Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Cedar Haven Operations Llc Dba Lake Forrest Health during CMS and state inspections, most recent first.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A facility failed to manage a respiratory illness cluster and did not consistently use empiric or transmission-based precautions for multiple residents with cough, congestion, shortness of breath, and other respiratory symptoms. The IP and DNS could not show that residents were tested for RSV or influenza or placed on precautions as symptoms emerged. The facility also failed to clean a resident’s BiPap equipment as required, and staff were observed entering precaution rooms without the required PPE, wearing PPE in the hallway, and failing to perform hand hygiene.
The facility failed to follow physician orders and its own policies for a resident receiving Trulicity for diabetes and for two residents with constipation. Staff documented repeated refusals of the weekly injection, but the LPN, NP, and DON were unaware of the pattern and there was no evidence the provider or nursing leadership were notified. The facility also did not carry out ordered bowel protocol interventions, including prune juice, MOM, and Bisacodyl, for two residents who went more than 72 hours without a BM, and staff could not provide evidence that the orders were followed.
Failure to provide competency-based training on C-Pap and Bi-Pap. The facility’s assessment listed Respiratory competencies for Trach, C-Pap, and Bi-Pap, but record review found no evidence that 5 of 5 nurses reviewed completed competency-based education on C-Pap or Bi-Pap use or maintenance. The Staff Developer acknowledged the training had not been completed, and the DON could not provide evidence that any nursing staff had received this education.
A resident with cirrhosis and ascites had a physician-ordered 1500 mL fluid restriction, but the record did not show meal-tray fluid amounts or nursing-calculated fluid allotments per facility policy. Surveyor observation and chart review found inconsistent and missing fluid-intake documentation, while staff confirmed they did not total intake per shift or track fluids from meal trays, and the DON and Administrator acknowledged staff did not know how much fluid the resident was actually consuming.
A resident with bipolar disorder and impaired safety awareness was identified as an elopement risk after an elopement attempt and was ordered to wear a wanderguard on the right arm with staff checks each shift. Surveyors later observed the device was not on the resident, an LPN confirmed it was missing, and a CNA reported the DON had removed it from the unit, while the DON said she thought it was an extra device. The record did not show additional interventions after the resident removed the wanderguard.
A resident with COPD and chronic respiratory failure was ordered oxygen at 2L, but surveyors observed the resident receiving 5L on multiple occasions. The resident stated the nurse sets up the oxygen, and an LPN initially believed the order was for 2-4L before confirming it was 2L. Surveyors also found the oxygen tubing was dated several days earlier than the weekly change order, and the DON could not provide evidence that the tubing had been changed as ordered.
Failure to provide and document pain management for a resident with pain triggers and ongoing breakthrough pain. The resident's MDS/CAA indicated a pain care plan was needed, but no pain care plan was initiated. An order to monitor pain daily was transcribed to every other day on the MAR, and multiple pain complaints were not documented as being addressed with ordered meds or non-pharmacological interventions. The DON and MDS nurses acknowledged the gaps.
Significant Medication Errors: An agency LPN gave one resident the roommate’s Oxycodone after failing to properly identify the resident, and another resident with dementia and anxiety missed an ordered afternoon dose of Seroquel when the MAR showed the medication was not administered. The DON/DNS could not explain the omission or provide evidence that the residents were kept free from significant medication errors.
Inaccurate resident record documentation was found for three residents. A resident with bipolar disorder had a Wanderguard removed, yet staff signed the MAR as if it remained in place and functional; an LPN documented Narcan as given when it was not; and another resident’s Seroquel was charted as not given because the resident was deceased, although the resident was not. The DON/DNS acknowledged the records were not accurate.
A resident with altered mental status and seizures was not treated with dignity when a nursing assistant commented on their odor in their presence and later covered the resident's consented video monitoring device with a pillow. The DON confirmed these actions and could not provide evidence that the resident's rights to respect and electronic monitoring were upheld.
A resident with a gastrostomy, requiring Enhanced Barrier Precautions (EBP), received care from two nursing assistants who did not wear gowns as mandated by facility policy. Despite clear signage and staff awareness of EBP requirements, video evidence and staff interviews confirmed non-compliance with gown use during high-contact care activities. The DON could not provide documentation of an effective infection control program related to EBP for this resident.
A resident with multiple chronic conditions was administered a combination of medications, including Schedule II narcotics, intended for another resident after a CMT became distracted and confused medication cups. The medications had been pre-poured by an RN and given to the CMT to administer, which was outside the CMT's scope of practice. The resident became unresponsive and required emergency intervention and hospital transfer due to the medication error.
A resident with multiple chronic conditions was hospitalized after being mistakenly given a combination of antipsychotics, antidiabetic agents, benzodiazepines, and narcotics intended for another resident. The error occurred when a medication aide, distracted during medication pass, administered the wrong medications, including Schedule II controlled substances, resulting in the resident becoming unresponsive and requiring emergency interventions such as Narcan and hospitalization.
A nursing assistant made inappropriate sexual comments and exposed her chest to a resident with a history of mental health conditions but intact cognition. The incident was witnessed and reported by another NA, and both staff statements confirmed the event. The facility failed to provide evidence that the resident was protected from sexual abuse as required by policy.
A facility failed to follow a physician's orders for a resident with multiple health conditions, including congestive heart failure and COPD, by not obtaining weekly weights as directed. The deficiency was confirmed during an interview with the DON, who acknowledged the oversight.
A resident with HIV did not receive their prescribed medication, BIKTARVY, for four days due to an alleged agreement for the family to provide it, which was undocumented. Staff interviews confirmed the missed doses and lack of documentation, while the resident was aware of the importance of not missing the medication.
A resident with a gastrostomy tube was administered Isosource 1.5 Cal nutritional formula without a current physician's order, following the discontinuation of the order. Despite the lack of a valid order, the resident continued to receive the formula at 60 ml/hour, as confirmed by an LPN and the DON, who could not provide an explanation for the discontinuation.
