Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Knopp Nursing & Rehab Center Inc during CMS and state inspections, most recent first.
Inaccurate MDS assessments failed to capture key diagnoses and meds for two residents. One resident’s MDS omitted depression, anxiety, and psychotropic/antidepressant use despite orders for fluoxetine and alprazolam and related care plan entries. Another resident’s MDS omitted Alzheimer’s disease and depression-related information despite hospital referral documentation, donepezil therapy, and a care plan noting depression and psych consult follow-up. The MDS Coordinator, DON, and RN A described limited review and no audit process for assessment accuracy.
Nurse aide competency requirements were not met for two NAs. Record review showed one NA had been employed well beyond 4 months without taking the required test, and another NA had no certificate of completion and unclear enrollment status in a competency program. The BOM and DON acknowledged the missing completion, and the DON stated there was no facility policy for nurse aide competency program completion.
Failure to complete annual nurse aide performance reviews and related in-service education: The facility did not complete required yearly performance reviews for three nurse aides, and the DON stated no staff performance reviews were done. The BOM was unsure where the reviews were kept, NA E said she had never had a scheduled review of her overall job performance, and the ADM said staff were only spoken to as needed rather than through a formal review process.
A resident’s bedside drawer contained a partially used tube of MediHoney gel, and an NA removed it during catheter care and applied it to the resident’s skin even though there was no order for MediHoney gel. The NA said she thought it was the same as barrier cream, while another NA said the usual barrier cream looked different and she had not checked with the nurse before care. The LVN and DON stated the gel should have been stored securely in the med cart or med room.
Insufficient food and nutrition staffing was identified when the facility went without a qualified dietician or other clinically qualified nutrition professional for a period and did not have a full-time dietary leader. The FSS worked less than 25 hours per week at the facility while also covering another facility, and interviews showed she was handling resident assessments and diet-related care decisions with the DON and speech therapist during the vacancy. Records showed a consultant RD agreement and policy calling for regular consultant visits, but the facility had not maintained a qualified dietician on site during the lapse.
The facility failed to maintain infection control in the laundry area and for a resident with a urinary catheter. Clean clothing was stored in the same room used to sort soiled laundry, no PPE was available in the sorting area, and the DON said she did not oversee laundry as part of infection prevention. A resident with a catheter did not have TBP initiated when first observed, later had Contact Precautions and EBP signs posted, and soiled linen was placed directly into a bin with other unbagged linen.
A resident council repeatedly raised concerns about dietary items, housekeeping, laundry, maintenance, and activities, but the facility did not document its responses, actions, or rationale. The AD said concerns were handled verbally or by text with dept heads and not recorded, while the DON was unsure whether the grievances from council meetings were being documented. Facility policy required prompt investigation, acknowledgment, and follow-up on complaints.
A resident admitted with weakness had a urinary catheter order and was observed with the catheter in place, but the baseline care plan did not include TBP or complete catheter care planning. The DON said she was responsible for care planning, had no formal process for creating or revising care plans, and believed staff would know the needed care from the MD orders; the resident’s door initially lacked TBP signage, and later had signs for Contact Precautions and EBP.
A resident with an indwelling urinary catheter did not receive proper catheter care when an NA grasped the tubing and cleansed in a way that made the tubing taut, causing the resident to verbalize discomfort. The NA also applied MediHoney gel to the resident’s skin without a physician order, believing it was barrier cream, while the LVN and DON confirmed there was no order for that product and that staff are trained to support catheter tubing to avoid traction during care.
RN coverage and DON designation deficiencies were identified when the facility did not have an RN on duty for 8 consecutive hours on two shifts because the assigned RN used PTO, and an LVN covered nursing care during those times. The facility also did not have a full-time RN DON; one RN identified herself as a Charge Nurse with no DON oversight duties, while the DON stated she was actually an ADON serving as acting DON until completing RN school.
Medication error rate exceeded the allowed threshold after observation and record review showed two residents had medication administration errors. An LPN gave one resident's Donepezil after the ordered time and failed to administer another resident's Pantoprazole because the dose was unavailable, while both MARs were documented as if the meds had been given; the DON stated the LPN should not have documented a med she did not administer.
A resident with severe cognitive impairment and physical dependency fell and broke her leg during a transfer when a CNA attempted to use a mechanical lift without the required assistance of another staff member. The facility failed to ensure staff followed protocols for resident transfers, and there was a lack of in-service training on the use of mechanical lifts.
