Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vineyards At Concord, The during CMS and state inspections, most recent first.
Failure to Ensure Effective Fall Prevention and Investigate Falls: A resident with severe cognitive impairment, a history of falls, osteoporosis, and major transfer assistance needs had repeated falls and near-falls. The resident was found on the floor without the walker, later fell again while trying to get back into bed, and ultimately sustained a displaced spiral fracture of the femur requiring surgical repair. The facility did not document a comprehensive root-cause investigation or show that an individualized fall program was developed, and the DON verified the ordered sensor alarm was not functioning and that the wrong alarm device was being used in the Broda chair.
Insufficient staffing led to delayed meal service and missed resident care. A resident was observed with a saturated brief and liner with a strong urine odor after not being toileted for quite some time, while the DON stated the facility was understaffed and resident care was being missed. The Administrator confirmed meals were not being served on time, and staffing records showed direct care staffing fell below the minimum requirement on two days.
Administrative oversight failed when the facility did not maintain sufficient staffing, did not have a qualified activities director, and limited key leaders’ work hours. The DON stated the facility was understaffed and that resident care was missed, staffing levels fell below the minimum requirement on two days in the survey look-back period, and observations showed only limited activities in the common area. The Administrator confirmed there was no current AD with the required qualifications, the LNHA was limited to 16 hours per week, the DON was working the floor and covering call-offs, and the DM was only permitted to work three days a week.
Surveyors found that during a lunch meal, pork and sauerkraut intended for residents on regular diets were prepared and served in a mechanically textured form to multiple residents whose orders specified regular diets. A dietary staff member stated she routinely prepares the meat this way so all residents receive similar-looking portions and to reduce choking risk, and also reported using milk in the pureed pork and sauerkraut to add calories and nutrients. Record review confirmed that numerous affected individuals were on regular diets, and facility leadership acknowledged that serving mechanically textured meat to these residents and not following the established puree recipe was inappropriate.
Advance directive policies and DNR care plans were not established or implemented for four residents. Residents with DNRCC-Arrest, DNRCC, and DNRCC-DNI orders had no related care plans in their records, and the FM stated the facility did not develop comprehensive advanced care plans and was unfamiliar with the regulation.
Activities program not directed by a qualified professional. Surveyors observed only music in the common area and one snack-making activity, with no activity director seen in the facility. The Administrator and Facility Manager confirmed the facility had no current activities director and no staff member with the required qualifications, while one resident said he was often bored and there was not much to do.
A resident with multiple chronic conditions kept Fluticasone Propionate in her purse at bedside and reported using it daily, even though there was no order or assessment allowing self-administration or bedside storage. An LPN later found the medication unavailable for administration, and the DON confirmed there was no supporting order or assessment; the LNHA also stated there was no policy on self-administration or medication storage. In addition, the facility’s medication cart contained multiple expired medications, which an LPN verified should have been discarded, and five residents had orders for those medications.
Meals were not prepared and delivered on time according to the dining schedule. Staff reported breakfast, lunch, and dinner service times, but observations showed residents waiting in the dining room while breakfast and lunch were delayed, with hall trays served before the dining room on one occasion. An aide and the Administrator acknowledged the facility was running behind and that meals were not being served on time. One resident was NPO, and the census was 27.
Menu Not Followed and Substitutions Not Documented: Staff did not follow the posted lunch menu, did not complete a substitution log, and prepared pork and sauerkraut as mechanical texture for residents on a regular diet. A cook also confirmed the meat was pureed with milk, and additional menu items were substituted without documentation; the next day, staff again confirmed a planned pasta substitute because ravioli was unavailable.
Improper food storage, labeling, and temperature monitoring were identified in the kitchen. Dry storage, freezer, and refrigerator items were found without dates or labels, including resident food brought in by family, drinks, and spices; a scoop was left in sugar, and a bag of oats was unsealed and stored on the floor. The dish machine sanitizer did not register chemical, the testing strips were expired, the thermometer was not accurate, and the meal temperature log was prefilled with missing entries.
Surveyors found that two residents with severe cognitive deficits and multiple chronic conditions, both dependent on staff for personal hygiene per their MDS and care plans, had long, jagged, and visibly dirty fingernails with brown material under the nail beds on repeated observations. Care plans for ADL self-care deficits and altered ADL function included staff responsibility for checking, trimming, cleaning nails, and assisting with ADLs, yet these interventions were not carried out. The DON confirmed the poor nail condition for both residents, and the LNHA acknowledged there was no facility policy addressing nail care.
Two residents with severe cognitive impairment and documented bladder incontinence care plans were not provided routine incontinence care or scheduled toileting. One resident, always incontinent and dependent on staff for toileting and hygiene, remained seated in the dining area for many hours until staff observed that his pants were saturated with urine, confirming that incontinence care had not been provided. Another resident, also always incontinent and care planned to be toileted every two hours, remained in the dining area for an extended period without toileting; when CNAs eventually provided care, they found a brief and liner completely saturated with strong ammonia-smelling urine, and staff acknowledged the resident had not been toileted for quite some time.
Two residents with severe cognitive impairment and documented abnormal weight loss experienced significant, ongoing weight decline while the facility failed to implement a comprehensive, resident-centered nutrition plan. For one resident with Alzheimer’s and prior hospital weight loss, an RD recommended supplements, but no specific supplement order was written, weights were not consistently updated in the EHR, meal intake percentages were frequently undocumented, and multiple MD/FNP visits did not address the continued weight loss. For another resident with protein-calorie malnutrition and multiple comorbidities, there was no initial comprehensive nutrition assessment, no care plan for weight loss, and no evidence that RD-recommended house shakes twice daily were implemented, despite marked weight drops. Facility staff inconsistently documented meal intake, used a non-standardized whey protein "house supplement" instead of the RD-recommended Ready Pass for most residents, and prepared this supplement without a set recipe, while the MD was unaware of its use.
