Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Mccrea Manor Nsng And Rehab Ctr Llc during CMS and state inspections, most recent first.
A resident with multiple complex conditions, including CHF with CKD stage 3, COPD, diabetes, fractures, and protein-calorie malnutrition, had a physician order for 1L NS IV at 100 cc/hr for dehydration that was not implemented in a timely manner. An LPN documented the order, but the IV was not started until later by an RN, who reported that prior nurses had refused to hang the IV. The DON, Interim DON, and ADON all confirmed that the IV infusion was not initiated within a timely period after the order was received, despite facility policy requiring the nurse who takes the order to execute it or ensure a safe hand-off.
A resident with multiple medical conditions, including COPD and chronic respiratory failure requiring O2 via nasal cannula, was care planned as at risk for injury related to smoking, with interventions requiring supervision during smoking and storage of all smoking items at the nurse station. During observation, surveyors found an open metal box containing a disposable e-cigarette on the resident’s over-bed tray, and the resident and CNAs confirmed the vape was kept in the room despite staff acknowledging it was not permitted. The DON confirmed the resident was not allowed to keep e-cigarette supplies in the room, and review of the facility’s smoking policy showed all smoking materials, including vapes, were required to be stored in locked boxes at the nurse station or designated area.
A resident with anxiety and other medical conditions, care planned for safe medication use, had multiple scheduled doses of clonazepam 0.5 mg PO BID not administered as ordered, with MAR entries coded to see nurses’ notes and incomplete documentation, including one missed dose with no corresponding progress note and no narcotic sign-outs for the omitted doses. Progress notes on some days cited waiting for pharmacy supply or a new prescription. Additionally, clonazepam 1 mg tablets were available while the order was for 0.5 mg BID, and on two occasions RNs documented wasting 0.5 mg of clonazepam with only a single nurse signature and no second witness, contrary to facility policy requiring two licensed nurse witnesses and signatures for controlled substance destruction.
Two residents who were cognitively intact and had signed consent forms for the COVID-19 vaccine did not receive the vaccine, and the vaccine was not ordered in their physician orders. One resident reported asking nursing twice about when the vaccine would be given but received no answer. The DON verified the vaccines had not been ordered or administered and stated the facility did not have a COVID-19 vaccine policy.
A resident with intact cognition and a history of mental health and medical conditions was served meals on disposable dishware and utensils without clear justification or reassessment, despite facility policy limiting such use to emergencies. Both the resident and staff were unaware of the reason for this intervention, and the Dietary Director confirmed that the practice had not been reviewed for continued appropriateness.
Failure to consistently implement fall-related toileting interventions for a resident with dementia, incontinence, and fall risk. The resident’s care plan included toileting after meals, but CNAs did not consistently provide toileting or incontinence care after meals, and one CNA was unsure whether the resident was on a toileting plan. The resident had multiple falls, including in the dining room, hallway, and shower area, with one fall causing a knot to the posterior head.
A resident with DM, muscle weakness, COPD, and anxiety signed consent for the pneumococcal vaccine, but the vaccine was not ordered or administered and no documented pneumococcal immunization was found. The resident reported she had signed consent months earlier and still had not received the vaccine, and the DON confirmed it had not been ordered or given despite the facility policy to offer influenza and pneumococcal vaccines to all residents.
Surveyors identified that staff did not date opened insulin pens for several residents, and undated pens were found in medication carts, including one for a resident no longer at the facility. Nurses acknowledged the lack of dating and proper disposal, which did not comply with manufacturer guidelines or facility policy.
Staff served only two ounces of rice pilaf to residents instead of the required three or four ounces, as specified by the menu and portion control guidelines. This error was confirmed during tray line observation and affected a large number of residents, with one resident excluded due to a no food by mouth order.
Surveyors found that the facility did not maintain a clean and sanitary environment, with dirty floors, trash, and personal care items left on the floor, discolored and stained flooring, and over-bed tables in disrepair. Staff and residents confirmed these issues, and the Administrator acknowledged that all staff are responsible for cleaning up spills and trash.
A resident with multiple medical and psychiatric diagnoses, who was assessed as cognitively intact, had his preference for sponge baths and right to refuse showers disregarded when staff contacted his POA to obtain permission to proceed with a shower against his wishes. Despite the resident's ability to make his own care decisions, staff deferred to the POA and completed the shower, failing to honor the resident's rights.
