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 Nazareth Living Care Center during CMS and state inspections, most recent first.
The facility failed to ensure oxygen concentrators were properly maintained and that continuous oxygen therapy was administered as ordered. Multiple concentrators in use and in storage lacked current QA or maintenance tags, one known non‑working concentrator was stored under a sink without an "out of order" label, and leadership confirmed there was no contract in place for vendor maintenance. A resident with severe pulmonary disease and recent ICU stay experienced worsening hypoxia while on oxygen, with family reporting that the concentrator was not delivering enough oxygen and EMS documenting low O2 saturation on 6 L/min via nasal cannula. Another resident with COPD and an order for continuous oxygen at 1 L/min was observed at the nurse’s station without her oxygen in place until an LVN was prompted by the surveyor. A further resident with pneumonia and dependence on supplemental oxygen had an order for 2–3 L/min, but the concentrator was set at 1.5 L/min, which the DON confirmed was below the ordered rate. A resident with asthma and pulmonary embolism was using a concentrator bearing a maintenance tag from several years prior, and the facility’s oxygen policy did not address concentrator maintenance, contributing to inconsistent and potentially inadequate oxygen delivery.
A resident with multiple chronic pain-related conditions, including fibromyalgia, rheumatoid arthritis, and multiple sclerosis, had a physician order for Pregabalin (Lyrica) 50 mg PO TID for pain, but the medication was not administered over multiple consecutive days because it was not available. The MAR documented missed doses with a code directing staff to progress notes, and nursing notes repeatedly stated the drug was not available or pending from the pharmacy. The medical director reported he was not notified that the resident was not receiving the ordered medication, and pharmacy staff stated they never received a faxed order needed to obtain physician confirmation and dispense this controlled substance. The DON and ADON confirmed that licensed staff were responsible for faxing controlled substance orders to the vendor pharmacy, and records showed the Pregabalin was not administered as ordered during this period.
Surveyors identified that the facility failed to maintain a functional nurse call system in multiple rooms, including bathrooms and bathing areas, when call lights showing as active on the nurse’s station panel did not ring or illuminate in the rooms or hallway domes. In one room, a confused resident’s call light was found unplugged on the bed, with a loose, taped wall plate that would not securely hold the cord, and staff had not ensured a work order was submitted. Dual call light systems in two rooms did not activate when tested, and staff, including an LVN, CNA, and the Director of Support Services, acknowledged that confused residents did not use the call lights, that call lights had been pulled out and stored in furniture, and that there was no documentation of the claimed routine call light testing or an existing call light policy.
A resident with multiple chronic conditions, depression, prior CVA with hemiplegia, and moderately impaired cognition repeatedly yelled, expressed a desire to leave, and made explicit threats to throw herself on the floor and out of bed and her wheelchair. Multiple LVNs documented these behaviors over several days but did not notify the physician or NP, despite facility policy and training requiring immediate consultation for significant mental status changes and self-harm threats. The resident was later found on the floor near her bed after reporting she fell while leaning forward in her wheelchair to reach the call light, and leadership and the Medical Director confirmed they had not been informed of the earlier threats or behavioral escalation.
A resident with Parkinson’s disease, dysphagia, and a PEG/G-tube had physician orders and MAR entries for continuous enteral feeding at 50 ml/hr with 50 ml free water flush every hour. During observation, the feeding pump was alarming, the attached water bag was empty, and the formula bottle was still half full, indicating that ordered water flushes were not being provided as prescribed. The assigned LVN stated she checked the resident every two hours and last checked about an hour earlier, when there was still water in the bag, but she could not recall the amount. The DON stated that licensed staff were trained and expected to follow enteral feeding orders and check feedings and hydration during rounds, and facility policy required adherence to physician orders for enteral feedings and flushes.
A resident with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, and COPD was admitted with orders for continuous O2 and bronchodilator therapy. On the day of admission, the resident experienced worsening hypoxia and SOB, with low O2 saturation and abnormal vital signs, leading to EMS transfer to the hospital after physician notification. One LVN acknowledged she did not document her full assessment of the resident’s change in condition or the presence of a family member at the time of transfer, and another LVN reported making two calls to the physician to confirm admission medication orders and to report the resident’s transfer but did not document either call. The DON and facility policy confirmed that licensed staff were expected to document assessments and physician communications in the electronic record, but this did not occur, resulting in incomplete and inaccurate medical records for the resident.
Call Lights Not Kept Within Reach: Three residents with significant cognitive and physical impairments were observed with call lights out of reach. One resident with severe cognitive impairment and dependence had the call light on the floor, another resident with Parkinson's disease and dependence had it behind the headboard, and a third resident with dementia and left hemiparesis had it tucked under a pillow on the affected side. Staff interviews confirmed call lights should be within reach and placed on the resident's dominant side when needed.
Failure to Provide Accessible Hydration: A resident with rhabdo and AKI, a resident with severe cognitive impairment and dehydration history, a resident with poor intake and a G-tube, and a resident with a recent spinal fracture were found without bedside water or dependent on staff/family to obtain fluids. Staff and leadership stated hydration was generally offered on request rather than on a set schedule, and interviews confirmed there was no formal monitoring system for residents without fluid restrictions.
Oxygen concentrator filters were not maintained for several residents receiving O2 therapy. A resident with respiratory failure was observed with a concentrator missing its filter and covered in dust, while other residents with COPD and cognitive impairment had concentrator filters with dust, lint, and hair collected on them. Staff gave conflicting statements about who was responsible for cleaning and monitoring the filters and how often this occurred, and the facility did not provide a policy on oxygen concentrator air filters.
Unsafe food storage, handling, and meal service practices were observed in the kitchen and dining room. Surveyors found spoiled produce, including discolored lettuce, molded tomatoes, and sprouted potatoes mixed with an overripened banana. Staff were also observed serving a resident’s cup from the wrong area, handling food with gloves after touching the refrigerator and floor without washing hands or changing gloves, and failing to properly monitor food temperatures during meal prep. Interviews and facility policies confirmed expectations for hand hygiene, glove changes, safe temperatures, and discarding contaminated food.
Incomplete documentation of a resident’s bruise and alleged second fall. A resident with moderate cognitive impairment and high assistance needs had an unwitnessed fall, then later developed a bruise around the L eye. An LVN documented the bruise without noting its size, color, or exact site, and the chart did not show notification of the DON, Administrator, or NP. No incident report was found for the resident’s allegation that he rolled out of bed and hit his head on the nightstand.
A facility failed to maintain its infection control program when oxygen equipment and foley drainage bags were not stored or positioned properly for several residents. A resident with respiratory failure was observed with a nasal cannula over the mouth and an oxygen mask left open to air, another resident was seen with the cannula over the eyes, one resident’s cannula was hanging on a wall nail, and another resident’s foley bag was lying on the floor. Staff stated these conditions were infection control issues and that the equipment should be kept clean, stored properly, and positioned off the floor.
Incomplete Staff Training and Orientation: The facility failed to ensure an Administrator, a Dietary Manager, and an LVN completed required communication and restraint reduction training as part of orientation or staff education. Record review showed the training documentation relied on general orientation materials, an employee handbook, and monthly Town Hall sessions, but the HR Director stated there was no policy for when new hires were expected to complete mandatory training and that he was responsible for tracking completion before staff provided direct care.
A resident’s foley bag was observed without a privacy cover and visible from the hallway. Staff interviews confirmed that privacy bags were required to protect dignity, and the facility’s catheter care policy stated the catheter bag should be stored in a privacy bag to maintain dignity. The resident had recently been admitted after a fall with spinal fractures.
Failure to Investigate Alleged Neglect and New Facial Bruising: A resident with moderate cognitive impairment and a recent unwitnessed fall developed new bruising around the eye, and staff documented the bruise only after family raised concerns. Staff believed the injury was related to the earlier fall, but there was no incident report or documented investigation of the resident’s allegation that he fell from bed during the night and hit his head on the nightstand. Interviews showed the DON and Administrator expected new injuries and allegations of neglect to be reported and investigated, but that did not occur for this event.
The facility failed to ensure two residents who were dependent for ADLs received needed grooming and hygiene assistance. One resident with cognitive impairment and a history of CVA and hemiplegia was observed with facial hair, while another resident with severe cognitive impairment and diagnoses including TIA and CVA was observed with long fingernails and debris under the nails. Staff stated CNAs and nurses were responsible for monitoring grooming, shaving, and nail care, but the observed care needs were not met.
Failure to Reposition a Dependent Resident Every 2 Hours: A resident with Parkinson’s disease, dysphagia, and G-tube status was dependent on staff for rolling and transfers and had a care plan calling for turning and repositioning every 2 hours. The resident was observed sitting up in bed in the same position across multiple observations, and an LVN later noted redness on the buttocks area, stating it could be caused by prolonged sitting in one position. Staff, including the DON and Administrator, stated residents were to be repositioned every 2 hours and monitored by nursing staff.
