Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Deer Meadows Rehabilitation And Nursing during CMS and state inspections, most recent first.
Facility staff did not ensure that medical provider orders, including medication, laboratory, and wound care orders, were signed by the prescribing provider for two residents. This included unsigned orders for blood tests, medications, and antipsychotic injections, with facility leadership confirming the lack of required provider signatures.
Facility staff did not obtain laboratory tests as ordered for two residents. One resident's urinalysis was not completed due to a specimen issue, and the provider did not reorder the test. Another resident with multiple diagnoses had a physician's order for several lab tests, but not all were completed as ordered, and the facility's policy on laboratory services was not followed.
Facility staff did not document investigation or resolution for four grievances, including one from a family member regarding concerns about urine appearance, wound care, and housekeeping. Required sections for investigation, corrective actions, and responses to complainants were left blank, and staff confirmed no additional information was available. This failure to follow the facility's grievance policy was confirmed through record review and staff interviews.
A resident admitted with an indwelling urinary catheter for neurogenic bladder did not have personal hygiene related to catheter care addressed in their baseline/admission care plan. Although the care plan noted the presence of the catheter, it lacked specific interventions for catheter hygiene. Interviews confirmed the omission, and the facility did not have a dedicated policy for catheter care, relying instead on external professional references.
A resident with an indwelling urinary catheter and intact cognition was admitted with orders for catheter care, but the comprehensive care plan failed to include interventions for personal hygiene or catheter care. Staff interviews confirmed the omission, and the facility lacked a specific policy for catheter care, relying instead on a professional reference for guidance.
Facility staff did not follow up on a resident's emergency department visit as directed, failing to obtain and review discharge documentation and to ensure follow-up on urine cultures. Additionally, staff did not consistently document the resident's urine output as ordered for an indwelling urinary catheter, with multiple shifts lacking required entries.
Facility staff did not consistently assess or provide treatment for a resident's sacral wound and left heel deep tissue injury, failing to document wound conditions, remove dressings for proper assessment, or ensure timely and consistent wound care as required by facility policy.
Facility staff did not ensure a resident with a surgical foot wound received consistent wound VAC care as ordered, with missing provider orders, lack of documentation of wound care on certain dates, and no evidence of required provider consultation. This resulted in a failure to follow facility policy for wound treatment management.
A resident with an indwelling urinary catheter did not receive appropriate catheter care from admission, as the care plan lacked hygiene interventions and there was no order for Foley care every shift until months later. Facility staff confirmed the absence of a catheter care policy, and catheter care was not documented until the order was established.
Facility staff failed to obtain a proper psychological evaluation before diagnosing a resident with schizoaffective disorder and starting antipsychotic medication. Invega was ordered and administered without evidence of non-pharmacological interventions or gradual dose reduction attempts. Additionally, staff did not document the resident's behaviors as required, and leadership confirmed the absence of both behavior monitoring and a psychological evaluation.
A resident with moderate cognitive impairment did not receive prescribed IV antibiotics as ordered due to issues with a PICC line and gaps in documentation. Despite alternate orders and eventual confirmation of PICC line placement, several doses of Ertapenem were not administered, and there was no documentation for Cubicin administration during the affected period.
Facility staff conducted a urinalysis for a resident without first obtaining a physician's order, despite the resident being cognitively intact and having multiple medical diagnoses. Review of clinical records and facility policy confirmed that the required practitioner order was missing prior to the laboratory test.
Facility staff did not maintain complete and accurate clinical records for a resident, as wound assessment details and wound care orders were either missing from the official record or lacked specificity regarding which wounds were being treated. Wound assessment information was found outside the clinical record, and wound care orders did not identify the specific wounds, contrary to facility policy.
The facility failed to document dietary staff training in safe food handling. A review showed that 12 dietary staff members lacked orientation documentation, and nine lacked safe food handling training records. The RFSD admitted there were no written policies for dietary staff orientation and training. Several days were identified where no trained dietary staff were scheduled.
The facility failed to properly dispose of and contain garbage and waste, as observed by surveyors. A dumpster was found with doors partially open and garbage hanging out, while medical gloves and foam containers littered the ground nearby. A garbage bag with adult briefs was in a lidless dumpster, and a cooking grease barrel was not fully closed. These issues were contrary to the facility's waste disposal policy.
The facility staff failed to provide adequate care for five residents, including not documenting a nurse assessment after a fall, not assessing a resident during a change in condition, and not following bowel protocols for two residents. Additionally, a physician's order to remove surgical staples was missed. These deficiencies were confirmed by the facility's clinical leadership during the survey.
The facility failed to provide a bed hold policy to five residents during hospital transfers, despite varying cognitive impairments. The policy requires a written notice to be given at transfer, but no documentation was found in the residents' files. The issue was discussed with the facility's administration, but no additional information was provided.
The facility staff failed to review and revise care plans for several residents and did not involve them in planning their care. Residents reported not attending care plan meetings, and records confirmed the lack of invitations and attendance. Additionally, a resident's care plan did not address medication use for blood clot prevention. The facility's policies required comprehensive care plans to be reviewed by the interdisciplinary team and involve the resident or their representative, but these were not met.
The facility staff failed to act on pharmacy recommendations for four residents, leading to deficiencies in medication regimen reviews. A resident's pharmacy recommendations were not documented, another's drug regimen review was not acted upon, and two residents' medication adjustments were delayed. Additionally, a resident's AIMS assessment was not completed. These actions violated the facility's policy requiring staff to act on pharmacist recommendations.
A medication cart was found unattended and unlocked in a hallway, with the responsible LPN not in line of sight, contrary to the facility's medication storage policy. The issue was discussed with the facility's leadership team.
