Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Centerburg Pointe during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow hand hygiene and medication handling practices during medication administration for two residents. An LPN handled oral medication tablets using a bare finger while transferring pills between a container and a medication cup lid. In a separate instance, an RN preparing multiple oral and liquid medications for a resident on Enhanced Barrier Precautions moved a pill between cups with bare hands, mixed liquid medications, and then donned gloves and a gown without performing hand hygiene. These actions did not follow facility policies requiring hand hygiene before medication preparation/administration and avoidance of bare-hand contact with medications.
A CNA physically and verbally abused a severely cognitively impaired resident who required extensive assistance with daily care. The CNA placed a hand over the resident's mouth and threatened to punch the resident after the resident spit, as confirmed by another CNA and facility investigation. The incident was determined to be deliberate abuse according to facility policy.
A resident with chronic pain and other medical conditions was not protected from the misappropriation of his prescribed Oxycodone when a nurse removed a card of medication from the cart with only one signature, contrary to policy. The resident subsequently did not receive his medication as ordered, and the facility was unable to account for approximately 23 missing tablets. Required procedures for controlled substance accountability were not followed, and the medication card was found partially shredded.
A resident with severe cognitive impairment and behavioral symptoms was subjected to physical abuse by a CNA during care, including verbal threats and having her mouth covered after spitting. Although the CNA was terminated following an internal investigation, the facility did not report the incident to law enforcement as required by policy, citing the request of the resident's power of attorney.
A resident with multiple chronic conditions received medications via gastric tube in a manner inconsistent with physician orders and facility policy. An RN crushed and combined all scheduled medications and a liquid supplement, administering them together without flushing the tube between each medication, resulting in a medication error rate of 19%, well above the acceptable 5%.
A CNA providing incontinence care to a resident under enhanced barrier precautions failed to remove gloves or perform hand hygiene after cleaning feces and before applying a clean brief, contrary to facility policy and CDC guidelines. The CNA was unaware of the requirement to change gloves when using PPE for EBP.
The facility failed to follow fluid restrictions for two residents with serious health conditions, leading to a deficiency. One resident with congestive heart failure and chronic kidney disease received more fluids than prescribed, partly due to family bringing in additional fluids. Another resident with end-stage renal disease also received excess fluids, as the kitchen staff was unaware of the restriction. Interviews confirmed the nursing and dietary departments did not adhere to fluid limits.
A facility failed to notify a physician about a resident's change in skin condition, violating its policy. The resident, with intact cognition and multiple diagnoses, had stage two pressure ulcers upon admission. Skin observations noted shearing to the gluteal fold and coccyx, but progress notes showed no physician notification. The policy mandates notifying the physician of significant condition changes, which was not followed.
The facility failed to notify the Ombudsman when residents were transferred or discharged, affecting three residents. A resident with cirrhosis and chronic kidney disease, another with malignant neoplasm and candida sepsis, and a third with portal vein thrombosis and major depressive disorder were not reported to the Ombudsman upon discharge. The DON confirmed the oversight, and the facility lacked a notification policy.
A facility failed to timely complete and submit a discharge MDS 3.0 assessment for a resident with multiple diagnoses, including spinal stenosis and chronic heart failure. The assessment was finalized but not submitted, with all sections completed on a later date. The resident had returned from a leave of absence and reported not returning to the facility. The DON confirmed the assessment was missed and completed late.
The facility failed to obtain discharge physician orders for three residents, contrary to its policy. One resident with cirrhosis and diabetes was discharged without a physician order, despite receiving a discharge summary and medication list. Another resident with malignant neoplasm and diabetes was discharged home after medication review, but without a physician order. A third resident with portal vein thrombosis and depression was discharged after reviewing paperwork with her mother, also without a physician order. Staff interviews confirmed the absence of required discharge orders.
A resident with multiple health conditions, including a self-care deficit, was found to have long, dirty nails despite a care plan requiring daily monitoring and trimming. The CNA acknowledged the issue and deferred nail care to hospice staff, indicating a lapse in the facility's adherence to the care plan.
The facility failed to obtain physician orders for therapy services for a hospice resident and did not follow recommendations for a vascular surgery consult for another resident with PVD. The hospice resident received unauthorized occupational therapy sessions, while the other resident's need for a vascular consult went unaddressed despite multiple recommendations. The DON confirmed these deficiencies.
The facility failed to monitor splint use for two residents with limited ROM. One resident with a left elbow contracture had no record of splint use despite a physician's order, and another resident with a left hand contracture reported inconsistent splint application. The DON confirmed the lack of monitoring for both cases.
