Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Hickory Ridge Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Unclean kitchen and dishwashing practices were observed in the dietary area. Mold and dried liquid droplets were seen on racks in a reach-in, food residue and crumbs were found under the steam table, and dried batter was on the mixer backsplash. In the dish area, the dish machine final rinse measured 169 degrees F, and a DA placed improperly stacked plate lids on top of plastic bowls, contrary to facility policy.
Multiple residents with conditions such as fractures, COPD, dementia, schizophrenia, diabetes, and severe malnutrition, all care-planned for potential nutritional issues and with orders for specific breakfast beverages, did not receive their ordered orange juice or other beverages during a breakfast meal. Dietary tickets and MD orders called for specified amounts of juice and, in one case, coffee, but observations showed these items were missing from trays. Staff later reported that new tray-line employees ran out of orange juice and did not provide an alternate juice, despite facility expectations that residents not on fluid restrictions receive a set amount of juice as part of their daily fluid intake.
Failure to perform hand hygiene during med pass. An LPN administered meds and a nutritional supplement to multiple residents without cleansing hands between resident contacts, and another LPN did the same during a separate med pass. Interviews verified the observations, and facility policy required hand hygiene before and after resident contact and as appropriate during medication administration.
A CNA with a prior disciplinary history for aggressive and foul language engaged in unprofessional conduct during a smoking break, using profanities and making sexually inappropriate comments about a male resident’s genitalia in the presence of that resident and his cognitively intact roommate. Multiple staff, including LPNs and another CNA, reported hearing a loud commotion and the CNA screaming or using profanities at the smoking area while residents were present, though they could not always identify the specific target of the language. The involved residents had significant psychiatric and neurologic diagnoses, with one having impaired cognition and the other intact cognition, and both later described or confirmed the inappropriate comments and profanities, demonstrating a failure to uphold resident dignity and respect.
A resident with dementia and impaired cognition alleged that a CNA made sexually explicit and profane comments to him during a smoke break, and his cognitively intact roommate later reported hearing the same inappropriate remarks. Multiple staff, including an LPN and a CNA, described a loud commotion at the smoking area and observed the CNA yelling and using profanities, but were unsure at whom the comments were directed. The Administrator did not recognize the roommate as a direct eyewitness, did not clarify conflicting witness statements, recorded the CNA’s name incorrectly, failed to list the CNA as the alleged perpetrator in the SRI, and inaccurately documented that the CNA had no prior disciplinary actions despite a previous final written warning for similar behavior. These inaccuracies and omissions resulted in an abuse investigation that was not thorough.
Surveyors found that the facility failed to implement required safety interventions for three residents. A resident who smoked, with an order and care plan requiring a fire-retardant apron, was observed smoking without the apron and with a burn hole on their pant leg. Another resident with a history of falls and an order for a wheelchair pressure alarm was seen transferring independently from a wheelchair to a bedside commode without the alarm sounding, and an LPN confirmed the alarm was present but not functioning and that a wheelchair wheel lock was broken. A third resident with dementia, Parkinson’s, and repeated falls, who had care-planned interventions for a "call don’t fall" sign and a call light within reach, was observed sitting in a recliner with the call light clipped out of reach and no "call don’t fall" sign in the room, despite documentation indicating the sign was in place.
The facility failed to follow ordered diets and fortified nutrition interventions for three residents identified as at risk for altered nutrition. One resident with a fracture and muscle weakness, ordered double entrees with eggs, grits, and meat at breakfast, reported incorrect portion sizes, and observation confirmed he did not receive double portions or meat. Another resident with anorexia and dementia, ordered fortified cereal and fortified eggs, did not receive fortified cereal at breakfast. A third resident with chronic cardiac and pulmonary conditions, ordered a no added salt mechanical soft diet with fortified cereal and fortified eggs, also did not receive fortified cereal. These omissions were confirmed by CNAs, dietary management, and the DON against the physician orders and existing care plans that required providing the ordered diets and honoring preferences.
