Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 The Merriman during CMS and state inspections, most recent first.
Failure to provide timely incontinence care led to skin breakdown. A resident with hospice services, cognitive impairment, and total dependence for toileting hygiene was found in a heavily soiled brief after going about 12 hours without documented incontinence care. Staff observed urine and feces in the room, and the resident reported that staff ignored her requests for help and that her buttocks felt open. Two open wounds were then seen on her buttocks, and the record also lacked a comprehensive initial wound assessment.
A resident who was not approved to self-administer meds had multiple OTC and Rx bottles with pills left on a dresser in the room, and an LPN confirmed the medications were there. Staff also found an open vial of Tubersol in the med refrigerator that was not in the original package and had no open date, despite manufacturer guidance requiring dating and timely discard after use.
Kitchen sanitation and equipment monitoring failures were observed when the ice machine sanitation log and cooler/freezer temp logs were not kept up to date, water repeatedly pooled on the floor near the steam table, and a dark mold-like substance and dirt/grime were seen on the backsplash, wall, and under the dishwasher. Staff also could not verify dishwasher chemical sanitation because test strips were unavailable or expired, and an LPN reported the 3-compartment sink was not sanitizing dishes.
Blocked Exit Door and Fire Safety Equipment: Two beds were stored end to end in a back hallway near rooms 17 to 22, and a manual wheelchair was placed in front of the exit door, fire pull station, and fire extinguisher box. An RN verified the blockage and stated she would find a way to get residents out in case of evacuation. Later, the MD verified the beds were still blocking the exit door.
A resident’s room was observed with gnats, food residue containers, wet clothing, and overflowing dirty laundry, and a second resident’s dentures were lost during a room move. The resident with lost dentures had no natural teeth, moderately impaired cognition, and could not afford replacement dentures, while the DON verified the dentures were lost during the move and had not yet been replaced.
Failure to provide routine hydration and document meal intakes: The facility did not routinely pass fresh ice water to three residents, despite care plans and an order calling for increased fluids, and one resident with DM, CKD, and malnutrition had multiple days with no meal intake documented. Residents reported having to ask for water, one resident said staff refused her request, and observations showed water service was not being provided as expected; the DON stated staff should have been passing ice water each shift.
Failure to Document and Address Care Conference Concerns: A resident with cognitive impairment, incontinence, and wound issues was found soiled and tearful, reporting she had not been changed for hours and had sore, open buttocks. A hospice RN had requested a care conference over concerns about delayed incontinence care and wound care, but the ADON did not document the meeting or the concerns in the medical record, and the DON said she was not aware of the issues. The record also showed no evidence of the conference or any documented resolution attempts.
A cognitively intact resident with multiple chronic conditions reported that a dietary aide cursed at her and refused to provide water when requested. The resident said the aide used profanity and racial slurs, and a staff witness described the aide as yelling, cursing, and slamming things while the kitchen was understaffed. The facility’s incident report later stated the allegation was unsubstantiated despite the resident’s complaint and witness observations.
Failure to timely report an allegation of verbal abuse. A cognitively intact resident reported that a Dietary Aide cursed at her and refused to provide water, and a witness later confirmed the aide was yelling, using profanity, and directing racial slurs at residents during an understaffed kitchen shift. The Dietary Director and DON did not immediately report the allegation to the Administrator as required by policy.
Failure to assess and implement smoking safety for a resident with COPD, heart failure, and moderately impaired cognition. The resident was incorrectly assessed as a non-smoker, had no smoking care plan in place until later, and was observed with a lighter and half-burned cigarette while heading toward the smoking area; additional smoking materials were later found in the resident’s room. An MDS LPN verified the smoking assessment was inaccurate and said the resident had repeatedly stated he was not a smoker.
A resident with ESRD, dialysis dependence, and impaired cognition missed multiple dialysis treatments because scheduled insurance transportation did not arrive and no driver was available. The record showed no pre/post dialysis assessments for the missed treatments and no documented evidence of reasonable efforts to ensure dialysis services were received; the DON verified the resident did not receive dialysis that week.
A resident with panic disorder, depression, chronic pain, and insomnia missed multiple scheduled doses of Xanax after the facility failed to timely reorder the medication. Records showed the drug was pending, unavailable, or awaiting a new script, and staff confirmed the prescription ran out of refills and the contingency supply was not used, resulting in nine missed doses and the resident reporting increased anxiety.
A resident with pleural effusion, COPD, HTN, HF, and lower-leg cellulitis had physician-ordered bilateral venous and arterial doppler studies for the lower legs, but the tests were not scheduled and no results were available in the record. The ADON verified the missed scheduling and stated nurses are expected to review written orders and arrange the ordered testing.
A resident with multiple chronic conditions and intact cognition reported tooth pain, gum inflammation, and missing teeth, and an APRN documented a tooth infection and poor tooth condition with an order for amoxicillin and a note that a dental appt would be scheduled. However, staff later could not find evidence of a dental exam after the infection, and the DON verified the resident was not assisted with making the dental visit as recommended.
Infection control was not maintained during wound care and incontinence care for two residents. One resident with a wound did not have EBP implemented, and an ADON handled soiled linens without gloves and left the room without hand hygiene. Another resident with a wound and incontinence needs had EBP signage and PPE available, but a CNA entered without a gown or hand hygiene and completed care using the same pair of gloves throughout.
Surveyors found that the facility did not provide adequate and appropriate eating utensils with resident meal trays. Observations showed meal trays being passed with only a spoon, sometimes plastic, and no additional utensils or napkins, with brown paper towels substituted instead. Dietary staff reported an ongoing shortage of metal silverware, napkins, and sometimes juice cups, and stated that plastic utensils were used for about half of all trays over several months. Several cognitively intact residents on various diets, some needing set-up assistance and others independent with eating, reported frequently receiving only a spoon, receiving plastic utensils for many meals, or occasionally receiving no utensils at all, and these reports were confirmed by concurrent observation of their lunch trays. Facility policy required that meals be served using reusable dishes and flatware, and administration acknowledged residents should receive appropriate silverware for all meals.
Two residents experienced neglect when staff failed to identify, treat, and communicate about worsening wounds, resulting in severe sepsis and amputation. In both cases, staff did not perform or document required skin assessments, failed to notify physicians, and did not follow up on external reports of wounds. Additionally, two other residents were subjected to verbal abuse by staff, with delayed investigation and lack of intervention by other staff members.
The facility did not complete required background checks, Nurse Aide Registry reviews, abuse registry checks, or reference checks for multiple staff members before hiring. Personnel files lacked evidence of these checks, and the background check log was incomplete. The HR Director and Administrator confirmed these omissions, and some staff had disciplinary actions or were involved in incidents without proper pre-employment screening.
The facility failed to provide proper wound care and physician oversight for two residents, resulting in hospitalization and severe outcomes, and did not conduct required background checks for multiple staff members. Investigations into abuse, neglect, and misappropriation were incomplete, and the facility did not maintain a safe environment, with ongoing issues of illicit drug use among residents and no effective policy to address it. These deficiencies demonstrated significant breakdowns in administrative oversight and had the potential to affect all residents.
A glass door used by families and ambulances was found broken with shattered glass for approximately two weeks. The DON and Administrator were aware of the issue, and although repair quotes were obtained, the door remained unrepaired with no documented follow-up, contrary to facility policy requiring prompt resolution of such concerns.
Multiple residents with substance use disorders engaged in ongoing illicit drug and alcohol use within the facility, including use of methamphetamine, cocaine, marijuana, and alcohol. Despite repeated positive drug screens, observed drug paraphernalia, and admissions of use, the facility did not implement specific interventions or update care plans to address illicit substance use. Staff and administrators confirmed that drug access was a common problem and that the facility lacked effective policies and actions to address substance abuse.
A resident with bilateral leg amputations and limited mobility was unable to reach the call light to request assistance, as it was not within reach and the resident could not self-propel the wheelchair. The resident had to call out for help until a CNA responded. Facility policy required call lights to be accessible at all times, but this was not followed in this instance.
A resident with multiple chronic conditions and intact cognition experienced unauthorized charges on their bank account totaling nearly $4,000. The facility identified the fraudulent activity but failed to conduct required interviews with staff or other residents as part of its investigation, resulting in an incomplete response to the misappropriation.
The facility did not complete and report the results of investigations into allegations of physical abuse and misappropriation involving two residents within the required five business days. In both cases, the investigations exceeded the mandated timeframe without documented extenuating circumstances, contrary to facility policy.
The facility did not conduct thorough investigations into allegations of abuse, neglect, and misappropriation involving three residents. In each case, required interviews with staff or key witnesses were not completed, and assessments or documentation were missing or incomplete, despite facility policy requiring comprehensive investigations.
A resident with multiple medical and behavioral health diagnoses was discharged on an emergency basis without proper documentation, including a discharge summary, recapitulation of stay, or a signed physician's order. The discharge was based on unsubstantiated allegations and lacked required signatures and supporting evidence, contrary to facility policy.
A resident with multiple sclerosis and a stage IV pressure ulcer did not receive wound care as ordered when staff failed to replace a dressing that had come off during incontinence care. The missing dressing was not reported or addressed by staff, resulting in the resident being left without the required wound treatment.
