Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Hollow Rehabilitation Center during CMS and state inspections, most recent first.
Failure to provide SNF ABN when Medicare skilled services ended. A resident with Alzheimer's disease, major depressive disorder, and unspecified encephalopathy was discharged from skilled services after a Medicare Part A skilled episode. The facility issued a NOMNC signed by the resident's representative, but the SNF ABN section was left blank and no SNF ABN was attached. The BOM stated she was unaware the SNF ABN needed to be provided, and the ED said the facility did not have a specific policy for SNF ABN and NOMNC notices.
Improper Food Handling and Chemical Storage During Meal Service: During lunch prep and service, a cook used gloved hands to handle multiple ready-to-serve food items, including grilled cheese sandwiches, hamburger buns, a cooked beef patty, lettuce, tomato, and cheese, without changing gloves or using utensils. Another staff member placed an open container of sanitation wipes on a service cart next to pre-made salad and fruit salad plates. The Dietary Manager and ED acknowledged that utensils should be used for service and that chemical wipes should be stored away from food.
A resident with multiple comorbidities, including DM, hyperlipidemia, depression, cerebral infarction, and a recent fracture, was ordered several scheduled medications at bedtime, including Tramadol, Atorvastatin, Farxiga, Remeron, Eliquis, and a protein supplement. A CMA reported making three attempts to administer the evening medications, during which the resident refused, spat out, and then regurgitated the crushed, thick medication mixture, ultimately receiving only part of the doses while the remainder was discarded. The MAR nevertheless showed all medications as given, and there was no documentation of vomiting, refusal, assessment, or MD notification in the clinical record. The DON stated she only learned of the incident after a family complaint, and the facility could not provide a medication administration policy that addressed this situation, resulting in missed doses and failure to follow pharmaceutical service requirements.
A resident with dementia, osteoporosis, and a prior femur fracture, who was care planned for Hoyer lift transfers due to muscle weakness, was transferred by a CNA without the required mechanical lift. During the transfer, the resident's legs gave out, resulting in a fall and a new femur fracture that required hospitalization and surgery. The care plan directive for mechanical lift use was not followed at the time of the incident.
A resident with dementia, osteoporosis, and a healing femur fracture was transferred from bed to wheelchair by a CNA without using the required Hoyer lift, as specified in the care plan. During the transfer, the resident's legs gave out, resulting in a fall and a new femur fracture that required hospitalization and surgery. Staff interviews and records confirmed the care plan was not followed at the time of the incident.
A resident with respiratory failure who required nebulizer treatments had their nebulizer mask and tubing stored in a drawer with other personal items, rather than in a plastic bag as required by facility policy. Nursing staff and the DON confirmed the mask should have been bagged to prevent infection, but this was not done, resulting in improper storage of respiratory equipment.
A resident who was not authorized to self-administer medications was found with multiple over-the-counter drugs stored at her bedside, contrary to facility policy and regulatory requirements. Staff interviews confirmed that medications should not have been left in the room and that family members sometimes brought in such items.
The facility did not promptly address or communicate responses to repeated grievances raised by the Resident Council regarding care and quality-of-life issues, such as call light wait times, staffing, and customer service. Despite grievances being submitted and some actions reportedly taken, residents were not informed of the outcomes, and written updates requested by the council were not provided, contrary to facility policy.
Two residents did not have comprehensive, person-centered care plans reflecting their current needs. One resident's use of chewing tobacco was not documented or addressed in the care plan, despite staff awareness. Another resident's right-hand contracture and OT services were not included in her care plan, and staff were unaware of the contracture. These omissions were identified through observation, interviews, and record review, and staff acknowledged the care plans were not updated to reflect the residents' needs.
Staff failed to provide timely and proper perineal care for a male resident after an incontinent episode, did not deliver prompt incontinence care to a female resident with a UTI, and did not maintain a foley catheter drainage bag below the bladder during a transfer for another male resident. These actions included not changing wipes between strokes, using soiled gloves, delays in responding to call lights, and improper handling of catheter equipment, all contrary to facility policy and staff training.
