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 Lakeside Health And Wellness during CMS and state inspections, most recent first.
Failure to provide catheter and perineal care: A resident with an indwelling Foley and dementia was observed multiple times without the ordered leg strap/stabilizer, with taut tubing and urine in the line. CNA and LVN interviews showed uncertainty and gaps in who completed catheter care, and staff reported the resident’s penis had split over time. Records showed orders for catheter care every shift and a policy requiring cleansing of the catheter-urethral junction and documentation of any problems, but no documentation of the penile split was found.
A facility failed to keep resident areas free of accident hazards when staff provided bed mobility and incontinent care to a resident who required 2-person assist, but only 1 staff member was present. In another room, a resident had a razor, shaving gel, and liquid air freshener stored at the bedside, and two other residents shared a bathroom where shaving cream was left on the countertop. Staff and leadership stated these items should have been secured or not present, and that care plans and room safety checks were not being followed.
A resident’s ordered Debrox was delayed and not clearly administered, with staff documenting refusal when the medication had not been delivered from the pharmacy. Another resident received only 1 puff of ordered Combivent instead of 2 puffs during med pass. A third resident’s morphine/diazepam suppositories were not counted each shift as required, and staff acknowledged controlled substances should be reconciled at every shift change.
Incorrect Portion Size Served at Lunch: A cook served ham portions that were smaller than the menu-required 3 oz serving for lunch. A surveyor observed 10 trays with small ham slices, and the cook later confirmed she pre-measured the meat before cooking but did not reweigh it after cooking, resulting in an under-portioned serving. The RD, Dietary Mgr, DON, and Administrator all stated the correct serving size was required and that the Dietary Mgr was responsible for ensuring staff followed the menu portion sizes.
Food Served Bland and Cold: The facility failed to provide palatable food served at an appetizing temperature for multiple residents and for a sampled lunch meal. Residents and family members reported bland, boring, salty, and cold food, and a Dietitian observed a lunch tray with lukewarm meatloaf, bland mashed potatoes, overcooked asparagus, and warm Jello. Staff said residents often complained about food being cold and sometimes returned trays to the kitchen or offered a new plate.
Dirty Ice Scoop Holder in Kitchen: The facility failed to keep the ice scoop holder clean in the main kitchen area, where black and brown substances were observed at the bottom of the bucket. A Dietary Aide confirmed the contamination, stated she was unaware the holder came off the wall, and noted residents could get sick from what appeared to be dirt and rust. The Dietary Manager, DON, and Administrator all stated the ice scoop and holder were expected to be cleaned daily to prevent cross-contamination and foodborne illness.
Incomplete and inaccurate wound documentation was found for two residents with multiple pressure injuries and wound care needs. One resident had wounds to the hip, heel, and shin, but weekly skin assessments did not consistently document those sites and one later entry lacked units of measurement. Another resident had documented heel wounds and wound care orders, but weekly skin tools and wound assessments were inconsistent, with some entries omitting the right heel and others documenting the left heel instead. Staff interviews confirmed confusion about who was responsible for documenting existing skin and wound conditions.
Infection Control and EBP Failures During Resident Care: Multiple residents with catheters, wounds, incontinence, or dialysis needs were involved in observed care where CNAs and an LPN failed to use proper hand hygiene, glove changes, gowns, or enhanced barrier precautions. Staff handled dirty linens without gloves, performed incontinent and catheter care with soiled gloves, and one resident’s EBP signage and PPE cart were missing from the room despite an order for precautions.
A resident with COPD, dementia, a urinary catheter, and frequent bowel incontinence was observed receiving incontinent care when a CNA made a mocking comment in a disrespectful tone while the resident had an active bowel movement and passed gas. The resident later said he felt ashamed and described staff as treating him roughly during perineal care. The LVN acknowledged the comment was inappropriate and that the door should have been closed, and the DON and Administrator stated staff were expected to treat residents with dignity and respect.
A facility failed to protect resident privacy and confidential information when an RN used a personal cell phone to text an NP about a resident’s medication error, symptoms, and last name, and when CNA and LVN staff provided incontinent care to another resident without closing the door or drawing the privacy curtain. The residents involved had significant medical needs, including atrial fibrillation, COPD, dementia, and assistance with toileting hygiene, and staff acknowledged the privacy lapses during interview.
Failure to Complete GDR for Antidepressant Use: A resident with COPD, dementia, and depression remained on Lexapro 15 mg daily even after pharmacy recommended a GDR to 10 mg daily. The DON could not provide documentation of the GDR, and interviews showed confusion over whether the NP had taken over medication review after the resident went on hospice; the resident’s care plan included monitoring for antidepressant adverse effects.
MDS assessments for two residents did not accurately reflect PASRR positive status for mental illness. One resident’s admission MDS and another resident’s annual MDS both marked PASRR negative in Section A1500, even though level II PASRR evaluations and care plans identified both residents as PASRR positive. The MDS Coordinator and MDS Consultant acknowledged the coding errors.
A resident with diagnoses including major depressive disorder, bipolar disorder, anxiety, and schizophrenia-related antipsychotic use had an MDS that did not reflect PASRR serious mental illness or IDD status. Record review showed one PASRR Level 1 screening said there was no evidence of mental illness, while a later screening indicated evidence of mental illness. Staff interviews confirmed the earlier PASRR Level 1 should have been corrected and reevaluated when the discrepancy was identified.
A resident with a hearing deficit reported missing hearing aids and told staff, including the SW, that she needed audiology services. Her family also repeatedly raised the issue. The SW said she was responsible for referrals to the audiologist and had checked the resident's room and contacted an agency, but no documented appointment was available. The DON and Administrator confirmed the SW was responsible for the referral, and the resident remained without the needed hearing device follow-up.
Oxygen Filter Not Cleaned as Ordered: A resident with COPD and nighttime oxygen had an oxygen concentrator filter that was observed with thick, grey, fuzzy material. Staff identified that the filter was supposed to be cleaned per MD order and facility procedure, but the assigned nurse could not confirm it was done, and the DON and Administrator stated nursing staff were responsible for completing and monitoring the task.
A resident with COPD and moderately impaired cognition continued receiving Mag-Oxide despite a pharmacist recommendation, NP approval to discontinue it, and an active order that was never clarified or implemented until surveyor intervention. The resident’s MAR showed the medication was still being administered, while the NP, DON, and Administrator stated they expected pharmacy recommendations and orders to be followed and could not identify who was responsible at the time.
Medications Left Unsecured on Medication Cart: An LVN left a vial of albuterol sulfate and a tube of diclofenac topical gel on top of the 200 hall nurse medication cart, unattended, while staff and residents were in the hallway nearby. The LVN said she forgot to put the medications back inside the cart after being called away, and the DON and Administrator stated medications should be secured at all times. Facility policy stated scheduled medications should be stored in a separate locked area within medication carts or the medication room.
A resident with dementia and intact cognition needed dentures, but the facility did not timely arrange routine dental services. The resident and her family repeatedly told staff, including the SW, that she needed dentures and had difficulty chewing without them. The dental agency said an alternate payor source was needed, but the SW did not follow up for clarification, and the BOM stated the payor issue was not addressed until later. The DON and Administrator identified the SW as responsible for initiating the referral and following up on payor source issues.
Two residents with personal refrigerators had temperature logs that were not properly checked and documented. One resident with PTSD, depression, anxiety, and moderate ADL needs had a log that had not been updated for several days, and another resident with dementia and severe cognitive impairment had a log last checked long before it was later found missing. The DON said staff on angel rounds were responsible for keeping the logs in place, and the Administrator said refrigerator temperatures were expected to be checked and logged daily.
A CNA was observed speaking loudly and in a demeaning manner to a male resident with severe cognitive impairment, prompting intervention by other staff who removed the resident and reported the incident. The resident's care plan documented significant communication and cognitive deficits, and staff statements confirmed the inappropriate interaction, which violated the facility's abuse prevention policy.
A CNA used a resident's debit card without permission to purchase personal items during a store outing, resulting in unauthorized charges of over $230. The resident, who had intact cognition and multiple medical conditions, identified the unauthorized purchases and reported the incident to the Activity Director, leading to an internal investigation.
A resident with severe cognitive and physical impairments was receiving a pureed diet per physician order, but the care plan was not updated to reflect this change. The MDS nurse was responsible for updating care plans but had not revised the document to match the current dietary order, despite facility policy requiring timely updates based on new interventions.
A resident with multiple chronic conditions did not have staples removed from the back of the head as ordered by a physician due to a failure to properly enter the order into the EMR system. The treatment nurse was unaware of the removal order, and the oversight was discovered during a survey, resulting in a delay in care.
A resident with COPD and other comorbidities was found using oxygen therapy without a current physician's order, and the oxygen tubing and water were not changed or dated as required. Staff interviews confirmed that the lack of an active order and failure to follow respiratory care protocols led to improper care and risk of infection.
