Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hilltop Village Nursing And Rehabilitation during CMS and state inspections, most recent first.
Pharmacist medication review findings were not followed up for a resident with Parkinson's disease, anxiety, and Alzheimer's disease. The resident's MAR showed Pramipexole was given as 1.75 mg TID, while the chart and blister pack instructions reflected conflicting dosing directions and a psychiatric NP note documented a total intended dose of 1.25 mg TID. Nursing staff were unaware of the discrepancy, the DON had not responded to the pharmacist's clarification request, and the MD later stated the intended total dose was 1.5 mg.
Incorrect Pramipexole Dose Administered: A resident with Parkinson's disease, anxiety disorder, and Alzheimer's disease received an incorrect total dose of Pramipexole. The MAR showed both a 1.5 mg order and a 0.25 mg order being given together for a total of 1.75 mg TID, while a pharmacist note questioned the dose and a psych NP note reflected a different intended total dose. Staff and the DON were unaware of the dosing instructions, and the MD stated the 0.25 mg order had not been discontinued.
Food service staff failed to keep cold foods at proper temperatures and used unsanitary glove handling during meal service. A cook measured tossed salad at 47 degrees F and fruit at 44 degrees F while the items were about to be plated, and the CDM stated cold foods needed to be below 41 degrees F. In a separate observation, parsley was placed on residents' lunch trays with gloved hands that were also touching plates and utensils, and the CDM stated tongs should have been used to avoid cross contamination.
Resident meal preference not honored: A resident with dementia and moderate cognitive impairment repeatedly requested that her dinner remain on her tray so she would not make a mess on the table, but an LVN and CNA initially told her they would clean up after her and removed the meal from the tray. Other residents at the table said they were fine with her preference, and the LVN later acknowledged the resident should have been able to keep her food on the tray because it was her right.
Missing consent for antipsychotic medication: A resident with schizophrenia and intact cognition received Perphenazine without evidence of the required state consent form in the record. The only consent found did not list the dose or frequency, and the DON and ADON acknowledged the form should have been signed before the medication was started.
A resident with cerebral infarction, ataxic gait, transient ischemic attack, and moderate cognitive impairment was supposed to have supervised smoking because he kept buying and hiding cigarettes and lighters and would not comply with supervised smoking times. He was observed smoking alone in the smoking area on two occasions, and he stated he smoked when he wanted because he kept smoking paraphernalia on his person. Staff said residents who smoke were supposed to be supervised and smoking items were supposed to be locked at the nurse's station, but there was no assigned staff member for smoke times.
Delayed Medication Administration: A resident with major depressive disorder and intact cognition did not receive several ordered meds, including an antidepressant, steroid, opioid, anxiolytic, and barbiturate, at the scheduled 8:00 AM time on multiple days. An RN gave the meds late on each occasion, the resident said the delays affected her mental health, and the DON stated timely administration matters because these meds take time to take effect.
Two residents were not served the menu dessert during lunch because the CDM incorrectly believed one resident on a mechanical soft diet and another resident on a diabetic diet could not receive carrot cake. Both residents had severe cognitive impairment and ordered diets that included the dessert per the menu. The CDM later stated the carrot cake was the menu item and that menus should be followed, but the kitchen had substituted carrot cake for bread pudding.
A resident with cerebral infarction, ataxic gait, TIA, and moderate cognitive impairment was supposed to smoke with supervision per the care plan, but was observed smoking unsupervised in the smoking area on two occasions. The resident said he smoked when he wanted because he kept smoking paraphernalia on his person or in his room. Staff stated residents who smoke were to be supervised, smoking items were to be locked at the nurse’s station, and there was no assigned staff member for smoke times, which was inconsistent with the facility’s smoking policy.
Insufficient Bedroom Square Footage in Multiple Resident Rooms: Multiple two-bed resident rooms were found to be below the required 80 sq ft per resident. During the entrance conference, the ADM acknowledged that some rooms did not meet the required square footage, and Form 3762 showed the listed rooms were certified as two-bed rooms without meeting the justification criteria. The measured rooms were documented at about 72.4 to 76.4 sq ft per resident.
A CNA removed towels and briefs from a resident's room without informing or seeking permission, despite the resident's cognitive intactness and care plan interventions for hoarding behavior. The resident became upset and expressed that the CNA did not communicate or explain the removal of her belongings. Nursing staff confirmed that there was no directive to remove these items and that such actions were not in line with resident rights or facility policy.
A resident's family reported to staff that an agency CNA provided rough care during toileting, leaving the resident visibly upset. The DON was informed but did not report the incident to the Administrator or state agency, interpreting it as rudeness rather than potential abuse. The incident was not documented or investigated as required by policy, and the Administrator only learned of the event after surveyor intervention.
A facility failed to investigate and document an allegation of rough care after a resident's family reported that an agency CNA was rough during toileting. The DON did not interview the resident or CNA, did not document the incident, and did not report it to the Administrator, contrary to facility policy. The Administrator only learned of the incident after surveyor intervention, and no investigation was initiated until that point.
A CNA failed to use a gait belt while transferring a resident who required maximum assistance, instead pulling the resident up by her pants during a transfer from the commode to a wheelchair. The resident, who had muscle weakness and urge incontinence, became upset, and family members reported the incident to staff. The facility did not have a policy for one-person or gait belt transfers, contributing to the deficiency.
Four residents with physician orders to self-administer medications were not properly assessed or care planned for this practice, and their ability to safely self-administer was not consistently evaluated by the interdisciplinary team. Medications were stored in unsecured locations, and some residents had medications not ordered for self-administration. Staff interviews revealed a lack of verification and documentation regarding whether self-administered medications were actually taken as ordered, and the DON was unaware of these lapses.
Four residents with physician orders for self-administration of medications were found storing their medications in unsecured locations such as unlocked drawers and on top of bedside tables. Interviews confirmed this was their usual practice, and the facility's policy did not address secure storage for these medications. The DON acknowledged the issue, and the deficiency was identified through observation, interviews, and record review.
