Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Corrigan Ltc Nursing & Rehabilitation during CMS and state inspections, most recent first.
Two residents were not managed under EBP as ordered. One resident with severe cognitive impairment and multiple stage 3 wounds received ADL care from hospice aides who wore gloves but no gowns despite an EBP sign and wound-related orders. Another resident returned after hip surgery with a surgical wound, but no EBP sign or supplies were in place on re-admission, and the admitting nurse said she was not aware EBP was required for surgical wounds. The DON confirmed staff training did not include EBP.
A resident with a history of stroke-related deficits and intermittent explosive disorder hit another resident with a fly swatter in the dining room after stating he wanted to aggravate him, while the other resident, who had Parkinson’s disease and schizoaffective disorder with moderate cognitive impairment, reported he was not hurt but was upset and moved away. The involved resident already had a care plan noting aggression and argumentativeness with staff, and the other resident had a behavior-related care plan tied to bipolar disorder, but neither care plan was revised to address this specific resident-to-resident altercation. Despite the facility’s policy requiring care plan changes and documentation of interventions after such incidents, the behavior toward other residents was not incorporated into a comprehensive, person-centered care plan with measurable objectives and timeframes.
Food Safety Deficiencies in Kitchen and Dining Room: The facility failed to follow food service safety practices when hamburger meat was observed thawing in hot water in a sink without continuous cold-water agitation, a gallon of expired milk was found in an ice chest with mostly melted ice, and an employee plated food with hair hanging out of a hairnet. RN D, the Dietary Mgr, and the Adm stated these issues could cause foodborne illness, and facility policy required proper thawing, proper hair restraints, and disposal of expired foods.
A facility failed to maintain dignity for two residents when catheter urine collection bags were left exposed or only partially covered during observations. One resident with sepsis, muscle weakness, and DM had no privacy cover on the catheter bag and was seen with the bag visible and the door open; another resident with dementia, hydronephrosis, and schizoaffective disorder was observed twice with a privacy bag only half placed over the urine collection bag. RN and the Administrator stated staff were responsible for ensuring catheter privacy covers were in place.
A resident with anxiety disorder, Alzheimer’s disease, and schizophrenia was receiving Lexapro and Seroquel, but the facility did not ensure a GDR was attempted or properly justified as clinically contraindicated. A consultant pharmacist flagged both psychotropic meds for review, and the prescriber’s response of “Disagree. Continue with same dose” was identified by the DON and Administrator as an inadequate rationale.
A resident with no cognitive impairment and another resident with severe cognitive impairment were each found with prohibited chemical products in their rooms: one had Povidone-Iodine 10% solution and the other had an all-purpose cleaning solution. No staff were present during either observation, and interviews confirmed that these items were not allowed in resident rooms and should have been stored separately by nursing or housekeeping staff.
A resident with Alzheimer’s disease, PVD, and poly-osteoarthritis had PRN morphine sulfate ordered for pain/dyspnea. The hospice RN discovered the remaining morphine tablets and narcotic count sheet were missing, and staff searched the facility but could not locate them. One nurse said she placed the empty blister pack and count sheet in the Business Office box, while another said the count was correct at shift change. Because the count sheet was missing, the facility could not reconcile the controlled medication inventory.
A CNA provided incontinent care to a resident with severe cognitive impairment and bowel and bladder incontinence without changing gloves or sanitizing hands when moving from dirty to clean tasks. While using the same gloves, the CNA touched the resident’s clean brief, gown, sheet, blanket, legs, and bed remote control. The CNA, another CNA, an LVN, an RN, the Regional RN, and the ADM all stated that gloves should be changed and hand hygiene performed during incontinent care when moving from dirty to clean.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and that supervision was lacking.
A resident with a history of MDRO and requiring contact isolation did not receive care in accordance with enhanced barrier precautions. An LVN failed to wear a gown while administering medication via a gastrostomy tube, despite signage indicating the need for such precautions. The DON confirmed that staff were expected to use enhanced barrier precautions for residents with indwelling medical devices.
The facility did not ensure that new staff, including two LVNs and two CNAs, completed mandatory effective communication training during orientation. This oversight was due to the training not being included in the computer system's Required Orientation Trainings. The BOM/HR confirmed the omission, and the administrator acknowledged the expectation for all new hires to complete required training before starting work.
