Below 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 Jamestown Place Health And Rehab during CMS and state inspections, most recent first.
Untimely Completion of Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required ARD + 14 day timeframe for five residents. Affected residents had significant medical and cognitive conditions, including ESRD, CHF, DM II, AFib, dementia, epilepsy, schizophrenia, dysphagia, CKD, malnutrition, and heart disease. The MDS RN confirmed the assessments were late and stated some delays occurred because she was working in two buildings.
Failure to complete required care conferences and update the care plan for code status. Three residents had no documented quarterly care conferences beyond earlier meetings, despite cognitive and medical conditions including dementia, cerebral palsy, malnutrition, and chronic disease; family, the resident, and SS all confirmed the lack of recent conferences. Another resident's care plan still listed Full Code/CPR even though the chart contained a signed DNR-CC order, and the MDS RN confirmed the discrepancy.
Fall interventions were not consistently in place and neuro checks were not documented after unwitnessed falls. A resident with dementia, repeated falls, and severely impaired cognition had a care-planned fall mat found away from the bed, and staff used call-light education after an unwitnessed fall even though the DON said it was not appropriate for that resident. In addition, neuro checks were not documented after unwitnessed falls or fall-related findings for several residents, including one with moderate cognitive impairment and others with severe impairment or multiple prior falls.
Infection control practices were not followed for multiple residents on TBP or EBP. Staff entered a resident's room on EBP without gowns and gloves, took a COVID-positive resident to the shower room while wearing only surgical masks, provided direct care to a resident on EBP without gown or glove use, exited a resident's room on droplet precautions without hand hygiene, and performed catheter care with soiled gloves before touching clean items and the resident. The DON, ADON, and CNA staff confirmed the observed practices did not match the required precautions.
Failure to Notify Responsible Parties of Significant Weight Loss: The facility did not notify responsible parties about significant weight loss for two residents. One resident with multiple neurologic and swallowing-related diagnoses lost 45 lbs and had a rapid 32-lb decline over 11 days, with no documented family notification. Another resident with dementia, schizoaffective disorder, COPD, and other diagnoses had documented significant weight loss over several months, and the wife reported she was not informed. The RD and DON verified the lack of documented notification.
Failure to Investigate Injuries of Unknown Origin: A resident with moderate cognitive impairment was found with bruising to the scalp, lip swelling, a skin tear, and later additional bruises to the forehead, cheek, and both hips. Staff and the DON noted the resident was not a reliable historian, but no abuse investigation was initiated because the resident said she had fallen. The facility policy required injuries of unknown origin to be reported and thoroughly investigated, with the Administrator initiating the investigation.
Failure to Report Injury of Unknown Origin: A resident with moderate cognitive impairment and multiple bruises, a lip swelling, and a skin tear was evaluated after staff identified unexplained injuries. The resident could not reliably explain how the injuries occurred, and the facility later documented additional bruising consistent with a possible fall, but the injury of unknown origin was not reported to the state agency as required by policy.
Failure to Thoroughly Investigate Injury of Unknown Origin: A resident with moderate cognitive impairment and multiple chronic conditions was found with bruising to the scalp/face, lip swelling, and a skin tear, but could not recall a fall or head trauma. Later, additional bruises were noted on both hips, and the resident gave inconsistent accounts of the injury. The facility did not report the injury of unknown origin or thoroughly investigate it as required by policy.
Missing Bed-Hold Notices and Ombudsman Notification: The facility failed to provide required bed-hold notices to two residents who were hospitalized, including residents with intact cognition and significant medical needs such as heart disease, CKD, respiratory failure, and obesity. The facility also could not verify that the State Ombudsman Agency was notified of another resident’s discharge due to hospitalization, despite staff stating email was used for transfer and discharge notifications.
A resident receiving hospice services had a delayed significant change MDS assessment. The resident had dementia with agitation, senile degeneration of brain, schizoaffective disorder, bipolar type, COPD, depression, and prostate cancer, and was documented as having severely impaired cognition with extensive assistance needs. An RN verified the assessment was not completed on time and stated it should have been completed earlier.
A resident with DM II, atrial fibrillation, major depressive disorder, PVD, and moderate cognitive impairment did not have a dental care plan created timely. The resident had a physician order for dental services, but the DON verified the plan was not in place until the surveyor asked about it. Facility policy required a comprehensive care plan within seven days of the resident assessment.
Missed Ordered Wound Vac Dressing Changes: A resident with DM II, AFib, MDD, and PVD had a wound vac ordered to be changed 3 times weekly, but the dressing was observed still dated from an earlier change and an RN confirmed it had not been changed as ordered, resulting in missed dressing changes.
Failure to Measure Pressure Wound on Admission and Readmission: A resident with a Stage IV sacral/coccyx pressure ulcer, respiratory failure, AFib, hypoxia/hypercapnia, incontinence, and obesity was admitted and later readmitted with an open sacral area, but the admission and readmission assessments did not include wound measurements. The wound was measured later by the wound nurse and wound physician, and the DON verified the measurements should have been obtained at both transitions of care.
A resident with dysphagia, hemiplegia, seizures, and underweight status experienced major weight loss after admission, including a rapid drop in body weight over a short period. The facility did not obtain ordered weekly weights or a requested reweight, and although Med Pass was marked as given on the MAR/TAR, the amount consumed was not documented for an extended period. The RD and DON confirmed the missing weight monitoring and incomplete supplement documentation.
Incomplete Dialysis Monitoring and Communication: A resident with ESRD, CHF, HTN, dementia, and severe cognitive impairment had physician orders for pre- and post-dialysis weights and vital signs, but the record lacked documentation that these were obtained consistently. The chart also showed pre/post dialysis communication forms were not completed thoroughly or were missing on multiple occasions, and an RCN confirmed the documentation gaps.
The facility failed to complete required care conferences for three residents and did not update one resident’s care plan in a timely manner. It also failed to document blood glucose monitoring for a resident with DM who was receiving insulin and Trulicity, despite provider notes indicating ongoing glucose monitoring was needed. In addition, a resident receiving divalproex had a valproic acid lab order every six months, but the most recent level in the record was outdated, and the DON confirmed it had not been completed as ordered.