Improper Dumpster Closure and Refuse Storage: The facility failed to keep the dumpster closed and the surrounding area free of debris. An observation showed multiple dumpster access points left open, and a mattress, hospital bed, and wooden pallet abandoned outside the dumpster. Staff interviews confirmed the dumpster should be closed when not in use, debris should not be left around it, and there was no recent in-service on waste disposal for nurses, CNAs, or dietary staff.
Staff failed to assist two residents with severe cognitive and physical impairments at eye level during meals, despite facility policy and training requiring this practice. Staff were observed standing while providing eating assistance, and interviews confirmed awareness of the expectation to sit at eye level for proper monitoring and resident comfort. The facility's procedures also specified that staff should be seated when assisting with feeding.
A resident with severely impaired cognition and a history of wandering was not provided with a comprehensive care plan addressing wandering behaviors, despite being listed as a wanderer. Facility records and staff interviews confirmed that the care plan lacked focus, goals, and interventions for wandering, and that this omission was contrary to facility policy and staff responsibilities.
A resident with severe cognitive impairment was admitted without a completed personal inventory sheet, as required by facility policy. The inventory form remained blank and was not updated, and staff interviews confirmed that the process for documenting personal belongings was not followed. Facility policy required a personal inventory list to be completed and included in the medical record, but this was not done.
A resident with an arterial ulcer on her right big toe did not receive scheduled wound care as per her care plan. The facility failed to perform the necessary wound care on one occasion, leading to a grievance from the resident. Interviews with staff revealed confusion about responsibility for the wound care, and the facility's policy on dressing changes was not followed.
A resident at an LTC facility, diagnosed with dementia and bipolar disorder, was at risk for falls due to a torn fall mat. The mat, intended to prevent injuries, was found to be in poor condition, exposing internal materials. Staff interviews revealed a lack of awareness and responsibility for replacing the mat, with no clear policy in place to address such hazards.
A resident with severely impaired cognition received oxygen therapy without a physician's order, despite facility policy requiring such orders for medications. The resident, who acquired COVID-19, was observed with a nasal cannula, but no orders were documented. Staff interviews confirmed the absence of orders, highlighting the risk of inadequate oxygen support.
The facility did not ensure residents and families could access the latest survey results. An empty storage bin meant to hold these documents was found, and staff were unaware of their location. Residents were also uninformed about their right to review these reports.
A facility failed to meet professional standards in administering nebulizer treatments to a resident. The staff did not assess or document the resident's respiratory status before and after treatment, as required by facility policy. The resident, on oxygen therapy for shortness of breath, received Pulmicort via nebulizer without proper pre- and post-treatment checks. Interviews revealed a lack of training and awareness among staff regarding nebulizer administration protocols.
The facility failed to maintain clean oxygen equipment and conduct necessary respiratory assessments for two residents. One resident's oxygen machine had a dirty filter, and nebulizer treatments were administered without pre- and post-assessment of respiratory status. Additionally, the facility did not post required oxygen signs on another resident's door, posing safety risks. Staff interviews revealed a lack of clarity and adherence to facility policies.
The facility failed to administer medications accurately and securely store them, affecting two residents. One resident did not receive the correct dosage of Gabapentin, while another's medications were improperly stored when not administered. Additionally, an LVN failed to sign the controlled drugs count record at shift change, risking drug diversion.
A LTC facility reported a 14% medication error rate involving three residents. Errors included incorrect dosage and failure to administer medication with food as per physician's orders. LVNs were observed making these errors, which involved a resident with diabetes, another with cerebral arteritis, and a third with end-stage renal disease.
The facility failed to properly store and handle medications, with issues observed in medication carts and the medication room. Medications were stored inappropriately after being poured, and controlled substances were not properly accounted for at shift changes. Glucose control solutions were not dated according to manufacturer guidelines, and the medication room was disorganized, with improper storage of IV bags and over-the-counter drugs.
The facility failed to provide food at an appetizing temperature, as CNAs left insulated meal cart doors open during tray distribution, leading to cold meals. Residents reported ongoing dissatisfaction with meal temperatures, and test trays confirmed food was below required temperatures. The Dietary Manager acknowledged the issue, but no system was in place to ensure cart doors remained closed, and the Administrator was unaware of the problem.
The facility was cited for multiple deficiencies in kitchen sanitation and food safety, including unclean floors, equipment, and storage areas, improper food handling practices, and failure to maintain equipment. Ongoing construction contributed to dust accumulation, and staff did not consistently use protective gear or follow proper procedures. These issues could pose a risk of foodborne illnesses to residents.
The facility failed to maintain accurate medical records for two residents regarding their restorative therapy care. One resident's care plan lacked documentation for therapy intended to maintain range of motion and facilitate ADLs, with no completion dates or progress notes. The second resident's family reported a lack of progress and questioned therapy provision, with the ADON unaware of therapy approval status. The DON could not find necessary documentation, highlighting a failure in maintaining complete and accurate records.
The facility's QAPI committee failed to address ongoing issues with meals being served cold to residents. CNAs were observed leaving insulated meal cart doors open during tray distribution, leading to cold meals. Residents reported this as a persistent problem, and test trays confirmed food temperatures were below required levels. The facility lacked documentation of actions taken to address these concerns.
The facility failed to address dietary concerns and complaints about cold food being served to residents. CNAs left insulated meal cart doors open, causing food to become cold. Despite resident complaints and discussions in meetings, no effective corrective actions or monitoring systems were implemented to resolve the issue.
The facility failed to maintain an effective Infection Prevention and Control Program, with staff not performing proper hand hygiene between resident interactions and during medication administration. An LVN did not use gloves or assess a resident's respiratory status during nebulizer treatment. Additionally, improper storage of medical supplies and equipment was observed, contributing to potential cross-contamination.
The facility failed to maintain essential kitchen and laundry equipment in safe operating condition. In the kitchen, the stove was missing control knobs and oven door handles, and the Robot Coupe's blade was broken. In the laundry room, dryers were missing control panel covers, and washers were leaking with rust and substance build-up. The Maintenance Director, new to the facility, was unaware of maintenance policies and was addressing the issues as quickly as possible.
The facility failed to maintain a safe and sanitary environment, with dust from construction affecting the kitchen and halls, and a lack of paper towels in the medication room. The kitchen had dust-covered equipment, a hole in the ceiling, and uncovered food pots. Plastic barriers were ineffective in containing dust, and the medication room lacked paper towels, as confirmed by the DON.
Two residents in the facility were not administered their medications with meals as ordered by their physicians, leading to a deficiency in care. One resident with cerebral arteritis received medication without food, while another with end-stage renal disease did not receive medications during meal times. The facility's policies require adherence to physician orders, but these were not followed, placing residents at risk of adverse drug effects.
A resident with urinary incontinence did not receive proper catheter care, as the catheter tubing was improperly placed and not secured with a leg strap, leading to potential risks of urinary tract infections and injury. Staff interviews revealed a lack of training and awareness regarding catheter care, and the facility's policy did not address the use of leg straps.
Failure to Maintain Oxygen Equipment and Administer Ordered Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care, including proper oxygen administration and equipment maintenance, for multiple residents requiring continuous oxygen therapy. Surveyors identified that the facility did not have a system or contract in place to ensure oxygen concentrators were serviced and maintained to deliver prescribed flow rates. Several concentrators in storage areas and in use lacked QA or maintenance stickers, and one concentrator stored under a hand sink was known by the DON to be non‑functional but was neither labeled as out of order nor stored separately. The ADON reported she did not know if there was a contract with an oxygen supplier for maintenance, and the Administrator, DON, and ADON confirmed there was no such contract at the time of the survey. One resident with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, COPD, and recent ICU hospitalization was admitted with orders for continuous oxygen at 2–6 L/min via nasal cannula and had a history of hypoxia and altered mental status. Facility documentation showed that upon arrival his oxygen saturation was low (around 73–80%) while on oxygen via nasal cannula, and staff reported he was placed on 6 L/min. A family member reported to staff and later to the Administrator that the oxygen equipment was not delivering enough oxygen, and an SBAR noted worsening hypoxia with oxygen saturation at 74% on nasal cannula and a family request to send the resident out because he was not receiving enough oxygen through the concentrator. EMS documentation indicated that nursing home staff reported the resident had been discharged from the hospital for hypoxia and that his oxygen saturation was 75% on 6 L/min via nasal cannula at the facility, prompting EMS activation. Another resident with COPD and an order for continuous oxygen at 1 L/min via nasal cannula was observed sitting at the nurse’s station without her oxygen in place, despite an order and care plan specifying continuous oxygen. The LVN at the nurse’s station stated she had not noticed the missing cannula until the surveyor pointed it out, and only then checked the resident’s oxygen saturation and returned her to her room to reapply the cannula and set the concentrator. A further resident with pneumonia, dependence on supplemental oxygen, acute and chronic respiratory failure with hypoxia, and Parkinson’s disease had an order for continuous oxygen at 2–3 L/min via nasal cannula, but was observed with the concentrator set at 1.5 L/min. The DON confirmed at the bedside that the concentrator was set below the ordered 2 L/min and stated the resident should be on 2 L/min as ordered. A fourth resident with asthma, pulmonary embolism with acute cor pulmonale, and shortness of breath had an order for continuous oxygen at 2–4 L/min via nasal cannula. During observation, the ADON demonstrated that the oxygen concentrator in use for this resident had a maintenance service tag dated 10/04/2019. The ADON stated the resident had just been changed to a different concentrator because her oxygen was changed to 5 L/min, and it was observed that the regulator was set at 5 L/min via nasal cannula. The facility’s written policy on oxygen therapy addressed reviewing physician orders and emergency use of oxygen for low saturations but did not include any policy or procedure for maintenance of oxygen concentrators, contributing to the lack of a structured system to ensure concentrators were functioning properly and delivering ordered flow rates. Interviews with the Medical Director confirmed awareness of standing orders for oxygen at 2–6 L/min via nasal cannula with shift oxygen saturation monitoring and that nurses could adjust liters within that range, but he was not aware that the facility lacked a system for vendor maintenance of concentrators. A vendor representative later described the type of maintenance required for concentrators, including filter care and oxygen concentration testing, underscoring that such maintenance had not been in place at the time of the identified events. Overall, the deficiency centers on the facility’s failure to maintain and monitor oxygen equipment and to consistently administer oxygen as ordered, as evidenced by unmaintained concentrators, lack of labeling of non‑functional equipment, and residents not receiving oxygen continuously or at the prescribed flow rates.
