Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurel View Village during CMS and state inspections, most recent first.
Incomplete insulin administration documentation was found for a resident with cognitive impairment, diabetes, and a need for assistance with daily care. Physician orders required insulin aspart at 7:00 a.m., 11:00 a.m., and 4:00 p.m. with dose adjustments based on BG levels, but the MAR for multiple months contained no documented evidence of how many units were actually given. The DON confirmed the record lacked this documentation.
Unnecessary Psychotropic Medication Use: A resident with cognitive impairment and diagnoses of anxiety, depression, and PTSD received PRN lorazepam on two occasions, but the record did not show any non-pharmacological interventions before the doses were given. The DON confirmed that no non-pharmacological interventions had been attempted before the PRN medication and that they should have been.
Failure to develop an individualized care plan was identified for a cognitively impaired resident who required staff assistance and had a fluid restriction order. Nursing notes showed the resident was drinking water from the humidifier, seeking water in bathrooms, and taking medicine cups from the med cart to fill with bathroom water, but no care plan was documented to address the resident’s non-compliance with fluid restrictions.
Failure to document RN assessment after change in condition: Two residents had documented changes in status, including low BP, inability to tolerate a sit-to-stand lift, and signs of not feeling well, but the record did not show RN assessment at the time those changes were first noted. One resident had HF and HTN; the other had dementia, depression, and Alzheimer’s disease. The DON confirmed the missing RN assessments should have been documented.
Failure to follow med orders for two residents. One resident with DM and cognitive impairment received incorrect doses of Novolog when BG values were below the ordered thresholds, and another resident with HTN received lisinopril even though SBP was below the hold parameter. The DON confirmed both med administration errors.
A facility failed to ensure ordered hand supports were in place for two residents with impaired hand function and contractures. One resident with a hx of stroke was ordered a left palm guard during the day, and another resident with hemiparesis and left hand contractures was ordered a left hand roll for contracture management, but repeated observations showed both devices were not in place. Staff and the DON confirmed the orders and that there was no documented refusal.
Improper Storage of Controlled Medication in Refrigerator: A small refrigerator in the main med room contained a bottle of liquid Ativan, but it was not stored in a separately locked, permanently affixed compartment. An RN confirmed the shelf holding the locked container could be removed from the refrigerator, and the NHA later confirmed the controlled med was not in a permanently affixed compartment.
A resident with cognitive impairment and a history of falls experienced a fall resulting in a skin tear and later reported shoulder pain. Although a nurse assessed the resident and documented the findings in investigation documents, this assessment was not included in the clinical record, leading to incomplete documentation.
The facility failed to follow physician's orders for bowel protocols for two residents, resulting in extended periods without bowel movements. Additionally, a resident did not have their Salonpas patch removed within the prescribed 12-hour period. These deficiencies were confirmed through interviews with the Nursing Home Administrator.
The facility's QAPI committee failed to address repeated deficiencies in following physician's orders, catheter care, and nutrition maintenance, as identified in a recent survey. Despite previous plans of correction involving audits and committee reviews, the same issues were cited again, indicating ineffective corrective actions.
Laurel View Village was cited for inaccuracies in MDS assessments for four residents, failing to accurately code the administration of medications such as diuretics, antianxiety, antibiotics, and anticonvulsants. These errors were confirmed through staff interviews and review of clinical records.
A facility failed to provide restorative nursing programs as per a resident's care plan, resulting in a deficiency. The resident, who required assistance due to Parkinsonism, had a care plan for active range of motion and ambulation programs, which were not consistently documented or completed. Staff interviews confirmed the lack of adherence to the care plan, and the Nursing Home Administrator acknowledged the documentation gaps.
A resident with an indwelling urinary catheter was found with the catheter bag and tubing in direct contact with the floor, contrary to facility policy. Additionally, the facility failed to document the resident's urinary output as required, with multiple instances of missing records across various shifts. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to provide a resident with recommended nutritional interventions, specifically ice cream twice a day, to address unplanned weight loss. Despite the dietician's recommendation, there was no documented evidence that the ice cream was provided, and the resident's weight decreased. Interviews revealed that the ice cream was not included in the resident's meal ticket, and the usual process for adding nutritional support items was not followed.