The facility failed to report allegations of abuse and neglect involving three residents. A resident with severe cognitive impairment was injured during a transfer by a single CNA, resulting in a broken leg. Another resident reported feeling threatened by a family member while on pass, and a third resident's oxygen supply was turned off by a roommate. These incidents were not reported to the state agency as required.
A facility failed to investigate and report allegations of abuse and neglect involving three residents. One resident suffered a broken leg during an improper transfer, another felt threatened by a family member while on pass, and a third had their oxygen therapy disrupted by a roommate. These incidents were not reported to the state agency, contrary to facility policy.
A facility reported a medication error rate of 7.69%, exceeding the acceptable 5% threshold. Two residents received medications incorrectly: one had an extended-release tablet crushed, and the other had a delayed-release capsule opened and mixed with applesauce. These actions were against FDA guidelines and were observed during administration. RN G acknowledged the errors and reported them to the DON.
A facility failed to involve a resident and their family in the care plan development process. The resident, with moderate cognitive impairment and no dementia diagnosis, was not invited to care plan meetings, contrary to facility policy. Interviews and record reviews confirmed the absence of invitations, despite claims by the ADON that they were sent.
A facility failed to develop a comprehensive care plan for a resident with depression, pneumonia, and dysphagia. The care plan lacked interventions for the resident's depression and antidepressant therapy, despite the resident being cognitively intact and taking antidepressants. Interviews revealed that the ADON was responsible for care plans but was unsure why the depression diagnosis was omitted, contrary to facility policy requiring comprehensive care plans.
A resident with hemiplegia and hemiparesis did not receive 18 out of 30 scheduled showers, as required by the facility's policy. Despite needing partial assistance for bathing, the resident reported only receiving showers once a week. The ADON suggested memory issues, but no dementia diagnosis was present. The facility's policy mandates showers three times weekly, which was not adhered to.
A resident was administered Mirtazapine, an antidepressant, without a documented diagnosis of depression. The resident's MDS assessment did not reflect a depression diagnosis, yet the medication was prescribed and administered for this condition. The ADON was unable to clarify the lack of diagnosis, indicating a failure to adhere to the facility's policy on unnecessary drugs.
A resident with a Full Code status was found unresponsive, and facility staff failed to provide timely CPR or call emergency services for 25 minutes. The nursing staff lacked current CPR certification, and the crash cart contained expired items. The resident, who had multiple medical conditions, passed away shortly after being admitted to the facility.
The facility failed to maintain accurate records and proper administration of controlled drugs, leading to discrepancies for several residents. A resident received incorrect doses of diazepam due to misinterpretation of packaging. Another resident's hydrocodone acetaminophen was tampered with, and an RN admitted to an error without proper documentation. Additionally, a third resident's medication records showed discrepancies between documented and actual administration, with the previous DON failing to report the issue.
A resident admitted with type 2 diabetes did not have insulin administration or blood glucose checks entered upon admission, despite hospital discharge orders indicating the need for insulin if glucose levels exceeded 150. Interviews revealed confusion among staff regarding responsibility for entering orders, and the facility's medication administration policy was not followed.
A nurse failed to administer hydrocodone acetaminophen to a resident with severe cognitive impairment and multiple diagnoses within the scheduled time frame, as per facility policy. The nurse cited being too busy and used a cheat sheet for tracking, leading to delayed documentation and administration. The DON confirmed that immediate documentation and adherence to scheduled times are required by facility policy.
Inaccurate MDS Assessments Failed to Capture Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that initial comprehensive assessments accurately reflected the residents’ status for 2 of 7 residents reviewed. For Resident #10, the admission record showed diagnoses including weakness and repeated falls, and the care plan and medication orders reflected treatment for depression and anxiety, including fluoxetine and alprazolam. However, the initial comprehensive assessment did not identify active diagnoses for depression or anxiety, even though the resident was receiving psychotropic, antidepressant, and anti-anxiety medications and the MDS indicated those drug classes were in use. For Resident #20, the admission record listed orthopedic aftercare, cognitive communication deficit, and weakness, and the hospital referral documented Alzheimer’s disease with donepezil ordered. The resident’s care plan also reflected depression and psychiatric follow-up, but the initial comprehensive assessment did not identify an active diagnosis for Alzheimer’s disease and did not show that the resident was taking antidepressant or anti-anxiety medications. The MAR reflected donepezil ordered for memory deficit, and the hospital referral identified Alzheimer’s disease, but this information was not coded on the MDS assessment. During interviews, the DON stated the MDS Coordinator was responsible for obtaining diagnosis and medication information for new admissions and that RN A signed and certified the assessments. The MDS Coordinator said she completed assessments using the electronic medical record, including physician, psychiatric, and hospital records, but could not recall why the diagnoses and medications were not coded correctly. RN A said she sometimes reviewed assessments against the medical record but was not tasked with auditing them for accuracy and was not sure who ensured accuracy. The DON stated there was no staff oversight or audits to ensure MDS assessment accuracy.
