Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Whitestone Care Center during CMS and state inspections, most recent first.
Inaccurate MDS assessments were completed for two residents. One resident with hemiplegia and hemiparesis had a quarterly MDS that showed no ROM impairment, even though observation found the right upper extremity flexed and not moved, with the resident using only the left arm for daily activities. Another resident admitted with an L3 fracture after a fall at home had an admission MDS that did not report the prior fall-related fracture, and the RNAC acknowledged both assessments were inaccurate.
A resident with depression, anxiety, and excoriation disorder continued to have episodes of skin picking, but the facility did not develop or implement a comprehensive person-centered care plan addressing her skin integrity needs. The record noted embarrassment about the condition and recommended non-pharmacologic interventions, supportive care, and redirection, yet the care plan did not include individualized tools or interventions for staff to use.
Controlled substance count records were not consistently completed for one medication cart. Facility policy required incoming and outgoing nurses to count Schedule II controlled substances and other potentially abusable medications at each shift change, but the narcotic count sheet for the first-floor A hall med cart had multiple missing outgoing nurse signatures. An RN confirmed the omissions, and the NHA was interviewed about the facility's failure to consistently implement the controlled drug record procedure.
Expired sterile dressing kits were found in a medication storage room on the second floor nursing unit. An observation with an LPN identified one sterile dressing change kit and four sterile dressing kits past expiration, and the NHA acknowledged the items were not maintained within expiration dates.
A resident with severe cognitive impairment and a history of falls, who required total staff assistance and a low bed position, was left unattended in an elevated bed by a nurse aide. The resident fell and later was found to have a comminuted distal femur fracture. The incident was substantiated as neglect due to failure to follow the care plan.
The facility failed to maintain the smoke-tight integrity of an exit stair tower door, affecting both floors. An observation revealed that the first floor's #2 stair tower door did not meet smoke-tight standards. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain its automatic sprinkler system, with missing ceiling tiles in the Mechanical and IT Server Rooms, a non-functional attic-level dry sprinkler system, and missing inspection reports. Additionally, the facility was overdue for required maintenance tasks, including internal valve and piping checks and sprinkler gauge recalibration.
The facility failed to maintain the generator set, as the low fuel level lamp was illuminated at the remote annunciator location, affecting both floors. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
A facility failed to ensure the accuracy of the MDS Assessment for a resident, as the Discharge MDS inaccurately indicated the resident was discharged to a hospital, while a nurse's note revealed the resident was discharged home with her son. This discrepancy was confirmed by the DON.
A resident with dementia and chronic kidney disease experienced significant weight loss over several months due to the facility's failure to maintain nutritional status. Despite being on a regular diet with supplements, the resident's weight declined by 23.5% over 195 days. Inconsistent documentation of bowel movements and inadequate interventions contributed to the deficiency.
A resident with dementia and chronic kidney disease experienced a delay in treatment due to the facility's failure to promptly notify the ordering practitioner of lab results indicating dehydration. Despite receiving lab results, the physician was not informed for approximately 24 hours, leading to a delay in initiating necessary interventions such as a midline catheter and supplemental fluids. The Director of Nursing confirmed the delay and acknowledged the facility's responsibility to ensure timely notification of lab results.
A facility failed to provide timely radiology services for a resident who fell and complained of shoulder pain. An x-ray was ordered but not completed promptly, leading to the resident being sent to the emergency room. Upon arrival, the resident refused the initially ordered x-ray and requested imaging of the opposite shoulder, which showed no fracture. The DON confirmed the x-ray was not completed as ordered.
Whitestone Care Center failed to prevent the development of a pressure ulcer in a resident with severe cognitive impairment and multiple health issues. Despite being at risk, the facility did not consistently implement preventative measures such as repositioning and heel elevation. A new unstageable pressure ulcer was discovered on the resident's left heel, highlighting the facility's non-compliance with care standards.
A resident was found unresponsive, and due to a misidentification of their code status by an RN, CPR was delayed by 30 minutes. The RN incorrectly consulted a physical chart instead of the electronic medical record, leading to the error. The delay in initiating CPR may have contributed to the resident's death, highlighting a systemic failure in emergency response protocols.
