Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pavilion At Edgefield For Nursing And Rehabili during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain sanitary conditions in all three linen closets used to store clean linens. In one closet, a large pile of socks was on the floor with dirty shoes on top, along with clothing, gowns, bedsheets, and trash stored on or near shelves with clean linens. In two other closets, an LPN observed bedsheets, trash bags, Styrofoam cups, and plastic bags on the floor and on shelves with clean linens, as well as visibly dirty shelves and sheets with black lint. The administrator confirmed that all residents use linens and towels from these closets, despite facility policy requiring separation of clean and soiled linens and reprocessing of any linen that falls to the floor.
A resident who was dependent on staff for transfers experienced two falls during a mechanical lift transfer when the lift pad strap broke and the lift's hydraulics failed, resulting in injuries. The resident, who had a history of falls and multiple medical conditions, was being assisted by two CNAs when the incidents occurred. The same lift was used for both attempts, with a different pad used after the first fall. The equipment was later removed from use following the incidents.
Kitchen sanitation and dishwashing practices were not followed. Staff did not consistently test the low-temp dishwasher sanitizer or the 3-sink sanitizer water, and one dietary aide did not know how to use the test strips. The dishwasher and sanitizer water were not being checked every 2 hours or every day, and more than 20 plate lids, plates, bowls, cups, and serving trays were observed stacked and stored wet. An admin verified the wet dishes and stated dishes and cookware are not to be put away wet due to sanitation concerns.
Inaccurate and Missing Code Status Information: Staff relied on unit code binders and the nurse station DNR book to verify code status, but those sources were often missing residents or showed code status that did not match the EMR. Several residents with significant cognitive impairment and complex diagnoses had DNRCC, DNR-CCA, or Full Code orders in the chart, while the paper binders were absent, incomplete, or incorrect, and the DON stated staff should have been using the EMR instead.
Surveyors found multiple areas with damaged walls, peeling molding and wallpaper, sticky and soiled bathroom floors, overflowing trash, and cigarette butts scattered around the smoking area. An LPN, CNA, AA, and the Administrator verified the conditions in resident bathrooms and the outdoor smoking space, and one resident affected had multiple chronic diagnoses and required staff help with ADLs.
Incomplete bed-hold notices and missing Ombudsman notifications were found for multiple residents transferred or discharged from the facility. Staff and record review showed that notices often listed only days used and remaining, without the bed-hold policy, room cost, or reason for transfer/discharge, and required transfer/discharge documentation was not consistently completed or sent, including for residents with serious conditions such as CHF, cancer, respiratory failure, and hemiplegia.
A resident with cerebrovascular disease, dementia, DM, CHF, CKD, and adult failure to thrive was moderately cognitively impaired, required staff help with ADLs, and used a wheelchair. Surveyors observed the resident lying in bed with the call light draped over a recliner and not within reach on two occasions, including when the resident was tearful and asking to be pulled up in bed. The ADON confirmed the call light was not within reach.
Lack of Documented Psychotropic Medication Education: A resident with multiple chronic conditions, including anxiety and ADHD, was prescribed several psychotropic meds, including antidepressants, a stimulant, and an anxiolytic. The record contained a general psychotherapy consent, but there was no documentation that the resident received education on the specific meds’ risks, benefits, or side effects in physician or nursing notes, and the Regional Clinical Consultant stated the consent form was used as education and that prescribers educated residents as part of standard practice.
A resident who was admitted from home with multiple serious diagnoses and was on hospice had no documented discharge planning in the care plan or progress notes, and there was no record of communication with the resident or her representative about transfer to another nursing facility. The DON and Administrator confirmed the medical record lacked the required discharge planning and related communication.
A facility failed to complete comprehensive, resident-specific care plans and involve residents or resident representatives in care planning for two residents. One resident with CHF, lung disease, and other chronic conditions had MDS assessments completed, but care conference documentation was missing for 2025 and the resident’s son said he had not been invited in a long time. Another resident with dementia, Alzheimer’s disease, malnutrition, and a fall history had a fall with a new order to offer a recliner in the lounge, but the comprehensive fall care plan was not updated to include that intervention.
Failure to provide personal hygiene care: A resident with Alzheimer's disease, dementia, and severe impairment in daily decision making had long, jagged fingernails with dirt and debris under the nail beds on repeated observations. Records showed no documented refusals of bathing or nail care, and a CNA said nails should be trimmed and cleaned with showers if needed, but an LPN stated the need for nail care had not been passed on.
A resident with Alzheimer’s disease, dementia, lymphedema, edema, and impaired cognition did not have ordered ACE wraps applied to both lower extremities as directed. The care plan and physician order required the wraps to be on in the morning and off in the evening, but observations showed the wraps were not in place, and an LPN confirmed they were not being worn as ordered.
Failure to Ensure Access to Hearing Aides: The facility failed to ensure a resident with impaired communication and hard of hearing received proper assistive devices to maintain hearing abilities. The resident had broken hearing aides, no hearing aides in place during observation, and a loud TV volume was noted. RN documentation identified minimal hearing impairment without hearing aides, and the Administrator stated social services was responsible for arranging hearing or vision exams.
A resident with multiple medical conditions and fall risk was transported in a wheelchair van and fell out of the chair while the vehicle was moving, resulting in rib fractures; the CNA reported limited training on the securement system and the facility had no transport, training, or maintenance logs. Another resident with dementia, Alzheimer’s disease, and a history of falls had incomplete neuro checks after an unwitnessed fall and was repeatedly observed without the ordered non-skid footwear.
