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 Majora Lane Ctr For Rehab & Nsg Care Inc during CMS and state inspections, most recent first.
A cognitively intact resident with multiple chronic conditions developed a personal relationship with a housekeeper who repeatedly discussed her financial problems and accepted money and use of the resident’s debit card for rent, car payments, household needs, and items for her children, while also using the card to buy snacks and personal items for the resident. Text messages showed the housekeeper acknowledging that the resident had given her "way too much" money, instructing him not to let anyone see him give her money, and emphasizing that no one could know they communicated outside of work. After the resident’s death, a friend and the resident’s daughter reported that the staff member had been taking money and attempting to access the resident’s debit card, and another resident reported knowing that the deceased resident had given his card to the housekeeper and paid some of her bills. These documented interactions demonstrated that the resident’s belongings and money were wrongfully used by staff.
The facility failed to record dishwasher temperatures and Quat sanitizer levels for multiple meal services, and a Dietary Coordinator confirmed the missing log entries. The facility also failed to ensure puree-prep equipment was air dried after cleaning; a cook retrieved a wet Robot Coup bowl and lid from the dishwasher and waved them to dry, splashing water in the prep area while preparing pureed food.
Two residents on a secured unit did not receive meaningful or preferred activities despite documented preferences and care plan directives. One cognitively intact resident with dementia and depression had care plan goals to participate in music, religious services, socialization, and other leisure pursuits, yet records showed minimal participation beyond some food events and bingo, and observations found the resident in common areas without structured or independent activities. Another resident, who was legally blind with communication and mobility deficits, had documented preferences for music and news, but activity logs showed almost no provision of these, and observations over several days found the resident in a recliner or in bed with no music or TV playing. Staff interviews confirmed there was no dedicated activity staff on the secured unit, activity staff did not routinely go there, only a few residents were occasionally brought off the unit for activities, and there were no daily, structured activities despite a policy requiring accommodation of resident activity preferences.
A resident with visual impairment, cognitive communication deficit, and mobility difficulties was repeatedly observed in a common-area recliner positioned at an angle, with legs and head hanging off the chair and against a handrail, without a blanket, entertainment, or fluids within reach. Staff at the nearby nurses’ station and the ADON did not reposition the resident or offer a pillow, and the resident was not offered ice cream or cake during an activity. Even after being assisted into a wheelchair at the resident’s request, no drink was made available. The ADON confirmed the resident had been left in this undignified position without food or fluids within reach, explaining the resident was placed in the area so staff could keep the resident in sight.
A resident with a history of stroke, contractures, and vascular dementia had physician orders and a care plan requiring a left-hand palm protector or hand roll splint to be applied daily and nightly with skin checks and hand hygiene. The Treatment Administration Record indicated these interventions were consistently completed, but repeated observations over several days showed the resident without any palm protector or splint in the affected hand while in bed, in a wheelchair, and during activities. An RN confirmed the device was not in place and had been missing from the room for several days, resulting in a failure to provide ordered ROM support for the resident’s contracture.
A resident with hypertension, hallucinations, weakness, and cognitive communication deficit was assessed as initially at moderate, then high risk for falls. After the resident was found on the floor beside the bed following a fall without injury, the fall care plan was revised to include a perimeter mattress to define the bed edges. During a subsequent survey observation, the bed was found to have only a regular flat mattress without perimeter sides, and the ADON confirmed the perimeter mattress was not in place despite the care plan and facility policy requiring fall interventions based on identified risk factors.
Staff failed to use appropriate dementia‑focused, person‑centered approaches with two residents who had dementia and documented behavioral symptoms. In one case, a resident with a history of aggression resisted a scheduled shower; despite a care plan directing staff to stop care when the resident became combative and to return later, staff proceeded with the shower while reporting being hit and having hair pulled, and an LPN delayed responding to repeated requests for help while the resident was reportedly aggressive. In the second case, a resident with dementia and a care plan for verbal aggression and disruptive behaviors became frustrated with a staff member’s child who was running around during smoke time and struck the child; afterward, an LPN who was the child’s parent, and not the resident’s nurse, confronted the resident and told the resident she could be charged with assault, taken to jail, and was “lucky” the LPN was staff, rather than using calm, dementia‑appropriate communication as outlined in facility training and care plans.
