Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Nottingham Village during CMS and state inspections, most recent first.
Food service equipment and storage areas were found unsanitary in the main kitchen and on Station 2 and Station 3. Observations showed dried spills, debris, food splatter, stained storage containers, uncovered utensils with exposed food contact surfaces, a soiled microwave with rust-colored areas, and dirty cabinets and freezer interiors. The NHA was informed of the findings.
Failure to provide individualized trauma-informed care for two residents with documented trauma histories. One resident had a history of his son being murdered, and another had a history of losing three children, including a stillborn child, and two miscarriages. Both care plans used the same general interventions such as compassion, rapport building, emotional support, and encouraging visits, but did not include resident-specific steps to identify triggers or prevent re-traumatization.
Failure to provide bathing per resident preference. A resident stated she was supposed to receive showers twice weekly but often only received a bed bath or one shower per week instead of the scheduled showers. Record review showed the bathing task had been changed several times per family request, the resident needed assistance with bathing and transfers, and there was no evidence she refused showers. The DON stated day shift aides thought the showers had already been completed because the resident was dressed by night shift.
A resident’s annual MDS incorrectly stated that the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, even though the resident had a PASRR II determination and DHS letter confirming the need for ongoing mental health services. The DON confirmed the MDS error.
A resident with MS and generalized muscle weakness had an order and care plan for a right bed enabler for positioning, but the bed was observed with bilateral enabler bars. The resident signed general side rail consent and assessment forms, yet the documentation did not specify whether only a right rail or bilateral rails were authorized. The facility’s bed measurement worksheet also documented bilateral foot rails and incomplete zone assessment, even though the bed did not have foot rails at the time of observation.
Medication administration errors caused the facility’s error rate to reach 5%. An LPN gave Omeprazole after a resident had already eaten breakfast, despite package insert directions to take it at least 1 hour before a meal, and gave Ondansetron and Imatinib to another resident in a way that did not follow the MAR’s special instructions for timing.
Failure to Administer Eligible Pneumococcal Vaccine: The facility failed to ensure that a resident received PCV20 after consent had been obtained. The resident’s record showed prior PPSV23 and PCV13 immunizations, making her eligible for PCV20 based on CDC guidance, and the IP confirmed that the vaccine was not given despite the resident being eligible and having consented.
A resident at Nottingham Village experienced inadequate pain management following a fall, despite having severe injuries and a pain assessment indicating significant discomfort. The facility did not follow its pain management policy, failing to administer prescribed medication or conduct further pain assessments. Interviews confirmed these deficiencies.
The facility did not maintain hazardous area enclosures as required, with unsealed wall penetrations around three copper pipes in the Soiled Utility area on Unit 3. This deficiency was confirmed during an exit interview with the Facility Administrator.
The facility failed to maintain the required sprinkler systems, affecting multiple smoke compartments. Observations revealed an unsealed penetration in the ceiling of the Environmental Service Room, a gap around a sprinkler escutcheon at the Nurse's Station, and a missing escutcheon in the Walk-In freezer. These issues were confirmed with the Facility Administrator.
The facility failed to maintain corridor door integrity, affecting one floor. Observations revealed that a door to a resident room was not smoke tight, and another door failed to latch properly. These deficiencies were confirmed during an exit interview with the Facility Administrator.
The facility failed to maintain a smoke barrier separation wall, affecting two smoke compartments. An observation revealed that the attic level smoke barrier separation wall door was not smoke tight when closed into the frame inside the Dietary storage area. This deficiency was confirmed during an exit interview with the Facility Administrator.
The facility failed to meet NFPA 101 standards for exits, as observed in one of ten smoke compartments. The basement level lacked two acceptable means of egress, a deficiency confirmed during an interview with the Facility Administrator.
The facility failed to assess the need for, obtain consent for, and evaluate entrapment risks of bed assistive bars for two residents. Observations revealed the presence of assist bars without proper documentation or consent. The Nursing Home Administrator confirmed the lack of necessary assessments and consent for the devices.
A resident with natural teeth did not receive routine prophylactic dental services, as confirmed by interviews and clinical record reviews. Despite a dental exam noting significant plaque buildup and recommending cleanings every six months, there was no evidence of such services being provided in the past year.
The facility's main kitchen had several deficiencies in food storage and sanitation, including expired food items, improper storage conditions, and unclean equipment. Observations revealed issues such as a hole in a macaroni bag, expired rosemary and blue food coloring, and ice accumulation on food boxes in the freezer. Additionally, orange juice and other food items were not used within required timeframes, and clean items were not protected from contamination. An employee was also seen without a beard guard in a food prep area.
The facility's arbitration agreements failed to ensure a neutral and fair process for three residents, as the agreements allowed the facility to select the arbitrator unless their chosen arbitrator was unavailable. This deficiency was confirmed through a review of the agreements and interviews with the Nursing Home Administrator and DON.
A resident with hemiparesis following a cerebral infarction was unable to reach her call bell due to its placement at the head of her bed, which was not accessible given her limited range of motion. This deficiency was observed and discussed with facility leadership.
A resident sustained a tibial plateau fracture and ligamentous knee injury, but the facility failed to investigate the cause of the injury as required by their abuse policy. Despite the resident's complaints of pain and subsequent medical findings, there was no documentation on how the injury occurred, and the DON confirmed the lack of investigation.
The facility inaccurately assessed two residents' conditions in their MDS. One resident with hemiparesis was incorrectly noted as having no upper extremity impairment, and another resident's discharge status was wrongly recorded as to a hospital instead of home. These errors were confirmed by the DON.
