Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Centre Care Rehabilitation And Wellness Services during CMS and state inspections, most recent first.
Food storage, sanitation, and temp monitoring were deficient in the main kitchen and a nursing unit kitchenette. Staff observed expired dry goods, torn oven mitts, debris on equipment and storage containers, a dirty and hard-to-read dish machine rinse gauge, repeated dish machine rinse temps below the required level, repeated cooler temps above the required limit, and multiple missing food temp log entries in both the main kitchen and the unit binder.
Delayed Assistance With ADLs and Toileting Needs: Staff failed to provide timely ADL assistance to dependent residents. One resident was left without full morning care and without documented assistance for multiple needs, another repeatedly called for a bedpan while staff delayed response until after she had started a BM, and two other residents reported long waits for toileting help and transfers, including call bell delays of about 30 minutes and up to an hour. MDS assessments showed dependence for toileting, hygiene, bed mobility, transfers, and related care needs.
A facility failed to follow ordered care for three residents. One resident did not have ordered nonskid socks or a heels up device in place even though staff documented them as present, another resident with AFTH and Type 2 DM did not receive ordered NSA shakes despite MAR entries and unavailable notes, and a third resident was observed wearing an abdominal binder without a physician order or care plan reference, while staff described its use with a PEG tube.
Medication error rate exceeded the allowed threshold. Surveyors calculated a 6.25% error rate based on 32 medication opportunities with 2 errors. In one case, an LPN gave a resident the wrong magnesium/calcium tablet strength compared with the active order for hypomagnesemia. In another, an LPN administered vitamin D3 400 units even though the resident’s order called for cholecalciferol 4000 units for vitamin D deficiency, and staff noted the pharmacy label still showed 400 units.
Pneumococcal immunization education and offer process deficient: The facility did not provide accurate education about current CDC guidance for PCV20/PCV21 and did not ensure that eligible residents were reoffered pneumococcal vaccine during ongoing stay. One resident’s declination form incorrectly stated no further vaccine was needed after PCV13 and PPSV23, another resident’s son declined based on outdated information, and two other residents had no evidence of a later vaccine offer after becoming eligible.
Missing COVID-19 Immunization Documentation for Staff and Residents: The facility failed to maintain required COVID-19 vaccine documentation for three staff members and two residents. Staff interviews showed the selected employees reported prior vaccination, but the facility had no records showing vaccine dates or type. For two residents, consent forms indicated they were up to date, but the date fields were blank and the facility had no evidence that immunization status was verified with family or the physician; one resident’s record showed the last COVID-19 vaccine was given years earlier.
The facility failed to develop person-centered care plans for two residents. One resident had an active Dexcom G7 CGM order, and staff reportedly checked the device, but no care plan addressed the CGM or related monitoring. Another resident was admitted for an infection requiring IV antibiotic therapy, had an IV pole and empty IV antibiotic bag in the room, and had no active care plan for the infection and antibiotic treatment until after the surveyor requested it.
A resident had a consultant pharmacist recommendation for lab monitoring, including A1C, FBS, TSH, and a lipid panel, to assess the safety and efficacy of medication therapy. The physician signed the recommendation, but the clinical record showed no evidence that the ordered lab monitoring was completed, and the NHA confirmed the finding.
An unsecured med cart was observed in a hallway with a drawer open, keys left on top, and resident information visible on an open laptop while staff were away from the cart. In a separate event, an LPN administered a resident's metoprolol even though the package did not specify whether it was tartrate or succinate, and later staff confirmed the labeling still did not identify the full medication name.
Failure to follow contact precautions for two residents. One resident had C. diff and another had ESBL in the urine, with doorway signs posted for contact precautions, but an RN entered without gown or gloves and did not perform hand hygiene as required, and a nurse aide and the resident’s husband were observed in the other resident’s room without gown or glove use. The husband stated staff had not educated him on the precautions, and the aide did not recognize that gown and glove use was needed when handling the lift sling.
Improper disposal of garbage and refuse was observed at the main dumpster area. Multiple disposable gloves, small paper items, a plastic spoon, and a personal hand sanitizer container were found on the ground near and outside the dumpster fence, and gloves were still present on a later observation.
The facility did not obtain informed consent for the use of side rails or enabler bars for two residents and failed to assess entrapment risk for two residents. One resident's family installed a side rail without facility assessment or consent, and another resident's record lacked documentation of informed consent for an enabler bar. Additionally, bed safety assessments for a third resident repeatedly omitted evaluation of a required entrapment zone.
A resident with a history of self-transferring and wandering was found with a large bruise on her right breast, and the facility's investigation was limited to only two staff statements, despite policy requiring broader staff interviews. The DON confirmed that no further investigation was conducted, resulting in a failure to thoroughly investigate the injury and rule out abuse.
A resident with a physician's order for Nuplazid, an antipsychotic used for hallucinations in Parkinson's disease, was not accurately coded as receiving an antipsychotic on two quarterly MDS assessments. This omission was confirmed by the DON and administrator after review of clinical records and staff interviews.