Surveyors found that the facility failed to maintain accurate and complete medical records for three residents. For a resident with lower-extremity skin issues, Aquaphor ordered three times daily was documented on the MAR as given even though no ointment was visible and the RN admitted signing before administration. For another resident on a bowel and bladder incontinence program, bladder program service records contained numerous blanks where two-hourly incontinence checks and toileting assistance should have been documented, and a CNA confirmed that aides sometimes forget to sign the log. For a third resident with severe cognitive impairment, malnutrition, and ongoing weight loss, meal intake records were frequently incomplete, with some days missing meals or all documentation, and both the dietician consultant and DON confirmed that intake documentation was not consistently recorded.
Surveyors found that staff failed to follow required transmission-based precautions for two residents. One resident on enhanced barrier precautions for chronic wounds and a urinary catheter was transferred via mechanical lift by two CNAs who did not wear required gowns and gloves, despite posted signage and available PPE. Another resident on airborne precautions for Covid had appropriate signage and PPE at the door, but there was no hand sanitizer immediately available at the room exit, no disinfectant wipes or designated area to clean reusable eye protection, and no used eyewear present, conditions that were confirmed by the ADON.
Improper Storage of Portable Oxygen Tanks: A resident with COPD, dysphagia, hemiplegia, cerebral infarction, and anemia had portable oxygen tanks found in the room, including two tanks secured in transport carts in the closet and another tank unsecured in a canvas bag by a chair. A CMA confirmed the tanks were in the resident’s room and stated portable oxygen tanks are to be stored in the oxygen storage room, while the facility policy required oxygen equipment no longer in use to be stored and secured in the oxygen storage area.
Surveyors identified that multiple residents in a secured unit were exposed to unsanitary conditions, including a broken and soiled toilet seat riser used daily by two residents, persistent foul odors, and a malfunctioning toilet in the only shower room. Staff and maintenance confirmed the ongoing issues, which included grime, rust, and mold in resident bathrooms, in violation of the facility's environmental services policy.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that ensure restraints are only used for medical treatment.
A resident who was dependent on staff for personal care and incontinent of bowel and bladder was not provided timely incontinence care. Staff confirmed that the resident was only changed in the morning and not checked or changed again until the evening, despite care plan requirements and standard practices. When care was finally provided, the resident's brief was saturated and her skin was red and sore.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility failed to ensure proper food storage and preparation, with expired moldy bread found in dry storage and improper cleaning of a food processor used for pureed meals. A staff member also compromised food hygiene by using a spoon for taste testing and then placing it back into the food. These actions affected the quality and safety of meals served to residents.
A resident's room contained an unsecured oxygen tank, despite the discontinuation of the oxygen order. Facility staff confirmed that oxygen tanks should be stored in a locked room, upright, and in a storage rack when not in use. The facility's policy requires tanks to be secured, yet the tank was improperly stored, indicating a lapse in safety protocol adherence.
A facility failed to implement Enhanced Barrier Precautions during wound care for a resident with a Stage III pressure ulcer. Despite a care plan and signage requiring the use of gowns and gloves, an LPN and the ADON only used gloves during the procedure. They later acknowledged forgetting to don gowns, contrary to the facility's policy aimed at preventing infection transmission.
A resident with severe cognitive impairment and incontinence was found to have redness and excoriation on the buttocks, which was not documented or treated promptly. Despite the care plan's interventions, the prescribed extra protection cream was not applied until the day after the condition was noted. Observations showed the resident in pain during care, and staff interviews revealed communication and documentation lapses, leading to non-compliance with the facility's wound care policy.
A resident with a history of a right humerus fracture and other conditions experienced inadequate pain management due to the facility's failure to document and reassess pain levels. Despite receiving pain medications, the resident's pain was not properly evaluated, and follow-up assessments were not conducted. The facility's electronic system and staff practices contributed to the deficiency, as confirmed by the DON.