A resident with severe cognitive impairment and orders for supervised smoking with a smoking apron was repeatedly observed smoking unsupervised and without the required protective equipment. Facility staff confirmed the resident was to be supervised and that safety protocols, including use of a smoking apron and staff presence, were not followed as outlined in the care plan and facility policy.
A resident with an indwelling Foley catheter did not receive timely or documented catheter care for ten days following hospital readmission. Medical records and progress notes lacked evidence of catheter care, and no physician's orders were in place until ten days after the resident's return. The DON confirmed the absence of orders and documentation, and the resident reported delays in incontinence care.
A resident admitted with fractures and post-surgical pain did not receive prescribed pain assessments or oxycodone for over two days due to failures in medication ordering and staff follow-up. The resident experienced significant pain, and staff interviews confirmed the delay was caused by lack of communication and adherence to the facility's pain management policy.
The facility failed to ensure physician oversight of wound care, resulting in two residents with significant wounds not receiving timely medical assessment or treatment. In both cases, wounds were documented by staff but not reported to a physician, and no wound treatments were initiated. The nurse practitioner involved was not wound certified, and the medical director was not informed of the residents' conditions. Both residents required hospital transfers for severe wound-related complications.
A medication error occurred when an LPN administered another resident's narcotic medication, Tramadol, to a resident who did not have an order for it. The error happened after the LPN mixed up medication cups while attempting to give medications in the hallway, failing to follow facility policy requiring verification of resident identity and proper medication administration.
A resident who required assistance with oral medication administration was found with an antibiotic pill left in a cup at the bedside after being told it was no longer needed. A CNA confirmed that medications should not be left with residents and that nurses are responsible for observing medication administration. Facility policy required timely administration and proper documentation, but these procedures were not followed in this instance.
A resident with chronic wounds and orders for Enhanced Barrier Precautions (EBP) received wound care from an LPN who failed to don a gown as required by facility policy and posted signage. Although gloves were used and PPE was available nearby, the LPN acknowledged not wearing a gown during the high-contact care activity, resulting in a breach of infection control protocols.
Dietary staff were found not wearing required hair restraints in the food preparation area, and several food items in the kitchen cooler were undated and unmarked. The dietary supervisor confirmed these issues, which were not in accordance with facility policies on food safety and sanitation.
The facility did not ensure that required discharge documentation and communication were completed for two residents, resulting in missing information in medical records and failure to relay important details, such as follow-up appointments, to receiving facilities. This occurred during a period of social worker turnover, with discharge planning responsibilities shared among staff.
The facility failed to provide sufficient dietary staff, resulting in delayed meal service for all residents. Observations and interviews revealed that meals were consistently late, with breakfast and lunch not served on time due to staffing shortages. The Dietary Manager acknowledged the issue and attributed it to insufficient staffing, although new hires had not yet started.
The facility's kitchen was found to have multiple sanitation issues, including dirty floors, equipment with food debris, and improperly stored food items. These conditions were confirmed by dietary staff, who cited short staffing as a reason for inadequate cleaning. The facility's policies on food storage and sanitation were not followed, potentially affecting all 53 residents receiving meals.
The facility failed to maintain clean and sanitary bathing and shower rooms for residents. Observations revealed a toilet with feces and no water, dirty floors, missing tiles, a leaking shower, and black substances on the walls. Used gloves and a dirty towel were also found. A housekeeper confirmed these conditions, and facility policies indicated that bathrooms and floors should be cleaned daily.
The facility failed to provide the correct serving size of mechanical soft meat to six residents on a mechanical soft diet. The menu required a #6 scoop for the Salisbury steak, but a #10 scoop was used instead, providing less than the prescribed amount. This error was confirmed by the Dietary Manager.
A resident's dignity was compromised due to wearing sweatpants that were too large, causing them to fall and expose his legs and brief in view of others. Despite being aware of the issue, facility staff did not provide a solution, citing the lack of a guardian or family to provide clothing and an inability to find appropriately fitting pants.
The facility failed to create person-centered care plans for residents with PTSD, specifically for two residents whose care plans lacked identification of specific triggers. Interviews with staff revealed a lack of awareness regarding these triggers, despite the facility's policy on trauma-informed care. This deficiency highlights a gap in staff training and communication regarding the needs of residents with PTSD.
A resident with a history of stroke and contracture was not wearing a prescribed hand splint as ordered, with the last documented application on January 12. Observations and interviews revealed staff were unaware of the splint's status, and it was found unused on the resident's dresser. The facility's policy required nursing staff to supervise the use of adaptive equipment.
Two residents in a LTC facility were found to be at risk due to inadequate supervision and enforcement of smoking policies. One resident, with schizophrenia, was observed smoking without a protective apron, resulting in burn holes in his clothing. Another resident, using oxygen, had smoking paraphernalia in his room, violating the facility's no-smoking policy. The facility's failure to conduct thorough assessments and enforce safety measures led to these deficiencies.
The facility failed to maintain clean and properly labeled respiratory care equipment for two residents. One resident had blood-stained BiPAP head straps that were not replaced, and another had unlabeled oxygen tubing, contrary to facility policy. Staff were unsure of the procedures, highlighting a need for policy review and training.
The facility failed to properly label and store insulin medications for three residents with type two diabetes mellitus. Insulin pens were found opened but not dated, and some lacked resident labels, contrary to facility policy and pharmacy guidelines. A nurse confirmed the oversight during an interview.
A resident with severe malnutrition and dysphagia was served mechanical soft Salisbury steak instead of the prescribed pureed meat. The Dietary Manager confirmed the error, noting that diet orders were being checked but had not yet been updated for this resident.
A resident with morbid obesity and poly osteoarthritis fell and sustained bilateral distal femur fractures while receiving incontinence care due to the facility's failure to provide a king bariatric bed. Despite the presence of three staff members, the resident slid off the queen bed, highlighting the need for a larger bed to prevent such incidents.
The facility failed to consistently monitor and record food temperatures, affecting meal palatability and safety for all residents. Observations showed missing temperature logs, and milk was served above the required temperature. Residents expressed dissatisfaction with the food quality, describing it as cold and institutional grade. The Dietary Director confirmed the inconsistencies, and a resident's daughter brought a refrigerator due to food inconsistency.
The facility failed to adhere to meal plans and resident preferences, affecting multiple residents. A resident with cellulitis did not receive the prescribed mighty shake and other items during lunch. Another resident with multiple sclerosis did not receive preferred yogurt and fruit, and the serving size of French toast sticks was incorrect. A third resident with alcoholic cirrhosis was missing bread and applesauce cake, while a resident with severe malnutrition did not receive a mighty shake or hot water for tea. The facility's policy to provide a diet meeting residents' needs was not followed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for a resident who was admitted with diagnoses including malignant neoplasm of the right bronchus or lung, hypertensive heart disease with heart failure, and chronic pain, and who was receiving hospice services. The resident was moderately cognitively impaired, always incontinent of bowel and bladder, used a wheelchair, and was dependent on staff for toilet hygiene and toilet transfers. Her physician orders directed staff to apply barrier cream to the groin and buttocks with episodes of incontinence for skin prevention, and the care plan identified her as needing assistance with toileting hygiene and personal hygiene. Record review showed the last documented incontinence care occurred the evening before the event, and there was no documented evidence of care for approximately 12 hours. During an observation, the resident was found in her wheelchair with a soiled pad on the bed, dry feces present, and a strong odor of urine and feces in the room. She tearfully stated that no one would change her, that staff ignored her or told her her aide was coming, and that she had been in the same brief for 12 hours. When a CNA later assisted her to bed, the brief was found full of urine and feces, and the resident stated her buttocks were very sore and felt open. At that time, two open wounds were observed on the resident’s left buttocks, described as pink with the first layer of skin removed. The CNA stated he had been assigned to the hall and that this was the first time he checked on her that day, and the LPN confirmed the odor of urine and stated staff should check the resident for incontinence every two hours. The record also showed no comprehensive initial wound assessment was completed when the skin area was found, and a later note documented superficial discoloration and chaffing to the inner bilateral buttocks without wound measurements, drainage information, or a full wound description. Hospice staff and facility leadership also acknowledged concerns about timely incontinence care and that the resident had been found in soiled briefs on prior occasions.
Medication Storage and Tuberculin Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were securely stored when Resident #8, who had diagnoses including Alzheimer's disease, type 2 diabetes, heart failure, high blood pressure, depression, and anxiety, had multiple over-the-counter medication containers and three prescription bottles with several pills in each container sitting on the dresser beside the bed in the resident's room. Review of the resident's self-administration assessment showed the resident required assistance with medication administration and was not approved to self-administer medications. The room door was open during observation, and an LPN verified the medications were present in the room and stated the resident did not take most of the medications observed. The facility also failed to properly label an open vial of Tubersol Tuberculin solution stored in the medication refrigerator. Observation showed the vial was half full, was not in the original package, and had no open date noted. An LPN verified the vial was open, undated, and not in the original package, and stated it should have been kept in the original package and dated when opened. The manufacturer's guideline reviewed stated a vial of Tubersol that has been entered and in use for 30 days should be discarded.