Failure to Timely Obtain and Administer Ordered Pregabalin for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely acquisition and administration of a prescribed controlled medication for pain. A resident with an original admission date of 12/24/25 and a readmission date of 01/22/26 had multiple chronic conditions, including fibromyalgia, rheumatoid arthritis, multiple sclerosis, COPD, and osteoporosis. The admission MDS showed moderately impaired cognition (BIMS score 12), frequent pain with interference in sleep and daily activities, and a reported pain level of 7/10. The physician’s order, reflected on the Order Summary Report dated 01/23/26, prescribed Pregabalin (Lyrica) 50 mg orally three times daily for pain. Review of the January 2026 MAR showed that Pregabalin doses scheduled for 7:00 a.m., 1:00 p.m., and 7:00 p.m. on 01/21/26, 01/22/26, and 01/23/26 were not administered, with code 8 entered directing staff to see progress notes. Nursing progress notes on 01/22/26 and 01/23/26, documented by LVNs and a medication aide, repeatedly stated that the Pregabalin was “med not available” or “pending.” A note on 01/24/26 at 7:43 a.m. again documented that the Pregabalin was not available from the pharmacy. Despite these repeated notations of unavailability over several days, the medication was not obtained and administered as ordered. Interviews and record reviews identified that the failure to obtain the medication was related to breakdowns in the ordering process for controlled substances. The medical director, who was the attending physician, stated he was not notified that the resident had not received Pregabalin for several days and noted that a designated agent at the facility could order controlled substances once a physician order was received. Pharmacy customer service staff reported that the Pregabalin order had not been faxed to the pharmacy and that narcotics are not dispensed without physician confirmation, which they obtain after receiving a faxed order from nursing that includes the physician’s contact information. The DON and ADON confirmed that licensed staff were responsible for faxing controlled substance orders to the vendor pharmacy so the pharmacy could obtain authorization and dispense the medication, and the MAR confirmed that Pregabalin was not administered as ordered on 01/21/26, 01/22/26, 01/23/26, and 01/24/26.
Failure to Maintain Functional Nurse Call System in Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a properly functioning nurse call system in multiple resident rooms, including bathrooms and bathing areas, and to ensure that call lights were operational and able to alert staff at the nurse’s station. During observation, the call light panel at the nurse’s station showed active call lights for several rooms, but the corresponding call lights did not ring or illuminate in the rooms or hallway light domes. In one room, the call light cord was found disconnected and lying on the resident’s bed, and the wall plate for the call light was taped to the wall and loose. When the LVN attempted to plug the call light back in, it would not stay in the socket and slipped out. Staff reported that the resident in that room was confused, did not use the call light, and that the resident’s son used the call light when present. Further observations and interviews showed that dual call light systems in two rooms did not activate in the rooms or on the hallway light domes when tested. The Director of Support Services acknowledged that the wall plate was loose and that nursing staff should have submitted a work order, but there was no indication that such a work order had been made. A CNA confirmed that a confused resident had pulled the call light off the wall and stored it in a nightstand drawer, and that the wall plate had been taped but she was unaware of any work order and had not noticed that the call lights showing on the panel were not ringing. The Director of Support Services stated he conducted call light tests every two weeks but was unable to provide any documentation of these tests when requested, and later stated that one of the dual call light cords was not working, which explained why the dome light and nurse’s station alarm did not activate. The Administrator reported that corporate staff had informed her there was no policy and procedure on call lights.
Failure to Notify Physician/NP of Resident’s Self-Harm Threats and Mental Status Change
Penalty
Summary
The deficiency involves the facility’s failure to consult with the resident’s physician or NP when there was a significant change in a resident’s mental status and when the resident voiced threats to harm herself. The resident was an older female with a complex medical history including fibromyalgia, rheumatoid arthritis, multiple sclerosis, COPD, osteoporosis, prior CVA with hemiplegia, depression, arthritis, and UTI. Her admission MDS showed moderately impaired cognition (BIMS 12), dependence in most ADLs and mobility, and a history of verbal behavioral symptoms such as screaming and cursing. Facility policy on change in condition required assessment, completion of SBAR, and timely physician notification for changes in physical or mental status. On multiple occasions, nursing notes documented that the resident was yelling and making threats to throw herself on the floor or out of bed and out of her wheelchair, and repeatedly stating she did not want to remain in the facility and wanted to call 911. On one date, an LVN documented that the resident was yelling and threatened to throw herself on the floor. Later that same day, another LVN documented that the resident continuously yelled and screamed throughout the shift, repeatedly stating her intent to throw herself out of bed and out of her wheelchair, expressing a desire to go home, and wanting to call 911. On a later date, another LVN documented that the resident was again making threats to throw herself on the floor and yelling. These behaviors represented a change in mental/psychosocial status and included explicit threats of self-harm. Despite these documented threats and behavioral changes, the involved LVNs acknowledged in interviews that they did not notify the physician or NP of the resident’s threats to hurt herself or her increased anxiety and agitation. They also acknowledged they had been trained to immediately report such threats to the physician or NP but did not provide a reason for failing to do so. The Medical Director, who was also the attending physician, confirmed that nursing staff had not reported the resident’s anxiety and threats to throw herself on the floor on the identified dates and stated he expected immediate notification when residents voiced threats to hurt themselves so that the situation could be evaluated. The DON and ADON similarly stated that nurses had been trained to immediately report such threats, but the notifications did not occur as required by facility policy and physician expectations. Subsequently, the resident was found on the floor next to her bed by an LVN, who reported that the resident stated she had been leaning forward in her wheelchair to reach her call light and fell, and that she promised she did not throw herself on purpose. The call light was documented as clipped to the resident’s gown within reach. The resident complained of pain and requested transfer to the hospital, and the POA requested hospital transfer. The DON and ADON reported that the LVN who found the resident on the floor did not inform them that the resident had previously threatened to throw herself from the wheelchair. The Medical Director and facility leadership confirmed that they had not been notified of the earlier threats and behavioral changes, which constituted a failure to follow the facility’s change in condition communication policy and to immediately consult with the physician/NP when the resident experienced a significant change in mental status and voiced threats of self-harm.
Failure to Administer Ordered Free Water Flushes With Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via G-tube received water flushes as ordered by the physician. The resident, an older male with Parkinson’s disease, dysphagia, and a history of PEG tube placement, had physician orders for continuous enteral feeding of Nutritional Formula 1.2 at 50 ml/hr with 50 ml free water flush every hour via G-tube. Review of the physician order summary and the January medication administration record confirmed these orders. During observation, the resident was in bed, awake and moaning, with the head of bed elevated and the enteral feeding pump alarming. The water bag connected to the enteral pump was empty, while the formula bottle was still half full. The water bag and formula bottle were both dated for the early morning of the same day by the night-shift nurse. During interview, the LVN assigned to the resident for the 6 AM–2 PM shift stated she was unaware that the feeding pump alarm was sounding and acknowledged that the alarm was due to the empty water bag. She reported that she checked the resident every two hours to ensure the enteral feeding was being administered according to physician orders and stated that the last time she checked the resident was at 1:20 p.m., at which time there was still water in the bag, though she could not recall the amount. The DON reported that licensed staff had been trained to administer enteral feedings according to physician orders and were expected to check enteral feedings during rounds to ensure feedings and hydration were being administered as ordered. The facility’s enteral feeding policy stated that the facility would follow physician orders and document feedings on the electronic MAR, but the observation of an empty water bag and active pump alarm demonstrated that the ordered free water flushes were not being administered as prescribed.