A resident receiving nutrition via a G-tube was documented as receiving Nutren 2.0 and Two Cal HN 2.0 formulas, despite these not being available in the facility. Instead, the resident was administered Isosource 1.5 Cal. Staff interviews confirmed the inaccurate documentation and unavailability of the prescribed formulas.
A resident with a history of atherosclerosis and dementia experienced ongoing left leg pain and swelling. Despite a physician's order for an orthopedic consult, the resident refused the initial appointment, and the facility failed to reschedule it or address the pain effectively. Staff interviews revealed a lack of communication and follow-up, leading to the resident's continued discomfort.
The facility failed to maintain effective infection control, particularly in using Enhanced Barrier Precautions (EBP) and Covid-19 protocols. Staff did not consistently wear required PPE during high-contact care for residents needing EBP, and Covid-19 positive residents were not adequately protected as staff entered rooms without proper PPE and neglected hand hygiene. Interviews confirmed these lapses, indicating systemic issues in infection control practices.
The facility failed to provide care in accordance with professional standards for two residents. One resident, with a hip fracture, did not have a physician's order for toe touch weight bearing, leading to independent ambulation without restrictions. Another resident, with schizoaffective disorder, refused an antipsychotic injection twice, and staff failed to notify the provider or reschedule the medication. Staff interviews revealed a lack of awareness and communication regarding these care needs.
A resident with opioid dependence did not receive Lorazepam as ordered due to a failure in medication delivery and administration. Despite the medication being available in the facility's pyxis machine, the resident missed five doses. Staff interviews revealed that the medication should have been administered immediately, and the delay was not communicated to the appropriate personnel.
A resident with moderately impaired cognition and a history of falls was not provided with the required frequent safety checks, leading to a fall and hip fracture. Despite the care plan indicating the need for checks every 20-30 minutes, staff were unaware of this requirement, and there was no documentation to ensure compliance.
A resident with severe cognitive impairment entered another resident's room and physically assaulted them by grabbing their neck. Staff intervened to separate the residents, but the incident was reported as a failure to protect residents from abuse. Both residents have severe cognitive impairments, and the event was acknowledged by the facility's Director of Nursing Services.
Two residents experienced communication difficulties with a non-English speaking NA, impacting their ability to convey needs for ADLs. Both residents have intact cognition and require extensive assistance. The NA, who works the 3:00 PM to 11:00 PM shift, confirmed her inability to understand English, and the facility's administrator acknowledged this language barrier.
The facility failed to support resident choice in shower preferences for two residents. One resident, with intact cognition, reported not receiving showers as per their preference, and records showed no evidence of showers in the last 30 days. Another resident, with severely impaired cognition, reported only two showers in six months, with no evidence of showers in the last 30 days. The administrator could not provide evidence of compliance with the residents' preferences.
A resident with dementia and cognitive impairment eloped from a facility due to inadequate supervision and incomplete wandering risk assessment. Despite being at moderate risk for wandering, necessary interventions were not implemented. The resident, requiring supervision while smoking, was not monitored outside the smoking area, leading to their unsupervised exit. They were found by police in the roadway, confused and wearing heavy clothing, highlighting the facility's failure to ensure safety.
A resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate behavior. Despite previous incidents, the facility failed to update the care plan or notify the physician, leading to the resident being left unsupervised and vulnerable. Staff interviews revealed that the resident was often left unsupervised in the victim's room, contributing to the incident.
The facility failed to provide a consistent activities program for residents on the North B Unit, resulting in residents being left alone or wandering without engagement. Scheduled activities were not held, and there was no activities calendar available. Residents with Alzheimer's and other conditions were observed without participation in group or one-on-one activities, despite care plans indicating the need for structured engagement. Staff interviews revealed a lack of awareness and insufficient staffing for activities, particularly on weekends.
The facility failed to provide adequate care and timely interventions for two residents. One resident experienced severe edema and wound issues without proper notification or intervention, leading to a hospital admission for DVT and paracentesis. Another resident had unresponsive incidents that were not reported to the provider, resulting in a lack of necessary assessments and interventions. The facility also failed to obtain an admission weight and address a fall incident appropriately.
The facility failed to maintain a sanitary and comfortable environment, with surveyors observing stained and odorous bathrooms across all units. Staff interviews confirmed the persistent issues, and a change in cleaning products was noted as ineffective. Additionally, the flooring and carpets were in poor condition, requiring repair or replacement.
Failure to Follow Physician Orders for Dysphagia Management and Vital Sign Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice and followed physician orders for a resident with significant swallowing difficulties and other complex medical conditions. The resident, admitted with diagnoses including seizure disorder, autonomic dysfunction, presence of a gastrostomy tube, bilateral upper extremity contractures, and dysphagia, was dependent on staff for eating. A physician’s order dated 1/6/2026 specified a house diet with minced and moist texture and thin liquids to be provided by spoon only. The care plan initiated on 12/4/2024 also identified swallowing difficulty and included an intervention to provide thin liquids via spoon. A community complaint and video footage from the resident’s room showed that during an overnight shift, a nurse gave the resident a drink using a straw while the resident was lying down and continued to provide liquids while the resident was coughing, contrary to the physician’s order and care plan. The DON confirmed, after reviewing the video, that the nurse provided thin liquids with a straw while the resident was not upright and continued despite the resident’s coughing. The facility also failed to follow a physician’s order related to monitoring for possible aspiration. A physician’s order dated 3/19/2026 directed staff to obtain and document the resident’s vital signs, including lung sounds, oxygen saturation, temperature, and signs and symptoms of aspiration such as coughing or runny nose, every shift for seven days. Review of the March 2026 Medication Administration Record showed that vital signs were not obtained during the 3:00 PM–11:00 PM and 11:00 PM–7:00 AM shifts on 3/23/2026, and the 11:00 PM–7:00 AM shift on 3/24/2026. In an interview, the DON stated she expected vital signs to be obtained and documented each shift as ordered and acknowledged that the facility failed to ensure physician orders were followed for this resident.