Surveyors found that the facility did not follow its Enhanced Barrier Precautions policy for two residents with invasive devices. One resident with a gastric feeding tube had tube feeding performed without gowns or gloves available in or outside the room, and no EBP orders were in place despite signage requiring gown and glove use for feeding tube care. Another resident receiving IV antibiotic therapy via a PICC/midline for pyothorax had IV medication administered by the DON, who used hand hygiene and gloves but did not don a gown or other required PPE, and the resident was not placed on EBP despite qualifying under facility policy.
Failure to Provide Dignified Meal Assistance: A resident with Huntington's disease and moderate cognitive impairment required max assist with eating, but was left waiting while other residents were served lunch first. When the resident finally received a meal, the CNA repeatedly left to assist others, obtain tea, and redirect another resident, and the resident was later wheeled out of the dining room with food still on the table. The resident stated it was routine to wait a long time to be fed and that watching others eat upset him.
Failure to Notify Physician of Significant Weight Loss: The facility did not notify the MD/CNP of significant wt loss for two residents with severe cognitive deficits and multiple chronic conditions. One resident had rapid wt loss from 109 lbs to 89.5 lbs, and another had a 19-lb loss over 60 days; the record lacked documentation that the physician was notified, despite a facility policy requiring immediate reporting of a 5-lb wt change within one month.
Missing Bed Hold Notice and Incomplete Discharge Summary: The facility failed to provide a resident with a written bed hold notice after transfer to an acute care setting and failed to send another resident a comprehensive discharge summary after planned discharge. One resident had multiple chronic conditions including dementia, CHF, AFib, and chronic pain, and was sent to an inpatient psych hospital with only the facility bed hold policy provided instead of the required bed hold details. Another resident, who had no cognitive deficit and was planning discharge to the community, left with medications and appointments documented, but the record lacked a full discharge summary, medication reconciliation, and discharge instructions.
A resident with multiple diagnoses, including pyothorax, anemia, atrial fibrillation, and depression, had an admission comprehensive MDS that was still in progress beyond the required 14-day window. The FM verified the assessment had not been completed within the first 14 days of the resident's stay, which did not meet RAI 3.0 requirements.
Incomplete care plans for alarm use and CPAP therapy. Two residents had physician-ordered interventions that were not addressed in their care plans. One resident with severe cognitive impairment, a fracture history, and fall risk had orders for a pressure pad alarm on the mattress and Broda chair, but the plan only addressed general fall precautions and a bed alarm, not the chair sensor alarm. Another resident with OSA and COPD had a CPAP order during sleep, but the care plan did not address CPAP use, and the FM confirmed no comprehensive plan existed.
Failure to comprehensively assess and weekly monitor a skin impairment. A resident with multiple chronic conditions, including DM, CKD, COPD, and HTN, was identified as at risk for skin breakdown and had MASD. Staff documented a small skin split on the inner buttocks and a small abrasion on the outer labia with an order for skin prep, but the record had no initial comprehensive assessment of the wounds and no weekly wound assessments. The DON confirmed the missing assessments, and the LNHA stated the facility had no policy for wounds that were not pressure ulcers or stasis ulcers.
A resident with OSA and COPD had CPAP ordered for use during sleep, but the record had no physician-ordered CPAP settings or cleansing instructions for the mask and tubing, and the care plan did not address CPAP use. During observation, the CPAP machine was sitting on the nightstand without a protective covering, and an LPN verified the mask was not stored in a protective covering; the FM and LNHA confirmed the missing orders and lack of a CPAP policy.
Medications were not available for administration for a resident with multiple chronic conditions, including AFib, HTN, DM, CKD, COPD, and GERD. An LPN observed that ordered B-Complex with Biotin and Folic Acid, Vitamin E 400, and fluticasone nasal spray were not on hand during morning med pass, and the LPN verified the meds were unavailable.
Medication Error Rate Exceeded Threshold: An LPN made 3 medication errors during a medication pass, resulting in a 12% error rate. An expired Omeprazole stock medication was prepared and administered to a resident, and two ordered medications were not available to give. The issue affected one resident during observation.
Several residents with cognitive and physical impairments experienced multiple falls that were not consistently reported or investigated by staff, and individualized fall care plans were either missing or incomplete. Interventions such as alarms, low beds, and fall mats were not always documented in care plans or supported by physician orders, despite facility policy requiring these actions.
A resident with cognitive impairment and multiple health conditions experienced several injuries, including facial bruising, a swollen foot, and fractures, after reporting being punched and stomped on by another resident. Despite staff observations and the resident's statements, the facility did not report these incidents or conduct a thorough investigation as required by policy and state regulations.
A resident with cognitive impairment and a history of falls experienced multiple injuries, including a swollen foot, facial bruising, and a fractured pelvis. Despite policy requirements, the facility did not fully investigate or report these injuries, and the administrator did not submit a self-reported incident or conduct further inquiry into the causes of the injuries.
The facility failed to complete a significant change PASARR for two residents after new mental health diagnoses were added. One resident with multiple diagnoses, including schizophrenia, had a new diagnosis of unspecified psychosis, while another resident with heart failure received a new diagnosis of schizoaffective disorder. Interviews with an LPN and the DON confirmed that the necessary PASARR updates were not conducted.
The facility failed to ensure stop dates for as-needed psychotropic medications for two residents. One resident had orders for Hydroxyzine and Xanax without stop dates, while another had a topical gel containing Ativan, Benadryl, Haldol, and Reglan also lacking a stop date. The Director of Nursing confirmed these omissions during the survey.