A resident with an indwelling urinary catheter suffered a 3.5 cm penile tear due to improper catheter care at an LTC facility. Despite a care plan requiring monitoring for catheter issues, the facility failed to secure the catheter properly, leading to friction and pulling. The injury was discovered by the resident's family, who reported inadequate care. The DON acknowledged the catheter was not given enough slack, contributing to the injury. The facility's policy on catheter care was not provided during the survey.
The facility failed to document the administration of controlled drugs for three residents, leading to discrepancies in medication records. A medication aide and an LVN did not record the administration of morphine, pregabalin, and Norco, respectively, during medication passes. This lack of documentation was acknowledged by the staff involved and highlighted by the DON and Administrator as a risk for medication errors and discrepancies.
A long-term care facility was found to have a medication error rate of 18.75%, involving two residents. One resident did not receive medications as prescribed due to improper administration by an LVN, who failed to follow physician orders for enteral medication administration. Another resident received incorrect medications and had a medication administered outside the prescribed time frame by an MA. The facility lacked competency checks for the staff involved, contributing to these errors.
The facility failed to provide palatable food at an appetizing temperature for three residents, who reported the food was often cold, bland, and overcooked. Observations confirmed these issues, and the Dietary Manager acknowledged receiving complaints. The Administrator noted that test trays were bland, highlighting a deficiency in meeting the facility's policy on food quality.
The facility's kitchen operations were found deficient in food safety standards. Dietary staff failed to wear hair restraints properly, and the dishwasher did not reach the required temperature for effective sanitation. Additionally, the correct chlorine test strips were not used, potentially risking foodborne illnesses. Interviews confirmed the importance of these measures, aligning with the facility's policy on utensil sanitation.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by staff not wearing PPE during care of a resident on isolation, improper glove changes and hand hygiene during incontinent care, and improper handling of linens. These actions posed risks of cross-contamination and infection spread among residents.
The facility failed to properly document advance directives for two residents. One resident's OOH-DNR form was incomplete due to a misunderstanding by the Social Worker, while another resident's preferred code status was not entered into the electronic medical record due to an oversight by nursing staff. These deficiencies could lead to confusion in emergencies.
A resident's medical records were left visible on an unattended medication cart, breaching confidentiality. The resident, with moderate cognitive impairment and multiple diagnoses, had her EMR left open by a medical assistant who entered a supply room. The DON and Administrator confirmed this was a HIPAA violation, stressing the importance of maintaining confidentiality.
A facility failed to include a resident's preferred code status in the baseline care plan, despite the resident having complex medical conditions. The social worker completed a code status assessment, but the information was not entered into the care plan. The MDS Coordinator acknowledged the omission, which was not corrected despite verbal discussions. The administration recognized the importance of including this information to respect the resident's wishes.
A resident with severe cognitive impairment was not assisted with facial hair removal, despite expressing embarrassment and the facility's policies emphasizing the importance of grooming and personal hygiene. The resident, receiving hospice care, required partial assistance, but staff did not address this need during care routines. Interviews revealed that staff were not specifically trained to look for facial hair, impacting the resident's dignity.
A facility failed to ensure proper administration of medications through a gastrostomy tube for a resident with multiple health conditions. The LVN did not confirm tube placement as ordered and improperly prepared medications by crushing them together. Interviews revealed a lack of competency checks for the LVN, and the facility's policy was not followed, posing a potential risk to the resident's health.
The facility failed to provide proper respiratory care for two residents. One resident's oxygen concentrator was not set according to the physician's order, while another resident's concentrator was found dirty. Staff interviews revealed confusion over responsibilities for equipment cleaning and monitoring, contributing to these deficiencies.
A resident in an LTC facility experienced significant medication errors when an LVN prepared to administer metoprolol despite low blood pressure and failed to administer Eliquis, mistaking it for a blood pressure medication. The resident, with a history of cerebral infarction and other conditions, was dependent on staff for care and received medications via a gastrostomy tube. The LVN crushed multiple medications together, contrary to the care plan, and did not confirm tube placement as ordered. The DON and Administrator acknowledged the errors and the potential for harm.
The facility failed to secure medication carts, leaving them unlocked and unattended. An RN, MDS Coordinator, and MA each left their respective carts unsecured, acknowledging the risk of unauthorized access to medications. The DON and Administrator emphasized the importance of locking carts for resident safety.
A facility failed to coordinate hospice care and maintain updated documentation for a resident with parkinsonism receiving hospice services. The hospice binder lacked updated information, including the certification of terminal illness and the plan of care. Interviews revealed unclear responsibilities and no policy to ensure current documentation, leading to inadequate care coordination.
The facility failed to ensure that RN N, an agency staff member, received necessary training on abuse, neglect, and exploitation. Despite claims of frequent in-services, there was no evidence that RN N completed the required training, either through the agency or the facility. Interviews revealed a lack of structured processes for training agency staff, contrary to the facility's policy requiring all staff to be trained before resident contact.
A resident with moderately impaired cognition was verbally abused by an agency nurse, who used derogatory language when the resident requested assistance. The incident was not promptly reported or addressed by the facility staff, leading to a deficiency in protecting the resident from abuse.
A resident with moderate cognitive impairment experienced verbal abuse from an RN employed through a staffing agency. The incident was not immediately reported by a witnessing CNA, leading to a delay in addressing the abuse. The facility failed to ensure the RN had completed necessary abuse training, contributing to the incident and putting residents at risk.
A resident with moderate cognitive impairment experienced verbal abuse from a nurse, which was not reported immediately as required. Despite multiple staff witnessing the incident, it was not communicated to the abuse coordinator or administrator. The facility's policy mandates prompt reporting of abuse, which was not followed in this case.
A resident with chronic health issues suffered physical abuse during a shower when a CNA used excessive force, resulting in injuries. Despite the resident's protests, the CNA continued the aggressive behavior, and the facility failed to immediately remove the CNA from resident care duties, placing the resident at further risk. Interviews revealed inconsistencies in the handling of the situation, and the facility's policy on abuse and neglect was not followed.
A resident with mild cognitive deficit and physical limitations was physically abused by a CNA during a shower, resulting in injuries. The facility failed to follow its abuse prevention policy by allowing the CNA to continue providing care after the incident. Staff interviews confirmed the failure to remove the alleged perpetrator from resident care duties, placing the resident at risk for further harm.
A LTC facility failed to provide proper pharmaceutical services, resulting in medication errors for three residents. One resident did not receive her prescribed Nifedipine despite its availability in the emergency kit. Another resident was mistakenly given Ativan and Trazodone due to a medication aide's error. A third resident did not receive her prescribed Amlodipine during a medication pass. The facility's policies on medication administration were not followed, leading to these deficiencies.
The facility failed to maintain effective infection control practices during resident care. A CNA used a soiled wipe on a resident's vaginal area, and another CNA did not perform hand hygiene between glove changes or when exiting and re-entering the room. Both CNAs left a trash bag with soiled gloves in the resident's room. The DON and Administrator confirmed these actions did not meet the facility's infection control expectations.
Failure to Provide Catheter and Perineal Care
Penalty
Summary
The facility failed to ensure a resident with an indwelling urinary catheter received appropriate catheter care and perineal care. Resident #10 was a male with COPD, unspecified dementia, and a need for assistance with personal care. His records showed he required assistance with toileting hygiene and had care plan interventions for perineal care after each incontinent episode. He also had physician orders for catheter care every shift and PRN, and for the catheter to be checked each shift to ensure it was stabilized with a leg strap or stabilizer. During observations, Resident #10 was found in bed without a catheter secure device in place, and the catheter tubing was taut and full of urine. The urinary catheter bag was hung on the side of the bed near the open door. Additional observations later the same day also showed the catheter was still not secured with a leg strap. CNA T stated she did not complete catheter care because the hospice aide had just provided care and the resident did not have a secure device, and she was unaware of when catheter care had last been completed. LVN B stated CNAs were responsible for catheter care and nurses were responsible for ensuring care was provided every shift and that a secure device was in place, but she had not had time to place one on the resident. Interviews further reflected concerns about the resident’s genital condition and catheter-related care. CNA V stated the resident’s penis had started splitting toward the end of 2025 and that the secure device helped prevent it from splitting more. The family member stated the resident did not have penile injury when admitted and had not been notified of a split penis. The facility’s records contained no documentation of the split penis in progress notes, and the urologist’s office reported no documentation of penile erosion or trauma in prior visits. The facility policy required gentle cleansing of the catheter-urethral junction, drying the area, and documenting any drainage, redness, bleeding, crusting, pain, or other problems, but the observations and interviews showed the catheter was not secured and catheter/perineal care was not consistently provided as ordered.