A facility failed to implement fall interventions and document a fall for a resident with impaired cognition and a history of falls. Despite the care plan requiring non-skid socks and accessible call lights, the resident was observed with regular socks and an out-of-reach call light. Staff confirmed the fall was not documented in the medical record, violating the facility's fall prevention policy.
A resident with severe cognitive deficits and multiple diagnoses had a Foley catheter incorrectly inserted, leading to no urine output being recorded for sixteen hours. The facility failed to monitor and document urine output as per standard practice, and the catheter was not reinserted correctly until the following day.
A facility failed to maintain the availability of pain management medications for a resident, leading to a deficiency in care. The resident, with multiple health issues, was without a Fentanyl patch for several days due to a lapse in obtaining a new prescription. Despite efforts by an RN to contact the pharmacy and request a new prescription, the facility did not secure the necessary order in time, resulting in the resident experiencing continuous pain.
A facility failed to complete pre and post dialysis assessments for a resident with end-stage renal disease, affecting their care. Despite the resident's complex medical conditions, assessments were inconsistently performed over several weeks. The DON confirmed the oversight, highlighting a lapse in care standards.
A resident with complex medical conditions did not have their medications held as ordered by the physician on dialysis days. Enulose and Metoprolol were administered contrary to the physician's instructions, as confirmed by the DON.
A resident with a complex medical history was administered Metoprolol despite having a systolic blood pressure below the prescribed threshold. The medication was not held as per the physician's order, which required it to be withheld if the systolic blood pressure was below 110 mmHg. This deficiency was confirmed by the DON.
A resident at risk for falls, dependent on staff for transfers, fell from a mechanical lift due to improper use of a cross-strap sling, which was not suitable for her needs. The incident occurred during a transfer from a wheelchair to a bed, resulting in the resident sliding out of the sling and falling to the floor. The root cause was identified as the use of an inappropriate sling type, which required leg straps to be crossed, a step that was not followed.
Failure to Follow Hand Hygiene and Medication Handling Practices During Medication Administration
Penalty
Summary
The deficiency involves failures in hand hygiene and medication handling for two residents during medication administration. For one resident with multiple diagnoses including cerebral infarction, hemiplegia, heart disease, morbid obesity, and type 2 diabetes, the care plan included administration of medications as ordered. During observation, an LPN removed two thiamine tablets from the container into the medication cup lid, then used a bare finger to hold one tablet in the lid while shaking the other tablet back into the container. The LPN confirmed she was not wearing gloves and acknowledged she should have discarded the tablets and started over. This practice conflicted with the facility’s medication administration policy, which required that medications not come into contact with any surface except the medication cup and that staff avoid touching medications with bare hands. For a second resident with extensive medical conditions including epilepsy, respiratory failure with hypoxia, tracheostomy, CHF, dysphagia, and dependence on a respirator, an RN prepared multiple medications according to the resident’s preference for crushed, whole, and liquid forms. The RN had three medication cups on the cart and, using bare hands, picked up a small white pill from one cup and moved it to another. The RN then donned gloves to open capsules and crush medications, mixed two liquid medications together, and later donned gloves and a gown in the resident’s room without performing hand hygiene beforehand, despite the resident being on Enhanced Barrier Precautions. The RN confirmed she had handled the pill with bare hands and had not washed or sanitized her hands before putting on gloves and a gown. These actions were inconsistent with the facility’s General Dose Preparation and Medication Administration policy and Infection Prevention and Control Program, which required appropriate hand hygiene before medication preparation and administration and avoidance of bare-hand contact with medications.
CNA Commits Physical and Verbal Abuse Against Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically assaulted a resident who was severely cognitively impaired and required substantial assistance with daily activities. The resident, who had a history of behavioral symptoms such as hitting, kicking, and pushing, as well as a tendency to refuse care, was subjected to inappropriate actions by the CNA. According to written statements and facility investigation documents, the CNA responded to the resident spitting by placing her hand over the resident's mouth and verbally threatening to punch the resident in the face. Another CNA witnessed the incident and confirmed the physical and verbal abuse. The facility's investigation revealed inconsistencies in the CNA's account of the incident, and the CNA was ultimately terminated for physical abuse. The facility's policy defines abuse as the willful infliction of injury or intimidation, and the actions of the CNA were found to be deliberate. This incident affected one resident directly but had the potential to impact all residents in the facility.
Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including cerebrovascular disease, chronic pain syndrome, and diabetes, was not protected from the misappropriation of his prescribed Oxycodone medication. The resident was cognitively intact and had a physician's order for Oxycodone 5 mg at bedtime. Documentation showed that a new card of thirty Oxycodone tablets was received and added to the medication cart, and one tablet was administered each evening for seven days. However, on a subsequent shift, the controlled substance inventory count sheet indicated the card was removed from the cart as empty, but only one nurse had signed the sheet, contrary to facility policy requiring two signatures for such removals. Further review of the Medication Administration Record (MAR) revealed that on several dates following the removal, the resident did not receive his Oxycodone due to the medication being unavailable, and on one occasion, a muscle relaxer was given instead. The resident reported no pain during these times. The facility was unable to locate the controlled substance count sheet for the removed Oxycodone, and it was recognized that approximately 23 tablets were missing. The Director of Nursing confirmed that the required procedures for controlled substance accountability were not followed, as only one nurse signed for the removal of the narcotic card, and the medication card was found partially shredded. Interviews with the resident and staff confirmed the medication was taken by a nurse, and the administration was aware of the situation. The nurse responsible for the single-signature removal was suspended pending investigation and later resigned. Facility policy required that controlled medications be counted with another designated staff member during key exchanges and that discrepancies be resolved before the off-going nurse leaves, but these procedures were not followed in this incident.
Failure to Report Staff-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an incident of staff-to-resident abuse to law enforcement authorities as required by policy and regulation. The incident involved a resident with severe cognitive impairment and behavioral symptoms, who became combative during incontinence care. During the incident, a CNA responded to the resident's aggression by stating she would hit the resident back, and after the resident spit at her, the CNA covered the resident's mouth with her hand. Another CNA present intervened and removed the resident from the situation. Written statements from both CNAs confirmed the physical interaction and verbal threats made by the CNA toward the resident. The facility's investigation led to the termination of the CNA involved for physical abuse. However, despite the clear policy requiring reporting of suspected crimes against residents to law enforcement, the facility did not notify the police about the incident. Documentation indicated that the decision not to report was made at the request of the resident's power of attorney. The facility's own policies define abuse as the willful infliction of injury or intimidation and require reporting of any reasonable suspicion of a crime to appropriate authorities.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by five medication errors out of 26 observed opportunities, resulting in a 19% error rate. During a medication administration observation, a registered nurse was seen preparing and administering medications for a resident with multiple diagnoses, including hypertension, COPD, traumatic brain injury, and obstructive hydrocephalus. The nurse obtained the resident's vital signs and appropriately held certain blood pressure medications due to low systolic blood pressure, as per physician orders. However, the nurse proceeded to crush and combine all other scheduled medications, including a liquid supplement, into a single cup, added water, and administered the mixture through the resident's gastric tube without flushing the tube between each medication. The nurse confirmed during an interview that medications were crushed, combined, and administered all at once, and that a water flush was not performed between each medication. The resident's orders specified that medications should be crushed but did not authorize combining them. Facility policy required that medications administered through an enteral tube be prepared and given separately, with a flush of at least 15 ml of water after each individual medication. The observed practice was not in accordance with these orders or facility policy, resulting in multiple medication administration errors for the resident.
Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) failed to follow proper infection control procedures during incontinence care for a resident who was under enhanced barrier precautions (EBP). The CNA donned a gown and gloves to provide care and used wipes to remove feces from the resident, who was always incontinent of bowel and bladder and had multiple medical diagnoses, including respiratory failure and diabetes. The CNA did not remove her gloves or perform hand hygiene before placing a clean incontinence brief on the resident and covering them with a sheet. Upon interview, the CNA confirmed she did not change gloves after cleaning feces and was unaware that glove changes were required when wearing PPE for EBP. Review of the facility's hand hygiene policy and CDC recommendations confirmed that hand hygiene should be performed before moving from a soiled to a clean body site and that glove use does not replace the need for hand cleaning. This lapse in infection control was observed and verified during the survey.
