Below 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 Green Meadows Skilled Nursing And Rehab during CMS and state inspections, most recent first.
Insufficient staffing and lack of consistent nurse leadership affected resident care needs. Surveyors found no DON or ADON present, and staffing schedules showed limited CNA coverage on some units despite many residents needing mechanical lifts, incontinence care, feeding assistance, and showers. Residents were observed or reported to be left in bed for meals, waiting too long for toileting help, and having soiled briefs, skin irritation, and missed bathing care. Staff and family members described frequent agency use, call-offs, and difficulty completing routine care when only two CNAs were assigned to a unit.
Unsafe and poorly maintained facility environment: The facility had leaking roofs, water-damaged and stained ceiling tiles, rusted and dirty shower fixtures, stained carpeting, and a foul odor from the soiled linen/trash room that spread into the hallway. A lobby restroom was closed because the ceiling was falling down, and a resident in a wheelchair ran into trash cans placed in a public hallway near leaking water. Staff confirmed the ongoing leaks, stained ceilings, and deteriorated conditions throughout multiple wings.
Resident dignity and independence during meals were not maintained when staff assisted residents while standing over them, left one resident waiting with a tray for an extended period, and failed to position another resident so she could reach her food. Two residents required total feeding assistance, one resident needed set-up and cueing, and another needed feeding more than half the time. A CNA and an LPN confirmed the observations, including that staff should be seated when assisting with eating and that residents should not be left waiting with food in front of them.
Unsanitary and Overheated Shower Room on E-Wing: The facility failed to maintain the E-Wing shower room in a sanitary, comfortable condition and within the required temperature range. An LPN and CNA observed a shower that could not be shut off, green corrosion on the shower and soap tray, rusted components, and a strong ammonia odor from the adjoining dirty laundry/trash room. The Maintenance Director confirmed the room was 82 degrees F and stated the unit had only one shower room for all 26 residents, while staff and a resident reported the room was excessively hot and the shower had ongoing leaks and other maintenance problems.
Failure to provide timely ADL assistance affected three residents who were dependent on staff for meals, toileting, and bathing. One resident who required a mechanical lift and help with eating was not always gotten up for lunch, another resident reported waiting too long for bedpan assistance and having bowel/bladder accidents with red, irritated peri-area skin, and a short-stay resident had no documented baths or showers despite a scheduled shower plan. The Administrator confirmed there was no evidence the resident received bathing before the family complaint.
A resident with stroke, diabetes, incontinence, and moderate cognitive impairment received incontinence care from two CNAs and an LPN. After the care was completed, one CNA touched the resident’s items while still wearing gloves, then removed the gloves and entered another resident’s room without performing hand hygiene before handling a lunch tray. The CNA confirmed the lapse, and the facility hand hygiene policy required proper hand hygiene to assist in the spread of infection.
The facility did not hold a required Quality Assessment and Assurance (QA) meeting in the first quarter of 2024, as mandated by their policy. The absence of attendance sheets or documentation was confirmed by the DON and Administrator, potentially impacting all 89 residents.
A long-term care facility failed to maintain a comprehensive infection control program, including delayed COVID-19 reporting, lack of staff illness policy, missing water management logs, improper medication administration, and inadequate tracking of potential outbreak illnesses. Multiple residents exhibited flu-like symptoms, but the DON did not suspect an outbreak due to the absence of elevated temperatures.
The facility failed to complete consistent staff evaluations for two CNAs, potentially affecting all residents except those on the E wing. One CNA, hired in 2022, did not receive a 90-day or yearly evaluation in 2023, with only one evaluation on file from 2024. Another CNA, hired in 2024, lacked a 90-day evaluation. The HR/Personnel Manager confirmed these oversights but was unsure of the reasons.
The facility failed to maintain a homelike environment in the memory care unit by allowing a basin to collect water from a ceiling leak outside a resident's room for months and not addressing disrepair in the walls of several residents' rooms. The resident, with Alzheimer's and other health conditions, was at moderate risk of falling, and the basin partially blocked the doorway. The Maintenance Supervisor admitted that maintenance issues were only addressed through a work order system, compromising the facility's policy on resident rights.
A resident with multiple medical conditions and a risk for falls was found on the floor after adjusting his lift chair. The facility removed the chair's remote to prevent further falls, but did not conduct a restraint assessment, violating regulations that require residents to be free from physical restraints unless medically necessary.
A facility failed to complete a Significant Change MDS assessment for a resident within 14 days of starting hospice care. The resident, with multiple health issues, began hospice services as ordered by a physician, but the required assessment was not documented. This was confirmed by the DON.
