Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Nursing Home, Inc during CMS and state inspections, most recent first.
The facility failed to ensure its QAPI/QAA activities addressed the full scope of pharmacy-related noncompliance after a complaint survey citation. The plan of correction focused only on receipt and accounting for fentanyl patches, while the facility remained out of compliance because meds were not always available for administration, including delayed reorders from the pharmacy, and nurses did not document for whom meds were removed from the automated dispensing system. Corporate Nurse #246 confirmed the facility’s focus was solely on fentanyl patch accounting.
A resident with multiple chronic conditions, right-sided hemiplegia, and frequent incontinence, who required maximal assistance with ADLs, was care planned to receive staff assistance with bathing and other hygiene needs. Documentation showed the resident was scheduled for showers twice weekly on day shift but received only one shower over several weeks, with no refusals recorded. The resident reported having only one bath/shower and otherwise being wiped with wet wipes, and the DON confirmed there was no documentation of the scheduled showers being provided and no facility bathing/showering policy.
A resident with multiple chronic conditions and an order for a Fentanyl 25 mcg patch every three days did not receive the ordered patch on one scheduled administration, with no documentation explaining the omission or recording pain level on the MAR. Pharmacy records showed four Fentanyl patches were delivered and signed for by an LPN, but the patches were never logged into the narcotic drawer. The LPN later stated she remembered only one narcotic card in the bag, believed the patches may have been discarded with the pharmacy bag, and admitted she signed the receipt without verifying it against the actual narcotics received. Subsequent Fentanyl doses for the resident were supplied from facility stock medications, and leadership confirmed the nurse should have reconciled the narcotics against the delivery slip and that there was no narcotic delivery policy in place.
The facility failed to provide adequate nursing staff to meet residents’ needs in a timely manner, resulting in prolonged waits for assistance with meals, toileting, and call light responses. Multiple residents and a family member reported delayed call light response, lack of timely help with ambulation and incontinence care, and concerns about safety. Surveyors observed several residents waiting extended periods between breakfast tray delivery and staff assistance, with food left uncovered and no offers to reheat or provide alternatives, while only two CNAs assisted about 13 residents in the dining room. Staff interviews confirmed that CNAs had to finish serving other residents before helping those needing feeding assistance, causing breakfast to be served much later than residents preferred. During meal periods, most CNAs were pulled into the dining room, leaving one CNA to monitor the hall, respond to call lights, and feed a resident, which led to call lights remaining unanswered for over 20 minutes and residents waiting in soiled briefs or in the bathroom without timely help.
Surveyors identified multiple infection prevention and control failures involving several residents, including a resident with pneumonia and impaired cognition whose soiled linens and used brief were left on the floor during care, and residents with diabetes whose blood glucose checks and insulin administration were performed by LPNs who did not perform hand hygiene and did not properly disinfect shared glucometers between uses. Additional residents receiving oral and nasal medications had their medications prepared and administered by LPNs who did not wash their hands before or after resident contact or before reentering the medication cart. A severely cognitively impaired resident with a chronic sacral wound and an indwelling catheter, care planned for Enhanced Barrier Precautions, received high-contact care from two CNAs who did not don gowns and did not perform hand hygiene while changing briefs, handling catheter tubing and bags, and transferring the resident. The facility also failed to carry out its Legionella Water Management Program, as the Administrator confirmed that required Legionella testing of the water system was either limited to ice machines in one year or not performed at all in the following year, despite the presence of unused rooms with stagnant water.
RN staffing was not maintained for at least 8 hours a day, 7 days a week. Review of staffing summaries showed multiple days when no RN was in the building for the required time, and the Administrator, DON, and Dir. HR confirmed the staffing gap.
Unsecured medication storage and expired medications were found in the facility. A skilled med cart was left unlocked and unattended in a hall with residents present, and the med refrigerator temperature log was not completed daily. Multiple expired OTC medications were found in the med room, and expired meds were also observed on three med carts, including zinc, fexofenadine, and milk of magnesia. The DON stated carts must be locked or monitored when not in use and refrigerator temperatures must be checked daily.
A facility failed to provide substantial bedtime snacks when dinner and breakfast were separated by more than 14 hours. Residents reported snacks were only available on request or if they could get them independently, and staff confirmed they did not go room to room offering snacks. The DNM stated dinner began at 4:45 P.M. and breakfast at 7:45 A.M., creating a 15-hour gap, while assisted-dining residents were served breakfast even later, with trays arriving around 9:35 A.M., 16 hours after the evening meal. The facility policy required no more than 14 hours between dinner and breakfast unless a nourishing bedtime snack was served.
A facility failed to timely implement QAPI corrective actions after surveyors identified missed monitoring of a resident’s pressure and non-pressure skin impairment and concerns about meal timing without a substantial bedtime snack for all residents. QA staff said action plans had been developed for wound documentation, weekly skin assessments, and wound rounds, but implementation was unclear or on hold amid DON turnover and staffing changes. The Administrator also said meal times had been changed by the dietary company without facility agreement and that snack provision had not yet occurred while meal times were still being adjusted.
QAPI committee meetings were not held at least quarterly. Sign-in sheets showed meetings occurred on a quarterly basis through one meeting, but the Administrator verified the committee had not met since September 2025. The facility’s QAPI policy required the committee to meet a minimum of quarterly.
The facility failed to provide timely meal assistance and scheduled showers to dependent residents. Several residents with dementia and other chronic conditions, who required staff help with eating, were seated in the dining room with uncovered trays placed in front of them and waited a prolonged period before CNAs began feeding them; staff did not offer to reheat cold food or provide alternatives when residents refused to eat. CNAs reported that only two staff assisted about a dozen residents in the dining room and that dependent residents routinely waited until all meals were served before receiving help, contrary to facility policy requiring prompt service and adequate staffing. In addition, a resident with dementia, mobility issues, and a history of stroke had a care plan for scheduled showers twice weekly, but documentation showed only one shower per week with no recorded refusals or evidence that the second scheduled shower was offered, and the administrator could not locate additional shower records.
Failure to Provide Individualized Resident Activities: Four residents with cognitive and physical impairments were not offered activities aligned with their preferences or provided meaningful stimulation. Records showed little or no activity participation, observations found residents sitting in common areas with no TV, music, or activities, and interviews with the AD, DON, LPN, CNA, residents, and family confirmed that residents in the caring corners were largely left without engagement. One resident also had no activity care plan, and the AD confirmed one-on-one activities were never offered or attempted.
Failure to provide ordered nutritional supplements and document fluid intake for two residents. One resident with dementia, malnutrition, and weight loss missed multiple Ensure doses because the supplement was unavailable, and staff acknowledged delays in changing the order after the formulary changed. Another resident with CHF, CKD, and dementia had an order to encourage >2,000 ml/day of fluids, but the MAR did not record the amount offered or consumed. A later supplement order for Carnation Instant Breakfast was also not consistently communicated to dietary and CNA staff.
Two residents with cognitive and behavioral disturbances received IM Haldol for acute episodes of agitation, paranoia, and physical aggression after refusing PO medications and nonpharmacological interventions were ineffective. In both cases, providers ordered one-time IM Haldol doses on multiple occasions, and family members were notified of the orders and involved in communication about the residents’ behaviors and treatment. One resident’s family later filed a grievance regarding IM Haldol use, and informed consent was documented only for Trazodone. Facility leadership confirmed there was no documentation that the risks or side effects of Haldol were discussed with either resident or their responsible parties prior to administration.
The facility failed to coordinate and document hospice services for a resident on hospice, as there was no hospice care plan or visit documentation in the chart or hospice binder, and staff were unaware of hospice visit schedules or the hospice plan of care despite a policy requiring communication with hospice. The facility also did not provide ongoing assessment and monitoring for non-pressure skin conditions in two residents: one with nummular eczema treated with clobetasol but lacking follow-up documentation, weekly skin assessments, or a care plan, and another with multiple abrasions, scabs, and a surgical incision whose skin impairments were not comprehensively assessed or measured weekly as required by the wound/skin policy.
A resident with multiple comorbidities and existing pressure ulcers was admitted and later readmitted with documented skin issues, but staff failed to complete comprehensive and ongoing skin assessments as required by facility policy. Initial documentation lacked measurements and detailed descriptions of pressure ulcers, and after readmission, only limited information on an abrasion, a heel scab, and a surgical incision was recorded, with no documented assessment of pressure ulcers. Despite the resident being followed by a wound clinic and having stage 3 pressure ulcers on the sacrum and right plantar foot per clinic notes, the facility did not complete the required weekly skin observation tools, and the DON confirmed there was no comprehensive documentation of wound status or healing.
Two residents did not receive timely bladder-related care, including delayed assessment and treatment of UTI symptoms and prolonged response to incontinence needs. One resident with cognitive and physical impairments, fully dependent for ADLs and incontinent of bowel and bladder, exhibited agitation, hallucinations, altered mental status, and dysuria, yet a physician-ordered urine dip was not obtained as scheduled, and a urine specimen was not collected and sent for testing until six days after symptoms were noted, despite later confirmation by an RN and the resident’s family that UTI signs were present. Another resident with intact cognition, a colostomy, spinal stenosis, and urinary incontinence, care planned for assisted toileting and frequent brief changes, activated the call light due to being wet but waited 41 minutes before a CNA responded; the brief was found full of urine, and both the CNA and DON acknowledged the delay was excessive.