Failure to Ensure Effective Fall Prevention and Investigate Falls
Penalty
Summary
The facility failed to ensure adequate fall risk and safety interventions were in place and functioning to prevent falls, and it failed to document and comprehensively investigate falls. One resident had multiple risk factors for falls, including severe cognitive impairment, a history of falls, osteoporosis, and need for substantial to maximal assistance with transfers. The resident’s care plan identified fall risk related to confusion, deconditioning, gait and balance problems, lack of awareness of safety needs, fall/fracture history, and medication use, with interventions including a bed alarm and reminders to use the call light and walker. The resident experienced repeated falls and near-falls in the facility. After one fall, the resident was found on the floor without the walker and wearing slippers without non-skid soles. Another incident occurred when the resident was found on the floor after trying to get back into bed, and the record showed the sensor alarm was in place and functioning at that time. The facility did not provide evidence of a comprehensive investigation to determine the root cause of the falls or to evaluate whether the fall interventions remained appropriate. The record also did not show that an individualized fall program was developed and implemented to prevent further falls. On a later occasion, the resident was found lying on the floor beside the bed after trying to get up without assistance and reported severe pain to the right lower extremity. The hospital discharge summary showed the fall resulted in a traumatic spiral fracture of the right distal femur with displacement, requiring open reduction and internal fixation of the right femoral shaft fracture and later a blood transfusion for acute blood loss anemia. A subsequent assessment documented severe cognitive impairment and dependence or substantial assistance for multiple activities, yet the resident was observed trying to get out of a Broda chair with a personal tab alarm in place instead of the ordered sensor alarm. The DON verified the sensor alarm was not functioning when the resident was found on the floor and confirmed the wrong alarm device had been used.
Insufficient staffing and delayed meal service
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and failed to have a licensed nurse in charge on each shift. Survey observations from 04/13/26 through 04/15/26 found meals being passed late. On 04/13/26 at 3:20 P.M., a resident was observed being wheeled from the dining room to her room for incontinence care; her pants were pulled down and she had a blue brief and a large liner that were completely saturated with urine and had a strong ammonia odor. A CNA stated the resident was supposed to be toileted every hour and a half, and another CNA stated she had not been toileted for quite some time. The DON stated on 04/14/26 that the facility needed help, was understaffed, and resident care was missed because of it. The Administrator confirmed on 04/15/26 that meals were not being served on time, and on 04/16/26 breakfast was ready but waiting on staff to serve. Review of the Survey Staffing Tool for 04/07/26 through 04/13/26 showed direct care staffing was below the minimum requirement on 04/07/2026 and 04/10/2026.
Administrative Oversight, Staffing, and Activities Program Deficiencies
Penalty
Summary
The facility failed to be administered in a manner that used its resources effectively and efficiently to ensure resident safety. The report states that the facility failed to maintain an activities program directed by a qualified activities professional, failed to maintain sufficient staffing to provide for resident care needs, and failed to ensure the LNHA, DON, and RD were permitted to work enough hours to effectively complete their jobs. These deficiencies were described as significant breakdowns in administrative oversight and were reported to have the potential to affect all 27 residents in the facility. During the survey, the DON stated that the facility was understaffed and that resident care was missed because of it. The Survey Staffing Tool showed that direct care staffing levels were below the minimum requirement on 04/07/2026 and 04/10/2026. Survey observations showed only music playing in the common area and one snack-making activity, and the Administrator confirmed that the facility did not have a current activities director and did not employ anyone with the required qualifications. The Administrator also stated she was only permitted to work 16 hours per week, the DON reported working the floor at least every Monday and Tuesday while also filling in for call-offs and time off, and the Administrator stated the dietary manager was part-time and only permitted to work three days a week.
Failure to Follow Regular Diet Orders When Serving Mechanically Textured Meat
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered diets by serving mechanically textured pork and sauerkraut to residents who were ordered regular diets. During a lunch observation, the scheduled meal of pork and sauerkraut, mashed potatoes, and bread pudding was prepared so that the pork and sauerkraut were mechanically textured and served in that form to residents on regular diets, affecting 18 residents who were ordered regular diets. The dietary associate who prepared the meal confirmed that she mechanically textures the pork so that all residents receive the same looking meat and to reduce choking hazards, and also confirmed that the pureed pork and sauerkraut were made with milk to add calories and nutrients. Review of medical records showed that these 18 residents were on regular diets, and the Administrator later confirmed that serving mechanically textured meat to residents on regular diets was not appropriate and that an existing puree recipe for the lunch meal had not been followed. This deficiency was cited under the requirement to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs and was investigated under Complaint Number 2984105.
Advance Directive Policies and DNR Care Plans Not Implemented
Penalty
Summary
The facility failed to establish, maintain, and implement written policies and procedures regarding residents’ rights to formulate an advance directive. During record review and interview, the facility administrator verified that written policies and procedures regarding advance directives had not been established, maintained, or implemented. The deficiency involved four residents reviewed for advance directives in a census of 27. Resident #3 had diagnoses including schizoaffective disorder, bipolar type, dysphagia, Parkinson’s disease, diabetes mellitus, cirrhosis of the liver, anemia, and other chronic conditions, and had a DNRCC-Arrest order and form, but no related care plan was found. Resident #4, with diagnoses including a displaced spiral fracture of the right femur, malnutrition, palliative care, anemia, osteoporosis, diabetes mellitus, and other conditions, had a DNRCC order and no related care plan. Resident #15, with diagnoses including neuropathy, peripheral vascular disease, vascular dementia, major depressive disorder, cerebral infarction, hypertension, gout, insomnia, and anxiety disorder, had a DNRCC-DNI order and no related care plan. Resident #18, with diagnoses including atrial fibrillation, heart disease, COPD, chronic kidney disease, diabetes mellitus, chronic pain syndrome, and sleep apnea, had a DNRCC-Arrest order and no related care plan. A Facility Manager stated the facility did not develop comprehensive advanced care plans and was unfamiliar with the regulation.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The facility failed to maintain an activities program directed by a qualified activities professional. During the annual survey, surveyors observed music playing in the common area throughout the days and one snack-making activity with residents, but no other activities were observed and no activity director was seen in the facility. The Administrator and Facility Manager confirmed that the facility did not have a current activities director and did not employ anyone with the required qualifications, stating that someone helped on weekends but did not meet the required qualifications. Resident #2 stated she did not have an issue with the activities because she mostly stayed in her room, watched TV, and did not wish to attend activities, and Resident #26 stated he was often bored and there was not much to do in the facility.
