Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Majestic Care Of Kent during CMS and state inspections, most recent first.
Medication storage refrigerators on the 100/200 halls were not kept at proper temperatures for safe medication storage. An LPN said temperatures were not always monitored daily and could be altered after the fact, and an RN confirmed the refrigerator held resident medications. The temperature log showed repeated readings at freezing levels, and the DON and Administrator acknowledged the refrigerator had been below the accepted cold storage range for medications.
Weights Not Monitored per MD Orders: Two residents, including one with vascular dementia, diabetes, and hemiplegia and another with DM2, malnutrition, and Alzheimer’s dementia, did not have weights obtained as ordered. The record showed missed monthly and weekly weights, no documented re-weighs after significant weight changes, and the DON confirmed the residents were not weighed according to the physician orders.
Adaptive feeding equipment was not provided as ordered for a resident with hemiplegia, DM2, and vascular dementia. The resident’s order required a high sided plate and rocker knife, and the care plan noted the need for both items at meals, but an observed lunch tray did not include either item. The resident said he frequently did not receive the rocker knife or high sided plate and that it made eating harder.
A deficiency occurred when evening medications were not administered to multiple residents on two units after a nurse left her shift and took the med cart keys, and the on-duty nurse refused to use available backup keys because they were not formally signed out. Residents with conditions such as CHF, COPD, diabetes, dementia, schizophrenia, Alzheimer’s disease, seizure disorders, and acute respiratory failure missed ordered doses of anticoagulants, antipsychotics, antidepressants, antiepileptics, antihypertensives, antidiabetics, inhalers, sleep aids, supplements, and nutritional products. MAR reviews showed that no nighttime medications were given on those units during that shift, despite a nurse being present in the building.
The facility failed to provide advance, written, and signed notification of room changes for three residents who were moved to different rooms. Each resident had significant medical conditions and required extensive ADL assistance; two had intact cognition and one had moderate cognitive impairment. Staff documented verbal discussions and agreement about the moves for two residents, and reported verbal notification for the third, but the intra-facility room change forms for all three were left unsigned by the residents or their representatives, and no written notices were issued as required by facility policy. During interviews, leadership acknowledged that only verbal notice was given and that no written documentation of the room-change notifications existed.
Surveyors found that the facility did not follow its own food labeling and kitchen sanitation policies. In the walk-in freezer, large opened bags of beef patties, chicken breasts, breaded chicken tenderloins, and peppers and onions were left unsealed and undated, contrary to facility policy requiring all opened or stored food items to be clearly labeled and dated. In the dishwasher sanitization area, walls beneath the rinse shelf and an open wall section with exposed wiring were covered with a black mold-like substance and dirt and debris, and the wall opening created for a new dishwasher installation had never been closed, leaving interior drywall and wiring exposed to contamination.
Failure to screen new staff against the NAR before hire and failure to promptly report and fully investigate an abuse allegation. A CNA was accused of shaking and yelling at one resident with dementia and arguing with another resident, but the report was not made immediately, the accused CNA was not removed right away, and the facility did not collect all witness statements or review personnel files as required by policy.
Food items were found unlabeled, undated, and expired in the dietary storage areas, including dry rice, bread crumbs, and a decorative sauce. The DM verified the findings and stated staff were expected to check dates daily and when preparing food items. Two residents were ordered NPO, and the facility census was 55.
The facility failed to have a written transfer agreement with a Medicare or Medicaid-certified hospital. Review showed the transfer agreement was signed only by the facility agent and not by the hospital, and the Administrator confirmed she could not locate a signed agreement.
QAPI committee failed to follow through on staff education concerns. Minutes showed repeated online education plans with very low staff participation, but the topic of the education was not identified, the same actions were repeated across meetings, and later QAPI minutes did not review online education or staff training. The Regional Nurse Consultant confirmed there was no QAPI meeting in January and that the facility had not followed the QAPI plan to improve staff training.
Missing Pre-Employment TB Testing for Two Staff Members: The facility failed to ensure TB testing was completed before two staff members began working. Personnel file review showed no evidence of initial TB testing for an LPN and a CNA, and HR staff confirmed they could not locate the records. The facility policy and TB risk assessment indicated baseline two-step TST screening was required upon employment for health-care workers.