Surveyors observed an LPN administering insulin to a resident with type 2 DM and daily insulin orders without priming either the lispro or Lantus insulin pens before dialing and giving the doses, contrary to manufacturer instructions requiring priming before each injection. The resident’s blood sugar was elevated, and the LPN confirmed the pens were not primed. This contributed to 2 errors in 25 opportunities, resulting in a medication error rate above the 5% threshold.
A resident with type 2 DM and daily insulin orders, including sliding-scale lispro and scheduled Lantus, received insulin injections from an LPN who did not prime either insulin pen before administration. After confirming the resident’s elevated blood glucose and full meal intake, the LPN dialed specific doses on both lispro and Lantus pens and administered them without priming. In a later interview, the LPN acknowledged not priming the pens, despite manufacturer instructions requiring priming before each injection to remove air and ensure proper pen function.
A resident with Alzheimer's disease, dementia, glaucoma, and macular degeneration was not permitted to choose her dining location and meal time. She stated she wanted breakfast no later than 9:00 A.M. and would eat in her room if needed, while her niece reported breakfast was being served much later than before. The SLP said the resident needed supervision for eating due to swallowing trouble, poor vision, and verbal cueing, and could eat in her room if adequate 1:1 supervision was available, but staffing was insufficient at the time.
Failure to Disburse Resident Funds After Death: The facility did not ensure that a deceased resident’s personal funds were returned within the required timeframe. A resident died in the facility, and review of the account showed $4,403.88 still in the resident’s personal fund account after death. The BOM and Administrator verified there had been no BOM at the facility for a period of time, and the Regional BOM confirmed the funds should have been returned within 30 days.
A facility posting on a skilled hall wall disclosed two residents’ appointment details, including one resident’s ophthalmology visit and another resident’s wound center visit, along with pickup times. An LPN confirmed the information would reveal private medical details such as a wound and vision issues. The residents’ records also showed diagnoses and wound-related findings, and the admission packet stated residents had the right to secure and confidential personal and medical records.
A resident with psychotic disorder with delusions and vascular dementia with anxiety was ordered Seroquel 12.5 mg at bedtime. A NP note stated the resident’s daughter reported the drug had been started for insomnia, and Medscape information reviewed by surveyors stated Seroquel was not approved for dementia-related psychosis. The DON said the resident had been admitted with the order from a prior setting but could not explain why the antipsychotic use outweighed the associated risk and confirmed the resident was not a short-term stay.
The facility failed to provide required transfer and bed-hold notices for two residents sent to the hospital, including one resident with severe agitation, paranoia, refusal of care, and combativeness, and another resident transferred from an oncology visit for a blood clot. The facility also failed to complete a discharge summary for a cognitively intact resident whose meds and discharge instructions were given to the daughter at discharge.
Failure to Complete and Submit Discharge MDS: The facility failed to ensure timely completion and submission of MDS assessments for one resident. A resident with osteoarthritis, osteoporosis, COPD, depression, and GAD had an admission MDS completed late, and the discharge MDS was not completed or submitted as required. RN verification confirmed the missing discharge MDS.
Accurate MDS assessments were not ensured for two residents. One resident's MDS incorrectly showed insulin use despite no insulin orders or MAR evidence, and another resident's admission MDS failed to capture documented wounds and ulcers, including a stage 3 pressure injury and a chronic foot ulcer. An RN verified the insulin coding error and stated wound clinic documentation was not available when the second MDS was coded.
Incomplete care plans were identified for two residents with skin conditions. One resident had multiple wounds, including pressure ulcers and a chronic non-pressure ulcer, but the care plan only addressed a surgical incision and did not reflect the actual wound findings. Another resident had nummular eczema with orders for topical treatment, yet no specific care plan was in place for the rash, and red circular areas were observed on the chest, abdomen, and arms.
Residents were not offered the opportunity to participate in care plan meetings or help develop their plans of care. One resident with cognitive intactness and mobility needs had no activities care plan and said he never had a care conference; another resident with MS and paraplegia said she was not invited, and RN could not find care conference documentation; a third resident with dysphagia, kidney disease, and chronic pain said she had not been asked to attend despite wanting input, and the record showed no evidence of ongoing care conference participation.
Failure to implement a restorative nursing program for a resident with dementia, muscle weakness, and difficulty walking. PT discharged the resident with a restorative referral for exercises and assisted walking to help maintain function, but the program was not placed in the care plan and was not provided. Interviews with the DOR, RN, MDS coordinator, RDCS, and CNAs confirmed no restorative nursing services were being delivered and staff had not been trained or assigned to carry out the program.
A resident with muscle weakness, difficulty walking, and poor vision had a history of falls, but the fall risk assessment lacked a score or risk level. The care plan included fall interventions such as a reacher, yet staff did not consistently know how to access the care plan, the reacher was found out of reach in the room, and the post-fall findings noted improper footwear and clutter were not reflected in the fall plan. The resident’s fall was unwitnessed, and documentation of the incident was incomplete.
Excessive Acetaminophen Administration: A resident with cellulitis, chronic venous hypertension, and moderate cognitive impairment received acetaminophen from two duplicate orders on the MAR. Nursing documentation showed daily totals up to 6,000 mg, and staff later identified one order as duplicative. The physician stated the usual upper limit would be 3,000 mg/day, while the product label warned of severe liver damage above 4,000 mg in 24 hours.
Failure to Offer Dental Services: A resident who was cognitively impaired and dependent on staff for oral hygiene had no dental care plan and no evidence of being offered or seen by a dentist after admission. The resident voiced concern about not having dental care and wanted to know whether she had any new cavities, while the Administrator confirmed there was no evidence the resident was ever offered or received dental services.
Failure to honor a resident’s food preferences occurred when staff did not consistently identify and serve requested meal alternatives. A resident with dysphagia, kidney disease, and chronic pain reported that she dislikes green beans but continued to receive them because staff no longer asked residents what they wanted for meals. Surveyors observed a lunch tray containing mixed vegetables with green beans, and the DM confirmed the resident should have received carrots instead. Staff stated residents generally receive whatever is on the menu and that there were no vegetable alternatives.
Inaccurate documentation of ostomy care was identified for a resident with a colostomy and bowel/bladder incontinence. The resident said the ostomy bag should be changed every three days but was only being changed weekly. The TAR showed ostomy care was signed off by LPNs as completed or refused, while interviews confirmed one LPN signed off care she did not perform and the RN who actually changed the bag did not document those treatments.
Failure to complete annual CNA performance evaluations. Review of four personnel files showed no annual appraisal for four CNAs, and the HR Director verified the evaluations had not been completed in the last year as required on each staff member’s anniversary date. Two CNAs also stated they did not receive an annual evaluation, and the facility policy required appraisals around 90 days and annually thereafter.
Nurse staffing information was not posted in a prominent, readily accessible location for residents, visitors, and staff. An LPN was unsure where the daily staffing information was posted, another LPN could not find it after searching, and the DON verified the posting was missing. The Unit Clerk stated she had removed the posting the prior evening and showed a blank sheet of paper she said was what she had removed.
Facility Assessment not updated after ownership change. The assessment still listed former personnel, an outdated medical director role, and an acuity-based staffing formula that the Administrator could not confirm would remain in use. It also failed to reflect agency staffing, new nursing and staff development positions, contracted dietary services, nonoperational transport vehicles, and changes in pharmacy, dental, therapy, and HIT providers.
A resident with severe cognitive impairment was left unattended with her lunch tray for 13 minutes before a State tested Nurse Aide (STNA) began assisting her while standing, contrary to the facility's policy requiring staff to sit next to residents during feeding.
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) informing them of their financial liability for continuation of skilled services not covered by Medicare. The Administrator confirmed that both residents should have been provided with the SNF ABN forms but were not.
The facility failed to ensure psychotropic medications ordered on a PRN basis had a specific duration for use, affecting two residents. One resident had an order for trazodone without a time limit, administered 13 times over two months. Another resident had an order for Ativan without a stop date, administered three times. The DON confirmed the lack of specific durations for these orders, contrary to the facility's policy.
The facility failed to monitor prophylactic antibiotic use for two residents. One resident received minocycline hydrochloride for skin without an active infection, and another received nitrofurantoin macrocrystal for UTI prophylaxis. The DON confirmed that the facility did not track prophylactic antibiotic use, contrary to the facility's policy.
The facility failed to notify the ombudsman in writing of resident transfers or discharges, affecting three residents reviewed for hospitalization and discharge. The Administrator confirmed the omission of required notifications since January 2024.