Unsafe resident environment and failure to follow care plans
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for four residents reviewed for accidents. One resident had a care plan that required two staff members for toileting, turning, repositioning in bed, and bed mobility because of impaired balance, stroke, and limited range of motion to the right shoulder, but staff provided incontinent care without another staff member present on one observation and later stated they had been providing care for that resident by themselves. The ADON, DON, and Administrator all stated the resident required two staff members and that staff were expected to follow the care plan. A second resident had a disposable razor, shaving gel, and liquid air freshener stored in the room, including on the bathroom countertop and under the television stand. The resident’s care plan required one staff assistant with personal hygiene, and the resident’s family member stated the items were brought in for the resident. On a later observation, the same items were still present in the room. Staff interviews reflected that razors, shaving cream, and air freshener should not have been stored at the bedside, and that staff were responsible for ensuring items were stored properly and securely. Two other residents shared a bathroom where a can of shaving cream was observed on the countertop. One resident had COPD and required supervision/touching assistance with personal hygiene including shaving, while the other resident had dementia and required one staff assistant with personal hygiene. Both residents stated the shaving cream did not belong to them. Staff who observed the room stated they had not noticed the item during rounds, and facility leadership stated shaving cream and razors should be stored in secured locations and that air freshener was not allowed in the building.
Medication administration delays, incorrect dosing, and controlled substance count failures
Penalty
Summary
Pharmaceutical services were not provided in a manner that assured accurate acquiring, receiving, dispensing, administering, and reconciliation of medications for multiple residents. The facility also did not maintain drug records in order or ensure controlled drugs were periodically reconciled as required. Surveyors identified issues involving a delay in obtaining and administering an ordered medication for one resident, an incorrect dose administered to another resident, and failure to count controlled substances each shift for a third resident. A resident with dementia, COPD, and bilateral sensorineural hearing loss had an order for Debrox ear drops to be given twice daily for cerumen impaction. The order started on 01/16/2026, but the MAR and progress notes showed documentation that did not clearly confirm administration, and several entries reflected refusal or other notation. The resident stated her ears felt stopped up and that staff would not clean them. An LVN said the ear drops had not been delivered from the pharmacy and that no one had contacted the pharmacy about the delay. Another LVN stated she charted the medication as refused because she was instructed to do so when the medication was not delivered. The DON and Administrator stated staff should have contacted the pharmacy and leadership when the medication was not delivered. A resident with dementia and asthma had an order for Combivent 2 puffs every 12 hours. During medication administration observation, an LVN gave only 1 puff instead of the ordered 2 puffs and stated she was nervous and did not pay attention. The DON and Administrator stated nurses were expected to follow the rights of medication administration and ensure the correct dose was given. A third resident with dementia, chronic pain syndrome, COPD, and hospice services had an order for morphine/diazepam suppositories as needed for pain/anxiety. The facility’s medication count sheet showed 12 suppositories received and none administered, and during observation the controlled substances were found in the medication storage refrigerator. The LVN stated she had not been counting the narcotics every shift, although she acknowledged they should be counted at the beginning and end of every shift. The DON and Administrator stated controlled substances should be counted each shift.
Incorrect Portion Size Served at Lunch
Penalty
Summary
The facility failed to ensure the lunch meal served met residents’ nutritional needs when [NAME] R did not follow the recipe for preparing ham on 01/19/26. During an observation at 12:12 p.m., the state surveyor noted 10 residents’ lunch trays with ham slices that appeared small. During an observation and interview at 12:56 p.m., [NAME] R said the dietary spreadsheet indicated the ham portion should be 3 ounces. She weighed the ham slice and found it was 2.1 ounces, then weighed 1.5 slices and found they measured 3 ounces. She stated she had pre-measured the ham before cooking and it weighed 3 ounces, but she did not reweigh it after cooking. [NAME] R said she should have reweighed the ham to ensure the correct weight before serving and that she did not realize she was serving the incorrect size until the surveyor intervened. She stated she was responsible for ensuring the correct amount of ham was served. The Registered Dietitian, Dietary Manager, DON, and Administrator all stated that the correct serving size was to be used and that the Dietary Manager was responsible for ensuring cooks followed the menu serving size. The Dietary Manager said the ham shrank during cooking and was not at the correct serving size, and the facility’s Portion Control policy stated portions should follow the specific portion sizes listed on the menus.
Food Served Bland and Cold
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for 16 of 23 residents, including Residents #64, #8, #50, #9, and 12 anonymous residents, and for 1 of 1 lunch meals reviewed. During interviews, Resident #64 said the food was bland and boring, Resident #8 said the food was not good and needed more flavor, Resident #50's family member said the resident sometimes received cold food, and Resident #9 said the food was not good and the ham was salty. During a confidential resident group meeting, 12 residents stated the food was always cold. During an observation and interview on 01/20/26, the Dietitian and six state surveyors sampled a lunch tray that included meatloaf, mashed potatoes, asparagus, and Jello. The Dietitian said the tray did not meet her expectations for flavor or temperature, stating the food was bland and did not retain its heat coming out of the kitchen. The meatloaf was lukewarm, the mashed potatoes were bland and needed more salt, the asparagus was overcooked, and the Jello was warm and not at the correct temperature. Staff interviews reflected that residents complained about food taste and cold trays, and staff often returned trays to be warmed or provided a new plate or something else instead.
Dirty Ice Scoop Holder in Kitchen
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 ice machine reviewed for kitchen sanitation. During an observation on 01/19/26 at 11:09 a.m., the ice scoop holder in the main kitchen area had a black and brown substance at the bottom of the bucket. During an observation and interview at 11:10 a.m., a Dietary Aide looked into the ice scoop holder and confirmed the presence of black and brown substances in the bottom of the bucket. She stated that the ice scoop was cleaned daily, but she was not aware that the ice scoop holder came off the wall. She also stated that residents could get sick from what looked like dirt and rust. The Dietary Aide then removed the ice scoop holder and ran it through the dishwasher, after which the black and brown substance was removed. During interviews on 01/22/26, the Dietary Manager stated kitchen staff were responsible for cleaning the ice scoop and holder and that the dietary aide was supposed to clean them daily to prevent cross-contamination. The DON stated she expected the ice scoop and ice scoop container to be cleaned daily to prevent foodborne illness, and the Administrator stated she did not expect the ice container to be dirty and that failure to keep it clean could spread germs. The facility policy titled, General Kitchen Sanitation, dated 10/01/2018, stated that all Nutrition & Food Service employees would maintain a clean, sanitary kitchen facility and that non-food-contact surfaces of equipment were to be cleaned at intervals as necessary to keep them free of dust, dirt, and food particles.
Incomplete and inaccurate wound documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation for 2 residents reviewed for medical records, both involving wound care. For one resident, the record showed diagnoses including COPD, unspecified dementia, and need for assistance with personal care. The resident had multiple pressure ulcers documented in the MDS, including three stage 3 pressure ulcers, one stage 4 pressure ulcer, and one unstageable pressure ulcer. The care plan identified wounds to the left hip, right heel, and right shin, and the order summary included wound care orders for those sites. During observation, the resident had wounds to the left hip, right shin, and right heel, but weekly skin assessments dated 12/26/25 and 12/30/25 did not document those wounds. A later weekly skin assessment dated 01/06/26 documented the three wound sites with measurements, but no unit of measurement was indicated. For the second resident, the record showed diagnoses including unspecified dementia, dysphagia following cerebrovascular disease, muscle weakness, and need for assistance with personal care. The resident’s MDS indicated bilateral lower extremity range-of-motion impairment, wheelchair use, incontinence of bowel and bladder, and two stage III pressure ulcers. The care plan identified a right heel stage III pressure injury and risk for impairment to the left heel, with an intervention to monitor and document location, size, and treatment of skin injury. The order summary included weekly skin assessments and wound care orders for the right heel. During observation, wound care was performed to the right heel, and the resident wore pressure-relieving boots to both feet, but no care was provided for the left heel during that observation. The weekly skin observation tools and wound assessments for the second resident were inconsistent with the wound history in the chart. Weekly skin observation tools dated 12/18/25 and 12/25/25 documented no new skin issues and did not document the right heel wound. A weekly skin observation tool dated 01/01/26 documented a stage III pressure injury to the left heel with measurements, but did not document the right heel wound. Weekly wound assessments dated 01/15/26 and 01/22/26 documented a right heel unstageable pressure injury. A wound evaluation and management summary dated 12/09/25 documented wounds to both the right and left heel, with the right heel stage III and the left heel unstageable. Staff interviews showed the treatment nurse documented only the wounds she was currently treating, while the floor nurse was responsible for weekly skin assessments; the DON and Administrator stated they expected accurate and timely documentation of skin and wound assessments.
