Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Gables Care Center during CMS and state inspections, most recent first.
The facility failed to identify infection trends in its IPC program, including repeated UTIs with E. coli, and did not trend organism data or provide related staff education. It also did not complete required daily water heater/boiler temperature checks under its Legionella water management program. Surveyors observed a CNA use the same gloves during incontinence care and application of Desitin, and an LPN fail to perform hand hygiene before redonning gloves and administering insulin after glucose monitoring.
A facility failed to provide baseline care plans within the required timeframe for multiple residents after admission. Records and interviews showed that residents with significant medical needs, including cardiopulmonary conditions, cognitive impairment, dysphagia, and renal dialysis dependence, did not receive or sign their baseline care plans until later, and in several cases there was no documentation that the resident or representative had been given a copy or informed of the plan.
Medication administration errors occurred when an LPN administered a contaminated Flomax capsule to a resident with BPH, crushed and gave ordered oral meds including ferrous sulfate and calcium carbonate with vitamin D to another resident, and gave Humalog insulin without priming the pen for a resident with DM. The DON verified the errors, and the facility’s medication error rate was 16% based on 4 errors in 25 opportunities.
Bed-Hold Notices Lacked Required Duration Information: The facility failed to provide written bed-hold notices that specified the duration of the bed-hold policy and the number of bed-hold days used or remaining for two residents transferred to the hospital. One resident had SOB, diminished lung sounds, and low O2 sat before EMS transfer, and another had sharp chest pain radiating to the jaw and clavicle before ER transfer. The SSD confirmed the notices did not include the required bed-hold details.
Two residents had inaccurate comprehensive assessments. One resident’s MDS documented intact cognition and adequate vision with corrective lenses, but the resident reported long-standing blurry distance vision, no eye exam or new glasses for over 10 years, and pending follow-up for an eye provider; SS confirmed the vision assessment and MDS were not accurate. Another resident’s significant change MDS stated hospice services were being received but did not reflect a prognosis of less than 6 months, despite the hospice certification documenting a terminal prognosis; the DON verified the MDS was inaccurate.
Incomplete Care Plans for Catheter Management and Pain: The facility failed to complete comprehensive care plans for two residents. One resident had an indwelling urinary catheter ordered, removed, and later reinserted, but the care plan did not include catheter care until later confirmed by the DON. Another resident had chronic pain, left shoulder pain, and diabetic neuropathy with scheduled pain-related medications, but the record showed no comprehensive pain care plan.
Failure to provide and document showers for a dependent resident. A resident with dementia, cognitive impairment, incontinence, dysphagia, and severe protein calorie malnutrition was dependent on staff for bathing and personal hygiene, with a care plan and shower schedule indicating routine showers. However, the bathing/shower record showed no showers or baths and no refusals during the month, and observation found poor hygiene, body odor, greasy hair, facial hair stubble, and food on the resident’s clothing and floor. CNA and DON interviews confirmed showers were to be documented in the EMR, but no documentation was present.
Failure to provide individualized activities for two residents. One resident with significant hearing and vision loss had a care plan for 1:1 visits, but records showed no evidence of those visits and she reported being bored, relying mainly on audio books, and not being offered outdoor time. Another cognitively intact resident had documented interests in news, favorite activities, outdoor time, and crossword puzzles, but the record showed no 1:1 activity visits and he reported the facility had not provided magazines or crossword puzzles despite his preferences.
Failure to Provide Needed Vision Services: A resident with multiple medical diagnoses and corrective lenses was not evaluated by the facility optometrist despite reporting poor distance vision and needing an eye exam. SS staff did not test distance vision, did not obtain consents for ancillary services, and relied on the resident being short-term and able to read admission paperwork to determine vision was adequate.
Improperly Applied Incontinence Brief Led to Pressure Injury A resident with multiple chronic conditions, frequent bowel and bladder incontinence, and high skin-breakdown risk developed an in-house acquired pressure injury on the right posterior thigh/gluteal crease area. Staff and the resident believed the wound was related to an incontinence brief being pulled too tight, and the wound was documented as a suspected deep tissue injury/unstageable pressure injury. The resident’s record also showed no evidence that ordered wound care was provided.
Incomplete Antibiotic Treatment for UTI: A resident with dementia, CKD, DM, incontinence, and a history of UTIs was sent to the ER after a fall and returned with a UTI diagnosis and an order for Cephalexin 500 mg BID for 10 doses. The eMAR showed only eight doses were administered, and the DON verified the order was not completed as written due to a transcription error in the electronic physician order.
Failure to provide adequate pain management for a resident with chronic pain and multiple pain-related diagnoses. The resident returned from the hospital with persistent left shoulder pain rated 5/10, later reporting severe pain and guarding the shoulder, while the record showed scheduled diclofenac and gabapentin but no documented PRN pain medication administration despite notes stating PRN meds were given. The OT eval noted severe pain limited testing, the skilled note showed unchanged pain, and the DON verified the resident had no pain care plan and no PRN pain meds were ordered or administered during the period reviewed.