Infection Control and Transmission-Based Precautions Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program for residents with respiratory symptoms and for residents exposed to an unidentified respiratory illness affecting multiple nursing units. Several residents had cough, congestion, shortness of breath, lethargy, poor appetite, or other cold-like symptoms, yet the record did not show that RSV, influenza, or COVID-19 testing was obtained in response to the cluster of respiratory illness in the building, and the residents were not placed on transmission-based precautions until the surveyor brought the issue to the facility’s attention. The Infection Preventionist acknowledged awareness of a resident with RSV and other residents with cold-like symptoms, but stated he did not test additional residents for RSV or influenza and did not place them on transmission-based precautions. The DNS also stated she had been in contact with the state infectious disease surveillance nurse about testing residents with respiratory symptoms, but could not provide evidence that the residents were tested according to facility policy and guidance. Resident 59 had diagnoses including RSV and pneumonia and was on transmission-based precautions for RSV. Resident 62 returned from the hospital with RSV. Resident 7 had a cough medication order and received guaifenesin, but the record did not show RSV, COVID-19, or influenza swabs or precautions despite respiratory symptoms and recent RSV-positive residents in the building. Resident 18 received guaifenesin for cough, and the record likewise did not show testing or precautions until the surveyor intervened. Resident 29 developed lethargy, poor appetite, and cough, was ordered a chest x-ray and duonebs, and was to have a respiratory panel if symptoms worsened; the record showed COVID-19 testing but no evidence of RSV or influenza swabs or precautions. Resident 34 complained of cold-like symptoms and had COVID-19 testing, but no evidence of RSV or influenza testing or precautions. Resident 36 had cold-like symptoms, COVID-19 testing, guaifenesin use, later respiratory distress, and hospital admission for pneumonia and influenza A, yet the record did not show RSV or influenza swabs or precautions. Resident 64 had cough medication use, cold-like symptoms, increased shortness of breath, abnormal breath sounds, and a nonproductive cough, but no evidence of RSV, COVID-19, or influenza testing or precautions. Resident 97 had chronic obstructive pulmonary disorder and chronic respiratory failure, received guaifenesin for cough, and had nasal congestion, shortness of breath with exertion, productive cough, and upper airway congestion, but the record did not show respiratory viral testing or precautions. The facility also failed to routinely clean a BiPap machine used by a resident with obstructive sleep apnea. The resident stated that the BiPap machine had not been cleaned since use began. The facility policy stated that the mask or pillow and tubing would be cleansed with warm soapy water at least weekly, but staff could not produce an order showing the cleaning schedule. An LPN stated the equipment should be cleaned on Tuesdays and that a task would appear in the MAR, but she could not find an order for the resident’s BiPap. The DNS believed respiratory therapy cleaned the machines, but acknowledged there was no order in place and could not provide evidence that weekly cleaning was being completed. The respiratory therapist stated she did not clean the tubing or masks and only wiped the outside of the machine. The facility further failed to follow transmission-based precautions for residents on contact, droplet, and enhanced barrier precautions. For one resident on contact and droplet precautions, signage outside the room required gown, gloves, mask, and face shield, but an LPN entered with the mask pulled below the chin, without gown, face shield, or gloves, then went to the medication cart and entered another resident’s room without hand hygiene. For another resident on contact and droplet precautions, a nursing assistant exited the room without a face shield, took the resident to the shower, wore the same gown and gloves in the hallway, and reentered the room without donning a face shield. For a third resident on enhanced barrier precautions for CRE colonization, a hospice nursing assistant provided morning care without wearing a gown as required by the posted precautions. Staff interviews confirmed the observed failures to follow the required PPE and hand hygiene practices.
Failure to Follow Medication Refusal Notifications and Bowel Protocol Orders
Penalty
Summary
The facility failed to follow and implement a physician’s order for insulin-related diabetes treatment for one resident with a diagnosis of diabetes. Resident ID #3 was admitted in May 2022 and had an order dated 4/3/2024 for Trulicity injection 0.74 mg once weekly on Wednesdays in the morning. The 2025 MAR showed staff documented refusals for 16 of 20 scheduled opportunities, but the record did not show that the attending physician or nurse management were notified of the repeated refusals as required by the facility’s medication administration policy. The record and staff interviews showed that the repeated refusals were not brought to the attention of nursing leadership or the provider. An LPN stated he was unaware the resident had been regularly refusing Trulicity, and the NP stated she did not recall being notified and would have expected staff to notify her. The DON also acknowledged she was unaware of the refusals and expected staff to notify both the physician and nursing leadership of repeated refusals. The facility also failed to follow its bowel protocol and physician’s orders for two residents who had no documented bowel movement for more than three days. Resident ID #8, who had diagnoses including dementia and constipation, had no bowel movement documented for five days, yet the MAR did not show administration of ordered prune juice or Milk of Magnesia after 72 hours without a bowel movement until the surveyor brought it to the facility’s attention. Resident ID #77, admitted with end stage renal disease, had no bowel movement documented for four days and then seven days on separate occasions, but the MAR did not show administration of the ordered Bisacodyl suppository after three days without a bowel movement. An RN and the DON both acknowledged they could not provide evidence that the bowel protocol or physician’s orders were followed for these residents.
Failure to Provide Competency-Based Training on C-Pap and Bi-Pap
Penalty
Summary
The facility failed to implement and maintain an effective training program for all new and existing staff members, as reflected in the lack of competency-based education for the use and maintenance of C-Pap and Bi-Pap machines for 5 of 5 nurses reviewed, including Staff C, E, G, H, and K. The Facility Assessment dated 7/16/2025 listed existing competencies on hire, quarterly, and annually for Respiratory care, including Trach, C-Pap, and Bi-Pap, but the record review did not reveal evidence that these staff members completed competency-based education related to C-Pap or Bi-Pap use or maintenance. During interview, the Staff Developer acknowledged that staff had not completed training related to the use or maintenance of C-Pap or Bi-Pap machines even though it was listed as an existing competency in the Facility Assessment. The DON was also unable to provide evidence that the facility had provided competency-based education on C-Pap or Bi-Pap use to any nursing staff, including Staff C, E, G, H, and K.
