Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Town Hall Estates during CMS and state inspections, most recent first.
Several residents admitted with complex medical needs did not have baseline care plans completed within 48 hours, resulting in missing documentation of mobility and supervision requirements. This included a resident who suffered a fall with fractures and another who was found on the floor after being left alone during toileting, despite requiring moderate assistance. Staff interviews confirmed that baseline care plans were overlooked and not completed as required.
Two residents were admitted without completed fall risk assessments or baseline care plans, resulting in falls with injuries. Staff did not consistently identify or address the need for assistive devices or supervision, and post-fall protocols were not always followed, leading to Immediate Jeopardy.
PRN Lorazepam Lacked Required Stop Date: A resident with dementia, TBI, HF, and anxiety received PRN lorazepam for agitation, but the order was not discontinued after the required 14 days and no prescriber rationale for continuing it was documented. The care plan addressed anti-anxiety meds and monitoring for behaviors and adverse effects, while an LVN and the DON acknowledged the missing stop date and stated PRN psychotropic orders were supposed to have a 14-day limit per facility policy.
Missed Significant Change MDS After Hospice Admission: The facility failed to complete a Significant Change MDS within the required timeframe after a resident began hospice services. The resident had diagnoses including dementia, TBI, HF, and anxiety, and the care plan noted a declining condition with hospice involvement. The DON stated the MDS was missed and later caught, and that missing an MDS could affect the resident’s plan of care.
MDS Did Not Reflect Depression Diagnosis: A resident with dementia and moderately impaired cognition had a quarterly MDS that listed antidepressant use, but her active dx did not include depression. Record review showed her care plan linked Bupropion and Mirtazapine to depression, and an active order for Bupropion ER was written for depression. The MD confirmed the resident had depression, and the DON stated the facility failed to place depression under her active dx.
Failure to document rationale for no change after pharmacist GDR recommendation. A resident with dementia and depression-related antidepressant use was receiving Bupropion ER 300 mg daily when the consultant pharmacist recommended a trial dose reduction because no behaviors were documented. The MD responded “No Changes,” but the rationale for not reducing the dose was not documented in the resident’s medical record as required by facility policy.
Unnecessary Drug Regimen: Missing Indication for Midodrine. A resident with CHF, respiratory failure, HTN, severe kidney disease, type 2 DM, atrial fibrillation, edema, tachycardia, and tachypnea had an order for Midodrine 10 mg PO TID with meals that did not include a diagnosis or adequate indication for use. The MD stated the medication was intended to treat low BP and that the dose had been increased from 5 mg based on recent BP readings, but the order still lacked the diagnosis it was treating.
An unlocked medication cart assigned to an LPN was observed unattended in front of the nurse's station with medications accessible to residents. The LPN stated she had gone to tend to another resident and did not lock the cart back, and the DON confirmed the facility policy required medication carts to be locked and the computer screen blank when not in use.
The facility failed to maintain a clean ice machine and failed to ensure CNAs sanitized their hands between tray distributions and setup assistance during meal service. Staff were observed serving ice from an ice machine with brown residue, and CNAs passed trays without gloves or hand sanitizing between residents. The DS stated staff were expected to sanitize hands between each tray distribution, and there was no sanitizing station in the dining area.
Incomplete Diagnosis Documentation for Resident on Antidepressant Therapy: A resident’s EHR active diagnoses list did not include depression even though her MDS, care plan, and medication orders showed treatment with antidepressants for depression. The MD stated the resident had major depressive disorder and was doing well on the current dose of Bupropion, while the DON confirmed the diagnosis was present but omitted from the active diagnoses list.
A CNA failed to maintain infection control during incontinent care when she dropped a clean brief onto the floor and then placed it on a resident instead of discarding it. The resident had severe cognitive impairment, was always incontinent, and was being treated for a UTI with antibiotics at the time. The DON stated the brief should have been replaced because it could pick up bacteria from the floor and transfer onto the resident.
A resident with severe cognitive impairment and a history of Alzheimer's, stroke, and other conditions was able to exit the facility through a door with a non-functioning wander guard alarm and no working contact alarm. The facility had been aware for years that three exit doors were not working with the alarm system, but repairs were not completed. Staff did not notice the resident's absence until he was seen outside, and interviews confirmed that malfunctioning alarms and lack of monitoring contributed to the incident.
A facility failed to follow skin assessment orders for two residents and did not provide timely incontinent care for another resident. Despite orders for weekly skin assessments, only sporadic checks were conducted, leading to unmonitored skin issues. Additionally, a resident with dementia was left in urine-saturated bedding for over two hours without receiving necessary care, contrary to facility policy requiring checks every two hours.
