Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Wesley Village during CMS and state inspections, most recent first.
Unsanitary Food Service Area Conditions: The facility failed to maintain sanitary food storage and service conditions after surveyors observed a visibly soiled handwashing sink with food debris in the basin, dust buildup on hood vent panels, broken wall tiles in the food cart storage area, and dirt and debris along the kitchen floor perimeter. The FSD confirmed the department was to be maintained in a sanitary manner.
A resident who was cognitively intact and had an order for a PRN bisacodyl suppository was given the medication while she said she was asleep and not given a real chance to refuse. The resident filed a grievance stating staff woke her and inserted the suppository before she was ready or fully aware, while the RN said the resident was informed and did not decline. The DON and NHA confirmed residents must be allowed to choose, accept, or refuse care and treatment.
Failure to Timely Assess and Manage Resident Pain: A resident with intact cognition and diagnoses including muscle weakness and DM repeatedly requested Tylenol overnight, but staff had no order and did not complete a pain assessment or further evaluate the complaint. The resident later reported severe generalized pain, discomfort from the bed mattress, and that no medication or non-pharmacologic intervention was provided; the DON could not show timely assessment, intervention, or documentation of effectiveness.
A resident with chronic heart failure received ciprofloxacin after a urine C&S identified pseudomonas aeruginosa that was resistant to the drug. The resident had a fever that resolved and denied abdominal pain, dysuria, and confusion. Despite the resistance result, a new order for ciprofloxacin was entered and one dose was administered before the medication was discontinued.
Meals were not consistently served at safe, appetizing temperatures and were often cold. A test tray on one unit showed hot items well below the 135 F standard, with lukewarm food and cold, rubbery toast after a 30-minute delay before tray delivery. Several cognitively intact residents with CHF or respiratory failure reported cold eggs, soup, and other meals, and one resident said trays often sat on carts for 20 to 45 minutes before being passed out.
Survey results were not fully posted in the lobby binder, and residents reported they did not know where the DOH survey results were located. The binder contained inspection results, but the most recent recertification survey results were missing, and the DON and NHA acknowledged the results had not been updated to include the latest recertification survey.
The facility failed to administer medications on time for a resident with Parkinson's disease and did not develop or document appropriate procedures for palliative care for two residents with dementia, including missing care plans, consents, and interdisciplinary documentation.
A resident with severe cognitive impairment was started on an antipsychotic medication without documented notification or informed consent from their designated representative. The facility's records did not show that the representative was informed of the medication, its risks, benefits, or alternative options, despite the resident's inability to provide informed consent.
A resident with a signed DNR preference had a conflicting physician order in the electronic medical record indicating CPR should be performed, despite no documentation of a change in the resident's wishes. The inconsistency was only corrected after surveyor inquiry, and the NHA confirmed that physician orders should have matched the resident's documented code status.
A resident with chronic respiratory failure and a physician's order for oxygen at 2.0 LPM via nasal cannula was found with the oxygen concentrator set at 0.0 LPM. The resident reported no airflow, and an LPN confirmed the oxygen should have been administered as ordered. The facility's policy requiring licensed nurses to follow physician's orders for oxygen therapy was not followed in this case.
A resident with dementia and pulmonary hypertension did not receive a comprehensive pain reassessment after the onset of pain, as required by facility policy. Staff administered PRN narcotic pain medication outside of prescribed parameters, including for lower pain levels and without evidence of shortness of breath, and continued to do so after the physician changed the order. There was no documentation of evaluation or modification of the pain management plan to address the resident's symptoms.
A resident with Alzheimer's disease and dysphagia did not receive lemon ice with meals as ordered by the physician to facilitate swallowing. Observations and staff interviews confirmed that the lemon ice was omitted from the resident's meal trays and was not included on the tray ticket, despite being part of the current physician orders.
The facility did not provide required written notices of facility-initiated hospital transfers to the State Long-Term Care Ombudsman representative for five residents. Although notices were given to residents and their representatives, there was no documentation that the Ombudsman was notified, and this lapse was confirmed by the administrator as an ongoing issue over several months.
The facility did not ensure that its arbitration agreement provided for a mutually convenient venue for both the resident and the facility. The admission agreement only allowed for arbitration at the facility or within a reasonable distance, without guaranteeing convenience for both parties, as confirmed by the NHA.