A facility failed to provide a resident with a divided plate as ordered by the physician, despite the resident's moderate cognitive impairment and need for set-up assistance with eating. The absence of the divided plate was observed during a meal and confirmed by an LPN.
The facility failed to follow physician orders for two residents. One resident received duplicate wound care treatments due to an old order not being discontinued, while another resident's physician was not notified when insulin was held due to low blood sugar levels. These deficiencies were confirmed by the DON.
A facility failed to follow physician's orders for a resident's suprapubic catheter care. The resident, who was dependent on staff for daily care, had orders for the catheter to be changed every four weeks. However, there was no documented evidence of catheter changes over a specified period, as confirmed by the Nursing Home Administrator.
A facility failed to maintain a therapeutic No Salt Added diet for a resident with kidney failure when their diet texture was downgraded to mechanical soft due to chewing difficulties. Despite physician's orders, there was no documentation to indicate the continuation of the therapeutic diet, as confirmed by the Nursing Home Administrator.
Incomplete Insulin Administration Documentation
Penalty
Summary
Clinical records were not maintained in a complete and accurately documented manner for one resident who was cognitively impaired, required assistance with daily care needs, received insulin, and had a diagnosis of diabetes. The resident’s comprehensive MDS assessment identified these conditions, and physician’s orders directed insulin aspart to be given at 7:00 a.m., 11:00 a.m., and 4:00 p.m. with specific dose adjustments based on blood glucose levels. Review of the resident’s MAR for February, March, April, and May 2026 showed no documented evidence of how many units of insulin were actually administered at those ordered times. The DON confirmed during interview that the resident’s clinical record did not contain documented evidence of how many units the resident received daily at the ordered times.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure one resident’s medication regimen was free from unnecessary psychotropic medications and failed to document that non-pharmacological interventions were attempted before giving an antianxiety medication. Resident 10’s quarterly MDS showed cognitive impairment and diagnoses of anxiety, depression, and PTSD, and physician orders included lorazepam 1 mg every 12 hours as needed. The resident received lorazepam on April 5, 2026 at 12:00 a.m. and on April 7, 2026 at 4:15 a.m., but the clinical record did not show any non-pharmacological interventions before those administrations. The facility’s psychotropic medication policy stated that such medications are to be used only when clinically indicated, at the lowest effective dose, and with gradual dose reduction and behavioral interventions in accordance with federal regulations. During an interview, the DON confirmed that no non-pharmacological interventions had been attempted before the as-needed medication and stated that they should have been.
Failure to Care Plan Fluid Restriction Non-Compliance
Penalty
Summary
Failure to develop and implement an individualized care plan was identified for Resident 5, who was cognitively impaired, sometimes understood and could sometimes understand others, and required staff assistance with daily care needs. The resident had a physician’s order for a 1500 cc fluid restriction and later an order directing that the humidifier no longer be filled with distilled water because the resident was drinking it. Nursing documentation stated that the resident had been attempting to obtain water in bathrooms, was observed drinking water from the humidifier, and was non-compliant with fluid restrictions by taking medicine cups from the med cart and filling them with water from the bathroom. There was no documented evidence that a care plan was developed to address the resident’s non-compliance with fluid restrictions, and the Nursing Home Administrator confirmed this during interview.