Failure to Adhere to Fluid Restrictions for Residents
Penalty
Summary
The facility failed to adhere to fluid restrictions for two residents, leading to a deficiency in maintaining their health. Resident #34, who was admitted with multiple diagnoses including congestive heart failure and chronic kidney disease, had a physician's order for a fluid restriction of 2,000 ml per day. However, records showed that this limit was exceeded on several occasions in March 2025, with both nursing and dietary departments providing more fluids than prescribed. The resident was noted to be non-compliant with fluid restrictions, and there was a history of family bringing in additional fluids. Resident #20, diagnosed with end-stage renal disease and other serious conditions, also had a fluid restriction order of 1,000 ml per day. Despite this, records from February and March 2025 indicated that both nursing staff and nurse aides consistently exceeded the fluid limits. The kitchen staff was reportedly unaware of the fluid restriction, contributing to the over-provision of fluids. There was no documentation indicating that Resident #20 was non-compliant with her fluid restriction. Interviews with the Director of Nursing confirmed the failure to follow fluid restrictions for both residents. The nursing staff and dietary department did not adhere to the prescribed fluid limits, leading to the deficiency. The facility's oversight in managing fluid intake for these residents resulted in a failure to maintain their health as required by their medical conditions.
Failure to Notify Physician of Resident's Skin Condition Change
Penalty
Summary
The facility failed to notify the physician of a change in a resident's skin condition, which is a deficiency in adhering to the facility's policy on resident change in condition. The resident, who had intact cognition, was admitted with multiple diagnoses including acute respiratory failure and pressure ulcers. Upon admission, the resident had three stage two pressure ulcers. On January 30, 2025, a skin observation noted shearing to the right and left gluteal fold, but there was no evidence in the progress notes from January 30 to February 7, 2025, that the physician was notified of this change. Further, on February 8, 2025, another skin observation revealed the resident had developed shearing to the coccyx. Again, the progress notes from February 8 to February 10, 2025, showed no evidence of physician notification regarding this change. The facility's policy requires that the physician be notified as soon as a change in condition is identified and the resident is stable, especially when the change impacts more than one area of the resident's health status or requires a revision to the care plan. This lack of communication with the physician regarding the resident's skin condition changes constitutes a failure to comply with the facility's policy.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman when residents were transferred or discharged, affecting three residents out of four reviewed for discharge. Resident #69, who had diagnoses including cirrhosis of the liver and chronic kidney disease, and Resident #174, with conditions such as malignant neoplasm and candida sepsis, were not reported to the Ombudsman upon discharge. Additionally, Resident #175, diagnosed with portal vein thrombosis and major depressive disorder, was also not reported. The facility's list of discharged residents for several months did not include these individuals, and the Director of Nursing confirmed the oversight. The facility did not have a notification to Ombudsman policy available for review.
Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to timely complete and submit a discharge Minimum Data Set (MDS) 3.0 assessment for a resident, affecting one of six closed records reviewed. The resident, who had diagnoses including spinal stenosis, chronic heart failure, adjustment disorder, generalized anxiety disorder, and functional quadriplegia, was admitted and later discharged from the facility. The discharge MDS assessment was finalized but not submitted, with all sections completed on March 12, 2025. A progress note indicated that the resident returned from a leave of absence on December 27, 2025, and reported they would not be returning to the facility. An interview with the Director of Nursing confirmed that the MDS assessment was missed and not completed until March 12, 2025.
Failure to Obtain Discharge Physician Orders
Penalty
Summary
The facility failed to obtain a discharge physician order for residents being discharged, affecting three out of four residents reviewed for discharge. Resident #69, who had diagnoses including cirrhosis of the liver and type two diabetes mellitus, was discharged without a physician order. The resident's progress notes indicated that the family took her home, and she was provided with a discharge summary and medication list, but no discharge order was documented in the medical record. Similarly, Resident #174, with diagnoses such as malignant neoplasm and type two diabetes mellitus, was discharged home without a physician order. The progress notes showed that the resident was alert and oriented, and the nurse reviewed medications with the resident and their power of attorney. Resident #175, diagnosed with conditions including portal vein thrombosis and major depressive disorder, was also discharged without a physician order. The progress notes indicated that the resident was discharged after reviewing the medication list and discharge paperwork with her mother. Interviews with facility staff confirmed the absence of discharge orders for these residents, which was contrary to the facility's discharge planning policy requiring a physician order for discharges.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to maintain the nails of a resident in a clean manner and at an appropriate length. This deficiency was identified during observations on two separate occasions, where the resident was found to have long, curved nails with dirt underneath. The resident, who was rarely or never understood and dependent on staff for personal hygiene, had a care plan that included monitoring and trimming of nails as part of daily activities of living (ADL) care. Despite this, the Certified Nursing Assistant (CNA) responsible for the resident's care acknowledged the condition of the nails and indicated that hospice would be asked to cut them during a bed bath, suggesting a lapse in the facility's adherence to the care plan.
