Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeview Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that insulin pens on two medication carts were not properly labeled or dated. On one cart, a Lantus Solostar insulin pen lacked an opened date, and an LVN acknowledged insulin should be dated because it is only effective for 28 days after opening. On another cart, a Tresiba FlexTouch insulin pen had neither a resident name nor an opened date; an LVN reported it was likely from the emergency kit and confirmed it should have been labeled with the resident’s name and open date. The DON stated her expectation that all insulin pens, including those from the emergency kit, be labeled with the resident’s identifying information and the date opened to prevent use of expired or incorrect insulin.
Failure to Document Abuse-Related Incidents The facility did not complete incident reports or document resident-to-resident altercations involving residents with severe cognitive impairment and significant care needs. One resident threatened two others in the lobby, and another incident involved a resident grabbing and squeezing another resident’s wrist, but the events were not documented in the incident system or the EMR for the residents involved. The facility also did not document an injury of unknown origin for a resident with multiple chronic conditions and cognitive impairment, and the Administrator could not find documentation of the related training.
Improper Food Labeling and Storage in Kitchen: Surveyors found multiple unlabeled and improperly stored food items in freezer #1, freezer #2, refrigerator #1, and the dry storage room. Items included open bags of frozen chicken wings and chicken parts, repackaged cauliflower, an open box of frozen egg rolls, sliced cheese, chicken base, and an open container of thickener. The Dietary Manager stated the items should have been sealed, labeled, and dated, and the Administrator said staff were expected to follow the facility’s food storage policies.
Inaccurate MDS Coding for Smoking Status and PASRR Status: The facility failed to accurately code two residents’ MDS assessments. One resident with COPD was a daily smoker who was observed smoking and confirmed by staff, but the MDS did not mark current tobacco use. Another resident with mild intellectual disabilities was PASRR positive and receiving habilitation services, but the annual MDS did not reflect PASRR status or related Level II conditions. The MDS Nurse, DON, and Administrator acknowledged the omissions and said the assessments were inaccurate.
A resident with dysphagia and a G-tube did not have EBP precautions included in the care plan, and no related interventions were documented. The resident’s order summary included daily G-tube site care, but there was no EBP precaution order. The DON and MDS nurse stated the care plan should have included EBP and that it was overlooked.
A resident with dry eye syndrome and severely impaired cognition had a Refresh Plus eye drop ampule left on his dresser on top of a covered bowl of cereal instead of being kept on a locked med cart. Staff gave conflicting accounts about how the eye drops were handled, and the DON and Administrator stated meds should not be left in any resident room.
A facility failed to maintain infection control when an LPN did not wear a gown during G-tube medication administration for one resident and did not wear a gown during wound care and a dressing change for another resident. One resident had a G-tube and moderately impaired cognition, and the other had chronic abdominal and thigh wounds requiring dressing changes. The DON and Administrator stated EBP should be used for residents with wounds and enteral devices, and the facility policy required gown and glove use for these high-contact care activities.
A resident with a stage 4 pressure ulcer experienced inadequate pain management during wound care after a debridement procedure. Despite a care plan that included pain medications and lidocaine application, the facility failed to consistently administer these interventions, leading to significant pain during treatments. Staff interviews revealed lapses in communication with the physician and inconsistent application of pain relief measures, contrary to the facility's pain management policy.
A resident experienced increased pain following a wound debridement, but the facility failed to notify the physician promptly. Despite the resident's complaints and requests for stronger pain medication, the staff did not contact the physician until several days later, leading to inadequate pain management.
A facility failed to maintain consistent communication with a dialysis center for a resident with end-stage renal disease, missing several dialysis communication forms. The resident was scheduled for dialysis three times a week, but the facility did not consistently send or receive the necessary communication forms, which are essential for monitoring the resident's condition. Staff interviews revealed lapses in completing these forms, and the facility lacked a monitoring system to ensure compliance with its dialysis protocol.
