Below 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 Willows Of Presbyterian Senior during CMS and state inspections, most recent first.
Unsanitary Ice Machine in Main Kitchen: The ice machines in the Main Kitchen were observed to contain a brown substance inside the machine. The Dietary Director confirmed the substance and could not verify when the ice machine was last sanitized.
Failure to Protect Resident Medical Information: Multiple resident rooms had posted signs with detailed care instructions visible to others, including meal assistance, shower schedules, lift use, positioning, ROM, and transfer restrictions. In addition, an unattended med cart at the nurses station had an open computer screen displaying identifiable resident information. The DON and an RN confirmed the confidentiality lapses.
Failure to recognize and manage physical restraints: a resident’s bed was placed against the wall, another resident had a mattress with raised edges that staff could not identify as bolsters or a concave mattress, and a third resident had bilateral side rails in use. The record lacked physician orders for some of the devices, and care plans and ongoing evaluations were missing for the restraint-related interventions. The residents had significant medical histories including Alzheimer’s disease, aphasia, epilepsy, hemiplegia, muscle weakness, and obesity.
Failure to Communicate Transfer Information: The facility did not document that required resident information was sent to the receiving provider for five sampled residents with facility-initiated transfers. The missing information included care plan goals, advance directive details, ongoing care instructions, resident representative information, and other data needed to meet each resident’s needs; the residents had diagnoses including HTN, anemia, aphasia, epilepsy, COPD, Alzheimer’s disease, depression, cancer, and low back pain.
Late Completion of Required MDS Assessments: The facility failed to ensure timely completion of comprehensive MDS assessments for four residents. An RN Assessment Coordinator confirmed that admission and annual MDSs were signed off after the required deadline for multiple residents, including assessments completed or finalized one to two days late.
Quarterly MDS assessments were completed late for three residents after the required 14-day completion window following the ARD. The RN Assessment Coordinator confirmed the facility did not ensure timely completion of the quarterly assessments for these residents.
Failure to provide appropriate respiratory care was identified for five residents with orders for oxygen therapy and, for some, nebulizer or BiPAP use. Staff observed missing dates on oxygen tubing and humidifier bottles, empty or out-of-date humidification, and respiratory equipment such as BiPAP masks and nebulizer tubing left out of bags when not in use. One resident’s oxygen was not connected and the nasal cannula was lying on the bed instead of in place. LPNs and the RN confirmed the findings, and the DON confirmed the facility failed to provide appropriate respiratory care for several residents.
Infection control deficiencies were identified when six residents' personal refrigerators lacked temperature logs and thermometers, despite facility policy requiring monitoring of refrigerator temperatures and sanitation. In addition, a resident with an indwelling urinary catheter and EBP precautions had the catheter drainage bag observed lying directly on the floor beside the bed, and the ADON/IP confirmed the finding.
Unsecured medications were found at the bedside of two residents without physician orders or care plans authorizing self-administration. One resident had HF, HTN, and HLD, and the other had HTN, depression, and DM; both had multiple medications left unsecured in their rooms, and an LPN confirmed the lack of required documentation.
A resident with HTN, arthritis, and osteoporosis was observed sitting in a recliner while the call bell was placed on the bed under the linens and out of reach. An RN confirmed the call bell was not accessible or available for the resident's use and that the resident's call bell needs were not accommodated.
A resident with diagnoses including infection and inflammatory reaction due to an internal right knee prosthesis, bacteremia, and CHF had a wound vac attached to the wheelchair for the knee, but review of physician orders showed no order for the wound vac. The DON confirmed the facility failed to obtain the required order.
A resident with GERD, Alzheimer's disease, and hemiplegia was observed wearing bilateral palm guards, but the chart lacked a physician order for the splints and the care plan did not include goals or interventions for their use. An RN confirmed residents should have orders for splints and braces and that these should be in the care plan, and the NHA later confirmed the missing resident-specific plan of care.
Missing PICC Line Orders and Care: A resident with cancer had a double lumen PICC line in the R upper arm for weekly fluids and chemotherapy, but the current chart lacked orders for PICC care and maintenance. Staff interviews confirmed the orders were missing, and the DON acknowledged the facility failed to provide adequate treatment and care for the PICC line.
Unsecured discontinued medications were found overfilled in a medication room bin and had not been disposed of or reconciled in a timely manner. The bin contained multiple meds, including Tylenol, Lovenox, Heparin, Scopolamine, Zofran, and others. An LPN said overnight staff write the meds up and use a reconciliation form, and the DON confirmed the lapse.
Improper storage of expired supplies and an unsecured medication cart were observed in the facility. In the Fourth Floor medication room, surveyors found expired needles, expired ESwab items, and an opened TB vial without an expiration date; an LPN and the DON confirmed the findings. Surveyors also observed the Third Floor West/Northwest medication cart left unlocked and unattended, and an RN confirmed it was not properly secured.
Several residents who required two-person or mechanical lift assistance for transfers were instead transferred by a single aide, resulting in injuries such as a head contusion and skin tears. In each case, staff were aware of the required transfer protocols but proceeded alone due to lack of available help or to expedite care. Additionally, an unexplained skin injury was not properly documented or investigated, with no physician notification or follow-up, as confirmed by staff and the DON.
Several residents who required two-person or mechanical lift transfers were transferred by a single CNA, despite clear physician orders and facility protocols. These actions resulted in actual harm, including a head contusion and skin tears, when staff proceeded with solo transfers due to lack of available help or urgency in resident needs. Staff interviews confirmed that transfer requirements were clearly communicated through daily planners and color-coded systems.
A resident with dementia and a history of wandering was able to exit the facility unsupervised despite being identified as an elopement risk and having an elopement protection device in place. The alarm system only sounded in the lobby, and staff did not hear it from the nursing unit, allowing the resident to leave through the front entrance, which was found ajar and off its hinges. The lack of adequate supervision and ineffective alarm coverage led to the resident being found outside in the parking lot by an LPN.