Failure to Accurately Document Resident Assessment and Physician Communication During Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation in accordance with its own policy and accepted professional standards for one resident. The resident, an older male with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, and COPD, was admitted from the hospital with ongoing respiratory issues, including shortness of breath, worsening hypoxia, and confusion. On admission, he had orders for continuous oxygen at 2–6 L/min via nasal cannula with oxygen saturation monitoring each shift, and scheduled Ipratropium-Albuterol inhalation for shortness of breath. An IDT nursing note documented that he was admitted following episodes of altered mental status, hypoxia, pulmonary fibrosis, and COPD, and that he was on 4–6 L/min of oxygen. On the day of admission, the resident experienced a change in condition with worsening hypoxia. An SBAR form documented that his oxygen saturation was 74% via nasal cannula and that his son reported the resident was not receiving enough oxygen through the concentrator and requested that he be sent out. An IDT nursing note by an LVN recorded that the resident complained of hypoxia and shortness of breath, with vital signs including BP 157/83, HR 122, respirations 30, and oxygen at 6 L/min, and that the physician was notified and ordered transfer to the ER via EMS, with the resident transferred to the hospital and a family member at bedside. However, during interview, this LVN stated she had assessed the resident when he was yelling that he could not breathe and arranged transfer to the ER, but she acknowledged she had not documented her assessment in the clinical record on that day and had not documented that the family member was in the room when the resident was transported. Another LVN reported that she made two telephone calls to the resident’s attending physician on the day of admission: one to confirm medication orders upon admission and a second to report that the resident had been sent to the hospital via EMS due to a change in condition. She stated that licensed staff had been trained to document in the clinical record when they called the physician to obtain orders or report changes in condition, but she did not document either of these calls in the resident’s record, citing multiple admissions that day and lack of time. The DON confirmed that licensed staff were trained to document resident assessments and physician or NP communications in the electronic record. Review of the facility’s Clinical Documentation policy showed that documentation was to be accurate, timely, reflective of care provided, and completed as close to the time of care as possible, including documentation of assessments and exceptions when care does not occur as planned, which was not followed in this case.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for 3 of 18 residents reviewed for call lights: Resident #1, Resident #4, and Resident #48. Resident #1 had a history of cerebral infarction, a BIMS score of 00 indicating severe cognitive impairment, and was dependent for care. His care plan included keeping the call light within reach and answering it in a timely manner. During observation, he was lying in bed with the call light on the floor next to the bed and out of reach. Resident #4 had a history of Parkinson's disease, dysphagia, and gastrostomy status, and was dependent for ADLs including grooming, hygiene, and transfers. His care plan identified fall risk and included leaving the call light within reach. During observation, his call light was behind the left side of the headboard and out of his reach. Resident #4 was unable to answer the surveyor's questions. Resident #48 had diagnoses including dehydration, hip fracture, UTI, dementia, seizure disorder, intracranial bleed with left hemiparesis, cervical cancer, stage IV sacral ulcer, and prior nephrostomy tube. Her MDS showed a BIMS score of 3 and dependence for multiple ADLs and mobility. She stated she did not use the call light and could not explain why. Later, she was observed slouching to her right side with the call light tucked under the pillow on her left side, the side affected by hemiparesis, and she asked the surveyor to lower the bed before CNA B assisted her. Staff interviews stated the call light should be within reach and placed on the resident's dominant side for residents with limited range of motion, and that all staff were responsible for repositioning call lights.
Failure to Provide Accessible Hydration
Penalty
Summary
The facility failed to ensure sufficient fluid intake and access to hydration for 4 of 4 residents reviewed for hydration access. During interview, observation, and record review, residents were found without water at the bedside or were dependent on staff to obtain fluids, while the facility did not have a regular system for tracking or offering hydration between meals or during physical activity. Facility staff stated that hydration was generally provided upon resident request, and multiple interviews confirmed there was no formal scheduled hydration monitoring system for residents without restrictions. Resident #39 was admitted with rhabdomyolysis and had a history of acute kidney injury and metabolic acidosis after being found incontinent on a couch, unable to ambulate or drink water. On observation, the resident was seated in a wheelchair near the door without water on the bedside table and stated staff did not bring hydration on a scheduled interval. Resident #48 had diagnoses including dehydration, hip fracture, and UTI, with severe cognitive impairment and dependence for eating and drinking. The resident stated staff did not bring water unless asked, and the bedside table had no hydration present. Resident #53 had a history of refusal to eat and drink, UTI, hypokalemia, and chronic kidney disease, and was scheduled for gastrostomy tube feedings; the resident was observed with dry, chapped lips, a cracked dry tongue, sunken eyes, tremors, and poor hygiene, while the gastrostomy equipment was present but not in use at the time of observation. Resident #87 had a recent spinal fracture and was unable to fully engage in conversation. The resident’s family member reported repeated difficulty getting water and stated a request for water made the prior day was never fulfilled, so the family provided their own water and electrolyte drinks. The family member confirmed hydration had been supplied by the family, and water and electrolyte bottles were observed on the nightstand. Additional observation of the Northwest wing hydration station showed the 5-gallon water container changed little over several hours while serving residents on that wing. Staff interviews confirmed that hydration was expected to be provided by nursing and CNA staff, but there was no set schedule for offering fluids and no formal monitoring system except for residents with restrictions or tube feedings. The facility policy stated fluids should be encouraged during and between meals and fresh water and ice should be provided at bedside, but staff and leadership described hydration as being offered mainly when residents asked for it.
Oxygen Concentrator Filters Not Maintained
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for residents receiving oxygen therapy. On 01/06/2026, Resident #4, who had respiratory failure, Parkinson’s disease, dysphagia, and a gastrostomy tube, was ordered continuous oxygen at 2 liters per minute via nasal cannula and was observed at 9:31 AM with an oxygen concentrator that had no filter in place and was covered in dust. Resident #7, who had COPD, anemia, and moderate cognitive impairment, was ordered oxygen at 1-2 liters per minute continuously. During an observation on 01/06/2026 at 10:22 AM, the resident’s oxygen concentrator air filter was observed with dust, strands of hair, and lint collected on it. Resident #28, who had COPD with acute exacerbation and severe cognitive impairment, had an order for oxygen via nasal cannula as needed to keep saturation above 90%, and on 01/06/2026 at 10:17 AM the oxygen concentrator was observed in operation with an air filter that appeared to have dust collected on it. Resident #77, who was dependent on supplemental oxygen and had moderate cognitive impairment, had an order for oxygen at 2 liters per minute at bedtime to maintain saturation above 90%. On 01/06/2026 at 9:42 AM, the oxygen concentrator air filter was observed with lint and hair. Interviews with CNA, LVN, ADON, and DON showed differing statements about who was responsible for cleaning and monitoring the filters and how often this was done. The facility’s in-service record stated that night shift CNA’s and nursing staff were responsible for changing oxygen tubing, canister, and nebulizer masks and cleaning oxygen concentrator filters weekly or when visibly dirty, but the facility did not provide a policy regarding oxygen concentrator air filters prior to survey exit.
Unsafe Food Storage, Handling, and Meal Service Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen and dining room. During kitchen observations, surveyors found 5 unwrapped lettuces with discoloration in the walk-in refrigerator, 4 tomatoes in the same refrigerator with 2 showing mold and touching the other tomatoes, and a cardboard box of approximately 35 potatoes under a prep table that contained sprouted potatoes and an overripened banana in the same box. These observations were made during the initial kitchen walkthrough and were confirmed by staff interviews as spoiled or contaminated food items. During meal service observation, a CMA grabbed a resident’s cup from the upper opening rather than from the bottom portion while serving it in the dining room. During another meal distribution observation, [NAME] G opened the refrigerator while wearing gloves and continued serving food by handling burger buns without changing gloves or washing hands, and the same practice was observed again moments later. The Dietary Manager was also observed opening the refrigerator with gloves on and continuing to serve food by handling burger buns without changing gloves or washing hands. During meal preparation observation, the Dietary Manager dropped a marker on the floor, picked it up while still wearing gloves, and then resumed work by handling grilled cheeses and sealing them for lunch without washing hands or changing gloves. He was also observed during puree meal preparation and side dish preparation when temperatures were not properly captured for 1 hot side and 1 cold side, and when the temperature of beef stock was first stated as 160 F but then retaken and found to be 53 F. Interviews with dietary staff and the Dietary Manager confirmed expectations for hand hygiene, glove changes after touching dirty surfaces, safe food temperatures, and discarding spoiled food, and the facility policies reviewed addressed hand washing, glove use, meal service, and safe food temperatures.