Failure to Obtain Physician Orders and Follow Practitioner Recommendations
Penalty
Summary
The facility failed to ensure physician orders were present for therapy services prior to delivering services to a resident receiving hospice care. The resident, diagnosed with Alzheimer's Disease, dementia, anxiety, bipolar disorder, and a history of falling, was admitted to hospice services and was a Do Not Resuscitate Comfort Care (DNR-CC) patient. Despite the absence of physician orders, the resident received eight occupational therapy sessions aimed at improving her sitting position in a wheelchair. The hospice interdisciplinary team’s plan of care did not include orders for rehabilitation services, and there was no documentation of physician orders for occupational therapy in the resident's medical records. The Director of Nursing and the Rehab Director confirmed the lack of physician orders for the therapy sessions provided. Additionally, the facility failed to follow a practitioner's recommendation for a vascular surgery consult for another resident with peripheral vascular disease (PVD) and other significant health conditions. Despite multiple recommendations documented by the resident's physician and Certified Nurse Practitioner (CNP) for a vascular surgery follow-up, the consult had not been arranged. Observations revealed the resident's feet were a dark purple color, indicating potential circulatory issues. The Director of Nursing acknowledged the oversight and noted that the hospital records indicated the resident was not appropriate for vascular surgery, yet the recommendations for follow-up had been documented for months without action.
Failure to Monitor Splint Use for Residents with Limited ROM
Penalty
Summary
The facility failed to monitor the use of splints for two residents with limited range of motion, leading to deficiencies in their care. Resident #4, who has a history of transient cerebral ischemic attack, contracture of the left elbow, and other medical conditions, was observed to have a splint in her room. However, her medical records from February 28 to March 16 did not indicate any use of the splint, despite a physician's order on March 17 for her to wear a left elbow brace for four to six hours daily. The Director of Nursing (DON) confirmed that there was no tracking or monitoring of Resident #4's splint usage in the medical record. Similarly, Resident #20, who has multiple diagnoses including end-stage renal disease, contracture of the left hand, and Parkinson's disease, was supposed to wear a left resting hand splint for six hours at bedtime. However, from October 30 to March 18, there was no documentation of the splint being applied. An observation on March 18 revealed that Resident #20's left hand was contracted into a tight fist. The resident reported that staff did not always provide the splint, and the DON acknowledged the lack of tracking or monitoring, despite claiming the resident was noncompliant. There was no evidence to support the claim of noncompliance.
Failure to Implement Fall Interventions and Document Falls
Penalty
Summary
The facility failed to ensure that fall interventions were in place and that falls were documented for a resident with a history of falls and severely impaired cognition. The resident, who had multiple diagnoses including dementia, epilepsy, and impaired mobility, was found sitting in the doorway of her bedroom after a fall, with her walker placed back beside her recliner. Despite the care plan specifying the use of non-skid socks and ensuring the call light was within reach, observations revealed the resident wearing regular socks and the call light being out of reach on multiple occasions. Interviews with facility staff confirmed the fall on March 16th was not documented in the resident's progress notes, and the post-fall huddle form was not part of the medical record. The facility's Fall Prevention and Management Policy required that all falls be reviewed and investigated, with individualized interventions implemented based on assessments. However, the lack of documentation and failure to adhere to the care plan interventions contributed to the deficiency in providing adequate supervision and accident prevention for the resident.
Improper Catheter Insertion and Monitoring
Penalty
Summary
The facility failed to ensure proper insertion and monitoring of an indwelling Foley catheter for a resident with severe cognitive deficits and multiple diagnoses, including hypertensive chronic kidney disease and neuromuscular dysfunction of the bladder. On the evening of 10/22/24, a nurse changed the resident's catheter using a 22 French 10 cc balloon due to the resident's behavior of playing in her stool and pulling at the catheter. Despite following sterile technique, the catheter was incorrectly inserted, which was not identified until the following morning when a CNA reported no urine output overnight. Upon examination, it was discovered that the catheter had been placed incorrectly, and a new catheter was inserted correctly, resulting in urine flow. The facility's Director of Nursing confirmed that standard practice requires urine output to be recorded at least every eight hours, which was not done in this case. The facility's policy also mandates repeating the catheterization procedure with a new sterile catheter if the initial insertion is incorrect, which was not adhered to, leading to a lapse in monitoring and documentation of the resident's urine output for sixteen hours.