The facility failed to ensure accurate comprehensive assessments for two residents, leading to documentation deficiencies. One resident was admitted with a Stage III pressure ulcer, but MDS assessments inaccurately indicated no ulcer. Another resident with hearing loss and prescribed Ativan for anxiety was inaccurately assessed as having adequate hearing and no anti-anxiety medication use. These discrepancies were confirmed by the DON.
The facility failed to develop comprehensive care plans for three residents, resulting in unaddressed medical needs. A resident receiving oxygen lacked a care plan for its use, another with constipation and diarrhea had no care plan for gastrointestinal issues, and a third with hearing loss and dialysis access had incorrect care plan details. These deficiencies were confirmed through observations and staff interviews.
The facility failed to provide proper respiratory care and documentation for two residents. One resident received oxygen without physician's orders or a care plan, and the oxygen tubing was not dated. Another resident's oxygen cannula was improperly stored on a wheelchair without a protective bag. These issues were confirmed by staff interviews and observations.
The facility failed to monitor vital signs and weights for two residents requiring dialysis, and did not maintain adequate communication with an outside dialysis center. This resulted in missing documentation of critical health metrics and communication forms, as confirmed by the DON and Dialysis Administrative Assistant.
The facility failed to date multi-dose insulin pens when first accessed, affecting three residents prescribed insulin. Observations revealed that insulin pens for these residents were not dated, and interviews with LPNs confirmed this oversight. The facility's policy requires recording the date of opening on multi-dose containers, which was not followed.
A facility failed to ensure a physician order was written before obtaining a lab test for a resident with diabetes and stroke. Despite a pharmacy recommendation for HgbA1c monitoring every three months, tests were conducted in three consecutive months without a physician order. The DON confirmed the absence of an order for the December test, noting the resident's multiple doctors sometimes ordered tests outside the office.
The facility failed to maintain accurate and complete medical records for three residents. A resident with quadriplegia was incorrectly documented as performing ADLs independently. Another resident's bowel movement records were incomplete, and a third resident's pain management records lacked documentation of non-pharmacological interventions. These deficiencies were confirmed by the DON, an LPN, and the ADON.
A resident with multiple medical conditions was involved in an altercation with a nurse, leading to allegations of verbal abuse. The facility failed to conduct a thorough investigation, as required by its policy, by not interviewing the resident or potential witnesses and allowing the accused nurse to continue working. The investigation relied on unsigned staff statements and lacked proper documentation, resulting in a deficiency.
A facility failed to remove a fall hazard outside a resident's doorway, where a yellow basin and wet floor sign were placed to collect water from a ceiling leak. The resident, at moderate risk of falling and using a rollator, had to maneuver around these obstacles. Staff confirmed the hazard's presence for months, and the Maintenance Supervisor admitted to not fixing the leak promptly.
A facility failed to provide a resident with nectar thick liquids as ordered, due to staff not following the manufacturer's instructions for thickening liquids. This affected a resident with dysphagia and had the potential to impact other residents on thickened liquid diets.
A facility failed to administer narcotic pain medication according to physician orders and did not encourage non-pharmacologic interventions before medication administration. A resident with multiple diagnoses received hydrocodone-acetaminophen for pain levels less than five, contrary to the order for pain levels between five and ten. The DON confirmed the inappropriate administration and lack of documentation for non-pharmacologic interventions, highlighting non-compliance with facility policies.
The facility's Quality Assurance policy was found deficient as it lacked comprehensive procedures, including the role of the Infection Control Preventionist, feedback mechanisms, and monitoring systems. The policy did not address how performance improvements would be evaluated and sustained, affecting all 89 residents. This was confirmed by the Director of Nursing and the Administrator.
The facility failed to provide bed hold notices to two residents before their hospital transfers. One resident, with multiple serious diagnoses, was transferred four times without receiving a notice, as the Business Office Manager only issued notices to Medicaid residents. Another resident with end-stage renal disease was also transferred without a notice, contrary to the facility's policy.
Two residents were affected by the misappropriation of narcotic medications by an LPN, who diverted 55 oxycodone tablets from one resident and one Norco tablet from another. The incident was discovered when a narcotic card was found missing, leading to the LPN's admission of diversion. The facility's policy on abuse prevention was violated, resulting in a deficiency that was later corrected.
