Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Kadima Rehabilitation & Nursing At Greenville during CMS and state inspections, most recent first.
A facility failed to ensure that active physician orders matched residents’ POLST code status for three residents. One resident with COPD, A-Fib, and anxiety had a POLST indicating DNR but no active code status order; another resident with dementia, hypothyroidism, and HTN had a POLST indicating DNR but a physician order for CPR; and a third resident with COPD, respiratory failure, and diabetes had a POLST indicating DNR but no active code status order. The DON confirmed the records were inconsistent and that physician orders and POLST should match.
Respiratory care equipment was not kept clean and one resident received oxygen without a physician order. A resident with COPD had a visibly dirty oxygen concentrator filter, another resident's nebulizer mask was left out instead of being stored in a plastic bag when not in use, and a third resident with respiratory failure was observed on oxygen via NC at 2 LPM even though the chart lacked an oxygen order. The DON and an LPN confirmed the equipment and order issues.
Food was improperly stored and handled in the main kitchen, pantry refrigerators, and a resident’s personal refrigerator. Surveyors found expired and undated food items, produce not stored properly, employee food mixed with facility food, and ice buildup in pantry refrigerators. During tray line service, a dietary employee handled chopped steak with gloved hands instead of using tongs. A resident’s personal refrigerator had food inside but no thermometer or temperature log, and the DON confirmed the facility was unaware of it.
Unclean and damaged wheelchairs were observed on Unit 1. One resident's wheelchair had dried debris and crumbs on the frame, and another resident's wheelchair had a nonworking left brake plus cracked, peeling, and missing armrest coverings. The DON confirmed the findings.
Failure to Provide Bed-Hold Notice and Transfer Information: The facility did not provide written bed-hold policy notice to two residents or their representatives when they were transferred to the hospital, and their records lacked evidence that necessary clinical information was communicated to the receiving provider. One resident had breast cancer, dementia, and A-fib; the other had COPD, respiratory failure, and diabetes. The DON confirmed the missing documentation.
The facility failed to obtain an active order for colostomy care for one resident with a colostomy, schizophrenia, and HTN, even though a prior order for appliance changes had been discontinued and the resident reported managing the colostomy independently for months. The facility also failed to follow physician orders for another resident with a PICC, with no evidence that Cathflo was given as ordered and multiple blank entries for ordered saline flushes; the resident reported the PICC was often not flushed at night, and the DON confirmed the missing documentation.
Unsafe storage of smoking materials: A resident with GERD, anxiety, HTN, and cognitive impairment was assessed as safe to smoke with an apron and supervision, and the resident was aware that cigarettes and a lighter were to be stored by the facility. However, staff observed the resident in a room with a pack of cigarettes and a disposable lighter on the bedside table, and an RN confirmed the items were not kept locked in the medication cart as required by policy.
The facility failed to properly store medications and failed to date two opened multi-dose vials of Aplisol in the Unit One med room. An LPN confirmed the vials should have open and use-by dates and could not determine whether they were within the 30-day use period. The same observation found two resident medications sitting on top of the refrigerator instead of being stored in the medication cart, and the DON confirmed this was improper.
Incomplete medication documentation was identified for a resident with sepsis due to MRSA, a left femur fracture, and anxiety. The E-MAR showed multiple blank entries for scheduled saline flushes, and the record lacked documentation that Cathflo was administered for a clogged PICC. The DON confirmed the clinical record was incomplete regarding medication administration documentation.
Failure to monitor oxygen saturation per physician order. A resident with CHF, respiratory failure with hypoxia, and COPD had an order for supplemental O2 via NC every shift for SOB, titrated to keep saturation at or above 92%. The clinical record lacked evidence that O2 saturation was monitored after a certain point, so staff could not determine whether the resident’s O2 needed to be adjusted to meet the ordered saturation target; the DON confirmed the missing documentation.
A resident with CHF, respiratory failure with hypoxia, and COPD tested positive for RSV at the hospital. The facility started isolation on return, but removed contact isolation after the resident was no longer febrile and symptomatic, rather than maintaining transmission-based precautions for the required duration under PADOH guidance.
Failure to Protect Resident With Suicidal Ideations From Self-Harm: A resident with a hx of suicidal ideations, PTSD, and severe pain voiced suicidal thoughts to the SSD, but the record showed no documented assessment, 1:1 monitoring, physician or RP notification, IDT review, care plan revision, item removal, or BH consult before the resident later used a break-away utility knife to cut the forearm and was sent out by EMS.
Incomplete admission inventories and resident records: The facility failed to maintain complete and accurate documentation for multiple residents. Several records lacked completed admission checklists and signed inventories of personal effects, and some inventories listed items such as clothing, mobility equipment, hearing aids, glasses, a laptop, a purse, braces, a cell phone, and personal papers without required signatures or evidence that belongings were inspected. An ADON and LPN confirmed the missing documentation.
The NHA and DON failed to effectively manage the facility to ensure proper supervision and consistent self-harm prevention interventions were in place. Record review and staff interviews showed the facility did not consistently maintain all safety interventions to prevent self-harm, despite the NHA’s responsibility to manage the facility in accordance with applicable standards and the DON’s responsibility to direct nursing services and maintain quality care.
