Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Muskingum Skilled Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with COPD and chronic respiratory failure asked to go to the hospital for worsening SOB, but the on-call provider ordered in-house monitoring and the resident was not told she could still request transfer; she later declined and was admitted with acute hypoxic respiratory failure and sepsis. The facility also did not start the bowel protocol for another resident with no BM for several days, did not coordinate hospice communication and records for multiple residents, and completed inaccurate skin assessments while missing transport and treatment issues for a resident with ongoing skin breakdown and rash.
The facility failed to provide enough nursing staff to meet resident needs and to maintain licensed nurse coverage on each shift. Residents and staff reported delayed call light response, late or incorrect medications, incomplete care such as showers and incontinence care, and difficulty getting timely follow-up. The ADON and other management staff were covering multiple roles and working the floor due to shortages, while infection control tracking and concern logging were not being maintained.
The facility failed to ensure food was prepared and served in a sanitary manner. A staff member handled bread without gloves and touched multiple slices, while other touched slices remained in the bag. The food prep area had dust, debris, and food splatters, and another staff member was observed handling tongs over chicken barehanded before the chicken was still served. The DM confirmed the findings.
Infection control program deficiencies were identified when a resident's nebulizer mask and tubing were observed lying directly on the bedside table instead of being stored per policy, and the facility failed to maintain an accurate infection control log or document staff N95 fit testing. Two residents had infections documented in the medical record, including ESBL E. coli and Proteus mirabilis, but those infections were not entered on the log, and the IP confirmed recent fit testing records could not be found despite staff needing N95s during recent respiratory outbreaks.
Infection Preventionist Lacked Dedicated Time for Infection Surveillance: The facility failed to ensure the IP had dedicated time to manage the infection prevention and antibiotic stewardship program. The RN/IP was also serving as ADON and wound nurse and was working three 12-hour floor shifts because of staffing shortages, leaving the infection control log incomplete and without tracking or trending. Two residents with UTIs had positive urine studies and one received Cipro despite resistance, but neither infection was entered on the infection control log.
Failure to Include Residents and IDT in Care Conferences: The facility did not ensure residents and the full IDT participated in care plan conferences for multiple residents. One resident with COPD and DM2 said she was never asked to attend her care conferences, and Social Services confirmed the resident and full IDT were not included. Other residents with complex medical needs, including HF, anemia, depression, cognitive impairment, and multiple chronic conditions, had care conferences where only the resident, representative, DON, or Social Services designee attended, with dietary, therapy, physician, and direct care staff not present or providing input.
Incomplete and inaccurate resident records were found for multiple residents. Assessments for one resident were created months late and back dated, death-related documentation was missing for two residents, hospice decline was not documented in another resident’s chart, and medication records for two residents did not match the events or orders. An LPN and the DON confirmed several of the documentation gaps and discrepancies.
A resident on hospice received another resident's meds during a med pass interruption, but hospice was not notified of the error when it occurred and the event was not documented in the chart. Another resident with severe cognitive impairment returned from the hospital with a new stage 2 sacral pressure ulcer, but the record did not show that the physician or responsible party was promptly notified of the new skin breakdown.
A resident with multiple chronic conditions, including DM2, COPD, MDD, GAD, OSA, Afib, and HTN, did not receive the NOMNC at least 2 days before the end of the Medicare Part A stay. Record review showed the notice was signed only 1 day before the last covered day, and the SSD confirmed the timing. Facility policy required the completed NOMNC to be given no later than 2 days before services ended.
Unsanitary Shared Bathroom Conditions: A resident shared a bathroom with an adjacent resident who reportedly urinated and had bowel movements on the bathroom surfaces and did not flush the toilet. Photos and a later tour confirmed urine and bowel movements on the floor and toilet, along with an unflushed toilet, and the HKS acknowledged prior concerns about the condition of the shared bathroom.
A resident with multiple chronic conditions had a wallet containing a credit card and driver's license go missing, and the wife said she reported it to a CNA and an LPN, but management was not notified. The Administrator, DON, and SSD were unaware of the missing wallet when the issue was raised by the surveyor, and no SRI was initiated at that time. The facility did not report the allegation of misappropriation timely to the state agency, despite policy requiring immediate communication and reporting within 24 hours for allegations not involving abuse or serious bodily injury.
A facility failed to timely investigate an allegation of misappropriation involving a resident’s missing wallet, which contained a credit card and driver’s license. The resident’s wife reported the wallet missing to CNA and LPN staff, but management was not aware until the surveyor raised the concern. The Administrator did not initiate an SRI right away and had not completed a full investigation when surveyed, despite the facility policy requiring immediate communication and investigation of alleged misappropriation.
A resident with PTSD, depression, anxiety, and a history of suicidal behavior did not have an individualized trauma-informed care plan. The record noted PTSD related to witnessing a fatal motorcycle crash, but the chart lacked documented triggers and individualized interventions. The resident reported panic attacks, poor sleep after Xanax was stopped, and triggers including motorcycles, loud noises, and certain words. SSD staff confirmed there was no comprehensive PTSD assessment or care plan with triggers or individualized interventions.
Failure to provide hygiene and bathing assistance: Two residents who were dependent on staff for ADLs were observed without adequate personal care. One resident with ESRD and AFib had long fingernails with debris and chin hair despite care plan directions for daily hygiene support, and another resident with COPD, DM2, malnutrition, amnesia, depression, and GERD was observed unkempt with dirty fingernails, food-stained clothing, and no pants on. The record for the second resident had no shower documentation for the month, and the DON confirmed there was no evidence of showers.
Air Mattress Set Incorrectly for Resident at Risk for Skin Breakdown: A resident with ESRD, atrial fibrillation, decreased mobility, incontinence, edema, oxygen use, and a history of pressure ulcers had an order for the bed to be on level four every shift, but observations and staff interviews confirmed the alternating air mattress was set to level five instead.
A resident with dementia and urinary incontinence had foul-smelling dark urine and was ordered a UA, but the specimen was not collected timely. The urine culture later showed >100,000 CFU/ml E. coli with ESBL, and Macrobid was ordered; however, the first dose was not given and only 13 of 14 doses were administered. The infection was not documented on the infection control log, and a second UA was also collected late.
