Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Achieve Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident admitted with acute and chronic respiratory failure with hypoxia, tracheostomy status, dysphagia, gastrostomy status, and dementia had a Baseline Care Plan marked complete even though it did not include trach care needs, suctioning requirements, respiratory monitoring, or admission interventions. The resident also had orders for NPO status, a size 8 cuffed trach, and O2 at 10 L via trach, and a progress note documented a trach, PEG tube, and a red area to the buttock.
A resident experienced misappropriation of their prescribed Percocet, leading to inadequate pain management. The resident, who was cognitively intact, reported being out of the medication for several days and was given Tylenol instead, which did not alleviate their pain. Discrepancies in medication administration records and conflicting accounts from an LPN led to her termination for failing to follow medication policy.
A facility failed to accurately document a resident's code status, leading to a significant deficiency. The resident, who was cognitively intact, had chosen to be a Full Code, but their EMR incorrectly indicated a DNR status. Interviews with LPNs revealed they would not initiate CPR based on this incorrect information, placing the resident at risk. The facility's policy required periodic reviews of advance directives, but this was not followed, resulting in Immediate Jeopardy.
The facility failed to maintain sanitation and food safety standards, affecting 151 residents. Observations revealed soiled food service equipment, ineffective sanitizing solutions, and improper food storage. Resident food storage areas lacked thermometers, and expired, undated food items were found. Staff did not follow proper hand hygiene, and meal carts were not cleaned between uses.
The facility's laundry room was found to be unsanitary, with grime and dust on washing machines, fans, and other equipment. Clean items were improperly stored in the dirty area, and the laundry chute was filled with dust. Interviews revealed a lack of a set cleaning schedule and inadequate cleaning due to space constraints.
The facility failed to maintain a clean and homelike environment in three of its four units, with significant cleanliness issues observed over four days. The 300 unit had soiled walls and floors, while a water-stained ceiling tile indicated a potential leak. Resident rooms and common areas, including bathrooms and floors near kitchen and nursing stations, had dirt buildup. These issues were confirmed by the Maintenance Director and Housekeeping Supervisor.
The facility did not follow its menu policy, affecting residents' nutritional needs. Two residents reported dissatisfaction with the food service, noting deviations from the menu and cold meals. Staff served incorrect portions and omitted menu items like rolls and hushpuppies, impacting 151 residents.
The facility failed to maintain safe electrical outlets in four resident rooms, affecting seven residents. Broken outlet covers and non-functioning outlets prevented residents from using essential devices like TVs and refrigerators. Despite reports to staff, the issues persisted for over a month, impacting residents' quality of life and exposing them to potential hazards.
A facility failed to maintain the dignity of a resident with Alzheimer's by not ensuring privacy during personal care. The resident, who was severely cognitively impaired, was exposed to a roommate while receiving incontinence care because the privacy curtain was not pulled. The CNA involved admitted to being distracted and forgetting to close the curtain, despite the facility's policy requiring privacy measures during care.
A facility failed to provide the required Advanced Beneficiary Notice of Non-Coverage (ABN) and Notice of Medicare Non-Coverage (NOMNC) to a resident when Medicare Part A services ended. The resident, who required various levels of assistance and had a BIMS score indicating cognitive intactness, did not receive the necessary notifications due to incomplete SNF Beneficiary Notification Review forms. The Administrator confirmed the oversight, attributing it to a possible misunderstanding by the Social Service Director.
The facility failed to provide adequate ADLs for two residents, resulting in poor personal hygiene. One resident did not receive regular showers as scheduled, while another had neglected nail care, leading to long, dirty fingernails and an odor from her hand. Inconsistent documentation and insufficient staffing contributed to these deficiencies.
The facility failed to provide a consistent activities program for residents on the secure/dementia care unit, affecting two residents with severe cognitive impairments. One resident, with a history of enjoying crime shows, was left without access to a TV or radio, while another resident with schizophrenia and aggressive behaviors received no organized activities due to staff shortages and a COVID outbreak. The absence of activities was confirmed by staff and acknowledged by facility management.