A female resident with intact cognition and a history of anxiety and depression was subjected to unwanted sexual exposure by a male resident with severe dementia and chronic wandering. The incident was reported by the resident to multiple staff, but an LVN dismissed the allegations and failed to notify leadership or initiate an investigation. The event only came to the attention of facility leadership after a third-party review, revealing a breakdown in abuse reporting and protection protocols.
A resident with intact cognition reported to staff that another resident exposed himself and masturbated at her doorway on multiple occasions. Despite these allegations being communicated to a CNA and an LVN, the incidents were not promptly reported to facility leadership or the State Survey Agency as required. The LVN dismissed the reports, and the administrator only became aware of the situation through a third-party, leading to a delayed investigation and lack of timely documentation or external reporting.
A resident with respiratory and mobility issues who required partial assistance for showering was left unsupervised by a CNA, resulting in the resident independently exiting the bathroom after waiting for help that did not arrive. The CNA admitted to leaving residents alone during showers, contrary to facility policy, and the incident was confirmed by an LVN and the DON.
A resident with asthma, COPD, and sleep apnea regularly used both oxygen and CPAP therapy, but the facility did not have active physician's orders or care plan interventions for CPAP therapy, and lacked orders for oxygen use while in the facility. Nursing staff and the DON confirmed these omissions, and facility policy requires such orders and care planning for respiratory care.
A resident with cognitive communication deficit was not served her lunch meal while others at her table were eating, leading to feelings of being left out. Despite previous training, staff failed to serve meals table by table, as acknowledged by the Administrator and ADON.
Several residents in a long-term care facility did not receive their scheduled showers due to staffing shortages. These residents, who required assistance with bathing, were left without care, leading to discomfort and a loss of dignity. The facility was short-staffed, with some staff members not showing up for their shifts, which resulted in missed showers and inadequate documentation.
A resident with cognitive and physical impairments was unable to reach their call light during a meal because it was wedged between the wall and mattress. This deficiency was observed when the resident attempted to call for assistance and was confirmed by a CNA who had to retrieve the call light. Interviews with staff, including the DON, highlighted the expectation that call lights should be within reach at all times, as per the facility's policy on assistive devices.
The facility failed to maintain a clean and homelike environment for a resident who had food residue on her wall, and in a hallway where a large barrel was used to contain a ceiling leak. The resident, with moderate cognitive impairment, was observed in a room with a dirty wall, and the hallway setup obstructed residents' movement, causing dissatisfaction.
Two residents in a LTC facility were found to have inaccurate MDS assessments. One resident was incorrectly documented as receiving an anticoagulant instead of an antiplatelet, while another resident's range of motion limitations were not accurately reflected, despite having contractures. These inaccuracies were confirmed by staff and could lead to inadequate care.
The facility failed to coordinate assessments with the PASRR program for two residents. One resident's PASRR Level 1 Screening did not reflect a developmental disability related to Multiple Sclerosis, and another resident's screening did not accurately reflect their mental illness. These discrepancies were confirmed by the MDS nurse, indicating a lack of adherence to the facility's policy requiring prompt referral for Level II resident reviews.
A resident with dysphagia was served a regular diet instead of a mechanically soft diet, and her preference against gravy was not accommodated, leading to decreased food intake. The CDM was unaware of the preference, and the dietary department was not informed of updated diet orders following the resident's hospital stay. This oversight in communication resulted in the resident receiving an incorrect diet.
A resident was prescribed a regular diet but was served a mechanical soft diet with gravy, which she disliked. Despite voicing her preference, the meal ticket was not updated, and the dietary department was not informed of the correct diet order. The DON confirmed the oversight in communication between nursing and dietary staff.
The facility failed to provide necessary special eating equipment for two residents during meal service, affecting their dignity and feeding independence. One resident, with severe cognitive impairment, was observed eating without a plate guard, resulting in food spillage. Another resident, with moderate cognitive impairment, struggled to eat without a divided plate. Staff interviews revealed that the required equipment was on back order, and the facility did not have enough available to meet residents' needs.
A LTC facility failed to maintain an effective infection control program, as evidenced by two incidents. A Medication Aide did not sanitize a blood pressure cuff between two residents, and a CNA failed to change gloves or wash hands while providing incontinent care. Both staff members acknowledged their oversights, despite having received infection control training. The DON confirmed the lapses in adherence to the facility's infection control policies.
The facility failed to meet the required square footage per resident in 15 rooms, with each room measuring between 72.4 and 76.4 square feet instead of the required 80 square feet for multiple resident rooms. The deficiency was confirmed during a survey, and the DON noted that some rooms were intended for single occupancy despite being certified for two residents.
The facility failed to protect residents from verbal abuse by staff, involving an RN and an OT. The RN was reported to have verbally abused two residents, making inappropriate comments about medication and personal hygiene. An OT called a resident a liar and contacted their previous employer, upsetting the resident. These incidents were witnessed by other staff members, and the facility's administrator stated that abuse is not tolerated.
A resident in an LTC facility missed 25 doses of Doxycycline due to a transcription error by an LVN, who entered the medication order incorrectly. The MAR confirmed the absence of administration, and a doctor's note suggested the resident's symptoms were likely neurological. The DON verified the error after a change in facility ownership.
