Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Treviso Transitional Care during CMS and state inspections, most recent first.
Failure to Report and Assess an Unwitnessed Fall: A resident with unsteadiness, poor coordination, and a history of falls was left on the toilet, later tried to transfer back to her wheelchair, and ended up on the floor. Two CNAs helped her back to bed but did not notify nursing, so no nurse assessment was completed at the time. The resident later reported back pain and hospital records showed an L1 compression fracture.
A facility failed to maintain a safe, clean, comfortable, and homelike environment when one resident’s room floor had dust, debris, and hardened white substance, and three residents had soiled bed linens that were not changed after showers or incontinent episodes. The residents involved had significant medical and cognitive needs, including dementia, CVA, CKD, HF, asthma, dysphagia, and dependence on staff for ADLs. Staff interviews confirmed CNAs were responsible for showers and linen changes, and the DON and Administrator expected these tasks to be completed and verified.
A resident with DM and severe cognitive impairment had repeated grievances about meals being served late, including dinner arriving very late and sometimes cold. The grievance log showed multiple resident council complaints about late meal service, and the family reported trays were often delayed when the resident ate in his room, raising concern about low blood sugar. The DON and Administrator acknowledged ongoing meal-timing complaints and that grievances were not being resolved promptly.
Incomplete care plans left several resident needs uncaptured in the plan of care. A resident with diabetes had insulin orders and glucose monitoring, but diabetes was not coded on the MDS or care planned. Another resident’s bathing preference was not included despite requests for showers, and a resident using a wheelchair safety belt had no restraint care plan or monitoring interventions. Two rehab residents had swallowing issues and active discharge plans on MDS, but those needs were not reflected in the care plans, and one resident on fluid restriction still had a water pitcher at the bedside.
Respiratory Care Orders Not Followed: Multiple residents with COPD, chronic respiratory failure, CHF, and tracheostomy status did not receive respiratory care as ordered. A resident’s O2 concentrator was set below the ordered rate, another resident’s trach order did not document the tube type, size, configuration, or cuff status, one resident’s O2 was set at the wrong liters and was connected to a cylinder near refill, and another resident’s O2 was set above the ordered rate while a nebulizer mask was left out of a bag when not in use. Staff stated nurses were responsible for following the ordered O2 settings, monitoring tanks, maintaining trach documentation, and storing nebulizer equipment properly.
A facility failed to assist 3 residents with routine dental care and failed to complete follow-up on dental referrals. One resident with broken implants reported difficulty eating and wanted repair, another reported tooth pain and said no one had followed up on her dental needs, and a third wanted dentures but said he never received updates. The SW said she handled dental referrals and follow-ups, but could not provide documentation of communication after the referrals, and the DON and Admin said the SW was responsible for these tasks.
Meal choices were not consistently honored for four residents with therapeutic diets and eating assistance needs. Residents reported receiving the wrong meals or only getting their ordered food part of the time, while CNAs, dietary staff, and nursing staff acknowledged that meal tickets were sometimes not followed and residents sometimes complained about incorrect food being served.
A resident with an indwelling urinary catheter and moderate cognitive impairment had a drainage bag observed on the floor and later dragging under his wheelchair. In the laundry room, a HSK/Laundry Supervisor folded clean blankets while letting them touch the floor. On a hall ice cooler, a CNA filled a resident’s cup directly over the cooler, spilling water into the ice supply and continuing to serve ice to residents.
Resident privacy and dignity were not maintained during catheter-related care for two residents. One resident’s catheter drainage bag privacy flap was left bunched up so the urine was visible while he was in his room and later in the lobby. Another resident was exposed during catheter care when two CNAs entered without knocking, left the privacy curtains open, and did not keep him covered while his roommate was present.
A resident with stroke-related weakness, chronic pain, and limited mobility reported new left foot pain that therapy relayed to nursing, but the NP/MD was not clearly notified at the time and the pain was not documented in nursing notes until after surveyor intervention. The resident said the pain prevented him from standing and participating in therapy, while staff gave inconsistent accounts about when the complaint was reported and whether it was communicated to the provider. The NP later stated she would expect notification of new pain, and the facility policy required prompt notification of changes in condition.
A resident with chronic pain syndrome, hemiplegia, osteoporosis, and other diagnoses was observed in a power wheelchair with a safety belt secured across her chest even though she could not remove it independently. Staff interviews showed multiple employees considered the belt a restraint, yet there was no restraint order and no restraint care plan, while the resident’s existing care plan only addressed fall risk and general safety measures.
MDS failed to accurately code a resident’s diabetes and insulin use. A cognitively intact resident had diabetes listed on the face sheet and was receiving basal insulin, sliding-scale lispro, and blood glucose checks, but the quarterly MDS did not identify diabetes and did not mark hypoglycemic medication use. The care plan also did not include diabetes, and staff interviews confirmed the diagnosis should have been coded and care planned.
Failure to Provide Baseline Care Plan Summary to Residents: The facility did not provide a copy of the baseline care plan summary to two newly admitted residents. One resident had pneumonia, DM2, and COPD and was hard of hearing and confused during interview; a family member said he did not recall receiving the baseline care plan. The other resident had cholecystitis, DM2, and HF, was identified as a fall risk, and said he did not get a copy of anything. Records and staff interviews did not show that the required summary was given to the resident or representative.
A resident with dysphagia, Parkinson’s disease, and lack of coordination, who required supervision and touching assistance with personal hygiene, was observed multiple times with long, dirty fingernails. The resident said he did not know where his nail clippers were or whether staff clipped his nails, and CNA, DON, and Admin interviews confirmed that CNAs were responsible for cleaning and trimming nails for residents unable to do so themselves.
A resident with a history of falls, rheumatoid arthritis, HTN, DM, and heart failure was transferred by CNAs using a mechanical lift in an unsafe manner. The lift was raised and moved with the base not in the wide position and the wheels not locked during lifting/lowering, despite the resident’s care plan requiring 2-staff transfers and staff stating the lift should be locked and stable during use.