A resident with ESRD, diabetes, COPD, CHF, and dependence on renal dialysis received hemodialysis three times weekly at an off-site center, but the facility did not complete or document required pre- and post-dialysis assessments. The care plan and physician orders called for monitoring lung sounds, edema, AV fistula bruit and thrill, shunt site, and overall condition, yet the medical record contained no facility assessments around dialysis treatments. The only available pre-/post-treatment data (vital signs, weights, condition, and medications) came from the dialysis center’s communication forms. An LPN stated she filled out a form in a binder sent with the resident but could not produce the binder or a sample form, and the DON confirmed no facility-completed assessments could be located, despite a policy requiring assessment and monitoring for residents receiving dialysis.
Failure to implement the abuse protocol when a resident alleged verbal abuse by an aide. The resident, who had CHF, HTN, A-fib, dementia, anxiety, depression, and liver cell carcinoma, reported that staff called him names and said he was going to die there, while records also showed behavioral issues and sexually inappropriate conduct. The DON and Administrator were unaware of the allegation until later, and the facility did not file the SRI within the required timeframe under its abuse policy.
Respiratory equipment was not maintained in a sanitary manner and oxygen orders were not individualized for two residents with COPD and other respiratory conditions. An LPN observed oxygen tubing without dates and with whitish residue, and a resident stated staff did not change the tubing very often. The DON stated the facility used oxygen orders written as 0 to 5 liters to allow nursing judgment to titrate oxygen, while staff also documented oxygen use inconsistently for one resident.
Failure to implement behavioral health interventions for a resident with dementia and PICA-like behaviors. The resident was documented eating non-food items, including plastic from a bedside table and materials from the wall, and was observed picking at bedding and the wall protector. The chart lacked orders and care plan interventions to monitor GI symptoms or the environment for damaged items, and an LPN confirmed the resident continued these behaviors.
A resident's medical record was not complete and accurate to reflect secured unit placement. The resident had diagnoses including epilepsy, bipolar disorder, suicidal ideation, impulsiveness, and anxiety, and the current physician orders did not include an order for secured unit residence after the prior order was discontinued. The MDS showed the resident was cognitively intact, had delusions and verbal behaviors, and needed supervision or touching assistance with ADLs. An LPN stated a physician's order was required for secured unit residence, and the DON said the facility did not have a secured unit policy.
The facility failed to ensure proper hand hygiene and PPE use, affecting multiple residents. A CNA and ADON did not perform hand hygiene between glove changes during incontinence care for a resident. Another resident, at risk for infection, was not provided with appropriate PPE during checks. Additionally, the CNA did not sanitize hands between delivering meal trays to different residents, contrary to facility policies.
A facility failed to specify the type of lift for a resident's safe transfers in their care plan, despite the resident being at high risk for falls due to multiple medical conditions. The care plan was revised to include a Hoyer lift without specifying the type, leading to potential safety risks. The oversight was confirmed by the facility's Administrator and Regional Clinical Director.
A resident with multiple diagnoses, including multiple sclerosis and dementia, was not consistently assisted with shaving his facial hair as required by his care plan. Despite his preference for an electric razor, the facility only provided disposable razors, which were inadequate for his needs. CNAs acknowledged the resident's need for assistance but cited a lack of time and resources as barriers to providing daily care.
The facility failed to ensure safe transfers and implement fall prevention measures for two residents. One resident fell during a transfer using a sit-to-stand lift due to a washcloth obstructing the lift's wheel, while another resident's care plan interventions, such as Dycem on the wheelchair and non-skid strips, were not in place. These deficiencies highlight a lack of adherence to safety protocols and care plans.
A facility failed to accurately document fall prevention measures for a resident at risk of falls due to multiple medical conditions. The care plan included interventions like a Dycem mat on the wheelchair and non-skid strips beside the bed, but these were missing during observations. Despite this, the treatment administration record inaccurately indicated their presence, as confirmed by staff interviews.
A resident with multiple health conditions, including dementia and diabetes, did not receive timely oral care as required by their care plan. Despite being dependent on staff for oral care, documentation showed multiple instances of missed care. Interviews and observations confirmed the deficiency, with staff attributing the responsibility to different shifts.
Unclean Kitchen and Dishwashing Practices
Penalty
Summary
Clean food service areas were not maintained in the kitchen. During observation of the kitchen with the Dietary Manager, mold and dried liquid droplets were seen on four of four racks in reach-in #1, and mold and dried liquid droplets were also seen on five of six racks in reach-in #1. The shelf underneath the steam table had food residue, food crumbs, and pieces of parchment paper, and the back splash of the mixer had dried batter on it. In the dish area, the final rinse of the dish machine registered 169 degrees Fahrenheit, and a Dietary Aide placed a rack of plate lids that were not stacked appropriately on top of a rack of plastic bowls. The Dietary Manager stated that racks should not be put on top of each other. Facility policy on infection control and dietary/food handling stated that the dish machine should have a final rinse of 180 degrees Fahrenheit and dishes should not be stacked one on top of another.