Misappropriation of Resident Funds by Housekeeping Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a housekeeper accepted money and financial assistance from the resident over an extended period. The resident, identified as Resident #65, was admitted with multiple medical diagnoses including sepsis, hypertension, type 2 diabetes mellitus, end stage renal disease, anxiety disorder, blindness in the left eye, bipolar disorder, and polyneuropathy. Facility records showed no listed contact person, and the resident was later discharged to an independent living facility. A quarterly MDS and progress notes documented that the resident was cognitively intact, with no evidence of cognitive impairment. Text messages between Resident #65 and Housekeeper #150 showed that the housekeeper discussed personal financial needs, including needing money for rent, car payments, tires, diapers and pull-ups for her children, and other expenses. In these exchanges, the resident repeatedly offered and provided money and use of his debit card to the housekeeper, including specific amounts such as $50, $160, $200, $450, and other sums. The housekeeper at times expressed feeling bad about taking more money and acknowledged that the resident had already given her “way too much,” but continued to accept funds and the use of the resident’s debit card. Messages also showed the housekeeper instructing the resident not to let anyone see him give her money and emphasizing that no one could know they communicated outside of work, indicating efforts to keep the financial relationship hidden from facility staff. Additional text messages documented that the resident gave the housekeeper his debit card to purchase items for him such as beef sticks, underwear, socks, soda, chips, candy, hair clippers, shampoo, toothpaste, and cough drops, while also allowing her to use the card for her own needs, including car payments, hotel stays, and toys and supplies for her children. The communications reflected a personal relationship in which the resident expressed affection and the housekeeper acknowledged that he wanted to help her financially, while she continued to accept money and card access. After the resident’s death, his friend and his daughter reported to the LNHA that a staff member had been taking money from him and having a relationship with him, and the daughter further reported that a nurse at the independent living facility had to stop the housekeeper from entering the resident’s apartment to obtain his debit card after he was hospitalized. Another resident reported knowing that the deceased resident had given his debit card to the housekeeper to buy things and had heard that he paid her bills after discharge. These events and communications formed the basis for the finding that the facility failed to ensure the resident was free from misappropriation of property by staff.
Missing Dishwasher Logs and Wet Puree Equipment During Food Preparation
Penalty
Summary
The facility failed to monitor and record dishwasher temperatures and Quatinary sanitizer solution levels for multiple meal services. During the initial kitchen tour, review of the monthly dishwasher temperature log showed blank entries for breakfast, lunch, and dinner on 01/02/26 and 01/03/26, and no temperature recorded for breakfast on 01/04/26. Review of the monthly sanitizer tracking log also showed no sanitation level recorded for dinner on 01/01/26 and no sanitation testing levels recorded for breakfast, lunch, and dinner on 01/02/26 and 01/03/26. The Dietary Coordinator confirmed the missing entries and stated he had been told that missing a couple of days or times during the month was okay. The facility also failed to ensure equipment used for pureed food preparation was adequately dried after cleaning and sanitizing. During observation of puree food preparation, a cook prepared chicken and noodle puree, removed the Robot Coup bowl and lid to run them through the dishwasher, and then retrieved the items while they were still wet before beginning broccoli puree. The cook waved the bowl and lid back and forth to increase drying time, causing water to splash throughout the preparation area. This was observed by the RDC, who attempted to intervene to ensure the bowl was dry before the broccoli puree was prepared.