A facility failed to provide necessary grooming and hygiene services for a diabetic resident who was unable to perform activities of daily living independently. The resident had overly long, thick, and jagged toenails, which were not maintained by the staff, despite the facility's policy and the resident's medical condition requiring such care. Interviews with staff confirmed the oversight, and there was no documentation of nail care in the resident's chart.
The facility was found to have deficient food storage and labeling practices, with multiple instances of improperly stored and unlabeled food items in the kitchen. Staff interviews revealed that although training had been provided, lapses occurred due to being busy. The dietary manager acknowledged responsibility and conducted weekly audits, but issues persisted. No residents were reported to have fallen ill, but the facility had previously received a citation for similar issues.
The facility failed to provide care according to professional standards, resulting in three residents experiencing falls without proper assessments or documentation. One resident with dementia fell and sustained injuries due to inadequate assistance, while another with impaired cognition suffered fractured ribs from an unwitnessed fall. A third resident was hospitalized with a scapula fracture after a fall. These deficiencies led to an Immediate Jeopardy situation, which was later addressed.
A resident in a LTC facility fell out of bed and sustained injuries due to a failure to provide the required two-person assistance during incontinence care. The care plan specified the need for two staff members due to the resident's high fall risk. Post-fall procedures were inadequately followed, with insufficient documentation and delayed reporting of the incident. The facility's response and adherence to fall protocols were lacking, contributing to the deficiency.
Three residents in an LTC facility did not receive necessary hygiene care as per their care plans, with inconsistencies in shower documentation. A resident with amputations was observed in stained clothing, another with a history of stroke had not received scheduled showers, and a third resident reported missed showers due to staffing issues. Staff interviews revealed confusion in documentation procedures.
The facility failed to ensure proper labeling and storage of drugs and biologicals, with issues in temperature monitoring of the medication refrigerator and loose pills in a medication cart. The middle hall refrigerator's temperature was not checked on several dates, and insulin syringes were stored without assurance of proper temperature. The East Hall medication cart contained loose pills, indicating a lack of organization and security. Staff interviews revealed confusion about responsibilities, with the night shift nurse responsible for temperature checks. The DON and ADON acknowledged these failures, emphasizing the importance of proper medication storage.
The facility failed to maintain accurate records of residents' bathing schedules, leading to inconsistencies in care. A resident was observed in the same stained clothing on consecutive days, while another reported not receiving showers as scheduled. Staff interviews revealed confusion in documentation processes, with expectations not being met.
A facility failed to include pain management in a resident's care plan, despite the resident having a diagnosis of low back pain and receiving pain medications. The resident experienced significant pain, and although the nursing staff administered medication when requested, the care plan lacked focus, goals, or interventions for pain management. Facility staff acknowledged the oversight, which was contrary to the facility's policy requiring comprehensive, resident-centered care plans.
The facility's kitchen failed to store and label food items according to professional standards, as observed during a survey. Items such as hash brown patties, meat products, and milk were found without proper labeling or dating. Staff interviews revealed a lack of adherence to the facility's food labeling and storage policy, which aligns with the 2022 FDA Food Code. This deficiency could risk residents' health due to potential foodborne illness.
The facility failed to post daily nurse staffing information and maintain records for the required period. On two observed days, staffing details were either missing or incomplete, and the facility did not retain staffing data from December 2022 to June 2024. Interviews revealed a lack of awareness among staff about the requirements for posting and retaining staffing information.
Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans for several residents within 48 hours of admission, as required by policy. Specifically, two residents admitted with significant medical conditions did not have baseline care plans that addressed their mobility abilities. One resident, admitted with diagnoses including urinary tract infection, hypoxemia, anxiety, and heart failure, experienced a fall resulting in multiple fractures and bruising. The medical record review showed that the baseline care plan for this resident was not completed, and staff interviews confirmed that the care plan was overlooked. Another resident, admitted for hospice respite with diagnoses such as malignant neoplasm of the pancreas, neoplasm-related pain, protein-calorie malnutrition, and elevated blood pressure, also did not have a completed baseline care plan. This resident was found on the bathroom floor with a laceration above the eyebrow after attempting to use the restroom with only partial assistance. The admission MDS indicated the need for moderate assistance with toilet transfers, but the baseline care plan was not completed to reflect these needs. Staff interviews revealed that the resident required active assistance during toileting and should not have been left alone, but this was not documented in a care plan. Additional residents were also found to have incomplete or missing baseline care plans upon review. One resident with a history of stroke, hemiplegia, and moderately impaired cognition had documentation of an initial care plan conference, but the baseline care plan was not fully completed. Another resident with multiple chronic conditions, including congestive heart failure and severe kidney disease, had an undated baseline care plan with blank sections for social services needs and goals. Staff interviews confirmed that the responsibility for completing baseline care plans was with the DON and ADON, but these were overlooked, and the importance of these plans in preventing falls and meeting residents' needs was acknowledged.