Fluid Restriction Not Properly Calculated or Tracked
Penalty
Summary
The facility failed to ensure that a resident with alcoholic cirrhosis of the liver with ascites received treatment and care in accordance with professional standards of practice for a prescribed 1500 mL fluid restriction. The resident’s care plan identified fluid overload or the potential for fluid volume overload related to cirrhosis with ascites, and a physician order dated 11/13/2025 specified a 2-gram sodium diet, regular texture, and a 1500 mL fluid restriction. However, the record did not show calculated fluid amounts to be provided on the resident’s meal tray or calculated amounts to be provided by nursing, as required by the facility policy for fluid restriction. Surveyor observation and record review showed inconsistent and incomplete documentation of the resident’s fluid intake. The dietary slip did not show calculated meal-tray fluid amounts, and the resident was observed with fluids at meals and at bedside, including a 480 mL soda at bedside and, on another observation, 1070 mL at breakfast along with multiple cups and a bottle of soda. The resident stated that he/she frequently visited the vending machine to buy soda. The paper tracker and electronic documentation contained missing meal intake entries and inconsistent totals, and staff interviews confirmed that nursing did not total fluid intake per shift, did not track fluids provided on meal trays, and could not show where vending machine soda was documented. The DON and Administrator acknowledged that the fluid restriction should have been broken down between dietary and nursing and that staff were unaware of how much fluid the resident was actually consuming.
Failure to Maintain Ordered Wanderguard for Elopement Risk
Penalty
Summary
The facility failed to ensure that a resident identified as an elopement risk received adequate supervision and the ordered assistive device for safety. The resident was readmitted with a diagnosis including bipolar disorder and had a care plan identifying impaired safety awareness, wandering, and an elopement attempt, with interventions including residence on a secure unit and a wanderguard to the right arm. After an elopement attempt in which the resident exited the building into the parking lot, the physician ordered a wanderguard to the right arm with staff to check placement every shift and functionality every night shift, and the medication administration record showed these orders were signed off as completed. Despite the order, surveyors observed on two occasions that no wanderguard was on the resident's right wrist. An LPN acknowledged the device was not on the resident as ordered, and a CNA stated the wanderguard had been taken off the unit by the DON, indicating the resident had not had it on. The DON stated she was unaware the resident did not have the wanderguard on and believed the device she removed from the unit was an extra wanderguard. The record did not show that any additional interventions were implemented after the resident removed the wanderguard.
Improper Oxygen Flow and Tubing Management
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with COPD and chronic respiratory failure with hypercapnia. The resident’s care plan stated that oxygen was used continuously at 2 liters, and a physician’s order dated 6/16/2025 directed oxygen at 2L every shift. However, surveyor observations showed the resident receiving 5L of oxygen instead of the ordered 2L on multiple occasions, including 12/29/2025 and several observations on 12/30/2025. During interview, the resident stated the oxygen should be at 2L and that the nurse sets it up. The surveyor also found that the resident’s oxygen tubing was not changed as ordered. A physician’s order dated 6/17/2025 directed weekly tubing changes every Tuesday, and the December 2025 TAR showed the task signed off as completed on 12/30/2025. Yet on 12/31/2025, the resident was observed using tubing dated 12/24/2025. Staff acknowledged the tubing date, and the DON stated she would have expected the resident to be receiving oxygen at 2L as ordered, but she could not provide evidence that the tubing had been changed weekly as ordered.
Failure to Provide and Document Pain Management
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services. Resident ID #12 was admitted with diagnoses including critical illness polyneuropathy, muscle spasm, and fracture of the sacrum/coccyx. The resident had a significant change in status MDS assessment on 10/15/2025 and was identified as having pain, which triggered the CAA Summary and CAA Worksheet. Those documents indicated that the resident's care plan should be updated to address pain, but review of the care plan failed to show that a pain care plan was initiated. During interview, the MDS Nurse acknowledged the resident triggered for pain and that the CAA indicated a care plan would be initiated, but she could not explain why it was not done. The DON stated she would expect the resident to have a care plan for pain in place. The resident also had an order to monitor pain daily, but the December 2025 MAR showed pain was monitored every other day instead of daily. The MDS Nurse stated the order had been transcribed incorrectly and should have populated daily. In addition, the resident reported breakthrough pain on multiple occasions, with pain ratings of 2, 4, 3, 3, and 7, but the record did not show that these complaints were addressed with pharmacological or non-pharmacological interventions. Staff were unable to find documentation of pain being addressed on those dates, and the DON was unable to provide evidence that interventions were used.
Significant Medication Errors
Penalty
Summary
The facility failed to keep residents free from significant medication errors for Resident ID #5 and Resident ID #53. Resident ID #5 was admitted in October 2025 with diagnoses including chronic pain syndrome and multiple sclerosis. During interview, the resident stated that an agency nurse gave him/her another resident’s medication at the beginning of the month, did not identify the resident, and told him/her the medication in the cup was for them. A progress note from the Director of Nursing Services documented that while passing medications, the agency nurse entered the room and called the roommate’s name, the resident responded, and the nurse then stated she had the resident’s Oxycodone 5 mg; the resident took and swallowed the medication before realizing it was the roommate’s medication. A medication error report stated that the LPN administered the roommate’s medication because she failed to identify the resident. Resident ID #53 was admitted in August 2025 with diagnoses including dementia and anxiety. The physician ordered Seroquel 50 mg daily in the afternoon, but review of the December 2025 MAR showed the medication was not administered on 12/28/2025. During interview, the DNS was unable to explain why the Seroquel was not given as ordered. The DNS was also unable to provide evidence that the facility kept Resident ID #5 and Resident ID #53 free from significant medication errors.
Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurately documented for three residents. For a resident with bipolar disorder and a Wanderguard order, the record showed the bracelet was to be checked every shift and its functionality checked every night shift, but the MAR was signed off as completed on multiple shifts after the resident had removed the Wanderguard. Surveyor observations found the Wanderguard was not on the resident’s right wrist, and staff interviews confirmed the device had been taken off and that a nurse had signed the MAR without actually visualizing the bracelet. For another resident, the MAR documented Narcan as administered and effective, but the nurse later stated the medication was not actually given and that the entry was a documentation error. For a third resident, the MAR and progress note documented that Seroquel was not administered because the resident was deceased, although staff later acknowledged the resident was not deceased. The DNS stated she expected resident records to be accurate and was unable to provide evidence that the medication records for these residents were complete and accurate.
Failure to Honor Resident Dignity and Electronic Monitoring Rights
Penalty
Summary
A deficiency was identified when a nursing assistant (NA) failed to treat a resident with respect and dignity during care. The NA was observed and acknowledged making a comment about the resident's odor within earshot of the resident, who was able to understand and respond to yes/no questions. This action was captured on video surveillance footage provided by the resident's family. The facility's policies require that all residents be treated with respect and dignity, and the Director of Nursing Services (DNS) was unable to provide evidence that the resident was treated appropriately in this instance. Additionally, the same NA was observed on video covering the resident's electronic monitoring camera with a pillow, despite the resident having provided consent for video surveillance and appropriate signage being posted in the room. The DNS confirmed that the NA covered the camera and could not provide evidence that the resident's right to use electronic monitoring equipment was respected. The resident involved had diagnoses including altered mental status and seizures and had been admitted to the facility several months prior to the incident.
Failure to Follow Enhanced Barrier Precautions for Resident with Gastrostomy
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically regarding the use of Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy. Facility policy mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices or wounds. Despite signage indicating EBP requirements in the resident's room, video surveillance footage on two separate dates showed that two nursing assistants provided morning care to the resident without wearing gowns, as required by policy. Interviews with the Infection Preventionist and the nursing assistants confirmed that the resident had been on EBP since admission and that staff were aware of the requirement to wear gowns and gloves during care. However, both nursing assistants acknowledged not wearing gowns during the observed care episodes. The Director of Nursing Services was unable to provide evidence that the facility maintained an infection control program to prevent the spread of infection related to EBP for this resident.
Significant Medication Error Due to Incompetent Medication Administration and Protocol Breaches
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to provide safe nursing and related services, as evidenced by a significant medication error involving a resident. A Certified Medication Technician (CMT) administered a cup of medications intended for another resident, which included multiple drugs such as Schedule II narcotics, anticonvulsants, antidiabetics, and other medications. This error occurred after the CMT became distracted during the medication pass, placed the wrong medication cup in the cart, and subsequently administered it to the wrong resident. The medications had been pre-poured by a Registered Nurse (RN), who also provided the narcotics to the CMT for administration, despite this being outside the CMT's scope of practice. The resident who received the incorrect medications had a medical history including heart failure, intellectual disabilities, and chronic obstructive pulmonary disease. Following administration of the wrong medications, the resident was found lethargic, unresponsive, and with pinpoint pupils. Emergency intervention was required, including the administration of Narcan and transfer to the hospital, where the resident received activated charcoal for overdose treatment. Interviews with staff revealed that the RN had signed out and prepared narcotics for one resident and gave them to the CMT to administer, which was not in accordance with scope-of-practice regulations. The CMT acknowledged being distracted and administering the wrong medications, including narcotics, to the resident. The Director of Nursing confirmed that the RN should not have delegated the administration of narcotics to the CMT and that medications should not have been pre-poured and left in the medication cart. These failures in following established medication administration protocols and scope-of-practice requirements resulted in a significant medication error and placed the resident in immediate jeopardy.
Resident Hospitalized After Receiving Another Resident's Medications
Penalty
Summary
A significant medication error occurred when a certified medication staff member, while distracted during the morning medication pass, administered a set of medications intended for one resident to another resident. The medications included antipsychotics, antidiabetic agents, benzodiazepines, narcotics, and other drugs, some of which were Schedule II controlled substances that medication aides are not permitted to administer according to state regulations. The error was facilitated by the nurse providing narcotics to the medication aide to administer, and by the medication aide pre-pouring and leaving the medications unattended in the medication cart. The resident who received the incorrect medications had a medical history including heart failure, intellectual disabilities, and chronic obstructive pulmonary disease. After receiving the wrong medications, the resident was found lethargic, unresponsive, and with pinpoint pupils. Emergency interventions were required, including the administration of two doses of Narcan, EMS transport, and subsequent hospitalization. The resident also received activated charcoal in the emergency room due to the overdose. Facility records and staff interviews confirmed that the medication aide signed off the administration of the medications in the wrong resident's Medication Administration Record (MAR). The nurse involved acknowledged giving the narcotics to the medication aide, and both staff members confirmed the sequence of events that led to the error. The Director of Nursing Services also acknowledged that the resident received another resident's medications, resulting in the need for emergency medical treatment and hospital admission for overdose.
Failure to Protect Resident from Sexual Abuse by Nursing Assistant
Penalty
Summary
A nursing assistant (NA), identified as Staff C, engaged in inappropriate conduct with a resident who had a history of bipolar disorder, anxiety, and adjustment disorder, but was assessed as cognitively intact with a BIMS score of 15. Staff C entered the resident's room, initiated conversation by complimenting the resident's appearance, and then lifted her own shirt to expose her chest while wearing a sports bra, stating that she too was 'sexy.' This incident was directly witnessed by another NA, Staff D, who immediately reported the behavior to the Director of Nursing Services (DNS). The facility's abuse prohibition policy defines sexual abuse as any non-consensual sexual contact, including unwanted intimate touching or exposure, regardless of the resident's cognitive status. The resident involved did not recall the incident during a surveyor interview, but statements from both Staff C and Staff D confirmed the inappropriate exposure and comments. The facility's investigation documented the sequence of events and the resident's reaction, but there was no evidence provided that the facility ensured the resident was kept free from sexual abuse as required by policy.