A facility failed to document and plan for a resident's cardiac pacemaker use. The resident, with a history of heart disease, indicated that her pacemaker alerts the facility to fluid accumulation, affecting her Lasix medication. However, her records lacked physician orders or a care plan for the pacemaker. The facility was unaware of the device's communication method or emergency procedures, and the device was not included in her care plan.
A facility failed to implement a restorative nursing program for a resident with hemiparesis following a stroke, as recommended by therapy. Despite discharge recommendations for passive and active range of motion exercises to maintain the resident's ability for daily tasks, there was no evidence that the program was implemented. Interviews confirmed that the program was never established, and nursing staff were not educated on it.
A facility failed to prevent potential complications from a dialysis access site for a resident requiring dialysis. The resident, who receives dialysis through a fistula in the right arm, reported that staff sometimes attempted to take blood pressure readings from the restricted arm. The clinical records lacked any indication of this restriction, which was confirmed by the DON. A sign indicating the restriction was placed only after the surveyor's inquiry.
The facility failed to provide adequate nursing staff, resulting in delayed call bell responses for two residents. One resident reported staff not returning after responding to her call bell, while another resident, needing assistance for toileting, experienced a 32-minute delay in response. The facility acknowledged these findings.
The facility failed to ensure proper labeling and secure storage of medications on Station III and for a resident. An unlocked medication cart was left unattended, accessible to unauthorized individuals. Additionally, a resident self-administered improperly labeled and expired eye drops, requiring assistance to open the bottle. These issues were confirmed by staff and acknowledged by the facility's administration.
A facility failed to implement transmission-based precautions for a resident with a UTI caused by an ESBL E-Coli, an MDRO. Despite the laboratory report indicating the presence of this MDRO, the facility did not initiate contact or enhanced barrier precautions as required by their policies. Observations and interviews confirmed the lack of isolation measures and the resident's dependency on staff for care without using necessary precautions.
A facility failed to offer and document the administration or refusal of an influenza vaccine for a resident during the 2024-2025 season. Despite the facility's policy requiring annual vaccination offers and documentation, there was no evidence of the vaccine being administered or declined. Interviews confirmed the absence of necessary documentation and contact with the resident's responsible party.
A resident did not receive a COVID-19 booster due to a lack of documented consent refusal from their responsible party. The facility's policy requires offering the vaccine and documenting consent or refusal, but no such documentation was found. Interviews confirmed the resident had not received any COVID vaccines since admission, and attempts to contact the responsible party were inadequately documented.
The facility did not meet the Act 52 Infection Control Plan requirements due to the absence of maintenance staff in infection control committee meetings. Attendance records from January to October 2024 showed no evidence of participation from the maintenance department. Interviews with the maintenance director and nursing home administrator confirmed this deficiency.
Food Service Areas and Equipment Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to maintain food service equipment in accordance with professional standards for food service safety and failed to store food in a sanitary manner in the main kitchen and on two nursing units, Station 2 and Station 3. In the main kitchen, an observation with the dietary manager found debris and multiple dried brown liquid spots on the floor under the coffee station, dried liquid splatter on the wall beside the area, and broken pieces of drywall on the corner of the wall. A metal utensil rack hanging over a food preparation table had cooking utensils stored uncovered with food contact surfaces exposed, and a metal sheet tray under the steamer held grill cleaning utensils along with dried debris and dried brown spills. A large white plastic storage bin on wheels under a preparation table had a significant amount of dried food on its top and exterior sides, a cardboard dispenser box of plastic film on the preparation table had dried food and liquid staining, and the lower shelves of the dry supply storage room had dust and debris on the shelf liners. In Station 2, the interior of the microwave was covered in dried food splatter and portions of the interior had peeled away, exposing rust-colored areas. The interior base of a cabinet under the sink contained multiple dried liquid spots, and a glass jar and vase were stored in that cabinet. In Station 3, the freezer above the refrigerator was soiled with debris and frozen spills, and the interior base of the cabinet under the sink area had black debris scattered throughout it with dried brown liquid stains. The Nursing Home Administrator was informed of these observations.
Failure to Provide Individualized Trauma-Informed Care
Penalty
Summary
The facility failed to implement individualized trauma-informed care for two residents reviewed for behavior and emotional status. Resident 95’s clinical record showed a Social History Assessment documenting a traumatic life event involving the murder of his son, and the care plan identified trauma-related adverse effects with a goal that the resident would not experience behavioral outbursts, mood swings, or physical aggression. The listed interventions included general measures such as continued communication, compassion, rapport building, encouraging visits, supporting autonomy, offering emotional support, and providing safety, but there were no specific individualized interventions describing how staff were to identify or eliminate triggers or mitigate re-traumatization related to the resident’s trauma. Resident 101’s record showed a Social History Assessment documenting traumatic life events including the loss of three children, one stillborn, and two miscarriages. The care plan similarly identified trauma-related adverse effects and set a goal that the resident would not have behavioral outbursts, mood swings, or physical aggression, with interventions focused on general communication, compassion, rapport, family involvement, autonomy, and emotional support. The plan did not include individualized interventions describing how staff were to eliminate triggers or prevent re-traumatization, and the trauma-related care plans for Residents 95 and 101 reflected the same goals and interventions without individualized information specific to each resident’s trauma. This information was reviewed with the Nursing Home Administrator.