Kitchen sanitation and equipment monitoring failures
Penalty
Summary
The facility did not ensure the kitchen and equipment were maintained in a clean and sanitary condition. During the initial kitchen tour, the ice machine sanitation log had last been completed on 06/16/26, and the temperature logs for the walk-in cooler and freezer had last been recorded on 06/30/26. Surveyors also observed water pooling on the floor next to the right side of the steam table, and Dietary Supervisor #331 stated the water continued to pool even after mopping and believed it came from the floor rather than a drain. A dark substance resembling mold was observed on the backsplash to the left of the three-compartment sink and on the wall behind the dishwasher, and the floor under the dishwasher was visibly dirty with dirt and grime. Dietary Director #303 was unable to check the chemical sanitation level of the low temperature dishwasher because test strips were not available at the time of the observation. On subsequent observations, water was again seen pooled on the floor adjacent to the steam table. Dietary Director #303 later found test strips for the dishwasher, but the Hydrion Chloride test strips were expired. During interview and observation, Corporate Maintenance Director #402 stated an estimate had been obtained to repair the pooled water in the kitchen, but no estimates were provided, and he described the substance behind the dishwasher and on the backsplash as dirt rather than mold. On 07/16/26, residents were observed eating breakfast from Styrofoam to-go containers, and [NAME] #218 stated the chemical sanitation in the three-compartment sink was not sanitizing dishes and would not be repaired until 07/22/26. Dietary Director #303 still had not obtained test strips for the dishwasher at the time of the later interview. Review of facility policy stated the food service area should be maintained in a clean and sanitary manner and that refrigerator and freezer temperatures must be checked and recorded twice daily.
Blocked Exit Door and Fire Safety Equipment
Penalty
Summary
The facility failed to maintain access to the exit door and failed to maintain access to the fire pull station and fire extinguisher in the back hallway where rooms 17 to 22 were located. During observation, two beds were stored end to end along the left side of the hallway against the wall, and a manual wheelchair was positioned at the end of the second bed directly in front of the exit door, fire pull station, and fire extinguisher box. The hallway had approximately two feet of space from the end of the second bed to the exit door, and the fire pull station and fire extinguisher box were not accessible. RN #510 verified that the beds and wheelchair were blocking the exit door, fire pull station, and fire extinguisher box, and stated she would find a way to get residents out in case of evacuation. Later, the Maintenance Director #252 verified the two beds were still blocking the exit door and stated staff know better than to block exit doors with medical equipment.
Unclean Resident Room and Lost Dentures During Room Move
Penalty
Summary
Resident #32’s room was not maintained in a clean and homelike condition. Resident #32 was admitted with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus with diabetic neuropathy, hyperlipidemia, and seizures. The quarterly MDS showed the resident was cognitively intact, used a walker or wheelchair, and required moderate assistance with several activities of daily living. During an interview with the Housekeeping Director, the room was observed to be infested with gnats, with two plastic containers containing food residue sitting on top of the air conditioning unit, wet clothing stuffed under the left side of the unit, and an overflowing garbage bag of dirty laundry on the floor next to the unit. The Housekeeping Director confirmed these observations. Resident #11’s dentures were lost during a room move, and the facility did not ensure reasonable care for the resident’s property. Resident #11 was admitted with diagnoses including COPD, cocaine use, and anxiety, and had moderately impaired cognition with a BIMS score of 13 out of 15. The resident had no natural teeth or dentures at the time of observation and stated that the dentures were lost during the March room move and that the facility was aware of it. The resident had a dentist appointment for denture replacement that required personal payment, which the resident could not afford. The DON verified that the dentures were lost during the room move and that the facility had not assisted with replacement at that time.
Failure to Provide Routine Hydration and Document Meal Intakes
Penalty
Summary
The facility failed to ensure ice water was offered routinely and at the frequency of resident requests for three residents, and it failed to ensure routine meal intakes were documented for one resident. The report states that the facility also did not follow its own hydration policy, which required CNAs to provide fresh ice water to residents each shift. The census was 48, and the deficiency was identified through observation, interview, record review, and policy review. Resident #64 was admitted with diagnoses including type I diabetes mellitus with diabetic neuropathy, chronic kidney disease stage III, protein calorie malnutrition, and hyperlipidemia. The care plan included monitoring for compliance with diet and documenting any problems. Review of the nutrition intake record for May and June 2026 showed multiple dates with no meal intake recorded for breakfast, lunch, and dinner, and the Regional Director of Clinical Operations confirmed that meals were not recorded on those dates. Resident #6 had diagnoses including malignant neoplasm of the right bronchus or lung, hypertensive heart disease with heart failure, and chronic pain, and had a BIMS score of 12 with moderate cognitive impairment. Her care plan included encouraging fluids for constipation risk and for bowel and bladder incontinence, skin impairment, and infection. She reported that staff did not routinely pass fresh water or ice and that she had to request it, and an empty cup was observed in her room. Resident #12, who had a BIMS score of 13 and diagnoses including diabetes, constipation, anxiety, fibromyalgia, bipolar disorder, and gait abnormalities, stated staff did not offer or pass water and that she had to ask for it; she also reported a dietary aide refused to give her water. Resident #30, who had diagnoses including COPD, type 2 diabetes, and depression, had an order to increase oral water intake up to 6 to 8 cups per day. Observation showed a utility room with an empty ice chest and a water cooler inside staff-only space, and a warm half-filled cup of water was found at the bedside; RN and CNA interviews confirmed fresh ice water was not being passed routinely and that residents were expected to come to the nurse's desk to ask for it.
Failure to Document and Address Care Conference Concerns
Penalty
Summary
The facility failed to ensure a resident’s right to a dignified existence and self-determination when concerns raised during a care conference were not documented or appropriately addressed. Resident #6 was admitted with diagnoses including malignant neoplasm of the right bronchus or lung, hypertensive heart disease with heart failure, and chronic pain. Her care plan identified her as having ADL self-performance deficits related to conditioning and weakness, and her MDS showed moderate cognitive impairment, bowel and bladder incontinence, and wheelchair use. The record also showed she was dependent for toileting hygiene and toilet transfers. During observation, Resident #6 was found in her room with a strong odor of urine and feces, and her incontinence pad was soiled with dry feces. She told staff she had not been changed and said she had been in the same brief for 12 hours. When a CNA later assisted her, the brief was full of urine and feces, and she stated her buttocks were very sore and felt open. Two open areas were observed on her left buttocks. The wound nurse stated she did not believe wound care was being completed as ordered and said nurses were documenting treatments as completed when they were not. The hospice RN reported she had requested a care conference because of concerns about timely incontinence care and wound care, and said she had repeatedly found the resident in soiled briefs. The ADON confirmed the care conference occurred and that concerns about timely incontinence care were discussed, along with the resident’s request that a specific CNA no longer provide care. However, the ADON did not document the care conference in the medical record, and the record contained no evidence of the conference or any documented concerns or resolution attempts. The DON stated she had not been made aware of the concerns and had not addressed them.
Resident exposed to verbal abuse by dietary aide
Penalty
Summary
The facility failed to ensure Resident #12 was free from verbal abuse. Resident #12 was admitted with diagnoses including diabetes mellitus type 2, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility. Her quarterly MDS showed a BIMS score of 13, indicating she was cognitively intact. She reported that on 07/12/26 she asked Dietary Aide #325 for a cup of water and was met with profanity and refusal, stating the aide said, "why the [expletive] are you knocking on this door" and "Don't knock [expletive] on this door," and did not give her water. Resident #12 stated she felt the interaction was verbally abusive and reported it to the Dietary Director. The resident’s account was supported by other statements and interviews. The Dietary Director confirmed the resident reported that the dietary aide cursed at her, and the Administrator later stated the incident had just been reported and an investigation would be completed. A witness statement from staff member #319 described the kitchen as understaffed and noted the dietary aide was cursing and slamming things; he also stated he heard her yell racial slurs and expletives, and that he did not see her obtain water for Resident #12. In a follow-up interview, Resident #12 stated she heard the aide say residents should stop asking for "[expletive]" and make racial slurs while saying she was only there to collect unemployment. The facility’s self-reported incident stated the allegation of verbal abuse was unsubstantiated, despite the resident’s report and the witness statements describing the aide’s behavior.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported timely. Resident #12, who was admitted on 02/21/26 and had diagnoses including diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility, had a BIMS score of 13 on the quarterly MDS, indicating cognitive intactness. The resident reported that a Dietary Aide cursed at her and refused to give her water after she asked for a cup of water, and she stated she felt the interaction was verbally abusive. She told the Dietary Director about the incident, but the report was not immediately escalated to the Administrator as required. Interviews and witness statements showed that the Dietary Aide was upset, yelling, and using racial slurs and profanity toward residents while the kitchen was understaffed. A witness stated the aide was cursing and slamming things, and later confirmed hearing her yell racial slurs and profanities at residents and that the behavior was verbally abusive. The witness also verified he did not report the incident even though he believed the aide was verbally abusive. The Administrator stated that all allegations of abuse, including verbal abuse, should be reported right away, and verified that this was not done. The facility policy required all allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property to be reported immediately to the Administrator or designee.