Failure to Provide Ordered Breakfast Beverages and Honor Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide beverages according to residents’ diet orders and stated preferences, specifically related to breakfast juice service. Multiple residents had care plans identifying potential for altered nutrition and interventions that included providing diets as ordered and honoring food and beverage preferences. Physician orders and dietary tickets specified that these residents were to receive orange juice or other beverages at breakfast, but observations on the breakfast meal service showed that these ordered beverages were not provided. For one resident with a fracture, muscle weakness, and osteoarthritis, the care plan called for honoring preferences and the physician ordered a regular diet with thin liquids and double entrees, including eight ounces of orange juice at breakfast; the breakfast tray did not include orange juice, and the resident reported that portion sizes, especially at breakfast, were not correct. Another resident with anxiety disorder, schizoaffective disorder, and osteoarthritis, who was dependent on staff for eating, was ordered a regular pureed diet with thin liquids and was supposed to receive orange juice and coffee at breakfast, but neither beverage was on the tray. A resident with anorexia, vascular dementia, and major depressive disorder, whose care plan included nutrient-dense foods and honoring preferences, was ordered a regular diet with fortified cereal and eggs and was supposed to receive orange juice at breakfast, but did not receive it. Additional residents were similarly affected. A resident with multiple sclerosis, COPD, and schizophrenia, who had intact cognition and required supervision for eating, was supposed to receive eight ounces of orange juice at breakfast but did not. A resident with metabolic encephalopathy, diabetes mellitus, and severe protein-calorie malnutrition, whose care plan included nutrient-dense foods and honoring preferences, was supposed to receive four ounces of orange juice at breakfast but did not. Another resident with chronic atrial fibrillation, COPD, and nicotine dependence, with intact cognition and needing supervision for ADLs, was also supposed to receive four ounces of orange juice at breakfast but did not. Staff interviews revealed that two new employees on the tray line ran out of orange juice and did not substitute another type of juice, and facility documentation showed that residents not on fluid restriction were expected to receive four ounces of juice at breakfast as part of their average daily fluid intake.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure staff used appropriate hand hygiene during medication administration. During observation on 01/08/26 from 8:23 A.M. to 8:39 A.M., LPN #388 dispensed and administered medications to Resident #19 and did not perform hand hygiene afterward, then immediately dispensed and administered medications to Resident #27 without hand hygiene, and then immediately administered medication to Resident #105. An interview with LPN #388 at 8:43 A.M. verified these findings. During observation on 01/08/26 from 8:45 A.M. to 9:11 A.M., LPN #435 dispensed and administered medications to Resident #137 and did not perform hand hygiene afterward, then immediately administered a nutritional supplement to Resident #116 without hand hygiene, and then immediately dispensed and administered medications to Resident #68. An interview with LPN #435 at 9:18 A.M. verified these findings. Facility policy titled Medication Administration-General Guidelines for Medication Administration, dated 06/21/17, stated medications were to be administered consistent with accepted standards of practice and hands were to be cleansed as appropriate. Facility policy titled Hand Hygiene, dated 11/28/17, stated hand hygiene was to be performed to prevent the spread of infection and before and after resident contact.