The facility failed to ensure a CNA had the required annual training hours. Review of the CNA’s personnel file showed a hire date in 2024 but no evidence of training hours, and HR staff confirmed they could not locate any training documentation. The issue involved one of two CNA files reviewed and had the potential to affect all 55 residents.
Unsafe and Unsanitary Resident Rooms and Bathrooms: Observation and interview found multiple resident rooms and bathrooms were not maintained in a safe, clean, and sanitary condition. Issues included food and liquid splatter on walls and ceilings, an exposed outlet with hanging wires, urine-stained bathroom tile and odors, a sticky bathroom floor, a stained pillow without a pillowcase, a missing floorboard, a partially missing curtain track, and an unsteady toilet safety rail. The Housekeeping Supervisor reported daily cleaning was not thorough and that repair requests had not been approved, and the RDN confirmed the observations.
A resident with multiple health conditions and a high fall risk was being transferred with a Hoyer lift by a CNA and an LPN when the lift's hook became unfastened, resulting in the resident falling and hitting her head. Both staff members reported not having recent or initial training on the lift, and facility policy requiring two trained staff and annual competency checks was not followed.
A resident with diabetes, hypertension, and heart failure did not receive prescribed doses of Insulin Lispro in the morning and Humalog sliding scale insulin at lunch, as required by physician orders. The DON confirmed these medications were not administered as documented in the medical record and care plan.
A resident with diagnoses including depression, insomnia, auditory hallucinations, delusional disorders, and psoriasis had a POA-signed authorization for resident funds, but the form lacked witness signatures. The BOM verified the authorization was not witnessed as required and stated the facility had no resident funds policy available for review.
A resident with personality disorder, breast cancer, insomnia, and mild cognitive impairment died in the facility, and the final disbursal of the resident's $75.77 balance was not completed within the required 30 days. The BOM did not disagree that the payment was late and stated the receptionist handled the disbursal; the facility also had no resident funds policy available for review.
A CNA reported that another CNA yelled at and shook one resident during care and argued with another resident, but the allegation was not immediately reported outside the facility as required. The residents involved included one with advanced dementia and hospice services and another cognitively intact resident. Staff interviews and the facility’s own timeline showed the concern was discussed among multiple staff over the course of the day before management and the SRI process were fully engaged, and the DNS and Administrator confirmed the report was not made immediately.
Incomplete Investigation of Abuse and Neglect Allegations: The facility did not thoroughly investigate allegations that a CNA yelled at and shook one resident and argued with another. The investigation relied on limited interviews, did not include all staff who worked the shift or other potentially affected residents, and did not review personnel records as required by policy. Leadership later acknowledged the investigation was not thorough and there was no evidence law enforcement was contacted.
A resident receiving HD three times weekly was not evaluated before and after dialysis treatments as ordered. The resident had multiple chronic conditions, including CKD, diabetes, heart disease, and anxiety/depression, but the dialysis communication records and binder contained blank or incomplete pre/post assessment forms.
Improper Storage of Medications in Resident Rooms: Two residents had Nystatin Powder left in their rooms during med pass, including bottles on a TV stand and tray table. An RN confirmed the meds should not have been left at bedside because there was no MD order for self-administration, and the facility policy stated meds were not to be left unattended in a resident’s room.
Incomplete resident record documentation was found for three residents. One resident with dementia and behavioral symptoms had a PRN lorazepam order and administration documented, but the chart lacked notes showing the behaviors, hospice request, and start of the medication. Two deceased residents also had missing charting, including the time of death, absence of vital signs, and notification of the hospice, family, physician, or guardian; staff confirmed the documentation was incomplete.
Medication Refrigerator Temperatures Below Accepted Range
Penalty
Summary
Medication storage refrigerators on the 100/200 halls were not maintained at proper temperatures for safe medication storage. During an interview, an LPN stated refrigerator temperatures in the medication room were not being monitored daily or written in after the fact, and said a digit could be added or changed to make the temperature appear higher than it was. The LPN also stated the medication refrigerators were too cold at times to safely store medications. Observation of the 100/200 hall medication storage refrigerator showed an internal temperature of 36 degrees Fahrenheit, and the RN confirmed it stored medications for residents on those halls. Review of the May 2026 Equipment Temperature Log showed temperatures recorded at freezing levels between 26 and 32 degrees Fahrenheit on multiple dates, with staff initials documented next to those readings. The DON acknowledged awareness that the refrigerator had been below 36 degrees at times, and the Administrator confirmed the log showed temperatures at or below 32 degrees Fahrenheit on multiple dates. The facility document stated refrigerators should be at 41 degrees Fahrenheit or below, but it did not include guidelines for the accepted cold holding temperature range for medications.