A resident with recent hospitalizations for pneumonia and appendectomy experienced a decline in functional status, but therapy services did not assess or intervene for over a week after a rehab referral was initiated. The resident and family reported increased difficulty with daily activities, and the family independently purchased a scooter to assist with mobility. The delay in therapy evaluation was confirmed by the DON, and the referral paperwork was not completed promptly.
A resident experienced significant weight loss over a one-month period, but staff did not obtain a reweight, notify the physician, or conduct an assessment as required by facility policy. No interventions were documented to address the resident's nutritional status, and the facility's registered dietitian was no longer employed at the time.
The facility's main kitchen had multiple sanitation and food storage deficiencies, including discarded items and expired food in the freezer, unlabeled and undated food items, and equipment with debris and stains. The dishwashing area had cleanliness issues and pest presence, with the dishwasher operating below required sanitization temperatures. Staff acknowledged the issues but failed to maintain professional standards.
A resident with cognitive impairment and a physician's order for a right hand splint to maintain range of motion did not have the splint consistently applied. Clinical records from September to October indicated repeated instances where the splint was unavailable or not found on the resident. Observations confirmed the absence of the splint, and staff interviews revealed difficulties in locating it, with the last laundering occurring about a week prior.
A facility failed to ensure a resident's participation in formulating an advance directive. Initially, the resident desired full resuscitation, but a later document indicated a DNR order based on verbal consent from the resident's daughter. The resident, assessed as cognitively intact, was not involved in this decision change, which was only addressed after surveyor questioning.
A facility failed to accurately assess a resident's mental health status. The resident's PASRR indicated a need for mental health services, but the admission MDS assessment incorrectly stated otherwise. This error was acknowledged by the Nursing Home Administrator and DON.
A facility failed to develop a care plan for a resident with a cardiac pacemaker, despite the resident's severe cognitive impairment and the presence of the device. The deficiency was identified during a clinical record review, which showed no care plan for monitoring or assessing the pacemaker, and was discussed with the facility's administration.
The facility failed to manage medical devices appropriately for three residents. A resident with a shoulder fracture lacked timely physician orders and therapy referrals for her sling. Another resident wore a back brace without documented justification or physician orders. Additionally, a resident with a cardiac pacemaker did not have his device needs incorporated into his care plan, and the facility failed to consult his cardiologist for proper monitoring. These deficiencies were confirmed by facility administration.
A resident at moderate risk for falls, requiring extensive assistance for bed mobility, fell and sustained injuries when a nurse aide attempted to reposition her alone. The care plan lacked specific instructions for the required assistance level, and the resident was using the wall for support, which was not a safe intervention.
The facility failed to ensure attending physicians addressed pharmacy recommendations for two residents. One resident's physician did not provide a rationale for not reducing medication doses, and another resident's attending physician was not consulted about psychotropic medications. The DON confirmed these communication and documentation lapses.
A facility failed to implement enhanced barrier precautions for a resident with a chronic wound and an indwelling medical device. Despite a care plan requiring gown and glove use during high-contact activities, an LPN did not wear a gown while performing wound care. The LPN believed a gown was unnecessary due to the absence of gowns on the resident's door, despite signage indicating otherwise.
The facility's main kitchen had a first aid kit with a significant dust build-up and expired items, including antiseptic towelettes, burn spray, and alcohol cleansing pads. The kit also contained empty packages and an open, expired burn treatment gel packet. These issues were discussed with the Nursing Home Administrator.
The facility failed to ensure self-determination for residents' wake time schedules, with staff waking residents as early as 5:30 AM without documented preferences or discussions with responsible parties. Observations and interviews confirmed that staff followed assignment sheets, disregarding individual resident choices.
The facility failed to properly store, secure, and label resident medications on two nursing units. A tube of Calmoseptine was found unsecured in a staff seating area, and another was found on top of a treatment cart. An unlabeled tube was also found on the wound treatment cart. Staff confirmed these medications should have been secured and labeled.
The facility failed to follow its infection control policies for handling contaminated linens and using PPE for a resident with an ESBL infection. Staff were observed not wearing gowns and improperly disposing of linens, despite clear signage and protocols. This lapse was confirmed through staff interviews, revealing confusion and lack of awareness about the resident's isolation status.
A resident with dementia and other cognitive impairments was taken to a medical appointment without notifying the responsible party, contrary to facility policy. The resident, who was totally dependent on staff, was out of the facility for six hours without any assistance from facility staff, and the transport company used does not provide attendants.