Indwelling Catheter Care Not Provided as Ordered: A resident with an indwelling Foley catheter and severe cognitive impairment did not have a catheter securement device in place during CNA-provided catheter care, and the tubing was observed pulling during care. The CNA stated the resident lacked a securement device and did not notify the nurse. Interviews with the LVN, ADON, ADM, and DON confirmed that securement devices were expected and that catheter care should follow facility policy, including proper cleaning technique and preventing traction on the tubing.
A resident with a history of falls did not have a functioning call light system, leading to a delayed response when the resident fell out of bed. The call light system in the room was malfunctioning, failing to alert staff at the nurse's station. Despite previous reports of the issue, the problem persisted, and staff were unaware of the malfunction's extent.
The facility failed to address resident grievances in a timely manner, with issues such as unmade beds, lack of snacks, and toilet paper shortages being raised by the Resident Council over several months without prompt resolution. Staff interviews revealed delays in communication and action, contrary to the facility's grievance policy requiring responses within five days.
The facility failed to transmit MDS assessments to CMS within the required 14 days for four residents, potentially affecting payments. Residents with various medical conditions had their assessments completed and transmitted late, with CMS issuing warnings for the delays. Staff interviews revealed challenges in managing the workload, contributing to the deficiency.
The facility failed to meet professional standards for food storage and sanitation. Cardboard boxes were improperly stored on the pantry floor, and there was a lack of cleanliness around kitchen equipment. Additionally, food items in the cooler and freezer were not properly labeled or dated, which could lead to unsanitary conditions and risks for residents. Interviews with the Dietary Manager and Administrator highlighted expectations for cleanliness and proper labeling, but these were not met, potentially risking foodborne illness.
The facility failed to complete quarterly MDS assessments on time for three residents, including those with severe cognitive impairment and multiple health issues. The delay was due to the high volume of assessments and care plans managed by the MDS Coordinator, who was supported by regional staff. The DON and ADM were aware of the issue, which affected both revenue and resident care.
A facility failed to accurately document a resident's fall history in the quarterly MDS assessment. The resident, an 82-year-old female with Parkinson's Disease, dysphagia, and depression, experienced a fall that was not recorded in the MDS. The MDS Coordinator admitted the oversight, highlighting the importance of accurate assessments for care planning. Interviews with staff revealed that the MDS is constructed from various sources and triggers necessary care plan items. The Administrator noted that inaccuracies could have financial implications and affect resident autonomy.
The facility failed to develop comprehensive care plans for two residents, one with Parkinson's Disease and another with significant weight loss. The care plans lacked necessary interventions and updates, potentially affecting resident care. Staffing changes and inadequate meetings contributed to these deficiencies.
The facility failed to update comprehensive care plans for two residents, leading to inaccuracies in their documented care needs. One resident's care plan did not reflect a change in diet, while another's care plan did not account for resolved medical conditions and discontinued treatments. Staff interviews revealed a lack of follow-through in updating care plans after interdisciplinary team meetings.
A resident in an LTC facility received duplicate doses of several medications, including metoprolol and venlafaxine, due to a failure in the facility's medication review process. The issue was identified by a CMA but was not escalated beyond the Unit Manager, leading to continued administration of the duplicate medications. The resident did not show immediate adverse effects, but the potential for harm was recognized by the DON.
A medication cart in the 400/500 hall was left unlocked and unattended by an LVN while administering medication to a resident. The cart contained various medications, including insulin pens and scheduled drugs. Interviews with staff confirmed that medication carts should always be locked when not in use to prevent unauthorized access.
A resident with severe cognitive impairment and multiple diagnoses required oxygen therapy, but the facility failed to change her oxygen tubing weekly as ordered. Observations showed the nasal cannula had not been replaced since a specified date, and interviews confirmed that night nurses were responsible for this task. The facility's failure to follow care plans and physician's orders could place residents at risk of respiratory infections.
A facility failed to maintain accurate records of a resident's controlled medication, Hydrocodone, prescribed for pain management. Discrepancies in medication counts were discovered, leading to an investigation involving the DON and pharmacy consultant. A CMA was suspected of administering medication without documentation, resulting in her suspension. The facility conducted drug tests on staff, which were negative, and implemented new processes to ensure accurate narcotic counts.
Failure to Report and Assess an Unwitnessed Resident Fall
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and failed to provide supervision to prevent avoidable accidents for one resident who had an unwitnessed fall. The resident was admitted with diagnoses including unsteadiness on feet, malaise, and lack of coordination. The MDS indicated the resident was cognitively intact, required partial or moderate assistance for transfers, was not able to transfer from the toilet due to medical condition or safety concern, and was frequently incontinent of bowel and bladder. The resident’s care plan identified a prior fall related to transferring from the toilet to the wheelchair without assistance and the wheelchair not being locked. The care plan also stated that the resident required one-person assistance for transfers and toileting, was at moderate risk for falls due to debility and generalized weakness, and that staff were to anticipate the resident’s needs. Hospital records showed the resident was evaluated after the fall and had an acute/subacute L1 compression fracture with mild anterior predominant height loss, along with a chronic appearing L3 compression deformity and multilevel degenerative changes. During interviews, the resident’s family member stated the resident told them she had fallen in the bathroom after being left on the toilet for about 5 minutes and then trying to transfer herself back to the wheelchair, which was not locked. The resident stated that CNA C helped her to the toilet and left her there, and that she later slipped from the wheelchair and landed on the floor before CNA C and CNA B helped her back up. CNA B and CNA C both acknowledged they found the resident on the floor and helped her back to bed, but neither notified a nurse. The DON and LVN stated they were not made aware of the incident at the time, and the DON stated the resident should have been reported to nursing so an assessment could be completed. The facility policy titled Falls - Clinical Protocol stated that the nurse shall assess and document/report findings after a fall and that staff will evaluate and document falls that occur in the facility.
