Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Rosemount Pavilion during CMS and state inspections, most recent first.
A resident with intact cognition and a coccyx pressure ulcer had wound treatment orders changed by the NP, but the facility did not implement the updated orders. The chart showed the active MD order only addressed sacral prevention, not the coccyx ulcer treatment, and during observation the resident’s coccyx wound had no dressing in place while staff provided incontinence care.
Delayed incontinence care was identified for a resident who was always incontinent of bowel and bladder and needed assistance from 2 staff for care. The resident used the call light for help, but it remained on for an extended period while staff were busy elsewhere, and the resident reported waiting since early morning for care. When CNAs finally entered the room, the resident’s attend was saturated with urine and feces, and staff confirmed care had not been provided since the start of the shift.
Infection control measures were not appropriately followed during wound care for a resident with a surgical abdominal wound, DM2, and AFib. An ADON donned two pairs of gloves, removed the old dressing, cleansed the wound, then removed only the outer gloves and continued measuring and dressing the wound without hand hygiene until the treatment was finished. The ADON confirmed the sequence, and the facility’s wound care policy required handwashing after removing the old dressing and again after completing the procedure.
Surveyors found that the facility did not develop or implement comprehensive, individualized care plans for several residents, resulting in generic interventions that failed to address specific needs such as pressure ulcers, trauma histories, mental health conditions, and complex medical diagnoses. Staff and the DON confirmed that care plans were incomplete or not tailored to each resident, and observations showed that important aspects of care, including use of medical devices and management of comorbidities, were not addressed in the care plans.
The facility did not appropriately assess or develop care plans for residents with PTSD or trauma histories, failing to identify causes, triggers, or implement interventions to minimize re-traumatization. Several residents with trauma-related diagnoses did not have individualized trauma-informed care plans, and staff confirmed that necessary assessments and interventions were not completed.
A resident with significant medical and cognitive needs was observed with an uncovered foley catheter drainage bag lying on the floor. The facility's care plan and catheter policy did not address the use of a dignity bag to cover the catheter, resulting in a failure to support the resident's right to privacy and dignity.
Surveyors found that MDS assessments did not accurately reflect the use of pressure relieving devices and mechanically altered diets for three residents. One resident with a pressure ulcer was not documented as having a specialty mattress, another was receiving a mechanical soft diet not reflected in the MDS, and a third with multiple wounds and an amputation was not recorded as having pressure relieving devices or scheduled repositioning, despite evidence to the contrary.
A resident with PTSD, insomnia, and Parkinson's disease was care planned for fall risk with a commode or urinal at bedside, but this intervention was not present during observation. An LPN confirmed the absence, and the DON stated the intervention had been removed from the care plan, though this was not updated at the time of review.
A resident with diabetes, chronic kidney failure, and pruritis did not receive wound care as ordered by the physician. An LPN applied Optifoam bandages and Kerlix wraps not specified in the orders, used wound cleanser instead of soap and water, and failed to date or initial some dressings. The dressings were also not changed as scheduled, and the LPN confirmed the care provided did not follow physician orders or facility policy.
A resident with multiple complex wounds and significant care needs did not have complete or adequate physician orders for pressure ulcer care. Recommendations from a wound care NP for nutritional supplements and vitamins were not transcribed, and the facility could not provide a policy for wound care orders. The DON confirmed the inadequacy of the orders, contributing to insufficient wound management.
A resident with multiple medical conditions was inaccurately assessed as a non-smoker on two facility smoking assessments, despite being listed as a supervised smoker and observed smoking with staff supervision. The DON confirmed the assessments were incorrect, and facility policy required accurate smoking assessments for all smokers.
A resident with multiple chronic conditions and a physician order for a fortified foods diet with regular texture and thin liquids was instead served a mechanical soft diet with double protein portions and fortified mashed potatoes. Staff interviews revealed confusion about the resident's correct diet order, and there was no documentation of a physician order for the diet change. The facility could not provide a policy on dietary orders, and the MDS did not reflect the altered diet.
A resident with complex cardiac and hypertensive conditions received both Metoprolol and Midodrine despite physician orders specifying to hold these medications based on specific blood pressure parameters. Nursing staff and leadership confirmed that the medications were not held as required, resulting in significant medication errors.
A resident with multiple chronic conditions had physician orders for quarterly CBC, BMP, and HgbA1C lab tests, but these were not obtained as scheduled over several months. An LPN confirmed that the required labs were missed during the specified periods.
Surveyors found that two residents with indwelling Foley catheters had their drainage bags lying uncovered on the floor, as confirmed by staff. One resident was non-compliant with catheter care instructions, and facility policies did not address infection prevention for Foley catheters.