Nurse Aide Competency Program Not Completed
Penalty
Summary
The facility failed to ensure that nurse aides who had worked more than 4 months were trained and competent, and that nurse aides who had worked less than 4 months were enrolled in an appropriate training and competency evaluation program. Record review of the facility’s employee list showed 6 nurse aides employed, including NA C and NA F, whose job titles were listed as N.A. rather than C.N.A. NA C’s hire date was 3/24/2024, and NA F’s hire date was 9/20/2025. The Nurse Aide Public Registry search did not show records for either NA C or NA F. During interview, the BOM stated that NA C had completed the requirements for the nursing assistant program but had not yet taken the test, and she was unsure why the test had not been taken. She also stated she was unsure whether NA F was enrolled in a competency program and did not have a certificate of completion for her. The DON stated she was aware that NA C and NA F had both been employed for greater than four months without completion of the required competency program, and explained that NA C had not taken the test due to personal issues. She said NA F had just reached four months of employment and had not taken her test yet due to issues with FBI fingerprinting, a name change after marriage, and credentialing from a nursing program completed outside the country. The DON also stated there was no facility policy related to competency program completion by nursing assistants.
Failure to Complete Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and failed to provide regular in-service education based on the outcome of those reviews for NA C, NA D, and NA E. Record review showed the facility had 5 total nurse aides employed, and 3 of them had been employed long enough to require annual performance reviews. The report identified that NA C, NA D, and NA E had hire dates of 3/04/2024, 5/20/2024, and 10/16/2024, respectively, and that no annual performance reviews had been completed for them. During interviews, the BOM said she was unsure where annual performance reviews were stored and was not sure whether they had been completed for NA C, NA D, or NA E. The DON stated she did not complete annual performance reviews for any staff member, including those nurse aides, and said the facility did not have a policy or procedure for that requirement. She also stated she was unaware it was required for licensure and that the annual skills competency used for all nurse aides was the same every year based on a facility template. NA E stated she had not ever had a scheduled review of her overall job performance, and the ADM said the facility did not complete annual performance reviews and instead talked to staff whenever needed.
Improper storage and use of MediHoney gel in a resident room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments when a partially used tube of MediHoney gel was found in Resident #45’s bedside table drawer during observation of routine catheter care. Resident #45 was admitted on 1/18/2026 with weakness, and the record review showed an order for barrier cream with incontinence care as needed, but no order for MediHoney gel application. During the observation, NA F removed the MediHoney gel from the resident’s drawer and applied it to the resident’s genitals, thigh creases, and buttocks while performing catheter care. During interview, NA F said MediHoney gel was the same as barrier cream and used for wounds, and she was unsure whether the resident had a physician’s order for it. NA E said the barrier cream she typically used did not look like the MediHoney gel and stated she normally asks the nurse to identify which cream to use, but she had not done so before providing care to Resident #45. LVN H stated the resident did not have an order for MediHoney gel as barrier cream and said the tube should have been stored securely in the medication cart or medication storage room. The DON said NA F should not have used any creams without asking the nurse and that the MediHoney gel should not have been stored in the resident’s room; she also stated the medication likely belonged to the previous occupant of the room.