Failure to Assess and Implement Smoking Safety
Penalty
Summary
The facility failed to assess and implement smoking safety for one resident reviewed for smoking safety. Resident #16 was admitted with diagnoses including pleural effusion, COPD, high blood pressure, heart failure, and cellulitis of the lower leg. The admission MDS showed moderately impaired cognition with a BIMS score of 10 out of 15 and wheelchair use for mobility. A smoking safety assessment dated [DATE] identified the resident as a non-smoker, and the care plan did not include smoking interventions until 07/14/26. On 07/13/26, surveyors observed Resident #16 self-propelling in a wheelchair toward the resident smoking area with a lighter and a half-burned cigarette in hand. Later that day, surveyors observed a half-burned cigarette on the floor by the dresser, another half-burned cigarette on the floor under the bed, and a lighter on the floor under the bed in the resident’s room. The updated care plan dated 07/14/26 stated the resident smoked cigarettes and verbalized adherence to the facility smoking policy, including keeping smoking materials secured in the room. An MDS LPN verified the smoking assessment was inaccurate and stated staff had repeatedly asked the resident about smoking safety, but the resident said he was not a smoker.
Missed Dialysis Due to Lack of Transportation
Penalty
Summary
The facility failed to ensure transportation was available for a resident who required dialysis services. Resident #2 was admitted with diagnoses including end stage renal disease, renal dialysis, asthma, depression, and type 2 diabetes, and the quarterly MDS showed moderately impaired cognition with a BIMS score of 11 out of 15, dialysis dependence, and use of a power wheelchair for mobility. The physician order specified transportation to the dialysis center on Monday, Wednesday, and Friday, with return to the facility by the named transportation van. The resident missed dialysis on Monday, Wednesday, and Friday during the week of 05/18/26 because the transportation company had no driver and no transportation was available. The medical record contained no pre/post dialysis assessments for those days and no documented evidence of reasonable efforts to ensure the resident received dialysis services. The resident stated that during May 2026 he missed dialysis treatments because insurance transportation did not come, and the dialysis center called the facility about the missed week of treatments. The DON verified the resident did not receive dialysis during that week due to no transportation being available.
Delayed Reordering of Antianxiety Medication
Penalty
Summary
The facility failed to ensure timely reordering of a resident’s antianxiety medication, Alprazolam (Xanax) 0.25 mg by mouth three times daily for panic disorder. The resident was admitted with diagnoses including panic disorder, psychoactive substance use, major depressive disorder, chronic pain, and insomnia, and had a BIMS score of 15 indicating intact cognition. Her care plan addressed altered mood related to depression, panic disorder, and anxiety and directed staff to administer medications as ordered and monitor for side effects and effectiveness. Progress notes and the MAR showed repeated gaps in the resident’s Xanax administration because the medication was pending from the pharmacy, not available, awaiting a new script, and later awaiting arrival from the pharmacy. The resident missed nine scheduled doses in July 2026. During observation, she was tearful and reported she had gone two days without her scheduled Xanax and was experiencing a lot of anxiety, stating the facility did not stay on top of ordering her medication and that this was a frequent occurrence. Staff interviews confirmed the prescription had run out of refills, the facility did not attempt to obtain a new prescription until after the medication was already unavailable, and although the medication was available in the contingency box, it was not pulled for administration.
Failure to Schedule Ordered Diagnostic Testing
Penalty
Summary
The facility failed to schedule ordered diagnostic tests for one resident reviewed for diagnostic testing. Resident #16 was admitted with diagnoses including pleural effusion, COPD, high blood pressure, heart failure, and cellulitis of the lower leg, and the admission MDS indicated moderately impaired cognition. Physician orders dated 07/01/26 included bilateral venous doppler and bilateral arterial doppler studies for the lower legs, but the resident’s record contained no results from those ordered tests. During interview on 07/16/26 at 10:53 A.M., the ADON verified that the bilateral venous doppler and bilateral arterial doppler had not been scheduled by the facility and stated that nurses are expected to review written physician orders and schedule the ordered testing.
Failure to Arrange Dental Follow-Up After Tooth Infection
Penalty
Summary
The facility failed to ensure a resident was scheduled for a dental appointment after she reported tooth pain and was found to have a tooth infection. The resident was admitted with diagnoses including diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility. Her quarterly MDS showed a BIMS score of 13, indicating she was cognitively intact. Her care plan did not include a related dental or teeth care plan, and her treatment history showed her last dental exam was on 03/06/25. On 04/24/26, an APRN documented that the resident was being seen for a toothache and gum inflammation, with the resident reporting the pain had worsened over several days and that Tylenol was not enough. The APRN noted visible gum inflammation and a tooth in poor condition, ordered amoxicillin for a tooth infection, and stated a dental appointment would be scheduled. Later observation showed missing bottom front teeth, and the resident reported she had told staff she needed to see a dentist because of discomfort and missing teeth, but she had not yet been seen. Social Services and the DON verified there was no evidence that a dental exam occurred after the infection and that the resident was not assisted with making a dental visit as recommended.
Infection Control Not Maintained During Wound Care and Incontinence Care
Penalty
Summary
Infection prevention and control was not maintained during wound care and transport of soiled linens for Resident #16. The resident was admitted with diagnoses including cellulitis of the lower leg, pleural effusion, high blood pressure, and heart failure, and had a physician order for daily wound care to the right foot. During observation, the resident’s room did not have Enhanced Barrier Precautions signage or PPE available, and staff confirmed that EBP had not been implemented for the resident’s wounds. Later, the ADON completed wound care, removed her gloves and sanitized her hands, then picked up soiled bed linens from the floor without gloves, carried them to the dirty utility room, placed them in the soiled laundry cart, and left the room without sanitizing or washing her hands. Infection control was also not maintained during incontinence care for Resident #6. The resident had diagnoses including malignant neoplasm of the right bronchus or lung, hypertensive heart disease with heart failure, chronic pain, and a leg wound, and had an order for EBP due to a wound with care planned every shift. The care plan directed staff to use gowns and gloves for high-contact care, and a sign and PPE cart were posted outside the room. During observation, the resident was found in a wheelchair with a soiled incontinence pad on the bed, dry feces present, and a strong odor of urine and feces in the room. A CNA entered the room, did not don a gown or wash his hands, applied gloves, assisted the resident onto the bed, and completed incontinence care using the same pair of gloves throughout before removing them and washing his hands at the end.
Failure to Provide Adequate and Appropriate Eating Utensils for Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate eating utensils and special eating equipment to residents during meals, as required by facility policy. Surveyor observations on the morning of 01/22/26 showed CNAs passing breakfast trays that contained only a metal spoon, with no additional silverware or utensils present or offered. Later that morning, a dietary aide was observed transporting 15–20 meal trays on an open cart, each tray containing only a plastic spoon placed on a folded brown paper towel next to the covered plate. Interviews with dietary staff revealed there was an ongoing shortage of metal silverware, resulting in plastic utensils being used for at least half of the residents’ trays for each meal. Staff also reported the kitchen had been out of napkins since 01/20/26 and was using folded brown paper towels from a hand towel dispenser instead, and that the facility sometimes ran out of juice cups. One dietary aide stated there had been a shortage of silverware and utensils for at least six months. Review of the facility’s policy titled "Use of Disposable Dishes/Flatware" indicated that resident meals were to be served using reusable dishes and flatware. Multiple residents with varying diagnoses and functional statuses reported and demonstrated that they frequently did not receive appropriate utensils with their meals. Cognitively intact residents on regular, mechanical soft, carbohydrate-controlled, or no concentrated sweets diets, some requiring set-up assistance and others independent with eating, stated they often received only a spoon, sometimes plastic utensils, and at times no utensils at all. Examples included residents reporting receiving only a spoon to eat meat or salad, receiving plastic utensils for about half of their meals, and occasionally having to eat with their fingers. During each of these interviews at lunchtime on 01/22/26, observations confirmed that the residents’ trays contained only a metal spoon. The administrator later confirmed that residents should receive appropriate silverware for all meals, consistent with facility policy. This deficiency represents non-compliance investigated under Complaint Number 2693876.
Failure to Prevent Neglect and Abuse Due to Inadequate Skin Management and Staff Conduct
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized skin management program, resulting in neglect of two residents with significant medical needs. One resident, who was severely cognitively impaired and dependent on staff for care, developed a worsening wound on the left lateral foot. Despite care plan interventions for skin breakdown prevention, weekly wound reports documented the wound's decline without evidence of physician notification or wound treatments being implemented. The wound nurse only worked one day per week, did not notify the physician, and did not add treatment orders to the treatment administration record. The resident's wound deteriorated to the point of severe sepsis, requiring hospital transfer and resulting in the resident not returning to the facility. Another resident, with end stage renal disease, diabetes, and a history of amputation, developed a right heel ulcer that was first identified by the dialysis center. The dialysis center attempted to communicate the finding to the facility multiple times without success. Facility staff continued to document no new skin issues in weekly assessments, and the physician was not made aware of the ulcer. The ulcer progressed to wet gangrene and necrotizing infection, ultimately requiring an above-the-knee amputation after hospital transfer. Interviews revealed that nursing staff were unaware of the wound, had not performed or documented required skin assessments, and failed to communicate changes in the resident's condition. Additionally, the facility failed to protect two other residents from verbal abuse by staff. In one case, a CNA was verbally aggressive and threatened a resident during an argument, as corroborated by multiple witness statements. The facility's investigation into the incident was delayed, and staff failed to intervene appropriately during the altercation. These deficiencies affected four residents and were substantiated through medical record review, interviews, and facility policy review.