Insufficient Nursing and CNA Staffing Affected Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing to meet residents’ total care needs and did not have a licensed nurse in charge on each shift as described in the report. During the survey, the DON was on vacation, the ADON position was not filled, and surveyors observed no DON and no ADON present at the facility. The facility’s annual assessment described an average daily census of 87-100 residents and a staffing plan based on resident acuity, but the schedules reviewed showed only one licensed nurse assigned to each of four units per shift and two to three CNAs per unit per shift, with some units staffed with only one to two CNAs. The facility also used agency staff and a transport aide to help cover resident care and transportation needs. The report identified multiple residents whose care needs were affected by the staffing pattern. One resident with stroke, hemiplegia, aphonia, heart failure, chronic lung disease, dysphagia, depression, and bilateral retinopathy was dependent on staff for eating, bathing, dressing, transferring, and mobility, and required a mechanical lift with two staff. That resident was observed lying in bed at lunch without a meal tray, and an LPN stated the resident had already been fed in bed because staff did not have time to get him up for the meal, even though he preferred to eat in his wheelchair. Another resident with end-stage renal disease, chronic respiratory failure, atrial fibrillation, Down syndrome, morbid obesity, depression, mild intellectual disabilities, anemia, dialysis, and hypertension was dependent for transfers, bathing, and dressing; the resident reported waiting too long for help to use the bedpan and having bowel and bladder accidents in bed, and staff observed redness and irritation to the peri area. A third resident with stroke, diabetes, dysarthria, anxiety, depression, impaired vision, left-sided weakness, and hypertension required a two-person mechanical lift and was incontinent of urine and bowel. During observed incontinence care, staff found the resident’s brief and bed soiled, and the resident’s buttocks and peri area were red and irritated with moisture-associated skin damage. The report also described a short-stay resident who required substantial to maximum assistance with toileting, dressing, bathing, and wheelchair mobility, and whose family reported the resident had not received a shower or bath since admission. The facility administrator confirmed there was no documentation showing the resident had received baths or showers before the complaint. Staff interviews also described frequent call-offs, agency staff no-call/no-shows, and difficulty getting residents up, dressed, and to meals when only two CNAs were assigned to a unit.
Unsafe and poorly maintained facility environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During observation, the men's restroom in the main lobby was posted as temporarily out of order, and the inside of the restroom had a hole in the ceiling over the toilet with rusted metal exposed. The Administrator confirmed the restroom was closed because of a roof leak that was causing the ceiling to fall down and could not confirm when it had been closed for public use. She also stated roof repairs were pending and had not yet been completed. Multiple areas throughout the facility showed water damage, staining, and deterioration. In the E Wing solarium, 13 ceiling tiles had brown stains, and an LPN confirmed the staining. In the lobby area, ceiling tiles around hanging lights, ceiling fans, and throughout common areas were observed with black, gray, or orange mold-like substance, which the Maintenance Director confirmed. He stated the ceilings had been leaking since he started at the facility and that stained tiles were changed when they got bad because the roof had not been repaired. He also reported a bucket had been placed under leaking tiles in the E Wing solarium. Additional observations on F Wing, A Wing, B Wing, and E Wing showed stained carpeting, a stained and dirty shower bed, rusted and dirty shower fixtures, stained ceiling tiles, a foul odor from the soiled linen and trash room that extended into the hallway, a leaking ceiling into a bucket in a resident hallway, and trash cans and caution signs placed in a public hallway where a resident in a wheelchair ran into the cans while trying to leave the wing. A resident adjacent to the soiled linen room reported occasionally noticing the odor, and another resident stated she avoided leaving her room, disliked the shower room and solarium, and found them dirty. The contractor later stated the roof replacement had been delayed and that the signed contract covered roof repairs for E and F wings, the public areas connecting the wings, and the multi-level portion of the building, but not A, B, C, or D wings.
Dining Assistance and Resident Dignity Not Maintained
Penalty
Summary
The facility failed to promote resident dignity and independence during dining by allowing staff to assist residents while standing over them, leaving residents without timely feeding assistance, and failing to position a resident so she could reach her meal. The deficiency involved four residents out of eleven observed for dining needs in a facility census of 93. The cited concern was that residents were not consistently provided a dignified dining experience and were not always assisted in a manner that supported their ability to eat. Resident #24 had diagnoses including Alzheimer’s disease, dementia, gastroesophageal reflux, major depressive disorder, hyperlipidemia, type 2 diabetes, peripheral vascular disease, and anxiety disorder. Her MDS showed a BIMS score of 2, indicating severe cognitive impairment, and she required substantial to maximum assistance with eating. Resident #87 had diagnoses including cerebral infarction due to embolism, unspecified dementia, vascular dementia, depression, GERD, and a pacemaker, with a BIMS score of 0 and partial to moderate assistance needed for most ADLs. Both residents had care plans that included assistance with meals as needed, and an undated facility document identified both as needing to be fed. During dining observation, Resident #65 sat with a tray in front of him for over 20 minutes without staff assisting or encouraging him to eat, and later an LPN sat to assist him. Resident #24 received her tray without a staff member seated with her, and a CNA briefly put food in her mouth while walking past before leaving to assist another resident. Resident #92 was brought to the dining room and placed sideways at the end of a table facing away from the table; when her tray was placed in front of her, she could not reach her food and needed help with tray setup and positioning to eat. Resident #24 was later observed being assisted while a CNA stood over her, and when the Speech Therapist left while assisting Resident #87, the CNA was left to assist both residents at the same time. A CNA confirmed these observations, and an LPN stated staff should be seated when assisting residents with eating and that residents should not have to wait with food in front of them for assistance.