QAPI/QAA Plan Focused Only on Fentanyl Patch Accounting
Penalty
Summary
The facility failed to ensure its QAPI and QAA activities addressed the full scope of regulatory noncompliance after a complaint survey citation related to pharmacy services. The cited issue involved the facility’s failure to reconcile narcotic medications delivered from the pharmacy with pharmacy delivery slips to ensure all listed narcotic medications were received. In its plan of correction, the facility focused only on accounting for receipt of fentanyl patches, and during the evaluation for compliance it was found that the facility remained out of compliance because medications were not always available for administration, including instances where medications were not reordered from the pharmacy in a timely manner. The facility also failed to ensure nurses documented for whom medications were removed from the automated medication dispensing system. During discussion of the concerns on 06/02/26 at 2:31 P.M., Corporate Nurse #246 confirmed the facility’s focus on meeting regulatory requirements was solely on the receipt and accounting for fentanyl patches.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers for a resident who was dependent on staff for activities of daily living (ADLs). The resident was admitted with multiple significant diagnoses, including cardiac conditions, diabetes, right-sided hemiplegia, cerebral infarction, edema, hypertension, insomnia, irritable bowel syndrome, congestive heart failure, benign prostatic hyperplasia, anxiety disorder, depression, prosthetic heart valve, cardiac pacemaker, degenerative disc disease, and gout. An admission MDS assessment documented that the resident had intact cognition but one-sided upper and lower body impairment, required maximal assistance for toilet hygiene, bathing, personal hygiene, and turning in bed, and was frequently incontinent of bladder and bowel. The care plan indicated the resident required assistance with ADLs due to advanced age, chronic health conditions, and recent hospitalization, with interventions including assistance with transfers via a butterfly transfer board and therapy services as needed. Review of the Documentation Survey Report showed the resident was scheduled to receive showers on the day shift on Tuesdays and Saturdays, but between 03/17/26 and 04/13/26, only one shower was documented as completed on 04/01/26. There was no documentation that the resident refused showers during this period, and progress notes from 03/17/26 to 04/15/26 contained no record of shower refusals. In an interview, the resident reported having received only one bath or shower since admission, stating that staff otherwise wiped him down with wet wipes. In a subsequent interview, the DON confirmed there was no documentation that the resident received the scheduled showers, and the Administrator reported that the facility did not have a bathing/showering policy. This resulted in a cited deficiency related to failure to ensure scheduled showers were completed for a dependent resident.
Failure to Reconcile Delivered Narcotic Patches With Pharmacy Delivery Slip
Penalty
Summary
The facility failed to reconcile narcotic medications delivered from the pharmacy with the pharmacy delivery slip upon delivery, resulting in missing Fentanyl patches for a resident. The resident had multiple chronic conditions including multiple sclerosis, hypertension, malignant neoplasm of the lymphoid, chronic pain, spinal stenosis, and polyneuropathy, and had a physician’s order for a Fentanyl 25 mcg patch to be applied every three days. Review of the MAR showed the Fentanyl patch was not administered as scheduled on 03/27/26, with no documentation explaining the missed dose and no pain level documented on the MAR. A pain assessment indicated the resident had experienced occasional pain in the last five days, though at the time of observation the resident had intact cognition, was sitting up in a wheelchair, eating dinner, and had no complaints of pain. The controlled substance delivery sheet showed that four Fentanyl 25 mcg patches were delivered for the resident and signed for by an LPN on 03/24/26 at 6:38 A.M. The LPN’s written statement indicated she remembered receiving only one narcotic card in the pharmacy bag, did not recall seeing the Fentanyl patches, and believed the patches may have been stuck in the bag and thrown away. She acknowledged signing the order receipt without verifying that the contents matched the delivery slip and without logging the patches into the narcotic drawer. Subsequent pharmacy transaction records showed that Fentanyl patches for the resident were later pulled from facility stock medications rather than from the originally delivered supply. The Regional Nurse confirmed that the nurse should have checked the narcotics in upon receipt and compared them to the pharmacy delivery slip, and it was noted that the facility did not have a narcotic delivery policy or procedure per the Administrator.
Insufficient Nursing Staff Leading to Delayed Meals and Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in a timely manner, particularly during meals and in response to call lights. During confidential interviews with 25 residents, nine residents and one family member reported that staffing levels were inadequate to provide timely assistance. Reported concerns included delayed responses to call lights, staff turning off call lights and not returning, lack of assistance with ambulation, and untimely toileting and incontinence care, as well as worries about safety in an emergency. The facility’s staffing policy required adequate staffing on each shift to ensure residents’ needs and services were met, but observations and interviews showed this was not consistently achieved. Multiple observations during breakfast service showed residents waiting extended periods between tray delivery and staff assistance, with food left uncovered and no offers to reheat meals. One resident was seated in the dining room shortly before 9:00 A.M., but her tray was not uncovered until after 9:30 A.M., and staff did not begin assisting her until nearly 10:00 A.M., after which she consumed only a small portion of her meal and was not offered to have it warmed. Another resident had a meal placed in front of her without a cover and did not receive feeding assistance for over 20 minutes; she ate toast with encouragement but stopped after the first bite of eggs, and staff did not offer to warm the food. A third resident’s tray was placed in front of him uncovered, and he did not receive assistance for about 18 minutes; after one bite he refused further food, and no alternative or reheating was offered. CNAs reported that residents who required assistance with eating had to wait until CNAs finished serving other residents on the units, resulting in breakfast often not starting until around 9:30–10:00 A.M. for those needing help, with typically only two staff assisting about 13 residents in the dining room. Additional observations showed delayed responses to call lights and untimely toileting and incontinence care. One resident activated his call light at 11:00 A.M. because he was wet and needed changing; the light remained on until 11:41 A.M., when a CNA returned from break and provided incontinence care, finding the resident’s brief full of urine. The CNA and the DON both acknowledged that a 41‑minute wait was too long. In another instance, a resident’s call light remained on for approximately 25 minutes while she waited for assistance to get out of the bathroom; she eventually ambulated to the nurses’ station to report the delay. A CNA explained that during meals, all but one CNA were required to assist in the dining room, leaving a single CNA to monitor the hall, respond to call lights, and feed a resident, which prevented timely responses to all call lights. Family and therapy staff also reported that residents were receiving breakfast significantly later than they had previously, and that one resident who required one‑on‑one supervision for safe eating could not be accommodated in her room due to insufficient staffing.
Widespread Infection Control and Water Management Failures
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices during resident care, medication administration, blood glucose monitoring, and environmental management. For one resident with pneumonia, muscle weakness, impaired cognition, and dependence on staff for toileting, a CNA was observed providing care with the room door open while soiled linens and a used adult brief were left on the floor. The CNA acknowledged that the dirty linens and brief were on the floor and stated she would pick them up after finishing care. The DON later confirmed that dirty linens were not to be placed on the floor and should be put in a bag. For residents with diabetes, staff did not follow hand hygiene and equipment disinfection policies during blood glucose monitoring and insulin administration. One cognitively intact resident with type 2 diabetes and acute kidney failure had an order for twice-daily blood sugar checks. An LPN removed a glucometer from the medication cart, entered the resident’s room, performed a fingerstick blood sugar check without cleaning the glucometer before use, then briefly wiped it with an alcohol pad afterward. The LPN returned the glucometer to the cart without performing hand hygiene before or after the procedure and confirmed that the device was used on multiple residents daily and that she had not cleaned it before use or washed her hands. Another resident with type 2 diabetes and chronic kidney disease, who received daily insulin, had a fingerstick blood sugar check and insulin administration performed by a different LPN who never washed her hands or used hand sanitizer before, between, or after entering and exiting the room. This LPN placed the glucometer on top of the cart, handled multiple insulin pens, administered insulin, then briefly wiped the glucometer for about 12 seconds before returning it to the cart, and confirmed she had not performed hand hygiene and believed this was the correct way to clean the glucometer. These practices did not follow the facility’s handwashing and cleaning/disinfecting policies or the Sani Wipe instructions requiring a two-minute wet time. Additional hand hygiene failures occurred during medication administration for residents with significant functional impairments. One severely cognitively impaired resident with radiculopathy, diabetes, and muscle weakness required assistance with ADLs. An LPN prepared 12 oral medications from the cart without hand hygiene, administered them along with a nasal spray, then returned the nasal spray to the cart without washing her hands before or after resident contact or before reentering the cart. Another cognitively intact resident with Parkinson’s disease and chronic kidney disease, who required ADL assistance, received 10 medications prepared in applesauce by a different LPN who also did not wash her hands before preparing the medications, after administering them, or before accessing the cart again to prepare medications for the next resident. These actions were inconsistent with the facility’s handwashing policy requiring hand hygiene before and after resident care and invasive procedures. The facility also failed to follow Enhanced Barrier Precautions (EBP) for a resident with severe cognitive impairment, a chronic sacral wound, and an indwelling catheter, who was care planned for EBP due to chronic wounds and device use. Two CNAs provided high-contact care, including a brief check and change, emptying the catheter bag, disconnecting and reconnecting catheter tubing, draining urine, dressing the resident, and transferring the resident via mechanical lift, without donning isolation gowns and without performing hand hygiene before, during, or after care. One CNA acknowledged the presence of an EBP sign at the room entrance instructing staff to wear gloves and a gown for high-contact activities such as transferring and device care, and both CNAs confirmed they had not worn gowns or performed hand hygiene. These actions did not comply with the facility’s EBP and handwashing policies. In addition to direct care issues, the facility did not implement its Legionella Water Management Program as written. The Administrator confirmed that in one year the facility only tested ice machines and did not perform required Legionella testing of the broader water system, and in the following year no Legionella testing was completed at all. The Administrator further confirmed that the facility used city water and that, despite contacting the water company, no Legionella testing was performed. The Administrator also acknowledged that there were empty resident rooms with private bathrooms and sinks where water could remain stagnant and that these areas were not tested in either year. These practices did not align with the facility’s Legionella Water Management Program policy, which required identification and monitoring of areas in the water system where Legionella could grow and spread, including storage tanks, water heaters, filters, aerators, showerheads, hoses, misters, humidifiers, and fountains, and required at least annual review of the program.