The facility did not ensure that two newly hired LVNs completed dementia management training during their orientation. The BOM/HR admitted to missing this requirement, and the Administrator emphasized the expectation for all new hires to complete necessary training before starting work.
The facility did not ensure QAPI training was completed for four new hires, including two LVNs and two CNAs, during their orientation. The BOM/HR admitted the training was not included in the required orientation trainings, leading to the oversight. The Administrator expected all new staff to complete necessary training before starting work, emphasizing the risk of staff being unaware of facility procedures.
The facility did not ensure compliance and ethics training was completed for four new employees during orientation. The training was missing from the Required Orientation Trainings in the computer system, leading to its omission. The BOM/HR and Administrator acknowledged the oversight, which could result in staff being unprepared to handle issues or interact appropriately with residents.
The facility did not ensure that two new CNAs completed dementia management training during orientation. The training was not included in the Required Orientation Trainings in the computer system, leading to its omission. The BOM/HR acknowledged the oversight, and the Administrator confirmed that all new hires were expected to complete required training before starting work.
The facility did not provide behavioral health training to four new employees, including two LVNs and two CNAs, during their orientation. The training was omitted from the Required Orientation Trainings in the computer system, as confirmed by the BOM/HR. The Administrator expected all new hires to complete this training before starting work, emphasizing the risk of staff being unprepared to handle resident issues.
A facility failed to ensure proper care for a resident with a g-tube by not administering water flushes per gravity as required. The resident, diagnosed with dysphagia, had specific orders for g-tube medication and water flushes, which were not followed by the LVN during an observed medication administration. This deviation from protocol was confirmed by the DON and Administrator, indicating a failure to adhere to the facility's policy on gastrostomy feedings.
A resident with Parkinson's disease and cerebral infarction did not receive Peridex mouthwash as ordered by her physician following a dental procedure. The medication was not available in the facility, and there was a lack of communication among staff regarding its unavailability. The DON was unaware of the issue, which could lead to increased infection and delayed healing.
The facility failed to ensure that a new CNA completed Resident Rights training during orientation. The BOM/HR acknowledged the oversight, and the Administrator emphasized the expectation for all new hires to complete required trainings before starting work, noting potential negative outcomes if staff are uninformed.
A resident with multiple health conditions and moderate cognitive impairment was verbally and physically abused by a CNA in a LTC facility. The CNA yelled, cursed, and aggressively removed the resident's clothes despite her resistance, leading to the resident feeling unsafe. The incident was reported by another CNA, and the facility's investigation confirmed the abuse.
A resident with a history of falls and multiple health conditions fell while entering a transport van due to a malfunctioning lift, resulting in knee pain. The facility failed to immediately notify the resident's physician and family, as required by policy, potentially delaying necessary medical care.
A resident's personal information was misappropriated by a CNA student, leading to attempted identity theft. The resident, with severe cognitive impairment, had their information used to apply for car loans and cash advances. The facility's failure to secure personal information and prevent access by unauthorized individuals resulted in this deficiency.
A resident with multiple health conditions was verbally and physically abused by a CNA, but the incident was not reported immediately as required. The delay in reporting by another CNA could have placed the resident at further risk. The facility's policy mandates immediate reporting of such incidents to prevent harm.
Failure to Use Enhanced Barrier Precautions for Two Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents who were identified for enhanced barrier precautions (EBP). One resident had chronic kidney disease, Alzheimer’s disease, severe cognitive impairment, and stage 3 pressure ulcers with multiple wound treatment orders. Her physician orders required staff to wear a gown and gloves for dressing, bathing, transferring, hygiene, toileting, device care, and wound care, but there was no EBP care plan available for review. During an observation, two hospice aides were providing ADL care in her room while wearing gloves but not gowns, despite an EBP sign posted at the door that specified gown and glove use for high-contact care activities. No EBP supplies were observed available for use in or near the room. Interviews confirmed that the hospice aides did not use gowns during care and one aide stated she had provided care to the resident for over a year and had never used a gown. The other hospice aide said she was filling in for the usual aide, did not notice the EBP sign, and provided a bed bath and incontinent care while wearing gloves and using hand sanitizer as needed. The DON, who also served as the Infection Preventionist, stated staff were trained to use EBP as necessary and confirmed that failure to follow EBP could contaminate clothes and spread infection from resident to resident. She also stated that anyone providing hands-on care should wear EBP and that signs were used to make outside providers aware of the precautions. The second resident was re-admitted after surgery for a left hip fracture and had a surgical wound/incision with physician orders for daily wound care. Her care plan later indicated that EBP would be used, and her physician orders required staff to wear a gown and gloves for wound care and other high-contact activities. However, when she returned to the facility, there was no EBP sign or supplies observed near her room, and the admitting nurse acknowledged she was not aware EBP was required for surgical wounds. The DON later confirmed that after reviewing the chart, there had been no EBP signage or supplies for this resident and stated this was an oversight by the admitting nurse. The RDC also confirmed that staff infection control training did not include EBP.