A resident with acute and chronic respiratory failure with hypoxia, pleural effusion, shortness of breath, and sleep apnea was ordered continuous O2 at 4 L via NC. During observation, the resident was found with the NC in place but the concentrator was off and set at 2 L; the resident said an aide had removed her C-pap and placed the NC on without turning the concentrator on. An LPN verified the O2 was off, found the resident's pulse ox was 80% on room air, and then turned the concentrator on, after which the saturation increased to 93%.
Failure to recognize and address pain promptly when a resident had a change in condition. A resident with multiple chronic diagnoses and frequent, severe pain reported new pain in the right great toe and right thumb, along with chronic back pain, and said his PRN opioid was not effective. Nursing documentation lacked a recorded pain level and pre-medication interventions, a pain assessment completed after the medication was incomplete, and staff reported only repositioning was used before giving pain medication. The DON could not provide physician notes to show a pain assessment was completed.
Missing Provider Follow-Up to Monthly Pharmacist GDR Recommendations: The facility failed to ensure medical provider review and follow-up to monthly pharmacist recommendations for GDR for three residents. For one resident with multiple chronic conditions including diabetes, heart disease, kidney disease, and anxiety, and for two other residents with complex medical histories including neuropathy, depression, heart failure, and chronic pain, the EMR showed monthly pharmacy reviews and some provider responses, but specific pharmacist recommendations were not documented for certain reviews and there was no documentation of provider notification, acknowledgement, or follow-up for those recommendations.
Failure to arrange dental services for a resident with lost or damaged dentures. A resident with dementia, anxiety, depression, seizures, and weakness had a long history of ill-fitting or broken lower dentures, but records did not show a timely dental referral or documentation explaining why one was not made. Notes later conflicted on whether he still had lower dentures, and the facility policy did not define when denture loss or damage was the facility’s responsibility.
The facility failed to honor food preferences and dietary orders for two residents. One resident who was cognitively intact reported not receiving her daily omelet and sausage lunch as ordered, and the Dietary Supervisor confirmed omelets were unavailable due to supply and budget issues. Another resident with DM and multiple chronic conditions did not receive ordered breakfast items such as tea, lactose free milk, apple juice, or sugar-free items, and staff confirmed the facility had been out of lactose free milk for about two weeks and had substituted or omitted ordered foods.
Failure to Provide Ice Water Between Meals: A resident with cerebrovascular disease, dementia, DM, CHF, CKD, and adult failure to thrive was observed in bed without ice water or any other drink available on the bedside table during the afternoon. The resident was tearful, requested assistance to be pulled up in bed, and had dry lips noted. A CNA confirmed the resident should be checked every two hours and did not have a drink available, and the ADON also confirmed no ice water or other drink was present.
A resident with dementia, impaired decision-making, and daily wandering had a care plan identifying her as an elopement risk and directing staff to document wandering and room-entry behaviors. However, CNA TASK records showed no behaviors documented for the prior 30 days, even though staff observed the resident entering other residents’ rooms daily and one CNA said staff had been told not to document behaviors in TASK. The DON verified that documenting no behaviors was not accurate.
Missing Hospice Communication Documentation: The facility failed to ensure coordination of care communication between a resident's hospice provider and the facility. The resident had multiple chronic diagnoses, was moderately cognitively impaired, required ADL assistance, and had been admitted to hospice services. The DON stated hospice notes were kept in a hospice binder at the nursing station, but the binder contained no hospice communication documentation or hospice progress notes, and an LPN confirmed the binder was empty. The facility policy required regular hospice-facility communication and documentation in each party's clinical record.
The facility failed to ensure the Infection Preventionist attended quarterly QA meetings. QA sign-in sheets showed meetings were held throughout the year, but there was no evidence the IP participated except in one meeting in June. An RN who had served as the IP since 2019 verified she was not attending the quarterly QA meetings.
Failure to perform hand hygiene and change gloves during incontinence care. A CNA cleaned stool from a resident’s buttocks and applied barrier cream, then continued touching the bed rail, bed, and blanket with the same gloved hands without removing gloves or performing hand hygiene. The ADON later confirmed the CNA did not change gloves before touching other surfaces and provided education on glove use and hand hygiene.
Failure to monitor antibiotic use: A resident with Alzheimer’s disease, dementia, and other chronic conditions was ordered Nitrofurantoin Mono-Mac for an E. coli UTI, and the MAR also showed Cefdinir use. The infection control log did not show an assessment to determine whether the antibiotic was appropriate and met criteria, and the IP/ADON confirmed McGeer Criteria had not been completed for the resident.
Two residents did not receive medications under proper infection control procedures when LPNs failed to perform hand hygiene at required times, including before and after medication administration and glove use, as confirmed by staff interviews and facility policy review.
Unsanitary Storage of Clean Linens in All Linen Closets
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to unsanitary storage of clean linens in three of three linen closets. During an observation of the second-floor clean storage linen closet with a CNA, a very large pile of socks was found on the floor with a dirty pair of shoes placed on top of the socks. Multiple items of clothing, hospital gowns, and bedsheets were also on the ground, and various items of trash were sitting on shelving units alongside clean linens. The CNA confirmed these conditions at the time of the observation. Additional observations on the first floor with an LPN revealed similar issues in two separate linen closets. In the 100-hall clean linen closet, multiple bedsheets, trash bags, Styrofoam cups, and plastic bags were on the floor, and Styrofoam cups and plastic bags of trash were stored on shelves with clean linens. In the 400-hall linen closet, Styrofoam cups and plastic bags were on the floor, and the shelves holding clean linens had visible dirt and splatter stains. Multiple sheets stored there had black lint on them. The LPN verified these findings. The Administrator later confirmed that all residents use the linens and towels from these facility linen closets. Facility policy states that soiled and clean linen should be separated at all times, that clean linen will remain hygienically clean through measures to protect it from environmental contamination, and that any linen that falls onto the floor or is not visibly clean after processing should be reprocessed.