The facility failed to administer insulin according to manufacturer guidelines and appropriate meal timing for three residents with diabetes. In one case, a resident with multiple comorbidities received insulin lispro well before receiving a meal tray and subsequently experienced a hypoglycemic episode requiring Glucagon. In two other cases, residents received Novolin R or insulin lispro based on sliding scale orders tied to meals, but insulin was administered about an hour or more before meals were actually served. An LPN reported routinely giving insulin one hour before meals, and the NHA acknowledged that insulin should be administered within a short time frame before or after meals per manufacturer instructions.
The facility failed to provide sufficient nursing staff and timely call light response, resulting in multiple residents waiting 30 minutes to several hours for assistance despite policies requiring prompt response and frequent checks on those unable to call for help. Resident council minutes and grievance logs documented ongoing concerns about delayed call bell response, especially on afternoon and night shifts. Several residents reported they no longer used their call bells because no one responded, with one resident instead propelling in a wheelchair to the nurses’ station for help. In one case, a resident with a Foley catheter who had activated the call bell for bleeding waited so long that they called 911 and were later found by the DON to have bleeding with large blood clots before being transferred to the hospital.
The facility failed to maintain a functional call bell system on one hall, where the installed system relied on a small digital display at the nurse's station that only briefly beeped, lacked overhead lights, and could show only a limited number of active calls. Staff had to go to the nurse's station and cross-reference a list to determine which room was calling and had no way to know if multiple calls were active without checking the display. Testing showed that one room’s call bell did not register on the digital unit on two separate days. A resident and family member reported that call bells had not been working adequately for months and resorted to using a tap bell and a cow bell so staff could hear them, while another resident’s representative reported that the call bell was not working for that resident.
A resident with paranoid schizophrenia, diabetes, and HTN eloped from the facility and was later identified as being at risk for elopement through an Elopement Risk Assessment. Despite facility policies requiring individualized care plans and specific revisions following any successful elopement, the resident’s comprehensive care plan did not include interventions for elopement risk or the actual elopement, a deficiency confirmed by the RN Assessment Coordinator during surveyor interview.
A resident with paranoid schizophrenia, diabetes, and hypertension eloped from the facility, but the clinical record contained no documentation of the elopement, the resident’s safe return, or notification of the physician or resident representative, contrary to the facility’s documentation policy. Review of the record also showed that elopement risk assessments were not completed on a quarterly basis as required, and interviews with the DON, RNAC, and NHA revealed uncertainty about the required frequency of these assessments and confirmed the absence of timely documentation.
A resident with an indwelling urinary catheter and multiple diagnoses, including bronchitis, hypertension, and diabetes, was receiving antibiotics for a UTI when surveyors observed the resident’s catheter drainage bag lying uncovered on the floor under the bed. Facility policy required catheter bags to be covered, properly positioned, and kept off the floor. An LPN and the Nursing Home Administrator both confirmed that the bag should have been covered and not in contact with an unclean surface, demonstrating a failure to provide essential catheter care and infection prevention measures.
A resident reported that their mail was being opened by facility staff before delivery, which was confirmed by the Nursing Home Administrator. This action violated the resident's right to privacy in written communications as outlined in facility policy.
The facility did not clarify a physician's order for surgical dressing care for a resident, resulting in the dressing remaining in place beyond the ordered removal date. Additionally, a physician's order for a UA C&S for another resident was not carried out in a timely manner, with the urine sample collected several days after the order was given.
A resident with end stage renal disease did not have required dialysis communication forms completed for several treatments, and multiple prescribed medications were not administered on dialysis days as ordered, with no evidence that the physician was notified of these omissions. Facility leadership confirmed these documentation and medication administration failures.
A multi-dose vial of Tirzepatide was found in a medication storage room without labeling to indicate the resident's name, date opened, or use by date. Facility policy requires such labeling for all medications in use. Both a registered nurse and nursing leadership confirmed the vial was in use and not properly labeled.
A resident's personal refrigerator was found without a thermometer and lacked any evidence of temperature monitoring or documentation, despite facility policy requiring regular checks and recording on the EMAR. Interviews with the ADON and an LPN confirmed the monitoring process was not followed, and the administrator acknowledged the deficiency.
A resident with dementia and age-related disability was found to have an acute hip fracture of unknown origin. The facility did not report this serious injury to the State Survey Agency within the required timeframe, as confirmed by the DON, despite regulations mandating immediate reporting of such incidents.
The facility did not meet the required NA staffing ratios on multiple occasions, failing to provide adequate care for its residents. The deficiency was confirmed through a review of staffing documents and staff interviews, revealing consistent shortages in NA coverage across day, evening, and overnight shifts.
The facility did not meet the required LPN staffing ratios on four occasions, failing to provide the mandated number of LPNs per resident during the day shift. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. A review of staffing documents revealed that the care hours were below the mandated minimum on several days, with the lowest being 2.72 hours per patient per day. This deficiency was confirmed by the Nursing Home Administrator.