Failure to Update Behavior Care Plan After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes addressing a resident’s behavior toward other residents after a documented incident of aggression. One male resident with diagnoses including hemiplegia and hemiparesis following stroke, intermittent explosive disorder, personality change due to a physiological condition, and anxiety disorder had a significant change MDS indicating he was cognitively intact (BIMS-15) and usually able to make himself understood and understand others, with no aggressive behaviors noted on that assessment. His existing care plan, dated several months prior, identified him as aggressive and argumentative with staff, with interventions such as administering medications as ordered, intervening to protect the rights and safety of others, and referral to counseling services. However, this care plan was not reviewed or updated to address his behavior toward other residents after a specific resident-to-resident incident. On a date in November, an incident report completed by an LVN documented that this resident, while in the dining room, hit another male resident with a fly swatter. When questioned, the resident stated that the other resident had called him his “kid brother” and that he wanted to aggravate him, so he hit him with the fly swatter. The facility’s investigation confirmed that the resident hit the other resident with a fly swatter, that both residents were separated and assessed, and that there were no injuries. The second resident, who had diagnoses including Parkinson’s disease, anxiety, and schizoaffective disorder–bipolar type, had a significant change MDS showing moderate cognitive impairment (BIMS-9), an acute change in mental status with fluctuating inattention and disorganized thinking, and no aggressive behaviors noted. His care plan identified a behavior problem related to bipolar disorder with weekly counseling services, but there is no indication in the report that his care plan was revised in response to the altercation. Interviews further clarified the circumstances and the lack of care plan revision. The second resident reported that the first resident hit him with a fly swatter to bother him after he referred to the first resident as his little brother, that he was not hurt, and that he was not afraid and remained friends with him. The first resident stated he hit the other resident to irritate him and not to cause harm. A third resident reported witnessing the incident, stating that the first resident was trying to irritate the second resident, who became upset and moved to another table, and that he had not previously seen the first resident hit this or any other resident. The Administrator and DON acknowledged there was no prior history of aggression by the first resident toward other residents and stated that the care plan was supposed to be reviewed and updated after the incident and upon readmission from a behavioral hospital, but this was not completed or saved in the electronic record. The facility’s own policy on resident-to-resident altercations required making necessary changes in care plan approaches for involved residents and documenting interventions and their effectiveness, which was not carried out in this case.
Food Safety Deficiencies in Kitchen and Dining Room
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During an observation on 9/15/2025 at 8:20 a.m., hamburger meat was found thawing in a kitchen sink in hot water, with no water continuously agitating the surface of the water. The water was steaming and hot to the touch. At the same time, a gallon of milk was observed out of date, with a September 13th, 2025 expiration date, and it was stored in an ice chest with mostly melted ice. During an observation on 9/15/2025 at 12:12 p.m. in the dining room, [NAME] E did not have all of her hair in a hairnet while plating food, and her hair was hanging out of the hairnet down her back. [NAME] E also brought out a bowl containing ice, mighty shakes, and a gallon of milk that had expired on September 13th. During interviews, RN D, the Dietary Manager, and the Administrator stated that improperly thawed meat, improperly worn hairnets, and expired food could cause foodborne illness, and the Administrator stated that facility policy required meat to be thawed properly, hairnets to be worn properly, and expired foods to be thrown out.