Failure to Provide Bathing Per Resident Preference
Penalty
Summary
The facility failed to provide bathing according to a resident’s stated preference for one of 32 residents reviewed. Resident 101 stated in interview that she was supposed to receive showers on Tuesdays and Fridays but was not getting them, and that this had happened again the day before the interview. She reported that staff would come in early, wash her up in bed, and dress her without taking her to the shower, and that her family member had previously discussed the issue with facility staff. She also stated that her shower schedule had changed over time, including from once weekly during the day to nighttime, then to twice weekly as she preferred, but she still only received one shower a week. Clinical record review showed Resident 101’s bathing task was initially scheduled on admission for a Tuesday day-shift shower, then changed several times, including to Thursday evening, back to Tuesday evening, and then to Tuesdays and Fridays on the day shift per family. The bathing record showed showers were provided on some Fridays, but the resident did not receive showers per preference on multiple Tuesdays, including one instance where a bed bath was given instead of a shower. There was no evidence that Resident 101 refused showering. The admission MDS dated October 20, 2025, showed the resident was dependent on staff for transfers and needed assistance with bathing. The DON stated that because the resident was dressed by night shift in the morning, day shift nurse aides thought the showers had already been completed.
Inaccurate PASRR Status on MDS
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident’s status for Resident 45. Clinical record review showed a PASRR dated November 2, 2023, that found the resident met criteria for further mental health review by DHS. A DHS letter dated November 7, 2023, confirmed that Resident 45 met criteria to require ongoing mental health services for a serious mental illness, to be arranged by the facility as a PASRR II. However, an annual MDS assessment dated July 24, 2025, incorrectly stated that Resident 45 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The DON confirmed this MDS error during interview on November 13, 2025.
Inadequate assessment of bed enabler bars
Penalty
Summary
The facility failed to appropriately assess the use of enabler bars for one of seven residents reviewed for accident hazards. Resident 10 had diagnoses of multiple sclerosis and generalized muscle weakness, and an MDS assessment showed a BIMS score of 15, indicating no cognitive impairment. The physician order dated August 5, 2025, specified a right bed enabler for positioning, and the care plan also identified a right bed enabler as an intervention. However, when the resident was observed in bed on November 12, 2025, the bed had bilateral enabler bars attached even though the order and care plan only indicated a right enabler bar. The resident stated the enabler bars were used to help with rolling and repositioning in bed. The resident signed a Side Rail Consent Form and a Side Rail Assessment Form on October 3, 2025, and both forms referenced side rails generally, but neither form specified installation parameters for only a right side rail or bilateral side rails. Facility documentation titled Bed System Measurement Device Test Results Worksheet, dated October 15, 2025, showed bilateral head rails and bilateral foot rails with zones one through four marked as pass, but the resident's bed did not have bilateral foot rails at the time of observation and the facility provided no documentation that the bed ever had foot rails. The worksheet did not include measurements or documentation for zones five through seven, and the Nursing Home Administrator stated it was unclear why staff assessed the bed as having foot rails.
Medication Error Rate Reached Five Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below five percent. Survey review found the facility had a five percent medication error rate based on 34 medication opportunities with two medication errors. The facility policy, Administration Procedures for All Medications, required staff to check the MAR for the physician’s order and, if unfamiliar with a medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. During a medication pass observation, an LPN administered Omeprazole 40 mg delayed release oral capsule to a resident after the resident had already finished breakfast, even though the package insert instructed that the medication be taken at least one hour before a meal. The resident confirmed breakfast had been completed, and the LPN acknowledged the medication was given after the meal and that there was no individualized physician order allowing administration outside the manufacturer’s instructions. During another medication pass observation, an LPN administered Ondansetron 8 mg and three Imatinib Mesylate 100 mg tablets to another resident. The resident’s MAR included special instructions that Ondansetron was to be given one hour prior to Imatinib, with Ondansetron scheduled for 8:00 AM and Imatinib for 9:00 AM.
Failure to Administer Eligible Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that an eligible resident received a pneumococcal vaccine after consent had been obtained. The facility policy stated that all residents would be offered pneumococcal vaccines unless medically contraindicated, already given, or refused, and that administration would follow current CDC recommendations. Clinical record review for the resident showed an immunization form dated November 9, 2023, indicating that the responsible party consented to the Prevnar 20 (PCV20) pneumococcal vaccine. Review of the resident’s immunization record showed prior pneumococcal vaccinations of PPSV23 on March 20, 2007, Prevnar 13 on February 23, 2018, and PPSV23 on March 22, 2019, all before admission to the facility. Based on the record, the resident was eligible for PCV20 five years after the last pneumococcal vaccine dose, which would have been March 22, 2024. During interview, the infection preventionist confirmed that the resident did not receive the PCV20 immunization that she was eligible for and had consented to receive.
Failure in Pain Management for Resident
Penalty
Summary
Nottingham Village was found to be non-compliant with the pain management requirements as outlined in 42 CFR Part 483, Subpart B. The facility failed to provide adequate pain management for a resident who had been admitted with severe injuries, including a displaced bimalleolar fracture and a displaced osteochondral fracture. On January 19, 2025, the resident was found on the floor, complaining of severe pain, which was assessed as a seven out of ten. Despite the resident's complaints and nonverbal signs of pain, the facility did not implement the pain management program as per their policy, which required pain assessment every shift and updating the physician if pain was not managed effectively. The facility's documentation revealed that the resident was not administered any as-needed Tylenol on the day of the incident, despite having an order for it. Furthermore, there were no further assessments of the resident's pain after the initial assessment on the first shift. Interviews with the resident and the Director of Nursing confirmed these findings, indicating a failure to adhere to the facility's pain management policy and to address the resident's severe pain adequately.