Failure to Maintain Resident Dignity Due to CNA’s Profane and Sexually Inappropriate Comments
Penalty
Summary
The deficiency involves failure to maintain resident respect and dignity when a CNA acted in an unprofessional and verbally inappropriate manner toward a resident during a smoking break. One resident involved had dementia and other psychiatric and neurologic diagnoses, with a BIMS score of 09 indicating impaired cognition but adequate hearing, clear speech, and ability to understand others. His care plan noted he could refuse care and repetitively ask questions, requiring assistance and cueing with ADLs. Another resident involved, his roommate, had mood, anxiety, PTSD, and depression diagnoses, with a BIMS score of 15 indicating intact cognition, adequate hearing, clear speech, and understanding, and no behaviors noted. On the date of the incident, the cognitively impaired resident reported that during a smoke break the CNA told him he had a very small penis and that her husband’s was bigger, and that she was swearing at him. He stated his roommate was next to him during the smoke break and overheard the comments, and that no other staff were present. The cognitively intact roommate later confirmed that the CNA made inappropriate comments to the first resident about the size of his penis and used profanities toward him during the smoking break, again stating that no other staff were present. Multiple staff accounts described a loud commotion and profanities used by the CNA in or near the smoking area in the presence of residents. Several LPNs reported hearing a commotion from the smoking area while they were in the conference room eating, then observing the CNA in the doorway handing out cigarettes and screaming or using profanities, though they were unsure exactly to whom the profanities were directed and did not hear specific threats. One LPN stated there were residents in the smoking area, described as the usual smokers, and another LPN stated there were no residents having behaviors or noted to be agitated at that time. A CNA reported seeing the CNA and two residents arguing at the smoking door and noted that the CNA had previously been observed treating residents without respect and dignity. The CNA’s personnel file documented a prior final written warning for arguing with the appearance of aggressive behavior and use of inappropriate, abusive, or foul language toward or in the presence of a resident, employee, or visitor, and a subsequent disciplinary action for similar behavior on the date of the incident. The employee handbook classified such conduct—arguing, aggressive behavior, or use of inappropriate, abusive, or foul language toward or in the presence of a resident, employee, or visitor—as a serious work rule violation, while residents and staff interviews and documentation established that the CNA’s conduct occurred in the presence of residents and included profanities and sexually inappropriate comments toward a resident.
Failure to Thoroughly Investigate Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of verbal abuse toward a resident with dementia and impaired cognition. The resident had multiple neurocognitive and psychiatric diagnoses, including unspecified dementia, alcohol-induced dementia, vascular dementia, anxiety, depression, insomnia, encephalopathy, and unspecified psychosis, and had a BIMS score of 09 indicating impaired cognition. The self-reported incident concerned a CNA allegedly making sexually explicit and profane comments to the resident during a smoke break. The facility’s SRI documented that the resident denied physical contact, that assessments showed no physical injury, and that interviews and assessments of other residents and staff revealed no additional concerns, leading the facility to unsubstantiated the abuse allegation. Multiple witness statements and interviews contained inconsistencies and omissions that were not reconciled in the investigation. The roommate’s initial statement, taken by the Administrator, was documented as secondhand information from the resident, and the Administrator later acknowledged being unaware that the cognitively intact roommate had actually been present during the incident and was not asked if he personally witnessed it. In a later interview, the resident reported that the CNA made explicit comments about his genitalia and used profanity toward him during the smoke break, and the roommate corroborated hearing these same inappropriate and profane comments directed at the resident, stating no other staff were present. Despite this, the SRI did not reflect the roommate as a direct eyewitness. Staff witness accounts also conflicted and were not fully reconciled. One LPN provided a handwritten statement describing hearing a loud commotion, seeing the CNA in the smoking doorway passing out cigarettes and “screaming profanities,” and being unsure who the CNA was yelling at; she later emailed a statement with similar content but without mention of residents’ behaviors, and later verified that the typed statement was inaccurate. Another LPN reported observing the CNA cursing and yelling near a common lounge area and that the CNA was sent home for her behavior. A CNA reported seeing the CNA and two residents arguing at the smoking door and noted the CNA had previously treated residents without respect and dignity. The Administrator acknowledged errors and omissions in the SRI, including the CNA’s last name being incorrect, failure to list the CNA as the alleged perpetrator, and inaccurately documenting that the CNA had no prior disciplinary actions, despite a prior final written warning for arguing and using inappropriate or foul language in the presence of a resident, employee, or visitor. These inaccuracies and incomplete witness follow-up demonstrate that the facility did not thoroughly investigate the verbal abuse allegation as required by its abuse policy.
