Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairfield Village Rehabilitation during CMS and state inspections, most recent first.
Menu portions were not followed during lunch service. The regular diet menu listed specific serving sizes for Asian noodles and mini egg rolls, but the Chef plated the noodles with tongs without measuring and served only one egg roll per plate. The Chef stated she was guessing the noodle portion size, while the DM and RD stated staff should measure servings and follow the menu exactly as written.
Food items in the refrigerator and freezer were repeatedly found undated, including meats, cheeses, vegetables, and frozen desserts, and a kitchen staff member was observed serving food without a hair net. Sanitation practices were also deficient when staff used sanitizer buckets without verifying the solution strength, continued using a bucket that did not test at the expected level, and handled food with gloves after cleaning surfaces without hand hygiene.
Failure to timely report alleged abuse or neglect incidents and investigation results: The facility did not notify SSA and APS as required for multiple resident incidents involving falls and injuries. A resident with metabolic encephalopathy and other diagnoses was found on the floor in the bathroom with pain and limited leg movement, another resident with CHF, AFib, and sepsis was found on the bathroom floor with a bruise and later sent to the hospital, and a third resident with a prior hip fracture and mobility issues was found after a loud crash with a head laceration and skin tear requiring ER transfer. SSA reporting was delayed for two residents, APS notification was not documented, and investigation results were not reported to SSA.
A facility medication refrigerator was repeatedly maintained below manufacturer-recommended temperatures, with logs showing temperatures between 32 and 35.5 degrees Fahrenheit for the month reviewed. RNs observed refrigerated stock including Aplisol for TB screening and multiple sealed resident medications such as insulin and ophthalmic solution, all labeled for specific residents, while the DON acknowledged the temperatures were too low. The facility policy required drugs and biologicals to be stored in locked compartments under proper temperature controls.
A deficiency was cited because breakfast and dinner were served 15 hours apart without a substantial evening snack being offered. Meal times were posted, but breakfast was served late, and a resident asked when breakfast would be served while waiting in the dining room. Staff and leadership reported that snacks were available only upon request, there was no formal snack program or dedicated snack time, and the Administrator was unsure who was responsible for providing snacks or how dementia residents were informed of snack availability.
Hand hygiene was not consistently performed during meal service, with CNAs observed touching residents and surfaces, delivering trays, and repositioning residents without changing gloves or cleaning hands. EBP was not implemented as ordered for residents with indwelling devices, as PPE and signage were missing or not used consistently, and staff showed inconsistent understanding of gown, glove, and mask requirements. The facility also stored PPD solution in a medication refrigerator at temperatures below the manufacturer’s required range, making the TB screening process for new admits inaccurate.
An RN diverted controlled medications belonging to two residents, including pain meds ordered for a resident with dementia and a resident with multiple fractures and cognitive deficits. The RN was stopped by police after leaving work and was found with facility medications in the residents’ names. The DON stated that prior narcotic counts relied on matching log sheets and counting individual contents, and staff did not detect the missing meds because the corresponding narcotic logs were also absent.
Inadequate Monitoring of Trazodone for Sleep: A resident with obstructive sleep apnea, anxiety, and insomnia received trazodone for sleep/anxiety, but the TAR did not document hours of sleep on two shifts after the order for sleep monitoring was entered. The DON stated trazodone required monitoring for adverse side effects and sleep hours, and that the missed documentation was overlooked during her record checks.
Failure to Investigate Alleged Neglect After Resident Fall: A resident with a hx of periprosthetic L hip fracture, difficulty walking, and muscle wasting sustained a fall after a loud crash was heard, resulting in a bleeding head laceration, nose laceration, and skin tear before transfer to the ER. Record review and interviews showed the ADM could not locate evidence of a thorough investigation into the alleged neglect, and the only related document was not identified as the investigation.
Missing transfer documentation for ER transport: A resident with multiple diagnoses, including metabolic encephalopathy, sepsis, and HTN, was found on the floor after a fall and was sent by EMS to the ER for right hip evaluation. The nursing note documented the fall and transfer, but the chart did not document the information sent to the receiving provider; the later discharge/transfer summary was completed hours after the transfer and did not show what was conveyed with EMS.
Failure to Provide Ordered Dining Assistance: A resident with dementia, Parkinson's disease, and Alzheimer's disease had moderate cognitive impairment and required setup/clean up assistance with dining, with orders for food to be cut up and finger foods offered when available. During meals, the resident was served food that was not fully cut up, had visible difficulty eating with hand tremors, and staff were present but did not provide dining assistance or assistive eating devices.
A resident at risk for skin breakdown developed MASD and buttocks/intergluteal cleft skin damage while ordered treatments and pressure-relief measures were not fully implemented. The resident had orders for zinc/Venelex, groin skin care, and an air overlay, but surveyors found the bed lacked the overlay and the care plan did not include interventions for the new skin issue; staff and the DON acknowledged the overlay had not actually been verified as in place and functioning.