Surveyors found that ordered medications were not available for administration to three residents, including cases where an LPN could not provide Clopidogrel, and other residents missed doses of medications such as Losartan, Amlodipine, and Phenobarbital due to pharmacy delivery delays. The DON, new to the facility, was aware of pharmacy issues but could not explain the specific incidents.
Staff failed to administer medications as ordered and in accordance with manufacturer guidance, resulting in a 12.9% medication error rate. Two residents received incorrect medications: one was given a multivitamin with minerals instead of the ordered multivitamin and did not receive a prescribed medication due to unavailability, while another received a multivitamin with minerals instead of the ordered type and was administered insulin from a Kwik-pen without a recorded open date, contrary to manufacturer instructions.
A resident received a lunch meal where the fish was served at 111°F, below the facility's required temperature of 135°F, resulting in the food being cold and unpalatable. Observations revealed confusion on the tray line and delays in serving, contributing to the deficiency.
Two residents with complex medical conditions had incomplete documentation in their MARs, with several scheduled medications not recorded as administered or offered. An agency RN was observed giving medications but failed to sign off, and the DON could not provide additional details for missing entries.
A resident with dementia in a secured memory care unit exhibited aggressive behaviors, and the facility failed to provide appropriate care. Despite having a care plan, staff struggled to manage the resident's behaviors, and prescribed medications were not administered. An interdisciplinary team meeting with the resident's family was not coordinated, and there were allegations of physical abuse by staff. The facility's dementia care policy was not followed, leading to a deficiency.
The facility failed to maintain a clean and sanitary kitchen, affecting nearly all residents receiving food. Observations revealed dirty floors, food-splattered equipment, and improperly labeled or dated food items in storage. The Dietary Manager confirmed these findings, which were contrary to the facility's Food Safety and Sanitation policy.
The facility failed to provide scheduled activities for residents in the memory care unit, affecting 15 out of 16 residents. Observations showed that during activity times, residents were left without structured engagement, with staff either on breaks or unaware of their responsibilities. The Activity Assistant assumed activities were conducted, but they were not, and the DON was unaware of communication regarding completed activities. The activity calendar showed limited scheduling, and despite training, activities were not implemented.
Several residents in the LTC facility did not receive wound and skin care treatments as ordered, leading to deficiencies in care. A resident with diabetes did not have their foot ulcer dressings changed regularly, and an offloading shoe was not provided. Another resident with blisters on the leg did not receive proper assessments or dressings, and ACE wraps were not applied. Additionally, a resident at risk for skin tears was not wearing prescribed protective gear, and another resident's PEG tube dressing was not in place. Staff interviews confirmed a lack of awareness and adherence to treatment orders.
The facility failed to update and individualize care plans for residents regarding smoking status and interventions, affecting several residents. One resident was allowed to keep smoking materials in his room against policy, while another had smoking materials without proper supervision. Additionally, a resident with impaired cognition was observed smoking without a required apron, and another resident at risk for falls was not wearing nonskid socks as per their care plan.
A facility failed to maintain contact isolation for a resident with an active HSV outbreak, as ordered by a physician. The resident's door signage inaccurately indicated enhanced barrier precautions instead of contact isolation, which required staff to wear PPE when entering the room. This error was confirmed by the DON and affected 12 other residents on the same unit.
A facility failed to set a resident's oxygen flow rate according to the physician's order. The resident, with multiple diagnoses including COPD and asthma, was supposed to receive oxygen at two liters per minute via nasal cannula. However, observations showed the flow rate was set at three liters per minute. Interviews with an LPN and the DON confirmed the discrepancy.
A resident's room was found to be in disrepair, with four holes in the drywall and a damaged electrical outlet recessed into the wall. The Maintenance Director confirmed these issues during an inspection.
The facility failed to provide proper pressure ulcer wound care for two residents. One resident did not receive the prescribed treatment for a sacrum wound, and the nurse did not follow hand hygiene protocols. Another resident's Stage 4 sacral ulcer was found without the required dressing, and a nurse aide did not report this to the nurse. The facility's wound care policy was not adhered to, resulting in deficiencies.