Failure to Complete Fall Risk Assessments and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that each resident received adequate supervision and assistive devices to prevent accidents. Two residents were admitted without completed fall risk assessments, as key sections such as gait/balance, medications, and vision were left unmarked. Baseline care plans for both residents were also not completed, and staff were not fully aware of the residents' needs for assistive devices or the level of supervision required. In one case, a resident with multiple diagnoses, including heart failure and hypoxemia, experienced a fall resulting in significant injuries, including rib and clavicle fractures. The fall risk assessment for this resident was incomplete, and there was confusion among staff regarding the use of assistive devices, with the resident using furniture for balance and a cane brought from home rather than a facility-provided walker. Another resident, admitted for hospice respite care with diagnoses including pancreatic cancer and malnutrition, also had an incomplete fall risk assessment and no baseline care plan. This resident was found on the bathroom floor with a head laceration after being left alone on the toilet by a CNA, despite requiring moderate assistance for transfers. The CNA had instructed the resident to use the emergency call light for assistance, but the resident experienced a syncopal episode and was transported to the emergency room. Staff interviews revealed inconsistent understanding of the residents' fall risks and the required level of supervision, with some staff believing that the presence of family or the resident's cognitive status reduced the need for fall precautions. Further review indicated that post-fall protocols, such as neurological checks and reporting, were not consistently followed. In one instance, an agency nurse failed to conduct a neuro check or post-fall evaluation and did not communicate the fall to the next shift. Facility policy required identification and documentation of fall risk factors and communication with residents and families, but these steps were not completed for the affected residents. The deficiencies led to the identification of Immediate Jeopardy due to the lack of timely and complete fall risk assessments, incomplete care plans, and inadequate supervision and follow-up after falls.
PRN Lorazepam Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure that Resident #25 was free from a chemical restraint not required to treat medical symptoms when the resident’s PRN lorazepam order was not discontinued after 14 days and no rationale was documented for continuing the medication. Resident #25 was admitted with diagnoses including unspecified dementia, traumatic brain injury, heart failure, and anxiety. The care plan identified use of anti-anxiety medications related to anxiety disorder and included monitoring for target behaviors such as pacing, wandering, disrobing, inappropriate responses to verbal communication, and violence or aggression toward staff or others, along with monitoring for adverse reactions to anti-anxiety therapy. Record review showed a physician order for lorazepam 0.5 mg by mouth every 4 hours as needed for agitation with a start date of 08/03/2025. The medication administration record showed the resident received lorazepam on 08/07/2025, 08/08/2025, and 08/16/2025. During interview, an LVN stated she was not sure why the PRN lorazepam did not have a stop date and acknowledged that PRN psychotropic medication should have a stop date. The DON stated staff were aware that PRN psychotropic medications had a 14-day stop date, that the stop date was sometimes overlooked, and that the facility needed a system to double check that a stop date was added. Facility policy stated PRN orders for psychotropic drugs are limited to 14 days unless the prescriber documents a rationale and duration for extension.
Missed Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment within 14 days after it determined, or should have determined, that Resident #25 had a significant change in physical or mental condition. Resident #25 was admitted to the facility with diagnoses including unspecified dementia, traumatic brain injury, heart failure, and anxiety. The resident’s comprehensive care plan reflected that the resident was receiving hospice care related to senile degeneration and a declining condition, with interventions for facility nursing staff to coordinate medical care with hospice nursing staff and for hospice to follow up with facility and family concerns. Record review showed a Significant Change in Status MDS dated later than the hospice admission, and it reflected that Resident #25 was receiving hospice services while a resident. During interview, the DON stated the facility has a remote MDS coordinator and that things are sometimes missed; she identified the Significant Change MDS for Resident #25 as one that had been missed and later caught. The DON also stated that missing an MDS assessment could affect the resident’s plan of care. The facility policy required completion of the MDS within 14 days after admission and within 14 days after it is determined that the resident has had a significant change in physical or mental condition.