A facility failed to prevent elopement for two residents, including one with severe cognitive impairment, due to inadequate supervision and reliance on a faulty alarm system. The facility lacked consistent checks on wander alert devices and did not maintain a clear record of residents at risk for elopement, leading to immediate jeopardy.
A resident with dementia and other health issues eloped from the facility, and although staff intervened and implemented safety checks, they failed to document a thorough assessment of the resident's condition upon return. Interviews revealed inconsistencies in staff recollection and issues with alarm audibility, contributing to the deficiency.
A resident with dementia and other health issues managed to exit the facility despite wearing a wander-guard anklet, revealing failures in the facility's monitoring and security systems. The wander-guard system was not functioning effectively, and staff were unaware of which residents were at risk of elopement. Additionally, there was no consistent practice to ensure the functionality of wander-guard devices, leading to a deficiency in resident safety.
A resident received multiple doses of opioid pain medications without attempts at non-pharmacological interventions first. The facility's records showed that staff administered Hydrocodone-Acetaminophen and Oxycodone without trying alternative pain relief methods, as confirmed by the Nursing Home Administrator and Assistant Director of Nursing.
The facility failed to attempt a gradual dose reduction (GDR) for a resident's psychoactive medications and did not justify an increase in another resident's medication. One resident's records lacked evidence of GDR attempts or recent psychiatric evaluations, while another resident's medication was increased without documented clinical necessity, despite no adverse effects from a prior reduction. These deficiencies were confirmed by facility staff during a survey.
The facility failed to maintain proper food storage and sanitation practices, increasing the risk of food-borne illness. Observations included spilled milk in the walk-in refrigerator, pooling water and a splattered ceiling in the dish room, and unlabeled Mighty Shakes in the tray line refrigerator. Additionally, a Speech Pathologist entered the kitchen without a hairnet, and dirty linen cans were coated with substances. The facility's policy required proper labeling of thawed shakes, which was not followed.
A resident with heart failure and a cardiac pacemaker experienced a significant weight gain over two days, totaling 14 pounds. Despite a physician's order to notify them of such changes, the facility failed to inform the physician of the resident's weight gain, as confirmed by the Nursing Home Administrator.
A facility failed to maintain a clean and sanitary environment for a resident with chronic pressure ulcers and dysphagia, requiring a feeding tube. Observations revealed a pungent odor, debris, and dried tube feeding formula splattered on the feeding pole and sticky carpeting. The Nursing Home Administrator confirmed the unsanitary conditions.
A resident with an implantable loop recorder, used to monitor heartbeats, was not included in their care plan. Despite the device being placed, the care plan did not address its presence or care, as confirmed by the DON.
A resident with anxiety exhibited increased behaviors such as constant yelling and arguing with a roommate, which were not addressed in their care plan. Despite a psychiatric consult, no new interventions were developed to manage these behaviors, and facility staff could not provide evidence of meeting the resident's behavioral health needs.
A facility failed to accurately account for controlled medications for a resident. Nursing staff signed out doses of Hydrocodone-Acetaminophen and Oxycodone, but the administration was not recorded on the MAR. This discrepancy was confirmed by the Nursing Home Administrator, indicating a deficiency in the facility's pharmaceutical services and record-keeping.
A resident with a nephrostomy tube was unnecessarily administered Cefdinir after reporting mild urinary symptoms, despite no further UTI symptoms. The antibiotic was discontinued after four doses when it was found to be ineffective against the colonized bacteria. The Infection Preventionist confirmed the administration was unjustified.
A facility failed to provide a resident and their representative with written notice of a facility-initiated transfer to the hospital. The absence of documentation for the transfer notice was confirmed by the Nursing Home Administrator and Assistant Director of Nursing.
A facility failed to follow the prescribed bowel protocol for a resident with a history of severe constipation, leading to a severe fecal impaction and hospital transfer. The facility did not administer the ordered bisacodyl suppository and skipped steps in the protocol without justification. Additionally, there was no documented pain or abdominal assessment prior to the resident's transfer.
Unsanitary Food Service Area Conditions
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in the food and nutrition services department. During the initial tour of the kitchen with the Food and Nutrition Services Director on February 10, 2026, at 8:50 AM, the handwashing sink was visibly soiled and contained four small chunks of canned fruit cocktail in the basin. Additional observations showed a thick layer of dust on the fins of the hood vent panels above the stove, two broken wall tiles creating a two-inch gap above the floor molding in the food cart storage area, and an accumulation of dirt and debris along the kitchen floor perimeter. The Food Service Director confirmed at the time of observation that the food and nutrition services department was to be maintained in a sanitary manner.