Infection Control and Enhanced Barrier Precautions Failures During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for multiple residents during observed care and record review. Resident #67 had dementia, chronic respiratory failure with hypoxia, benign prostatic hyperplasia, an indwelling catheter, and frequent bowel incontinence. During observed incontinent care, CNA E wore gloves but did not put on a gown despite enhanced barrier precautions being ordered. CNA E cleaned the resident, removed a dirty brief, applied a clean brief while still using the dirty gloves, and did not change the brief after stool remained under the scrotum. CNA E also handled a top sheet with dried blood spots without gloves before placing it in a bag. CNA E stated she was not aware the resident required enhanced barrier precautions and said she was in a rush. Resident #79 had dementia, stroke, anxiety, high blood pressure, and was frequently incontinent of bowel and bladder. During observed incontinent care, CNA H wiped the resident’s front, turned her, and wiped her buttocks without performing hand hygiene or changing gloves between dirty and clean tasks. CNA H later changed gloves, washed her hands, and completed care. CNA H stated she did not perform hand hygiene or change gloves after wiping the resident and acknowledged this could cause cross-contamination. Resident #8 had a stage 3 pressure ulcer to the left heel, diabetes, severe cognitive impairment, and required maximum assistance with ADLs. Observation showed there was no enhanced barrier precautions posting or PPE cart outside the room on one day, and the treatment nurse stated the signage and cart had been removed because the resident was thought to be going home. Resident #10 had COPD, dementia, a urinary catheter, and pressure wounds. During observed catheter and incontinent care, CNA T and LVN B only wore gloves, did not use enhanced barrier precautions, and CNA T did not perform hand hygiene before, during, or after care. Resident #4 had end stage renal disease and received hemodialysis; record review showed enhanced barrier precautions were ordered, but the DON and Administrator stated the signage and PPE cart were expected to be outside the room and used during direct care. The facility policy on infection prevention did not include enhanced barrier precautions, while the separate enhanced barrier precautions policy described gown, gloves, and hand hygiene for high-contact activities.
Resident Was Mocked During Incontinent Care
Penalty
Summary
The facility failed to treat a resident with respect, dignity, and care in a manner that protected the resident’s rights during incontinent care. Resident #10 was a [AGE]-year-old male with COPD, unspecified dementia, and a need for assistance with personal care. His records showed he required assistance with toileting hygiene, had a urinary catheter, and was frequently incontinent of bowel. During observation, CNA T and LVN B were providing incontinent care while the resident had an active bowel movement and passed gas. During that care, CNA T stated, "Thanks, [Resident 10]," in a mocking tone. The resident later stated he felt ashamed of how he was being treated and described staff as treating him roughly during perineal care. The resident’s care plan included providing perineal care after each incontinent episode, and the resident’s representative reported being unsatisfied with the care and believing he was not being treated with respect and dignity. LVN B stated the comment made by CNA T was inappropriate and acknowledged the door should have been closed during care, but it was not. CNA T also stated the comment could have been taken wrong and hurt the resident’s self-esteem, and she admitted the comment was inappropriate. The DON and Administrator stated staff were expected to treat residents with dignity and respect, and both acknowledged the resident was at risk for humiliation.
Failure to Protect Resident Privacy and Confidential Information
Penalty
Summary
The facility failed to ensure confidential resident information was protected when RN G used her personal cell phone to text the facility NP about Resident #28. Resident #28 was a male resident with atrial fibrillation and intact cognition, with a BIMS score of 14. After the resident reported feeling dizzy and lightheaded and was found to have a nicotine patch on his right shoulder, RN G sent a text message to the NP that included the resident’s last name and described the medication error, symptoms, and continued monitoring. The nurse’s note did not document whether the NP was notified, and the NP did not respond to the text. The facility also failed to provide privacy during incontinent care for Resident #10. Resident #10 was a male resident with COPD, dementia, and need for assistance with personal care. His records showed he required assistance with toileting hygiene and had a care plan intervention for perineal care after each incontinent episode. During observation, CNA T and LVN B were seen providing incontinent care without closing the door or drawing the privacy curtain. During interview, LVN B stated the door should have been closed and said she forgot to close it, and CNA T stated the door did not remain shut during care. Resident #10 was described as alert and labile during interview, and the resident representative reported dissatisfaction with the care and believed the resident was not being treated with respect and dignity. The facility policy titled Resident Rights stated residents have the right to privacy and confidentiality and to communicate in person and by mail, email, and telephone with privacy. The DON and Administrator stated staff were expected to provide privacy and protect resident rights, and the Administrator stated the risk of not using a secure device was release of secure information or HIPAA violation.
Failure to Complete GDR for Antidepressant Use
Penalty
Summary
The facility failed to ensure that Resident #10, a [AGE]-year-old male admitted with COPD, unspecified dementia, and need for assistance with personal care, received a gradual dose reduction and behavioral interventions for psychotropic medication use. The resident’s records showed diagnoses including depression, and his care plan identified antidepressant use for depression with multiple monitoring interventions listed for possible adverse reactions. A medication regimen review for the period 12/02/25 to 12/06/25 recommended a gradual dose reduction of Lexapro from 15 mg daily to 10 mg daily. Despite that recommendation, the resident’s order summary showed an active order for escitalopram 15 mg daily with no end date, and the MAR showed he continued to receive Lexapro 15 mg daily throughout January 2026. During interviews, the DON stated she was unable to provide documentation of a GDR for the resident’s Lexapro. The DON also stated that when the resident went on hospice, the facility NP should have taken over medication care and monitoring, but the NP said she never took over the medication regimen review. The DON and Administrator both stated the GDR process should have been completed and that the resident was at risk of being over- or under-medicated and having unnecessary medications.
MDS Did Not Accurately Reflect PASRR Positive Status
Penalty
Summary
The facility failed to ensure that the MDS accurately reflected PASRR status for 2 residents reviewed for accuracy of MDS assessments. Resident #3’s admission MDS, completed after admission, indicated she could make herself understood, understood others, and had a BIMS score of 12, reflecting cognitive intactness, but Section A1500 marked her as not currently considered by the state level II PASRR process to have serious mental illness or intellectual disability. However, the PASRR level II evaluation completed on 12/15/25 identified Resident #3 as PASRR positive for mental illness, and her care plan also documented her as PASRR positive. Resident #3’s diagnoses included PTSD, depression, and anxiety. Resident #68’s annual MDS similarly marked Section A1500 as not currently considered by the state level II PASRR process to have serious mental illness or intellectual disability, indicating PASRR negative status. In contrast, the PASRR level II evaluation completed on 01/07/25 identified Resident #68 as meeting the PASRR definition of mental illness, and her comprehensive care plan documented her as PASRR positive for mental illness. Resident #68’s diagnoses included depression, bipolar disorder, and anxiety. During interviews, the MDS Coordinator stated Resident #3’s admission MDS should have reflected mental illness and PASRR positive status, and the MDS Consultant stated Resident #68’s annual MDS should have been marked yes because she was PASRR positive and that the incorrect coding was a mistake on her part.
Incorrect PASRR Screening for Resident with Mental Illness History
Penalty
Summary
The facility failed to ensure assessments were coordinated with the PASRR program to the maximum extent practicable for 1 of 8 residents reviewed for PASRR. Resident #41 was a female originally admitted with diagnoses including major depressive disorder, bipolar disorder, anxiety, and a personal history of other mental and behavioral disorders. Her care plan also reflected use of antipsychotic medication related to schizophrenia and bipolar disorder, and her annual MDS showed a BIMS score of 9, indicating moderately impaired cognition. The MDS also indicated she was not currently considered by the state level II PASRR process to have serious mental illness or intellectual disability, and no PASRR conditions were checked on that assessment. Record review showed a PASRR Level 1 screening dated 09/23/21 stated the resident had no evidence or indicator of dementia or mental illness, while a later PASRR Level 1 screening dated 05/25/23 stated she had evidence of mental illness. A referral entity assessment also reflected a history of depression and bipolar disorder. During interviews, the resident stated she always had a history of mental illness. The MDS Coordinator stated the previous MDS Coordinator was responsible for ensuring PASRR Level 1 was completed accurately and that a Form 1012 should have been completed to correct the inaccurate Level 1 and determine whether a new screening was needed. The MDS Consultant and Administrator also stated that if a Level 1 was incorrect or a diagnosis was added, the resident should be reevaluated for services and the discrepancy should be rectified.
Failure to Arrange Audiology Services for Resident with Missing Hearing Aids
Penalty
Summary
The facility failed to ensure a resident received proper treatment devices to maintain hearing abilities and failed to assist with making an audiology appointment after the resident reported missing hearing aids. Resident #61 was a female with dementia listed on the face sheet, but her quarterly MDS reflected a BIMS score of 15 and indicated she made herself understood, understood others, and had adequate ability to hear. Her comprehensive care plan identified a communication problem related to a hearing deficit and included interventions such as anticipating needs and validating messages by repeating aloud. The physician order summary also showed an active order for audiological care PRN. During interview, Resident #61 stated she had two pairs of hearing aids taken from her and that she had told several staff members, including the social worker, that she needed hearing aids. Her family member stated he repeatedly spoke with staff, including the social worker, about her needing hearing aids and said the facility kept giving excuses for why she had not been seen by the ear doctor. The social worker stated she was responsible for sending referrals to the audiologist, had spoken with the resident and family about the missing hearing aids, checked the resident's room without finding them, and had spoken with an agency about hearing aids but did not have documentation of the December contact. The DON and Administrator both stated the social worker was responsible for making the referral to the audiologist, and the Administrator stated she was not monitoring the social worker because she was not aware of a problem with residents receiving services.