Facility staff used incorrect serving utensil sizes, leading to deficiencies in meeting residents' dietary needs. A DSM used a 3 oz. utensil for corn and a 4 oz. utensil for mechanical soft pizza, instead of the required 4 oz. and 6 oz. utensils. Another DSM used a 3.25 oz. utensil for buttered noodles, instead of the correct 4 oz. utensil. These issues were discussed with the facility's leadership.
The facility's dietary staff failed to follow menus and recipes, serving unwashed lettuce with incorrect ingredients, cake without icing, and mashed potatoes instead of buttered noodles due to supply and preparation issues. These discrepancies were confirmed by the Dietary Manager and discussed with facility administration.
The facility failed to provide palatable and attractive food, as evidenced by improperly maintained food temperatures and poor meal presentation. Residents reported dissatisfaction, noting that cookies were placed directly on vegetables, causing them to become soggy. The facility's food preparation policy was not followed, leading to repeated discussions with facility leadership.
The facility failed to maintain proper food safety and hygiene practices. Dietary staff did not wear required beard covers, and several food items were improperly stored or expired. A resident's pudding was found curdled and dated over two weeks prior. Serving bowls were stored improperly, and a staff member used an incorrect method to clean a food thermometer.
The facility staff failed to ensure that two residents and/or their representatives were given the opportunity to develop an advanced directive. One resident had moderate cognitive impairment, while the other had intact cognition. In both cases, there was no documented evidence that the facility staff addressed the residents' or representatives' desire to formulate an advanced directive. The Director of Social Services acknowledged the lack of documentation.
The facility failed to document and communicate necessary information during the transfer of two residents to a hospital. One resident with severe cognitive impairment was sent for evaluation due to a blood clot, but no transfer form or essential information was documented. Another resident with mild cognitive impairment was found unresponsive and sent to the ER, yet no transfer form or documentation was provided. The facility staff could not produce the required documentation during the survey.
The facility failed to provide written transfer notices to three residents or their representatives, as required by policy. One resident with moderate cognitive impairment and two others with intact or borderline cognition were transferred to a hospital without receiving the necessary documentation. The absence of written notices was confirmed by the ADON and discussed with the facility's leadership during the survey.
A facility failed to conduct a PASRR screening for a resident with schizoaffective disorder and depression, who was approved for a short-term stay without further review. The resident exhibited behaviors such as hitting fists on a table and cursing loudly. The oversight was acknowledged by the social worker, who was not employed at the time of the incident. The deficiency was discussed with the facility's leadership.
A facility failed to implement a baseline care plan for a resident with a PASRR Level I Screen indicating serious mental illness or intellectual disability. The care plan lacked necessary PASRR information, despite facility policy requiring such details. This omission was confirmed by facility leadership during a survey review.
The facility failed to implement comprehensive care plans for two residents. One resident on anticoagulants was not reported to a physician for hematuria, despite care plan instructions. Another resident with severe cognitive impairment did not receive the planned activity engagement, with limited documentation of participation. These deficiencies were discussed with facility staff, but no additional information was provided before the exit conference.
Two residents did not receive a person-centered activity program as per their care plans, with inconsistent activity provision and lack of documentation. One resident, with severe cognitive impairment, and another, cognitively intact, both had limited engagement in activities, contrary to facility policy.
A resident's prescribed Lidocaine Pain Relief patch was unavailable, prompting staff to obtain an alternative order for a Menthol Pain patch. This deficiency was noted during a medication administration observation and discussed with facility leadership, highlighting a lapse in maintaining adequate medication supplies.
A facility failed to ensure a correct diagnosis for a resident's psychotropic medication. The resident was prescribed Aripiprazole for delirium with manic/psychotic symptoms without supporting documentation. A consultant pharmacist's recommendation for diagnosis review was unclear, and later documentation indicated a different diagnosis of depression with mood disorder. The issue was discussed with the facility's administrative staff.
A facility failed to maintain a medication error rate below 5%, with errors affecting a resident who received incorrect doses of fluticasone nasal spray and furosemide tablets. The resident, with intact cognition, was administered one 40 mg tablet of furosemide instead of two, and one spray of fluticasone per nostril instead of two, during a medication pass by an LPN.
A resident's DDNR form was found incomplete, lacking certification of the resident's decision-making capability and authority for the DDNR issuance. The MDS assessment showed moderate impairment in decision-making. Facility policy requires accurate and complete documentation, which was not adhered to in this case.
An LPN failed to perform hand hygiene between administering medications to two residents. The LPN handled items on a resident's bedside table and then prepared medications for another resident without washing hands. The facility's policy requires hand hygiene before and after administering medications, which the LPN acknowledged not following. The issue was discussed with the facility's administration.
Failure to Obtain Provider Signatures on Medical Orders
Penalty
Summary
Facility staff failed to ensure that medical provider orders were signed by the ordering provider when entered into residents' clinical records by non-prescribing staff. For one resident with moderate cognitive impairment, multiple orders—including laboratory tests, medication prescriptions, and wound care instructions—were not signed by the prescribing medical provider. The Director of Nursing confirmed that some wound care orders remained unsigned, and facility policy required that verbal orders be signed by the provider at the next visit or within a specified timeframe. Additionally, for another resident, staff did not ensure that several orders for an antipsychotic medication were signed by the nurse practitioner who prescribed them. The orders, which included both one-time and recurring intramuscular injections, lacked the required provider signatures. The Director of Nursing and Regional Director of Clinical Services acknowledged the absence of signatures on these orders, and the nurse practitioner and medical director involved were no longer employed at the facility.