Pharmacy MRRs were not thoroughly addressed for three residents. One resident with multiple chronic conditions remained on Amitriptyline after the PCP deferred to psych and neuro without follow-up; another resident with dementia and depression was on Remeron, Cymbalta, and Lexapro, but the pharmacist’s duplicate-therapy and interaction concerns were not addressed by the psych provider; and a third resident with CKD, seizures, and pain diagnoses had a flagged Pregabalin and opioid combination, yet the response relied on a pain specialist who had not seen the resident since admission. The DON confirmed gaps in follow-up and documentation.
Inadequate Nourishing Snack Options: A resident with dementia, obesity, and multiple chronic conditions was found to have frequent access to candy, soda, chips, cookies, and ice cream, while the snack cart lacked fruits and other nutrient-dense or low-calorie options. The resident and her son reported a strong preference for sweets, and the son voiced concern about significant weight gain and the facility’s practice of offering snacks all the time.
A resident with dementia, incontinence, and significant assistance needs was given oral Cipro for a presumed UTI without diagnostic confirmation. The infection log and McGeer’s Criteria showed only urinary frequency and urgency, which did not meet UTI criteria, and no urine specimen or culture was obtained before or after antibiotics were started. The IP stated the resident did not meet criteria and had told the provider an antibiotic was not indicated, but the provider wanted treatment started anyway.
Survey Results Not Readily Available to Residents: Residents reported they could not locate the facility’s annual and complaint survey results and were unaware of the most recent complaint survey findings. Survey results were posted in framed displays above countertop level and were not easily accessible to wheelchair-bound residents, and the survey results binder in the conference room did not include the most recent annual survey or the most recent complaint survey results. The DON confirmed the binder was missing those results.
The deficiency centers on the administrator’s failure to lead and operate the facility in a way that supports residents’ highest practicable well-being, as required by her job description and the facility’s resident rights policy. Staff, residents, and resident representatives consistently reported that the administrator was unapproachable, rude, and condescending, frequently yelling at staff in public areas such as the nurse’s station in front of residents, visitors, and other staff, and threatening staff jobs and paychecks when they attempted to advocate or raise concerns. Multiple residents stated that the administrator rarely interacted with them, showed favoritism toward certain residents, dismissed or cut off their concerns, and did not follow up, leaving them feeling that she did not have their best interests at heart. Several staff and residents described a tense, toxic atmosphere and a pervasive fear of retaliation that made both staff and residents afraid to report issues or advocate for care, with one resident becoming tearful and expressing fear of being discharged after speaking with surveyors. Complaints about the administrator had been made to corporate HR and the compliance line, but staff perceived little or no follow-up, while the administrator also served as the facility’s compliance officer, further contributing to concerns about reporting and accountability.
Surveyors found that the facility failed to provide adequate, individualized activities and sufficient activity staffing. Resident council minutes and staff and resident interviews described activities being cut short, loss of live entertainment and in-person religious services, and use of activity staff for non-activity tasks such as snack passing and obtaining menu selections. Activity calendars showed limited variety, no separate programming for cognitively impaired residents, and very few one-on-one or independent activities. Observations during a bingo session showed several cognitively impaired residents present without needed assistance or meaningful participation. Records for two residents with dementia, anxiety, and mobility issues showed care plans calling for daily 1:1 room visits by activity staff, but there was no documentation that these visits occurred over several months, despite a facility policy stating that activities should reflect residents’ cultural and religious interests and be tailored with appropriate accommodations.
The facility failed to ensure a resident with contractures received appropriate services to maintain mobility and prevent further decrease in range of motion. Despite the care plan indicating the need for double washcloth rolls in both hands, the resident was observed without them on multiple occasions. Staff interviews confirmed the washcloths were not applied as required.
The facility failed to ensure that an indwelling urinary catheter drainage bag and tubing were not resting on the floor for a resident with urinary retention. Observations confirmed the catheter drainage bag and tubing were touching the floor under the resident's wheelchair, which was against the facility's policy. An LPN verified this issue.
A resident was inappropriately prescribed ciprofloxacin for a UTI despite showing no symptoms, which did not meet the McGeer Criteria for treatment. The physician continued the antibiotic after being notified by the Infection Preventionist/LPN, contrary to the facility's Antibiotic Stewardship Program policy.
Infection control program, water monitoring, and hand hygiene failures
Penalty
Summary
The facility failed to identify and address infection trends in its infection prevention and control program. Review of monthly infection control logs for November 2025 through April 2026 showed 29 treated UTIs, including 10 that tested positive for E. coli, seven with no culture or corresponding organism, and six cultured for other identified organisms. The monthly infection reports for the same period noted no trends each month and did not include data collection or analysis for specific organisms. The infection preventionist, RN #80, stated that E. coli was the most common organism cultured for UTIs, but she had not trended infections by organism type and had not completed further investigation into possible causes. She also denied providing infection control education related to incontinence care or the spread of E. coli. The facility also did not adequately monitor water temperatures under its Legionella water management program. The program stated that hot water heaters/boilers were to be checked daily at 135 to 160 degrees, but the water temperature logs only showed weekly checks for residents' room water temperatures and no evidence of daily checks for the water heater/boiler system. The Maintenance Director stated he was unaware that daily water temperature checks were required and had not been completing them. CDC guidance reviewed by surveyors stated that hot water should be stored above 140 degrees F and circulated water should not fall below 120 degrees F, with frequent monitoring based on the water management program. Surveyors also observed infection control lapses during resident care and medication administration. During incontinence care for one resident, a CNA performed perineal care, removed a soiled brief, and continued using the same gloves to scoop Desitin from a multi-use container and apply it to the resident's gluteal folds and perineal area, changing gloves only once and not performing hand hygiene after glove removal. In another observation, an LPN performed glucose monitoring and then left the resident's room, returned with supplies, donned new gloves, and administered insulin without washing her hands after removing the prior gloves or before redonning gloves. Facility policies stated that gloves do not replace hand hygiene and that medications are to be administered in a manner to prevent contamination or infection.