Plan Of Correction
1. Resident # 1's Pain has been re-assessed and is reporting her pain is being managed. 2. DON / Designee will audit the month of February MAR's to identify residents reporting over 7 pain. These residents will be assessed along with input from their PCP to determine if a new pain management regimen is necessary. 3. DON will conduct education with licensed nurses on the facility's pain management policy and include pain management focus when assessing residents post injury or accident. 4. DON / designee will audit random MAR's to determine if residents reporting over 7 pain are being managed properly; weekly x 4 weeks. DON / designee will audit IR's with reported injuries to validate pain has been assessed and managed properly; weekly x 4 weeks. Results of these audits will be reported to the QAPI team. 5. Date of compliance 3/13.
Unsealed Wall Penetrations in Soiled Utility Area
Penalty
Summary
The facility failed to maintain hazardous area enclosures as required by NFPA 101 standards. During an observation on December 16, 2024, at 10:05 a.m., it was noted that the Soiled Utility area on Unit 3 had unsealed penetrations in the wall around three copper pipes. This deficiency affects one of the two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator on the same day at 12:00 p.m.
Plan Of Correction
1. The penetration areas around the copper pipes were resolved with the application of a silicone caulk-filler. 2. Corrective action occurred on 12/16/24. 3. Administrator / Designee will educate maintenance staff on K321 and regarding hazardous area wall penetration issues. 4. Maintenance staff will conduct random inspections of other potential hazardous areas to determine that no other penetration issues are identified. Inspections to be done weekly x4 weeks and results submitted to the QA Committee.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the required sprinkler systems in three specific locations, affecting four out of ten smoke compartments. During an observation on December 16, 2024, it was noted that the Environmental Service Room in Unit 3 had an unsealed penetration in the ceiling. Additionally, the Nurse's Station in Unit 3 had an unsealed gap around a sprinkler escutcheon. Furthermore, the Walk-In freezer in the Dietary area was missing an escutcheon. These deficiencies were confirmed during an exit interview with the Facility Administrator on the same day.
Plan Of Correction
1. Unsealed penetration in the ceiling of Environmental Service Room was adjusted and corrected. Sprinkler Escutcheon at station 3 nurses station causing the gap was adjusted and is back into place. Missing escutcheon for walk-in freezer has been ordered. 2. Issue in the Environmental Service Room and Nursing station 3 noted above were corrected on 12/16/24. The missing escutcheon for sprinkler head in walk-in freezer is scheduled to be replaced on 12/27/24. 3. Administrator / Designee will educate maintenance staff regarding K353 maintenance of required sprinkler systems. 4. Maintenance Staff will conduct random inspections of other smoke compartments containing sprinkler heads to identify other similar issues. Inspections will be done weekly x 4 weeks and results reported to QA committee.
Deficiency in Corridor Door Integrity
Penalty
Summary
The facility failed to maintain the integrity of two corridor openings, which affected one of the two floors. During an observation conducted on December 16, 2024, it was noted that the door to Resident Room 125 on Unit 1 was not smoke tight when latched into the frame. This indicates that the door did not meet the required standards for resisting the passage of smoke, which is a critical safety feature in long-term care facilities. Additionally, the door to Resident Room 120 on the same unit failed to latch into the frame when tested. This deficiency was confirmed during an exit interview with the Facility Administrator on the same day. The failure of these doors to function properly compromises the safety measures intended to protect residents from smoke in the event of a fire, as they do not provide the necessary barrier to prevent smoke from entering the corridor.
Plan Of Correction
1. Resident Room Doors 125 & 120 had adjustments made to the frames to eliminate the gap and ensure smoke tight closure. 2. Corrective action was completed on 12/16/24. 3. Administrator / Designee will educate maintenance staff on K363 regarding corridor doors and maintaining sufficient smoke tight closure. 4. Maintenance Staff will conduct random inspections of resident room doors to identify other potential closure issues. Inspections will be conducted weekly x 4 weeks and results will be submitted to the QA committee.
Smoke Barrier Separation Wall Deficiency
Penalty
Summary
The facility failed to maintain a smoke barrier separation wall, which affected two out of ten smoke compartments. During an observation on December 16, 2024, at 11:12 a.m., it was noted that the attic level smoke barrier separation wall door was not smoke tight when closed into the frame, specifically inside the Dietary storage area. This deficiency was confirmed during an exit interview with the Facility Administrator on the same day at 12:00 p.m.
Plan Of Correction
1. A door latch mechanism will be installed on the attic door to correct the gap and wall separation. 2. The door latch will be installed on 12/27/24. 3. Administrator / Designee will educate maintenance staff on K374 regarding smoke barrier wall separation deficiencies. 4. Maintenance staff will conduct random inspections of other similar areas to identify other potential issues. Inspections will be conducted weekly x4 weeks and results will be reported to the QA committee.
Deficiency in Required Exits for Smoke Compartment
Penalty
Summary
The facility was found to be non-compliant with the National Fire Protection Association (NFPA) 101 standards regarding the number of exits required for each story and smoke compartment. Specifically, the deficiency was identified in one of the ten smoke compartments within the facility. During an observation conducted on December 16, 2024, at 10:00 a.m., it was noted that the basement level of the facility did not have two acceptable means of egress as required. This finding was confirmed during an exit interview with the Facility Administrator on the same day at 12:00 p.m.