Food Storage, Sanitation, and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store and prepare food items in a safe and sanitary manner and failed to maintain equipment in a sanitary condition in the main kitchen and in the Mills Nursing Unit kitchenette. During observation of the main kitchen, the dry goods storage area contained two boxes of mustard, including an opened box with several containers that had a best-if-used-by date of March 4, 2026 and another unopened box with a best-if-used-by date of May 9, 2026. A container of ground cloves had a best-by date of July 20, 2025. In the same area, red oven mitts were torn with underpadding showing, debris was accumulated on top of the oven, and two basins holding plastic lids had debris in the bottoms. Observation of the dish machine showed it was a hot-water sanitizing machine with two visible temperature gauges. The rinse temperature gauge had a bent dial plate, debris in the bottom, and moisture inside, and it was difficult to read during two observed cycles. Facility records for July 2026 showed multiple dish machine rinse temperatures below the required 180 degrees Fahrenheit, including readings of 178, 179, 172, 174, 174, 178, 172, and 175 degrees, with no corrective action documented for those entries. The facility documentation also stated staff were to notify the supervisor immediately if water temperatures were not reaching acceptable standards. Facility records for Cooler #6 showed repeated temperatures above the required 41 degrees Fahrenheit throughout July 2026, with documented readings of 42, 43, and 44 degrees on multiple days. Review of prepared food temperature logs for the main kitchen showed missing documentation for breakfast, lunch, and supper on July 13 and July 15, 2026. Observation of the Mills Nursing Unit food temperature log binder showed multiple missing entries for breakfast, lunch, and supper across several dates in July 2026, and there was no evidence that the food served on those dates and meals was prepared or served at appropriate temperatures.
Delayed Assistance With ADLs and Toileting Needs
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living for dependent residents, including help with toileting, hygiene, transfers, feeding, and other basic care needs. The deficiency was identified through clinical record review, observation, and interviews with residents, staff, and family members for four residents who were dependent on staff assistance for multiple ADLs. Resident 52’s MDS assessments showed dependence for eating, toileting, bed mobility, showers/bathing, personal hygiene, and transfers. On observation, she was found in bed without her protective helmet on her head, with the helmet on her bedside stand. Staff interviews established that one nurse aide had not provided care that morning, another staff member fed breakfast but did not provide other ADL care, and no staff documented assistance for bed mobility, incontinence care, dressing, eating, hygiene, restorative range of motion, personal hygiene, positioning devices, oral care, or mechanical lift transfer for the relevant dates reviewed. Resident 11’s record showed dependence for toileting, bed mobility, and personal hygiene. She was observed repeatedly yelling for a bedpan while her call bell was activated, and staff did not respond for an extended period. When a nurse aide finally entered the room, the resident reported she had already started having a bowel movement. The aide left, returned later, and only then began care; stool was noted protruding from the resident’s rectum, and the aide did not initially have a bedpan available. Resident 157’s annual MDS showed substantial/maximal assistance needs for toileting hygiene. His toilet pull cord call bell was activated for an extended period, and the signal indicated staff response approximately 30 minutes after activation. During interview, he stated he had to wait half an hour in the bathroom for help on two occasions and that staff did not come timely when he rang the call bell. Resident 177’s significant change MDS showed dependence for toileting, bathing, dressing, personal hygiene, bed mobility, and chair-to-bed transfers. She and her son reported that she waited at least an hour for staff assistance to be transferred from her wheelchair to bed, with her son staying to support her because she was falling asleep and staff did not come right away.
Failure to Follow Ordered Devices and Supplementation
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered assistive devices and failed to meet professional standards of practice for an abdominal binder for three residents. For Resident 17, the clinical record showed orders for a heels up device and nonskid socks, but observations on multiple occasions showed the resident did not have the gripper socks on and did not have the heels up device in place. The resident stated he had not worn the gripper socks in a long time and did not use the heels up device, while nursing documentation on the Treatment Administration Record indicated both items were in place on the same dates. The Nursing Home Administrator confirmed staff documented the devices as in place when they were not. For Resident 13, who had diagnoses including Adult Failure to Thrive and Type 2 Diabetes, the record showed an order for a house no sugar added shake every day and evening shift as supplementation, and the care plan included providing supplements as prescribed. The MAR showed multiple entries coded as 9 for the house shake, but progress notes for those occasions were unavailable or not available, and the Nursing Home Administrator confirmed the shakes were available but were not provided. For Resident 10, staff observed a white abdominal binder in place, and an LPN stated the binder had been worn prior to the observation and was removed for soiling, care, and PEG tube work. However, the record contained no physician order for the abdominal binder or for skin checks related to it, and the care plan did not mention the binder. Progress notes documented the binder being saturated with BM, the resident fussing with the PEG tube and abdominal binder, and a physician note described the PEG tube with the binder overlying it.
Medication error rate exceeded the allowed threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent; surveyors calculated a 6.25 percent error rate based on 32 medication opportunities with 2 medication errors. During observation of a medication pass for one resident, an LPN administered a Slow Magnesium/Calcium oral tablet 70-117 mg, while the active physician order called for Slow Magnesium/Calcium Delayed Release 64-106 mg, 1 tablet by mouth every morning and at bedtime for hypomagnesemia. During another medication pass observation, an LPN administered vitamin D3 400 units to a second resident. The resident’s active physician order, dated January 23, 2026, directed staff to administer cholecalciferol oral tablet 100 micrograms (4000 units), 1 tablet by mouth in the morning for vitamin D deficiency. An LPN later stated that the pharmacy supply continued to label the resident’s vitamin D3 supplement as 400 units, and confirmed that the physician order required 4000 units in the morning.