Unclean Rooms and Unchanged Bed Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents, and failed to ensure clean bed linens for four residents reviewed. The deficiency was identified through observation, interview, and record review, and involved Resident #12, Resident #30, Resident #34, and Resident #39. The facility policy titled Homelike Environment - Quality of Life stated residents are to be provided with a safe, clean, comfortable, and homelike environment, including clean bed and bath linens in good condition. Resident #12 was a male with diagnoses including dysphagia following cerebrovascular disease, hypertension, hyperlipidemia, neuromuscular dysfunction of the bladder, gastrostomy, and dementia. His MDS showed a BIMS of 00 and severe cognitive impairment, and he was dependent on staff for toileting, dressing, and bathing. During observations, his room floor around and under the dresser, chair, and bedside table was covered in dust and dirt, with visible debris scattered on the floor and floor mat. Five thick white hardened puddles of a substance were observed beside and under the bed. A housekeeper stated she had attempted to clean the white substance but had not been successful, and the Environmental Services Supervisor stated the substance was later removed easily once she was notified. Resident #30, Resident #34, and Resident #39 each had bed linens that were not changed after care needs. Resident #30, who had dementia, arthritis, an unsteady gait, and required assistance with personal care, stated her bedding had not been changed after a shower and an incontinent episode, and she placed a fitted sheet across the bed herself while waiting for staff. Resident #34, who had dementia and cerebrovascular disease and required assistance with toileting, dressing, and bathing, stated the aide did not have time to change the bed linens after her shower, and the fitted sheet showed several light brown-tinged circular stains on repeated observations. Resident #39, who had angina pectoris, chronic kidney disease, heart failure, asthma, dysphagia, hypertension, hyperlipidemia, and moderate cognitive impairment, was observed with dirty yellow and orange stains on the top sheet, brownish-tinged pillowcase edges, two large dark brown stains on the blanket, and a strong musty odor in the room. Staff interviews stated CNAs were responsible for showers and linen changes, and the DON and Administrator stated they expected showers and linen changes to be provided and verified.
Failure to Resolve Grievances About Late Meal Service
Penalty
Summary
The facility failed to promptly resolve grievances related to meals being served late for 1 of 6 residents reviewed for grievances, Resident #54. The report states that grievances raised during Resident Council on 03/07/2025, 04/04/2025, 06/02/2025, and 07/03/2025 all involved concerns that dinner was not served on time, including meals being served at 7:00 PM, 9:00 PM, and late and cold. The grievance log documented responses such as in-service training for dietary staff and, in one instance, an issue with the tray system and missing meal tickets. Resident #54 was an older male admitted with diagnoses including type 2 diabetes, pain, unsteadiness on feet, and an elevated white blood count. The quarterly MDS indicated he was understood and understood others, had highly impaired hearing, clear speech, adequate vision with corrective lenses, and a BIMS score of 06 indicating severe cognitive impairment. His care plan identified a potential for hypo/hyperglycemia related to diabetes with Accu-Chek and sliding scale orders. During interview, the resident's family member stated meals were always late when Resident #54 ate in his room on hall 400 and that trays would sometimes arrive after 2:00 PM. The family member expressed concern about low blood sugar during those late mealtimes and stated the resident was later moved to the 100 hall and encouraged to eat in the dining hall so meals would be served on time. The DON and Administrator both acknowledged ongoing complaints about late meal delivery, and the Administrator stated grievances should be addressed in a timely manner and that unresolved complaints could occur when grievances were not addressed timely.
Incomplete Care Plans for Diagnoses, Preferences, Restraint Use, Swallowing, and Discharge Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents whose assessments and records showed needs that were not reflected in their plans of care. For Resident #3, the quarterly MDS dated 6/5/2025 did not code diabetes even though the resident had orders for Insulin Glargine at bedtime and Lispro per sliding scale before meals, and the care plan revised on 7/15/2025 did not identify diabetes. Staff interviews confirmed that diabetes should have been care planned and that the resident was receiving insulin and blood glucose checks three times daily. For Resident #5, the quarterly MDS showed severe cognitive impairment, dependence for bathing and dressing, and need for substantial assistance with personal care, while the care plan addressed self-care deficits and transfers but did not reflect the resident’s bathing type or preference. The resident stated he was receiving bed baths, wanted showers, and had not received one despite asking. Staff interviews showed mixed understanding about who was responsible for bathing him, with hospice aides providing bed baths and facility staff discussing his shower request, but the bathing preference was not care planned. For Resident #8, the resident was observed in a power wheelchair with a black safety belt across the chest, and staff acknowledged the belt functioned as a restraint because the resident could not remove it independently. The care plan did not include a restraint plan or monitoring interventions, and the MDS coordinator confirmed there was no restraint care plan. For Resident #75 and Resident #97, admission MDS assessments identified swallowing difficulties and active discharge planning, but their care plans did not reflect those needs. Resident #97 also had a care plan intervention stating no water pitcher at the bedside for a fluid restriction, yet a water pitcher with clear liquid was observed at the bedside, and staff stated the intervention was known but not consistently followed.
Respiratory Care Orders Not Followed
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for four residents who had physician-ordered oxygen therapy or tracheostomy-related care. Resident #40 had diagnoses including emphysema and COPD, was cognitively intact, and had an order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During observations, the resident’s oxygen concentrator was set at 1 liter per minute instead of the ordered rate. Staff interviews stated that nursing was responsible for ensuring oxygen was set at the ordered volume and that incorrect settings could leave residents short of breath and with lowered oxygen saturation. Resident #13 had chronic respiratory failure, asthma, stenosis of the larynx, and tracheostomy status, with intact cognition. The record showed tracheostomy-related orders for humidifier changes, tubing and collar changes, cleansing, suctioning, and trach collar use, but the order summary did not reflect a physician order for the tracheostomy type, size, configuration, or whether the cuff was inflated or deflated. During observation, the resident had a Shiley XLT 6.0 tracheostomy tube in place and the pilot balloon was flat or deflated. Staff stated that the tracheostomy order should have been in the medical record so the correct tracheostomy size would be known. Resident #41 had COPD, chronic respiratory failure, and heart failure, with severely impaired cognition, and had an order for oxygen at 4 liters per minute via nasal cannula continuously. Observations showed the resident’s oxygen was set at 2.5 liters per minute, 3.5 liters per minute, and 3 liters per minute at different times, and one oxygen cylinder was near the refill mark while in use. Staff stated the resident should have been on 4 liters per minute and that nurses were responsible for ensuring oxygen tanks did not run out while in use. Resident #97 had myocardial infarction, CHF, COPD, and acute and chronic respiratory failure, with intact cognition, and had an order for oxygen at 2 liters per minute via nasal cannula every shift. During observation, the oxygen flowmeter was set at 3 liters per minute, and the resident’s nebulizer mask was left on the nightstand rather than stored in a bag when not in use. Staff stated the mask should be stored in a bag to prevent germs and cross contamination.