Physician Orders Did Not Match POLST Code Status
Penalty
Summary
The facility failed to ensure that active physician orders reflected residents’ end-of-life wishes as documented on their Pennsylvania POLST forms for three residents. Facility policy stated that residents are presumed to consent to CPR unless there is documentation in the medical record showing a DNR order, and that all DNR orders must be rewritten by the attending physician for each admission or readmission. Review of the clinical records showed that Resident R14 had diagnoses including COPD, A-Fib, and anxiety, and had a POLST indicating DNR, but the current physician orders lacked evidence of code status. Resident R38 had diagnoses including dementia, hypothyroidism, and high blood pressure, and had a POLST indicating DNR; however, a physician order dated in the record indicated CPR, creating inconsistency between the POLST and the physician orders. Resident R50 had diagnoses including COPD, respiratory failure, and diabetes, and had a POLST indicating DNR, but current physician orders also lacked evidence of code status. During interviews, the DON confirmed that Resident R14’s record lacked active physician orders reflecting code status and that Resident R38’s physician orders and POLST were not consistent, and further confirmed that resident physician orders and POLST should match regardless of the POLST.
Respiratory Equipment Not Kept Clean and Oxygen Given Without an Order
Penalty
Summary
The facility failed to promote cleanliness and help prevent the spread of infection related to respiratory care equipment for two residents. One resident with COPD, atrial fibrillation, and anxiety had an order for oxygen via nasal cannula every shift for shortness of breath and another order to change oxygen tubing, change the humidification bottle, cleanse the oxygen filter, and inspect easy foam wraps every night shift every Monday. On observation, the resident was sitting in a wheelchair with supplemental oxygen in place at 2 lpm, and the oxygen concentrator filter on the back of the unit had a large amount of gray fluffy substance covering the entire filter. The DON confirmed the filter contained a large amount of gray dusty substance and should be cleaned. A second resident with COPD, respiratory failure, and diabetes had an order for albuterol sulfate inhalation nebulization solution via nebulizer every eight hours as needed for wheezing. Observations showed the resident's nebulizer mask lying in the bedside drawer and later on top of the bedside stand, and it was not stored in a plastic bag when not in use. An LPN confirmed the nebulizer mask was not stored in a plastic bag and should have been. The facility also failed to obtain a physician's order for oxygen therapy for another resident with respiratory failure, diabetes, and high blood pressure. That resident was observed wearing oxygen via nasal cannula connected to an oxygen concentrator delivering 2 liters per minute, but the clinical record lacked evidence of a physician's order for oxygen therapy, and an LPN confirmed the missing order.
Food Storage and Sanitary Handling Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the main kitchen, two pantry refrigerators, and one resident’s personal refrigerator. In the main kitchen on 6/23/26, surveyors found four pitchers of lemonade dated 6/13/26, one pitcher of tomato juice dated 6/10/26, and a bag of carrot sticks, cucumber slices, and celery sticks dated 6/19/26 that had been stored beyond the facility’s three-day limit. Also observed were an opened pitcher of iced tea, a rotten green bell pepper not stored in a bag, a package of Swiss cheese, and a container of beef base without open dates. Employee food items, including a package of pepperjack cheese, a Twix candy bar, and two bottles of water, were stored with facility food in the large refrigerator. The Dietary Manager confirmed the expired and undated items should have been discarded or labeled, the pepper should have been bagged and discarded, and employee items belonged in the breakroom refrigerator. During tray line observation, Dietary Employee E5 assembled hot plates and then handled chopped steak with gloved hands instead of using tongs, rubbed the gloved hands together, and continued plating meals. In the Unit 4 pantry refrigerator, surveyors found six cartons of chocolate milk expired on 6/20/26 and ice buildup in the freezer; in the Unit 1 pantry refrigerator, they found one carton of chocolate milk and one peanut butter and jelly sandwich expired on 6/19/26, along with ice buildup in the refrigerator. For Resident R121’s personal refrigerator, surveyors observed food items stored inside but found no thermometer and no recorded temperatures. The DON confirmed the facility was unaware of the personal refrigerator and that there was no thermometer or temperature record for it.
Unclean and Damaged Wheelchairs
Penalty
Summary
The facility failed to maintain a clean, homelike environment and ensure residents' wheelchairs were in working order on Unit 1. Facility policy stated the environment would be safe, clean, comfortable, and homelike. On observation, one resident was sitting in a wheelchair with dried dirty substance down the right side of the chair and crumbs and debris on the frame. Another resident was sitting in a wheelchair with the left brake not working, the left armrest plastic covering cracked and peeling with foam exposed underneath, and the right armrest missing the foam and plastic covering. The DON later confirmed that the first resident's wheelchair was unclean with dried debris and that the second resident's wheelchair armrests were in disrepair and the left brake was broken and needed repair.
Failure to Provide Bed-Hold Notice and Transfer Information
Penalty
Summary
The facility failed to provide the resident and/or resident representative with a written notice of the bed-hold policy, including how long a bed could be held during a leave of absence and the cost per day, for two residents who were transferred to the hospital. Facility policy stated that upon discharge to a hospital, the Social Service Department or the Administrator's designee would contact the resident or responsible party by telephone and in writing to inform them of the hospital discharge and the 15-day Medicaid bed hold. However, the clinical record for one resident admitted with breast cancer, dementia, and A-fib showed a hospital transfer and did not contain evidence that the necessary clinical information was communicated to the receiving health care provider or that the bed-hold policy was provided upon transfer or within 24 hours. The clinical record for a second resident admitted with COPD, respiratory failure, and diabetes also showed hospital transfers and lacked evidence that necessary clinical information was communicated to the receiving health care provider or that the bed-hold policy was provided upon transfer or within 24 hours. During interview, the DON confirmed that both residents' records lacked evidence that necessary clinical information was communicated to the receiving health care provider and lacked evidence that the resident and/or representative were provided with a copy of the facility bed-hold policy upon transfer or within 24 hours of transfer. The deficiency was cited under 28 Pa. Code 201.18(e)(1) Management and 28 Pa. Code 201.29(c.3)(2) Resident rights.