A resident with chronic lymphedema and circulatory deficits did not receive prescribed compression wraps due to a delay in order fulfillment by the DME provider. Despite repeated entries in the system, the facility failed to apply the wraps, leading to worsened edema. The Regional Director of Clinical Services and the DON acknowledged the delay and deficiency in care.
Two residents in a facility did not receive restorative nursing care as ordered by their physicians. One resident, with a history of stroke, was not provided with a carrot for her hand or a wedge for her leg, while another resident did not have a required hand splint applied. The Restorative Aide had been reassigned to CNA duties, leading to a lack of implementation of the restorative program. The Director of Nursing was unaware of these deficiencies, resulting in a failure to provide necessary care.
A resident experienced significant weight loss due to the facility's failure to monitor weights, implement interventions, and track meal intake. Despite having a care plan, the facility did not conduct weekly weight checks or notify the physician of the weight loss. Staff interviews revealed a lack of awareness and communication regarding the resident's condition.
The facility failed to administer oxygen according to physician orders for two residents and lacked physician orders for another resident's oxygen use. One resident received less oxygen than prescribed, while another received more. Additionally, a third resident used oxygen without any physician order or documentation. Observations revealed issues with equipment cleanliness and adherence to prescribed oxygen levels, as confirmed by staff interviews.
A facility failed to accurately document a resident's physician's orders after readmission from the hospital, leading to incomplete medical records. The resident required specific care, including a diet, foley catheter, and fluid restriction, which were not entered into the EMR. The DON confirmed the oversight, and the Regional Director noted the absence of a specific policy for entering orders.
A facility failed to conduct and document a thorough investigation into an alleged staff-to-resident abuse incident involving a resident with severe cognitive impairment. Although staff statements were collected, there was no evidence that residents were interviewed or that the investigation's conclusions were properly documented. The administrator confirmed the lack of documentation and substantiation for the investigation.
Incomplete Baseline Care Plan for Resident With Tracheostomy
Penalty
Summary
The facility failed to ensure the Baseline Care Plan included required information related to a resident's tracheostomy status for 1 of 1 residents reviewed for baseline care planning. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, tracheostomy status, dysphagia, gastrostomy status, and dementia. Physician orders included NPO status, a size 8 cuffed tracheostomy, and oxygen at 10 L via tracheostomy continuously every shift. Review of the resident's Baseline Care Plan, marked completed in the EHR, showed the resident was cognitively impaired but contained no documentation of tracheostomy care needs, suctioning requirements, respiratory monitoring, or admission interventions. A progress note documented that the resident had a trach and PEG tube and a red area to the buttock. The DON stated the Baseline Care Plan should have addressed the resident's tracheostomy prior to being marked as completed.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of narcotic medication, specifically Percocet, which was intended for pain management. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was admitted with diagnoses including polyneuropathy, paraplegia, and anxiety. The medication monitoring records indicated discrepancies in the administration of Percocet, with two tablets unaccounted for. LPN1 signed off on administering the medication on dates when it was not available, and conflicting accounts were given regarding a medication error. The resident reported being out of Percocet for a couple of days and experiencing pain, which was inadequately managed with Tylenol. The investigation revealed inconsistencies in LPN1's statements, leading to her termination for failure to follow medication administration policy. LPN2 confirmed that the narcotic sheets showed the last administration of Percocet was on a previous date, and the medication had run out. Despite being aware of the shortage, LPN2 did not document the medication as unavailable due to previous instructions, instead coding it incorrectly as refused. The facility's administrator acknowledged the discrepancies and the changing stories from LPN1, which contributed to the decision to terminate her employment. The resident's pain was not effectively managed due to the misappropriation and mismanagement of the medication.
