Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pavilion At Creekwood during CMS and state inspections, most recent first.
Surveyors found controlled meds with broken blister seals taped in medication carts on multiple halls, including Tylenol #3 and hydrocodone, while an RN stated the seals were not noticed during narcotic counts. Surveyors also found a discharged resident’s lorazepam still stored in a cart. The DON stated broken-seal narcotics should be wasted with 2 nurses and discharged residents’ meds should be removed from carts when the resident leaves.
A facility failed to ensure proper medication labeling and storage on multiple med carts. One resident’s Trelegy Ellipta and another resident’s Breo Ellipta were found without opening dates, and an unopened Lantus SoloStar insulin pen for a third resident was stored unrefrigerated in the med cart instead of being kept refrigerated per manufacturer guidance. Staff stated nurses were responsible for dating medications after opening and refrigerating insulin that required it.
Improper Food Storage and Labeling in Kitchen: Surveyors found opened dinner rolls in the walk-in freezer with the inner bag unsealed, plus unsealed lettuce heads and partially used mixed salad greens in the walk-in refrigerator without labels or use-by dates. The Morning Cook said she checks food storage daily and would discard the items, and the Dietary Mgr acknowledged the food should have been closed and labeled/dated.
Failure to Knock or Announce Entry to Resident Room: A resident with moderate cognitive impairment, dementia, diabetes, and HTN had a care plan directing staff to announce themselves and keep the call light within reach. The resident reported her incontinent brief was wet and she could not call for help because the call light was out of reach on a nightstand. An LVN entered the room without knocking or announcing herself, placed the call light on the resident’s stomach, and left without speaking to her; the DON confirmed staff are expected to knock and announce themselves when entering a resident room.
A facility failed to keep call lights within reach for two residents who needed assistance with toileting and incontinence care. One resident with dementia and extensive care needs said she could not find or reach her call button, which was on a nightstand, while another resident with brain degeneration reported waiting at least an hour for help because her call button had fallen to the floor. Staff and the DON acknowledged that call lights are expected to be within reach, and the facility policy required the same.
A resident admitted for respite care remained in the facility beyond the expected short stay after the family extended the stay twice, but the Comprehensive MDS Assessment was not completed within the required 14-day timeframe. The MDS Coordinator said she was not informed of the second extension and only started the admission MDS once she learned the resident had stayed longer than planned.
A resident admitted with interstitial lung disease and oxygen needs missed a prednisone dose because the admission order was not accurately transcribed to the physician orders or MAR. Staff interviews showed confusion about who was responsible for entering the titrating steroid order, and the MAR reflected the medication start date as the next day instead of the ordered start date. The DON stated the transcription failure contributed to the missed dose and medication error.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
The facility experienced a 24% medication error rate due to improper administration practices. A resident received crushed Nifedipine ER, contrary to its instructions, while another resident's medications were administered over four hours late. These errors were linked to staff workload and non-adherence to medication protocols.
A resident reported that a CNA refused to provide incontinent care, but the facility failed to document or formally address the grievance. The ADON acknowledged the issue but did not file a grievance, and the Administrator was unaware of the incident, indicating a lapse in following the facility's grievance policy.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with serious medical conditions, as required by policy. The MDS Coordinator confirmed the oversight, acknowledging the risk of a state citation. The absence of a care plan could impact the delivery of effective, person-centered care.
A facility failed to ensure accurate narcotic counts for a resident's medication, leading to a discrepancy in the medication cart. The resident, with multiple medical conditions, was prescribed pain medications, but the narcotic log showed mismatches between the count sheet and the actual tablets. Interviews revealed that the nurse on duty signed the wrong narcotic sheet, and the charge nurse did not correct the inconsistency promptly.
A resident with a history of arthritis and osteoporosis fell in the bathroom and was not properly assessed by RN C, who failed to notify the physician as required by the facility's policy. The resident later reported severe pain and was found to have a clavicle fracture after being sent to the hospital. The facility's investigation revealed lapses in following the fall management policy.
A resident with a history of stroke and impaired mobility was left unattended in a shower chair by a CNA, leading to a fall and head injury. The resident's care plan did not address fall risks related to shower chairs, and the CNA admitted to neglecting the resident by leaving him alone. Interviews revealed inconsistent staff training on neglect and supervision, contributing to the incident.