Failure to Follow Physician's Orders for Resident Weights
Penalty
Summary
The facility failed to meet professional standards of quality by not following a physician's orders for a resident who was readmitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and acute kidney failure. The physician had ordered weekly weights to be obtained starting on March 8, 2025. However, a review of the resident's electronic medical record and progress notes revealed that the weights were not recorded on March 8, 2025, or March 15, 2025, as ordered. This deficiency was identified during a surveyor interview with the Director of Nursing Services, who acknowledged that the weights were not completed as required.
Failure to Administer HIV Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Bictegravir-Emtricitabine-Tenofovir (BIKTARVY), a medication prescribed for HIV treatment. The resident, who was admitted in March 2025 with diagnoses including HIV and dialysis dependence, did not receive the prescribed medication on four consecutive days. The Electronic Medication Administration Record (EMAR) for March 2025 showed no evidence of administration on the specified dates. Nursing progress notes indicated that the medication was expected to be brought in by the resident's family, and a filled prescription was available at the community pharmacy. Interviews with staff and the resident revealed that the medication was not administered due to an alleged agreement for the family to provide it, which was not documented. The resident was aware of the missed doses and had informed the facility of the importance of not missing the medication. Staff members, including the Registered Nurse, LPN, Administrator, and Director of Nursing Services, acknowledged the missed doses and the lack of evidence for the agreement. The Medical Director was informed of the initial unavailability but was unaware of the continued missed doses.
Failure to Follow Physician's Orders for G-tube Nutrition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the administration of nutrition via a gastrostomy tube (G-tube). The resident, who was admitted with diagnoses including protein-calorie malnutrition, dysphagia, and a gastrostomy tube, had a physician's order for Isosource 1.5 Cal nutritional formula to be administered four times a day, which was discontinued on December 23, 2024. However, the resident continued to receive the Isosource 1.5 Cal without a current physician's order on multiple occasions after the discontinue date. Surveyor observations and staff interviews revealed that the resident was administered Isosource 1.5 Cal at 60 ml/hour without a valid physician's order. Staff A, a Licensed Practical Nurse, confirmed the administration of the formula and was unable to provide evidence of a current physician's order. The Director of Nursing Services also acknowledged the lack of a physician's order and could not explain why the order was discontinued. This deficiency highlights a failure in following physician's orders and ensuring proper documentation for the resident's nutritional care.
Inaccurate Documentation of G-tube Nutrition Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving nutrition via a gastrostomy tube. The resident was admitted with diagnoses including protein-calorie malnutrition, dysphagia, and a gastrostomy tube. Physician's orders were in place for Nutren 2.0 and Two Cal HN 2.0 formulas to be administered via the G-tube. However, the Medication Administration Record (MAR) inaccurately documented that these formulas were administered, despite their unavailability in the facility. During a surveyor observation, it was noted that the resident was being administered Isosource 1.5 Cal instead of the prescribed formulas. Staff interviews revealed that the facility did not have the Nutren 2.0 or Two Cal HN formulas available, and the resident had been receiving Isosource 1.5 Cal since admission. The Administrator and Director of Nursing Services acknowledged the discrepancy, confirming that the orders were signed off inaccurately and the prescribed formulas were not available at the facility prior to the observation.
Failure to Provide Timely Orthopedic Care
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The resident, who was admitted in July 2023 with diagnoses including atherosclerosis of bilateral legs and dementia, had a physician's order for an orthopedic consult due to chronic bilateral knee pain. Despite the resident's complaints of left leg pain and swelling, and a scheduled orthopedic appointment on December 4, 2023, the resident refused to attend the appointment. The facility did not reschedule the appointment or address the ongoing pain effectively, as evidenced by continued complaints of pain and swelling in the resident's left leg. Interviews with staff revealed a lack of communication and follow-up regarding the resident's condition. The LPN acknowledged the resident's pain regimen was ineffective, and the Nurse Practitioner was unaware of the resident's continued pain after the missed appointment. The Director of Nursing Services confirmed the resident's refusal to attend the initial appointment but did not ensure a rescheduled appointment until it was brought to their attention by the surveyor. This lack of timely intervention and communication resulted in the resident experiencing ongoing pain and discomfort.
Infection Control Deficiencies in PPE Usage and Covid-19 Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for several residents. Surveyor observations revealed that staff did not adhere to the required use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities for residents with conditions necessitating EBP. For instance, a nursing assistant was observed transferring a resident with wounds without wearing a gown, despite the resident being on EBP. Additionally, there was a lack of EBP signage and PPE supplies at the doors of residents who required such precautions, indicating a systemic issue in implementing EBP protocols. Further deficiencies were noted in the facility's handling of Covid-19 precautions. Residents who tested positive for Covid-19 were not adequately protected as staff failed to don the necessary PPE, including gowns, gloves, and face shields, when entering their rooms. This was observed when a certified medication technician entered a Covid-19 positive resident's room without the required PPE and failed to perform hand hygiene, subsequently delivering trays to other residents. Similarly, laundry staff entered another Covid-19 positive resident's room without PPE and did not perform hand hygiene, citing language barriers as a reason for not understanding the posted precautions. Interviews with staff, including the Infection Preventionist and the Director of Nursing Services, confirmed that the expected protocols were not followed. They acknowledged that staff should have worn the appropriate PPE and performed hand hygiene as per the facility's signage and infection control policies. The lack of adherence to these protocols highlights significant lapses in the facility's infection prevention and control measures, particularly in the context of EBP and Covid-19 precautions.