Failure to Assist Residents With Dental Referrals and Follow-Up
Penalty
Summary
The facility failed to assist residents in obtaining routine dental care for 3 of 3 residents reviewed for dental services, and failed to ensure adequate follow-up was completed on dental referrals for Residents #35, #100, and #37. Record review showed no dental referral had been made for any of the three residents in the electronic data record. The facility’s Dental Services policy stated it was the policy to assist residents in obtaining routine and emergency dental care, including annual oral inspection, dental cleaning, fillings, denture adjustments, and limited prosthodontic procedures. Resident #35 was re-admitted to the facility with diagnoses including acute kidney failure, heart failure, hypertension, and altered mental status. Her Quarterly MDS indicated she had a BIMS of 12, was moderately cognitively impaired, and had natural teeth. During observation and interview, she stated her implants broke, she was observed with only anchorage implant wires present in her mouth, and she said no one at the facility had ever visited with her regarding repair of her implants. She stated she had difficulty eating most of the time unless food was soft and wanted her implants repaired so she could have a better variety of food. Resident #100 was admitted with diagnoses including CHF, hypertension, cerebrovascular disease, and hyperlipidemia. Her Quarterly MDS indicated she was cognitively intact, required maximum assistance with toileting, dressing, and bathing, and did not have mouth or facial pain or difficulty chewing. During interview, she stated she had pain in her teeth and that it had been a very long time since anyone in the facility had followed up with her regarding her dental needs. Resident #37 was admitted with diagnoses including cerebral infarction, COPD, hypertension, cerebrovascular disease, and hyperlipidemia. His Quarterly MDS indicated he had a BIMS of 0, could not complete the interview, and required maximum assistance with toileting, dressing, and bathing. During observation and interview, he stated he did not have any teeth and wanted dentures, and said the facility was supposed to be letting him know something but never had. The Social Worker stated she was responsible for dental referrals and follow-ups, but could not provide documentation of communication after the referral for Resident #35's dental implants, Resident #100's post dental visit status, or Resident #37's Medicaid financial update regarding dental services for dentures.
Meal Choices Not Honored for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents received meal choices that matched what they ordered for 4 of 22 residents reviewed for accommodation of meal choices. The deficiency involved Resident #13, Resident #41, Resident #75, and Resident #97, all of whom had documented medical conditions and diet needs, including therapeutic diets and assistance or supervision with eating. The report states that the residents did not consistently receive the food they requested, and that meal tickets and resident choices were not reliably honored. Resident #13 had Type 2 diabetes and chronic respiratory failure, a BIMS score of 15, and required supervision for eating. Her care plan identified her as at risk for weight fluctuations and directed that she be provided her prescribed diet and observed closely during mealtimes. During observation, she had an uneaten salad at her bedside and said she had not received what she asked for and eventually settled on a salad. Resident #41 had COPD, chronic respiratory failure, heart failure, and nutritional anemia, with a BIMS score of 4 and supervision needed for eating. She stated that she received the food she ordered only about 50% of the time and described the food as what one would expect in a nursing home. Resident #75 had CHF, Type 2 diabetes, hemiplegia, and hemiparesis following cerebral infarction, with a BIMS score of 12, setup needed for eating, and signs of a possible swallowing disorder. He said it did no good filling out the lunch form because he would not get what he ordered. Resident #97 had myocardial infarction, CHF, COPD, and acute and chronic respiratory failure, with a BIMS score of 15, setup needed for eating, and signs of a possible swallowing disorder. He said he had a loss of appetite since admission and reported a 50/50 chance of receiving what he ordered for meals. Staff interviews confirmed that CNAs collected meal choices, dietary staff plated food, and residents sometimes did not receive the meal according to their meal ticket. Staff also stated that residents complained about not getting what they ordered and that the issue could lead to residents refusing to eat or experiencing weight loss.
Infection Control Lapses With Catheter Care, Laundry Handling, and Ice Service
Penalty
Summary
The facility failed to maintain infection prevention and control practices for a resident with an indwelling urinary catheter. Resident #9 was admitted with diagnoses including urinary tract infection, heart failure, chronic kidney disease, ESBL resistance, weakness, and lack of coordination, and his MDS indicated moderate cognitive impairment and dependence on staff for most ADLs. He was on Enhanced Barrier Precautions and had a care plan for an indwelling catheter for urine retention. During observation, his urinary catheter drainage bag was attached to the side of his bed and sitting on the floor, and later the bag was observed dragging on the floor under his wheelchair in his room while his RP was visiting. The facility also failed to prevent contamination of clean laundry in the laundry room. During observation, the Housekeeping/Laundry Supervisor removed clean facility blankets from a wire hamper and folded them while allowing the corners of four blankets to touch the floor. The blankets were then placed on the counter near other laundry items before being taken to the dirty side of the laundry room. The supervisor stated the blankets could not touch the floor because the floor was contaminated. In addition, the facility failed to maintain proper infection control when ice was served on Hall 100. CNA D filled a resident’s water cup with ice directly over the ice cooler, causing water to overflow into the cooler and run down her hand into the ice supply, and then continued serving ice to residents. The DON stated residents’ cups should not be filled over the ice cooler because of the high risk of cross contamination, and the Administrator stated staff were responsible for ensuring cross contamination was not occurring and that fresh ice and water were served daily per policy.