Weights Not Monitored per Physician Orders
Penalty
Summary
The facility failed to ensure resident weights were monitored according to physician orders for two residents. Resident #12, admitted with diagnoses including hemiplegia, type 2 diabetes mellitus, and vascular dementia, had a physician order for monthly weights on the fifth of each month. The record showed no monthly weight documented for December 2025, and when staff were unable to obtain a weight on 12/05/25, there was no evidence of a second attempt the next day or in later progress notes. The January 2026 MAR showed the ordered weight as not applicable, and the clinical weight summary later showed a weight entered by the DON on 01/23/26 at 147.3 pounds. For Resident #12, the record also showed no monthly weight documented for February 2026. On 02/05/26, the MAR recorded a weight of 161.1 pounds, reflecting a 13.8-pound, 9.3% gain from the prior weight, but there was no evidence of a re-weight to confirm the change and no progress note addressing the weight change. The March and April 2026 MARs again indicated the weight as not applicable, and weights entered in the clinical weight summary were documented by the DON. On 05/05/26, the monthly weight was not obtained, and the next recorded weight on 05/06/26 was 167 pounds, an 18-pound, 12% gain over the prior month, with no evidence of a re-weight to verify accuracy or confirm the significant gain. The DON confirmed that residents with significant weight changes were to receive a re-weight within 24 hours and that Resident #12 was not weighed according to physician orders and re-weights were not completed when indicated. Resident #48, admitted with diagnoses including type 2 diabetes mellitus, moderate protein-calorie malnutrition, and Alzheimer's dementia, had weights recorded after admission and later had physician orders for monthly weights and then weekly weights. The record showed a weight of 122.5 pounds on 03/03/26, and physician notes on 03/05/26 and 03/09/26 referenced a weight decrease and awaited weekly weights. The next recorded weight was 120.5 pounds on 04/02/26, showing that ordered weekly weights were not obtained as directed. The DON confirmed that Resident #48 was not weighed according to physician orders and confirmed the documented weights. The facility policy required weights within three days of admission, weekly weights for new admissions and residents at nutritional risk, and re-weighs when significant changes were noted.
Adaptive Feeding Equipment Not Provided as Ordered
Penalty
Summary
Failure to provide adaptive feeding equipment occurred for Resident #12, who had diagnoses including hemiplegia, type 2 diabetes mellitus, and vascular dementia. The resident’s quarterly MDS assessment indicated intact cognition and that he required set up for eating. A physician order dated 10/30/25 specified a regular diet with a high sided plate and a rocker knife, and the care plan last revised on 04/26/26 noted nutrition risk related to diabetes mellitus, hypertension, hemiplegia, and mild cognitive impairment, with the need for a high sided plate and rocker knife at meals. During observation on 05/20/26 at 1:20 P.M. with the RD, Resident #12’s lunch tray did not include the ordered high sided plate or rocker knife. At the time of the observation, the resident stated he frequently did not get the rocker knife or high sided plate and that it made it harder for him to eat his meals. The facility policy on Adaptive Feeding Equipment stated dietary must be notified of adaptive equipment needs and ensure the equipment is placed on the tray at each meal.