Pharmacist Medication Review Not Followed Up for Pramipexole Order Discrepancy
Penalty
Summary
The facility failed to ensure medication irregularities reported by the consulting pharmacist were reported to the attending physician, the medical director, and the director of nursing, and that the reports were acted upon for one resident reviewed for medications. Resident #4 was an [AGE]-year-old female with Parkinson's disease, anxiety disorder, and Alzheimer's disease. Her quarterly MDS submitted 8/13/2025 showed a BIMS score of 14, indicating intact cognition. A psychiatric NP progress note dated 8/5/2025 documented a treatment plan for Pramipexole totaling 1.25 mg three times daily. Resident #4's active physician orders included Pramipexole 0.25 mg tablet, give 1 tablet by mouth 3 times a day, with instructions to give with 1 mg to equal 1.25 mg for Parkinson's, and Pramipexole 1.5 mg tablet, give 1 tablet by mouth 3 times a day for Parkinson's. The MAR showed the resident received both tablets, totaling 1.75 mg three times a day in June, July, and August 2025. The consulting pharmacist's medication regimen review dated 6/23/2025 asked whether the total dose was 1.75 mg TID and noted the 0.25 mg order in PCC read to equal 1.25 mg, but the follow-through column contained no additional notation for the resident. During interview, the resident reported no concerns with her medication regimen. Two blister packs observed on 8/26/2025 contained Pramipexole 1.5 mg tablets and 0.25 mg tablets, and the 0.25 mg package instructed to give with 1 mg to equal 1.25 mg. Nursing staff stated the resident had been receiving a total dose of 1.75 mg and were unaware of the instructions on the order and blister pack. The DON stated the order should have reflected 1.75 mg total and said she would contact the MD to clarify the order, while later the DON and MD stated the intended dosage was 1.5 mg total and that the 0.25 mg order had not been discontinued in May 2025. The pharmacist stated she had requested clarification on the dosage but had not received a response.
Incorrect Pramipexole Dose Administered
Penalty
Summary
The facility failed to ensure Resident #4 was free from unnecessary drugs when the resident received an incorrect total dose of Pramipexole. Resident #4 was an [AGE]-year-old female with diagnoses including Parkinson's disease, anxiety disorder, and Alzheimer's Disease, and her quarterly MDS reflected a BIMS score of 14. Her active physician orders listed Pramipexole 0.25 mg three times daily with instructions to give with 1 mg to equal 1.25 mg for Parkinson's, and also Pramipexole 1.5 mg three times daily for Parkinson's. Record review of the MAR showed Resident #4 received both doses, totaling 1.75 mg three times daily, during June, July, and August 2025. The consulting pharmacist documented a recommendation questioning whether the total dose was 1.75 mg TID and noted the 0.25 mg order read to equal 1.25 mg, but the follow-through section had no additional notation. A psychiatric NP progress note stated the intended total dose was 1.25 mg three times daily, while later interviews with the DON and MD stated the intended dosage was 1.5 mg total and that the 0.25 mg order had not been discontinued in May 2025. During observation, two blister packs for the resident contained Pramipexole 1.5 mg tablets and 0.25 mg tablets, with the 0.25 mg package instructing to give with 1 mg to equal 1.25 mg. Staff stated they were unaware of the additional instructions and that the resident had been receiving a total dose of 1.75 mg.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed. During an observation on 08/27/25 at 11:47 AM, [NAME] F took the temperature of the tossed salad and found it to be 47 degrees F, and took the temperature of the fruit and found it to be 44 degrees F. These foods were about to be used and plated for lunch trays, and the CDM later stated that the tossed salad and fruit were not at proper temperatures and needed to be cooled before meal service because cold foods needed to be below 41 degrees Fahrenheit. During another observation on 08/27/25 at 12:06 PM, [NAME] G was putting parsley on residents' lunch meals with gloved hands that were also being used to touch residents' plates and utensils on the meal tray. The CDM stated that [NAME] G should have used tongs to place the parsley on the food. Later interviews confirmed that tongs should have been used because [NAME] G was touching everything with the same hands used to handle the parsley, which could cause cross contamination. Record review of the facility's Food safety policy stated that hands must be washed before putting on gloves and after removing gloves, as well as between tasks and between handling raw meats and ready-to-eat foods, and the Food temperatures policy stated that cold foods should be maintained at a maximum of 41 degrees F.
Resident Meal Preference Not Honored
Penalty
Summary
The facility failed to ensure Resident #61 was treated with respect and dignity when she requested to keep her dinner meal on her food tray while eating so she would not make a mess on the dining table. Resident #61 was a female admitted with diagnoses including dementia, cognitive communication deficit, need for assistance with personal care, and lack of coordination. Her quarterly MDS reflected a BIMS score of 10 out of 15, indicating moderate cognitive impairment, and that she needed setup or clean-up assistance for eating. Her care plan stated she was able to feed herself with setup assist by one person. During observation, Resident #61 repeatedly stated that she wanted her dinner to remain on her tray. LVN C and CNA E told her they would clean up after her and not to worry, but the resident continued to request that her meal stay on the tray because she did not want a mess in her area. Other residents at the table stated they were okay with her meal remaining on the tray and that this was her preference. LVN C later stated Resident #61 should be able to have her food on the tray if she wanted because it was her right. CNA E stated she removed the meal from the tray because Resident #61 said it was okay, and added that if the resident wanted it left on the tray, she would have left it there.
Missing Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident had the right to be informed of, and participate in, her treatment when Resident #107 received the antipsychotic medication Perphenazine for schizophrenia without evidence in the medical record of the required state consent form 3713. Resident #107 was admitted and re-admitted with a diagnosis of schizophrenia, and her quarterly MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition. Her order summary showed Perphenazine 4 mg by mouth daily and 12 mg at bedtime for schizophrenia, but the only consent located in the record was a psychoactive medication consent dated 06/16/25 that did not include the dosage or frequency of the medication. The record also showed a care plan problem related to adverse reaction risk from polypharmacy, with an intervention to discuss the number and type of medications and potential drug interactions and side effects. During interviews, the ADON stated psychoactive medication consent should be completed before a resident takes a psychoactive medication and when it is changed, and the DON stated Resident #107 started Perphenazine at the end of May and that the 3613 should have been signed before the resident started the medication. The DON and ADON further acknowledged the form should have been signed before the medication was started. Resident #107 stated she was okay with every medication she took and had given consent for every medication she took.
Unsupervised Smoking and Accessible Smoking Paraphernalia
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents for one resident reviewed for smoking. Resident #51 was admitted with diagnoses including cerebral infarction, ataxic gait, and transient cerebral ischemic attack, and his quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. His care plan stated that he was a smoker who required supervision and was at risk for smoking-related injury because he kept buying and hiding cigarettes and lighters and would not comply with supervised smoking times. On observation, Resident #51 was seen smoking alone in the smoking area on two separate occasions. During interview, he stated that he smoked when he wanted because he kept smoking paraphernalia on his person. Staff interviews confirmed that residents who smoke were supposed to be supervised, that smoking paraphernalia were supposed to be locked at the nurse's station, and that smoking assessments were completed by nursing. However, staff also stated there was no assigned staff member for smoke times. The facility policy stated that it had a responsibility to oversee smoking and provide supervision to maintain an accident-free environment, and that matches, lighters, e-pens, and similar items would not be accessible to residents needing supervision and/or assistance with smoking.