MDS Did Not Reflect Resident’s Depression Diagnosis
Penalty
Summary
The facility failed to ensure that Resident #26’s assessment accurately reflected her status when her quarterly MDS assessment dated 5/16/2025 did not document depression as an active diagnosis. Resident #26 was a [AGE]-year-old female admitted on [DATE] with diagnoses including high blood pressure, diabetes mellitus, hyperlipidemia, non-Alzheimer’s dementia, adult failure to thrive, muscle weakness, lack of coordination, GERD, muscle wasting and atrophy, and ataxia. Her MDS indicated she was receiving an antidepressant, and her BIMS score was 10, showing moderately impaired cognition. Record review showed Resident #26’s care plan, last revised 6/11/2025, identified use of Bupropion and Mirtazapine related to depression. However, her active diagnoses report as of 08/21/2025 did not list depression, even though her active orders included Bupropion ER 300 mg daily for depression. In interviews, the MD stated the resident had a diagnosis of depression and was doing well on antidepressant medication, and the DON stated the facility failed to place depression under her active diagnoses.
Failure to Document Rationale for No Change After Pharmacist GDR Recommendation
Penalty
Summary
The facility failed to ensure that all medications reviewed by the licensed pharmacist were reported to the attending physician and that, when no change was made to a medication, the physician documented the rationale in the resident’s medical record for Resident #26. The deficiency involved the physician’s response to a pharmacist recommendation for a gradual dose reduction of Bupropion HCl ER 300 mg daily, which was ordered for depression. Resident #26 was a 92-year-old female with diagnoses including high blood pressure, diabetes mellitus, hyperlipidemia, non-Alzheimer’s dementia, adult failure to thrive, muscle weakness, lack of coordination, GERD, muscle wasting and atrophy, and ataxia. Her quarterly MDS indicated she was taking an antidepressant and had a BIMS score of 10, showing moderately impaired cognition. Her care plan listed Bupropion and Mirtazapine for depression, and her active diagnoses report did not list depression as of 08/21/2025. The pharmacist’s 04/07/2025 consultation report stated that the resident was receiving Bupropion-ER 300 mg daily and recommended considering a reduction to 150 mg daily on a trial basis because no behaviors were being documented. The medication consultation report showed it was sent to the physician on 04/07/2025, and the physician response was “No Changes,” signed on 04/10/25. During interview, the MD stated he would document his review, the action taken, and a rationale if no action was taken on the individual printed sheets provided by the pharmacist, and he stated his rationale for not reducing the dose was that the resident was doing well and he did not want an increase in depressive episodes. The facility policy required the physician to provide and/or document a rationale when a medication was not modified and stated that psychotropic medications should receive gradual dose reductions unless clinically contraindicated.
Unnecessary Drug Regimen: Missing Indication for Midodrine
Penalty
Summary
The facility failed to ensure that Resident #44’s drug regimen was free from unnecessary drugs by not having an adequate indication documented for Midodrine HCl 10 mg. Resident #44 was an elderly female admitted to the facility with diagnoses including CHF, respiratory failure, HTN, severe kidney disease, type 2 DM, iron deficiency, elevated WBC count, atrial fibrillation, edema, tachycardia, and tachypnea. Her baseline care plan had blank entries under Social Services needs/goals, and the order dated 8/19/2025 for Midodrine 10 mg by mouth three times daily with meals did not list a diagnosis for use. During interview, the MD stated he first saw Resident #44 on 8/19/2025 and that Midodrine was needed to combat her low blood pressure. He also stated the prior dose had been 5 mg and was increased because of recent blood pressures, and that the order should have included the diagnosis it was treating. The facility policy titled Medication Monitoring stated each resident’s drug regimen is reviewed to ensure it is free from unnecessary drugs, including drugs without adequate indications for use.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored properly for 1 of 2 medication carts reviewed. During continuous observation on 08/19/2025 at 1:04 PM, the medication cart assigned to LVN E and located in front of the nurse's station on the Middle Hall was unattended and unlocked for approximately 3 minutes, and medications were accessible to residents. No residents were observed near the cart at that time. During an interview on 08/19/2025 at 1:07 PM, LVN E stated she had been attending to another resident and did not lock the cart back when she went to tend to another resident. She stated that a negative outcome of leaving the cart unlocked was that a resident could get into it and get medication, and that she was required to ensure the cart was locked and the computer was blank before leaving it unattended. The DON stated in an interview on 8/19/2025 at 1:56 PM that the policy required the medication cart to be locked and the computer screen blank when not in use. Record review of the facility policy titled, Storage of Medications, dated April 2007, stated that all drugs and biologicals shall be stored in a safe, secure, and orderly manner and that carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
Food Safety Lapses in Ice Machine Cleaning and Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to store, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed. During an observation on 08/19/2025 at 9:00 AM, the only ice machine in the kitchen had brown residue in the upper back area directly above the ice, and staff were observed serving residents drinks with ice from that machine. On 08/21/2025 at 2:00 PM, the same ice machine again had brown residue on the upper back part of the machine. Record review showed the facility had hired a maintenance worker from a third-party vendor for routine maintenance, and the invoice noted the ice machine and bin were cleaned, inspected, descaled, and sanitized on 08/21/2025. The facility also failed to ensure staff sanitized their hands between tray set-ups and tray distribution. On 08/19/2025 at 12:00 PM, three CNAs assisting with meal service did not sanitize their hands between giving residents their trays. On 08/20/2025 at 12:00 PM, three CNAs were observed passing residents' trays without gloves and without sanitizing between tray delivery and setup assistance. There was no sanitizing station in the dining area, and the CNAs used a single sink in the dining area to wash their hands before starting tray service. In interview on 08/21/2025 at 8:47 AM, the DS stated that staff assisting with handing out trays were expected to sanitize their hands between each tray distribution and that housekeeping refilled the sanitation stations in the dining room.