Failure to Address Significant Weight Loss and Poor Nutritional Intake: A resident with DM2, dysphagia, HF, and other chronic conditions experienced marked wt loss, low albumin, and poor PO intake while meal documentation was incomplete. The resident’s intake records showed many meals at 0-25% or 26-50% consumed, with several refusals, and the resident later developed a Stage 2 coccyx pressure ulcer. The dietician stated the resident had significant wt loss, believed weekly weights were being done when the order was for monthly weights, and was not aware of the new pressure ulcer.
Failure to provide ordered oxygen therapy and appropriate respiratory care for two residents. One resident with COPD and chronic respiratory failure was observed on oxygen set above the ordered flow rate, while another resident with COPD and respiratory failure walked without oxygen, then developed labored breathing, pale lips, delayed responses, and reported feeling unable to breathe; oxygen was not applied until after the resident was returned to the dining room, when SpO2 was 67%.
Failure to provide trauma-informed care for two residents with PTSD was identified. One resident with PTSD and depression had a care plan that addressed stress and communication but did not identify triggers, and SS confirmed no comprehensive assessment had been completed. Another resident with PTSD, anxiety, depression, and a history of suicidal behavior had documented trauma history, but records and behavioral assessments did not include triggers or individualized interventions. Interviews with SS, the visiting behavioral health LSW, and the DON confirmed the missing comprehensive PTSD assessments and care planning details.
A resident with a Foley catheter received Ciprofloxacin for a UTI even though the urine culture showed the organism was resistant and the infection surveillance form was completed inaccurately. Another resident had PRN narcotic pain medication orders without pain parameters, and the DON confirmed staff had no guidance for when to administer the meds, leading to unnecessary pain medication administration.
A resident with multiple chronic conditions, including long QT syndrome, COPD, diabetes, dementia, and hospice services, received another resident’s morning medications after a CMA was interrupted during the med pass and confused the two roommates. The wrong meds included agents such as buprenorphine, carvedilol, propranolol, lisinopril, amlodipine, and baclofen. The record lacked a documented comprehensive assessment, progress note, and written provider orders after the error, and staff noted the resident slept most of the day and was not himself afterward.
Hospice plans, certifications, and progress notes were not maintained in the facility records for three residents receiving hospice services, and the facility did not identify a hospice contact designee. One resident’s hospice binder could not be located, and the DON stated staff often had to call hospice to obtain notes and plans of care. Records for two closed cases also lacked hospice documentation even though hospice services were in place and the MDS reflected hospice use.
Two residents with bladder impairments did not receive adequate indwelling catheter care or education upon discharge. One resident was admitted with an indwelling catheter, but the admission assessment inaccurately recorded them as continent and without a catheter. There was no evidence of catheter care or urine sample collection as ordered. The second resident also did not receive documented catheter care or education during their stay. Interviews confirmed the lack of documentation and education, leading to a deficiency identified during a complaint investigation.
The facility failed to provide timely and effective pain management for three residents following falls that resulted in injuries. One resident with a hip fracture was not given adequate pain relief and was sent to the ER nearly 20 hours after the fall. Another resident with a shoulder fracture did not receive pain medication until over four hours later, and no non-pharmacological interventions were initiated. A third resident with a fracture was not provided with any pain management before being transferred to the ER over five hours after the fall. The facility did not develop comprehensive pain management plans for these residents.
A resident with dementia and other conditions was observed lying diagonally in bed due to inadequate bed size, causing discomfort and potential pressure issues. Despite being independent in bed mobility, the resident's feet hung over the edge, and interviews confirmed that repositioning would not resolve the issue.
The facility failed to conduct care conferences in conjunction with MDS reviews for two residents. One resident with heart failure and other conditions did not have a care conference documented for a November MDS. Another resident with dementia and other diagnoses had a care conference scheduled a month late. Interviews revealed scheduling issues and lack of documentation, contrary to the facility's policy requiring timely coordination and invitations for care conferences.
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. A resident with Alzheimer's and impaired balance was found with their bed not in the low position, contrary to their care plan. Another resident with cognitive impairment lacked a dycem in their wheelchair, as required for fall prevention. These oversights were confirmed by staff, indicating a failure to adhere to prescribed safety measures.
The facility failed to implement proper pressure ulcer interventions for three residents, leading to deficiencies in care. A resident developed Stage II pressure ulcers due to lack of repositioning and incorrect bed settings. Another resident's low air loss mattress was set incorrectly, and a third resident's mattress was unplugged and deflated, compromising pressure ulcer prevention. Staff were unaware of proper mattress operation, and there was a lack of documentation for necessary interventions.
Failure to honor hospital transfer request, bowel protocol, hospice coordination, and skin assessment accuracy
Penalty
Summary
The facility failed to ensure a resident with chronic obstructive pulmonary disease and chronic respiratory failure received care consistent with her request to be sent to the hospital when her breathing worsened. The resident had a documented change in respiratory condition with shortness of breath, coughing, sputum production, and increased anxiety. On one occasion, the resident asked to go to the hospital for difficulty breathing, but the on-call medical provider directed staff to monitor her in-house. The record did not show that the resident was informed of that decision or given another opportunity to request hospital transfer, and there was no documentation of a full assessment such as lung sounds, additional vital signs, or physical findings at that time. The resident’s respiratory status continued to decline after that request. Nursing documentation later showed shortness of breath, productive cough, and secretions, and the resident’s oxygen saturation dropped to 89 percent despite oxygen being in place. She was then sent to the hospital and admitted for acute hypoxic respiratory failure, sepsis, and pulmonary infiltrates. Hospital records stated she had shortness of breath for about a week with increased coughing and sputum production, required increased oxygen on admission, and was treated for sepsis secondary to pneumonia and acute hypoxic respiratory failure. The facility also failed to initiate its bowel protocol for a resident who had no bowel movement for five consecutive days. The resident had standing orders for milk of magnesia, a suppository, and an enema if no bowel movement occurred, followed by physician notification if the sequence did not produce results. Review of bowel movement documentation and the MAR showed no bowel movement from 04/26/26 through 04/30/26 and no PRN bowel interventions were given during that period. The DON confirmed there was no bowel movement and no intervention for five days. In addition, the facility failed to coordinate hospice services effectively for multiple residents. One resident under hospice care received another resident’s medication, and hospice was not notified of the medication error until the following day. The record also contained no evidence of hospice notes or a hospice plan of care in the electronic record or hospice binder for that resident. The DON stated hospice providers did not always follow up with staff and that the facility had three hospice providers serving residents. The facility also failed to complete accurate skin assessments and ensure transportation to appointments for a resident with significant skin problems. The resident had ongoing rash, open skin areas, itching, and later suspected psoriatic disease with severe scalp and back involvement. The record showed multiple dermatology appointments were missed or delayed because of transportation problems or cancellation, and one appointment was refused by the resident. The resident’s skin treatment orders changed several times, including steroid, antifungal, and pimecrolimus orders, but the pimecrolimus cream was never applied. A skin assessment also failed to include an open abdominal area that staff later observed.