Unmonitored self-administered insulin pump regimen. A resident with DM2 used an Omnipod insulin pump that he managed himself, including changing the pod every 3 days and adjusting insulin based on his own blood sugar readings. The MAR showed routine blood sugar checks and that the resident self-managed the pump, but an LPN stated staff could not determine how much insulin he was administering, and the DON stated the facility did not know how much insulin he was receiving from the pump.
Dietary Preferences Not Reflected in Meal Service: A resident with DM2 and other diagnoses reported that meals were too sweet and that the facility did not provide the requested low sugar and low sodium foods noted in the chart. The physician’s order included those preferences, but the meal ticket did not reflect them, and the resident was served regular diet items such as oatmeal, fruit in light syrup, bagel, and cream cheese.
Failure to Obtain C&S Before Antibiotic Treatment for UTI: The facility did not ensure its antibiotic stewardship program included antibiotic use protocols and monitoring. Two residents were treated for UTI with antibiotics ordered from urinalysis results, but no culture and sensitivity report was obtained to identify the organism or antibiotic susceptibility. The DON stated she was unsure why the cultures were not done and acknowledged that a culture is needed to determine the organism to treat.
Pneumococcal vaccine consent was not properly documented for a resident admitted after joint replacement surgery and with a left artificial knee joint. The resident had signed a Pneumococcal Vaccine Consent form, but it did not show a date, consent for administration, or a declination. The DON stated the vaccine was not given and there was no way to determine whether the resident declined it.
The facility failed to ensure that four residents' drug regimens were free from unnecessary psychotropic drugs, as these medications were administered without corresponding diagnoses or adequate indications for use. A resident was given Lorazepam for anxiety without documented justification, while another was prescribed Quetiapine for insomnia without proper documentation. Similarly, Hydroxyzine was prescribed for anxiety without a documented diagnosis, and Duloxetine and Ambien were given without corresponding diagnoses for depression and insomnia. The lack of proper documentation highlights a deficiency in the facility's medication management practices.
The facility was cited for deficiencies in food safety and handling practices. Personal items were stored on drying racks for clean dishes, and food was improperly stored in the freezer. Staff were observed handling food unsafely, including touching food with bare hands and using unclean utensils. Interviews confirmed these actions violated facility protocols.
A facility failed to maintain proper infection control during medication administration and blood sugar monitoring for a resident. An LPN touched multiple surfaces with gloved hands before handling medications and did not perform hand hygiene between tasks. Alcohol prep pads were placed on unclean surfaces, and used lancets were improperly disposed of in regular trash cans. The DON acknowledged these practices were against facility policy.
A facility failed to document a change in condition for a resident who passed away, despite new treatments and family requests for hospice care. Nursing staff did not record any changes leading up to the resident's death, and there was a lack of communication regarding the resident's status and the family's wishes.
A resident with multiple stage 3 pressure ulcers did not receive necessary treatment according to physician orders, leading to inconsistencies in care. The facility failed to change dressings as required, with significant gaps noted between changes. Interviews revealed a lack of clarity and communication regarding treatment schedules, contributing to the deficiency in care.
A resident with multiple diagnoses, including a fractured femur and fibromyalgia, experienced severe pain that was not adequately managed by the facility. Despite high pain scores and frequent complaints, the resident's pain management plan was not reassessed or adjusted, and non-pharmacological interventions were inconsistently applied. Interviews with staff revealed communication gaps and a lack of awareness about the resident's pain issues.
A resident with hypertension was administered Metoprolol Tartrate despite having a systolic blood pressure below the physician's specified parameters. Conflicting medication orders and a lack of clarity among nursing staff led to this oversight. The DON confirmed that the medication should not have been given and that the older order should have been discontinued.
A resident was prescribed antibiotics for a UTI without a culture and sensitivity report to confirm susceptibility, violating the facility's antibiotic stewardship program. Despite abnormal urinalysis results, no culture was obtained, and the DON did not follow up with the lab. The facility's policy required review of antibiotic use, which was not followed, resulting in a deficiency.
Menu Portions Not Followed During Lunch Service
Penalty
Summary
The facility did not have menus that were prepared in advance and followed as written, as shown during the lunch meal service. The regular diet menu for 5/27/26 listed Egg Drop Soup (6 ounces), General Tso's Chicken (3 ounces), Asian Noodles (4 ounces), Oriental Blend Vegetables (4 ounces), and Mini Egg Rolls (2 each). During observation of lunch plating, the Chef served Asian noodles with tongs and the amount varied from plate to plate rather than being measured, and only one egg roll was placed on each regular diet plate. During interview, the Chef stated she was serving noodles by guessing the portion size and had been doing so for a long time. The DM stated staff should measure food servings with scoops and that menus should be followed exactly as written. The RD stated kitchen staff were expected to follow the menu's serving size and that any menu changes would have to be approved by the dietitian.