Failure to Maintain Mechanical Lift Equipment Results in Resident Falls
Penalty
Summary
A deficiency occurred when a facility failed to ensure that mechanical lift equipment was maintained in a safe and working condition, resulting in an avoidable fall for a resident. The resident, who had multiple diagnoses including schizoaffective disorder, metabolic encephalopathy, obesity, and a history of falls, was totally dependent on staff for transfers and required the use of a mechanical lift with two-person assistance. During a transfer from wheelchair to bed, the mechanical lift pad's strap broke, causing the resident to fall, hitting the bed and landing on the floor. Staff then attempted to use a different lift pad with the same mechanical lift, but the hydraulics failed, resulting in a second fall where the resident sustained injuries to the forehead, nose, left hand, and knee. The resident was assessed by nursing staff after each fall and was sent to the emergency room for evaluation. The resident reported pain and injuries, but no fractures were found. Witness statements from the CNAs involved confirmed that the lift pad was inspected prior to use and that the resident was balanced during the transfer attempts. Both CNAs and the nurse described the sequence of events, including the strap breaking and the hydraulic failure, which led to the resident falling from approximately waist height on both occasions. Observations and interviews confirmed that the same mechanical lift was used for both transfer attempts, with a different pad used for the second attempt. The mechanical lift and pad involved in the incidents were later removed from use. The facility's failure to ensure the mechanical lift and its accessories were in safe working condition directly led to the resident's falls and subsequent injuries.
Kitchen sanitation and dishwashing practices were not followed
Penalty
Summary
The kitchen was not maintained in a sanitary manner because staff did not consistently check sanitizer levels for the low temperature dishwasher or the three-sink sanitizer water. During observation, Dietary Aide #990 stated she had never checked the dishwasher sanitizer since starting at the facility and did not know which test strips to use or how to test the sanitizer water for correct levels. Dietary Aide #200 stated he only periodically checked the sanitizer solution, not every day, and said there was no record of when the dishwasher sanitizer or the three-sink sanitizer were checked. He also verified the dishwasher and sanitizer water were not being checked every two hours or every day, despite a wall sign stating to change water every two hours. The kitchen observation also showed dishes were being put away wet. More than 20 plate lids, 20 plates, 20 bowls, 20 cups, and all serving trays were stacked and stored while still wet. [NAME] #100 verified the wet dishes and instructed staff to rewash them, and stated dishes and cookware are not to be put away wet due to sanitation concerns. The facility policy required sanitizer concentration to be maintained at the correct level based on periodic testing at least once per shift, and the dishwasher owner's manual stated staff should test the bottom of glasses with litmus paper and maintain sanitizer concentration between 50 ppm and 100 ppm.
Inaccurate and Missing Code Status Information
Penalty
Summary
The facility failed to ensure resident code status was accurate and consistently available to staff for multiple residents, including residents with DNRCC and DNR-CCA orders as well as residents with Full Code orders. Review of records and interviews showed that code status information in the electronic medical record did not always match the paper code binders kept on the units, and in several cases the binders did not contain any code status information at all for the resident. Staff members stated they used the binders at the nurse’s station or on the unit to verify code status, while the DON stated staff should be using the electronic documentation and was unaware that staff were relying on the binders. Resident #15 had diagnoses including dementia, fracture of the left femur, emphysema, severe protein calorie malnutrition, Alzheimer’s disease, ataxia, muscle weakness, bradycardia, and a history of falling. The resident was severely impaired for daily decision making on the quarterly MDS. Physician orders included a DNRCC order, and the EMR contained signed DNRCC documents, but the unit code binder did not contain the resident’s code status. During interview, an LPN stated there was no paper code record on the unit for guidance, while a CNA identified a code binder at the nurse station, but Resident #15 was not listed in it. Similar findings were identified for other residents. Resident #12, who had dementia, cerebral infarction, chronic kidney disease, and severe cognitive impairment, had a Full Code order in the chart, but the secured unit code binder did not contain the resident’s code status. Resident #32, who had Alzheimer’s disease, dementia, epilepsy, severe protein malnutrition, chronic kidney disease stage 3, and was severely impaired and dependent for all care, also was absent from the second floor code binder despite a Full Code order. Resident #10 and Resident #27 had DNR-CCA orders in the EMR and signed physician forms, but the binder at the nurse’s station either listed the resident as Full Code or contained no advanced directive documents. Resident #01 also had a DNR-CCA order in the EMR and signed physician documentation, but there was no code status sheet or order in the DNR code book at the nurse’s station.