Pneumococcal Immunization Education and Offer Process Deficient
Penalty
Summary
The facility failed to provide accurate education regarding pneumococcal immunization and failed to ensure that each resident was offered a pneumococcal immunization unless medically contraindicated for four of five residents reviewed for immunization concerns. The facility policy stated that residents would be offered pneumococcal vaccines at admission and ongoing as needed, with administration based on current CDC recommendations, but the policy did not specify how often residents would receive education about pneumococcal immunizations or how often they would be offered vaccines during ongoing admission. Resident 157 was admitted with a history of receiving Prevnar 13 and Pneumovax, and based on shared clinical decision-making was eligible for PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine. Although a declination form dated at admission showed the resident declined a pneumococcal vaccine, there was no evidence the facility reoffered the vaccine during the two years since admission. Resident 177 had previously received Pneumovax 23 and Prevnar 13 and was also eligible for PCV20 or PCV21 after 5 years, but her son declined the vaccine at admission because he believed she had already received it, and there was no evidence the facility educated him that current CDC guidance supported PCV20 or PCV21. Resident 11 had received Pneumovax 23 years earlier, and the consent/declination form stated she declined because she already received the vaccine, but the form incorrectly indicated that no further vaccination was warranted if both PCV13 and PPSV23 had been given and did not reflect current CDC guidance for PCV20 or PCV21 after 5 years. Resident 17 had received Prevnar 13 and Pneumovax 23 and was eligible for PCV20 or PCV21 five years after the last dose, but the record contained no evidence that the facility offered the vaccine after that time. The infection control prevention coordinator confirmed the facility’s pneumococcal immunization plan and the findings for these residents.
Missing COVID-19 Immunization Documentation for Staff and Residents
Penalty
Summary
The facility failed to maintain required documentation of COVID-19 immunization status for three staff members reviewed for vaccination records and for two residents reviewed for immunization concerns. The report states that the facility was expected to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible individuals after education, and document vaccination status, refusals, and related information. Review of the facility policy showed that vaccination information was to be recorded in the resident medical record and that staff vaccination records were to be maintained in the employee medical file, including documentation of vaccine status as indicated by NHSN. For staff, the facility could not provide documentation showing the date or vaccine type of COVID-19 immunizations for Employees 6, 21, and 22. Employee 6 reported receiving COVID-19 immunizations around 2020 with no immunizations since, Employee 21 reported being initially fully vaccinated with no immunizations since 2021, and Employee 22 reported receiving initial COVID-19 immunizations plus one booster around 2022 with no immunizations since then. The facility’s records initially listed the COVID-19 vaccination status of 247 of 249 staff as unknown, and later information showed some staff as fully vaccinated, partially vaccinated, exempt, or not vaccinated, but the facility still had no data showing the date or vaccine type for the selected staff. For residents, Resident 175’s record contained no data showing when she last received a COVID-19 immunization, and her husband signed a consent form stating she was up to date, but the date received field was left blank. The facility had no evidence that immunization status was verified with her husband or physician. Resident 11’s record also had a blank date field on the consent form, even though she refused the vaccine because she had received the current recommended COVID-19 vaccine; however, her immunization record showed her most recent COVID-19 vaccine was given on March 12, 2021. The record contained no evidence that the facility attempted to verify that she had received COVID-19 immunizations per current CDC guidance.
Missing Care Plans for CGM Monitoring and IV Antibiotic Treatment
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident 16 related to a Dexcom G7 continuous glucose monitoring device and associated resident monitoring and assessment. Clinical record review showed an active order for the Dexcom G7, and during an interview the resident stated that staff routinely look at the CGM device. However, the resident’s clinical record contained no care plan developed for the CGM device or for the monitoring and assessment associated with its use. The facility also failed to implement a care plan for Resident 13 related to ongoing infection and antibiotic treatment. Clinical record review showed diagnoses including aneurysm of specified arteries and methicillin susceptible staphylococcus aureus infection, and the significant change/five-day MDS indicated the resident received IV medication on admission and while a resident, as well as antibiotic medication. The resident stated the main reason for admission was an infection requiring IV antibiotic therapy, and observation showed an IV pole and empty IV antibiotic bag in the room. Further review found no care plan in place for the resident’s infection with antibiotic treatment until after the surveyor requested it.
Failure to Complete Ordered Pharmacist-Recommended Lab Monitoring
Penalty
Summary
The facility failed to ensure that the resident's attending physician addressed and responded appropriately to consultant pharmacy recommendations for one of five residents reviewed, Resident 17. The facility policy for Consultant Pharmacist Reports stated that the consultant pharmacist performs a comprehensive monthly review of each resident's medication regimen, identifies irregularities from sources including the MAR, prescriber orders, progress notes, the RAI, laboratory and diagnostic test results, behavior monitoring information, staff input, and resident assessment or observation, and reports findings and recommendations to the DON, Medical Director, and attending physician. For Resident 17, a consultant pharmacist recommendation dated February 16, 2026, requested lab monitoring including A1C, FBS, TSH, and a lipid panel to ensure safety and efficacy of medication therapy. The physician signed the recommendation on February 17, 2026, but review of the clinical record showed no evidence that the facility completed the recommended lab monitoring. The Nursing Home Administrator confirmed these findings during interview on July 31, 2026, at 11:02 AM.