Failure to Implement Safe Smoking and Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and adequate supervision to prevent accidents for three residents. One resident with chronic atrial fibrillation, COPD, and nicotine dependence, cognitively intact and requiring supervision for ADLs, had a physician’s order and care plan requiring use of a fire-retardant smoking apron when smoking. During observation in the designated smoking area, the resident was seen smoking without the required apron and had a cigarette burn hole on the left pant leg. A CNA confirmed the absence of the apron and stated she had previously informed a nurse that the resident needed a smoking apron. The DON later verified that both the physician’s order and care plan required the apron. A second resident, admitted with stroke, dementia, epilepsy, unsteadiness on feet, chronic kidney disease, and weakness, was cognitively intact, required supervision or touching assistance for transfers, and had two or more falls since admission. The resident had a physician’s order for a wheelchair pressure alarm with placement and function to be checked every shift, and the care plan identified fall risk with an intervention for a chair alarm. During observation, the resident self-propelled in a wheelchair and independently transferred to a bedside commode; although an alarm pad and speaker were present on the wheelchair, the alarm did not sound when the resident transferred. An LPN confirmed the alarm should have sounded, verified it was not disconnected or turned off, and that it did not function correctly. When assisting the resident back to the wheelchair, the LPN also found the left wheel lock was broken and did not lock. A third resident, admitted with Alzheimer’s disease, Parkinson’s, dementia, repeated falls, weakness, unsteadiness on feet, and a history of falling, had a physician’s order for a “call don’t fall” sign and was assessed as at risk for falls due to multiple falls in the last 90 days, cognitive behaviors, ambulation problems, and unsteady transfers. The care plan included interventions to analyze previous falls, place a “call don’t fall” sign in the room, and ensure the call light was within reach. A prior fall investigation documented that the resident had fallen while independently ambulating when the call light was not in reach, and a “call don’t fall” sign was added as a new intervention. On observation, the resident was sitting in a recliner near the hallway side of the room, with the call light clipped to the room divider curtain out of reach and no “call don’t fall” sign present. An LPN confirmed that fall-risk interventions include a “call don’t fall” sign and call light in reach, and verified both the absence of the sign and that the call light was out of reach, despite TAR documentation indicating the sign was in place.
Failure to Follow Ordered Diets and Fortified Nutrition at Breakfast
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered diets and nutritional interventions as prescribed for three residents, despite identified risks for altered nutrition. One resident with a history of upper right tibia fracture, muscle weakness, and osteoarthritis had physician orders for a regular diet with regular texture, thin liquids, and double entrees at all meals, including eggs, grits, and meat at breakfast due to risk for malnutrition. His care plan directed staff to provide the ordered diet and honor preferences. He reported that portion sizes, especially at breakfast, were not correct. Observation of his breakfast tray showed he did not receive double portions and received no meat, which was confirmed by a CNA and later verified by the DON against the physician’s orders. A second resident with anorexia, vascular dementia, and major depressive disorder had orders for a regular diet with regular texture, thin liquids, and fortified cereal and fortified eggs at breakfast, with a care plan addressing potential alteration in nutrition and interventions to provide the ordered diet, honor preferences, and offer nutrient-dense foods. Observation of this resident’s breakfast showed that fortified cereal was not provided, which was confirmed by a CNA and verified by the DON against the physician’s orders. A third resident with chronic atrial fibrillation, COPD, and nicotine dependence had orders for a no added salt, mechanical soft diet with thin liquids and fortified cereal and fortified eggs at breakfast, with a care plan to provide the ordered diet and honor preferences. Observation of this resident’s breakfast tray showed that fortified cereal was not provided, which was confirmed by the Corporate Dietary Manager. The Dietary Manager reported that two new employees on the trayline being trained must have missed the fortified cereals. The facility’s “Food First Program” policy stated that honoring resident food and beverage preferences and incorporating them into the diet is an effective intervention when managing nutritional status.
Failure to Perform and Document Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure a resident who required dialysis received ongoing assessments of condition before and after dialysis treatments, as required by facility policy and physician orders. The resident had been admitted with multiple diagnoses including end stage renal disease, diabetes mellitus, dependence on renal dialysis, morbid obesity, COPD, and CHF, and received dialysis three times per week at an off-site location. The care plan noted the resident frequently refused dialysis and included interventions such as monitoring lung sounds, edema, shunt site, bruit and thrill, and maintaining communication with the dialysis center. Physician orders included checking the left arm AV fistula for bruit and thrill every shift and documented the scheduled dialysis days and times. Medical record review revealed no evidence that the facility completed pre-treatment or post-treatment assessments related to the resident’s dialysis sessions. Although the dialysis center’s communication forms from several months documented pre- and post-treatment weights, vital signs, condition, and medications administered, these were completed by the dialysis center, not the facility. An LPN reported that the resident had a binder taken to dialysis and that she filled out a form with vital signs and any signs or symptoms of pain or sickness, but she could not produce the binder or a sample of the form. The DON confirmed she was unable to locate any pre- or post-dialysis assessments completed by facility staff and verified that the available communication forms were from the dialysis center, not the facility, despite the facility’s Dialysis Management policy requiring assessment and monitoring for complications.