Eight residents with conditions such as dementia, depression, and Alzheimer's disease, all identified as high risk for wandering or elopement, were found to have nearly identical care plans that lacked person-centered interventions or goals. Despite documented risk factors and facility policy requiring individualized care plans, the interventions and objectives were generic and not tailored to each resident's specific needs or behaviors, resulting in a deficiency.
The facility did not report to the state agency an allegation that staff improperly destroyed medications no longer prescribed for a resident. Although the Nursing Home Administrator and DON were aware of the incident and began an internal investigation, they failed to notify the state agency as required by facility policy and regulations.
A resident with a history of falls, epilepsy, and muscle weakness suffered a patella fracture when her leg fell off a wheelchair footrest and became caught during transport from an appointment. Despite the resident expressing pain, the van driver did not notice or report the incident immediately, resulting in actual harm. Facility documentation and staff interviews confirmed inadequate supervision and assistance in preventing the accident.
The facility failed to provide a safe, clean, and homelike environment for several residents. Observations revealed gouges in walls, missing transition strips creating safety hazards, and wheelchairs covered in dust and grime. These issues were confirmed by staff interviews, indicating a lack of maintenance and cleanliness in the facility.
The facility failed to provide proper respiratory care for four residents, as observed by surveyors. A resident with dementia had undated nebulizer equipment not included in the care plan. Another resident had an oxygen concentrator without physician orders or a care plan, with equipment found on the floor. A third resident's care plan did not reflect physician orders for oxygen, and the equipment was undated. Lastly, a resident with COPD had improperly stored nebulizer tubing. The DON confirmed these deficiencies.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. A resident with multiple health conditions was found with a cup of pills on the bedside table and mentioned dropping a pill without knowing its location. An RN confirmed there were no orders for self-administration, highlighting a lapse in medication management procedures.
A facility failed to complete a quarterly MDS assessment for a resident within the required timeframe. The resident's admission MDS assessment was completed, but no subsequent assessments were done, resulting in a 62-day overdue quarterly assessment. This deficiency was confirmed by the RN Assessment Coordinator.
The facility failed to ensure accurate MDS assessments for two residents. One resident with aphasia and dysphagia had conflicting information in their assessment, while another resident with Parkinson's Disease had an incorrect discharge status recorded. Staff interviews confirmed these inaccuracies.
The facility failed to update a resident's care plan to reflect a physician's order for fluid restriction, instead instructing staff to encourage fluids. This discrepancy was confirmed by the DON, highlighting a failure to revise the care plan according to the resident's current medical needs.
The facility failed to support two residents in their daily living activities. One resident with aphasia and dysphagia lacked a communication care plan and device, while another resident with dysphagia and hemiplegia was not assisted out of bed for meals as ordered. Staff confirmed these deficiencies, acknowledging the lack of appropriate services.
The facility failed to document vital signs parameters on the MAR for two residents as per physician orders, and did not discontinue incisional care for a resident once healed. One resident with high blood pressure did not have bedtime blood pressure documented, and another resident's blood pressure was not recorded as required. Additionally, a resident's wound care continued despite the incision being healed. Staff confirmed these deficiencies.
A resident admitted with a stage 3 pressure ulcer on the coccyx did not receive proper assessment and treatment. The facility failed to document the ulcer's details and omitted necessary cleansing instructions in physician orders. Additionally, there was no comprehensive care plan for the ulcer, as confirmed by facility staff.
A facility failed to provide physician-ordered contracture management for a resident with hemiplegia, as the resident did not receive her palm guard on shower days. The resident reported that staff did not apply the palm guard, and an LPN confirmed the oversight. The DON and Nursing Home Administrator acknowledged the failure to follow the care plan.
A nurse aide trainee, Employee E12, worked beyond the four-month certification period without obtaining certification, as required by federal regulations. Despite completing the training program, E12 failed the written exam and continued to provide direct care to residents. The facility's administration confirmed this oversight, which affected one of five employees reviewed.
A facility failed to develop and implement a person-centered care plan for a resident with dementia, as required. The resident was admitted with a diagnosis of dementia, and assessments indicated moderate cognitive impairment. However, from mid-April to late September, there was no documentation of a care plan addressing the resident's dementia and cognitive loss. This deficiency was confirmed by the RN Assessment Coordinator.
The facility failed to provide food items consistent with prescribed diet orders for two residents. One resident was given thin fluids instead of nectar/mildly thick consistency, and another was served thin iced tea instead of nectar thick liquids. Both discrepancies were confirmed by nursing staff and acknowledged by the DON.
The facility failed to provide adaptive feeding devices for a resident with dementia, orthostatic hypotension, and acute kidney failure. The resident's care plan required a Kennedy cup with meals, but during an observation, the resident did not have the cup at lunch. This was confirmed by both an RN and the DON.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, affecting three residents with various medical conditions. This lack of documentation was confirmed by a medical records employee.
A resident with multiple health conditions, including unsteadiness on feet and a right artificial knee, was injured during a transfer when a nurse aide failed to follow the physician's order for a two-person transfer. The nurse aide, unaware of the resident's transfer status, attempted the transfer alone, resulting in a skin tear on the resident's leg. The facility's policy required two-person assistance for mechanical lifts, which was not adhered to in this instance.
The facility failed to meet the nutritional and special dietary needs of a resident with dementia, COPD, and CHF, due to an unstructured meal delivery system and inadequate substitutions for prescribed supplements. Observations and staff interviews revealed disorganized meal service and supply issues with the prescribed Boost Plus supplement.
The facility failed to maintain accurate clinical records for a resident with dementia, COPD, and CHF. The resident was given Ensure instead of the prescribed Boost Plus without updating the physician's orders, and a required low air loss mattress was not in place as per the physician's order.
Unsanitary Ice Machine in Main Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the Main Kitchen. During an observation on 9/22/25 at 9:30 a.m., the ice machines in the main kitchen were found to contain a brown substance inside the machine. During an interview on 9/22/25 at 9:50 a.m., the Dietary Director confirmed the brown substance in the ice machine and could not verify the last time it was sanitized.