Unsafe and Unclean Resident and Common Areas
Penalty
Summary
The facility failed to maintain a clean environment free of cigarette butts, trash, damaged drywall, molding, wallpaper, and dirty floors. Observations identified damaged and peeling molding and wall surfaces in Resident #5’s bathroom, including molding coming off the wall by the shower and door, a plastic wall surface taped with thick silver duct tape, plastered and unpainted wall areas, and scraped lower walls. A Licensed Practical Nurse verified the molding, plastic wall surface, and drywall damage affecting the resident’s room. In the bathroom between the rooms of Residents #12 and #13, surveyors observed holes in the wall behind the commode, molding off the wall, and wallpaper coming off the wall, which the Administrator verified. Additional observations showed Resident #67’s bathroom floor was sticky and smeared with blackened streaks, with shoes sticking to the floor during handwashing; an LPN verified the dirty, sticky condition and attributed it to altered cleaning time because the resident was in isolation. In the outdoor smoking area, cigarette butts were observed in the cracks of the sidewalk, in and under bushes, and beside the Smoker’s Outpost, and an Activities Aide confirmed the littered condition and stated the area behind the structure usually had cigarette butts and debris from employees who smoked there. Resident #27’s bathroom trash can was full and overflowing onto the floor, and the floor was sticky with black shoe imprints; a CNA confirmed the overflowing trash and soiled floor. The resident had diagnoses including cellulitis of the right lower limb, chronic ulcer of the right lower limb, chronic heart failure, multiple sclerosis, and anxiety, and the MDS indicated a BIMS score of 13 and need for staff assistance with ADLs. Resident council minutes also noted concerns about trash being picked up every two to three days.
Incomplete bed-hold notices and missing Ombudsman notifications
Penalty
Summary
The facility failed to provide complete bed-hold notices and Ombudsman notifications for transferred and discharged residents. Record review and staff interviews showed that for multiple residents, the facility sent bed-hold letters that only listed the number of bed-hold days used and remaining, but did not include the bed-hold policy, the per-diem room cost, or the reason for transfer or discharge. The facility also did not consistently complete transfer forms or send required discharge information with residents when they were sent to the hospital. Resident #04, who had diagnoses including heart failure, lung disease, contractures, heart disease, anemia, chronic back pain, high blood pressure, and degenerative joint disease, was transferred to the hospital on multiple occasions. The record showed bed-hold notices were sent for some hospitalizations, but staff confirmed that one bed-hold notice was not sent while the BOM was on vacation and that the facility did not complete a transfer form for one hospitalization. The BOM stated she only sent the notice of available bed-hold days and did not provide the bed-hold policy or cost. The DON confirmed the transfer form was not completed, and the Administrator stated the facility had not been notifying the LTC Ombudsman of resident transfers and discharges. Resident #79, who had diagnoses including malignant neoplasm of the tongue, acute respiratory failure, type 2 diabetes, severe protein malnutrition, CHF, and hemiplegia, was sent to the hospital after a seizure-like event and respiratory arrest. The facility sent a certified letter listing bed-hold days available, but it did not include the room cost or reason for transfer/discharge, and no Ombudsman notification was provided. The Administrator later acknowledged that the Ombudsman notification was not timely and did not identify which residents were included. Resident #81’s record also lacked complete discharge documentation, including a complete discharge summary, recapitulation of stay, communication to the receiving nursing facility, and notice to the Ombudsman. Resident #56’s record showed a hospital transfer after critical labs, and the bed-hold notice again only stated days used and days remaining, with the BOM confirming that the policy and cost were not provided.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a dependent resident. Resident #10 was admitted with diagnoses including cerebrovascular disease, dementia, diabetes mellitus, congestive heart failure, chronic kidney disease, and adult failure to thrive. The quarterly MDS dated 06/24/25 indicated the resident was moderately cognitively impaired and required staff assistance with ADLs, and the resident used a wheelchair for mobility. During observation on 09/18/25 at 1:26 P.M., the resident was lying in bed and the call light was observed draped over the recliner and not within reach. A later observation on 09/18/25 at 3:28 P.M. again found the resident lying in bed, tearful, and requesting to be pulled up in bed, with the call light still draped over the recliner and not within reach. The ADON confirmed at 3:30 P.M. that the resident's call light was not within reach.
Lack of Documented Psychotropic Medication Education
Penalty
Summary
The facility failed to provide education on psychotropic drug use, including the risks, benefits, and side effects, for one resident reviewed for psychotropic medication use. The resident was admitted with diagnoses including pneumonia related to inhalation of food and vomit, diabetes, vascular disease, heart disease, kidney disease, fatty liver, high blood pressure, ADHD, overactive bladder, anxiety, fibromyalgia, and anemia. A general psychotherapies consent was signed on admission, but the record did not contain documentation tied to the specific psychotropic medications prescribed for the resident, including Bupropion, Duloxetine, Nortriptyline, Adderall, and Ativan. The medical record also did not show education documented in physician progress notes dated 06/26/25, 06/30/25, and 07/21/25 for Adderall, Bupropion, Nortriptyline, or Ativan. Nursing progress notes from 06/25/25 through 09/16/25 likewise did not indicate that education was provided regarding psychotropic medication use, risks, benefits, or side effects. During interview, the Regional Clinical Consultant stated the psychotherapy consent form was used for education and that prescribers educated residents on medications as part of standard practice.
Failure to Document and Communicate Discharge Planning
Penalty
Summary
The facility failed to ensure the transfer and discharge of Resident #81 was documented in the medical record and failed to communicate appropriate information to the receiving facility. Resident #81 was admitted from home with diagnoses including malignant neoplasm of unspecified bronchus, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of bone, diabetes, peripheral vascular disease, left hip arthritis, history of pulmonary embolism, acquired absence of lung, and anxiety disorder, and she was a hospice patient at the time of admission. Review of the medical record showed a care plan dated 06/09/25 that did not address discharge planning, and progress notes did not reveal any communication or planning with the resident or her representative for discharge to another nursing facility. The DON confirmed the lack of discharge planning and communication, and the Administrator also confirmed the record did not contain the necessary care planning or documentation showing the facility assisted with arrangements for the resident to go to another nursing facility.