Missed Evening Medication Administration on Two Units Due to Key and Staffing Issues
Penalty
Summary
The deficiency involves the facility’s failure to administer ordered evening medications to multiple residents on specific units on 02/21/26. On that evening, residents with various diagnoses, including cellulitis, hypothyroidism, obesity, diabetes mellitus, congestive heart failure, lymphedema, COPD, emphysema, atrial fibrillation, necrotizing fasciitis, acute respiratory failure, dementia, schizophrenia, Alzheimer’s disease, seizure disorders, and insomnia, did not receive their prescribed nighttime medications. Medication Administration Record (MAR) reviews for 16 residents showed that a wide range of medications were not given, including antidiabetic agents, anticoagulants, antipsychotics, antidepressants, antiepileptics, antihypertensives, cholesterol-lowering agents, sleep aids, inhalers, supplements, nutritional products, and other routine medications. For example, one resident with cellulitis, hypothyroidism, and obesity did not receive a probiotic, desmopressin, levothyroxine, collagen supplement, protein supplement, and an antihistamine. Another resident with type 2 diabetes mellitus, morbid obesity, and depression did not receive colchicine. A resident with congestive heart failure, lymphedema, and diabetes insipidus missed doses of ezetimibe, metformin, collagen supplement, acetaminophen, gabapentin, and a protein supplement. Residents with COPD, emphysema, and atrial fibrillation did not receive multiple medications including melatonin, montelukast, Protonix, trazodone, apixaban, metoprolol, omega-3, Pulmicort, senna, Combivent, Haldol, and Tylenol. Additional residents with recent admissions and serious conditions such as necrotizing fasciitis and acute respiratory failure missed evening doses of atorvastatin. Other residents with dementia, Alzheimer’s disease, schizophrenia, vascular dementia, atrial fibrillation, senile brain degeneration, catatonic schizophrenia, intermittent explosive disorder, seizures, visual hallucinations, and overactive bladder also did not receive their ordered evening medications. These included donepezil, divalproex, melatonin, trazodone, Zyprexa, Seroquel, Ativan, Flomax, gabapentin, Keppra, magnesium oxide, memantine, metformin, Prilosec, Remeron, rivaroxaban, hydroxyzine, Symbicort, fluphenazine decanoate, aspirin, risperidone, benztropine, clonazepam, thiamine, Lantus, Eliquis, Humalog, and various nutritional supplements such as Ensure Plus, Magic Cup, Glucerna, and ProStat. The inaction that led to this deficiency was that no nighttime medications were administered to residents on the 300 and 400 halls during that shift, despite the presence of a nurse in the facility. Interviews with the Administrator and DON clarified the sequence of events leading to the missed medication administration. The Assistant Director of Nursing (ADON) had been called in to work the day shift and, when her shift ended at 7:00 P.M., her replacement did not arrive. The ADON then left the facility, quit her job, and dropped the medication cart keys at the Administrator’s home. Although there was still a nurse in the facility and extra medication cart keys were available in the Administrator’s office, the nurse on duty refused to take the keys because they had not been formally signed out to her. As a result, no residents on the 300 and 400 halls received their prescribed nighttime medications on that date. The facility’s self-reported investigation confirmed that the nurse left around 7:30 P.M. with the medication cart keys and that no nighttime medications were administered on those halls during that shift.
Failure to Provide Required Written Notice for Resident Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide advance, written notification of room changes, signed by the resident or their representative, for three residents who experienced intra-facility room moves. Facility policy required that, prior to making a room or roommate change, residents and their representatives receive advance written notice in a language and manner they understand, including the reasons for the move. For one resident admitted with COPD, chronic respiratory failure, and obesity, with intact cognition and extensive ADL assistance needs, a progress note documented that staff discussed a room move with the resident and her daughter and that they agreed; however, the intra-facility room change form dated the following day was not signed by the resident or her representative. A second resident, admitted with hypertensive chronic kidney disease, GERD, and obesity, had moderate cognitive impairment and required extensive ADL assistance. A progress note documented that this resident was informed of a room move, agreed to it, and was observed telling others about the move, but the corresponding intra-facility room change form was not signed by the resident or a representative. A third resident, admitted with limb girdle muscular dystrophy, neuromuscular bladder, and osteoarthritis, had intact cognition and extensive ADL assistance needs. For this resident, there were no progress notes documenting a discussion of the room change, and the intra-facility room change form was also unsigned by the resident or representative. During interviews, the social worker and administrator confirmed that room changes occurred for all three residents, that no written notice of the transfer was given, and that they believed 24-hour verbal notice was appropriate, which did not meet the facility’s written-notice requirement.