A resident with advanced dementia and on hospice care continued to receive scheduled tramadol despite family concerns about overmedication, excessive sedation, and weight loss. The family requested limiting pain medication to nighttime or as needed, but staff did not adjust the regimen or communicate directly with the family. The facility lacked a policy for opioid use or over-sedation management, and the resident’s condition and family concerns were not promptly or adequately addressed.
Failure to Implement Coccyx Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to ensure treatment orders for a resident with a pressure ulcer were implemented timely and appropriately. Resident #79 was admitted with diagnoses including an open wound of the right knee, atrial fibrillation, and anxiety disorder, and the admission MDS dated 03/22/26 assessed the resident as having intact cognition. The care plan revised 04/02/26 identified an alteration in skin and included interventions to administer treatments as ordered. The Wound Assessment Report dated 04/20/26 documented Moisture Associated Skin Dermatitis to the coccyx with orders to cleanse with wound cleanser, apply triad cream with collagen particles, and leave open to air twice a day. A later Wound Assessment Report dated 04/27/26 documented a pressure ulcer to the coccyx with orders to cleanse the wound with wound cleanser, apply a collagen dressing cut to fit the wound bed, and cover with a silicone bordered superabsorber, changing daily and as needed. A subsequent report dated 05/04/26 showed the pressure ulcer was still present with the same treatment orders. However, the active physician order dated 04/13/26 only included a prevention order for the sacrum using triad cream with collagen particles and leaving it open to air every shift, and did not include the coccyx pressure ulcer treatment order. During observation on 05/06/26 at 10:00 A.M., staff were providing incontinence care and the resident had a small wound to the coccyx without a dressing in place. The ADON confirmed that NP #501 changed the wound treatment orders on 04/27/26 but the facility had not implemented them.
Delayed Incontinence Care
Penalty
Summary
Incontinence care was not provided in a timely manner for a resident who was admitted with diagnoses including open wound of the right knee, atrial fibrillation, and anxiety disorder. The resident’s admission MDS, dated 03/22/26, assessed the resident as having intact cognition and as always incontinent of bowel and bladder. The care plan, revised 04/02/26, identified bladder incontinence and directed staff to apply barrier cream as ordered and provide peri-care after each incontinent episode. On 05/05/26, the resident’s call light for a shared room remained lit for an extended period while staff were observed caring for other residents. The resident stated she had placed the call light on because she needed incontinence care and could not do it herself, and said CNA #147 had previously entered the room and said she would get assistance and return. The resident reported she had not received incontinence care since approximately 5:45 A.M. when night shift completed final rounds. When CNA #147 and CNA #166 entered the room at 9:56 A.M., they confirmed the resident had not received incontinence care since day shift began at 7:00 A.M. and began care. The resident was observed to be incontinent of bowel and bladder, and the attend was saturated with urine and feces. The facility policy on Incontinence Management stated that timely response to resident needs was part of maintaining dryness and promoting intact skin.
Infection Control Not Followed During Wound Care
Penalty
Summary
Infection control measures were not appropriately implemented during wound care treatment for Resident #72, who was admitted with diagnoses including colostomy hemorrhage, type 2 diabetes mellitus, and atrial fibrillation. The resident’s 5-Day MDS, dated 03/11/26, indicated intact cognition and the presence of a surgical wound with surgical wound care provided. During observation on 05/04/26 at 1:45 P.M., the ADON entered the room to provide abdominal wound care, performed hand hygiene, and donned two pairs of gloves. After removing the old dressing, cleansing the wounds, and applying skin prep, the ADON removed only the outer gloves and continued the wound care with the inner gloves still on, without performing hand hygiene. The ADON then measured the wounds and applied the new dressing before removing the remaining gloves and performing hand hygiene. In interview, the ADON confirmed she had worn two pairs of gloves, removed one pair in the middle of the treatment, and did not perform hand hygiene except before and after the wound care was completed. Facility policy titled Wound Care, reviewed 08/2024, stated that hands should be washed and dried before applying gloves, hands should be washed and dried thoroughly after removing the old dressing, and hands should be washed thoroughly after completion of wound care.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans that addressed all identified needs for seven residents out of twenty reviewed during the annual survey. Surveyors found that care plans often contained only generic interventions and did not include individualized strategies based on each resident's diagnoses, conditions, or personal history. For example, one resident with a stage three pressure ulcer and orders for specific interventions such as a specialty mattress and heel protectors had a care plan that lacked individualized interventions and did not address the resident's inability to use certain equipment as intended. Several residents with mental health diagnoses, trauma histories, or complex medical conditions did not have care plans that addressed the full scope of their needs. One resident with PTSD had a care plan that only referenced access to psychiatry and psychosocial services, without identifying triggers or specific interventions to prevent re-traumatization. Another resident with a history of trauma and anxiety related to loud noises had no care plan addressing these issues, despite the resident's own report of distress and coping strategies. Additionally, residents with multiple comorbidities, such as heart failure, hypertension, diabetes, and recent fractures, had care plans that omitted key diagnoses and related interventions, such as cardiovascular disease management, pain control, or pressure ulcer prevention. Observations and interviews confirmed that care plans were incomplete or not individualized, and that staff, including the DON, acknowledged these deficiencies. In some cases, care plans did not address significant medical issues such as viral hepatitis, cirrhosis, depression, insomnia, or the use of medical devices like indwelling catheters and wound vacs. The lack of comprehensive care planning was evident through both documentation review and direct observation of residents and their care environments.