Incomplete care planning and missing resident/family involvement
Penalty
Summary
The facility failed to develop comprehensive, resident-specific care plans and to include resident and resident representative involvement in the care planning process for two residents. For one resident, the record showed admission with diagnoses including heart failure, lung disease, right-hand contracture, heart disease, anemia, chronic back pain, high blood pressure, and degenerative joint disease of the cervical and lumbar spine. The MDS assessments were completed on multiple dates, but the record contained only one care conference summary, and there were no other care conference summaries completed to coincide with the MDS assessments and care plan revisions. The resident’s son stated he had participated in care conferences in the past but had not been invited to one in a long time, and the DON confirmed there were no care conferences or care conference notes completed in 2025 for this resident. For the second resident, the record showed admission with diagnoses including dementia, left femur fracture, emphysema, severe protein calorie malnutrition, Alzheimer’s disease, ataxia, muscle weakness, depression, anxiety, constipation, GERD, insomnia, scoliosis, kyphosis, tremor, history of falling, and hypothyroidism. The resident had a fall risk plan of care identifying multiple risk factors, and after a fall in the dayroom, the immediate intervention was to offer a recliner chair when in the lounge. Physician orders reflected that intervention, but the comprehensive fall plan of care was not updated to include it. The DON verified the care plan was not updated for the recliner use, and the facility’s fall policy did not include adding interventions to the comprehensive plan of care.
Failure to Provide Personal Hygiene Care
Penalty
Summary
The facility failed to provide personal hygiene care to a resident who was dependent on staff for assistance with activities of daily living. Resident #13 was admitted with diagnoses including Alzheimer's disease, dementia, hypertension, and anxiety, and had a care plan related to ADL self-care deficits, anxiety, dementia, and psychoactive drug use. The resident also had an order for placement on a secured memory care unit for a therapeutic environment and was assessed as severely impaired for daily decision making on the quarterly MDS assessment. Record review showed no documented bathing or nail care refusals in nurse notes from May 2025 through September 2025 and no documented shower refusals. However, observations showed the resident's fingernails were long, jagged, and had debris and dirt under the nail beds on multiple occasions. The Administrator observed the resident's fingernails with dirt under the nail beds and asked if she wanted a spa day, but the resident did not respond. A CNA stated that nails are to be trimmed and cleaned with showers if needed, and an LPN later stated it had not been passed on that the resident needed nail care completed.
Failure to Apply Ordered Bilateral Leg ACE Wraps
Penalty
Summary
The facility failed to ensure Resident #44’s bilateral lower leg ACE wraps were applied as ordered by the physician. Resident #44 was admitted with diagnoses including Alzheimer’s disease, dementia, left bundle branch block, lymphedema, edema, anxiety, and muscle weakness, and the quarterly MDS indicated moderately impaired cognition with assistance needed for activities of daily living. The care plan identified the resident as at risk for impaired skin integrity related to edema and fragile skin and directed staff to apply ACE wraps to both lower extremities in the morning and remove them in the evening. The physician order also directed ACE wraps to be applied to both lower extremities, on in the morning and off in the evening. During observation, the resident did not have ACE wraps applied to either lower extremity, and a later observation again showed the wraps were not in place. An LPN confirmed the resident was not wearing the ACE wraps as ordered.
Failure to Ensure Access to Hearing Aides
Penalty
Summary
The facility failed to ensure residents received proper assistive devices to maintain hearing abilities. This deficiency affected Resident #22, whose medical record showed multiple diagnoses including vascular dementia, mild cognitive impairment, essential tremor, generalized anxiety disorder, major depressive disorder, and chronic lymphocytic leukemia in remission. The care plan identified impaired communication related to anxiety, cognitive impairment, depression, and hard of hearing, and noted that the resident had received replacement hearing aides, with audiology referral as needed. A progress note also documented possible hearing loss with normal conversational tones and stated that the resident had hearing aides that were broken, with the warranty expired in 2022 and a recommendation for audiology referral to determine eligibility for a new set. During observation and interview, Resident #22 stated he was supposed to wear hearing aides in both ears but had not had them for some time because they broke. He was unsure whether he had recently had an appointment to get them repaired and did not know what had happened to them. Observation showed the resident’s television turned up very loud and no hearing aides in either ear. RN #670 confirmed during MDS review that the resident was identified as minimally hearing impaired and did not have hearing aides. The Administrator stated it was the responsibility of social services to arrange hearing or vision exams, and that the previous social service representative had been terminated and the new representative had been with the facility for one week.