Failure to Timely Implement Physician Order for IV Fluids
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely implementation of a physician’s order for IV fluids for one resident. The resident had multiple significant diagnoses, including age-related osteoporosis, hypertensive heart and chronic kidney disease with heart failure stage 3, COPD, type 2 diabetes mellitus, multiple right-sided rib fractures, fractures of the right ulna styloid process and shaft of the right radius, and protein-calorie malnutrition. A handwritten physician order dated 02/17/26 directed that 1 liter of normal saline be administered intravenously at 100 cc/hr. This order was signed by an LPN on 02/18/26. The MAR/TAR for 02/18/26 showed an order for 0.9% normal saline IV, 1 liter every 24 hours for dehydration, to run at 100 ml/hr starting at 6:30 p.m., and documentation indicated that an RN initiated a peripheral IV in the left antecubital space at that time with normal saline running at 100 ml/hr. Interviews revealed that the IV order was not carried out in a timely manner after it was received. The RN who started the IV stated that two nurses before her had refused to hang the IV and that she was told by the DON that they had to hang it, while the DON denied instructing any nurse to start the IV or having knowledge of nurses refusing to do so. The DON confirmed that the IV infusion order was not initiated timely on 02/18/26 and stated that the RN had all day to start the IV and administer the fluids per the physician’s order. The LPN who signed the order reported she might have taken the IV order and believed the dayshift nurse was to start the IV. The Interim DON confirmed that timely IV administration would be within a few hours of receiving the order and that this did not occur. The ADON also confirmed the IV infusion order was not initiated timely and denied knowledge of instructing a nurse to start the IV or of any refusals. The facility’s Physician Orders policy stated that the nurse who takes the physician order is responsible for executing it or providing a safe hand-off to the next nurse, which did not occur as required in this case.
Unsecured E-Cigarette Supplies Kept in Resident Room
Penalty
Summary
The facility failed to ensure smoking supplies were locked and secured as required by facility policy and the resident’s care plan. One resident, admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, acute and chronic respiratory failure with hypoxia, epilepsy, COPD, alcohol abuse, cannabis use, and tobacco use, had a quarterly MDS indicating intact cognition. The resident’s care plan, dated 02/13/26, identified risk for injury related to smoking, cigarettes, and electronic devices, with interventions specifying that the resident was to be supervised at all times while smoking, wear a smoking apron, and have all smoking items kept at the nurse station. During observation on 03/18/26 at 10:49 A.M., the resident was seen in bed with oxygen via nasal cannula, and an open red metal box containing a disposable e-cigarette (vape) was on the over-bed tray next to the bed. The resident confirmed that he kept the vape in his room in the red box. Two CNAs separately confirmed that the resident had his e-cigarette vape in his room, and one CNA stated he was not permitted to have it there. The DON also confirmed the resident was not permitted to keep e-cigarette supplies in his room. Review of the facility’s “Lionstone Smoking” policy, revised 10/15/24, showed that no smoking materials are permitted with the resident or in their room and that all smoking materials, including vapes, must be kept in lock boxes at the nurse station or designated area. This constituted non-compliance with the requirement to keep smoking materials secured.
Failure to Administer and Reconcile Clonazepam per Orders and Controlled Substance Policy
Penalty
Summary
The deficiency involves the facility’s failure to administer and reconcile a controlled medication, clonazepam, according to physician orders and facility policy for one resident. The resident was admitted with diagnoses including encephalopathy, low back pain, cervical spinal stenosis, and anxiety, and had a care plan identifying increased risk of adverse reactions related to opiate use, with interventions to administer medications as ordered and monitor for side effects. The admission MDS showed intact cognition. Physician orders for February directed clonazepam 0.5 mg PO BID for anxiety. Review of the MAR/TAR showed that multiple scheduled doses (one morning dose on the first day of the month, both morning and evening doses on the second day, and both morning and evening doses on the sixteenth day) were marked with a code indicating “Other/See Nurses Notes,” and the narcotic sign-out sheet showed no corresponding sign-outs for these doses. Progress notes lacked any entry for the missed dose on the first day, while notes on the second and sixteenth days documented that clonazepam was not administered due to awaiting medication from the pharmacy or a new prescription. The Interim DON confirmed that five doses were missed, contrary to the facility’s medication administration policy requiring medications to be given safely, timely, and as prescribed. The deficiency also includes improper handling and documentation of controlled substance wasting for the same resident’s clonazepam. The narcotic sign-out sheet showed clonazepam 1 mg available with an order for 0.5 mg BID, and entries on two consecutive days documented that RNs each wasted 0.5 mg of clonazepam but signed the waste with only a single signature and no second witness, despite facility policy requiring all controlled substance destruction to be witnessed by at least two nurses with both signatures recorded. The Interim DON confirmed that only one signature appeared for each waste event. One RN stated she always had a witness and speculated the other nurse may have walked away without signing, while the other RN reported she had not been aware at the time that two nurse witnesses and signatures were required. The facility’s controlled substance policy specified adherence to state and federal laws and required two licensed nurse witnesses and a record for each drug destruction, which was not followed in these instances.