Food Storage and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial kitchen tour, multiple food items in the refrigerator and freezer were observed without dates, including celery chunks, mozzarella cheese, cheese slices, sliced roast beef, garlic bread, frozen carrots, frozen meat patties, meatballs, and tiramisu. A male kitchen staff member was also observed serving food on the tray line without wearing a hair net. On a follow-up tour, additional items were found undated, including chicken breasts in liquid, carrots in water, sliced pepperoni, and beef patties, with several frozen items open to air. Sanitation practices were also observed to be deficient during food service. A chef was seen wiping counters with a rag from the sanitation bucket, placing a strip into the solution, and continuing to use the bucket even though the strip did not change color and the solution was not at the stated 400 PPM level. Later, another chef filled a sanitation bucket without checking the sanitation level, cleaned shelves with the bucket water, kept the same gloves on while plating cake, changed gloves without performing hand hygiene, and touched multiple surfaces and resident food with gloved hands. Interviews with the Dietary Manager and Registered Dietitian confirmed that opened foods should be dated, kitchen staff should wear hairnets and beard covers, and sanitizer levels should be checked before use.
Failure to Timely Report Alleged Abuse or Neglect Incidents and Investigation Results
Penalty
Summary
The facility did not ensure that alleged violations involving abuse or neglect were reported immediately, no later than 2 hours after the allegation was made when applicable, to the State Survey Agency (SSA) and Adult Protective Services (APS), and did not ensure that the results of the investigation were reported to the SSA within 5 working days. For 3 of 42 sampled residents, the facility also did not report the alleged violations to APS. The deficiencies involved residents 48, 66, and 67. Resident 48 had diagnoses including metabolic encephalopathy, sepsis, adult failure to thrive, cataracts, vertigo, hypertension, and supraventricular tachycardia. The resident was found on the floor in the bathroom after being heard yelling out by a nurse. The nursing note documented that the resident was found lying faceup with the back in contact with the floor, with the head in the shower area and the lower body outside the shower. The resident could not bend the right leg and had pain when the nurse tried to bend it. The facility’s abuse investigation was reviewed, but no documentation was found that APS was notified of the incident, and the SSA was not notified of the investigation results. Resident 67 had diagnoses including syncope, CHF, atrial fibrillation, metabolic encephalopathy, sepsis, and ventricular tachycardia. The resident was found on the floor in the bathroom, reported hitting the back, and a bruise was observed. The resident was transferred to the hospital for evaluation. The SSA was notified 14 hours after the incident occurred, and no documentation was found that APS was notified or that the SSA received the investigation results. Resident 66 had diagnoses including periprosthetic fracture of the left hip joint, difficulty walking, and muscle wasting and atrophy. The resident was found on the floor after a loud crash was heard, with a bleeding head injury, a large laceration above the left eye and on the nose, and a skin tear to the back of the head. The resident was sent to the ER for treatment. The facility’s initial report to the SSA was approximately 28.5 hours after the incident, no APS notification was documented, and the SSA was not notified of the investigation results; the Administrator stated she could not locate an investigation for the incident.
Improper Refrigerated Storage of Medications and TB Testing Solution
Penalty
Summary
Drugs and biologicals were not stored in locked compartments under proper temperature controls, and access to the medication storage refrigerator was not maintained in a manner consistent with the facility policy. On 5/27/26, RN 3 and RN 4 observed the medication storage refrigerator at 32.5 degrees Fahrenheit, and RN 3 confirmed that the facility’s TB testing solution and residents’ overstocked medications were stored in that refrigerator. The Director of Nursing stated that the refrigerator temperature should be adjusted if it was 32.5 degrees Fahrenheit, but the temperature logs for May 2026 showed the refrigerator was documented between 32 and 35.5 degrees Fahrenheit for 25 of 25 days. The refrigerator contained multiple residents’ refrigerated medications, including Aplisol for TB skin testing and sealed bottles or pens of Latanoprost, Ozempic, Tresiba, Admelog, Humalog, Toujeo Max SoloStar, and Lantus labeled for residents 9, 10, 19, 30, 37, 59, 76, 77, 78, 79, and 80. The manufacturer instructions for these medications stated they should be stored refrigerated between 36 and 46 degrees Fahrenheit, but the recorded temperatures were below that range throughout the month. RN 4 stated that medications stored outside the manufacturer’s recommended temperature range could become less effective. During interviews, RN 3 stated that if a medication froze, the facility would call the pharmacist and follow the pharmacist’s advice. The DON later reviewed the temperature logs and stated the documented temperatures were too low and had not been communicated to her. The facility’s Medication Storage policy required drugs and biologicals to be stored in locked compartments under proper temperature controls, with only authorized personnel having access, and required refrigerated medications to be stored in a secured location.