Incomplete Documentation of Resident Bruise and Alleged Second Fall
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for a resident who had a recent unwitnessed fall and later developed a bruise to the left eye. The resident was a male with a BIMS score of 12, indicating moderate cognitive impairment, and required substantial to total assistance with transfers and mobility. His care plan identified him as at risk for falls and injuries. He also had a history of idiopathic pulmonary fibrosis, chronic respiratory failure, and liver cirrhosis. Record review showed the resident had an unwitnessed fall and was found on the floor, with neurological checks ordered and completed afterward. On a later date, LVN L documented that the resident had a bruise on the left eye and denied pain, and the resident stated it was from a previous fall. However, the documentation did not include a description of the bruise by appearance, size, color, or site. LVN M later documented discussion with the resident and family about the bruising and the resident’s statement that he rolled out of bed, but the progress notes did not show that the DON, Administrator, or Nurse Practitioner were notified of the acute change. The record also did not contain an incident report for the resident’s allegation of a second fall during the night, when he reportedly fell out of bed and hit his head on the nightstand. During interview, the resident and family stated the resident had two falls over the weekend and that the bruise was not present when they visited earlier, but was observed later with dark purple bruising around the left eye. Staff interviews confirmed that the bruise was not documented when first observed and that the nurse responsible acknowledged failing to document the acute change, including the bruise’s appearance and who was notified. The DON and Administrator stated staff were responsible for documenting changes of condition and completing incident reports for injuries.
Infection Control Lapses With Oxygen Equipment and Foley Catheter Placement
Penalty
Summary
The facility failed to maintain an infection prevention and control program for residents on transmission-based precautions when oxygen equipment and urinary catheter drainage bags were not handled and stored as expected. Resident #4, who had respiratory failure, Parkinson’s disease, dysphagia, gastrostomy status, and an order for continuous oxygen at 2 liters per minute via nasal cannula, was observed sleeping with the nasal cannula over the open mouth while the oxygen concentrator was on. An oxygen mask was also observed at the bedside, open to air and not bagged or stored. Resident #73, who had a history of nontraumatic intracranial hemorrhage and required supplemental oxygen via nasal cannula for shortness of breath, was observed sleeping in a wheelchair with the nasal cannula placed over the eyes. During the observation of Resident #73, the surveyor notified LVN L and requested the oxygen level to be read. The oxygen meter did not read results until after LVN J placed the same nasal cannula back into the resident’s nostrils. Resident #73’s oxygen saturation was then read at 92% on supplemental oxygen via nasal cannula. The resident was responsive throughout the interaction and no signs of respiratory distress were observed. Staff interviews indicated that nasal cannulas or masks left out in the open or placed on a resident’s eyes or mouth were considered an infection control issue, and that staff were responsible for storing and replacing the equipment properly. Resident #7, a 95-year-old resident with anemia and moderate cognitive impairment, had an order for oxygen at 1 to 2 liters per minute via nasal cannula continuously. During observation, the resident’s nasal cannula was hanging from a nail on the wall while not in use. Resident #28, who had chronic kidney disease stage 3, severe cognitive impairment, and an indwelling suprapubic urinary catheter order using a closed drainage system, was observed with the foley catheter lying on the floor next to the bed. Interviews with CNA I, LVN J, and the DON stated that foley bags were to be kept hanging below the bladder and off the floor, and that bags on the floor were considered an infection control issue. Facility records also showed prior in-service education on catheter care and oxygen administration.
Incomplete Staff Training and Orientation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff consistent with their expected roles. During personnel file review, the Administrator and an LVN were found not to have completed communication training, and the Dietary Manager, the Administrator, and the LVN were found not to have completed orientation training for restraint reduction, despite having been employed for several months. Record review showed that 6 employees had the same completion date for communication training, but the training completed in June was titled communication. It was also reviewed that 5 employees had the same completion date for restraint reduction training, but the training completed in March was titled behavioral health and included notes on restraint reduction. The facility’s orientation packet contained general orientation information and only mentioned training under dementia training, while the employee handbook included a statement that the facility would not use physical or chemical restraints for discipline or convenience. During interview, the Human Resources Director stated the facility used monthly Town Hall meetings for annual trainings and that new hires completed orientation and then monthly trainings for topics not included in orientation. He stated there was no policy for when new hires were expected to complete mandatory training and identified himself as responsible for ensuring training was completed before staff provided direct care and for maintaining training documentation. He also stated that staff without training might not know how to handle concerns or where to seek assistance, and that it was unacceptable for staff to work with uncompleted training.
Foley Bag Left Uncovered and Visible From Hallway
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when Resident #87’s foley bag was left without a privacy bag and was visible from the hallway. On 01/06/2026 at 1:46 PM, surveyors observed the foley bag on the resident’s bedframe and visible from the hallway. The resident was a [AGE] year-old female admitted on 01/05/2026 after a fall at home that resulted in fractures to Lumbar 1 and 2 and a suspected fracture to Thoracic 1. During interviews, CNA B stated that foley bags were not supposed to be without a privacy bag and identified CNAs and nurses as responsible for ensuring the bag was covered. LVN D stated that privacy bags were used to uphold residents’ privacy and were required for all residents with foley bags. The ADON and DON also stated that foley bags should be in privacy bags to conserve dignity and that CNAs and nurses were responsible for ensuring they were covered during rounds. The facility’s Catheter Care policy stated to store the catheter bag in a privacy bag to maintain dignity.
Failure to Investigate Alleged Neglect and New Facial Bruising
Penalty
Summary
The facility failed to ensure that an allegation of neglect involving a resident with a recent fall and new bruising to the left eye was thoroughly investigated and that abuse or neglect was ruled out while the matter was in progress. The resident was a male admitted on 11/26/25 with a BIMS score of 12, indicating moderate cognitive impairment. His care plan identified him as at risk for falls and injuries, and his medical history included idiopathic pulmonary fibrosis, chronic respiratory failure, and liver cirrhosis. He had an unwitnessed fall on 01/02/26 and was placed on neurological checks, which were completed without issues identified. Progress notes showed that on 01/05/26, nursing staff documented bruising to the resident’s left eye. One nurse noted the resident said the bruise was from a previous fall, while another documented that the resident and family discussed the bruising and that the resident stated he had rolled out of bed during the night. The record did not include documentation of the alleged second fall or the bruising until these notes were entered, and there was no incident report related to the resident’s allegation that he fell during the night, hit his head on the nightstand, and returned to bed. The resident was observed with dark purple bruising around the left eye during the surveyor’s observation, and the family stated the bruise was not present when they visited earlier in the weekend. Interviews showed that staff were aware of the bruising and believed it was related to the earlier fall, but the allegation of a second fall and possible head injury was not documented as an incident or investigated as an allegation of neglect or injury of unknown origin. The LVN who first noted the bruise stated he informed the family and physician about the earlier fall and believed the bruise was related to that event. The other LVN stated the new bruise was a change of condition and that the physician, DON, and Administrator were to be notified when staff became aware. The DON stated changes in condition were to be investigated to confirm what happened and to confirm there was no abuse, and the Administrator stated staff were expected to notify her so the facility could investigate and ensure resident safety. Facility policy required timely investigation of alleged abuse, neglect, mistreatment, injuries of unknown origin, or accidents, including gathering evidence, interviewing witnesses, reviewing records, and examining relevant documentation.
Failure to Provide Needed Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance to maintain grooming and personal hygiene for two residents. Resident #6, a female with a BIMS score of 12, a history of depression, cerebral infarction, and hemiplegia, was assessed as dependent for personal hygiene including shaving. Her care plan required extensive assistance with personal hygiene and oral care, yet on 01/06/2026 she was observed with hair on her chin and facial hair was still present during the observation and interview. Resident #80, a male with a BIMS score of 06 and diagnoses including transient ischemic attack and cerebral infarction without residual deficits, was also dependent for personal hygiene. His care plan directed staff to provide assistance as needed with grooming, bathing, and personal hygiene with one person staff. On 01/06/2026, he was observed with long fingernails and dark debris under the nails on his right hand. During the interview, he stated his nails had not been cut and that staff had not asked whether he wanted them trimmed, and he said he would like them trimmed. Staff interviews showed that CNAs and nurses were responsible for checking, cleaning, and trimming fingernails and for monitoring residents for shaving and grooming needs. Staff stated residents were showered on a regular schedule and that nails were checked during showers, but the observations showed that these grooming needs were not met for the two residents identified. Facility records also showed an ADL in-service on nail care and grooming, and the facility policy stated it was responsible for providing necessary care to residents unable to carry out ADLs on their own to maintain proper grooming and hygiene.
Failure to Reposition a Dependent Resident Every 2 Hours
Penalty
Summary
The facility failed to ensure that Resident #4 received repositioning at least every two hours in accordance with the resident’s care plan and staff statements. Resident #4 was admitted with a history of Parkinson’s disease, dysphagia, and gastrostomy status, and the quarterly MDS indicated the resident was rarely or never understood and was dependent on staff for rolling left and right and for transfers. The care plan, revised 04/28/2025, identified the resident as at risk for alteration in comfort and pain and directed staff to assist with turning and repositioning every 2 hours and as needed to aid in comfort. On 01/06/2026, Resident #4 was observed sitting up in bed facing the TV at 9:31 AM, 11:38 AM, 1:40 PM, and 3:00 PM. During an observation and interview at approximately 3:05 PM, LVN K requested to perform a skin assessment and observed redness on the resident’s buttocks area, stating it could be caused by sitting in the same position for a prolonged period of time. LVN K, CNA I, the DON, and the Administrator all stated residents were to be repositioned every 2 hours, and that nursing staff were responsible for monitoring or ensuring repositioning occurred. The facility’s policy on turning and repositioning stated the programs should be individualized, organized, planned, documented, monitored, and evaluated based on the resident’s needs.