Resident Privacy and Dignity During Catheter Care
Penalty
Summary
The facility failed to treat residents with respect and dignity and to provide care in a manner that promoted maintenance or enhancement of quality of life for 2 of 22 residents reviewed. One resident had an indwelling urinary catheter and moderate cognitive impairment, with diagnoses including urinary tract infection, heart failure, chronic kidney disease, ESBL resistance, weakness, and lack of coordination. During observations, the resident’s catheter drainage bag privacy cover flap was bunched up under the hanging hook on the wheelchair and was not covering the urine in the drainage bag while the resident was in his room and later while he was in the lobby area in front of the nurses’ station. The resident stated he did not know the catheter bag was not covered and said he would not want his urine seen by everyone when he was out in the hallways. Staff interviews confirmed the privacy cover flap was intended to cover the urine in the bag for privacy and that if it was not covered, it could be embarrassing for residents. Multiple staff members, including CNA, LVN, ADON, DON, and the ADM, stated staff were responsible for ensuring the catheter bag was covered and that the cover was meant to protect resident privacy and dignity. A second resident had diagnoses including heart failure, neuromuscular dysfunction of the bladder, dementia, major depressive disorder, and generalized anxiety disorder, and required substantial to maximal assistance for toileting hygiene with an indwelling catheter. During observed catheter care, two CNAs entered the room without knocking, the resident’s privacy curtains were left open, and the resident was exposed when his covers were lowered and his brief was removed. The resident’s roommate was present in the room. Staff interviews and facility policies stated that staff were expected to knock before entering, close privacy curtains, and cover residents during personal care to provide privacy, dignity, and bodily privacy.
Failure to Notify Physician of New Foot Pain
Penalty
Summary
The facility failed to consult with the resident’s physician and representative when there was a significant change in condition for one resident who complained of left foot pain. The resident had diagnoses including cerebral infarction, left-sided hemiplegia and hemiparesis, chronic embolism and thrombosis of the right lower extremity, chronic pain syndrome, weakness, and lack of coordination. He was cognitively intact with a BIMS score of 13, dependent on staff for bathing, toileting, and dressing, and received pain medication as needed. Record review showed the resident’s care plan addressed osteoarthritis, recurrent deep vein thrombosis, limited mobility, and potential for pain, with directions to observe, document, and report changes. Nursing notes from 8/18/25 through 8/26/25 did not document the left foot pain until after surveyor intervention. The resident told surveyors on 8/24/25 that his left foot hurt so badly he could not stand on it and could not do therapy, and he said staff were aware and he was waiting for an x-ray. On 8/26/25, an LVN documented that the resident reported pain to the inside of his left foot and that the physician was notified and an x-ray order was obtained. Therapy documentation indicated a PTA reported the foot pain to nursing on 8/21/25 and said he was going to consult the physician about possibly getting an x-ray. The NP’s 8/21/25 note documented the resident had acute left knee pain and other positive review-of-systems findings, but it did not mention left foot pain. During interviews, nursing staff gave inconsistent accounts about whether the pain had been reported and whether the NP had been notified. The NP stated she would expect to be notified of new pain and said the nurse did not report left foot pain to her that day. The facility’s policy required prompt notification of the resident, attending physician, and representative of changes in condition, and within 24 hours except in emergencies.
Unplanned wheelchair seatbelt used as a restraint without order or care plan
Penalty
Summary
The facility failed to ensure that a resident was free from a physical restraint when Resident #8 was observed using a black safety belt on her wheelchair even though the belt was not included in the resident’s care plan and there was no restraint order documented in the report. Resident #8 was a cognitively intact female with diagnoses including chronic pain syndrome, left-sided hemiplegia, hypertension, osteoporosis, and neuromuscular dysfunction of the bladder. Her MDS indicated she had no functional impairment in her upper extremities, impairment in both lower extremities, and required substantial assistance with personal care. During observation, Resident #8 was seen sitting in her power wheelchair with the safety belt secured across her chest. She stated that she wanted the belt on because she slid out of her wheelchair, and she said she was unable to remove the seatbelt independently. Staff interviews reflected that the belt was considered a restraint by multiple employees, including a CNA and an LVN, because Resident #8 could not unlock it herself. The CNA stated the belt had been on since she started working at the facility and that she would unlock it when the resident returned to bed. The resident’s care plan addressed fall risk and included interventions such as anticipating needs, keeping the call light within reach, and educating the resident and family about safety reminders, but it did not include a seatbelt or restraint. The MDS Coordinator stated Resident #8 did not have a care plan for restraints, and the DON stated the CNA had not asked a nurse before placing the seatbelt on the resident. The facility’s restraint policy stated restraints are only to be used for the resident’s safety and well-being, after other alternatives fail, and never for staff convenience or fall prevention, and defined inappropriate use of equipment to prevent mobility as a restraint.
MDS Failed to Reflect Diabetes and Insulin Use
Penalty
Summary
The facility failed to ensure Resident #3’s quarterly MDS accurately reflected her diagnosis and treatment status. The resident’s face sheet listed diabetes among her diagnoses, and her MAR and order summary showed she was receiving Insulin Glargine at bedtime and Lispro per sliding scale before meals for diabetes. However, the most recent MDS did not identify her as diabetic, and section N0415 was not marked for hypoglycemic medication use even though section N0350 indicated insulin injections were given in the last 7 days. Resident #3 was a cognitively intact female with a BIMS score of 14 and was readmitted with diagnoses including fracture of the lower end of the left tibia, neuromuscular dysfunction of the bladder, malignant neoplasm of the uterus, and diabetes. Her care plan, revised on 7/15/2025, did not indicate that she was diabetic. The record review also showed she was receiving blood glucose checks three times daily. During interviews, the LVN, MDS Coordinator, ADON, DON, and ADM all acknowledged that diabetes should have been coded on the MDS and care planned, and that the resident was receiving insulin for diabetes. The facility’s policy on the Resident Assessment Instrument stated that disease diagnoses and health conditions should be identified when related to the resident’s ADL status, cognitive status, mood and behavior, medical treatment, nursing monitoring, or risk of death. Despite this, the MDS Coordinator stated the quarterly assessment did not indicate diabetes, and the care plan did not reflect the diagnosis. The DON and ADM both stated they expected diabetes to be coded on the MDS and included on the care plan, and the DON said the MDS and care plan were updated by the MDS Coordinator and herself.