Removal Plan
- Resident #46 was transferred to the hospital and did not return to the facility.
- Resident #20 was transferred to the hospital for emergent treatment. The resident returned to the facility. Upon return, Resident #20 was re-assessed for pressure injury risk with a Braden scale, a skin assessment was completed, pressure reducing device were ordered and implemented and weekly skin assessments and wound care chart audits were implemented.
- The Director of Nursing (DON) and Assistant Director of Nursing (ADON) #504 completed assessments on all residents.
- Regional Nurse #566 educated the DON and ADON #504 on wound identification, staging and dressing changes.
- The facility initiated a plan for the DON/designee to audit 100% of skin assessments, weekly wound reports, and dialysis communication logs for eight weeks. Inaccurate findings would be reported to the facility Quality Assessment and Performance Improvement (QAPI) committee. Audits would be reviewed in monthly QAPI meetings to assess processes and performance of staff through proper identification and compliance.
- Regional Nurse #566, the DON and ADON #504 initiated education for all nurses on accurate wound documentation, wound documentation process and wound rounding expectations.
- ADON #504 contacted the dialysis center to verify processes for return communication for residents with wounds or new orders.
- The facility implemented a Monthly Dialysis Foot Check form. This form would be sent to the Dialysis Center monthly by the DON/designee for communication when they do monthly skin checks.
- Regional Nurse #566, the DON and ADON #504 completed additional education and competencies for all licensed nurses related to wound identification and staging.
- The DON and ADON #504 completed in-service education for Certified Nursing Assistant (CNA) staff on early reporting of skin changes.
- All full time and part time licensed nurses were evaluated for competencies and completed return demonstrations for wound assessment and documentation (for a simulated wound). Competencies were completed by the DON and ADON #504. Licensed staff off or who worked as needed (PRN) would have competencies evaluated before their next shift on the floor.
- The DON revised the facility Resident Return admission Checklist to include wound verification and order reconciliation for all returning residents. Education on the new form was provided to licensed nurses by the DON and ADON #504. The checklist would also be reviewed by the DON or ADON #504 upon admission. These would be monitored during any new admission or readmissions to facility. New staff would also be educated by the nurse training them on this form.
- The DON and ADON #504 provided education for all nursing and CNA staff on proper wound care and to alert nurse if a resident dressing had come off or needed replaced.
- The facility implemented staff training on the facility Abuse, Neglect & Misappropriation policy.
- The Administrator sent a message out to all staff on the definition of neglect. Receptionist #808 was calling each staff person to educate, offer time for questions and express understanding.
- The facility implemented a plan to randomly ask three staff members per week for four weeks about the definition of neglect.
- A root cause analysis was conducted related to the incidents of neglect. The facility identified the root cause of neglect for Resident #46 and Resident #20 was the facility's failure to provide ordered wound care and monitor wound status. There were no systems to verify treatment completion, escalate concerns, or ensure nursing accountability.
- The facility implemented a plan for the Administrator or designee to complete audits for three residents three times per week for four weeks then monthly for two months to identify potential areas of neglect to include showers, medication administration and wound care.
Failure to Complete Pre-Employment Background and Registry Checks for Staff
Penalty
Summary
The facility failed to conduct required background checks, Nurse Aide Registry (NAR) reviews, abuse registry checks, and reference checks for multiple employees prior to hire. Personnel files for several staff members, including CNAs, LPNs, and an activities assistant, lacked evidence of these checks. In some cases, the background check log did not include the employees, indicating that no background check was completed. The facility also failed to maintain a complete and accurate background check log, with some logs missing information for staff hired prior to certain years. Interviews with the Human Resources (HR) Director confirmed that reference checks were not completed prior to hire, and that the facility's practice was to proceed with hiring after two unsuccessful attempts to contact references. The HR Director also confirmed that there was no evidence of NAR or abuse registry checks for several employees. In one instance, a background check found in a personnel file did not belong to the employee in question. The HR Director stated that missing documentation was due to previous HR management and changes in facility ownership, resulting in lost files and incomplete records. The Administrator and Regional Director of Operations (RDO) demonstrated a lack of understanding regarding the difference between the abuse registry and the NAR, with the Administrator stating she thought they were the same. The RDO confirmed that, in the past, reference checks were considered complete after two documented attempts, regardless of whether references were actually obtained. Several employees had disciplinary actions or were involved in self-reported incidents, but there was no evidence that required pre-employment checks were completed for them. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Breakdown in Administrative Oversight, Wound Care, Staff Vetting, and Resident Safety
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to protect resident safety and prevent neglect. Specifically, there were significant lapses in wound care and physician oversight for two residents, resulting in one resident being hospitalized with severe sepsis due to a worsening foot wound and another resident requiring hospitalization and an above-the-knee amputation after a diabetic ulcer was not identified or treated. The facility lacked a systematic and comprehensive skin management program, which contributed to these incidents of neglect and actual harm. Additionally, the facility did not conduct required pre-employment criminal background checks, Nurse Aide Registry (NAR) checks, abuse registry checks, or personal and professional background checks for multiple staff members, including CNAs, LPNs, and other personnel. The Human Resources Director confirmed the absence of these checks and the lack of an accurate background check log. One CNA, who had been involved in multiple self-reported incidents (SRIs) for abuse allegations and had several disciplinary actions, was among those for whom no background checks were completed. These failures in staff vetting increased the risk to all residents. The facility also failed to thoroughly investigate allegations of abuse, neglect, and misappropriation. In several cases, investigations were incomplete, with missing staff interviews, lack of resident assessments, and conflicting or uncollected witness statements. Furthermore, the facility did not maintain a safe environment, as evidenced by multiple incidents of illicit drug use and possession among residents, with staff and contracted behavioral health specialists reporting ongoing substance abuse issues that were not addressed by administration. The facility lacked a policy for handling confirmed illicit substance use among residents, and there was no evidence that these or other concerns were addressed through the facility's quality assurance or QAPI program.
Failure to Repair Broken Glass Door in Timely Manner
Penalty
Summary
A glass door leading outside from the nursing unit was observed to be broken, with shattered glass covering the bottom half of the door. The DON confirmed the door had been in this condition for approximately two weeks. The Administrator stated that the door was used by families and ambulances, acknowledged awareness of the issue, and indicated that although quotes for repair had been obtained, the door had not yet been fixed. Review of a work request form showed a request to repair the broken glass was made, and calls for repair quotes were documented, but there was no follow-up information available. Facility policy requires that concerns be reported and addressed promptly to maintain a safe, clean, and comfortable environment, but this was not followed in this instance.
Failure to Provide Safe Environment and Effective Substance Abuse Program
Penalty
Summary
The facility failed to provide a safe environment free from drugs and alcohol and did not have an effective substance abuse program, as evidenced by multiple residents engaging in ongoing illicit drug and alcohol use while residing in the facility. Several residents with histories of substance use disorders, including opioid dependence, cocaine abuse, and alcohol abuse, were repeatedly found to be using illicit substances such as methamphetamine, cocaine, marijuana, and alcohol. Despite positive drug screens, observed drug paraphernalia, and admissions of ongoing use, the facility did not implement specific interventions to prevent or reduce illicit drug use, nor did it update care plans to address these issues. Staff interviews confirmed that drug access was a common problem and that the facility was not taking adequate action to address it. In one case, a resident with a history of opioid dependence and major depressive disorder tested positive for multiple illicit substances on several occasions, including methamphetamine, cocaine, and marijuana, without corresponding prescriptions. The resident's care plan lacked interventions specific to illicit drug use, and staff reported finding drug paraphernalia in the resident's room. The facility's behavioral health specialists stated that their recommendations for interventions were not implemented, and the administrator confirmed there was no policy addressing confirmed illicit substance use among residents. The facility's only response to suspected drug use was to notify the physician, as per their outdated policy. Other residents were also involved in incidents of drug use and related behaviors. Two residents sharing a room were found with an unknown visitor in possession of drugs, and one was observed performing sexual acts in exchange for substances. The facility failed to follow its own abuse and exploitation policies in response to this incident. Another resident with a history of alcohol and cocaine abuse was repeatedly found intoxicated, involved in altercations, and observed using marijuana in the facility, with no documented follow-up or interventions by staff. Interviews with staff and administrators confirmed a lack of cohesive care and policy regarding substance abuse, and that the facility had not taken effective steps to address the ongoing drug problem.
Failure to Ensure Call Light Accessibility for Non-Ambulatory Resident
Penalty
Summary
A deficiency was identified when a resident with significant mobility impairments, including bilateral leg amputations and use of a manual wheelchair, was found unable to access their call light. The resident, who was cognitively intact and required varying levels of assistance for activities of daily living, expressed a desire to lie down but could not reach the call light to request help. Observation confirmed that the call light was not within reach, and the resident was unable to self-propel the wheelchair due to the placement of the wheels and his physical limitations. During the incident, the resident resorted to yelling for staff assistance, at which point a CNA entered the room to provide help. The CNA confirmed that the resident could not independently move the wheelchair and that the call light was not accessible at the time. Facility policy required that call lights remain within reach of residents at all times, and alternative call systems should be provided if traditional call lights were not usable. This failure to ensure call light accessibility was found during a complaint investigation and affected one of several residents identified as unable to self-ambulate.