Insufficient Food and Nutrition Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietician. Surveyor interviews and record review showed the facility did not employ a qualified dietician or other clinically qualified nutrition professional from October 2025 to January 2026, and the facility also did not have a full-time director of food and nutrition services. The Food Service Supervisor (FSS) worked less than 25 hours per week at the facility, while also working between two facilities owned by the company. During an interview, the FSS said a new dietician had just been hired on a consultation basis that week, but she had not yet been introduced to the dietician and was not familiar with the contract. She stated the prior dietician resigned abruptly in October 2025 and that the facility had difficulty finding a consultant dietician because it is in a rural area. The FSS said she was responsible for resident assessments, collaborating with the physician, DON, speech therapist, residents, and families to develop individual plans of care, and she believed she was meeting the tasks required of a dietician or other clinically qualified nutrition professional. The DON stated she and the FSS worked together on resident diet changes and that they could identify changes in residents and recommend diet changes with the speech therapist. The DON acknowledged the facility had been without a qualified dietician or other clinically qualified nutrition professional for a period, though she could not recall the dates. The ADM stated the FSS was not a full-time dietary manager and that a dietician had recently been hired on a consultation basis for 16 hours per month. Record review showed an agreement for dietary consultant services dated 1/14/2026 and facility policy stating a qualified dietitian would serve as consultant and make regular scheduled visits of 16 or 20 hours each month depending on census.
Infection Control Failures in Laundry Handling and Resident Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for the laundry area and for Resident #45. In the laundry room, a movable rack and a fixed rack of clean clothing on hangers were observed stored in the same room where soiled linens and clothing were sorted. The laundry aide identified that area as the sorting location and stated the clean clothing should not have been stored there because it could become contaminated, while the ADM later confirmed clean clothing should not be stored in that area due to potential contamination. During the same observation, no PPE was available in the laundry sorting area. The laundry aide stated that linen received in a red bag was considered infectious and should be washed separately, but said the staff used disposable gloves only and did not have gowns. She also stated she had not received training related to infection prevention or control. The DON, who said she was the Infection Preventionist, stated she did not oversee the laundry process because she did not think it related to infection prevention, did not know whether laundry aides should use PPE when handling potentially infectious laundry, and had not provided PPE or guidance to laundry aides because she did not view the laundry area as a threat of infection spread. Resident #45, a new admission with weakness and a urinary catheter, did not have TBP initiated at the time of an observation when no signage or PPE cart was present outside the room. The resident’s record did not show an admission MDS submission, and the care plan and order summary did not reveal TBP orders or care planning. Later, signs were observed on the resident’s door for Contact Precautions and EBP. During catheter care, soiled linen from the resident was placed directly into a lidded bin on top of other soiled, unbagged linen. Staff stated red bags were only used when linen was heavily soiled with bodily fluids, and the DON stated soiled linen from a resident on Contact Isolation did not need to be bagged before being placed in the soiled linen bin.
Resident Council Grievances Not Documented or Responded To
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances and recommendations concerning resident care and life in the facility. Review of resident council meeting minutes from July 2025 through December 2025 showed repeated concerns raised by the group about dietary items, housekeeping, laundry, maintenance, and activities, but there was no documentation of the facility’s responses, actions, or rationale regarding those concerns. During interviews, the resident council stated that the AD took the monthly minutes and heard their concerns, but they did not receive information about the outcome of the grievances and wanted that to change. The AD stated that residents brought grievances directly to her, that she addressed them verbally with department heads or by text message, and that she did not document the actions taken or whether the resident council received a response. She also stated that if grievances were not responded to and actions were not taken, residents could feel unimportant. The DON stated that the ADM was the grievance coordinator and that the AD normally handled complaints, but she was not sure whether the grievances identified during resident council meetings were being documented. The AD and DON later agreed that moving forward they would document resident council grievances on a standard grievance form and provide responses verbally and in writing. Facility policy required prompt efforts to resolve grievances, acknowledgment of complaints, investigation of all complaints, and follow-up with the resident or family.
Baseline Care Plan Missing TBP and Catheter Care Instructions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #45 that included the instructions needed to provide effective and person-centered care within 48 hours of admission. Resident #45 was an [AGE]-year-old female admitted to the facility with weakness. Her record showed a physician order for a urinary catheter, and the care plan report documented that she had a catheter and included instructions to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. The care plan report did not include care planning for TBP. On observation, Resident #45 was seen with a urinary catheter in place, and her room initially did not have signage indicating TBP. A later observation showed two signs on her door, one for Contact Precautions and one for EBP. The DON stated she was primarily responsible for care planning, did not have a formal process for creating and revising care plans, and believed the existing catheter-related care plan was sufficient because staff would know the care needed from the physician's orders. The facility policy stated that the care plan must include measurable objectives and timetables to meet the resident's needs and that a temporary care plan would be completed by the admitting nurse for every new patient, but no additional pages or related policies were provided.