Improper Frozen Food Storage and Unsanitary Dishwasher Area
Penalty
Summary
Surveyors identified that the facility failed to maintain safe food storage and sanitary kitchen conditions, affecting all 51 residents who received food prepared in the kitchen. During a kitchen tour, the walk-in freezer contained one large bag each of beef patties, chicken breasts, breaded chicken tenderloins, and peppers and onions that were opened and undated. A kitchen aide and a facility staff member confirmed that these items should have been sealed and dated to prevent freezer burn, and facility policy on labeling and dating required all food items prepared, opened, or stored in the kitchen to be clearly labeled and dated to maintain food safety and prevent spoilage. Surveyors also observed unsanitary conditions in the dishwasher sanitization area. There was a large amount of black mold-like substance covering the walls below the rinse shelf where the automatic dishwasher was placed, as well as an open wall area approximately six by six inches with exposed wires that were also covered in the black mold-like substance and accumulated dirt and debris. The maintenance director confirmed that the wall opening had been created for installation of the new automatic dishwasher but was never closed, leaving the interior drywall and wiring exposed to the mold-like substance and debris. These conditions were inconsistent with the facility’s kitchen sanitation policy, which required storage, preparation, and serving areas, as well as equipment, to be clean, organized, and free of spills, mold, or buildup.
Failure to Screen Staff and Properly Investigate Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy related to screening staff against the Nurse Aide Registry prior to employment, and also failed to timely report, thoroughly investigate, and effectively educate staff regarding abuse. Review of personnel files showed that CNA #561 was hired on 08/22/24 without a Nurse Aide Registry check until 03/06/25, and there was no evidence that [NAME] #569 or Activity Assistant #585 were checked against the registry before hire. The Administrator confirmed staff were to be checked against the registry before working with residents to rule out findings of abuse and neglect. The deficiency also involved an allegation of staff-to-resident neglect concerning CNA #555, Resident #23, and Resident #49. Resident #49 had Alzheimer’s disease, vascular dementia with behavioral disturbance, psychotic disorder, mood affective disorder, dysphagia, constipation, generalized anxiety disorder, and was dependent for dressing; he also had a legal guardian and was receiving hospice services. Resident #23 had Asperger’s syndrome, morbid obesity, depression, type 2 diabetes, insomnia, was cognitively intact, and was dependent for dressing and personal hygiene. CNA #561 reported that CNA #555 yelled at and shook Resident #49 while dressing him and later argued with Resident #23. The facility’s SRI and witness statements reflected conflicting accounts, including statements that CNA #555 shook Resident #49’s shoulders and mocked him by repeating words associated with his communication pattern, while CNA #555 denied shaking the resident and denied abusing either resident. The investigation was not handled in accordance with the facility policy. The report and witness accounts showed that CNA #561 did not report the allegation immediately, and CNA #555 remained in the facility until the end of her shift rather than being removed right away. The facility did not collect statements from all staff working the affected shift, did not interview or assess residents on all relevant halls, did not review personnel files as part of the investigation, and did not thoroughly document the reporting sequence. The Administrator later confirmed the SRI was not thoroughly investigated, did not follow the facility’s abuse protocol, and that multiple staff did not report the allegation immediately as required.
Food Labeling and Dating Deficiency
Penalty
Summary
Foods were not labeled, dated, or removed when expired in the dietary area. During observation in the dry storage room, an unlabeled and undated container of dry brown rice was found along with two expired bags of bread crumbs with an expiration date of 08/01/25. In the walk-in cooler, a bottle of raspberry decorative sauce was found dated 01/27/25. The Dietary Manager verified these findings at the time of observation and stated she was supposed to check food dates daily and that staff were to check dates when preparing food items. Review of the resident diet list showed that Resident #2 and Resident #50 were ordered nothing-by-mouth, and the facility census was 55.
Missing Signed Hospital Transfer Agreement
Penalty
Summary
The facility failed to have a written transfer agreement with one or more hospitals certified by Medicare or Medicaid to ensure residents could be moved quickly to the hospital when medical care was needed. Review of the hospital-nursing facility transfer agreement dated 12/31/24 showed that the hospital had not signed the agreement, and only the facility agent had signed it. During interview on 09/03/25 at 8:22 A.M., the Administrator stated she was unable to find a signed transfer agreement with a hospital and confirmed that the only agreement located was the unsigned 12/31/24 document.
