Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcv Health Care Facilities, Inc during CMS and state inspections, most recent first.
A resident with dementia and impaired cognition was observed in a common dining area when an RN lifted the resident’s shirt, exposed the resident’s bare stomach, and gave an injection in front of other residents. The RN confirmed the injection was administered in the common area, and the DON stated injections should be given in a private area or resident room. The facility policy stated residents have the right to respect and dignity.
A resident with major depressive disorder, anxiety disorder, and moderate cognitive impairment had a PRN Ativan order for anxiety with no stop date. Pharmacy noted the medication needed a stop date, but the order remained active beyond 14 days without documented rationale, and the DON confirmed the recommendation was not followed.
Care conferences were not completed on time for one resident with DM2, major depressive disorder, anxiety disorder, and moderate cognitive impairment. The resident required assistance with eating, toileting, transfers, dressing, and bathing, yet only one care conference was documented since admission. The SWA confirmed care conferences were expected quarterly, and the facility policy required them at least every three months.
A resident with CHF, depression, osteoarthritis, and a left tibia fracture was admitted at moderate risk for pressure sores and initially had no pressure wounds. Although heel elevation and repositioning were listed in the care plan, no heel-floating intervention was in place before a discolored blister was found on the left heel, and the skin assessment did not include measurements or a detailed description. The DON, MD, and WNP all confirmed the wound was not documented and measured in detail when first identified.
An unlocked treatment cart and open nursing area were observed in the SCU with no staff in sight while several cognitively impaired, independently mobile residents were present. An LPN confirmed the cart was unlocked, and the DON later confirmed wound supplies and topical meds were in the cart, along with hazardous chemicals stored under an unlocked sink cabinet despite policy requiring locked storage.
Incorrect minced and moist diet consistency: Staff failed to serve foods in the ordered texture for three residents with cognitive impairment and multiple medical conditions, including dementia and dysphagia. Observations showed a minced and moist chicken patty that was watered down and oatmeal-like, soup that was pureed in texture, and turkey a la King that was very runny and spread across the plate. A RR also reported the food appeared soupy, and a CNA confirmed the meals were too runny for the ordered diet.
Improper Refrigeration of Milk and Other Drinks: The facility failed to keep refrigerated drinks at proper temperatures. The MCU refrigerator measured 48 degrees F, and milk stored inside was found at 46.7 degrees F and 51 degrees F. A CNA confirmed that three residents consumed milk from the refrigerator even though it was not in an acceptable temperature range. The facility policy required refrigerated foods to be kept between 32 and 41 degrees.
Failure to use required PPE during EBP: A resident with a left heel wound and urinary catheter care needs had an EBP sign outside the room directing staff to wear gloves and a gown for wound care and other high-contact activities, but an RN performed wound care without a gown and returned to the room without one after getting scissors. The RN said she did not normally wear gowns for wound care, while the DON stated the resident was in EBP and staff should have followed the policy.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
Surveyors found that staff did not accurately document opioid pain medication administration for two hospice residents. For one cognitively impaired LTC resident with multiple chronic conditions, a scheduled morphine dose recorded on the eMAR was entered on the PRN morphine page of the controlled drug log instead of the scheduled page. For another resident with Alzheimer’s disease, cerebrovascular disease, and other comorbidities, several PRN oxycodone doses were recorded on the controlled drug log but had no corresponding entries on the eMAR, despite facility policy requiring electronic signing of the eMAR after medication administration.
Failure to Maintain Resident Dignity During Injection Administration
Penalty
Summary
The facility failed to maintain Resident #59’s dignity during medication administration. Resident #59 was admitted with diagnoses including Alzheimer’s disease, dementia, major depressive disorder, and anxiety disorder, and the most recent MDS showed moderately impaired cognition and dependence for toileting and bathing. The care plan identified impaired cognitive function related to dementia. During observation, Resident #59 was seated in the common dining area with 13 other residents when RN #42 entered the room, lifted the resident’s shirt, exposed the resident’s bare stomach, and administered an injection in the common area. RN #42 confirmed the injection was given while the resident was in the common area, and the DON stated injections should be administered in a private area or resident room. The facility policy on Resident Rights stated residents had the right to respect and dignity.
PRN Ativan Order Extended Beyond Allowed Time Without Documented Rationale
Penalty
Summary
The facility failed to ensure an as needed psychotropic medication was not ordered for more than 14 days without adequate documented rationale. Resident #2 was admitted with diagnoses including type II diabetes mellitus, major depressive disorder, and anxiety disorder, and had moderate cognitive impairment with a BIMS score of 10. The resident required setup with eating, was dependent for toileting, transfers, and dressing, and needed substantial assistance with bathing. A physician order dated 04/28/26 showed Ativan 1 mg, to give 1 tablet by mouth every four hours as needed for anxiety, with no stop date. Review of the order on 06/24/26 showed no stop date had been addressed, and there was no documented rationale in the medical record for extending the medication beyond 14 days. A pharmacy recommendation in May 2026 stated the resident's as needed Ativan needed a stop date and required discontinuation or a new order, and the DON verified on 06/25/26 that the recommendation was not followed and the PRN Ativan order extended beyond 14 days without adequate documented rationale.