Failure to Accurately Document Resident's Code Status
Penalty
Summary
The facility failed to accurately document a resident's wishes regarding their code status, which led to a significant deficiency. The resident, identified as R110, was cognitively intact and capable of making their own decisions, as evidenced by a perfect score on the Brief Interview for Mental Status (BIMS). Despite this, the resident's electronic medical record (EMR) incorrectly indicated a Do Not Resuscitate (DNR) status, contrary to the resident's documented choice of being a Full Code. This discrepancy was confirmed through a review of the resident's advance directive form, which clearly showed the resident's preference for resuscitation in the event of a sudden failure of a vital function. Interviews with facility staff revealed a lack of awareness regarding the resident's true code status. Two Licensed Practical Nurses (LPNs) stated they would not initiate cardiopulmonary resuscitation (CPR) based on the incorrect DNR status in the EMR. This misunderstanding placed the resident at risk of not receiving life-saving measures, as the staff relied on the inaccurate information in the EMR rather than the resident's documented wishes. The facility's policy on residents' rights regarding treatment and advance directives mandates periodic reviews of such directives as part of the comprehensive care planning process. However, the facility failed to adhere to this policy, as the resident's code status had been incorrect since the order was placed. The Administrator confirmed the error, acknowledging that the resident's code status had not been accurately reflected in the medical record, which constituted Immediate Jeopardy at F578.
Removal Plan
- Resident #110 Code Status medical record was updated to reflect their Advance Directive Form.
- All residents have the potential to be affected by this alleged deficient practice.
- On admissions all residents will be listed as full code unless documented is provided. The Interdisciplinary team will review advance directives. All new admissions will be reviewed in effort to ensure substantial compliance. Random audits will be reviewed in effort to ensure substantial compliance.
- Director of Nursing (DON)/Designee conducted a facility-wide assessment to determine if any other residents were affected by this alleged deficient practice. Any identified concerns were corrected. The DON/Designee reeducated all licensed practical nurses and registered nurses to review code status order entry. Any staff not currently working will be educated prior to the start of next shift.
- All Licensed Nursing staff were educated by the Director of Nursing/Designee, the outcome of the Immediate Jeopardy ensuring that Residents have the right to formulate advanced directives. Any staff not currently working will be educated prior to the start of the next shift until all staff have been educated.
- DON/Designee will complete random audits using an Advance Directive audit tool for all new admissions. Random audits to be conducted in effort to ensure substantial compliance. Any negative findings will be corrected, and this will be discussed at the Facility monthly Facility Quality Assessment and Performance Improvement (QAPI) meeting.
Sanitation and Food Safety Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen and resident food storage areas, potentially affecting 151 of 157 residents. Observations revealed that food service equipment and areas were soiled and in need of cleaning. Specifically, shelves under the coffee pot and sheet pan racks were covered with visibly soiled aluminum foil, and a food processor and canola oil container were stored on a soiled shelf. Additionally, drawers containing food utensils were rusty and soiled with food particles, and food scoops had dried food on them. Sanitizing solutions used for cleaning food preparation counters were found to be ineffective, testing at zero parts per million (ppm) instead of the required 150 to 400 ppm. This was observed on multiple occasions, with staff using these solutions to clean counters. Furthermore, the dry food storage room contained open and unsealed boxes of kosher salt and containers of spices that were visibly soiled and greasy. Some food items, such as paprika and ranch dressing, were not stored according to manufacturer's instructions, leading to potential cross-contamination. In the resident food storage areas, refrigerators lacked thermometers, making it impossible to determine if they were maintained at safe temperatures. Expired and undated food items were found, including sliced apples, tomato juice, and Mighty Shake nutritional supplements. Additionally, staff failed to follow proper hand hygiene practices, as observed when a staff member did not change gloves after handling soiled items before returning to food service. Meal carts used for transporting resident trays were also found to be soiled and not cleaned between uses, further compromising food safety.