Failure to Timely Order and Administer COVID-19 Vaccines
Penalty
Summary
The facility failed to ensure two residents timely received COVID-19 vaccines after they had signed consent forms. Resident #26, admitted with diagnoses including diabetes mellitus, muscle weakness, COPD, and anxiety, was cognitively intact and consented to receive the COVID-19 vaccine, but the immunization record showed no COVID-19 vaccines had been given and December 2025 physician orders did not include the vaccine. Resident #26 reported signing consent in October and stated she had asked nursing twice about when she would receive the vaccine, but staff had not been able to provide an answer. Resident #4, admitted with diagnoses including end stage renal disease, bipolar disorder, and diabetes mellitus, was also cognitively intact and consented to receive the COVID-19 vaccine, but the immunization record showed no COVID-19 vaccines had been administered and December 2025 physician orders did not include the vaccine. A COVID-19 vaccination policy was requested but not available for review. The DON stated the expectation was that after a resident signed consent, the vaccine should be ordered and administered within a week or two, and verified that both residents' COVID-19 vaccines had not been ordered or administered and that the facility did not have a COVID-19 vaccine policy.
Failure to Provide Appropriate Dishware and Silverware to Promote Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident was provided with appropriate dishware and silverware to promote dignity during meals. Record review showed that the resident, who had diagnoses including major depressive disorder, essential hypertension, and generalized anxiety disorder, was cognitively intact and had been receiving disposable dishware and utensils. The use of disposables was originally implemented due to the resident discarding smokeless tobacco into mugs and bowls, but there was no evidence of reassessment to determine if this intervention was still necessary. The resident's care plan indicated a risk for malnutrition, and the use of disposables was discontinued at a later date, but during the period reviewed, the resident continued to receive paper plates and plastic utensils without clear justification. Interviews with the resident and staff confirmed that the resident was unaware of the reason for receiving disposable dishware, and staff could not provide an explanation. The Dietary Director acknowledged that the intervention had been in place since the previous year and that no reassessment had occurred to determine if regular dishware and silverware should be reinstated. Facility policy stated that disposables should only be used in emergency situations, yet multiple residents, including the one reviewed, were receiving them outside of such circumstances.
Failure to Consistently Implement Fall Toileting Interventions
Penalty
Summary
The facility failed to ensure Resident #49’s fall interventions were consistently implemented. Resident #49 was admitted with diagnoses including Alzheimer’s disease, vascular dementia, and anxiety disorder, and the record showed the resident was at risk for falls. The fall care plan included an intervention dated 06/25/25 to toilet the resident after meals. The resident’s significant change MDS showed memory problems, frequent bowel and bladder incontinence, and dependence for toileting. Survey observations and interviews showed the toileting intervention was not consistently carried out. On 12/15/25, after the resident was in the dining room, CNA #626 provided incontinence care but did not take the resident to the restroom toilet. CNA #626 stated she was unsure whether the resident was on a toileting plan and did not know if the resident was continent or incontinent. On 12/17/25, after breakfast, the resident was taken back to her room and put in bed without incontinence care or toileting being provided. CNA #610 stated the resident was not on a toileting program and was not provided incontinence care or toileting after breakfast. The resident had also experienced multiple falls, including a fall in the dining room, a fall in the hallway, and a fall in the shower area with a knot to the posterior head.