Failure to Protect Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information for five of seven resident rooms observed. During a tour on 9/29/25, multiple signs containing resident-specific care information were observed posted in resident rooms and visible to others. In one room, a sign listed meal assistance, shower days and times, and use of a Hoyer lift at all times until further notice. In another room, signs listed detailed instructions for right upper extremity range of motion, palm guard use, skin checks, positioning in wheelchair, and arm support. Additional posted signs included instructions for wheelchair positioning, leg rests, soft collar use, midline neck positioning, transfer restrictions involving the right arm, and a note stating not to apply pink cream. The DON confirmed these observations and acknowledged the facility failed to maintain confidentiality for the five resident rooms identified. The facility also failed to maintain confidentiality on one of nine medication carts. During an observation on 10/1/25, the Third Floor West/Northwest Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. An RN confirmed the observation and agreed the facility failed to maintain confidentiality of residents' medical information as required.
Failure to Recognize and Manage Physical Restraints
Penalty
Summary
The facility failed to identify several bed-related interventions as possible physical restraints, failed to obtain physician orders for some of the devices used, failed to develop person-centered care plans, and failed to provide ongoing re-evaluation of the need for restraints for three residents. Facility policy defined physical restraints to include devices or placements that restrict a resident’s freedom of movement, including placing a chair or bed close enough to a wall to prevent rising or getting out of bed, and using a concave mattress that prevents independent exit from bed. The facility also had a policy stating bed rails are considered restraints when used to limit freedom of movement and that their use should be addressed in the care plan. Resident R6 had diagnoses including GERD, Alzheimer’s disease, and hemiplegia. During observation, the resident was lying in bed with the left side of the bed pushed against the wall. A physician order dated 9/30/24 indicated the bed was to be moved against the wall at the family’s request for better visitation and mobility. The resident’s comprehensive care plan did not include goals or interventions related to the bed being against the wall, and the clinical record did not show assessments or ongoing evaluations for that placement. Resident R9 had diagnoses including aphasia, epilepsy, and anemia. During observations, the resident’s mattress had bilateral raised edges on the top and bottom portions, and staff were unsure whether the raised edges were bolsters or a concave mattress. The resident’s active physician orders did not include an order for bolsters or a concave mattress, the care plan did not address their use, and the clinical record did not show assessments or ongoing evaluations for them. Resident R18 had diagnoses including high blood pressure, muscle weakness, and obesity, was dependent on staff to roll left and right, and was coded as using bed rails less than daily as a restraint. The resident was observed in bed with bilateral side rails applied, the physician order indicated bilateral side rails on a bari-bed, and the care plan did not include goals or interventions related to the side rails.
Failure to Communicate Transfer Information
Penalty
Summary
The facility failed to make certain that necessary resident information was communicated to the receiving health care provider for five of five sampled residents with facility-initiated transfers. Review of the facility’s Transfer and Discharge policy dated August 2025 indicated that orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge. However, for Residents R7, R9, R10, R14, and R17, the clinical record contained no documented evidence that the facility communicated the residents’ care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, or other information necessary to meet the residents’ specific needs at the receiving facility. The records showed that Resident R7 was transferred to the hospital and later returned to the facility, with diagnoses including high blood pressure, anemia, and hyperlipidemia. Resident R9 had diagnoses of aphasia, epilepsy, and anemia; Resident R10 had anemia, high blood pressure, and COPD; Resident R14 had hyperlipidemia, arthritis, and Alzheimer’s disease; and Resident R17 had depression, cancer, and low back pain. During an interview on 10/14/25 at 10:04 a.m., the DON confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for these five residents.
Late Completion of Required MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set assessments were completed within the required time frame for four of seven residents reviewed. The Resident Assessment Instrument User's Manual dated October 2024 stated that an admission MDS must be completed no later than 14 calendar days after admission and an annual MDS no later than the ARD plus 14 calendar days. Resident R16 was admitted on 8/27/25 and the MDS was completed on 9/9/25, but not signed off as completed until 9/10/25, one day after the due date. Resident R18 had an annual ARD of 6/6/26 and the MDS was signed off on 6/22/25, two days after the due date. Resident R47 had an annual ARD of 5/27/25 and the MDS was signed off on 6/11/25, one day after the due date. Resident R80 was admitted on 7/7/25 and the MDS was completed on 7/20/25, but not signed off as completed until 7/21/25, one day after the due date. During interview, the RN Assessment Coordinator confirmed the facility failed to make certain the comprehensive MDS assessments were completed in the required time frame for these residents.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
Quarterly MDS assessments were not completed within the required time frame for three of seven residents reviewed. The RAI User's Manual dated October 2024 stated that quarterly MDS assessments must be completed no later than 14 calendar days after the ARD. Resident R19 had a quarterly ARD of 6/28/25 and the MDS was signed as completed on 7/15/25, three days after the due date. Resident R77 had a quarterly ARD of 6/24/25 and the MDS was signed as completed on 7/10/25, two days after the due date. Resident R137 had a quarterly ARD of 6/3/25 and the MDS was signed as completed on 6/19/25, two days after the due date. During interview, the RN Assessment Coordinator confirmed the facility failed to ensure the quarterly MDS assessments were completed in the required time frame for these three residents.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for five residents who had physician orders for oxygen therapy and, in some cases, nebulizer or BiPAP use. Facility policy required oxygen tubing and masks/cannulas to be changed weekly and as needed if soiled or contaminated, humidifier bottles to be changed when empty or weekly, and delivery devices to be kept covered in a plastic bag when not in use. The cited residents had diagnoses including COPD, heart failure, ESRD, anemia, hypertension, dementia, depression, diabetes, and sleep apnea, and each had orders for oxygen therapy or related respiratory treatments. For Resident R1, who had oxygen therapy and nebulizer treatments ordered, staff observed oxygen tubing without a date, a humidification bottle dated 9/3/25, and nebulizer tubing without a date and not stored in a bag when not in use. The LPN confirmed these findings. For Resident R10, who had orders for oxygen and bedtime BiPAP, staff observed the humidification bottle dated 9/18 and later empty, and the BiPAP mask stored on the dresser rather than in a bag while not in use. The RN confirmed the bottle was empty and out of date and that the BiPAP mask was not stored in a bag. For Resident R98, a portable oxygen tank in the room had tubing without a date and was not stored in a bag when not in use, and an LPN confirmed the finding. For Resident R126, staff observed the oxygen tubing was not hooked to the oxygen machine, the nasal cannula was lying on the bed instead of in the resident’s nostrils, and the oxygen tubing and humidification bottle had no dates; an LPN confirmed the missing dates. For Resident R134, oxygen tubing was not dated and nebulizer tubing was not dated and was not stored in a bag when not in use; an LPN confirmed these findings. The DON later confirmed the facility failed to provide appropriate respiratory care for Residents R1, R98, R126, and R134.