Unsanitary Conditions in Laundry Room
Penalty
Summary
The facility failed to maintain cleanliness and organization in the laundry room, leading to unsanitary conditions. Observations revealed that the designated dirty area had two large washing machines covered with white dried material, gray grime, and dust. A fan on the floor was caked with dust and grime, and a blue bin on the floor contained dust, black material, and a glove. A partially ripped plastic bag with pillows and three pillows not in bags were lying directly on the floor. Paper towels, gloves, and blankets were also found on the floor. The laundry dispenser was caked with dust and grime, and a large plastic bag filled with clean washcloths was improperly stored on the floor in the dirty area. In the designated clean area, six dryers had a moderate amount of dust on top, and a silver cart with a microwave, coffee pot, and other items was very dusty. The refrigerator, hot water heater, and windowsill were also covered in dust. The laundry chute in another area was filled with dust and had dust strings hanging inside. Interviews with the laundry aide and housekeeping supervisor revealed a lack of a set cleaning schedule, inadequate cleaning due to space constraints, and improper storage of clean items in the dirty area. The housekeeping supervisor acknowledged the need for cleaning and confirmed that the laundry chute required attention.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in three of its four units, specifically the 100, 200, and 300 units. Observations conducted over four days revealed several areas with significant cleanliness issues. The 300 unit had soiled walls with scuffs and a dark brown buildup on the floors along the baseboards, as well as heavy dirt accumulation around door frames to the kitchen and employee lounge. Additionally, a water-stained and drooping ceiling tile was observed in the corridor leading to the shower room, indicating a potential leak. Further observations noted dirt buildup in resident rooms, including along walls, vents, and under closets, with dust and debris on heaters. Bathrooms also had dirt accumulation along walls and behind toilets. Common areas such as the floor in front of the refrigerator behind the nursing station on the 200 unit and the floor under and beside the ice maker on the 100 unit were heavily soiled. These observations were verified by the Maintenance Director and Housekeeping Supervisor, who acknowledged the need for cleaning and maintenance in these areas.
Failure to Follow Menu and Serve Correct Portions
Penalty
Summary
The facility failed to adhere to its policy regarding menu preparation and service, which resulted in a deficiency affecting the nutritional needs of residents. The policy required that menus be posted in advance and followed as posted, but during the survey, it was observed that the menu was not followed for two residents. Specifically, the facility was supposed to serve buttered corn and hushpuppies to residents on regular diets, and seasoned carrots and a dinner roll to those on mechanical soft diets. However, the staff served lima beans instead of carrots and did not provide any rolls or hushpuppies. The Dietary Manager confirmed that the scoop sizes used for serving were incorrect, further deviating from the menu requirements. Interviews with two residents revealed dissatisfaction with the food service, noting that the food was often not as per the menu and was frequently served cold. One resident mentioned that the menu was not followed about 75% of the time. The staff member responsible for serving the meal admitted to making changes to the menu without explanation and forgetting to prepare the required bread items. This failure to follow the menu as planned had the potential to impact the nutritional intake and satisfaction of 151 out of 157 residents consuming food at the facility.