Failure to Provide Baseline Care Plan Summary to Residents
Penalty
Summary
The facility failed to provide the resident and their representative with a summary of the baseline care plan for 2 of 6 residents reviewed for baseline care plans, Resident #60 and Resident #114. The report states that this summary was not reflected in the medical record for either resident, and the facility’s documentation did not show that a copy of the baseline care plan summary had been provided. Resident #60 was a [AGE]-year-old male admitted with pneumonia, type 2 diabetes, and chronic obstructive pulmonary disease. He was his own responsible party, was admitted less than 21 days before the review, and had a 48 Hour Care Plan dated 8/18/25 signed by the MDS Coordinator. During observation and interview, a family member said he was present at admission and did not recall Resident #60 receiving a baseline care plan. Resident #60 was hard of hearing, and when asked about it, he appeared confused and shook his head. Resident #114 was a [AGE]-year-old male admitted with calculus of the gallbladder with acute cholecystitis, type 2 diabetes, and heart failure. He had no responsible party listed, was admitted less than 21 days before the review, and his care plan report identified moderate fall risk related to gait and balance problems and a full code status. His admission care conference summary and medical record did not reflect that a copy of the baseline care plan summary was provided, and during interview he said he did not get a copy of anything. Staff interviews showed differing understanding of who was responsible for the baseline care plan and for ensuring the resident or responsible party received a copy.
Failure to Maintain Resident Fingernail Hygiene
Penalty
Summary
The facility failed to provide the necessary services to maintain personal hygiene for one resident reviewed for ADLs. Resident #59 was admitted with diagnoses of dysphagia, Parkinson’s disease, and lack of coordination. The annual MDS indicated the resident had a BIMS score of 15 and required supervision and touching assistance with personal hygiene. During observations, Resident #59 was seen with long and dirty fingernails on multiple occasions. During an interview, the resident said he did not know where his nail clippers were or whether staff clipped his nails, and his hands were shaking. Staff interviews confirmed that CNAs were responsible for cleaning and trimming the nails of residents who could not do so for themselves, and the DON and Administrator both stated that residents dependent for care should have their nails cleaned and trimmed.
Unsafe Mechanical Lift Transfer During Resident Move
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and failed to ensure adequate supervision and assistance devices were used to prevent accidents for one resident who was reviewed for accidents and supervision. The resident had diagnoses including a history of left tibia fracture, diabetes, a history of falls, rheumatoid arthritis, hypertension, and heart failure. Her MDS indicated a BIMS score of 14, showing she was cognitively intact, used a wheelchair for mobility, and required moderate assistance with most ADLs. Her care plan, last reviewed on 7/15/25, identified an ADL self-care performance deficit related to disease process, required two staff participation with transfers, and noted she was at risk for falls. During an observation on 8/26/25, CNA G and CNA D used a mechanical lift to transfer the resident from bed to wheelchair. CNA G positioned the lift over the resident, attached the lift pad, and raised the resident with the lift legs straight rather than in the wide position. CNA G did not lock the lift wheels during lifting, then pulled the resident away from the bed, turned the lift to the right, and pushed the resident toward the wheelchair before opening the lift legs to the wide position and lowering her into the wheelchair. During interviews, CNA D stated the lift wheels should be locked when raising or lowering a resident and the lift legs should be in the wide position during lifting and moving for stability. CNA G stated the wheels should be locked when lifting a resident and that the lift legs should be in the wide position during lifting for stability, while also describing that the legs would not be opened to the wide position during moving. The ADON, DON, and ADM each stated the lift wheels should be locked during raising and lowering and the base should be in the wide position when lifting and moving the resident. The facility policy on mechanical lifts stated the lift should be stable and locked, and FDA guidance cited in the report stated to keep the base of the patient lift at maximum open position.
Indwelling Catheter Care Not Provided as Ordered
Penalty
Summary
Resident #25, a male with diagnoses including neuromuscular dysfunction of the bladder, dementia, ESBL resistance, and chronic kidney disease stage 4, had an indwelling Foley catheter and required substantial to maximal assistance with toileting hygiene. His care plan noted that his responsible party preferred he wear only a leg bag at times because he forgot the bag was attached to the bed and had pulled the Foley out multiple times. The order summary included Foley catheter care every shift and as needed, and the facility policy stated that perineal care for a male resident with an indwelling catheter included washing from the urethra outward and holding the tubing to avoid traction or unnecessary movement. During observation on 8/25/25, CNA D provided catheter care while Resident #25 was in bed, but the resident did not have a catheter securement device in place. The surveyor observed the catheter tubing was not secured and was pulled during care. CNA D cleaned the lower abdomen, groin creases, underside of the penis, and then moved toward the urethra and catheter junction. The resident’s privacy curtain was open during the care, and the resident complained of being cold when his covers were lowered. During interviews, CNA D stated the resident did not have a securement device and that she did not notify the nurse afterward. LVN F, the ADON, the ADM, and the DON all stated that a resident with an indwelling catheter should have a securement device, that the device helps prevent pulling and dislodgement, and that catheter care should be performed according to facility policy. The ADON and DON also stated that Resident #25’s behavior of removing securement devices should have been care planned, and the DON said not providing proper catheter care and not using securement devices could lead to a negative outcome.
Failure to Ensure Functioning Call Light System
Penalty
Summary
The facility failed to ensure that a resident had a functioning call light, which is a critical component for residents to request assistance. This deficiency was identified for a resident who had a history of falls and required substantial assistance with activities of daily living (ADLs). The resident's care plan specifically included the intervention to ensure the call light was within reach and to encourage its use for assistance. However, the call light system in the resident's room was not functioning properly, as it did not make an audible noise at the nurse's station, leading to a delay in response when the resident fell out of bed. On the morning of the incident, the resident fell from his bed and was unable to get back up. Another resident in the room attempted to call for help by pressing the call light button, but no staff responded because the call light system was malfunctioning. The family member of the resident was informed of the fall by another resident and arrived at the facility to find the resident on the floor. The family member reported that the nurses were unaware of the activated call light due to the malfunction, which had been an ongoing issue. Interviews with staff revealed that the malfunctioning call light system had been reported previously, but the issue persisted. The maintenance director had attempted to fix the system by replacing a component in the bathroom, but the problem with the bedroom call light remained unresolved. Staff members were unaware of the malfunction's extent, and the lack of an audible alert at the nurse's station contributed to the delayed response to the resident's fall.