A resident with a history of depression and severe cognitive impairment expressed suicidal ideation, but the LVN on duty failed to follow the facility's suicide policy. The LVN did not notify the DON or Administrator and did not implement required suicide precautions, leaving the resident at risk. Other staff members were unaware of the situation, highlighting a communication breakdown and failure to adhere to policy.
A resident with a documented DNR order was subjected to full resuscitation efforts after choking, as the facility staff failed to communicate the DNR status to EMS. The resident, who had multiple health issues, became unresponsive, and despite having a DNR, was given CPR for 43 minutes. The LVN on duty did not inform EMS of the DNR due to the chaotic situation, leading to the initiation of life-saving measures contrary to the resident's wishes.
A long-term care facility failed to provide necessary pharmaceutical services for five residents, resulting in missed medication administrations. One resident did not receive Clozapine for two weeks due to issues with obtaining a REMS form and lab results, leading to increased psychosis symptoms. Other residents missed various medications due to unavailability, with no documented follow-up actions. Staff interviews highlighted issues with medication ordering and delivery processes.
A resident was prescribed Seroquel without adequate indications for its use, as the facility failed to ensure a proper diagnosis was documented. The resident, with multiple medical conditions, was admitted from a hospital where Seroquel was started without a listed diagnosis. Facility staff admitted to selecting inappropriate diagnoses due to procedural limitations and inexperience. The facility's policy required a specific diagnosis for psychotropic drug use, which was not followed, risking unnecessary medication use.
The facility failed to store food properly in the kitchen's refrigerator and freezer, with items left open and exposed to air, and food found on the freezer floor. Despite daily checks by the Dietary Supervisor, these lapses in food storage could lead to contamination, violating professional standards for food service safety.
A resident with severe cognitive impairment and multiple medical conditions, including being at risk of dehydration, was not provided with requested assistance in a timely manner. Despite activating her call light for hot tea to soothe a sore throat, staff failed to fulfill her request, leading to feelings of neglect. The facility's policy on responding to call lights was not followed, resulting in a deficiency.
Controlled Medications Improperly Stored and Discharged Resident Medication Left in Carts
Penalty
Summary
The facility failed to maintain a system of records for the receipt and disposition of controlled drugs in sufficient detail to allow accurate reconciliation on 3 of 4 medication carts reviewed. Surveyors observed controlled medications stored in medication carts with broken blister seals that had been taped closed, including Tylenol #3 300 mg on the 400 hall cart and hydrocodone 5-325 mg on the 200 hall cart. In both instances, the pills remained inside the damaged blister packs when inspected by surveyors, and the nurses stated they were responsible for checking narcotic blister packs during shift counts. Resident #60 was admitted with diagnoses including type 2 diabetes mellitus with foot ulcer and had a care plan addressing pain related to impaired mobility and a diabetic wound with osteomyelitis. The resident had an active order for acetaminophen-codeine 300-30 mg every 4 hours as needed. During observation, the resident’s Tylenol #3 blister pack had 4 broken seals and was secured with clear tape in the medication cart. The RN stated she did not notice the broken seals during the narcotic count and acknowledged that damaged blister packs could present issues with drug diversion and contamination. Resident #68 had diagnoses including diabetes mellitus and a care plan addressing pain management. The resident had an active order for hydrocodone 5-325 mg every 4 hours as needed. Surveyors observed the resident’s hydrocodone blister pack in the 200 hall medication cart with 2 broken seals and the capsule still inside. Resident #120 had been discharged, yet lorazepam 0.5 mg remained stored in the 300 hall medication cart. The RN stated the discharged resident’s medication should have been removed from the cart, and the DON stated narcotics with broken seals should be wasted and witnessed by two nurses and that discharged residents’ medications should be removed from medication carts as soon as the resident is discharged.