Improper Dumpster Closure and Refuse Storage
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 1 facility dumpster. On 01/07/2026 at 1:15 PM, an observation of the exterior dumpster showed that 3 of the 4 access points were left open, including the 2 side sliding metal doors and 1 plastic overhead lid. At 1:17 PM, additional observation showed a mattress, a hospital bed, and a wooden pallet abandoned around the exterior of the dumpster. During interviews, the Dietary Manager stated the dumpster was not in appropriate condition because it was left open for rodents and insects to access, and he identified himself as responsible for maintaining the dumpster’s cleanliness and closure. Dietary Aide H stated all staff members were responsible for closing the dumpster after use and said she had never received an in-service on waste disposal. The Director of Maintenance stated the dumpster needed to be closed when not in use and that debris could not be around it, but he denied having a policy in place for dumpsters, trash cans, or waste. The DON stated staff needed to tie and close trash bags before discarding them and close the dumpster after use, and she stated there was no recent in-service or training for waste disposal provided to nurses and CNAs. The Administrator stated all employees and vendors used the dumpster and that it was expected to be kept closed and free of debris around the area. The facility policy dated 06/2019 stated waste would be disposed of to prevent disease transmission, dumpsters would be covered and closed at all times, and the area around the refuse dumpster would be kept clean, odor free, and rodent free.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance with eating were treated with dignity and respect, specifically by not assisting them at eye level during mealtimes. Observations revealed that two residents with significant cognitive impairments and physical limitations were assisted with eating by staff who remained standing rather than sitting at eye level, contrary to facility policy and training. One resident, a male with COPD, dementia, and altered mental status, required supervision and set-up help for eating, while another, a female with cognitive communication deficits and generalized weakness, required supervision during meals. During meal observations, staff members, including a CNA and a staff person (SP), were seen assisting these residents while standing, which did not align with the facility's established procedures for dining assistance. Interviews with staff confirmed that they were aware of the expectation to be seated at eye level when assisting residents with eating, and that this practice was part of their training and competencies. One CNA, who was in training, brought chairs to the staff after noticing they were standing, and acknowledged the importance of being at eye level for proper monitoring and resident comfort. Further interviews with the DON and other staff reiterated that sitting at eye level was a standard practice intended to promote resident comfort and allow for better observation during feeding. The facility's written procedure also specified that qualified nursing staff should sit down when assisting residents with eating. Despite this, the observed failure to follow these procedures resulted in a lack of dignity and potentially inadequate monitoring for the residents involved.
Failure to Develop and Implement Care Plan for Resident's Wandering Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's history of wandering. Record reviews showed that although the resident was listed as a wanderer on the facility's list, there was no corresponding focus, goal, or intervention for wandering in the resident's care plan. The resident had a severely impaired cognition as indicated by a BIMS score of 3, and was diagnosed with altered mental status and UTI. However, the clinical risk assessment and MDS did not code for wandering, and the care plan did not reflect this behavior. Interviews with the DON, MDS, and Administrator confirmed that the resident's wandering behavior should have been care planned, and that it was the responsibility of the MDS department to ensure care plans were accurate and complete. The lack of a care plan for wandering was acknowledged as an oversight, with staff stating that care plans are necessary to inform staff of resident needs and to provide appropriate care. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident, but this was not followed in this case.
Failure to Complete Resident Personal Inventory on Admission
Penalty
Summary
The facility failed to maintain complete and accurate records for a resident upon admission, specifically by not completing a personal inventory sheet as required by facility policy. The resident, an elderly female with severe cognitive impairment as indicated by a BIMS score of 02, was admitted with age-related cognitive decline. Review of her admission documents showed that the inventory form, which should have listed her personal belongings, was left blank and was not updated at any point after admission. The admission packet required the resident or responsible party to complete this inventory, and the facility's policy stated that it was responsible for accounting for all resident belongings. Interviews with the DON and Administrator confirmed that the inventory process was not followed for this resident. The DON acknowledged that the inventory sheet was missing and that nurses were responsible for its completion, while the Administrator stated that the process was shared among nursing and other staff. Both confirmed that there was no documentation of the resident's belongings, and the DON had not previously noticed the omission. The facility's policy and documentation guidelines required a personal inventory list to be completed on admission and included in the medical record, but this was not done for the resident in question.
Failure to Provide Scheduled Wound Care for Resident
Penalty
Summary
The facility failed to provide treatment and care based on the comprehensive plan of care for a resident with an arterial ulcer on her right big toe. The resident, who was admitted to the facility with a diagnosis of Peripheral Artery Disease and other conditions, had orders for wound care to be performed three times a week. However, on one occasion, the wound care was not performed as scheduled. The resident's care plan required assessment of the wound bed and surrounding skin for signs of infection or complications, but the wound care was not documented on the specified date. Interviews with facility staff revealed a lack of clarity and communication regarding who was responsible for performing the wound care on the missed date. The assigned nurse for the shift did not perform the wound care, assuming it was the responsibility of the Wound Care Nurse, who was not present. The Director of Nursing confirmed that the resident had complained about the missed wound care, and although the wound did not worsen, the failure to provide care as ordered was acknowledged. The facility's policy required dressing changes to follow specific guidelines, which were not adhered to in this instance.
Torn Fall Mat Poses Risk for Resident at LTC Facility
Penalty
Summary
The facility failed to ensure that the environment for a resident, who was at risk for falls, was free from accident hazards. Specifically, the fall mat intended to prevent injuries for a resident diagnosed with dementia and bipolar disorder was found to be torn, exposing the internal foam and materials. This condition was observed during an inspection, and it was noted that the torn mat could pose a risk of falling if stepped on. The resident's care plan indicated that she was at risk for falls and required extensive assistance with activities of daily living, including transfers and walking. Interviews with facility staff revealed a lack of awareness and responsibility regarding the condition of the fall mat. The Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) acknowledged the mat's poor condition and the associated risks but had not taken action to replace it. The Director of Nursing (DON) and the Director of Rehabilitation (DOR) also recognized the hazard but indicated that there was no clear policy or procedure for addressing such issues. The maintenance and rehabilitation departments had differing views on who was responsible for replacing or repairing the mat, leading to further inaction.
Resident Received Oxygen Without Physician Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who was receiving oxygen therapy without a physician's order. The resident, a female with severely impaired cognition, was admitted to the facility without any diagnosis that warranted oxygen use. Despite this, she was observed receiving oxygen via a nasal cannula from 10/20/24 to 10/25/24 without any documented physician orders. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that the resident had acquired COVID-19 and was receiving breathing treatments, but there were no orders for oxygen therapy documented in the resident's records. The facility's policy requires that all medications, including oxygen, must have a physician's order, and the nurses are responsible for ensuring these orders are in the system. However, the DON acknowledged that the resident was on oxygen at 4 liters per minute without the necessary orders. The lack of proper documentation and physician orders for oxygen therapy could potentially place residents at risk of receiving incorrect or inadequate oxygen support. Interviews with other staff members, including a Licensed Vocational Nurse (LVN), highlighted the importance of maintaining oxygen saturation above 90 percent and the potential negative outcomes of not having proper orders in place.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents and their families had access to the results of the most recent survey conducted by Federal or State surveyors, as well as any plan of correction in effect. During an observation and interview, it was noted that a clear storage bin, intended to hold the survey results, was empty. The receptionist confirmed that a binder containing the last survey inspection results should have been in the bin but was unable to locate it. The receptionist mentioned that the administrator had the survey binder in his office, indicating a lack of proper accessibility for residents and their families. In a group interview, eleven residents were unaware of their right to review past survey reports or where to find them. Additionally, the Unit Manager was also unaware of the location of the survey binder. The surveyor requested the facility's policy and procedure on posting previous surveys, but it was not provided before the surveyor's exit. This lack of accessibility and awareness among staff and residents led to the deficiency, as it hindered the residents' ability to exercise their rights to be informed about the facility's survey citation history.