Failure to Obtain Ordered Laboratory Tests for Two Residents
Penalty
Summary
Facility staff failed to obtain laboratory tests as ordered by medical providers for two residents. For one resident with moderate cognitive impairment, a urinalysis was ordered but not completed due to a specimen issue, as documented by the laboratory. The clinical record did not contain results for the test, and the medical provider signed the laboratory report without reordering the test. The facility's policy requires timely provision or obtaining of laboratory services as ordered by a provider, but this was not followed in this instance. For another resident who was cognitively intact and had diagnoses including schizoaffective disorder and type 2 diabetes mellitus, there was a physician's order for multiple laboratory tests to be performed on admission or the next lab day. The order was active for a period, and while some lab tests were documented as obtained, the clinical record did not contain reports for all dates indicated in the medication administration record. The regional director of clinical services clarified that the lab orders should have been entered for three days and then discontinued, but the physician's order was not followed as written. The facility's policy on laboratory services was not adhered to in both cases.
Failure to Investigate and Resolve Resident and Family Grievances
Penalty
Summary
Facility staff failed to provide evidence of investigating and resolving four documented grievances, as required by their own grievance policy. One grievance, submitted by a family member on behalf of a resident, included concerns about urine appearance, wound care, and housekeeping. The grievance form lacked documentation in the sections for investigation, analysis, corrective actions, and response to the complainant. Staff interviews confirmed that no additional information or evidence of follow-up was available for this grievance. Additionally, three other grievances were identified with incomplete documentation, specifically missing entries for investigation, analysis, corrective actions, and responses to the individuals who lodged the grievances. These deficiencies were confirmed through review of facility records and staff interviews, including discussions with the Social Worker, Regional Director of Clinical Services, and Administrator. The facility's policy requires prompt investigation and written or verbal responses to grievances, but these steps were not documented or completed for the four grievances in question.
Failure to Address Catheter Care in Baseline Admission Care Plan
Penalty
Summary
Facility staff failed to ensure that a baseline/admission care plan addressed personal hygiene related to indwelling urinary catheter care for one resident. The resident was admitted with an indwelling urinary catheter due to a diagnosis of neurogenic bladder. Although the baseline/admission care plan noted the presence of the catheter, it did not include specific interventions for personal hygiene related to catheter care. The resident's Minimum Data Set (MDS) assessment indicated intact cognition, and the resident was able to make self understood and understand others. Interviews with the Director of Nursing (DON) confirmed that the baseline/admission care plan discussed personal hygiene in general but did not specifically address catheter-related hygiene. The Regional Director of Clinical Services (RDCS) reported that the facility did not have a policy for indwelling urinary catheter care and instead relied on a professional reference for guidance. The survey team found that the facility's policy required baseline care plans to include the minimum healthcare information necessary to properly care for a resident, but this was not met in the case of the resident with the indwelling catheter.
Failure to Address Catheter Care in Comprehensive Care Plan
Penalty
Summary
Facility staff failed to ensure that a comprehensive care plan addressed personal hygiene related to indwelling urinary catheter care for one resident. The resident was admitted with a diagnosis of neurogenic bladder and had physician orders for an indwelling urinary catheter. The resident's Minimum Data Set (MDS) assessment documented the presence of the catheter and indicated that the resident had intact cognition and was able to communicate effectively. Despite this, the comprehensive care plan only noted the presence of the catheter and did not include specific interventions for personal hygiene or catheter care. Interviews with the Director of Nursing (DON) confirmed that the care plan lacked details on urinary catheter care, even though facility expectations were for catheter care to be performed at least daily, with actual orders specifying care every shift. The facility did not have a specific policy for indwelling urinary catheter care and instead relied on a professional reference, which recommended cleaning the catheter area with soap and water during daily bathing. The deficiency was identified through staff interviews and clinical record review, and was discussed with facility leadership.
Failure to Follow-Up on ED Visit and Monitor Urine Output
Penalty
Summary
Facility staff failed to provide appropriate follow-up and documentation for a resident who returned from an emergency department visit. After the resident was seen in the emergency department for fatigue, discharge instructions directed a follow-up with a nurse practitioner regarding urine cultures. However, there was no documentation in the clinical record indicating when the resident returned to the facility, nor evidence that staff obtained or reviewed the emergency department documentation in a timely manner. The Director of Nursing confirmed that only an EKG was initially found and that staff did not attempt to obtain the full emergency department records or follow up on the urine cultures as instructed. Additionally, the resident had medical orders for an indwelling urinary catheter with urine output to be documented every shift. Review of the clinical record revealed that staff failed to document urine output for at least nine shifts over a two-week period. This lack of documentation was confirmed during interviews with facility leadership, who acknowledged the absence of required nursing notes and monitoring as ordered by the medical provider.
Failure to Consistently Assess and Treat Pressure Ulcers
Penalty
Summary
Facility staff failed to consistently assess and provide treatment for pressure areas in one resident, specifically neglecting to document and address a sacral wound and a left heel deep tissue injury. Skin assessments conducted on two occasions noted a covered sacral wound but did not include any description of the wound's condition or appearance, nor was there evidence that the dressing was removed to assess the underlying skin. The facility's own policies require detailed documentation and assessment of wounds, including removal of dressings and description of wound characteristics, which was not followed in this case. Additionally, there were no care orders for the sacral area at the time of the resident's admission, and the first documentation of the open area was only made after a change in the resident's condition. The resident's clinical records also showed lapses in the provision and documentation of wound care. Orders for treatment of the left heel deep tissue injury were delayed, and treatment administration records did not provide evidence that care was consistently given to the left heel or coccyx wounds on specific dates. These failures were confirmed by facility leadership during interviews, who acknowledged that assessments and treatments were not performed or documented as required by facility policy.