RN Staffing Requirement Not Met
Penalty
Summary
The facility failed to ensure that a Registered Nurse was providing services at least eight hours a day, seven days a week. Review of the Daily Nurse Staffing Summaries from 04/20/26 through 06/01/26 with the Director of Human Resources revealed that there was not an RN in the building for at least eight hours a day, seven days a week on 04/24/26, 05/02/26, 05/03/26, 05/16/26, 05/17/26, and 05/28/26. The facility census was 80 residents, and the deficiency was identified through record review and interview. During interviews on 06/01/26, the Administrator and DON confirmed there was no RN in the building for at least eight hours a day, seven days a week, and the Director of Human Resources also confirmed this staffing issue.
Unsecured medication storage and expired medications
Penalty
Summary
The facility failed to ensure medications were stored in a safe and secure manner and failed to ensure medications were not expired. During observation, a skilled medication cart in the residential hall was found unlocked with the computer open and no staff in view, while residents were present in the hall. The Unit Manager confirmed the cart had been left unlocked and unattended while the nurse was in a resident room. The facility identified one medication room and six medication carts, and the issue had the potential to affect all 73 residents residing at the facility. Observation of the medication storage room revealed a medication refrigerator with a temperature log that was not completed daily, including missing entries for multiple dates in March 2026. The refrigerator contained an RSV prefusion injection, five boxes of flu vaccine injections, two secured starter kits with multiple medications visible inside, and two Shingrix vials. The over-the-counter stock area contained several expired medications, including hemorrhoidal ointment, naproxen, guaifenesin, acidophilus probiotic, melatonin, coenzyme Q10, zinc, and ocular vitamins. Additional observations on medication carts found a partially used bottle of expired zinc on the skilled cart, a partially used bottle of fexofenadine on the Verranda cart, and a mostly used bottle of expired milk of magnesia on the Long Hall cart. The DON stated expired medications were to be disposed of before expiration and that medication carts had to be locked or monitored when not in use, and refrigerator temperatures had to be monitored daily.
Failure to Provide Bedtime Snacks When Meal Interval Exceeded 14 Hours
Penalty
Summary
Meals and snacks were not served at times in accordance with residents’ needs, preferences, and requests because the facility did not provide substantial nutritional evening snacks when the time between dinner and breakfast exceeded 14 hours. During a resident council meeting, 12 residents stated bedtime snacks were only provided upon request or if residents were able to go get them independently. The Activity Director stated that if a resident could not take themselves to the snack area, a snack could be requested to be brought to them. The Dietary Manager stated dinner began at 4:45 P.M. and breakfast began at 7:45 A.M., creating a 15-hour interval between meals, and that the kitchen did not send a specific bedtime snack even though snacks were stocked each day. Staff interviews confirmed that staff did not go room to room to offer all residents snacks at bedtime and that only residents who were able could request snacks. The Dietary Manager also stated the assisted-dining room meal times were not exact, and staff reported breakfast in that area was served around 9:30 A.M. to 9:45 A.M. and dinner around 5:30 P.M. daily. Observation showed breakfast trays arrived in the assisted-dining room at 9:35 A.M., which was 16 hours after the substantial evening meal and breakfast the following day. The facility policy stated there would be no more than 14 hours between a substantial evening meal and breakfast the next day unless a nourishing bedtime snack was served, and that all residents would be offered a bedtime snack.
Delayed QAPI Implementation for Wound Monitoring and Meal Timing Issues
Penalty
Summary
The facility failed to timely implement its QAPI corrective actions for identified regulatory deficiencies. During the survey, concerns were identified regarding staff failure to monitor pressure and non-pressure skin impairment for Resident #32, and concerns were also identified regarding meal times without a substantial bedtime snack being offered to all residents. Corporate Nurse #503 verified that weekly assessments for Resident #32’s pressure and non-pressure skin impairment had not been completed. She stated the deficiency had already been identified by the QA committee and that an action plan had been developed regarding increased pressure ulcer quality measure numbers, wound measurements, weekly skin assessments not being entered into the computerized charting system, review of treatment orders to ensure residents with wounds were seen during wound rounds, and review of weekly skin observations for completion. The Administrator stated the QA committee had been addressing wounds and skin impairment, but when asked what part of the plan had been implemented, she said she would have to find out. She also stated the contracted dietary company changed meal times without an agreement with the facility, and that there was too much time between dinner and breakfast, requiring snacks to be provided, but this had not occurred because the facility was still working on adjusting meal times. The Administrator did not provide dates for any action taken and stated staff turnover of key personnel had made it impossible to implement the QA plans, with development of those programs still in process. Corporate Nurse #503 stated the wound-related plans were developed, but the new DON had only recently started and the survey began shortly after, so the plan was put on hold; she was unable to state whether the plan had ever been initiated. The DON stated she found a QA plan to improve wound care when she started, but she had no idea how Resident #32’s lack of wound assessments were not identified or addressed, and she could not locate evidence that the previous DON had initiated implementation of the plans.
QAPI Committee Did Not Meet Quarterly
Penalty
Summary
The facility failed to conduct quality assurance committee meetings at least quarterly. Review of the sign-in sheets showed quality assurance committee meetings were held on 12/23/24, 03/25/25, 06/25/25, and 09/25/25. During an interview on 03/19/26 at 8:25 A.M., the Administrator verified that the facility had not held a quality assurance committee meeting since September 2025 and stated the facility continued to identify regulatory concerns and plan corrective actions. Review of the facility’s QAPI policy, effective 09/23/24, showed the committee was scheduled to meet a minimum of quarterly.
Failure to Provide Timely Meal Assistance and Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with meals to dependent residents and to provide showers according to the established schedule. One resident with dementia, difficulty walking, chronic kidney disease, anxiety, and on hospice required substantial/maximal assistance for eating and was dependent for all other ADLs. Over the prior month, this resident’s meal intake declined from 26–50% to 0–25%, and then to not eating. On the observed morning, the resident was seated in the dining room at 8:53 A.M., breakfast trays arrived at 9:15 A.M., and her uncovered tray was placed in front of her at 9:32 A.M., but staff did not sit to assist her until 9:58 A.M. The CNA then offered food and drink, and the resident consumed about 10–20% of the meal; the CNA did not offer to reheat the food. Another resident with cerebral atherosclerosis, peripheral arterial disease with intermittent claudication, and adult failure to thrive had impaired cognition, required setup or clean-up assistance with eating, and was dependent for all other ADLs. The care plan for weight loss or malnutrition included encouragement to eat, recording meal intake, and providing supplements. On the observed morning, this resident’s uncovered breakfast tray was placed in front of him at 9:35 A.M., and the CNA did not begin assisting until 9:53 A.M. The resident took one bite and then did not want to eat more, and the CNA did not offer to warm the food or provide an alternative. A third resident with hypertension, diabetes, and Alzheimer’s disease had impaired cognition, was dependent for eating and all ADLs, and had a care plan requiring setup, cueing, reminders, and assistance with feeding. This resident’s uncovered meal was placed in front of her at 9:35 A.M., and the CNA did not assist until 9:53 A.M.; the CNA did not offer to warm the food. The resident ate toast with encouragement but refused further eggs after the first bite. Staff interviews confirmed that residents needing assistance with eating are brought to the dining room and must wait until aides finish serving meals on the unit, resulting in no set breakfast time other than around 9:30 A.M. and delays until about 10:00 A.M. before staff can sit to assist dependent residents. CNAs reported that only two staff are typically in the dining room to assist 13 residents at all meals, causing residents to wait and food to become cold. The facility’s Dining Room Service policy stated that meals will be served promptly to maintain adequate temperature and appearance and that adequate staff should be available to assist individuals who need help. Additionally, another resident with dementia, gait and mobility abnormalities, acute kidney failure, history of stroke, and cognitive communication deficit had a care plan indicating assistance with ADLs and a shower schedule on day shift Monday, Thursday, and as necessary. Review of shower documentation over several weeks showed only one shower per week on Thursdays, with no documentation of a second scheduled shower being offered or provided and no refusals recorded for the missed showers, despite the administrator confirming that all showers should be documented in the point-of-care records and being unable to locate additional documentation that showers were offered or provided per schedule.