Failure to Provide Meaningful and Preferred Activities on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful and preferred activities for residents on the secured unit, specifically for Resident #9 and Resident #11, despite identified preferences and care plan interventions. Resident #9, admitted with dementia, major depressive disorder, anxiety, and other medical conditions, had a BIMS score indicating intact cognition and a care plan stating the resident felt it was important to listen to music, be around animals, watch TV, play bingo, socialize, go outside in good weather, and attend religious services. The care plan directed staff to invite, encourage, and assist the resident to activities of interest and to provide supplies for independent leisure activities. Activity calendars showed that music, religious services, food activities, and bingo were regularly scheduled, but participation records for December showed Resident #9 did not attend any music or religious activities, only some food and bingo events, and observations during survey showed the resident in common areas without involvement in any structured or independent activity. Interviews with staff confirmed that the secured unit did not have an assigned activity person and that activity staff did not go to the secured unit to conduct activities. The Activity Coordinator stated that only three or four residents who could sit for 15 to 30 minutes were brought off the secured unit for activities, and verified that residents on the secured unit did not participate in certain scheduled activities such as bread day, although bread was passed to them. The Program Director for the secured unit stated that “Social Circle” on the activity log could mean puzzles, crafts, coloring, or other various activities, and that movies and watching TV were considered the same activity. The Program Director further stated that music was played during meals and the TV was on the rest of the time, and that these were considered daily activities for Resident #9, along with talking and interaction in common areas. However, the Program Director also verified there were no daily, structured activities on the secured unit and that nursing staff only did activities when able. For Resident #11, who was legally blind with a cognitive communication deficit, difficulty walking, and high blood pressure, the activity care plan documented that it was important to him to listen to music, keep up with the news, participate in group activities, go outside, attend religious services, and have snacks between meals. Review of daily activity logs over several weeks showed that the only documented music exposure occurred when musical entertainment performed at the facility, and there was only one entry for crafts, with no entries indicating that the resident listened to music or kept up with the news as preferred. Multiple observations over several days found Resident #11 lying or sitting in a recliner in a common area near the front desk and main entrance, or resting in bed, without music or TV playing. The Activity Coordinator confirmed that the resident had been seated in the common area for the past two days with no music or news playing, despite these being documented as important activity choices for him. The facility’s policy on Resident Activity Preferences stated that the facility would accommodate resident activity preferences through the comprehensive assessment and care planning process, which was not followed in these cases.
Failure to Provide Dignified Seating and Access to Fluids
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences for appropriate and dignified seating and access to fluids. The resident had been admitted with diagnoses including legal blindness, cognitive communication deficit, difficulty walking, and high blood pressure, and had a physician’s order for a regular texture diet with thin liquids. On multiple observations, the resident was found lying or seated in a recliner in a common area near the front desk and main entrance, positioned at an angle with both legs hanging off the side of the footrest and the head hanging off or leaning against a handrail. The resident was not covered with a blanket, had no music or TV for engagement, and had no fluids within reach despite the diet order for thin liquids. Over several observation times, staff seated at the nearby nurses’ desk did not reposition the resident, offer a pillow, or otherwise adjust the resident’s seating to a more appropriate or dignified position, even as visitors walked past. When the ADON stopped to talk with the resident, the resident was still not repositioned. During an activity where ice cream and cake were being passed, the resident was not offered either item while seated in the common area recliner, and there continued to be no water cup available. Later, when the resident requested to be transferred from the recliner to a wheelchair, staff assisted with the transfer, but the resident still had no drink available within reach. In an interview, the ADON confirmed the resident had been lying in the recliner at an angle, was not repositioned, and had no food or fluids within reach, and stated the resident was brought to the common area so staff could keep the resident within their sight.
Failure to Implement Ordered Palm Protector for Contracture Management
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered range of motion support for a resident with a left-hand contracture. The resident was admitted with multiple diagnoses including stroke, contractures, vascular dementia, hypertension, depression, and anxiety, and required staff assistance with ADLs while having intact cognition. Physician orders directed that a left-hand palm protector be applied each morning and removed at bedtime with skin integrity checks each shift, and that the resident tolerate a hand roll splint or palm protector nightly, with the left hand thoroughly washed and dried before and after use. The resident’s ADL functional status care plan also specified use of a palm protector to the left hand for contracture management. The Treatment Administration Record for the review period showed these orders as completed as written. However, multiple observations over several days showed the resident without a palm protector or hand roll splint in the left hand while in bed, in a wheelchair, and participating in activities. On each observed occasion, no palm protector was visible despite the active orders and documented completion on the TAR. In an interview, an RN confirmed that the resident did not have a palm protector in place and reported that the device could not be found in the room and had been missing for several days. This discrepancy between physician orders, care plan, documented implementation, and actual practice led to the cited deficiency for failure to maintain range of motion for a resident with contracture.
