, #13, and #39 also had no quarterly care conferences documented after their last recorded meetings, and the Administrator verified that the conferences were overdue based on the facility’s quarterly schedule.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure proper infection control practices for residents placed on enhanced barrier precautions (EBP). Resident #19 had diagnoses including urinary tract infection, anemia, colostomy status, and bipolar disorder, and the quarterly MDS showed no cognitive deficits and need for substantial to moderate assistance with ADLs. During observation of the resident’s room, there was no posted sign indicating EBP and no PPE cart near the room. The ADON, who stated she was the Infection Preventionist, verified that PPE and a sign should have been present. Resident #88 had diagnoses including diabetes mellitus with diabetic polyneuropathy, moderate protein-calorie malnutrition, a chronic ulcer of the right heel and midfoot with necrosis of muscle, vascular dementia, peripheral vascular disease, and hypertension. The active physician orders and care plan required EBP for an open foot wound, including contact precautions, a sign outside the room, and gowns and gloves outside the room. Observation showed no sign on the door and no PPE cart outside the room, and the ADON verified these omissions. In addition, CNA #52 provided incontinence care to Resident #85, who had Alzheimer’s disease, dementia, severe cognitive deficits, incontinence, and total dependence for toileting, without washing hands before or after care; the CNA stated she forgot to wash her hands. The facility also failed to ensure hand hygiene during medication administration for two residents observed.
Failure to Offer and Document Resident Vaccinations
Penalty
Summary
The facility failed to provide or offer pneumococcal vaccination to all five residents reviewed for pneumococcal vaccines, failed to provide or offer influenza vaccination to three of the five residents reviewed for influenza vaccines, and failed to provide or offer COVID vaccination to four of the five residents reviewed for COVID vaccines. The census was 86. Review of the facility policy dated 04/28/25 stated that influenza and pneumococcal vaccines are offered to all residents, but record review showed missing immunization documentation or no vaccines given or documented for multiple residents. Resident #19 was admitted on 10/10/24 with diagnoses including COPD, respiratory failure, asthma, colostomy status, anxiety, and anemia, and was cognitively intact; the immunization record showed no vaccinations given or documented. Resident #02 was admitted on 7/10/25 with psychosis, diabetes, malnutrition, sleep apnea, insomnia, and a muscle disorder, and had severe cognitive deficits; the record showed no pneumococcal or COVID vaccines given or documented, although influenza vaccine was documented as given on 10/05/25. Resident #04, admitted on 07/23/20 with paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse, had intact cognition and no pneumococcal, influenza, or COVID vaccines given or documented. Resident #88, admitted on 12/29/23 with diabetes mellitus with neuropathy, malnutrition, a chronic heel and midfoot ulcer, anxiety disorder, schizoaffective disorder, vascular dementia, and peripheral vascular disease, had moderately impaired cognition and no pneumococcal or COVID vaccines given or documented; influenza vaccine was documented as refused. Resident #90, admitted with osteomyelitis, diabetes mellitus with foot ulcer, and bipolar disorder, had a BIMS score of 12; the record showed no pneumococcal or influenza vaccines given or documented, and COVID vaccine was documented as refused on 12/08/23. During interview on 12/15/25, the DON confirmed the missing vaccines and stated all vaccines were documented under the immunizations tab, and also stated the facility does not have a specific policy regarding COVID vaccines related to residents.
Unsecured Handrails in Memory Care Hallway
Penalty
Summary
The facility failed to ensure that handrails on the Memory Care Unit were firmly secured to the wall. During observation, the handrail between the nursing station and the hallway leading to the outdoor smoking area was found not secured to the wall, and the handrail on the right side of that hallway was also not properly secured. An STNA interviewed at the time verified that the handrails were not secured. The facility policy titled Resident Environmental Quality, dated 08/2022, states that corridors should be equipped with firmly secured handrails. The issue had the potential to affect all 20 independently mobile residents identified on the Memory Care Unit, including Residents #07, #22, #25, #27, #38, #41, #43, #44, #54, #56, #58, #59, #64, #69, #75, #77, #80, #82, #85, and #88.