Medication Storage and Expired Medication Handling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely for a resident who had diagnoses including atrial fibrillation, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, COPD, GERD, and obstructive sleep apnea. The resident’s MDS indicated no cognitive deficit, and the record showed orders for B-Complex with Biotin and Folic Acid, Vitamin E, and Fluticasone Propionate Nasal Suspension. The resident had deferred medication administration to facility staff, but the record contained no self-medication administration assessment to determine whether the resident could self-administer medications. A progress note documented that the resident kept Fluticasone Propionate Nasal Suspension in her purse at bedside along with a Symbicort inhaler and stated she used the medication every morning and every night. During observation, an LPN prepared the resident’s morning medications and the facility did not have the Fluticasone Propionate Nasal Suspension available to administer. The DON confirmed there was no physician order or assessment allowing the resident to keep the medication at bedside and self-administer it, and the LNHA verified the facility had no policy addressing self-administration of medications or medication storage. The facility also failed to dispose of expired medications on the medication cart. Observation of the facility’s only medication cart identified seven expired medications, including Vitamin B1, two cranberry products, a probiotic, zinc, omega 3, Senokot, and omeprazole, with expiration dates ranging from 11/2024 through 03/26. The LPN verified the medications were expired and should have been discarded. Five residents had orders for the medications found expired on the cart, and the LNHA verified the facility had no policy addressing self-administration of medications or medication storage.
Meals Not Served Timely
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services, resulting in meals not being prepared and delivered on time according to the dining schedule. Staff interviews identified that breakfast was scheduled for 7:45/8:00 A.M., lunch for 11:45/12:00 P.M., and dinner for 4:30/5:30 P.M., with dining staff consisting of a cook and occasionally a hospitality aide. Observations showed lunch had not started for 11 residents in the dining room at 12:21 P.M., breakfast was still not being served at 8:50 A.M. on another day while residents waited in the dining room, and lunch service on 04/15/26 did not begin in the halls until 12:50 P.M. and in the dining room until 1:03 P.M. Staff confirmed the facility was running behind and waiting on hall trays before serving the dining room, and the Administrator acknowledged meals were not being served on time. The facility identified one resident who was NPO, and the census was 27.
Menu Not Followed and Substitutions Not Documented
Penalty
Summary
The facility failed to follow the posted menu, complete a substitution log when menu items were changed, and prepare a meal in accordance with the ordered diet. The report identified one resident who was NPO, and the facility census was 27 residents. The menu for lunch on 04/15/26 listed pork and sauerkraut, mashed potatoes, and pumpkin bread pudding, but observation at 12:15 P.M. showed lunch being prepared as pork and sauerkraut made into a mechanical texture, mashed potatoes instead of scalloped potatoes, and apple bread pudding instead of pumpkin bread pudding. During interview, the cook confirmed the pork was made mechanical texture for residents on a regular diet so they would receive the same looking meat and to reduce choking hazard. She also confirmed she did not follow the menu and pureed the pork and sauerkraut with milk, stating she used milk to add calories and nutrients. Later interview confirmed the lunch meal did not follow the menu and no substitution log was completed. Observation at 1:10 P.M. showed pork and sauerkraut served as mechanical soft instead of regular diet, with mashed potatoes substituted for scalloped potatoes and apple bread pudding served instead of pumpkin bread pudding. The next day, lunch was observed as ravioli with meat sauce on the menu, but staff confirmed there was no ravioli and a pasta substitute would be used; the substitution log could not be located.
Improper Food Storage, Labeling, and Temperature Monitoring
Penalty
Summary
Food was not stored appropriately and the kitchen environment was not maintained in a sanitary manner. During a walk-through of the dry storage area, a scoop was found in the sugar container, a 50-lb bag of oats was not sealed or dated and was stored on the floor, and beans, sugar, and rice containers had no dates. In the freezer, bags of green beans, cauliflower, broccoli, carrots, tater tots, and hashbrowns had no dates. In the refrigerator, pepperoni was dated 01/26/26, deli cheese had no date, a veggie and fruit tray had no date, and mustard had no label or date. Resident food brought in by family or visitors was also found without dates or labels, including cubed cheese, grapes, cuties, red seedless grapes, and a styrofoam box of food. Drink containers of juice, house shake, tea, and lemonade were not labeled or dated. On a later observation, vegetable and potato bags in the freezer and a half-gallon bag of what appeared to be kielbasa had no date or label, and resident food in the refrigerator continued to be undated. Spices including onion powder, salt, cinnamon, cayenne pepper, dill weed, granulated garlic, and paprika were not dated. The dish machine sanitizer did not register chemical, testing strips were expired, and the sanitizer still did not register until the dish machine was primed. The thermometer used for meal temperatures was not working accurately, and the food temperature log for 04/15/26 was prefilled; the log also had no meal temperatures recorded for 03/30/26 and 03/31/26. The staff member interviewed stated she had made a mistake.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary nail care for residents who were dependent on staff for activities of daily living (ADLs), specifically personal hygiene. One resident with severe cognitive impairment, multiple diagnoses including neuropathy, peripheral vascular disease, vascular dementia, cerebrovascular accident, and other chronic conditions had a care plan intervention directing staff to check nail length and trim and clean nails on bath day and as necessary. Despite this, surveyor observations on two consecutive days showed the resident’s nails were long, jagged, and had a brown substance under the nail bed. The DON confirmed during interview that the resident’s nails were in need of nail care. Another resident, also with severe cognitive impairment and multiple diagnoses including hypertensive heart disease, atrial fibrillation, dementia with anxiety, Alzheimer’s disease, psychosis, and gastrointestinal conditions, had a care plan for altered ADL function. Interventions included providing set-up, supervision, cues, and assistance through completion of ADLs, encouraging participation at the resident’s optimal level, and providing oral care daily and as needed. The MDS indicated the resident was dependent on staff for toileting and personal hygiene and did not reject care. However, surveyor observations on two consecutive days found this resident’s nails were long, jagged, and dirty with a brown substance under the nails. The DON verified that the nails were in need of care, and the LNHA reported that the facility had no policy related to care of residents’ nails. This deficiency was cited under a complaint investigation.