Unsafe Transport Securement and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to ensure residents were safe from accident hazards and that adequate supervision was provided as needed. One event involved a resident with diagnoses including atherosclerotic heart disease, seizures, mild cognitive impairment, chronic lymphocytic leukemia, muscle weakness, vascular dementia, and anxiety. The resident’s care plan identified a fall risk related to a history of falls, decreased safety awareness, medications, poor balance, psychoactive drug use, non-compliance with safety interventions, and leukemia. While being transported in the facility van to a physician appointment, the resident fell from his wheelchair when the driver braked too fast. The resident reported that the wheelchair was secured and he was belted, but he fell forward and struck the desk area of the van. He was later evaluated in the ED and diagnosed with mildly displaced rib fractures of the left fifth through seventh ribs. The transportation event showed that the wheelchair securement was not properly used. The CNA who drove the van stated he had strapped the resident into the wheelchair using straps on the wheels and had connected a shoulder strap and lap belt, but the resident still fell to the floor while the van was moving. The CNA reported he had been trained only through two days of bus orientation by a former activity director and had no manual or workbook for the securement system. The DON stated she believed the CNA could decide whether the resident had an injury and allowed him to continue to the appointment after the fall because nothing was broken. The facility also had no evidence of transportation logs, staff in-service or training logs, or maintenance logs for the wheelchair securement system, and the Administrator stated he had just obtained the user instructions and was uncertain which employees had been trained. A second resident with dementia, Alzheimer’s disease, ataxia, muscle weakness, a history of falling, and severe cognitive impairment had two falls reviewed. After an unwitnessed fall in the room beside the bed, neurological checks were initiated, but three consecutive sets of neurological checks were not completed during the ordered monitoring period. In another fall, the resident was found transferring unassisted with a raised hematoma to the head, and witness statements showed the resident had been observed barefoot or with only one sock on before the fall. The resident’s care plan included an intervention for non-skid footwear at all times, but observation later showed the resident in bed with bare feet, and the DON verified that non-skid footwear was not applied at all times.
Failure to Provide Ordered Continuous Oxygen
Penalty
Summary
The facility failed to provide a resident who required supplemental oxygen with the needed support. Resident #34 was readmitted with diagnoses including acute and chronic respiratory failure with hypoxia, pleural effusion, and shortness of breath. The physician orders called for continuous oxygen at four liters via nasal cannula every shift, and the care plan identified impaired respiratory status related to hypoxia, respiratory failure, shortness of breath, and sleep apnea, with interventions including oxygen via nasal cannula at four liters continuously. During observation, the resident was found lying in bed with the oxygen nasal cannula tubing on, but the oxygen concentrator was not turned on and was set at two liters per minute. The resident stated she did not realize her oxygen was off and reported that an aide had removed her C-pap around 6:00 A.M. and placed the nasal cannula on, but did not turn the concentrator on. An LPN verified that the concentrator was off when it should have been delivering continuous oxygen at four liters, checked the resident's oxygen saturation, and found it was 80% on room air. After the LPN instructed the resident to take deep breaths and turned the concentrator on, the resident's oxygen saturation increased to 93%.
Failure to Recognize and Address Resident Pain Promptly
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #73 when there was a change in condition. The resident was admitted with diagnoses including acute diastolic heart failure, acute respiratory failure with hypoxia, COPD, acute pulmonary edema, ulcerative pancolitis, Alzheimer's disease with late onset, atrial fibrillation, osteoarthritis of the right shoulder, mood disorder, and dementia in other diseases. The most recent MDS showed a BIMS of 15 and indicated the resident had frequent, severe pain. On 09/18/25 at 9:54 P.M., the resident received Hydrocodone-Acetaminophen 5-325 mg one tablet PRN for pain, but the progress note did not document a pain level or interventions provided before administration. A later note at 11:12 P.M. stated the medication was effective and pain was zero. A comprehensive pain assessment completed three hours after the medication did not include pain location, type, duration, frequency, or whether the pain was continuous or intermittent, and it indicated the resident had no pain and that rest was the only effective intervention. The care plan identified a focus for risk of pain related to multiple conditions, with interventions to monitor for pain and notify the physician of any complaint of pain. The record did not reveal any orders for non-narcotic pain medications or interventions. During interview, the resident stated he did not believe his pain was being managed and reported new pain at the base of his right great toe and right thumb for about three weeks, along with chronic back pain; he said the toe was red, swollen, painful to touch, and shooting in nature, and that the medicated gel he had been given did not work. An LPN stated the resident had been complaining of pain in his right great toe and right thumb for at least two weeks and that the only intervention before medication was repositioning. The DON stated nurses document pain on the MAR and that physician documentation was requested but not provided, and the facility did not provide physician notes to show whether a physician pain assessment had been completed.
Missing Provider Follow-Up to Monthly Pharmacist GDR Recommendations
Penalty
Summary
The facility failed to ensure medical provider follow-up to monthly pharmacist recommendations for gradual dose reduction (GDR) for three of five residents reviewed. For Resident #01, who was admitted with diagnoses including pneumonia related to inhalation of food and vomit, diabetes, vascular disease, heart disease, kidney disease, fatty liver, high blood pressure, ADHD, overactive bladder, anxiety, fibromyalgia, and anemia, the EMR showed monthly pharmacy reviews completed with pharmacist recommendations on 06/26/25, 07/09/25, and 09/02/25. Although detailed recommendations were documented for 06/26/25 and medical provider follow-up occurred on 06/27/25, there was no documentation of the specific recommendations for 07/09/25 or 09/02/25 and no documentation that the medical provider was notified or reviewed those recommendations. For Resident #03, admitted with diagnoses including intestinal fistula, aftercare for joint replacement, UTI, diabetes with neuropathy, history of right breast cancer, low back pain, nicotine dependence, depression, high blood pressure, blood clots in the legs, and anemia, monthly pharmacy medication reviews were completed and pharmacist recommendations were documented on 03/14/25, 04/07/25, 04/27/25, 06/02/25, 07/09/25, and 09/02/25. Medical provider acknowledgement or follow-up was documented for several of those recommendations, but there was no documentation of the specific recommendations made on 03/14/25 and no documentation of provider review or follow-up for that review. For Resident #04, admitted with diagnoses including heart failure, lung disease, contracture of the right hand, heart disease, anemia, chronic back pain, high blood pressure, and degenerative joint disorder of the cervical and lumbar regions, monthly pharmacy medication reviews were completed and pharmacist recommendations were documented on multiple dates, but there was no documentation of medical provider review and follow-up for the recommendation made on 05/28/25.