Meal Timing and Snack Availability Deficiency
Penalty
Summary
The facility did not provide at least three meals daily with no more than 14 hours between a substantial evening meal and breakfast the following day, and there was no substantial evening snack being offered. Scheduled meal times were posted, with breakfast set for 7:30 AM to 8:30 AM, lunch for 12:00 PM to 1:00 PM, and dinner for 5:15 PM to 6:30 PM. Observation on 5/27/26 showed the first breakfast meal was served at 7:47 AM, a resident in the dining room asked at 8:51 AM whether breakfast would be served that morning, and the last breakfast meal was not served until 9:08 AM to a resident in the 100 hallway, who stated it was about time. Interviews with RN 5, CNA 3, the DON, and the Administrator showed there was no formal snack program or dedicated snack time. RN 5 stated residents could ask for snacks and that biscuits and crackers were available. CNA 3 stated snacks such as yogurt, applesauce, jello, cookies, saltine crackers, cream cheese, peanut butter, cereal, soup, and ice cream were available, but snacks were not given out unless requested. The DON stated snacks were available in the dining room and that CNAs should chart when they gave a resident a snack, while the Administrator stated she was not sure who was responsible for providing snacks and was not sure how dementia residents were made aware of snack availability.
Infection Control Failures in Hand Hygiene, EBP, and TB Screening
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During lunch service, a CNA was observed assisting residents in the dining room while wearing gloves and touching multiple surfaces and residents without changing the gloves. Another CNA delivered meal trays to residents, repositioned a resident in a recliner, exited the room without performing hand hygiene, and then picked up another tray and entered a second resident’s room. The same CNA was also observed delivering a tray, opening crackers for a resident, and moving a resident in a wheelchair without performing hand hygiene. The DON stated that staff should perform hand hygiene anytime they touch a patient or the patient’s personal space, should change gloves after assisting a patient, and should perform hand hygiene after exiting a resident room after delivering a meal tray. Enhanced Barrier Precautions were not being implemented as ordered for residents with indwelling medical devices. One resident had a urinary catheter and a care plan intervention for EBP, yet no EBP sign or PPE was observed at the room. Another resident with diagnoses including hydronephrosis, ureteral stricture, presence of urogenital implants, and UTI had an order for EBP due to a wound or indwelling medical device, but PPE was not observed at the room and the resident stated staff do not wear gowns when providing care. A third resident with infection and inflammatory reaction due to an indwelling urethral catheter, UTI, and sepsis also had EBP orders and a care plan intervention, but no PPE was observed at the room. Staff interviews reflected inconsistent understanding of EBP requirements, including when to use gowns, gloves, and masks, and one RN was observed in a resident’s room without a gown or mask while administering eye drops and adjusting the catheter bag. The facility’s TB screening process for new admissions was inaccurate because the PPD testing solution was stored in a medication refrigerator that was below the manufacturer’s required temperature range. The refrigerator thermometer was observed at 32.5 degrees Fahrenheit, and the temperature logs for the month showed 25 of 25 days documented between 32 and 35.5 degrees Fahrenheit. The Aplisol manufacturer instructions stated it should be stored at 36 to 46 degrees Fahrenheit and not frozen, and that improper storage may result in loss of potency and inaccurate test results. The DON stated the temperatures were too low and that if the PPD solution was compromised, TB skin test results would be inaccurate. Staff stated that new admissions received two-step TB skin testing and that the PPD solution in the medication refrigerator was the only solution available in the facility.
Controlled medications from two residents were diverted by an RN
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money when a staff RN diverted controlled medications belonging to two residents. Resident 68 was admitted with diagnoses including a right humerus fracture, pneumonia, and dementia, and had orders for Pregabalin and oxyCODONE for pain. Resident 73 was admitted with diagnoses including multiple left rib fractures, a left clavicle fracture, a history of traumatic brain injury, and cognitive communication deficit, and had an order for oxyCODONE-acetaminophen for pain. On 1/15/26, the State Survey Agency received a facility-reported incident stating that an RN was stopped by police after leaving work and was found in possession of medications from the facility in the names of the two residents. The facility stated the medications were returned and that the residents did not miss doses. The incident involved Resident 68’s Pregabalin and oxyCODONE and Resident 73’s oxyCODONE, which had been removed from the facility while the RN was working the night shift. The DON stated that prior to the incident, narcotic counts were based on reconciling the narcotic log sheet and manually counting individual contents in blister cards or patches, but the total units of narcotics in the cart were not manually counted. The DON also stated that discontinued narcotics were kept in the medication cart until collected for destruction, and staff did not notice the missing medications for Residents 68 and 73 during shift change counts because the corresponding narcotic log sheets were also absent.