Infection Control Deficiencies With Personal Refrigerators and Urinary Catheter Care
Penalty
Summary
The facility failed to properly monitor resident personal refrigerators to ensure food was properly stored and maintained for six residents. Facility policy stated that the infection prevention and control program was designed to provide a safe, sanitary, and comfortable environment, and the refrigerator/freezer policy required safe maintenance, temperatures, sanitation, and monthly tracking sheets with time, temperature, initials, and action taken. During observations, six residents had small personal refrigerators in their rooms, and each refrigerator lacked a temperature log showing daily monitoring and lacked a thermometer to determine acceptable temperature ranges. During the observations on the unit, Resident R44, R144, R57, R150, R43, and R159 each had a small personal refrigerator on a counter in the room. For each of these refrigerators, there was no temperature log with daily monitoring and no thermometer present to determine acceptable temperature ranges. The Director of Nursing stated that the facility ordered thermometers for all personal refrigerators and confirmed that the facility failed to properly monitor the residents' personal refrigerators. The facility also failed to maintain proper infection control practices related to an indwelling urinary catheter for Resident R8. Resident R8 was admitted to the facility with diagnoses including diverticulitis, atrial fibrillation, and bullous pemphigoid, and the MDS indicated an indwelling catheter. The care plan identified the resident as having an indwelling urinary catheter related to skin breakdown and needing enhanced barrier precautions due to potential for infectious disease. During observation, the catheter draining bag was seen lying directly on the floor beside the bed, and the ADON/Infection Preventionist confirmed the observation.
Unsecured Medications Found Without Orders or Care Plans for Self-Administration
Penalty
Summary
The facility failed to determine that self-administration of medications was clinically appropriate for two residents. Facility policy stated that residents may self-administer medications only if the interdisciplinary team determines the practice is clinically appropriate, with documentation by staff and the practitioner, and with medications stored in a safe and secure place. For Resident R45, review of the clinical record showed diagnoses of heart failure, high blood pressure, and hyperlipidemia. During observation, a tube of Voltaren gel, a bottle of Miralax, and Systane eye drops were found lying unsecured on the counter in the resident’s room. The physician orders did not include an order for self-administration of medications, and the care plan did not address self-administration. For Resident R166, review of the clinical record showed diagnoses of high blood pressure, depression, and diabetes. During observation, a bottle of Venlafaxine ER 150 mg pills, a bottle of liquid pain reliever, a bottle of Emetrol, and a tube of Voltaren gel were found lying unsecured on the counter in the resident’s room. The physician orders did not include an order for self-administration of medications, and the care plan did not address self-administration. During a tour and interview, an LPN confirmed the unsecured medications at bedside and confirmed the absence of a physician order or care plan for self-administration for both residents.
Call Bell Not Accessible to Resident
Penalty
Summary
The facility failed to accommodate the call bell needs for one resident. The resident was admitted to the facility and had an MDS dated 9/19/25 that listed diagnoses of high blood pressure, arthritis, and osteoporosis. During an observation on 9/29/25 at 9:43 a.m., the resident was sitting in a recliner in the room while the call bell was placed on the bed, under the linens, and out of reach. During an interview at 9:50 a.m., an RN confirmed the call bell was not accessible and unavailable for the resident's use, and stated that the facility failed to accommodate the resident's call bell needs.
Failure to Obtain Physician Order for Wound Vac
Penalty
Summary
The facility failed to obtain a physician order for a wound vac for Resident R189. The resident was admitted with diagnoses including infection and inflammatory reaction due to an internal right knee prosthesis, bacteremia, and congestive heart failure. The admission MDS dated 9/29/25 indicated the diagnosis remained current. During an interview on 9/29/25 at 10:30 a.m., Resident R189 was observed with a wound vac attached to the left side of the wheelchair and stated it was for the knee. Review of physician orders dated 9/24/25 showed no order for the wound vac. During an interview on 9/29/25 at 1:30 p.m., the DON confirmed the facility failed to obtain an order for the resident's wound vac.
Failure to Include Palm Guards in Care Plan and Orders
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility who required equipment and assistance to maintain or improve mobility. Resident R6 was admitted with diagnoses including GERD, Alzheimer's disease, and hemiplegia. During observations on 9/29/25 and 10/1/25, R6 was seen wearing bilateral palm guards, and a nurse aide and RN both confirmed the resident was wearing them. The RN stated that residents would have an order for splints and braces and that it would be in the care plan. Review of the resident's active physician orders on 10/1/25 failed to include an order for bilateral palm guards. Review of the comprehensive care plan also failed to include goals and interventions related to the resident's bilateral palm guard use. The Nursing Home Administrator later confirmed that the facility failed to develop a comprehensive resident-specific plan of care for R6 related to limited mobility and the use of this equipment.
Missing PICC Line Orders and Care
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident’s PICC line in accordance with professional standards of practice. Resident R17 was admitted with diagnoses including depression, cancer, and low back pain, and during an observation the resident was lying in bed with a double lumen PICC line in the right upper arm. The resident stated the line was used for weekly fluids and chemotherapy medication. A review of physician orders showed an order for 0.9% Sodium Chloride Solution, one liter every Wednesday, but the current physician orders reviewed on 10/1/25 did not include any orders related to the PICC line, including care and maintenance. During interviews, the CRNP stated the orders likely fell off the chart and said new orders would be entered, while the Unit Manager LPN stated she would contact the hospital to obtain the PICC line length for the facility’s records and confirmed the PICC orders were missing. The DON later confirmed the facility failed to provide adequate treatment and care for the PICC line for one of two residents reviewed.