Failure to Arrange Dental Services for Lost or Damaged Dentures
Penalty
Summary
The facility failed to refer a resident with lost or damaged dentures for dental services, and failed to document why a referral did not occur within three days. Resident #22 had multiple diagnoses including vascular dementia, mild cognitive impairment, generalized anxiety disorder, major depressive disorder, seizures, and muscle weakness. His care plan identified a dental problem related to upper and lower dentures, with notes that his lower dentures had not fit well and later were not present. The dental summary showed repeated complaints over time that the lower dentures were too loose, and on 07/09/24 the resident was seen for broken dentures that were sent to a dental lab for repair, with no subsequent documentation that they were returned and fit for use. Additional records showed conflicting documentation about the resident’s denture status. A nursing progress note dated 12/05/24 stated he only had upper dentures, while later MDS notes entered in 05/27/25 and 08/19/25 described him as edentulous with upper dentures and lower dentures that did not fit. During interview, the resident stated he had uppers but not downers and did not believe he still had bottom dentures. The administrator stated social services was responsible for arranging dental services, and the facility policy on dental services stated dentures would be protected from loss or damage to the extent practicable and replaced at the resident’s expense, but it did not identify circumstances when loss or damage was the facility’s responsibility or address how such dentures would be handled.
Failure to Honor Resident Food Preferences and Dietary Orders
Penalty
Summary
The facility failed to ensure residents’ food choices related to needs and preferences were honored for two residents reviewed for food service. One resident was cognitively intact with diagnoses including cellulitis of the right lower limb, chronic ulcer of the right lower limb, chronic heart failure, multiple sclerosis, and anxiety. The resident stated she orders omelets every day for lunch and had not received one for two days, and she complained before a CNA brought an extra sausage patty. The lunch ticket showed a regular diet with a 2000 cc fluid restriction and a daily lunch order of a cheese omelet, sausage patty, and chocolate milk, with special instructions that the resident wanted an omelet and sausage every day. The Dietary Supervisor confirmed the facility had been out of omelets for the last couple of days and said the next shipment was not due until the following Thursday, adding that she was unable to order enough omelets due to budget concerns. A second resident with diagnoses including pneumonia related to inhalation of food and vomit, diabetes, vascular disease, heart disease, kidney disease, fatty liver, high blood pressure, ADHD, overactive bladder, anxiety, fibromyalgia, and anemia had dietary orders for a consistent carbohydrate diet with regular texture and thin liquids. The breakfast meal ticket specified hot tea with two sweeteners, lactose free milk, and apple juice, with low-calorie sweeteners noted for meals. Observation of the resident’s tray showed only hot water with no tea bags, no milk, and no apple juice. The resident reported the kitchen was often out of lactose free milk, often forgot tea bags, and brought regular syrup instead of sugar free syrup for French toast; she also said she had ordered oatmeal but was given waffles instead. When CNA staff asked if she wanted something else, the kitchen reported breakfast service was over and offered cold cereal, which the resident declined because there was no lactose free milk. A staff member confirmed the facility had been out of lactose free milk for approximately two weeks and verified the resident’s meal ticket required lactose free milk and low-calorie sweetener with meals.
Failure to Provide Ice Water Between Meals
Penalty
Summary
The facility failed to ensure ice water was provided to residents between meals, affecting one resident reviewed for hydration/nutrition. Resident #10 was admitted with diagnoses including cerebrovascular disease, dementia, diabetes mellitus, congestive heart failure, chronic kidney disease, and adult failure to thrive. The quarterly MDS dated 06/24/25 indicated the resident was moderately cognitively impaired and required staff assistance with ADLs. On 09/18/25 at 1:26 P.M., the resident was observed lying in bed with no ice water or other drink on the bedside table. Later that day at 3:28 P.M., the resident was again observed lying in bed, tearful and requesting to be pulled up in bed, with no ice water or other drink available and dry lips noted. CNA #860 confirmed at 3:25 P.M. that the resident should be checked every two hours and did not have ice water or a drink available. The ADON also confirmed at 3:30 P.M. that the resident did not have ice water or any other drink available.
Inaccurate behavior documentation for a wandering resident
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #12 in the area of behaviors. Resident #12 was admitted with diagnoses including dementia, cerebral infarction, attention and concentration deficit, chronic kidney disease stage 2, restlessness and agitation, anxiety disorder, major depressive disorder, insomnia, muscle weakness, and chronic pain. The quarterly MDS described the resident as severely impaired for daily decision making, continuously inattentive, with continuous behaviors of disorganized thinking and altered level of consciousness, daily wandering, and residence on a secure locked unit. The resident’s plan of care identified her as an elopement risk and wanderer related to disorientation to place, impaired safety awareness, wandering aimlessly, and intruding on the privacy or activities of others, with interventions to document wandering behavior and attempted diversional interventions in the behavior log. However, review of CNA TASK documentation showed staff were not documenting behaviors, with no behaviors recorded for the last 30-day period and areas for wandering and entering other residents’ rooms left unmarked. Observation showed Resident #12 in another resident’s room sitting in a recliner, and CNA interviews stated the resident wandered into other residents’ rooms every day and that staff had been told not to document behaviors in TASK. The DON stated aides were to document behaviors in electronic TASK and verified that documenting no behaviors was not accurate.