Failure to Report and Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse protocol when an allegation of verbal abuse involving Resident #80 was reported to staff. Resident #80 was admitted with diagnoses including congestive heart failure, hypertension, atrial fibrillation, dementia without behavioral disturbance, anxiety disorder, high risk heterosexual behavior, major depressive disorder, and liver cell carcinoma. A quarterly MDS assessment documented the resident as cognitively intact and without behaviors, while nursing and psychiatric notes described sexually inappropriate behavior, cursing, grabbing, delusions, and agitation toward staff. The resident told the psychiatric nurse practitioner that nursing staff were calling him names, but no self-reported incident was filed with the state agency for the allegation documented in the psychiatric note. During interviews, Resident #80 stated that aides called him abusive names, told him everyone was going to die there, and said he stank and was going to die there. He reported that he had told nursing staff, but they brushed it off. The Administrator and DON stated they were not aware of the allegation until later and confirmed the psychiatric nurse practitioner had not informed them of the resident’s complaint. The facility later identified CNA #350 as the aide involved, suspended her pending investigation, and filed a self-reported incident after the allegation had already been raised, despite the facility policy requiring all allegations of abuse to be reported to administration and the state agency within the required timeframe.
Respiratory Equipment Not Kept Sanitary and Oxygen Orders Not Individualized
Penalty
Summary
The facility failed to ensure respiratory equipment was maintained in a sanitary manner and failed to ensure oxygen orders were individualized to meet resident-specific needs. This involved two residents who were reviewed for respiratory care, with the potential to affect other residents who used oxygen. The report states the facility census was 141 and that 20 residents utilized oxygen. Resident #127 had diagnoses including dementia, COPD, and protein-calorie malnutrition. Her care plan identified respiratory deficiencies related to COPD, allergic rhinitis, emphysema, and shortness of breath on exertion. Physician orders included respiratory monitoring, oxygen saturation checks every shift while on oxygen, weekly oxygen tubing/cannula changes, and oxygen at 0 to 5 liters by nasal cannula to maintain saturation of 90%. The TAR showed documentation that she received 8 liters of oxygen on one night shift and that oxygen liters were documented as not applicable on another date. During observation, she was on 3 liters of oxygen, and the tubing was not dated to show it had been changed per the weekly order. Resident #136 had diagnoses including COPD, acute and chronic respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, and congestive heart failure. Her care plan identified respiratory deficiencies and the need for oxygen related to COPD and chronic respiratory failure. Physician orders included respiratory monitoring, oxygen saturation checks every shift while on oxygen, weekly oxygen tubing/cannula changes, and oxygen at 0 to 5 liters by nasal cannula to maintain saturation of 90%. During observation, she was on 2 liters of oxygen and the tubing had a whitish residue on the outside. She stated staff did not change the tubing very often, and the tubing was not dated. An LPN verified the tubing was not dated and stated some staff did not date oxygen tubing when changing it. The DON stated she was unsure why the oxygen orders were written as 0 to 5 liters instead of individualized orders and explained the facility used that range to allow nursing judgment to titrate oxygen.
Failure to Implement Behavioral Health Interventions for PICA Behaviors
Penalty
Summary
The facility failed to ensure behavioral health interventions were implemented for Resident #45, who had diagnoses including dementia with behavioral disturbance, anxiety disorder, hearing loss, peripheral vascular disease, chronic kidney disease, and type 2 diabetes mellitus. The record showed the resident had PICA-like behavior documented by the NP on 11/21/25 and 12/28/25, and on 12/29/25 the resident was observed eating the plastic rim off the bedside table, after which nursing staff educated and redirected the resident and initiated a request for a new tray table. On 01/06/26, the resident was seen by an NP for behavioral concerns, and nursing staff confirmed the resident had been eating non-food items over the past year, including plaster from the wall and items pulled from the recliner. Review of physician orders from 12/01/25 to 01/07/26 showed no orders to monitor the resident for GI symptoms related to PICA and no orders to monitor the physical environment for broken or damaged items that could be ingested. The care plan identified altered health maintenance, altered mood or behavior, and altered cognitive function, with goals related to avoiding injury and appropriate affect, but it did not include interventions to monitor GI symptoms or the environment for damaged items. During observation on 01/12/26, the resident was seen picking at the bed linen and mattress, spitting phlegm on the hard plastic wall protector, and moving it around with a finger. An LPN confirmed the resident continued to pick at the wall and eat materials from the wall and verified there were no orders or interventions to monitor GI symptoms or damaged items. The Administrator stated the facility does not have a behavior management policy and follows the regulations.