Failure to Document RN Assessment After Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse completed and documented an assessment after changes in condition for two residents. One resident had a comprehensive MDS showing cognitive intactness, required assistance with daily care, and diagnoses including heart failure and high blood pressure. The record showed blood pressure readings of 84/60 and 80/50 on separate dates, and a nursing note documented that the resident was not able to tolerate the sit-to-stand lift. There was no documented evidence that a registered nurse assessed the resident for the low blood pressure readings or the change in condition related to inability to tolerate the lift. The DON confirmed that the resident should have been assessed and that the assessment should have been documented in the medical record. For the second resident, the quarterly admission MDS showed severe cognitive impairment with diagnoses including dementia, depression, and Alzheimer's disease. A progress note documented that the resident's son said he thought his mother was "brewing something" and could tell by her face that she was not feeling well. Later that same day, an activity note stated the resident appeared not to feel well, but there was no documented evidence that a registered nurse assessed the resident at those times. The next morning, an LPN notified the RN that the resident was not looking good, at which time the resident was assessed and the physician was updated. The DON confirmed that there should have been documented RN assessment for the earlier changes in condition.
Failure to Follow Medication Administration Orders
Penalty
Summary
The facility failed to follow physician’s orders for medication administration for two residents. Resident 17 had a diagnosis of diabetes, was cognitively impaired, rarely understood and was rarely understood by others, and required staff assistance with daily care needs. The resident’s orders included Novolog insulin at 7:00 a.m. with instructions to give 8 units if blood glucose was less than 80 mg/dL and to hold the insulin if blood glucose was less than 70 mg/dL. On April 22, the resident’s blood glucose was 71 mg/dL, but 11 units of Novolog were administered during the 7:00 a.m. medication pass. Resident 17 also had an order for Novolog at 4:00 p.m. with instructions to give 5 units if blood glucose was less than 80 mg/dL and to hold the insulin if blood glucose was less than 70 mg/dL. On April 22, the resident’s blood glucose was 78 mg/dL, but 13 units of Novolog were administered. Resident 33 was cognitively intact, required assistance with daily care needs, and had hypertension. The resident’s order was for lisinopril 5 mg daily, with instructions to hold the medication if systolic blood pressure was less than 100 mmHg or heart rate was less than 60 bpm. On April 26, the resident’s blood pressure was 98/66 mmHg, but 5 mg lisinopril was administered.
Failure to Maintain Ordered Hand Supports for Two Residents
Penalty
Summary
The facility failed to ensure that ordered interventions were in place for two residents with impaired mobility and hand function. Resident 4 had a history of stroke with decreased hand muscle function and increased weakness of the left arm and hand, and the care plan identified impaired left-side mobility and potential for decline in skin integrity. A physician order required a left palm guard to be in place in the left hand during the day, but observations on multiple occasions showed the palm guard was not in place. Staff interviews confirmed the order should have been followed, and the DON confirmed there was no documented evidence that the resident refused the intervention. Resident 33 had diagnoses including hemiparesis with decreased hand muscle function and increased weakness of the left arm and hand, and the care plan directed that a left hand roll be utilized as ordered for left hand contractures and hemiparesis. A physician order required the resident to use a handroll in the left hand during the day for contracture management, but repeated observations showed the handroll was not in place. A nurse aide stated the handroll should be utilized, and the DON confirmed the left hand towel roll was to be in place per physician order and was not, with no documented evidence of refusal.
Improper Storage of Controlled Medication in Refrigerator
Penalty
Summary
The facility failed to provide a separately locked, permanently affixed compartment in the refrigerator for storage of a controlled drug in one of two medication rooms reviewed. During observation of the main medication room, one small refrigerator contained one bottle of liquid Ativan, a controlled medication used to treat anxiety, and the medication was not stored in a secured, permanently affixed locked compartment. The locked compartment was attached to a shelf, but the shelf could be easily removed from the refrigerator. An RN confirmed at the time of the observation that the shelf containing the locked container was removable, and the NHA later confirmed that the bottle of liquid Ativan was not in a permanently affixed compartment and should have been.
Incomplete Clinical Record Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for one resident. An admission MDS assessment indicated that the resident was cognitively impaired, dependent on staff for daily care, and had a history of falls. On the day of the incident, the resident experienced a fall and sustained a skin tear, with subsequent complaints of shoulder pain. Although a registered nurse assessed the resident following the fall and documented the assessment in the facility's investigation documents, this assessment was not included in the resident's clinical record. The Nursing Home Administrator confirmed that the investigation documents were not part of the clinical record, resulting in incomplete documentation for the resident.