Failure to Follow Orders for Colostomy Care and PICC Medication Administration
Penalty
Summary
The facility failed to obtain an active physician’s order for colostomy care for one resident with a colostomy, schizophrenia, and high blood pressure. The resident’s record showed an admission date of 4/14/25 and a prior order dated 6/2/25 for changing the colostomy appliance, wafer, and barrier ring every day shift every Thursday, but that order was discontinued on 12/25/25 and no current order was present. During interview, the resident stated the facility used to care for the colostomy but that he/she had been changing it for months. The facility also failed to follow physician’s orders for medication administration for another resident with sepsis due to MRSA, a left femur fracture, and anxiety. The record included an order for Cathflo Activase 2 mg IV one time only for a clogged PICC, but the chart and progress notes lacked evidence that it was administered as ordered. In addition, an order for 0.9% saline flush 10 mL IV every shift, and before and after every IV medication, had 86 opportunities for documentation, with 71 completed and 15 blank. The resident stated the facility often would not flush the PICC at night as ordered and it would get clogged, and the DON confirmed the records lacked evidence that Cathflo and saline flushes were administered in accordance with physician’s orders.
Unsafe storage of smoking materials
Penalty
Summary
The facility failed to ensure a safe environment related to smoking for one resident who smoked at the facility. The facility’s Smoking Policy stated that designated smoking areas were outside the building, smoking restrictions applied to all smoking methods, and smoking supplies for all residents were to be kept locked in the medication cart and provided to the resident upon request. Resident R48 was admitted on 2/12/26 with diagnoses including GERD, anxiety, and high blood pressure. The resident’s Quarterly MDS dated 5/15/26 showed a BIMS Summary Score of 8, indicating cognitive impairment. A Smoking Assessment completed on 2/12/26 indicated the resident was safe to smoke with an apron and supervision and was aware the facility needed to store the lighter and cigarettes. However, on 6/24/26 at 1:00 p.m. and 1:30 p.m., the resident was observed sitting in a wheelchair in the room with one pack of cigarettes and a disposable lighter on the bedside table. An RN confirmed at 1:30 p.m. that the cigarettes and lighter were on the bedside table and stated they were supposed to be kept locked in the medication cart in the smoking area.
Improper Medication Storage and Undated Aplisol Vials
Penalty
Summary
The facility failed to properly store medications and failed to properly date two multi-dose vials of Aplisol in the Unit One medication storage room. A facility policy on storage of medications stated that medications are to be stored in a safe, secure, and orderly manner, and that no discontinued, outdated, or deteriorated medications are to be available for use in the facility. The manufacturer's instructions for Aplisol stated that vials should be inspected for particulate matter and discoloration before administration and discarded if either is seen, and that vials in use for more than 30 days should be discarded. During an observation of the Unit One medication storage room, two opened multi-use vials of Aplisol in the refrigerator were not dated with an opened or use-by date. An LPN confirmed that the vials should be dated after opening and could not determine whether they had been opened within 30 days. In the same medication storage room, two resident medications were observed sitting on top of the refrigerator instead of being stored properly in the medication cart. The LPN confirmed that the medications should have been in the medication cart and not on top of the refrigerator. The DON later confirmed that multi-use vials should be dated with open and use-by dates and that resident medications should not be stored on top of refrigerators in the medication room.
Incomplete Medication Administration Documentation
Penalty
Summary
Accurate and complete medication documentation was not maintained for one resident with an admission date of 4/13/26 and diagnoses including sepsis due to MRSA, fracture of the left femur, and anxiety. Facility policy required medications to be documented immediately after administration or refusal, and nursing documentation to be clear, pertinent, and accurate. Review of the resident’s May 2026 E-MAR showed a physician order for saline flush solution 0.9% to be given every shift and before and after IV medications, but out of 86 opportunities, 15 entries were left blank and only 71 were documented as completed. The resident’s record also included a physician order for Cathflo Activase Injection Solution Reconstituted, 2 mg IV one time only for a clogged PICC, but the E-MAR and progress notes lacked documentation that Cathflo was administered. During an interview, the DON confirmed that the resident’s clinical records were incomplete regarding medication administration documentation.
Failure to Monitor Oxygen Saturation per Physician Order
Penalty
Summary
The facility failed to monitor oxygen saturation according to a physician’s order for one resident with congestive heart failure, respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident was admitted on 1/28/26 and had an order dated 4/29/26 for supplemental oxygen via nasal cannula every shift for shortness of breath, with oxygen to be titrated to maintain saturation greater than or equal to 92 percent. The resident’s clinical record did not contain evidence after 5/9/26 that oxygen saturation levels were being monitored. Because of this lack of documentation, staff were unable to determine whether the resident’s supplemental oxygen needed to be adjusted to maintain the ordered saturation level. During an interview on 6/8/26, the DON confirmed that the record lacked evidence of oxygen saturation monitoring after 5/9/26 and that staff were unable to determine whether oxygen needed to be titrated to maintain saturation greater than or equal to 92 percent per the physician’s order.