Delayed Baseline Care Plans After Admission
Penalty
Summary
The facility failed to ensure residents were provided baseline care plans within 48 hours of admission, affecting five residents sampled for baseline care plans, including residents #6, #38, #84, and #102. Record review showed resident #6 was admitted with diagnoses including cardiomegaly, pleural effusion, anxiety, constipation, and atrial fibrillation. The baseline care plan was dated 02/19/26, but there was no documentation that the resident was provided information or received a copy until 02/26/26, when the resident signed the document. During interview, resident #6 stated they did not believe they had been part of a care plan conference of any kind. Resident #84 was admitted with diagnoses including hypertension, acute respiratory failure with hypoxia, abnormalities of gait and mobility, acute myocardial infarction, ventricular tachycardia and fibrillation, hypotension, cerebral infarction, and exacerbation of COPD, and was cognitively intact for daily decision-making. Resident #38 was admitted with diagnoses including senile degeneration of the brain, dysphagia, muscle wasting, and acute pulmonary insufficiency following nonthoracic surgery, and was severely impaired for daily decision-making. Resident #102 was admitted with diagnoses including dependence on renal dialysis, hypertension, and peripheral vascular disease, and was cognitively intact for daily decision-making. For residents #84, #38, and #102, the electronic baseline care plans were unsigned and undated, and there was no evidence the residents or their representatives were provided the baseline information or received copies within the required timeframe. Interviews with the residents and the ADON confirmed the baseline care plans were not provided timely and were signed later without documenting the date received.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in four medication administration errors out of 25 opportunities for an error rate of 16%. This affected three residents reviewed for medication administration. Resident #89, admitted with benign prostatic hyperplasia with lower urinary tract symptoms, was ordered Flomax 0.4 mg daily. During morning medication administration, an LPN dispensed the Flomax capsule onto the top of the medication cart, where white granules were observed scattered on the surface, then picked up the capsule and administered it to the resident. The LPN later verified that a new capsule should have been used because the medication had been contaminated. Resident #66, admitted with calculus of kidney and ureter, anemia, iron deficiency anemia, and vitamin D deficiency, was ordered Calcium Carbonate 600 mg with Vitamin-D 5 mcg and ferrous sulfate 325 mg daily. During observation, an LPN prepared Calcium Carbonate 600 mg with Vitamin-D 10 mcg and ferrous sulfate 325 mg, placed the medications in a plastic sleeve, crushed them, and mixed them in applesauce before administering them. The LPN verified the observation, and the DON later confirmed the errors. Resident #40, admitted with diabetes mellitus, was ordered Humalog Kwikpen 25 units before meals and at bedtime. During insulin administration, an LPN obtained the pen and a new needle, checked the glucose, dialed 25 units, and administered the insulin without priming the pen. The LPN verified she did not prime the pen, and the DON confirmed insulin pens should be primed prior to dosing.
Bed-Hold Notices Lacked Required Duration Information
Penalty
Summary
The facility failed to ensure residents or their representatives received written notice that specified the duration of the facility’s bed-hold policy at the time of transfer. Record review showed Resident #65, who had diagnoses including obstructive sleep apnea, chronic respiratory failure, heart failure, myocardial infarction, nicotine dependence, and type 2 diabetes, developed shortness of breath, diminished lung sounds with little air movement, and an oxygen saturation of 91% on room air. After an albuterol treatment did not improve the resident’s condition and the resident reported generalized abdominal pain, the Medical Director was notified, EMS was contacted for transfer to a local ER, and the family was notified. The bed-hold notice for this transfer did not document how many bed-hold days had been used or how many remained. Record review also showed Resident #74, who had diagnoses including pulmonary hypertension, type 2 diabetes, COPD, stage 4 CKD, insomnia, bradycardia, and atrial fibrillation, reported sharp chest pain radiating to the left jaw and clavicle and stated it was unlike anything previously experienced. The Medical Director was notified, the resident was sent to a local ER, and the family was notified. Bed-hold notices associated with the resident’s hospital transfers did not include documentation of the number of bed-hold days used or the number remaining. The Social Service Designee confirmed that the bed-hold notices for Resident #65 and Resident #74 did not include this information, and the facility policy required written information specifying the duration of the state bed-hold policy and related reserve bed payment information.