Medication error rate exceeded 5% during a med pass when two errors were found among 28 medications administered. One resident’s ordered Keppra was unavailable for the LPN to give, and an RN crushed a resident’s Potassium Chloride ER tablet even though it was not to be crushed. The resulting error rate was 7.14%.
A resident with DM, CKD, heart disease, malnutrition, and a coronary graft had weekly potassium labs ordered with results to be faxed to a nephrology physician. The facility did not document notifying the nephrology physician or the facility NP/MD of elevated potassium values, and there was no documentation for a missed potassium lab result or any physician response.
Failure to provide dental services was identified for one resident with DM, AFib, MDD, and PVD. The resident was last seen by a dentist in August 2024, with no subsequent dental visits documented despite a physician order for dental services and an MDS showing moderate cognitive impairment and need for ADL assistance. An RCN confirmed the resident had not been seen by a dentist since that time, and the facility policy stated dental care should be provided through a consultant dentist retained by the facility.
Failure to Follow Ordered Fluid Restrictions: Three residents with physician-ordered fluid restrictions were found to have bedside water tumblers and other fluids available despite ordered limits. Staff, including CNAs, an RN, the RD, and the DON, stated they were unaware of the restrictions or that the care plans lacked accurate fluid restriction details. One resident with ESRD and dialysis received breakfast fluids over the ordered limit, another with DM and CKD was given coffee and had soda accessible, and a third with respiratory failure had a full water tumbler at bedside. The facility policy required removal of bedside fluids for residents on fluid restriction.
Missing COVID-19 Vaccine Education and Documentation: The facility failed to document education on the benefits and risks of the COVID-19 vaccine for two residents reviewed. One resident with ESRD, CHF, dementia, and severe cognitive impairment refused the vaccine, but the record lacked education documentation and a signed declination form. Another resident with hemiplegia and hemiparesis had no documentation of vaccine administration or education to the resident or representative, and the DON confirmed the missing record entries.
Multiple areas of the facility, including hallways, the dining room, and kitchen, were found with stained and bulging ceiling tiles, active leaks, and dirty air vents containing dust and debris. Staff interviews confirmed ongoing water damage and unaddressed leaks, with damaged wallboard and open areas around plumbing. These conditions did not meet the facility's policy for a safe and clean environment and had the potential to affect all residents.
Multiple residents experienced persistent environmental issues, including leaking faucets, inadequate hot water, and noisy bathroom lights, with staff aware but not resolving the problems. Additional hazards such as cracked parking lots and broken sidewalks were observed, and maintenance staff confirmed the concerns. The facility did not provide a specific maintenance policy when requested.
The facility did not ensure that multiple residents, including those with cognitive impairment and significant medical needs, received the required two showers per week. Medical records, staff and resident interviews, and observations confirmed that several residents missed scheduled showers, with some citing insufficient aide staffing as a reason. Facility policy requires regular bathing for cleanliness and comfort, but this standard was not met.
Surveyors found that several residents did not receive fresh water throughout the day, with staff only providing water upon request rather than routinely. In addition, a resident with significant weight loss did not receive a prescribed nutritional supplement at lunch because staff were unaware of the order. These deficiencies were confirmed through observations, interviews, and record reviews.
Three residents with significant cognitive or physical impairments were not promptly assisted with eating during a meal service. One resident waited 45 minutes before being served and assisted, another waited to be fed, and a third was not seated properly and needed repeated cues to eat. Only one CNA was present to assist multiple residents, resulting in delays and a lack of dignified care, contrary to facility policy.
The facility did not resolve repeated resident council complaints about cracks and holes in the driveway, resulting in incidents where residents in wheelchairs became stuck. Despite ongoing reports to administration and staff, concerns were not addressed in a timely manner, and residents felt their issues were ignored.
A resident with cognitive impairment and a history of elopement left the facility unsupervised, traveled to a nearby gas station, and was returned after intervention by a third party. Despite care plan interventions and facility policy requiring timely reporting, the administrator did not file a Self-Reported Incident with the state agency.
The facility did not ensure meaningful activities were provided as scheduled, with several activities not occurring and limited variety offered. Multiple cognitively intact residents expressed dissatisfaction with the lack of daily and weekend activities, and the Activity Director confirmed the absence of a formal activity policy and insufficient staffing contributed to the deficiency.
A resident with dementia, seizure disorder, and schizophrenia, who was identified as an elopement risk and had a wander guard device in place, was able to leave the facility undetected. Staff heard the door alarm but did not see the resident exit, and the wander guard alarm was only partially functional. The resident was later found at a nearby gas station and safely returned. The deficiency resulted from inadequate supervision and a malfunctioning wander guard alarm system.
A shortage of nursing staff resulted in delays and inadequate assistance for several residents who required help with eating. On the day reviewed, only one CNA was present in the dining area to assist residents, while others were occupied elsewhere, leading to prolonged wait times and improper positioning for residents dependent on staff for feeding. Staff confirmed that this staffing issue was a daily problem.
Untimely Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS assessments within the required timeframe of no later than 14 days after the ARD for five residents reviewed (#02, #04, #17, #19, and #29). Review of the medical records and MDS completion logs showed that Resident #02 had a quarterly MDS with an ARD of 11/01/25 that was completed on 11/17/25. Resident #04 had diagnoses including type II DM, atrial fibrillation, major depressive disorder, and PVD, and the quarterly MDS was not completed until 01/14/26. Resident #17, with diagnoses including dementia, epilepsy, schizoaffective disorder, bipolar type, and schizophrenia, had a quarterly MDS that was not completed until 01/08/26. Resident #19, who had dementia, dysphagia, HTN, adult failure to thrive, and a history of venous thrombosis, had a quarterly MDS start date of 10/06/25 and a due date of 10/30/25, but the actual completion date was 11/17/25. Resident #29, with diagnoses including diabetes, heart disease, CKD, malnutrition, and coronary graft, had a quarterly MDS start date of 12/29/25 and a due date of 01/12/26, but the actual completion date was 01/15/26. The MDS RN verified that the assessments for Residents #02, #04, #17, #19, and #29 were not completed timely as required by RAI guidelines and stated that the RAI manual was used as the procedural guide for MDS completion. For Residents #04 and #17, the MDS RN stated the delay occurred because she was working in two buildings.