Failure to Provide Routine Incontinence Care and Scheduled Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide routine incontinence care and toileting as outlined in residents’ care plans. One resident with severe cognitive impairment, vascular dementia, and multiple comorbidities was care planned for bladder incontinence with interventions such as establishing voiding patterns, monitoring intake and output, encouraging fluids, and monitoring for UTI symptoms. The resident was documented as always incontinent of bladder and frequently incontinent of bowel, and dependent on staff for toileting and personal hygiene. On the survey date, the resident was observed sitting at the dining room table continuously from the start of the survey in the morning until mid-afternoon. By 3:15 P.M., the resident’s pants were visibly wet near the groin, and a CNA confirmed the pants were saturated with urine and that routine incontinence care had not been provided. Another resident, also with severe cognitive impairment, dementia, Alzheimer’s disease, and multiple other diagnoses, had a care plan for actual bladder incontinence related to dementia and need for assistance with personal care. Interventions included toileting every two hours, assistance with toileting and cleansing, use of double briefs to protect dignity, provision of peri-care to maintain cleanliness and dryness, and observation for UTI signs and symptoms. The resident was assessed as always incontinent of bowel and bladder and dependent on staff for toileting and personal hygiene, with no documented refusal of care on the day in question. On that day, the resident was observed sitting at the dining room table from early morning until mid-afternoon without being toileted. When two CNAs finally provided incontinence care, they found the resident wearing a blue brief and a large liner that were completely saturated with strong ammonia-smelling urine. One CNA stated the resident was supposed to be toileted every hour and a half, and the other CNA acknowledged the resident had not been toileted for quite some time.
Failure to Assess, Monitor, and Implement Nutritional Interventions for Residents With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide a comprehensive, resident-centered plan of care to prevent, timely identify, and treat weight loss, as well as failures in obtaining, documenting, and monitoring weights, documenting meal intake, and providing and preparing nutritional supplements as ordered. For one resident with Alzheimer’s disease, generalized anxiety, and abnormal weight loss, the RD/Administrator recommended adding four ounces of a nutritional supplement between or with meals, but no specific supplement type was documented and no corresponding physician order was entered. Despite documented abnormal weight loss prior to admission and subsequent significant weight loss after admission, multiple progress notes by the FNP and the Medical Director did not address the ongoing weight loss beyond general statements to monitor weight and intake. The resident’s weight declined from 156.8 lbs. prior to admission to 132 lbs. in February and then to 125.5 lbs. in April, yet there were no physician orders for supplements as recommended by the RD, and the resident’s meal ticket did not include any nutritional supplements. The same resident’s care plan, revised later for a nutritional problem related to weight loss prior to admission, contained general interventions such as encouraging compliance with diet and medications, monitoring weights as necessary, and providing supplements when awake or when intake was less than 75 percent. However, there was no evidence that specific supplement orders were written or implemented, and the MDS assessment did not reflect the resident’s weight loss. Meal intake documentation for this resident was incomplete and inconsistent, with multiple dates where no meal percentages were recorded and unclear documentation regarding whether supplements were received or accepted. Observation during a lunch meal showed the resident receiving a sandwich and grapes in the lobby, with no supplement observed. The RD acknowledged that staff were not consistently completing meal intake documentation, and the Medical Director stated he was unaware of the severe weight loss because current weights were not updated in the electronic record, making it appear that the weight had stabilized. For another resident with multiple diagnoses including moderate protein-calorie malnutrition, osteoporosis, diabetes, delusional disorder, and a history of falls and fractures, the facility also failed to adequately assess and address nutritional needs and weight loss. This resident experienced significant weight loss from 109 lbs. on admission to 103.5 lbs. within about two weeks, and then to 102.5 lbs., with the RD documenting that the resident was underweight for age and had a 5.9 percent weight loss in 30 days. The RD recommended adding house shakes twice daily for additional calories and protein and reported that the resident was added to the supplement list, but there was no evidence in the medical record that these recommendations were implemented. The resident’s weight later dropped to 89.5 lbs., a 12.68 percent loss in five days, without documentation of a reweigh to verify accuracy. There was no initial comprehensive nutritional assessment from the first admission to determine nutritional needs, and no care plan addressing the resident’s nutritional status or weight loss. Interviews revealed that the house supplement was made from a whey protein powder blend with creatine and amino acids, prepared without a standardized recipe, and that most residents received this house supplement rather than the Ready Pass supplement the RD had recommended for residents needing nutritional support. The Medical Director was not aware the whey protein powder was being used.