Resident Was Not Given Opportunity to Refuse Suppository
Penalty
Summary
The facility failed to ensure Resident 128 was afforded the opportunity to make an informed treatment decision and refuse care when a bisacodyl laxative suppository was administered. Resident 128 was admitted with acute respiratory failure and was cognitively intact, with an MDS BIMS score of 15. A physician order was in place for bisacodyl suppository 10 mg as needed for bowel management, and the MAR showed the suppository was given on December 20, 2025, at 6:59 AM. Resident 128 later stated she was upset because she was sleeping when the nurse supervisor entered her room, woke her up, and inserted the suppository before she was ready or awake enough to understand what was happening. The grievance stated she was not given the opportunity to wake up and fully understand what staff wanted to do. In contrast, the RN stated the resident was told they would be giving her a suppository and that the resident did not decline it, while the nurse aide said she did not remember anything out of the normal. The DON and NHA confirmed residents are to be afforded the opportunity to choose, accept, or refuse care, including medication and treatments.
Failure to Timely Assess and Manage Resident Pain
Penalty
Summary
The facility failed to timely assess and implement interventions to address a resident’s pain. Resident 2 had diagnoses of muscle weakness and diabetes and an admission MDS dated January 22, 2026, showed a BIMS score of 15, indicating intact cognition. A pain assessment completed on the evening of January 20, 2026, indicated the resident was pain-free, but nursing documentation at 4:41 AM on January 21, 2026, stated the resident was up most of the night asking for Tylenol. The note indicated the facility had no physician orders for Tylenol and that staff on the 3 PM to 11 PM shift told the resident there were no orders to administer it. There was no indication that a pain assessment was completed with the overnight complaint or that staff further assessed why Tylenol was being requested. A nurse’s note on January 22, 2026, at 12:05 PM documented complaints of overnight pain and that the physician assistant ordered Tylenol 650 mg every 24 hours as needed. The record did not show that the facility attempted to contact the physician for further direction during the evening or night shift. During interview, the resident stated she was very uncomfortable in bed, that the mattress was shot, that her entire body hurt, and that she wanted medication or another intervention so she could sleep; she rated her pain as 9 out of 10 and stated she was not given medication or a non-pharmacologic intervention to relieve it. The DON was unable to provide evidence that the resident’s pain was accurately and timely assessed, that interventions were implemented to alleviate pain, or that the effectiveness or outcome of interventions was documented.
Unnecessary Antibiotic Given Despite Culture Resistance
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics when Resident 83 received ciprofloxacin despite a urine culture and sensitivity showing the organism was resistant to that medication. Resident 83 was admitted with chronic heart failure and, on January 4, 2026, had a temperature of 101.9 F that later resolved. The progress note from that date stated the resident denied abdominal pain, dysuria, and confusion, and indicated that if clinical infection was suspected, antibiotics should be started after urine cultures were obtained. A urine culture and sensitivity collected on January 4, 2026, and reported on January 7, 2026, identified pseudomonas aeruginosa and showed resistance to ciprofloxacin. Despite those results, a new physician order for ciprofloxacin 500 mg twice daily for five days was entered on January 7, 2026, and the resident received one dose that evening. The medication was discontinued the next morning. During interview, the Infection Preventionist confirmed the resident received ciprofloxacin after the culture and sensitivity and confirmed the organism was resistant to ciprofloxacin.
Meals Served Cold and Not Palatable
Penalty
Summary
The facility failed to serve meals that were palatable and at safe and appetizing temperatures for a test tray completed on the [NAME] Unit during breakfast and for five sampled residents. Survey findings showed that hot foods must be maintained at or above 135 F, but the test tray items were served below that standard: oatmeal at 121 F, omelet at 115 F, Canadian bacon at 110 F, and wheat toast that was cold and rubbery. The food tasted only lukewarm and was not palatable at the temperature served. Dietary staff placed the test tray in the meal delivery cart at 7:50 AM, and unit staff did not begin distributing trays until 8:20 AM, creating a 30-minute delay before residents were served. Resident interviews and record reviews showed similar concerns with meal temperature. Resident 82, who was cognitively intact and had chronic respiratory failure with hypoxia, reported that trays often sat for 30 to 45 minutes before being passed out and that food was often cold. Resident 83, who was cognitively intact and had chronic heart failure, said soup was too cold to enjoy. Resident 20, who was cognitively intact and had heart failure, reported that eggs were frequently served cold and required reheating. During a resident group interview, Residents 44 and 105 also reported repeated concerns about cold meals, with Resident 44 stating breakfast was the most frequent problem and that trays remained on carts for at least 20 minutes before delivery. The Nursing Home Administrator confirmed that food is to be palatable and served at safe and appetizing temperatures and that trays were to be timely served upon arrival to the nursing unit.