QAPI Committee Did Not Follow Through on Staff Education
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee identified and followed through on staff education. Review of QAPI minutes and Performance Improvement Plan documentation showed repeated plans related to online education that did not include continued corrective action, revision when needed, or changes when the plan appeared ineffective. The minutes from 03/12/25 showed staff reviewed concerns for January and February 2025, and that online education had started in February 2025 with only 14% staff participation. The plan was to provide training, post signs in the breakroom, review the topic during monthly in-services, and have a gift card giveaway, but the minutes did not specify what the online education was. The 06/02/25 QAPI minutes showed staff reviewed concerns for March and April 2025, with online education compliance at 17% in March and 19% in April. The same plan was repeated, including breakroom signs, monthly in-services, and a gift card giveaway, and again the minutes did not identify the online education topic. The 07/17/25 QAPI minutes showed staff reviewed concerns for May and June 2025, but online education and staff training were not reviewed. The 08/29/25 QAPI minutes, completed after the survey team raised concerns about lack of staff education, stated online education was going poorly and that deficiencies were cited during the annual survey regarding staff education. Interview with the Regional Nurse Consultant confirmed there was no QAPI meeting in January 2025 and that the facility had not followed the QAPI plan to ensure staff training improved.
Missing Pre-Employment TB Testing for Two Staff Members
Penalty
Summary
Provide and implement an infection prevention and control program was cited after the facility failed to ensure tuberculosis (TB) testing was completed before staff began working. Review of LPN #536's personnel file showed a hire date of 05/05/25, but there was no evidence that TB testing was completed prior to or upon employment. Review of CNA #561's personnel file showed a hire date of 08/22/24, but there was no evidence that TB testing was completed prior to or upon employment. During interview on 09/03/25 at 2:46 P.M., Regional Human Resources #600 and Human Resources #590 verified they could not locate initial TB testing for either staff member, and RHR #600 stated a two-step TB test was done upon hire for all new employees. Review of the facility policy and TB risk assessment showed the facility had a TB screening program and baseline skin testing was to be performed with a two-step TST for health-care workers upon employment.
Missing Annual CNA Training Documentation
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants had 12 hours of annual training as required. Personnel file review for CNA #561 showed a hire date of 08/22/24, but there was no evidence of any training hours in the file. During interview on 09/03/25 at 2:46 P.M., Regional Human Resources #600 and Human Resources #590 confirmed they could not locate any evidence of training hours for CNA #561, and Regional Human Resources stated that CNAs were aimed to receive at least 12 hours annually for training. This deficiency involved one of two CNA files reviewed and had the potential to affect all 55 residents.
Unsafe and Unsanitary Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain resident rooms and bathrooms in a safe and sanitary condition for four residents. Observation and interview in Resident #31’s room revealed splatters of food on all four walls and the ceiling, and the outlet by the bed was unattached from the wall with wires hanging out. The Housekeeping Supervisor stated that Resident #31 throws food at the wall and will put feces on the wall, and that staff were supposed to clean daily but had not been wiping the walls thoroughly. Additional observations of other resident rooms showed dirty ceilings with multiple brown splatters, a partially missing privacy curtain ceiling track with no privacy curtain, a missing floorboard near an air-conditioning unit, and a bathroom that smelled of urine with a brown toilet rim and sticky floor. One resident’s pillow was stained brown and had no pillowcase. Another resident’s bathroom tile was heavily stained brown from urine, the room smelled of urine, and the toilet safety rail was unsteady because one piece on the right leg was missing. The Housekeeping Supervisor stated he submitted requests for items to be fixed but they were not approved, and the Regional Director of Nurse Consultants confirmed the observations.
Resident Fall During Mechanical Lift Transfer Due to Staff Training and Supervision Lapses
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls and dependent on staff for transfers, was not safely transferred using a mechanical Hoyer lift. The resident, who had multiple diagnoses including dementia, catatonic disorder, and impaired mobility, had a documented history of recent falls. On the day of the incident, the resident was being transferred with the assistance of a CNA and an LPN. During the transfer, the front left hook of the Hoyer lift became unfastened, causing the resident to fall from the lift and hit her head on the floor. The resident was sent to the emergency room and returned with no noted injuries. Interviews revealed that the CNA believed the resident may have attempted to move the Hoyer strap and could not recall her last training on the lift. The LPN, who was assisting, did not witness the hook check as she was gathering supplies at the time. After the fall, the LPN checked the equipment and found all straps in working order. Both staff members indicated a lack of recent or initial training on the Hoyer lift. Facility policy required two staff for mechanical lift transfers and annual competency documentation, but this was not followed, contributing to the incident.