Failure to Follow Physician's Orders for Bowel Protocols and Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding bowel protocols for two residents and medication administration for another resident. For one resident, the facility did not administer the prescribed Dulcolax suppository and Fleets enema after Milk of Magnesia proved ineffective, resulting in the resident not having a bowel movement for seven days. Similarly, another resident did not receive the prescribed Milk of Magnesia and Dulcolax suppository on the third and fourth day without a bowel movement, as ordered by the physician, leading to extended periods without bowel movements. Additionally, the facility did not follow physician's orders for a third resident regarding the administration of a Salonpas patch. The patch was applied multiple times without documented evidence of its removal within the prescribed 12-hour period. These failures were confirmed through interviews with the Nursing Home Administrator, highlighting a lack of adherence to established protocols and physician's orders for these residents.
Plan Of Correction
(Bowel) An Immediate Remedy could not occur for Resident 4 and 41 in this situation as the events occurred in the past. A audit/review of all other current residents in the facility shows that all residents have had appropriate administration of all bowel protocols where necessary. The Bowel Protocol Policy was reviewed and updated by Nursing Administration and Medical Director. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated on the bowel protocol policy. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with the Bowel Protocol Policy three times a week for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting. (Patch) An Immediate Remedy could not occur for Resident 27 as this situation as the events occurred in the past. An audit/review of orders was completed with no other resident prescribed as needed topical patches. The Transdermal Patch Policy was reviewed and updated by the Nursing Administration and Medical Director. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated on the bowel protocol policy. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with the documentation of removal of as needed transdermal patches three times a week for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Repeated Deficiencies in Physician Orders, Catheter Care, and Nutrition
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in a recent survey. The survey, which concluded on April 16, 2025, highlighted recurring issues that were previously noted in a survey ending May 23, 2024. These issues included failures to follow physician's orders, provide proper care of urinary catheters, and maintain nutrition for residents. The deficiency related to following physician's orders was initially identified in the May 2024 survey. The facility had developed a plan of correction that involved conducting audits and reporting the results to the QAPI committee. However, the recent survey found that the QAPI committee was ineffective in addressing these issues, as the same deficiency was cited again under F684. Similarly, the facility's plan to address deficiencies in catheter care and nutrition maintenance, which also involved audits and QAPI committee reviews, proved ineffective. The recent survey cited the facility under F690 for failing to maintain compliance with catheter care regulations and under F692 for nutrition maintenance. These repeated deficiencies indicate that the QAPI committee's efforts to correct and monitor these issues were insufficient.
Plan Of Correction
The current Quality Assurance Performance Improvement program has been reviewed by the Director of Quality and Compliance. The repeat deficiencies have been reviewed, and audits have been developed to provide accurate data collection and process improvement. The Director of Quality and Compliance will review Quality Assurance and Performance Improvement Minutes. Education has been provided to the Interdisciplinary Team regarding repeat deficiencies. Audits for repeat deficiencies will be completed per their individual plan of corrections. All audits will be reviewed at the Quality Assurance and Performance Improvement Quarterly meeting, where a Root Cause Approach will evaluate new and recurrent deficiencies. Revision or extension of audits will be discussed with the Interdisciplinary Team. Any audits that need to be reviewed will be done at that time.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
Laurel View Village was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the accuracy of Minimum Data Set (MDS) assessments for four residents. The facility failed to accurately code the administration of specific medications in the MDS assessments. For Resident 15, the MDS assessment did not reflect the administration of a diuretic medication, Valsartan-hydrochlorothiazide, despite physician orders and Medication Administration Records (MARs) indicating daily administration. Similarly, Resident 23's MDS assessment failed to indicate the administration of lorazepam, an antianxiety medication, which was ordered and documented as administered four times daily. Resident 28's MDS assessment inaccurately reflected the administration of Silver Sulfadiazine cream, a topical antibiotic, which was applied daily as per physician orders and Treatment Administration Records (TARs). Additionally, Resident 38's MDS assessment did not accurately reflect the administration of carbamazepine, an anticonvulsant medication, despite documentation of its administration. These inaccuracies were confirmed through staff interviews, including with the Registered Nurse Assessment Coordinator, who acknowledged the coding errors in the MDS assessments for these residents.