Failure to Timely Order and Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure Resident #26 timely received the pneumococcal vaccine. Resident #26 was admitted on 02/19/2025 with diagnoses including diabetes mellitus, muscle weakness, COPD, and anxiety, and was assessed as cognitively intact. The resident signed a pneumococcal vaccine consent form on 10/09/25, but review of the immunization record showed no documented pneumococcal vaccines had been given. Review of December 2025 physician orders showed the vaccine had not yet been ordered. During interview, the resident stated she signed consent in October and had still not received the vaccine, and the DON confirmed the pneumococcal vaccine had not been ordered or administered. The facility policy, Influenza and Pneumococcal Disease Prevention dated 04/28/25, stated influenza and pneumococcal vaccines are offered to all residents.
Failure to Date and Dispose of Opened Insulin Pens
Penalty
Summary
Surveyors found that the facility failed to ensure opened insulin pens were properly dated for use and disposal, as required by professional standards and manufacturer guidelines. During medication administration, a registered nurse used an insulin Lispro Kwik-pen for a resident without an open date recorded on the pen, despite being aware of the requirement. Manufacturer information specifies that insulin pens should not be used for more than 28 days after opening, but the pen in use did not have documentation of when it was first opened. Further observations revealed additional undated, opened insulin pens for three other residents in two medication carts. One LPN confirmed the presence of an undated insulin pen for a resident who was no longer at the facility, indicating a lack of proper medication disposal. The facility's own policy requires medications to be stored in their original, labeled containers and for expired or discontinued medications to be removed and disposed of appropriately. These findings demonstrate a failure to comply with medication labeling and storage requirements.
Failure to Serve Correct Portion Sizes of Rice Pilaf
Penalty
Summary
The facility failed to ensure that appropriate portion sizes of rice pilaf were served to residents, as required by the facility's menu and portion control guidelines. According to the menu spreadsheet, residents were to receive four ounces of rice pilaf, except for those on carbohydrate-controlled diets who were to receive three ounces. However, during an observation of the tray line, it was found that only two ounces of rice pilaf were being served. This discrepancy was confirmed by a staff member at the time of observation and upon review of the spreadsheet. The incorrect portion sizes affected 33 residents and had the potential to affect 69 out of 70 residents, with one resident on a no food by mouth order. The facility's policy emphasized the importance of portion control to ensure nutritional adequacy, but the established procedures were not followed during meal service.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean and sanitary environment in resident rooms and common areas. Specific findings included dirty floors, personal care items and trash such as a used toothette, disposable glove, plastic bottle, crayon, hairbrush, paper, and plastic bag found on the floors or under beds. There was also a white substance on the floor, and a build-up of dirt around toilet bolts in bathrooms. Over-bed tables were found in disrepair, with stripping pulled away or taped, and some flooring was discolored or stained, indicating a lack of thorough cleaning. These conditions were observed in the rooms of twelve residents during medication administration and routine checks. Staff interviews confirmed the environmental concerns, with a CNA/med tech and an RN acknowledging the cleanliness issues and disrepair, and the RN stating she was unaware of the facility's cleaning schedule. The Administrator verified the observations and agreed that staff should address spills and trash regardless of their roles. Residents also reported dissatisfaction with the cleanliness of their rooms and bathrooms, noting discolored and dirty floors. The deficiency was identified during investigations related to two specific complaint numbers.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding personal care, specifically related to bathing preferences. The resident, who had chronic kidney disorder, bipolar disorder, major depressive disorder, generalized muscle weakness, and required assistance with activities of daily living, was assessed as cognitively intact and able to make his own decisions. The care plan indicated that staff should assist with bathing according to the resident's preferences, and a preference evaluation showed the resident preferred sponge baths and valued having his brother involved in care discussions. Despite this, nursing documentation revealed that when the resident refused a shower, staff contacted his Power of Attorney (POA) to obtain permission to proceed with the shower against the resident's wishes, citing concerns about soiled linens and hygiene. The POA ultimately gave permission for the shower, and staff proceeded to bathe the resident. Further review and interviews confirmed that the resident had not been deemed incompetent and did not have a guardianship assigned, meaning his right to make decisions about his care remained intact. The Administrator and DON acknowledged that the POA's authority did not override the resident's choices as long as he was capable of making his own decisions. The incident demonstrates that the facility did not respect the resident's expressed preferences and right to refuse care, as required by regulations, and instead deferred to the POA despite the resident's cognitive ability to make his own choices.
