Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cardinal Woods Skilled Nursing & Rehab Ctr during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment was struck by another resident with a known history of aggression on the secured unit. Staff and witness statements described the aggressive resident hitting, pushing, or punching the victim, who fell to the floor and later developed rib fx and a pneumothorax requiring hospitalization, a chest tube, and transfer to another facility. The incident also involved an aide being assaulted during the event.
Incomplete Investigation of Resident-to-Resident Physical Abuse: The facility did not complete a thorough abuse investigation after an altercation on a secured dementia unit in which one resident struck another and a nurse aide was also assaulted during the intervention. Although staff interviews and some resident statements were obtained, an available resident witness with moderate cognitive impairment was not interviewed despite later describing that he saw one resident hit another and the victim fall to the floor. The Administrator stated only residents with a BIMS of 13 or higher were interviewed.
A resident with severe cognitive impairment, heart failure, dysphagia, morbid obesity, and psychiatric diagnoses experienced major unplanned weight loss while the facility failed to maintain consistent weight monitoring, reassess her nutrition status, or implement effective interventions. Meal intakes were poor, trays were left untouched while she slept, and staff reported she often refused weights because she feared the mechanical lift. The RD documented significant weight loss and low intake, but no further assessment or provider notification was documented, and the resident ultimately lost 27.85% of her body weight over about three months.
Food storage and kitchen sanitation deficiencies were identified when the walk-in refrigerator was observed at 49 degrees F on two occasions, above the facility’s stated range, and milk served on a lunch meal test tray was 48 degrees F after being sent to the units before the meal trays arrived. Surveyors also observed the ice machine with cracked plastic, a frayed door seal, and dust on the filter and vents, while the last documented cleaning was months earlier.
Fall interventions were not implemented for a resident with severe cognitive impairment, repeated falls, dementia, and an unsteady gait. The care plan and MD order required the bed to remain in the lowest position and a floor mat to be placed beside the bed, but after an unwitnessed fall while the resident was trying to get out of bed, the post-fall review and staff statements showed the bed had been left high and the mat was not at bedside. An LPN and CNAs confirmed the bed and mat were not set as ordered when the fall occurred.
A resident with severe cognitive impairment and multiple chronic conditions, including CHF, was not given a comprehensive, updated care plan to address cardiovascular needs, Lasix therapy, or repeated weight refusals. The record showed long gaps in weights, repeated refusals tied to fear of the mechanical lift, and staff confirmed the care plan did not include goals or interventions for these issues.
Two residents were not protected from abuse by peers, resulting in one resident being physically assaulted and another subjected to unwanted sexual advances. Both incidents involved residents with cognitive or behavioral issues, and staff were aware of prior risk factors but did not prevent the abuse.
A resident with a history of aggressive behaviors physically assaulted another resident with quadriplegia, causing multiple contusions and requiring emergency medical evaluation. The aggressive resident's care plan lacked specific interventions for his known behavioral issues, and staff reported ongoing concerns about safety prior to the incident.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in pain and abnormal foot rotation. Staff delayed notifying the physician for several hours and continued to transfer the resident despite worsening pain and functional decline. The DON instructed staff not to send the resident to the hospital or notify the physician, even as the resident's condition deteriorated. The resident was eventually sent to the ER, where a displaced femoral neck fracture was diagnosed, requiring surgery. Facility policy for prompt physician notification and follow-up after falls was not followed, resulting in actual harm.
A resident with chronic pain and multiple comorbidities did not receive prescribed Oxycodone as documented by an LPN, who instead provided Tylenol and Baclofen. The resident and a guest reported the missing doses, and the narcotic count sheet and medication card were found to be missing. Investigation revealed that three Oxycodone tablets were unaccounted for and had been misappropriated by the LPN, resulting in a failure to safeguard the resident's medication.
A resident with multiple behavioral and mental health diagnoses was admitted without a comprehensive baseline care plan addressing their specific needs. The care plan lacked individualized interventions for mental health and behavioral concerns, despite documented incidents of aggression and facility policy requiring such guidance. LPNs confirmed the care plan was incomplete and did not direct staff on managing the resident's complex behaviors.
A resident with a complex medical history did not receive their morning medications in a timely manner, as they were administered late by an LPN. The facility's policy required medications to be given within one hour of their prescribed time, but the resident received them at 11:45 A.M., well past the scheduled time.