Failure to Adhere to Nebulizer Treatment Protocols
Penalty
Summary
The facility failed to ensure that services provided to Resident #6 met professional standards of quality, specifically in the administration of nebulizer treatments. Licensed staff did not assess the resident's respiratory status before and after administering the nebulizer treatment, as required by the facility's policy and procedure. This included failing to document the resident's respiratory rate, lung sounds, and oxygen saturation pre- and post-treatment. The lack of assessment and documentation was observed during a medication pass, where the LVN did not perform the necessary checks or use gloves and proper hand hygiene. Resident #6, a 94-year-old female, was on oxygen therapy for shortness of breath, as outlined in her care plan. Despite having no documented pulmonary diagnosis or symptoms such as shortness of breath, the resident was receiving Pulmicort inhalation suspension via nebulizer for low oxygen saturations. The physician's orders required specific observations and documentation before and after nebulizer treatments, which were not adhered to by the staff. Interviews with the LVN, DON, and ADON revealed a lack of training and awareness regarding the proper administration of nebulizer treatments. The LVN admitted to not knowing the necessity of assessing the resident's respiratory status and had not been trained on nebulizer administration at the facility. The DON and ADON were unaware of the lack of documentation and training, indicating a gap in oversight and adherence to the facility's policies and procedures for nebulizer therapy.
Deficiencies in Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, specifically in the management of oxygen therapy and nebulizer treatments. For one resident, the oxygen machine's filter was observed to be dirty with multiple layers of dirt, indicating it had not been cleaned for months. This was confirmed by interviews with staff, who were unclear about the responsibility for maintaining the oxygen equipment. The Director of Nursing (DON) acknowledged the issue but downplayed the risk, stating that the machine would alert staff if it malfunctioned. However, the facility's policy required weekly cleaning of the oxygen equipment, which was not adhered to. Additionally, the same resident receiving nebulizer treatments did not have their respiratory status assessed before and after treatment, as required by the facility's policy. The Licensed Vocational Nurse (LVN) administering the treatment was unaware of the need for such assessments and did not follow proper infection control practices, such as using gloves and washing hands. The DON and Assistant Director of Nursing (ADON) admitted that there was no documentation of respiratory assessments in the Medication Administration Record, and they were unsure when the last training on nebulizer administration had occurred. For another resident, the facility failed to post an oxygen sign on the door, which is a safety measure to alert staff and visitors of the presence of oxygen in the room. The absence of this sign could lead to staff overlooking the need to check oxygen levels or tanks, and it poses a fire hazard if flammable items are brought into the room. Interviews with the Unit Manager and ADON confirmed the expectation for signs to be posted and the potential risks associated with their absence. The facility's policy required such signage, but it was not implemented in this case.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and secure storage of medications. Specifically, for one resident, the facility did not administer Gabapentin according to the physician's order. The resident, a 90-year-old female with diabetes mellitus and diabetic polyneuropathy, was prescribed Gabapentin 100 mg, two capsules, three times a day. However, during a medication pass, the LVN only poured one capsule instead of the required two. This discrepancy was noticed by the surveyor, and the LVN had to retrieve another blister packet to administer the correct dosage. Another deficiency was observed with a 67-year-old male resident with end-stage renal disease. The LVN prepared medications, including Docusate Sodium and Gabapentin, but the resident was not present to receive them as he was at a dialysis center. Instead of disposing of the medications as per facility policy, the LVN stored them in the medication cart, intending to administer them later. This action was against the facility's policy, which requires medications to be wasted if not administered as ordered. Additionally, the facility failed to ensure proper documentation of controlled substances. An LVN did not sign off on the Controlled Drugs-Count Record after verifying the controlled substances with the oncoming nurse at the change of shift. This oversight was acknowledged by the LVN, who later signed the record after being reminded by the surveyor. The facility's policy mandates that both the nurse coming on duty and the nurse going off duty verify and sign the controlled substance count to ensure accuracy and prevent drug diversion.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 14% due to four errors out of 27 opportunities. These errors involved three residents and were observed during medication administration by two licensed vocational nurses (LVNs). The errors included incorrect dosage and failure to administer medication with food as per physician's orders. One resident, a 90-year-old female with diabetes mellitus and diabetic polyneuropathy, was prescribed Gabapentin 100 mg, two capsules to be taken three times a day. During an observation, LVN A was found to have poured only one capsule instead of the prescribed two. The LVN acknowledged the mistake, citing a lack of medication in the blister packet, and corrected the error by obtaining another capsule from the medication room. Another resident, a 47-year-old female with cerebral arteritis, was prescribed Pentoxifylline ER 400 mg to be taken with food. LVN A administered the medication while the resident was participating in a group activity without food. The LVN justified the timing by stating the medication could be given within an hour of the scheduled time, assuming the resident would eat soon. Additionally, a 67-year-old male with end-stage renal disease was prescribed medications to be taken with meals, but the administration did not align with the meal schedule. The facility's policies require medications to be administered as per physician's orders, including with meals or food when specified.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications, as observed in two of three medication carts and one medication room. Medications were stored inappropriately after being poured, and controlled substances were not properly accounted for at shift changes. Specifically, an LVN poured medications for a resident who was not present and stored them in the medication cart, contrary to training protocols. Additionally, an LVN failed to sign the Controlled Medication Count Records Sheet after verifying the counts with the oncoming nurse, which is a required procedure. The facility also did not adhere to manufacturer specifications for glucose control solutions and test strips. Observations revealed that the glucometer control solutions were opened and not dated, and the staff was unaware of the manufacturer's guidelines for discarding these solutions after a specified period. This oversight was confirmed by the DON and ADON, who acknowledged the lack of awareness regarding the proper management of glucose control solutions. Furthermore, the medication room was found to be in disarray, with dust, stains, and particles on the floor, and IV bags stored improperly on the floor. Over-the-counter drugs were not stored according to their routes of administration, with various medications mixed together on the shelves. These storage issues were contrary to the facility's policies and procedures, which require medications to be stored safely and according to manufacturer recommendations.
Failure to Maintain Food Temperature and Quality
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for three diet test trays reviewed for food temperatures. Observations revealed that CNAs were leaving the doors open to the insulated meal cart while distributing trays, causing the food to become cold. This issue was observed on multiple occasions, and residents reported that meals were consistently delivered cold to those eating in their rooms. The Dietary Manager confirmed that the CNAs had been trained to keep the cart doors closed, but this practice was not being followed, resulting in food temperatures below the required levels. During a group interview, residents expressed ongoing dissatisfaction with the temperature of their meals, indicating that this was a persistent problem. The Dietary Manager acknowledged that the insulated meal cart was left open during tray distribution, which contributed to the cold food issue. Test tray sampling confirmed that food temperatures were below the required standards, with items like Tamale Pie recorded at 125 degrees Fahrenheit. The Dietary Manager stated that food should be reheated to 165 degrees Fahrenheit, but this was not consistently happening. The facility's Administrator, ADON, Dietary Manager, and Maintenance Director discussed resident concerns about cold food in department head meetings, but no written records were kept to document actions taken. The Administrator was unaware of the ongoing issue with the insulated meal cart and the cold food temperatures. The Dietary Manager also noted that there was no system in place to ensure the cart doors remained closed during meal service. Additionally, a review of the facility's Quality Assurance Monitor revealed that residents had voiced concerns about food temperature and quality, but these issues were not adequately addressed in the facility's QAPI minutes.
Deficiencies in Kitchen Sanitation and Food Safety
Penalty
Summary
The facility was found to have multiple deficiencies in its food storage, preparation, and service areas, as observed by surveyors. The kitchen was not maintained in accordance with professional standards, with dust, grease, and food particles found on floors, equipment, and storage areas. The refrigerator contained dried food particles, and perishable foods such as jalapeno peppers and cabbage were not discarded despite showing signs of spoilage. Additionally, opened food containers were not stored in sealed containers, and food preparation tables and equipment were not kept free of dust. The facility also failed to maintain kitchen equipment in proper working order, with missing and cracked control knobs on stoves, missing oven door handles, and a broken blade on the Robot Coupe food processor. The kitchen environment was further compromised by ongoing construction, which contributed to the accumulation of dust and debris. The plastic barriers intended to contain construction dust were not completely sealed, allowing dust to infiltrate food preparation areas. Furthermore, essential equipment such as the deep fryer and vents were not kept free of dust and grease build-up. Staff practices also contributed to the deficiencies, with kitchen staff failing to use hair nets and beard guards consistently, and not adhering to proper food handling procedures. For instance, a staff member was observed checking food temperatures without using gloves or a thermometer holder, and another staff member did not wash hands after picking up a pan from the floor. The facility also failed to post current menus in the dining room, and the food on the steam table was not maintained at the appropriate temperature, posing a risk of foodborne illnesses to residents.
Inadequate Documentation of Restorative Therapy for Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, specifically regarding their restorative therapy care. For one resident, the care plan lacked documentation for restorative therapy, which was intended to help maintain range of motion and facilitate activities of daily living (ADLs). Despite being approved for therapy, there was no documentation of completion dates or progress notes, and the resident was reportedly in pain and unable to tolerate certain interventions. The Director of Therapy acknowledged that there should have been a documented care plan, but it was not filled out. For the second resident, the family expressed concerns about the lack of progress in the resident's condition and questioned whether therapy was being provided, as the resident's condition appeared to be worsening. The Assistant Director of Nursing (ADON) was unaware of the resident's therapy approval status, and the Director of Therapy confirmed that the resident had been on restorative therapy but lacked proper documentation. The Director of Nursing (DON) was unable to find the necessary care plan documentation, and it was noted that progress notes should be completed daily and accurately, a responsibility that fell to the ADON.