Unsecured medication cart and incomplete medication labeling
Penalty
Summary
Medication security was not maintained on the third-floor nursing unit when an unattended medication cart was observed in the hallway with one drawer partially opened and extended, the cart unlocked, keys left on top of the cart, and the laptop computer lid open with resident information displayed on the screen. No staff returned to the cart during the observation until a registered nurse exited a resident's room. The nurse acknowledged that the medication drawer had been open, that the push-button lock securing the cart doors had been left open, and that she did not have the cart keys with her while she was in the resident's room and out of sight of the cart. She also acknowledged that a male resident with dementia was standing on the other side of the cart with his walker. Medication labeling was not complete for a resident's metoprolol 25 mg medication during administration. The medication package did not identify whether the drug was metoprolol tartrate or metoprolol succinate. The LPN administering the medication stated that the physician order was for metoprolol tartrate and that she had to search the internet and compare a picture of the tablet with the packaging description to confirm the medication supplied by pharmacy. A later interview confirmed that a new supply of the resident's metoprolol continued to be labeled without the full name of the medication, and staff stated they would not know which version pharmacy supplied based on the labeling alone.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to implement transmission-based precautions for residents on the third-floor nursing unit. Resident 157 had an active physician order dated July 25, 2026, for Contact Precautions due to C. diff positive status. On July 28, 2026, a sign on the doorway instructed staff not to use alcohol-based sanitizer and to use soap and water, to don gloves on entry, and to wear a gown upon entry. During observation, an RN entered the room with medications without donning a gown or gloves, leaned close to the resident’s face to speak to him because he was hard of hearing, placed her hands on the armrest of his recliner, and did not wash her hands before leaving the room. The RN later exited the room wearing a gown and gloves, doffed them in the hallway next to the medication cart, disposed of them in the cart-mounted garbage receptacle, and did not perform hand hygiene before touching the medication cart and keys. Resident 175 had a laboratory report dated July 23, 2026, confirming Klebsiella pneumoniae ESBL in a urine specimen collected July 21, 2026, and a sign on the doorway indicated contact precautions. During observation, the resident’s husband was in the room without gown or glove use, and a nurse aide was also in the room without a gown or gloves. The husband stated staff had not educated him to wear protective equipment and said staff had his wife upset because they wore gowns and gloves for the first time. The LPN confirmed the resident required contact precautions due to ESBL in the urine, and the nurse aide stated she did not wear a gown and gloves when attaching the lift sling because she was only hooking it up, even though she had placed the sling under the resident earlier.
Improper Disposal of Garbage and Refuse at Dumpster Area
Penalty
Summary
The facility failed to properly contain and dispose of garbage at the main dumpsters located in the rear of the facility. During observation on July 28, 2026, multiple disposable gloves, at least 11 in total, were seen on the ground adjacent to the dumpsters and outside the perimeter fence around the dumpster area. The same area also contained small discarded paper items, a plastic spoon, and a personal hand sanitizer container. A follow-up observation on July 31, 2026, found three disposable gloves still on the ground adjacent to the dumpsters.
Failure to Obtain Informed Consent and Complete Bed Rail Safety Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of side rails or enabler bars for two out of three residents reviewed, and did not assess entrapment risk for two out of three residents. For one resident with generalized muscle weakness and difficulty walking, a side rail was observed in use, but there was no documentation of informed consent or an entrapment risk assessment. The resident's family had brought and attached the side rail to the bed after admission, but the facility did not complete the required assessments or obtain consent. Interviews with facility leadership confirmed the absence of these documents. Another resident with generalized muscle weakness and mobility issues was observed using an enabler bar, but there was no evidence of informed consent in the clinical record, despite staff documentation indicating otherwise. For a third resident, enabler bars were present on both sides of the bed, and while bed safety assessments were performed periodically, the assessment for one entrapment zone (Zone 6) was consistently left incomplete. These findings were confirmed through interviews and record reviews, indicating lapses in both documentation and assessment procedures related to bed rail and enabler bar use.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a complete and thorough investigation of an injury of unknown origin for one resident. Clinical record review showed that the resident, who was known to transfer herself and wander with poor safety awareness, was observed with a 5 cm by 4 cm purple bruise on the top of her right breast. The resident was unable to explain how the bruise occurred. The facility's investigation included an assessment and measurement of the bruise, and an interdisciplinary team reviewed the incident, noting the resident's habit of carrying large pitchers of drinks on her chest, which was considered consistent with the injury. Abuse was ruled out based on this information. However, the investigation only included two staff witness statements: one from a nurse aide who observed the bruise and one from an LPN who was informed of the bruise by a registered nurse. The Director of Nursing confirmed that no further investigation was completed, despite facility policy requiring statements from all staff assigned to the resident and any staff with direct knowledge of the incident on the three shifts prior to discovery, unless a cause was identified. The lack of a comprehensive investigation into the injury of unknown origin constituted a deficiency.
Inaccurate MDS Assessment for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one resident. Clinical record review showed that the resident had a physician's order for Nuplazid, an antipsychotic medication, which was prescribed to be taken orally at bedtime. However, quarterly MDS assessments completed on two separate dates did not indicate that the resident was receiving an antipsychotic medication. This discrepancy was confirmed through interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged that the MDS assessments were not accurately coded to reflect the resident's medication regimen. The resident involved had a documented order for Nuplazid to treat hallucinations associated with Parkinson's disease, but this was not reflected in the required MDS documentation, resulting in an inaccurate assessment of the resident's care needs.