Incomplete Diagnosis Documentation for Resident on Antidepressant Therapy
Penalty
Summary
The facility failed to maintain Resident #26’s medical record in accordance with accepted professional standards because her diagnosis of depression was not listed in the active diagnoses section of the EHR. Record review showed that Resident #26 was a [AGE]-year-old female admitted with multiple diagnoses including high blood pressure, diabetes mellitus, hyperlipidemia, non-Alzheimer’s dementia, adult failure to thrive, muscle weakness, lack of coordination, GERD, muscle wasting and atrophy, and ataxia. Her quarterly MDS indicated she was receiving an antidepressant and had a BIMS score of 10, showing moderately impaired cognition. Her comprehensive care plan identified use of antidepressant medications, Bupropion and Mirtazapine, related to depression, and her orders showed Bupropion HCl ER 300 mg daily for depression. The active diagnoses report dated 08/21/2025 did not list depression. During interview, the MD stated he had documented his review of pharmacist GDR recommendations on the consultant sheets and said Resident #26 was doing well on the current dose of Bupropion, with a diagnosis of major depressive disorder noted in his notes. The DON stated the resident did have a diagnosis of depression and was being treated with an antidepressant, but it was not listed in the active diagnoses.
Infection Control Failure During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA B applied a clean brief to Resident #32 after the brief had been dropped onto the floor during incontinent care. During observation on 8/20/2025 at 3:35 PM, CNA B was seen checking and changing Resident #32's brief, dropped the clean brief onto the floor beside the bed, picked it up, and placed it on the resident. CNA B later stated that after dropping the brief, she should have gotten a new one because of cross contamination, but she was distracted by conversation with the resident's family members and did not think about what had happened. Resident #32 was an [AGE] year-old female admitted with multiple diagnoses including CAD, HTN, orthostatic hypotension, GERD, renal insufficiency/failure, DM, hyponatremia, hyperlipidemia, thyroid disorder, arthritis, non-Alzheimer's dementia, Parkinson's disease, seizure disorder, and depression. Her MDS indicated she was always incontinent and had a BIMS score of 02, showing severely impaired cognition. Her care plan included checking her at least every 2 hours for incontinence and washing, rinsing, and drying soiled areas. Records also showed she was being treated for a UTI with antibiotics at the time of the event. The DON stated that the brief should have been discarded and replaced because it could pick up bacteria from the floor and transfer onto the resident.
Failure to Repair Door Alarms Leads to Resident Elopement
Penalty
Summary
The facility failed to identify and eliminate known and foreseeable accident hazards in the environment, specifically by not repairing malfunctioning door alarms for several years. Three exit doors, including the one used during the incident, were not functioning with the wander guard alarm system, and one of these doors also lacked a working contact (noise) alarm. The facility was aware of these issues, as confirmed by interviews with the maintenance director and DON, but repairs were not completed, and there was no clear documentation or follow-up on previous repair proposals. The malfunctioning doors provided access to the outside of the building, and the lack of effective alarms meant that staff were not alerted when a resident exited the facility. A male resident with Alzheimer's disease, a history of stroke, dysphasia, heart failure, a pacemaker, and lack of coordination was admitted with significant cognitive impairment, as indicated by a BIMS score too low to complete the assessment. His care plan included interventions for risk of elopement, such as ensuring the wander guard was working, and he had an order for staff to monitor the wander guard device every shift. Despite these interventions, the resident was able to exit the facility through a basement egress door without triggering an alarm. Video surveillance showed the resident leaving the building, crossing parking lots, and walking along a busy street before being returned by a staff member who saw him outside. The facility was unaware of his absence until he was seen by staff outside the building. Staff interviews revealed that the wander guard system had not been working on three doors for years, and the contact alarm on the door used during the elopement was also broken at the time of the incident. The maintenance director was responsible for weekly checks but was unsure why repairs had not been completed. The administrator was unaware that the door was not working, and there was no policy for continuous camera monitoring. Staff also reported that frequent alarms from other doors had become background noise, leading to alarms being ignored. The facility's policies required identification and mitigation of hazards, including malfunctioning equipment and disabled alarms, but these were not followed, resulting in the resident's elopement.