Failure to Implement Care-Planned Fall Intervention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as being at risk for falls. The resident was admitted with diagnoses including high blood pressure, hallucinations, weakness, and cognitive communication deficit. A Falls Risk Observation completed at admission showed a moderate fall risk with a score of eight, and a subsequent Falls Risk Observation increased the resident’s status to high risk with a score of 14. A Safety Event report documented that the resident experienced a fall without injury when found lying on the floor beside the bed in the early morning hours, with the only intervention in place at the time being the bed in the lowest position. Following this fall, the resident’s fall care plan was revised to include a perimeter mattress to help define the edges of the bed. However, during a later observation, surveyors noted that the resident’s bed had a regular flat mattress with no perimeter sides in place. In an interview, the ADON confirmed that the resident did not have a perimeter mattress and instead had a regular flat mattress, and stated that the resident had moved into the current room sometime in October. Review of the facility’s Fall Investigation policy showed that the interdisciplinary team is required to review current interventions and implement additional fall interventions based on residents’ risk factors, but the perimeter mattress intervention that had been added to the care plan was not in place for this resident.
Failure to Provide Appropriate Dementia‑Focused Care and Responses to Behavioral Incidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff had the skills and used appropriate approaches to provide person‑centered dementia care to two residents with dementia and behavioral symptoms. For one resident with dementia, depression, anxiety, psychosis, and documented physical and verbal aggression, the care plan specified that staff should offer alternatives when care was refused, allow the resident to make choices, maintain a calm environment, approach slowly and calmly, and stop care if the resident became combative, ensuring safety and returning later. Progress notes documented that this resident was confused, resistive, and combative at times, with increased restlessness, anxiety, and verbal aggression. On the night in question, staff reported the resident initially agreed to a shower but then became combative in the shower room, pulling a staff member’s hair and exhibiting aggressive behaviors. According to staff statements and the self‑reported incident, a resident assistant and a trainee CNA reported that the resident was combative during the shower and that they were being hit, bitten, and having hair pulled. The RA sought guidance from an RN, who advised using two aides and suggested one aide watch or hold the resident’s hands as a distraction so the resident would not grab, hit, or pull hair. The RA and CNA reported feeling that they were being forced to complete the shower despite the resident’s resistance. The LPN on duty acknowledged knowing that the resident did not want to be showered and that staff had asked her for help multiple times while they were agitated and reporting aggression. The LPN did not immediately enter the shower room, continued other tasks, and only later went in, at which time she found the resident agitated but not aggressive and used a redirection strategy (offering to take the resident back to her “baby”) to complete drying and dressing. Another CNA later provided care without issues. The LPN verified that if a resident became combative or agitated, staff should stop what they were doing, and also verified she did not immediately assess the situation in the shower room to ensure the resident’s safety. The second component of the deficiency concerns the facility’s failure to ensure staff approached a resident with dementia appropriately after a behavioral incident. This resident had dementia without behavioral disturbance listed among diagnoses but had a care plan for verbal aggression, hallucinations, false accusations, yelling, argumentativeness, insulting comments, and threatening statements, with interventions including removing the resident from overstimulating situations and moving the resident to a quiet, calm environment when behaviors escalated. During an evening smoke break, a staff member’s seven‑year‑old child was outside in the courtyard running around while residents smoked. Multiple statements indicated that the resident became frustrated with the child’s behavior and struck or punched the child in the stomach. The child went inside crying and reported being hit, and a red mark was observed on the child’s abdomen. After the incident, the LPN who was the child’s mother, and who was not the resident’s nurse and had not witnessed the event, confronted the resident near the nurse’s station. The LPN asked if the resident had hit her child; when the resident confirmed, the LPN told the resident that many children come into the facility and that the resident did not have the right to hit children. The LPN further told the resident that she could be charged with assault, could be taken to jail, and that the resident was “lucky” she was a staff member because someone else might press charges. Other staff and resident statements corroborated that the LPN told the resident she was lucky she was there or in there, that she could be leaving in a police car, and that it was not acceptable to hit other people’s children. The LPN acknowledged she was upset, spoke sternly, and believed she was educating the resident about not hitting children, despite knowing the resident had dementia and that the facility was the resident’s home. The facility assessment and training materials indicated that staff were to receive dementia management, person‑centered care, and communication training, but the events described show that staff responses to these residents’ dementia‑related behaviors did not align with the planned dementia‑care approaches.