Delayed Therapy Assessment Following Resident Decline
Penalty
Summary
A deficiency was identified when a resident, previously independent in activities of daily living, experienced a decline in functional status following two recent hospitalizations for pneumonia and an appendectomy. Despite the resident and her family reporting increased difficulty with mobility and daily tasks, and the family independently purchasing a scooter to assist her, there was no evidence that therapy services had assessed or intervened in response to her decline. The resident stated she was not receiving therapy, and the family confirmed that the decision to purchase a scooter was made without input from therapy staff. Clinical record review showed that a rehabilitation referral was initiated due to the resident's change in condition, but the referral was not completed or acted upon for nine days. The therapy assessment was only performed after concerns were raised by the surveyor, revealing a significant decline from the resident's prior level of function. The Director of Nursing confirmed that the therapy evaluation was delayed, and the referral paperwork was not completed in a timely manner, resulting in a lack of appropriate assessment and intervention for the resident's change in condition.
Failure to Assess and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to provide timely assessments and implement interventions to maintain acceptable nutritional status for a resident who experienced significant weight loss. According to facility policy, residents with a weight change of five pounds or more in a month should be reweighed within 24 hours, and if the change is validated as significant, the registered dietitian must assess the resident, investigate the cause, and determine necessary interventions. The policy also requires notification of the physician, charge nurse, family, and registered nurse assessment coordinator in the event of significant weight changes. Clinical record review showed that a resident experienced a 15-pound (6.79%) weight loss in one month, which met the facility's criteria for significant weight loss. However, there was no evidence that staff obtained a reweight, notified the physician, or conducted an assessment of the weight loss. Additionally, no interventions were documented to address the resident's nutritional status. The Nursing Home Administrator confirmed these findings and stated that the registered dietitian was no longer employed by the facility at the time.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed during an initial tour. The walk-in freezer contained discarded items on the floor, including food pieces and a hair net, and had expired gluten-free rolls, with one package open to the air. The prep area had a drawer with debris and a stainless steel shelf with dust and stains. Equipment such as a commercial mixer and warmer units had dried stains and debris, and a soup kettle was improperly covered with a garbage lid and stained plastic. The oven had a build-up of debris, and cans on a cart were stained. Food items lacked proper labeling and dating, including garlic, salt and pepper, and a baking pan with an unlabeled food item. The walk-in cooler contained improperly stored sandwiches and other food items without proper labeling or dating. A roll of ham was dripping onto a box of pork tenderloin, and garden salad bags were past their best-by dates. The dishwashing area had multiple cleanliness issues, including dried stains on the dishwasher, a crusted substance on a shelf, and splash stains on the wall. There was a build-up of debris under the dishwasher, and a garbage receptacle had dried stains and debris. Winged insects and ants were observed in the dishwashing area and kitchen, indicating a pest control issue. The dishwasher's temperature gauges were inaccurate, with the rinse temperature consistently below the required level for sanitization. Employee 1, a cook, was observed using the dishwasher without recording temperatures, and the Director of Dining and maintenance staff acknowledged the issue, stating they had contacted a repair company. The report was reviewed with the Nursing Home Administrator, highlighting the facility's failure to adhere to professional standards for food storage, preparation, and equipment maintenance.
Failure to Implement Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to assess and implement physician-ordered treatment to maintain range of motion for a resident identified as having range of motion concerns. The resident, who had a cognitive impairment with a BIMS score of 6, had a physician's order dated August 10, 2023, for a right hand splint to be worn at all times except during care. The care plan also indicated the need for the splint due to the resident's self-care performance deficit related to their medical history, requiring staff assistance for daily activities. Despite these orders, the clinical record revealed multiple instances from September 7, 2024, to October 8, 2024, where the splint was not available or not found on the resident. Observations on October 6 and October 8, 2024, confirmed the absence of the splint on the resident's right hand. Interviews with staff, including a licensed practical nurse and laundry staff, indicated that the splint was sometimes removed by the resident and could not be located, with the last known laundering occurring approximately one week prior to the interview. This information was reviewed with the Director of Nursing on October 8, 2024.
Failure to Ensure Resident Participation in Advance Directive Decisions
Penalty
Summary
The facility failed to ensure that Resident 127 participated in formulating an advance directive, which is a violation of the resident's rights. The clinical record review revealed that Resident 127 had initially signed a Medical Treatment Guidelines document indicating her desire for full resuscitation. However, a subsequent document signed by two facility staff indicated that Resident 127's daughter gave verbal consent to withhold resuscitation efforts, resulting in a DNR order. This change in medical treatment was not documented as having involved Resident 127's participation, despite her being assessed as cognitively intact. During an interview with the Nursing Home Administrator and the Director of Nursing, it was confirmed that there was no evidence of Resident 127's involvement in the decision to change her advance directives. The facility only discussed the change with Resident 127 after the surveyor's questioning. This lack of documentation and failure to involve the resident in the decision-making process led to the deficiency noted in the report.