Surveyors found that medications, including controlled substances, antifungal powder, and eye drops, were not properly labeled or stored. Two residents had controlled medications with broken blister pack seals left in the medication cart, while antifungal powder and Systane eye drops were found at the bedside of several residents without physician orders. Additionally, a prescribed medication was left on a resident's bedside table after refusal, contrary to facility policy. Staff interviews confirmed that these practices did not follow required procedures for medication storage and administration.
Surveyors found that food items in the facility's kitchen were not consistently labeled or dated, with trays of liquids lacking identification and an expired block of cheese present in the refrigerator. Additionally, a dented can was found in dry storage. Dietary staff interviews revealed inconsistent labeling practices, and facility policy requiring proper labeling and timely use of food was not followed.
Staff failed to consistently follow infection prevention and control protocols, including proper use of PPE and hand hygiene, during incontinence care, wound care, and food service. Multiple residents were affected as CNAs and an LVN did not change gloves or perform hand hygiene between dirty and clean tasks, handled soiled linens improperly, and delivered food trays without sanitizing hands between residents.
A medication cart audit revealed that a resident received Tramadol HCL 50 mg tablets five times after the medication had expired. Staff interviews indicated that while medication counts were done at shift changes, there was no clear record of recent cart audits, and expired medication was not removed as required by facility policy.
A resident with severe cognitive impairment and multiple health conditions developed a bruise and a wound that were not documented or reported to the physician or responsible party. Staff were unaware of the injuries, and no incident report or required notifications were completed, in violation of facility policy.
Two residents who were dependent on staff for ADL care did not receive proper personal hygiene services, including regular fingernail cleaning and scheduled showers, as required by their care plans. One resident had dirty, overgrown fingernails, and another received only one shower in two weeks, despite being fully dependent on staff for bathing. Staff interviews and documentation confirmed that these deficiencies occurred due to lack of adherence to facility policies and care plans.
A resident admitted with a PICC line for IV therapy did not have the line dressing changed within the required 7-day interval as ordered by the physician and facility policy. The dressing remained unchanged since hospital discharge, and documentation falsely indicated the change had occurred. Nursing staff and administration confirmed the oversight, which resulted in the resident being at risk for infection due to the overdue dressing change.
Two residents with severe cognitive impairment and incontinence were not provided timely incontinence care, leading to prolonged periods without being checked or changed. Despite facility protocols requiring checks every two hours, staff interviews revealed challenges in adhering to this schedule due to meal service and staffing issues. Hospice aides and facility staff failed to detect and address incontinence in a timely manner, resulting in residents being found soaked or with bowel movements.
The facility failed to use gait belts during transfers for two residents, one with moderate cognitive impairment and another with severe cognitive impairment. Both residents required substantial assistance with toileting, and staff did not adhere to the facility's policy of using gait belts, increasing the risk of falls and injuries.
A resident was seriously injured when an unscheduled CNA entered the facility and stabbed him multiple times. The resident, who required substantial assistance due to various medical conditions, was attacked in his room, resulting in stab wounds to the neck, chest, and arm. The incident was discovered by an LVN who provided first aid until EMS arrived. The CNA fled but was later arrested. The facility's security measures failed to prevent the CNA's unauthorized access, leading to the resident's hospitalization.
Failure to Provide SNF ABN at End of Medicare Skilled Services
Penalty
Summary
The facility failed to ensure that a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was provided when Resident #4 was discharged from skilled services. Resident #4 was an [AGE]-year-old female with diagnoses including Alzheimer's disease, major depressive disorder, and unspecified encephalopathy. Review of the Medicare SNF Beneficiary Protection Notification Review worksheet showed her Medicare Part A skilled services episode began on 10/14/25 and her last covered day, due to voluntary discharge, was 01/08/26. Section 1 of the worksheet for the SNF ABN was left blank, while Section 2 indicated that a Notice of Medicare Non-coverage (NOMNC) had been given. The NOMNC, dated 01/05/26, stated that Medicare skilled services would end on 01/07/26 and was signed by the resident's representative. A copy of the NOMNC was attached, but no SNF ABN form was attached. During interview, the BOM stated she had only been in the position since January 2026 and had not previously done the job, and she had not been aware that the SNF ABN needed to be provided before the interview. The ED stated residents had the right to know what was covered and what was not, and an email response from the ED stated the facility did not have a specific policy for SNF ABN and NOMNC notices and used Medicare website documents and MLN instructions.