Electrical Outlet Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain electrical outlets in safe operating conditions in four resident rooms, affecting seven residents. Observations revealed broken outlet covers and non-functioning outlets, which prevented residents from using essential devices such as televisions, refrigerators, and charging their personal devices. The Maintenance Director confirmed the issues, and an electrician verified the non-functioning outlets, but the problems persisted for over a month. Residents and family members reported the issues to staff, but the problems were not addressed in a timely manner, leading to inconvenience and potential safety hazards. Residents affected by the non-functioning outlets included those who were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. Interviews with residents and staff revealed that the electrical issues had been ongoing for several weeks, with some residents having to use common areas to watch television or charge their devices. Despite reports to the Maintenance Director and other staff members, the issues remained unresolved, impacting the residents' quality of life and potentially exposing them to electrical hazards.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain and promote the dignity of a resident, identified as R123, by not ensuring privacy during personal care. R123, who was admitted with Alzheimer's disease and was severely cognitively impaired, was observed receiving incontinence care without the privacy curtain being pulled. This oversight occurred while R123's roommate, who was alert and oriented, was present and able to observe the care being provided. The incident was noted during an observation where a Certified Nursing Assistant (CNA) was providing care to R123 without ensuring the privacy curtain was closed, thus exposing R123's lower body. Interviews with the CNA involved and other staff members, including a Licensed Practical Nurse (LPN) and the Director of Nurses (DON), confirmed that the facility's policy required staff to maintain resident privacy by using clothing, blankets, and privacy curtains during personal care. The CNA admitted to being distracted and forgetting to pull the curtain, while the DON stated that all staff were educated on the facility's dignity policy during orientation. This failure to adhere to the policy placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment.
Failure to Provide Beneficiary Notices
Penalty
Summary
The facility failed to provide the Advanced Beneficiary Notice of Non-Coverage (ABN) and the Notice of Medicare Non-Coverage (NOMNC) to a resident, identified as R136, who was reviewed for Beneficiary Notification among 36 sample residents. This oversight occurred when Medicare Part A services ended for R136 on December 22, 2024. R136 was admitted to the facility with diagnoses including neurological conditions, urinary tract infection, diabetes, and depression. The resident's Minimum Data Set (MDS) indicated a need for various levels of assistance with daily activities and a Brief Interview for Mental Status (BIMS) score of 12, showing cognitive intactness. The facility's SNF Beneficiary Notification Review forms were incomplete, and the necessary notices were not provided. During an interview, the Administrator confirmed the omission and suggested that the Social Service Director might not have understood the importance of completing and providing these forms due to the low number of residents covered by Medicare Part A.
Failure to Provide Adequate ADLs for Residents
Penalty
Summary
The facility failed to provide appropriate Activities of Daily Living (ADLs) for two residents, R145 and R115, to maintain adequate personal hygiene. R145, who was cognitively intact and required assistance with various ADLs, did not receive regular showers as per the facility's schedule. Despite being scheduled for showers three times a week, records and interviews revealed that R145 went extended periods without a shower, receiving them only sporadically. The facility's documentation was inconsistent, and there were discrepancies between the shower schedule and the actual showers provided, as noted by the Occupational Therapy Assistant and the Director of Nursing. R115, who was severely cognitively impaired and required maximum assistance for personal care, was observed to have long, dirty fingernails with black material underneath and an offensive odor from her left hand. Despite the facility's policy that licensed nurses should trim the nails of residents with diabetes, and CNAs should clean them, R115's nail care was neglected. Interviews with staff indicated that there were not enough personnel to provide adequate nail care, and the issue of the odor from R115's hand was not reported to the nursing staff as required. The facility's policies on ADLs, including bathing and nail care, were not adhered to, resulting in inadequate personal hygiene for both residents. The Director of Nursing acknowledged that showers were supposed to be provided consistently, and the CNAs were responsible for documenting and reporting any issues. However, the lack of proper documentation and communication among staff contributed to the deficiencies in care for R145 and R115.
Failure to Provide Consistent Activities Program
Penalty
Summary
The facility failed to provide a consistent activities program for residents on the secure/dementia care unit, specifically affecting one resident with paranoid schizophrenia, traumatic brain injury, and severe cognitive impairment. This resident, who was ambulatory and often found in communal areas, had a care plan that included interventions to manage behaviors such as wandering and aggression. However, due to a COVID outbreak and the absence of the designated activity staff member, no organized activities were provided for several weeks, as confirmed by staff interviews. Another resident, who was non-verbal and severely cognitively impaired, was also affected by the lack of activities. This resident had a history of enjoying crime shows and horror movies but was observed lying in bed without access to a television or radio. Despite being placed on a one-on-one activity schedule, the resident had not received these interactions due to staffing shortages and a recent COVID outbreak. Interviews with staff revealed that the resident used to watch television with a roommate who had since moved, leaving the resident without access to preferred activities. The absence of organized activities for these residents was acknowledged by the facility's Regional Director of Clinical Services and the Activity Director, who were unaware of the situation until informed. The lack of activities was attributed to the absence of the activity staff member and the impact of a COVID outbreak, which led to a failure in following the facility's policy to provide an ongoing activities program tailored to residents' needs and preferences.