Resident catheter bags left exposed to public view
Penalty
Summary
The facility failed to treat residents with respect and dignity for 2 of 14 residents reviewed for resident rights when catheter urine collection bags were exposed to the public or not properly covered. Resident #3, a male admitted with diagnoses including Streptococcal sepsis, muscle weakness, and type 2 diabetes, had a BIMS score of 13 and required maximal assistance for transfers. He was observed on 9/15/25 with his catheter bag exposed and no privacy cover, and again on 9/16/25 lying in bed with his catheter bag visible to the public and his door open, with no privacy bag over the urine collection bag. Resident #18, a female admitted with diagnoses including dementia, hydronephrosis, and schizoaffective disorder, had a BIMS score of 10 and was dependent for all needs. She was observed on 9/15/25 at 9:05 a.m. and again at 3:12 p.m. with her catheter bag exposed to the public; a privacy bag was present but only half placed on the urine collection bag, leaving the bottom half exposed. During interviews, an RN stated nurses and CNAs were responsible for ensuring privacy covers were on catheter bags, and the Administrator stated the CNA or assigned nurse should ensure the privacy covers were in place.
Failure to Document Proper Rationale for Psychotropic GDR
Penalty
Summary
The facility failed to ensure that a resident who was receiving psychotropic medications had gradual dose reductions and behavioral interventions attempted unless clinically contraindicated. Resident #35 was a female with diagnoses including anxiety disorder, Alzheimer’s disease, and schizophrenia. Her annual MDS indicated she was usually able to understand others and make herself understood, and her BIMS score was 15, indicating intact cognition. Her medication orders included escitalopram 10 mg daily and quetiapine 100 mg twice daily. A consultant pharmacist/physician communication identified both Lexapro and Seroquel as psychoactive medications due for review and requested evaluation for a trial dose reduction or documentation that a dose reduction was clinically contraindicated. The physician response was documented as “Disagree. [continue with] same dose.” During interviews, the DON stated this was not a good rationale for not attempting a GDR, and the Administrator stated the physician should have provided a proper rationale for continuing the dose. The facility policy stated that residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions unless clinically contraindicated.
Prohibited chemicals left in residents’ rooms
Penalty
Summary
The facility failed to keep prohibited items out of two residents’ rooms, leaving Povidone-Iodine 10% solution in one resident’s room and an all-purpose chemical cleaning solution in another resident’s room. Resident #3 was admitted with diagnoses including Streptococcal Sepsis, muscle weakness, and Type 2 diabetes, had a BIMS score of 13 with no cognitive impairment, required maximal assistance for transfers, and had a care plan problem for impaired visual function and ADL self-care performance deficit. During observation, a bottle of Povidone-Iodine 10% solution was found on a dresser next to the resident’s refrigerator, and the resident did not know what the solution was for; no staff were present providing care at the time. Resident #31 was admitted with diagnoses including Alzheimer’s disease, General Anxiety Disorder, and adult failure to thrive, had a BIMS score of 06 indicating severe cognitive impairment, and was dependent or required moderate assistance with most ADLs. During observation, a bottle of all-purpose chemical cleaning solution was found in the resident’s room with no staff actively cleaning. During interview, RN D stated that iodine and chemical cleaning solutions were not allowed in residents’ rooms and should be stored separately, and the Administrator stated that these items should not have been left in residents’ rooms and that cleaning products should be kept by housekeeping while iodine should be kept on the nurses’ medication cart.
Controlled Drug Count Not Reconciled
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for one resident receiving morphine sulfate for pain/dyspnea. Resident #28 was an elderly female with Alzheimer’s disease, peripheral vascular disease, and poly-osteoarthritis, and her annual MDS indicated she was unable to complete the BIMS interview and was sometimes able to make herself understood and understand others. Her physician order was for morphine sulfate 15 mg by mouth every 12 hours as needed, starting 08/07/25. Record review showed the morphine was not administered during August 2025, and in September 2025 it was administered on 09/12/25 and 09/13/25. An investigative report stated that on 09/15/25 a hospice RN was reviewing medications for refills and discovered that the remaining morphine tablets were missing, along with the narcotic count sheet. Staff searched medication carts, the med room, drug destruction areas, medication storage, and the shredder box, but the medication and count sheet were not found. The report stated that the medication had been ordered in a quantity of 10 tablets and that 2 tablets had been given, leaving 8 tablets presumed missing, but there was no count sheet to verify the amount. Interviews documented that one nurse said she administered the last dose on 09/13/25 and placed the empty blister pack and narcotic count sheet in the Business Office box before the end of shift, while another nurse said there were still 8 or 9 pills left after her administration on 09/12/25 and that the count was correct at shift change. The DON stated the nurse should have followed the facility’s procedure for disposal of controlled medications and that the empty medication card should have been torn and shredded, but the facility was unable to locate the morphine medication or the count sheet and could not reconcile the drug. The facility policy required controlled substances to be monitored and reconciled, with end-of-shift counts by incoming and outgoing nurses and proper documentation of waste or disposal.