Medication Storage and Labeling Deficiencies in Multiple Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, administering, and disposal of medications for 3 of 4 medication carts reviewed. During observation of the 300 Hall nurses cart, Resident #47’s Trelegy Ellipta inhaler did not have an opening date. Resident #47’s record showed diagnoses including asthma and COPD/respiratory failure, and the active physician order directed use of Trelegy Ellipta once daily with instructions to rinse the mouth after each use. During observation of the 200 Hall nurses cart, Resident #90’s Breo Ellipta inhaler also had no opening date. Resident #90’s record showed diagnoses including asthma and COPD, and the active physician order directed Breo Ellipta once daily with instructions to rinse the mouth after each use. The RN stated she was unaware the inhaler, which expires 6 weeks after opening, required dating after opening and stated nurses were responsible for ensuring medication in the cart was dated after opening. During observation of the 400 Hall nurses cart, Resident #58’s unopened Lantus SoloStar insulin pen was stored unrefrigerated in the medication cart. Resident #58’s record showed diabetes mellitus and an active order for Lantus SoloStar insulin. The manufacturer’s guide stated unopened Lantus should be stored in the refrigerator before opening. The RN stated the unopened insulin should be refrigerated until opened and dated, and the DON stated nurses were responsible for dating medications after opening and refrigerating medications that required it.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation, a 11.25-lb box of dinner rolls was found on a shelf in the walk-in freezer with the box opened from the top and the plastic bag holding the rolls also open. A white sticker on the box read 4/7/2026. In the walk-in refrigerator, a clear plastic bag of lettuce heads was observed stored unsealed without a use-by date on the packaging. A bag of mixed salad greens was also observed in the walk-in refrigerator after having been previously opened and partially used, wrapped several times in clear plastic wrap without a label or use-by date. The Morning Cook stated she checked food storage each morning to ensure items were labeled and dated, and said she would throw the items away. The Dietary Manager stated she was made aware of the exposed and undated food items, said food should have been closed and labeled/dated, and reported the Morning Cook threw away the dinner rolls after the surveyor identified them. The facility policy titled Food Safety in Receiving and Storage stated opened packages should be tightly resealed to prevent contamination or placed in covered containers, and food removed from original packages should be identified with the common name of the food.
Failure to Knock or Announce Entry to Resident Room
Penalty
Summary
The facility failed to treat a resident with respect and dignity and to provide care in a manner that promoted maintenance or enhancement of quality of life when LVN A entered Resident #79’s room without knocking or announcing herself. Resident #79 was a female with a BIMS score of 9 indicating moderate cognitive impairment, and diagnoses included unspecified dementia, Type II diabetes, and hypertension. She required extensive assistance for bed mobility, transfer, and toilet use. Her care plan directed staff to announce themselves by name and position and call her by name because of impaired visual function, and also identified her as a fall risk with the call light to be kept within reach at all times. During observation and interview, Resident #79 stated her incontinent brief was wet and needed to be changed, and she had not told anyone because she could not find her call button. The call button was observed on a nightstand, and the resident stated she was not sure who placed it there and could not reach it. LVN A was informed that the resident needed to be changed and could not call for assistance because the call light was out of reach. LVN A then entered the room, placed the call light on the resident’s stomach, and left without knocking or announcing herself. LVN A stated staff are required to knock on every resident’s door and say their name, and the DON stated staff are expected to knock and announce who they are when entering a resident room.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure the call light system in two residents’ rooms was positioned within reach and accessible to them. Resident #79 had a quarterly MDS assessment showing severe dementia, diabetes, hypertension, and extensive assistance needs for bed mobility, transfers, and toileting. Her care plan identified the need for side rails for turning and repositioning and included keeping the call light within reach, including at all times because she was a fall risk. During observation, she stated her incontinent brief was wet and needed changed, but she had not told anyone because she could not find her call button; it was observed on a nightstand and she said she could not reach it. Resident #28 had diagnoses of senile degeneration of the brain and essential hypertension and required assistance with bed mobility, toileting, transfers, and ambulation. During observation, she reported needing her incontinence brief changed and said she had been waiting at least an hour because she could not reach her call button. The call button was observed on the floor beside her bed, out of reach, and she stated it had fallen off earlier that morning. Staff interviews confirmed that residents use the call button for incontinence assistance and that call lights should be within reach, and the DON stated residents who cannot access their call buttons would not be able to call for assistance. The facility policy also stated to ensure the call light is placed within the resident’s reach.