Inadequate Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate nursing staff were available to meet resident needs and to have a licensed nurse in charge on each shift. Review of the facility assessment showed staffing levels were based on resident acuity and population, but the assessment did not include the type of staff needed or the number of staff required. Interviews with the Scheduler, DON, and other staff showed the facility routinely relied on a mix of RN, LPN, and medication tech coverage, while the ADON was working on the floor due to staffing shortages and also serving as the Infection Preventionist and wound nurse. The MDS nurse worked limited days, and management staff were covering multiple roles, including floor nursing, scheduling, human resources, admissions, marketing, activities, and medical records. Residents and staff described delayed responses to call lights, delayed medications, and incomplete care. One resident reported medications were sometimes not given until late at night and call lights on the hall remained unanswered for extended periods. Another resident stated call lights were not answered timely, staff sometimes said they would return and did not come back, medications were not administered timely, and ice was not passed timely. A third resident reported call lights could take up to three hours to be answered and that medications were sometimes wrong or delayed. An LPN stated it was very stressful being the only nurse on midnight shift and that she did not always have time to document care provided. The facility also lacked evidence of infection control tracking and concern monitoring. Review of the infection control log showed no evidence a log had been started, and an RN confirmed infections had occurred but tracking and trending had not been started. Review of the concern log showed no concerns recorded each month, despite the Ombudsman reporting an open case related to call light response time and staff attitude. Staff and a contracted employee reported that showers, incontinence care, turning, and follow-up on changes in condition were not being completed timely, and that the facility had difficulty finding staff to assist residents.
Unsanitary food handling and food prep conditions
Penalty
Summary
The facility failed to ensure food was prepared and served in a sanitary manner. During observations in the food preparation area, a staff member reached into a bag of bread without gloves and touched four pieces of bread while making a grilled cheese sandwich; the Dietary Manager instructed her to throw the bread away, wash her hands, and get new bread with gloves on, but the two other pieces of bread that had been touched were not removed from the bag. The food prep area also had dust and debris on the window sill, large amounts of dust around the ceiling air vent and sprinkler system waterlines, and food splatters on the walls. Later, a staff member was observed holding tongs over a bin of chicken while barehanded, dropped the tongs into the chicken, removed them, and grabbed a new pair of tongs; the remaining chicken in the bin was still served. The Dietary Manager confirmed all findings.
Infection Control Program Deficiencies
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not properly store nebulizer masks and tubing and did not maintain a comprehensive infection control log or ensure staff were fit tested. Resident #19, who was admitted with diagnoses including end stage renal disease, atrial fibrillation, chronic respiratory failure, and COPD, had an order for albuterol sulfate inhalation nebulization treatment as needed for shortness of breath or congestion. Observations showed the resident's nebulizer mask and tubing laying directly on the bedside table while the resident was in bed and later while seated in a wheelchair. The Maintenance Director and a CNA both confirmed the nebulizer equipment was lying directly on the bedside table, and the facility policy stated the nebulizer cup should be stored at bedside on a paper towel or in a plastic bag after treatment. The infection control log was incomplete and did not reflect infections identified in the record. Review of the infection control binder showed outbreaks of COVID, Flu A, and RSV, and the facility policy required N95 fit testing initially and annually thereafter. The Infection Preventionist stated she could not find evidence that new hires or current employees had been fit tested in the past year, even though staff were required to wear N95 respirators during recent outbreaks. Closed record review showed Resident #48 had a urine culture with greater than 100,000 CFU/ml of ESBL E. coli, and Resident #31 had a urine culture growing Proteus mirabilis with Cipro resistance, but neither infection appeared on the infection control log. The May 2026 infection control log had no infections recorded, and the Infection Preventionist confirmed that Resident #31 and Resident #48 were not logged.
Infection Preventionist Lacked Dedicated Time for Infection Surveillance
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) had dedicated time to carry out infection prevention and control duties and maintain a comprehensive infection control program. Review of the May 2026 infection control log showed no evidence of tracking or trending as of 05/13/26. During interview, the Scheduler confirmed RN/Infection Preventionist #117 had started working three 12-hour floor shifts on 04/12/26 after previously working five 8-hour shifts, and that she was also the ADON and Wound Nurse. RN #117 stated she had been working three 12-hour shifts on the floor for the prior three weeks because of a nursing shortage and had not yet started the May infection control log, although she reported there had been five or six infections in May and she was trying to work on the log during her free time. Review of the facility assessment dated 01/2026 showed no evidence identifying the IP or the hours required to maintain the infection control and antibiotic stewardship program, and the facility’s Infection Prevention and Control Program and Antibiotic Stewardship policy did not include designated time for the IP. Record review also showed Resident #48 was admitted with a UTI and had a final urinalysis on 04/20/26 showing greater than 100,000 CFU/ml of ESBL E. coli, but the infection was not entered on the 04/2026 infection control log. Resident #31 was admitted with acute kidney failure and urinary retention, had a urine culture on 05/02/26 growing 25-30,000 Proteus mirabilis resistant to Cipro, and received six doses of Cipro 500 mg for a UTI; this potential infection also was not logged on the 04/2026 or 05/2026 infection control logs. RN #117 confirmed both residents’ infections were not logged despite the IP’s responsibility for the infection control program.