The facility's kitchen failed to meet food safety standards, with issues such as a dirty fryer, improperly stored and labeled food, and a lack of temperature monitoring in the dining room freezer. The Dietary Manager and staff were unaware of these deficiencies, and cleaning logs showed non-compliance with established procedures.
A resident with severe cognitive impairment and multiple health conditions was found to have their call light repeatedly out of reach, despite being dependent on staff for assistance. The facility's staff, including a CNA and the DON, acknowledged the importance of call light accessibility, yet the deficiency persisted, indicating a failure to accommodate the resident's needs.
The facility failed to maintain a clean and homelike environment in the back dining room, as evidenced by cobwebs, dead bugs, and dust on the windowsill. The Housekeeping Supervisor and Administrator acknowledged the oversight, noting that the windowsills should be cleaned multiple times a week. The facility's policy emphasizes the importance of a clean and orderly environment.
A resident with end-stage renal disease was receiving dialysis three times a week, but this was not reflected in her MDS assessment. The DON and MDS Coordinator acknowledged the oversight, which could affect care monitoring. The Administrator stressed the importance of accurate MDS coding for proper reimbursement and care representation.
A facility failed to update a resident's care plan to include necessary interventions for weight loss, such as weekly weights and Ensure Plus administration, despite these being part of the resident's physician orders. Interviews with staff revealed confusion over responsibility for care plan updates, with the MDS Coordinator admitting to missing these critical interventions. The facility's policy requires care plans to be comprehensive and revised as conditions change, which was not followed in this instance.
A resident with hemiplegia and a UTI was found with wet bed sheets and clothing due to inadequate incontinent care. Despite being on antibiotics, the resident required substantial assistance with toileting. Observations revealed that staff did not perform timely rounds, leading to the resident remaining wet overnight. Interviews highlighted the importance of prompt care to prevent skin breakdown and infection, but there was a lack of communication and documentation regarding the resident's care needs.
A facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the resident's triggers and did not document them in the care plan. Despite the resident's history of paranoid schizophrenia, PTSD, and other mental health conditions, the facility did not adequately assess or address his trauma history, leading to potential re-traumatization. Interviews with staff revealed a lack of awareness and documentation regarding the resident's PTSD diagnosis and triggers, contrary to the facility's policy on trauma-informed care.
Two residents received blood pressure medications outside of ordered parameters, leading to significant medication errors. A resident with renal disease was given amlodipine despite low blood pressure, and another with cerebral infarction received carvedilol under similar conditions. The LVN involved was aware of the parameters but followed incorrect training advice. The DON admitted to a lack of monitoring systems, and the Administrator emphasized the need for protocol adherence.
The facility failed to maintain proper infection control when Laundry Aide H distributed clean clothing with a partially covered linen cart, exposing the clothes to potential contamination. Interviews revealed that the aide was aware of the need for complete coverage but believed the blanket used was adequate. The Housekeeping Supervisor and Administrator confirmed the requirement for full coverage to prevent exposure to germs, aligning with the facility's policy.
Improper Labeling and Dating of Insulin Pens on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and dating of insulin pens on two medication carts. On the East Hall medication cart, a Lantus Solostar pre-filled insulin pen was observed without an opened date. When interviewed, LVN A stated she did not know why the insulin was not dated and acknowledged that insulin should be dated when opened because it is only good for 28 days after opening. The facility’s Medication Administration policy indicated that medications are to be administered safely and as prescribed, and that insulin pens containing multiple doses are for single-resident use only. On the [NAME] Hall medication cart, surveyors observed a Tresiba FlexTouch insulin pen without a resident name or opened date. LVN B stated the pen was probably from the emergency kit and confirmed that insulin from the emergency kit should be labeled with the resident’s name and an open date to ensure the correct person receives the correct medication and because insulin pens are only good for 28 days after opening. The DON stated she expected insulin pens labeled by the pharmacy with a resident’s name to be dated when opened, and that pens taken from the emergency kit should be labeled with the resident’s name, date of birth, and the date opened. The DON further stated that dating insulin ensures residents are not given expired or ineffective medication and that labeling each pen with the correct resident name ensures the right person receives the right medication.