Failure to Complete Comprehensive MDS Assessment Timely
Penalty
Summary
The facility failed to complete a Comprehensive MDS Assessment within 14 calendar days after admission for Resident #28, who was admitted with diagnoses including senile degeneration of the brain and essential primary hypertension. Review of the resident’s electronic medical record showed no evidence that an MDS Assessment had been completed as of the record review date. During interview, the MDS Coordinator stated the resident originally entered the facility as a respite resident for four days, but the family extended the stay twice, resulting in the resident remaining in the facility for more than 14 days. The MDS Coordinator stated she was not informed that the second respite extension had occurred, which was why the assessment was not completed within the required timeframe. She stated that once she learned of the extension, she initiated an admission MDS Assessment that was still in progress and notified admissions/administration to communicate any future respite extensions to her.
Missed Prednisone Dose After Admission Order Was Not Transcribed
Penalty
Summary
The facility failed to ensure that a resident was free from a significant medication error when prednisone orders were not accurately transcribed on admission. The resident was a [AGE]-year-old male who had been admitted from the hospital with interstitial lung disease and required oxygen. His baseline care plan reflected that he needed oxygen, with interventions to administer oxygen as ordered and observe for signs and symptoms of shortness of breath and decreased perfusion. The resident’s discharge orders from the hospital included a prednisone taper beginning with 80 mg daily for two days, with the start date listed as 03/03/2026. However, the prednisone order was not transcribed onto the facility’s physician orders or MAR on admission, and the medication was not administered as ordered on 03/03/2026, resulting in a missed dose. The March 2026 MAR showed the prednisone start date as 03/04/2026, and there was no prednisone order dated 03/03/2026. Interviews showed confusion among nursing staff about who was responsible for entering the prednisone order and verifying admission medications. One nurse manager stated she did not see a note asking her to enter the order, another nurse stated she was not aware the resident missed medication, and another stated she had difficulty entering the titrating prednisone order and left a note for the oncoming nurse. The DON stated the order was not transcribed to the MAR on admission and that the failure to accurately transcribe the order contributed to the missed dose and medication error. The facility’s policy reflected that medication reconciliation is the primary mechanism for validating medication orders.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 24% error rate during the survey. This deficiency was observed in the administration of medications to two residents. One resident, with severe cognitive impairment and multiple diagnoses including hypertension and diabetes, was administered Nifedipine ER in a crushed form by a medication aide (MA A), despite the medication's instructions explicitly stating it should not be crushed. Crushing the extended-release medication could lead to an overdose or side effects, as it alters the intended gradual release of the drug. Another resident, also with severe cognitive impairment and various health conditions such as chronic kidney disease and heart failure, received their morning medications significantly later than prescribed. The medications, scheduled for 7 am, were administered at 11:18 am by another medication aide (MA B). This delay was attributed to the high number of residents requiring medication at the same time, which MA B had previously reported to the Director of Nursing (DON). The late administration of medications, particularly those for blood pressure, could affect their therapeutic efficacy. Interviews with the medication aides and the DON revealed awareness of the issues, with MA A acknowledging the error in crushing the medication and MA B highlighting the challenge of timely administration due to workload. The facility's policy requires medications to be administered within one hour of the scheduled time, and the staff had been recently in-serviced on this protocol. However, these practices were not adhered to, leading to the observed deficiencies.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances and to document the grievance process adequately for a resident who expressed concerns about care. The resident, who was cognitively intact and had a history of diverticulitis and anxiety disorder, reported an incident where a CNA refused to provide incontinent care during the night shift. Despite the resident informing the Assistant Director of Nursing (ADON) about the issue, no formal grievance was filed, and the incident was not documented in the facility's grievance reports. The ADON acknowledged the resident's complaint as a customer service issue but did not follow the facility's grievance policy, which requires documentation and investigation of grievances. The Administrator was unaware of the incident until the surveyor's inquiry, highlighting a lapse in communication and procedure adherence. The facility's grievance policy outlines specific steps for handling grievances, including completing a grievance form, which was not done in this case.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. This deficiency was identified during a review of the resident's records and an interview with the MDS Coordinator. The resident, a cognitively intact female, was admitted with serious medical conditions including diverticulitis with perforation and abscess, as well as an anxiety disorder. Despite these conditions, there was no evidence of a baseline care plan being completed in the electronic medical records. The MDS Coordinator confirmed the absence of a baseline care plan for the resident and acknowledged the risk of receiving a citation from the State due to this oversight. The facility's policy mandates the development and implementation of a person-centered care plan within 48 hours of admission, but this was not adhered to in this case, potentially compromising the delivery of effective and person-centered care to the resident.