Missing Hospice Communication Documentation
Penalty
Summary
The facility failed to ensure coordination of care communication between Resident #10's hospice provider and the facility. Resident #10 was admitted to the facility with diagnoses including cerebrovascular disease, dementia, diabetes mellitus, congestive heart failure, chronic kidney disease, and adult failure to thrive. The quarterly MDS assessment dated 06/24/25 indicated the resident was moderately cognitively impaired and required staff assistance with ADLs. A physician order dated 09/16/25 showed the resident was admitted to hospice services. During interview, the DON confirmed the resident's EMR did not contain hospice communication documentation and stated that hospice documentation and progress notes were maintained in an individual hospice binder at the nursing station. However, observation of Resident #10's hospice binder at the nursing station revealed no hospice communication documentation or hospice progress notes. An LPN confirmed hospice progress notes and hospice communication documents were kept in the hospice binders and verified that Resident #10's hospice binder was empty of any documentation. Review of the facility policy titled Addendum to Hospice Contract stated that hospice and the facility shall communicate regularly and as needed for each hospice patient and that each party is responsible for documenting such communication in its respective clinical records.
Infection Preventionist Did Not Attend Quarterly QA Meetings
Penalty
Summary
The facility failed to ensure the Infection Preventionist attended quarterly Quality Assurance meetings. Review of QA meeting sign-in sheets showed meetings were held on 10/08/24, 01/07/25, 04/05/25, and in June 2025, but there was no evidence that the facility's Infection Control Preventionist participated in the QA meetings other than in June 2025. During an interview on 09/23/25 at 1:00 P.M., Registered Nurse #500 stated she had served as the facility Infection Preventionist since 2019 and verified that she was not attending the quarterly QA meetings. The census was 63.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The facility failed to follow proper hand hygiene and glove use during incontinence care for Resident #04, who was admitted with diagnoses including heart failure, lung disease, contracture of the right hand, heart disease, anemia, chronic back pain, high blood pressure, and degenerative joint disorder of the cervical and lumbar regions. The resident’s most recent quarterly MDS showed dependence on staff for personal care, moderately impaired cognitive skills for daily decision making, wheelchair use for mobility, and that the resident was always incontinent of bladder and bowels. During observation, a CNA cleaned stool from the resident’s buttocks and applied a thick layer of pink barrier cream to the buttocks and inner thighs, then did not remove gloves or perform hand hygiene. The CNA then fixed the bed rail, adjusted the bed, and grabbed and adjusted the resident’s blanket with the same gloved hands that had barrier cream on them. The ADON later stated the CNA had said she did not change her gloves before touching other surfaces in the room and should have.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to ensure the appropriate use of antibiotics for one resident reviewed for unnecessary medications. Resident #44 was admitted with diagnoses including Alzheimer's disease, dementia, left bundle branch block, lymphedema, edema, anxiety, and muscle weakness. A physician order dated 07/18/25 directed Nitrofurantoin Mono-Mac 100 mg, one capsule by mouth in the morning and at bedtime for seven days for an E. coli urinary tract infection. The July 2025 MAR also showed the resident was started on Cefdinir 300 mg on 07/19/25. Review of the Infection Control Log for July 2025 showed Resident #44 was ordered Nitrofurantoin Mono-Mac 100 mg, one capsule by mouth in the morning and at bedtime for seven days for a UTI, with a start date of 07/19/25. There was no evidence of an assessment to determine whether the antibiotic was appropriate and met criteria. During interview on 09/23/25 at 4:09 P.M., the Infection Preventionist/ADON stated she uses McGeer Criteria to determine if an antibiotic is appropriate, but this had not been completed for Resident #44. The facility policy titled Antibiotic Stewardship, dated December 2016, stated antibiotics will be prescribed and administered under the guidance of the facility's antibiotic stewardship program and that the purpose of the program is to monitor antibiotic use in residents.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control procedures during medication administration for two residents. For one resident with a history of cerebral infarction and chronic pain syndrome, an LPN did not perform hand hygiene before preparing medications, before donning gloves, after removing gloves, or before and after administering medications. The LPN handled the medication cart, computer, and administered medications without performing hand hygiene at any of the required steps. The LPN confirmed during interview that hand hygiene was not performed as required. For another resident with metabolic encephalopathy, an LPN washed hands before administering medications but failed to perform hand hygiene after completing medication administration. The LPN acknowledged forgetting to perform hand hygiene after the task. The Director of Nursing confirmed that facility policy requires hand hygiene before and after each resident interaction during medication administration, as well as before donning and after removing gloves. Facility policies reviewed emphasized the importance of hand hygiene as the primary means to prevent healthcare-associated infections and specified the required moments for hand hygiene.
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 561 citations issued within 25 miles in the last 12 months — including the 5 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 Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Nursing Home, Inc | 0.2 mi | ★★★★★ | 11 | 0 |
| Canton Christian Home | 0.7 mi | ★★★★★ | 14 | 0 |
| The Pines Healthcare Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Hall Of Fame Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 8 | 0 |
| Astoria Skilled Nursing And Rehabilitation | 2.5 mi | ★★★★★ | 3 | 1 |
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 June 2026) and official state health department websites.