Failure to Provide and Document Physician-Ordered Wound VAC Care
Penalty
Summary
Facility staff failed to consistently provide appropriate treatment and services for a resident with a surgical wound on the left foot, specifically regarding the use of a wound vacuum-assisted closure (VAC) device. Although hospital discharge paperwork and initial facility documentation indicated that a wound vac was to be used continuously except during dressing changes, the resident's clinical record did not contain corresponding medical provider orders for the wound vac. There was also no documentation of provider consultation with the surgeon regarding wound vac management, despite the resident's moderate cognitive impairment and the presence of a surgical wound requiring specialized care. Additionally, the clinical record lacked evidence that wound care orders, such as cleaning and dressing changes, were carried out on specified dates. The Treatment Administration Record (TAR) did not show that wound care was provided on at least one documented occasion. Facility policy required wound treatments to be provided and documented according to physician orders, and in the absence of such orders, the physician was to be notified. However, these steps were not followed, resulting in a failure to ensure proper wound care management for the resident.
Failure to Provide Timely Indwelling Urinary Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate indwelling urinary catheter care for one resident who was admitted with a diagnosis of neurogenic bladder and required a catheter. The resident's care plan acknowledged the presence of the indwelling urinary catheter but did not include interventions or instructions for personal hygiene related to catheter care. Clinical documentation showed a delay in providing personal hygiene care for the catheter, and there was no documented order for Foley care every shift until several months after admission. Treatment Administration Records indicated that catheter care was not initiated until this order was in place. Interviews with the Director of Nursing and Regional Director of Clinical Services confirmed that the care plan lacked specific interventions for catheter hygiene and that the facility did not have a policy addressing indwelling urinary catheter care. The facility relied on a professional reference for guidance, which recommended daily cleaning of the catheter area. The deficiency was identified through staff interviews, document review, and clinical record review, which collectively demonstrated that the resident did not receive the required catheter care from admission until the appropriate order was implemented.
Failure to Ensure Proper Diagnosis and Behavior Monitoring Before Antipsychotic Use
Penalty
Summary
Facility staff failed to ensure a correct diagnosis prior to initiating an antipsychotic medication for one resident. The resident's clinical record showed that a new diagnosis of schizoaffective disorder was added more than three months after admission, and this diagnosis was not supported by evidence of a psychological or psychiatric evaluation. The diagnosis was first documented by a nurse practitioner in a hand-written progress note, but the facility was unable to clarify the meaning of the documentation, and there was no supporting evaluation from a psychologist or psychiatrist in the clinical record. Following the new diagnosis, the nurse practitioner ordered Invega, an atypical antipsychotic, for the resident. Multiple orders for Invega were written and administered, with the medication specifically indicated for schizoaffective disorder, depressive type. The resident's Minimum Data Set (MDS) assessment did not list schizophrenia or related disorders as an active diagnosis, and the care plan was revised to include schizoaffective disorder only after the medication was ordered. There was no evidence that non-pharmacological interventions or gradual dose reductions were attempted prior to starting the antipsychotic medication. Additionally, the facility failed to monitor and document the resident's behaviors as required. Although there was an order to document specific behaviors every shift, the Medication Administration Records for the relevant months did not contain any evidence that staff documented the resident's behaviors. Interviews with facility leadership confirmed the lack of behavior documentation and the absence of a psychological evaluation or referral related to the new diagnosis.
Failure to Administer Antibiotics as Ordered Due to PICC Line Issues and Documentation Gaps
Penalty
Summary
Facility staff failed to ensure that a resident received antibiotics as ordered by the medical provider. The resident, who had moderate cognitive impairment, was prescribed Ertapenem 1 gram IV for the morning of 8/21/24, followed by a six-week course of daily morning IV Ertapenem starting 8/22/24, and Cubicin 700 mg IV at bedtime for six weeks starting 8/21/24. Documentation revealed that the initial dose of IV Ertapenem on 8/21/24 was not administered as ordered, and subsequent doses were held on 8/22/24, 8/23/24, and 8/24/24. Nursing notes indicated that issues with the resident's PICC line prevented administration of IV antibiotics, and an alternate order for IM Ertapenem was given on 8/22/24. However, there was no documentation addressing the administration of IV Cubicin as ordered during this period. Further review showed that after the PICC line was replaced and confirmed for use, the morning dose of IV Ertapenem on 8/24/24 was still held, despite documentation that the line was ready and an IV antibiotic had been administered the previous evening. The survey team discussed these findings with facility leadership, highlighting the failure to administer antibiotics as ordered and the lack of appropriate documentation for medication administration during the period when the PICC line was being replaced and confirmed.
Laboratory Test Performed Without Physician Order
Penalty
Summary
Facility staff failed to obtain a physician's order prior to performing a urinalysis for one resident. The resident had diagnoses including schizoaffective disorder and type 2 diabetes mellitus and was assessed as cognitively intact. A laboratory report in the resident's clinical record showed that a urinalysis with microscopic examination was conducted, but review of the physician's orders revealed no documentation of an order for this test. The facility's policy requires laboratory services to be provided or obtained only when ordered by a qualified practitioner. This issue was confirmed through staff interview and review of facility documentation.
Incomplete Clinical Records and Unclear Wound Care Orders
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for one resident, specifically regarding wound assessment documentation and wound care orders. The resident's clinical record did not include wound assessment details such as measurements and descriptions of wounds upon admission. Instead, wound assessment information was found on a spreadsheet maintained by MDS staff, which was not part of the resident's official clinical record. The Director of Nursing confirmed that this documentation was not included in the resident's medical record. Additionally, the resident's clinical record contained two wound care orders that did not specify which wound each order was intended to address. Both orders described wound care procedures but failed to identify the specific wound for treatment. Facility policy requires that each resident's medical record be accurate, complete, and contain sufficient detail about care provided, but this was not followed in the case of this resident. The issue was discussed with facility leadership during the survey.