Failure to Provide Individualized Resident Activities
Penalty
Summary
The facility failed to ensure residents were offered activities that matched their interests and supported psychosocial well-being. Review of records, observations, interviews, and the facility’s activity policy showed that four residents reviewed for activities did not have evidence of meaningful activity participation or individualized activity support. The activity calendar listed limited scheduled offerings, and for several residents there was no documentation that the activities were actually offered or completed. Resident #22 had diagnoses including dementia, difficulty walking, chronic kidney disease stage 3, anxiety, and a solitary pulmonary nodule. Her MDS showed impaired cognition, and her care plan identified self-directed activities such as watching TV and listening to music. However, activity documentation for February and the following month showed no participation, and observations repeatedly found her seated in a Broda chair in the common area with her eyes closed and no TV, music, or other activities provided. Her daughter stated the resident liked church and music, but staff now just sat her in the caring corner and maybe turned the TV on. Staff interviews confirmed floor staff did not have time to provide activities and residents in the caring corners were not getting activities all day. Resident #30 had diagnoses including poor memory, cognitive impairment, muscle weakness, and chronic pain. Her care plan identified self-directed activities such as watching TV programs in her room, but there was no documentation of activity participation. Observations found her seated in the common area with her eyes closed and no music, TV, or activities going on. Resident #31 had dementia, glaucoma, macular degeneration, and muscle weakness, and her care plan identified preferences for bingo, group reminiscing, holiday celebrations, and movie watching. She stated she usually sat with nothing to do and only went to bingo if staff came to take her. Observations again showed her in the common area with no TV or music and no activities available. Interviews with the AD, LPN, CNA, and DON confirmed that residents in the caring corners were generally just sitting there and not receiving meaningful stimulation. Resident #57 had muscle wasting and atrophy and neurocognitive disorder with Lewy bodies. His MDS indicated it was very important to keep up with the news and participate in religious services, and he was cognitively intact with mobility assistance needs. He did not have an activity care plan, and the AD confirmed he was not on the list for one-on-one activities over the prior 12 months. The AD also stated one-on-one activities were never offered or attempted, and she did not know his likes or dislikes. The resident stated he wished he had more to do, liked reading sports magazines and getting manicures, and said no one at the facility asked him what he enjoyed doing. The facility policy stated activities programming must reflect residents’ schedules, preferences, goals, choices, and rights, but the records and interviews showed these residents were not provided individualized activity support consistent with those preferences.
Failure to Provide Ordered Supplements and Document Fluid Intake
Penalty
Summary
The facility failed to ensure that residents received nutritional supplements as ordered and failed to document the amount of fluid offered and consumed when a physician ordered encouragement of fluid intake. These failures involved two residents reviewed for nutrition concerns, with additional residents identified by the facility as having orders for Ensure. The census was 73. One resident had diagnoses including Alzheimer's disease, mild protein calorie malnutrition, adult failure to thrive, and abnormal weight loss. The resident was severely cognitively impaired, had impairment to both upper extremities, and required partial/moderate assistance with eating. The care plan identified risk for nutritional complications related to dysphagia, vitamin deficiency, adult failure to thrive, malnutrition, and abnormal weight loss. A physician ordered Ensure twice daily for malnutrition risk, but the order did not specify the amount to administer. The MAR showed multiple missed doses across January, February, and March, and progress notes documented that Ensure was unavailable on several dates. Staff interviews confirmed the supplement was not consistently available, and the RD and administrator acknowledged delays and problems related to the supplement transition and ordering process. Another resident had diagnoses including acute kidney failure, muscle wasting and atrophy, dementia, congestive heart failure, and anemia. A physician ordered fluids greater than 2,000 ml/day, but the MAR only showed checkmarks indicating fluids were encouraged and did not document the amount offered or consumed. RN verification confirmed there was no tracking of the fluids offered each shift. The same resident also had a later nutritional supplement order for Carnation Instant Breakfast, which was changed in the nutrition assessment to fortified cereal and Med Pass because the original supplement was not going to be available. However, the meal ticket did not reflect the fortified cereal, dietary staff stated the kitchen had not yet started the fortified cereal and had not received the list of changes, and CNA staff stated they were unaware of the supplement order unless it appeared on the dietary ticket or nurses informed them.
Lack of Informed Consent for IM Haldol Use in Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their responsible parties were informed of the risks of antipsychotic (Haldol) use prior to administration. For one resident with muscle wasting, difficulty walking, chronic venous hypertension with ulcers, CHF, and moderate cognitive impairment, behavior notes documented episodes of severe agitation, paranoia, physical and verbal aggression, refusal of oral medications, and rejection of care. In response, an NP ordered a one-time IM dose of Haldol, and later that same day a physician ordered a second one-time IM dose after the resident again became severely agitated and refused oral medications, including PRN Ativan. The resident’s son was notified of the orders and was present during some of the episodes, but there was no documentation that the risks of Haldol use were discussed with either the resident or her son. Subsequent documentation for this same resident showed continued severe paranoia, delusions, refusal of medications and care, and combative behavior, leading to additional IM Haldol administrations. Notes indicated that attempts had been made to initiate oral antipsychotic medication but were unsuccessful due to refusals, and that non-pharmacological interventions were not effective. The facility informed the family that there were no other interventions staff could initiate in the nursing setting and that the resident would benefit from transfer to a geriatric psych facility. Despite multiple Haldol injections and ongoing communication with the family about the resident’s condition and care needs, the corporate nurse later verified there was no documentation that the risks of Haldol had been discussed with the resident or her son. For a second resident with diagnoses including a left humerus fracture, metabolic encephalopathy, abnormal gait and mobility, history of falls, heart disease, and parkinsonism, the care plan identified risk for complications related to psychoactive medication use. The resident had intact cognition and required assistance with ADLs. Behavior notes documented episodes of paranoia, belligerence, attempts to crawl out of bed, physical aggression toward staff, refusal of PO medications, and belief of being held without permission, leading an NP to order IM Haldol on two separate occasions for safety after nonpharmacological measures were ineffective. A grievance was later filed by the family regarding the use of IM Haldol for an acute change in behavior, and an informed consent form for Trazodone was signed by the resident’s wife with potential side effects reviewed. However, there was no documentation that Haldol side effects or risks were discussed with the wife prior to either IM Haldol administration, and the corporate nurse confirmed the absence of such documentation.
Failure to Coordinate Hospice Care and Monitor Non-Pressure Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate treatment and care according to orders, resident preferences, and goals, specifically related to hospice coordination and skin/wound management. One resident with cerebral atherosclerosis, peripheral arterial disease, and adult failure to thrive had a physician order for hospice admission and a care plan noting hospice services and a poor prognosis. However, there was no hospice care plan or visit documentation from hospice nurses or aides in the electronic record, paper chart, or hospice binder. The LPN unit manager stated he did not know when hospice visits occurred or details of the hospice plan of care, and the administrator acknowledged the facility should collaborate with hospice and maintain a copy of the hospice care plan and documentation. The hospice RN confirmed hospice had admitted the resident but had not provided the facility with a care plan or nursing documentation, despite a facility policy requiring communication between the center and hospice to ensure quality care. The facility also failed to provide routine assessment and monitoring for a non-pressure skin condition in a resident with chronic diastolic CHF and stage 3 chronic kidney disease. This resident had a documented nummular eczema rash on the chest, back, arms, and abdomen, with an order for clobetasol ointment twice daily. After an initial assessment and treatment order, there was no further documentation or follow-up on the eczema in the medical record after a specific early December date, even though the clobetasol treatment continued. During an observation of incontinence care, the resident was noted to have multiple red, circular areas of varying sizes on the abdomen, chest, and arms. The LPN unit manager and the regional director of clinical services confirmed there was no nursing follow-up documentation, no weekly skin assessments, and no care plan addressing the nummular eczema. A third deficiency involved another resident with multiple medical conditions, including pain, muscle wasting and atrophy, gait abnormalities, peripheral vascular disease, osteoarthritis, iron deficiency anemia, and hypertension, who had several non-pressure skin impairments. Initial admission assessments documented scabs on both elbows and bruising on the left buttock without measurements, and after a hospital stay for spinal surgery and readmission, an abrasion on the left buttock, a scab on the left heel, and a surgical incision on the back of the neck were noted, with incomplete measurements and descriptions. The DON verified that, aside from the admission assessments, there were no comprehensive assessments or documentation of healing for any of the resident’s skin impairments, even though the resident was followed by a wound clinic. Corporate nursing staff confirmed that facility policy required a licensed nurse to complete a skin observation tool at least every seven days for any wound or skin impairment, and acknowledged that the resident’s non-pressure skin impairments were not assessed weekly by the facility or the wound clinic.
Failure to Perform Required Weekly Skin Assessments for Resident With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to complete routine and comprehensive skin assessments for a resident with existing pressure ulcers and other skin impairments, as required by facility policy. On admission, the resident’s nursing assessment documented pressure ulcers on the bottom of the left foot and right outer heel, but did not include measurements or detailed descriptions of these ulcers. The resident was later discharged for planned spinal surgery and then readmitted, at which time the admission assessment noted an abrasion on the left buttock with measurements, a scab on the left heel with measurements, and a surgical incision on the back of the neck without measurements or description. There was no assessment of any pressure ulcer at readmission, and no subsequent skin assessments or documentation of wound healing were found in the medical record, despite a posted notice indicating the resident had a wound clinic appointment. Wound clinic notes obtained by the facility showed that the resident had a stage 3 pressure ulcer on the sacrum and a stage 3 pressure ulcer on the right plantar foot. The DON confirmed that, aside from the limited admission assessments, the facility had no comprehensive assessments or documentation of healing for any of the resident’s skin impairments. Corporate nursing staff stated that the facility had a single wounds/skin impairments policy, which required a licensed nurse to complete a skin observation tool at least every seven days detailing any wounds or skin impairments. Corporate Nurse #503 verified that the resident’s non-pressure-related skin impairment was not assessed weekly by either the facility or the wound clinic, demonstrating noncompliance with the facility’s own wound/skin assessment policy.