A resident in a long-term care facility was found unresponsive, but due to a misidentification of their code status, CPR was delayed by 30 minutes. The staff initially believed the resident had a DNR order, leading to a failure to initiate life-saving measures promptly. This delay may have contributed to the resident's death, highlighting a systemic failure in emergency response protocols.
A resident with significant care needs suffered serious injuries, including a fractured thumb and closed head injury, due to neglect in a facility. The resident, requiring maximum assistance and a mechanical lift for transfers, was left unattended by a nurse aide who failed to report the fall. The facility's staff did not conduct a prompt assessment or initiate neurological checks, leading to a delay in addressing the resident's injuries.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate MDS assessments for two residents. The RAI User's Manual requires the assessment to accurately reflect the resident's status and to include direct observation and communication with the resident and direct care staff on all shifts. For Resident 4, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, a quarterly MDS indicated no impairment in ROM for the upper and lower extremities. However, an observation on December 4, 2025, at 8:50 AM showed the resident's right upper extremity in a flexed position close to the upper body, and the resident did not move the right upper extremity, using only the left upper extremity for daily activities, including moving the wheelchair. The RNAC acknowledged that the quarterly MDS did not accurately reflect the limited ROM of the right upper extremity. For Resident 11, who was admitted with an unspecified fracture of the third lumbar vertebra and had progress notes indicating admission from an acute care facility after a fall at home with an L3 burst fracture, the admission MDS stated the resident did not have any fracture related to a fall in the six months prior to admission/entry or reentry. This conflicted with the documented fall at home that resulted in a fracture. The RNAC acknowledged that the admission MDS did not accurately reflect the fall with fracture prior to admission.
Failure to Individualize Care Plan for Skin Picking Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan that addressed Resident 69’s skin integrity needs related to skin picking. Resident 69 was admitted with diagnoses including depression and anxiety, and a psychiatry progress note dated April 30, 2025 documented excoriation (skin picking disorder) with increased skin picking related to anxiety. The note also stated the resident was embarrassed about the condition and covered scars and open areas on her forehead with a mask or Band-Aid, and it recommended staff use non-pharmacologic interventions, supportive care, and redirection as needed. A review of progress notes from April 2025 through December 2025 showed the resident continued to have episodes of skin picking throughout the stay. The clinical record contained no documented evidence that the facility developed and implemented a person-centered care plan reflecting the resident’s skin integrity needs or identifying tools and nonpharmacological interventions to attempt to prevent further skin picking. During interview, the DON and surveyor reviewed the findings and confirmed the comprehensive person-centered care plan did not reflect the resident’s skin integrity needs.
Controlled Substance Count Sheets Not Signed by Outgoing Nurses
Penalty
Summary
The facility failed to implement procedures to promote accurate controlled medication records on one of two medication carts observed. A review of the facility policy, Inventory Control of Controlled Substances, showed that incoming and outgoing nurses were required to count all Schedule II controlled substances and any medications with potential for abuse or diversion at each shift change. However, the Shift verification of Controlled Substance Count form for the first-floor A hall Nursing Unit medication cart showed multiple instances where the outgoing nurse did not sign that the narcotic count was completed and correct. The missing outgoing nurse signatures were documented on July 28, 2025; August 9, 2025; September 17, 2025; September 23, 2025; September 24, 2025; and November 11, 2025. Employee 2 RN confirmed on December 4, 2025, that the narcotic sheet for the first-floor A hall nursing unit medication cart was not signed off by the outgoing nurses on those dates. The Nursing Home Administrator was interviewed on December 4, 2025, regarding the facility's failure to demonstrate consistent implementation of procedures for promoting accurate controlled drug records.
Expired Sterile Dressing Kits Found in Medication Storage
Penalty
Summary
The facility failed to ensure that biologicals were stored within the expiration date in one of two medication storage areas. Review of the facility policy on Storage and Expiration Dating of Medications and Biologicals stated that medications and biologicals with an expired date on the label are to be stored in accordance with manufacturer or supplier guidelines. During an observation of the medication storage room on the second floor nursing unit, one sterile dressing change kit was found expired, along with four additional sterile dressing kits that were also expired. The Nursing Home Administrator later acknowledged that the biologicals were not maintained within the expiration dates.