Improper Catheter Care and Unauthorized Cream Use
Penalty
Summary
The facility failed to ensure appropriate catheter care and appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident was admitted with weakness and had a physician’s order for a urinary catheter and barrier cream with incontinence care, but the record did not show an order for MediHoney gel. During observation, an NA performed catheter care while grasping the catheter tubing near the resident’s knees and wiping the tubing away from the resident, causing the tubing between the resident’s genitals and the NA’s hand to become taut. The resident verbalized discomfort approximately three times while the tubing was pulled. After catheter care, the NA asked another NA to obtain barrier cream and then removed a partially used tube of MediHoney gel from the resident’s drawer. The NA applied MediHoney gel to the resident’s genitals, thigh creases, and buttocks and stated she believed it was the same as barrier cream and used for wounds. She was unsure whether the resident had an order for it and had not asked the nurse before providing care. The LVN stated the resident did not have an order for MediHoney gel as barrier cream, and the DON stated NAs are trained to grasp catheter tubing near the body and cleanse away from the grasped area to prevent dislodgement. The facility policy also stated to hold catheter tubing to one side and support it to avoid traction or unnecessary movement during care.
RN Coverage and DON Designation Deficiencies
Penalty
Summary
The facility failed to use the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week for 2 of 141 days reviewed for sufficient staffing. Record review of RN A’s timesheets showed 8 hours of paid time off on 9/24/2025 and 10/9/2025, and the DON stated in interview that the facility did not have RN coverage on those shifts because RN A did not work them due to personal commitments. The DON said an LVN was staffed during those times to provide nursing care. The facility also failed to designate a registered nurse to serve as the DON on a full-time basis. Record review showed the facility’s DON document listed RN qualifications, but in observation and interview RN A identified herself as a Charge Nurse and said she was not the DON and had no oversight or management responsibilities beyond signing MDS assessments. She stated she had previously been asked to serve as DON but declined. In interview, the DON stated her job title was ADON and that she was serving as the acting DON until she completed the RN program, while also stating that RN A was the actual DON responsible for overseeing her work.
Medication Error Rate Exceeded Threshold
Penalty
Summary
Medication error rates were found to be 8%, exceeding the 5% threshold, based on observation, interview, and record review for 2 of 4 residents and 2 of 25 medication administration observations. Resident #36 had an order for Donepezil HCl 5 mg by mouth once daily at 7:00 AM for Alzheimer's disease with late onset, and the MAR showed initials and a check mark on 1/19/2026 indicating the medication had been given. However, during observation on 1/19/2026 at 8:33 AM, LVN G administered the Donepezil tablet to Resident #36 after the ordered time. Resident #37 had an order for Pantoprazole Sodium 40 mg by mouth once daily at 8:00 AM for GERD, and the MAR also showed initials and a check mark on 1/19/2026 indicating the medication had been given. During observation on 1/19/2026 at 8:46 AM, LVN G was preparing medications for Resident #37 and stated the resident did not have an available dose of Pantoprazole, she was unsure where to obtain it, and she would skip the medication and ask the DON. The DON later stated the facility policy allowed medications to be given within one hour before or after the ordered time, that LVN G had not informed her of the missing Pantoprazole, and that LVN G should not have documented a medication she did not administer.