Failure to Follow Skin Assessment Orders and Provide Incontinent Care
Penalty
Summary
The facility failed to ensure that skin assessment orders for two residents were followed. Resident #1, a female with dementia and schizoaffective disorder, had an order for weekly skin assessments starting from December 2024. However, only four skin assessments were conducted between December 2024 and March 2025, despite the resident developing a facility-acquired skin issue in March 2025. Similarly, Resident #2, a female with blindness and diabetes, had an order for weekly skin assessments from February 2025, but only one assessment was recorded. Both residents had facility-acquired skin issues that were not adequately monitored or documented as per the orders. The facility also failed to provide adequate incontinent care for Resident #3, a female with metabolic encephalopathy and dementia. On March 6, 2025, the resident was observed in her room with bedding saturated with urine. Despite being checked by a CNA multiple times, the resident was not provided with incontinent care for over two hours. The CNA acknowledged that the resident was a heavy wetter and required more frequent checks, but failed to change the resident's brief during the observed period. Interviews with facility staff, including CNAs and LVNs, revealed that the facility's policy required residents to be checked every two hours for incontinence. However, this policy was not adhered to, particularly for residents who could not communicate their needs, such as Resident #3. The Director of Nursing confirmed that skin assessments and incontinent care were not conducted as required, which could lead to skin breakdown and other complications.
Failure to Provide Necessary ADL Services for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living independently, specifically in maintaining proper grooming and personal hygiene. The resident, a male with a history of chronic pain, heart attack, cerebral infarction, and Type 2 diabetes, was observed with yellowish, thick, and overly long toenails with uneven jagged edges. Despite the resident's inability to trim his own toenails due to his diabetic condition and limited mobility, the facility did not ensure that his toenails were properly maintained, which could lead to skin tears and infection. Interviews with facility staff, including LVNs and the DON, confirmed that the resident required toenail care and that the nurses were responsible for providing this care, especially for diabetic residents. However, there was no documentation in the resident's chart indicating that he was receiving the necessary nail care. The facility's policy on activities of daily living stated that residents unable to perform these activities independently should receive appropriate support and assistance, but this was not adhered to in the case of the resident, leading to the deficiency.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitation, as observed during a survey of the kitchen. The survey revealed multiple instances of improperly stored food items, including an open bag of cumin without a date, containers of applesauce and prunes with outdated labels, and a tray of partially frozen hotdogs left outside the refrigerator. Additionally, there were unlabeled and undated items such as milk, sliced cheeses, lunch meat, potatoes, hash browns, and okra found in the walk-in fridge and freezer. Interviews with the dietary manager (DM) and staff confirmed that these items should have been labeled and dated, and that the facility had previously received a citation for similar issues. Staff interviews indicated that they had received training on proper food storage but admitted to lapses due to being busy. The DM acknowledged responsibility for ensuring proper food storage and mentioned conducting weekly audits, although issues persisted. The assistant director (AD) and director of nursing (DON) also recognized the importance of proper food storage to prevent foodborne illnesses, although no residents were reported to have fallen ill. The facility's policy on food labeling and dating was reviewed, but it was undated and did not appear to be effectively implemented.
Failure to Conduct Assessments and Document Falls
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This deficiency was identified for three residents who experienced falls and subsequent injuries. The facility did not conduct necessary assessments or document the incidents properly, which led to an Immediate Jeopardy (IJ) situation. Resident #1, a female with dementia and a history of falls, experienced a fall on 05/06/24. The facility failed to conduct a fall assessment or skin assessment following the incident. Additionally, the care plan required a two-person assist for bed mobility, which was not adhered to, resulting in the resident slipping out of bed and sustaining an abrasion and bruising. The facility did not document the fall or conduct follow-up assessments, and the resident's family later requested an ER evaluation due to visible bruising. Resident #2, with severely impaired cognition and a history of falls, had an unwitnessed fall on 06/23/24, resulting in fractured ribs. The facility did not document the fall or conduct a fall assessment. Similarly, Resident #4, who required substantial assistance, fell and was sent to the hospital with a scapula fracture. The facility failed to document the fall and complete necessary assessments. These failures in documentation and assessment led to the identification of an Immediate Jeopardy situation, which was later removed after corrective actions were initiated.