Plan Of Correction
Minimum Data Set (MDS) assessment for Residents 28, 38, 23, 15 was updated and resubmitted. Residents who have a Minimum Data Set (MDS) completed and require coding related to care needs have the potential to be affected. These individuals' Minimum Data Set were reviewed for accuracy. Education will be obtained for both Nursing Home Administrator, Registered Nurse Assessment Coordinator (RNAC), the Employee responsible for completion of the assessment, and any other individuals responsible for coding and/or auditing of the Minimum Data Set. Registered Nurse Assessment Coordinator reviewed the accuracy of assessments related to coding residents' abilities and care needs via Resident Assessment Instrument (RAI) manual. Registered Nurse Assessment Coordinator (RNAC) will reference the 3.0 Drug Class Index to confirm drug class when completing Section N (N0415. High risk Drug Classes: Use and Indication) of the Minimum Data Set Version 3.0 to assist and ensure accuracy of the Minimum Data Set. Updated 3.0 Drug Class Index obtained to ensure all classifications are accurate and reflective of any new medications. Director of Compliance or Designee will ensure Compliance going forward through auditing of the Minimum Data Set. The auditing will occur at the following schedule: 2 Clinical Records weekly for 4 weeks, followed by 4 clinical records twice monthly for 2 months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Provide Restorative Nursing Programs
Penalty
Summary
The facility failed to ensure that restorative nursing programs were provided according to the resident's plan of care for one resident. The deficiency was identified through a review of facility policies, clinical records, and interviews with residents and staff. The facility's policy on restorative nursing programs required individualized programs with measurable goals, overseen by a restorative nursing coordinator, and documented by restorative aides. However, documentation for the resident's restorative active range of motion and ambulation programs was missing on multiple dates. The resident involved was cognitively intact and required substantial assistance with lower body dressing, moderate assistance with upper body dressing, and substantial assistance with transfers and ambulation. The resident had a diagnosis of Parkinsonism, which affects movement. The care plan included a restorative active range of motion program using weights and a restorative ambulation program with a walker, both of which were not consistently documented as completed. Interviews with staff confirmed the lack of documentation and completion of the restorative programs as per the care plan. The Nursing Home Administrator acknowledged the absence of documented evidence for the completion of the resident's restorative programs on the specified dates and shifts. This lack of adherence to the care plan and documentation requirements led to the identified deficiency.
Plan Of Correction
An immediate remedy could not be implemented for Resident 29 as events occurred in the past. To ensure compliance and accuracy going forward, active range of motion for the certified nursing assistant to complete was added to this resident. An audit/review of all other residents' restorative nursing plans was completed. Active range of motion for the certified nursing assistant was added to those residents who had an active range of motion program assigned to the Restorative Nursing Assistant. The Restorative Nursing Program policy was reviewed by Nursing Management and the Medical Director; the policy was updated. This policy will be educated and reviewed with all current Healthcare Nursing Staff, and acknowledgements will be obtained and documented. All newly hired staff, as well as temporary (agency) staff, are to be educated on the Restorative Nursing Program/Policy Schedule and Execution of Tasks. An additional Restorative Nursing Assistant to fill in when the Restorative Nurse Aide is absent has been identified and trained. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with documentation of the Restorative Nursing Program daily for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Ensure Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling urinary catheter, as evidenced by the catheter bag and tubing being observed in direct contact with the floor, without a privacy bag or barrier. This was confirmed by a nurse aide and the Nursing Home Administrator, who acknowledged that the catheter bag should have been placed in a basin, which was found under the resident's bed. The resident, who was cognitively intact and required assistance with care needs, had a diagnosis of obstructive uropathy and a physician's order for a suprapubic catheter. Additionally, the facility did not adhere to its policy of measuring and documenting urinary output for residents with indwelling catheters every shift. A review of the resident's records revealed multiple instances where urinary output was not documented across various shifts from February to April. The Nursing Home Administrator confirmed the lack of documentation for the specified dates and shifts, indicating a failure to comply with the facility's policy on intake and output measurement.