Oxygen Filter Not Cleaned as Ordered
Penalty
Summary
Resident #41, a female with COPD, was assessed as having a BIMS score of 9 and received oxygen therapy. Her comprehensive care plan included oxygen therapy per MD order, and the physician order report showed an active order for oxygen at 2-3 liters per minute at bedtime. The resident also had an active physician order to check the oxygen filter for placement and cleanliness every night every Sunday. During observations on 01/19/26 and 01/20/26, Resident #41's oxygen concentrator filter was noted to have a thick, grey, fuzzy material. On 01/22/26, RN G observed the filter with the surveyor and stated it definitely needed to be cleaned. LVN P stated she was responsible for cleaning the filter on 01/18/26 but could not remember for sure whether she changed it, and she stated not changing the filter put the resident at risk for a respiratory infection. The DON and Administrator stated nursing staff were responsible for cleaning the filter according to the physician order and facility procedure, which required external filters to be washed every seven days with soap and water.
Failure to Implement Pharmacist Recommendation to Discontinue Medication
Penalty
Summary
The facility failed to act on a pharmacist’s recommendation to discontinue Mag-Oxide 400 mg given each morning for Resident #41. The resident’s record showed an active order for Mag-Oxide 400 mg daily as a supplement, and the pharmacist’s recommendation to physician dated 05/08/25 stated the medication was no longer necessary and should be discontinued. The NP agreed with the recommendation and signed on 05/15/25 to discontinue the medication, but the order was not clarified or implemented until surveyor intervention on 01/22/26. Resident #41’s record showed she was admitted with COPD, had a BIMS score of 9 indicating moderately impaired cognition, and had a care plan addressing altered cardiovascular status related to hyperlipidemia, CAD, HTN, and CHF. The MAR showed she continued to receive Mag-Oxide daily from 01/01/26 through 01/22/26. During interview, the NP stated she expected orders to be followed and that whoever handled the GDR was responsible for discontinuing the Mag-Oxide; she also stated the risk of not discontinuing it was elevated magnesium level which could cause heart issues. The DON and Administrator stated they expected nursing staff to ensure pharmacy recommendations were implemented timely, and both said they could not identify who was responsible at the time because they were not employed then.
Medications Left Unsecured on Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards for 1 of 4 medication carts reviewed, the 200 hall Nurse Medication Cart. During an observation and interview on 01/21/2026 at 4:57 PM, one vial of albuterol sulfate 2.5 mg/3 ml and one tube of diclofenac topical gel 1% were observed on top of the 200 hall Nurse Medication Cart, unattended, in the hallway. Multiple staff and residents were present in the area around the cart when the medications were left out. LVN A stated someone called her to take them to the dining room and she forgot to put the medications back inside the medication cart. She also stated she should not leave medications on top of the medication cart because someone could take them. The DON stated medications should not be left on top of the medication cart and said she had not noticed any medications not stored properly. The Administrator stated she expected all medications to be secured at all times. Record review of the facility policy titled, "6. Delivery, Receipt, and Storage of Medication," stated scheduled medications should be stored in a separate locked area within the medication carts or medication room.
Failure to Timely Arrange Dental Services for Dentures
Penalty
Summary
The facility failed to assist Resident #61 in obtaining routine dental services for dentures in a timely manner. Resident #61 was a female resident with dementia, but her quarterly MDS reflected a BIMS score of 15 and that she made herself understood and understood others. Her care plan identified a potential for oral/dental problems related to being edentulous, and it noted that she had upper and lower dentures but lost them prior to admission. Her physician order summary also included PRN dental care. During interview, Resident #61 stated she needed dentures and said she had told several staff members, including the social worker, about needing them. She reported that not having dentures made it hard to chew her food. Her family member also stated he repeatedly spoke with staff, including the social worker, about her needing dentures. The dental agency’s customer care representative stated Resident #61 needed an alternative payor source before being seen. The social worker stated she was responsible for sending referrals and scheduling dental services, and she had spoken with Resident #61 and her family about the need for dentures. She stated she received an email from the dental agency indicating Resident #61 would not be seen due to her payor source, but she did not follow up with the agency for clarification and thought the agency would notify the resident about what documents were needed. The BOM stated the social worker had not asked about the resident’s payor source until the day of the interview and that the resident had a lapse in coverage before later renewing it. The DON and Administrator stated the social worker was responsible for initiating the referral process for dentures and following up on payor source issues.
Personal Refrigerator Temperature Logs Not Maintained
Penalty
Summary
The facility failed to ensure safe and sanitary storage of resident food items for two residents with personal refrigerators. Resident #3, a cognitively intact female with PTSD, depression, anxiety, and moderate assistance needs for ADLs, had a refrigerator temperature log that was last dated 01/14/26 during observations on 01/19/26 and 01/20/26. During the 01/20/26 interview, she stated, “Oh shit, that's not good for me.” The log was later observed updated through 01/23/26. Resident #52, a male with dementia, a BIMS score of 3, and extensive assistance needs including total assistance for transfers and maximal assistance for toileting, dressing, bathing, and bed mobility, also had problems with his refrigerator temperature log. On 01/19/26, the refrigerator had a temperature log that was last checked on 1/6/2025, and the resident was unsure who logged the temperatures. On 01/22/26, the temperature log was missing, and he said he was unsure where it was and thought his kids may have checked it. The DON stated guardian angels' rounds were responsible for ensuring the logs were kept in place, and the Administrator stated staff were expected to check and log refrigerator temperatures daily.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was observed standing over a male resident with severe cognitive impairment, loudly talking and telling the resident, "you tripping," in response to the resident's statements. The resident, who had a history of cerebral infarction, ataxia, osteoporosis, hypertension, and radiculopathy, was wheelchair-bound and required varying levels of assistance with activities of daily living. The resident's care plan noted communication deficits, impaired cognitive function, and short-term memory loss, with interventions including task segmentation, cueing, reorientation, and supervision. Multiple staff members witnessed or were aware of the incident. One CNA overheard the loud and demeaning manner in which the CNA spoke to the resident, removed the resident from the situation, and informed the nurse. A licensed vocational nurse (LVN) also overheard the CNA speaking condescendingly and intervened by asking the CNA to clock out and leave, then notified the Abuse Coordinator. Written statements from these staff members corroborated the observations of patronizing and demeaning language directed at the resident. Interviews with the resident and his family revealed that neither recalled the incident or reported feeling unsafe, and the family had not observed any changes in the resident's mood or behavior. However, the facility's policy requires that residents be free from abuse, mistreatment, and neglect, and the actions of the CNA were inconsistent with this policy. The deficiency was identified based on staff observations and statements, as well as a review of the resident's records and care plan.
Misappropriation of Resident Funds by CNA During Outing
Penalty
Summary
A certified nursing assistant (CNA) used a resident's debit card to purchase personal items totaling $230.83 during an outing to a local store, without the resident's permission. The resident, a male with diagnoses including spinal stenosis, spondylosis, dementia, hypertension, Parkinsonism, and dysphagia, was assessed as having intact cognition and was able to identify which items were his and which were not. The resident reported the unauthorized purchases to the Activity Director after the outing, specifying that the CNA had bought items for herself using his funds. The Activity Director confirmed the resident's report and notified facility leadership, prompting an investigation. The CNA claimed the cashier was at fault for scanning her items with the resident's, but did not return to the facility after being suspended pending investigation. Facility records and interviews confirmed that the CNA's actions constituted misappropriation of the resident's property, as defined by facility policy, which prohibits the use of a resident's belongings or money without consent.
Failure to Update Care Plan Following Change in Diet Order
Penalty
Summary
The facility failed to review and revise the care plan for a resident after a change in dietary orders, as required. Record review showed that the resident, who had multiple diagnoses including dementia, dysphagia, COPD, peripheral vascular disease, obstructive uropathy, osteoarthritis, and depression, was admitted and readmitted with significant cognitive and physical impairments. The comprehensive MDS assessments indicated the resident required a mechanically altered diet, and physician orders dated 10/01/2025 specified a regular diet with pureed texture. However, the resident's care plan, last revised on 08/04/2025, continued to list a regular mechanical soft diet with thin liquids and was not updated to reflect the new pureed diet order. Observation confirmed that the resident was receiving a pureed diet, and the resident reported having received 'baby food' for some time. Interviews with the MDS nurse and DON revealed that care plan updates were the responsibility of the MDS nurse, who acknowledged ongoing updates to individual care plans. The DON and Administrator both stated that care plans should be updated as orders are received and reviewed quarterly, and that discrepancies between care plans and physician orders could result in harm. Facility policy requires care plans to be revised based on changing needs and current interventions, but this was not followed in this instance.