Unsecured discontinued medications left unreconciled in medication room
Penalty
Summary
The facility failed to dispose of or reconcile discontinued medications in a timely manner in the Fourth Floor Medication Room. Review of the facility’s Medication Disposal-Non-controlled Medications policy dated August 2025 stated that discontinued medications and medications left in the facility after a resident’s discharge or death should be disposed of in a timely manner, and that any non-controlled medication product that is discontinued should be documented on a Medication Reconciliation form. During a medication room review, a plastic bin overfilled with unsecured and unaccounted-for medications was observed sitting in the corner of the room. The bin contained multiple discontinued or leftover medications, including Tylenol, Lovenox injections, Omeprazole, Gas Relief, Immodium, Lactated ringers, Zebeta, Atenolol, Namenda, Heparin, Scopolamine patches, Zofran, Tylenol suppositories, Zoloft, Mucinex, Latanoprost eye drops, Zyprexa, and Seroquel. An LPN stated that overnight staff write the medications up and that a reconciliation form is used, and the DON confirmed the facility failed to dispose of or reconcile the medications in a timely manner.
Improper Storage of Expired Supplies and Unsecured Medication Cart
Penalty
Summary
The facility failed to properly store medical supplies in the Fourth Floor Medication Room. During a medication storage room review, surveyors observed three 27-gauge needles expired, twelve 23-gauge needles expired, eleven additional 23-gauge needles expired, three ESwab items expired, and a tuberculosis vial that was opened and did not have an expiration date. An LPN confirmed these findings during interview, and the DON later confirmed that the facility failed to properly store medical supplies in one of the medication rooms. The facility also failed to properly secure a medication cart while it was not in use. During an observation, the Third Floor West/Northwest Medication Cart at the nurses station was left unlocked and unattended. An RN confirmed this observation during interview and confirmed that the facility failed to properly secure the medication cart while it was not in use.
Failure to Ensure Adequate Supervision and Assistance During Resident Transfers Resulting in Harm
Penalty
Summary
The facility failed to ensure residents were free from neglect by not providing adequate supervision and assistance during transfers, resulting in actual harm to multiple residents. In several documented incidents, residents who required two-person assistance or mechanical lifts for transfers were instead transferred by a single nursing aide, contrary to physician orders and facility policy. This led to injuries including a head contusion for one resident and skin tears for two others. In each case, the aides involved acknowledged they were aware of the required transfer status but proceeded alone due to the unavailability of additional staff or in an attempt to expedite care. One resident with diagnoses including high blood pressure, glaucoma, and anemia sustained a head contusion after a CNA transferred her independently instead of using the required mechanical lift with two staff. Another resident with high blood pressure, hyperlipidemia, and diabetes suffered a skin tear to her lower extremity during a solo transfer by a CNA, despite being ordered for a two-person mechanical lift assist. A third resident, with high blood pressure, heart failure, osteoporosis, and moderate cognitive impairment, also sustained a significant skin tear when transferred by a single aide, who admitted knowing the resident's two-person assist status but was unable to find help at the time. Additionally, the facility failed to document, assess, and investigate an unexplained skin injury for one resident, as required by policy. There was no record of physician notification, assessment, or follow-up for a skin condition that required a dressing, and staff interviews confirmed that the appropriate procedures were not followed. The DON and other staff confirmed these failures to ensure adequate supervision, adherence to transfer protocols, and proper incident documentation, resulting in neglect and actual harm to the residents involved.
Failure to Provide Adequate Supervision and Assistance During Resident Transfers
Penalty
Summary
Multiple residents who required two-person assist or mechanical lift transfers were transferred by a single nurse aide, contrary to physician orders and facility policy. In each case, the assigned aide was aware of the resident's transfer status, as indicated by daily planners, color-coded stickers, and shift reports, but proceeded to transfer the resident alone due to the unavailability of additional staff or in an attempt to expedite care. These actions resulted in actual harm to the residents, including a head contusion and skin tears. One resident with diagnoses including high blood pressure, glaucoma, and anemia sustained a contusion to the left side of her head after a CNA, acting alone, attempted to transfer her from the toilet without using the required Sara lift and second staff member. The CNA admitted to transferring the resident independently to hurry the process, which led to both the resident and the aide bumping heads. The resident developed a raised, bruised area on her head as a result. Two other residents, both with significant medical histories such as high blood pressure, diabetes, heart failure, and osteoporosis, suffered skin tears during transfers. In both cases, the CNAs assigned to them acknowledged that they were aware of the two-person assist requirement but proceeded to transfer the residents alone because they could not find available help and the residents urgently needed assistance. These transfers resulted in actively bleeding skin tears that required immediate first aid. Interviews with other staff confirmed that transfer statuses are clearly communicated and that staff are educated not to transfer residents alone when two-person assistance is required.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as high risk for wandering, resulting in an elopement event. Upon admission, the resident was assessed as not at risk for elopement, but subsequent documentation showed wandering, exit-seeking behaviors, and impaired safety awareness. Despite these behaviors, the resident was able to exit the facility unsupervised through the front entrance, which was found ajar and off its hinges, with the elopement protection device (EPD) alarm sounding only in the lobby area. Staff did not hear the alarm from the nursing unit, and the resident was last seen in her room before being found outside in the parking lot by an LPN. The resident had a history of dementia, atrial fibrillation, and previous falls, and was noted in progress notes to wander aimlessly, enter other residents' rooms, and exhibit delusions. The care plan and physician orders indicated the use of an EPD and daily checks, but these interventions did not prevent the resident from leaving the building. Staff interviews and documentation revealed that the resident was able to force open the front doors, which, while equipped with an EPD system, could be pushed open due to their fire door function. The alarm system was not audible throughout the facility, limiting staff's ability to respond promptly. The deficiency was confirmed by the Nursing Home Administrator and DON, who acknowledged that the lack of adequate supervision and ineffective alarm coverage led to the resident's elopement. The incident was classified as immediate jeopardy due to the failure to ensure the safety of a resident at high risk for wandering, as required by facility policy and state regulations.