Delayed Response to Resident Grievances
Penalty
Summary
The facility failed to address and document the grievances and recommendations of the resident group in a timely manner, as required by regulations. Over a period of three months, from February to April 2024, the Resident Council raised concerns about various issues, including medicine being left at the bedside, unmade beds, unchanged linens on shower days, lack of snacks, and frequent shortages of toilet paper. Despite these grievances being documented during Resident Council meetings, the facility did not respond or document their responses until May 2024, well beyond the expected timeframe. Interviews with residents and staff revealed ongoing issues with the facility's response to grievances. Residents expressed that their concerns were repeatedly raised during council meetings without receiving timely feedback or resolution. Staff members, including the Housekeeping Supervisor and the Dietary Manager, acknowledged the issues but indicated that resolutions were either delayed or not effectively communicated to the residents. The new DON and ADM, who were not in their positions during the initial grievances, recognized the lack of timely responses and the potential negative impact on residents. The facility's grievance policy, which mandates a response within five working days, was not adhered to, leading to resident dissatisfaction and a sense of being ignored. The Social Service Director, responsible for investigating grievances, did not ensure timely communication of resolutions to the residents. The lack of prompt action and documentation of responses to the grievances contributed to the deficiency identified by the surveyors.
Delayed MDS Transmissions in LTC Facility
Penalty
Summary
The facility failed to ensure that each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for four residents. This deficiency was identified during interviews and record reviews, which revealed that the MDS assessments for Residents #149, #24, #16, and #5 were not transmitted within the required timeframe. The delay in transmission could potentially affect the timeliness of payments to the facility. Resident #149, an elderly female with diagnoses including stroke and heart failure, had her MDS assessment signed by the MDS Nurse but was not transmitted until three days later. Similarly, Resident #24, who had severe cognitive impairment and required assistance with activities of daily living (ADLs), had her MDS transmitted late. Resident #16, with moderately impaired cognition, and Resident #5, also with moderately impaired cognition, both had their assessments completed and transmitted well beyond the 14-day requirement, with warnings issued by CMS for late submission. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), highlighted challenges in keeping up with the volume of MDS assessments due to staffing limitations. The MDS Coordinator was responsible for numerous tasks, including reviewing clinical records, completing various MDS types, and coordinating with insurance companies. The DON, who was new to the facility, was unaware of the late submissions but acknowledged the heavy workload of the MDS nurse. The facility's policy indicated that MDS assessments should be transmitted no later than 31 days after completion, but this was not adhered to in these cases.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in their kitchen. Cardboard boxes containing frying oil were found on the pantry floor, contrary to the facility's policy that requires items to be stored at least six inches above the floor. Additionally, the outside of a microwave and the wall next to a beverage table were observed to have brown buildup and dry brown splashes, respectively, indicating a lack of cleanliness and sanitation. Furthermore, food items in the walk-in cooler and freezer were not properly labeled or dated, with some items being completely unlabeled, which goes against the facility's policy and the FDA's FIFO procedures. Interviews with the Dietary Manager and the Administrator revealed that there was an expectation for all equipment to be clean and for food items to be properly labeled and dated. The Dietary Manager, who was new to the facility, acknowledged that she was working on a cleaning schedule and that the kitchen staff were responsible for maintaining cleanliness and labeling food items. The Administrator confirmed that improper storage and cleanliness could lead to unsanitary conditions and that unlabeled food items could pose a risk of serving expired food or incorrect diets. Despite these expectations, the deficiencies observed during the survey indicate a failure to meet these standards, potentially placing residents at risk of foodborne illness and food contamination.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for three residents. Resident 24, an elderly female with severe cognitive impairment and multiple diagnoses including acute kidney failure and Parkinson's disease, did not have her quarterly MDS submitted until after the due date. Similarly, Resident 16, who has moderately impaired cognition due to a stroke, and Resident 5, who suffers from metabolic encephalopathy and dementia, also had their assessments completed and transmitted late. The delay in completing these assessments was acknowledged by LVN E, who was providing regional support to the facility's MDS Coordinator. LVN E admitted that several MDS assessments were late and attributed this to the challenge of managing the volume of assessments and care plans due each month. The MDS Coordinator, who was responsible for a wide range of duties including completing all MDS assessments and care plans, confirmed that there were delays and that support was being provided to address the backlog. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were aware of the issue, with the DON having recently started in her role and the ADM being informed by LVN E. Both acknowledged the importance of timely MDS completion for revenue and resident care. The facility's adherence to RAI and CMS guidelines was noted, but the late submissions were recognized as a deficiency in meeting these standards.