The facility failed to maintain palatable food temperatures, affecting 81 residents. Initially, lunch tray temperatures met requirements, but a test tray later showed significantly lower temperatures by the time it was served. The Dietary Manager confirmed the deficiency.
The facility failed to provide accurate and timely Notice of Medicare Non-Coverage (NOMNC) letters, affecting three residents. The NOMNC letters contained incorrect last covered dates, lacked appeal agency contact information, and omitted resident names or identifying numbers. Additionally, residents did not receive the required 48-hour notice to appeal their discharge dates.
A resident experienced a significant weight loss, dropping from 242 to 211 pounds over six months. Despite a recommendation from a dietitian for weekly weight checks, the facility failed to conduct these checks. The resident, who was cognitively intact and had a history of mental health issues, was on a psychoactive drug regimen. The facility's policy on weight assessment and intervention was not followed.
A resident, requiring substantial assistance with showers, was left unattended, leading to a fall and right hip fracture. Despite a care plan intervention to never leave the resident alone, staff failed to supervise, resulting in the incident. The resident, with a history of falls and using a power wheelchair, was unsupervised for about thirty minutes before the fall occurred.
A resident with a known cheese allergy was served au gratin potatoes containing cheddar cheese. Despite the allergy being documented in the care plan and electronic medical record, the meal ticket did not indicate the allergy, leading to the resident being served the allergen. The facility's policy on food allergies was not followed.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #96 had a history of dementia, severe cognitive impairment, hearing impairment, hallucinations and delusions, and required assistance with bathing but was otherwise documented as independent with transfers and walking once standing. His care plan addressed his communication deficits with interventions such as facing him when speaking and using a dry erase board or hand gestures. On 06/23/26, staff witnessed Resident #87, who had diagnoses including dementia with behavioral disturbance, schizoaffective disorder, Parkinsonism, vascular dementia, depression, anxiety, and schizophrenia, become aggressive on the secured unit. Records showed Resident #87 had a prior history of hitting other residents and physical aggression, and his care plan identified a potential for physically aggressive behaviors. During the incident, staff observed Resident #87 swinging at Resident #96, and multiple witness statements described Resident #87 hitting, pushing, or punching Resident #96, who fell backward or to the floor after being struck. The facility’s incident report also stated Resident #87 told Resident #96 not to look at him, then hit him, and a nurse aide was also assaulted when intervening. Resident #96 was initially documented as having no apparent injury, but later developed pain, decreased range of motion, weakness, and non-verbal pain behaviors. Imaging showed acute right fifth through ninth rib fractures with displacement and a right pneumothorax. He was hospitalized with a large right-sided pneumothorax, lung collapse, and altered mental status, required a chest tube under sedation, and remained hospitalized until 07/01/26 before discharge to another facility at the family’s request. Interviews with staff, the DON, the Administrator, and the resident’s family confirmed that Resident #96 was struck by Resident #87 and sustained the injuries described.