Failure to Consistently Apply and Document Lymphedema Boot Therapy
Penalty
Summary
The facility failed to provide care and services as ordered for a resident with lymphedema, as evidenced by inconsistent application and documentation of lymphedema boots. The resident was admitted with diagnoses including lymphedema and had intact cognition. Physician orders specified that nursing staff were to apply lymphedema boots for one hour, twice daily, to reduce swelling. However, review of the Medication Administration Records (MAR) for several months showed incomplete and inconsistent documentation, with no clear evidence that the boots were applied as ordered. The MAR did not allow for proper documentation of the required one-hour duration, and entries were often marked only as 'on' or 'off' without time specifics. Multiple observations and interviews confirmed that the resident did not have the lymphedema boots applied during several day and night shifts, and the resident reported never refusing the treatment. The resident stated she could not apply the boots herself and required assistance, which was not consistently provided. Staff interviews corroborated that the boots were rarely applied, and the DON acknowledged the MAR was not set up to document the treatment as ordered. There was no documented evidence that the boots were applied as prescribed or that the resident refused the treatment.
Failure to Provide Timely Lunch Meal to Resident
Penalty
Summary
The facility failed to provide a resident with three meals a day as required by policy. On observation, a resident had not received their lunch by 2:10 P.M., despite having requested a ham sandwich and a bowl of soup from the alternative menu. The resident confirmed in an interview that they had not received lunch at that time. The DON also confirmed that the resident did not receive their lunch. Review of the facility's policy indicated that lunch should be served daily at 12:30 P.M., but this was not followed in this instance.
Failure to Provide Handwashing Access for Bariatric Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for handwashing access for three residents with bariatric mobility needs. Resident #13, admitted with morbid obesity, acute and chronic respiratory failure with hypoxia, and a ventral hernia, had intact cognition, used a bariatric wheelchair, and required setup or clean-up assistance for personal hygiene. The resident reported that the wheelchair could not fit through the bathroom doorway, that she could not ambulate far enough to reach the sink, and that after using the bedside commode she was given hand sanitizer instead of access to a handwashing sink. She stated the nearest shower and bathing area was one hallway away and was not a practical option for washing her hands after toileting. Resident #15, admitted with lymphedema, GERD, and hyperlipemia, also had intact cognition, used a bariatric wheelchair, and required assistance with toileting and personal hygiene. The resident verified that the wheelchair could not fit into the room bathroom and that she could not always walk safely to the sink, stating there was no other way to wash her hands except during biweekly shower days. Resident #55, admitted with diabetes, respiratory failure, morbid obesity, and hypertension, had intact cognition, used a bariatric wheelchair, and required maximal assistance for personal hygiene. He stated he could not get into the bathroom to wash his hands because he could not walk that far safely and the wheelchair would not fit through the doorway, and that he was only provided hand sanitizer and bed baths twice a week. The Therapy Director and DON verified that these residents could not safely access the in-room bathroom sinks and that the shower room was too far away to meet their frequent handwashing needs.
Incomplete Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was completed for one resident reviewed for discharge summaries. Resident #94 was admitted with diagnoses of unspecified combined systolic and diastolic congestive heart failure and chronic venous insufficiency, and had a planned discharge home. The resident’s MDS assessment showed intact cognition and indicated the resident required setup or clean-up assistance for eating, oral hygiene, toileting, showering/bathing, dressing, and personal hygiene, and was occasionally incontinent of bowel and bladder. Review of the medical record showed the discharge summary was not completed. The discharge summary was filled out by social services and therapy, but not by dietary, activities, or the nursing team. The Administrator confirmed during interview that the discharge summary was not completed. Facility policy stated that the nurse caring for the resident at the time of discharge is responsible for ensuring the discharge summary is complete.
Failure to Develop Timely Fall Care Plan
Penalty
Summary
The facility failed to develop and implement a fall care plan for Resident #66, who was identified as being at risk for falls. The resident was admitted on 10/09/24 with diagnoses including right hip fracture, COPD, hypothyroidism, unsteadiness on feet, depression, cognitive communication deficit, and restless legs syndrome. The Fall Risk Evaluation dated 12/10/24 showed the resident was at risk for falls, and the MDS assessment showed severely impaired cognition and dependence on staff for transfers, toileting, and bathing. On 01/14/25, the resident had an unwitnessed fall in her room while walking from the bathroom to the bed with her pants around her ankles and without a walker; she sustained a swollen knot to the back of the head, was sent to the hospital, and returned on 01/17/25 with a diagnosis of sepsis. Review of the record showed the fall care plan was not initiated until 08/04/25, then discontinued on 08/25/25 and restarted the same day. The DON verified that the resident did not have a fall care plan developed until 08/04/25, and the facility policy required a comprehensive care plan within seven days of completion of the resident assessment.