Unsanitary and Overheated Shower Room on E-Wing
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable shower room on the E-Wing memory care unit, and failed to maintain the shower room temperature between 71 degrees Fahrenheit and 81 degrees Fahrenheit. During observation, the wall-mounted shower in the E-Wing shower room was running continuously and could not be shut off, and the room was very warm. The shower area had light green corrosion around the shower and soap tray, the heater and floor drain were rusted, and the shower room was attached without doors to the dirty laundry and trash room, where a strong ammonia odor was present. An LPN confirmed these conditions during the observation and stated she would not feel clean if she had to shower there because of the heat and odor. The Maintenance Director later checked the room temperature and found it to be 82 degrees Fahrenheit, and stated the facility should be kept between 70 and 80 degrees Fahrenheit. He also stated there were no ventilation or exhaust fans in the shower rooms, only transfer grills, and that he had been unable to get parts to fix the shower for months. Staff interviews confirmed the E-Wing had only one shower room for all 26 residents on the unit, with no other shower areas available on the E-Wing. A resident reported the shower never stopped and that it was very hot in the shower room, and a CNA stated the room was so hot she almost vomited or passed out when showering residents and that the corrosion made the soap dish unsanitary. Work orders documented repeated problems with the shower faucet, dripping water, temperature issues, and a missing floor drain cover.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for residents who were dependent on staff, including timely incontinence care, getting residents up for meals, and bathing/showering as scheduled. The deficiency involved three residents reviewed for provision of care, while the facility identified 56 residents who needed assistance with incontinence care, bathing/showering, and use of a mechanical lift to be set up in a chair for meals. The facility census was 93. Resident #109 had diagnoses including stroke with hemiplegia, aphonia, heart failure, chronic lung disease, dysphagia, major depression, and bilateral retinopathy. His MDS showed he was cognitively intact but dependent on staff for eating, oral hygiene, bathing, dressing, transferring, and mobility, and he required a mechanical lift and two staff for transfers. He also had bowel and bladder incontinence. During observation, he was found lying in bed at lunchtime with no meal tray present, and an LPN stated he had just eaten lunch with assistance from a nursing aide and that staff did not have time to get him up for lunch, though they planned to do so soon. Later, the resident stated he liked to be up in his chair for lunch and dinner but that staff did not always get him up for lunch. Resident #114 had diagnoses including end stage renal disease, chronic respiratory failure, atrial fibrillation, Down syndrome, morbid obesity, depression, mild intellectual disabilities, anemia, kidney dialysis, and hypertension. He was cognitively intact and dependent on staff for transfers and bathing/dressing, and he reported he could control his bowels and bladder but sometimes had to wait too long for help with the bedpan and would have bowel or bladder accidents in bed. He also reported his bottom was sore and that the nurse told him it was red that morning. CNA #186 confirmed the resident’s peri area was red and irritated and reported it to the nurse. Resident #184, a short-stay resident with diagnoses including shingles, chronic lung disease, heart failure, hypertension, bilateral leg pain, and generalized weakness, was cognitively intact and required substantial to maximum assistance with toileting, dressing, bathing/showering, and wheelchair mobility. Her shower schedule called for showers twice weekly, but the facility had no documentation that she received baths or showers from admission through the date of the daughter’s complaint, and the Administrator confirmed there was no evidence documented that she had received baths or showers before the complaint.
Hand Hygiene Not Performed After Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during incontinence care for one resident. Resident #113 was admitted with diagnoses including stroke, diabetes, dysarthria, anxiety, depression, impaired left eye, left-sided weakness from stroke, and high blood pressure. The resident’s annual MDS showed a two-person transfer with a mechanical lift, incontinence of urine and bowel, and a BIMS score of 11/15, indicating moderate cognitive impairment. During observation of incontinence care, two CNAs gathered supplies, performed hand hygiene, and donned clean gloves before transferring the resident to bed with a mechanical lift and providing perineal care with soap and water. The resident’s buttocks were observed to be red and irritated with moisture associated skin damage, and an LPN verified the area and applied Triad cream. After care, one CNA did not remove her gloves before touching the resident’s call light, bed rails, and blankets, then removed her gloves and did not perform hand hygiene before entering another resident’s room to remove a lunch tray. The CNA confirmed she did not perform hand hygiene after removing gloves and before entering the next room. The facility policy stated that hand hygiene will be properly performed to assist in the spread of infection.