Failure to Follow Physician Orders for Staple Removal
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with physician orders and professional standards of practice. Specifically, a male resident with multiple diagnoses, including congestive heart failure, hypertension, diabetes type II, chronic kidney disease stage 3, and peripheral vascular disease, returned from the emergency room with two staples in the back of his head following a fall. Physician orders directed that the staples be removed five days after insertion. However, the order to remove the staples was not properly entered into the electronic medical record (EMR) system, resulting in the treatment not being scheduled or completed as ordered. Observations and interviews revealed that the treatment nurse was monitoring the staples but was unaware of the removal order due to the order not appearing on the Treatment Administration Record (TAR). The MDS nurse was aware of the presence of staples and the scheduled removal but did not know if the removal had occurred. The DON confirmed that the order was inaccurately coded in the EMR, preventing the treatment nurse from being prompted to remove the staples. The resident was observed with staples still in place beyond the ordered removal date, and the issue was only identified during the survey process.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy. Specifically, the resident did not have a current physician's order for oxygen use, and there were no orders in place for changing the oxygen tubing and water or for cleaning the filter. Observations revealed that the resident was using oxygen via nasal cannula at 2.5 L/min with undated tubing and an empty water bottle that had not been changed since a previous date. Interviews with nursing staff and the DON confirmed that the tubing and water were not changed or dated as required, and that the lack of an active order for oxygen contributed to the oversight. The facility's policy required verification of a physician's order and periodic checking of the water level but did not specify the frequency for changing tubing. The resident involved had a history of chronic obstructive pulmonary disease, emphysema, a pulmonary nodule, dementia, and high blood pressure. The care plan indicated a need for oxygen therapy per medical orders, but the most recent order had been discontinued months prior. Staff interviews acknowledged that the failure to maintain proper respiratory care practices, including changing and dating the tubing and water, and the absence of a current order, placed the resident at risk for infection and improper oxygen administration. The deficiency was identified through observation, record review, and staff interviews.
Inadequate Catheter Care Leads to Resident Injury
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, resulting in a significant injury. The resident, a male with a history of chronic obstructive pulmonary disease, dementia, benign prostatic hyperplasia, and urinary retention, was admitted to the facility with an intact cognition and required assistance with daily activities. Despite having a care plan that included monitoring for catheter-related issues, the facility did not properly secure the resident's Foley catheter, leading to a 3.5 cm tear in his penis and necessitating an emergency room visit. The deficiency was identified when the resident's family member noticed a malodor and blood in the resident's groin area, prompting an assessment that revealed the penile tear. The family member reported that the facility had not been providing the necessary catheter care, which was corroborated by the Director of Nursing (DON), who acknowledged that the catheter was not given enough slack, causing friction and pulling. The DON admitted that the staff failed to ensure the catheter was properly secured, which contributed to the injury. Interviews with the staff and the resident's family confirmed that the penile erosion was not present upon the resident's admission to the facility. The facility's failure to secure the catheter properly and provide adequate care was further highlighted by the absence of documentation regarding the injury in the resident's medical records. The facility's policy on Foley catheter care was requested but not provided during the survey, indicating a lack of adherence to established protocols for catheter maintenance.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to establish a system for the accurate reconciliation and documentation of controlled drugs, which affected three residents. The deficiency was identified through observations, interviews, and record reviews. For Resident #8, the facility did not ensure that the medication aide (MA V) accurately documented the administration of morphine, a controlled medication, on the narcotic record. This oversight occurred during a medication pass when MA V administered the morphine tablet but failed to record it, potentially leading to discrepancies in medication records. Similarly, for Resident #22, MA V did not document the administration of pregabalin, another controlled medication, on the narcotic record. This failure was observed during a medication pass, where MA V removed the pregabalin tablet from the narcotic box and administered it without recording the action. MA V acknowledged the oversight, noting that it could result in medication errors or discrepancies since the administration was not documented at the time. For Resident #15, a licensed vocational nurse (LVN W) failed to document the administration of Norco, a controlled medication, on the narcotic record. During a random controlled drug count, a discrepancy was found between the expected and actual count of Norco tablets. LVN W admitted to administering the medication but not recording it due to being busy with other residents. The Director of Nursing (DON) and the Administrator both emphasized the importance of immediate documentation to prevent errors and ensure medication accountability.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 18.75% due to 12 errors out of 64 opportunities. This involved two residents, one of whom did not receive their scheduled morning medications as prescribed. The errors were identified during a survey, which included observations, interviews, and record reviews. Resident #57, a male with multiple diagnoses including cerebral infarction and congestive heart failure, was affected by improper medication administration. The resident's care plan required medications to be given as ordered, without cocktailing, and with specific procedures for enteral administration. However, LVN W crushed and mixed all medications together, contrary to the physician's orders, and failed to administer certain medications due to a misunderstanding of their purpose. Additionally, the nurse did not verify the placement of the gastrostomy tube as required, which could have led to further complications. Resident #18, a female with dementia and other gastrointestinal issues, also experienced medication administration errors. MA X administered a multivitamin instead of the prescribed multivitamin with minerals and failed to give Reglan within the specified time frame before meals. This deviation from the physician's orders was acknowledged by MA X, who admitted to not having the correct medication on the cart and administering Reglan outside the prescribed time window. The facility's Director of Nursing confirmed the lack of competency checks for the staff involved, which contributed to these errors.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for three residents. Residents reported that the food was often cold, bland, and overcooked. During interviews, Resident #14 mentioned that the food was usually too cold, Resident #6 stated that the food lacked taste and was overcooked, and Resident #39 described the food as bland. Observations by surveyors confirmed these complaints, noting that the food was bland and not served at the appropriate temperature. The Dietary Manager acknowledged receiving complaints about the food and agreed that the food sampled was bland. The Administrator also noted that test trays he sampled were bland and expressed expectations for the dietary staff to ensure food was served at appropriate temperatures and was appetizing. The facility's policy on test trays emphasized the importance of providing food that is appealing, palatable, and served at the correct temperature, but this was not consistently achieved, leading to the deficiency.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Dietary staff did not wear hair restraints properly, with hair visibly protruding from hairnets, which could lead to contamination of food. This was observed with two dietary staff members during meal preparation. Additionally, the dishwasher was not operating at the required temperature of 120°F during the wash cycle, registering only 115°F, which is insufficient for proper sanitation. Furthermore, the dietary aide was unable to locate the correct chlorine test strips necessary for verifying the dishwasher's sanitation effectiveness. Interviews with the dietary aide, maintenance employee, and dietary manager confirmed the importance of maintaining proper hair coverage and dishwasher temperature to prevent foodborne illnesses. The dietary aide acknowledged the oversight in hair coverage and the significance of maintaining the correct dishwasher temperature for sanitization. The maintenance employee reiterated the need for the dishwasher to reach 120°F to kill bacteria effectively. The dietary manager emphasized the expectation for staff to use hairnets correctly and to utilize test strips for ensuring dish sanitation. The facility's policy on mechanical cleaning and sanitation of utensils mandates a wash water temperature of at least 120°F and the use of test kits to measure the concentration of sanitizing solutions.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. One significant issue involved the MDS Coordinator not applying personal protective equipment (PPE) before flushing a resident's PICC line, despite the resident being on contact isolation precautions due to an active infection. This oversight was acknowledged by the MDS Coordinator, who admitted that not wearing PPE posed a risk of infection transmission. The Director of Nursing (DON) and the Administrator both confirmed that staff were expected to wear PPE when providing care to residents on isolation to prevent the spread of infection. Another deficiency was observed during the provision of incontinent care to a resident by a CNA. The CNA failed to change gloves and perform hand hygiene after removing a dirty brief and before applying a clean one. Additionally, the CNA touched various surfaces in the resident's room with dirty gloves, including the wipes container, which was then returned to the linen cart, posing a risk of cross-contamination. The CNA admitted to being in a hurry and not following proper procedures, which could lead to urinary tract infections in residents. The DON emphasized the importance of proper glove changes and hand hygiene during incontinent care to prevent infections. Further issues were noted with the handling of linens. A hospice aide was seen carrying unbagged dirty linens down the hall, and a CNA left a bag with trash and an unbagged bed pad on the floor in a resident's room. Additionally, clean linen carts on two halls were found with their covers open, which could lead to contamination of the linens. Staff interviews confirmed that these practices were against the facility's infection control policies, and the DON and Administrator both stated that proper procedures should be followed to prevent cross-contamination and ensure resident safety.