Failure to Provide Varied Activities to Meet Resident Needs
Penalty
Summary
The facility failed to provide varied activities to meet residents’ needs and interests. Review of the activity calendars for October, November, and December 2025 showed the same routine offerings from 9:30 A.M. to 11:30 A.M. each day, consisting of exercise, a hydration cart, and table games, with only two to three activities a week at 5:00 P.M. There were no activities listed after 5:00 P.M. and no religious program listed on Sundays or any other day of the week. Activity participation logs from 12/01/25 through 12/10/25 showed 10 to 20 of the same residents attending all activities, no participation in the morning exercise class, and no one-on-one participation logs provided for December 2025. Resident #13 had acute and chronic respiratory failure with hypoxia, a ventral hernia without obstruction or gangrene, and dependence on respirator status, and had intact cognition with a BIMS score of 15. The resident stated she received an activity calendar but preferred group evening activities, and there were only a few days each week when a group activity was planned at 5:00 P.M., which was also the dinner meal time. Resident #15 had lymphedema, GERD without esophagitis, morbid obesity, and hyperlipemia, had intact cognition with a BIMS score of 15, and was assessed as often feeling socially isolated; she stated she liked group outings because she felt lonely, but the facility bus had needed repair for several months and no other arrangements had been made. Resident #39 had type 2 diabetes mellitus with diabetic neuropathy, diabetes mellitus, and unsteadiness of feet, had intact cognition with a BIMS score of 15, required a wheelchair for mobility, and stated the activities were boring and not varied; he liked group outings and being with others, but the bus was not working and there had been no outings for nearly a year. The Activity Director stated many residents requested bus outings and evening activities after 5:00 P.M., the bus had been broken down for two years, no alternative outings had been arranged, and there were no activities scheduled after 5:00 P.M. or on more than two days a week.
Failure to Arrange Requested Outside Vision Services
Penalty
Summary
The facility failed to arrange vision services outside of the facility as requested for Resident #04. The resident was admitted on 07/23/20 and had diagnoses including paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse. The quarterly MDS assessment indicated intact cognition, independence with eating, substantial/maximal assistance with bed mobility, and dependence with transfers, bathing, and dressing. During interview, the resident stated he was unable to see out of his left eye and was unable to get someone in the facility to make him an eye appointment. An eye care chart note dated 07/24/25 showed the facility optometry provider saw the resident and recommended corrective lenses, but the resident refused to fill the prescription because he wanted another eye doctor to perform an exam outside the facility. The medical record contained no documented evidence that an outside vision appointment was scheduled, and the RDCO verified there was no record of follow-up regarding the resident's request to see an optometrist in the community.
Weights Not Completed as Ordered for Residents With Significant Weight Loss
Penalty
Summary
The facility failed to ensure weights were completed as ordered for three residents reviewed for nutrition. Resident #04, who had diagnoses including paraplegia, bipolar disorder, anxiety, depression, panic disorder, nicotine dependence, schizophrenia, opioid dependence, and cocaine abuse, had a documented 16.6-pound weight loss triggered on 07/06/25. The nutrition note recommended that the resident be reweighed and placed on weekly weights if the loss was verified, and the physician signed agreement with those recommendations on 07/23/25. However, the medical record reviewed on 12/10/25 showed no documented evidence that the resident was reweighed or that weekly weights were completed, and the RDCO verified this during interview. Resident #10, who had multiple sclerosis, aphasia, pulmonary embolism, depression, dementia, and protein-calorie malnutrition, also triggered for significant weight loss on multiple nutrition progress notes, with recommendations and a physician order for weekly weights. Review of the record on 12/10/25 showed no documented evidence that weekly weights were completed. Resident #48, who had cerebral infarction, malnutrition, and end stage renal disease, was ordered daily weights on night shift, but the weight summary showed weights only on selected dates rather than daily, and the MAR/TAR contained no additional weights or refusals. The DON verified that Resident #48 was not weighed daily as ordered. The facility policy stated residents would be weighed monthly and as ordered, and if there was a 5% or greater change from the previous month, the resident would be reweighed.