Failure to Maintain RSV Isolation for Required Duration
Penalty
Summary
The facility failed to implement infection control practices by not maintaining transmission-based precautions for the required duration after a resident tested positive for RSV. Facility policy identified transmission-based precautions as an added infection control measure used with standard precautions for patients infected or colonized with certain pathogens, and Pennsylvania Department of Health guidance stated that for positive RSV, contact isolation precautions should remain in place until symptoms resolve or for seven days, whichever is longer. Resident R1 was admitted with diagnoses including CHF, respiratory failure with hypoxia, and COPD, and tested positive for RSV at the hospital on 3/15/26. The Nursing Home Administrator stated that isolation was started when the resident returned from the hospital on 3/15/26, but the isolation was removed on 3/18/26 because the resident no longer had a fever and no longer had symptoms. The NHA later confirmed that the facility did not isolate the resident for the required duration related to the positive RSV test.
Failure to Protect Resident With Suicidal Ideations From Self-Harm
Penalty
Summary
The facility failed to implement sufficient safety precautions for a resident with a documented history of suicidal ideations, and the deficiency resulted in an Immediate Jeopardy situation. The resident had diagnoses that included stroke, suicidal ideations, and PTSD, and the care plan for suicidal ideations included interventions such as one-on-one observation as indicated, psych consult as needed, documentation of behaviors, physician notification, and redirection from negative thoughts and feelings. On 4/14/26, the Social Services Director documented that the resident expressed fear about not surviving the night because of cancer and pain, and after speaking with the nursing supervisor about medication concerns, the resident stated, "I might as well kill myself." The resident requested to speak with the supervisor, and the SSD informed the nursing supervisor of that request. The record contained no evidence that the nursing supervisor assessed the resident, placed the resident on one-on-one observation, kept staff with the resident until the nurse supervisor or change nurse arrived, notified the attending physician or responsible party, involved the interdisciplinary care plan team, revised the care plan, removed items that could be used for self-harm, or obtained a behavioral health consult. The resident was later seen by psychiatric professionals on 4/20/26 and 4/24/26, but the record did not show that the suicidal threats were addressed or reviewed. On 4/27/26 at about 8:00 a.m., the resident was found with significant blood on the bed sheets, floor, trash can, and clothing after staff entered the room to deliver breakfast. The resident stated, "I cut myself so I can go to heaven," and assessment showed several horizontal lacerations to the left forearm. Staff cleansed the area, applied pressure, called 911, and the resident was transported by EMS. Witness statements placed the resident outside the room earlier that morning, and facility leadership later confirmed they could not determine how the resident obtained the break-away utility knife used in the incident.
Incomplete admission inventories and resident records
Penalty
Summary
The facility failed to maintain complete and accurate resident records for six of seven residents reviewed. A facility policy required an inventory of all resident valuables on admission, with staff recording the quantity and description of each item and obtaining signatures from staff and the resident or representative. However, Resident R1’s admission checklist did not document that the inventory was completed and signed, and the Inventory of Personal Effects lacked the resident/representative signature. Resident R2’s record lacked evidence of a completed admission checklist and/or Inventory of Personal Effects. Resident R3’s record lacked a completed admission checklist, and the Inventory of Personal Effects for clothing items was not signed by the resident and/or representative. Resident R4’s record lacked a completed admission checklist, and the Inventory of Personal Effects listed clothing items, a shaving kit, hearing aids and glasses, a laptop computer, and a purse, but there was no evidence the purse contents were inspected and the form was not signed by facility staff. Resident R5’s record lacked evidence of a completed admission checklist, and the Inventory of Personal Effects listing clothing items, multiple orthopedic braces, a cell phone and charger, and personal papers was not signed by facility staff. Resident R6’s record lacked evidence of a completed admission checklist, and the Inventory of Personal Effects on admission listed clothing items, stuffed animals, and a yellow ring without signatures from the resident/representative or facility staff. A later Inventory of Personal Effects for Resident R6 stated the resident refused inspection of belongings and possessed two plastic bags of clothes, but that form also was not signed by the resident or facility staff. During interview, the Assistant DON and LPN confirmed the lack of documentation for Residents R1 through R6. The residents reviewed had diagnoses including stroke, suicidal ideations, PTSD, dementia, recurrent depression, anxiety disorder, bipolar disorder, amputation with phantom limb pain, schizophrenia, mood disorder, and intentional self-harm by jumping from a high place.
Failure to Ensure Supervision and Self-Harm Prevention Interventions
Penalty
Summary
The facility failed to administer operations in a manner that enabled effective and efficient use of resources because the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure proper supervision and self-harm prevention interventions were consistently implemented. Review of facility records and job descriptions showed that the NHA was responsible for managing the facility in accordance with applicable federal, state, and local standards and for ensuring the highest degree of quality care, while the DON was responsible for directing nursing services in accordance with federal, state, and local standards and maintaining the highest degree of quality care. Staff interviews and record review identified that the facility did not consistently supervise and maintain all safety interventions intended to prevent self-harm for residents, and the NHA and DON did not fulfill their essential job duties to ensure federal and state guidelines and regulations were followed.