Failure to Assess and Obtain Consent for Bed Assistive Devices
Penalty
Summary
The facility failed to obtain consent for, assess the need for, and assess entrapment risks from bed assistive bars for two residents. For Resident 19, observations revealed the presence of assist bars mounted bilaterally at the head of her bed. However, the facility could not provide documentation of an assessment for the need of the assistive device, an assessment of potential entrapment risks, or consent obtained prior to the installation of the device. It was only after the surveyor's questioning that a new physician's order and relevant assessments and consent forms were completed. Similarly, for Resident 108, observations showed the presence of assist bars, but the facility lacked documentation of an assessment for the need of the assistive device, an assessment of potential risks, or consent obtained prior to the installation. The Nursing Home Administrator confirmed that Resident 108 was unable to use the assist bars, and there was no documentation to support their use. The deficiency was identified through observation, clinical record review, and staff interviews.
Plan Of Correction
1. Resident # 19 has been assessed for need, consented on the risk and benefits, and an entrapment inspection completed for her bed positioning device. Resident #108 no longer has bed positioning devices. 2. DON/designee will conduct a sweep to determine if other residents using siderails or positioning devices have a current assessment of need, risk and benefits consent, and a completed entrapment inspection on record. 3. Licensed Nurses and Rehab Staff will be educated on CFR Code 483.25(n) and the Center's policy regarding bedrail use in a skilled nursing facility. 4. DON/designee will conduct weekly sweeps to validate residents using bedrails or bed positioning devices have documented evidence of assessment of need, risk and benefit consent, and current entrapment risk inspection. Audit will be conducted weekly x 4 weeks, and then monthly x 3 months. Results of the audits will be submitted to the QAPI team. 5. Date of Compliance 1/30/2024
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine prophylactic dental services for a resident, identified as Resident 62, who was reviewed for dental concerns. An interview with Resident 62 revealed that he had natural teeth but had never received a cleaning from a dental hygienist or professional, and he was responsible for brushing his own teeth. An interview with the Director of Nursing confirmed the absence of evidence showing that a hygienist or dental professional had provided preventative cleaning for Resident 62 in the past year. A progress note from the facility's consulting dental provider, dated September 17, 2024, indicated an annual exam by the dentist, revealing heavy soft plaque and food debris buildup, light hard calculus deposits, moderate gingival inflammation, and a moderate risk for caries. The recommended treatment plan was for preventative cleanings every six months, but there was no clinical record evidence that these cleanings were provided in the past year.
Plan Of Correction
1. Resident 62 to have dental cleaning by dental professional. 2. DON/Designee will audit current residents who resided in the Center during the past 12 months to identify those who may have not received a dental cleaning. 3. DON/Designee will educate nursing staff on 483.55(b). 4. DON/Designee will conduct random audits weekly X 4 weeks and then monthly X 3 months to validate residents have received or have been offered dental cleaning in prior 12 months. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food items and maintain equipment in a safe and sanitary manner in the main kitchen. During an initial tour, several issues were observed, including a bag of elbow macaroni with a hole and no open or use-by date, and a temperature control unit with a significant accumulation of a black substance on the vents. An open container of whole rosemary had an expired use date, and an open container of blue food coloring had an unreadable use-by sticker. In the walk-in freezer, cardboard boxes containing food items were found under circulation fans with a large accumulation of ice. The walk-in cooler contained orange juice containers that were not used within the required 10 days of thawing, as well as low-fat cottage cheese and cubed cheese with expired use-by dates. Further observations revealed several clear containers of pudding, a thawed box of hot dogs, and a container of hot dog chili sauce with expired use-by dates. A large bag of shredded lettuce and baked lima beans also had expired use-by dates. Clean items stored on wire racks were not protected from mop splash during floor cleaning. A green plastic tray in the sink next to the dishwasher had a build-up of a black substance, and temperature control units and machines had visible dust and black build-up. Additionally, an employee was observed without a beard guard while working in a food prep area. These findings were reviewed with the dietary manager and administrative staff.
Plan Of Correction
1. No residents were affected by deficient practice. Expired food items have been discarded; surfaces found to have dust and debris have been cleaned; other issues found have been resolved. Employee # 7 counselled for failing to wear beard guard. 2. Administrator / designee will conduct a kitchen inspection to determine if other expired food items exist; storage of items on bottom shelves have lining protection; equipment, vents, and other surfaces are free from dust / stains / debris; staff are wearing proper hair restraining devices. 3. Administrator / designee will conduct training with all Dietary personnel on CFR 483.60 (i)(1)(2) and the Center's Policy regarding Food Procurement / Storage / Sanitation. 4. Administrator / designee will monitor for compliance by conducting routine kitchen audit inspections at least weekly x 4 weeks and then monthly x 3 months. Results of the inspections will be submitted to the QAPI team. 5. Date of Compliance 1/30/2024.
Deficient Arbitration Agreement Process
Penalty
Summary
The facility's arbitration agreements were found to be deficient in ensuring a neutral and fair arbitration process for three residents who had signed these agreements. The agreements stipulated that the arbitration would be administered by an arbitrator services company designated by the facility. If this company was unable or unwilling to serve, the facility would then select an alternative arbitration service. This process did not guarantee that both parties would mutually agree upon a neutral arbitrator unless the facility's chosen arbitrator was unavailable. The deficiency was identified during a review of the arbitration agreements signed by three residents and confirmed through interviews with the Nursing Home Administrator and the Director of Nursing. The facility's current arbitration agreements did not provide for mutual selection of a neutral arbitrator, which was confirmed by the Nursing Home Administrator. This failure to ensure a neutral arbitration process was in violation of resident rights and management responsibilities as outlined in the relevant state codes.