Failure to Individualize Care Plans for High-Risk Wandering Residents
Penalty
Summary
The facility failed to ensure that residents identified as high risk for wandering or elopement had person-centered care plans individualized to their specific needs. Eight residents with diagnoses such as dementia, depression, heart failure, and Alzheimer's disease were identified as having behaviors or histories that placed them at risk for wandering or elopement. Each of these residents had completed elopement evaluations indicating risk factors such as aimless wandering, history of elopement attempts, and verbal expressions of wanting to leave the facility. Despite these individualized risk factors, a review of the care plans for all eight residents revealed that the plans were nearly identical, lacking specific interventions or goals tailored to each resident's unique needs and behaviors. The care plans included generic goals such as maintaining resident safety, ensuring happiness with daily routines, and preventing residents from leaving the facility unattended. Interventions listed were also generic, including assessing for fall risk, providing diversions, monitoring for fatigue, and offering structured activities, without any customization based on the resident's personal history or preferences. The facility's own policies required comprehensive, person-centered care plans with measurable objectives and timetables, as well as ongoing assessment and revision as resident conditions changed. However, interviews and documentation confirmed that the facility did not meet these requirements for the eight residents at high risk for wandering or elopement, resulting in a deficiency under state regulations for admissions policy and nursing services.
Failure to Report Misappropriation of Resident Property to State Agency
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency as required by policy and regulation. Specifically, staff members were alleged to have improperly destroyed medications that were no longer prescribed for residents. The Nursing Home Administrator and Director of Nursing were aware of these allegations and initiated an internal investigation, but did not notify the state agency of either the allegation or the ongoing investigation. Facility policy defines abuse to include misappropriation of resident property and requires reporting such allegations to the appropriate agencies. This omission was confirmed during staff interviews and through a review of facility documents submitted to the state agency.
Failure to Prevent Accident During Resident Transport Resulting in Knee Fracture
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents, resulting in actual harm to a resident who sustained a patella (knee) fracture. The resident, who had diagnoses including epilepsy, a history of falls, and muscle weakness, was cognitively intact according to the most recent assessment. During transport back to the facility from an appointment, the resident's left leg fell off the wheelchair footrest and became caught under the wheelchair. Despite the resident expressing pain and asking the driver to stop, the driver continued pushing the wheelchair, unaware of the injury until alerted by the resident's reaction and bystanders. Documentation and staff interviews confirmed that the van driver did not notice the resident's leg had fallen off the footrest and did not immediately report the incident. The resident continued to experience pain, and subsequent imaging revealed a mid-patella fracture. The facility's own policy required thorough investigation and timely response to incidents, but the lack of adequate supervision and failure to promptly recognize and address the resident's distress directly led to the injury.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for eight residents. Observations revealed gouges in the walls behind the beds of two residents, indicating a lack of maintenance in their living spaces. Additionally, two residents' rooms had missing transition strips at the entrance to the bathrooms, creating uneven surfaces that posed safety hazards. These deficiencies were confirmed during a tour and interview with the Unit Manager. Furthermore, several residents were observed in wheelchairs that were covered with dust, dried debris, and grime. The wheelchairs of four residents were noted to have frames, undercarriages, and wheels that were not clean, with one resident's wheelchair having a right lateral support and brakes grossly corroded with dried grime and debris. These observations were confirmed by interviews with nursing aides and an environmental aide, highlighting the facility's failure to maintain a sanitary and orderly environment as required by federal regulations.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide specialized respiratory care in accordance with professional standards for four residents. Resident R12, diagnosed with Non-Alzheimer's Dementia, anxiety, and depression, had a physician order for Ipratropium-Albuterol Inhalation Solution via nebulizer, but the care plan did not include this treatment. The nebulizer equipment was found undated and improperly stored on the dresser. Resident R24, with high blood pressure, Non-Alzheimer's Dementia, and depression, had an oxygen concentrator in the room without physician orders or a care plan for oxygen administration. The equipment was undated, and the nasal cannula was found on the floor. Resident R44, diagnosed with asthma, anxiety, and depression, had physician orders for oxygen administration, but the care plan did not reflect this. The oxygen equipment in the room was undated. Resident R60, with dysphagia, COPD, and hemiplegia, had a physician order for Ipratropium-Albuterol Solution, but the nebulizer tubing was improperly stored. The Director of Nursing confirmed the facility's failure to provide respiratory care according to professional standards for all four residents.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to assess the ability of a resident to self-administer medications, which is a requirement for ensuring safe medication management. Resident R46, who was admitted with diagnoses including morbid obesity, congestive heart failure, and diabetes mellitus, was observed with a cup containing four pills on the bedside table. The resident mentioned having dropped a pill and was unaware of its location. During an interview, a Registered Nurse confirmed that there were no orders for the resident to self-administer medication, indicating a lapse in following the facility's policy that requires written orders for medication administration.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for Resident 144 within the required timeframe. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly assessments must be completed no more than 92 days after the Assessment Reference Date (ARD) of the most recent assessment, with a completion date no later than 14 days after the ARD. Resident 144 had an admission MDS assessment completed on June 6, 2024, but there was no evidence of any subsequent MDS assessment, including a quarterly assessment, being completed after that date. A review of the resident's clinical record on November 21, 2024, indicated that the quarterly MDS assessment was due by September 20, 2024, making it 62 days overdue. This deficiency was confirmed by the Registered Nurse Assessment Coordinator during an interview on November 21, 2024.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to a deficiency. For Resident R36, who was admitted with diagnoses of aphasia and dysphagia, the MDS assessment contained conflicting information. Section B indicated that the resident was understood, while Section C stated that the resident was rarely or never understood, and the Brief Interview for Mental Status (BIMS) was not completed. Interviews with staff confirmed that Resident R36 could not be understood, highlighting the inaccuracy in the MDS assessment. For Resident R158, who was admitted with Parkinson's Disease, high blood pressure, and anxiety, the MDS assessment inaccurately recorded the discharge status. Despite a progress note indicating a hospital transfer due to altered mental status and other health issues, the MDS stated the resident was discharged to home/community. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the inaccuracies in the MDS assessments for both residents, demonstrating a failure to accurately capture the residents' conditions.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for Resident R316 to accurately reflect the resident's current medical status. Resident R316 was admitted with diagnoses including congestive heart failure, asthma, and atrial fibrillation. The Minimum Data Set assessment confirmed these diagnoses were current. Despite a physician's order for a fluid restriction of 1800 ml, the Resident Care Plan Summary Report instructed staff to encourage fluids. This discrepancy was confirmed by the Director of Nursing during an interview, indicating a failure to revise the care plan in accordance with the resident's needs.