Missed G-tube Dressing Care
Penalty
Summary
The facility failed to ensure a resident's gastrostomy tube (G-tube) was cared for according to physician orders. Resident #11 was admitted on 04/15/21 with diagnoses including dysphagia, type 2 diabetes mellitus, dementia with behavioral disturbance, hypertension, and gastro-esophageal reflux disease. A physician order dated 07/30/25 directed that the resident's G-tube dressing be changed daily on the night shift and as needed. Review of the October and November 2025 TAR showed multiple missed dressing changes, including on 10/03/25, 10/07/25, 10/15/25, 10/30/25, 11/10/25, 11/11/25, 11/18/25, 11/19/25, and 11/27/25. On 12/15/25 at 1:35 P.M., observation of the resident with the ADON showed approximately one quarter inch of crust build-up around the G-tube insertion site, and the ADON verified that the area should have been cleaned. The resident's quarterly MDS indicated moderately impaired cognition and that the resident was dependent or required maximum assistance for ADLs.
Improper Oxygen Administration
Penalty
Summary
Failure to provide oxygen appropriately was identified for one resident with COPD, anxiety disorder due to known physiological condition, unspecified dementia with mood disturbance, seizures, schizophrenia, hyperlipidemia, hypertension, schizoaffective disorder, bipolar disorder, and major depressive disorder. The resident’s care plan, initiated on 08/30/25, addressed altered respiratory status/difficulty breathing related to COPD and included interventions to administer medications/puffers as ordered, keep the head of bed elevated to prevent shortness of breath when lying flat, and provide oxygen as needed per orders. The quarterly MDS assessment documented moderately impaired cognition. During observation on 12/08/25 at 10:55 A.M., the resident was lying in bed with an oxygen cannula in place, but the oxygen tubing was not connected to the concentrator, even though the concentrator was running. An LPN verified at 10:57 A.M. that the resident was supposed to be receiving oxygen and confirmed the tubing was not connected to the concentrator. Review of the active December 2025 physician orders showed no order for oxygen use, and the RDCO confirmed on 12/10/25 at 1:17 P.M. that there was no active physician order for oxygen. The facility’s Oxygen Concentrator policy stated oxygen is administered under a physician’s order except in an emergency and that connections must be secure for the concentrator, tubing, connectors, and nasal cannula.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate was not greater than 5%, based on observations and staff interviews involving two of three residents reviewed for medication administration. Resident #13 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, ventral hernia without obstruction or gangrene, and dependence on ventilator status, and had intact cognition with a BIMS score of 15. During medication administration observation, the LPN preparing Resident #13’s medications found the cart was out of cetirizine hydrochloride and replaced it with loratadine, both allergy medications. The LPN confirmed she would have given loratadine instead of the ordered cetirizine if the surveyor had not intervened, and also verified that spironolactone 50 mg was not given because it was on order since 12/06/25. Resident #19 was admitted with diagnoses including COPD, UTI, and chronic respiratory failure with hypoxia, and also had intact cognition with a BIMS score of 15. The resident was dependent on staff for medication administration. Review of the MARs showed multiple missed doses of Depakote 125 mg across October, November, and December 2025, and the 12/10/25 MAR showed sertraline 50 mg and Depakote 125 mg blank for the morning administration. During observation, an LPN failed to administer Depakote delayed release 125 mg because none was available and also failed to administer the additional sertraline 50 mg. The LPN confirmed both medications were not given. The facility policy stated medications were to be administered as prescribed and staff were to follow the five rights.
Missed IV Antibiotic Doses
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for one resident reviewed for IV medication. Resident #90 was admitted with osteomyelitis, type 2 diabetes mellitus with foot ulcer, and bipolar disorder, and the most recent MDS assessment showed moderate intact cognition with a BIMS score of 12. Physician orders dated 10/17/25 directed the resident to receive daptomycin sodium chloride intravenous solution 1000 mg in 0.9 percent sodium chloride 100 mL once daily at bedtime for osteomyelitis from 10/17/25 until 12/08/25. Review of the November 2025 MAR showed the resident did not receive the ordered daptomycin on 11/10/25, 11/11/25, 11/18/25, and 11/27/25. During interview on 12/11/25 at 1:03 P.M., the DON confirmed the resident did not receive the antibiotic on those dates and stated the resident should have received it as ordered. Facility policy titled General Guidelines for Medication Administration stated medications are administered as prescribed.