Failure to Complete Required Care Conferences and Update Code Status Care Plan
Penalty
Summary
Care conferences were not completed as required for three residents reviewed. Resident #07, who had diagnoses including dementia with agitation, senile degeneration of the brain, schizoaffective disorder, bipolar type, COPD, repeated falls, depression, GERD, and prostate cancer, had severely impaired cognition on the comprehensive MDS and required varying levels of assistance with eating, bed mobility, transfers, toileting, and bathing. His wife stated she did not recall a recent care conference, and the record showed care conferences only on three prior dates with no additional conferences documented. Social Services verified he had not had a care conference since the last documented one and stated care conferences should be completed at least every three months. Resident #22, who had cerebral palsy, protein-calorie malnutrition, major depressive disorder, hypothyroidism, and colon cancer, had moderately impaired cognition on the comprehensive MDS and required assistance with eating, bathing, bed mobility, transfers, and toileting. The record showed only three care conferences with no further documentation, and Social Services verified no care conference since the last recorded date, stating they should occur at least every 3 months. Resident #29, who had diabetes, heart disease, chronic kidney disease, malnutrition, and coronary graft, had intact cognition and required assistance with eating and mobility; his care conference log showed no care conference since the last recorded date, and he stated he had not had one in awhile. Social Service Designee #154 verified he had no care conference since that date and stated a care conference should be offered to the resident and responsible party each quarter. In addition, Resident #06's care plan was not updated to match her code status: the record showed a signed DNR-CC order, but the care plan still listed her as Full Code with CPR interventions. MDS RN #159 confirmed the discrepancy between the medical record and the care plan.
Fall interventions not maintained and neuro checks not documented after unwitnessed falls
Penalty
Summary
The facility failed to ensure care-planned fall interventions were in place for a resident with repeated falls and severely impaired cognition, and it failed to implement appropriate interventions after an unwitnessed fall. Resident #07 had diagnoses including dementia with agitation, senile degeneration of the brain, COPD, repeated falls, and prostate cancer. The resident’s care plan identified a fall mat to the left side of the bed as an intervention, but observations showed the fall mat was not positioned next to the bed as intended; it was found several feet away on one occasion and not in the vicinity of the bed on another. Staff confirmed the mat was not in an effective location, and the DON verified that education about using the call light was not an appropriate intervention after the unwitnessed fall because of the resident’s severely impaired cognition. The facility also failed to complete ordered neurological checks after an unwitnessed event for Resident #06. The resident had diagnoses including arthropathy, hypertension, chronic kidney disease, and muscle weakness, and had moderate cognitive impairment. After the resident was found with a bruise on the scalp, swelling of the upper lip, and a skin tear on the wrist, the NP ordered neuro checks along with monitoring for worsening signs and measures to reduce fall risk. Review of the record showed no documented evidence that the ordered neuro checks were completed, and the DON verified the lack of documentation. Neuro checks were also not documented after unwitnessed falls or fall-related events for Residents #07, #19, #25, and #29. Resident #07 had an unwitnessed fall when attempting to self-transfer, and no neuro checks were documented afterward. Resident #19 had an unwitnessed fall followed by bruising on the left ankle, with no documented neuro checks and no documented thorough investigation of the bruising. Resident #25 experienced multiple unwitnessed falls, and no documented neuro checks were found after any of them. Resident #29 also had an unwitnessed fall with no documented neuro checks afterward. The DON and RCN verified the absence of documented neuro checks for these residents, and the facility policy stated that a resident-centered fall prevention plan would be implemented with relevant interventions to minimize serious consequences of falling.
Infection Control Practices Not Followed for Residents on Precautions
Penalty
Summary
The facility failed to implement appropriate infection control practices for residents on transmission-based precautions. Resident #7 had an order for enhanced barrier precautions related to a suprapubic catheter, but when the ADON and a CNA entered the room and pulled the resident up in bed, neither staff member donned gowns and the ADON did not wear gloves. The room sign also indicated contact precautions, and the ADON confirmed she was the infection control designee and that staff should have worn a gown and gloves upon entering the room. The RCN later verified the signage was incorrect and that the resident was actually on EBP, with gown and glove use required for the care provided. Resident #6 tested positive for COVID-19 and had an order for contact/droplet isolation in a private room with all services provided in the room for 10 days. Observation showed there was no signage on the room indicating droplet precautions, and the CNA and resident left the room and went to the common shower room while both wearing surgical masks. The CNA stated she performed the shower while wearing a surgical mask and did not don a gown, and later confirmed the resident was COVID-19 positive and that she should have worn an N-95 mask and gown. The RCN stated residents positive for COVID-19 should be bathed in their room or masked if going to the shower room, and staff should wear an N-95 mask and gown. Resident #29 had an order for EBP and a sign on the door stating staff should wear a gown, mask, and gloves for direct care, but the ADON applied oxygen via nasal cannula and touched the resident's face, nose, and ears without wearing a gown or gloves. Resident #9 had contact/droplet precautions for COVID-19, and a CNA entered the room wearing a surgical mask, then exited without washing hands and continued walking in the resident-occupied hallway with the same mask. For Resident #4, who had an indwelling catheter and EBP, a CNA performed catheter care and did not change gloves during or after care, then touched clean linens, bed controls, the bedside table, and the resident with soiled gloves. The facility policy stated hand hygiene should be completed immediately before touching a resident, before moving from a soiled body site to a clean body site on the same resident, and after contact with contaminated surfaces.