Failure to Conduct Required QA Meeting in First Quarter of 2024
Penalty
Summary
The facility failed to conduct a Quality Assessment and Assurance (QA) meeting during the first quarter of 2024, which is a requirement as per their policy dated September 2021. This policy mandates that the QA committee meet at least quarterly to identify and address quality assessment and assurance issues. Upon review, no attendance sheets or documentation were provided to confirm that such a meeting took place in the specified period. The Director of Nursing (DON) and the Administrator both verified the absence of records indicating that a QA meeting was held during this time. This deficiency had the potential to affect all 89 residents in the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies. The facility did not report a positive COVID-19 case for Resident #235 to the local health department (LHD) in a timely manner. The resident tested positive on January 26, 2025, but the LHD was not notified until February 4, 2025, which was nine days later. The Director of Nursing (DON) acknowledged the delay and could not provide evidence of an earlier notification attempt. The facility also lacked a policy for managing staff illness. Interviews revealed that management staff had been ill, but there was no clear guidance on when staff should stay home. The Administrator and Assistant Director of Nursing (ADON) confirmed the absence of a policy, and the facility defaulted to CDC guidelines, which recommend staying home for 24 to 48 hours after symptoms improve. This lack of policy could lead to inconsistent handling of staff illnesses. Additionally, the facility did not maintain water management logs for 2023, as confirmed by the Maintenance Director. There was also an observation of improper medication administration, where a Licensed Practical Nurse (LPN) failed to clean the rubber seal of a multi-use insulin pen before use. Furthermore, there was no tracking or trending of potential outbreak illnesses, despite multiple residents exhibiting flu-like symptoms. The DON did not suspect an outbreak due to the absence of elevated temperatures, but several residents reported symptoms such as vomiting and diarrhea within a short period, raising concerns about infection control practices.
Inconsistent Staff Evaluations for CNAs
Penalty
Summary
The facility failed to consistently complete staff evaluations for two Certified Nursing Assistants (CNAs), which had the potential to affect all residents except those on the E wing where the CNAs had not worked. CNA #367, hired on 11/09/22, did not receive a 90-day or yearly evaluation in 2023, with the only evaluation on file dated 11/14/24. An interview with the Human Resources (HR) / Personnel Manager confirmed the absence of these evaluations and was unsure why they were missed. Similarly, CNA #370, hired on 10/07/24, did not have a 90-day evaluation in her file, which was also confirmed by HR/Personnel Manager #316, who was uncertain about the reason for the oversight.
Facility Fails to Maintain Homelike Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a homelike environment in the E wing, specifically in the memory care unit, by allowing a basin to collect water from a ceiling leak outside a resident's room for an extended period. This issue persisted for months, as confirmed by staff interviews, and was not addressed promptly. The resident, who had Alzheimer's disease and other health conditions, was at moderate risk of falling, and the basin partially blocked the doorway, posing a potential hazard. Additionally, the facility did not maintain the walls in several residents' rooms, which were in disrepair with gouges and marks that removed or peeled back the paint. These conditions were observed in nine residents' rooms, affecting the overall homelike atmosphere of the unit. Family members and staff confirmed that the state of the walls was not homelike and would not be acceptable in a home setting. The Maintenance Supervisor acknowledged the issues during an environmental tour and admitted that maintenance concerns were only addressed through a work order system, which did not include regular tours to identify problems. The facility's policy on resident rights emphasizes a dignified existence, which was compromised by the conditions observed in the memory care unit.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that Resident #82 was free from physical restraints, as required by regulations. Resident #82, who had multiple medical conditions including metabolic encephalopathy, respiratory failure, and diabetes, was at risk for falls due to incontinence, decreased strength, and poor balance. The care plan included various interventions to prevent falls, such as using a bed alarm and keeping the bed in the lowest position. However, after an incident where the resident was found on the floor with the lift chair in a high position, the facility decided to place the lift chair remote in a pocket to discourage the resident from adjusting it. This action was taken without conducting a restraint assessment, which is necessary to determine if the intervention restricts the resident's freedom of movement. The Director of Nursing confirmed that the remote was taken away as an intervention to prevent the resident from falling out of the chair, as he lacked the strength to remain seated when the chair was adjusted. Despite the facility's policy stating that restraints should not be used for fall prevention and only after other alternatives have been tried unsuccessfully, the remote was removed without proper assessment. The facility's policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident, which was applicable in this case as the resident could not access the remote to adjust the chair independently.
Failure to Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident within 14 days of initiating hospice services. The resident, who was admitted with multiple diagnoses including cerebral infarction, protein-calorie malnutrition, and heart failure, among others, began receiving hospice care as per a physician's order dated January 12, 2025. However, a review of the medical record showed no evidence of the required assessment being completed within the specified timeframe. This deficiency was confirmed during an interview with the Director of Nursing on February 10, 2025.