Neglect Resulting in Resident Fall and Femur Fracture
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of falls, and muscle weakness was left unattended in an elevated bed by a nurse aide. The resident required total staff assistance for activities of daily living, including bed mobility and transfers, and the care plan specified that two staff members were needed for these tasks, with the bed to be kept in the lowest position for safety. Despite these requirements, the nurse aide left the resident alone while the bed was raised to retrieve a washcloth from the bathroom, resulting in the resident falling from the bed. Following the fall, the resident was found on the floor on her left side, holding onto the enabler bar, with her legs bent underneath her. Initial assessments by nursing staff did not reveal any visible injuries or signs of pain, and neurological checks were within normal limits. The resident was assisted back into bed using a Hoyer lift, and care was provided by two staff members as per protocol. The nurse aide involved was educated on the importance of following the care plan and not leaving residents unattended in elevated beds. Subsequent follow-up revealed swelling of the resident's right knee, and an x-ray confirmed a displaced and overlapping comminuted distal fracture of the right femur. The incident was investigated and substantiated as neglect, as the nurse aide failed to follow the resident's plan of care, directly resulting in the fall and serious injury.
Stair Tower Door Lacks Smoke-Tight Integrity
Penalty
Summary
The facility failed to maintain the smoke-tight integrity of an exit stair tower door, affecting both floors of the building. During an observation on February 4, 2025, at 11:32 a.m., it was noted that the door of the #2 stair tower on the first floor did not meet the required smoke-tight standards. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day.
Plan Of Correction
K-0225 Smoke Enclosures 1. Stair Tower door was adjusted to close and meet smoke tight integrity. 2. Facility audit was completed of all doors. 3. Monthly Audits will be completed X4 months and then quarterly after with results reviewed in QAPI.
Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system, as evidenced by several deficiencies observed during a survey. On the second floor, ceiling tiles were missing in the Mechanical Room, and similar issues were noted in the first floor IT Server Room. Additionally, the attic-level dry sprinkler system was found to be non-functional at the time of the survey. The facility also lacked an automatic sprinkler system inspection report for the fourth quarter of 2024, and was overdue for the required five-year internal valve, internal piping, and sprinkler gauge recalibration or replacement. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
K-0353 Sprinkler Systems 1. Ceiling tiles were lacking within the second floor Mechanical Room and ceiling tiles within the first floor IT Server Room were repaired. Attic-level dry sprinkler system was repaired and placed in service. Quarterly Sprinkler inspection was completed 2/2025. Five-year, internal valve, internal piping, and sprinkler gauge recalibration/replacement was also completed. 2. Audit will be competed for areas of missing ceiling tiles weekly x 4 then monthly x2. Sprinkler reports will be monitored for missing inspection pieces. Findings will be reviewed in QAPI.
Generator Set Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the generator set, as evidenced by an observation on February 4, 2025, at 11:50 a.m., which revealed that the low fuel level lamp was illuminated at the remote annunciator location. This deficiency affected both floors of the facility. During an exit interview with the Facility Administrator and the Facilities Manager on the same day, between 12:30 p.m. and 12:40 p.m., the emergency generator set deficiency was confirmed.
Plan Of Correction
K-0919 Generator Low Fuel Light was corrected. Maintenance Director job description reviewed and signed to ensure knowledge of expectation and responsibilities clear. Maintenance Director/designee will perform generator check to ensure no issues on Panel or with Unit weekly X4, then monthly X2 with results reviewed in QAPI.