Failure to Administer Insulin in Accordance With Manufacturer Guidelines and Meal Timing
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin in accordance with manufacturer guidelines and good nursing principles for three residents with diabetes. Facility policy required medications to be administered as prescribed and in accordance with good nursing practices. Manufacturer instructions for Humalog (insulin lispro) specified administration within 15 minutes before or immediately after a meal, and for Novolin Regular within 30 minutes before or immediately after a meal. For one resident with diabetes, CHF, and COPD, the record showed a blood sugar of 336 at 5:00 p.m. on 2/26/26, and 10 units of insulin lispro were administered per sliding scale by an LPN. At approximately 5:45 p.m., the resident had not yet received a meal tray and subsequently experienced a hypoglycemic episode requiring administration of Glucagon at 5:50 p.m. and again at 6:10 p.m. Another resident with diabetes, altered mental status, hypertension, and coronary artery disease had an order for Novolin R sliding scale with meals. On 3/05/26, the blood sugar at 11:30 a.m. was 315, and 5 units of Novolin R were administered by an LPN, but the lunch meal was not delivered until 1:25 p.m. That same day, the resident’s evening blood sugar at 4:00 p.m. was 276, and 4 units of Novolin R were given, while dinner was not served until 6:50 p.m. A third resident with diabetes, COPD, gastrointestinal hemorrhage, and hypovolemic shock had an order for insulin lispro sliding scale with meals; on 3/05/26, a blood sugar of 236 at 4:00 p.m. led to administration of 3 units of insulin lispro, while dinner was not served until 6:49 p.m. During interview, the LPN who administered the insulin to the latter two residents stated that insulin was typically given one hour before meals, and the Nursing Home Administrator confirmed insulin should be administered within a short time span before or after meals per manufacturer guidelines.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and timely call light response to meet residents’ needs, as required by facility policy and job descriptions. The facility’s call light policy and CNA/RN job descriptions state that staff must respond to call lights and resident needs promptly, check frequently on residents unable to call for help, and that all employees must answer call lights regardless of department. Resident Council minutes over a three‑month period documented repeated concerns that call bells were not answered as timely as residents preferred, particularly on afternoon and midnight shifts. Grievance logs from the same period showed multiple complaints of residents waiting from 30 minutes up to two to three hours for assistance after activating their call bells. Interviews conducted with multiple residents and a resident representative confirmed ongoing delays of 30 minutes or more in call bell response, with some residents reporting they had stopped using their call bells because staff did not respond. One resident reported waiting two hours for assistance on a specific evening. Another resident stated they had to self‑propel in a wheelchair to the nurses’ station to obtain help. During an observation, a resident with a Foley catheter was found in bed, upset and calling out for a nurse, and reported having activated the call bell approximately 1 hour and 45 minutes earlier due to bleeding; this resident ultimately called 911 and was found by the DON to have bleeding with large blood clots before being transferred to the hospital. The DON acknowledged that all residents should have their call bells answered in a timely manner and that waiting 30 minutes or more for staff response was unacceptable.
Failure to Maintain Functional Call Bell System on 500 Hall
Penalty
Summary
The facility failed to ensure that the call bell system was adequately working on one of six halls (500 hall/Unit 1), as required by its policy that mandates a call bell or alternative device be within reach of each resident in their room, toilet, or bathing area, with staff alerted by visual and audible signals. The installed call system used an oblong digital unit at the nurse's station that displayed two-digit numbers corresponding to room and bathroom call bells and emitted three beeps when the first call was activated. However, the system did not provide ongoing audible alerts, did not illuminate overhead lights down the hall or outside resident rooms, and could only display up to eight active calls at a time. When more than one call bell was activated, subsequent calls displaced earlier numbers on the display without additional sound or visual alerts, and any calls beyond eight were not displayed until earlier calls were cleared. Staff reported that to identify which resident was calling, they had to go to the nurse's station, view the two-digit number on the unit, and then cross-reference a separate list to match the number to a resident room. On the 500 hall, testing and observation revealed that call bell number 47, associated with a specific room, did not display on the digital unit when activated on two consecutive days, a problem confirmed by a CNA and the DON. A resident and family member reported that call bells had not been working adequately for several months, and that the resident had been provided a tap bell by the facility while the daughter purchased a cow bell so staff could hear it. Another resident representative reported that the call bell was not working for that resident. Staff interviews confirmed they had no way to know if more than one call bell was activated unless they physically went to the nurse's station to look at the digital unit, and that the system’s limited display and lack of continuous audible or visible alerts impeded their awareness of active calls. These observations and interviews demonstrated that the call system on the 500 hall was not reliably functioning as intended by facility policy.