Failure to Implement Enhanced Barrier Precautions for Residents With Feeding Tube and IV/PICC Line
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy and maintain appropriate infection prevention and control practices for residents with invasive devices. For one resident with severe dementia, metabolic encephalopathy, Alzheimer’s disease, essential hypertension, dysphagia, and a gastric feeding tube, surveyors observed a tube feeding procedure during which no personal protective equipment (PPE) was available either outside or inside the room, and no gown was worn. Staff confirmed that proper PPE was not worn, that no gowns or gloves were set up outside or inside the room, and that the resident did not have EBP orders in place, despite a sign on the door stating that staff must wear gloves and a gown for high-contact care activities including feeding tube care. Review of the medical record confirmed there were no physician orders for EBP for this resident. For another resident admitted with pyothorax and multiple comorbidities, including anemia, prosthetic heart valve, osteoporosis, nicotine dependence, convulsions, hyperlipidemia, depression, pleural effusion, hypothyroidism, mood disorder, atrial fibrillation, and generalized anxiety disorder, the plan of care documented a pneumonia-like condition related to empyema and ongoing IV antibiotic therapy. Physician orders included maintaining a midline IV, flushing the IV line with normal saline, assessing the midline site every shift, maintaining and changing the dressing, and administering daily IV Ceftriaxone Sodium for pyothorax. During observation of the DON administering IV Ceftriaxone via a PICC line, the DON washed her hands, administered oral medications, set up the IV medication, washed her hands again, donned gloves, flushed the line, and connected the medication, but did not don a gown or mask for EBP. In interview, the DON verified she had not used PPE for EBP and acknowledged the resident was not on EBP, although the resident should have been under the facility’s EBP policy, which requires gowns and gloves for residents with open routes to their interior body, including feeding tubes and IVs, and PPE stations set up with gowns and gloves outside or just inside the doorway.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to ensure dignity and respect were shown to a resident who required maximum assistance with eating. Resident #16 had diagnoses including Huntington's disease, anxiety, and depression, and the quarterly MDS indicated a BIMS score of 09 out of 15, showing moderate cognitive impairment. During dining room observation, the resident was seated with 11 other unidentified residents waiting for lunch at 12:00 P.M., but the meal was served to the other residents at 12:26 P.M. while Resident #16 did not receive lunch at that time. Later observations showed Resident #16 received a meal at 1:30 P.M., with CNA #127 initially present to assist, but the CNA repeatedly left the table to assist other residents, obtain tea, and redirect another resident. At 1:58 P.M., CNA #127 asked if Resident #16 was done and then wheeled the resident out of the dining room; one bowl of food that had been offered during the meal was removed from the table. CNA #127 confirmed she was the only aide in the dining room and that Resident #16 had been waiting since noon for lunch. Resident #16 stated it was routine to wait a long time to be fed and that watching other residents eat upset him. The facility policy stated residents would be provided with dignity, assistance, and patience at meal times.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician or CNP of significant weight loss for two residents reviewed for nutrition. Resident #4 was admitted with diagnoses including displaced spiral fracture of the right femur, moderate protein calorie malnutrition, anemia, osteoporosis, diabetes mellitus, and severe cognitive impairment. Weight records showed 109 pounds on admission, 103.5 pounds about three weeks later, and then 89.5 pounds several days after that, reflecting a 13-pound loss in five days. The medical record contained no documented evidence that the physician or CNP was notified of the weight loss on the dates identified, and the LNHA verified this during interview. Resident #15 was admitted with diagnoses including neuropathy, peripheral vascular disease, vascular dementia, major depressive disorder, cerebral infarction, hypertension, gout, insomnia, and anxiety disorder, and had severe cognitive deficit. The resident’s care plan identified nutrition/hydration risk related to chronic disease, modified diet, mood changes, confusion, history of weight changes, and skin integrity issues. Weight records showed a decline from 205 pounds on admission to 176 pounds within about two months, including a 19-pound loss in 60 days, and the record showed no documented evidence that the physician or CNP was notified of the weight loss on the date identified. The facility policy stated that any five-pound weight change within one month should be immediately reported to the physician.
Missing Bed Hold Notice and Incomplete Discharge Summary
Penalty
Summary
The facility failed to provide a written bed hold notice when Resident #10 was transferred to an acute care setting. Resident #10 was admitted on 03/24/25 and later readmitted on 02/12/26 with diagnoses including anxiety disorder, heart failure, osteoarthritis, atrial fibrillation, dementia with behavioral disturbances, chronic pain, Alzheimer's disease, polycythemia vera, polyneuropathy, peripheral venous insufficiency, depression, hypertensive heart disease, hypertension, GERD, insomnia, and peripheral vascular disease. The resident was discharged to an inpatient psychiatric hospital, and the discharge summary showed the resident was given the facility's bed hold policy instead of written information that included the duration of the state bed hold policy, the reserve bed payment policy, the amount of bed holds left, and the rate to continue the bed hold if state-paid bed hold days were exhausted. The LNHA verified the resident had not received a bed hold notice containing all required components. The facility also failed to provide a comprehensive discharge summary for Resident #20 after a planned discharge to the community. Resident #20 was admitted on 03/27/26 with diagnoses including pyothorax, anemia, elevated WBC count, heart valve replacement, prosthetic heart valve, osteoporosis, nicotine dependence, convulsions, hyperlipidemia, depression, pleural effusion, hypothyroidism, mood disorder, atrial fibrillation, and generalized anxiety disorder. The resident's MDS showed no cognitive deficit and that the resident wanted to discharge to the community, with discharge planning already underway. The resident was discharged with a family member per request, and the record showed only the medications sent with the resident and the resident's initials acknowledging receipt. There was no evidence of a discharge summary with a recapitulation of the resident's stay, a final summary of status, reconciliation of pre-discharge and post-discharge medications, or discharge education. The DON confirmed she had the resident initial a document listing home medications and appointments, and later verified that no discharge summary with the required elements had been sent.
Late Completion of Admission Comprehensive MDS
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was completed within the first 14 days for one resident (#20) of 15 sampled residents. Resident #20 was admitted on 03/27/26 with diagnoses including pyothorax, anemia, elevated white blood cell count, heart valve replacement/prosthetic heart valve, osteoporosis, nicotine dependence, convulsions, hyperlipidemia, depression, pleural effusion, hypothyroidism, mood disorder, atrial fibrillation, and generalized anxiety disorder. Review of the resident's admission comprehensive MDS assessment showed it was still in progress more than 14 days after admission. During an interview on 04/14/26 at 10:51 A.M., the Facility Manager verified that the comprehensive MDS was still in progress and had not been completed within the first 14 days of the resident's stay. The RAI 3.0 user's manual states the admission comprehensive assessment must be completed no later than the fourteenth calendar day of the resident's stay.