Failure to Document Resident-to-Resident Incidents and Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its written abuse prohibition policy when it did not complete incident reports and did not document resident-to-resident incidents involving multiple residents. The policy stated that incident reports would be completed for both the perpetrator and the victim when resident-to-resident incidents occurred, and that injuries of unknown origin would be reported within 24 hours. Record review showed that an incident on 05/01/2025 involved Resident #34, Resident #13, and Resident #25 at a table in the front lobby, where Resident #34 became upset, told the other residents to shut up, and threatened to kill them if they did not stop. A witness statement identified LVN A as the nurse when the incident occurred, but the incident was not documented in the incident report system or in the electronic medical records for any of the three residents. Resident #34 had diagnoses including cerebral infarction, spastic hemiplegia affecting the right dominant side, and intermittent explosive disorder. His quarterly MDS indicated severe cognitive impairment with a BIMS score of 6, and his care plan identified a potential for physical aggression and directed staff to analyze triggers, assess and anticipate needs, and monitor and document signs of danger to self or others. Resident #13 had diagnoses including senile degeneration of the brain and cerebral palsy, with a BIMS score of 0 and dependence on staff for toileting, hygiene, bathing, and eating setup. Resident #25 had diagnoses including hemiplegia and hemiparesis following cerebral infarction and dementia, with a BIMS score of 0 and dependence on staff for personal care and eating setup. Despite the involvement of all three residents in the incident, the incident report system did not show the event for Resident #34, Resident #13, or Resident #25, and their electronic records did not contain documentation of the event. A second resident-to-resident incident occurred on 07/19/2025 involving Resident #34 and Resident #7. The investigation summary stated that Resident #34 and Resident #7 argued in the front lobby, Resident #34 told Resident #7 to shut up, and then grabbed and squeezed her right wrist as she reached toward him. A volunteer intervened and separated them, and the nurse assessed Resident #7 with no injury and no complaints of pain. Resident #7 had vascular dementia, a BIMS score of 0, and was dependent on staff for all ADLs; her care plan identified a potential for physical aggression toward other residents related to cognitive impairment. However, the incident report system did not show the event for Resident #7, and her electronic medical record did not contain documentation of the incident. The facility also failed to document an injury of unknown origin for Resident #45. Resident #45 had diagnoses including severe obesity, diabetes, muscle weakness, major depressive disorder with psychotic symptoms, hypertension, and anxiety disorder. Her records showed severe cognitive impairment on one quarterly MDS and moderate impairment on another, with dependence on staff for most ADLs. The provider investigation report for 07/31/2025 stated that she had a bruise on her chest and said staff had dropped the left bar, but she did not know which CNAs were getting her up. The incident report system did not show an incident for that date, and the Administrator stated he could not find documentation of the training that was completed related to the incident. The DON stated the incident report should have been updated or a new one made, and that the only training had been done prior to the incident.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards in the kitchen during observation and interview. In freezer #1, surveyors found an open, unlabeled clear plastic bag of frozen chicken wings and an unlabeled clear plastic bag of frozen chicken parts. In freezer #2, surveyors found a sealed bag of cauliflower that was unlabeled after being repackaged, and an open cardboard box containing a clear plastic bag of frozen egg rolls that was not sealed. In refrigerator #1, surveyors found a sealed bag of sliced cheese that was unlabeled and an open container of chicken base that was unlabeled. In the dry storage room, surveyors found an open and unsealed container labeled thickener. The Dietary Manager stated the chicken wings and chicken parts should have been labeled with content and date opened, and said the cauliflower had been repackaged after the original bag was damaged during delivery but should have been labeled and dated at that time. He also stated frozen foods should be sealed to prevent freezer burn and that open or repackaged foods should be labeled with the content, open date, and/or expiration or use-by date. He further stated dry storage containers should be labeled and resealed after use to prevent air exposure or contamination. The Dietary Manager said he was not aware that the frozen items in freezers #1 and #2 and the foods and cooking base in refrigerator #1 were not sealed, labeled, and dated appropriately. The Administrator stated he expected kitchen staff to follow policies requiring open items to be closed or sealed and labeled and dated when opened. Facility policy required food removed from original containers to be labeled and dated, open items to be tightly sealed, and food storage to follow expiration guidelines. The report also cited FDA Food Code provisions requiring food to be protected from contamination and packaged food to be labeled.