Failure to Ensure Availability of Ordered Medications
Penalty
Summary
The facility failed to ensure that ordered medications were available for administration to residents, as observed and documented in three separate cases. In one instance, an LPN was unable to administer Clopidogrel to a resident because the medication was not available at the time of the medication pass. Another resident, with multiple diagnoses including type two diabetes mellitus with a foot ulcer, COPD, and protein-calorie malnutrition, had several medications, including Losartan Potassium and Amlodipine, not administered due to waiting on pharmacy delivery, as noted in the electronic Medication Administration Record (MAR). Additionally, a resident with epilepsy did not receive Phenobarbital on multiple occasions because the medication was not available, with MAR notes indicating the physician was aware and the facility was awaiting pharmacy delivery. The Director of Nursing, who had only recently started at the facility, was unable to provide explanations for the unavailability of these medications but acknowledged being aware of ongoing pharmacy-related issues.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to administer medications as ordered and in accordance with manufacturer guidance, resulting in a medication error rate of 12.9% (four errors out of 31 opportunities). For one resident, a physician order required Clopidogrel bisulfate 75 mg to be given once daily in the morning, and a separate order specified a multivitamin without minerals. On the day of observation, the LPN preparing medications reported that Clopidogrel was unavailable and instead prepared and administered a multivitamin with minerals, contrary to the physician's order. This resulted in two medication errors for this resident. For another resident, physician orders included a daily multivitamin and insulin Lispro with specific dosing instructions based on blood glucose levels. The RN prepared and administered a multivitamin with minerals instead of the ordered multivitamin, and administered 24 units of insulin Lispro using a Kwik-pen that did not have an open date recorded, despite manufacturer instructions that the pen should not be used more than 28 days after opening. The RN was made aware of the missing open date but proceeded with administration, resulting in two additional medication errors. The facility's policy required verification of the right drug, dose, route, rate, time, and resident prior to administration, which was not followed in these instances.
Failure to Serve Food at Safe and Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature, as required by its own Food Temperature Guidelines. During observation of the lunch tray line, it was noted that there was confusion regarding which carts had been served, and meals were being held in a warmer while waiting for residents to decide on their dining location. A test tray prepared directly from the steam table showed the fish was served at 111 degrees Fahrenheit, which was below the facility's standard of greater than 135 degrees at point of service. The fish was reported to taste cool, and a resident later stated that the fish served for lunch was cold and unappetizing.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately reflected the administration of medications for two residents. For one resident with multiple diagnoses including type 2 diabetes, foot ulcer, and morbid obesity, the March 2025 Medication Administration Record (MAR) lacked documentation of morning medications being administered on a specific date. The ordered medications included several critical prescriptions such as mag ox, fluoxetine, buspirone, pantoprazole, metformin, meloxicam, losartan, iron-vitamins, aspirin, and amlodipine. The Director of Nursing (DON) confirmed that an agency RN was scheduled and observed administering medications but did not sign off on the MAR before leaving her shift. For another resident with complex conditions such as multiple sclerosis, schizoaffective disorder, narcolepsy, and chronic pain syndrome, the February 2025 MAR showed no documentation of several scheduled medications being offered or administered on multiple occasions. These included riboflavin, vitamin D, Zyrtec, guaifenesin, Keppra, modafinil, senna S, baclofen, sucralfate, and simvastatin. The DON was unable to provide further details regarding the lack of documentation for these medication administrations.