Failure to Change Gloves and Perform Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents reviewed for infection control practices. The deficiency involved a resident with hypertension, diabetes, dementia, and Alzheimer’s disease who had a BIMS score of 3, indicating severe cognitive impairment, and who was always incontinent of bowel and bladder. Her care plan identified impaired cognitive function/dementia and bowel and bladder incontinence. During an observation and interview, a CNA provided incontinent care to the resident with another CNA assisting. The CNA did not change her gloves or sanitize her hands until after she had finished care and repositioned the resident. While using the same gloves, she touched the resident’s clean brief, gown, sheet, blanket, legs, and the bed remote control. The CNA stated that she failed to change her gloves and forgot to do so. During interviews, the CNA said she got confused and touched clean items and the resident with dirty gloves, which she identified as an infection control issue and a risk of contamination. The assisting CNA, an LVN, an RN, the Regional RN, and the ADM all stated that staff should change gloves and sanitize hands when moving from dirty to clean during incontinent care, including after cleaning the front peri area and before going to the back area, and again after cleaning the back area. Record review showed the CNA was proficient in handwashing and perineal care, and facility policies stated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and that gloves should be removed and hands washed after incontinent care.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or inactions leading to this deficiency were observed by surveyors, but no further details about the individuals involved or the exact nature of the hazards are provided.
Failure to Use Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN G during a medication administration for a resident with a gastrostomy tube. The resident, who was admitted with a history of Multi Drug Resistant Organism (MDRO) and required contact isolation, was not provided care in accordance with enhanced barrier precautions. Specifically, LVN G did not wear a gown while administering medication, despite a sign on the resident's door indicating the need for such precautions. Interviews conducted during the investigation revealed that LVN G acknowledged the oversight and confirmed her training on contact isolation and enhanced barrier precautions. The Director of Nursing (DON) also stated that nursing staff were expected to use enhanced barrier precautions for residents with indwelling medical devices to prevent the spread of MDROs. The facility's policy on Enhanced Barrier Precautions, dated August 2022, outlined the requirement for gowns and gloves during high-contact resident care activities, including device care such as feeding tubes.
Failure to Provide Effective Communication Training to New Staff
Penalty
Summary
The facility failed to ensure that four new employees, specifically two Licensed Vocational Nurses (LVN A and LVN B) and two Certified Nursing Assistants (CNA C and CNA D), received mandatory training in effective communication during their orientation. This deficiency was identified through interviews and record reviews, which revealed that the communication training was not included in the Required Orientation Trainings in the computer system. As a result, the training was not completed for these employees. The Business Office Manager/Human Resources (BOM/HR) confirmed during an interview that the training was omitted from the orientation process. The facility administrator acknowledged the expectation that all new hires should complete required training before starting work, noting that the lack of training could lead to staff being unprepared to handle issues or interact appropriately with residents.
Failure to Provide Dementia Management Training to New LVNs
Penalty
Summary
The facility failed to ensure that two new employees, LVN A and LVN B, received the required training on dementia management during their orientation period. LVN A was hired on 03/29/24, and LVN B was hired on 04/22/24. A review of employee files confirmed that neither had completed the necessary dementia management training. During an interview, the BOM/HR acknowledged that the training had not been completed and admitted to overlooking this requirement. The Administrator expressed that all new hires were expected to complete the required training before starting work, highlighting the potential for staff to be unprepared to handle issues or interact appropriately with residents.
Failure to Complete QAPI Training for New Staff
Penalty
Summary
The facility failed to ensure that Quality Assurance and Performance Improvement (QAPI) training was completed for four new employees during their orientation. The employees involved were two Licensed Vocational Nurses (LVN A and LVN B) and two Certified Nursing Assistants (CNA C and CNA D), who were hired between March and July 2024. A review of employee files revealed that these staff members did not receive QAPI training as part of their orientation process. During interviews, the Business Office Manager/Human Resources (BOM/HR) acknowledged that the QAPI training was not included in the required orientation trainings in the computer system, resulting in the oversight. The Administrator expressed that she expected all new hires to complete the required training before starting work, highlighting the potential negative outcome of staff being unaware of facility procedures and appropriate resident care.