Incomplete record for secured unit placement
Penalty
Summary
The facility failed to ensure Resident #135's medical record was complete and accurate to reflect secured unit placement. Resident #135 was admitted with diagnoses including epilepsy, bipolar disorder, suicidal ideation, impulsiveness, anxiety, and need for assistance with personal care. Review of the current physician orders showed there was no order for the resident to reside in a secured unit, and the order for placement on a secured unit was discontinued on 12/03/24. The quarterly MDS assessment showed the resident was cognitively intact, exhibited delusions and verbal behaviors, and required supervision or touching assistance for activities of daily living. During interviews, an LPN stated a resident required a physician's order to reside in a secured unit, the DON stated the facility did not have a secured unit policy, and another LPN verified Resident #135 did not have a current order to reside in a secured unit.
Inadequate Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper hand hygiene and the implementation of enhanced barrier precautions, affecting multiple residents. Specifically, during incontinence care for Resident #65, the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) did not perform hand hygiene between glove changes. The ADON assisted with removing soiled linens and changing gloves multiple times without washing hands, while the CNA also failed to perform hand hygiene after handling soiled materials and before obtaining clean linens. Resident #8, who was at risk for infection due to multiple health conditions, was not provided with appropriate personal protective equipment (PPE) during incontinence checks. The CNA entered the resident's room and performed tasks without donning the required gown, despite signage indicating the need for enhanced barrier precautions due to the resident's wound. This oversight was confirmed by both the CNA and the ADON present during the observation. Additionally, during meal service, the CNA did not perform hand hygiene between delivering meal trays to different residents. After assisting Resident #8, who refused the meal, the CNA returned the tray without washing hands and proceeded to deliver and assist with Resident #58's meal. This lack of hand hygiene was acknowledged by the CNA, who was unaware of the requirement to sanitize hands between handling meal trays for different residents. The facility's policies on hand hygiene and infection prevention were not adhered to, as observed in these instances.
Care Plan Deficiency in Specifying Transfer Equipment
Penalty
Summary
The facility failed to ensure that the care plan for a resident clearly specified the type of lift to be used for safe transfers, leading to a deficiency. The resident, who was at high risk for falls due to multiple medical conditions including dementia, anxiety, and impaired cognition, had a care plan that initially included interventions to maintain a clutter-free environment. However, the care plan was later revised to include the use of a Hoyer lift for transfers without specifying the type of lift, such as a mechanical, power, overhead, or stand-up lift. The deficiency was identified during a review of the resident's health status note, which indicated that the resident was assessed and safely transferred using a sit-to-stand mechanical lift. Despite this assessment, the care plan was not updated to reflect the specific type of lift that should be used, leading to confusion and potential safety risks. The facility's Administrator and Regional Clinical Director confirmed the oversight during an interview, acknowledging that the care plan did not accurately reflect the resident's assessed needs for safe transfers.
Failure to Assist Resident with Daily Shaving
Penalty
Summary
The facility failed to consistently assist a resident, identified as Resident #17, with shaving his facial hair on a daily basis, as required by his care plan. Resident #17, who has multiple diagnoses including multiple sclerosis, stroke, and dementia, was admitted with a care plan indicating he needed assistance with activities of daily living (ADLs) such as bathing and grooming, including shaving. Despite this, observations and interviews revealed that Resident #17 had thick, unshaven facial hair and expressed dissatisfaction with the lack of assistance provided by the facility. He stated that he preferred an electric razor, which the facility did not provide, and that the disposable razors available were inadequate for his needs. Interviews with Certified Nursing Assistants (CNAs) revealed that while they were aware of Resident #17's need for assistance with shaving, they were unable to consistently provide this care. CNA #153 noted that the facility only had disposable razors, which were unsuitable for Resident #17's coarse facial hair, and CNA #154 admitted she did not have time to assist him daily. The nursing assistant job description requires CNAs to assist residents with ADLs, including personal hygiene, but the facility's failure to provide adequate resources and time for staff resulted in non-compliance with Resident #17's care plan. This deficiency was investigated under Complaint Number OH00161220.