Failure to Assess and Care Plan for Trauma and PTSD in Residents
Penalty
Summary
The facility failed to ensure that residents with Post Traumatic Stress Disorder (PTSD) or a history of trauma were appropriately assessed to identify the causes of their trauma, potential triggers, and to implement care plans aimed at minimizing re-traumatization. Record reviews and interviews revealed that for five residents with PTSD or trauma histories, there were no comprehensive assessments conducted to determine the specific causes of their trauma or to identify triggers that could lead to re-traumatization. In several cases, care plans either did not exist or lacked interventions tailored to the residents' trauma-related needs. For example, one resident with multiple diagnoses including PTSD and severely impaired cognition had no care plan addressing the cause of PTSD, potential triggers, or interventions to reduce re-traumatization. Another resident, cognitively intact and reporting symptoms consistent with trauma, was not provided with a care plan that addressed her trauma or included interventions for staff to use in case of adverse reactions. Similarly, a resident who experienced a traumatic motor vehicle accident and exhibited emotional distress had no further assessment or care plan related to trauma triggers or symptoms. Additional residents with trauma histories, including one with PTSD and another with acute pain due to trauma and anxiety disorder, were not adequately assessed for causes or triggers of their trauma. Their care plans either lacked trauma-specific interventions or were entirely absent. Interviews with the DON confirmed that these assessments and care plans had not been completed, and that the facility had not taken steps to minimize the risk of re-traumatization for these residents.
Failure to Provide Dignity Bag for Foley Catheter
Penalty
Summary
Resident #233, who was admitted with multiple complex medical conditions including a right leg amputation, stage four sacral pressure ulcer, diabetes mellitus type two, and cognitive impairment, was observed to have an indwelling foley catheter. The resident was dependent on staff for activities of daily living and had a care plan in place for catheter management, which included positioning the catheter bag and tubing below the bladder and away from the entrance room door, as well as monitoring for signs of infection and documenting intake and output. However, the care plan and facility policy did not address the use of a dignity bag to cover the catheter drainage bag. On two separate occasions, the resident's foley catheter drainage bag was observed uncovered and lying on the floor. This was confirmed by a CNA during an interview. The facility's catheter policy, revised recently, did not include any guidance on covering the catheter bag with a dignity bag to enhance the resident's privacy. This omission resulted in a failure to honor the resident's right to dignity and privacy as required.
Inaccurate MDS Assessments for Pressure Devices and Diet Orders
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the use of pressure relieving devices and mechanically altered diets for three residents. For one resident with a history of pressure ulcer, morbid obesity, and diabetes, the MDS did not indicate the presence of a specialty mattress, despite documentation and observation confirming its use for several months. The Director of Nursing confirmed that the MDS assessment did not accurately reflect the use of the pressure reducing device. Another resident with Alzheimer's disease, malnutrition, and other chronic conditions was assessed on the MDS as not receiving a mechanically altered diet, even though dietary records, meal tickets, and staff interviews confirmed the resident was receiving a mechanical soft diet with double protein portions and fortified foods. There was also a lack of clear documentation regarding the diet order change, and staff were uncertain about the current diet order until it was updated in the electronic medical record during the survey. A third resident with multiple pressure ulcers, a recent amputation, and cognitive impairment was not documented on the MDS as having pressure relieving devices or being scheduled for turning and repositioning, despite observations and staff interviews confirming the use of a low air loss mattress, pressure relieving cushion, heel protector, and regular repositioning. The MDS Coordinator acknowledged that the MDS did not accurately reflect the resident's use of these devices and interventions.