Failure to Provide Adequate Assistance and Supervision
Penalty
Summary
The facility failed to ensure that Resident #1 received the required two-person assistance during incontinence care, as specified in her care plan. This oversight occurred when CNA D provided care independently, resulting in the resident falling out of bed and sustaining an abrasion on her back and bruising on her face. The resident's care plan clearly indicated the need for extensive assistance by two staff members for bed mobility, personal hygiene, and toileting due to her high risk for falls, confusion, and impaired balance. Following the incident, there was a lack of appropriate follow-up and documentation. The progress notes from 05/07/24 through 05/09/24 did not reflect any post-fall follow-up, and no fall assessments were documented in the assessment log from 05/06/24 through 05/15/24. Additionally, the MDS Nurse did not update the care plan with new interventions after the fall, and there was no evidence of a fall log being maintained. Interviews with staff revealed inconsistencies in the understanding and execution of post-fall procedures, including the completion of neuro checks and thorough assessments. The facility's response to the fall was inadequate, as evidenced by the delayed reporting of the incident and the lack of immediate medical evaluation for the resident's injuries. The ADM did not initially report the fall because it was witnessed, and the fall was only reported after bruising appeared. The primary MD expressed concern over the absence of neuro checks, which are standard when a resident hits their head during a fall. The facility's documentation practices and adherence to fall protocols were insufficient, contributing to the deficiency in providing adequate supervision and assistance to prevent accidents.
Inconsistent Hygiene Care and Documentation for Residents
Penalty
Summary
The facility failed to ensure that three residents received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #8, a female with multiple health conditions including chronic viral hepatitis C, diabetes, and amputations, was observed wearing the same stained shirt on consecutive days and had food particles around her mouth and on her hands. Her care plan required total dependence on staff for showering three times a week, but records showed inconsistencies in the documentation of her showers, with discrepancies between the shower log and shower sheets. Resident #12, a female with a history of stroke, diabetes, and other health issues, was also dependent on staff for showers and transfers. Her care plan specified showering on certain days, but documentation was inconsistent, with discrepancies between the shower log and shower sheets. Observations revealed that she was wearing the same shirt on consecutive days and had not received a shower as scheduled. Despite her positive comments about the care received, she could not recall when she last had a shower. Resident #13, a female with chronic pain syndrome, depression, and other health conditions, was dependent on staff for bathing and personal hygiene. Her care plan required showers three times a week, but she reported not receiving them as scheduled due to staffing issues. Documentation inconsistencies were noted between the shower log and shower sheets. Observations confirmed her reports, as she was found in bed with a sheet over her face, indicating discomfort. Interviews with staff revealed confusion and lack of adherence to documentation procedures, contributing to the deficiencies in care.
Medication Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as well as maintaining appropriate temperature controls for medication storage. Specifically, the middle hall medication refrigerator was not monitored for temperature on multiple dates, and insulin syringes were stored inside without assurance of proper temperature maintenance. Interviews with staff revealed confusion about responsibility for temperature monitoring, with the night shift nurse ultimately identified as responsible. The Director of Nursing (DON) acknowledged that the lack of temperature monitoring did not meet expectations and could result in medications not working properly. Additionally, the East Hall medication cart was found to contain three loose pills, indicating a failure to maintain organized and secure medication storage. The Licensed Vocational Nurse (LVN) responsible for the cart admitted that nurses should check for expired or loose medications and keep the carts clean, ideally on a weekly basis. The Assistant Director of Nursing (ADON) and DON both emphasized the importance of proper medication storage and organization, noting that loose pills could lead to missed doses or incorrect medication administration. The facility's policy on medication storage requires drugs and biologicals to be stored in their original packaging and for nursing staff to maintain clean and safe storage areas.