Inaccurate MDS Assessment of Resident's Fall History
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Set (MDS) assessment for a resident accurately reflected the resident's history of falls. The resident, an 82-year-old female with diagnoses of Parkinson's Disease, dysphagia, and depression, had a documented fall in her room while attempting to go to the restroom. This incident was not recorded in the MDS assessment, which indicated no falls had occurred since the last assessment. The MDS Coordinator acknowledged the oversight, stating that the fall should have been included in the MDS, as it is crucial for accurate care planning. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the MDS assessment is constructed using various sources, including hospital records and discussions with the resident. The MDS triggers items on the Care Area Assessment (CAA) that are necessary for the care plan. The Administrator expressed that accurate MDS assessments are expected to provide a clear picture of the resident, and inaccuracies could affect the facility financially and impact the resident's autonomy. The facility's policy emphasizes the importance of accurate assessments to maintain or improve residents' medical status and functional abilities.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which could potentially impact their quality of care and life. Resident #13, an 82-year-old female with Parkinson's Disease, dysphagia, and depression, did not have a care plan addressing her Parkinson's Disease diagnosis and treatment. Despite having a moderate cognitive impairment and requiring assistance with activities of daily living, her care plan lacked specific interventions related to her condition, even though she was prescribed carbidopa-levodopa. Resident #44, a female with diabetes, dementia, and fibromyalgia, experienced significant weight loss of over 15% in 180 days, yet her care plan did not address this issue. Despite being dependent on staff for daily activities and having severe cognitive impairment, her care plan lacked interventions or goals related to her weight loss. The resident was unaware of her weight loss and expressed a desire to reduce her weight to alleviate caregiver burden. Interviews with facility staff revealed that the MDS Coordinator was responsible for creating and updating care plans but had not done so due to recent staffing changes and a lack of regular meetings. The Director of Nursing acknowledged the MDS Coordinator's workload and had arranged for additional nursing support to assist with care plans. The facility's policy emphasized the importance of updating care plans based on comprehensive assessments, but this was not adhered to, leading to deficiencies in resident care.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for two residents. Resident #13's care plan was not updated to reflect a change in her diet from puree with nectar thickened liquids to puree with honey thickened liquids, despite a physician's order indicating this change. The care plan dated 06/13/2024 still reflected the old diet order, which could lead to inappropriate dietary interventions. Resident #44's care plan was not revised to reflect multiple changes in her medical condition and treatment. Her care plan, dated 05/16/2024, inaccurately indicated that she had an indwelling catheter, was receiving hypnotic medication daily, had a pelvic abscess, used tobacco daily, had a pressure ulcer to her left heel, had a UTI, was on antibiotic therapy, was on anticoagulation therapy, and was on IV therapy. However, records showed that these conditions and treatments had been resolved or discontinued by various dates in 2024. Observations confirmed that Resident #44 no longer had a catheter, pelvic abscess, or pressure ulcer, and was not receiving IV therapy. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that care plans were supposed to be reviewed and revised during care plan meetings with the interdisciplinary team. However, the MDS Coordinator admitted that she did not ensure changes were made to residents' care plans after these meetings. The DON confirmed that the MDS Coordinator was responsible for updating care plans and that they should accurately reflect the resident's current condition to guide care. The facility had a consultant and an assistant to help with care plan updates, but these resources were not effectively utilized to prevent the deficiencies identified.
Duplicate Medication Administration in Resident's Drug Regimen
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, resulting in the administration of duplicate medication therapy. The resident, an 85-year-old female with diagnoses including dementia, COPD, Type 2 diabetes, and vitamin deficiency, received duplicate doses of several medications, including metoprolol, venlafaxine, trazadone, pantoprazole, MiraLAX, and vitamin D3. This was discovered through observation, interview, and record review, revealing that the resident received multiple doses of the same medications over a period of time. The issue arose when a CMA noticed the duplicate orders on the MAR and reported it to the Unit Manager, who instructed her to continue administering the medications as listed. The CMA, trusting the Unit Manager's guidance, continued to administer the medications despite her reservations. The DON was unaware of the duplicate therapy until informed by the surveyor, and the facility's system for checking new orders failed to catch the duplication due to a change in personnel and the timing of the pharmacy consultant's review. Interviews with staff revealed that the duplicate medication administration was not reported beyond the Unit Manager, and the charge nurses were not aware of the issue unless informed by the CMA. The resident did not exhibit any immediate adverse effects from the duplicate therapy, as confirmed by a tele-med exam conducted by the MD. However, the potential for harm was acknowledged by the DON, who stated that duplicate drug therapy could lead to serious health consequences.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with one of the medication carts for the 400/500 hall. During an observation, LVN B left the medication cart unlocked while administering medication to a resident. The cart was left unattended and out of sight for several minutes, during which time three housekeepers were present in the hallway. LVN B acknowledged that the cart was not locked and admitted that someone could access the medications, which could lead to unauthorized use. Further observations revealed that the medication cart contained various medications, including over-the-counter drugs, insulin pens, and scheduled medications. Interviews with LVN C, the ADON, the ADM, and the DON confirmed that medication carts should always be locked when not in use to prevent unauthorized access. The facility's policy on medication storage, revised in April 2017, mandates that all drugs and biologicals be stored securely and that medication carts should not be left unattended if open.
Failure to Change Oxygen Tubing for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing as required. Resident #24, a female with severe cognitive impairment and multiple diagnoses including acute kidney failure, Parkinson's disease, and anemia, was dependent on staff for assistance with activities of daily living and required oxygen therapy. The resident's care plan and physician's orders specified that the oxygen tubing should be changed weekly and labeled, but observations revealed that the nasal cannula had not been replaced since 6/17/24, despite the requirement to change it weekly. Interviews with the facility's administration and nursing staff confirmed that the responsibility for changing the nasal cannula lay with the night nurses. Both the administrator and the director of nursing acknowledged that the failure to change the oxygen tubing could place residents at risk of respiratory infections. The deficiency was identified through observations and interviews, highlighting a lapse in following the care plan and physician's orders for Resident #24's respiratory care.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate records of controlled medication for a resident, specifically Hydrocodone, which was prescribed for pain management. The resident, a male with a history of a displaced mid-cervical fracture of the left femur, cervical disc disorder, rheumatoid arthritis, and low back pain, was prescribed Hydrocodone to manage his pain. The medication administration record indicated that the resident received two doses of Hydrocodone, but discrepancies were found in the medication count, leading to concerns about the accuracy of medication administration records. Interviews with facility staff revealed that there was an incident where a Certified Medication Aide (CMA) was off on her counts, and another CMA had to cover the shift. The CMA who was off on counts was suspected of administering medication without proper documentation, leading to her suspension. The Licensed Vocational Nurse (LVN) and Assistant Director of Nursing (ADON) confirmed that there was a discrepancy in the Hydrocodone count, and the facility had to conduct a thorough investigation with the pharmacy consultant to account for the discrepancies. The Director of Nursing (DON) and other staff members were involved in addressing the issue, including conducting drug tests on staff, which returned negative results. The DON implemented new processes to ensure accurate narcotic counts and documentation. Despite these efforts, the initial failure to maintain accurate records of controlled substances posed a risk to the residents' health and well-being, as it could lead to improper administration of medication.
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 208 citations issued within 25 miles in the last 12 months — including the 16 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 Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Longview Hill Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 13 | 0 |
| Avir At Longview | 1.6 mi | ★★★★★ | 8 | 0 |
| Heritage At Longview Healthcare Center | 1.8 mi | ★★★★★ | 1 | 0 |
| The Oaks At Longview | 1.8 mi | ★★★★★ | 8 | 0 |
| Buckner Westminster Place | 2 mi | ★★★★★ | 0 | 0 |
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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.