Narcotic Count Discrepancy in Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, leading to a discrepancy in the narcotic count on the medication cart. The resident, a female with multiple medical conditions including diverticulitis, sepsis, and anemia, was prescribed Hydrocodone-Acetaminophen and Acetaminophen with codeine for pain management. However, the medication administration record showed inconsistencies in the narcotic count, with the narcotic log reflecting a mismatch between the count sheet and the actual number of tablets in the medication card. Interviews with the nursing staff revealed that the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) did not administer any pain medication to the resident, and the ADON confirmed that the narcotic count was correct during the shift change. However, the Director of Nursing (DON) discovered that the nurse on duty had mistakenly signed the wrong narcotic sheet, leading to the discrepancy. The facility's policy requires controlled substances to be accounted for at each shift change, but the charge nurse failed to identify and correct the inconsistency in a timely manner.
Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. This deficiency was identified when a resident, who required moderate assistance for toileting and ambulating, fell in the bathroom and was not properly assessed by the nursing staff. The resident, who had a history of arthritis, osteoporosis, and seizure disorder, was found on the toilet after reportedly falling while ambulating with a walker. Despite the resident's report of the fall, RN C did not perform a full assessment or notify the physician, as required by the facility's fall management policy. The incident occurred when the resident was found on the toilet by a CNA, who reported the fall to RN C. The resident had been medicated with Tylenol #3 shortly before the fall and initially denied pain. However, later that night, the resident's husband was called by the resident, who reported being in excruciating pain. The husband requested that the resident be sent to the hospital, where a CT scan revealed a right clavicle fracture. The facility's investigation into the incident revealed that RN C did not conduct a head-to-toe assessment or notify the physician, as she was unsure if the resident had actually fallen. Interviews with facility staff, including the DON, revealed that the nurse was responsible for assessing a resident after a fall, including conducting a full range of motion and pain assessment, and notifying the physician and family. The DON was unaware that RN C had not assessed the resident after the fall and emphasized the importance of thorough investigations to prevent recurrence. The facility's policy required that all falls, whether witnessed or unwitnessed, be treated as such, with appropriate assessments and notifications made.
Resident Left Unattended in Shower Chair Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents and injury for a resident who was dependent on staff for tub/shower transfers. The resident, who had a history of stroke, hemiplegia, and aphasia, was left unattended in a shower chair by a CNA. The CNA had wheeled the resident to the side of his bed, locked the wheels, and left to find assistance for transferring the resident back to bed. During this time, the resident fell out of the shower chair, resulting in a hematoma on his head and requiring hospitalization. The resident's care plan indicated he was at risk for falls due to impaired mobility, diabetes, incontinence, and decreased cognition. However, the care plan did not address fall risks related to shower chairs. The CNA involved in the incident admitted to leaving the resident unattended and acknowledged that this constituted neglect. The CNA stated that she was in a hurry and had another resident waiting, which contributed to her decision to leave the resident alone. Interviews with facility staff revealed a lack of consistent in-service training on neglect and the importance of not leaving residents unattended in shower chairs. The RN on duty at the time of the incident did not consider the situation as neglect, despite acknowledging the resident's inability to control his left side and history of sliding out of chairs. The facility's DON and Administrator recognized the incident as neglect, highlighting a failure to provide necessary supervision and assistance to prevent harm to the resident.