Delayed Care Conferences
Penalty
Summary
Care conferences were not completed in a timely manner for one resident reviewed. The resident was admitted on 12/23/25 with diagnoses including type II diabetes mellitus, major depressive disorder, and anxiety disorder. The MDS assessment showed moderate cognitive impairment with a BIMS score of 10, and the resident required setup with eating, was dependent for toileting, transfers, and dressing, and required substantial assistance with bathing. Review of the care conference notes showed only one care conference since admission, dated 04/07/26. During interview, the Social Worker Assistant verified that care conferences were to be completed quarterly and confirmed the resident had received only one care conference since admission. The facility policy stated care conferences were to support interdisciplinary communication, individualized care planning, discharge planning, and resident/family involvement, and were to be conducted at least quarterly for long-term care residents.
Incomplete Assessment and Delayed Interventions for Heel Blister
Penalty
Summary
The facility failed to ensure a resident’s pressure-related skin changes were thoroughly assessed and that interventions were initiated to prevent pressure ulcer development for an at-risk resident. The resident was admitted with diagnoses including CHF, dysthymic disorder, major depressive disorder, osteoarthritis, pathological fracture, iron deficiency, insomnia, and fracture of the shaft of the left tibia. On admission, the resident had intact cognition with a BIMS score of 13, required setup with eating, and was dependent for toileting, bathing, dressing, and transfers. The resident had no pressure wounds on admission but was identified as at risk for pressure wounds, and the baseline care plan included heel elevation, repositioning, and barrier cream. A risk assessment dated on admission identified the resident as at moderate risk for pressure sores. A progress note documented a discolored blister on the left heel, and all parties were notified, with an order for an ABD pad for padding and protection. However, the TAR showed no interventions in place to float the heels before the blister was identified, and a physician order for Sage boots to both heels when in bed was not entered until several days later. A twice weekly skin assessment identified a blister but did not include measurements or a description. The DON confirmed there was no mention of the heel blister until it was documented in the progress note, no treatments were in place until later, and measurements were not completed until after that. The MD and WNP both stated their expectation that wounds be measured and described in detail when first identified.
Unlocked treatment cart and hazardous chemicals accessible in SCU
Penalty
Summary
The facility failed to ensure residents were free from potential hazards in the Special Care Unit. Review of the medical record showed Resident #11 had altered mental status, chronic atrial fibrillation, unspecified dementia, and unspecified glaucoma, with severely impaired cognition and care plan documentation noting impaired cognitive function, impaired thought processes, and orientation to self only. Resident #33 had unspecified dementia, other seizures, and altered mental status, with severe cognitive impairment, wandering behavior, and dependence for toileting and bathing. Resident #37 had Parkinsonism, dementia, anxiety disorder, cognitive social or emotional deficit, and major depressive disorder, with moderately impaired cognition, disorganized thinking, and wandering behavior. During observation on 06/23/26, the treatment cart next to the nursing area was unlocked, the right half door of the nursing station was open to the common area, and no staff were in sight in the common area while eight residents were present, including the three residents identified as independently mobile. An LPN confirmed the treatment cart was unlocked and the nursing area door was open. Later, the DON confirmed the treatment cart contained multiple wound supplies and topical medications, and also confirmed that a bottle of liquid bleach, liquid furniture polish, spray bottle of laundry cleaner, liquid disinfectant cleaner, and liquid multi-surface cleaner were stored under the sink in an unlocked cabinet in the SCU nursing area. The facility policy stated hazardous chemicals shall be stored in locked cabinets or locked housekeeping closets when not in direct use and remain inaccessible to residents at all times.
Incorrect minced and moist diet consistency
Penalty
Summary
The facility failed to ensure foods were prepared and served in the correct consistency for residents ordered minced and moist diets. This affected three residents reviewed: one resident with diagnoses including glaucoma, pulmonary embolism, chronic kidney disease, anemia, chronic atrial fibrillation, dementia, anxiety, and congestive heart failure; one resident with insomnia, diabetes mellitus, hypothyroidism, heart failure, hypertension, major depressive disorder, fibromyalgia, and dementia; and one resident with major depressive disorder, dementia, anxiety disturbance, and dysphagia. The residents were documented as cognitively impaired and required varying levels of assistance with eating and other activities of daily living. During observation, the minced and moist chicken patty for one resident appeared very watered down and spread across the plate with an oatmeal-like consistency, and the vegetable soup had a smooth, pureed texture. A resident representative reported the food appeared watered down and soupy. For another resident, the turkey a la King was spread across the plate with a brown liquid ring, and the CNA stated it appeared too runny and was stirred rapidly to thicken it like gravy. For the third resident, staff observed the turkey a la King was very runny and spread across the plate. The facility policy for minced and moist foods stated the food should be very soft, moist, and have minimal liquid separation, with little to no liquid separating from the food.