Inaccurate MDS assessments for vision status and hospice prognosis
Penalty
Summary
The facility failed to ensure comprehensive assessments were accurate for two residents. For one resident, the medical record showed admission diagnoses including hypertension, acute respiratory failure with hypoxia, abnormalities of gait and mobility, acute myocardial infarction, ventricular tachycardia and fibrillation, hypotension, cerebral infarction, and exacerbation of COPD. The admission MDS and 5-day MDS documented the resident as cognitively intact for daily decision-making and having adequate vision with corrective lenses, but the resident stated he had not seen an eye doctor or had new glasses for over 10 years, had blurry distance vision, and was waiting for an eye exam and new glasses. Social Services confirmed a comprehensive vision exam had been completed and that the MDS assessments were not accurate, and also stated the resident’s vision had not been evaluated while using his glasses. For another resident, the medical record showed admission diagnoses including senile degeneration of brain, dysphagia, muscle wasting, and acute pulmonary insufficiency following nonthoracic surgery. The hospice initial certification documented hospice admission with a prognosis of six months or less if the terminal illness ran its normal course. However, the significant change MDS stated the resident was receiving hospice services but did not have a prognosis of less than six months life expectancy. The DON verified that the MDS assessment was not accurate.
Incomplete Care Plans for Catheter Management and Pain
Penalty
Summary
The facility failed to ensure comprehensive care plans were completed for two residents reviewed for care plans. Resident #39 was admitted with diagnoses including insomnia, dementia, anxiety, constipation, hypertension, depression, gastroesophageal reflux disease, and dysphagia. Progress notes showed an indwelling urinary catheter was ordered, left in place, removed, and later reinserted after the resident had not voided for 12 hours and stated they felt like they needed to go but could not. Review of the care plan completed on 02/06/26 showed no documentation of a care plan for the indwelling urinary catheter on 04/27/26, 04/28/26, or 04/29/26. The DON confirmed the resident did not have a comprehensive care plan for the catheter until 04/29/26. Resident #5 was admitted with diagnoses including chronic pain, unspecified contracture, cerebral infarction, chronic gout, osteoarthritis of the left shoulder, and diabetic neuropathy. The 5-day MDS showed the resident was moderately impaired for daily decision-making, received scheduled and PRN pain medications, and had frequent moderate pain that affected sleep and daily activities. Physician orders in April 2026 included Diclofenac Sodium External Gel 1% to the left shoulder four times daily for chronic pain and Gabapentin 100 mg twice daily for diabetic neuropathy. Review of the medical record found no evidence of a pain plan of care for the resident, and the DON confirmed the resident did not have a comprehensive plan of care for pain.
Failure to Provide and Document Showers for a Dependent Resident
Penalty
Summary
The facility failed to ensure dependent residents received adequate hygiene and showers, affecting one resident who was dependent on staff for showering and bathing and required substantial to maximal assistance with personal hygiene. The resident had diagnoses including dementia, gastric ulcer with perforation, dysphagia, severe protein calorie malnutrition, cardiac arrhythmia, cognitive impairment, and incontinence. The 5-day admission MDS showed the resident was severely impaired for daily decision-making. The Kardex and shower schedule indicated the resident was to receive showers on Tuesday and Friday dayshift. Review of the bathing and shower documentation for the month showed the resident had received no showers or baths and had no shower refusals. The care plan included interventions for assistance with bath/shower, explanation of care, and support with ADLs. On observation, the resident had facial hair stubble, uncombed greasy hair, body odor, and food spitting on his shirt sleeve and the floor next to his wheelchair. The resident stated he needed staff help with ADLs. CNA interview confirmed shower schedules were posted and that baths and showers were to be documented in the computer the same day care was provided. The DON verified there was no documented evidence of any showers or baths during the month and stated staff reported the resident had received showers, but none were documented.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide activities to meet the needs and interests of two residents, including a resident with a history of subdural hemorrhage, stroke affecting the right dominant side, macular degeneration, hearing loss, constipation, depression, and hypertension, and another resident with diagnoses including hypertension, acute respiratory failure with hypoxia, gait and mobility abnormalities, acute myocardial infarction, ventricular tachycardia and fibrillation, hypotension, cerebral infarction, and COPD exacerbation. Both residents were cognitively intact and had documented activity preferences and care plans that included one-on-one activities when they did not participate in group activities. For the first resident, activity records showed participation in walking/wheeling, listening to radio/television, and news/current events, with refusals for bingo, coffee, group discussion, religious services/studies, cards, arts and crafts, and social parties. The care plan called for one-on-one visits by staff if she did not attend group activities, but the 1:1 activity logbook, care plan, and binder had no evidence of such visits. Observations showed the resident sitting alone in her room using headphones and an audio book, and she reported being very hard of hearing and practically blind, that she got bored during the day, and that her only regular activity was listening to audio books brought by her niece. She also stated she previously enjoyed gardening, card games, and church, but staff had not offered to take her outside to the gazebo. For the second resident, the activity assessment identified that it was very important for him to keep up with the news, do his favorite activities, and go outside when the weather was good, and his care plan noted interests in fishing, being outdoors, watching and playing sports, and crossword puzzles, with one-on-one activities planned. However, the record showed no evidence of one-on-one activities provided between the admission period reviewed and the survey date. The resident stated staff gave him a daily list of activities but did not stay, that he liked bingo but had not attended because he had not been feeling well, and that he liked magazines and crossword puzzles but would need his daughter to bring them because the facility had not provided them. The Activities Director confirmed crossword puzzles were available and should have been provided, and also verified there was no evidence the resident had received the one-on-one activities identified in his care plan.