Failure to Notify Responsible Parties of Significant Weight Loss
Penalty
Summary
The facility failed to notify residents’ responsible parties of significant changes in condition, specifically significant weight loss, for two residents reviewed. Facility policy required notification of the resident’s representative when there was a significant change in physical, mental, or psychosocial status, and the weight assessment policy identified 5% weight loss in one month and 10% weight loss in six months as significant, with greater losses considered severe. Resident #25 was admitted with multiple diagnoses including right-sided facial and skull fractures, hemiplegia and hemiparesis following cerebral infarction, dysphagia, muscle weakness, seizures, generalized anxiety disorder, and underweight status. The resident’s weight decreased from 164.4 pounds at admission to 119 pounds, a loss of 45 pounds or 27% in less than six months. The record also showed a rapid loss of 32 pounds in 11 days between 07/22/25 and 08/01/25, and an additional loss of about 8% from 12/02/25 to 01/02/26. Review of progress notes showed no documented notification to the resident’s family or other authorized representatives about the significant weight loss, and the resident’s daughter stated she was not notified before noticing the resident was considerably thinner during a visit around Thanksgiving. Resident #07 was admitted with diagnoses including dementia with agitation, senile degeneration of the brain, schizoaffective disorder, bipolar type, COPD, depression, GERD, and prostate cancer. Weight records showed a decline from 208.5 pounds in February 2025 to 184 pounds in August 2025 and 178.5 pounds in September 2025, reflecting an 11.7% loss between February and August and a 14.5% loss between March and September. The MDS documented severely impaired cognition and weight loss of 5% or more in the last month or 10% or more in the last 6 months. The resident’s wife stated she had noticed weight loss but had not been notified by the facility, and the record contained no documented evidence that the responsible party was informed. The RD and DON both verified the significant weight loss and confirmed there was no documented notification to the responsible party.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy when Resident #06 was found with injuries of unknown origin. Resident #06 had an admission date of 11/09/25 and diagnoses including arthropathy, hypertension, chronic kidney disease, and muscle weakness. The admission MDS dated 01/15/25 showed a BIMS score of 8, indicating moderate cognitive impairment. A physician progress note dated 01/07/26 documented that the resident was seen for a bruise on the right side of the scalp, swelling of the upper left lip, and a skin tear on the left wrist. The resident reported hitting a hand on a screen door but could not recall any head trauma, said she was walking around the facility, and did not remember falling. The NP recommended monitoring and neuro checks per protocol. A nursing note dated 01/10/26 documented additional bruising on the upper forehead near the hairline and cheek, and the resident stated she had fallen in her room but could not recall when or where. A full skin assessment also identified bruises on both hips. The DON stated the injuries were identified by nursing staff and confirmed the resident was not a reliable historian, but an investigation was not done because the resident reported she had fallen. The CNP stated the resident did not tell her the injuries were from a fall and did not consider the resident a reliable historian. The Administrator stated that if injuries of unknown origin were identified, the abuse policy should be followed until abuse or neglect was ruled out, and that an SRI should be submitted and an investigation started if the cause was not determined. The facility policy required reports of abuse, including injuries of unknown origin, to be reported and thoroughly investigated by facility management, with the Administrator responsible for initiating the investigation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency for one resident who was reviewed for falls. The resident had diagnoses including arthropathy, hypertension, chronic kidney disease, and muscle weakness, and had a BIMS score of 8 indicating moderate cognitive impairment. On 01/06/26, the nurse practitioner saw the resident for an acute visit after staff identified a bruise on the right side of the scalp, swelling of the upper left lip, and a skin tear on the left wrist. The resident said she had hit her hand on a screen door but could not recall any head trauma, reported walking around the facility, and did not remember falling. The nurse practitioner recommended monitoring the bruising and lip swelling and continuing neuro checks and fall-risk monitoring. A later nursing note documented that staff observed bruising on the upper forehead near the hairline and cheek, and when asked, the resident said she had fallen in her room and did not tell anyone. The resident could not recall the date or time of the fall, and a full skin assessment also found two bruises, one on each hip. The resident's vital signs, range of motion, and neuro checks were within normal limits, and the physician and family were notified. Review of the facility's SRIs showed that the injury of unknown origin first documented on 01/06/26 was not reported to the state agency. The administrator stated that injuries of unknown origin should be handled under the abuse policy until abuse or neglect was ruled out and verified that an SRI was not created when the injuries were first identified.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident with a history of arthropathy, hypertension, chronic kidney disease, muscle weakness, and moderate cognitive impairment. The resident was noted to have bruising on the right side of the scalp, swelling of the upper left lip, and a skin tear on the left wrist during an acute visit with the NP, and the resident could not recall any head trauma or a fall. The NP documented that the resident was not a reliable historian and recommended monitoring the bruising, lip swelling, and neurological status, along with fall-risk measures and close monitoring. A later nursing note documented additional bruising on the right upper forehead near the hairline and cheek, and the resident then stated she had fallen in her room but could not recall the date or time. A full skin assessment also identified two bruises, one on each hip. Although the physician and family were notified, the facility did not report the injury of unknown origin first documented on the resident’s face and scalp, and the Administrator confirmed that the injury was not thoroughly investigated. The facility’s abuse policy required reports of injuries of unknown origin to be reported and thoroughly investigated, with the administrator responsible for initiating the investigation.
Missing Bed-Hold Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide bed-hold notices to hospitalized residents. Record review and staff interview showed that Resident #29, who had diagnoses including diabetes, heart disease, chronic kidney disease, malnutrition, and coronary graft, was hospitalized multiple times, and the Regional Clinical Nurse verified there was no documentation that the resident received the required bed-hold notices for those hospitalizations. Resident #29’s MDS showed intact cognition and need for set assistance with eating and partial assistance with mobility. The facility also failed to provide the required bed-hold notice for Resident #32, who had diagnoses including respiratory failure with atrial fibrillation, hypoxia and hypercapnia, incontinence, and obesity. The resident’s MDS showed intact cognition, maximum assistance with mobility, and set-up assistance for meals. In addition, the facility failed to notify the State Ombudsman Agency of Resident #36’s discharge due to hospitalization; the Social Services Manager stated the facility used email for such notifications, but no documented evidence was available to verify that the Ombudsman was notified of the discharge.