Lack of Documented Dietary Staff Training in Safe Food Handling
Penalty
Summary
The facility staff failed to provide documented evidence of dietary staff training related to safe food handling. During a review of the training and education records of 12 dietary staff members working independently, it was found that none had documentation of orientation, and nine lacked documentation of training in safe food handling. The Regional Food Service Director (RFSD) acknowledged the absence of written policies for the orientation and training of dietary staff. A blank orientation form provided by the RFSD did not specifically address safe food handling, although it was suggested that topics related to state and federal regulations might cover this area. The dietary schedule revealed several full and partial days where no dietary staff member with documented safe food handling training was scheduled to work.
Improper Disposal and Containment of Facility Waste
Penalty
Summary
The facility staff failed to ensure proper disposal and containment of garbage and waste, as observed by the surveyor and the Dietary Manager. During the inspection of the garbage disposal area, one of the facility's dumpsters was found with its doors partially open, with a garbage bag hanging out. Additionally, medical gloves, foam bowls, and a foam clam shell container were found on the ground near the dumpsters. A bag of garbage containing disposable adult briefs and blue pads was placed in a dumpster without a lid, allowing potential animal access. Furthermore, a barrel used for disposing of used cooking grease was observed with its lid not completely closed, with aluminum foil hanging out. The facility's policy on garbage disposal, reviewed in December 2022, mandates that refuse containers and dumpsters should have tightly fitting lids and be kept covered when not in use, with the surrounding area kept clean to minimize debris and pest attraction. These observations were discussed with the facility's administrative and clinical leadership team.
Deficiencies in Resident Care and Protocol Adherence
Penalty
Summary
The facility staff failed to provide adequate care and services for five residents, as identified in the survey report. For Resident #82, the staff did not document an assessment by a licensed nurse after the resident experienced a fall. Despite being notified of the fall, there was no immediate post-fall assessment recorded before the resident was assisted back to their wheelchair. This lack of documentation was confirmed by the Director of Nursing (DON) during the survey. Resident #36 experienced a change in condition that led to a hospital transfer, yet there was no documented assessment by a licensed nurse, including vital signs, on the day of the incident. The absence of this critical assessment was acknowledged by the Regional Director of Clinical Services (RDCS) during discussions with the survey team. Similarly, Resident #15's bowel protocol was not followed according to the medical provider's standing orders, as the resident did not receive the prescribed Milk of Magnesia after three days without a bowel movement. Additionally, Resident #258's physician's order to remove surgical staples was not executed, as confirmed by interviews with the Assistant Director of Nursing (ADON) and the wound nurse. The oversight was attributed to a missed order. Lastly, Resident #73's bowel protocol was not adhered to, with no evidence of Milk of Magnesia or Dulcolax administration before the use of Fleet enemas, as required by the protocol. These deficiencies were discussed with the facility's administration and clinical leadership during the survey process.
Failure to Provide Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility staff failed to provide evidence of a bed hold policy being given to five residents during their transfers to hospitals or therapeutic leaves. The residents involved were identified as having varying levels of cognitive impairment, with some being unable to communicate effectively. Despite the facility's policy requiring that a written notice of the bed hold policy be provided to residents or their representatives at the time of transfer, no such documentation was found in the residents' files. For Resident #13, who had severe cognitive impairment, there was no evidence of a bed hold notice being provided when the resident was hospitalized in June 2024. Similarly, Resident #68, with mild cognitive impairment, was transferred to a hospital in June 2024 without evidence of receiving the bed hold policy. Resident #56, who had intact cognition, was also transferred without receiving the necessary documentation in February 2024. Additionally, Resident #98, with intact cognition, and Resident #36, with moderate cognitive impairment, were transferred to hospitals in May 2024 without evidence of the bed hold policy being provided. The facility's policy clearly states that a signed and dated copy of the bed hold notice should be kept in the resident's file, but this was not adhered to in these cases. The survey team discussed these deficiencies with the facility's administration, but no further information was provided before the exit conference.
Failure to Review and Revise Care Plans and Involve Residents
Penalty
Summary
The facility staff failed to ensure the comprehensive care plans for several residents were reviewed and revised by the interdisciplinary team, and did not involve the residents or their representatives in planning their care. For Resident #88, the staff did not reassess the effectiveness of interventions or update the activity care plan to meet the resident's needs, despite the resident's severe cognitive impairment. The activity director admitted to being behind on assessments and not completing required progress notes every ninety days. Resident #23, who was cognitively intact, reported not attending activity programs and not being involved in care plan meetings. The facility's records showed no evidence of the resident's participation in care plan meetings since the baseline meeting. Similarly, Resident #73, also cognitively intact, stated they had not been invited to care plan meetings since the initial one. The facility's documentation confirmed the lack of invitations and attendance records for these meetings. For Resident #28, the facility staff did not reassess or update the activity care plan, and the resident reported never attending a care plan meeting. Additionally, Resident #82's care plan failed to address the use of medications for blood clot prevention, and there was no evidence of the resident's involvement in care plan meetings. The facility's policies required comprehensive care plans to be reviewed and revised by the interdisciplinary team and to involve the resident or their representative, but these requirements were not met.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility staff failed to act on pharmacy recommendations for four residents, leading to deficiencies in medication regimen reviews. For Resident #83, the facility did not provide evidence of completed pharmacy recommendations for September 2023 and May 2024. Despite the pharmacist's notes indicating that medication regimen reviews were completed, the Assistant Director of Nursing (ADON) was unable to locate the recommendations. The facility's policy requires that written communications from the pharmacist become a permanent part of the resident's medical record, which was not adhered to in this case. Resident #8's drug regimen review from May 2024 was not reported to or acted upon by the medical provider. The resident's clinical record indicated a recommendation for a gradual dose reduction of Divalproex, which was not addressed as the medication remained active. The facility's policy mandates that staff act upon all recommendations, but this was not followed, as evidenced by the missing signature from the medical provider on the recommendation report. For Resident #28, the facility failed to provide evidence of drug regimen reviews being reported and acted upon for several months. Recommendations regarding medication adjustments and oral care were not addressed in a timely manner, with some actions delayed by months. Similarly, Resident #56's medication regimen review recommendation for an AIMS assessment was not addressed by a medical provider, and no evidence of the assessment was found in the resident's clinical record. These failures highlight a pattern of non-compliance with the facility's policy on medication regimen reviews.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility staff failed to store all medications and biologicals in a locked storage compartment on one of the nursing units, specifically unit 1 hall C. During an observation on August 5, 2024, at 9:18 AM, a surveyor noted a medication cart in the hallway that was unattended and unlocked. The staff member responsible for the cart was observed in a resident's room, interacting with a resident, and was not in the line of sight of the medication cart. This lapse in protocol was confirmed when the Licensed Practical Nurse (LPN) assigned to the cart acknowledged the oversight, admitting that the cart should have been locked while unattended. The facility's policy on medication storage, revised on December 1, 2022, clearly states that all drugs and biologicals must be stored in locked compartments and that during medication passes, medications must be under the direct observation of the person administering them or locked in the storage area/cart. This policy was not adhered to, as evidenced by the unlocked and unattended medication cart. The issue was discussed with the Assistant Director of Nursing shortly after the observation and later with the facility's administrative and clinical leadership team, but no further information was provided to the survey team before the exit conference.