Inaccurate Comprehensive Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate comprehensive assessments for two residents, leading to deficiencies in their care documentation. Resident #82 was admitted with a Stage III pressure ulcer to the sacrum, as noted in a wound evaluation. However, both the Admission and Discharge Minimum Data Set (MDS) assessments inaccurately indicated that the resident did not have a pressure ulcer. This discrepancy was confirmed by the Director of Nursing during an interview, highlighting a failure in accurately documenting the resident's condition upon admission and discharge. Resident #44's comprehensive assessment also contained inaccuracies. The resident, who had profound hearing loss in the right ear and moderately severe high-frequency sensorineural hearing loss in the left ear, was inaccurately assessed as having adequate hearing. Additionally, the resident was prescribed Ativan for anxiety, which was administered on specific dates, yet the MDS assessment failed to reflect the use of anti-anxiety medication. The Director of Nursing confirmed these inaccuracies, indicating a failure to accurately document the resident's hearing status and medication use.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #67, who was admitted with conditions including pulmonary embolism and heart failure, was observed receiving oxygen via nasal cannula on multiple occasions. However, there were no physician orders or care plans in place for the use and maintenance of oxygen equipment, as confirmed by interviews with the LPN and the Director of Nursing (DON). Resident #71, diagnosed with multiple conditions including cerebral infarction and constipation, had physician orders for various medications to manage constipation and diarrhea. Despite this, there was no care plan addressing these gastrointestinal concerns. The resident reported experiencing constipation for several days at a time and occasionally required assistance with toileting. Interviews with the resident and a CNA confirmed these issues, and the DON verified the absence of a care plan for these concerns. Resident #44, with diagnoses including end-stage renal disease and hearing loss, had no care plan addressing their profound hearing impairment or the correct dialysis access site. The resident had a history of ear wax removal and hearing difficulties, which were not reflected in the care plan. Additionally, the care plan incorrectly focused on a dialysis catheter instead of the left upper arm fistula, which was the actual access site in use. Interviews with the resident, DON, and Assistant Director of Nursing confirmed these discrepancies.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to ensure proper respiratory care for Resident #67, who was admitted with diagnoses including pulmonary embolism, heart failure, hypertension, and type two diabetes mellitus. There were no physician's orders for oxygen use or maintenance of oxygen equipment, and the care plan did not include oxygen use. Observations on two separate days revealed Resident #67 was receiving oxygen via nasal cannula, but the oxygen tubing was not dated. Interviews with the LPN and the Director of Nursing confirmed the absence of orders and a care plan for oxygen use, as well as the lack of documentation for oxygen administration on specific dates. Additionally, the facility did not properly store the oxygen cannula for Resident #2, who had multiple diagnoses including cerebral infarction and heart failure. An observation showed the portable oxygen tank nasal cannula was hanging on the back of the resident's wheelchair without a protective bag. This was verified by the Director of Nursing. The facility's policy, dated September 2021, required a physician's order to determine the need for oxygen, which was not followed in these cases.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide adequate dialysis care and services for two residents, leading to deficiencies in monitoring vital signs and weights before and after dialysis sessions. Resident #52, who was admitted with diagnoses including end-stage renal disease, type two diabetes mellitus, dependence on renal dialysis, and heart failure, had multiple instances where vital signs and weights were not documented on dialysis days. Specific dates were noted where pre-dialysis vital signs, weights, and other critical health metrics were missing from the records, indicating a lack of adherence to the physician's orders and facility protocols. Similarly, Resident #239, also diagnosed with end-stage renal disease and other chronic conditions, experienced lapses in documentation of vital signs and weights associated with dialysis treatments. The facility failed to maintain proper communication with the outside dialysis center, as evidenced by missing dialysis communication forms on several occasions. This lack of documentation and communication was confirmed through interviews with the Director of Nursing and the Dialysis Administrative Assistant, who acknowledged the inconsistencies in sending and receiving the necessary forms. The facility's dialysis services and coordination agreement required staff to provide a dialysis communication form with each resident, listing vital signs, weights, and any changes in condition. However, this protocol was not consistently followed, leading to gaps in the residents' medical records. The Director of Nursing verified these deficiencies, highlighting a systemic issue in the facility's management of dialysis care and communication with external providers.
Failure to Date Multi-Dose Insulin Pens
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens were dated when first accessed, affecting three residents who were prescribed insulin. During medication administration observations, it was noted that a Humulin 70/30 Kwikpen and a Lantus SoloStar pen for two residents, as well as a Novolin 70/30 FlexPen for another resident, were not dated. Interviews with the LPNs administering the medications confirmed the absence of dates on the insulin pens. The facility's policy on administering medications requires that the date of opening be recorded on multi-dose containers, but this was not adhered to in these instances.