Delayed Medication Administration
Penalty
Summary
Pharmaceutical services were not provided in a timely manner for one resident who was admitted with diagnoses including major depressive disorder and had a BIMS score of 15 out of 15, indicating intact cognition. Record review showed that ordered medications including Duloxetine HCl 30 mg, dexamethasone 4 mg, Methadone HCl 10 mg, Lorazepam 0.5 mg, and PHENobarbital 15 mg were scheduled for 8:00 AM but were administered late on multiple days by Nurse A. On one day, Duloxetine, dexamethasone, Lorazepam, Methadone, and PHENobarbital were given around 10:17 AM to 10:19 AM instead of 8:00 AM. On another day, the same medications were administered at 1:32 PM rather than 8:00 AM, and on a third day they were given between 9:48 AM and 9:51 AM instead of 8:00 AM. During interview and observation, the resident was crying and stated she had not received her medications on time and that it affected her mental health. Nurse A stated she was late giving medications and gave no reason for the delay, and the DON stated timely administration was important because medications take time to take effect, including pain and psychiatric medications. The facility policy stated medications should be requested, received, and administered in a timely manner as ordered by the authorized prescriber.
Menu Not Followed for Two Residents at Lunch
Penalty
Summary
The facility failed to follow the menu for two residents during lunch meal service when carrot cake was substituted for the original dessert and was not served to all residents who were supposed to receive it. Resident #24 was admitted with diagnoses including dementia, muscle wasting and atrophy, vitamin B12 deficiency, and vitamin D deficiency, and had a BIMS score of 06 out of 15 indicating severe cognitive impairment. Resident #24 had an order for a regular diet with mechanical soft texture and thin consistency, and the care plan directed dietary staff to provide the diet as ordered. Resident #76 was admitted with diagnoses including cognitive communication deficit, dysphagia, and anxiety disorder, and had a BIMS score of 04 out of 15 indicating severe cognitive impairment. Resident #76 had an order for a regular diet with regular texture and thin consistency, and the care plan reflected dietary instructions including NAS regular diet, regular texture, thin consistency, and controlled carbohydrate diet. During observation and interview, Resident #24 stated they were not served carrot cake like the residents around them and did not know why they were not served it. Resident #76 also stated she did not receive carrot cake and wanted it. The CDM stated Resident #24 could not get carrot cake because of the mechanical soft diet and Resident #76 could not get carrot cake because she was on a diabetic diet. The CDM later stated the carrot cake was the same item listed on the menu and menus should be followed, and explained the kitchen did not have the original dessert, bread pudding, so carrot cake was substituted. The facility menu for the week reflected frosted carrot cake was offered to diabetic residents and residents on a mechanical soft diet, and the facility policy stated menus must be followed.
Failure to Supervise Smoking Resident and Secure Smoking Materials
Penalty
Summary
The facility failed to follow its smoking policy for one resident who was identified as a smoker requiring supervision. Resident #51 was admitted with diagnoses including cerebral infarction, ataxic gait, and transient cerebral ischemic attack, and his quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. His care plan dated 08/05/2025 stated that he was a smoker with supervision and would adhere to the facility’s tobacco/smoking policies. Resident #51 was observed smoking unsupervised in the smoking area on 8/25/2025 at 11:53 a.m. and again on 8/26/2025 at 9:47 a.m. During interview, the resident stated he smoked when he wanted because he kept smoking paraphernalia on his person or in his room. Staff interviews confirmed that residents who smoke were supposed to be supervised, that smoking paraphernalia were to be locked at the nurse’s station, and that there was no assigned staff member for smoke times. The facility policy stated that it had a responsibility to oversee residents’ use of smoking materials and provide supervision, and that matches, lighters, e-pens, and similar items would not be accessible to residents needing supervision and/or assistance with smoking.
Insufficient Bedroom Square Footage in Multiple Resident Rooms
Penalty
Summary
Rooms #1-5, 7-9, 12-14, 21, 27, 28, and 46 did not meet the required bedroom square footage for multiple resident rooms. During the entrance conference on 08/25/25, the ADM stated that some rooms did not meet the required square footage. A review of Form 3762 (Room Size Waiver) signed by the Administrator on 08/26/25 showed that these rooms were certified as two-bed rooms and did not meet the justification criteria. A review of the undated list of rooms meeting less than the required square footage showed that Rooms #1-5, 7-9, 12-14, 21, 27, 28, and 46 were measured at between 144.8 and 152.8 square feet total, which equaled approximately 72.4 to 76.4 square feet per resident. The report identified these rooms as falling below the required 80 square feet per resident in multiple-occupancy rooms.
Failure to Respect Resident's Personal Space and Belongings
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident's room, supplies, and personal space with respect, contrary to the resident's rights to dignity and self-determination. The resident, a cognitively intact female with chronic obstructive pulmonary disease, major depressive disorder, and generalized anxiety disorder, was known to require supervision for showering and set-up assistance for dressing. The care plan also noted a history of hoarding towels and linens, with interventions focused on positive interaction and calm communication. The incident began when the CNA removed approximately ten towels from the resident's room without informing or seeking permission from the resident, who was outside on a smoke break at the time. The CNA stated that towels were removed due to facility shortages and that this was a routine practice when supplies were low. The CNA also admitted to previously removing briefs from the resident's room, leaving only a small supply, and did not notify or seek direction from nursing staff before doing so. The CNA acknowledged being trained on resident rights and the importance of seeking permission before entering a resident's room or taking belongings but did not follow this protocol in this instance. The resident expressed distress and frustration over the removal of her towels and briefs, stating that the CNA did not ask before taking the items and that it made her feel upset and unsure of the CNA's intentions. Interviews with nursing staff confirmed that there was no directive to remove towels or briefs from resident rooms and that such actions were not appropriate. The facility's policy emphasized treating residents with kindness, respect, and dignity, and staff interviews reiterated that residents have the right to their belongings and to be asked before items are removed from their rooms.