Incomplete Investigation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an allegation of resident-to-resident physical abuse involving Resident #96 and Resident #87. The incident was reported after staff stated residents on the locked dementia unit were getting into an altercation, during which Resident #87 told Resident #96 not to look at him, then hit Resident #96. A nurse aide intervened and was hit and had her hair pulled, and Resident #86 pulled Resident #87 off the aide. The facility separated the residents, placed them on 15-minute checks, completed head-to-toe assessments with no significant findings, notified responsible parties, and obtained staff and resident interviews. The allegation was later unsubstantiated by the facility. The investigation was incomplete because the facility did not interview all available resident witnesses. The facility self-reported incident investigation contained written statements from Resident #44 and Resident #6, but the Administrator later verified that Resident #37 was also in the dining room when the incident occurred and was able to be interviewed. Resident #37 had a BIMS score of 11, indicating moderate cognitive impairment, and stated he saw Resident #87 strike Resident #96 with a fist and saw Resident #96 fall to the floor. The Administrator stated he only interviewed residents with a BIMS of 13 or higher and that other residents only had skin checks completed. Facility policy required all allegations of abuse to be thoroughly investigated and for witnesses to be interviewed and documented completely and thoroughly.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive, individualized, and effective nutrition program for a resident with multiple medical conditions, including major depressive disorder, bipolar disorder, schizophrenia, heart failure, dysphagia, morbid obesity, edema, and a history of weight and lab refusals. The resident had severe cognitive impairment, required staff assistance with eating, and was bedbound. Her care plan identified risk for altered nutrition and hydration and included monitoring meal intake, obtaining weights, and reporting refusals to eat, but no new interventions were added when her intake declined and her weight loss became significant. The resident’s weight history showed a prolonged gap in monitoring, with no documented weight for over a year before a weight was obtained in February 2026. On March 20, 2026, she weighed 223.0 pounds, reflecting a 22.6% loss from the prior recorded weight of 288.0 pounds in approximately one month. A dietitian note on April 2, 2026 documented that meal intake averaged less than 25%, estimated needs were not being met, and the resident had nausea and vomiting; the only documented intervention was Ensure Clear three times daily. The record contained no evidence of an in-person reassessment after the significant weight loss, no further documented interventions, and no continued monitoring until another weight was obtained on May 25, 2026. By May 25, 2026, the resident weighed 207.8 pounds, showing an additional 6.82% loss and a total loss of 27.85% in about three months. Meal intake documentation from May 8 through May 21 showed average intake of less than 50%, and two days of meal intake were not documented. Observations showed the resident asleep in bed with untouched meal trays, and staff stated they did not wake her for meals and left trays in the room if she might wake up. Staff also reported she frequently refused weights because she was afraid of the mechanical lift, yet the facility did not use an alternative method to monitor her weight. The physician and nurse practitioners were not notified of the additional weight loss, and therapy was not consulted for possible interventions related to transfers or eating assistance.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure foods were stored and served at appropriate temperatures and failed to maintain kitchen equipment in a clean and sanitary manner. During observation, the walk-in refrigerator temperature was 49 degrees F on 05/18/26 and again on 05/19/26, and the Food Service Manager verified both readings. Facility policy titled, Food Storage, stated refrigerator temperatures were to be between 37 degrees F and 40 degrees F. During a lunch meal test tray observation on 05/20/26, the hot foods were maintained at a safe temperature, but the milk temperature was 48 degrees F. The Food Service Manager stated the milk had been sent to the units around 11:30 A.M. on a beverage cart before the lunch trays arrived. In addition, the kitchen ice machine had cracked plastic, a frayed door seal, a dusty filter, and dust on the output vents. The Maintenance Supervisor stated maintenance was responsible for cleaning the top part of the ice machine every six months, and the Machine Activity Log showed the last documented ice machine cleaning was on 09/10/25.
Fall Interventions Not Implemented
Penalty
Summary
The facility failed to ensure fall interventions were implemented for a resident with severe cognitive impairment, repeated falls, and unspecified dementia. The resident’s care plan identified the resident as high risk for falls due to decreased awareness of own safety, unsteady gait, osteoarthritis, and dementia, and included keeping the bed in the lowest position and placing a floor mat beside the bed. A physician order also directed that a floor mat be placed to the side of the bed with placement verification every shift and as needed. After an unwitnessed fall while the resident was attempting to get out of bed, the post-fall evaluation and facility investigation documented that the bed had been left in the high position and no floor mat was in place at the bedside. Staff witness statements and interviews confirmed that the bed remained elevated and the mat was not positioned next to the bed at the time of the fall. An LPN stated it was believed the wound nurse and wound team left the room without notifying staff that the bed remained elevated and the floor mat was not positioned next to the bed.
Failure to Update Care Plan for CHF, Lasix Therapy, and Weight Refusals
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and updated for a resident with multiple diagnoses, including major depressive disorder, lymphedema, peripheral vascular disease, morbid obesity, heart failure, atrial fibrillation, hypertension, anxiety disorder, schizophrenia, bipolar disorder, psychosis, and hyperlipidemia. The resident’s MDS showed severe cognitive impairment, and a physician order required Hoyer lift transfers with two staff members. An order also required monthly weights on specific days each month, and the resident was prescribed Lasix 40 mg by mouth twice daily every other day for morbid obesity until it was discontinued in March 2026. Review of the record showed the resident was weighed on one date in January 2025 and then not again until February 2026. Nursing and dietary notes documented repeated refusals of weights, including multiple refusals in January, February, April, and May 2026. The current care plan, initiated in 2017, did not include a care area, goal, or interventions for CHF or for Lasix therapy under cardiovascular status, and it did not address the resident’s refusals of weights related to fear of the mechanical lift. Staff interviews confirmed the resident was terrified of the mechanical lift and often refused weekly weights, and the MDS coordinator and DON acknowledged the care plan had not been updated to address the resident’s CHF, Lasix use, or weight refusals.