Inaccurate MDS Coding for Smoking Status and PASRR Status
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for 2 of 14 residents reviewed. For one resident with chronic obstructive pulmonary disease and a documented smoking history, the admission MDS assessment did not indicate current tobacco use even though the resident was identified in the admission/readmission evaluation as currently smoking cigarettes, was observed smoking during the survey, and stated that she smoked daily. Facility staff also confirmed that she smoked daily, that her smoking supplies were kept by staff, and that she was monitored during smoking episodes. The MDS Nurse acknowledged that the resident smoked during the look-back period and said the tobacco use item had been overlooked on the MDS. For another resident with mild intellectual disabilities and frontal lobe/executive function deficits, the annual MDS did not indicate PASRR positive status or complete the related Level II PASRR conditions. The resident’s care plan identified her as PASRR positive and noted specialized services, and the LIDDA Individual Profile and Habilitation Service Plan showed she was receiving habilitation services. During interview, the resident stated she received habilitation and independent services through PASRR and had routine visits from a LIDDA representative. The MDS Nurse confirmed the resident was PASRR positive, was receiving habilitation and individualized specialized services, and said the annual MDS should have reflected that in section A. The MDS Nurse stated she was responsible for completing MDSs in the facility, with the DON and Regional Case Mix serving as backup reviewers for some MDSs. The DON and Administrator both stated that the smoking status and PASRR status had been overlooked on the respective MDS assessments and that the assessments were not accurate. The facility policy required use of the most up-to-date RAI manual for timely and accurate coding, and the RAI manual excerpts cited in the report specified coding for current tobacco use and PASRR/ID-DD status.
Missing EBP Care Plan for Resident with G-Tube
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #3’s EBP precautions related to a G-tube. Resident #3 was an 81-year-old male admitted to the facility with diagnoses including dysphagia and a gastrostomy tube for feeding, hydration, and medications. His annual MDS dated 01/08/2026 reflected a BIMS score of 09, indicating moderate cognitive impairment. Review of the most recent care plan showed that EBP precautions were not developed and no interventions were included for the resident’s G-tube-related needs. Resident #3’s physician order summary dated 01/05/2026 reflected an order for cleaning the G-tube site with normal saline, patting dry, and covering with a dressing daily, but there was no EBP precaution order. During interview, the DON stated the MDS nurse was responsible for developing the care plan and said EBP should have been included but was overlooked. The MDS nurse stated that she and the DON were responsible for developing care plans and that the DON was ultimately responsible for signing off on them for accuracy and completion. The facility policy on comprehensive person-centered care plans stated that the plan must describe services to be furnished, incorporate identified problem areas and risk factors, and reflect recognized standards of practice.