Failure to Timely Report Allegation of Rough Care and Potential Abuse
Penalty
Summary
The facility failed to report an allegation of rough care and possible abuse involving a resident, as required by federal and state regulations. The incident involved a cognitively intact female resident who required maximum assistance with transfers and was being assisted by an agency CNA. The resident's family reported to staff that the CNA had provided rough care during toileting, specifically stating that the CNA pushed the resident down onto the toilet and wiped her roughly, which left the resident visibly upset. The family initially reported the incident to another CNA (who was also the facility scheduler), who then informed the DON. The DON did not speak directly to the resident and did not report the incident to the Administrator or the state survey agency, as required by policy and regulation. The DON interpreted the family's complaint as an issue of rudeness and improper use of a gait belt, rather than as a potential abuse allegation. The DON removed the CNA from caring for the resident but did not initiate a formal report or investigation as required. The CNA involved was allowed to continue working in the facility for at least one additional day before being sent home. The incident was not documented in the facility's self-reported incidents system, and there was no evidence that the Administrator was informed until surveyors intervened and began asking questions. Interviews with staff and the Administrator revealed confusion and inconsistency regarding what was reported and how it was handled. The Administrator only became aware of the incident after surveyor intervention and stated that she would have expected the DON to report the incident if it had been described as abuse. The facility's abuse policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation of resident property, but this policy was not followed in this case. The failure to report the allegation in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate and Document Allegation of Rough Care
Penalty
Summary
The facility failed to thoroughly investigate and document an allegation of rough care and treatment for one resident. The incident involved a cognitively intact female resident who required maximum assistance with transfers and had a care plan indicating the need for one staff member to assist with toileting and transfers. The resident's family reported concerns that an agency CNA provided rough care during toileting, specifically stating the CNA pushed the resident down onto the toilet and was rough when wiping. The family reported the incident to a staff member, who then informed the DON. However, there was no documentation of a formal investigation, and the facility's grievance records did not reflect the complaint. Interviews revealed inconsistencies in staff responses and actions. The CNA scheduler, who was informed of the incident by the family, reported the matter to the DON but did not directly notify the Administrator. The DON stated she did not consider the incident to be abuse, did not interview the resident or the CNA involved, and was unable to produce any documentation or notes regarding the incident, stating that any notes had been shredded. The DON also did not report the incident to the Administrator, as required by facility policy. The Administrator only became aware of the incident after being questioned by a surveyor and confirmed that no investigation had been initiated prior to surveyor intervention. The facility's policy requires all reports of abuse, neglect, or mistreatment to be thoroughly investigated and documented, with findings reported to appropriate agencies. In this case, the facility did not follow its own policy, as there was no evidence of a thorough investigation or documentation of the incident involving the resident. The lack of investigation and documentation could place residents at risk by failing to address and resolve allegations of abuse or neglect.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA), identified as agency staff, failed to use a gait belt while transferring a resident who required maximum assistance with transfers. The resident, a cognitively intact female with diagnoses including generalized muscle weakness and urge incontinence, was care planned to require one-person assistance and the use of a gait belt for transfers and toileting. Despite this, the CNA assisted the resident from the commode to a wheelchair without a gait belt, instead pulling the resident up by her pants, which caused distress to the resident and concern from her family members. Family members reported that the CNA was rough during the transfer and did not use the gait belt that was available in the room. The resident was visibly upset after the incident, and family members relayed their concerns to facility staff. The facility scheduler and the Director of Nursing (DON) were both informed of the incident, with the DON confirming that a gait belt should have been used for safety during transfers. The CNA admitted to not using a gait belt and described assisting the resident by pulling her up by her pants due to the resident's foot getting stuck and her knee locking during the transfer. Further review revealed that the facility did not have a policy in place for one-person or gait belt transfers. The DON acknowledged that agency staff were not provided with additional training and that the facility relied on removing agency staff who did not meet expectations. The lack of a clear policy and failure to ensure the use of appropriate transfer techniques led to the deficiency in providing adequate supervision and assistance devices to prevent accidents.
Failure to Assess, Monitor, and Care Plan for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents with physician orders for self-administration of medications were properly assessed, monitored, and care planned for this practice. Four residents with orders to self-administer medications were not consistently evaluated by the interdisciplinary team for their ability to safely self-administer, and their care plans did not include interventions or focus areas related to medication self-administration. In several cases, documentation of assessments was missing, outdated, or not present in the residents' electronic medical records, and care plan meetings did not reflect discussion or planning for self-administration. Observations revealed that residents were storing medications in unsecured locations, such as unlocked dresser drawers or on top of bedside tables, and in some cases, residents possessed medications that were not ordered for self-administration. For example, one resident had two medications in his possession without physician orders for self-administration and reported difficulty applying a topical medication to an area not specified in the physician's order. Another resident was found with over-the-counter eye drops not prescribed by the facility physician and was unable to articulate the appropriate use of the medication. Interviews with staff, including the DON and nursing staff, indicated a lack of consistent verification and documentation regarding whether self-administered medications were actually being taken as ordered. Staff reported that there was no process for documenting self-administration on the MAR, and verification of administration was not routinely performed. The DON was unaware of these gaps in practice and acknowledged that care plans should include planning for self-administration of medications. The facility's policy required that the interdisciplinary team and physician determine a resident's capacity for self-administration, but this was not consistently implemented.