Inadequate Monitoring of Trazodone for Sleep
Penalty
Summary
The facility did not ensure adequate monitoring for a resident who was given a psychotropic medication. Resident 60 was admitted with diagnoses including obstructive sleep apnea, anxiety disorder, and insomnia. A physician ordered trazodone 50 mg at bedtime for sleep/anxiety, and then ordered documentation of the number of hours of sleep per shift twice daily. On review of the May 2026 TAR, the hours of sleep were not documented on 5/24/26 and 5/25/26. During an interview, the DON stated that trazodone required monitoring for adverse side effects and hours of sleep to ensure there were no interruptions of sleep throughout the night, that monitoring began when the resident was admitted, and that the resident’s hours of sleep were not charted until 5/26/26. The DON stated she did not know why the hours of sleep were not documented and that the missed documentation was overlooked during her double checks.
Failure to Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility did not ensure that an alleged violation of neglect was thoroughly investigated for Resident 66. Resident 66 was admitted with diagnoses including periprosthetic fracture of the left hip joint, difficulty walking, and muscle wasting and atrophy. On 7/22/25, the resident was found on the floor after a loud crash was heard, and the resident sustained a fall with a bleeding laceration to the head, including a large laceration above the left eye, a laceration on the nose, and a skin tear to the back of the head. The resident was transferred to the ER for treatment, and the spouse was present in the room at the time of the incident. During record review and interviews, the administrator was unable to locate an investigation into the resident’s fall and alleged neglect. A document related to the fall was found, but it was not identified as the investigation. The administrator stated that incidents were reported to her and that investigations would include interviews with staff, residents, and witnesses, along with a written summary submitted to the SSA within 5 days of the incident, but no evidence of such an investigation for this event was available in the record.
Missing transfer documentation for ER transport
Penalty
Summary
The facility did not document in Resident 48’s medical record the information that was provided to the receiving provider when the resident was transferred to the Emergency Room. Resident 48 was admitted with diagnoses including metabolic encephalopathy, sepsis, adult failure to thrive, cataracts, vertigo, hypertension, and supraventricular tachycardia. After the resident was heard yelling out and found lying faceup on the floor with the head in the shower area and the lower body outside the shower, the nurse documented that the resident could not bend the right leg and had pain when the leg was moved. The resident was told she needed to go to the hospital for evaluation of the right hip and was transported by EMS to the ER at the husband’s choice of hospital. The nursing progress note documented the fall and transfer, but it did not include the information sent with EMS to the receiving provider. The discharge/transfer summary later documented that the resident was transferred to the hospital and included the diet order, last bowel movement, ADLs, bed hold policy, and a summary of the incident, along with a note that medication/treatment flowsheets were given upon discharge. The discharge summary was completed almost 6 hours after the resident had already been transferred to the ER. The DON stated that staff should send the resident’s facesheet, POLST, current doctor’s orders, and a note of why the resident was sent out, and stated that the information sent to the receiving provider was not documented anywhere in Resident 48’s medical record.
Failure to Provide Ordered Dining Assistance
Penalty
Summary
The facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless the resident's clinical condition made such diminution unavoidable. Resident 11 had diagnoses including dementia, hallucinations, Parkinson's disease, and Alzheimer's disease, and a MDS assessment showed a BIMS score of 09, indicating moderate cognitive impairment. The MDS also indicated that the resident required setup or clean up assistance with dining, and the diet order directed that food be cut up and finger foods be offered when available. During lunch, Resident 11 was served turkey that was not diced or cut up. The resident had difficulty eating, with shaking hands and inability to bring the fork to the mouth, while staff were present but did not offer dining assistance. The resident continued to eat with difficulty, did not use assistive eating devices such as built-up utensils or a lipped plate, and later told staff he was finished after consuming 50% of the meal. During breakfast the next day, the resident was served pancakes, eggs, and bacon, and only the pancakes were cut up, while staff again were present but did not offer dining assistance.
Failure to Implement Ordered Skin Care and Pressure Relief Measures
Penalty
Summary
The facility did not ensure that Resident 54 received treatment and care in accordance with orders, the comprehensive care plan, and the resident’s preferences after the resident developed skin breakdown at the facility. Resident 54 was admitted with diagnoses including fracture of the right lower leg, orthopedic aftercare, type 2 diabetes mellitus, and muscle wasting and atrophy. The resident was identified as at risk for pressure ulcers with a Braden score of 16, and orders were entered for zinc/Venelex mixture to the bilateral buttocks, treatment for redness and soreness in the groin area, and an air overlay to the bed to alleviate pressure to bony prominences. Although the air overlay order was initiated, the treatment administration record showed checks on two days indicating the overlay was functioning properly, but survey observation found the resident’s bed did not have an air mattress overlay in place. The resident was observed with skin issues to the buttocks/intergluteal cleft, and the skin issue note documented a new in-house moisture associated skin damage wound with blanchable erythema, dry peeling skin, and excoriation. The care plan addressed risk for alteration in skin integrity, but no interventions were identified for the moisture associated skin damage of the buttocks. Staff interviews showed CNA and LPN awareness of skin concerns, and the DON stated the air mattress should have been placed when ordered and that the TAR checks did not mean staff actually verified the overlay was on and functioning.