Failure to Maintain Meal Temperatures
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to take necessary actions to improve performance and did not measure or track the success of any implemented actions. This deficiency was highlighted by the facility's failure to address ongoing concerns about meals being served cold to residents. Observations revealed that Certified Nursing Assistants (CNAs) were leaving the doors of the insulated meal cart open while distributing trays, which resulted in meals being delivered cold to residents who ate in their rooms. This issue was confirmed through interviews with residents who reported that cold meals were a persistent problem. Further observations and interviews with the Dietary Manager confirmed that the insulated meal cart was left open during meal distribution, which contributed to the food cooling down. The Dietary Manager acknowledged that CNAs had been trained to keep the cart doors closed to maintain meal temperatures, but this practice was not being followed. Test trays sampled during the survey showed that food temperatures were below the required levels, indicating that the meals were not being kept hot enough. The Dietary Manager admitted that there was no system in place to ensure the cart doors remained closed during meal service. Interviews with the facility's Administrator, Assistant Director of Nursing (ADON), Dietary Manager, and Maintenance Director revealed that while concerns about cold food had been discussed in morning meetings, no written records or QAPI minutes documented these discussions or any actions taken. The Administrator was unaware of the ongoing issue with the meal cart doors being left open and the resulting cold food temperatures. Additionally, the facility lacked documentation of the dietitian's recommendations for conducting monthly test tray audits to monitor food temperatures, further indicating a gap in the facility's quality assurance processes.
Failure to Address Dietary Concerns and Cold Food Service
Penalty
Summary
The facility failed to ensure that the Quality Assurance (QA) committee developed and implemented appropriate plans of action to address dietary concerns identified in group interviews and a Satisfaction Survey conducted by the consultant dietitian. Specifically, the facility did not address complaints regarding cold food being served to residents who ate in their rooms. Observations revealed that Certified Nursing Assistants (CNAs) left the doors of the insulated meal cart open while distributing trays, causing the food to become cold. This issue was reported by residents as an ongoing problem, with no effective measures taken to resolve it. During an interview with the Dietary Manager, it was confirmed that CNAs had been trained to keep the insulated meal cart doors closed to maintain food temperature, but this practice was not consistently followed. Test trays sampled during the survey showed that food temperatures were below the required levels, indicating that the meals were not being kept warm as needed. The Dietary Manager acknowledged the lack of a system to ensure the insulated cart doors remained closed during meal service, contributing to the problem of cold food being served. The facility's Administrator and Dietary Manager admitted that there was no documentation in the Quality Assurance and Performance Improvement (QAPI) minutes regarding the complaints about cold food and menu issues. Despite discussions in morning department head meetings, no written records were kept to demonstrate actions taken to address these concerns. Additionally, the facility did not have a system in place to monitor food temperatures and meal service effectively, as recommended by the dietitian. The lack of a corrective action plan and monitoring system contributed to the ongoing issue of cold food being served to residents.
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. A CNA did not perform hand hygiene between assisting residents with meals, despite acknowledging the need to do so. The CNA admitted to forgetting to sanitize hands and mentioned a lack of sanitizer, although sanitizer was available. Additionally, the facility's Director of Nursing (DON) confirmed that staff were trained to sanitize hands between residents to prevent cross-contamination. Another deficiency was observed during a medication pass, where an LVN did not use gloves or perform hand hygiene when administering a nebulizer treatment. The LVN failed to assess the resident's respiratory status before and after the treatment and did not wash hands after removing the nebulizer mask. The DON acknowledged that gloves should have been used to prevent cross-contamination. Furthermore, another LVN was observed not changing gloves between residents during medication administration, citing a shortage of gloves, although the DON stated there was no shortage. Additional issues included improper storage of medical supplies and equipment. A plastic container used for storing IV bags was found on the floor, and opened packages of gauze were not stored in sealed bags. The facility also failed to keep crash carts and linen cart covers free of dust and tears, respectively. These practices could contribute to cross-contamination and the spread of infection, as noted in the facility's policies and procedures on infection control.
Deficiencies in Kitchen and Laundry Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen and laundry equipment in safe operating condition. In the kitchen, the stove was found to be missing three control knobs, which were kept on a shelf above the stove due to their tendency to fall off. Additionally, the oven doors were missing handles, and multiple control knobs on the stove were cracked, greasy, and dusty. The Dietary Manager, who had been working at the facility for a few months, confirmed these observations and noted the issues had been present since her employment began. Furthermore, the Robot Coupe's blade was broken, contributing to the equipment deficiencies in the kitchen. In the laundry room, Dryer #1 was missing the metal cover on the top and the cover to the control panel, while Dryer #2 was also missing the control panel cover. Two washers were reported to be leaking water, with a white substance build-up and rust on their bases. The floor in front of the washers had rust and a black substance, and there was water on the floor and wall next to the washers. The Maintenance Director, who started working at the facility in April 2024, acknowledged these issues and stated he was unaware of any maintenance policies or procedures. He expressed that he was addressing the equipment problems as quickly as possible.
Environmental Deficiencies in Kitchen and Medication Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in several areas, including three of five halls, the kitchen, and a medication room. Observations and interviews revealed that the kitchen equipment vents in the food preparation area were full of dust, and there was a large hole in the ceiling with a missing electrical cover on a kitchen light. Water pipes had ruptured, causing water to drip from the ceiling to the kitchen floor, and part of the ceiling had been removed for repairs. Metal pots containing food were uncovered on the stove, and doors had chipped paint and were dusty. The Dietary Manager acknowledged the presence of dust due to ongoing construction and a lack of lids to cover pans on the stove. Despite training, dietary staff struggled to maintain cleanliness due to the construction dust. Interviews with CNAs revealed that the dust problem began on a recent Saturday and affected the tile floors, dining room tables, chairs, and nurse's stations. Plastic barriers intended to contain the dust were ineffective, as they were not completely sealed, and one barrier had been removed and was on the floor. Additionally, in the medication room, there were no paper towels in the dispenser by the hand sink, which was confirmed by the DON, who stated that the medication room should be cleaned daily and housekeeping should ensure paper towels are available.
Failure to Administer Medications with Meals as Ordered
Penalty
Summary
The facility failed to implement a comprehensive person-centered plan of care for two residents regarding their medication administration. Resident #41, a 47-year-old female with cerebral arteritis, was prescribed Pentoxifylline ER 400 mg to be taken with food. However, during a medication pass, the medication was administered by LVN A without food while the resident was engaged in a group activity. The LVN justified the timing by stating that medications could be given one hour before or after the scheduled time, assuming the resident would be eating something. Resident #48, a 67-year-old male with end-stage renal disease, was prescribed Calcium Acetate and Sevelamer Carbonate to be taken with meals. Observations revealed that the facility's meal schedule was not adhered to, as the medications were not administered during meal times as ordered. The DON confirmed that medications ordered to be given with meals must be administered accordingly, and staff had been trained to follow these orders. The attending physician emphasized the importance of administering medications with food or meals to prevent adverse drug effects. The facility's policy on medication administration requires adherence to the physician's orders and the 8 Rights of medication administration. Despite these policies, the facility's failure to administer medications as ordered placed the residents at risk of adverse drug effects and a decline in their health status.
Inadequate Catheter Care for Resident with Urinary Incontinence
Penalty
Summary
The facility failed to provide appropriate care for a resident with urinary incontinence, specifically in managing the resident's indwelling catheter. Observations revealed that the catheter tubing was improperly placed, with the tubing rolled up next to the resident's leg and the catheter bag hanging on the wheelchair's side, touching the wheel. Additionally, the resident's subpubic catheter was not secured with a leg strap, which is necessary to prevent potential injury and ensure proper urine flow. Interviews with staff, including a CNA, LVN, and the DON, confirmed that the catheter care was not in compliance with the facility's standards, as the resident did not have a leg strap, and the catheter bag was not placed in a privacy bag. The resident, who has a history of type 2 diabetes mellitus and benign prostatic hyperplasia, expressed discomfort and concern about the catheter tugging, which led him to place the tubing under his leg to avoid pulling. The facility's catheter care policy did not mention the use of leg straps, and staff interviews indicated a lack of training and awareness regarding proper catheter care. The administrator was unaware of the frequency of catheter care training, and an RN stated that she had not received any training from the facility, relying on her education from school. This lack of proper catheter management and training could place residents at risk of urinary tract infections and injury.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 297 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain Villa Nursing Center | 2.1 mi | ★★★★★ | 27 | 0 |
| Mountain View Health & Rehabilitation | 4.1 mi | ★★★★★ | 31 | 2 |
| Grace Pointe Wellness Center | 4.2 mi | ★★★★★ | 22 | 0 |
| St. Teresa Nursing & Rehab Center | 5.3 mi | ★★★★★ | 18 | 0 |
| Vista Hills Health Care Center | 6.2 mi | ★★★★★ | 16 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.