Failure to Complete Compliance and Ethics Training for New Employees
Penalty
Summary
The facility failed to ensure that compliance and ethics training was completed for four new employees during their orientation. Specifically, LVN A, LVN B, CNA C, and CNA D did not receive the required training upon their hire dates. This oversight was due to the training not being included in the Required Orientation Trainings in the computer system, as acknowledged by the BOM/HR during an interview. The Administrator confirmed that all new hires were expected to complete the necessary training before starting work, highlighting the potential negative outcome of staff being unprepared to handle issues or interact appropriately with residents.
Failure to Complete Dementia Management Training for New CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed dementia management training during their orientation period. This deficiency was identified for two new CNAs, referred to as CNA C and CNA D, who were hired on 07/25/24 and 05/09/24, respectively. A review of employee files revealed that neither CNA had completed the required dementia management training. During an interview, the Business Office Manager/Human Resources (BOM/HR) acknowledged that the training was not included in the Required Orientation Trainings in the computer system, resulting in its omission. The Administrator confirmed that all new hires were expected to complete required training before starting work, and the lack of training could lead to staff being unprepared to handle issues or interact appropriately with residents, particularly those with dementia.
Failure to Provide Behavioral Health Training During Orientation
Penalty
Summary
The facility failed to ensure that behavioral health training was completed for four new employees, specifically two Licensed Vocational Nurses (LVN A and LVN B) and two Certified Nursing Assistants (CNA C and CNA D), during their orientation. The employee files indicated that these staff members, hired between March and July 2024, did not receive the required behavioral health training. During interviews, the Business Office Manager/Human Resources (BOM/HR) acknowledged that the training was not included in the Required Orientation Trainings in the computer system, resulting in its omission. The Administrator expressed that she expected all new hires to complete the necessary training before starting work, highlighting the potential negative outcome of staff being unprepared to handle resident issues appropriately.
Failure to Properly Administer G-Tube Water Flushes
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received appropriate care and services to prevent complications. Specifically, the facility did not ensure that the Licensed Vocational Nurse (LVN) flushed the resident's gastrostomy tube (g-tube) with 30 cc of water before and after administering medication by gravity, as per the physician's orders and facility policy. This oversight was observed during a medication administration session, where the LVN pushed water into the g-tube instead of allowing it to flow by gravity, which could lead to potential gastric complications. The resident involved was admitted with a diagnosis of dysphagia and had orders for all feedings and medications to be administered via g-tube, with specific instructions for water flushes before and after medication administration. The facility's policy on gastrostomy feedings emphasized the importance of giving water flushes slowly and not forcing them, to prevent g-tube clogging or gastric issues. Interviews with the LVN, Director of Nursing (DON), and the Administrator confirmed that the water flushes should have been administered per gravity, highlighting a deviation from the established protocol.
Failure to Administer Ordered Medication
Penalty
Summary
The facility failed to provide pharmaceutical services by not administering Peridex mouthwash to a resident as ordered by her physician. The resident, a female with Parkinson's disease and cerebral infarction, was supposed to receive Peridex mouth/throat solution twice daily for 14 days following a dental procedure involving the extraction of four teeth. However, the Medication Administration Record indicated that the resident did not receive the mouthwash on several consecutive days. Interviews with staff revealed that the Peridex was not available in the facility, and there was a lack of communication among staff members regarding the unavailability of the medication. The Licensed Vocational Nurse (LVN) responsible for ordering the medication was off work for three days, and upon returning, discovered that the Peridex had not been delivered. The Director of Nursing (DON) was unaware of the situation and emphasized the importance of administering medications as ordered to prevent potential negative outcomes such as increased infection and delayed healing.