Failure to Ensure Professional Standards of Care
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident ID #21, who was admitted with mantle cell lymphoma and anxiety disorder, the facility did not have a physician's order for toe touch weight bearing status after the resident suffered a fall resulting in a left hip fracture. Despite recommendations from the hospital and physical therapy for toe touch weight bearing, the resident was found to be ambulating independently, and staff were unaware of the weight bearing restrictions. This lack of communication and documentation led to the resident not receiving the appropriate care as per the hospital's recommendations. For Resident ID #35, who was admitted with schizoaffective disorder and dementia, the facility failed to follow its medication administration policy. The resident had a physician's order for Invega Sustenna, an antipsychotic medication, to be administered every 28 days. However, the resident refused the medication on two occasions, and there was no evidence that the staff notified the provider or attempted to reschedule the injection. The staff's failure to communicate the refusals to the provider or nursing management resulted in the resident not receiving the necessary medication as prescribed. Interviews with staff, including nursing assistants, LPNs, and the Director of Nursing Services, revealed a lack of awareness and communication regarding the residents' care needs and medication refusals. The Nurse Practitioner also confirmed that she was not informed of the hospital's recommendations or the medication refusals, which would have prompted her to take further action. These deficiencies highlight a breakdown in communication and adherence to professional standards of practice within the facility.
Failure to Administer Lorazepam as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Lorazepam. The resident, who was admitted with a diagnosis including opioid dependence, had a physician's order for Lorazepam to be administered twice daily for seven days. However, the medication was not administered as ordered on two occasions due to it not being delivered by the pharmacy. This resulted in the resident missing five doses of Lorazepam. Interviews with staff revealed that the medication was available in the facility's pyxis machine, an automated medication dispensing system, and most nurses had access to it. The Licensed Practical Nurse who entered the order and the Director of Nursing Services both acknowledged that the medication should have been administered immediately. The Nurse Practitioner also expected the medication to be started on the day it was ordered and to be notified if it was unavailable. Despite these expectations, the resident did not receive the medication until four days after it was ordered.
Failure to Provide Adequate Supervision for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who required frequent safety checks. The resident, admitted in June 2024 with diagnoses including mantle cell lymphoma and anxiety disorder, was found to have moderately impaired cognition. On 9/18/2024, the resident fell in their room and was sent to the emergency room, later returning to the facility with a left hip fracture. The resident's care plan indicated a risk for falls due to weakness and pain, with an intervention for frequent safety checks due to impulsivity. However, staff interviews revealed that the resident was not on frequent safety checks as required by the care plan. The Director of Nursing Services acknowledged the need for frequent safety checks every 20-30 minutes but could not explain why staff were unaware of this requirement. Additionally, there was no documentation to confirm that safety checks were being conducted, and the Director of Nursing Services did not expect staff to document these checks. This lack of awareness and documentation contributed to the failure in providing the necessary supervision to prevent the resident's fall and subsequent injury.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. Resident ID #2, who has severe cognitive impairment and a history of dementia with psychotic disturbance, entered the room of Resident ID #1, who also has severe cognitive impairment and a history of Alzheimer's disease. Despite being told to leave, Resident ID #2 grabbed Resident ID #1 by the neck. Staff members intervened to separate the residents, but the incident highlights a failure to prevent physical abuse. The incident was reported to the Rhode Island Department of Health, and staff statements corroborated the event. A housekeeper witnessed the altercation and called for assistance, while a nursing assistant and a nurse responded to separate the residents. The Director of Nursing Services acknowledged the occurrence of the incident. Despite the intervention, the facility's inability to prevent the altercation constitutes a deficiency in protecting residents from abuse.
Language Barrier in Resident Care
Penalty
Summary
The facility failed to provide an environment that promotes the maintenance or enhancement of the quality of life for residents whose primary language is not the dominant language of the staff providing care. Specifically, two residents, identified as Resident ID #1 and Resident ID #2, were unable to effectively communicate their needs to a Nursing Assistant (NA) on the 3:00 PM to 11:00 PM shift, who does not speak English. Resident ID #1, who has intact cognition and is totally dependent on staff for transfers and requires extensive assistance for activities of daily living (ADLs), expressed difficulty in communicating with the NA due to the language barrier. Similarly, Resident ID #2, who also has intact cognition and requires extensive assistance for ADLs, reported that the NA regularly assigned to their room attempts to communicate using signs and gestures, which is ineffective. During interviews, the NA, identified as Staff A, confirmed her inability to understand English, especially when spoken quickly, and was only able to respond to questions when asked in French. The facility's administrator acknowledged that Staff A is a full-time employee who does not speak English, which further substantiates the communication barrier experienced by the residents.
Failure to Support Resident Choice in Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice regarding weekly showers for two residents. Resident ID #1, who was readmitted in June 2023 with diagnoses including dysphagia, contractures, and anarthria, was found to have an intact cognition with a BIMS score of 15 out of 15. Despite being totally dependent on staff for transfers and requiring extensive assistance for bathing, the resident reported not receiving morning care or showers as per their preference. The resident's care plan indicated that showers were very important, yet there was no evidence of showers being provided in the last 30 days. Similarly, Resident ID #3, readmitted in September 2020 with diagnoses of muscle weakness, unsteadiness, and major depressive disorder, had a severely impaired cognition with a BIMS score of 6 out of 15. Despite this, the resident was interviewable and reported having only two showers in the last six months. The facility's records failed to show evidence of showers being provided in the last 30 days, and the administrator could not provide evidence of compliance with the residents' shower preferences.