Medication Left at Resident Bedside
Penalty
Summary
The facility failed to ensure drugs were stored in a locked compartment and labeled and dated correctly when a Refresh Plus eye drop ampule was found sitting on top of a covered bowl of cereal on a resident’s dresser. The resident was a male re-admitted to the facility with diagnoses including dry eye syndrome and need for assistance with personal care. His quarterly MDS indicated he was usually able to understand others, could usually make himself understood, and had a BIMS score of 3, indicating severely impaired cognition. His care plan identified impaired visual function related to eyeglasses and dry eye syndrome, with nursing interventions to administer Refresh Plus as ordered. The resident’s order summary showed orders for Refresh Plus Ophthalmic Solution, one drop in both eyes at bedtime and one drop in both eyes in the morning for dry eye syndrome. During observation, the eye drop ampule was on the dresser in the resident’s room, on top of his covered bowl of cereal. The resident said he guessed the girl left the medication for him to take but it was closed so it had not been used, and he said he usually did not do it himself. Later observation showed the eye drops were no longer on the dresser. An LVN said she did not know where the resident got the eye drops and removed the ampule from the room. Another LVN said she always made sure to give the eye drops and remove the empty ampule after use. The DON and Administrator stated medications should be on a locked medication cart and not left in any resident room.
Failure to Use Enhanced Barrier Precautions During G-tube Medication Administration and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 residents observed for infection control. Resident #3 was an 81-year-old male with a gastrostomy tube, moderately impaired cognition, and an order for daily G-tube site care. During a medication administration via the G-tube, the LVN donned gloves, checked placement, and administered the medication and water flushes, but did not wear a gown. There was no EBP signage outside the resident’s room at the time of observation, and the LVN stated she forgot to wear a gown even though she had been trained on EBP and knew she should have applied it before entering the room. Resident #31 was a cognitively intact male with chronic wounds/open skin areas to the abdomen and right thigh, requiring wound care and dressing changes. His care plan identified enhanced barrier precautions during high-contact care activities such as wound care, and physician orders directed wound care to the affected areas. During observation of the dressing change and wound care, the LVN provided care without wearing a gown. The LVN stated she had been trained on EBP but forgot to wear a gown during the wound care and dressing change. The DON stated staff had been trained on infection control and enhanced barrier precautions and that EBP should be followed for residents with open wounds, tube feedings, IVs, foley catheters, and tracheostomies. The Administrator stated all staff should adhere to EBP when providing high-contact care for residents with wounds, tube feedings, IVs, tracheostomies, and indwelling devices, and that residents requiring EBP should have orders, signage on the doors, and care plans indicating the required precautions. The facility policy reviewed by surveyors stated that EBP includes gown and glove use during high-contact resident care activities and that wound care and enteral medication administration require enhanced barrier precautions.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident during wound care, specifically after a wound debridement procedure. The resident, who had a stage 4 pressure ulcer, reported increased pain following the debridement performed by the Wound Care NP. Despite having a care plan that included administering pain medication prior to treatments, the facility did not consistently ensure that the resident received appropriate pain relief, leading to the resident experiencing significant pain during wound care procedures. The resident's medical history included conditions such as low back pain, gout, and rhabdomyolysis, and he was dependent on staff for various activities of daily living. The resident's care plan specified the use of medications like oxycodone, hydrocodone-acetaminophen, and Tylenol for pain management, as well as the application of lidocaine prior to wound care. However, the facility's staff did not consistently apply these interventions, and there were lapses in communication with the physician regarding the resident's increased pain following the debridement. Interviews with facility staff revealed that the resident had been experiencing increased pain since the debridement, but the staff did not promptly notify the physician or adjust the pain management plan accordingly. The resident expressed that the pain was severe during wound care, describing it as a burning sensation, yet the staff did not consistently apply lidocaine or ensure the effectiveness of the pain medications administered. The facility's policy on pain management was not adequately followed, resulting in the resident enduring unnecessary pain during wound care procedures.