Failure to Update and Implement Fall Prevention Interventions on Care Plan
Penalty
Summary
The facility failed to ensure that fall prevention interventions on a resident's care plan were reviewed and revised for accuracy. A resident with diagnoses including PTSD, insomnia, and Parkinson's disease was identified as being at risk for falls, with a care plan intervention specifying the use of a commode or urinal at bedside. During observation, it was noted that neither a commode nor a urinal was present at the resident's bedside. This was confirmed by an LPN, who acknowledged the absence of the intervention. The DON later confirmed that the intervention was no longer appropriate and had been removed from the care plan, but this update was not reflected in the care plan at the time of the survey.
Failure to Provide Wound Care as Ordered by Physician
Penalty
Summary
The facility failed to provide wound care treatments as ordered by the physician for a resident with multiple medical conditions, including diabetes mellitus, chronic kidney failure, and pruritis. The resident's care plan included interventions for eczematous areas and skin tears, with specific physician orders for cleansing and treating the left shoulder, left arm, and right forearm using designated products and techniques. However, observations revealed that the resident had an Optifoam bandage applied to the arm below the right elbow and the left shoulder, which were not ordered by the physician. Additionally, Kerlix dressings on both lower arms were saturated with blood and had not been changed according to the prescribed schedule, as indicated by the dates and staff initials on the dressings. During wound care treatment, an LPN was observed using wound cleanser instead of soap and water, applying Optifoam bandages and Kerlix wraps not specified in the physician's orders, and failing to date or initial some dressings as required by facility policy. The LPN confirmed that the wound care provided did not follow the physician's orders, acknowledging that Xeroform and a non-adherent bandage should have been used on the right arm and Triad cream with open air exposure on the left arm. Review of facility policy confirmed that treatments were to be applied as ordered and dressings were to be properly labeled, which was not done in this case.
Incomplete Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that physician orders for pressure ulcer care contained sufficient information to provide adequate care for a resident with multiple complex wounds. The resident, who had a history of right leg amputation, stage four sacral pressure ulcer, diabetes, and other comorbidities, was dependent on staff for activities of daily living and had cognitive impairment. Upon review, the physician orders for wound care lacked complete and specific instructions, and recommendations from the wound care nurse practitioner for nutritional supplements and vitamins to aid wound healing were not transcribed into the physician orders. Additionally, the assessment did not document the use of pressure-reducing devices or repositioning interventions at admission. Observations confirmed the resident had a low air loss mattress and pressure-reducing cushion in use, and was positioned appropriately. However, the Director of Nursing acknowledged that the wound care orders were incomplete and inadequate for the resident's needs. The facility was unable to provide a policy for wound care orders and treatment, further contributing to the deficiency in ensuring proper pressure ulcer care and prevention.
Inaccurate Smoking Assessments for Supervised Smoker
Penalty
Summary
The facility failed to ensure that smoking assessments were accurately completed for a resident who smoked, resulting in a deficiency related to accident hazards and supervision. Record review showed that the resident, who had diagnoses including a pressure ulcer, morbid obesity, and diabetes mellitus, was admitted to the facility and assessed as having intact cognition. The resident's care plan identified a risk for injury related to smoking, with interventions requiring supervision at all times and storage of smoking items at the nurses station. However, facility Smoking and Safety assessments completed on two occasions inaccurately indicated that the resident did not smoke, despite the resident being listed as a supervised smoker on the facility's list and being observed smoking with staff supervision in the designated area. Interviews confirmed that the resident had been smoking at the facility since admission, with staff assisting her outside to smoke daily. The DON acknowledged that the completed assessments were inaccurate, as the resident was indeed a supervised smoker. Facility policy required that all residents who smoke be assessed using a smoking assessment and only allowed to smoke in designated areas if determined to be safe smokers. The inaccurate completion of the smoking assessments for this resident constituted a failure to ensure the area was free from accident hazards and that adequate supervision and assessment were provided to prevent accidents.
Failure to Provide Physician-Ordered Diet to Resident
Penalty
Summary
The facility failed to ensure that a resident's meals were provided as ordered by the physician. A review of the medical record for a resident with multiple diagnoses, including Alzheimer's disease, protein calorie malnutrition, and dementia, showed a physician order for a fortified foods diet with regular texture and thin liquids, along with a house supplement three times daily. However, observation of a lunch meal revealed the resident received a mechanical soft diet with double portions of protein and fortified mashed potatoes, which did not match the physician's order. The resident's meal ticket and dietary manager both confirmed the mechanical soft diet, but there was no documentation of a physician order for this change in the medical record or nursing notes. Interviews with staff revealed confusion regarding the resident's current diet order. The MDS Coordinator confirmed the MDS did not reflect a mechanically altered diet, and an LPN admitted to changing the diet order in the electronic medical record without clear documentation of the source of the order. The Director of Nursing also confirmed the absence of documentation for the diet change. The facility was unable to provide a policy related to dietary orders, further highlighting the lack of proper documentation and communication regarding dietary changes for the resident.