Survey Results Not Fully Posted
Penalty
Summary
The facility failed to post the most recent survey results, including surveys, certifications, complaint investigations from the preceding 3 years, and any plan of correction in effect. During a resident council interview, five alert and oriented residents stated they did not know where the facility posted the Department of Health survey results. An observation of the reception area showed survey inspection results were available in a binder in the lobby, but review of the binder found the most recent recertification survey results were missing, including the recertification survey from May 9, 2025. The DON and NHA acknowledged that the Department of Health survey results had not been updated to include the most recent recertification survey results.
Failure to Administer Medications Timely and Lack of Palliative Care Procedures
Penalty
Summary
The facility failed to provide quality care by not administering medication according to physician orders and not developing appropriate procedures for palliative care. For one resident with Parkinson's disease, there were multiple documented instances where Carbidopa-Levodopa was administered significantly later than the prescribed times, ranging from over one hour to more than three hours late, despite facility policy requiring administration within one hour of the scheduled time. The Nursing Home Administrator confirmed that medications should be administered timely in accordance with physician orders and professional standards of practice. Additionally, the facility did not establish or follow proper procedures for implementing palliative care for two residents with dementia. In one case, after a resident's representative requested a transition to palliative care, there was no documented palliative care plan, no signed consent, and no supporting notes from a physician or social worker. In another case, a resident's representative requested palliative care with specific directives, but the clinical record lacked documentation of a clinical diagnosis or rationale for palliative care, as well as a comprehensive care plan, signed consent, and interdisciplinary progress notes. Interviews with facility leadership confirmed the absence of documentation outlining the clinical rationale or medical necessity for palliative care orders and the lack of a facility policy or established criteria for determining eligibility for palliative care services. These deficiencies were cited under relevant state codes for resident care policies and nursing services.
Failure to Inform Resident Representative of Psychotropic Medication Initiation
Penalty
Summary
The facility failed to ensure that a resident's representative was informed of the initiation of a psychotropic medication, including the associated risks, benefits, and alternative treatment options. The resident in question was admitted with diagnoses of dementia and encephalopathy and was assessed as being severely cognitively impaired, with a BIMS score of 05. Despite having a designated power of attorney as a resident representative, the clinical record showed that consent for the antipsychotic medication Seroquel was documented as verbal consent from the resident, with no evidence that the representative was informed or involved in the decision-making process. Further review of the resident's records revealed no documentation that the responsible party was notified about the new medication, nor that the risks, benefits, or alternative treatments were discussed. The resident received Seroquel for an extended period before the representative inquired about the medication and expressed opposition to its use. The facility was unable to provide documentation of the pre-hospital medication list supplied by the representative, and the Nursing Home Administrator confirmed the absence of documentation regarding notification or informed consent from the resident's representative.
Failure to Align Physician Orders with Resident's Documented Code Status
Penalty
Summary
The facility failed to ensure that physician orders were consistent with a resident's documented code status preference. A review of the clinical record for a resident with diagnoses including hypertension and epilepsy showed that the resident had completed and signed a CPR Status form indicating a preference not to receive cardiopulmonary resuscitation (CPR) if their heart or breathing stopped. Despite this, the electronic medical record contained a physician order listing the resident's code status as CPR, which was not in accordance with the resident's documented wishes. There was no evidence in the record that the resident had changed their decision or participated in any discussion to update their previously signed CPR Status form. The inconsistency between the physician order and the resident's expressed wishes was only corrected after it was identified by surveyors. The Nursing Home Administrator confirmed that physician orders are expected to match the resident's signed CPR Status form and acknowledged that the discrepancy should have been addressed prior to surveyor identification.