Failure to Protect Residents from Peer Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by other residents, resulting in actual harm. In one incident, a resident with dementia and impaired cognition, who required supervision for mobility and had a history of hallucinations and wandering, was assaulted by his roommate. The assault involved inappropriate physical contact, choking, and digital penetration, resulting in physical injuries such as abrasions, scratches, a sore throat, and rectal tenderness. The resident was assessed by staff, transferred to the hospital for evaluation, and law enforcement was notified. Despite the evidence and the resident's account, the facility's self-reported incident documentation indicated the event was unsubstantiated due to insufficient evidence. In another incident, a resident with Alzheimer's disease and anxiety disorder, who was cognitively intact and independent in activities of daily living, was subjected to unwanted sexual advances by another resident known to have a history of attempting sexual activity with peers. The aggressor entered the resident's room, refused to leave when asked, and proceeded to pull down the resident's clothing and touch him inappropriately. Staff intervened and separated the residents, and both were placed on frequent checks. The facility was aware of the aggressor's prior behaviors and had previously attempted to manage them with medication changes and provision of a pleasure device. The facility's policy defined abuse and outlined procedures for assessment and reporting, but the incidents demonstrate a failure to prevent and protect residents from abuse by peers. Both incidents involved residents with cognitive impairments or behavioral histories, and in both cases, the facility did not prevent the abusive events despite prior knowledge of risk factors.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with quadriplegia and multiple comorbidities, including COPD, chronic pain syndrome, and anxiety disorder, was physically assaulted by another resident with a known history of verbal and physical aggression, dementia with behavioral disturbances, PTSD, and impulse disorder. The assault occurred when the aggressive resident approached the victim and, after a brief exchange, punched the resident in the face, head, and neck approximately 20 times. The victim sustained facial and scalp contusions, headache, and neck pain, requiring evaluation and treatment in the emergency room, including X-rays and a CAT scan, which showed no broken bones but confirmed contusions and the need for follow-up with a concussion specialist. Prior to the incident, the aggressive resident had documented behavioral issues, including previous episodes of verbal and physical aggression toward staff and other residents. The baseline care plan for this resident noted mental health and behavioral concerns but failed to specify the nature of these concerns or outline any interventions to address them. Progress notes and staff interviews confirmed that the resident's aggressive behaviors were ongoing and that staff and other residents felt unsafe around him. Despite these known risks, the care plan lacked adequate interventions to manage the resident's behaviors or to protect others in the facility. The facility's policy required measures to address the needs of residents and minimize the possibility of abuse, including addressing problematic resident behaviors. However, the lack of specific interventions and failure to implement effective behavioral management strategies for the aggressive resident resulted in a serious incident of resident-to-resident abuse. Staff accounts and documentation indicated that the aggressive resident's behaviors were not adequately managed, leading to actual harm to another resident.
Failure to Notify Physician and Delay in Care After Resident Fall Resulting in Harm
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the physician after an unwitnessed fall with injury involving a resident who was severely cognitively impaired. The resident was found to have pain and abnormal rotation of the left foot following the fall, but the physician was not notified until over four hours later. Despite clear signs of pain and functional decline, including increased difficulty with transfers and the resident vocalizing pain, staff continued to transfer the resident multiple times without obtaining further physician orders or additional assessment. Throughout the following day, the resident's pain intensified, and he became increasingly unable to bear weight, requiring assistance from three staff members for transfers. Staff administered acetaminophen for pain, but the resident continued to exhibit severe pain, especially during movement. Although a femur x-ray was ordered and returned negative, a hip x-ray was not promptly obtained, and the resident was not transferred to the hospital until the physician was finally updated and gave the order. Interviews revealed that staff were instructed by the DON not to send the resident to the hospital and to withhold physician notification, despite ongoing severe pain and functional decline. The resident was eventually sent to the emergency room, where he was diagnosed with an acute displaced femoral neck fracture requiring surgical intervention. The facility's failure to promptly notify the physician, delay in obtaining appropriate diagnostic imaging, and continued transfers without proper orders resulted in actual harm to the resident. Facility policy required prompt physician notification and follow-up for falls with injury, which was not followed in this case.
Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of their narcotic pain medication. The resident, who had diagnoses including rheumatoid arthritis, chronic pain syndrome, peripheral vascular disease, and gout, was cognitively intact and generally independent in activities of daily living. The resident was prescribed Oxycodone for severe pain, along with other pain medications, and was to receive these medications as needed according to physician orders. On specific dates, the resident reported not receiving their prescribed Oxycodone as requested, instead being given Tylenol and Baclofen by an LPN. The resident was aware of the appearance and effects of their medications and stated that the pain relief expected from Oxycodone was not achieved. Documentation on the Medication Administration Record indicated that Oxycodone was signed out as administered three times by the LPN, but the resident and a guest both stated that these doses were not actually given. Additionally, the narcotic count sheet and the empty medication card could not be located, and the pharmacy confirmed that the resident should have had enough medication remaining. Interviews with staff and review of witness statements revealed inconsistencies in the LPN's account of medication administration and the handling of the narcotic count sheet. The LPN reported the medication as depleted and removed the count sheet and card, which were subsequently missing. The facility's investigation, after initial mismanagement, determined that three tablets of Oxycodone were unaccounted for and had been misappropriated by the LPN, constituting a failure to protect the resident's property as required by facility policy.
Failure to Develop and Implement Person-Centered Baseline Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive baseline care plan for a newly admitted resident with complex behavioral and mental health needs. Upon admission, the resident had diagnoses including COPD, vascular dementia with behavioral disturbances and agitation, PTSD, anxiety, and impulse disorder, and was known to exhibit confusion, mood swings, aggression, and wandering. The baseline care plan completed two days after admission lacked specific information and interventions regarding the resident's mental health and behavioral concerns, despite these being checked as areas of need. No individualized instructions, triggers, or interventions were documented for the resident's PTSD, impulse disorder, or dementia-related behaviors. Subsequent progress notes documented incidents of verbal and physical aggression, including an episode where the resident became aggressive after being denied a smoke break, resulting in police and EMS involvement and temporary transfer to the hospital for psychiatric evaluation. Interviews with LPNs confirmed that the baseline care plan was incomplete and did not provide necessary guidance for staff regarding the resident's mental health and behavioral needs. Facility policy required that baseline care plans include person-centered instructions and interventions based on the resident's diagnoses and needs, which was not met in this case.
Medication Administration Delay for a Resident
Penalty
Summary
The facility failed to ensure that a resident received medications in a timely manner, as evidenced by a review of medical records, observations, interviews, and policy review. The resident, who was cognitively intact and not capable of self-administering oral medications, had a complex medical history including schizoaffective disorder, bipolar disorder, diabetes, and hypertension, among others. The medication administration record indicated that the resident's morning medications were scheduled to be given at specific times, with some to be administered at breakfast and others at 8:00 A.M. However, on a particular day, the resident reported receiving his morning medications at 11:45 A.M., which was confirmed by an LPN who acknowledged administering the medications late. The facility's policy on medication administration required that medications be given in a safe and timely manner, specifically within one hour of their prescribed time unless otherwise specified. The facility's listed medication times indicated that one-time-a-day medications should be administered between 4:00 A.M. and 10:00 A.M., with medications given with meals to be administered at 8:00 A.M. The late administration of medications to the resident was a deviation from these guidelines, representing a deficiency in the facility's compliance with its medication administration policy.
Deficiency in Maintaining Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that foods were served at a palatable temperature, potentially affecting 81 of the 83 residents. On the day of observation, the lunch tray line initially met temperature requirements with the baked ham at 202 degrees F, buttered noodles at 184 degrees F, and cabbage at 180 degrees F. However, a test tray assembled later showed significantly lower temperatures by the time it reached the unit and was served. The ham was at 126 degrees F, the noodles at 108 degrees F, and the cabbage at 111 degrees F, which were deemed too low for palatability. The Dietary Manager verified these temperatures, confirming the deficiency in maintaining appropriate food temperatures during service.