Failure to Care Plan for Resident Elopement Risk After Actual Elopement
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive, individualized plan of care addressing elopement risk for one resident. Facility policies on MDS/RAI/care planning, Resident Elopement, and Resident Elopement Follow-Up Procedure required that each resident have a written, individualized care plan and that any resident with a successful elopement be reassessed, with additional interventions identified and incorporated into the plan of care, including modifications for increased elopement risk and monitoring as needed. Review of the resident’s clinical record showed that an Elopement Risk Assessment was completed on 2/26/26 and identified the resident as being at risk for elopement. The resident, admitted on 11/7/14, had diagnoses including paranoid schizophrenia, diabetes, and high blood pressure. Information submitted by the facility showed that the resident eloped from the facility on 2/26/26. Despite this event and the completed Elopement Risk Assessment, review of the comprehensive plan of care did not reveal any care plan addressing the resident’s risk for elopement or the actual elopement. During an interview on 3/6/26, the RN Assessment Coordinator confirmed that the resident’s comprehensive plan of care did not include a care plan for elopement risk or the actual elopement, in contrast to the facility’s stated policies.
Failure to Document Elopement Incident and Complete Quarterly Elopement Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and timely documentation related to an elopement incident and to follow its own policies for elopement risk assessment. Facility policy on documentation required nursing documentation to be concise, clear, pertinent, accurate, and to communicate the resident’s status and provide an accurate accounting of care and monitoring. A separate policy on resident elopement required that residents be reassessed at least quarterly for elopement risk. One resident, admitted with diagnoses including paranoid schizophrenia, diabetes, and hypertension, eloped from the facility on 2/26/26. However, the clinical record progress notes contained no documentation of the elopement event, the resident’s safe return, or notification of the physician and/or resident representative. Review of the resident’s elopement risk assessments showed they were completed on 1/14/25, 4/17/25, and 2/26/26, with no evidence that these assessments were performed on a quarterly basis as required by policy. During interviews, the DON confirmed that the clinical record lacked documentation of the elopement, the resident’s return, and required notifications, and stated that a risk management entry and/or progress note should have been completed. The DON and RNAC reported they were unsure how often elopement risk assessments were to be completed, and the NHA was also unable to verify the required frequency at the time of interview. The NHA confirmed that the resident’s record lacked evidence of quarterly elopement risk assessments, resulting in noncompliance with state regulations governing medical records and nursing services.
Failure to Maintain Indwelling Catheter Bag Off Floor and Covered
Penalty
Summary
The facility failed to follow its own catheter care policy for a resident with an indwelling urinary catheter. The policy dated 11/2024 required that residents with indwelling catheters receive appropriate care, including maintaining catheter drainage bags off the floor, ensuring the catheter is anchored, and keeping the drainage bag covered and properly positioned. Resident R1, admitted on 12/24/25 with diagnoses including bronchitis, hypertension, and diabetes, was identified in the clinical record as currently receiving a seven-day course of antibiotics for a urinary tract infection. During an observation on 1/27/26 at 11:44 a.m., Resident R1’s urinary catheter drainage bag was seen lying uncovered on the floor under the bed, without any covering over the bag. In an interview at 11:50 a.m., an LPN (Employee E3) confirmed that the catheter bag was on the floor and acknowledged that the bag should be covered and maintained off the floor for infection control. In a separate interview at 12:40 p.m., the Nursing Home Administrator also confirmed that the catheter bag should be covered and not touch an unclean surface due to the risk of infection. These observations and interviews established that the facility did not ensure essential catheter care and infection prevention measures for this resident.
Failure to Ensure Resident Mail Privacy
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened, as required by facility policy and resident rights regulations. Review of the facility's policies confirmed that residents have the right to privacy in written communications, including the right to send and promptly receive unopened mail. During an interview, a cognitively intact resident reported that the facility was opening their mail prior to delivery, which the resident identified as an invasion of privacy. The Nursing Home Administrator confirmed that some of the resident's mail was being opened before being given to the resident.
Failure to Clarify and Follow Physician Orders for Wound Care and Urine Testing
Penalty
Summary
The facility failed to clarify a physician's order regarding surgical dressing care for one resident. The resident was admitted with an order stating that an Aquacel dressing should have been removed on a specific date and the incision left open to air. However, upon arrival at the facility several days later, the Aquacel dressing was still intact, indicating that the order was not followed or clarified as required by facility policy. The Director of Nursing confirmed that the conflicting orders should have been clarified with the physician. Additionally, the facility did not follow a physician's order to obtain a urinalysis and culture & sensitivity (UA C&S) in a timely manner for another resident. The order was written for the test to be performed due to symptoms of dysuria and frequency, but the urine sample was not collected until several days after the order was given. The clinical record lacked evidence that the test was collected promptly, as required by the physician's instructions.
Failure to Document Dialysis Communication and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate records of dialysis communication and did not ensure that medications were administered according to physician's orders for a resident receiving dialysis. A review of the Memorandum of Agreement between the facility and the dialysis provider required the exchange of relevant information regarding the resident's condition and treatment, and facility policy mandated documentation of dialysis care in the medical record. However, the clinical record for a resident with diagnoses including diabetes, end stage renal disease, and respiratory failure lacked evidence of completed dialysis communication forms for multiple scheduled dialysis treatments. Additionally, the resident's care plan included an intervention to ensure medication administration times did not conflict with the dialysis schedule. Despite this, the Medication Administration Records showed that several prescribed medications were not administered on dialysis days, with the reason documented as Leave of Absence. There was no documentation that the physician was notified about the missed or altered medication administration times on these days. Interviews with facility leadership confirmed the absence of required dialysis communication documentation and the failure to administer medications as ordered, as well as the lack of physician notification regarding these omissions. These findings were cited under multiple state regulations related to licensee responsibility, management, medical records, and nursing services.