Improper Food Handling and Chemical Storage During Meal Service
Penalty
Summary
The facility failed to use proper food handling procedures during lunch preparation and service. During observation, [NAME] A picked up a prepared grilled cheese sandwich with her gloved hand and placed it on a plate for lunch service. Later, [NAME] A reached into a plastic bag with her gloved hand, removed a hamburger bun, separated the bun, and placed it on a resident's plate. Without changing her glove, she then picked up a cooked ground beef patty and placed it on the bun, and continued plating lunch trays without changing gloves while using her hand to pick up grilled cheese sandwiches, hamburger buns, ground beef patties, lettuce, and cheese. During interview, [NAME] A stated she was not supposed to pick up food items with gloved hands and should have used a utensil such as tongs. During lunch observation, [NAME] B used sanitation wipes to clean the serving line and then placed the wipe container on the service cart that contained pre-made salad and fruit salad plates. The container was left open, and the wipes were hanging down the side of the container next to the food. [NAME] B stated she was not supposed to place the wipes there next to the food because it could cause cross-contamination. The Dietary Manager stated staff were expected to use proper utensils during service and that the wipes should have been flipped shut and not placed next to prepared food. The ED stated staff should follow the chemicals policy and procedure for storing the wipes away from food. The policy on chemical storage stated chemical supplies will be kept separate from food and paper storage.
Failure to Administer and Document Medications After Resident Vomiting Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for a cognitively intact resident with multiple complex medical conditions. The resident, an older female with diagnoses including a left tibia fracture, type 2 DM, paroxysmal atrial fibrillation, cerebral infarction, chronic kidney disease, hyperlipidemia, depression, edema, and other conditions, had multiple scheduled medications ordered, including Tramadol for pain, Atorvastatin for hyperlipidemia, Farxiga for DM, Remeron for depression, Eliquis for cerebral infarction, and Protein Oral Liquid for wound healing. The resident’s care plan and orders directed that medications be administered as ordered, with monitoring for side effects, effectiveness, and documentation of relevant symptoms such as nausea and vomiting. On the date in question, CMA A was responsible for administering the resident’s medications, including the bedtime doses of Tramadol, Atorvastatin, Farxiga, Remeron, Eliquis, and Protein Oral Liquid. The MAR reflected that all of these medications were documented as administered by CMA A. However, CMA A later reported that each time she administered medications to the resident that day, the resident regurgitated the medications. During the evening medication pass, CMA A stated she made three attempts to administer the medications: on the first attempt, the resident refused; on the second attempt, the resident spat the medications out; and on the third attempt, while a family member was present, the resident again regurgitated the medications. CMA A stated that on the last attempt she gave the resident half of the medications and, when the resident could not keep them down, she threw the remaining medications away, but she was unable to specify which medications were actually taken or discarded. Despite these events, the clinical record, including the MAR and nursing notes, contained no documentation of the resident’s vomiting, no assessment of the resident’s condition related to the regurgitation, and no evidence of physician notification or monitoring for adverse events. CMA A acknowledged awareness of the vomiting episodes and stated that protocol required reporting such events to the nurse and documenting when a resident refused or vomited medications, but there was no documentation to support that this occurred. The DON reported that she only became aware of the vomiting incident after a family complaint several days later. The resident’s family member described witnessing CMA A crush the medications into a thick, pasty mixture, administer approximately half by spoon, observe the resident regurgitate the medications, and then state that the remaining portion was thrown away because the resident was not going to keep it down. The facility was unable to provide a medication administration policy that addressed these practices, and the failures resulted in the resident missing at least one dose each of Tramadol, Atorvastatin, Farxiga, Remeron, Eliquis, and Protein Oral Liquid on that date. The survey findings specifically note that these failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life.