Delayed Significant Change MDS Assessment
Penalty
Summary
The facility failed to ensure a significant change MDS assessment was completed in a timely manner for one resident receiving hospice services. The resident was admitted on 10/09/24 with diagnoses including dementia with agitation, senile degeneration of brain, schizoaffective disorder, bipolar type, COPD, depression, and prostate cancer. A significant change MDS assessment documented that the resident had severely impaired cognition and required setup/cleanup assistance with eating, partial/moderate assistance with bed mobility and transfers, and substantial/maximal assistance with toileting and bathing, but the assessment was not completed until 11/21/25. The resident began receiving hospice services on 10/06/25, and RN #159 verified during interview that the significant change assessment was not completed until 11/21/25 and stated it should have been completed by 10/19/25.
Delayed Dental Care Plan Development
Penalty
Summary
The facility failed to ensure a dental care plan was created timely for one resident reviewed for dental services. The resident was admitted with diagnoses including type II diabetes mellitus, atrial fibrillation, major depressive disorder, and peripheral vascular disease, and the Quarterly MDS assessment showed moderate cognitive impairment with a BIMS score of six, along with needs for setup with eating, dependent toileting and transfers, partial assistance with bathing, and substantial assistance with dressing. A physician order dated 07/10/25 included referrals to a podiatrist, dentist, audiologist, and ophthalmologist. During interview on 01/21/26 at 3:55 P.M., the DON verified the resident did not have a dental care plan until 01/21/26 when the surveyor questioned its whereabouts. The facility policy stated that a comprehensive care plan was to be developed within seven days of completing the resident assessment.
Missed Ordered Wound Vac Dressing Changes
Penalty
Summary
The facility failed to ensure a resident’s wound vac dressing was changed as ordered. Resident #04, who had diagnoses including DM II, atrial fibrillation, major depressive disorder, and PVD, had a physician order for a continuous wound vac at 125 mmHg to be changed every Monday, Wednesday, and Friday every shift. The resident’s care plan identified surgical wounds to the right foot with wound vac treatment in place, and the Quarterly MDS showed moderate cognitive impairment with a BIMS score of six and substantial assistance needed with dressing. Review of the record showed the wound vac to the right foot was changed on 01/12/26, but an observation on 01/20/26 found the dressing still dated 01/12/26. RN #157 confirmed the dressing had not been changed since 01/12/26, meaning the resident missed three dressing changes. The facility policy titled Wound Care stated that wound care procedures require verification of a physician’s order and review of the resident’s care plan before assembling equipment and supplies.
Failure to Measure Pressure Wound on Admission and Readmission
Penalty
Summary
The facility failed to thoroughly assess a resident's pressure wound upon admission and readmission. Resident #32 was admitted to the facility, discharged to the hospital, and then readmitted with diagnoses including a Stage IV pressure ulcer, respiratory failure with atrial fibrillation, hypoxia and hypercapnia, incontinence, and obesity. The Admissions Data Collection document for the admission dated 12/19/25 noted an open area on the sacrum but did not include a measurement of the pressure wound. The readmissions Data Collect document dated 01/03/26 also noted an open area on the sacrum and identified the wound as a stage IV pressure wound, but again did not include a measurement. The Weekly Pressure Ulcer documentation dated 01/08/26 later measured the sacrum wound at 2.5 cm by 3.0 cm by 2.5 cm depth, and the Wound Evaluation Summary dated 01/15/26 measured the coccyx wound at 2.3 cm by 3.0 cm by 2.5 cm depth. RN #151, the wound nurse, and the DON both verified the wound should have been measured on admission and readmission, and the DON stated there were no hospital documents available to verify the wound measurements prior to admission and readmission.
Failure to Monitor Weight Loss and Document Nutritional Supplement Intake
Penalty
Summary
The facility failed to implement and carry out physician orders intended to maintain acceptable nutrition status for Resident #25, who was admitted with diagnoses including oropharyngeal dysphagia, hemiplegia and hemiparesis following cerebral infarction, seizures, generalized anxiety disorder, muscle weakness, underweight status, and fractures of the orbital floor and facial/skull bones. The resident’s weight decreased from 164.4 lbs. on admission to 119 lbs. within less than six months, including a rapid loss of 32 lbs. in 11 days and an additional loss of about 8% of body weight from 129 lbs. to 119 lbs. The record showed a physician order for weekly weights for four weeks after admission, but there was no documentation that weekly weights were obtained in July or August 2025, and no reweight was documented until 09/01/25 after the significant loss had already occurred. A dietary progress note documented weight warning and recommended Med Pass 120 mL three times daily, along with a reweight, but the record did not show the reweight was obtained when requested. Although the August and September 2025 MARs and TARs marked the Med Pass supplement as administered, there was no documentation of the amount consumed from the start of the order until 09/17/25. The RD stated the resident remained high nutritional risk and continued losing weight despite interventions, and also stated a health shake supplement had been recommended but was not found on the active physician orders when reviewed. The DON confirmed the resident’s weight measurements had not been obtained or recorded as ordered for July and August 2025.
Incomplete Dialysis Monitoring and Communication
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care/services for a resident who required dialysis. Resident #02 was admitted with ESRD requiring dialysis and also had CHF, anxiety disorder, HTN, and dementia. The quarterly MDS indicated the resident had severe cognitive impairment and required substantial to maximum staff assistance for showers, bed mobility, and transfers and was dependent on staff for toilet hygiene. Physician orders dated 10/29/25 directed the facility to obtain pre-dialysis and post-dialysis vital signs and weights, and a dialysis order dated 10/22/25 specified treatment at a dialysis center every Monday, Wednesday, and Friday with a 12:00 P.M. chair time. Review of the medical record showed no documentation that post-dialysis weights or vital signs were obtained on 12/01/25, 12/08/25, 12/12/25, 12/26/25, or 12/26/25. The record also lacked documentation that pre-dialysis weights or vital signs were obtained on 12/08/25, 12/22/25, and 12/26/25. In addition, pre/post dialysis communication forms were not completed thoroughly on 12/12/25, 12/19/25, 12/26/25, 12/29/25, and 12/31/25, and there was no documentation that the form was completed on 12/01/25. The RCN confirmed the record did not support that pre/post dialysis vital signs and weights were obtained or that dialysis communications were completed consistently or thoroughly in December 2025.