Delayed UTI Management and Incontinence Care Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and treatment for a resident with signs and symptoms of a urinary tract infection (UTI). One resident with cognitive impairment, severe physical impairment, and total dependence for ADLs was care planned for bowel and bladder incontinence with interventions to keep the skin clean and dry. Progress notes documented that the resident exhibited behavioral changes, including agitation, hallucinations, altered mental status, and complaints of burning pain with urination. A physician order was obtained to perform a urine dip and notify the physician, but the urine dip ordered on 12/16/25 was not obtained as scheduled. Subsequent documentation showed that the urine dip was not actually completed until several days later, when the resident was straight catheterized and a urine dip revealed positive nitrites, leukocytes, and blood, consistent with a UTI. An antibiotic was then started, and a UA with culture and sensitivity was ordered. The unit manager RN later confirmed that the resident had signs and symptoms of a UTI on 12/15/25 and that the urine sample was not collected and sent out until six days later, stating that the specimen should have been collected and sent immediately. The resident’s daughter reported that in December the resident had UTI symptoms and was not started on an antibiotic for six days, and that staff had told her the resident was at baseline and did not have a UTI. The deficiency also includes failure to provide timely incontinence care for another resident with intact cognition, a colostomy, spinal stenosis, weakness, and inability to control bowel or bladder. This resident’s care plan called for staff assistance with toileting, frequent checking and changing of briefs, and provision of toileting hygiene with brief changes. Surveyors observed the resident’s call light on and, upon interview, the resident stated he had turned it on because he was wet and needed changing and that staff did not always respond timely. The call light remained on for 41 minutes before a CNA entered to provide incontinence care, at which time the resident’s brief was full of urine. The CNA and the DON both acknowledged that 41 minutes was too long for a call light to remain unanswered for a resident needing staff assistance.
Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors in 25 medication administration opportunities, resulting in an 8% error rate. The affected resident had type 2 diabetes mellitus and was moderately cognitively impaired, with physician orders for multiple insulin regimens, including insulin lispro per sliding scale, a fixed daily dose of insulin lispro with instructions to adjust based on meal intake, and a daily morning dose of Lantus. The resident’s care plan identified risk for complications and blood glucose fluctuations related to diabetes and insulin use, with an intervention to administer insulin as ordered. During observation, an LPN checked the resident’s blood sugar, which was 332, and confirmed the resident had eaten 100% of breakfast. The LPN then prepared the resident’s insulin by dialing 34 units on the lispro pen and 50 units on the Lantus pen without priming either pen before setting the doses. The LPN proceeded to administer both insulin injections without performing the priming step. In a subsequent interview, the LPN confirmed that she did not prime the insulin pens prior to dialing in and administering the doses. Manufacturer instructions for the KwikPen, reviewed by surveyors, specified that the pen must be primed before each injection to remove air and ensure proper function, indicating that the observed practice did not follow the manufacturer’s directions for use.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The deficiency involves the failure to ensure a resident was free from significant medication errors when insulin pens were not primed according to manufacturer instructions prior to administration. The resident had type 2 diabetes mellitus, was moderately cognitively impaired, and had physician orders for multiple insulin regimens, including insulin lispro via sliding scale, a scheduled daily dose of insulin lispro, and a morning dose of Lantus. The resident’s care plan identified a risk for complications and blood glucose fluctuations related to diabetes and insulin use, with an intervention to administer insulin as ordered. On the day of observation, an LPN checked the resident’s blood sugar, which was 332, and confirmed the resident had eaten 100% of breakfast. The LPN then removed the resident’s lispro and Lantus insulin pens from the medication cart, dialed the lispro pen to 34 units and the Lantus pen to 50 units, and did not prime either pen before dialing in the doses. The LPN proceeded to administer both insulin injections without priming. In a subsequent interview, the LPN confirmed that she had not primed the insulin pens prior to administration. Manufacturer instructions for the KwikPen specified that the pen must be primed before each injection to remove air and ensure proper function, outlining specific steps to select 2 units, hold the pen needle-up, tap to collect air bubbles, and push the dose knob until insulin is seen at the needle tip before dialing the prescribed dose.
Resident Dining Choice and Meal Timing Not Honored
Penalty
Summary
The facility failed to permit a resident to choose dining location and meal time. Observations showed breakfast was served in the dining room for residents who needed assistance or supervision with eating between 9:30 A.M. and 9:48 A.M., and Resident #31 was observed later in her room with her breakfast tray on an overbed table. Resident #31 had diagnoses of Alzheimer's disease, dementia, glaucoma, and macular degeneration. Her quarterly MDS indicated she was usually able to make herself understood, was able to understand, and was severely cognitively impaired, with moderately impaired vision. Resident #31's niece stated the resident used to finish eating by 9:00 A.M. but was now receiving breakfast much later and said it was ridiculous that residents did not get to eat breakfast until 10:00 A.M. Resident #31 stated she would like to receive breakfast no later than 9:00 A.M. and would eat in her room if needed to get breakfast earlier. The SLP stated Resident #31 was on the speech therapy caseload, coughed with meals and with straws, required supervision for eating due to trouble swallowing, poor vision, and the need for verbal cues, and ate better with a tray table because the dining table was too high. The SLP also stated Resident #31 could eat in her room per her wishes if there was adequate staff to provide one-on-one supervision, but there was insufficient staff at the time to do so.
Failure to Disburse Resident Funds After Death
Penalty
Summary
The facility failed to ensure that all resident funds were disbursed within 30 days of death. Resident #100 was admitted on [DATE] and expired in the facility on [DATE]. Review of the resident funds account showed that as of [DATE], $4,403.88 remained in Resident #100’s personal fund account and had not been disbursed after the resident’s death. During interview on [DATE] at 11:03 A.M., the Business Office Manager and the Administrator verified that there had not been any BOM working at the facility since [DATE], and the Regional BOM confirmed that resident funds are to be returned within 30 days upon death and that this had not occurred for Resident #100.
Failure to Protect Resident Privacy
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when the facility posted resident appointment information on a wall in the skilled hall. On 03/09/26 at 6:40 A.M., a posting was observed that identified Resident #61 as having an ophthalmologist appointment at an eye surgery center with a pickup time, and identified Resident #32 as having a wound center appointment with a pickup time. The posting disclosed information that would inform others that Resident #32 had a wound and that Resident #61 had vision issues. Resident #61's record showed diagnoses including traumatic subdural hemorrhage and zoster ocular disease, and documentation confirmed an eye surgeon appointment. Resident #32's record showed diagnoses including peripheral vascular disease, polyneuropathy, iron deficiency anemia, and generalized muscle weakness, and an admission nursing assessment documented an abrasion on the left buttock, a scab to the left heel, and a surgical incision to the back neck. The facility's admission packet included Resident Rights and Facility Responsibilities stating residents had the right to secure and confidential personal and medical records.
Unjustified antipsychotic use in resident with dementia
Penalty
Summary
The facility failed to ensure a resident had indications for use of an antipsychotic medication. Resident #13 had diagnoses including psychotic disorder with delusions and vascular dementia with anxiety, and the medication orders included Seroquel 12.5 mg every night at bedtime. A nurse practitioner note dated 05/14/26 stated the resident’s daughter reported Seroquel had been started for insomnia, and due to concerns for QT prolongation the daughter was informed to avoid Seroquel upon discharge. A discharge planning assessment indicated the resident was expected to stay in the facility long term. Drug information reviewed from Medscape stated Seroquel was not approved for dementia-related psychosis and that elderly residents with dementia-related psychosis treated with antipsychotic drugs were at increased risk of death. The DON stated the resident had been in the residential care facility before admission and had been admitted with the Seroquel order, but could not provide information showing why the medication use in a resident with dementia outweighed the associated risk, and verified the resident was not a short term stay.
Missing transfer, bed-hold, and discharge documentation
Penalty
Summary
The facility failed to ensure required transfer and bed-hold notifications were provided when two residents were sent to the hospital. One resident with diagnoses including muscle wasting, difficulty walking, cellulitis, chronic venous hypertension with bilateral lower extremity ulcers, and CHF became increasingly agitated, paranoid, and delusional, refused medications, food, liquids, and care, and was combative with staff. The NP documented that the family was spoken with and that the resident would benefit from transfer to a geriatric psychiatric facility, but no transfer or bed-hold notices could be located, and the corporate nurse verified the written notices were unavailable even though the son was present at the time of transfer. A second resident with diagnoses including acute kidney failure, asthma, cognitive communication deficit, dementia, and CHF was sent from an oncology appointment to the ER for a blood clot and was to be admitted to the hospital. The record showed no written bed-hold notification, and the Administrator verified the resident was not provided one. The facility also failed to complete a discharge summary for another resident with diagnoses including a benign heart neoplasm, HTN, CHF, depression, generalized muscle weakness, dementia, and IBS. That resident was cognitively intact and had discharge planning underway, and medications and discharge instructions were provided to the daughter at discharge, but the LPN verified that a discharge summary/recapitulation of stay was not completed.
Failure to Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to ensure timely completion and submission of MDS assessments for one resident reviewed. Resident #18 was admitted on 09/23/25 with diagnoses including osteoarthritis, osteoporosis, COPD, depression, and generalized anxiety disorder, and was discharged on 10/15/25. The resident’s admission MDS with an ARD of 09/30/25 was completed on 10/08/25, and the discharge MDS with an ARD of 10/15/25 was not completed. During interview on 03/18/26 at 4:45 P.M., RN #434 verified that the discharge MDS was not completed and was not submitted as required.