Failure to Include Residents and Interdisciplinary Team in Care Conferences
Penalty
Summary
The facility failed to ensure residents and the interdisciplinary team participated in the care planning process, including care plan conferences, for four of five residents reviewed. The deficiency involved Residents #1, #4, #28, and #31, and the facility census was 38. The report states that care conferences were held on Thursdays, but the required interdisciplinary team members did not consistently attend, and residents were not asked to participate in their own conferences. Resident #1 was admitted with chronic obstructive pulmonary disease and type II diabetes. Care conference sign-in sheets showed attendance by the resident's representative, the DON, and Social Services on one date, and only the representative and Social Services on another. The resident stated she had not been asked to participate in care conferences and would like to do so. Social Services confirmed the resident was not asked to participate and that not the entire interdisciplinary team attended the conferences. Resident #4 had diagnoses including Tourette's, heart failure, anemia, and depression, and a quarterly MDS showed moderate cognitive impairment, dependence for multiple activities of daily living, incontinence, and a feeding tube. A care plan meeting record showed the resident, representative, Social Services designee, and DON were present, but the meeting minutes stated not all members of the interdisciplinary team were present. Resident #28, who had intact cognition and multiple complex diagnoses, attended some prior conferences, but later notes showed only the resident and Social Services designee were present. The resident stated she had never been invited or attended a care conference in two years at the facility, and Social Services confirmed the only staff present at some meetings were herself and the DON, with dietary, therapy, physician, and direct care staff not attending or providing input. Resident #31, who had diagnoses including heart failure, kidney failure, COPD, pneumonia, sepsis, atrial fibrillation, edema, pain, and anxiety, had care conference notes showing attendance by the resident, Social Services, and DON on several occasions, and only the resident and Social Services designee on another. The resident stated he had never attended or been asked to attend a care conference, and Social Services confirmed the limited attendance at those meetings.
Incomplete and inaccurate resident records
Penalty
Summary
The facility failed to ensure resident medical records were complete, accurate, and readily accessible for five residents. For one resident with diagnoses including type 2 diabetes, schizoaffective disorder, major depressive disorder, generalized anxiety disorder, seizures, sleep apnea, hypertension, GERD, bipolar disorder, and mild intellectual disabilities, the PHQ 2-9, social determinants of health, and BIMS assessments had effective dates of 01/08/26 but were not created until 05/01/26. The social service designee stated these assessments should be completed with the MDS or at least quarterly and confirmed they were approximately four months late and back dated. For another resident with dementia who died in the facility, the record contained a hospice note showing an LPN called hospice to request a visit to pronounce the resident, but the progress notes did not show when staff found the resident unresponsive or when hospice or family was notified. A late entry note later documented the resident was confirmed dead at 10:41 P.M. The LPN stated a medication tech asked her to check on the resident because the resident had expired, and she confirmed that neither she nor the medication tech documented when the resident was found or when hospice or family were notified. A third resident with protein-calorie malnutrition had hospice documentation showing the facility noted a decline, with the resident appearing pale, lethargic, diaphoretic, and hypotensive at 83/42, but the facility progress notes contained no evidence of that decline on the date hospice documented it. The record also had no progress notes from several days before the resident was found unresponsive and pronounced dead. An LPN confirmed she had been told the resident was passing and had low blood pressure, checked on the resident during the night, but did not document her findings. For another resident with end stage renal disease and hyperlipidemia, the MARs showed oxycodone administration entries that did not match the order quantity, and the DON confirmed the total tablets marked on the MARs exceeded the six tablets ordered. The DON later stated nurses were signing the MAR for oxycodone instead of the current oxycodone-acetaminophen order, and that the documentation error did not match the actual narcotic sign-out times. For a resident with multiple chronic conditions including encephalopathy, osteomyelitis, COPD, diabetes, dementia, depression, anxiety, pain, and other diagnoses, a medication error report documented that the wrong medication was given when a CMA administered medication to the wrong bed in a shared room. The resident’s record did not contain documentation of the medication error incident for the days immediately following the event, and the DON confirmed hospice was not notified until the next day and that new monitoring orders were received but never written in the chart.
Failure to Notify Hospice, Provider, and Representative of Significant Resident Changes
Penalty
Summary
The facility failed to ensure that a resident's hospice service and medical provider were notified after a medication error, and failed to ensure that a resident's physician and resident representative were notified after a new skin alteration was identified. One resident was admitted with multiple chronic diagnoses including encephalopathy, osteomyelitis, COPD, diabetes, dementia, depression, anxiety, peripheral vascular disease, malnutrition, and pain, and was receiving hospice services related to hypertension and heart disease. The resident's care plan directed staff to contact hospice for changes in condition and medication as ordered. On the day of the medication error, a CMA administered another resident's medications to the resident after being interrupted during the medication pass. The medication error investigation and electronic report documented that the resident received the roommate's medications, including medications such as carvedilol, propranolol, lisinopril, amlodipine, aspirin, baclofen, buprenorphine, venlafaxine, pantoprazole, thiamine, folic acid, ascorbic acid, and sennosides. The record showed the provider and DON were notified, and the resident was monitored, but there was no documented evidence that hospice was notified at the time of the error. The resident's medical record also lacked documentation of the medication error event, and hospice documentation later showed hospice staff learned of the error after the fact. A second resident was admitted with diagnoses including hypoglycemia, type 2 diabetes, dysphagia, heart failure, major depressive disorder, insomnia, hallucinations, osteoarthritis, and mood disorder, and had severe cognitive impairment on MDS assessment. After returning from the hospital, the resident was documented as having a stage two pressure ulcer to the sacrum with a non-blanchable area and a small open wound. The record did not contain documentation that the resident's physician or representative was notified of the new skin alteration, despite facility policy requiring prompt notification of the physician and responsible party when a new skin area is identified.
Late Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare non coverage (NOMNC) to Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay. Closed record review showed Resident #50 was admitted with diagnoses including type 2 diabetes, COPD, nicotine dependence, major depressive disorder, generalized anxiety disorder, obstructive sleep apnea, atrial fibrillation, and hypertension. The resident’s Beneficiary Protection Notification showed the last covered day of Part A services was 11/11/25, but the notice was signed and dated by the resident on 11/10/25, indicating it was provided only one day before coverage ended. Social Service Designee #108 confirmed the last covered day and that the resident received the notice on 11/10/25. Facility policy stated that a completed NOMNC must be given no later than two days before termination of services.
Unsanitary Shared Bathroom Conditions
Penalty
Summary
The facility failed to ensure a shared resident bathroom was maintained in a sanitary manner. Resident #31 reported that the male resident sharing the bathroom from the adjacent room urinated and had bowel movements all over the bathroom and did not flush the toilet. Resident #31 provided photos from his phone that showed urine and bowel movements on the floors and toilet, along with an unflushed toilet. The Housekeeping Supervisor confirmed that Resident #31 had voiced concerns about the other resident missing the toilet when urinating and not flushing, and stated that bathrooms were cleaned daily and upon request, including additional cleanings requested by Resident #31. During a random tour, the Maintenance Director observed urine on the floor, urine on the toilet rim, and a toilet that had not been flushed in Resident #31's bathroom, and confirmed these findings.