Failure to Obtain Physician Order for Lab Test
Penalty
Summary
The facility failed to ensure a physician order was written prior to obtaining a laboratory test for a resident. The resident, who had diagnoses including type two diabetes mellitus and stroke, was cognitively intact and had medication orders for diabetes management. A pharmacy recommendation requested monitoring of HgbA1c every three months. However, HgbA1c levels were obtained in October, November, and December without a corresponding physician order. The Director of Nursing (DON) confirmed the absence of an order for the December test, explaining that the resident saw multiple doctors who sometimes ordered lab tests outside the office.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for three residents. For one resident with quadriplegia, the medical records inaccurately documented that the resident independently performed transfers and bathing, despite being dependent on staff for all activities of daily living (ADLs). This discrepancy was confirmed by the Director of Nursing (DON) during an interview. Another resident reported issues with constipation, and the review of bowel movement records revealed incomplete documentation, with missing entries for specific shifts, which was also verified by the DON. Additionally, the facility did not document non-pharmacological interventions attempted before administering pain medications to a resident with multiple medical diagnoses, including end-stage renal disease. The medication administration record (MAR) showed the administration of pain relievers, but there was no documentation of the specific non-pharmacological interventions attempted, as required by the physician's orders. This lack of documentation was confirmed during interviews with a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON).
Inadequate Investigation of Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure the protection of a resident during an investigation of alleged emotional/verbal abuse and did not conduct a thorough investigation into the allegations. The incident involved a resident with multiple medical conditions, including systemic lupus erythematosus, osteomyelitis, right-sided weakness following a stroke, stage four kidney disease, and heart disease. The resident was reported to have been aggressive with a phlebotomist during a blood draw, leading to an altercation with a nurse, who was later accused of verbal abuse. The facility's investigation was inadequate, as it did not include a documented interview with the resident or other potential witnesses, such as the phlebotomist. The nurse accused of abuse was allowed to continue working during the investigation, contrary to the facility's policy, which required immediate suspension of any employee accused of abuse. The investigation relied on unsigned statements from staff members, and there was no evidence of attempts to contact the phlebotomist for an interview. The facility's policy required thorough investigation and documentation of all allegations of abuse, including interviews with witnesses and involved parties. However, the investigation lacked proper documentation and failed to follow the established procedures, resulting in a deficiency. The lack of documentation and failure to suspend the accused nurse during the investigation were significant oversights in the facility's handling of the incident.
Failure to Remove Fall Hazard Outside Resident's Doorway
Penalty
Summary
The facility failed to ensure that the area outside Resident #55's doorway was free from potential fall hazards. Resident #55, who was at moderate risk of falling due to conditions such as Alzheimer's disease, COPD, and an unsteady gait, had a yellow plastic basin and a wet floor sign blocking part of his doorway. These items were placed to collect water from a ceiling leak, creating a potential fall hazard. Despite the resident's cognitive impairment and need for supervision when walking, the basin and sign remained in place for months, requiring the resident to maneuver around them with his rollator. Interviews with staff confirmed the presence of the basin and sign for an extended period, with no immediate action taken to address the leak or remove the hazard. The Maintenance Supervisor acknowledged the ongoing leak and admitted to not calling a roofer to fix it, despite the issue persisting for about a month or two. The facility's policy on falls, which mandates identifying interventions to reduce fall risks, was not adhered to in this instance, leading to the deficiency being cited under Complaint Number OH00161264.
Failure to Provide Nectar Thick Liquids as Ordered
Penalty
Summary
The facility failed to ensure that Resident #42 received nectar thick liquids as ordered, which was necessary due to the resident's medical conditions, including oropharyngeal dysphagia, dementia, and schizophrenia. The resident's care plan and physician orders specified a diet of mechanical soft texture and nectar thick consistency liquids. However, during an observation, it was noted that the coffee provided to Resident #42 was not of the correct nectar thick consistency. Certified Nursing Assistant #368 confirmed that she had not added the correct amount of thickening product to achieve the required consistency, as per the manufacturer's instructions. Interviews with staff, including a Speech Language Pathologist and a Licensed Practical Nurse, revealed that there was a misunderstanding or lack of adherence to the manufacturer's instructions for preparing nectar thick liquids. The staff had been using an incorrect amount of thickener, resulting in liquids that were too thin for residents requiring nectar thick consistency. This deficiency was identified during a complaint investigation and had the potential to affect other residents on thickened liquids diets.