Failure to Implement Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, consistent with the resident's rights and needs as identified in the comprehensive assessment. The care plan specified that the resident, who had dementia, osteoporosis, and a history of left femur fracture, required the use of a Hoyer lift for all transfers due to muscle weakness and inability to bear weight. Despite this, a CNA attempted to transfer the resident without the mechanical lift, contrary to the care plan instructions. During the transfer, the resident's legs gave out, and the CNA lowered her to the floor. The resident was subsequently assessed by nursing staff and began complaining of pain in her left leg after being returned to bed. Emergency services were called due to the extent of her pain, and the resident was transferred to the hospital, where she was diagnosed with a left distal femur fracture requiring surgical intervention. Interviews and record reviews confirmed that the care plan intervention requiring a Hoyer lift for transfers was not followed at the time of the incident. Staff statements and documentation indicated that the resident's care plan was clear about the need for mechanical lift assistance, but this directive was not implemented, resulting in a fall and serious injury.
Failure to Follow Care Plan for Safe Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required a mechanical lift for transfers. The resident, an elderly female with dementia, osteoporosis, and a healing left femur fracture, was care planned to be transferred using a Hoyer lift due to muscle weakness and an alteration in musculoskeletal status. Despite this, the CNA attempted to transfer the resident from her bed to her wheelchair without the mechanical lift and without assistance, contrary to the documented interventions in the care plan. During the transfer, the resident's legs gave out, and the CNA assisted her to the floor. The resident was then placed back in bed, after which she began complaining of pain in her left leg. The nurse on duty assessed the resident, and due to the extent of pain upon movement and touch, emergency services were called. The resident was transferred to the hospital, where she was diagnosed with a left distal femur fracture that required surgical intervention. Interviews and record reviews confirmed that the care plan specified the use of a Hoyer lift for all transfers, and staff were aware of the resident's transfer status. The CNA involved did not follow the established protocol, resulting in a fall and injury. The incident was self-reported by the facility, and staff interviews indicated knowledge of the importance of following care plans for safe resident transfers.
Improper Storage of Nebulizer Mask for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with acute and chronic respiratory failure with hypoxia was not provided respiratory care consistent with professional standards and the facility's own policies. The resident, who was cognitively intact and receiving oxygen therapy, had a physician's order for Budesonide inhalation via nebulizer twice daily. During an observation, the resident's nebulizer mask and tubing were found stored in a drawer with other personal items and not placed in a bag as required. The resident was unaware that the mask should have been bagged. Interviews with nursing staff and the DON confirmed that the nebulizer mask should have been stored in a plastic bag when not in use to prevent infection, and that it was the nurse's responsibility to ensure proper storage. The facility's policy specifically required nebulizer equipment to be stored in a dated, resident-labeled plastic bag between uses. This failure to follow policy and professional standards resulted in the resident's respiratory equipment being improperly stored.
Unsecured Medication Storage in Resident Room
Penalty
Summary
Facility staff failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as required by state and federal regulations. During an observation, a cognitively intact female resident with dementia, osteoporosis, and a recent femur fracture was found with a plastic container of over-the-counter medications, including Voltaren cream, Pepto Bismol chewable tablets, saline nasal spray, Icy Hot pain relief cream, and Mentholatum ointment, on her bedside table. The resident stated the medications were kept there for her use, but her care plan did not indicate she was permitted to self-administer medications. Interviews with nursing staff, the DON, and the Executive Director confirmed that the resident was not authorized to self-administer medications and that medications should not be left in her room. Staff also noted that family members sometimes brought items, including medications, into the resident's room. The facility's medication storage policy requires nursing staff to maintain secure storage of all medications, which was not followed in this instance.