Plan Of Correction
The remedy could not be immediate as the events occurred in the past. All residents with Urinary Catheters were identified and a documentation Audit was completed. The Input and Output Measurement policy was reviewed and updated. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff and Hospice Agencies that provide care are to be educated on the documentation of output. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with documentation of output in indwelling catheters three times weekly for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting. (Catheter Bag touching the Floor) Upon immediate investigation it was determined that all necessary supplies were in place to ensure that residents Urinary Catheter and any accompanying tubing were not in direct contact with the floor, however due to the residents bed being placed in the appropriate care Planned position, the bed frame had inadvertently crushed the basin allowing for the tubing and bag to be in contact with the floor. As this facility considers this a random unusual occurrence, the following will be completed in efforts to ensure that staff continue to remain educated and diligent in ensuring the mentioned deficiency does not occur. Policy was reviewed for accuracy and appropriateness. The Director of Nursing, Assistant Director of Nursing (Infection Preventionist), Healthcare Nursing Leadership, or designee will conduct visual audits for staff compliance with ensuring urinary Catheter Bags and Tubing are meeting Infection Control Standards three times weekly for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Implement Recommended Nutritional Interventions
Penalty
Summary
The facility failed to implement recommended nutritional interventions for a resident identified as being at nutritional risk. The dietician had recommended that the resident, who had cognitive impairment and unplanned weight loss, be provided with ice cream twice a day to address her weight loss and decreased food intake. However, there was no documented evidence that the ice cream was provided as recommended. The resident's weight decreased from 130.7 pounds to 125.5 pounds over a period of approximately one month. Interviews with the dietician and dietary manager revealed that the ice cream was not included in the resident's meal ticket, and there was no order in the clinical record for the ice cream to be provided twice a day. The dietician believed the resident was receiving the ice cream or an equivalent supplement, but this was not the case. The dietary manager confirmed that the usual process of adding nutritional support items to a resident's diet was not followed, resulting in the resident not receiving the recommended nutritional intervention.
Plan Of Correction
(Magic Cup) Immediately for Resident 12, Order was obtained for Magic Cup and added to resident tray ticket. An audit/review of all other current residents in the facility ordered supplements/interventions were reviewed for accuracy and appropriateness. Policy was Reviewed by Dietary Management, Medical Director, Nursing Administration and Dietician for accuracy. This Policy will be educated and reviewed with All current Registered Nurses and Dieticians; acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated, as necessary. Dietary Management or Designee will inspect the supplements provided at meal service. Audits will be completed with one meal per day x 7 days for two weeks. Then one meal per day x 3 days for two weeks. Finally, one meal a day x 1 day for one week and/or as needed. Dietitian or Designee will Audits items ordered in Care plans, physician orders and tickets/labeled snacks as appropriate. The Dietician is the responsible Dietary staff member who reviews and accepts orders in Electronic Medical Record (EMR) to know if supplements are being consumed. Dietician Audits for Care plans, physician orders and tickets/labeled snacks as appropriate Audits need to be completed once weekly x 5 weeks and/or with changes to supplement orders. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices as ordered by the physician for a resident, identified as Resident 23, who was moderately cognitively impaired and required set-up assistance with eating. The resident had a physician's order to use a divided plate to facilitate easier access to food, as indicated in the resident's meal ticket for the noon meal. However, during an observation on April 15, 2025, at 12:02 p.m., it was noted that the resident did not have the divided plate while eating in the dining room. This was confirmed by an interview with a Licensed Practical Nurse at the time of the observation.