Failure to Maintain Accurate Medication, Toileting, and Nutritional Intake Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for multiple residents. For one resident with morbid obesity, depression, chronic venous stasis, lymphedema, anemia, and pulmonary hypertension, the nurse practitioner ordered Aquaphor to be applied to both lower extremities three times daily. The MAR showed scheduled administration times in the morning, afternoon, and evening. On one review date, the morning Aquaphor dose had not been signed as given, and later that same day the MAR reflected that the afternoon dose had been signed out by an RN. However, direct observation shortly afterward revealed no visible Aquaphor on the resident’s lower legs, and the resident reported that no one had applied it all day. The administrator confirmed there was no Aquaphor visible despite the MAR being signed for that time frame, and the RN acknowledged she had signed for administration before actually applying the medication. Another resident, admitted with heart failure, stroke with right-sided paralysis, cognitive and language deficits, morbid obesity, depression, and bowel and bladder incontinence, had an MDS showing a severely impaired BIMS score and participation in a bladder and bowel incontinence program. The care plan called for a routine bowel and bladder program with staff checking and offering toileting assistance every two hours. Review of the Bladder Program Service Delivery Records for several months showed numerous blanks where staff were to document incontinence checks and toileting assistance, including multiple specific dates in one month with no entries at all. A CNA interview confirmed that CNAs are expected to perform and document two-hourly checks and toileting, that the documentation is kept in a logbook at the nurses’ desk, and that aides, including the interviewed CNA, sometimes forget to sign the logs. A third resident with Alzheimer’s disease, schizoaffective disorder, bipolar disorder, severe protein-calorie malnutrition, anxiety, paranoid schizophrenia, cerebral palsy, and major depressive disorder had a care plan identifying risk for altered nutrition and preferences for sweets, pop, milk, ice cream, pudding, and yogurt, with variable oral intake and acceptance of supplements. The MDS showed severe cognitive impairment and interventions including supplements and menu alternatives. Weight records showed ongoing weight loss, and dietician notes documented significant percentage weight loss over 90 and 180 days, low BMI, variable intake from 1% to 100%, and use of multiple nutritional supplements. Review of meal intake documentation revealed missing entries, including days where only dinner was documented and days with no meal intake documentation at all. The regional dietician consultant and the DON both verified that meal intake documentation for this resident was incomplete or missing in the electronic record.
Failure to Maintain Transmission-Based and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain required transmission-based precautions for residents on enhanced barrier and airborne precautions. One resident with a history of stroke, contractures, vascular dementia, hypertension, depression, and anxiety had physician orders for enhanced barrier precautions related to chronic wounds and an indwelling urinary catheter. The resident’s care plan required use of gowns and gloves during high-contact care activities, with signage and PPE supplies available at the room. Surveyors observed two CNAs transferring this resident from bed to wheelchair using a mechanical lift without wearing gowns or gloves, despite the posted enhanced barrier precautions sign and PPE being available. One CNA acknowledged that gowns and gloves should have been worn during the transfer. Another resident, admitted with diagnoses including Covid, intracranial hemorrhage, and fall with injuries at home, had physician orders for airborne transmission-based precautions, including remaining in the room with all services brought to the room. Signage at the room instructed all persons entering to clean hands when entering and before leaving, and to wear gown, gloves, mask, and eye protection, with HCP additionally required to use an N95 mask. Surveyors observed that, although PPE was available at the door, there was no hand sanitizer immediately available upon exiting the room, the nearest dispenser being down the hallway. There were also no disinfectant wipes or designated area to clean and disinfect used eyewear, and no used eyewear was present in the room or PPE storage. The ADON confirmed the absence of hand sanitizer at exit, the lack of disinfectant wipes and cleaning area for eyewear, and the lack of used eyewear in the PPE storage, despite facility policy requiring appropriate use of transmission-based precautions.