Failure to Notify Physician of Increased Pain Post-Debridement
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, specifically increased pain following a wound debridement. The resident, who had a stage 4 pressure ulcer, experienced increased pain after the procedure performed by the Wound Care NP. Despite the resident's complaints of increased pain, the facility did not inform the physician promptly, which could have led to inadequate pain management. The resident's medical records indicated that he was receiving various pain medications, including oxycodone and hydrocodone, but there was no documentation of increased pain or the debridement procedure in the progress notes. The resident reported increased pain during wound care, describing it as a burning sensation, and requested stronger pain medication. However, the facility staff did not contact the physician until several days later to address the resident's pain management needs. Interviews with facility staff revealed that the resident's pain was not adequately assessed or communicated to the physician. The staff acknowledged the resident's increased pain but failed to take timely action to adjust the pain management plan. The facility's policy on pain management emphasized the importance of addressing pain and notifying the physician of any changes, but this was not followed in the resident's case.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center for a resident requiring dialysis services. The resident, a female with end-stage renal disease, was scheduled to receive dialysis three times a week. However, the facility did not consistently send or receive dialysis communication forms on multiple occasions, which are crucial for monitoring the resident's condition and ensuring proper care. Interviews with staff revealed that the dialysis communication sheets were not consistently completed or sent. The charge nurse at the dialysis clinic noted that sometimes they received the communication sheets and sometimes they did not. The facility's LVN acknowledged the importance of these sheets for communication and monitoring but admitted that some sheets might have been missed, especially after the resident was moved to a different room. The Director of Nursing (DON) and the Administrator both recognized the importance of the dialysis communication forms for ensuring proper communication and monitoring of the resident's condition. However, there was no monitoring system in place to ensure that the communication forms were consistently completed and sent. The facility's policy required a communication form to accompany the resident to and from the dialysis center, but this protocol was not consistently followed.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food safety standards in its kitchen, as observed during a survey. The cooking area was found to have a dirty fryer with dark oil and crumbs, and a toaster with crumbs around it. In the dry storage room, an opened loaf of bread was improperly sealed and not dated, and an opened container of enchilada sauce was not refrigerated as required. In the right freezer, an opened box of corn dogs was not sealed properly, resulting in freezer burn. The refrigerator in the kitchen contained an opened box of bacon that was not sealed, and a container of leftover beans that was not discarded after the appropriate time. Additionally, a gallon of chocolate milk was found past its best-by date. The survey also revealed that the top freezer in the dining room lacked a thermometer, and its temperature was not being monitored. The freezer contained 18 loaves of frozen bread and had a thick brown residue on the second shelf of the door, which had leaked onto the bottom. Dietary staff were not aware of the need to monitor the freezer's temperature separately from the refrigerator. The Dietary Manager admitted to not being aware of the residue and the lack of a thermometer, and acknowledged that the dietary staff should have been monitoring temperatures and cleaning the freezer. Interviews with the Dietary Manager and Administrator highlighted a lack of adherence to food safety protocols. The Dietary Manager admitted to cleaning the fryer only once a week and not ensuring that opened food items were properly sealed and dated. The Administrator expected food to be covered, sealed, and dated, and for temperatures to be monitored to prevent serving spoiled food. The facility's cleaning logs and policies indicated a lack of compliance with established procedures for food storage and cleanliness, contributing to the deficiencies observed during the survey.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach while the resident was in bed, which is a deficiency in accommodating the needs and preferences of the resident. The resident, a male with severe cognitive impairment and multiple health conditions including vascular dementia and the absence of both legs above the knee, was dependent on staff for various activities of daily living. The care plan for the resident indicated that he was at high risk for falls and required his call light to be within reach to request assistance. However, during multiple observations, the call light was found on the floor, out of the resident's reach, which could delay assistance and decrease the resident's quality of life. Interviews with staff, including a CNA and the DON, revealed that the staff were aware of the importance of ensuring call lights were within reach for residents to communicate their needs. The DON acknowledged that the call light should be within reach when staff leave the room, and the Administrator emphasized that the call light is the resident's only means of communication. Despite this understanding, the call light was repeatedly found out of reach, indicating a failure in the facility's responsibility to ensure reasonable accommodation of the resident's needs.