Failure to Timely Report Missing Resident Property
Penalty
Summary
The facility failed to ensure an allegation of misappropriation of property was reported timely to the state agency for one resident whose wallet, containing a credit card and driver's license, was reported missing. The resident was admitted with multiple diagnoses including encephalopathy, osteomyelitis, COPD, diabetes, obesity, depression, anemia, long QT syndrome, anxiety, pain, peripheral vascular disease, vitamin deficiencies, restless legs syndrome, gastritis, constipation, occlusion and stenosis, hypomagnesemia, hyperglycemia, hyperlipidemia, and nocturia. The concerns log for the prior five months did not show any concern related to the missing wallet. The resident's wife stated the wallet went missing a few weeks after admission and later confirmed she had reported it to a CNA and an LPN in February 2026, but staff were unable to locate it. The wife also confirmed the wallet contained the resident's credit card, driver's license, and a picture of her, and she had a friend cancel the credit card. The resident's sister also confirmed the wife had reported the missing wallet to staff. The Administrator, DON, and SSD stated they were not aware the wallet was missing when the surveyor raised the concern. The Administrator did not initiate a self-reported incident when the wife first reported the wallet missing or when the surveyor reported the missing wallet to facility leadership. The Administrator stated she did not do so because the wife did not indicate the wallet was stolen and it was only missing. Review of the facility's self-reported incidents showed no report had been initiated until after the survey process had already identified the issue. The facility policy stated allegations were to be communicated immediately to the Administrator or designee and reporting of allegations not involving abuse or serious bodily injury must not exceed 24 hours.
Failure to Timely Investigate Missing Resident Wallet
Penalty
Summary
The facility failed to timely investigate an allegation of misappropriation involving Resident #41’s wallet, which reportedly contained a credit card, a driver’s license, and a picture of his wife. Resident #41 was admitted with multiple diagnoses including encephalopathy, osteomyelitis, COPD, diabetes, obesity, depression, anemia, anxiety, pain, peripheral vascular disease, and cognitive impairment. Review of the concerns log for the prior five months showed no concern had been documented regarding the missing wallet, and the facility had not initiated a self-reported incident when the wallet was first reported missing by the resident’s wife or when the surveyor later notified the Administrator, DON, and SSD that the wallet was missing. Interviews showed the resident’s wife reported the wallet missing to CNA #132 and an LPN in February 2026, and staff looked for it but could not locate it. The wife later confirmed the wallet had been missing for weeks after admission and that she had a friend cancel the credit card, but the resident still did not have his driver’s license. The resident’s sister also confirmed the wife had reported the missing wallet to staff and identified the contents of the wallet. The Administrator, DON, and SSD stated they were not aware the wallet was missing when the surveyor raised the concern. The Administrator did not initiate a self-reported incident until after the survey process was underway and stated she did not do so because the wife did not say the wallet was stolen and only said it was missing. The Administrator also stated she had not completed an investigation, aside from interviewing a few staff members requested by the surveyor. The facility policy required allegations of misappropriation to be communicated immediately to the Administrator or designee, with investigation beginning immediately and reporting of allegations not involving abuse or serious bodily injury within 24 hours.
Failure to Develop Individualized Trauma-Informed PTSD Care Plan
Penalty
Summary
The facility failed to ensure a resident had an individualized trauma-informed plan of care. Resident #28 was admitted with diagnoses including personality disorder, depression, generalized anxiety, PTSD, personal history of suicidal behavior, and benzodiazepine, sedative, hypnotic, or anxiolytic dependence in remission. The psychiatric note documented PTSD related to watching a friend wreck and die on a motorcycle when she was younger, with the resident reporting that the event replays in her head, and noted a history of attempted suicide. However, the record did not contain documented evidence of PTSD triggers or individualized interventions. The quarterly psychosocial/behavioral assessment also identified PTSD but did not include triggers or individualized interventions. A risk for impaired social interaction care plan listed several triggers and general interventions, including encouraging positive communication, verbalizing feelings, medication per order, notifying the physician of decline, offering psych services, providing positive reinforcement, referring to counseling/psychiatry, and providing education on community resources and support groups. During interview, the resident stated her PTSD was related to multiple life events, including witnessing a motorcycle crash and death, a house fire that killed her pets, and a bad relationship, and she reported panic attacks, poor sleep since Xanax was stopped, and triggers such as motorcycles, loud noises, and certain words. Social services confirmed there was no comprehensive PTSD assessment or comprehensive care plan for PTSD with triggers or individualized interventions and stated they did not know the resident's PTSD triggers.
Failure to Provide Hygiene and Bathing Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff received assistance with personal hygiene and bathing. Resident #19, admitted with diagnoses including end stage renal disease and atrial fibrillation, had a care plan stating she required assistance with ADLs due to debility and weakness, including daily hygiene and showering assistance. Her MDS indicated intact cognition, no behaviors, and dependence on staff for personal hygiene. Observations showed she was resting in bed with long fingernails and a dark brown substance underneath, and later seated in a wheelchair with long, dark brown nails and long chin hairs. A CNA confirmed the fingernails were long with a dark substance underneath and acknowledged the resident had chin hair; the resident stated her nails needed to be taken care of. Resident #25, admitted with diagnoses including COPD, type 2 diabetes mellitus, malnutrition, amnesia, abdominal aortic aneurysm, depression, and GERD, had a Medicare 5-day MDS showing a BIMS score of 14, no behaviors, and dependence on staff for oral hygiene, toileting, showering and bathing, dressing, footwear, transfers, and mobility. The resident was also always incontinent of bowel and bladder. An observation showed the resident appeared unkempt, wearing a white shirt with food and spilled items on it, long dirty fingernails, and no pants on. The record contained no shower sheets or documentation that the resident received or refused showers or bathing for the month reviewed, and the DON confirmed there was no evidence the resident had received any showers during that month.