Failure to Implement Suicide Precautions for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental illness or psychosocial adjustment difficulty, specifically in the case of a resident who expressed suicidal ideation. The resident, who had a history of depression and severe cognitive impairment, expressed a desire to harm herself on one occasion. Despite this, the Licensed Vocational Nurse (LVN) on duty did not follow the facility's suicide policy, which required immediate notification of the Director of Nursing (DON), Administrator, and the implementation of suicide precautions. The LVN, identified as LVN O, did not notify the DON or the Administrator about the resident's suicidal statements. Instead, the LVN only informed the resident's family member, who was unable to assist due to personal health issues. The LVN also failed to implement the required 15-minute checks or other suicide precautions as outlined in the facility's policy. This lack of action left the resident at risk of self-harm, as the facility's policy was not followed, and the necessary interventions were not put in place. Interviews with other staff members revealed a lack of communication and awareness regarding the resident's suicidal ideation. The subsequent shift was not informed of the resident's statements, and the necessary precautions were not taken. The facility's policy required immediate action and communication with the appropriate personnel, which was not adhered to, resulting in a deficiency that placed the resident and potentially others at risk.
Removal Plan
- Resident #1 was assessed by psychiatry services and resident was not deemed a threat to herself, per psychiatry provider transfer to hospital not appropriate at this time and resident agreed.
- Social Services Director completed a suicide ideation assessment and resident was not deemed a threat to herself.
- Resident #1 will continue to follow up with psychiatry while remaining in the facility.
- A review of the facility activity report and the 24-hour reports were reviewed by the Director of Nursing/Designee to identify additional residents that have voiced suicidal ideation. None were identified.
- Licensed Nurses and Social Services Director will be re-educated by the Director of Nursing/Designee on suicidal precaution management.
- If a resident voices or indicates in some manner suicidal ideations, the licensed nurse will implement 1:1 supervision immediately and notify the Social Services Director.
- If a safe environment cannot be maintained with 1:1 supervision, the resident will be transported to an acute care setting for evaluation and treatment.
- The Social Services Director will complete the Columbia Suicide Severity Rating Scale in the medical record.
- Should the assessment reveal concerns, the Social Services Director will immediately notify the administrator, DON, and primary physician for further orders.
- Licensed Nurses not receiving this education will receive it prior to their next scheduled shift.
- The Director of Nursing/designee will review the 24-hour report and facility activity report in clinical morning meeting Monday - Friday to identify residents who have voiced or are indicating in some manner suicidal ideations and validate assessments and notifications were completed.
- This will be completed by the weekend supervisor on the weekends.
- Ad Hoc QAPI was held.
- The Medical Director was notified of the Immediate Jeopardy and contents of this plan.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor the rights of a resident who had a Do Not Resuscitate (DNR) order in place. The resident, an elderly female with multiple diagnoses including anxiety disorder, cognitive communication deficit, and chronic obstructive pulmonary disease, had a documented DNR status. Despite this, when the resident became unresponsive due to choking, the Licensed Vocational Nurse (LVN) on duty did not inform the Emergency Medical Services (EMS) of the resident's DNR status, leading to the initiation of full resuscitation efforts, including CPR, which lasted approximately 43 minutes. The incident occurred when the resident was found unresponsive and turning blue after choking on food. The LVN attempted to perform the Heimlich maneuver and called a Code Blue, but failed to communicate the resident's DNR status to the EMS upon their arrival. As a result, EMS proceeded with resuscitation efforts, including chest compressions and intubation, under the assumption that the resident was a full code. The resident was transported to the hospital where resuscitation efforts continued until the time of death was called. Interviews with facility staff revealed a lack of communication and adherence to protocol regarding the resident's DNR status. The LVN admitted to not informing EMS of the DNR due to the chaotic situation. Other staff members, including Certified Nursing Assistants (CNAs) and another LVN, were either unaware of the resident's DNR status or did not ensure that the information was communicated to EMS. The facility's policies and procedures for handling DNR orders and emergency situations were not followed, leading to the failure to respect the resident's end-of-life wishes.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of five residents, resulting in deficiencies related to the accurate acquiring, receiving, dispensing, and administering of medications. For Resident #1, the facility did not administer Clozapine, an antipsychotic medication, for two weeks due to issues with obtaining a REMS form and current lab results. This lapse led to increased symptoms of psychosis, including delusional thoughts and hallucinations, as reported by staff and documented in psychiatric assessments. Resident #2 did not receive several medications, including Buspirone, Gabapentin, and Trazadone, the day after admission due to unavailability. There was no documentation in the clinical chart indicating the medications were not available or what follow-up actions were taken by the facility. Similarly, Resident #3 did not receive multiple medications, such as Calcitriol and Eliquis, the day after admission, with no documentation of follow-up actions in the clinical chart. Resident #4 also experienced a lack of medication administration, including Carvedilol and Quetiapine Fumarate, the day after admission, with no documentation of follow-up actions. Resident #5 did not receive Flonase allergy spray for approximately two months since admission, with repeated documentation of the medication being unavailable and no follow-up actions recorded. Interviews with facility staff revealed issues with medication ordering and delivery processes, contributing to these deficiencies.