Incorrect Serving Utensil Sizes Used for Resident Meals
Penalty
Summary
The facility staff failed to use the correct size of serving utensils when plating residents' food, leading to deficiencies in meeting the residents' dietary needs. On the evening of 7/29/24, a Dietary Staff Member (DSM) was observed using a 3 oz. serving utensil for corn and a 4 oz. serving utensil for mechanical soft pizza, contrary to the menu specifications of 4 oz. and 6 oz., respectively. The Dietary Manager confirmed the discrepancy, and the utensils were subsequently changed to the correct sizes. Additionally, on 7/31/24, another DSM reported using a 3.25 oz. serving utensil for buttered noodles, whereas the correct utensil should have provided a 4 oz. serving. These observations were discussed with the facility's administrative and food services leadership during a meeting with the survey team.
Failure to Follow Dietary Menus and Recipes
Penalty
Summary
The facility staff failed to consistently follow menus for resident meals, as observed during a survey. On one occasion, a dietary staff member prepared a tossed salad without washing the lettuce first and included onions, which were not part of the recipe, while omitting carrots, which were required. Additionally, the evening meal included cake without icing due to a delivery issue, deviating from the menu that specified cake with icing. The Dietary Manager confirmed the absence of icing was due to it not being delivered. Further discrepancies were noted when dietary staff served mashed potatoes instead of buttered noodles because they ran out of noodles, having prepared only one bag instead of the required two. On another occasion, strawberry cake without icing was served instead of the menu-listed strawberry shortcake, as the facility lacked strawberries and whipped cream. These issues were discussed with the facility's administration and regional directors during meetings with the survey team.
Deficiency in Food Presentation and Temperature
Penalty
Summary
The facility staff failed to provide food that was palatable and attractive, as evidenced by multiple observations and resident interviews. On one occasion, the cook checked the temperatures of food on the steam table and reported them as satisfactory. However, upon review, it was found that several food items, including mechanical soft pizza, pureed cream corn, and pureed pizza, were below the required temperature of 135°F. The Dietary Manager rechecked and reheated these items after being informed of the issue. Additionally, residents reported dissatisfaction with the presentation of their meals. One resident, who was cognitively intact, expressed that the food was unappealing, noting that a cookie was placed directly on top of vegetables, causing it to become soggy. This was a recurring issue, as other residents also reported similar experiences with their meals, indicating a pattern of improper food handling and presentation. The facility's policy on food preparation emphasizes the importance of serving food that is palatable and attractive, yet the observed practices did not align with these guidelines. The dietary manager acknowledged that cookies should have been wrapped to prevent them from becoming soggy, but this was not consistently done, leading to resident dissatisfaction. The issue was repeatedly discussed in meetings with facility leadership, but no further information was provided to the survey team before the exit conference.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility staff failed to adhere to proper food safety and hygiene protocols, as observed during a survey. Dietary staff members were seen working in the kitchen without wearing required beard covers, which was confirmed by the Dietary Manager as a violation of the facility's policy on personal hygiene. Additionally, several food storage issues were identified, including improperly stored chicken noodle soup with ice crystals, expired broccoli soup, and frozen items such as French toast and breaded fish that should not have been kept. These items were not discarded in a timely manner, contrary to the facility's policy on date marking for food safety. Further observations revealed a bowl of vanilla pudding on a resident's nightstand that was dated over two weeks prior and appeared curdled, indicating it was not discarded within the required timeframe. The storage of serving bowls was also problematic, with some resting on a window ledge with debris and dead insects. Additionally, a dietary staff member was observed using an inappropriate method to clean a food thermometer, using a wet towel from a bucket containing a soap/cleaning solution instead of an alcohol wipe, as instructed by the Dietary Manager.
Failure to Facilitate Advanced Directives for Residents
Penalty
Summary
The facility staff failed to ensure that two residents, identified as Resident #36 and Resident #46, and/or their representatives were given the opportunity to develop an advanced directive. For Resident #36, the Minimum Data Set (MDS) assessment indicated moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Despite this, there was no documented evidence in the clinical records that the facility staff addressed the resident's or the representative's desire to formulate an advanced directive. The Director of Social Services confirmed the absence of such documentation. Similarly, for Resident #46, who was assessed with intact cognition and a BIMS score of 15 out of 15, there was no evidence in the clinical documentation that the facility staff discussed the formulation of an advanced directive with the resident or their representative. The Director of Social Services mentioned that the topic might have been discussed during the admission care planning process but was not documented. The survey team discussed these findings with the facility's administrative and clinical leadership, highlighting the lack of documentation regarding advanced directives for both residents.