Inconsistent Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for residents, specifically regarding their bathing and showering schedules. For Resident #8, there was a discrepancy between the shower log in the PCC and the shower sheets, with records showing different dates for when showers were given or refused. Observations revealed that the resident was wearing the same stained clothing on consecutive days, indicating a lack of proper hygiene care. The resident was unable to answer questions, further complicating the assessment of her care. Resident #12 also experienced inconsistencies in her shower documentation. The records in the PCC did not match the shower sheets, and the resident reported not receiving a shower as scheduled. Despite her cognitive impairment, she expressed satisfaction with the care but could not recall her last shower. Observations showed her in the same clothing on consecutive days, suggesting a lapse in personal hygiene care. Resident #13's records also showed discrepancies between the PCC and shower sheets. The resident reported not receiving showers as scheduled due to staffing issues, and her room had multiple reminders of her shower schedule. Interviews with staff revealed confusion and inconsistency in documenting and filing shower records, with expectations for documentation not being met. The facility's policy on personal care documentation was not adhered to, leading to incomplete and inaccurate records.
Deficient Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the care plan did not address the resident's need for pain management, despite the resident having a diagnosis of low back pain and receiving both scheduled and as-needed pain medications. This oversight was identified during a review of the resident's care plan, which lacked focus, goals, or interventions for pain management, even though the resident's pain management needs were documented in the physician's orders and triggered on the MDS assessment. The resident, an elderly female with a history of coronary artery disease, heart failure, Alzheimer's disease, and low back pain, was observed to experience pain and discomfort. During observations, the resident was seen grimacing and reported a pain level of 8, although she acknowledged that the nursing staff were responsive in administering pain medication when requested. Interviews with facility staff, including the MDS Nurse and the Director of Nursing (DON), revealed that the interdisciplinary team (IDT) was responsible for updating care plans, and the MDS Nurse was expected to ensure that care plans reflected the resident's needs as identified in the MDS assessment. The facility's policy required that each resident have a resident-centered care plan developed and reviewed by the IDT, with participation from the resident or their representative. The policy also stipulated that a registered nurse was responsible for the formulation and implementation of nursing care plans, while other disciplines were responsible for non-nursing care plans. However, the failure to include pain management in the resident's care plan indicated a lapse in adherence to this policy, potentially affecting the resident's quality of life and care.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitation in their kitchen, as observed during a survey. Several food items, including hash brown patties, irregularly shaped meat products, and opened containers of whole milk and Lactaid whole milk, were found without proper labeling or dating. Additionally, a large metal pan containing an orange substance resembling a gelatin dessert was not labeled or dated. These observations indicate a lack of compliance with the facility's policy for labeling and storing food, which requires time and temperature-sensitive foods to be labeled, dated, and refrigerated at 41 degrees F or less, with a discard period of 4-5 days if not consumed. Interviews with staff members revealed a lack of awareness and adherence to the facility's food labeling and storage policy. One staff member admitted to not having read the policy, while another acknowledged the importance of proper labeling and storage to prevent foodborne illness and ensure food freshness. The facility's undated policy, which aligns with the 2022 FDA Food Code, outlines the procedures for labeling and storing food, emphasizing the need to follow manufacturer's storage instructions and dates for commercially prepared foods. The failure to comply with these standards could place residents at risk of foodborne illness.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily and included the total number and actual hours worked by both licensed and unlicensed nursing staff. This deficiency was observed on two specific days, 6/25/24 and 6/26/24, where the required staffing information was either missing or incomplete. Observations on 6/25/24 revealed that no staffing information was posted at 9:35 AM and 10:23 AM, and when a Daily Staffing Sheet was posted at 12:33 PM, it lacked the necessary details. On 6/26/24, no staffing information was posted at 10:15 AM. Interviews with the Director of Nursing (DON) and a Certified Nursing Assistant (CNA) responsible for posting the information revealed a lack of awareness regarding the specific requirements for the staffing form and the retention policy for these records. Additionally, the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months, as required by state law. The facility did not retain staffing data from December 2022 through June 26, 2024. Interviews with the Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed that they were unaware of the retention requirements and the specific information that needed to be included on the staffing form. The facility's policy on posting direct care daily staffing numbers was not followed, which could potentially place residents and visitors at risk of not knowing the current staffing levels and not being able to request the staffing data for the last 18 months.
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 32 citations issued within 25 miles in the last 12 months — including the 1 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 Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Hillsboro | 0.5 mi | ★★★★★ | 15 | 0 |
| Avir At Itasca | 10.5 mi | ★★★★★ | 5 | 0 |
| West Rest Haven | 13.5 mi | ★★★★★ | 5 | 1 |
| Whitney Nursing And Rehabilitation Center | 13.9 mi | ★★★★★ | 2 | 0 |
| Renaissance Rehabilitation And Healthcare Center | 16.6 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.