Plan Of Correction
1. Residents #19, 62 and 68 have been offered a new arbitration agreement which meets compliance. 2. Administrator / Designee will conduct a sweep of all current in-house residents to identify who has a signed arbitration agreement not meeting the required language. 3. Administrator / designee will contact NV legal representatives to seek assistance in reconstructing an Arbitration Agreement that meets regulatory requirement. A regulatory compliant arbitration agreement will be re-offered to all current residents/ patient reps. 4. Administrator / designee will conduct random audits of new admissions, weekly x4 weeks and then monthly x 3 months. Results of the audits will be submitted to the QAPI team. 5. Date of Compliance 1/30/2025
Failure to Accommodate Resident's Call Bell Accessibility
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 108, regarding the accessibility of a call bell. Resident 108 was admitted with a diagnosis of hemiparesis following a cerebral infarction, affecting her right dominant side and limiting her range of motion. During interviews and observations conducted on December 3 and 4, 2024, it was noted that Resident 108 was unable to reach her call bell, which was attached to the top of the assist bar rail at the head of her bed. This issue was discussed with the Nursing Home Administrator and Director of Nursing on December 5, 2024. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services, indicating a failure to reasonably accommodate the resident's needs and preferences.
Plan Of Correction
1. Resident 108 call bell corrected, care plan that she prefers it on the side of affected limb. 2. DON/Designee to do a sweep of residents to make sure call bells accessible to resident. 3. DON/Designee will educate nursing staff about call bell accessibility, policy and on 483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. 4. DON/Designee will do a random audit weekly x4 and monthly x3 to ensure call bell placement. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Investigate Resident's Injury
Penalty
Summary
The facility failed to implement its abuse policy regarding the investigation of an unknown injury for a resident. The policy, last reviewed on July 18, 2024, requires the use of an incident reporting system to report, investigate, and track all unusual incidents, including those of unknown origin. However, the facility did not complete an investigation into the cause of a resident's injury, which was necessary to rule out the potential for abuse and neglect. The resident, identified as Resident 28, complained of right leg pain, which was initially treated with Tylenol but proved ineffective. Subsequent medical evaluation revealed a tibial plateau fracture and ligamentous knee injury. Despite these findings, there was no documented evidence in the resident's clinical record indicating how the injury occurred. An interview with the Director of Nursing confirmed that the facility did not conduct an investigation into the injury, as required by their policy.
Plan Of Correction
1. Resident 28 has a completed Incident Report and investigation summary regarding the unknown Fracture. 2. DON/Designee will audit the past 30 Incident / Accident reports to determine if other injuries of unknown origin have been investigated properly. 3. DON/Designee will educate nursing Staff on making sure that incidents of unknown origin are resolved and abuse has been ruled out, and abuse prohibition policy. 4. DON/Designee will do a random audit weekly x4 and monthly x3 of Incident Reports to validate complete investigation including to rule out abuse for injuries of unknown origin. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to ensure accurate assessments of residents' conditions, as evidenced by discrepancies in the Minimum Data Set (MDS) assessments for two residents. Resident 108, admitted with hemiparesis following a cerebral infarction, was incorrectly assessed as having no impairment in her upper extremities, despite her own report of limited range of motion on her right side. This error was confirmed by the Director of Nursing. Similarly, Resident 112's MDS inaccurately recorded his discharge status as being to a hospital, while nursing documentation indicated he was discharged to his home. This discrepancy was also confirmed by the Director of Nursing.
Plan Of Correction
1. MDS for Resident 108 has been modified to reflect impairment. Resident 112 MDS modified to reflect correct discharge placement. 2. DON / Designee will audit recent MDS completed in the past 30 days to identify other potential inaccuracies. 3. DON/Designee will educate RNACs on 483.20(g) Accuracy of Assessments. 4. DON/Designee will do a random audit weekly x4 and monthly x3 to accuracy of MDS assessments. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Document and Plan for Cardiac Pacemaker Use
Penalty
Summary
The facility failed to ensure quality of care for a resident with a cardiac pacemaker. The resident, who has a history of heart disease and heart failure, indicated that her pacemaker device alerts the facility when fluid accumulation is detected in her body, prompting adjustments to her Lasix medication. However, a review of her clinical records revealed no physician orders or care plan addressing the presence and management of the pacemaker. The resident's diagnoses included acute on chronic heart failure and paroxysmal atrial fibrillation, and her admission records noted a history of heart ablation and an AICD. During an interview with the Director of Nursing and the Nursing Home Administrator, it was confirmed that the facility was unaware of how the pacemaker device communicates with the monitoring company or the necessary emergency procedures to ensure its continued functioning during utility interruptions. The device was not included in the resident's plan of care, indicating a lack of comprehensive documentation and planning for the resident's cardiac needs.