Failure to Provide Needed Vision Services
Penalty
Summary
The facility failed to ensure vision services were provided as needed for Resident #84. The resident was admitted with multiple diagnoses including hypertension, acute respiratory failure with hypoxia, gait and mobility abnormalities, acute myocardial infarction, ventricular tachycardia and fibrillation, hypotension, cerebral infarction, and COPD exacerbation. The admission MDS and 5-day MDS indicated the resident was cognitively intact and had adequate vision with corrective lenses. The order summary allowed ancillary services including optometry evaluations and treatment as indicated, and the baseline care plan stated the resident had adequate vision, while the social services section of the care plan was blank. The vision appointment listing showed the resident was not on the optometrist schedule for the facility visit on 04/09/26 and there was no evidence he was evaluated then. During interview, the resident stated he needed an eye exam, had not seen an eye doctor since being at the facility, and it had been over 10 years since his last eye exam or new glasses. He reported he could read close up but could not see far away even with his glasses, and said social services had told him the optometrist would not return for four months and that they would contact a community eye provider, but no appointment had been arranged. Social services stated the resident was not seen because he was considered short-term and had no vision concerns, that distance vision was not tested, and that consents for ancillary services were not obtained.
Improperly Applied Incontinence Brief Led to Pressure Injury
Penalty
Summary
The facility failed to ensure a resident’s incontinence brief was applied correctly, resulting in the development of a pressure injury on the right proximal posterior thigh/right gluteal crease area. Resident #74 was admitted with multiple chronic conditions including pulmonary hypertension, type 2 diabetes, COPD, stage 4 chronic kidney disease, insomnia, bradycardia, and atrial fibrillation. The resident’s care plan identified risk for impaired skin integrity related to incontinence, reduced bed mobility, thin fragile skin, and easy bruising, and the quarterly MDS showed the resident was frequently incontinent of bowel and bladder and required extensive assistance with toileting, bathing, dressing, transfers, and mobility. Record review showed the resident was at risk for pressure injuries, with a Braden score of 16 and interventions for repositioning, toileting/incontinence care, and pressure-reducing devices. The medical record documented a new wound on the right gluteal fold/right proximal posterior thigh that was identified as an in-house acquired pressure injury, described as an unstageable pressure injury presenting as a deep tissue injury. The wound care NP documented the area as a suspected deep tissue injury measuring 1.8 cm by 0.9 cm by 0.1 cm with purple epithelium and dermis present. The resident’s MAR and TAR showed no evidence that the ordered wound care from the Medical Director was provided. Staff interviews indicated the wound was believed to be related to the incontinence brief being pulled too tight and its location near the gluteal crease. The resident stated she thought the wound may have been caused by the brief being too tight. An LPN stated the wound was not present when the resident returned from the hospital, that the facility believed it was from the brief being pulled too tight, and that the resident was frequently incontinent with loose bowels and moisture-associated skin damage. Weekly skin checks before the wound was identified did not note an area on the right posterior proximal thigh.
Incomplete Antibiotic Treatment for UTI
Penalty
Summary
The facility failed to ensure a resident was treated for a urinary tract infection as ordered. Resident #78 was admitted with diagnoses including late onset Alzheimer's disease, chronic kidney disease stage 3, diabetes mellitus, incontinence, and urinary tract infections. The resident's MDS assessment showed severe impairment for daily decision-making and frequent urinary incontinence. On 04/03/26, the resident was found sitting on her buttocks in the doorway of another resident's room, hit the side of her head on the doorway, and slid to the floor, after which she was sent to the ER for evaluation. The resident returned from the ER the same day with a diagnosis of UTI and an order for Cephalexin 500 mg twice daily for a total of 10 doses. The urine culture showed greater than 100,000 colony count of E. coli. Review of the eMAR showed the resident received only eight doses of Cephalexin between 04/04/26 and 04/07/26, with no evidence of the last two ordered doses being given. The DON verified that the resident was diagnosed with a UTI, was ordered 10 doses of Cephalexin, and that the order was not completed as written because the electronic physician order defaulted to the following day, resulting in a transcription error and only eight doses being administered.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to provide adequate care and services to manage Resident #5’s pain. The resident was admitted with diagnoses including chronic pain, unspecified contracture, cerebral infarction, chronic gout, osteoarthritis of the left shoulder, and diabetic neuropathy. The 5-day MDS showed the resident was moderately impaired for daily decision-making, received scheduled and PRN pain medications, and had frequent moderate pain that affected sleep and daily activities. After hospitalization for congestive heart failure, the resident returned to the facility and was documented as having left anterior shoulder pain rated 5/10, described as constant, aching, and worse with movement, with non-medication interventions not providing relief. The record showed Diclofenac Sodium External Gel 1% was ordered topically four times daily for chronic pain and Gabapentin 100 mg twice daily for diabetic neuropathy, but there was no documented evidence that PRN pain medication was actually administered on 04/26/26, despite progress notes stating it was given. The resident continued to report pain rated 5/10 on subsequent assessments, and the OT evaluation noted the left upper extremity strength was not tested due to severe pain. The skilled evaluation also documented unchanged pain rated 5/10. The eMAR showed repeated pain complaints on 04/27/26 and 04/28/26, and there was no evidence of PRN pain medication administration between 04/26/26 and 04/30/26. The medical record contained no comprehensive pain care plan, and the DON verified the resident had pain not responsive to scheduled Diclofenac 1%, no PRN pain medications were ordered or administered during that period, and no pain care plan was present.