Failure to Administer Diabetes Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications for diabetes management were administered as ordered by the physician for one resident. The resident, who had diagnoses including diabetes mellitus, hypertension, and heart failure, was admitted with physician orders for Insulin Lispro to be given in the morning and at night, as well as Humalog sliding scale insulin to be administered based on blood sugar readings at multiple times throughout the day. Review of the Medication Administration Record showed that Insulin Lispro was not given in the morning and Humalog sliding scale insulin was not administered at lunch on a specific date. The resident's care plan indicated that staff should administer medications as ordered, and facility policy required medications to be administered according to physician orders. The Director of Nursing Services confirmed that the insulin doses were missed as documented.
Resident Funds Authorization Not Witnessed
Penalty
Summary
The facility failed to ensure that authorizations for resident funds were witnessed for one resident reviewed for resident funds. Resident #42 had an admission date of 07/19/22 and diagnoses including depression, insomnia, auditory hallucinations, delusional disorders, and psoriasis. The record also showed that Resident #42 had a power of attorney. Financial records revealed an authorization for resident funds signed by the POA on 05/05/25, but the form did not include any witness signatures. During interview on 09/03/25 at 8:45 A.M., the Business Office Manager verified that Resident #42's resident funds authorization was not witnessed as required and stated the facility did not have a policy regarding resident funds available for review at the time of the interview.
Late Final Disbursement of Deceased Resident Funds
Penalty
Summary
The facility failed to ensure the final disbursal of a deceased resident's funds was completed within 30 days as required. Resident #64 had diagnoses including personality disorder, breast cancer, insomnia, and mild cognitive impairment, and expired in the facility. Financial records showed the resident had a balance of $75.77, and the resident statement indicated the check for the remaining funds was issued after the 30-day limit had been exceeded. During interview, the Business Office Manager was informed that the final disbursement was late and did not disagree. The Business Office Manager also stated that the receptionist, not she, completed the disbursal and that the facility did not have a policy regarding resident funds available for review at the time of the interview.
Failure to Immediately Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to report allegations of abuse and neglect immediately after staff members reported that a CNA yelled at and shook one resident during dressing care and argued with another resident. The allegation involved two residents, one with Alzheimer’s disease, vascular dementia with behavioral disturbance, psychotic disorder, mood affective disorder, dysphagia, constipation, anxiety, and hospice services, and another resident who was cognitively intact and his own responsible party. The report states that the allegation was not reported to another agency when it was first brought forward, even though the facility policy required immediate reporting of abuse, neglect, mistreatment, exploitation, and misappropriation allegations. According to the investigation timeline and witness statements, CNA #561 told multiple staff members that CNA #555 shook Resident #49 while dressing him and later argued with Resident #23. LPN #536 was informed, asked CNA #555 to leave the area, and directed assessments and interviews, but the allegation was not immediately escalated outside the facility. The timeline shows that staff discussed the allegation over the course of the day, with management becoming involved later, and the facility’s own records reflected that the allegation was not reported right away as required. The Administrator later confirmed that CNA #555 worked the entire shift and did not go home early because the allegation had not been reported timely. Resident #49 was not interviewable due to cognition, and Resident #23 denied concerns when interviewed by staff, though later told surveyors that a CNA had been verbally abusive to him months earlier and had a snarky attitude. The facility’s policy required care team members to immediately report allegations to the Administrator and DOH, and required that if a staff member was accused or suspected, the staff member be immediately removed from the facility pending investigation. The DNS and Administrator confirmed during interviews that the allegation involving the two residents was not reported immediately as required.