Inaccurate MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) Assessment for a resident, which is a federally mandated standardized assessment used to plan resident care. The deficiency was identified during a review of clinical records and the Resident Assessment Instrument (RAI), as well as through staff interviews. Specifically, the Discharge MDS Assessment for a resident who was admitted on October 28, 2024, and discharged on November 15, 2024, inaccurately indicated that the resident was discharged to a short-term general hospital. However, a discharge nurse's note from the same date revealed that the resident was actually discharged home with her son. This discrepancy was confirmed by the director of nursing during an interview on January 30, 2025.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. MDS for resident # 74 was corrected and submitted at the time of survey. To identify like residents that have the potential to be affected, the MDS Nurse/designee will complete a 14-day look back of section A2105, discharge stats to ensure it is coded correctly. To prevent this from happening again, the Regional Reimbursement coordinator/designee will educate the RNAC on appropriate coding for section A2105 on the MDS. To monitor and maintain ongoing compliance, the RNAC will review all discharges weekly x 4 then monthly x 2 to ensure that Section A2105 is coded correctly. Results will be reviewed at QAPI.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by significant weight loss over several months. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, experienced a weight loss of 23.5% over 195 days. Despite being on a regular diet with nutritional supplements and fluids, the resident's weight continued to decline, indicating a failure to maintain nutritional status. The resident's care plan identified increased nutrition and hydration risk, yet interventions such as offering alternate foods and monitoring nutritional needs were insufficient to prevent significant weight loss. The facility's documentation revealed inconsistent recording of the resident's bowel movements, making it difficult to assess the onset and severity of diarrhea, which was reported by the resident and confirmed by staff. The lack of timely and thorough documentation hindered the facility's ability to address the resident's nutritional and hydration needs effectively. Interviews with the Director of Nursing confirmed the facility's failure to document and address the resident's diarrhea and weight loss adequately. The facility did not provide evidence that the resident's weight loss or dehydration was unavoidable, highlighting a deficiency in maintaining the resident's nutritional status and electrolyte balance as required by regulations.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Step 1 Resident # 1 loose bowel movements followed up MD/RP on 1/8/2025. Resident #1 weight loss stabilized 2 weeks post loss identification on 1/29/2025. Step 2 To identify like residents that have the potential to be affected, an in-house audit of progress notes and point of care documentation for last 2 weeks to verify that bowel movements documented accurately with MD/RP follow-up as applicable. In-house audit of residents with weight loss in last 14 days to ensure adequately investigated and followed up timely. Step 3 To prevent this from happening again, DON/designee will educate the licensed staff on documentation and follow-up in resident change in condition. DON/designee will educate the C.N.A staff on documentation in point of care changes in the resident continence and consistency of bowel movement and notification of the licensed nurse. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with changes in condition per week for 4 weeks, then monthly for 2 months to ensure timely follow-up. To monitor and maintain compliance, the DON/designee will conduct audits of 5 residents' bowel management point of care documentation to ensure that documentation accurately reflects resident bowel status per week, then monthly for 2 months to ensure compliance. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Delayed Notification of Lab Results Leads to Treatment Delay
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results for a resident, leading to a delay in treatment. The resident, who was admitted with dementia and chronic kidney disease, experienced increased diarrhea and nausea. A physician ordered laboratory tests, including a CBC, CMP, and MAG, which were collected and reported back to the facility. However, there was no documented evidence that the physician received or acted upon these results for approximately 24 hours. The laboratory results indicated significant dehydration, with elevated BUN and creatinine levels, and a decreased potassium level. Despite these findings, the physician's order for a midline catheter insertion and supplemental fluids was not initiated until approximately 30 hours after the laboratory results were reported. The resident received additional fluids and continuous IV treatment, but these interventions were delayed by more than 40 hours after the laboratory report indicated dehydration. The Director of Nursing confirmed the delay in implementing interventions and treatment to address the resident's dehydration. The DON acknowledged that it is the facility's responsibility to ensure the physician is promptly provided with laboratory results. The report highlights the facility's failure to adhere to its policies and procedures for notifying practitioners of laboratory results that fall outside of clinical reference ranges.
Plan Of Correction
Step 1 Resident #1 labs were followed up on 1/10/2025. Step 2 To identify like residents that have the potential to be affected, an in-house audit of labs completed for the last 2 weeks to ensure abnormal lab studies were followed up with the physician in a timely manner. Step 3 To prevent this from happening again, DON/designee will educate the licensed staff on following up with abnormal lab studies with physician in a timely manner. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with orders for labs per week for 4 weeks, then monthly for 2 months to ensure labs followed up with physician in a timely manner. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to ensure the timely provision of radiology services for a resident who was admitted with conditions including unspecified deep vein thrombosis, gout, and anxiety. The resident, who was cognitively intact, experienced a fall and subsequently complained of right shoulder pain. A physician ordered an x-ray of the right shoulder to rule out a fracture. However, the x-ray was not completed in a timely manner, as confirmed by a review of the resident's clinical record during the survey. On the day of the survey, a STAT x-ray was ordered, but the mobile x-ray company had not completed the imaging by 8:30 PM. Consequently, the resident was sent to the emergency room for the x-ray. Upon arrival, the resident refused the right shoulder x-ray and requested imaging of the left shoulder instead. The left shoulder x-ray was completed and showed no acute fracture. The Director of Nursing confirmed that the x-ray was not completed as originally ordered, indicating a failure in the facility's responsibility to provide timely diagnostic services.