Air Mattress Set Incorrectly for Resident at Risk for Skin Breakdown
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured when the facility failed to keep an alternating air mattress on the ordered setting for Resident #19. Resident #19 was admitted with diagnoses including end stage renal disease and atrial fibrillation, and the care plan identified the resident as at risk for impaired skin integrity related to decreased mobility, periods of bowel and bladder incontinence, bilateral lower extremity edema, oxygen via nasal cannula, a history of pressure ulcers, and a preference to lie on the back. The care plan included interventions such as elevating heels off the mattress, using heel protectors as tolerated, inspecting skin during daily care, applying lotion as needed, using a low air loss mattress, and pressure reduction devices if ordered. The resident had an order dated 10/01/25 to ensure the bed was on level four every shift and as needed, but observations on 05/05/26 at 7:51 A.M. and 1:31 P.M. showed the air mattress set to level five. Interviews on 05/06/26 with the Maintenance Director and a CNA both confirmed the mattress was set to level five. The facility policy on Pressure Ulcer Prevention Intervention stated that preventative skin measures should be implemented based on resident risk factors and that the interdisciplinary team should consider facility policy, standard of practice, and resident goals/preferences/advanced directives before implementation.
Delayed UTI Testing and Missed Antibiotic Dose
Penalty
Summary
The facility failed to ensure timely collection of urinalysis specimens and failed to administer antibiotics per order for a urinary tract infection for one resident. The resident was admitted with diagnoses including dementia, anemia, scoliosis, and ulcerated proctitis, and the annual MDS indicated the resident was always incontinent of urine. The resident’s care plan and alteration in elimination documentation directed staff to administer treatments per order, monitor for signs and symptoms of UTI such as foul-smelling urine, cloudy urine, sediment, and decreased output, and notify the physician of changes. A progress note documented foul-smelling dark urine and a new order for urinalysis, with instructions to attempt collection if it could not be obtained the following Monday morning. The record showed no evidence that the urinalysis was attempted or collected on multiple intervening days, and no assessments or signs and symptoms of UTI were documented during that period. The urine was later collected by straight catheterization, labeled, and sent for testing; the culture grew greater than 100,000 CFU/ml Escherichia coli with ESBL and was sensitive to Macrobid. Hospice was notified of the results, and a hospice physician ordered Macrobid 100 mg twice daily for seven days. The MAR showed the resident received only 13 of the 14 ordered doses of Macrobid, with the first dose not administered and coded as 9 with no documented explanation. A handwritten contingency medication list showed Macrobid was available, and the infection control log did not document the resident’s infection. The second urinalysis was also ordered and not collected timely. During interview, the RN/IP confirmed both urinalyses were not collected timely, the first Macrobid dose was not administered as ordered, the order was not extended to ensure all 14 doses were given, and the positive urinalysis results were not documented on the infection control log.
Failure to Address Significant Weight Loss and Poor Nutritional Intake
Penalty
Summary
The facility failed to ensure appropriate interventions were implemented for a resident with significant weight loss and compromised nutritional status. The resident was admitted with diagnoses including hypoglycemia, type 2 diabetes, dysphagia, heart failure, major depressive disorder, hallucinations, and mood disorder. The care plan identified the resident as being at risk for altered nutrition and hydration related to diabetes and a mechanically altered diet, with a goal of adequate nourishment and no significant weight changes. An order for monthly weights was placed, and the resident’s quarterly MDS showed use of a wheelchair, assistance needs for eating and personal care, and a therapeutic diet of low salt, low cholesterol, and diabetic. The resident’s weight record showed a decline from 226.0 lbs to 195.0 lbs over five months, representing a 13.72% weight loss. Laboratory work showed low albumin levels of 3.3 g/dl and then 2.5 g/dl. The nutritional evaluation documented weight loss of 5% or more in one month or 10% or more in six months, inadequate protein and oral intake, altered nutrition related to labs, and nutritional risk related to type 2 diabetes mellitus, significant weight loss, and poor PO intake. The resident’s estimated needs were 2,455 calories and 98 grams of protein. Meal intake records from 04/08/26 through 05/05/26 were incomplete, with no documentation for 23 meals out of 78 served. Of the meals with documentation, many showed poor intake, including 26 meals with 0-25% consumed, 13 meals with 26-50% consumed, and seven refused meals. Orders were later placed for a house supplement juice drink three times daily, Remeron, and a reduced carbohydrate mechanical soft diet with fortified foods. The resident also developed a new Stage 2 coccyx pressure ulcer, which progressed from a very small wound to a larger partial-thickness wound. The facility dietician stated the resident had significant weight loss, believed he was being weighed weekly when the order was for monthly weights, and was not aware the resident had developed a new pressure ulcer.
Failure to Provide Ordered Oxygen Therapy and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not administering oxygen as ordered and by not ensuring appropriate oxygen use for two residents. Resident #19 had diagnoses including end stage renal disease, atrial fibrillation, chronic respiratory failure, and COPD, and had an order for humidified oxygen via nasal cannula at 3 liters per minute continuously with oxygen saturation checks each shift. However, observations on 05/05/26 showed the resident using oxygen via nasal cannula set at 4 liters per minute, and staff interviews confirmed the oxygen was set above the ordered flow rate. The facility policy for nasal cannula stated the oxygen concentrator knob should be adjusted to the provider-prescribed flow rate. Resident #15 had diagnoses including COPD, hypertension, muscle weakness with difficulty walking, and type 2 diabetes, and had orders for continuous oxygen at 3 liters per minute for shortness of breath and COPD. The resident’s care plan identified altered respiratory function and respiratory failure, with interventions to administer oxygen as ordered and monitor oxygen saturation. On 05/04/26, the resident walked to the dining room without oxygen, and was later observed with pale lips, labored breathing, delayed responses, and stating she could not breathe and felt like she was going to pass out. When the RN arrived, the resident was still short of breath; oxygen was not applied until after the resident was guided back into the dining room, and vital signs then showed an oxygen saturation of 67%.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure residents with known trauma received trauma-informed care for two residents reviewed for behaviors, including one resident with PTSD and depression and another resident with PTSD, depression, anxiety, and a history of suicidal behavior. For the resident with PTSD and depression, the care plan addressed stress reduction and positive communication, but it did not identify any triggers. The psychosocial/behavioral assessment also did not add further information, and the MDS noted intact cognition, no behaviors, and a PTSD diagnosis. Social Services stated the resident had not had a comprehensive assessment completed and the care plan did not identify triggers. For the resident with PTSD, the record showed a history of traumatic events, including witnessing a friend die in a motorcycle crash, a house fire that killed pets, and a bad relationship. Psychiatric documentation noted PTSD that was stable on Zoloft and Xanax, but there was no documented evidence of triggers or individualized interventions. The quarterly psychosocial/behavioral assessment also did not include triggers or individualized interventions. A care plan listed several trauma-related issues and general interventions, but it did not show individualized triggers or specific interventions tied to the resident’s trauma history. Interviews confirmed the gaps in assessment and care planning. Social Services and the visiting behavioral health LSW confirmed the residents did not have comprehensive PTSD assessments or care plans that identified triggers or individualized interventions. The facility policy stated that residents with trauma history or PTSD should be assessed for potential trauma-related triggers upon admission, quarterly, and with significant change, with identified triggers documented and care-planned appropriately. The DON also confirmed the resident with PTSD had not been seen by mental health again until 10/2025 after firing the psychologist, and that medication changes related to anxiety and PTSD were being addressed by different providers.