Failure to Maintain Pain Management Medication Availability
Penalty
Summary
The facility failed to maintain the availability of ordered pain management medications for a resident, leading to a deficiency in providing safe and appropriate pain management services. Resident #33, who was admitted with multiple diagnoses including acute respiratory failure, cellulitis, dysphagia, and chronic congestive heart failure, was cognitively intact and experienced mild depression. The resident had orders for a Fentanyl patch to be changed every 72 hours and Oxycodone as needed for pain. However, the resident reported experiencing continuous pain and went without the Fentanyl patch for 10-12 days due to issues with prescription refills. The March 2025 medication administration record indicated that Resident #33 was without a Fentanyl patch from March 9 to March 14. A progress note from March 6 documented that RN #47 contacted the pharmacy for a refill, but was informed that a new prescription was needed. Despite a request being placed on the physician's medication refill voicemail, the facility did not obtain a current order from the physician until March 14. The Director of Nursing confirmed the lapse in obtaining the necessary prescription, resulting in the resident not receiving the Fentanyl patch during this period.
Failure to Complete Dialysis Assessments
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were consistently completed for a resident requiring dialysis services. The resident, who had a range of complex medical conditions including end-stage renal disease, diabetes, and chronic heart failure, was scheduled for dialysis three times a week. Despite the critical nature of these assessments in monitoring the resident's health status before and after dialysis, the facility did not complete them as required. Specific instances of incomplete or missing assessments were documented over a period from early February to mid-March. The Director of Nursing confirmed that the pre and post dialysis assessments were not being completed with every dialysis treatment. This oversight affected the resident's care, as the assessments are crucial for identifying any immediate health concerns related to dialysis. The facility's failure to adhere to the care plan and physician orders for dialysis assessments represents a significant lapse in the standard of care provided to the resident.
Medication Administration Error on Dialysis Days
Penalty
Summary
The facility failed to ensure that a resident's medication was held as ordered by the physician. The resident, who had a complex medical history including end-stage renal disease, diabetes, and heart failure, was prescribed Enulose and Metoprolol with specific instructions to hold these medications on dialysis days. However, a review of the Medication Administration Record revealed that Enulose was not held on three dialysis days, and Metoprolol was not held on two of those days. This oversight was confirmed during an interview with the Director of Nursing.
Failure to Follow Medication Parameters
Penalty
Summary
The facility failed to adhere to medication parameters for a resident, leading to a deficiency in medication administration. The resident, who had a complex medical history including end-stage renal disease, type one diabetes mellitus, and chronic diastolic heart failure, was prescribed Metoprolol tartrate with specific instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 beats per minute. However, on March 10, 2025, the medication was administered despite the resident's systolic blood pressure being recorded at 106 mmHg, which was below the specified threshold. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the medication was not held according to the prescribed parameters.
Improper Use of Mechanical Lift Sling Leads to Resident Fall
Penalty
Summary
The facility failed to use a mechanical lift sling pad correctly, resulting in a fall from a mechanical lift. This incident involved a resident who was at risk for falls due to impaired mobility and was dependent on staff for all care and Activities of Daily Living (ADL) tasks, including transfers using a mechanical lift. During a transfer from a wheelchair to a bed, the resident rolled out of the top right side of the lift sling, falling approximately 4.5 feet to the floor and landing on her right shoulder and right side of her face. The incident occurred when the resident was being assisted by a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), and a Respiratory Therapist (RT). The resident had been elevated out of the wheelchair, and as the CNA moved the wheelchair away, the resident began sliding out of the sling. The investigation revealed that the sling used was a cross-strap sling, which was not appropriate for the resident, who required a full body lift sling. The cross-strap sling required the leg straps to be crossed between the resident's legs, which was not done during the transfer, leading to the fall. The Director of Nursing (DON) confirmed that the root cause of the fall was the improper use of a cross-strap lift sling. The sling was not suitable for the resident's needs, and the lower straps were not crossed as required. The resident did not sustain any acute injury from the fall, only an abrasion to the top of her right shoulder. The facility's policy on mechanical lifts was not adhered to, as the sling used was inappropriate for the resident's condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Centerburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Centerburg Respiratory & Specialty Rehab Ctr | 0.6 mi | — | 0 | 0 |
| Bennington Glen Nursing & Rehabilitation Center | 8.9 mi | ★★★★★ | 15 | 0 |
| Country View Of Sunbury | 10.9 mi | ★★★★★ | 0 | 0 |
| Johnstown Pointe Nursing & Rehabilitation Center | 11 mi | ★★★★★ | 0 | 0 |
| Morrow Manor Nursing Center | 11.8 mi | ★★★★★ | 16 | 0 |
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