Improper Refrigeration of Milk and Other Drinks
Penalty
Summary
The facility failed to ensure drinks were stored and served at an appropriate temperature. During observation of the Memory Care Unit refrigerator, the thermometer measured 48 degrees F, and the Director of Maintenance confirmed the refrigerator temperature and stated the food was not cold to touch. Later observation and interview with the Dietician and Dietary Manager showed refrigerated drinks, including milk stored in the door at 46.7 degrees F and a gallon of milk on the middle shelf at 51 degrees F; both confirmed that items requiring refrigeration would be thrown out. A Certified Nurse Aide confirmed that three residents consumed milk from the refrigerator unit that was not in an acceptable temperature range. The facility policy stated refrigerated foods should be stored between 32 and 41 degrees.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff providing direct care to a resident with enhanced barrier precautions wore the required personal protective equipment during care. Resident #3 was admitted with diagnoses including CHF, dysthymic disorder, major depressive disorder, osteoarthritis, pathological fracture, iron deficiency, insomnia, and a fracture of the shaft of the left tibia. The resident was cognitively intact, had an order for urinary catheter care, and had a treatment order for a left heel wound that included betadine, a dry dressing, and Kerlix. Review of the care plan showed no goal or intervention for enhanced barrier precautions, and current orders for June 2026 showed no order for EBP. During observation, RN #105 completed wound care to the resident’s left heel in the room without wearing a gown, left the room to get scissors, and returned to continue the dressing change without a gown. The EBP sign outside the room directed caregivers to wear gloves and a gown for high-contact care activities including dressing, bathing, transferring, changing linens, hygiene, changing briefs, device care or use, and wound care. RN #105 stated she did not normally wear gowns during wound care, only with open wounds, and confirmed the EBP sign. The DON stated the resident did not have an active order for EBP or have it in the care plan, but also stated the resident was in EBP and staff should be following the policy. The facility policy stated an order for EBP would be obtained for residents with chronic wounds and indwelling medical devices.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Inaccurate Documentation of Opioid Pain Medication Administration
Penalty
Summary
Surveyors identified a failure to ensure accurate documentation of opioid pain medication administration for two residents receiving hospice care. For one cognitively impaired, long-term care resident with diagnoses including Parkinsonism, anemia, dementia, psychosis, hypertension, and anxiety, the eMAR showed an order for Morphine Sulfate oral solution 20 mg/mL, 0.25 mg by mouth every eight hours for pain, and a separate PRN order for 0.25 mg every two hours as needed for pain. The eMAR reflected a 0.25 mg dose given at 5:00 A.M. under the scheduled every-eight-hours order, but review of the Controlled Drug Log showed that this same 5:00 A.M. dose was documented on the PRN morphine log page instead of the scheduled morphine log page. The DON confirmed that the entry was made on the incorrect Controlled Drug Log page. For another resident with diagnoses including cerebral infarction, Alzheimer's disease, atrial fibrillation, anxiety disorder, Type II diabetes mellitus, dysphagia, and unspecified convulsions, who was also on hospice and later expired in the facility, there were discrepancies between the Controlled Drug Log and the eMAR for PRN oxycodone administration. The resident had orders for Oxycodone HCl 5 mg by mouth twice daily for pain and Oxycodone HCl 5 mg every four hours PRN for pain. The Controlled Drug Log showed PRN oxycodone 5 mg doses administered on two separate dates at multiple times (including 8:00 P.M., 1:00 A.M., and 11:00 P.M.), but the corresponding PRN administrations were missing from the eMAR on those dates. The DON verified that the PRN oxycodone doses were documented on the Controlled Drug Log under the PRN order page but were not documented on the eMAR, contrary to the facility’s Medication Administration Policy requiring the individual administering the medication to electronically sign the eMAR after giving the medication.
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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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Nursing homes near Mason
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Cedar Village. | 0.6 mi | ★★★★★ | 30 | 0 |
| Chesterwood Atc | 2 mi | ★★★★★ | 0 | 0 |
| Mason Health Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Heritagespring Healthcare Center Of West Chester | 2.6 mi | ★★★★★ | 3 | 1 |
| Lodge Nursing & Rehab Center | 3.8 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.