Failure to Respond to Resident Council Grievances and Communicate Outcomes
Penalty
Summary
The facility failed to act promptly upon grievances raised by the Resident Council regarding issues of resident care and life within the facility. Over the course of four consecutive monthly Resident Council meetings, concerns were repeatedly voiced by residents, including issues such as residents being left in bed and missing activities, concerns about staffing, nails not being cut, long wait times for call lights and medications, agency aides not being responsive, internet service problems, aides turning off call lights without returning, and customer service issues. Despite these concerns being documented in meeting minutes and submitted as grievances, there was no evidence that the facility addressed these concerns following the meetings. Additionally, the Resident Council members were not notified about any facility actions taken to address or resolve their concerns in subsequent meetings. Residents specifically requested written updates from each department regarding their previous concerns, but did not receive any such responses. The Activity Director confirmed that grievances were submitted to the appropriate departments and the Administrator, but was unaware if the Resident Council ever received a response. The Administrator stated that grievances were addressed and filed with the responsible departments, and that some actions were taken, but communication of these actions to the Resident Council as a whole did not occur, with only the Resident Council President being informed verbally. The Resident Council President confirmed that while some improvements were noticed, the same concerns persisted and the lack of a written response from the facility was a significant issue for the residents. The facility's grievance policy requires that all grievances and recommendations from resident or family groups be considered and responded to verbally, including a rationale for the response, and that the findings and corrective actions be communicated to the person filing the grievance. However, the facility did not follow this policy, resulting in residents not being informed of the outcomes of their concerns.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interviews, and record reviews. For one resident, who had a history of paraplegia, seizure disorder, and spina bifida, the care plan did not reflect his use of chewing tobacco, despite multiple staff members, including the DON and Executive Director, being aware of this behavior. The resident was observed using chewing tobacco at his bedside, and staff interviews confirmed ongoing awareness of this practice. However, the care plan and MDS documentation did not address tobacco use, and there was no policy or guidance in place regarding smokeless tobacco, nor any documentation of counseling or risk mitigation related to this behavior. For another resident, who had Alzheimer's disease, rheumatoid arthritis, osteoporosis, and significant physical debility, the care plan failed to address a contracture in her right hand or the occupational therapy (OT) services she received. The resident was observed with a contracture affecting two fingers of her right hand, and staff interviews revealed a lack of awareness and documentation regarding this condition. Although OT had previously worked with the resident and made recommendations, these were not incorporated into the care plan, and there was no documentation of ongoing interventions or resident preferences related to the contracture. The facility's policy requires that care plans be comprehensive, person-centered, and updated as residents' conditions change, including measurable objectives and timetables. In both cases, the care plans did not reflect the residents' current needs or the services provided, as identified in assessments and through staff and resident interviews. This lack of documentation and individualized planning was confirmed by the MDS Coordinator and other staff, who acknowledged the omissions and the need for care plan updates.
Deficient Incontinence and Catheter Care Leading to Increased UTI Risk
Penalty
Summary
Staff failed to provide timely and appropriate perineal care to a male resident who was occasionally incontinent of bladder and frequently incontinent of bowel. On one occasion, two CNAs did not check or change the resident from 6:00 a.m. to 10:25 a.m., despite the resident being saturated in urine and having soiled bed linens. During the care, the CNAs did not change the surface of the peri-wipes with each stroke, used soiled gloves to apply barrier cream, and disposed of dirty linens on the floor. Both CNAs acknowledged they were aware of proper procedures but did not follow them, citing workload and frustration as contributing factors. A female resident with a history of urinary tract infection, stroke, and Parkinson's disease was not provided timely incontinence care during the overnight shift. The resident and her family reported delays in response to call lights, resulting in the resident remaining in wet clothing and bedding for extended periods. Observations revealed the resident had significant redness in the perineal area, and staff interviews confirmed that she was found soaked multiple times during the night and in the morning. There was confusion among staff regarding room assignments, and some staff were instructed not to enter the resident's room, further contributing to lapses in care. Another male resident with a foley catheter and colostomy was not provided appropriate catheter care during a transfer with a mechanical lift. Staff placed the urinary drainage bag on the resident's lap and abdomen, elevating it above the level of the bladder, which caused urine to back up in the tubing. Both CNAs involved stated they were aware of the requirement to keep the drainage bag below the bladder but were unsure how to do so during a mechanical lift. The facility's policies and staff training documents confirmed the expectation to maintain the drainage bag below the bladder at all times.