Unmonitored self-administered insulin pump regimen
Penalty
Summary
The facility did not ensure that Resident 54’s drug regimen was free from unnecessary drugs because the resident’s insulin administration through his Omnipod insulin pump was not adequately monitored. Resident 54 was admitted with diagnoses including fracture of the right lower leg, orthopedic aftercare, type 2 diabetes mellitus, and muscle wasting and atrophy. During interviews, Resident 54 stated that his blood sugars at the facility were terrible, that his insulin was infused through the Omnipod pump, that he changed the pump himself every 3 days, and that he monitored his blood sugars and adjusted his insulin accordingly. He also stated that he did not tell the nurses how much insulin he had administered. Record review showed orders for the resident to manage his own insulin pump, change the Omnipod every 3 days as needed, have blood sugars printed for MD review every Sunday night shift, and receive finger stick blood sugar checks before meals and at bedtime. The MAR documented blood sugar checks at 7:00 AM, 11:00 AM, 4:00 PM, and 9:00 PM, and a check mark for the resident managing his own insulin pump and changing it every 3 days. An LPN stated there was no way to determine how much insulin the resident was self-administering, and the DON stated the facility did not have the equipment to manage the pump refill and did not know whether staff were tracking how much insulin the resident was getting from the pump.
Dietary Preferences Not Reflected in Meal Service
Penalty
Summary
The facility did not provide each resident with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs, taking into consideration resident preferences. For 1 of 42 sampled residents, Resident 54, who had diagnoses including type 2 diabetes mellitus, fracture of the right lower leg, orthopedic aftercare, and muscle wasting and atrophy, the facility did not provide the requested low sugar and low sodium food preferences that were documented in the medical record to help manage diabetes. Resident 54 stated that the facility did not provide a diabetic diet and that breakfast items such as oatmeal were too high in sugar for him to eat. The physician’s order was for a regular diet with regular texture and thin consistency, with special instructions noting a preference for low sugar and low sodium foods and beverages. However, the meal ticket did not include those preferences, and the resident was served items including a fruit bowl and bagel with cream cheese; the dietary manager stated the kitchen was not aware of the low sugar or low sodium preference and that the resident was served a regular diet. The dietary manager also stated the tropical fruit blend served was in light syrup and contained 20 grams of sugar per 1/2 cup.
Failure to Obtain Culture and Sensitivity Before Treating UTIs
Penalty
Summary
The facility did not ensure that its antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Based on interview and record review, the facility prescribed antibiotic therapy for urinary tract infections for 2 of 42 sampled residents without obtaining a culture and sensitivity report to identify the organism and determine which antibiotic it was susceptible to. The facility policy on Antibiotic Stewardship Surveillance stated that all clinical infections treated with antibiotics would undergo review by the infection preventionist and that antibiotic data would be used to guide individual resident antibiotic prescribing practices. Resident 74 was admitted with diagnoses including methicillin susceptible staphylococcus aureus infection classified elsewhere and a UTI. A urinalysis with culture was obtained and documented abnormal urine nitrite and trace blood, but the lab result form had a handwritten order for Macrobid 100 mg by mouth twice a day for 5 days, and the MAR documented administration for UTI from 3/6/26 through 3/10/26. The DON stated the lab indicated not to do a culture and she did not know why it was not done, and there was no documentation from the nurse explaining why the culture was not obtained. Resident 75 was admitted with a diagnosis of UTI. A urinalysis documented abnormal urine nitrite, protein greater than 300, and trace ketones, and the lab result form had a handwritten order for Cefdinir 300 mg by mouth twice a day for 7 days. The MAR documented administration for UTI from 3/3/26 through 3/9/26. The DON stated she was not sure why a culture was not obtained and that there should be a culture to determine the organism to treat.
Pneumococcal Vaccine Consent Not Documented
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after it was determined that the facility did not ensure residents were offered the pneumococcal immunization unless medically contraindicated or declined. For Resident 12, who was admitted with diagnoses including aftercare following joint replacement surgery and presence of a left artificial knee joint, the medical record contained a signed Pneumococcal Vaccine Consent form. However, the form did not include a date, did not document consent for administration of the vaccine, and did not document a declination of the vaccine. During an interview on 5/28/26 at 10:12 AM, the DON stated that the pneumococcal vaccine was not administered to Resident 12 and that there was no way to determine whether the resident declined the vaccination.