Missed monitoring and care planning deficiencies
Penalty
Summary
The facility failed to ensure care conferences were completed as required for three residents reviewed for care conferences, and it also failed to ensure care plans were updated in a timely manner for one resident reviewed for advanced directives. The report also identified a deficiency related to Resident #04’s drug regimen and monitoring: the resident was admitted with diagnoses including DM, morbid obesity, HTN, chronic kidney disease Stage III, and depression, and was ordered Trulicity weekly and insulin glargine every evening. Although a physician note stated the resident’s blood glucose had been well-controlled on current medications and directed continued monitoring, the medical record contained no documentation showing blood glucose levels were obtained after 10/30/25. The quarterly MDS indicated the resident had severe cognitive impairment and required varying levels of staff assistance with bathing, toileting hygiene, and transfers, and also received seven days of insulin. The DON stated blood glucose should be monitored at least daily because the resident still received insulin daily, and NP #500 stated the expectation was for daily blood glucose checks for a resident receiving daily insulin. The report also identified Resident #07 as having an admission date of 10/09/24 with diagnoses including dementia with agitation, senile degeneration of brain, COPD, and prostate cancer. The resident was ordered divalproex sodium 250 mg by mouth twice daily, and a routine lab order required valproic acid levels every six months. However, the most recent valproic acid level in the record was from 10/16/24, and the DON verified on interview that the level had not been completed every six months as ordered. The comprehensive MDS assessment showed the resident had severely impaired cognition.
Medication Error Rate Exceeded During Medication Pass
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during a medication administration pass. During observation of medication administration for four residents, two medication errors were identified out of 28 medications administered, resulting in a 7.14% medication error rate. One error involved Resident #33, who had diagnoses including Alzheimer's disease, COPD, and emphysema, and was ordered Keppra 500 mg twice daily for seizures; at the morning medication pass, the LPN was unable to administer the Keppra because it was unavailable and had to be ordered from the pharmacy. A second error involved Resident #31, who had Parkinson's disease, moderate intellectual disabilities, and major depressive disorder, and was ordered Potassium Chloride ER 10 mEq daily for hypokalemia. During the medication pass, the RN crushed the Potassium Chloride ER tablet. When questioned, the RN stated she was unsure whether it could be crushed, and later verified that it was not supposed to be crushed. The facility policy stated medications were to be administered safely and in accordance with prescriber orders.
Failure to Notify Physician of Abnormal Potassium Results
Penalty
Summary
The facility failed to notify the physician of abnormal laboratory results for one resident reviewed for labs. Resident #29 was admitted with diagnoses including diabetes, heart disease, chronic kidney disease, malnutrition, and coronary graft, and had intact cognition with assistance needs for eating and mobility. The resident was on a carbohydrate-controlled, no added salt diet and had physician orders dated 02/19/25 for weekly potassium levels every Wednesday with results to be faxed to a designated nephrology practice physician. Review of potassium lab tests showed elevated values on 12/24/25, 12/31/25, and 01/14/26, and an error was documented for the 01/07/26 potassium test with no result available. Nursing progress notes from 12/91/25 through 01/21/26 did not show documentation that the potassium results were faxed to the nephrology physician, and progress notes and entries by NP #500 from 12/19/25 through 01/21/26 did not show acknowledgement of the elevated potassium levels. RN #157, NP #500, the nephrology physician group medical records staff, and the DON all verified there was no documented evidence that the nephrology physician or the facility physician was notified of the elevated potassium results or the missed laboratory result.
Failure to Provide Dental Services
Penalty
Summary
Provide or obtain dental services for each resident was not met for one resident reviewed for dental services. Resident #04 was admitted with diagnoses including diabetes mellitus, atrial fibrillation, major depressive disorder, and peripheral vascular disease. The medical record showed the resident was seen by a dentist in August 2024, but there were no subsequent dental visits documented. A physician order dated 07/10/25 directed the resident to receive dental services, and the MDS assessment dated 12/16/25 indicated the resident had moderate cognitive impairment and required assistance with ADLs. During interview on 01/21/26, the Regional Clinical Nurse confirmed the resident had not been seen by a dentist since August 2024. The facility policy titled Dental Consultant stated dental care should be provided through the services of a consultant dentist retained by the facility.
Failure to Follow Ordered Fluid Restrictions
Penalty
Summary
Therapeutic diets were not followed as ordered for three residents who had physician-ordered fluid restrictions. One resident with end stage renal disease, CHF, COPD, severe cognitive impairment, and dialysis orders had a 1500 cc fluid restriction with specific nursing and dietary limits, but was observed with a bedside water tumbler containing the full nursing allotment plus breakfast fluids that exceeded the ordered breakfast limit. The resident stated she was unaware of the restriction, and staff including a CNA and RN stated they did not know she was on a fluid restriction. The RD and DON stated the restriction should have remained in place and that bedside fluids should not have been accessible. A second resident with diabetes, heart disease, and CKD had an 1800 cc fluid restriction, but the order initially lacked dietary and nursing limits. The resident had a bedside water tumbler, received coffee when requested, and had soda in the room refrigerator. The resident stated he did not know he was on a fluid restriction, and staff stated they were unaware of the restriction and continued to provide fluids. The care plan posted inside the closet door did not document the restriction, and the RD and DON stated the resident should have had specific dietary and nursing limits to monitor intake. A third resident with respiratory failure, atrial fibrillation, hypoxia, and hypercapnia had a 2000 cc fluid restriction, but the order also lacked dietary and nursing limits. The resident had a full water tumbler at the bedside and stated she knew she was on a fluid restriction but had not received counseling about it. Staff stated they did not know she was on a fluid restriction and would not have provided bedside water if they had known. The care plan inside the closet door did not include the restriction, and the facility policy required removal of water pitchers and cups from the room for residents on fluid restriction.