Inaccurate Assessment of Resident's Mental Health Status
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for one resident who was reviewed. The clinical record for this resident showed a Preadmission Screening and Resident Review (PASRR) completed on July 17, 2024, which indicated a positive screen for serious mental illness, necessitating a Level II PASRR. A subsequent letter from the Department of Human Services Office of Mental Health and Substance Abuse Services, dated July 25, 2024, confirmed the resident's eligibility for mental health services, requiring the facility to provide or arrange for these services. However, the admission Minimum Data Set (MDS) assessment dated August 1, 2024, inaccurately indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. This discrepancy was identified during an interview with the Nursing Home Administrator and Director of Nursing on October 6, 2024, who acknowledged the incorrect coding on the resident's admission MDS assessment regarding her PASRR determination.
Failure to Implement Care Plan for Resident with Pacemaker
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with a cardiac pacemaker. The clinical record review revealed that the resident, who had a biventricular pacemaker implanted in March 2020, was assessed with severe cognitive impairment. Despite this, there was no care plan developed related to the pacemaker or associated monitoring and assessment. This deficiency was identified during a review of the resident's clinical record, which lacked documentation of a care plan addressing the pacemaker, and was discussed with the Nursing Home Administrator and Director of Nursing.
Deficiencies in Medical Device Management for Residents
Penalty
Summary
The facility failed to provide the highest practicable care regarding the use of medical devices for three residents. Resident 155 was observed with a sling immobilizing her left arm and shoulder, following a fall that resulted in a shoulder fracture. Despite returning from the hospital with a discharge summary recommending the use of a sling and swath for immobilization, there was no documented evidence of physician orders or a therapy referral for her fracture until six days later. This delay in obtaining appropriate orders and care for Resident 155's fracture was confirmed by the facility's Administrator and Director of Nursing. Resident 167 was observed wearing a back brace without any documented evidence in her clinical record to justify its use. There were no physician orders, care plans, or therapy evaluations regarding the back brace, and it was later revealed that the brace was brought in by the resident's family for comfort. Additionally, Resident 66, who had an implanted cardiac pacemaker, did not have his pacemaker needs incorporated into his care plan. The facility failed to contact his cardiologist to determine the correct implementation of his pacemaker check machine, leaving the facility unaware of the necessary monitoring requirements. These deficiencies were confirmed through interviews with the facility's administration.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate interventions to prevent a fall for a resident identified as being at moderate risk for falls. The resident, who required extensive assistance from two staff members for bed mobility due to inadequate core strength and balance, experienced a fall when a nurse aide attempted to reposition her alone. During the incident, the resident rolled onto the floor, sustaining skin tears on both elbows and a closed hematoma above her left eyebrow. The care plan did not specify the number of staff required for safe repositioning, and the resident was accustomed to using the wall to stabilize herself, which was not a safe or approved intervention. Interviews and clinical record reviews revealed that the resident's care plan lacked clear instructions regarding the level of assistance needed for bed mobility. The Director of Nursing confirmed that there was no clinical evidence indicating the required assistance level at the time of the fall. The resident reported that she was instructed by aides to use the wall for support, which led to her foot slipping and the subsequent fall. The facility's investigation corroborated the resident's account, highlighting the absence of appropriate interventions to prevent the fall.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to ensure that the attending physicians addressed pharmacy recommendations for two residents. For Resident 195, the clinical record showed that the Interdisciplinary Team Evaluation recommended a gradual dose reduction of Buspar, Seroquel, and Trazodone. However, the physician's response did not address these specific medications and lacked a clinical rationale for not reducing the doses. Furthermore, a subsequent evaluation indicated that the physician had never met the resident and did not provide an order for dose reduction, with the Director of Nursing confirming that the recommendation was sent to the wrong physician. For Resident 84, the Interdisciplinary Team Evaluation noted the use of psychotropic medications Citalopram, Mirtazapine, and Risperdal, with a physician agreeing not to reduce the dosages. However, the physician consulted was not the resident's attending physician, and there was no evidence that the attending physician received a consultant pharmacist report or documented an evaluation of the medications. The Director of Nursing confirmed these findings, indicating a lack of proper communication and documentation regarding the resident's medication management.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling medical device and a chronic wound, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. The resident, identified as having a history of a multi-drug resistant organism, required the use of gown and gloves during high-contact care activities. Despite the facility's plan of care initiated on June 7, 2024, which included specific instructions for donning gown and gloves, an observation on October 6, 2024, revealed that a licensed practical nurse (Employee 3) did not wear a gown while performing wound care on the resident's right foot. Employee 3 admitted to not wearing a gown because she believed it was unnecessary due to the absence of gowns on the resident's door. This was despite the presence of an EBP sign instructing staff to use gown and gloves for wound treatments. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing, highlighting a lapse in adherence to infection prevention and control protocols.
Deficiency in Kitchen First Aid Kit Maintenance
Penalty
Summary
The facility failed to maintain a safe and clean environment in the main kitchen area. During an observation, a first aid kit attached to the wall was found to have a significant build-up of dust on its exterior. Additionally, the kit contained expired antiseptic towelettes, an open triangular bandage box with no bandages, and burn spray with the plastic cap removed, which was also expired. Inside the first aid kit, there were multiple empty packages, expired alcohol cleansing pads, and a container of burn treatment gel with an open, expired gel packet placed back in the box. These findings were reviewed with the Nursing Home Administrator.