Failure to Support Residents' Daily Living Activities
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the ability of two residents to carry out activities of daily living. Resident R36, who was admitted with diagnoses of aphasia and dysphagia, did not have a care plan addressing her communication needs. Despite having expressive aphasia and being rarely understood, the resident was not provided with a communication device. This was confirmed by both a Licensed Practical Nurse and the Director of Nursing, who acknowledged the lack of appropriate services to support the resident's communication abilities. Resident R60, admitted with dysphagia, depression, and hemiplegia, had physician orders to be out of bed for meals to aid in lung function and swallowing. However, during an observation, the resident was found eating lunch in bed, contrary to the physician's orders. The resident reported that staff did not assist her out of bed on shower days, which was confirmed by an LPN. The Director of Nursing and Nursing Home Administrator acknowledged the failure to provide the necessary treatment and services to support the resident's dining and eating needs.
Failure to Document Vital Signs and Discontinue Healed Incisional Care
Penalty
Summary
The facility failed to document vital signs parameters on the medication administration record (MAR) as per physician orders for two residents. Resident R24, diagnosed with high blood pressure, dementia, and depression, was prescribed losartan to be administered at bedtime with a condition to hold the medication if blood pressure was less than 110. However, the MAR from November 5 to November 19 did not document the blood pressure at bedtime, and the blood pressure log showed recordings on nine occasions, none of which were at bedtime. Similarly, Resident R70, diagnosed with high blood pressure, dementia, and anxiety, was prescribed amlodipine besylate with a condition to hold if systolic blood pressure was less than 100. The MAR from November 12 to November 19 did not document the blood pressure, and the blood pressure log recorded only once before the medication started. RN Employee E8 confirmed the lack of documentation for both residents. Additionally, the facility failed to discontinue incisional care for Resident R151 once the incision was healed. Resident R151, with a diagnosis of dementia, thyroid disorder, and hip fracture, had an order for daily wound care on an upper back incision. The treatment administration record indicated the treatment was administered from November 1 to November 17. However, an observation on November 19 revealed the incision was healed, and no dressing was in place as ordered. Unit Manager Employee E2 acknowledged forgetting to discontinue the order, and the Director of Nursing confirmed the facility's failure in both documenting vital signs parameters and discontinuing incisional care once healed.
Failure to Properly Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure proper assessment and treatment of a pressure ulcer for a resident, identified as R72, who was admitted with a stage 3 pressure ulcer on the coccyx. Upon admission, the clinical assessment did not document any pressure injuries, but a subsequent skin check revealed a 5 x 5 cm open area on the coccyx, lacking detailed description and staging. The facility's physician orders from 10/11/24 to 10/15/24 included applying a butterfly dressing but omitted necessary cleansing instructions for the stage 3 pressure ulcer, which is inconsistent with professional standards of practice. The facility's documentation and care planning were inadequate, as evidenced by the absence of a comprehensive pressure ulcer care plan for Resident R72. Interviews with the Director of Nursing, Resident Nurse Assessment Coordinator, and Wound Care Nurse confirmed the lack of appropriate physician orders and care planning. The facility's failure to document and implement a care plan for the pressure ulcer was acknowledged by the Nursing Home Administrator, highlighting a deficiency in meeting the resident's medical and nursing needs as per regulatory requirements.
Failure to Provide Contracture Management for a Resident
Penalty
Summary
The facility failed to provide physician-ordered contracture management interventions for Resident R60, who was admitted with diagnoses including dysphagia, depression, and hemiplegia. According to the care plan, Resident R60 was supposed to wear a palm guard daily from morning until dinner time. However, during an observation and interview, it was noted that the resident was not wearing the palm guard, and she reported that staff did not apply it on her shower days. An LPN confirmed that the resident was not taken out of bed on shower days, which likely led to the omission of the palm guard application. The Director of Nursing and Nursing Home Administrator acknowledged the failure to adhere to the care plan for Resident R60.
Non-Certified Nurse Aide Worked Beyond Allowed Period
Penalty
Summary
The facility failed to ensure that a nurse aide trainee, identified as Employee E12, who did not become certified within the required four-month period, was not working in the facility. According to Title 42 Code of Federal Regulations S483.35(d), a facility must not use any individual as a nurse aide for more than four months unless they have completed a training and competency evaluation program. Employee E12 completed the training program but was unable to pass the written exam, resulting in the individual providing direct care to residents without certification. The documentation reviewed indicated that Employee E12 continued to work as a nurse aide on multiple dates despite not having obtained certification within the 120-day requirement. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the facility's failure to comply with the certification requirement for nurse aides. The deficiency was identified for one of five employees reviewed, highlighting a lapse in the facility's adherence to regulatory standards for nurse aide certification and employment.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for a resident diagnosed with dementia, leading to a deficiency. The resident, identified as Resident 67, was admitted with a diagnosis of dementia, which involves loss of memory, language, problem-solving, and other cognitive abilities that interfere with daily life. The Minimum Data Set Assessment dated 4/4/24 indicated that the resident's cognition was moderately impaired. However, a review of the clinical record from 4/17/24 through 9/22/24 showed no evidence that the facility had created or implemented a care plan to address the resident's dementia and cognitive loss. This was confirmed by an interview with the Registered Nurse Assessment Coordinator, who acknowledged the lack of documentation for a care plan prior to 9/23/24.