Unlabeled Multi-Dose Tirzepatide Vial Found in Medication Room
Penalty
Summary
Surveyors found that a multi-dose vial of Tirzepatide, a prescription medication used for type 2 diabetes and weight loss, was stored in the Unit One medication room without being labeled with the resident's name, the date it was opened, or the date it should be used by. Facility policy requires that all medications be stored in a safe, secure, and orderly manner, and that drug containers must have complete and legible labels, including the resident's name and relevant dates. During the observation, a registered nurse confirmed that the vial was opened and in use but lacked the required labeling. The Director of Nursing and Assistant Director of Nursing also confirmed that the vial was missing this information and acknowledged that it should have been properly labeled.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor the temperature of a resident's personal refrigerator as required by facility policy. The policy stated that personal refrigerators must include a thermometer and be subject to the same regular temperature monitoring as other facility refrigerators, with documentation of temperatures. Observation revealed that a resident had a personal refrigerator in their room without a thermometer and without any visible temperature log sheet. Further inspection of the refrigerator confirmed the absence of a thermometer. Interviews with the Assistant Director of Nursing and an LPN confirmed that temperatures for personal refrigerators were supposed to be documented on the resident's electronic medication administration record (EMAR) every shift. However, review of the resident's EMAR showed no evidence that temperatures had been monitored or recorded. The Nursing Home Administrator also confirmed that the refrigerator lacked a thermometer and that there was no evidence of temperature monitoring for the resident's personal refrigerator.
Failure to Timely Report Serious Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an incident involving a resident who sustained a serious bodily injury of unknown origin. According to facility documentation and staff interviews, a resident with dementia and age-related disability was found to have an acute fracture of the left proximal femur, as confirmed by x-ray. The injury was determined to be of unknown origin, and there was no documentation of any recent falls. The facility's policy and federal regulations require that such incidents, especially those involving serious bodily injury of unknown source, be reported immediately, but not later than two hours after discovery. Despite these requirements, the incident was not reported to the State Survey Agency until several days after the resident's injury was identified. The Director of Nursing confirmed during an interview that the reporting did not occur within the required timeframe. The delay in reporting was in direct violation of both facility policy and federal regulations regarding the timely notification of authorities in cases of suspected abuse, neglect, or injuries of unknown source.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios across multiple shifts over several weeks. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. This deficiency was observed on numerous dates between November 2024 and January 2025, as evidenced by a review of the facility's nursing staffing documents and confirmed through staff interviews. The staffing shortages were significant, with the facility often having fewer NAs than required for the number of residents present. For instance, on several occasions, the facility had a census of over 100 residents but failed to provide the necessary number of NAs to meet the regulatory requirements. The Nursing Home Administrator acknowledged these staffing deficiencies during an interview, confirming the facility's failure to comply with the mandated NA ratios on the specified dates and shifts.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in Nursing Aide ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on staffing ratios for Nurses aides, call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing(DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. Nursing Aid Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews NA ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement(QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation. Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet NA needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly thereafter. QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on the day shift on four specific dates. The regulation mandates a minimum of one LPN per 25 residents during the day. However, on 11/22/24, with a census of 105 residents, only 4.00 LPNs worked when 4.20 were required. On 12/10/24, with 103 residents, 4.00 LPNs worked instead of the required 4.12. On 1/06/25, with 101 residents, 4.00 LPNs worked when 4.04 were needed, and on the same day with 102 residents, 4.00 LPNs worked when 4.06 were required. The Nursing Home Administrator confirmed these staffing shortages during an interview on 1/15/25.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in Licensed Practical Nurse (LPN) ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on staffing ratios for Licensed Professional Nurses (LPN), call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing (DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. LPN Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews LPN ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement (QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation. Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet LPN needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly thereafter. QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on twelve out of fourteen days reviewed. The deficiency was identified through a review of the facility's nursing staffing documents and confirmed during an interview with the Nursing Home Administrator. Specific dates were noted where the hours of direct resident care fell below the required minimum, with the lowest being 2.72 hours per patient per day. This shortfall in staffing levels was acknowledged by the Nursing Home Administrator, indicating a consistent failure to meet the mandated care hours over the specified periods.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in PPD not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on Staffing ratios and PPD, call off policies, and attendance expectations to be completed by DON/designee and human resources. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. Staffing will be monitored daily by DON/Designee as well as NHA at end of stand up meeting. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/DON. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Staffing audits to be completed at monthly QAPI meeting. Audits will consist of PPD and deployment zones for the day which may indicate patterns for intervention. This will include unit, days of any missed PPD if any, and corrective actions pursued or utilized at the time of the event. QAPI has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility. Facility continues to investigate local education centers and community events for recruitment opportunities.
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 259 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Paul Homes | 2.6 mi | ★★★★★ | 0 | 0 |
| Avalon Springs Care Center | 11.4 mi | ★★★★★ | 6 | 0 |
| Hermitage Nursing And Rehabilitation | 12 mi | ★★★★★ | 4 | 0 |
| Quality Life Services - Mercer | 12 mi | ★★★★★ | 8 | 0 |
| Saint John Xxiii Home | 12.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.