Incomplete Care Plans for Alarm Use and CPAP Therapy
Penalty
Summary
The facility failed to develop a comprehensive plan of care to address resident needs and conditions for two residents. One resident had an admission and readmission history that included a displaced spiral fracture of the right femur, moderate protein calorie malnutrition, neuromuscular dysfunction of the bladder, palliative care, anemia, osteoporosis, diabetes mellitus, insomnia, hypertensive heart disease, hyperlipidemia, delusional disorder, hypertension, and a history of falling and nontraumatic fracture. The resident’s significant change MDS showed severe cognitive deficit and daily use of a bed alarm. Physician orders included a pressure pad alarm to the mattress and Broda chair to alert staff when the resident was getting out of bed every shift for safety, but the care plan only addressed fall risk in general and use of a bed electronic alarm, with no intervention addressing the alarm in the Broda chair or ensuring the sensor alarms were functioning. During observation, the resident was seen sitting on the edge of the Broda chair seat trying to get out of the chair, with a personal tab alarm in place instead of the ordered sensor alarm. The string attached to the tab alarm was long enough for the resident to attempt to get out of the chair without disconnecting to alert staff. A second resident had diagnoses including atrial fibrillation, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, COPD, GERD, and obstructive sleep apnea. The resident’s MDS indicated no cognitive deficit and that a CPAP machine was not utilized, but physician orders directed CPAP use during sleep to improve respiratory quality related to obstructive sleep apnea and COPD. The care plan did not address CPAP use, and the Facility Manager verified that no comprehensive plan of care addressed the CPAP machine.
Failure to Assess and Monitor Skin Impairment
Penalty
Summary
The facility failed to comprehensively assess a skin impairment when it was first identified and failed to complete weekly assessments afterward for one resident. The resident was admitted with diagnoses including atrial fibrillation, diabetes mellitus, chronic kidney disease, COPD, hypertension, chronic pain syndrome, and other chronic conditions. The medical record showed the resident had no cognitive deficit on the comprehensive MDS assessment, was at risk for skin breakdown, and had moisture associated skin damage. The care plan included interventions such as prompt peri-care, skin checks with showers, barrier cream or ointment as needed, pressure relief devices, and turning and repositioning while in bed. Progress notes documented that the resident’s buttocks/coccyx was assessed for wounds and that a small split in the skin on the left inner buttocks and a small abrasion on the right outer labia were observed, with an order for skin prep twice daily. However, the record contained no documented evidence of an initial comprehensive assessment of the skin split or abrasion and no documented weekly assessment of these wounds. The DON verified there was no initial comprehensive assessment or subsequent weekly assessment, and the LNHA verified the facility had no policy to address wounds that were not pressure ulcers or stasis ulcers.
CPAP Orders, Cleaning, and Storage Not Addressed
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #18, who was admitted with diagnoses including obstructive sleep apnea, COPD, atrial fibrillation, hypertension, diabetes mellitus, chronic kidney disease, and other chronic conditions. The resident’s MDS indicated no cognitive deficit. Physician orders dated 02/21/26 directed CPAP use during hours of sleep to improve respiratory quality related to obstructive sleep apnea and COPD, but the record contained no physician order for the CPAP settings and no cleansing instructions for the CPAP delivery mask or tubing. The resident’s care plan also did not address CPAP use. During observation on 04/15/26 at 9:45 A.M., the resident’s CPAP machine was seen sitting on the nightstand with no protective covering, and the LPN verified the CPAP delivery mask was not stored in a protective covering. Later that day, the Facility Manager confirmed there were no physician orders for the CPAP settings and no cleansing instructions for the mask and tubing. The LNHA also verified the facility had no policy addressing the use of a CPAP machine.
Medications Not Available for Administration
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure medications were available for administration for Resident #18. The resident was admitted on 02/19/26 with diagnoses including atrial fibrillation, allergic rhinitis, hyperlipidemia, osteoarthritis, constipation, atherosclerotic heart disease, anxiety disorder, hypertension, chronic pain syndrome, diabetes mellitus, chronic kidney disease, COPD, GERD, and obstructive sleep apnea. The resident's comprehensive MDS assessment indicated no cognitive deficit. Physician orders dated 02/20/26 included B-Complex with Biotin and Folic Acid one tablet daily, Vitamin E 400 capsule daily, and Fluticasone Propionate Nasal Suspension 50 mcg, one spray in each nostril twice daily for allergies. During observation on 04/15/26 at 9:11 A.M., LPN #102 prepared the resident's morning medication and the facility did not have B-Complex with Biotin and Folic Acid, Vitamin E 400 capsule, or Fluticasone Propionate Nasal Suspension 50 mcg on hand to administer. At 9:16 A.M., the LPN verified the medications were not available.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, with 25 opportunities for error observed and 3 medication errors made for a 12 percent error rate. This affected one resident (#18) of two residents observed during the medication pass, in a facility with a census of 27. Review of the resident’s monthly physician orders identified orders for Omeprazole 40 mg by mouth daily, B-Complex with Biotin and Folic Acid one tablet by mouth daily, and Vitamin E 400 capsule by mouth daily. During observation of the morning medication pass, an LPN prepared two Omeprazole 20 mg capsules from a stock bottle with an expiration date of 03/26 and placed them in a clear plastic cup. The LPN did not have B-Complex with Biotin and Folic Acid or Vitamin E 400 capsule available to administer. The LPN then administered the expired Omeprazole 20 mg capsules, and later verified in interview that the capsules were expired and that the other ordered medications were not on hand.