Plan Of Correction
1. Resident 68 care plan, orders were updated to reflect the pacemaker being present. 2. There are no other current residents in the Center with a pacemaker who would be affected by the deficient practice. 3. Nursing staff will be educated on 483.25 and making sure that resident with cardiac medical devices are care planned and ordered. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that any residents with pacemakers have orders and care plans as appropriate. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Implement Restorative Nursing Program for Resident with Limited ROM
Penalty
Summary
The facility failed to implement a restorative nursing program for a resident with limited range of motion, as recommended by therapy. Resident 108, who was admitted with hemiparesis following a cerebral infarction affecting her right side, was not provided with the necessary passive and active range of motion exercises. These exercises were recommended by physical therapy to maintain her ability for clothing management and daily hygiene tasks. Despite the therapy discharge documentation noting that staff were trained to perform these exercises, there was no evidence in the clinical record that the program was implemented. An interview with the resident confirmed that she no longer received physical therapy, and an interview with the physical therapist revealed that a range of motion program was never established for her. Additionally, nursing staff were not educated on the program. These findings were confirmed with the Director of Nursing, indicating a lapse in the facility's responsibility to provide appropriate care to maintain or improve the resident's range of motion.
Plan Of Correction
1. Resident 108 to be re-evaluated by therapy to make sure appropriate for RNP program to the lower extremities. 2. DON/Designee will audit the past 30 days of therapy discharges to an RNP to identify if other residents been affected. 3. DON/Designee will educate Therapy on 483.25(c) (3), and policy named Restorative Policy. 4. Rehabilitation supervisor/Designee will do an audit weekly x4 and monthly x3 to assure that RNP programs were communicated with nursing staff to implement. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Implement Dialysis Access Site Care
Penalty
Summary
The facility failed to implement appropriate care to prevent potential complications from a dialysis access site for a resident requiring dialysis services. The resident, who undergoes dialysis treatment three times a week through a fistula located over his right bicep, reported that staff occasionally attempted to take blood pressure readings from his right arm, despite his instructions to use his leg. There were no indicators in the resident's room or clinical records to restrict the use of his right arm for blood pressure assessments or blood draws. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the right arm limb restriction was not included in the resident's plan of care until after the surveyor's inquiry. This oversight posed a risk of potential damage to the resident's dialysis fistula. A subsequent observation revealed that a sign was placed above the resident's bed to indicate the restriction, but this was only after the issue was raised by the surveyor.
Plan Of Correction
1. Resident 62 care plan updated, special instructions updated, and order placed not to use right arm for BP, veni-punctures. 2. Currently there are no other dialysis patients in the Center that could be potentially affected by the same deficient practice. 3. DON/Designee will educate nursing staff on 483.25(1), and policy Dialysis. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that all new dialysis residents have appropriate orders and care plans for affected limbs related to fistulas. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Delayed Call Bell Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically in responding to call bells in a timely manner. Resident 19 reported that when she rings her call bell, staff would come in and say they would return, but they never did. This indicates a lack of follow-through in addressing her needs. Additionally, Resident 52, who was assessed as cognitively intact and requiring extensive assistance for toileting, experienced a significant delay in response to her call bell. On December 3, 2024, Resident 52's call bell was not answered for 32 minutes, and when a nurse aide finally entered her room, the aide left immediately without providing the necessary assistance. Resident 52, who has a diagnosis of irritable bowel syndrome and had not had a bowel movement for three days, required a bedpan to move her bowels. Despite this urgent need, the nurse aide prioritized collecting breakfast trays over attending to Resident 52's call for help. The call bell was answered a second time only after 35 minutes from the initial call. The facility's administration acknowledged these findings, which highlight the deficiency in nursing services as per the relevant state codes.
Plan Of Correction
1. Resident 52 call bell answered at the time of need, Resident 19 made sure all needs are met. 2. DON/Designee will do a random audit of residents to make sure that call bells are being answered timely to see if any other residents affected. 3. DON/Designee will educate nursing staff on 483.35(a), and policy named call bells. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure call bells are being answered timely and all needs have been met of the resident. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications and biologicals on one of its nursing units, Station III, and for a specific resident, Resident 29. During an observation, a medication cart was found unlocked and unattended in a busy area of the nursing station, making it accessible to non-licensed staff, visitors, and other residents. This situation persisted for several minutes until it was confirmed by a licensed practical nurse. Such inattention to securing medications poses a risk of unauthorized access and potential misuse. Additionally, during a medication administration observation, a licensed practical nurse allowed Resident 29 to self-administer eye drops that were improperly labeled and stored. The eye drops were kept in a zippered pouch with other personal items, had a label that was rubbing off, and were not marked with the resident's name or administration details. The eye drops were also expired, and the resident required assistance to open the bottle. The nurse only realized the eye drops were expired after being informed by the surveyor. These findings were acknowledged by the facility's Administrator and Director of Nursing.
Plan Of Correction
1. Medication cart was locked at the time of the finding. Resident 29 eye drops (expired) were discarded and obtained new. 2. There are no other residents to protect in a similar situation. 3. DON/Designee will educate nursing staff on labeling and storage of drugs and biologicals. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that medication carts are locked, and medications are appropriately stored. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Implement Transmission-Based Precautions for MDRO
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident who was readmitted from the hospital with a urinary tract infection (UTI) caused by an extended-spectrum beta-lactamases (ESBL) E-Coli, a multiple drug-resistant organism (MDRO). Despite the laboratory report indicating the presence of this MDRO, the facility did not initiate contact or enhanced barrier precautions as required by their policies. The resident's care plan did not include these precautions, and there was no evidence of isolation measures being implemented upon the resident's readmission or after the final laboratory report. Observations and interviews revealed that the resident was incontinent of bowel and bladder and dependent on staff for care, which included the use of incontinence briefs. However, staff did not use isolation gowns or post signs indicating the need for enhanced barrier or contact precautions. The Director of Nursing confirmed the lack of evidence for implementing these precautions, and a nurse aide confirmed the resident's incontinence and dependency on staff for care without using the necessary precautions.