Plan Of Correction
Step 1 Resident # 64 x-ray was obtained on 1/29/2025 with no negative findings. Step 2 To identify like residents that have the potential to be affected, an in-house audit of radiology/diagnostics studies was completed for the last 2 weeks to ensure that diagnostics were completed and followed up in a timely manner. Step 3 To prevent this from happening again, the DON/designee will educate the licensed staff on following up with radiology/diagnostics studies with the physician in a timely manner. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with orders for radiology/diagnostics studies per week for 4 weeks, then monthly for 2 months to ensure diagnostic tests are followed up in a timely manner. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Failure to Prevent Pressure Ulcers
Penalty
Summary
Whitestone Care Center was found to be non-compliant with federal and state regulations regarding the prevention and treatment of pressure ulcers. The facility failed to develop and implement adequate care and services to prevent the development of pressure ulcers for a resident. This resident, who was admitted with severe cognitive impairment and multiple health issues including Fournier gangrene, Type 2 diabetes, and cerebral infarction, was identified as being at risk for pressure ulcers. Despite this, the facility did not take sufficient preventative measures. The resident's care plan included interventions such as providing a pressure-reducing mattress and wheelchair cushion, incontinence care, and repositioning every two hours. However, there was no documented evidence that these measures were consistently implemented. Specifically, the facility did not document turning and repositioning the resident every two hours or elevating the resident's heels off the bed, which are critical actions to prevent pressure ulcer development. A new unstageable pressure ulcer was discovered on the resident's left heel, which was not identified in the facility's weekly skin assessment but was noted by an outside wound consultant. The facility's failure to document and implement preventative measures, such as pressure relief for the resident's heels, contributed to the development of this pressure ulcer. The Nursing Home Administrator confirmed the lack of documented evidence for the timely and consistent implementation of these preventative measures.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Step One Resident #1 no longer resides at the community. Resident #1 wound consultant recommendations implemented on November 14, 2024. Step Two To identify like residents that have the potential to be affected, the DON/designee conducted a whole house review of physician/nursing ordered pressure reduction interventions and validated proper placement, cross-referencing the device list. The DON/designee will conduct an in-house review of wound consultant reports to ensure timely follow-up of recommendations. Step Three To prevent this from happening again, the DON/designee will educate the licensed nursing staff and CNA staff on the utilization and review of the device list ordered interventions and the importance of ensuring they are in place. To prevent this from happening again, the DON/designee will educate the licensed nursing staff on timely follow-up of wound care consultant recommendations. To prevent this from happening again, the DON/designee will educate the Department Head staff on the use of the device list which lists ordered interventions and ensuring during concierge rounds the importance of ensuring they are in place. Step Four To monitor and maintain ongoing compliance, the DON/designee will conduct an audit of 5 residents per week for 4 weeks, then monthly for 2 months to ensure all ordered interventions are in place. The DON/designee will conduct an audit of 5 residents with orders for wound consults per week, then monthly for 2 months to ensure timely follow-up to recommendations. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Failure to Provide Timely CPR Due to Code Status Misidentification
Penalty
Summary
The facility failed to provide prompt cardiopulmonary resuscitation (CPR) intervention consistent with a resident's advanced directives, resulting in a deficiency. A resident, identified as CR1, was found unresponsive in their room by a nurse aide. The nurse aide called for assistance, and a registered nurse (RN) responded but incorrectly identified the resident's code status as 'do not resuscitate' (DNR) by consulting a physical chart instead of the electronic medical record. This error led to a delay in initiating CPR for the resident, who was actually designated as 'full code' and should have received immediate resuscitative efforts. The RN Supervisor, Employee 2, failed to verify the resident's identity and correct code status, resulting in a 30-minute delay in providing life-sustaining measures. During this time, the RN incorrectly notified another resident's family of their loved one's death, further compounding the error. It was only after the oncoming RN Supervisor, Employee 3, arrived and observed the error that CPR was initiated, but by then, significant time had elapsed since the resident was found unresponsive. The delay in initiating CPR may have contributed to the resident's subsequent death, as CPR was not started until 30 minutes after the resident was found unresponsive. The facility's failure to follow proper emergency response protocols and accurately verify the resident's code status placed the resident in immediate jeopardy, representing a systemic failure to ensure the health and safety of residents requiring emergency care.