Failure to Maintain Cleanliness in Dining Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment in the back dining room, as evidenced by the presence of numerous cobwebs, dead bugs, and a thick layer of gray dust on the windowsill. This condition was observed on three separate occasions over a three-day period. The Housekeeping Supervisor acknowledged that the housekeeping staff, including herself, were responsible for cleaning the dining room, which included the blinds, windowsills, and walls. However, she admitted that the windowsill had not been cleaned due to time constraints. The Administrator confirmed that the housekeeping staff were tasked with ensuring the cleanliness of the back dining room and stated that the windowsills should have been cleaned at least three to four times per week. The Administrator noted that the facility had recently removed decorations to add fall decorations but had not yet cleaned the windowsill. Both the Housekeeping Supervisor and the Administrator emphasized the importance of maintaining a clean environment to prevent cross-contamination and promote resident happiness and comfort. The facility's Homelike Environment policy, revised in February 2021, reflects the expectation of a clean, sanitary, and orderly environment.
Inaccurate MDS Assessment for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that the MDS assessment for a resident accurately reflected her dialysis treatments. The resident, who was diagnosed with end-stage renal disease, was receiving dialysis three times a week at a dialysis center. However, the Quarterly MDS assessment did not indicate that the resident was receiving dialysis, which was a significant oversight. The Director of Nursing (DON) and the MDS Coordinator both acknowledged that the dialysis should have been coded on the MDS assessment, but it was missed. This inaccuracy in the MDS assessment could potentially affect the monitoring and care provided to the resident. Interviews with the DON and the MDS Coordinator revealed that they were responsible for reviewing and signing the MDS assessments. The DON admitted to possibly missing the dialysis entry, while the MDS Coordinator confirmed that the dialysis should have been included. The Administrator emphasized the importance of accurate MDS coding for proper reimbursement and to ensure that the resident's care needs were accurately represented. The facility's MDS Coding Policy requires the use of the most up-to-date Resident Assessment Instrument manual for accurate coding, which was not adhered to in this case.
Failure to Update Resident's Care Plan for Weight Loss Interventions
Penalty
Summary
The facility failed to ensure that a resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan for a resident with diagnoses including anxiety, protein-calorie malnutrition, muscle wasting, and dysphagia was not updated to reflect the need for weekly weights and the administration of Ensure Plus three times a day. This oversight was identified during a record review and interviews with facility staff, revealing that the care plan did not include these critical interventions despite being part of the resident's physician orders. Interviews with facility staff, including an LVN, the DON, the Administrator, and the MDS Coordinator, highlighted a lack of clarity regarding responsibility for updating care plans. The MDS Coordinator acknowledged missing the inclusion of the resident's weight loss interventions in the care plan, which was crucial for ensuring proper care by CNAs. The facility's policy mandates that care plans be comprehensive, person-centered, and revised as residents' conditions change, but this was not adhered to in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, leading to a deficiency in care. The resident, a male with a history of hemiplegia and hemiparesis following a cerebral infarction, was found with wet bed sheets and clothing up to his shoulders, with brown edges around the wet spots. This incident occurred on the morning of 11/18/24, and the resident reported having been wet all night. The resident had a urinary tract infection diagnosed on 11/13/24, and was on antibiotic treatment. Despite the resident's ability to communicate and use a urinal, he required substantial assistance with toileting hygiene and was frequently incontinent of urine. Observations and interviews revealed that the facility staff did not perform timely incontinent care for the resident. The CNAs responsible for the resident's care acknowledged the wet condition of the bed and the need for a full linen change. However, there was uncertainty about when the last rounds were completed by the night shift, and the day shift staff only began their rounds after breakfast. The CNAs and LVN interviewed emphasized the importance of prompt incontinent care to prevent skin breakdown and worsening of infections, but there was a lack of communication and documentation regarding the resident's condition and care needs. The facility's Director of Nursing and Administrator stated that incontinent rounds should be completed regularly, with specific expectations for the timing of rounds. However, there was a discrepancy in the execution of these rounds, as evidenced by the resident's condition. The Regional Nurse reported that the night shift NA claimed to have checked the resident early in the morning, but no documentation was provided to support this claim. The facility's policy for bladder incontinence was requested but not provided, indicating a potential gap in procedural adherence or documentation.