Plan Of Correction
1. Resident 103 has no current active infection, contact precautions not needed. Resident 103 does not have targeted MDRO and elimination is contained and covered as described by QSO-24-08-NH, so no enhanced barrier precautions are needed. Policy "enhanced barrier precautions" to be updated to make sure reflect proper QSO guidance on enhanced barrier precautions. 2. There are no other residents to protect in a similar situation. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80(a)(1)(2)(4)(e)(f) and QSO-24-08-NH. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that residents are on the appropriate precautions. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to offer and administer an influenza immunization to one of the five residents reviewed for immunizations, specifically Resident 3. According to the facility's policy, residents without medical contraindications should be offered the influenza vaccine annually between October 1st and October 31st. However, a review of Resident 3's clinical records revealed no evidence of receiving the influenza vaccine for the 2024-2025 season, despite having received it in previous years. The facility's policy also requires documentation of vaccine education and informed consent or refusal, which was missing in Resident 3's records. During interviews, Employee 8, a registered nurse and infection control prevention coordinator, confirmed the absence of documentation regarding the administration or declination of the vaccine for Resident 3. The facility could not produce an informed consent for the 2024-2025 influenza vaccine, nor evidence of any contact with Resident 3's responsible party to obtain consent or refusal. This lack of documentation and failure to follow the facility's vaccination policy led to the identified deficiency.
Plan Of Correction
1. Resident 3 family contacted to see if they receive consent if they want the influenza vaccine. 2. Infection Control Preventionist (IP) /designee to do audit to make sure that all consents for influenza for current residents have either been received back or contact to determine administration. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80(d)(1)(2). 4. Infection Control Preventionist (IP)/Designee will do an audit weekly x4 and monthly x3 to make sure new residents have determination of influenza vaccine. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Failure to Document COVID-19 Vaccine Consent for Resident
Penalty
Summary
The facility failed to offer and administer a COVID-19 immunization booster to a resident, identified as Resident 3, who was reviewed for immunizations. The facility's policy requires that each resident be offered the COVID-19 vaccine unless medically contraindicated or already immunized, with proper documentation of consent or refusal. Resident 3 was admitted to the facility in May 2022, and her immunization history showed she did not receive a COVID booster in October 2023 because her responsible party refused consent. However, the facility could not provide documentation of this refusal. Interviews with Employee 8, a registered nurse and infection control staff, confirmed that Resident 3 did not receive any COVID vaccines since her admission, and there was no documentation of consent refusal in her medical record. Despite attempts to contact Resident 3's responsible party for consent, the facility failed to document these efforts adequately. The deficiency was discussed with the Director of Nursing and the Nursing Home Administrator, highlighting the lack of documentation and failure to offer the vaccine as per the facility's policy.
Plan Of Correction
1. Resident 3 family contacted to see if they receive consent if they want the COVID-19 vaccine. 2. Infection Control Preventionist (IP) /designee to do audit to make sure that all consents for COVID-19 vaccine for current residents have either been received back or contact to determine administration. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80 (d)(3)(i)-(vii) COVID-19 Immunization. 4. Infection Control Preventionist (IP) /Designee will do an audit weekly x4 and monthly x3 to make sure new residents have determination of COVID-19 vaccine. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.
Infection Control Committee Lacks Required Maintenance Staff Participation
Penalty
Summary
The facility failed to comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. The plan mandates the inclusion of a representative from various departments, including medical staff, administration, laboratory, nursing, pharmacy, physical plant, patient safety, infection control, and the community. However, upon review of the infection control committee meeting attendance records from January to October 2024, it was found that there was no evidence of participation from a physical plant representative, specifically maintenance staff. Interviews conducted with the maintenance director and the nursing home administrator confirmed the absence of maintenance department representation in the infection control committee meetings. The maintenance director acknowledged that he had not attended any meetings and confirmed the lack of attendance from his department upon reviewing the attendance signatures. This deficiency was further corroborated by the nursing home administrator and the director of nursing, who confirmed the absence of required members at the meetings as per the available documentation.
Plan Of Correction
1. No residents were affected by the deficient practice. 2. There are no other residents to protect in a similar situation. 3. The IDT / ABX Stewardship and Infection Control Committee will be educated on the ACT 52 requirement specifically regarding required member participation. 4. Administrator / designee will audit the 4th quarter ABX Stewardship / Infection Control Committee to validate attendance by all required members per the ACT 52 Standard. 5. Date of Compliance 1/30/2025.
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 201 citations issued within 25 miles in the last 12 months — including the 1 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 Northumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunbury Skilled Nursing And Rehabilitation Center | 3.5 mi | ★★★★★ | 11 | 0 |
| Nursing And Rehabilitation At The Mansion | 3.5 mi | ★★★★★ | 9 | 0 |
| Buffalo Valley Lutheran Villag | 7.1 mi | ★★★★★ | 19 | 0 |
| Milton Rehabilitation And Nursing Center | 7.4 mi | ★★★★★ | 1 | 0 |
| Manor At Penn Village, The | 7.4 mi | ★★★★★ | 16 | 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 July 2026) and official state health department websites.