Failure to Provide Accurate and Timely NOMNC Letters
Penalty
Summary
The facility failed to provide the required 48-hour notice for the last covered day of therapy, failed to provide the correct last covered day, failed to provide appeal information, and did not place the resident name or identifying number on the Notice of Medicare Non-Coverage (NOMNC) letters. This deficiency affected three residents who were reviewed for liability notices. Specifically, the NOMNC letters for these residents contained incorrect last covered dates, lacked the appeal agency's contact information, and omitted resident names or identifying numbers. Resident #342's NOMNC letter indicated services ended on 03/22/24, but the last covered day should have been 03/21/24. Resident #343's NOMNC letter showed services ended on 04/19/24, but the last covered day should have been 04/18/24, and the resident did not receive the required 48-hour notice. Similarly, Resident #344 signed the NOMNC on the same day services ended, without the required notice period. Interviews with the Social Service Coordinator and the Administrator confirmed these deficiencies, and it was revealed that the facility lacked a policy for beneficiary notices, relying instead on Medicare guidelines.
Failure to Monitor Resident's Weight Loss
Penalty
Summary
The facility failed to follow the recommendations to monitor the weight of a resident after a significant weight loss. Resident #65, who was cognitively intact, had a history of post-traumatic stress disorder, depression, anxiety, bipolar disorder, and congenital hydrocephalus. The resident was on a psychoactive drug regimen and had a care plan that included monitoring for changes in appetite or weight. Despite these measures, the resident experienced a 12.81 percent weight loss over six months, dropping from 242 pounds to 211 pounds. A dietary note from a registered dietitian on 07/11/24 recommended weekly weight checks for the resident due to significant weight change. However, the facility did not conduct these weekly weight checks as recommended. Interviews with the registered dietitian and the Regional Director of Clinical Services confirmed that the facility received the recommendation but failed to implement it. The facility's policy on weight assessment and intervention, which aims to prevent and monitor undesirable weight loss, was not adhered to in this case.
Resident Left Unattended in Shower Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall with injury for Resident #58, who was assessed as requiring substantial/maximal assistance with showers. Despite the care plan intervention that required staff to never leave the resident unattended during showers, Resident #58 was left unsupervised, resulting in a fall and a right hip fracture. The resident had a history of falls, poor safety awareness, and non-compliance with fall interventions, and was using a power wheelchair for mobility. On the day of the incident, the resident was left unattended in the shower for about thirty minutes. Agency STNA #305, who was responsible for the resident at the time, did not supervise or assist the resident during the shower. The resident attempted to pick up a blanket from the floor, which led to the fall. The nursing note and witness statements confirmed the lack of supervision, and the facility's administrator verified the care plan requirement for supervision was not followed, resulting in the fall and injury.
Failure to Prevent Exposure to Known Food Allergens
Penalty
Summary
The facility failed to ensure that residents with food allergies and/or intolerances did not receive those foods at meals. This deficiency affected Resident #15, who had a known allergy to cheese. Despite the allergy being documented in the resident's care plan and electronic medical record, Resident #15 was served au gratin potatoes containing cheddar cheese during lunch. The meal ticket on the lunch tray did not indicate the cheese allergy, and the resident confirmed that he had informed the facility of his allergy multiple times. The facility's concern report from a previous date also indicated that the resident had been receiving cheese despite the known allergy, and the tray card was supposed to have been updated to reflect this allergy. During an interview, the Regional Dietary staff confirmed that food allergies are loaded into the tray ticket system and periodically cross-referenced with the electronic medical record. However, the tray ticket for Resident #15 did not list the cheese allergy, leading to the resident being served a meal containing cheese. The facility's policy on food allergies and intolerances, revised in October 2008, states that residents with food allergies will be identified upon admission and steps will be taken to prevent exposure to allergens. This policy was not followed, resulting in the resident being served food containing an allergen.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 111 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Health Care | 3.3 mi | ★★★★★ | 3 | 0 |
| Rae Ann Geneva | 4.4 mi | ★★★★★ | 9 | 0 |
| Geneva Center For Rehabilitation And Nursing | 5.4 mi | ★★★★★ | 7 | 0 |
| Pine Grove Healthcare Center | 5.6 mi | ★★★★★ | 2 | 0 |
| Austinburg Nsg And Rehab Ctr | 10.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.