Failure to Ensure Safe Transfers and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the safe transfer of Resident #65, resulting in a fall. Resident #65, who had a high risk for falls due to multiple medical conditions including dementia and impaired cognition, was being transferred using a sit-to-stand lift. During the transfer, the lift tilted to one side, causing the resident to fall. The incident was attributed to a washcloth under the bed that caught on the lift's wheel, leading to the tilt. The CNA involved was aware that two staff members should assist with the lift but was alone during the transfer. Additionally, the facility did not maintain the care planned interventions for Resident #137, who was also at risk for falls due to various medical conditions such as diabetes, pulmonary disease, and visual disturbances. The care plan included specific interventions like placing a Dycem on the wheelchair and non-skid strips beside the bed, which were not in place during observations. This lack of adherence to the care plan was verified by staff, indicating a failure to implement necessary fall prevention measures. The facility's policy on fall management requires an interdisciplinary plan of care to be developed and updated as necessary to reflect each resident's safety needs. However, the failure to ensure the environment was free of hazards and to implement care plan interventions for these residents led to deficiencies in providing adequate supervision and maintaining a safe environment, as evidenced by the incidents involving Residents #65 and #137.
Inaccurate Documentation of Fall Prevention Measures
Penalty
Summary
The facility failed to ensure accurate documentation of fall prevention interventions for a resident, identified as Resident #137, who was at risk of falls due to multiple medical conditions including diabetes, pulmonary disease, and cerebral vascular disease. The resident's care plan, initiated on December 5, 2023, included specific interventions such as keeping the bed in the lowest position, using a Dycem mat on the wheelchair, and placing non-skid strips next to the bed. However, during observations on January 27 and January 28, 2025, it was noted that the Dycem mat was missing from the wheelchair and the non-skid strips were absent from the floor beside the bed. Despite the absence of these interventions, the treatment administration record (TAR) for the period from January 1 to January 27, 2025, inaccurately documented that the Dycem mat and non-skid strips were in place. Interviews with a Certified Nursing Assistant and the Assistant Director of Nursing confirmed the discrepancy between the documented interventions and the actual conditions observed in the resident's room. This deficiency was investigated under Complaint Number OH00161120, highlighting a failure to adhere to the American Nurses Association guidelines for accurate and accessible documentation, which is crucial for ensuring safe and quality nursing practice.
Failure to Provide Timely Oral Care
Penalty
Summary
The facility failed to provide timely oral care for a resident who required assistance with personal care. The resident, who had intact cognition and was dependent on staff for bed mobility, transfers, and oral care, was admitted with diagnoses including schizoaffective disorder, type two diabetes, morbid obesity, and unspecified dementia. The resident's care plan indicated a risk for oral problems due to impaired dentition, with interventions to provide oral care at least daily. However, the oral care task sheet revealed multiple instances where oral care was not documented as completed over a period of several weeks. Interviews and observations confirmed the deficiency. The resident reported not receiving daily oral care and had not received it on the morning of the survey. An STNA admitted to not completing the resident's oral care, attributing the responsibility to third shift staff. Further interviews with the ADONs verified the lack of documentation for oral care on specific dates. An observation of the resident's oral cavity revealed caked-on food debris, confirming that oral care had not been completed. This deficiency was investigated under a specific complaint number.
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 1,074 citations issued within 25 miles in the last 12 months — including the 6 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.
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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 Akron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Merriman | 0.6 mi | ★★★★★ | 19 | 1 |
| Divine Rehabilitation And Nursing At Canal Pointe | 1.1 mi | ★★★★★ | 2 | 0 |
| Ohio Living Rockynol | 1.2 mi | ★★★★★ | 0 | 0 |
| Highland Square Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 5 | 1 |
| Falls Village Skilled Nursing & Rehabilitation | 3.5 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.