Improper Storage of Portable Oxygen Tanks
Penalty
Summary
The facility failed to store portable oxygen tanks in an oxygen storage area for one resident with diagnoses including cerebral infarction, dysphagia, hemiplegia, COPD, and anemia. Review of the resident’s medical record showed no physician orders for oxygen use and no care plan implementation for oxygen use. During observation, two portable oxygen tanks with regulators were found separately secured in transport carts in the closet area of the resident’s room behind the door, and another portable oxygen tank was found unsecured in a canvas bag for wheelchair use, leaning upright in a chair near the window. A CMA confirmed the tanks were in the resident’s room and stated portable oxygen tanks are to be stored in the oxygen storage room and not in a resident’s room. The facility policy stated that when oxygen is discontinued or ordered PRN, oxygen equipment no longer in use will always be stored and secured in the oxygen storage area.
Failure to Maintain Clean and Homelike Environment in Secured Unit
Penalty
Summary
Surveyors found that the facility failed to maintain a clean and homelike environment in the secured unit, affecting all 17 residents living there. Observations revealed that a shared bathroom used by two residents had a plastic toilet seat riser that was broken, smeared with stool, and stained with dried urine, emitting a foul odor. Despite being used daily by both residents, the seat remained uncleaned and in disrepair over multiple days. One of the residents using the seat was moderately cognitively impaired and required extensive assistance with mobility and toileting, while the other was frequently incontinent and needed assistance with hygiene and transfers. Staff confirmed the condition of the toilet seat and that both residents used it, even though only one had an order or care plan for its use. Further observations in the secured unit's only shower room revealed that the toilet was not consistently flushing for approximately two weeks, despite repeated notifications to maintenance. The floor around the toilet was dirty with significant dirt and grime buildup, and the caulking in the shower stall was discolored with black/grey mold. Maintenance staff confirmed the presence of rust and grime around the toilet and acknowledged recent cleaning and repairs for mold in the shower area. The facility's policy required maintaining a clean and sanitary environment, but these conditions were not met, as verified by staff and maintenance interviews.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with a history of urinary tract infections, hemiplegia, hemiparesis, and muscle weakness, who was dependent on staff for personal care and incontinent of bowel and bladder, was not provided timely incontinence care. The resident's care plan required staff to check and provide incontinence care as needed, and staff interviews confirmed that residents should be checked and changed every two hours and as needed. However, observation and interviews revealed that the resident was only changed in the morning before being transferred to a wheelchair and was not checked or changed again until the evening. During the day, the resident remained in her wheelchair without being offered incontinence care, and staff confirmed that she was not checked or changed after the initial morning care. When incontinence care was finally provided in the evening, the resident's brief was found to be saturated, bulging, and foul-smelling, and her buttocks were red. The resident reported feeling sore and confirmed that this was the first time she had been changed since the morning.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care processes for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information and proper record-keeping were not consistently followed. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure proper food storage and preparation practices in the kitchen, affecting the quality and safety of meals served to residents. During an observation, six loaves of expired wheat bread with visible mold were found in the dry storage area. The Dietary Coordinator confirmed the findings and removed the bread, acknowledging that all residents, except for two who were NPO, could have potentially received the moldy bread. The facility's policy on dry storage and supplies emphasized the importance of storing non-perishable food to optimize safety and quality, which was not adhered to in this instance. Additionally, the facility did not maintain cleanliness standards for the Robo-coupe food processor used to prepare pureed meals for two residents. The processor was observed to be wet and not properly cleaned before use, with visible food remnants from previous use. Furthermore, a staff member was seen using a plastic spoon to taste test a pureed mixture and then placing the same spoon back into the food, compromising its hygiene. The Dietary Coordinator and the staff member confirmed these observations, which violated the facility's policy requiring clean equipment for preparing pureed diets.