Failure to Document and Communicate Transfer Information
Penalty
Summary
The facility staff failed to ensure appropriate documentation and communication of necessary information during the transfer of two residents to a hospital. For one resident, who had severe cognitive impairment, the facility did not complete a transfer form or document any information that was sent to the hospital. The resident was sent to the hospital for further evaluation due to a blood clot in the left lower extremity, but there was no record of essential information such as contact details for the physician, resident representative, advanced directives, or care plan goals being communicated to the receiving institution. Similarly, for another resident with mild cognitive impairment, the facility staff did not provide a transfer form or document the transfer of critical information to the hospital. This resident was found unresponsive and was sent to the emergency room for evaluation and treatment. Despite notifying the resident's father and the on-call supervisor, there was no documentation of a transfer form or any follow-up note indicating what information was sent with the resident. The facility's Director of Nursing and other staff were unable to produce the necessary documentation during the survey, indicating a failure in the transfer process.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility staff failed to provide written transfer notices to three residents or their representatives, as required by facility policy and regulations. Resident #107, who had moderate cognitive impairment, was transferred to a local hospital without receiving a written notice of transfer. The facility's Assistant Director of Nursing (ADON) confirmed the absence of such documentation. Similarly, Resident #98, who had intact cognition, was transferred without a written notice being provided. The survey team found no evidence of the required documentation during their review. Additionally, Resident #56, who had borderline cognition, was transferred to a hospital without receiving a written transfer notice. The facility's policy mandates that transfer notices be provided as soon as practicable, but the surveyors found no evidence that this was done for the three residents in question. The lack of documentation was discussed with the facility's administrative and clinical leadership, including the Administrator, Director of Nursing (DON), and Regional Directors, during the survey process.
Failure to Conduct PASRR Screening for Resident
Penalty
Summary
The facility staff failed to conduct a PASRR screening for a mental disorder or intellectual disability for one resident. The resident's PASRR document, dated 11/7/23, indicated a serious mental illness or intellectual disability and approved a short-term convalescence stay of up to 60 days without further PASRR review. The document also stated that if the resident needed to stay longer than 60 days, a new Level I screen must be submitted by the nursing home staff. The resident was admitted on 12/26/23, and the necessary follow-up screening was not conducted. The resident, diagnosed with schizoaffective disorder and depression, was observed exhibiting behaviors such as hitting fists on a table and cursing loudly, with no apparent target. The comprehensive person-centered care plan noted the potential for verbal aggression related to the resident's schizoaffective disorder. During an interview, the social worker acknowledged the oversight, stating they were not employed at the facility at the time and were unaware of the issue. The deficiency was discussed with the facility's administrative and clinical leadership, but no further information was provided to the survey team before the exit conference.
Failure to Implement Baseline Care Plan for Resident with PASRR Needs
Penalty
Summary
The facility staff failed to develop and implement a baseline care plan for a resident that included the necessary instructions to provide effective and person-centered care. The deficiency was identified for a resident who had a PASRR Level I Screen indicating evidence of a serious mental illness or intellectual disability. The PASRR document specified that the resident was approved for a short-term convalescence stay of up to 60 days in a Medicaid-accepting nursing home, with a requirement for the facility to provide any listed mental health and/or IDD services during the resident's stay. Upon review, it was found that the baseline care plan for the resident, dated the same day as the PASRR document, had a blank section labeled PASRR, which should have contained the necessary information to address the resident's mental health needs. The facility's policy on baseline care plans required that PASRR recommendations be included if applicable. This omission was confirmed during a meeting with the Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing, and other facility leaders, who acknowledged that the section should have been completed.
Failure to Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility staff failed to implement a comprehensive care plan for two residents, leading to deficiencies in their care. For Resident #258, the staff did not notify the physician of hematuria, despite the resident being on anticoagulant medication for atrial fibrillation, which increased the risk of abnormal bleeding. The resident's care plan included an intervention to observe and report signs of bleeding to the physician, but there was no evidence in the clinical record that the physician was informed about the blood observed in the catheter tubing on multiple occasions. For Resident #88, the facility staff did not implement a comprehensive, person-centered activity care plan. The resident, who had severe cognitive impairment and multiple diagnoses including Bipolar Disorder and Chronic Kidney Disease, was supposed to participate in two to three activities per week for ninety days. However, the activity participation records showed limited engagement, with only a few one-to-one activities documented over several months. The activity director admitted to not having time to document activities and stated that the resident rarely got out of bed, indicating a lack of adherence to the care plan. The survey team discussed these concerns with the facility's administration and clinical staff, but no further information was provided before the exit conference. The facility's policies on resident self-determination and comprehensive care plans emphasize the importance of developing and implementing plans that meet residents' needs, but these were not followed in the cases of Residents #258 and #88.
Failure to Provide Person-Centered Activity Program
Penalty
Summary
The facility staff failed to provide an ongoing, person-centered activity program to support resident choice, interests, and physical, mental, and psychosocial well-being for two residents. Resident #88, who has severe cognitive impairment and multiple health conditions including Bipolar Disorder and Chronic Kidney Disease, was not provided with the activities as outlined in their care plan. The care plan specified that the resident should participate in two to three activities per week, but records showed that activities were not consistently provided. The activity director admitted to not having time to document activities, and there was a lack of documentation for group or self-directed activities. Resident #28, who is cognitively intact and has conditions such as Chronic Obstructive Pulmonary Disease and Major Depressive Disorder, also did not receive the activities as per their care plan. The care plan indicated that the resident should participate in two to three activities per week, but the records showed limited one-to-one activities and no documentation of group or self-directed activities. The resident expressed that they did not attend activities at the facility, and there were no activity progress notes found in the clinical record. The facility's policy requires an ongoing program to support residents' activity choices based on comprehensive assessments and care plans. However, the facility failed to adhere to this policy, as evidenced by the lack of consistent activity programming and documentation for both residents. This deficiency was discussed with the facility's administration and other relevant staff during multiple meetings, but no further information was provided to address the concern before the exit conference.