Failure to Secure Self-Administered Medications in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used by residents with physician orders for self-administration were stored in locked compartments, as required by regulation. Four residents with intact cognition and various medical conditions, including neuralgia, neuropathy, asthma, glaucoma, and chronic pain, were observed storing their self-administered medications in unsecured locations within their rooms. Specifically, medications were found in unlocked dresser drawers, unlocked nightstand drawers, and on top of bedside tables and nightstands, making them accessible to others. Interviews with the residents confirmed that these unsecured storage methods were their usual practice. The Director of Nursing (DON) acknowledged that four residents had physician orders to self-administer medications and stated that staff believed medications were safely stored by keeping them out of reach. However, the DON also indicated that residents were instructed not to keep medications in visible or easily accessible places, which was inconsistent with the observed practices. A review of the facility's policy on self-administration of medications revealed that it did not address the storage of medications in residents' rooms. The lack of secure storage for self-administered medications was identified through direct observation, resident interviews, and record review, demonstrating a failure to prevent unintended access to medications by other residents.
Failure to Protect Resident from Sexual Abuse and Inadequate Reporting
Penalty
Summary
A deficiency occurred when the facility failed to protect a female resident with a history of anxiety disorder, depression, and recent joint replacement from abuse, specifically unwanted sexual exposure by another male resident with severe cognitive impairment and a history of wandering. The female resident reported that the male resident entered her room in a wheelchair and masturbated in front of her. She disclosed the incident to multiple staff members, expressing distress and fear. Documentation in her progress notes confirmed her reports of the male resident's behavior on two consecutive nights. Despite the resident's reports, the staff response was inadequate. A CNA who received the allegations reported them to an LVN on at least two occasions, but the LVN dismissed the concerns, attributing them to confusion and did not escalate the report to facility leadership as required. The LVN did not speak to the resident about the allegations or initiate any investigation, and there was no immediate notification to the administrator or abuse coordinator. The incident only came to the attention of facility leadership after a third-party professional discovered documentation of the event during a chart review, significantly delaying the facility's awareness and response. The male resident involved had a documented history of chronic wandering and was previously observed engaging in sexually inappropriate behavior in a communal area. However, there was no evidence that the facility implemented additional behavioral interventions or supervision in response to these behaviors prior to the incident. The facility's policies required prompt investigation and reporting of abuse allegations, but these procedures were not followed, resulting in a failure to ensure the resident was free from abuse and to report the incident in accordance with federal guidelines.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported within the required two-hour timeframe to the administrator and State Survey Agency (SSA), as mandated by federal and state regulations. Specifically, a female resident with a history of anxiety disorder, depression, and recent joint replacement surgery reported to staff that a neighboring male resident had exposed himself and masturbated at her doorway on multiple occasions. The resident was cognitively intact at the time, as indicated by a recent BIMS score of 15. Despite the resident reporting these incidents to multiple staff members, including a CNA and an LVN, the allegations were not promptly reported to facility leadership or the SSA. The CNA who received the initial reports from the resident stated that she informed the LVN on at least two separate occasions, but the LVN was dismissive and attributed the allegations to resident confusion. The LVN did not report the allegations to the administrator or initiate an investigation, believing the matter was already known or not credible. The social worker only became aware of the incident through a third-party professional and subsequently notified the administrator and initiated an assessment. The administrator confirmed that she was not notified by staff and only began an investigation after being informed by the social worker, well after the initial allegations were made. The facility's internal investigation confirmed the identity of the alleged perpetrator, a male resident with severe cognitive impairment and a history of wandering and inappropriate behavior. However, the incident was not documented in the facility's incident report log for the relevant month, and there was no evidence that the incident was reported to the SSA as required. Interviews with facility leadership revealed uncertainty about reporting requirements and a lack of immediate notification procedures, despite existing policies mandating prompt reporting of abuse allegations.
Resident Left Unsupervised During Shower
Penalty
Summary
A deficiency occurred when a resident with diagnoses including asthma, COPD, lack of coordination, muscle weakness, and unsteadiness on feet, who required partial assistance for showering, was left unsupervised in the shower by a CNA. The resident reported being assisted into the shower and then left alone, after which he used the call light for help but did not receive a response. The resident experienced difficulty breathing due to the heat and humidity and, after waiting approximately 20 minutes, independently ambulated to his wheelchair and exited the restroom without assistance. Interviews confirmed that the CNA left the resident unsupervised to assist another resident or obtain supplies, despite facility policy requiring supervision during showers. The resident reported the incident to an LVN, who confirmed the resident's account. The CNA acknowledged leaving residents unsupervised at times and recognized the potential for harm, such as slipping. The DON confirmed awareness of the incident and facility policy against leaving residents unsupervised during bathing.
Failure to Ensure Physician Orders and Care Planning for Respiratory Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with multiple respiratory diagnoses, including asthma, COPD, and obstructive sleep apnea. The resident was observed to use both an oxygen concentrator and a CPAP device, and confirmed using the CPAP every night and oxygen as needed. However, a review of the resident's medical record revealed there were no active physician's orders for CPAP therapy or for oxygen use while at the facility, despite evidence of regular use. The care plan only addressed PRN oxygen use and did not mention CPAP therapy or its maintenance. Interviews with nursing staff and the DON confirmed that the resident should have had signed physician's orders and care planning for CPAP therapy, and that staff should be monitoring the application of respiratory devices. Facility policy also requires verification of physician's orders and review of the care plan prior to oxygen administration. The lack of appropriate orders and care planning for the resident's respiratory therapies constituted a failure to provide care consistent with professional standards and the resident's comprehensive care plan.