Incomplete Investigation of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect involving two residents, one with advanced cognitive impairment and one who was cognitively intact. Resident #49 had diagnoses including Alzheimer's disease, dysphagia, vascular dementia with behavioral disturbance, psychotic disorder, and mood affective disorder, had a legal guardian, and was receiving hospice services. Resident #23 had diagnoses including Asperger's syndrome, morbid obesity, depression, type 2 diabetes, and insomnia and was his own responsible party. A self-reported incident dated 07/27/25 alleged that CNA #555 yelled at and shook Resident #49 while dressing him and later argued with Resident #23. The allegation was reported by CNA #561 to nursing leadership, and the facility initiated an investigation and determined the allegation to be unsubstantiated. The investigation relied on limited witness information and did not include all staff who worked the affected shift or all residents who may have been exposed. The facility's timeline showed that after the allegation was reported, staff interviewed Resident #23, who denied concerns and said he felt safe, and assessed Resident #23 and Resident #49 for pain and skin issues. Social services later met with Resident #23, who again denied abuse and stated he felt safe. However, interviews during survey revealed that CNA #573 and CNA #565, who worked on the date and shift of the allegation, were not asked to provide statements, and no resident interviews or skin checks were completed for residents on the 100 and 200 halls even though staff floated across the facility. The facility also did not review personnel files as required by its policy, and the Administrator confirmed the investigation was not thorough. The facility policy required interviewing the resident, the accused, all witnesses, employees who worked closely with the accused or alleged victim, and other residents if abuse or neglect was alleged, as well as reviewing employment records if the accused was a staff member. The policy also stated that if a crime was suspected, law enforcement would be notified within the required timeframe. During survey, the DNS and Administrator acknowledged there was no evidence police were contacted and that the responsible parties reportedly did not want police called. The report concluded that the facility failed to thoroughly investigate the allegations of abuse and neglect.
Missing Pre- and Post-Dialysis Assessments
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when the facility failed to ensure Resident #7 was evaluated before and after hemodialysis treatments. Resident #7 was admitted with diagnoses including diabetes, CKD stage 3, major depressive disorder, generalized anxiety disorder, dependence on renal dialysis, heart disease, GERD, and vitamin D deficiency, and the quarterly MDS dated 06/20/25 indicated the resident was cognitively intact. Physician orders dated 04/21/25 required a pre- and post-assessment on dialysis days. However, review of the Dialysis PRE/POST Communication Record for 09/01/25, 09/02/25, and 09/03/25 showed the assessments were not completed, and the dialysis binder contained only blank dialysis forms with no completed forms.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
Medications were improperly stored and secured when two bottles of Nystatin Powder were found in Resident #55’s room on her television stand during medication administration, and a bottle of Nystatin Powder was also observed on the tray table of her roommate, Resident #10. The RN verified that the medications should not have been left in either resident’s room because the physician had not ordered medications to be left at bedside for self-administration. Review of the facility’s Medication Administration policy dated 01/02/24 stated that medications were not to be left unattended in the resident’s room.
Incomplete Resident Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete resident records for three residents. For one resident with diagnoses including Alzheimer’s disease, dysphagia, constipation, generalized anxiety disorder, vascular dementia with behavioral disturbance, psychotic disorder, and mood affective disorder, the record showed a PRN lorazepam order and a hospice verification that the order was active, and the MAR showed lorazepam was administered and ineffective. However, nurses’ notes before the administration did not document behaviors, the need for lorazepam, the request from hospice for a new medication, or the start of the medication. The UM/LPN verified during interview that the expected documentation was missing. For two deceased residents, the records did not show complete documentation of the events surrounding their deaths. One resident’s closed record showed hospice evaluated the resident and new orders were received, but the record did not indicate when vital signs were absent or when the resident actually expired, and there was no documentation that hospice or the family were notified. Another resident’s record showed the resident expired in the facility, but nursing progress notes did not document the time of death or whether the physician and guardian were notified; a medication note only stated medication was not given due to the resident expiring. Interviews with the RN, RNC, and DON confirmed the missing documentation, and the facility policy required accurate, complete, and timely documentation in the medical record.
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 1,009 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kent
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Stow | 1.3 mi | ★★★★★ | 19 | 0 |
| Tamarack Ridge Health And Rehabilitation | 3.1 mi | ★★★★★ | 2 | 0 |
| The Pavilion At Stow For Nursing And Rehabilitatio | 3.4 mi | ★★★★★ | 0 | 0 |
| Hudson Springs Nursing And Rehab | 3.6 mi | ★★★★★ | 16 | 0 |
| Heather Knoll Retirement Village | 4 mi | ★★★★★ | 2 | 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.