Improper Labeling and Storage of Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of drugs and biologicals. During observations of medication carts, it was found that two residents' controlled medications (hydrocodone acetaminophen) had blister packs with broken seals, with the pills still inside and taped, rather than being discarded as required. The responsible RN stated that while narcotic counts were performed at shift change, the physical condition of the blister packs was not checked, and she was unaware of when or how the seals were broken. The DON confirmed that such pills should be discarded and that nurses are responsible for checking blister packs for broken seals and expiration dates during shift changes. Further deficiencies were observed regarding the storage and administration of antifungal powder and Systane eye drops. For two residents, antifungal powder was found stored at the bedside and applied by CNAs without a physician's order, and in one case, the powder was retrieved from a resident's chest of drawers. Interviews revealed that CNAs accessed antifungal powder from a cabinet behind the nurse's station and applied it as needed, without nursing assessment or orders. Additionally, Systane eye drops, which were not ordered by a physician, were found at the bedside of two residents, who reported bringing them from home and using them independently. Another deficiency involved a resident's prescribed Tums (calcium carbonate) being left on the bedside table after the resident declined to take it during medication administration. The assigned MA admitted to leaving the medication at the bedside, despite knowing this was not permitted. Staff interviews confirmed that medications, including over-the-counter products, should not be left at the bedside and must have a physician's order and record of administration. The facility's policy requires all drugs and biologicals to be stored securely and not left in resident rooms or at the bedside.
Failure to Properly Store, Label, and Monitor Food Items
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards for food storage, preparation, and service in its only kitchen. Specifically, food items in the refrigerators were not consistently labeled or dated, as evidenced by trays of various liquids in clear plastic cups that lacked identification or date markings. Additionally, an unopened block of sliced cheese was found to be past its manufacturer’s use-by date, and the Dietary Manager confirmed it was expired. In dry storage, a can of black beans was found with a dent on the bottom seal, and the Dietary Manager acknowledged it should be discarded due to the dent. Interviews with dietary staff revealed inconsistent practices regarding labeling and dating of food items. Dietary aides and cooks were responsible for labeling food and liquids in the refrigerators, as well as items in the freezer and dry goods area. The facility’s policy required all leftover and refrigerated foods to be covered, labeled, and dated, and to be used within specified timeframes or discarded. However, observations indicated these procedures were not consistently followed, resulting in expired and improperly labeled food being present in storage areas.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program for multiple residents, as evidenced by direct observations of staff not adhering to required infection control protocols. In several instances, certified nursing assistants (CNAs) and a licensed vocational nurse (LVN) did not perform hand hygiene or change gloves appropriately during incontinence and wound care. For example, two CNAs provided incontinence care to a resident on enhanced barrier precautions due to a venous access device without donning gowns, failed to perform hand hygiene before gloving, and handled soiled linens improperly by placing them on the floor. The same staff did not change gloves or perform hand hygiene between dirty and clean tasks, and one CNA re-entered the room and donned new gloves without hand hygiene after leaving the room. Another resident receiving incontinence care was attended by two CNAs who, despite initially following some PPE protocols, failed to change gloves and perform hand hygiene between dirty and clean care steps. One CNA applied antifungal powder and handled resident belongings with soiled gloves, and only washed hands after completing all care tasks. Similar lapses were observed with another CNA during incontinence care, who changed gloves multiple times without performing hand hygiene, citing irritation from hand sanitizer as a reason for non-compliance. During wound care, an LVN changed gloves between wound sites but did not perform hand hygiene before re-gloving. In the dining area, a CNA was observed delivering food trays and handling residents' food items with bare hands, without performing hand hygiene between each tray delivery. The CNA also touched her clothing and other surfaces between tasks, further increasing the risk of cross-contamination. Interviews with staff and administration confirmed awareness of the required protocols, but also revealed inconsistent understanding and application of hand hygiene expectations, particularly regarding the frequency of hand hygiene during food service and resident care activities. Facility policies reviewed indicated clear requirements for hand hygiene and PPE use, which were not consistently followed by staff.