Failure to Ensure Resident Self-Determination in Wake Time Schedules
Penalty
Summary
The facility failed to ensure self-determination for residents' choices related to wake time schedules for 21 of 34 residents sampled. Observations and interviews revealed that residents were being woken up and dressed for the day as early as 5:30 AM without documentation that this was part of their normal routine or discussed with their responsible parties. This practice was confirmed by multiple staff members who indicated that they were expected to get certain residents up and ready for the day based on assignment sheets and lists provided by the administration. Clinical record reviews for the affected residents showed varying degrees of cognitive impairment, with many residents having severe or moderate cognitive impairments due to conditions such as dementia. For example, Resident 1 had a BIMS score of 7 indicating severe cognitive impairment, while Resident 18 had no cognitive impairment but expressed a preference not to be woken up before 7:00 AM. Despite these varying levels of cognitive function, there was no documentation in the clinical records to support that early wake times were part of the residents' normal routines or that these preferences were discussed with their responsible parties. The observations and interviews conducted on April 9, 2024, revealed that the facility's practice of waking residents early was not aligned with promoting and facilitating resident self-determination. Staff members confirmed that they followed lists and assignment sheets that dictated which residents to wake up early, without considering individual preferences or documented routines. This deficiency was reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to honor residents' rights to self-determination regarding their wake times.
Failure to Properly Store and Label Medications
Penalty
Summary
The facility failed to properly store, secure, and label resident medications and biologicals on two of five nursing units. On the [NAME] Nursing Unit, a tube of Calmoseptine labeled with Resident 8's name was found in an unsecured staff seating area, easily accessible to anyone passing by. Additionally, another tube of Calmoseptine labeled with Resident 6's name was found unsecured on top of a treatment cart in the hallway. A partially used, unlabeled tube of Calmoseptine was also found on the wound treatment cart. Interviews with staff confirmed that these medications should have been secured and properly labeled. The Director of Nursing acknowledged that the medications should be labeled and secured in the treatment carts.
Failure to Adhere to Infection Control Policies
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection regarding transmission-based precautions on one of its nursing units. Specifically, the facility did not adhere to its own policies for handling contaminated linens and the use of personal protective equipment (PPE) for a resident with an ESBL infection. The policy required that dirty linens be placed in a yellow laundry bag and tied, and that staff wear gowns and gloves when handling these linens. However, observations revealed that staff were not following these protocols. Employee 1 was seen handling contaminated linens without a gown and placing them in a blue bag instead of a yellow one. Employee 2 also entered the resident's room without a gown and was unclear about the resident's isolation status. The resident in question had a history of cognitive impairment and was frequently incontinent of urine. The resident's clinical records indicated that they were on contact precautions due to an ESBL infection in the urine. Despite clear signage on the resident's door indicating the need for contact precautions, staff failed to comply with the required PPE protocols. This lapse in protocol was confirmed through staff interviews, where it was evident that there was confusion and a lack of awareness about the resident's isolation status and the proper procedures to follow. The deficiency was reviewed with the Nursing Home Administrator and Director of Nursing, who acknowledged the failure to adhere to infection control policies. The facility's policies clearly outlined the steps to prevent the spread of infection, including the use of gowns and gloves and the proper disposal of contaminated linens. However, the observations and staff interviews indicated a significant gap in the implementation of these policies, leading to a potential risk of infection spread within the facility.
Failure to Involve Responsible Party in Resident's Medical Appointment
Penalty
Summary
The facility failed to provide the highest practicable care for a resident by not involving the responsible party in the resident's medical appointment. The facility's policy requires the responsible party to be involved whenever possible, and if the resident is competent, they may attend the appointment alone. However, the resident in question had a diagnosis of dementia, depression, cognitive communication deficit, mood disturbance, psychotic disturbance, and anxiety, and was assessed as not capable of making her own decisions and at high risk for falls. Despite this, the facility did not notify the responsible party of the resident's orthopedic appointment, which was a follow-up for a previous fall with a fracture. The responsible party confirmed that she was not informed of the appointment and would have attended if she had been aware of it. The resident was transported to the appointment by a company that does not provide attendants to accompany residents during their appointments. The resident, who was totally dependent on staff for care, was out of the facility for six hours without any assistance from facility staff. The facility does not have an agreement or contract with the transport company and simply calls the company and receives a bill. The Administrator and Director of Nursing acknowledged these findings, indicating a failure to adhere to the facility's policy and ensure the resident's safety and well-being during the appointment.
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What surveyors actually found near you
We read the 111 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bellefonte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Juniper Village At Brookline-rehabilitation And Sk | 4.2 mi | ★★★★★ | 2 | 0 |
| Village At Penn State, The | 4.3 mi | ★★★★★ | 10 | 0 |
| Foxdale Village | 4.7 mi | ★★★★★ | 0 | 0 |
| Embassy Of Hearthside | 5.7 mi | ★★★★★ | 43 | 0 |
| Valley View Haven, Inc | 16.6 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.