Inaccurate MDS Coding for Insulin Use and Wounds
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents. For one resident with diagnoses including stage two chronic kidney disease, CHF, Alzheimer's disease, depression, anxiety disorder, and restless leg syndrome, a quarterly MDS with an assessment reference date of 11/21/25 indicated insulin injections were received seven of the last seven days. However, review of the resident's November 2025 physician orders and MAR from 11/14/25 to 11/21/25 showed no evidence of insulin administration. An RN later verified the MDS was inaccurate regarding insulin administration. For another resident with diagnoses including pain, COPD, cirrhosis of the liver, and peripheral vascular disease, hospital records dated 02/03/26 showed left plantar and right medial foot ulcers. The admission nursing assessment documented an abrasion on the left buttock, a scab on the left heel, and a surgical incision to the back of the neck, but the admission MDS indicated no unhealed pressure ulcers, no venous or arterial ulcers, and no diabetic foot ulcer or other open lesions on the foot. A wound clinic note dated 03/02/26 later documented a stage three pressure injury acquired on 02/05/26 and a chronic non-pressure left foot ulcer acquired on 02/10/26. The RN stated she had no wound clinic documentation when she coded the MDS and only had the admission nursing assessment information available.
Incomplete Care Plans for Skin Conditions
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for two residents reviewed for care planning. Resident #32 had diagnoses including pain, muscle wasting, COPD, cirrhosis of the liver, peripheral vascular disease, iron deficiency anemia, and generalized muscle weakness. A nursing admission assessment noted an abrasion on the left buttock, a scab on the left heel, and a surgical incision on the back of the neck. Orders were entered for wound care to the buttock abrasion and surgical wound, and a plan of care identified the resident as at risk for pressure ulcer related to advanced age, chronic health conditions, and immobility. A later plan of care addressed skin impairment and referenced treatments as ordered, but no further skin assessments were located in the medical record. When wound clinic notes were obtained, they showed a stage three sacral pressure ulcer acquired on 02/05/26, a partial thickness chronic non-pressure ulcer acquired on 02/10/26, and a stage three pressure ulcer to the right plantar foot acquired on 02/02/26. The RN confirmed she had never created a care plan for the actual pressure ulcers or the non-pressure ulcer because she did not have access to the wound clinic notes and had not been informed of the skin impairment. Resident #56 was admitted with diagnoses including chronic diastolic CHF and CKD stage three. A CNP assessment documented nummular eczema rash on the chest, back, arms, and abdomen, with an order to cleanse with normal saline and apply clobetasol 0.05% twice daily. A physician order later directed clobetasol ointment 0.05% to the chest, abdomen, and arms every day and evening shift for rash. The quarterly MDS indicated the resident was cognitively intact and had applications of ointments/medications other than to feet. However, the care plan did not include a specific plan for rash or eczema. During observation, the resident had multiple red, circular areas on the abdomen, chest, and arms, and the RDCS confirmed the resident did not have a care plan for the nummular eczema condition.
Residents Not Offered Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that three residents were offered the opportunity to participate in their care plan meetings and development of their plans of care. Resident #57 was admitted on 06/10/25 with diagnoses including muscle wasting and atrophy and neurocognitive disorder with Lewy bodies. The quarterly MDS indicated the resident was cognitively intact, had no upper or lower extremity impairment, used a walker for mobility, and required assistance with eating and walking. The record showed no care plan for activities and no evidence that Resident #57 was ever offered or participated in a care conference. The resident stated he never had a care plan meeting and never participated in developing his plan of care. The Director of Recreation confirmed he had not been participating in activities, was not receiving one-on-one activities, and did not have an activities care plan. The Administrator found only one typed, unsigned note referencing a care plan meeting and stated the resident should have had meetings on admission and quarterly. Resident #64 had diagnoses including multiple sclerosis, paraplegia, depression, heart disease, and constipation, and the quarterly MDS indicated she was cognitively intact. She stated she was not invited to participate in care plan meetings. RN #434 could not locate documentation of care conferences and stated the staff member who had sent invitations was no longer employed; she also did not know whether Resident #64 had ever been invited. Resident #84 was admitted on 04/25/24 with diagnoses including dysphagia, kidney disease, and chronic pain. Her annual MDS indicated it was very important that she and her family be involved in discussions about her care, and the quarterly MDS showed intact cognition. The record showed no care plan for activities and no evidence she was ever offered or participated in a care conference, with the last care conference note dated 03/05/25. Resident #84 stated she had not been asked to attend a care conference and would like to attend and have input on her plan of care. The Administrator verified that Resident #84 should have had care plan meetings on admission and quarterly.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to implement a restorative nursing program that therapy had recommended for a resident after discharge from PT to help maintain functional ability. The resident had diagnoses including dementia, muscle weakness, and difficulty walking, and MDS assessments showed severe cognitive impairment with increasing dependence for ADLs, including eating, oral hygiene, toileting hygiene, dressing, bathing, transfers, and mobility. The care plan identified the resident’s need for assistance with ADLs related to advanced age, chronic health conditions, cognitive impairment, a history of deficits from a cardiovascular accident, and weakness. Record review showed PT treated the resident for a decline in transfer status and, at discharge, completed a restorative services transfer form recommending a program six times per week using a 1.5-pound cuff weight, ball, t-band, and a front wheeled walker, with assistance to walk 65 feet and cues for directional changes. The form was signed as transferred to restorative care, but the restorative program/services were not placed in the resident’s plan of care for staff to implement. Observation found the resident sitting in a chair, awake, and looking directly at the surveyor but not responding verbally. Interviews confirmed the restorative program was not being provided. The Director of Rehab stated the referral had been left for the restorative nurse, but the position had changed and the current RN was not responsible for restorative nursing. The RN stated there were no restorative nursing programs being provided for any residents. The MDS coordinator noted the resident’s January assessment showed some decline in function compared with the prior assessment but could not provide evidence the resident had been discussed in stand-up meeting. The RDCS stated the facility no longer had a restorative nurse or restorative CNA, and CNAs stated they had never been trained or provided restorative exercises, had not used bands or balls with the resident, and did not walk the resident the recommended distance.
Incomplete Fall Prevention Program and Poor Staff Access to Resident Information
Penalty
Summary
The facility failed to ensure a comprehensive, resident-centered fall prevention program was implemented for a resident with a history of falls and serious fall risk factors. The resident was admitted with diagnoses including muscle wasting and atrophy of multiple sites, muscle weakness, neurocognitive disorder with Lewy bodies, and difficulty walking. The record showed falls shortly after admission, including one that caused a skin tear, but the fall risk assessment dated 12/08/25 did not include a score or risk level. The quarterly MDS also documented impaired vision and use of a walker, while the resident reported poor eyesight and not wearing glasses. The care plan identified the resident as at risk for falls and included interventions such as keeping the bed in the lowest position, placing common items within reach, and later providing a reacher. However, the post-fall investigation for the 02/13/26 fall documented that the resident was wandering in his room, was not wearing proper footwear, was using his walker, and the environment was not free of clutter. The fall was unwitnessed, and no progress note documented the incident. The resident later described falling while using his walker near his room entrance, and a CNA stated he had been reaching for his remote, which was on a stand next to his recliner. Staff interviews showed inconsistent access to resident fall-prevention information. An RN MDS Coordinator confirmed the fall risk assessment had no score and did not know whether the resident was high or low risk. A CNA stated she looked only at the task bar and did not see the reacher intervention, while another CNA said she did not know how to access the care plan and relied on the Kardex. Observation showed the resident’s reacher was on the floor in the corner of the room under a chair, and the resident could not reach it. The RDCS confirmed the CNA documentation system did not show the reacher intervention and that the post-fall findings about improper footwear and clutter were not addressed in the care plan as fall prevention interventions.
Excessive Acetaminophen Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when Resident #88 received acetaminophen in an excessive dose. Resident #88 had diagnoses of cellulitis and chronic venous hypertension with ulcer of both lower extremities and was moderately cognitively impaired on the admission MDS. The December 2025 MAR showed two acetaminophen orders entered on 12/09/25: one for 500 mg, two tablets before meals at 7:30 A.M., 11:00 A.M., and 4:00 P.M., and another for 500 mg, two tablets three times daily at 9:00 A.M., 2:00 P.M., and 9:00 P.M. MAR review showed that a total of 6,000 mg was administered on 12/16/25, 5,000 mg on 12/17/25, 6,000 mg on 12/18/25, 4,000 mg on 12/19/25, and 6,000 mg on 12/20/25. On 12/21/25, staff documented that one of the orders was duplicative. After the 7:30 A.M. dose was given, the before-meals order was discontinued. The physician stated the upper limit he would order was 3,000 mg/day and could not find where the medication was ordered that way, while corporate nursing review found one nurse denied giving acetaminophen from both orders but otherwise the MAR documented administration of each ordered dose. The Tylenol label warned that severe liver damage might occur if more than 4,000 mg of acetaminophen was taken in 24 hours.