Failure to Complete Ordered Vancomycin Trough Lab
Penalty
Summary
The facility failed to ensure laboratory tests were completed as ordered for one resident. The resident was admitted with diagnoses including pyogenic arthritis, MRSA bacteremia, anxiety, anemia, and stimulant abuse, and had intact cognition on the comprehensive MDS. Physician orders included IV vancomycin 1000 mg every eight hours for MRSA/bacteremia and an order placed the next day for a vancomycin trough every Thursday, with results to be faxed to the infectious disease clinic. Later, an order was entered to hold vancomycin until Monday and start a vancomycin trough on Monday, with instructions to call the physician with the results and fax them to the pharmacy for dosing. A progress note documented that the nurse called the lab to verify the vancomycin trough, and the lab stated the resident was not in the system and no lab draw had been completed. The on-call nurse practitioner was notified and gave instructions related to holding the vancomycin and obtaining a stat trough on Monday. Review of the medical record showed no documented evidence that a vancomycin trough was completed during the resident's admission, and the DON verified the labs were not completed as ordered.
Failure to Follow Up on Dental Surgery Appointment
Penalty
Summary
The facility failed to follow up timely on dental recommendations for one resident who had been scheduled for a surgical dental appointment. The resident was admitted with diagnoses including Type 2 diabetes mellitus with diabetic neuropathy, diabetes mellitus, and unsteadiness of feet, and the most recent MDS showed intact cognition with a BIMS score of 15. The resident required supervision or touching assistance for eating and oral hygiene, and had a physician order for a regular diet. Nursing notes documented that the resident’s surgical dental appointment could not be completed because of increased blood pressure, and the dental office was to reschedule and update the facility. There were no further nursing progress notes or documented evidence that the facility followed up on the dental surgical appointment, and there was no documented evidence of attempts to control the blood pressure in advance of the surgery. Dental progress notes later stated the resident wanted sedation for extractions and that blood pressure needed to be under control. During observation, the resident had very few lower teeth, many of which were broken or decayed, and stated he needed to see an oral surgeon because he wanted his teeth pulled for denture fitting, had some pain when eating meals, could eat more variety of foods, and wanted dentures to look better. The DON verified the resident should have had a follow-up dental surgery appointment and that there was no documented evidence the facility had attempted to make one after the prior appointment.
Lack of Visual Privacy in Shared Resident Room
Penalty
Summary
The facility failed to ensure that shared rooms provided full visual privacy for residents when privacy was needed. Based on observation, staff interviews, and policy review, no privacy curtain was present in the room shared by two residents, and this was verified by an STNA during the survey observation. The deficiency affected two residents out of two reviewed for privacy in a facility census of 86. Resident #56 was admitted on 07/03/24 and had diagnoses including unspecified dementia with behavioral disturbance, protein-calorie malnutrition, encephalopathy, acute kidney failure, type 2 diabetes mellitus without complications, and hyperlipidemia. A quarterly MDS assessment showed severely impaired cognition and need for supervision with eating and bed mobility, partial/moderate assistance with oral hygiene and toileting, and substantial/maximal assistance with bathing, dressing, and personal hygiene. Resident #59 was admitted on 10/14/21 and had diagnoses including Alzheimer's disease with late onset, severe protein-calorie malnutrition, cerebrovascular disease, and anxiety disorder. A quarterly MDS assessment showed severely impaired cognition and dependence on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and transfer, with setup assistance for eating and partial/moderate assistance for bed mobility.
Failure to Perform Hand Hygiene Between Handling Dirty and Clean Dishes
Penalty
Summary
A deficiency was identified when a staff member in the kitchen was observed handling both dirty and clean dishes without performing hand hygiene in between tasks. The staff member loaded dirty dishes onto racks, pushed them through the dish machine, and then immediately unloaded clean dishes from the other side without washing her hands or using any hand hygiene measures. This process was repeated multiple times, with the staff member alternating between handling dirty and clean dishes without any observed handwashing or sanitizing of hands. During an interview, the staff member confirmed that she did not perform hand hygiene after handling dirty dishes and before touching clean ones. She explained that her coworker had stepped away, and she was trying to keep the workflow moving. The facility's policy, reviewed as part of the investigation, requires employees to wash their hands after handling dirty dishes. This failure to follow hand hygiene protocols had the potential to affect all 87 residents who received food from the kitchen.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide medications as ordered by a physician, affecting one resident out of three reviewed for medication administration. The resident, who was cognitively intact and required assistance with activities of daily living, had a physician's order for Adderall to be administered twice daily. However, the controlled drug administration records and Medication Administration Records (MAR) revealed that the medication was not administered on multiple occasions over a period of several weeks. Interviews with the resident and the Director of Nursing (DON) confirmed that the Adderall was not available for administration on the specified dates, and staff had sometimes signed off the medication as administered in the MAR when it was not available. The DON was unaware of the missed doses until questioned by the surveyor. The facility's policy on administering medications required that medications be administered in accordance with the orders, including any required time frame, which was not adhered to in this case.