Failure to Provide Prescribed Diet Consistency
Penalty
Summary
The facility failed to provide food items consistent with the prescribed diet orders for two residents. Resident R60 had a physician's order for a regular diet with pureed texture and nectar/mildly thick consistency fluids. However, during an observation, Resident R60 was given a yellow, thin fluid instead of the prescribed nectar/mildly thick consistency. An LPN confirmed that Resident R60 had previously received regular apple juice instead of the required nectar/mildly thick apple juice. The Director of Nursing confirmed that Resident R60 should have received nectar thick liquids as ordered. Similarly, Resident R74 had a physician's order for a regular diet with mechanical soft ground meat texture and nectar/mildly thick consistency fluids. During dining observations, Resident R74 was served thin iced tea instead of the prescribed nectar thick liquids. A Registered Nurse confirmed these findings, and the Director of Nursing acknowledged that Resident R74 should have received nectar thick liquids as ordered.
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices as required for two of five residents, specifically for a resident with dementia, orthostatic hypotension, and acute kidney failure. According to the resident's care plan dated 8/19/24, a Kennedy cup was to be provided with meals. However, during an observation on 11/18/24, the resident did not have the Kennedy cup during lunch as care planned. This was confirmed by an interview with a Registered Nurse and the Director of Nursing, who acknowledged that the resident should have had the specified cup as per the care plan.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by regulations. This deficiency was identified for three residents who were transferred to the hospital and subsequently returned to the facility. Specifically, there was no documented evidence that Residents R131, R77, and R96 or their representatives were provided with written information about the facility's bed-hold policy at the time of their respective hospital transfers. Resident R131, with diagnoses including anxiety disorder, depression, and diabetes mellitus, was transferred to the hospital on March 23, 2024, without receiving the required notification. Similarly, Resident R77, who had heart failure, hyperlipidemia, and dysphagia, was transferred on two occasions, July 26, 2024, and October 23, 2024, without the necessary documentation. Resident R96, with a history of a right humerus fracture, repeated falls, and hyperlipidemia, was also transferred on November 9, 2024, without being informed of the bed-hold policy. This oversight was confirmed during an interview with Medical Records Employee E7.
Failure to Provide Two-Person Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not providing a two-person transfer as per the physician's order. The incident involved a resident who had been admitted with diagnoses including hyperlipidemia, hypertension, unsteadiness on feet, a right artificial knee, and chronic kidney disease. The resident's care plan and physician's order specified that transfers should be conducted with a mechanical lift and assistance from two persons. However, on the evening of the incident, a nurse aide attempted to transfer the resident alone, resulting in a skin tear on the resident's right lower leg. The nurse aide involved in the incident reported that she was unaware of the resident's transfer status because the information was not available on the report paper she had. She relied on the resident's statement that she could transfer regularly. The nurse aide admitted to transferring the resident alone, which led to the resident's leg being injured, possibly by the wheelchair or bed. The facility's policy required that mechanical lifts be operated by two nursing or therapy personnel, and the nurse aide's actions were contrary to this policy. Interviews with staff revealed that the facility had a color-coded system to indicate transfer status, and the nurse aide had been oriented to this system. However, the nurse aide did not have the necessary information at the time of the incident. The facility's investigation confirmed that the nurse aide did not follow the protocol for a two-person transfer, as required by the resident's care plan and physician's order. This failure resulted in the resident sustaining a skin tear during the transfer.
Failure to Meet Nutritional and Dietary Needs
Penalty
Summary
The facility failed to meet the daily nutritional and special dietary needs for one resident (Resident R1) and lacked a structured meal delivery system to ensure accurate and timely meal service. Resident R1, who has diagnoses of dementia, chronic obstructive pulmonary disease, and congestive heart failure, was observed not receiving a lunch tray on one occasion and not receiving the prescribed Boost Plus supplement on multiple occasions. The care plan for Resident R1 included specific dietary requirements, such as a regular diet with mechanical soft, ground meat texture, and Boost Plus twice a day, which were not consistently met. Observations and interviews revealed that the meal delivery system was disorganized, leading to missed or incorrect meal deliveries, and the facility had ongoing supply issues with the prescribed nutritional supplement, resulting in inadequate substitutions that did not meet the resident's nutritional needs. During meal service observations, staff were seen struggling to locate meal tickets and delivering incorrect trays. Interviews with staff confirmed that the facility had not had Chocolate Boost Plus for some time and was substituting it with chocolate milk, which did not provide equivalent nutritional value. The Registered Dietitian acknowledged the supply issues and confirmed that the substitutions were not nutritionally adequate. The Nursing Home Administrator and Director of Nursing confirmed the deficiencies, highlighting the facility's failure to provide accurate and timely meals and supplements as per the residents' dietary needs.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed. Resident R1 was admitted with diagnoses of dementia, chronic obstructive pulmonary disease, and congestive heart failure. The physician orders dated 3/20/24 indicated that Resident R1 was to receive Boost Plus twice a day. However, the Medication Administration Record showed that Boost Plus was administered from 3/1/24 through 3/19/24, despite the facility not having Boost Plus in stock. Instead, Ensure was being given, but the physician's orders were not updated to reflect this change. The Director of Nursing confirmed that the nurses were documenting the administration of Boost Plus inaccurately and that the physician's orders should have been updated accordingly. Additionally, Resident R1 had a physician order from 2/13/24 for a low air loss mattress to be checked by a nurse every shift. However, an observation on 3/20/24 revealed that Resident R1 had a perimeter mattress instead. The Director of Nursing confirmed that the low air loss mattress was not in place and that the physician order needed to be updated. This failure to ensure complete and accurate clinical records was confirmed by the Director of Nursing during the interview.
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 1,210 citations issued within 25 miles in the last 12 months — including the 21 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 Oakmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmar Village Health & Rehab Center | 1.3 mi | ★★★★★ | 31 | 1 |
| Longwood At Oakmont | 2.3 mi | ★★★★★ | 12 | 0 |
| Seneca Place | 3.1 mi | ★★★★★ | 0 | 0 |
| Southwestern Veterans Center | 4.9 mi | ★★★★★ | 11 | 0 |
| Kadima Rehabilitation & Nursing At Cheswick | 5.3 mi | ★★★★★ | 24 | 2 |
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.