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care, specifically for one resident who was reviewed for trauma-informed care. The resident, a male with a history of paranoid schizophrenia, PTSD, personality disorder, and major depression, was not adequately assessed for his history of trauma. The comprehensive care plan for this resident did not address his PTSD triggers, which could potentially lead to re-traumatization and severe psychological distress. Interviews with various staff members, including a Licensed Vocational Nurse (LVN), Social Worker (SW), Minimum Data Set (MDS) Coordinator, Certified Nursing Assistant (CNA), Director of Nursing (DON), and the Administrator, revealed a lack of awareness and documentation regarding the resident's PTSD diagnosis and triggers. The LVN and SW were unaware of the resident's specific triggers, and the MDS Coordinator acknowledged that the care plan should include identified triggers to ensure proper care. The CNA and DON also emphasized the importance of staff being aware of any triggers to provide appropriate care. The facility's policy on trauma-informed and culturally competent care requires universal screening of residents for possible exposure to traumatic events and the development of individualized care plans that address past trauma. However, the policy was not effectively implemented, as evidenced by the lack of documentation and awareness of the resident's PTSD triggers. This oversight could lead to re-traumatization and negatively impact the resident's quality of life.
Medication Administration Errors for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of blood pressure medications. Resident #13, a female with end-stage renal disease and hypertension, was administered amlodipine despite her blood pressure being below the ordered parameters. The medication was given by LVN G when Resident #13's systolic blood pressure was 99, which was below the threshold of 100 as per the physician's order. Similarly, Resident #41, a female with cerebral infarction, atrial fibrillation, and hypertension, was administered carvedilol when her blood pressure was also below the ordered parameters. LVN G administered the medication when Resident #41's systolic blood pressure was 95, below the required threshold of 100. Both instances of medication administration were contrary to the physician's orders, which specified holding the medication if the blood pressure was below certain levels. Interviews revealed that LVN G was aware of the parameters but administered the medications based on her judgment and training from other nurses, who advised giving the medication if the blood pressure was borderline. The Director of Nursing (DON) acknowledged that the medications should not have been administered outside the parameters and admitted there was no system in place to monitor medication administration compliance. The Administrator expected adherence to proper protocols and indicated that the DON was responsible for oversight, with the RN supervisor monitoring on weekends.
Inadequate Linen Cart Coverage During Laundry Distribution
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a linen cart by Laundry Aide H. During an observation, it was noted that Laundry Aide H was distributing clean clothing to residents with the linen cart only partially covered by a blanket, leaving the clothing exposed. This action was contrary to the facility's policy, which requires that clean linen carts be completely covered to prevent environmental contamination and ensure the clothes remain hygienically clean. Interviews with Laundry Aide H and the Housekeeping Supervisor revealed that Laundry Aide H was aware that the linen cart should be completely covered to prevent exposure to germs, but mistakenly believed the blanket used was sufficient. The Housekeeping Supervisor confirmed that a flat white sheet should be used to cover the linen cart completely. The Administrator also emphasized the importance of covering the linen cart to protect the clothes from pathogens and dirt during transport from the laundry room to residents' closets. The facility's policy on laundry and linen handling, reviewed in January 2023, supports these practices to maintain a safe and aseptic environment.
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What surveyors actually found near you
We read the 176 citations issued within 25 miles in the last 12 months — including the 5 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winnsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Winnsboro | 0.1 mi | ★★★★★ | 0 | 0 |
| Quitman Wellness & Rehabilitation | 13.4 mi | ★★★★★ | 11 | 0 |
| Cypress Springs Wellness & Rehabilitation | 16.7 mi | ★★★★★ | 4 | 0 |
| Avir At Pittsburg | 19.4 mi | ★★★★★ | 13 | 0 |
| Rock Creek Health And Rehabilitation | 20.9 mi | ★★★★★ | 15 | 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.