Failure to Administer Oxygen Therapy per Physician's Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician's orders for one resident. The resident, who had a diagnosis of chronic respiratory failure with hypoxia, had a physician's order for oxygen to be delivered via nasal cannula at 2.0 liters per minute. However, during an observation, the oxygen concentrator was found set at 0.0 liters per minute, and the resident reported not feeling any airflow from the nasal cannula. The facility's policy requires licensed nurses to initiate and monitor oxygen therapy per physician's orders, but this was not followed in this instance. A review of the clinical record and interviews confirmed that the resident should have been receiving continuous oxygen at the prescribed rate. The discrepancy was identified during a staff interview, and it was acknowledged that the oxygen was not being administered as ordered. The resident's blood-oxygen saturation was measured at 93% at the time of the incident, and the resident denied experiencing shortness of breath or distress. The Nursing Home Administrator confirmed the facility's responsibility to ensure that care is provided in accordance with physician's orders and the resident's plan of care.
Failure to Reassess and Appropriately Manage Resident Pain
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not conducting a comprehensive reassessment of the resident's pain status and prescribed PRN medications, as required by facility policy. The resident, who had diagnoses including dementia and pulmonary hypertension, was admitted with no reported pain and was not on scheduled pain medication. However, after the onset of pain, there was no documented evidence that a comprehensive pain assessment was completed to identify the cause of pain or to develop an individualized pain management plan. Despite having a care plan that included monitoring and evaluating pain interventions, staff administered narcotic pain medication outside of the prescribed parameters. Specifically, Morphine Sulfate, which was ordered for pain levels 6-10 or for shortness of breath, was given multiple times for pain levels of 4-5 and without evidence of shortness of breath. Additionally, after the physician changed the order to indicate use only for shortness of breath, staff continued to administer the medication without documentation of this symptom. There was no evidence in the clinical record that the facility evaluated the cause of the resident's pain, reassessed the appropriateness of PRN medications, or modified the care plan in response to the resident's emerging symptoms. The Director of Nursing confirmed that a comprehensive pain assessment was not completed as per policy, and that narcotic medication was administered without proper indication or reassessment. This resulted in a failure to ensure that pain management was based on comprehensive reassessment and the individual needs of the resident.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A resident with diagnoses including Alzheimer's disease and oral phase dysphagia had a physician order for a pureed no added salt (NAS) diet with lemon ice at meals, following a speech therapy recommendation to use lemon ice to facilitate oral movement and swallowing. Despite this order, observations during two separate lunch meals revealed that the resident did not receive lemon ice on her meal tray, and the meal tray ticket did not include the lemon ice order. Interviews with facility staff, including an LPN and the Certified Dietary Manager (CDM), confirmed that the lemon ice was not provided as ordered and was not listed on the tray ticket, despite being part of the current physician orders. This failure resulted in the resident not receiving the prescribed therapeutic diet as required by the physician's order.
Failure to Notify Ombudsman of Facility-Initiated Transfers
Penalty
Summary
The facility failed to provide copies of written notices regarding facility-initiated hospital transfers to the representative of the Office of the State Long-Term Care Ombudsman for five residents. Clinical record reviews showed that these residents were transferred to the hospital on various dates and subsequently readmitted to the facility. While written notices of the transfers were given to the residents and their representatives, there was no documented evidence that the required notifications were sent to the Ombudsman representative as mandated. An interview with the nursing home administrator confirmed that there was no documentation showing that copies of the transfer notices were sent to the Ombudsman for the identified residents. Furthermore, the administrator acknowledged that this failure to notify the Ombudsman representative was not limited to these cases but was a consistent issue for resident transfers from July 2024 through May 2025.