Failure to Hold Blood Pressure Medications per Physician Parameters
Penalty
Summary
The facility failed to ensure that blood pressure medications were administered according to physician-ordered parameters for a resident with multiple diagnoses, including congestive heart failure, atrial fibrillation, diabetes, and hypertension. The resident was prescribed Metoprolol tartrate with instructions to hold the medication if systolic blood pressure was less than 120 mmHg or pulse was less than 60 bpm, and Midodrine hydrochloride with instructions to hold if systolic blood pressure was greater than 120 mmHg. Medical record review showed that these parameters were not followed on multiple occasions, with Metoprolol administered when the resident's systolic blood pressure was below 120 mmHg and Midodrine given when systolic blood pressure was above 120 mmHg. Interviews with nursing staff and facility leadership confirmed that both medications were administered despite blood pressure readings that met the criteria for holding the medications. The medication administration record documented several instances where the medications were not held as ordered, and both the LPN and DON acknowledged that the medications should have been held based on the resident's blood pressure readings. This failure resulted in significant medication errors for the resident.
Failure to Perform Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests ordered by a physician were performed as required for one resident. The resident, who had diagnoses including a pressure ulcer of the right heel, morbid obesity, and diabetes mellitus, was admitted to the facility and assessed to have intact cognition. Physician orders specified that a Complete Blood Count (CBC) with differential, Basic Metabolic Panel (BMP), and Hemoglobin A1C (HgbA1C) were to be drawn and resulted every three months in January, April, July, and October. However, a review of laboratory results showed that none of these tests were obtained for the resident from January through May of the review year. This was confirmed by an LPN during an interview, who acknowledged that the required laboratory tests had not been completed as ordered in January or April.
Failure to Keep Foley Catheter Drainage Bags Off the Floor
Penalty
Summary
Surveyors observed that the facility failed to ensure that indwelling Foley catheter drainage bags were kept off the floor for two of three residents reviewed with indwelling catheters. For one resident with a history of neurogenic bladder, cirrhosis, BPH, and other conditions, repeated observations showed the catheter bag lying on the floor without a dignity cover. The resident was noted to be non-compliant with keeping the catheter bag off the floor and not using the cover, as confirmed by an LPN who stated the resident drags the bag on the floor. The resident's care plan documented non-compliance with catheter care, including not hanging the bag and not keeping the cover on, with interventions focused on education and documentation of non-compliance. Another resident with a history of traumatic amputation, stage four pressure ulcer, diabetes, and cognitive impairment was also observed with a Foley catheter drainage bag lying uncovered on the floor. Staff confirmed the observation. The resident's care plan included instructions to position the catheter bag and tubing below the bladder and away from the entrance, but did not specifically address keeping the bag off the floor. Additionally, facility policies on infection control and catheter care did not address infection prevention measures related to Foley catheters.
Failure to Address Family Concerns of Overmedication and Opioid Side Effects
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not timely and appropriately assessing family concerns regarding possible overmedication. The resident, who had diagnoses including Alzheimer's disease, dementia, bipolar disorder, and was on hospice care with a prognosis of less than six months, was prescribed tramadol 50 mg twice daily for pain, along with non-pharmacological interventions as tolerated. Despite documentation in the medical record and pain assessments indicating the resident had no pain, the resident continued to receive scheduled opioid medication. Observations showed the resident was frequently sleeping and difficult to arouse, and the family reported concerns about excessive sedation and weight loss, requesting that pain medication be limited to nighttime or as needed for pain. Interviews with staff confirmed that the resident continued to receive tramadol twice daily, and the DON acknowledged awareness of the family’s concerns but had not directly communicated with the family or adjusted the medication regimen. The facility lacked a policy related to opioid medication or management of over-sedation, and there was no evidence that the family’s request or the resident’s condition was promptly or adequately addressed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Portsmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hill View Skilled Nursing And Rehabilitation Cente | 3.1 mi | ★★★★★ | 1 | 0 |
| River Run Healthcare Of Portsmouth | 4.3 mi | ★★★★★ | 1 | 1 |
| Portsmouth Health And Rehab | 4.6 mi | ★★★★★ | 0 | 0 |
| Bridgeport Health Care Center | 4.9 mi | ★★★★★ | 9 | 0 |
| Rest Haven Nursing Home | 5 mi | ★★★★★ | 0 | 0 |
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