Inadequate Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the drug regimens for four residents were free from unnecessary psychotropic drugs, as these medications were administered without corresponding diagnoses or adequate indications for use. Resident 30, who was admitted with multiple diagnoses including heart failure and chronic respiratory failure, was given Lorazepam for anxiety without documented justification. The resident was reported to be cognitively intact and had no documented change in condition that would warrant the use of this medication. The Director of Nursing (DON) acknowledged the lack of documentation for the anti-anxiety medication order. Resident 83 was prescribed Quetiapine Fumarate initially for depression and then for insomnia, but the facility did not provide adequate documentation to support the use of this medication for insomnia. The DON stated that the diagnosis of insomnia was appropriate for the off-label use of Quetiapine, but there was no clear documentation linking the medication to a specific diagnosis. Similarly, Resident 136 was prescribed Hydroxyzine for anxiety without a documented diagnosis of anxiety disorder, and the DON confirmed the absence of a corresponding diagnosis in the medical records. Resident 139 was given Duloxetine for depression and Ambien for sleep, yet there was no documentation of a diagnosis of depression or insomnia in the resident's medical records. The DON noted that the resident was on these medications at home and had requested the continuation of Ambien, but the facility failed to document a corresponding diagnosis. The lack of proper documentation and justification for the use of these psychotropic medications highlights a deficiency in the facility's medication management practices.
Deficiencies in Food Safety and Handling Practices
Penalty
Summary
The facility was found to have several deficiencies in food storage, preparation, and service, which did not adhere to professional standards for food service safety. Observations revealed that personal items such as cellphones and a bluetooth speaker were stored on a drying rack meant for clean dishes and utensils. In the kitchen freezer, food items like blueberries were improperly stored with open packaging, and boxes of coconut cream pies and breadsticks were placed directly on the floor. Additionally, the servery area had food splatters on the ceiling tiles above food preparation areas, indicating a lack of cleanliness. During meal service, staff members were observed handling food in an unsanitary manner. The Head Certified Nursing Assistant (CNA) was seen touching food with bare hands, including using her finger to move peas on a resident's plate and allowing her earpiece to fall into a plate of pasta before serving it. Furthermore, an ice cream scoop was improperly rinsed and reused without proper cleaning. Interviews with the Head CNA and Dietary Manager confirmed that these practices were against the facility's protocols, which require the use of gloves when handling food and proper cleaning of utensils between uses.
Infection Control Lapses During Medication and Blood Sugar Monitoring
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Licensed Practical Nurse (LPN) during medication administration and blood sugar monitoring for Resident 85. The LPN was observed touching multiple surfaces, including the medication cart and computer equipment, with gloved hands before handling medications directly with the same gloves. This practice was contrary to the facility's policy, which emphasized hand hygiene as the primary means to prevent infection spread. The LPN did not change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. During the blood sugar monitoring process, the LPN made four attempts to obtain a reading, changing gloves between attempts but failing to perform hand hygiene. Alcohol prep pads were placed on unclean surfaces, such as the resident's bedside table and the glucose monitor, before use. Additionally, used lancets were improperly disposed of in regular trash cans instead of sharps containers, further violating infection control protocols. Resident 85, who had multiple medical conditions including diabetes and a recent orthopedic procedure, was at risk due to these lapses in infection control. The Director of Nursing acknowledged the improper practices, noting that medications should not be touched with gloved hands after touching other surfaces, and that used lancets must be disposed of in sharps containers. The facility's hand hygiene policy, last revised in 2019, was not adhered to during these observed incidents.
Failure to Document Change in Condition Before Resident's Death
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, as evidenced by the lack of documentation regarding a change in condition prior to the resident's passing. The resident, who had a history of diverticulitis, heart failure, and chronic respiratory failure, was admitted to the facility and passed away with no documented change in condition. On the day before the resident's death, a physician's note indicated that the resident was stable and showing improvement, with ongoing supportive care planned. Nursing progress notes from the day before the resident's death indicated that the resident was alert, oriented, and did not exhibit any immediate signs of distress. However, the next nursing note, recorded in the early hours of the following day, simply noted that the resident's vitals had ceased, with no documentation of any change in condition leading up to this event. Interviews with the nursing staff revealed that there was an expectation to document changes in condition, but there was a lack of clarity and communication regarding the resident's status and the family's wishes. The Director of Nursing confirmed that there was no documentation of a change in condition, despite the initiation of new treatments such as a nebulizer and Lasix, and the family's request for hospice care. The lack of documentation and communication regarding the resident's condition and the family's wishes contributed to the deficiency, as the facility did not adhere to professional standards of practice in monitoring and documenting the resident's condition and care.