Failure to Ensure Fair Arbitration Venue Selection
Penalty
Summary
The facility failed to ensure a neutral and fair arbitration process by not providing clear language in its admission agreement that guarantees both the resident or resident representative and the facility mutually agree on a convenient venue for arbitration. The reviewed admission agreement specified that arbitration would occur either at the facility or at a site within a reasonable distance of the facility, subject to mutual agreement, but did not explicitly state that the location must be convenient for both parties. During an interview, the Nursing Home Administrator confirmed that the agreement only offers these two options and does not address the convenience for both the resident and the facility.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and effective safety measures to prevent elopement for two residents, leading to immediate jeopardy. Resident CR1, who was admitted with diagnoses including dementia and severe cognitive impairment, was identified as an elopement risk. Despite having a wander alert device, the resident was able to exit the facility unsupervised. The facility's reliance on the alarm system was insufficient, as the system failed to prevent the resident from leaving the premises. The incident occurred when a visitor reported seeing the resident outside, prompting staff to intervene and redirect the resident back inside. The facility's policies and procedures for managing elopement risks were inadequate. Staff interviews revealed a lack of consistent checks on the functionality of wander alert devices and insufficient training on identifying and managing elopement risks. The facility did not have a comprehensive system to monitor residents at risk of elopement, and there was no documentation of regular checks on the wander alert devices or the doors' functionality. This oversight contributed to the residents' ability to leave the facility unsupervised. Additionally, the facility's failure to maintain a clear and updated record of residents at risk for elopement further exacerbated the issue. Staff members were unaware of which residents were at risk, and there was no centralized system to communicate this information across different units. The lack of a coordinated approach to monitoring and preventing elopement placed residents in immediate jeopardy, as evidenced by the incidents involving Resident CR1 and another resident with similar risks.
Failure to Document Post-Elopement Assessment
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not thoroughly conducting and documenting a professional nursing assessment of a resident's clinical status following an elopement. The incident involved a resident with dementia, syncope, unsteadiness, weakness, and gait abnormalities, who was admitted to the facility. On the evening of the incident, the resident, identified by a wander-guard anklet, attempted to leave the facility and was found outside by a visitor who notified the staff. The staff, including two registered nurses, responded to the situation. The resident was redirected back to her room, and immediate interventions such as 15-minute safety checks were implemented. However, the facility's documentation did not include a comprehensive assessment of the resident for injury after she was returned to the facility. Interviews with the nursing staff revealed inconsistencies in their recollection of the event, and it was confirmed that the alarms were not audible in certain areas of the facility, which may have contributed to the delay in response. The facility's failure to document a thorough assessment of the resident's condition post-elopement was confirmed by the Assistant Director of Nursing. Despite the implementation of safety checks and communication with the resident's family, the lack of documented evidence of a full assessment highlights a deficiency in the facility's adherence to professional nursing standards and documentation practices.
Failure to Prevent Resident Elopement Due to Inadequate Monitoring
Penalty
Summary
The facility's administration failed to effectively use its resources to ensure resident safety, specifically in monitoring resident whereabouts and preventing elopement. This deficiency was identified through a series of observations, clinical record reviews, and staff interviews. A resident with dementia and other health issues, who was identified as an elopement risk, managed to exit the facility. The resident was found outside the building, having asked a visitor for a ride, which prompted the visitor to notify the facility. Despite having a wander-guard anklet, the resident was able to leave the premises, indicating a failure in the facility's monitoring and security systems. The incident revealed several lapses in the facility's procedures and staff actions. The wander-guard system, which was supposed to prevent such incidents, was not functioning effectively. During a test conducted by the state surveyor, it was found that the facility's doors could be opened with minimal pressure, even when the wander-guard was active. Additionally, there was a lack of clear communication and documentation regarding residents at risk of elopement, as staff members were unaware of which residents were at risk and how to ensure the functionality of the wander-guard system. Interviews with staff members highlighted further issues, such as the absence of a comprehensive system to track and monitor residents at risk of elopement across different units. Staff members were not equipped with tools to check the functionality of wander-guard bracelets, and there was no consistent practice in place to ensure these devices were working. The facility's failure to implement effective safety measures and supervision placed residents at risk, leading to the cited deficiency under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not attempting non-pharmacological interventions before administering opioid pain medications. The clinical record review revealed that the resident had physician's orders for Hydrocodone-Acetaminophen and Oxycodone HCL to be given as needed for pain levels 6-10. However, the Medication Administration Records (MAR) for June and July 2024 showed that the staff administered these medications multiple times without attempting non-pharmacological methods to alleviate the resident's pain first. Specifically, in June 2024, the resident received 14 doses of Hydrocodone-Acetaminophen, all without prior non-pharmacological interventions. In July 2024, the resident received 5 doses of Hydrocodone-Acetaminophen and 26 doses of Oxycodone, with only a few instances where non-pharmacological interventions were attempted. An interview with the Nursing Home Administrator and the Assistant Director of Nursing confirmed the lack of consistent attempts to use non-pharmacological methods before administering as-needed pain medications.