Inadequate Dementia Care and Medication Management
Penalty
Summary
The facility failed to provide appropriate dementia care for a resident diagnosed with Alzheimer's disease and dementia with mood disturbances. The resident, who resided in a secured memory care unit, exhibited resistive-to-care behaviors, including verbal and physical aggression towards staff and other residents. Despite having a care plan in place that included interventions such as approaching the resident in a calm manner and providing a quiet environment, the staff struggled to manage the resident's behaviors effectively. The resident's care plan was not adequately followed, as evidenced by multiple incidents where the resident became aggressive and required multiple staff members to manage. The resident's medication regimen was adjusted by a psychiatry nurse practitioner, including a gradual dose reduction of Seroquel, an antipsychotic medication. However, the as-needed Ativan prescribed for agitation and anxiety was not administered during February and March, despite the resident's ongoing aggressive behaviors. The facility's failure to utilize the prescribed medication and coordinate an interdisciplinary team meeting with the resident's wife to discuss behavior management contributed to the deficiency. Additionally, there was an allegation of physical and verbal abuse involving the resident, where staff members were accused of holding the resident down and covering his mouth. Interviews with staff revealed that the resident often became violent during care, and staff resorted to physical interventions to manage his behaviors. The facility's policy on dementia and behavioral health guidelines emphasized non-restraint interventions, which were not adhered to, further highlighting the deficiency in providing appropriate dementia care.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary condition, as observed during an initial tour with the Dietary Manager. The kitchen floor was found to be dirty with food splatter, pieces of paper, and dried food debris, particularly underneath equipment. The microwave had food splatter on all sides and burnt food on the bottom. Additionally, the grill had food residue, and the grill pan contained french fries and food pieces. The prep table under the grill was also covered in food debris. The Dietary Manager confirmed that the grill was not in use due to a lack of power. Further inspection of the walk-in refrigerator revealed an undated and unlabeled food container on the floor, along with containers of soup, black olives, and sliced tomatoes that were neither labeled nor dated. The walk-in freezer contained an open bag of pepper steak and a bag of breaded patties, both of which were not labeled or dated. The Dietary Manager verified these findings. The facility's undated Food Safety and Sanitation Review policy included a checklist for ensuring cleanliness and sanitation, which was not adhered to, as evidenced by the observations. The policy required all food to be covered, labeled, and dated, and all equipment to be cleaned after use or on a daily basis.
Failure to Provide Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide adequate activities for residents in the memory care unit, affecting 15 out of 16 residents. Observations revealed that during scheduled activity times, residents were left without structured activities. For instance, at 3:02 P.M., the television was merely playing music, and an STNA was observed taking a break instead of engaging residents in activities. Another STNA confirmed the absence of activities while managing resident care. The Director of Nursing acknowledged that one STNA was supposed to conduct activities while another attended to residents not participating, but agency staff were not informed of their responsibilities. The Activity Assistant admitted to assuming that staff would play movies and engage residents with daily chronicles, but these activities were not actually conducted. The DON was unaware of how STNAs communicated completed activities to the activity department. A review of the activity calendar showed only two scheduled activities per day, with no evening activities. Despite an in-service training instructing STNAs to conduct activities at specific times, these were not implemented, leading to a lack of engagement for the memory care residents.
Deficiencies in Wound and Skin Care Management
Penalty
Summary
The facility failed to implement wound-related treatments as ordered for several residents, leading to deficiencies in care. Resident #9, who had a history of diabetes and multiple ulcers, did not receive proper wound care as per physician orders. The resident's left foot ulcer was not dressed as frequently as required, and the offloading shoe prescribed to aid in healing was not provided. Observations revealed that the resident's dressings were not changed regularly, and interviews with staff confirmed a lack of awareness and follow-through on the prescribed treatments. Resident #18, with a history of respiratory failure and cognitive impairment, also experienced deficiencies in skin care. The resident had orders for skin assessments and specific dressings for blisters on the right lower leg, but these were not consistently documented or applied. Observations showed that the resident's blisters were not properly treated, and the ACE wraps ordered for the resident's legs were not applied as required. Interviews with staff revealed a lack of knowledge about the resident's condition and the necessary treatments, leading to inadequate care. Resident #34 and Resident #45 also experienced deficiencies in care. Resident #34, who was at risk for skin tears, was not wearing the prescribed TED hose and geri sleeves, which were intended to protect against skin damage. Similarly, Resident #45 did not have the PEG tube dressing in place as ordered, which is crucial for preventing infection and irritation. These oversights were confirmed through observations and staff interviews, highlighting a pattern of non-compliance with physician orders and facility policies.