Inadequate Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. The resident, who was admitted with multiple stage 3 pressure ulcers, did not receive wound care according to physician orders. There was a discrepancy between the physician's orders and the wound clinic's orders, leading to inconsistencies in the treatment provided. The resident's dressings were not changed as frequently as required, with significant gaps in care noted between dressing changes. The resident, who had a history of chronic foot wounds and was diagnosed with conditions including osteomyelitis, diabetes mellitus, and severe sepsis, was observed with both feet wrapped in dressings that lacked proper dating. Interviews with nursing staff revealed a lack of clarity and communication regarding the resident's treatment schedule and shower days, which were supposed to coincide with dressing changes. The facility's documentation showed that the resident's dressings were not changed according to the prescribed schedule, with some dressings left unchanged for up to five days. Interviews with the Director of Nursing and the Wound Nurse indicated that there was a breakdown in the process of updating and following treatment orders. The facility's policy required systematic assessment and treatment of pressure injuries, but the execution of these policies was inadequate. The failure to adhere to the treatment schedule and the lack of proper documentation and communication among staff contributed to the deficiency in care for the resident's pressure ulcers.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 83, who was admitted with multiple diagnoses including a displaced fracture of the right femur, fibromyalgia, and other chronic conditions. Despite the resident's complaints of severe and uncontrolled pain, the facility did not reassess her pain effectively or adjust her pain management plan according to her needs. The resident reported experiencing significant pain in her right leg and back, which was not adequately addressed by the facility's staff. The resident's medical records indicated that she was on as-needed pain medication, specifically Hydrocodone-Acetaminophen, but there were no scheduled pain medications provided. The resident frequently reported high pain scores, often reaching 8 out of 10, and expressed that her pain interfered with her sleep and daily activities. Despite these reports, the facility did not implement non-pharmacological interventions consistently or reassess the effectiveness of the pain management plan. Interviews with facility staff, including CNAs and LPNs, revealed a lack of communication and follow-up regarding the resident's pain complaints. The Director of Nursing was unaware of the resident's ongoing pain issues, and there was no evidence of physician notification or adjustment of the pain management plan. The facility's failure to adhere to its own pain management protocol resulted in inadequate care for the resident, as her pain was not effectively managed or reassessed in a timely manner.
Inadequate Monitoring of Resident's Drug Regimen
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen, resulting in the administration of a medication outside the parameters set by a physician's order. Resident 24, who was admitted with diagnoses including an intertrochanteric fracture of the left femur, a fracture of the lower end of the left radius, essential hypertension, and hyperlipidemia, was involved in this incident. The resident had a physician's order for Metoprolol Tartrate, which specified that the medication should be held if the systolic blood pressure was less than 100 or the apical pulse was less than 60. Additionally, there was another order to hold the medication if the systolic blood pressure was less than 90 and/or the diastolic blood pressure was less than 50, with instructions to notify the physician if the medication was held for three consecutive doses. On January 5th, 2025, the resident was administered Metoprolol Tartrate despite having a systolic blood pressure of 96, which was below the specified parameter. Interviews with nursing staff revealed confusion regarding which order to follow when there were conflicting parameters. The Director of Nursing confirmed that the medication should not have been administered and that the older order should have been discontinued when the new order was placed. This oversight in medication administration highlights a deficiency in the facility's process for managing and updating physician orders, leading to the inappropriate administration of medication to Resident 24.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that its antibiotic stewardship program included appropriate protocols and a system to monitor antibiotic use for one resident. The resident, who was admitted with multiple diagnoses including a urinary tract infection (UTI), was prescribed antibiotics without a culture and sensitivity report to confirm the organism's susceptibility to the prescribed medication. Initially, the resident was given Bactrim for five days, followed by Cefdinir, which was not completed due to the resident's discharge. Despite abnormal urinalysis results indicating a potential infection, no culture was obtained to verify the need for the antibiotics. The Director of Nursing (DON) acknowledged that the laboratory did not perform a culture and sensitivity test, and there was no follow-up to determine why the test was not conducted. The facility's infection control log noted that a culture was not obtained because it did not meet the laboratory's criteria, but the DON did not verify this with the lab. The facility's policy on antibiotic stewardship required review of antibiotic use to ensure appropriateness, but this was not adhered to in this case, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 112 citations issued within 25 miles in the last 12 months — including the 2 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 Layton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Mountain Care- Clearfield | 2.8 mi | ★★★★★ | 6 | 0 |
| Thatcher Brook Rehabilitation & Care Center | 3.7 mi | ★★★★★ | 0 | 0 |
| Pine View Transitional Rehab | 5.2 mi | ★★★★★ | 0 | 0 |
| Mountain View Health Services | 5.5 mi | — | 14 | 1 |
| South Ogden Post-acute (cascades At South Ogden) | 5.9 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.