Pharmacy Review Recommendations Not Timely Addressed
Penalty
Summary
The facility failed to thoroughly address pharmacy recommendations in a timely manner for three residents reviewed for unnecessary medications. A licensed pharmacist completed monthly medication regimen reviews and identified irregularities, but the facility did not document timely or complete follow-up with the prescribing providers as required by policy. The report states this involved Resident #2, Resident #78, and Resident #83 out of six residents reviewed for unnecessary medications. For Resident #2, who had diagnoses including left above-knee amputation, right below-knee amputation, chronic pain syndrome, vascular disease, hypertension, diabetes, heart disease, stage 3 kidney disease, degenerative joint disease of the cervical spine, and carpal tunnel syndrome, the pharmacist noted Amitriptyline was potentially inappropriate for older adults under Beers Criteria and asked for review and monitoring. The PCP responded that the medication was ordered by psychiatry and neurology, and the DON signed the review, but there was no evidence of notification or follow-up with the psychiatrist or neurologist regarding the recommendation. For Resident #83, who had osteoarthritis, acute kidney failure, GERD, seizures, CKD stage 3, and polyneuropathy, the pharmacist identified the combination of Pregabalin and Oxycodone-Acetaminophen as a potentially clinically important drug-drug interaction and asked the physician to review the regimen and monitoring. The Medical Director noted the prescription was monitored by a pain specialist, but the DON confirmed the resident had not been seen by the pain clinic since admission and had no scheduled appointment. For Resident #78, who had Alzheimer’s disease with late onset, anxiety, and unspecified depression, the resident was receiving Remeron, Duloxetine, and Escitalopram. The pharmacist recommended review of Lexapro and Cymbalta due to major interaction and duplicate therapy concerns, but there was no physician response addressing the recommendation, and the psychiatric provider note did not address the duplicate therapy or interaction concerns.
Inadequate Nourishing Snack Options
Penalty
Summary
The facility failed to ensure suitable and nourishing snack options were available for a resident who had a regular diet and was noted to have obesity with a BMI of 36.4. The resident’s medical record showed diagnoses including osteoarthritis, heart disease, high blood pressure, dementia with behavioral disturbances, depression, asthma, and a history of right knee replacement and left knee arthritis. The quarterly nutrition assessment noted the resident had snacks and candy in her room, attended most food-related activities, and was eating ice cream daily from the ice cream parlor, with limited snacking encouraged. During observation and interviews, the resident stated she loved Snickers candy bars, and her son reported she had gained over 20 pounds since admission, had a sweet tooth, and would eat Snickers and Pepsi if available. The son also said she hoarded snacks in her room and had asked at quarterly meetings that the facility not offer snacks all the time. Observation of the snack cart showed items such as cookies, chips, ice cream, and sugary drinks, but no fruits, Jello, sugar-free products, or cottage cheese. The dietary technician confirmed the snack cart items were not nutrient dense or low-calorie and stated snack carts are supposed to offer fruits in addition to the other items provided.
Failure to Confirm UTI Before Starting Antibiotics
Penalty
Summary
The facility failed to perform antibiotic stewardship for one resident when it did not confirm a urinary tract infection (UTI) with diagnostic testing before starting and continuing antibiotic therapy. Resident #77 was admitted with diagnoses including severe dementia with psychotic behaviors, depression, anxiety, atrial fibrillation, hypertension, anemia, insomnia, and moderate protein-calorie malnutrition. The resident’s quarterly MDS assessment showed a brief interview for mental status score of 14/15, indicating the resident was cognitively intact at the time of assessment, and the resident was frequently urinary incontinent, always incontinent of bowel, and required varying levels of assistance with bathing, dressing, toileting hygiene, transfers, and mobility using a wheelchair. Review of the infection log showed the resident was diagnosed with a UTI and prescribed oral Cipro for 5 days after the facility documented new onset urinary frequency and increased urinary urgency. However, the McGeer’s Criteria infection form indicated the resident had only those two symptoms and did not meet criteria for a UTI or require infection surveillance. The medical record showed no urine specimen or urine culture was ordered or obtained before or after the antibiotic was started. The infection preventionist stated she knew the resident did not have a urine culture and did not meet criteria for a UTI or infection surveillance, and she recalled telling the provider that an antibiotic was not indicated and requesting a urine culture, but the doctor wanted the antibiotic started anyway because it was Friday and did not want to address concerns over the weekend.