Failure to Provide Adequate Supervision and Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents for a resident who required assistance with transfers. On a specific date, a CNA attempted to transfer a resident using a mechanical lift without the required assistance of another staff member. This resulted in the resident falling and suffering a broken right leg, which required surgical repair. The resident had been assessed as needing more than one staff member for assistance with transfers due to severe cognitive impairment and physical dependency. The incident occurred when the CNA, who was an agency employee, attempted to transfer the resident alone despite being warned by an LVN not to do so. The resident was known to be non-compliant and combative during transfers, which further necessitated the need for two-person assistance. The facility's records indicated that the resident was dependent on staff for all transfers, and this information was supposed to be available to staff through a care plan and a shower book binder, which was not updated to reflect the resident's needs. Interviews with facility staff revealed a lack of in-service training on the proper use of mechanical lifts and the required number of staff for transfers. The facility's failure to provide adequate training and ensure that staff followed established protocols for resident transfers contributed to the incident. The facility's administration acknowledged the deficiency and took steps to address the issue, but the immediate jeopardy situation was identified due to the failure to prevent the accident and ensure resident safety.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and exploitation in a timely manner for three residents. Resident #140, who had severe cognitive impairment and required assistance from more than one staff member for transfers, was injured during a transfer conducted by a single CNA using a mechanical lift. The resident fell, resulting in a broken leg that required surgical repair. Despite the severity of the injury, the facility's administration did not report the incident to the state agency, as they believed it was not reportable since the injury was witnessed. Resident #17, who had intact cognition, reported feeling vulnerable and threatened while on a pass with a family member. The resident described an incident where she was nude and scared by a drunken, bloodied family member, leading her to crawl to safety. This allegation of abuse was documented by a CNA and the social worker but was not reported to the administrator or state agency for investigation. Resident #5, who had severe cognitive impairment and required oxygen therapy, was involved in an incident where her oxygen supply was turned off by Resident #17 because it was too loud. This action was documented in a grievance form by the social worker, who advised Resident #17 of the danger posed to Resident #5. However, the allegation of neglect was not reported to the administrator or state agency. The facility's policy on abuse, neglect, and mistreatment was not followed, as these incidents were not thoroughly investigated or reported as required.
Failure to Investigate and Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate and report allegations of abuse, neglect, and exploitation for three residents. Resident #140, who had severe cognitive impairment and required assistance from more than one staff member for transfers, was injured during a transfer conducted by a single CNA using a mechanical lift. The resident fell, resulting in a broken leg that required surgical repair. Despite the severity of the injury, the facility did not report the incident to the state agency, as the administrator and ADON concluded it was not a reportable event since the injury was witnessed. Resident #17, who had intact cognition, reported feeling vulnerable and threatened by a family member while out on pass. The resident described an incident where she was nude and scared by a drunken, bloodied family member, leading her to crawl to safety. This allegation of abuse was documented by a CNA and acknowledged by the social worker, but it was not reported or investigated by the facility's administration. Resident #5, who had severe cognitive impairment and required oxygen therapy, was allegedly neglected when Resident #17 turned off her oxygen concentrator and removed her nasal cannula because it was too loud. This incident was documented in a grievance form, but the facility's administration did not recognize it as an allegation of neglect or abuse, and it was not reported or investigated. The facility's policy on abuse, neglect, or mistreatment was not followed, as these incidents were not thoroughly investigated or reported to the appropriate state agencies.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7.69% due to two medication errors involving two residents. The errors were identified during observations, interviews, and record reviews. RN G administered medications incorrectly to two residents, leading to the deficiency. The first resident, who had severe cognitive impairment and was under hospice care, was prescribed ranolazine 500mg extended-release tablets for heart-related chest pain. Despite the physician's order to administer medications via a PEG tube only if the manufacturer allowed, RN G crushed the extended-release tablet, which should have been swallowed whole according to FDA guidelines. This action was observed during medication administration. The second resident, also with severe cognitive impairment and under hospice care, was prescribed duloxetine 30mg delayed-release capsules for depression. RN G opened the capsule and mixed its contents with applesauce, contrary to FDA guidelines that state the capsule should be swallowed whole. This error was similarly observed during medication administration. RN G acknowledged the errors and reported them to the DON and medical director. The facility's medication error policy emphasizes the importance of avoiding significant medication errors, which was not adhered to in these instances.