Failure to Implement GDR and Justify Medication Increase
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychoactive medications for one resident and failed to clinically justify the increase of psychoactive medication for another resident. Resident 44, who was admitted with schizoaffective disorder and Parkinson's disease, was prescribed Invega Trinza, Sertraline, and Abilify. A pharmacist recommended a GDR for these medications, but the physician deferred to psychiatry without providing a clinical rationale. No evidence of a GDR attempt or recent psychiatric evaluation was found in the resident's records, which was confirmed by the Nursing Home Administrator and Director of Nursing. Resident 69, diagnosed with major depressive disorder, stroke, and aphasia, had their Zyprexa dosage reduced following a pharmacy review. Despite no adverse effects or behavioral changes noted after the reduction, the dosage was increased again without documented clinical justification. The pharmacist requested documentation to support the increase, but none was provided, as confirmed by the Director of Nursing. These deficiencies were identified during a survey, highlighting the facility's failure to adhere to regulatory requirements for psychoactive medication management.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the kitchen, it was observed that there was milk spilled underneath the shelves in the walk-in refrigerator. In the dish room area, a significant amount of water was pooling on the floor, and a ceiling tile was bowed with gaps near the vent, along with a red/brown substance splattered on ceiling tiles above the dish machine. Additionally, during the lunch tray line meal service, a Speech Pathologist entered the kitchen area without wearing a hairnet. Further observations revealed that inside the tray line reach-in refrigerator, a tray of approximately forty 4-ounce cartons of Mighty Shakes was not dated with a thaw date, contrary to the manufacturer's instructions. In the resident's main dining room, two white plastic cans used for dirty linens were coated with splattered substances. In the East Unit Medication Room, several Mighty Shakes and nutritional juice drinks were not labeled or dated. The facility's policy indicated that frozen shakes should be labeled with a use-by date of fourteen days once thawed, and the day of preparation or opening is considered Day 1. The Nursing Home Administrator confirmed that sanitary practices should be maintained to prevent foodborne illness.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to timely consult with the physician regarding a significant weight gain experienced by a resident diagnosed with heart failure and equipped with a cardiac pacemaker. The resident was admitted with a physician's order to monitor daily weight due to heart failure, with instructions to notify the physician if a 3-pound weight gain in 24 hours or a 5-pound weight gain in one week was observed. On June 30, 2024, the resident's weight increased by 9.2 pounds in one day, a 5.08% weight gain, yet there was no documented evidence that the physician was notified of this significant change. The resident's weight continued to increase, reaching 195.2 pounds on July 1, 2024, marking an additional 4.8-pound gain in 24 hours and a total of 14 pounds over 48 hours. Despite this continued weight gain, there was still no documented evidence of timely physician notification. An interview with the Nursing Home Administrator confirmed the facility's failure to notify the physician of the resident's significant weight gain on both June 30 and July 1, 2024.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident, identified as Resident 111, who was admitted with chronic pressure ulcers and dysphagia, requiring a feeding tube for nutrition and hydration. During an observation, a pungent odor was detected in the resident's room. Additionally, a plastic spoon and debris were found underneath the resident's tube feeding pole. Dried tube feeding formula was observed splattered on the tube feeding pole and the carpeting below, which was sticky to walk on. An interview with the Nursing Home Administrator confirmed that the room was not maintained in a clean and sanitary condition.
Failure to Include Cardiac Device in Care Plan
Penalty
Summary
The facility failed to timely develop and implement a person-centered care plan for a resident with an implantable cardiac recording device. Resident 69, who was admitted with diagnoses of anxiety, seizures, and stroke, had an implantable loop recorder placed on October 1, 2023. This device records the heartbeat continuously and requires a transmitter at the bedside to send information to the healthcare provider. However, a review of the resident's care plan, initially dated the same day as the device placement, revealed that it did not address the presence or care of the implantable loop recorder. The Director of Nursing confirmed during an interview that the device was not included in the resident's care plan.
Failure to Address Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that a resident received timely and necessary behavioral health care to maintain their highest practicable mental and psychosocial well-being. The resident, who was admitted with a diagnosis of anxiety, exhibited behaviors such as constant yelling for help and arguing with their roommate. These behaviors increased in frequency starting in June 2024, as documented in the resident's progress notes. Despite these documented changes, the resident's most recent psychiatric consult did not address the increased anxiety and behaviors, nor was there any indication that a potential room change was considered to alleviate the resident's discomfort with their roommate's preference for keeping the privacy curtain closed. During the survey ending in July 2024, it was found that no new or revised behavioral interventions were added to the resident's care plan to manage or modify the resident's behaviors. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that they could not provide evidence that the resident's behavioral health needs were met or that services were provided to promote the resident's highest practicable physical, mental, and psychosocial well-being.