Deficiencies in Smoking Policies and Fall Risk Management
Penalty
Summary
The facility failed to ensure that resident comprehensive care plans were updated and individualized, particularly concerning the residents' smoking status and interventions. This deficiency affected four residents who were reviewed for smoking. For instance, Resident #9 was permitted to smoke independently but kept smoking materials in his room, contrary to the facility's policy. The care plan did not specify smoking times or whether Resident #9 was safe for unsupervised smoking. Interviews with staff revealed a lack of awareness about the resident's care plan allowing storage of smoking materials in his room. Similarly, Resident #13 had moderate cognitive impairment and was found to have smoking materials in his room, which was against the facility's policy. The care plan did not include interventions related to his ability to roll his own cigarettes or specify his supervision needs. Staff interviews indicated uncertainty about whether Resident #13 was considered an independent smoker and a lack of knowledge about any care plan interventions regarding the storage of smoking materials in his room. Additionally, Resident #31, who had severely impaired cognition, was observed smoking without a smoking apron, which was a care plan intervention to prevent accidental injury. The facility also failed to ensure Resident #53, who was at risk for falls, was wearing nonskid socks as per his care plan. This oversight was confirmed by a staff member during an observation. The facility's policy on falls and fall risk management emphasized resident-centered approaches, which were not implemented in this case.
Failure to Maintain Contact Isolation for Resident with HSV
Penalty
Summary
The facility failed to maintain contact isolation as ordered for a resident with an active herpes simplex virus (HSV) outbreak. The resident was admitted with diagnoses including hemiplegia, hemiparesis, bipolar disorder, and polyneuropathy, and exhibited intact cognition. Despite a physician's order for contact isolation dated 08/30/24, the signage on the resident's door indicated enhanced barrier precautions instead. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that the signage was inaccurate. Contact precautions required staff to don personal protective equipment (PPE) when entering the resident's room, whereas enhanced barrier precautions required PPE only during direct care. This oversight affected 12 other residents residing on the same unit.
Oxygen Flow Rate Not Set as Ordered
Penalty
Summary
The facility failed to ensure that a resident's oxygen flow rate was set according to the physician's order, affecting one resident who was reviewed for respiratory care. Resident #34, who was admitted with diagnoses including chronic obstructive pulmonary disease, asthma, dementia, diabetes mellitus, congestive heart failure, and atrial fibrillation, was receiving oxygen therapy. The resident's medical record indicated an order for oxygen at two liters per minute via nasal cannula. However, observations on two occasions revealed that the oxygen flow rate was set at three liters per minute. Interviews with an LPN and the Director of Nursing confirmed that the oxygen flow rate was not set as ordered by the physician.
Room Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a resident's room in good repair, affecting one of the 22 residents reviewed for environmental concerns. During an observation, it was noted that the resident's room had four holes in the drywall behind the recliner and a damaged electrical outlet that was recessed into the wall. The Maintenance Director confirmed these deficiencies during an interview.
Failure to Implement Pressure Ulcer Wound Care as Ordered
Penalty
Summary
The facility failed to ensure proper pressure ulcer wound care for two residents, leading to deficiencies in their treatment. Resident #4, who had diagnoses including acute respiratory failure, multiple sclerosis, and chronic pain syndrome, was readmitted with orders to treat pressure ulcers on the sacrum and right buttock. However, the prescribed treatment for the sacrum wound was not implemented for several days, and during an observation, the wound care was not performed according to the physician's orders. The nurse did not follow proper hand hygiene protocols between treating different wounds, and the correct dressing was not applied to the sacrum wound. Resident #19, diagnosed with dementia, hypothyroidism, and major depressive disorder, had a Stage 4 sacral pressure ulcer that required specific dressing. During an observation, it was found that the dressing was not in place as ordered. A nurse aide confirmed that the resident did not have a dressing during incontinence care earlier in the day and failed to report this to the nurse. The facility's wound care policy outlines specific steps for wound care, which were not followed in these cases, leading to the identified deficiencies.
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 626 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alliance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canterbury Villa Of Alliance | 1 mi | ★★★★★ | 3 | 0 |
| Altercare Of Alliance Ctr For Rehab & Nc Inc | 1.9 mi | ★★★★★ | 0 | 0 |
| Roselawn Gardens Nursing & Rehabilitation | 2.1 mi | ★★★★★ | 0 | 0 |
| Bel Air Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Green Meadows Skilled Nursing And Rehab | 4.4 mi | ★★★★★ | 6 | 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.