Failure to Involve Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and/or the resident's representative were involved in the development and implementation of the resident's person-centered plan of care. Specifically, the facility did not invite or include the input of a resident and their family member in Care Plan Conference meetings. This oversight was identified for one resident who was reviewed for care plans. The resident, a male with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following a cerebral infarction, and dysphagia, had a BIMS score indicating moderate impairment but no diagnosis of dementia. Interviews and record reviews revealed that the resident and their family member were not invited to any care plan conference meetings prior to a specific date, despite the family member's regular visits to the facility. The facility's ADON claimed that invitations were sent, but no evidence of such invitations was found in the resident's records. The facility's policy requires the inclusion of the resident and their family or POA in the interdisciplinary team for care planning, but this was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is consistent with the resident's rights and includes measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. Specifically, the care plan for a resident with diagnoses including pneumonia, depression, and dysphagia did not include any interventions or mention of the resident's diagnosis of depression or antidepressant therapy. This oversight was identified during a review of the resident's care plan, which was found to be a five-page document lacking these critical elements. Interviews conducted with the Assistant Director of Nursing (ADON) and the Administrator (ADM) revealed that the ADON was responsible for ensuring care plans were completed correctly and addressed all areas of care. However, the ADON was uncertain why the resident's diagnosis of depression was not included in the care plan, despite the expectation that care plans should be done correctly. The facility's policy, dated 2005, requires that care plans include measurable objectives and timetables to meet a resident's needs as identified in the comprehensive assessment, which was not adhered to in this case.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, Resident #28, who required partial/moderate assistance for bathing due to conditions such as hemiplegia and hemiparesis following a cerebral infarction, did not receive 18 out of 30 scheduled showers between July and October 2024. The resident's care plan indicated a self-care performance deficit related to these diagnoses, and the facility's policy required residents to be showered a minimum of three times weekly. However, the resident's shower log showed significant non-compliance with this schedule. Interviews with Resident #28 and their family member revealed that the resident was only receiving showers once a week, contrary to the facility's policy and the resident's care plan. The Assistant Director of Nursing (ADON) suggested that the resident and family member might not remember the shower schedule correctly, implying possible dementia, although no such diagnosis was present in the resident's records. The Director of Nursing (DON) and Administrator (ADM) acknowledged the expectation for residents to receive showers on their scheduled dates, yet the records indicated otherwise.
Unnecessary Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, who had not been diagnosed with depression, was not given psychotropic medication unnecessarily. Specifically, a resident was administered Mirtazapine, an antidepressant, without a documented diagnosis of depression. The resident's comprehensive MDS assessment did not reflect a diagnosis of depression, and the resident's BIMS score indicated moderate cognitive impairment. Despite this, the resident's medication administration record showed that Mirtazapine was prescribed and administered for depression. During an interview, the Assistant Director of Nursing (ADON) was unable to explain why the resident did not have a documented diagnosis of depression and was uncertain about who was responsible for ensuring the correct diagnosis for psychotropic medications. The facility's policy on medications and drug regimen reviews indicated that unnecessary drugs are those given without a diagnosis or reason, highlighting a failure in adhering to this policy. This deficiency could potentially place residents at risk of receiving unnecessary medications.
Failure to Provide Basic Life Support to Resident
Penalty
Summary
The facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, who had a Full Code status, was found unresponsive with no pulse or respirations. Despite the professional standards of practice, the facility staff did not obtain an AED or call emergency services for 25 minutes after the resident was found. The nursing staff also lacked current CPR certification, which contributed to the delay in providing life-saving measures. The resident involved was an elderly male with multiple medical conditions, including acute osteomyelitis, type 2 diabetes mellitus, ischemic cardiomyopathy, and chronic heart failure. He was admitted to the facility after a below-the-knee amputation and was noted to have intact cognition. However, his face sheet did not list his code status, and a care plan was not available. The nursing notes indicated that the resident was admitted after dinner service and passed away around midnight the following day. The incident was further compounded by the lack of proper emergency protocol adherence. The LVN on duty found the resident unresponsive and began chest compressions alone, without obtaining the AED or calling for emergency services immediately. The crash cart contained expired items, and the logs for daily checks were incomplete. Interviews with staff revealed that they were not adequately trained or certified in CPR, and the facility's policies for emergency equipment checks were not consistently followed.
Removal Plan
- The facility needs to ensure nursing staff are trained for emergencies to include CPR and AED and emergency response items are in place.
- DON and ADON will have every licensed staff in facility CPR certified.
- DON and ADON started training in AED/CPR training.
- Set up a mandatory in-service for all nursing staff.
- All nurses and CNAs were in serviced in person and were allowed to demonstrate skills to ADON on how to correctly perform CPR.
- In serviced all nursing staff on the use of AED and had them demonstrate to ADON how to fully use the AED machine.
- Nursing staff were able to properly demonstrate to ADON DON proper use of both AED and crash cart location use of and items were identified in crash cart and demonstrated to nursing staff.
- Crash cart will be revised nightly per night shift nurse, there is a current log that we implemented in a binder in nurses station.
- ADON will check log once a week and sign off on log once checked that week.
- Administrator to review these logs at the end of month every month to ensure compliance.
- Safety checks were performed in person per Administrator to ensure the safety of our residents.
- Implemented all nursing staff be current with CPR status.
- Held an in-house in-service training for all licensed personnel.