Medication Administration Documentation Failure
Penalty
Summary
The facility failed to accurately document medication administration for a resident diagnosed with osteoarthritis and ADHD. The resident was cognitively intact and required assistance with activities of daily living. A physician's order was in place for the administration of Adderall, five milligrams, two tablets twice daily. However, the controlled drug administration records indicated that Adderall was not administered on several dates, while the Medication Administration Records (MAR) inaccurately documented that the medication was given on some of these dates. Interviews with the resident and the Director of Nursing (DON) confirmed the discrepancies in medication administration. The resident reported not receiving Adderall for approximately two weeks, and the DON acknowledged that the medication was unavailable on specific dates. Despite this, staff had signed off on the MAR as if the medication had been administered. The facility's policy on administering medications requires that the individual administering medications record the administration in the medical record, which was not adhered to in this case.
Failure to Include Activities in Resident Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that included activities for three residents, affecting their overall care. Resident #9, who was cognitively intact and required assistance with various activities of daily living, had interests in arts and crafts. However, the care plan for this resident did not include any activities. Similarly, Resident #13, who was also cognitively intact and required supervision and assistance with daily activities, had interests in word puzzles and watching television, but their care plan was also missing activities. Resident #45, with cognitive skills for independent decision-making and requiring set-up assistance for daily living activities, had interests in arts, crafts, bingo, cards, and board games, yet their care plan lacked any mention of activities. Interviews with the Activities Director and the RN MDS Coordinator confirmed that the responsibility for completing and updating residents' activity care plans was not fulfilled for these residents. The facility's care planning policy mandates that a comprehensive care plan be developed within seven days of completing the resident assessment (MDS) and should be based on the resident's comprehensive assessment. The policy also specifies that the care planning team, including the activity director/coordinator, is responsible for developing these individualized care plans. Despite these guidelines, the care plans for Residents #9, #13, and #45 were incomplete, lacking the necessary inclusion of activities.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required eight consecutive hours of Registered Nurse (RN) coverage, as mandated by regulations, during the first quarter of the 2024 fiscal year. This deficiency was identified through a review of the Payroll-Based Journal (PBJ) report and staffing schedules, which revealed multiple days without the necessary RN coverage. Specifically, on 02/03/24, 02/04/24, 02/10/24, 02/11/24, 02/17/24, 02/18/24, 03/30/24, and 03/31/24, no RN was scheduled for the required duration. The absence of RN coverage was confirmed through an interview with the Administrator, who acknowledged the lack of scheduled RN hours on these dates. This deficiency had the potential to affect all 92 residents residing in the facility.
Failure to Provide Perineal Care for Incontinent Resident
Penalty
Summary
The facility failed to ensure perineal care was provided for a resident who was incontinent of bladder and bowel. Medical record review for the resident revealed an admission with multiple diagnoses, including congestive heart failure, asthma, hypotension, and neuromuscular dysfunction of the bladder. The resident required extensive assistance with activities of daily living (ADL) and was coded as incontinent. Despite the care plan indicating the need for perineal care with each incontinence episode, documentation showed only two instances of perineal care being provided during the night shift over a 30-day period. The resident reported that STNAs put two incontinent pads on her at night and did not check her until the morning, leaving her wet and cold. The Director of Nursing confirmed the lack of documentation and stated that the resident should be checked and changed every two hours. The facility's policy on incontinence care did not provide directions for documentation related to the task. The deficiency was identified during a complaint investigation and was verified through medical record reviews, observations, and interviews with the resident and staff. The facility census at the time was 87, and this deficiency affected one of three residents reviewed for incontinent care.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Indianspring Of Oakley | 1.5 mi | ★★★★★ | 0 | 0 |
| Madeira Healthcare Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Astoria Place Of Silverton | 1.8 mi | ★★★★★ | 10 | 0 |
| St. Theresa Care Center | 1.9 mi | ★★★★★ | 3 | 0 |
| Arc At Cincinnati | 2.1 mi | ★★★★★ | 38 | 0 |
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