Failure to Offer Dental Services
Penalty
Summary
Provide routine and 24-hour emergency dental care for each resident was not met when the facility failed to ensure one resident was offered dental services. Resident #1 was admitted on 01/14/25 and had diagnoses including spinal stenosis, thoracolumbar region, and muscle weakness. The annual MDS assessment showed the resident was cognitively impaired and dependent on staff for oral hygiene, and there was no dental care plan in the record. Review of the medical record found no evidence that the resident was offered or seen by a dentist since admission. During interviews, the resident stated concern that she had not seen a dentist since admission and wanted to make sure she did not have any new cavities; she also reported asking staff about seeing the dentist but could not recall who she asked. Observation showed the resident had all natural teeth with dark discoloration on the upper and lower teeth. The Administrator confirmed the resident had not been seen by a dentist since admission and that there was no evidence she was ever offered or received dental services.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor resident food preferences for one resident reviewed for meal preferences. Resident #84 was admitted with diagnoses including dysphagia, kidney disease, and chronic pain, and the MDS indicated intact cognition and a mechanically altered diet. The resident stated that staff used to ask what residents wanted to eat for the next meal, but that practice stopped, and she reported that she does not like green beans yet continues to receive them. She also stated that the kitchen has an anytime menu, but no one comes around to ask her about it, and she reported being served green beans the day before the surveyor interview. During the survey, staff stated residents get whatever was on the menu and there were no alternatives for vegetables. Observation of the resident’s lunch tray showed mixed vegetables with green beans, baked beans, ground kielbasa sausage, a roll, and a brownie. The lunch meal ticket did not list green beans as a dislike. The Dietary Manager verified the resident should have received sliced carrots instead of the mixed vegetables because the mixed vegetables contained green beans, and stated the cook did not realize she was to receive carrots. The Dietary Manager also stated all residents get what was on the menu even if they do not like it, and if they want something different, they can tell staff when the meal is delivered. The facility policy stated that dining services or designee will obtain food and beverage preferences, dislikes, and allergies/intolerances before a permanent meal ID card/ticket is written, and that meal ID cards/tickets will be used during meal service to ensure food preferences are honored.
Inaccurate Documentation of Ostomy Care
Penalty
Summary
The facility failed to ensure medical records were accurate for one resident with a colostomy and inability to control bowel or bladder. The resident’s record showed an order to change the ostomy bag every three days, cleanse the surrounding skin with normal saline, keep the area dry, and apply nystatin powder before placing a new ostomy bag/wafer and as needed. The resident stated that the ostomy bag was supposed to be changed every three days but was only being changed once a week. Review of the TAR for March 2026 showed ostomy care was signed off as completed on several dates by an LPN, and one date was marked refused by the same LPN. Another LPN also signed off that the treatment had been completed. During interviews, one LPN stated the resident only wanted the unit manager RN to change the ostomy bag, and another LPN verified she was not the nurse who completed the treatments but had signed off that she did. The DON stated nurses were to only mark a treatment completed if they actually completed it, and if a resident refused or a PRN treatment was completed, it should be signed off by the nurse who completed it. The RN stated he changed the resident’s ostomy bag on two dates but did not document it, and also verified he did not complete the ostomy bag treatments that were signed off by others.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for all certified nursing assistants (CNAs). Review of four personnel files showed no annual evaluation for CNA #331, CNA #330, CNA #308, and CNA #317 for 2025. CNA #331 had a hire date of 02/27/20, CNA #330 had a hire date of 07/12/23, CNA #308 had a hire date of 06/13/14, and CNA #317 had a hire date of 07/19/23. During interview, the Human Resources Director verified that annual evaluations had not been completed for these CNAs in the last year and stated they should have been completed annually on each staff member's anniversary date. Two CNAs also stated they did not receive an annual evaluation in 2025. The facility policy titled Performance Appraisal stated employees are to receive a performance appraisal around 90 days and annually thereafter.
Nurse Staffing Information Not Posted
Penalty
Summary
The facility failed to ensure nursing staff information was posted in a prominent, readily accessible location for residents, visitors, and staff. On 03/09/26 at 5:45 A.M., observation showed that no nurse staffing information was posted in the facility. During interviews later that morning, an LPN stated staff assignments were available at the LTC hall nursing desk but she was unsure where the staffing information for the day was posted, and another LPN was also unsure where the information was posted and was unable to find it after searching. At 7:28 A.M., the DON stated the nurse staff posting was usually on a clipboard outside the Administrator's office, but verified it was not posted. The DON then spoke with the Unit Clerk, who stated she had removed the posting the evening before and provided a pristine sheet of paper from a notebook, stating it was what she had removed.
Facility Assessment Not Updated After Ownership Change
Penalty
Summary
The facility failed to update its Facility Assessment after a change in ownership so that it accurately reflected changes that had been incorporated or were in the process of being incorporated. The assessment, last updated on 07/15/25, listed five individuals as involved in completing the assessment, but four of those individuals were no longer employed by the facility. The medical director listed in the assessment still saw residents but no longer held the medical director position. The assessment also described staffing needs using an acuity-based formula and identified the same five individuals as responsible for ongoing review of policies and procedures. During interview, the Administrator stated ownership changed on 12/15/25 and verified the assessment had not been updated after new ownership began. The Administrator confirmed several changes were not reflected, including the use of agency staff, the addition of a skin nurse position, plans for an afternoon shift supervisor, a staff development coordinator, and an extra nurse on the skilled unit. The facility had also changed dietary staffing needs because dietary services were now contracted, and the on-boarding process had changed. In addition, the transport van and pickup truck listed in the assessment were not operational, the pharmacy provider had changed, dental provider changes were not reflected, therapy was no longer under contract as listed, and the health information technology company had changed. The Administrator verified the assessment needed to be updated to be accurate.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident #68, who had severe cognitive impairment and was dependent on staff for eating assistance. On the observed date, Resident #68 was left unattended with her lunch tray for approximately 13 minutes before a State tested Nurse Aide (STNA) began assisting her. The STNA stood beside Resident #68 while feeding her, which was against the facility's policy that required staff to sit next to residents while providing feeding assistance. The Director of Nursing confirmed that the expectation was for staff to sit next to residents during feeding to ensure safety, comfort, and dignity. The facility's policy on Assistance with Meals, dated March 2022, also emphasized that residents who could not feed themselves should be fed with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents while assisting them with meals.
Failure to Provide SNF ABN Forms
Penalty
Summary
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) informing them of their financial liability for continuation of skilled services not covered by Medicare. Resident #72, admitted with multiple diagnoses including non-traumatic chronic subdural hemorrhage and breast cancer, was not given an SNF ABN form when issued a Notice of Medicare Non-Coverage (NOMNC) form, despite remaining in the facility until her discharge. Similarly, Resident #73, admitted with diagnoses such as chronic myelomonocytic leukemia and atrial fibrillation, was also not provided an SNF ABN form when issued his NOMNC form. The Administrator confirmed that both residents should have been provided with the SNF ABN forms but were not.
Failure to Ensure Specific Duration for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure psychotropic medications ordered on an as-needed (PRN) basis had a specific duration for use, affecting two residents. Resident #26 had an order for trazodone 12.5 mg at bedtime as needed, with no time limit or documentation for re-evaluation. The medication was administered 13 times over March and April 2024. The Director of Nursing (DON) confirmed the lack of a specific duration for the trazodone order during an interview on April 3, 2024. Similarly, Resident #335 had an order for Ativan 0.5 mg four times a day as needed, also without a stop date. The resident received three doses of Ativan in March and April 2024. The DON verified that the Ativan order did not have a time limit but should have been limited to 14 days unless extended by the physician. The facility's policy stated that PRN psychotropic medications should be limited to 14 days unless the prescriber documented a rationale for extending the use.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to monitor prophylactic antibiotic use, affecting two residents. Resident #36 had a physician's order for minocycline hydrochloride 50 mg twice daily for skin, despite no active skin infections being documented in the medical record. The Director of Nursing (DON), who also served as the Infection Preventionist, confirmed that the facility did not monitor or track antibiotics for prophylactic use, following the instructions of her predecessor. Resident #23 had a physician's order for nitrofurantoin macrocrystal 50 mg every other day for urinary tract infection prophylaxis, which was administered as ordered. Similar to Resident #36, the DON confirmed that the facility did not monitor or track the use of prophylactic antibiotics. The facility's policy on antibiotic stewardship, dated August 2023, required all resident antibiotic regimens to be documented on an approved antibiotic surveillance tracking form, which was not followed.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to ensure the ombudsman was notified, in writing, of the residents' transfer or discharge. This deficiency affected three residents reviewed for hospitalization and discharge. Resident #79, admitted with diagnoses including malignant neoplasm of the bladder and secondary malignant neoplasm of bone, was discharged without the ombudsman being notified. Resident #80, admitted with diagnoses including aftercare following joint replacement surgery and atherosclerotic heart disease, was also discharged without notification to the ombudsman. Additionally, Resident #2, admitted with diagnoses including atrial fibrillation and end-stage heart failure, was transferred to the hospital due to vaginal bleeding without the ombudsman being informed. The Administrator confirmed that the facility did not provide the required written notices to the ombudsman for these transfers and discharges since January 2024.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 711 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pavilion At Edgefield For Nursing And Rehabili | 0.2 mi | ★★★★★ | 38 | 0 |
| Canton Christian Home | 0.8 mi | ★★★★★ | 14 | 0 |
| The Pines Healthcare Center | 2 mi | ★★★★★ | 4 | 0 |
| Hall Of Fame Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 26 | 0 |
| Mckinley Nursing | 2.6 mi | ★★★★★ | 45 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bethany Nursing Home, Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.