Inadequate Indication for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the prescription of Seroquel (quetiapine fumarate) for a resident without adequate indications for its use. The resident, a female with multiple medical diagnoses including metabolic encephalopathy, was admitted to the facility from a hospital where Seroquel was started. However, there was no diagnosis listed on the hospital transfer orders to justify the use of this antipsychotic medication. The facility's records indicated that the resident was administered Seroquel daily for a period without a proper diagnosis to support its use. Interviews with facility staff revealed systemic issues in the process of assigning diagnoses for medications. LVN F admitted to selecting pre-existing diagnoses from the resident's face sheet, even if they were not appropriate, due to limitations in the facility's procedures and the inexperience of new nurses. The ADON and MDS Coordinator also acknowledged that the process for determining and documenting the correct diagnosis for antipsychotic medications was flawed, with the responsibility often falling on the charge nurse or being corrected later by the physician or MDS Coordinator. The facility's policy on the use of psychotropic drugs emphasized the need for a comprehensive assessment and a specific diagnosis for the use of such medications. However, the policy was not adhered to in this case, as the resident's medical record did not show adequate documentation of a diagnosed condition warranting the use of Seroquel. This oversight placed the resident at risk for potential adverse effects from unnecessary medication use.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen's refrigerator and freezer. During an inspection, it was noted that a box of homestyle ring donuts and a box of turkey bacon were left open and exposed to air in the refrigerator. Similarly, in the freezer, a box of sweet yeast steakhouse roll dough was found open and exposed to air. Additionally, a cup of unidentified green-colored food and a piece of clear tape were found on the freezer floor. These conditions indicate improper food storage practices that could potentially lead to food contamination. The Dietary Supervisor, during an interview, stated that she conducted daily walk-throughs of the kitchen, including the refrigerator and freezer, to ensure proper food storage. She also mentioned performing weekly sanitation audits to maintain cleanliness, particularly on the freezer floor. Despite these measures, the observed deficiencies suggest lapses in maintaining the standards outlined in the facility's policy on food safety in receiving and storage, as well as the Food and Drug Administration Food Code. The failure to properly store food could expose residents to food-borne illnesses.
Failure to Accommodate Resident's Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as Resident #15, who was severely cognitively impaired and on isolation precautions for COVID-19. The resident had a history of multiple medical conditions, including heart failure, hypertension, and dementia, and was at risk of dehydration. On the day of the incident, the resident activated her call light to request hot tea to soothe her sore throat. However, the staff, including an LVN and a CNA, did not promptly respond to her request. The LVN, occupied with another task, asked the state surveyor to answer the call light and later informed the CNA to check on the resident. The CNA entered the room but did not fulfill the resident's request for hot tea and subsequently went on a break without providing the requested assistance. Interviews with the resident revealed that she felt ignored as she did not receive the hot tea she requested and only received a drink when her lunch tray was delivered. The DON confirmed that the expectation was for staff to respond to call lights and fulfill residents' needs, and acknowledged that the CNA should have provided the hot tea before going on break. The facility's policy on responding to call lights emphasized the importance of meeting residents' needs, which was not adhered to in this instance, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 968 citations issued within 25 miles in the last 12 months — including the 48 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 Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Mansfield | 1.7 mi | ★★★★★ | 0 | 0 |
| Mansfield Medical Lodge | 2.1 mi | ★★★★★ | 17 | 0 |
| Matlock Place Health & Rehabilitation Center | 3.8 mi | ★★★★★ | 10 | 2 |
| Arbrook Plaza | 7.5 mi | ★★★★★ | 12 | 0 |
| Town Hall Estates Arlington, Inc. | 8 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.