Deficiencies in Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the proper completion of an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form for a resident. The resident, an elderly female with multiple diagnoses including dementia, had a DNR code status indicated on her face sheet and care plan. However, the OOH-DNR form was not completed accurately as the witnesses only signed in the section for two witnesses and did not sign at the bottom of the form as required. The Social Worker, responsible for ensuring the DNRs were completed, misunderstood the signing requirements, and the Director of Nursing (DON) was unsure of the correct procedure. This oversight could lead to confusion in a life-or-death situation. Another resident, a female with a history of epilepsy, schizoaffective disorder, and heart failure, did not have her preferred code status documented in the physician orders or on the face sheet. Although a code status assessment was completed indicating her preference for full code status, the necessary physician order was not placed in the electronic medical record. The nursing staff, responsible for entering this information, missed the order because it was not part of the standard admission batch orders. The Assistant Director of Nursing (ADON) acknowledged the importance of having the code status readily available but had not audited the resident's chart. The facility's policy on Do Not Resuscitate Orders requires that a DNR form be completed and signed by the attending physician and resident, and placed prominently in the medical record. The Corporate Regional Nurse provided this policy during the investigation. The Administrator and DON both recognized the importance of having the code status included in admission orders and on the face sheet to ensure staff can quickly identify a resident's wishes in an emergency. However, these procedures were not followed, leading to the deficiencies noted in the report.
Breach of Resident Confidentiality Due to Unattended EMR
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical records, specifically for a resident with a history of diabetes mellitus, bipolar disorder, and anxiety. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, had her electronic medical record (EMR) left open and visible on an unattended medication cart. This occurred when a medical assistant (MA) left the cart to enter a supply room without closing the EMR screen. During interviews, the MA acknowledged the oversight and recognized the importance of closing the EMR screen to protect the resident's personal information. The Director of Nursing (DON) and the Administrator both confirmed that the expectation was for the EMR screen to be locked when not in use to maintain confidentiality. The Administrator identified the incident as a HIPAA violation and a breach of resident information, emphasizing that all staff are responsible for ensuring the confidentiality of resident information.
Failure to Include Code Status in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included the necessary healthcare information for a resident, specifically omitting the resident's preferred code status. This deficiency was identified for a resident who was admitted with multiple complex diagnoses, including epilepsy, schizoaffective disorder, traumatic brain injury, and heart failure. The baseline care plan did not address the resident's preferred code status or advanced directive, which is a critical component of person-centered care. Interviews revealed that the social worker completed a code status assessment indicating the resident's preference for a full code status, but this information was not entered into the baseline care plan. The MDS Coordinator, responsible for ensuring the completion of the baseline care plan, acknowledged that the code status section did not auto-populate due to the timing of the assessment. Despite verbal discussions about the resident's code status, the omission was not corrected in the written care plan. The facility's administration recognized the importance of including the code status in the baseline care plan to respect the resident's wishes, but the error was not caught during the review process.
Failure to Assist Resident with Facial Hair Removal
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal hygiene for a resident, specifically in assisting with facial hair removal. The resident, a female with severe cognitive impairment due to dementia, was observed with approximately 1-inch black and gray facial hairs on the sides of her mouth. Despite being able to communicate and understand others, the resident was not offered assistance with facial hair removal, which she expressed embarrassment about when asked by the surveyor. The resident was receiving hospice services and required partial to moderate assistance with personal hygiene. The comprehensive care plan indicated that the resident needed one staff member to assist with personal hygiene and oral care, and adjustments were to be made to compensate for her changing abilities. However, the hospice CNA, who provided care three times a week, did not notice or offer assistance with facial hair removal, and the facility staff did not address this need during their care routines. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that facial hair removal was typically performed during bathing, but staff had not asked the resident if she needed assistance. The DON and Administrator acknowledged the importance of offering facial hair removal to maintain the resident's dignity, but staff were not specifically trained to look for facial hair during daily rounds. The facility's policies on ADLs and CNA standards of clinical practice emphasized the importance of assisting residents with grooming and personal hygiene, yet this was not adequately implemented for the resident in question.
Failure to Ensure Proper Administration of Enteral Medications
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received appropriate treatment and services to prevent complications. Specifically, the facility did not confirm the placement of the gastrostomy tube as ordered by the physician. The resident, a male with a history of cerebral infarction, essential hypertension, congestive heart failure, gastrostomy status, and dysphagia, was dependent on staff for feeding and other personal care needs. The care plan required checking the tube placement and gastric contents per facility protocol, but this was not consistently done. During an observation, LVN W was seen preparing the resident's medications by crushing them together, contrary to the physician's orders which specified that medications should not be cocktailed. LVN W did not confirm the gastrostomy tube placement via auscultation as required before administering medications. The surveyor intervened before the medications were administered. LVN W admitted to not following the correct procedure and acknowledged the risk of adverse reactions and tube displacement due to her actions. Interviews with the Director of Nursing (DON) and the Administrator revealed that there was no competency skills check-off for LVN W regarding medication administration via the gastrostomy tube. Both the DON and the Administrator confirmed that medications should be administered separately and that tube placement should be verified as per the physician's orders. The facility's policy also outlined these procedures, but they were not followed, leading to a potential risk for the resident's health.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For Resident #56, the oxygen concentrator was not set according to the physician's order. The resident, who has chronic obstructive pulmonary disease, was observed with her oxygen set between 3-4 liters per minute, despite the physician's order specifying 2 liters per minute. LVN A confirmed the discrepancy and acknowledged the importance of adhering to the physician's order to prevent potential harm from incorrect oxygen levels. For Resident #43, the facility did not ensure the cleanliness of the oxygen concentrator. The resident, who has chronic respiratory failure, was observed with a concentrator covered in dust and debris. RN D, who provided care to the resident, admitted to not noticing the dirt and believed the Staffing Coordinator was responsible for cleaning. However, the Staffing Coordinator stated that housekeeping, CNAs, or nurses should handle the cleaning. The DON emphasized the importance of maintaining clean equipment to prevent infections. Interviews with the DON and the Administrator highlighted the need for regular checks on oxygen settings and cleanliness. The facility's policy on oxygen administration did not address the cleaning of oxygen concentrators, contributing to the oversight. The lack of clarity on responsibilities for cleaning and monitoring oxygen settings led to these deficiencies, potentially compromising resident safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of metoprolol and Eliquis. On the date in question, LVN W prepared to administer metoprolol to the resident despite the resident's low blood pressure, which was contrary to the physician's orders. Additionally, LVN W did not prepare to administer Eliquis, an anticoagulant, mistakenly believing it was a blood pressure medication. This oversight could have placed the resident at risk of medical complications due to not receiving the therapeutic effects of their medications. The resident involved was a male with a history of cerebral infarction, essential hypertension, congestive heart failure, gastrostomy status, and dysphagia. The resident was dependent on staff for various activities of daily living and received medications through a gastrostomy tube. The resident's care plan included specific instructions for medication administration, such as not cocktailing medications and ensuring blood pressure was checked before administering certain medications. During the medication administration process, LVN W crushed multiple medications together, which was against the facility's policy and the resident's care plan. The LVN also failed to confirm the placement of the gastrostomy tube via auscultation as ordered by the physician. The Director of Nursing and the Administrator both acknowledged that the medications should have been administered as per the physician's orders, and the failure to do so could have resulted in harm or a change in the resident's condition.
Medication Carts Left Unlocked in Facility
Penalty
Summary
The facility failed to ensure that all drugs were stored in locked compartments, accessible only by authorized personnel, for three of six medication carts reviewed. Specifically, the 100-200 nurses' cart was left unlocked and unattended at the nurses' station by an RN, who admitted to forgetting to lock it. The RN acknowledged the importance of keeping medication carts locked to prevent drug diversion or adverse effects from incorrect medication use. Additionally, the MDS Coordinator left the treatment cart unlocked while attending to a resident's PICC line, and the medication cart for hall 300-400 was left unsecured by an MA. Both staff members recognized their responsibility to lock the carts and the potential risk of residents accessing medications not intended for them. The DON and Administrator both stated their expectations for staff to lock medication carts before leaving them unattended, emphasizing the importance of this practice for the safety of residents and visitors.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, which compromised the quality of care. Specifically, the facility did not ensure that the hospice records for a resident were included in their records at the facility. This lack of documentation and coordination could potentially place residents at risk of receiving inadequate end-of-life care. The resident in question was an elderly female with a diagnosis of parkinsonism, who had been receiving hospice services at the facility. Despite having a terminal prognosis and being on hospice care, the facility's records were not updated with the necessary hospice documentation, including the certification of terminal illness and the updated plan of care and medication since August. Interviews with facility staff and hospice representatives revealed a lack of clarity and responsibility regarding the maintenance of hospice documentation. The hospice nurse was responsible for updating the hospice binder with the necessary paperwork, but during a period when the regular hospice nurse was on vacation, the substitute nurse found that the binder lacked updated information. Facility staff, including an LVN and the Corporate Regional Nurse, indicated that there was no policy in place to ensure the hospice binder was checked for current documentation. The Director of Nursing (DON) and the Administrator were uncertain about who was responsible for ensuring the facility had the most updated hospice information, suggesting that Admissions or Medical Records might typically handle it. This lack of clear responsibility and procedure contributed to the deficiency in hospice care coordination.