Resident Elopement Due to Inadequate Supervision and Incomplete Risk Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and interventions for a resident identified as a moderate risk for wandering, leading to an elopement incident. The resident, who was admitted with diagnoses including dementia, Wernicke's encephalopathy, and traumatic brain injury, was assessed to have moderately impaired cognition. Despite being at a moderate risk for wandering, the facility did not implement necessary interventions such as the application of a wanderguard or frequent checks. Additionally, a subsequent wandering risk assessment was incomplete, failing to accurately assess the resident's cognitive orientation and medication use, which would have maintained the resident's moderate risk status. On the day of the incident, the resident was last seen by staff at approximately 9:00 AM sitting outside the facility. The resident, who required supervision while smoking due to cognitive loss, was not adequately monitored when not in the designated smoking area. The smoking attendant confirmed that she did not supervise residents outside the smoking area, and the Assistant Director of Nursing stated that residents assessed as wander risks should be accompanied to and from the smoking area. However, the facility did not ensure this protocol was followed, resulting in the resident eloping from the facility. The resident was found by a police officer after being reported by a community member as confused and laying in the roadway. The resident was transported to the hospital, where it was noted that they were wearing unseasonably heavy clothing and were unsure of their location or what had happened. The facility's failure to provide adequate supervision and complete the wandering risk assessment accurately placed the resident at risk for harm, as evidenced by the unsupervised exit and subsequent discovery on the roadway.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents with severely impaired cognition. Resident ID #1, who has aphasia, Alzheimer's disease, and dementia, was found in a vulnerable situation with Resident ID #2, who has major depressive disorder with severe psychotic disorder, anxiety disorder, and insomnia. Both residents reside on a secured unit and have a BIMS score of 0, indicating severely impaired cognition. The incident occurred when a nursing assistant observed Resident ID #2 stroking Resident ID #1's genitalia, with Resident ID #1 unable to consent due to cognitive impairment. Prior to the incident, there were multiple instances of inappropriate behavior by Resident ID #2 that were not adequately addressed by the facility. These included an attempt to kiss the Assistant Director of Nursing Services and previous incidents of inappropriate behavior towards staff and other residents. Despite these behaviors, there was no evidence that the physician was notified or that Resident ID #2's care plan was updated to include interventions to mitigate or monitor such behaviors. The facility's inaction in addressing Resident ID #2's inappropriate behaviors and failure to update the care plan contributed to the incident of sexual abuse. Staff interviews revealed that Resident ID #2 was often left unsupervised in Resident ID #1's room, despite previous combative behavior when asked to leave. The lack of intervention and monitoring placed Resident ID #1 and other cognitively impaired residents at risk for harm.
Failure to Provide Adequate Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and preferences of residents on the North B Unit, a secured/locked unit. The surveyor's observations and interviews revealed that scheduled activities were not consistently held, and there was no evidence of an activities calendar being available or posted for residents. The Director of Recreation provided a monthly activities calendar upon request, but several scheduled activities, such as Afternoon Devotionals and Friday Flicks, did not occur as planned. Resident ID #7, who has Alzheimer's disease, major depressive disorder, and anxiety disorder, was observed multiple times sitting alone or falling asleep in the activity/dining room without participating in any group or one-on-one activities. The resident's care plan included structured activities like walking outside and reading, but these were not offered. Similarly, Resident ID #4, with dementia and anxiety disorder, was observed alone in their room without engagement in activities, despite their care plan emphasizing the importance of socialization and exercise. Resident ID #6, with Alzheimer's disease and vascular dementia, was also observed alone or wandering without participating in activities, despite their care plan's focus on simple, structured activities. Additionally, Resident ID #5, with Alzheimer's disease and major depressive disorder, lacked a social care plan and was observed pacing and standing alone. Interviews with staff revealed a lack of awareness of the activities calendar and insufficient staffing to provide activities, particularly on weekends, leading to residents wandering more frequently.
Failure to Provide Adequate Care and Timely Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, leading to significant deficiencies. Resident ID #1, who was on hospice care with chronic pain and pancreatic cancer, experienced fluctuating and severe edema in the lower extremities, which was not adequately addressed by the facility staff. Despite assessments indicating 4+ pitting edema, no interventions or orders were implemented, and the provider was not notified of the resident's increasing edema and pain. The resident eventually requested to go to the hospital, where an acute DVT was diagnosed. Additionally, the resident's abdominal girth was not measured as ordered due to the unavailability of a measuring tape, and the resident was admitted to the hospital for a paracentesis procedure. Further deficiencies were noted in the management of Resident ID #1's wounds. An open area on the resident's right lower extremity was identified but not reported to the provider, and no new interventions or orders were implemented. The wound nurse was not made aware of the new wounds until several days later, and the resident experienced significant pain during wound care. Additionally, the resident experienced a fall, but there was no evidence of an assessment or notification to the physician, nor were any interventions put in place to prevent future falls. The facility also failed to obtain an admission weight for the resident as ordered. Resident ID #2, who had dementia and type two diabetes mellitus, experienced two unresponsive incidents that were not properly addressed. On both occasions, the provider was not notified, and no interventions were implemented. The Nurse Practitioner was unaware of these incidents and indicated that an assessment and lab orders would have been conducted if informed. The facility staff failed to alert the on-call provider when the Nurse Practitioner did not return the call, leading to a lack of appropriate response to the resident's change in condition.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility was found to have failed in maintaining a safe, sanitary, and comfortable environment for residents, staff, and the public across all four units observed. Surveyor observations revealed that multiple bathrooms, including those in resident rooms, staff areas, and public spaces, had heavy accumulations of yellow and brown stains in the toilet bowls, accompanied by a strong odor of urine. These conditions were corroborated by interviews with various staff members, including registered nurses, nursing assistants, and housekeepers, who confirmed the persistent presence of stains and odors over several months. The housekeepers noted a change in cleaning products from Clorox bleach to Ecolab 73 Disinfecting Acid Bathroom Cleaner, which they reported as ineffective in removing the stains. Additionally, the surveyors observed that the flooring throughout the facility, including resident rooms, hallways, and office areas, was scuffed, and the carpets were heavily stained. The facility's Administrator acknowledged the need for repair or replacement of the flooring. These findings were based on community complaints submitted to the Rhode Island Department of Health, which alleged issues with cleanliness and sanitation, contributing to an uncomfortable environment. The facility's leadership, including the Director of Nursing Services and the Administrator, acknowledged the deficiencies observed by the surveyors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 611 citations issued within 25 miles in the last 12 months — including the 19 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 Smithfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stillwater Assisted Living And Skilled Nursing Com | 2.4 mi | ★★★★★ | 1 | 0 |
| Greenville Operations Ri Llc Dba Greenville Skille | 2.5 mi | ★★★★★ | 16 | 1 |
| Heritage Hills Nursing & Rehabilitation Center | 4.9 mi | ★★★★★ | 21 | 2 |
| Holiday Retirement Home Inc | 5.2 mi | ★★★★★ | 9 | 0 |
| Lincolnwood Rehabilitation And Healthcare Center | 5.3 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.