Unnecessary Medication Use and Inappropriate Antibiotic Treatment
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications. One resident with diagnoses including chronic systolic heart failure, acute kidney failure, COPD, pneumonia, sepsis, urinary retention, paroxysmal atrial fibrillation, prostatic hyperplasia, GERD, edema, obstructive and reflux uropathy, Barrett’s esophagus with dysplasia, opioid dependence, hypertension, and anxiety had an indwelling Foley catheter and was treated for a UTI with Ciprofloxacin 500 mg twice daily for five days. The urine culture later showed Proteus mirabilis that was resistant to Ciprofloxacin, and the resident received 6 of the 10 ordered doses. The McGeer infection surveillance form was completed as a UTI without an indwelling catheter even though the resident had a Foley catheter, and the organism section was left blank. The infection control log for April and May 2026 did not show the resident on the log for UTI or treatment of UTI. During interview, the resident stated he was treated for a UTI with the incorrect antibiotic. The RN/Infection Preventionist confirmed the resident did not meet criteria for antibiotic treatment and had received an antibiotic without justification. She also confirmed the McGeer form was completed inaccurately because the resident had a urinary Foley catheter and did not have greater than 100,000 of an organism. A second resident with end stage renal disease and hyperlipidemia had orders for pain medications including Tylenol PRN, oxycodone PRN for post-surgery, and oxycodone-acetaminophen PRN for pain. The orders for the narcotic medications did not include pain parameters to guide administration. The DON confirmed there were no parameters in place for the narcotic medications to guide staff on when to administer them, resulting in unnecessary pain medication administration.
Significant medication error with missing assessment and documentation
Penalty
Summary
The facility failed to prevent a significant medication error involving one resident who was admitted with diagnoses including encephalopathy, COPD, diabetes mellitus, asthma, dementia, major depression, long QT syndrome, insomnia, pain, peripheral vascular disease, and carotid artery stenosis. The resident was full code, had allergies to Duloxetine, Morphine, and Betadine, and was receiving hospice services for hypertensive heart disease. His medication regimen included Atenolol, Oxybutynin, Plavix, Zoloft, Gabapentin, Lantus, Metformin, Cephalexin, Combivent, and Tramadol. During the morning medication pass, a CMA was interrupted by two other residents who came to the medication cart. The CMA then entered the room shared by the resident and his roommate and administered the roommate’s medications to the resident in bed B instead of the intended resident in bed A. The roommate’s medications included Amlodipine, Ascorbic acid, Aspirin, Baclofen, Buprenorphine, Carvedilol, Folic acid, Lisinopril, Pantoprazole, Propranolol, Thiamine, Venlafaxine, and Sennosides. The facility’s investigation identified the wrong-medication event, but the resident’s record did not contain a comprehensive assessment, vital sign documentation, or a progress note describing the incident. The record also lacked documentation of follow-up nursing assessments and lacked evidence of provider orders being entered after the error. The DON confirmed that the NP was notified and gave verbal orders to monitor the resident and hold sedative medication because the resident would likely sleep all day after receiving Buprenorphine, but those orders were never written. The resident reportedly slept the remainder of the day and until lunch the next day, and staff later noted he was not himself. The facility policy required assessment, documentation, notification of the prescriber, implementation of new orders, and close monitoring after a significant medication error, but those elements were not documented in the resident’s medical record.
Hospice Records and Contact Designee Not Maintained
Penalty
Summary
The facility failed to ensure hospice plans and hospice visits were maintained in the facility records and failed to identify a facility contact designee for hospice services for three residents receiving hospice care. Resident #41 was admitted with multiple diagnoses including encephalopathy, osteomyelitis, COPD, diabetes mellitus, asthma, dementia, depression, anxiety, pain, peripheral vascular disease, and other chronic conditions. The hospice contract required regular communication between hospice and the facility, documentation of communications in each party’s records, immediate notification of hospice for changes in condition, and maintenance of complete records, but the resident’s electronic record and hospice binder contained no hospice notes or hospice plan of care. The DON stated hospice staff usually communicated when entering the building but did not always follow up before leaving, and the facility had to call hospice to obtain notes and plans of care. Closed record review for Resident #47 showed admission with diagnoses including protein calorie malnutrition, senile degeneration of the brain, hemiplegia, diabetes, dementia, anxiety, and depression, and the resident expired while under hospice services for senile degeneration. The record contained no hospice certification, hospice plan of care, or hospice progress notes, despite the hospice contract stating the facility and hospice would maintain an integrated medical record containing documents related to hospice care and hospice personnel involvement. The DON confirmed the facility did not have the hospice certification, plan of care, or progress notes and had to call hospice to obtain records. Resident #48 was admitted with diagnoses including dementia, scoliosis, ulcerated proctitis, depression, anemia, anxiety, and GERD, and later expired. The resident’s hospice plan of care indicated hospice would collaborate with facility staff, and the quarterly MDS showed hospice services were being received, but the electronic and paper records contained no hospice certification, plan of care, or progress notes. Interviews with the DON, Medical Records staff, and the SSD showed uncertainty about who the hospice contact designee was, and none of them identified themselves as that designee. The DON later stated she would be the facility’s contact designee for hospice.