Improper Storage of Oxygen Tank in Resident's Room
Penalty
Summary
The facility failed to prevent a potential accident hazard by not properly storing a compressed gas cylinder (oxygen tank) in a resident's room. The resident, who had been admitted with diagnoses including pneumonia, major depressive disorder, chronic kidney disease, diabetes, and osteoarthritis, had a physician's order for continuous oxygen at two liters per minute via nasal cannula. This order was discontinued, yet an unsecured oxygen tank was observed leaning against the wall of the closet in the resident's room. Interviews with facility staff, including a housekeeper and a registered nurse, confirmed that oxygen tanks should not be stored in resident rooms without being in a storage cart and should be kept in a locked room, upright, and in a storage rack when not in use. The facility's policy on oxygen storage also mandates that tanks be stored in a well-ventilated, protected area and secured by a chain, strap, or on a cart. Despite a staff in-service on the proper handling of compressed gas cylinders, the oxygen tank was improperly stored, indicating a lapse in adherence to safety protocols.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a Stage III pressure ulcer on the left buttock. The resident, who was admitted with diagnoses including Alzheimer's Disease and acute respiratory failure with hypoxia, had a physician's order and care plan requiring EBP due to the chronic wound. The care plan specified that EBP supplies should be available in the resident's room, with signage to alert caregivers, and that personal protective equipment (PPE) such as gowns and gloves should be used during high-contact care activities. During an observation, it was noted that a sign outside the resident's room instructed staff to wear gowns and gloves for high-contact care, including wound care. However, when an LPN and the Assistant Director of Nursing (ADON) entered the room to perform wound care, they only applied gloves and did not don gowns as required. Both staff members later confirmed in an interview that they had forgotten to apply gowns, despite the signage and availability of PPE in the room. The facility's policy on Enhanced Barrier Precautions, updated earlier in the year, mandates the use of gowns and gloves during high-contact care to prevent the transmission of communicable diseases and infections.
Failure to Document and Treat Resident's Skin Condition Timely
Penalty
Summary
The facility failed to ensure timely documentation and treatment of a resident's skin condition, specifically redness and excoriation on the buttocks. The resident, who had severe cognitive impairment and required extensive assistance with personal care, was found to have redness and painful areas on the buttocks during a skin assessment. Despite the presence of redness, the condition was not documented in the progress notes, and the prescribed treatment was not applied promptly. The resident's care plan indicated a risk for skin breakdown due to incontinence, and interventions included applying moisture barrier cream after each incontinent episode. However, the facility's records did not show evidence of the application of the prescribed extra protection cream until the day after the condition was noted. Observations by surveyors revealed that the resident cried out in pain during incontinence care, and the redness and excoriation were visibly apparent. Interviews with staff, including the Director of Nursing and nursing assistants, revealed a lack of communication and documentation regarding the resident's skin condition. The facility's policy required nurses to assess and document skin issues, but the process was not followed, leading to a delay in treatment. The deficiency was identified during an investigation of a complaint, highlighting non-compliance with the facility's wound care policy.
Inadequate Pain Management Documentation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate documentation and timely treatment of pain for a resident with a history of a right humerus fracture, major depressive disorder, and a leg laceration. The resident's care plan included interventions for pain management, such as assessing pain, encouraging the resident to rate their pain, and medicating per physician orders. However, on a specific day, the resident's pain was not properly documented or managed, as evidenced by missing pain level assessments and inadequate follow-up on the effectiveness of administered pain medications. On the day in question, the resident was observed to be in pain, with a grimace and reluctance to get out of bed due to discomfort. Despite receiving pain medications, including acetaminophen and oxycodone-acetaminophen, there was no documentation of the resident's pain level on a scale of one to ten. Interviews with staff revealed that the electronic system required a follow-up pain assessment, but this was not completed, and the resident's pain level was not reassessed after medication administration. The Director of Nursing confirmed that the resident's pain management orders were not correctly set up in the electronic system, leading to a lack of appropriate follow-up. The facility's policy on pain assessment and management emphasized the importance of evaluating both verbal and non-verbal signs of pain and ensuring effective pain management. However, the failure to document and reassess the resident's pain level resulted in inadequate pain management for the resident.
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.
Illustrative
What surveyors actually found near you
We read the 148 citations issued within 25 miles in the last 12 months — including the 1 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 Millersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Scenic Pointe Nursing And Rehab Ctr | 2.2 mi | ★★★★★ | 6 | 0 |
| Sycamore Run Nursing And Rehab Ctr | 2.8 mi | ★★★★★ | 4 | 0 |
| Walnut Hills Nursing Home | 10.3 mi | ★★★★★ | 0 | 0 |
| Oak Pointe Nursing & Rehabilitation | 13.1 mi | ★★★★★ | 0 | 0 |
| Wayne County Care Center | 16.8 mi | ★★★★★ | 4 | 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.