Failure to Report, Investigate, and Care Plan for Resident Falls
Penalty
Summary
The facility failed to ensure that resident falls were properly reported, investigated, and that individualized fall care plans were in place for all residents reviewed for falls. Four residents with significant cognitive and physical impairments experienced multiple falls, yet their incidents were not consistently documented or investigated according to facility policy. In several cases, there was no evidence of incident reports or investigations following falls, and fall interventions were either missing from care plans or not supported by physician orders. One resident with Alzheimer's disease and muscle weakness experienced several falls, including sliding out of bed and a chair, but not all incidents were reported or investigated, and interventions such as a pull string tab alarm, low bed, and fall mat were not included in the care plan or physician orders. Another resident with severe cognitive impairment and physical limitations had a care plan that identified fall risk but lacked specific interventions, and a fall incident was not reported or investigated. A third resident with dementia and impaired cognition experienced a fall with no subsequent care plan or investigation, and no fall interventions were ordered by a physician. A fourth resident with Huntington's disease and a history of repeated falls was found on the floor after rolling out of bed and later fell from a specialized chair, but there was no evidence of fall investigations or care plans addressing fall risk. Staff interviews confirmed these deficiencies, and a review of facility policy indicated that falls should be investigated and care plans updated, which was not consistently done for these residents.
Failure to Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
This deficiency occurred when the facility failed to report suspected resident-to-resident abuse and injuries of unknown origin to the appropriate authorities, as required by both facility policy and state regulations. A resident with Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive, who was at risk for falls, experienced multiple injuries including a swollen and discolored right foot, facial bruising and swelling, a cut lip, and later, significant bruising and fractures to the right hand and hip. Documentation in the medical record and staff statements indicated that the resident reported being punched in the face and having her foot stomped on, and a CNA documented that the resident stated she had been hit by another resident. Despite these reports and visible injuries, the incidents were not reported to state agencies or law enforcement as required. The facility's internal investigation into the altercation between the two residents was limited. The administrator reviewed the incident and determined that no further investigation was warranted, and did not submit a Self-Reported Incident (SRI) to the state. Additionally, subsequent injuries to the resident's hand and hip were not reported or investigated as potential abuse or neglect. The facility's policy clearly required immediate notification of state officials and law enforcement in cases of suspected abuse or injury of unknown origin, but this protocol was not followed. Interviews with the administrator confirmed that the incidents were not reported because he did not consider them to be abuse, despite the resident's statements and physical injuries. The lack of reporting and investigation into these incidents resulted in non-compliance with regulatory requirements for timely reporting and investigation of suspected abuse, neglect, or injuries of unknown origin.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
This facility failed to ensure that all injuries of unknown origin were properly investigated, as required by policy. A resident with Alzheimer's disease, muscle weakness, anxiety, and adult failure to thrive, who was at risk for falls, experienced multiple injuries during their stay. The resident was admitted with moderately impaired cognition and had a care plan in place to address fall risk and safety needs. On one occasion, the resident was found with a swollen and discolored right foot and was transferred to the hospital for evaluation. Later, the same resident was noted to have facial swelling and bruising, and reported being punched in the face and having their foot stomped on. Staff documented an altercation between this resident and another, with both residents interviewed, but the investigation was limited and did not address all injuries. The administrator determined no further investigation was warranted and did not submit a self-reported incident or conduct further inquiry into subsequent injuries, including a right hand injury and a fractured pelvis. Facility policy required immediate investigation and documentation of all allegations or incidents of abuse or injury, including written statements from witnesses and involved parties. Despite this, the administrator confirmed that no investigation or report was completed for the resident's right hand injury or fractured pelvis, and the incident was not reported as required. This failure to investigate and report all injuries of unknown origin constituted a deficiency in the facility's response to alleged violations.
Failure to Complete PASARR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a significant change Preadmission Screening and Resident Review (PASARR) for two residents following the addition of new mental health diagnoses. Resident #3, who was admitted with multiple diagnoses including hypertension, dementia, and schizophrenia, had a new diagnosis of unspecified psychosis added on 07/21/22. Despite this significant change, the facility did not complete a new PASARR designation. This was confirmed during an interview with a Licensed Practical Nurse (LPN) who verified that the new PASARR had not been completed. Similarly, Resident #7, admitted with diagnoses such as muscle weakness and heart failure, received a new diagnosis of schizoaffective disorder on 10/13/22. The quarterly Minimum Data Set (MDS) assessment indicated that the resident was rarely or never understood, yet no significant change PASARR was completed following the new diagnosis. This oversight was confirmed by the Director of Nursing (DON) during an interview, acknowledging that the necessary PASARR was not conducted for Resident #7.
Failure to Ensure Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure a stop date for as-needed psychotropic medications for two residents during the annual survey. Resident #14, who was admitted with diagnoses including anxiety disorder, had active physician orders for Hydroxyzine and Xanax, both antianxiety medications, without a specified stop date. The Director of Nursing confirmed the absence of stop dates for these medications, which were ordered on an as-needed basis. Similarly, Resident #15, admitted with Alzheimer's disease, dementia with anxiety and agitation, and depression, had an active physician's order for a topical gel containing a mixture of Ativan, Benadryl, Haldol, and Reglan to be applied every four hours as needed for agitation. This order also lacked a stop date. The Director of Nursing confirmed the absence of a stop date for this medication order as well. These findings affected two of the five residents reviewed for unnecessary medications, with the facility census being 21.
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 139 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Of Valley View | 2.3 mi | ★★★★★ | 2 | 0 |
| National Church Residences Chillicothe | 10.7 mi | ★★★★★ | 11 | 0 |
| Westmoreland Place | 11 mi | ★★★★★ | 0 | 0 |
| Greenfield Skilled Nursing And Rehabilitation | 11.3 mi | ★★★★★ | 10 | 0 |
| Hopewell Grove Rehabilitation And Healthcare | 11.7 mi | ★★★★★ | 10 | 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 July 2026) and official state health department websites.