Failure to Implement Physician's Orders for Compression Wraps
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with chronic lymphedema and circulatory deficits. The resident, who was moderately cognitively impaired, was observed with notable edema in her feet and legs, which worsened as she stood throughout the day. Despite a physician's order for tubular compression wraps to be applied daily, there were no records of the wraps being applied or removed as prescribed. The order was initially placed on 11/16/24, but the necessary equipment was not provided by the contracted DME provider, leading to a significant delay in treatment. The Regional Director of Clinical Services acknowledged the delay, noting that the order had been repeatedly entered into the system without fulfillment. The Director of Nursing expressed that the delay was unacceptable and contrary to her expectations for timely processing and execution of treatment orders. The lack of action in obtaining and applying the compression wraps as ordered by the physician resulted in a deficiency in the care provided to the resident.
Failure to Provide Ordered Restorative Nursing Care
Penalty
Summary
The facility failed to provide appropriate restorative nursing care to two residents, R115 and R71, as ordered by their physicians. R115, who was admitted with diagnoses including type two diabetes mellitus and a history of stroke with hemiparesis, was ordered to participate in a restorative nursing program five times a week for range of motion (ROM) exercises and to have a carrot placed in her left hand and a wedge to her left leg for positioning. However, observations revealed that R115 did not have the carrot or wedge as ordered, and interviews with staff indicated a lack of awareness and implementation of these orders. The Restorative Aide (RA) had not been providing restorative services for several months due to being assigned as a CNA, and the Director of Nursing (DON) was unaware of the missing devices. R71, who had a history of stroke with hemiparesis and hemiplegia, was ordered to wear a left-hand brace for six hours per day. Despite this order, R71 reported not having seen rehabilitation staff for several days and not having the splint applied. The Therapy Director confirmed that the splint was to be worn daily, but the order for restorative nursing was delayed, and the RA was not informed of R71's need for the splint. The DON confirmed that the RA had not worked in her role for several months, and the responsibility for applying the splint fell to the nursing staff, who did not fulfill this duty. The facility's failure to ensure the implementation of restorative nursing programs as ordered by physicians for R115 and R71 resulted in a lack of necessary care and support for these residents. The absence of communication and coordination among staff, as well as the reassignment of the RA to CNA duties, contributed to the deficiency in care. This oversight had the potential to negatively impact the residents' range of motion and overall well-being.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as R123, by not adequately monitoring weights, implementing necessary interventions, and tracking meal intake. R123, who was admitted with multiple diagnoses including heart failure, renal insufficiency, diabetes mellitus, major depression, and anemia, experienced significant weight loss over a three-month period. Despite having a Nutrition Care Plan in place to prevent malnutrition, the facility did not consistently monitor or report significant weight changes to the physician, nor did they implement weekly weight checks as required by their policy. R123's weight records showed a drastic decrease from 118.2 pounds to 92.5 pounds over a few months, indicating a 21.3% weight loss. The facility's policy required weekly weight monitoring for residents with weight loss, but this was not done. Additionally, there was a lack of documentation regarding R123's meal and snack intake on several occasions, and the Registered Dietician's evaluation was delayed and contained conflicting information about the resident's weight loss. Interviews with staff revealed a lack of awareness and communication regarding R123's weight loss. The Director of Nurses and Licensed Practical Nurse were not informed of the significant weight loss, and the Registered Dietician did not notify the team or take timely action. The facility's failure to investigate the weight loss, notify the physician, and implement appropriate interventions contributed to the deficiency in maintaining R123's nutritional health.
Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper oxygen administration for two residents, R400 and R87, as per physician orders. R400, who was in a persistent vegetative state with chronic respiratory failure and hypoxia, was observed using a tracheostomy collar with an oxygen concentrator set at 6 liters per minute (LPM) instead of the prescribed 8 LPM. Despite multiple observations, the oxygen concentrator could not be adjusted to the correct setting, as confirmed by an LPN and the Director of Nurses (DON). Similarly, R87, diagnosed with chronic obstructive pulmonary disease and congestive heart failure, was observed using a nasal cannula with the oxygen concentrator set at 2.5 and 3 LPM, contrary to the physician's order of 2 LPM. The oxygen equipment was not dated, and the concentrator was found to be crusted with white stains. An LPN acknowledged the discrepancy in the oxygen setting and the DON confirmed the expectation for staff to adhere to physician orders. Additionally, R71, who had a history of stroke and other conditions, was using oxygen without a physician's order. Despite the resident's report of long-term oxygen use, there was no documentation of oxygen orders, care plan, or monitoring in the clinical record. Observations revealed the oxygen unit was dirty, and the filter was full of lint. An LPN confirmed the absence of a physician order and the need for cleaning the oxygen unit. The DON reiterated the requirement for physician orders and proper documentation for oxygen use.
Incomplete Documentation of Physician's Orders
Penalty
Summary
The facility failed to ensure that the medical record accurately and completely reflected the physician's orders for a resident who was reviewed for medical records. The resident, who had been admitted to the hospital for altered mental status, was readmitted to the facility with the same physician's orders as before the hospital admission. However, upon review, it was found that the nurse did not enter the resident's previous orders into the electronic medical record (EMR). These orders included a specific diet, a foley catheter, acute charting for a hemodialysis catheter site, and a fluid restriction, among others. As a result, these orders were absent from the January orders and the medication administration record. During interviews, the Director of Nursing confirmed that the resident still required the same care and that the orders had not been entered into the January physician's orders, leading to incomplete and inaccurate records. The Regional Director of Clinical Services noted that there was no specific policy for entering physician's orders into medical records, and the nurses followed a General Nursing Admission Checklist during admissions or readmissions. This oversight had the potential to impact the resident's care, as the necessary orders were not documented in the medical records.
Failure to Conduct and Document Thorough Abuse Investigation
Penalty
Summary
The facility failed to ensure a thorough investigation and proper documentation of an alleged staff-to-resident abuse incident involving a resident with severe cognitive impairment and a history of dementia, altered mental status, and cognitive communication deficit. The incident involved a certified nurse aide (CNA) allegedly being physically aggressive with the resident, including grabbing the resident's wrist tightly and handling the resident roughly. Witness statements were collected from involved staff, but there was no documentation indicating that any residents, including the affected resident, were interviewed as part of the investigation. Additionally, the facility's records did not include evidence of how the decision was made to allow the accused CNA to return to work following suspension, nor was there documentation to support the thoroughness of the investigation. The administrator confirmed that there was no additional documentation available to substantiate the investigation or its conclusions, and acknowledged that the abuse allegation should have been substantiated based on the available information.
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 38 citations issued within 25 miles in the last 12 months — 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 Anderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare - Anderson | 2.2 mi | ★★★★★ | 0 | 0 |
| Linley Park Post Acute | 2.4 mi | ★★★★★ | 8 | 0 |
| Richard M Campbell Veterans Nursing Home | 3.8 mi | ★★★★★ | 0 | 0 |
| Iva Post-acute | 13 mi | ★★★★★ | 5 | 0 |
| Piedmont Post-acute | 17 mi | ★★★★★ | 7 | 0 |
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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.