Survey Results Not Readily Available to Residents
Penalty
Summary
The facility failed to provide residents with easy access to the most recent survey results. During the Resident Council meeting, residents reported they were unable to locate the facility’s annual and complaint survey results and were not aware of the results of the most recent complaint survey conducted on 02/11/26. The Resident Council President, Resident #65, stated he wanted to know the results of the February survey. Observation at the main nurse’s station for halls 100, 200, and 300 showed two black-framed postings labeled as past survey results for 2 years and 1 year, but the frames were positioned above countertop level and were not easily accessible to wheelchair-bound residents. The survey results visible in the frames were dated 03/03/17, 03/31/16, 12/10/15, 10/23/14, 09/11/14, and 05/31/18. The survey results binder in the main conference room contained survey results dated 12/31/24, 09/11/25, and 11/25/25, but it did not include the most recent annual survey completed on 04/12/24 or the most recent complaint survey results from 02/11/26. The DON confirmed the binder was missing those most recent survey results.
Administrator’s Conduct Creates Fearful, Non-Supportive Environment and Undermines Resident Rights
Penalty
Summary
The deficiency involves the facility’s failure to administer the facility in a manner that enabled all residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The administrator’s job description required her to lead, guide, and direct operations in accordance with regulations and facility policies, ensure compassionate quality care, perform rounds to know residents by name and sight, be available and approachable to staff and residents, manage and minimize facility risk, and promote and protect resident rights. The facility’s Resident Rights policy required that all residents be treated equally and that staff be educated on resident rights and the facility’s responsibility to properly care for residents. Resident council minutes documented that residents wanted administration to be more present with them, and the administrator was also listed on the corporate compliance poster as the facility’s compliance officer, meaning complaints called into the compliance line would be forwarded to her. Multiple interviews with staff, residents, and resident representatives described the administrator as unapproachable, rude, condescending, and prone to yelling at staff in front of residents, visitors, and other staff. Anonymous employees reported fear of retaliation if they spoke with the state survey agency or raised concerns, stating that staff who advocated for residents or voiced suggestions were threatened, demoted, or felt their jobs were at risk. Several employees described specific incidents where the administrator entered units and loudly demanded that aides leave and return for another shift, threatening that their paychecks would be affected, and where she screamed at nurses at the nurse’s station about issues such as a medication cart or mask use, took photos with her cell phone, and belittled staff in public areas. These events were witnessed by residents, visitors, and families, and staff reported that residents were startled, uncomfortable, and fearful, and that the environment felt tense and unsafe. Residents and their representatives reported that the administrator did not interact with most residents, showed favoritism toward certain residents, and did not listen to or follow up on resident concerns. A resident stated that the administrator rarely visited residents, always turned down requests, and made it hard for staff to do their jobs. Multiple residents and anonymous residents reported that when they brought up concerns, the administrator became defensive, cut them off, and did not take action, and that they felt she did not have their best interests at heart. One resident was observed crying after speaking with the state survey agency, expressing fear of being “kicked out” of the facility for reporting concerns about the administrator. Residents and staff also reported that good staff had already left and more might leave due to how the administrator spoke to them, and that residents felt they no longer had a voice and were afraid to advocate for themselves because of fear of retaliation. During a resident council meeting, after the administrator and DON left the room, residents stated they wanted a new administrator, described feeling that their concerns were dismissed or minimized with explanations about money or numbers they did not understand, and reiterated that the administrator yelled at staff in front of residents and visitors and treated residents differently. Corporate Human Resources reported that multiple complaints about the administrator had been called in over the past year, though it was unclear whether any formal disciplinary action had been taken. Staff noted that complaints to the corporate compliance line did not appear to result in follow-up and expressed concern that the administrator’s role as compliance officer might affect how complaints were handled. Across interviews, staff and residents consistently described a toxic, tense atmosphere, lack of administrative support, fear of retaliation, and a perception that the administrator did not prioritize residents’ needs, care, or interests. These actions and inactions by the administrator, in contrast to the expectations in her job description and the facility’s Resident Rights policy, resulted in the facility not being administered in a manner that enabled all residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Adequate, Individualized Activities and Sufficient Activity Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide activities that met all residents’ needs and to maintain adequate activity staffing. Resident Council minutes documented residents reporting that activities were being cut short due to insufficient staff and that live musical entertainers were no longer provided. The Administrator responded that activities were not being shortened because of staffing and explained that entertainers were now required to have a tax identification number to be issued a 1099, and that no entertainers were willing to comply. Review of activity calendars for several months showed only one facility-wide calendar with no separate programming for residents with cognitive impairments, limited variety in scheduled activities, and very few one-on-one or independent activities/room visits. Activities were largely repetitive, consisting of daily coffee and discussion with distribution