Failure to Complete Resident Rights Training for New CNA
Penalty
Summary
The facility failed to ensure that a new employee, CNA C, completed the required Resident Rights training during orientation. CNA C was hired on 07/25/24, but the training was not completed as part of the orientation process. This oversight was confirmed during an interview with the BOM/HR, who acknowledged that the training had been missed. The Administrator also confirmed that all new hires are expected to complete required trainings before starting work, highlighting the potential negative outcome of staff being unaware of procedures for resolving issues or interacting appropriately with residents.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with multiple diagnoses, including type 2 diabetes, hypothyroidism, schizophrenia, bipolar disorder, major depression, and anxiety disorder. The resident, who had moderate cognitive impairment, was usually able to make herself understood and understood others. On the evening of the incident, the resident was resistive to care, refusing to have her clothes changed, which was documented in her care plan. The abuse occurred when CNA A yelled, cursed, and aggressively removed the resident's clothes after the resident refused to comply. The resident reported shoulder pain following the incident, although no physical injuries were observed. The incident was reported by another CNA who overheard the altercation and noted the change in CNA A's tone to one that was cruel and angry. The resident confirmed the abuse during interviews with facility staff and the Ombudsman, expressing that she felt unsafe with CNA A providing her care. The facility's investigation confirmed the verbal and physical abuse, and CNA A was suspended during the investigation. The resident's care plan included interventions to allow her to make decisions about her treatment regimen and to provide clear explanations of care activities, which were not followed during the incident. The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program emphasized the residents' right to be free from abuse, which was violated in this case.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to immediately inform a resident, consult with the resident's physician, and notify the resident's representative following an accident that resulted in injury. This deficiency was identified for one of the ten residents reviewed for notification of changes. The incident involved a resident who fell while attempting to enter a transport van, resulting in knee pain that required physician intervention. The resident, a female with a history of cerebral infarction, peripheral vascular disease, type 2 diabetes, major depression, and anxiety disorder, was cognitively intact and required assistance for mobility. On the day of the incident, the transport van's lift was not functioning, necessitating the resident to use the van steps. During this process, the resident's knee gave out, causing her to fall onto a staff member. Although the resident initially reported no pain, she later complained of knee pain upon returning to the facility. Despite the resident's complaints of pain, the facility staff did not notify the resident's physician or responsible party immediately. The resident's representative only became aware of the fall after the resident mentioned it the following day. The facility's policy required that such incidents be reported to the physician and family, but this was not done in a timely manner, potentially delaying necessary medical care.
Misappropriation of Resident's Personal Information by CNA Student
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal information by a CNA student, leading to attempted identity theft. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including Parkinson's disease and schizophrenia. The resident's personal information, such as date of birth and social security number, was used by the CNA student to attempt to obtain car loans and cash advances without the resident's knowledge or consent. The facility's administrator was informed of the incident by the resident's family member, who discovered the misuse of personal information when reviewing the resident's mail. The CNA student, who was no longer employed at the facility at the time of discovery, had allegedly accessed the resident's information either verbally, from the resident's room, or from the resident's paper chart. The administrator reported the incident to the local police department for investigation. Observations revealed that resident paper charts, including the resident's personal information, were easily accessible at the nurses' station. Despite training on abuse, neglect, and misappropriation of property, the CNA student was able to exploit the resident's information. The facility's policies on securing personal information and preventing misappropriation were not effectively implemented, leading to this deficiency.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by federal regulations. Specifically, a certified nursing assistant (CNA B) did not report an incident of verbal abuse involving another CNA (CNA A) and a resident until the following morning, well beyond the mandated two-hour reporting window. This delay in reporting could potentially place residents at risk for further abuse and neglect. The incident involved a resident with multiple diagnoses, including type 2 diabetes, hypothyroidism, schizophrenia, bipolar disorder, major depression, and anxiety disorder. The resident was usually able to make herself understood and had moderate cognitive impairment. On the evening of the incident, CNA A was overheard by CNA B verbally abusing the resident, using a cruel and angry tone, and physically forcing the resident to remove her clothing against her will. The resident later confirmed the verbal and physical abuse, although no physical marks or bruising were observed. Interviews with facility staff revealed that CNA B reported the incident to the Licensed Vocational Nurse (LVN C) the following morning, who then informed the Director of Nursing (DON) and the Administrator. The facility's policy requires immediate reporting of abuse allegations to the charge nurse, DON, or Administrator. The delay in reporting by CNA B was acknowledged by the DON and Administrator, who emphasized the importance of timely reporting to prevent further harm to residents.
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 80 citations issued within 25 miles in the last 12 months — including the 8 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 Corrigan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diboll Nursing And Rehab | 12 mi | ★★★★★ | 17 | 0 |
| Groveton Nursing Home | 19 mi | ★★★★★ | 4 | 0 |
| The Bradford At Brookside | 19.7 mi | ★★★★★ | 12 | 0 |
| Pinecrest Retirement Community | 22.5 mi | ★★★★★ | 2 | 0 |
| Castle Pines Health And Rehabilitation | 23.2 mi | ★★★★★ | 1 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Corrigan Ltc Nursing & Rehabilitation.
100% money-back within 48 hours.
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.