Expired Medication Administered Due to Inadequate Cart Audits
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that expired medication was removed from a medication cart. During an observation and record review of a medication cart on Hall B, it was found that a card of Tramadol HCL 50 mg for a resident had an expiration date that had already passed. Despite this, the medication was administered to the resident five times after its expiration date, as confirmed by the medication log. Interviews with staff revealed that medication counts were performed at shift changes, but there was uncertainty about when the last audit of the cart had been conducted. The LVN acknowledged that administering expired medication could be ineffective, and the DON stated that expired medications should be discarded and that nurses were responsible for checking expiration dates during shift changes and before administration. The facility's policy also required immediate removal and disposal of outdated medications, but this procedure was not followed in this instance.
Failure to Notify Physician and Responsible Party of Resident Injury
Penalty
Summary
The facility failed to notify a resident's physician and responsible party after the resident sustained a bruise to her right hand and a dime-sized wound on her right underarm. The resident, who was severely cognitively impaired and required extensive assistance with activities of daily living, was observed to have these injuries during surveyor visits. There was no documentation in the nurse's notes or incident reports regarding the injuries, nor any evidence that the physician or family had been notified as required by facility policy. Multiple staff interviews revealed a lack of awareness and communication regarding the injuries. Certified Nursing Assistants (CNAs) who provided care to the resident could not specify when the injuries occurred, and some believed the injuries were related to blood draws or skin tears during care. Nursing staff, including the Assistant Director of Nursing (ADON) and Registered Nurses (RNs), were unaware of the injuries until informed by the surveyor. The treatment nurse and ADON confirmed that no incident report had been completed, and the responsible party had not been notified until the time of the survey. Facility policy required prompt notification of the physician and resident representative in the event of accidents, injuries, or changes in condition. Despite these requirements, the facility did not follow protocol for assessment, documentation, or notification regarding the resident's injuries. The lack of communication and documentation was confirmed by interviews with the Director of Nursing (DON) and Executive Director, who both stated they had not been informed of the injuries prior to the survey. The responsible party also confirmed she had not been notified until contacted by the surveyor.
Failure to Provide ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, a female with multiple sclerosis, dementia, and depression, was observed with dirty and overgrown fingernails. Her care plan indicated she required substantial to maximum assistance with ADLs, and nail care was to be performed by CNAs weekly or as needed. However, her fingernails were not cleaned or trimmed as required, and she was unable to communicate about their condition. Another resident, a female with a history of cerebrovascular accident and hemiplegia, was dependent on staff for bathing. Her care plan specified that she should receive showers three times a week and as needed. Documentation and observation revealed that she received only one shower in a 14-day period, and her skin was noted to be oily and flaky. The resident reported not having had a shower since her recent hospital stay, and staff interviews confirmed that scheduled showers were missed without proper documentation or follow-up. Facility policies required daily cleaning and regular trimming of fingernails, as well as scheduled showers to promote cleanliness and comfort. Staff interviews indicated that CNAs were responsible for providing these services and notifying charge nurses of any refusals or issues. However, the lack of adherence to these policies resulted in residents not receiving appropriate hygiene care as outlined in their care plans.