Inappropriate Administration of Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that narcotic pain medications were administered according to physician orders and that non-pharmacologic pain relief interventions were encouraged prior to medication administration. This deficiency affected a resident with multiple diagnoses, including end-stage renal disease, muscle weakness, spondylolisthesis, osteoarthritis, hydronephrosis, and chronic gout. The resident's care plan indicated a potential for pain related to these conditions, with interventions including administering medications per physician orders. However, the resident's January 2025 Medication Administration Record (MAR) showed that hydrocodone-acetaminophen was administered for pain levels less than five, contrary to the physician's order, which specified administration for pain levels between five and ten. The Director of Nursing (DON) confirmed that the medication was given inappropriately for pain levels less than five and acknowledged that non-pharmacologic interventions should have been tried and documented before administering the medication. The facility's policy on pain assessment and management emphasized recognizing pain, implementing management approaches, and using specific strategies for different pain levels. Additionally, the facility's policy on administering medications required adherence to physician orders. The deficiency was identified during a complaint investigation, indicating non-compliance with the facility's policies and procedures.
Deficiency in Quality Assurance Policy and Procedures
Penalty
Summary
The facility failed to establish comprehensive written policies and procedures related to the Quality Assurance (QA) process, which had the potential to affect all 89 residents. The existing Quality Assessment and Assurance policy, dated September 2021, outlined that the committee would include the Administrator, the Director of Nursing Services, a physician designated by the facility, and other staff members. This committee was tasked with identifying issues affecting the quality of care and services provided to residents, meeting at least quarterly to address these issues, and developing and implementing corrective plans for identified deficiencies. However, the policy was found lacking in several critical areas. The policy did not include the role or participation of the Infection Control Preventionist (ICP) in the QA process. Additionally, it failed to address procedures for feedback, data collection, and monitoring, including adverse event monitoring. The policy also lacked information on how actions taken to ensure performance improvement would be evaluated and tracked to ensure that improvements were realized and sustained. These deficiencies were confirmed by the Director of Nursing and the Administrator, who verified that the facility did not have any additional policies regarding QA beyond the corporate policy from September 2021.
Failure to Provide Bed Hold Notices Before Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to two residents, Resident #52 and Resident #82, prior to their transfers to the hospital. Resident #82, who had multiple diagnoses including metabolic encephalopathy and respiratory failure, was discharged to the hospital on four occasions without receiving a bed hold notice. The Business Office Manager admitted that bed hold notices were only given to Medicaid residents, which resulted in Resident #82 not receiving the required notice. Additionally, a family member of Resident #82 confirmed that they did not recall receiving any bed hold notice during the hospital transfers. Similarly, Resident #52, who had diagnoses such as end-stage renal disease and heart failure, was transferred to the hospital without a bed hold notice being provided. The Business Office Manager confirmed that Resident #52 did not receive a bed hold notice at the time of transfer. The facility's policy, dated September 2021, stated that a copy of the bed hold policy should be provided to the resident and their family or legal representative before and during a transfer for hospitalization or therapeutic leave, which was not adhered to in these cases.
Medication Misappropriation by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, specifically affecting two residents. Resident #20, who was admitted with chronic pulmonary edema, disorganized schizophrenia, and chronic respiratory failure with hypercapnia, had an order for oxycodone 5 mg to be administered as needed for pain. Similarly, Resident #28, admitted with end-stage renal disease, diabetes, and chronic gout, had an order for Hydrocodone-acetaminophen (Norco) 5-325 mg for pain management. The deficiency was identified when a Licensed Practical Nurse (LPN) reported the diversion of narcotic medications. The incident came to light when LPN #826 noticed a missing narcotic card and reported it to the nurse supervisor. Subsequently, LPN #964 admitted to diverting a total of 55 oxycodone tablets from Resident #20 and one Norco tablet from Resident #28. This admission was made to the Director of Nursing (DON) after the LPN had already left the facility. The facility's records and interviews confirmed the misappropriation of medications, which was substantiated by a self-reported incident (SRI) and further investigation by a criminal investigator. The facility's Abuse Prevention Program policy emphasizes the residents' right to be free from abuse, neglect, and misappropriation of property. However, the actions of LPN #964 violated this policy, leading to the misappropriation of narcotics intended for residents' pain management. The deficiency was identified as an incident of past noncompliance that was corrected prior to the survey, but it highlighted a significant lapse in the facility's medication administration and monitoring processes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 701 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Of Louisville Ctr For Rehab & Nsg Care | 2.5 mi | ★★★★★ | 1 | 0 |
| Canterbury Villa Of Alliance | 3.5 mi | ★★★★★ | 3 | 0 |
| Mccrea Manor Nsng And Rehab Ctr Llc | 4.4 mi | ★★★★★ | 15 | 0 |
| Saint Joseph Care Center | 4.6 mi | ★★★★★ | 17 | 0 |
| Louisville Gardens Care Center | 4.7 mi | ★★★★★ | 17 | 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.