Resident Not Served Lunch Promptly
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not serving her lunch meal while other residents at her table were eating. On the specified date, Resident #94, who had a cognitive communication deficit and required setup assistance for eating, was observed without her lunch meal while two other residents at her table were already eating. A fellow resident had to signal the nursing staff to indicate that Resident #94 had not been served. Resident #94 expressed that this situation occurred frequently, although she could not specify how often, and stated that she felt left out when it happened. The facility's Administrator and Assistant Director of Nursing (ADON) acknowledged during an interview that serving residents table by table was important for quality of care. They admitted that this issue had been a problem in the past, and staff had been trained to serve all residents at a table before moving to the next. However, they speculated that the nursing staff might have been nervous due to the presence of the state agency, despite knowing the correct procedure. The facility's policy on dignity, revised in February 2021, emphasized that residents should be treated with dignity and respect at all times.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary services to maintain good personal hygiene. Specifically, five residents did not receive their scheduled showers on a particular day due to staffing issues. These residents were dependent on staff for assistance with bathing, and the failure to provide this care could lead to a loss of dignity and diminished quality of life. Resident #9, a male with intact cognition but incontinent of bowel and urine, did not receive a shower on the scheduled day. His care plan required extensive assistance with bathing three times a week. Similarly, Resident #36, a female with quadriplegia and intact cognition, was scheduled for showers three times a week but missed her scheduled shower due to short staffing. She expressed discomfort and sadness due to the lack of care. Other residents, including Resident #19, who had osteoarthritis and diabetes, and Resident #13, with multiple sclerosis and dementia, also missed their scheduled showers. The facility was short-staffed on the day in question, with several staff members not showing up for their shifts. This led to a situation where the available staff could not meet the residents' needs, resulting in missed showers and inadequate documentation of care provided.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to communicate their needs to the staff. During an observation, the resident was found sitting up in bed with their lunch meal, and when asked by the surveyor how they would normally get staff's attention, the resident attempted to reach for the call light. However, the call light was wedged between the wall and the mattress, making it inaccessible to the resident. This situation was confirmed when a CNA entered the room and had to pull the call light out from its wedged position. The resident in question had been admitted with diagnoses including Hemiplegia and Hemiparesis following a cerebral infarction affecting the right dominant side, and vascular dementia. The resident's care plan indicated a communication problem, requiring staff to anticipate their needs. Interviews with facility staff, including a CNA and the DON, confirmed that the call light should always be within the resident's reach, and it was the nursing staff's responsibility to ensure this. The facility's policy on assistive devices and equipment also supports the need for such devices to be accessible to residents to aid in their mobility, safety, and independence.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident #17, who was observed with food residue on the wall next to her bed. Despite the resident's habit of wiping her hands on the wall, the housekeeping staff did not adequately clean the area, as confirmed by observations and interviews with staff members. The resident, who has moderate cognitive impairment and requires assistance with personal hygiene, was found in a room with a dirty wall on multiple occasions. The housekeeping supervisor was informed of the issue, but improvements were minimal. Additionally, the facility did not ensure a homelike environment in the D-wing hallway, where a large industrial barrel was placed to contain a ceiling water leak. This setup obstructed the hallway and affected residents' ability to move freely, as noted by residents and staff. The barrel, positioned under a dripping ceiling, was a temporary solution that had been in place for about two weeks, causing inconvenience and dissatisfaction among residents. The maintenance director acknowledged the issue and considered using a smaller container to minimize obstruction.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks for inadequate care. Resident #7's quarterly Minimum Data Set (MDS) inaccurately documented the resident as receiving an anticoagulant medication, when in fact, the resident was receiving Clopidogrel, an antiplatelet medication. This error was confirmed by the MDS nurse, who acknowledged that Clopidogrel should not have been coded as an anticoagulant. The MDS nurse had access to the Resident Assessment Instrument (RAI) for reference but did not utilize it correctly in this instance. Resident #51's quarterly MDS inaccurately reflected that the resident did not have upper or lower range of motion limitations, despite having contractures in both upper and lower extremities. This inaccuracy was confirmed through observation and interviews, where the resident expressed limited mobility in his limbs. The MDS Coordinator acknowledged the inaccuracy and emphasized the importance of accurate MDS assessments to ensure residents receive the necessary assistance, as the MDS drives the care plan. The Director of Nursing stated that a review of the MDS and care plans would be conducted.
Failure to Coordinate PASRR Assessments
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program under Medicaid, specifically for two residents reviewed for PASRR. Resident #29's PASRR Level 1 Screening did not accurately reflect a diagnosis of developmental disability related to Multiple Sclerosis, despite the resident having been diagnosed with Multiple Sclerosis on 01/29/2022. The care plan for Resident #29 indicated a physical functioning deficit related to Multiple Sclerosis, but the PASRR Level 1 Screening showed no evidence of mental illness, intellectual disability, or developmental disability. This discrepancy was confirmed during an interview with the MDS nurse, who was unaware if the PASRR 1 had been updated after the resident's admission. Similarly, Resident #13's PASRR Level 1 Screening did not accurately reflect the resident's mental illness, despite a diagnosis of schizoaffective disorder, bipolar type, and Multiple Sclerosis. The PASRR Level 1 Screening for Resident #13 was positive for mental illness but did not include evidence of intellectual or developmental disability. The MDS nurse confirmed that Resident #13 had a Mental Illness/Dementia Review, despite the diagnosis of mental illness and Multiple Sclerosis. The facility's policy requires prompt referral for a Level II resident review for any resident with a newly evident or possible intellectual disability or related condition, which was not adhered to in these cases.
Failure to Provide Correct Diet and Accommodate Food Preferences
Penalty
Summary
The facility failed to provide a mechanically soft diet to a resident who required it due to oropharyngeal phase dysphagia, instead serving a regular diet during a lunch meal. Additionally, the resident had expressed a preference against gravy, which was not accommodated, leading to decreased food intake. The resident, who was cognitively intact, had previously communicated this preference to staff, but it was not reflected in her meal ticket. The Certified Dietary Manager (CDM) was unaware of the resident's preference and stated that gravy was part of the mechanical soft diet recipe, which was believed to prevent choking hazards. The Director of Nursing (DON) and the CDM acknowledged that the resident should have been on a regular diet following a hospital stay, but the dietary department had not been informed of the updated diet orders. The facility's policy on therapeutic diets emphasizes that diets should align with residents' informed choices and preferences, but this was not adhered to in this case. The oversight in communication between nursing staff and the dietary department resulted in the resident being served an incorrect diet, which could potentially affect other residents with specific diet orders.