Failure to Protect Resident from Misappropriation of Funds
Penalty
Summary
A resident with diagnoses including heart failure, hypertension, diabetes, and depression, and with intact cognition, experienced unauthorized charges totaling $3,941.66 on their bank account. The charges were discovered by the Business Office Manager (BOM) after the resident was unable to access funds at a store. The BOM reviewed the resident's bank statements and identified multiple unapproved transactions related to DoorDash and Lyft, which the resident did not make. The BOM reported the incident to the police, cancelled the resident's debit card, and contacted the bank, which was able to reverse only three months of the fraudulent charges, although the activity had been ongoing for approximately six months. The facility's investigation into the misappropriation was incomplete, as there were no interviews conducted with staff or other residents who may have been involved or had knowledge of the incident. The Administrator confirmed that neither staff nor residents were interviewed regarding the missing funds and stated that the case was referred to the Attorney General's office. The facility ultimately unsubstantiated the self-reported incident, citing a lack of evidence identifying who took the resident's money, despite the facility's policy requiring interviews with the resident, the accused, and all witnesses during such investigations.
Failure to Timely Complete and Report Abuse and Misappropriation Investigations
Penalty
Summary
The facility failed to complete and report the results of investigations into allegations of abuse and misappropriation to the State agency within the required five business days. In one instance, a cognitively intact resident with diagnoses including depression, alcohol abuse, and kidney failure was involved in a physical altercation with another resident, resulting in an investigation that was completed in six business days. In another case, a cognitively intact resident with chronic medical conditions such as COPD, diabetes, and malnutrition reported missing personal items, including a wallet, ID, debit card, and cash. The investigation into this misappropriation allegation was completed in eight business days. The Administrator confirmed that neither investigation was completed and reported within the mandated timeframe, and there was no documentation of extenuating circumstances to justify the delays. Facility policy requires that such investigations be completed within five days unless special circumstances are present, but no such circumstances were identified or documented for these cases. This deficiency was identified during a complaint investigation and affected two of four residents reviewed for self-reported incidents.
Failure to Conduct Thorough Investigations of Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation involving three residents. In one case, a resident with depression, anxiety, cognitive communication deficit, and dementia reported $353 missing. The facility's investigation included interviews with other residents but did not include any staff interviews, contrary to facility policy. The administrator confirmed that staff were not interviewed and acknowledged the investigation was not thorough. In another instance, a cognitively intact resident involved in an altercation with another resident was not assessed, and vital signs were not obtained. The investigation contained conflicting witness statements, and a key witness, the therapist who initially reported the incident, was not interviewed. In a third case, a resident reported missing personal items, including a wallet and $500. The investigation did not confirm if all staff were interviewed due to uncertainty about when the items went missing, and there was no personal inventory to verify ownership of the wallet. The administrator confirmed the investigation was incomplete. Facility policy required interviews with all relevant parties, but this was not consistently followed.
Failure to Document and Complete Appropriate Resident Discharge
Penalty
Summary
The facility failed to provide evidence of an appropriate discharge for a resident, including the completion of a discharge summary or recapitulation of stay, and did not document the details of the discharge in the medical record. The resident, who had multiple diagnoses such as osteomyelitis of vertebrae, asthma, substance abuse, anxiety, bipolar disorder, hypertension, depression, and muscle weakness, was cognitively intact at the time of discharge. The discharge was executed with less than 30 days' notice, citing an emergency due to alleged endangerment of safety in the facility. The discharge location was a local hotel, and the discharge notice was not signed by the resident or facility staff. Review of the facility's investigation revealed a lack of written statements from residents or staff, with the only evidence being hearsay reported by the Administrator. The resident denied the allegations of illicit drug distribution. There was no documentation in the medical record regarding the need for immediate discharge, no discharge summary, and no signed physician's order for the discharge. A verbal order was claimed to have been received but was not signed by the medical director. The facility's policy required a discharge order and a summary of information to ensure continuity of care, but these steps were not followed in this case.
Failure to Complete Ordered Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when staff failed to ensure that pressure ulcer treatments were completed as ordered for a resident with multiple sclerosis and a stage IV pressure ulcer of the penis. The physician's order required nightly cleansing, application of Skin Prep and collagen filler, and covering the wound with an ABD pad. Record review showed the treatment was performed on one date, but during observation the following morning, the wound dressing was not in place. The resident reported that the dressing had come off during incontinence care the previous night and had not been replaced. An LPN confirmed that there was no dressing in place at the time of observation. Further review and interviews revealed that staff did not notice or report the missing dressing during incontinence care, despite the dressing being found in the resident's brief. The facility's policy required consistent treatment protocols for pressure injuries to aid healing, but this protocol was not followed. The deficiency was identified during a complaint investigation and affected one of three residents reviewed for pressure ulcers.
Failure to Provide Required Supervision and Safety Equipment During Resident Smoking
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of schizophrenia, muscle weakness, and hypertension was not provided with adequate supervision while smoking, as required by physician orders and the care plan. The resident had orders for supervised smoking with a smoking apron due to an increased risk of injury, including dropping ashes on themselves and being unable to safely light or extinguish tobacco products. Despite these orders and care plan interventions, observations revealed the resident was left unsupervised in the designated smoking area on multiple occasions and was not wearing the required smoking apron. Additionally, the resident was seen picking up and smoking a discarded cigarette from another resident, further demonstrating a lack of supervision and adherence to safety protocols. Interviews with facility staff, including the Administrator, DON, and ADON, confirmed that the resident was supposed to be a supervised smoker and that the smoking apron was not being used as intended. The facility's smoking policy required staff or volunteer supervision during designated smoking times and that all smoking materials be kept in a secure area for supervised smokers. However, these procedures were not followed, resulting in unsupervised smoking and the absence of required protective equipment for the resident.
Failure to Provide Timely Foley Catheter Care and Documentation
Penalty
Summary
The facility failed to provide timely and documented Foley catheter care for a resident who returned from the hospital with an indwelling catheter. Medical record review showed that after the resident's return, there was no evidence of catheter care being provided or documented for a period of ten days. Progress notes repeatedly indicated the catheter was intact, but did not mention any catheter care. The treatment administration records and physician's orders also lacked any orders or documentation for Foley catheter care during this period. Catheter care orders were not initiated until ten days after the resident's return, despite the resident's care plan identifying risks associated with the indwelling catheter, such as infection and skin decline, but not specifying interventions for catheter care. Interviews with the DON confirmed the absence of catheter care orders and documentation during this time. The resident reported that incontinence care was not provided in a timely manner. The deficiency was identified during a review of activities of daily living for three residents, with this resident being affected. The facility census at the time was 45.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident admitted with multiple medical conditions, including spondylolisthesis, lumbar region, and compression fractures. Upon admission, the resident had physician orders for pain assessment every shift and for 10 mg oxycodone to be administered every four hours as needed for pain. However, the resident did not receive a pain assessment or the prescribed pain medication for approximately two and a half days after admission. The medication was not available in the facility until 7:28 P.M. on the third day, and the first dose was administered at 7:44 P.M. the same day. Documentation confirmed that the resident experienced significant pain during this period, with a pain rating of six out of ten, and reported being unable to get out of bed due to pain following surgery and internal stitches. Interviews with facility staff, including the DON and ADON, revealed that the delay in pain management was due to failures in ordering and following up on the resident's pain medication. Staff did not complete the required pain assessments, and there was a lack of communication and accountability regarding the ordering and administration of the prescribed oxycodone. The facility's own pain management policy, which required assessment and collaboration with the physician to manage pain, was not implemented in this case. The resident reported that staff blamed each other for the delay, and the facility's investigation confirmed the medication was not ordered or available as required.
Failure to Ensure Physician Oversight of Wound Care
Penalty
Summary
The facility failed to ensure that wound care for residents was overseen by a physician, resulting in a lack of appropriate medical oversight and treatment for residents with significant wounds. In one case, a resident with multiple comorbidities, including diabetes and cognitive impairment, developed a worsening wound on the left foot. Despite weekly wound reports documenting the decline of the wound, there was no evidence that a physician was notified or that wound treatments were initiated. The wound nurse only measured the wound and did not assess it or communicate with the physician, and the nurse practitioner involved was not wound certified. The resident was eventually transferred to the hospital with severe sepsis due to the untreated wound, and the hospital expressed concerns about the extent of the wounds. Another resident with end stage renal disease, diabetes, and a history of amputation developed an ulcer on the right heel, which was identified by the dialysis center but not documented or reported by facility staff in weekly skin assessments. The dialysis center attempted to notify the facility about the ulcer, but there was no evidence of follow-up or physician notification. The resident's condition deteriorated, and upon eventual hospital transfer, was found to have a necrotizing soft tissue infection requiring emergency above-the-knee amputation. The physician confirmed he was not made aware of the wound until after the resident was hospitalized. Interviews with facility staff and review of facility policy revealed that there was no physician oversight of wound care, and the nurse practitioner providing wound care was not wound certified nor supervised by a wound certified provider. The medical director was not informed of the residents' wounds and did not oversee wound care. Facility leadership confirmed they were unaware that wound care was not being overseen by a physician, contrary to facility policy requiring the medical director to oversee the medical care of all residents.