Failure to Initiate Timely CPR Due to Misidentification of Resident's Code Status
Penalty
Summary
The facility's administration failed to effectively use its resources to promote resident safety by not implementing established procedures for timely cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, as per a resident's advanced directive. This deficiency was identified for one out of five sampled residents, referred to as Resident CR1. The facility's policy required licensed nurses, respiratory therapists, and van drivers to hold active CPR certificates from an American Heart Association (AHA) approved provider, with in-person skills verification. However, during an emergency, the staff failed to follow these procedures. On the day of the incident, a nurse aide found Resident CR1 unresponsive and called for help. An RN responded but incorrectly identified the resident as having a do-not-resuscitate (DNR) order, based on a physical chart that was misidentified. This error led to a delay in initiating CPR. The RN left the room to consult with another RN Supervisor, who upon arrival, realized the mistake and initiated CPR approximately 30 minutes after the resident was found unresponsive. Emergency Medical Services (EMS) were called, but the delay in CPR initiation may have contributed to the resident's death. The facility's investigation revealed that the RN Supervisor failed to verify the resident's identity and code status before deciding not to initiate CPR. This oversight resulted in a 30-minute delay in providing life-sustaining measures, placing the resident in immediate jeopardy. The Nursing Home Administrator confirmed the failure to identify the resident's code status and perform necessary emergency procedures, leading to the termination of the RN involved. The deficiency was cited under the Code of Federal Regulatory Groups for Long Term Care, indicating a systemic failure to ensure the health and safety of residents requiring emergency care.
Neglect Leads to Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in serious injuries, including a fractured thumb and a closed head injury. The resident, who was admitted with diagnoses of cerebral infarction, dysphagia requiring enteral feeding, and diabetes, required maximum assistance with personal care and the use of a mechanical lift for transfers. Despite these needs, the resident was left unattended by a nurse aide, Employee 1, who was providing care alone when the resident rolled out of bed. Employee 1 did not report the fall and instead sought the assistance of another nurse aide to return the resident to bed without using the mechanical lift. The facility's investigation revealed inconsistencies in staff accounts and a lack of immediate and thorough assessment following the incident. Employee 1 and another nurse aide failed to report the fall, and the licensed nursing staff did not conduct a prompt assessment or initiate neurological checks despite the resident's visible injuries. Surveillance footage and witness statements indicated that the resident was not properly attended to, and the necessary protocols for handling such incidents were not followed. The facility's administrative staff confirmed that the nursing staff neglected to provide the necessary care to prevent physical harm to the resident. The failure to adhere to the resident's care plan, which required two staff members and a mechanical lift for transfers, and the lack of timely reporting and assessment of the resident's condition, contributed to the severity of the injuries sustained.
What surveyors are citing around you — mapped
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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 128 citations issued within 25 miles in the last 12 months — including the 5 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stroudsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stroudsburg Post Acute Nursing & Rehabilitationllc | 3.5 mi | ★★★★★ | 22 | 0 |
| Sapphire Care And Rehab Center | 3.7 mi | ★★★★★ | 13 | 0 |
| Slate Belt Health & Rehabilitation Center | 8.4 mi | ★★★★★ | 6 | 0 |
| Clover Rest Home | 8.9 mi | ★★★★★ | 0 | 0 |
| Brookmont Healthcare And Rehabilitation Center | 10.6 mi | ★★★★★ | 10 | 0 |
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