Missing COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure residents were provided education on the benefits and risks of the COVID-19 vaccination before vaccination status was documented or refusal was recorded. This deficiency affected two of five residents reviewed for vaccinations in a facility with a census of 30 residents. Review of the facility policy stated that each resident should be offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, and that education regarding the benefits, risks, and potential side effects should be provided before the vaccine was offered. Resident #02 was admitted with diagnoses including ESRD, CHF, anxiety disorder, HTN, and dementia, and an MDS assessment showed severe cognitive impairment with substantial to maximum assistance needed for ADLs. The medical record showed the resident refused the COVID-19 vaccine, but there was no documentation of education on the risks and benefits of the vaccine and no signed declination form. Resident #25 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction and generalized anxiety disorder, and the record did not include documentation of COVID-19 vaccine administration or education to the resident or resident representative regarding the risks and benefits of the vaccine. The DON confirmed the missing documentation for Resident #25, and Regional Clinical Nurse #160 confirmed the missing education documentation and declination form for Resident #02.
Failure to Maintain Safe and Clean Environment Due to Water Damage and Unclean Air Vents
Penalty
Summary
The facility failed to maintain a safe and clean environment, as evidenced by multiple observations of water damage, staining, and debris throughout various areas. Surveyors observed stained and bulging ceiling tiles, active leaks, and water dripping in the dining room, kitchen, and hallways. Air vents in several hallways were found to be dirty, with dust and debris present, and some ceiling tiles were bulging or had visible water damage. Staff interviews confirmed the presence of these issues, including active leaks in the kitchen and dining room, as well as ongoing water damage in the administrator's office. The wallboard under the kitchen sink was also damaged with open areas around the sink pipe. Review of facility policies indicated that residents are to be provided with a safe, clean, and comfortable environment, and have the right to a dignified existence. However, the observed conditions did not meet these standards, potentially affecting all 30 residents in the facility. The findings were corroborated by staff members, including CNAs, a physical therapy assistant, a dietary aide, an LPN, and the administrator, who all verified the ongoing issues with leaks, water damage, and unclean air vents.
Failure to Maintain Safe and Homelike Environment Due to Environmental Deficiencies
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple environmental deficiencies observed and reported. In several resident rooms, bathroom lights made loud screeching noises, faucets leaked, and hot water temperatures were consistently below acceptable levels, ranging from 82.7 to 88.3 degrees Fahrenheit. Residents reported that these issues had persisted for several days to weeks, with staff aware of the problems but no effective resolution. Residents described receiving lukewarm washcloths for care due to the lack of hot water, and staff apologized for the inconvenience. The maintenance staff member confirmed the environmental concerns upon his return from a two-week absence, acknowledging he had received messages about the water temperature issues but could not recall to whom he reported them. Additional environmental hazards were identified in the facility's common areas, including cracks in the blacktop parking lot and broken, uneven sidewalks with loose chunks of cement, creating potential safety risks. The corporate RN verified the presence of these hazards and acknowledged that the parking lot and sidewalk conditions should have been addressed. The facility did not provide a specific policy regarding environmental maintenance, stating only that they follow standard protocol, which was not produced upon request. These findings affected all 11 residents reviewed for environmental conditions, with a total facility census of 34.
Failure to Provide Required Bathing Frequency
Penalty
Summary
The facility failed to ensure that residents received two showers per week as required, affecting five residents reviewed for bathing. Medical record reviews, observations, and interviews revealed that several residents, including those with severe cognitive impairment, dependence for activities of daily living, and significant medical conditions such as encephalopathy, dementia, end stage renal disease, and aftercare for fractures, did not receive the required number of showers. For example, one resident received only two showers out of eight opportunities, while another received only two out of eleven, with some refusals documented but most missed showers unexplained. Residents were not out to the hospital during these periods, indicating the missed showers occurred while in the facility. Interviews with residents and staff confirmed the lack of adequate bathing, with one resident reporting that showers were missed due to insufficient aide staffing, particularly at night, and being observed with an odor of urine and unkempt appearance. Review of facility policy indicated that bathing is intended to promote cleanliness, comfort, and skin observation, but documentation and staff interviews verified that the required bathing frequency was not maintained for the affected residents.
Failure to Provide Adequate Hydration and Nutritional Supplements
Penalty
Summary
The facility failed to ensure that residents received adequate hydration and nutritional supplements as ordered. Observations and interviews revealed that multiple residents did not have fresh water provided throughout the day. Specifically, four residents were found with either empty or outdated water cups in their rooms, and staff confirmed that water was only provided upon resident request rather than routinely. Residents reported that their water cups had not been refilled daily, and staff interviews corroborated that water was not consistently passed out unless specifically asked for by the resident. Additionally, the facility failed to provide a prescribed nutritional supplement to a resident with significant weight loss. The resident, who was severely cognitively impaired and dependent for eating, had a physician's order for a magic cup supplement to be given at lunch. Observations during a lunch meal showed that the supplement was not present on the resident's tray, and both the assigned CNA and the Dietary Manager were unaware of the order to provide the supplement at lunch. This oversight was confirmed through staff interviews and review of the resident's care plan and dietary orders. The deficiencies were identified through medical record reviews, resident and staff interviews, direct observations, and policy review. The facility's own policies required hydration support and implementation of interventions for weight loss, but these were not followed for the affected residents. The findings were documented under a specific complaint investigation, and the facility census at the time was 34.