Medication Error Due to Improper Administration Practices
Penalty
Summary
A medication error occurred when a Licensed Practical Nurse (LPN) administered the wrong medication to a resident with diagnoses including schizophrenia, hypertension, and a history of falls. The LPN had two different residents' medications in cups at the top of the medication cart. While attempting to administer medication in the hallway, the LPN knocked over the cups, replaced the medications, and then gave the resident the medications. After administration, the LPN realized that the resident had received another resident's narcotic medication, Tramadol, which was not ordered for him. Review of the resident's medical record confirmed there was no physician's order for Tramadol for this resident. The facility's policy required staff to verify resident identity and administer medications according to orders, which was not followed in this instance. The Director of Nursing confirmed the medication error and stated that staff are not permitted to pre-pour multiple residents' medications at one time.
Improper Medication Storage at Bedside
Penalty
Summary
A deficiency occurred when a medication was found improperly stored at a resident's bedside. The resident, who had a history of a left foot fracture, difficulty walking, and muscle weakness, was assessed as cognitively intact but required assistance with oral medication administration. During an observation, a clear plastic cup containing a white pill, identified as an antibiotic, was found at the resident's bedside. The resident confirmed that he had been told he no longer needed the medication and therefore did not take it. A certified nurse aide confirmed the presence of the pill and acknowledged that nurses were responsible for observing residents taking their medications and that medications should not be left with residents. Facility policy required medications to be administered within one hour of the prescribed time and documented as refused if not taken, with self-administration only permitted if the resident was deemed capable by the physician and care team. The incident was identified during a complaint investigation and involved a failure to ensure medications were properly stored and administered according to policy.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control practices during wound care for a resident with chronic venous ulcers and other medical conditions, including congestive heart failure and diabetes mellitus. The resident had a physician's order and care plan in place for Enhanced Barrier Precautions (EBP) due to open wounds, which required the use of gowns and gloves during high-contact care activities such as wound care. Signage outside the resident's room indicated the need for EBP, and personal protective equipment (PPE) was available in a cart down the hall. During an observation of wound care, the LPN cleansed her hands and donned gloves but did not put on a gown as required by the EBP protocol. When questioned, the LPN confirmed that the resident was on EBP and acknowledged that she had not donned a gown prior to providing wound care. Review of the facility's policy confirmed that EBP, including the use of gowns, was indicated for residents with wounds. This failure to adhere to established infection control procedures constituted a deficiency as documented in the report.
Failure to Label Food and Use Hair Restraints in Kitchen
Penalty
Summary
Surveyors observed that dietary staff in the kitchen failed to wear required hair restraints while in the food preparation area, as both a cook and a dietary aide were not wearing hair coverings at the time of inspection. Additionally, a review of the kitchen cooler revealed multiple food items, including a pan of hamburgers in broth, a bucket of meatballs, and a pan of hamloaf, that were undated and unmarked. The dietary supervisor confirmed these observations. Facility policies reviewed indicated that proper labeling and dating of food, as well as the use of hair restraints, are required for food safety and sanitation.
Failure to Document and Communicate Required Discharge Information
Penalty
Summary
The facility failed to ensure that resident medical records contained all required discharge information and that appropriate information was communicated to the receiving facility for two residents reviewed for discharge planning. For one resident with diagnoses including aftercare following major joint replacement, dementia, and osteoarthritis, the medical record lacked documentation indicating the resident was being discharged or specifying the receiving facility. Additionally, a scheduled follow-up medical appointment was not communicated to the receiving facility, resulting in a missed appointment. The discharge summary only generically referenced transfer to another nursing home, and the resident signed the summary without clear documentation of the discharge plan. For another resident with chronic obstructive pulmonary disorder, sleep apnea, and diabetes, the medical record similarly lacked documentation regarding the discharge or the destination facility. The discharge summary again only referenced transfer to an unnamed nursing home. Interviews with the Administrator and DON revealed that during a period of social worker turnover, discharge planning responsibilities were shared among staff, leading to gaps in documentation and communication. The facility's discharge policy required providing an appropriate summary of information at discharge, which was not met in these cases.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to ensure sufficient dietary staff for timely meal service, affecting all residents who received meals from the kitchen. Observations during the initial tour of the kitchen revealed that breakfast trays were being plated late, with only three staff members present. Interviews with dietary staff confirmed that the kitchen was short-staffed, leading to delays in meal service. Residents reported that meals were consistently late, with one resident specifically noting that breakfast had not been received by 10:35 A.M., despite being scheduled for 8:00 A.M. Further observations showed that by 12:58 P.M., no meal carts were present in the nursing unit and dining areas, indicating that lunch had not been served on time. A CNA confirmed that lunch had not been delivered yet. The Dietary Manager acknowledged receiving complaints about late meals and attributed the issue to insufficient staffing. Although new staff had been hired, they had not yet started working, leaving the facility unable to meet the scheduled meal times.
Sanitation Deficiencies in Kitchen Affecting Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 53 residents receiving meals. During an initial tour of the kitchen, several sanitation concerns were observed. The floor of the small storage room was dirty with dirt stains and debris under the storage racks. The stove had a heavy build-up of stains and food debris, and the prep table across from the stove had moderate food debris and stains. The robotcoup, a blender used to mechanically alter food, had various dried food debris and stains. Additionally, a fan next to the robotcoup had a moderate amount of dust on the blades and cover. The floor where the steamer and plate warmer were located had dirt stains, crumbs, and debris, and the small silver counter/stand the mixer sat on had food crumbs and stains. Further observations revealed that Walk-in cooler #1 had debris, a cracked egg with dried yolk, an old onion, and debris under the racks. Unlabeled and undated food items were found in the cooler. Both walk-in freezers had food crumbs and debris on the floor. The dry storage area had over 15 boxes of food items stored directly on the floor. The ice machine had dried, sticky stains on top, and there were dirty towels on the three-compartment sink. A cart next to the steam table had plates and insulated bottoms with crumbs and stains. The dish machine area had dirt stains, debris, and standing water under the machine. Dietary staff confirmed these findings and attributed them to short staffing, which hindered proper cleaning. The facility's policies on food storage and sanitation were not adhered to, as evidenced by the conditions observed.
Deficiency in Maintaining Clean Bathing and Shower Rooms
Penalty
Summary
The facility failed to maintain clean and sanitary bathing and shower rooms for residents, excluding 20 residents identified as not using these facilities. During an observation, the toilet in the bathing room was found to have no water and contained feces, with no signage indicating it was out of use. The floor was dirty with dirt buildup around the edges. In the shower room, missing tiles, a leaking shower, and a black substance on the wall were noted, along with black/brown grout. Used gloves, a dirty towel on an old chair, and gritty dirt buildup were also observed. A housekeeper confirmed these conditions, and a review of facility policies revealed that bathrooms and floors should be cleaned daily and maintained in a clean, safe, and sanitary manner.
Incorrect Serving Size for Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure the correct serving size of mechanical soft meat was provided to six residents who were on a mechanical soft diet. The menu for the lunch meal on January 22, 2025, included Salisbury steak, mashed potatoes, and lima beans. According to the menu/diet spreadsheet, the mechanical soft diet required a #6 scoop, which provides 5.33 ounces of ground Salisbury steak. However, during the lunch tray line service, the dietary staff used a #10 scoop, which only provided 3.20 ounces. This discrepancy was confirmed by the Dietary Manager, who verified that the incorrect scoop was used, affecting six residents who had physician orders for a mechanical soft diet.
Resident's Dignity Compromised by Ill-Fitting Clothing
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #5, had properly sized clothing, which compromised his right to dignity. Resident #5, who was cognitively intact but experienced hallucinations and delusions, was observed multiple times with sweatpants that were too large, causing them to fall to his ankles and expose his legs and disposable brief. This occurred in various locations, including his room, the hallway, and the outside smoking area, where other residents and staff could see him. Despite being aware of the issue, the facility staff, including CNAs and the Assistant Director of Nursing, acknowledged the problem but did not provide a solution, citing the lack of a guardian or family to provide clothing and an inability to find appropriately fitting pants. The facility's policy on Resident Rights, revised in December 2016, states that residents have the right to a dignified existence. However, the facility did not uphold this policy for Resident #5, as evidenced by the repeated observations of his ill-fitting clothing and the staff's failure to address the issue adequately. Interviews with staff confirmed the ongoing problem, yet no effective action was taken to ensure Resident #5 had clothing that maintained his dignity.
Failure to Develop Person-Centered Care Plans for PTSD Residents
Penalty
Summary
The facility failed to develop person-centered care plans for residents with Post Traumatic Stress Disorder (PTSD), specifically for Resident #10 and Resident #29. Both residents had pertinent diagnoses including PTSD, and their care plans lacked identification of specific triggers that could lead to re-traumatization. Resident #29's care plan mentioned a history of trauma but did not list any specific triggers, despite the resident's admission that large crowds caused anxiety. Similarly, Resident #10's care plan did not address PTSD or identify triggers, even though the resident reported that big groups of people and aggressive communication were triggers. Interviews with facility staff, including a Certified Nursing Assistant, a Registered Nurse, an Activity Aide, and the Social Services Director, revealed a lack of awareness regarding the specific PTSD triggers for Residents #10 and #29. The staff were either unaware of the residents' triggers or did not believe they had the ability to inquire about them. This lack of knowledge and communication among staff members contributed to the deficiency in providing appropriate care for residents with PTSD. The facility's policy on Trauma Informed Care, which was revised in March 2019, stated that nursing staff would be trained on trauma assessment and identifying triggers. However, the deficiency indicates that this training was not effectively implemented, as evidenced by the staff's lack of awareness and the absence of specific triggers in the care plans for the affected residents. The facility's failure to adhere to its own policy and adequately address the needs of residents with PTSD led to the identified deficiency.