Inaccurate Accounting of Controlled Medications
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of controlled medications for a resident. The clinical records and controlled drug records review revealed discrepancies in the administration of Hydrocodone-Acetaminophen and Oxycodone for a resident. On multiple occasions, nursing staff signed out doses of these medications, but the administration was not recorded on the resident's Medication Administration Record (MAR). Specifically, doses were signed out on June 28, July 3, July 5, July 6, and July 11, 2024, but were not documented as administered on the MAR. The resident had physician orders for Hydrocodone-Acetaminophen and Oxycodone to be administered as needed for pain levels 6-10. Despite these orders, the lack of documentation on the MAR indicates a failure in the facility's procedures for tracking the administration of controlled substances. The Nursing Home Administrator confirmed these inconsistencies during an interview, highlighting a deficiency in the facility's pharmaceutical services and record-keeping practices.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic drugs. Resident 19, who was admitted with chronic kidney disease, kidney stones, and heart disease, had a nephrostomy tube in place. After an emergency room visit for a dislodged nephrostomy tube, antibiotic therapy was stopped as the resident's urine culture showed colonized bacteria that were not causing harm. Later, the resident reported irritation and slight burning during urination, prompting a physician to order a urinalysis and subsequently prescribe Cefdinir, an antibiotic, without further symptoms of a urinary tract infection being documented. The resident received four doses of Cefdinir before the attending physician discontinued the antibiotic, opting to wait for the final urine culture and sensitivity results. The urine culture later revealed that the organisms were resistant to Cefdinir. An interview with the Infection Preventionist confirmed that the administration of Cefdinir was not clinically justified, indicating a failure in the facility's pharmacy and nursing services to prevent unnecessary drug use.
Failure to Provide Transfer Notice
Penalty
Summary
The facility failed to provide written notices of a facility-initiated transfer to a resident and the resident's representative. Specifically, Resident 69 was transferred to the hospital on May 29, 2024, and subsequently readmitted to the facility. However, there was no documented evidence that the resident and the resident's representative received written notice of this transfer. This deficiency was confirmed during an interview with the Nursing Home Administrator and Assistant Director of Nursing on July 18, 2024, who acknowledged the lack of documentation for the transfer notice.
Failure to Follow Bowel Protocol and Conduct Assessments
Penalty
Summary
The facility failed to provide prescribed treatment necessary to manage constipation for a resident with a history of severe constipation and fecal impaction. The resident was admitted with a bowel regimen that included multiple laxatives and a protocol to follow if no bowel movement occurred. Despite this, the resident did not have a bowel movement for several days, and the facility did not follow the prescribed steps in the bowel protocol. Specifically, the resident received Milk of Magnesia (MOM) but did not receive the subsequent bisacodyl suppository as ordered, and an enema was administered without documented justification for skipping the intermediate steps. The resident's daughter reported that her mother was in excruciating pain, prompting a transfer to the hospital. However, there was no documented pain or abdominal assessment in the resident's clinical record prior to the transfer. The hospital confirmed a severe fecal impaction, which was not adequately addressed by the facility's staff. Upon the resident's return to the facility, there was no evidence that the hospital's recommendation for daily MOM was initiated. The Director of Nursing confirmed that the facility failed to administer the physician-ordered bowel protocol and did not conduct thorough assessments of the resident's abdomen and pain. This lack of adherence to the prescribed treatment and failure to document assessments led to the resident experiencing severe constipation and pain, ultimately resulting in a hospital transfer.
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.
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What surveyors actually found near you
We read the 466 citations issued within 25 miles in the last 12 months — including the 6 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 Pittston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Of East Mountain | 2.5 mi | ★★★★★ | 18 | 1 |
| Highland Manor Rehabilitation And Nursing Center | 2.7 mi | ★★★★★ | 3 | 0 |
| Third Avenue Health & Rehab Center | 4.1 mi | ★★★★★ | 13 | 0 |
| Heinz Transitional Rehabilitation Unit | 4.1 mi | ★★★★★ | 2 | 0 |
| Riverstreet Manor | 4.1 mi | ★★★★★ | 25 | 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.