Failure to Provide Prescribed Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was prescribed and provided to a resident as ordered by the attending physician. Specifically, a resident who was prescribed a regular diet was instead provided with a mechanical soft diet during lunch on 07/09/24. This discrepancy was observed when the resident expressed dissatisfaction with the meal, particularly due to the presence of gravy, which was not to her preference. The resident had previously communicated her dislike for gravy to the staff, but no action was taken to adjust her meal preferences accordingly. The resident's meal ticket incorrectly reflected a mechanical soft diet, which included gravy, contrary to the doctor's order for a regular diet. The issue was further compounded by a lack of communication between the nursing staff and the dietary department. The Director of Nursing (DON) confirmed that the nursing staff failed to provide the necessary communication form to update the dietary department about the resident's prescribed regular diet. The Certified Dietary Manager (CDM) was unaware of the resident's diet change until after the incident, indicating a breakdown in communication and adherence to the facility's policy on therapeutic diets. The facility's policy requires that diets be determined in accordance with the resident's informed choices and physician's orders, which was not followed in this case.
Failure to Provide Special Eating Equipment for Residents
Penalty
Summary
The facility failed to provide necessary special eating equipment and utensils for two residents during meal service, which could affect their dignity and feeding independence. Resident #21, who has severe cognitive impairment and dysphagia, was observed eating without a plate guard, resulting in food spilling onto her clothes. Despite her care plan and meal ticket indicating the need for a plate guard, staff did not provide one, and it was noted that the dietary manager mentioned they were on back order. Similarly, Resident #63, with moderate cognitive impairment and a history of stroke, was observed struggling to eat without a divided plate, which was part of her dietary requirements. Staff interviews revealed that the facility did not have enough divided plates available, and they were also on back order. The deficiency was further highlighted by staff interviews, where it was revealed that the dietary manager had ordered the necessary equipment weeks prior, but they were still awaiting delivery. The facility's policy on assistive devices and equipment, which mandates the provision and supervision of such devices for resident independence and safety, was not adhered to. The lack of available equipment and the failure to ensure residents had the necessary tools for eating compromised the residents' ability to eat independently and maintain their dignity.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving improper care practices. In the first incident, a Medication Aide did not sanitize a blood pressure cuff between using it on two residents. This oversight was confirmed by the Medication Aide, who acknowledged forgetting to disinfect the cuff, despite having received infection control training within the year. The Director of Nursing (DON) also confirmed that the cuff should have been sanitized between uses to prevent cross-contamination. In the second incident, a Certified Nursing Assistant (CNA) failed to change gloves or wash hands while providing incontinent care to a resident. The CNA touched a bed remote with gloved hands and then proceeded to provide care without changing gloves or sanitizing hands. Additionally, the CNA handled both soiled and clean incontinent pads with the same gloves. The CNA admitted to realizing the mistake after the fact and confirmed having received infection control training within the year. The DON confirmed that the CNA should have changed gloves and sanitized hands after touching contaminated surfaces. Both incidents highlight lapses in adherence to the facility's infection control policies, which require cleaning and disinfecting reusable items between residents and proper hand hygiene practices. The facility's policies, dated 2001 and 2019, respectively, emphasize the importance of these practices to prevent the transmission of infections.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide bedrooms that met the required square footage per resident, as specified by regulations. Specifically, 15 out of 99 rooms were found to be deficient in size, with each room measuring between 72.4 and 76.4 square feet per resident, instead of the required 80 square feet for multiple resident rooms. This deficiency was identified during a survey conducted on July 20, 2024, where measurements were taken and confirmed by the Maintenance Director. The rooms in question were certified for two beds each, yet they did not meet the necessary space requirements. During an interview, the Director of Nursing (DON) mentioned that certain rooms were designated as small and were intended for single occupancy, although they were certified for two residents. The DON was unable to clarify the meaning of the acronym SCU, which was used to label these rooms. A review of the facility's documentation, including Form 3740 and an undated list of rooms with insufficient square footage, confirmed the deficiency. This failure could potentially impact the quality of life for residents by limiting space for personal effects and movement within their rooms.
Verbal Abuse Incidents Involving Staff and Residents
Penalty
Summary
The facility failed to ensure residents' right to be free from verbal abuse, affecting three of the seven residents reviewed for abuse. Specifically, RN A was reported to have verbally abused two residents. In one incident, RN A was witnessed telling a resident that they wanted to spray them with Ativan spray because they were getting on their nerves. In another instance, RN A told a different resident that they couldn't get clean because the staff were busy feeding others. These incidents were corroborated by a CNA who witnessed RN A's behavior. Additionally, the facility failed to protect another resident from verbal abuse by an occupational therapist (OT). The OT was reported to have called the resident a liar and proceeded to verify the resident's past employment by contacting their previous employer, which upset the resident. This incident was witnessed by a physical therapy assistant (PTA) staff member. The facility's administrator, who was not familiar with these incidents due to a recent change in ownership, stated that abuse is not tolerated. The facility's abuse and neglect policy prohibits any form of abuse, including verbal abuse.
Medication Transcription Error Leads to Missed Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the error involved the transcription of a medication order for Doxycycline, an anti-infective prescribed for epididymitis. The Licensed Vocational Nurse (LVN) responsible for transcribing the order incorrectly entered it to be administered every 21 days instead of for 21 days. As a result, the resident missed 25 doses of the medication over a period from early to mid-April. A review of the Medication Administration Record (MAR) confirmed the absence of Doxycycline administration during this time frame. Additionally, a doctor's note from mid-April indicated a trial of Doxycycline for possible epididymitis, although the physician noted that the resident's symptoms were likely neurological and not related to any physical abnormalities. The Director of Nursing (DON), who was not in the position at the time of the incident, verified the missing medication doses upon review.
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Illustrative
What surveyors actually found near you
We read the 105 citations issued within 25 miles in the last 12 months — including the 3 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kerrville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor View Nursing & Rehabilitation | 2.7 mi | ★★★★★ | 3 | 1 |
| Avir At Kerrville | 3.6 mi | ★★★★★ | 21 | 0 |
| River Hills Health And Rehabilitation Center | 4.6 mi | ★★★★★ | 7 | 0 |
| Avir At Comfort | 16.6 mi | ★★★★★ | 10 | 0 |
| Knopp Nursing & Rehab Center Inc | 20.5 mi | ★★★★★ | 17 | 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.