Deficiency in Medication Availability for Resident
Penalty
Summary
The facility staff failed to ensure the availability of a prescribed medication for a resident, leading to a deficiency in pharmaceutical services. During a medication administration observation, it was noted that a Lidocaine Pain Relief patch, ordered for a resident, was not available. Consequently, the staff had to contact the resident's medical provider to obtain an alternative order for a Menthol Pain patch, which was then administered. This incident highlights a lapse in maintaining adequate medication supplies as per the facility's protocol. The resident involved was assessed with a Minimum Data Set (MDS) indicating intact or borderline cognition, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The deficiency was identified during a surveyor's observation and was discussed with the facility's Director of Nursing, Assistant DON, and Regional Director of Clinical Services. The facility's medication administration policy, which mandates keeping the medication cart clean, organized, and stocked, was not adhered to, resulting in the need for an alternative medication order.
Failure to Ensure Correct Diagnosis for Psychotropic Medication
Penalty
Summary
The facility staff failed to ensure a correct diagnosis for the use of a psychotropic medication for a resident. The resident's Minimum Data Set (MDS) assessment indicated intact or borderline cognition, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. A consultant pharmacist recommended a review of the resident's antipsychotic medication, Aripiprazole, as it lacked an allowable diagnosis to support its use. The recommendation included a list of potential diagnoses, and one was circled with a note that was unclear, possibly indicating discontinuation. Despite this, an order for Aripiprazole was placed for delirium with manic/psychotic symptoms, but no documentation supported this diagnosis. The Director of Nursing (DON) later reported that the medical provider who signed the pharmacy recommendation could not clarify their response. A progress note dated after the initial order indicated a different diagnosis of depression with mood disorder for the Aripiprazole. The survey team discussed the issue with the facility's administrative staff, highlighting the discrepancy in the documented reason for the medication and the lack of supporting documentation for the initial diagnosis of delirium with manic/psychotic symptoms.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, as evidenced by two medication administration errors occurring during 30 opportunities, resulting in a medication error rate of 6.67%. These errors affected Resident #14, who was administered an incorrect dose of fluticasone nasal spray and furosemide tablets. Specifically, the resident received one 40 mg tablet of furosemide instead of the prescribed two tablets, and one spray of fluticasone in each nostril instead of the prescribed two sprays. Resident #14's Minimum Data Set (MDS) assessment indicated that the resident was able to make themselves understood and understand others, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, suggesting intact or borderline cognition. The errors were observed during a medication pass by LPN #9, who did not adhere to the facility's medication administration protocol, which includes verifying the medication administration record (MAR) against the medication source to ensure correct resident name, medication name, form, dose, route, and time.
Incomplete DDNR Form and Documentation Deficiency
Penalty
Summary
The facility staff failed to maintain complete and accurate clinical documentation for a resident, specifically regarding the Durable Do Not Resuscitate (DDNR) form. The DDNR form, dated May 1, 2024, was incomplete as it lacked critical information. The section where the individual completing the form certifies whether the resident is capable or incapable of making an informed decision about medical treatment was not answered. Additionally, the section that should be completed when a resident is determined incapable of making an informed decision was also left unanswered. The resident's Minimum Data Set (MDS) assessment, with an Assessment Reference Date of May 16, 2024, was signed as completed on May 30, 2024. The assessment indicated that the resident was sometimes able to make themselves understood and sometimes able to understand others, with moderate impairment in decision-making regarding daily life tasks. The facility's documentation policy, reviewed and revised on December 1, 2022, requires that each resident's medical record accurately represents their experiences and includes sufficient details about their care. The survey team discussed these documentation deficiencies with the facility's administrative and clinical leadership.
Failure in Hand Hygiene During Medication Pass
Penalty
Summary
The facility staff failed to perform proper hand hygiene during a medication pass and pour observation. On August 1, 2024, an LPN did not perform hand hygiene between administering medications to two residents. The LPN administered medications, including an inhaler, to a resident in the first bed and handled items on the resident's bedside table. They then proceeded to the medication cart to prepare medications for the next resident without performing hand hygiene in between. The LPN acknowledged the lapse in following the facility's policy, which requires hand hygiene before and after administering medications to each resident. The facility's policy, revised on December 1, 2022, confirmed the expectation for hand hygiene during medication administration. Additionally, a document titled 'Handwashing Competency Skills: Infection Control' indicated that the LPN had participated in a skills fair covering hand hygiene on July 22, 2024. The issue was discussed with the facility's administration, including the Administrator, Director of Nursing, Assistant Director of Nursing, and the Regional Director of Clinical Services, but no further information was provided to the survey team before the exit conference.
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 29 citations issued within 25 miles in the last 12 months — 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 Abingdon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Abingdon Health & Rehab Center | 3.1 mi | ★★★★★ | 0 | 0 |
| The Rehab Center At Bristol | 11.1 mi | ★★★★★ | 8 | 0 |
| Maple Grove Nursing & Rehab Center | 13.7 mi | ★★★★★ | 1 | 0 |
| Nhc Healthcare, Bristol | 16.7 mi | ★★★★★ | 3 | 0 |
| Valley Rehabilitation And Nursing Center | 16.7 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.