of the Daily Chronicle, weekly Bible study and church services, and bingo three times per week. Interviews and observations showed that activity staff were being used for non-activity tasks and that residents with higher needs were discouraged from attending group activities. An activities staff member reported that the facility previously had pastors come in for Sunday services but now relied on televised services, and a resident expressed a desire for more religious services, particularly Catholic, stating that television services were not interactive. Observations showed an activities assistant hurriedly delivering the Daily Chronicle with minimal interaction and later spending nearly two hours going room to room obtaining menu selections for the next day’s meals. Multiple residents and staff reported that the activities department lacked sufficient staff, that one activity aide was routinely diverted to pass snacks and obtain menus, and that staff had been told by the Administrator not to bring residents to group activities if they needed help, as it was considered unfair to other residents. Anonymous employees stated that residents who were not cognitively intact or were significantly disabled were not to attend activities like bingo if they could not participate independently, and that in-person religious services had not occurred for approximately two months. Specific residents’ records and observations further demonstrated unmet activity needs. One resident with severe dementia, anxiety, depression, insomnia, and impaired mobility had a care plan calling for daily one-on-one room visits by activity staff to promote socialization and reduce boredom, but electronic records for three consecutive months showed no documentation that these visits occurred. Another resident with moderate dementia, anxiety, difficulty walking, and anorexia had a similar care plan for daily one-on-one room visits, also without any documented completion over the same three-month period. During a bingo activity observed with about 20 participants, two activity assistants were present, but one resident sat with eyes closed and no active participation despite having a bingo card and chips, and two cognitively impaired residents were seated without adequate assistance; one was not given a bingo card or chips and continuously chewed on a blanket, and another could not follow the game despite having a card and chips. An employee reported that there was room for improvement in activities, that there were not enough activities, residents were bored, and residents felt their activity suggestions were not being considered. These findings contrasted with the facility’s written activities policy, which stated that activities would reflect residents’ cultural and religious interests and be person-appropriate, with accommodations in schedules, supplies, and timing to optimize participation.
Failure to Maintain Range of Motion Interventions
Penalty
Summary
The facility failed to ensure a resident with contractures received appropriate services to maintain mobility and prevent further decrease in range of motion. Resident #51, who was admitted with multiple diagnoses including Parkinson's disease, diabetes mellitus, and contracture of the left hand, was observed on multiple occasions without the prescribed double washcloth rolls in both hands. The care plan, dated 08/25/23 and revised on 04/10/24, indicated the need for these washcloths to prevent further decline in range of motion. However, observations on 04/10/24 and 04/11/24 revealed that the resident did not have the washcloths in place as required by the care plan. The Minimum Data Set (MDS) quarterly assessment indicated that Resident #51 had severe cognitive impairment and was dependent on staff for various activities of daily living. Despite this, the intervention to place double rolled washcloths into the resident's hands was documented as completed for the day shift on 04/11/24. Interviews with a State tested Nursing Assistant (STNA) and a Registered Nurse (RN) Supervisor confirmed that the washcloths were not applied as per the care plan, highlighting a failure in following the prescribed interventions to maintain the resident's range of motion.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter drainage bag and tubing were not resting on the floor for Resident #3, who had an intact and independent cognition level and used an indwelling urinary catheter due to urinary obstruction causing urinary retention. Observations on multiple occasions revealed the catheter drainage bag and tubing were touching the floor under the resident's wheelchair. An interview with an LPN confirmed that the urinary catheter drainage tubing and bag were resting on the floor, which was against the facility's policy. The facility policy, revised on 07/01/23, explicitly stated that catheter tubing and bags should not rest on the floor.
Inappropriate Antibiotic Use for Asymptomatic Resident
Penalty
Summary
The facility failed to ensure appropriate antibiotic use and that infections met treatment criteria, affecting one resident. Resident #25, who was admitted with multiple diagnoses including dementia, dysphagia, and chronic obstructive pulmonary disease, was prescribed ciprofloxacin for a urinary tract infection (UTI) based on a urinalysis showing greater than 100,000 CFU/ml Klebsiella Pneumonia. However, the resident exhibited no symptoms of a UTI, which did not meet the McGeer Criteria for treatment. Despite this, the physician chose to continue the antibiotic after being notified by the Infection Preventionist/LPN. The facility's Infection Control Log and policy on Antibiotic Stewardship Program indicated that the use of ciprofloxacin was not justified based on the resident's lack of symptoms. The Infection Preventionist/LPN confirmed that there was no indication for the antibiotic and that the physician was informed but opted to proceed with the treatment. This failure to adhere to the facility's policy and the McGeer Criteria resulted in inappropriate antibiotic use for Resident #25.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 189 citations issued within 25 miles in the last 12 months — including the 3 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hopedale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carriage Inn Of Cadiz Inc | 6.2 mi | ★★★★★ | 2 | 0 |
| Dixon Healthcare Center | 10 mi | ★★★★★ | 18 | 0 |
| Sienna Skilled Nursing & Rehabilitation | 10.9 mi | ★★★★★ | 24 | 0 |
| Sienna Hills Nursing & Rehabilitation | 12.2 mi | ★★★★★ | 0 | 0 |
| Steubenville Country Club Manor | 12.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.