Failure to Ensure Resident Wore Hand Splint as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #21, wore a hand splint according to the physician's order. Resident #21, who has a history of chronic pain, hemiplegia, hemiparesis following a stroke, and anxiety disorder, was prescribed a left resting hand splint to be worn in the morning and removed in the evening. The medical record indicated that the resident had been receiving occupational therapy to address increased assist needs and worsening left upper extremity tone due to a contracture. Despite the discharge recommendation to continue using the splint, documentation revealed that the splint was not applied on multiple occasions, and the last recorded application was on January 12, 2025. Observations and interviews conducted on January 21 and 22, 2025, confirmed that Resident #21 was not wearing the splint, and staff members, including CNAs and therapy personnel, were unaware of the reasons for this lapse. The splint was found on top of the resident's dresser, indicating it was not in use. The Director of Nursing confirmed the lack of documentation regarding the splint's application, which was supposed to be recorded by the aides. The facility's policy on adaptive equipment, revised in January 2024, stated that the use of such equipment should be supervised by nursing staff to help residents maintain their physical well-being.
Smoking Hazards and Inadequate Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #5 and Resident #29, were free from potential accident hazards related to smoking. Resident #5, who was admitted with diagnoses including schizophrenia and generalized muscle weakness, was observed smoking without wearing a smoking apron, despite having multiple burn holes in his clothing. The Assistant Director of Nursing (ADON) had assessed Resident #5 as a safe independent smoker without thoroughly inspecting his clothing for burn holes, which was a requirement of the smoking assessment. This oversight led to Resident #5 continuing to smoke unsafely, as evidenced by his habit of throwing lit cigarette butts on the ground and the presence of burn holes in his clothing. Resident #29, who had diagnoses including chronic obstructive pulmonary disease and was on oxygen, was found to have smoking paraphernalia in his room, despite a facility policy that prohibited smoking in areas where oxygen was in use. An observation revealed the presence of a lighter, a metal pipe with soot, and a vape device in Resident #29's room, along with a sign indicating no smoking due to oxygen use. Resident #29 admitted to previously smoking in his room, which was a violation of the facility's smoking policy. The facility's smoking policy did not adequately address the risks associated with residents who smoked and used oxygen, contributing to the unsafe conditions. The facility's failure to enforce its smoking policy and ensure adequate supervision and safety measures for residents who smoke resulted in potential accident hazards. The lack of thorough assessments and supervision allowed unsafe smoking practices to continue, posing risks to the residents and the facility. The observations and interviews conducted during the survey highlighted these deficiencies, which affected the safety and well-being of the residents involved.
Deficiencies in Respiratory Care Equipment Maintenance
Penalty
Summary
The facility failed to maintain clean and sanitary conditions for respiratory care equipment for two residents. Resident #21, who has chronic obstructive pulmonary disease (COPD) and a cancer lesion, was observed with dirty and blood-stained head straps on his BiPAP machine. Despite having a growth on his head that bled, the straps were not replaced or cleaned, contrary to the physician's order to replace the BiPAP mask, headgear, and tubing every three months. The facility's policy did not address the cleanliness of the head straps, and the manufacturer's guide emphasized the importance of regular cleaning. Resident #34, also diagnosed with COPD, had oxygen tubing that was not labeled with the date of the last change, as required by the facility's policy. The tubing was supposed to be changed weekly, but the staff, including RN #500, were unsure of the policy details. The Director of Nursing confirmed the lack of labeling and acknowledged the need for staff training on the oxygen administration policy. The facility's policy required oxygen tubing and masks/cannulas to be changed weekly and as needed if soiled or contaminated.
Failure to Properly Label and Store Insulin Medications
Penalty
Summary
The facility failed to ensure that insulin medications were accurately labeled and stored according to professional principles, affecting three residents with type two diabetes mellitus. During an observation of medication cart #2, it was found that insulin pens for these residents were opened but not dated, and some did not have labels with the residents' names. This lack of proper labeling and dating could lead to the use of outdated medications, as the facility's policy requires medications to be dated when opened and discarded after 28 days. The medical records for the affected residents showed that they were prescribed various types of insulin, including Humalog, Fiasp, and Toujeo, which require specific storage conditions. The facility's policy and pharmacy guidelines mandate that these insulins be refrigerated until use and dated upon opening. However, the observation revealed that these guidelines were not followed, as confirmed by an interview with a registered nurse who acknowledged the oversight. This deficiency in medication management was identified during a survey, highlighting a failure in adhering to established protocols for medication storage and labeling.
Resident Served Incorrect Food Texture
Penalty
Summary
The facility failed to ensure that Resident #9 received food prepared in a form designed to meet their individual needs. Resident #9, who was diagnosed with severe protein-calorie malnutrition, dementia without behavioral disturbance, and oropharyngeal phase dysphagia, was identified as requiring a pureed food texture. However, during an observation of Resident #9's lunch meal, it was noted that the resident was served mechanical soft Salisbury steak instead of the prescribed pureed meat. The meal ticket on the lunch tray indicated that the resident should have received mechanical soft with pureed meat only. The Dietary Manager confirmed that Resident #9 was served the incorrect food texture and acknowledged that the diet orders were being checked against meal tickets but had not yet been updated for Resident #9.
Failure to Provide Appropriate Bed Size Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide necessary interventions to prevent a fall with injury for a resident who was dependent on staff for incontinence care and personal hygiene. The resident, who had diagnoses including morbid obesity and poly osteoarthritis, required a king bariatric bed rather than the queen bed provided. This inadequacy was identified as the root cause of the fall that resulted in actual harm. On the day of the incident, the resident was being provided incontinence care by multiple staff members when she slid off the mattress and was assisted to the floor, resulting in bilateral distal femur fractures. The resident had been bedbound for four years and used a wheelchair for two of those years. The incident occurred despite the presence of three staff members, including two CNAs and an agency CNA, who were assisting with the resident's care. Interviews with staff revealed that the resident required maximum assistance with activities of daily living and typically needed three to four staff members to assist with rolling in bed. The facility's quality assurance program identified the need for a larger bed as the root cause of the fall, indicating a failure to implement an adequate fall prevention plan tailored to the resident's specific needs.
Inconsistent Food Temperature Monitoring and Resident Dissatisfaction
Penalty
Summary
The facility failed to ensure that food temperatures were consistently monitored and recorded, which affected the palatability and safety of meals served to all 55 residents. The Food Temperature Log forms from 12/15/24 to 01/06/25 showed numerous instances where temperatures were not recorded for breakfast, lunch, and dinner. Observations on 01/06/25 revealed that food temperatures were not documented, and the milk served was above the required temperature of 40 degrees Fahrenheit. Interviews with residents indicated dissatisfaction with the food quality, describing it as cold and institutional grade. The Dietary Director confirmed the inconsistencies in temperature checks and acknowledged the blank sections in the Food Temperature Logs. A resident's daughter expressed concerns about the inconsistency of the food, leading her to bring a refrigerator to the resident's room. The facility's Food and Nutrition Services policy, revised in 10/2017, mandates that each resident receives a nourishing, palatable, and well-balanced diet, considering their preferences, which was not adhered to in this instance.
Failure to Follow Meal Plans and Preferences
Penalty
Summary
The facility failed to ensure that the menus and meal plans were followed as planned, affecting several residents. Resident #9, who was admitted with conditions including cellulitis and peripheral vascular disease, did not receive the mighty shake, applesauce cake, or bread as per the menu and meal ticket during lunch. The Director of Nursing (DON) confirmed the discrepancy during an observation. Resident #13, diagnosed with multiple sclerosis and anxiety disorder, also experienced issues with meal delivery. The resident's breakfast and lunch trays did not include the preferred items such as yogurt, fruit, and cottage cheese as indicated on the meal ticket. The Dietary Director confirmed that the breakfast pizza was not delivered, and the substitute should have been scrambled eggs and toast. Additionally, the serving size of French toast sticks was incorrect. Resident #27, with diagnoses including alcoholic cirrhosis and anxiety, did not receive the correct portion size of French toast sticks and was missing bread and applesauce cake during lunch. Similarly, Resident #44, who had severe protein-calorie malnutrition, did not receive the mighty shake or hot water for tea as per the meal ticket. The facility's policy requires that each resident is provided with a diet that meets their nutritional and dietary needs, which was not adhered to in these cases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,240 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Akron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Ridge Nursing & Rehabilitation Center | 0.6 mi | ★★★★★ | 19 | 0 |
| Ohio Living Rockynol | 0.8 mi | ★★★★★ | 0 | 0 |
| Highland Square Nursing And Rehabilitation | 0.8 mi | ★★★★★ | 0 | 0 |
| Divine Rehabilitation And Nursing At Canal Pointe | 1.5 mi | ★★★★★ | 0 | 0 |
| Wyant Woods Healthcare Center | 3.9 mi | ★★★★★ | 5 | 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 October 2026) and official state health department websites.