- Touched on the topic of AED location as well as the importance of the devices and crash carts not being occluded or in their assigned place.
- New implemented mandatory for all licensed personnel to have current status of CPR training and current card demonstrating so.
- All PRN staff follow guidelines as mentioned.
- Business office manager to check licensed personnel file to ensure compliance.
- Included CNA D and CNA E in in service to implement importance of CNA role during code to call for help.
- Our policy states 2 CPR certified staff for each shift we are complying currently.
- A mock code was presented per ADON to the following nurses; RN G, LVN H, DON LVN, LVN J, K RN, CNA D, CNA E, LVN L.
- Plan in place is to in service PRN nurses before any scheduled shift.
- Set up a follow up in service.
- All 11 of 12 nursing staff CPR were verified or completed a hands-on CPR course.
- LVN M was removed from the schedule until she completed a hands-on CPR course.
Medication Mismanagement and Documentation Errors
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs, leading to discrepancies in the administration and documentation of medications for several residents. For Resident #10, the facility dispensed an incorrect number of diazepam pills, contrary to the physician's orders. The staff signed out two tablets of 2 mg diazepam on multiple occasions, despite the order being for one tablet. This discrepancy was attributed to a possible misunderstanding of the packaging, as the LVN involved suggested the tablets might have been half tabs or 1 mg tabs, but this was not documented. Resident #11's medication was tampered with, as observed in a blister pack of hydrocodone acetaminophen, where two pills had broken seals and were taped over. RN K admitted to mistakenly administering the wrong dosage to another resident and attempted to rectify the error by replacing the pill, which was not properly documented. This incident highlights a lack of verification and proper documentation, as well as a failure to report the error to the appropriate authorities. For Resident #13, there was a significant discrepancy between the documented administration of hydrocodone acetaminophen and the actual medication received by the resident. The MAR indicated that 32 doses were dispensed, but the resident's statement and the MAR showed fewer doses were administered. The facility's administrator was informed of the issue by RN G, but the previous DON failed to report the discrepancies, possibly due to a personal relationship with the involved LVN. This lack of oversight and accountability contributed to the misappropriation of medication.
Failure to Enter Admission Orders for Insulin and Blood Glucose Checks
Penalty
Summary
The facility failed to ensure that a resident had appropriate physician orders for immediate care upon admission. Specifically, the resident, who was admitted with a diagnosis of type 2 diabetes mellitus, did not have orders for insulin administration or blood glucose checks entered upon admission. The resident's hospital discharge summary included orders for regular insulin to be administered as needed if glucose levels exceeded 150, but these orders were not reflected in the facility's records. The resident's blood glucose was not checked, and there was no care plan available in the clinical record. Interviews with facility staff revealed a lack of clarity and responsibility regarding the entry of admission orders. An LVN stated that orders should be entered prior to a resident's arrival but indicated that she was not responsible for entering them. The administrator believed the LVN was responsible for entering the orders, while the previous DON, who had resigned, was not present at the time of admission. The facility's policy on medication administration emphasized the importance of preparing, administering, and documenting medications accurately, but this was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide timely medication administration, which is crucial for resident safety and well-being. Specifically, RN K did not administer hydrocodone acetaminophen to Resident #12 within the one-hour window before or after the scheduled time, as per the facility's policy. This resident, who has severe cognitive impairment and multiple diagnoses including Parkinson's disease, migraines, spinal stenosis, and a psychotic disorder, was at risk due to the improper timing of medication administration. RN K admitted to being too busy with other residents, leading to delays in medication administration and documentation. She used a cheat sheet to track medications and often documented after administering to multiple residents, which contributed to the errors. The Director of Nursing (DON) confirmed that staff should document narcotics immediately after dispensing and follow a systematic process for medication administration. The facility's policies on narcotic storage and medication administration emphasize immediate documentation and adherence to scheduled times, which were not followed in this instance.
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.
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What surveyors actually found near you
We read the 82 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
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 Fredericksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Fredericksburg | 0.4 mi | ★★★★★ | 2 | 1 |
| Avir At Enchanted Rock | 0.5 mi | ★★★★★ | 19 | 1 |
| Knopp Healthcare And Rehab Center Inc | 2.3 mi | ★★★★★ | 9 | 0 |
| Avir At Comfort | 19.7 mi | ★★★★★ | 10 | 0 |
| Hilltop Village Nursing And Rehabilitation | 20.5 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.