Plan Of Correction
Licensed Practical Nurse on the unit immediately provided Resident 23 with fresh food and appropriate divided plate. Immediately after meal services, the Dietary Aid, which was responsible for providing the plate, was re-educated on the order for residents' adaptive equipment and noted that it was present on the meal ticket to ensure compliance. The Adaptive Equipment Policy was reviewed with no change needed. It will be educated and reviewed with all current staff which assist with meal service. Acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff and Hospices which assist with meals are to be educated, as necessary. An audit/review was completed for all Adaptive equipment ordered for residents with a visual analysis on the equipment being noted on residents' meal tickets as well as successful execution on providing appropriate equipment to the residents. Dietary Management or Designee will inspect the use of adaptive equipment at meal service. Audits to ensure compliance will occur at the following Schedule: Initially, one meal per day x 7 days for two weeks, followed by one meal per day x 3 days for two weeks and finally one meal a day x 1 day for one week and/or as needed. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.
Failure to Follow Physician Orders and Notify Physician
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents. For Resident 7, who was cognitively intact and had a colostomy, there was a failure to discontinue a previous wound care order after new orders were received. On May 20, 2024, a new order was issued for the resident's periostomy wound care, but the previous order from April 29, 2024, was not discontinued. As a result, both wound care orders were documented as administered on May 20, 21, and 22, 2024, which was confirmed by the Director of Nursing. For Resident 28, who was cognitively intact and had diabetes, the facility did not notify the physician when insulin was held due to low blood sugar levels. The resident's blood sugar levels were recorded as low on several occasions, and the bedtime dose of insulin was held on those dates. However, there was no documented evidence that the physician was notified, which was confirmed by the Director of Nursing. This failure to follow protocol for notifying the physician when insulin was held constitutes a deficiency in care.
Failure to Follow Catheter Care Orders
Penalty
Summary
The facility failed to follow physician's orders for the care of an indwelling urinary catheter for one resident. Resident 30, who was rarely or never understood or able to understand and was dependent on staff for daily care tasks, had an indwelling suprapubic catheter. A urology consult ordered the catheter to be changed every four weeks. However, a review of the resident's clinical records, including Treatment Administration Records and nursing notes, showed no documented evidence that the catheter was changed between January 30, 2024, and March 2, 2024. An interview with the Nursing Home Administrator confirmed the lack of documentation for the catheter changes as ordered during this period.
Failure to Maintain Therapeutic Diet for Resident
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident, identified as Resident 51, who was cognitively intact and required extensive assistance for daily care needs. The resident had a diagnosis of kidney failure and was initially on a No Salt Added diet with regular texture and thin liquids, as per physician's orders dated February 29, 2024. On May 4, 2024, a nurse's note indicated that the resident was experiencing prolonged chewing, leading to a referral to speech therapy and a precautionary downgrade of the diet to mechanical soft. A subsequent speech therapy note on May 7, 2024, confirmed the resident's difficulty in chewing, resulting in a physician's order for a regular diet with mechanical soft ground texture and thin liquids. However, there was no documented evidence that the therapeutic No Added Salt diet was continued when the texture was downgraded, which was confirmed by the Nursing Home Administrator on May 21, 2024.
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 237 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Davidsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concordia At Arbutus Park | 2.7 mi | ★★★★★ | 14 | 0 |
| Windber Woods Senior Living & Rehabilitation Ctr | 3.2 mi | ★★★★★ | 16 | 0 |
| Quality Life Services - Westmont | 4.3 mi | ★★★★★ | 4 | 0 |
| Richland Nursing And Rehab | 4.3 mi | ★★★★★ | 12 | 0 |
| Heritage Ridge Senior Living At Johnstown | 4.4 mi | ★★★★★ | 21 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.