Inadequate Abuse Training for Agency Staff
Penalty
Summary
The facility failed to provide adequate training to their staff, specifically to RN N, on recognizing and reporting abuse, neglect, exploitation, and misappropriation of resident property. Despite the Director of Nursing (DON) and the Administrator stating that frequent in-services on abuse were conducted, it was unclear if RN N, who was employed through an agency, had received any such training. The facility relied on the staffing agency to provide abuse training to their staff, but there was no confirmation that RN N had completed this training either through the agency or the facility. Interviews with the Administrator, Regional Compliance Nurse, Human Resources, and the Staffing Coordinator revealed a lack of a structured process for ensuring agency staff received necessary abuse and neglect training. The facility's policy required all staff to attend training sessions on resident rights and abuse prevention before having any resident contact, but this was not consistently applied to agency staff. The absence of documented training for RN N highlighted a gap in the facility's compliance with their own policies, potentially placing residents at risk.
Failure to Protect Resident from Verbal Abuse by Agency Nurse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a nurse employed through a staffing agency. The incident involved a resident who reported that a nurse called her derogatory names when she requested assistance with adjusting the air conditioning. The resident, who had a moderately impaired cognition, expressed feeling scared and awful due to the nurse's attitude and language. The incident was reported to the facility's administration, but the nurse involved was not immediately contacted for a statement. Interviews with various staff members revealed inconsistencies in the reporting and handling of the incident. A CNA witnessed the verbal abuse but did not report it, assuming that the RN supervisor would handle the situation. The RN supervisor, however, was not informed of the specific details of the verbal abuse. The Director of Nursing (DON) and the Administrator were aware of the incident but did not take immediate steps to obtain a statement from the agency nurse or ensure she was removed from the facility to protect the residents. The facility's policy on abuse and neglect clearly states that verbal abuse is not tolerated, yet the response to the incident was inadequate. The facility relied on the staffing agency to provide abuse training to agency staff, and there was uncertainty about whether the nurse involved had received any training from the facility. The lack of immediate action and communication among staff members contributed to the deficiency in protecting the resident from verbal abuse.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of a resident who experienced verbal abuse from a registered nurse (RN) employed through a staffing agency. The incident involved the RN making a derogatory comment to the resident, which was not immediately reported by a certified nursing assistant (CNA) who witnessed it. The CNA assumed that another staff member would handle the situation, leading to a delay in reporting the abuse to the appropriate authorities within the facility. The resident involved was a female with a moderately impaired cognitive status, as indicated by her BIMS score of 12. She required assistance with various activities of daily living and was on anti-anxiety medication. The verbal abuse incident made her feel awful and scared, as she was uncertain about the RN's future actions. Despite the resident's distress, the facility's Director of Nursing (DON) and Administrator were not informed of the incident until much later, highlighting a breakdown in communication and reporting procedures. Additionally, the facility did not ensure that the RN had completed the necessary abuse training, as required by their policies. The DON and Administrator were unaware if the RN had received any abuse training, either from the staffing agency or the facility itself. This lack of training and oversight contributed to the failure to prevent and address the abuse incident promptly, putting residents at risk of unreported abuse and neglect.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by regulations. This deficiency was identified in the case of a resident who was subjected to verbal abuse by a nurse. The incident occurred when a resident requested to be taken outside to smoke, and the nurse responded with a derogatory comment. Despite multiple staff members being present, the incident was not reported to the abuse coordinator or the administrator as required. The resident involved was a female with a moderately impaired cognition, as indicated by her BIMS score. She was admitted to the facility with a diagnosis of a displaced spiral fracture of the right tibia and required assistance with various activities of daily living. The resident reported feeling awful and scared following the verbal abuse incident, which was not immediately addressed by the facility staff. Interviews with staff revealed a lack of communication and reporting of the incident. A CNA who witnessed the event did not report it, assuming another staff member would handle it. The RN supervisor on duty was unaware of the incident, and the DON and Administrator were not informed until later. The facility's policy on abuse and neglect mandates prompt reporting of such incidents, which was not adhered to in this case.
Failure to Protect Resident from Abuse During Shower
Penalty
Summary
The facility failed to protect a resident from physical abuse by a CNA during a shower. The incident occurred when the CNA used excessive force while rubbing the resident's chest, resulting in a 5 cm superficial laceration, surrounding bruising, and closed fractures of the 2nd and 3rd ribs. The resident, who had a history of chronic respiratory failure, muscle contractures, and rheumatoid arthritis, required maximum assistance for activities of daily living and was dependent on a wheelchair. Despite the resident's protests and requests to stop, the CNA continued the aggressive behavior, causing physical harm. Following the incident, the resident was not immediately protected from further contact with the CNA. The CNA continued to provide care to the resident after the shower incident, which was against the facility's policy to protect residents from harm during investigations of abuse allegations. The resident expressed fear and anxiety about being in the shower room with new staff and was visibly upset and scared during the transfer back to bed. The facility's failure to immediately remove the CNA from resident care duties placed the resident at risk of further harm. Interviews with staff and the resident's family member revealed inconsistencies in the handling of the situation. The resident's family member provided evidence that contradicted the facility's initial assessment of the incident. The facility's administrator and staff failed to adequately separate the alleged perpetrator from the resident, and there was a lack of immediate action to ensure the resident's safety. The facility's policy on abuse and neglect was not followed, leading to a situation of immediate jeopardy for the resident.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and mistreatment of residents, as evidenced by an incident involving a resident who was physically abused by a CNA in the shower room. The resident, who had a history of chronic respiratory failure, muscle weakness, and mild cognitive deficit, required maximum assistance for activities of daily living. During a shower, the CNA reportedly used excessively hot water and scrubbed the resident's chest aggressively, resulting in a skin tear and rib fractures. Despite the resident's protests, the CNA continued the aggressive behavior, and another CNA who entered the room did not intervene appropriately. The incident was further compounded by the failure of the charge nurse, LVN D, to immediately remove the alleged perpetrator, CNA A, from resident care duties. Instead, CNA A was allowed to continue providing care to the resident after the incident, which is a direct violation of the facility's abuse prevention policy. The policy clearly states that employees accused of abuse should be reassigned to non-resident care duties or suspended without pay pending investigation. This failure to follow protocol placed the resident at risk for further harm and demonstrated a lack of adherence to established procedures for handling abuse allegations. Interviews with staff and the resident revealed that the incident was not handled according to the facility's policies. The resident expressed fear and anxiety about being in the shower room with new staff, and staff members acknowledged that the alleged perpetrator should have been immediately removed from resident care. The facility's failure to protect the resident during the investigation of the abuse allegation highlights a significant lapse in ensuring resident safety and compliance with abuse prevention policies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to medication errors and omissions. Resident #2 did not receive her prescribed Nifedipine for hypertension on a specific date, despite the medication being available in the facility's emergency kit. The Medication Aide (MA) responsible did not recall the incident, and it was noted that only a nurse could access the emergency kit. The Director of Nursing (DON) confirmed that the emergency kit should be used when medications are not delivered on time. Resident #3 was mistakenly administered Ativan and Trazodone, medications not prescribed to her, due to an error by MA D. The MA had pre-prepared another resident's medication and inadvertently gave it to Resident #3 after being distracted by a phone call. The error was immediately recognized and reported, and the resident was assessed and found stable. The MA acknowledged the mistake and received education on proper medication administration procedures. Resident #4 did not receive her prescribed Amlodipine during a medication pass observed by a surveyor. MA C, who administered the medications, initially claimed to have given the Amlodipine but later could not produce the medication card as evidence. The DON and Administrator emphasized the importance of following physician orders and not pre-preparing medications. The facility's policy on medication administration was reviewed, highlighting the need for accuracy and adherence to prescribed orders.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the care of a resident. CNA A was observed using a disposable wipe visibly soiled with feces to clean a resident's vaginal area, instead of disposing of it and using a clean wipe. This action was acknowledged by CNA A, who admitted the importance of using a clean wipe to prevent infections. CNA B was observed failing to perform hand hygiene between glove changes, before exiting the resident's room, and prior to re-entering the room. CNA B acknowledged the oversight and recognized the importance of hand hygiene in preventing the spread of bacteria and infections. Additionally, both CNAs failed to remove a trash bag containing dirty gloves visibly soiled with feces from the resident's room after providing care. Interviews with the DON and the Administrator confirmed that the facility's expectations for infection control were not met. Both emphasized the importance of disposing of soiled wipes, performing hand hygiene, and removing contaminated items from resident rooms to prevent cross-contamination and infections. The facility's policies on hand hygiene and care for residents with urinary incontinence were not adhered to during the observed incident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 161 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kemp
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kemp Care Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Mabank Nursing Center | 7.5 mi | ★★★★★ | 15 | 0 |
| Avir At Kaufman | 11.2 mi | ★★★★★ | 19 | 0 |
| Sunflower Park Health Care | 11.4 mi | ★★★★★ | 19 | 0 |
| Kerens Care Center | 20.5 mi | ★★★★★ | 1 | 1 |
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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.