Inadequate Catheter Care and Education for Residents
Penalty
Summary
The facility failed to provide adequate indwelling catheter care and education for two residents with bladder impairments. Resident #44 was admitted with a history of metabolic encephalopathy, pneumonia, severe protein-calorie malnutrition, bladder neck obstruction, hydronephrosis, generalized anxiety, malignant neoplasm of the prostate, and depression. Despite having an indwelling catheter upon admission, the admission assessment inaccurately recorded the resident as continent of bladder and without a catheter. Additionally, there was no evidence of catheter care being performed from the date of admission to discharge, and a urine sample ordered for collection was not obtained. Furthermore, neither the resident nor the family received education on catheter care upon discharge. Resident #45, admitted with benign prostatic hyperplasia and an indwelling catheter, also did not receive documented catheter care during their stay. The medical records lacked evidence of any orders for catheter care, and there was no documentation of education or instructions provided to the resident or family upon discharge. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the absence of documented catheter care and education for both residents. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with providing necessary catheter care and education. The lack of documentation and failure to follow through with physician orders and discharge instructions contributed to the deficiency, affecting the quality of care provided to the residents.
Inadequate Pain Management After Falls
Penalty
Summary
The facility failed to provide effective and timely pain management for three residents following falls that resulted in injuries. Resident #35 experienced a fall with a hip fracture and was not provided with adequate pain management. Despite showing significant verbal and non-verbal indicators of pain, the resident was not given any pharmacological or non-pharmacological interventions until being sent to the emergency room nearly 20 hours after the fall. Upon return from the ER, the resident continued to exhibit signs of pain, but no comprehensive pain management plan was developed or implemented. Resident #22 suffered a fall resulting in a non-displaced fracture of the shoulder. Although the resident reported a high level of pain immediately after the fall, pain medication was not administered until over four hours later. The facility did not initiate any non-pharmacological interventions to address the resident's pain, and no individualized pain management plan was developed following the incident. The resident's pain was not adequately assessed or managed, leading to prolonged discomfort. Resident #24 also experienced a fall resulting in a fracture, and the facility failed to provide timely pain management. The resident was not given any pharmacological or effective non-pharmacological interventions before being transferred to the emergency room over five hours after the fall. The facility did not develop a comprehensive plan of care to address the resident's pain, and there was a lack of documentation and follow-up on the resident's pain management needs.
Inadequate Bed Size for Resident
Penalty
Summary
The facility failed to provide a bed of appropriate size for a resident, leading to discomfort and potential pressure issues. The resident, who was admitted with diagnoses including syncope, dementia, hyperlipidemia, and intellectual disabilities, was observed on multiple occasions lying diagonally in bed with his feet hanging over the edge. Despite being independent in bed mobility, the resident expressed discomfort due to the need to lie diagonally, which increased pressure on his right hip. Interviews with the resident and a State Tested Nursing Assistant confirmed that moving the resident further up in the bed would not alleviate the issue, as his toes would still touch the footboard. The Director of Nursing acknowledged that the resident always lays diagonally in bed.
Failure to Conduct Timely Care Conferences with MDS Reviews
Penalty
Summary
The facility failed to ensure care conferences were offered in conjunction with Minimum Data Set (MDS) reviews, affecting two residents. Resident #2, who was admitted with diagnoses including heart failure, atrial fibrillation, hypertension, and anemia, had quarterly MDS assessments completed on several dates. However, there was no record of a care conference held in conjunction with the MDS completed in November 2023. An interview with Resident #2 revealed that the resident could not recall having care conferences. Similarly, Resident #39, admitted with diagnoses including syncope, dementia, hyperlipidemia, and intellectual disabilities, had quarterly MDS assessments completed on various dates. The care conference for Resident #39 was not completed in conjunction with the MDS completed in May 2024. Interviews with the social worker and activity director revealed scheduling issues and lack of documentation for the care conferences. The facility's policy indicated that the MDS nurse is responsible for coordinating routine care conferences, and social services should send out invitations two weeks prior, which was not adhered to in these cases.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. Resident #3, who was admitted with conditions such as Alzheimer's disease, dementia, and impaired balance, was identified as being at risk for falls. Despite the care plan specifying that the bed should be kept in a low position to prevent falls, observations revealed that the bed was not in the lowest position, and the bed controller was out of the resident's reach. This oversight was confirmed by an LPN, indicating a failure to adhere to the prescribed fall prevention measures. Similarly, Resident #12, who had diagnoses including congestive heart failure and moderate cognitive impairment, was also at risk for falls. The care plan included the use of a dycem in the resident's wheelchair to prevent slipping. However, observations and interviews with a STNA revealed that the dycem was missing from the wheelchair, and attempts to locate it were unsuccessful. This indicates a lapse in ensuring that the necessary fall prevention equipment was in place, as outlined in the facility's fall prevention policy.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure proper pressure ulcer interventions were in place for three residents, leading to deficiencies in care. Resident #36, who was at risk for skin breakdown, was observed multiple times with heels not elevated and without proper repositioning, despite having a care plan that included these interventions. The resident developed Stage II pressure ulcers on both heels, and there were no documented refusals of care. Additionally, the resident's bed was not set to the correct comfort level as per physician orders, and there was no order to turn and reposition the resident. Resident #26, who had two Stage 4 pressure ulcers, was found to have an incorrect weight setting on their low air loss mattress, which was set to 450 pounds despite the resident weighing less than 200 pounds. This incorrect setting was verified by the Assistant Director of Nursing, who noted that aides frequently bump into beds, potentially altering settings. The facility failed to monitor and adjust the mattress settings appropriately, which is crucial for the resident's skin integrity. Resident #12, who required maximum assistance for bed mobility, had a low air-loss mattress that was not turned on during observations. The mattress was found to be unplugged, and staff were unaware of how to operate it properly. The mattress remained deflated, compromising the resident's pressure ulcer prevention. There was also no physician order for the low air-loss mattress, indicating a lack of proper documentation and oversight in ensuring the resident's care needs were met.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 189 citations issued within 25 miles in the last 12 months — including the 3 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 Beverly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Landing Nursing And Rehabilitation | 11 mi | ★★★★★ | 1 | 0 |
| Waterview Pointe Nursing & Rehabilitation | 12.8 mi | ★★★★★ | 0 | 0 |
| Harmar Place Nursing And Rehabilitation | 13.1 mi | ★★★★★ | 1 | 0 |
| Arbors At Marietta | 13.1 mi | ★★★★★ | 5 | 0 |
| Marietta Heights Post Acute | 13.7 mi | — | 63 | 2 |
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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.