Failure to Timely Change PICC Line Dressing per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of cellulitis and recent sepsis was admitted with a PICC line in place for IV therapy. Physician orders and facility policy required the PICC line dressing to be changed every 7 days using sterile technique. Documentation indicated the dressing was due to be changed, but observation revealed the dressing was still dated from the hospital admission and had not been changed since the resident's arrival. The resident confirmed that the dressing had not been changed during her stay. Review of the medication administration record showed the dressing change was signed off as completed, but the nurse later admitted this was an error and the dressing had not actually been changed. Interviews with nursing staff and administration confirmed that the dressing change order was not initially entered upon admission and was only obtained several days later. Despite daily line flushes and checks, the overdue dressing change was not identified or addressed until it was brought to the attention of staff during the survey. The failure to change the PICC line dressing as ordered and per professional standards placed the resident at risk of infection.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, both of whom required extensive assistance due to severe cognitive impairment and limited mobility. Resident #2, who was always incontinent of bladder and bowel and received hospice services, was not checked for incontinence from 9:00 a.m. to 1:30 p.m. on the day of observation. Despite being in the common area and later taken to the dining room, staff did not check her for incontinence. It was only after lunch that the hospice CNA found her soaked in urine and provided the necessary care. Similarly, Resident #3, who also had severe cognitive impairment and was dependent on staff for toileting hygiene, was not checked for incontinence from 9:35 a.m. to 1:45 p.m. on the same day. Although hospice aides attended to her in the morning, they did not change her brief as they did not detect any wetness or odor. It was only later in the afternoon that facility staff provided incontinence care, discovering a moderate-sized bowel movement and slight skin redness. Interviews with facility staff, including CNAs and the DON, revealed that residents were supposed to be checked every two hours for incontinence, regardless of hospice care. However, due to meal service schedules and staffing challenges, this protocol was not consistently followed. The facility's policy on perineal care emphasized the importance of cleanliness and infection prevention, which was not adhered to in these cases.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to ensure the use of gait belts during resident transfers, which is a critical safety measure to prevent falls and injuries. On December 10, 2024, a CNA did not use a gait belt while transferring a resident from a wheelchair to the toilet. The resident, who was moderately cognitively impaired and had limited range of motion due to a stroke, required substantial assistance with toileting. The CNA assisted the resident by pulling up on the back of her pants instead of using a gait belt, which is against the facility's policy for safe resident transfers. Another incident involved a hospice aide who also failed to use a gait belt while assisting a severely cognitively impaired resident with incontinence care. The resident, who had Alzheimer's disease and was dependent on staff for toileting, was assisted to stand without a gait belt, leading to her knees buckling. The hospice aide acknowledged forgetting to use the gait belt, which is essential for stabilizing residents during transfers. Interviews with staff, including the ADON and DON, revealed a lack of consistent training and adherence to the facility's policy on the use of gait belts. The facility's policy mandates the use of gait belts for safe lifting and movement of residents to prevent injuries. The absence of documented training and the failure to use gait belts during transfers highlight a significant oversight in ensuring resident safety.
Resident Stabbed by Unscheduled CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA entered the resident's room and inflicted multiple stab wounds, resulting in serious injuries that required hospitalization. The resident, a 95-year-old male with a history of various medical conditions including a neck fracture, osteoporosis, depression, cerebrovascular disease, polyneuropathy, dysphagia, COPD, muscle wasting, and prostate cancer, was cognitively intact and required substantial assistance with personal hygiene and toileting. The incident occurred when the CNA, who was not scheduled to work, entered the facility using a door code and attacked the resident with a knife, causing stab wounds to the neck, chest, and arm. The attack was discovered by an LVN who responded to a CNA's alert about the presence of the unscheduled CNA in the resident's room. Upon entering the room, the LVN found the resident bleeding profusely and called for help, applying pressure to the wounds until EMS arrived. The CNA fled the scene but was later apprehended by law enforcement. The facility had video footage of the CNA entering and exiting the facility and the resident's room, which was turned over to the police. Interviews with staff and residents revealed that the CNA had previously entered the facility earlier in the night, looked at the staffing book, and left, only to return later and commit the attack. Staff initially believed the CNA was attempting to steal time by clocking out without being scheduled. The facility's failure to prevent the CNA from accessing the building and the resident's room led to the serious injury of the resident, highlighting a significant lapse in security and monitoring procedures.
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 118 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sherman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Sherman | 3.1 mi | ★★★★★ | 3 | 0 |
| Texoma Healthcare Center | 5.9 mi | ★★★★★ | 16 | 0 |
| Avir At Sherman | 6.5 mi | ★★★★★ | 5 | 0 |
| Beacon Hill | 9.8 mi | ★★★★★ | 10 | 0 |
| Meadowbrook Care Center | 11.2 mi | ★★★★★ | 4 | 1 |
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.