Failure to Ensure Dignity and Timely Assistance During Meals
Penalty
Summary
The facility failed to ensure that residents who required assistance with eating were treated with dignity and respect. Three residents with significant cognitive and physical impairments were observed during a lunch period where their needs were not promptly or appropriately addressed. One resident, who was severely cognitively impaired and dependent for eating, was brought to the dining room but was not served lunch or assisted to eat until 45 minutes later. Another resident, who was cognitively intact but physically dependent for eating, was left waiting to be fed after being brought to the dining room. A third resident, with moderate cognitive impairment and requiring setup and cues for meals, was not seated close enough to the table and had to be prompted and physically moved to access her meal. A CNA confirmed she was the only aide present in the dining area and had to assist multiple residents with eating, resulting in delays and a lack of dignified care. The facility's policy required all employees to treat residents with kindness, respect, and dignity, but these standards were not met during the observed meal service. The findings were based on direct observation, staff interview, and policy review.
Failure to Address Resident Council Concerns About Unsafe Driveway
Penalty
Summary
The facility failed to address and resolve concerns raised by the resident council regarding the condition of the facility driveway, which was repeatedly reported as having cracks and holes. Resident council meeting minutes documented ongoing complaints over several months about the driveway's poor condition, including specific incidents where residents in wheelchairs became stuck in the cracks. Residents expressed frustration that their concerns were not being addressed or resolved by administration, despite being reported multiple times. Interviews with residents and staff confirmed that complaints submitted to the administration were not answered in a timely manner, if at all. The Activity Director, who facilitated the council meetings, stated that she relayed concerns to the Administrator but acknowledged that responses were lacking. The facility's policy indicated that resident council feedback should be reviewed by the QAPI committee, but there was no evidence that the concerns about the driveway were resolved or appropriately addressed.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to report an incident of resident elopement to the state agency as required. A resident with diagnoses including non-Alzheimer's dementia, seizure disorder, and schizophrenia, who had a documented history of elopement and was identified as an elopement risk, left the facility without staff knowledge. The resident was supposed to be monitored with a wander guard device and redirected from exit areas, according to the care plan. Despite these interventions, the resident exited the facility, traveled to a nearby gas station, and entered a vehicle with a man known to the station manager. The manager, upon realizing the resident was from the facility, arranged for the resident to be returned. The administrator confirmed during an interview that a Self-Reported Incident (SRI) was not filed because she did not believe neglect had occurred, even though the resident was cognitively impaired and had left the facility unsupervised. Facility policy required reporting of such incidents within federally mandated timeframes, but this was not followed. The deficiency was identified during a complaint investigation and was based on medical record review, staff interview, and policy review.
Failure to Provide Meaningful and Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities as scheduled for its residents, as evidenced by a review of the activity calendar, direct observation, staff and resident interviews, and medical record review. On the observed date, scheduled activities such as mail delivery and manicures did not occur, and bingo was conducted by a resident rather than staff. The activity calendar showed repetitive and limited activities, with mail delivery listed daily as an activity, which the Activity Director acknowledged was not meaningful. The Activity Director also confirmed that activities were not completed as scheduled due to the absence of an activity helper, and that weekends lacked any activities for residents. Three residents reviewed for activities, all of whom were cognitively intact, expressed dissatisfaction with the lack of variety and frequency of activities, particularly on weekends. One resident, who was dependent for most activities of daily living, wished for more than two days of activities per week. Another resident, who served as the council president and bingo caller, stated that more activities were needed and noted the recent absence of an activity helper. The facility did not have a formal activity policy and relied on standard practice, which contributed to the deficiency.
Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Wander Guard Alarm
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate interventions and supervision to prevent an elopement by a resident who was assessed as being at risk for elopement. The resident, who had diagnoses including non-Alzheimer's dementia, seizure disorder, and schizophrenia, had a documented history of eloping from home. Physician orders were in place for the resident to wear a wander guard alarming device, with instructions for staff to check its placement and function regularly. The care plan also included interventions such as monitoring the device, redirecting the resident from exit doors, and providing redirection when visitors were present. On the day of the incident, the resident was found to be missing from the facility. Staff statements indicated that the door alarm was heard and subsequently disarmed, but the resident was not immediately located. The wander guard alarm was reportedly only functioning on one side of the door, and staff did not hear it activate. The resident was later found at a nearby gas station and was being transported across town by an acquaintance when the gas station manager recognized the resident and contacted the facility. The resident was returned without injury. Documentation and interviews revealed that while the door alarm was functioning, the wander guard alarm was not fully operational at the main entrance and employee entrance. Staff were engaged in other duties at the time of the incident and did not immediately respond to the alarm or notice the resident's absence. The facility's policy required identification of residents at risk for elopement and implementation of safety interventions, but these measures were not sufficient to prevent the resident's elopement in this instance.
Insufficient Staffing Led to Delays in Resident Feeding Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of all residents, specifically in assisting residents with eating. On the date reviewed, staffing records showed only two nurses and three CNAs were available to care for 34 residents, with one CNA out of the building accompanying a resident to dialysis. Observations and interviews confirmed that only one CNA was present in the dining area to assist residents who required help with eating, while other aides were occupied feeding residents in the hallways. This resulted in delays and inadequate assistance for residents who were dependent on staff for eating. Three residents were directly affected by this staffing shortage. One resident with severe cognitive impairment and total dependence for eating was not served or assisted with lunch until 45 minutes after being brought to the dining room. Another resident, who was cognitively intact but fully dependent for eating, waited in the dining room before being fed. A third resident with moderate cognitive impairment required cues and physical assistance to eat, but was not positioned properly at the table and had to wait until staff could help her. Staff interviews confirmed that insufficient staffing was a daily occurrence, impacting the timely feeding and care of residents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 225 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jamestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Xenia Health And Rehab | 10.5 mi | ★★★★★ | 1 | 0 |
| Alpine Nursing And Rehabilitation Center | 10.5 mi | ★★★★★ | 0 | 0 |
| Atrium Nursing And Rehabilitation | 10.5 mi | ★★★★★ | 8 | 0 |
| Overbrook Landing Health And Rehabiliation | 11.4 mi | — | 0 | 0 |
| Autumn Years Nursing Center | 12.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.