Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland Ridge Rehab Center during CMS and state inspections, most recent first.
Dietary services failed to consistently match resident diet orders and maintain food service operations during a staffing lapse. During tray line observation, only regular, ground, and puree diets were announced, while staff said a resident on a CCD relied on a spouse to call the kitchen for meal choices. The RD later found a tray ticket listed CCD even though the provider order was for a regular diet, and a diet audit identified 34 residents with CCD orders and one resident with a renal diet. Staff also reported the dietary manager and other dietary staff had quit, leaving the administrator and HR director to cook meals, with a fill-in cook brought in for dinner.
Food storage, labeling, and hand hygiene failures were observed in the kitchen and all 4 unit nutrition rooms. Surveyors found expired and improperly stored food, unlabeled and undated prepared items, dirty refrigeration equipment, and food kept under unsanitary conditions. Dietary staff were also observed entering the kitchen without hair restraints or beard nets, and a cook changed gloves and handled food without performing hand hygiene.
Baseline care plans were not provided, reviewed, or completed for several newly admitted residents. Records showed blank or missing BCP documentation for residents with significant medical needs, including respiratory failure, CHF, CKD, sepsis, fractures, and cognitive impairment, and interviews with residents, family, and an LPN confirmed that copies were not received or reviewed. One resident had no evidence of any admission Nursing Collection Tool or BCP in the chart.
Incomplete Comprehensive Care Planning and Resident Participation: The facility failed to include a cognitively intact resident and/or representative in care plan reviews, and failed to develop comprehensive care plan focus areas for PTSD and self-administration of medications for multiple residents. Records showed bedside medications were ordered for two residents, but there was no documented self-administration assessment or corresponding CCP focus, and one resident’s CCP did not include PTSD despite documented diagnoses.
Failure to Provide Nail Care and Bathing Assistance: Multiple residents were found without needed ADL support, including long, jagged, or painful nails and missed showers. Residents with cognitive impairment and significant medical conditions reported delayed or absent nail care, and one resident stated showers were missed after a room change. Records and staff interviews showed inconsistent bathing documentation and no timely nail care despite facility policy requiring regular nail cleaning, trimming, and at least two baths or showers per week.
Failure to Assess Residents for Self-Administration of Medications: The facility did not complete required self-administration assessments for two residents who kept medications at bedside. One resident had moderate cognitive impairment and had Systane eye drops, Voltaren cream, and Neosporin ointment on the over-bed table, while the record only showed an order for Systane and no assessment. Another resident was cognitively intact and had orders to keep Flonase and Chloraseptic at bedside, but no assessment was in the chart when reviewed.
Failure to provide required Medicare beneficiary notices. Two cognitively intact residents did not receive the proper notices related to Medicare coverage and non-coverage: one resident should have received an ABN and another should have received a NOMNC. The SW confirmed the notices had not been given when the surveyor requested them, and one ABN was provided later that day.
Facility staff failed to notify the state LTC ombudsman of a resident transfer/discharge to a higher level of care. The resident had multiple serious diagnoses, including sepsis, CKD stage 3, AFib, malnutrition, and moderate cognitive impairment (BIMS 8/15), and was sent to the ER for Hgb 7 and severe abdominal pain. SW stated the transfer/discharge list was printed, but there was no evidence it was sent to the ombudsman.
Failure to Follow Up on Pharmacy Recommendations: The facility did not follow up on pharmacist recommendations for two residents. One resident had a history of TBI, MDD, and metabolic encephalopathy with severe cognitive impairment and was receiving an antipsychotic, antidepressant, and antibiotic. Another resident had dementia, delusional disorder, psychotic disorder, and MDD with severe cognitive impairment and was receiving antipsychotics, antianxiety meds, antidepressants, opioids, and anticonvulsants. In both cases, the chart noted that an MRR was completed and recommendations were written to the provider, but the pharmacy reports could not be located.
Unsecured medications were found in two residents' rooms. An LPN left hydrocortisone in one resident's room unattended, and survey staff observed Voltaren cream and Neosporin ointment on another resident's over-the-bed table without orders in the chart at the time. Both residents had moderate cognitive impairment based on BIMS scores, and one resident's record only authorized bedside storage for Systane eye drops.
Food service concerns were not adequately addressed after multiple residents reported cold meals, watery eggs and vegetables, missing condiments, and no snacks at night. Resident council minutes showed repeated complaints that dietary concerns were not being resolved, and an LPN stated snack carts were not stocked consistently, leaving staff to obtain snacks from the kitchen or use items kept in the nursing office. Surveyors also found unit pantries with out-of-date items and limited safe snacks available, while the ADM said prior complaint follow-up documentation was unavailable.
Infection control practices were not followed during medication administration and resident care. An RN handled medications with bare hands during a med pass, including opening a capsule and pouring the contents into pudding. Linens and a wet washcloth were observed on the floor in resident rooms, an incentive spirometer was found under a resident's bed, and a CPAP mask was left uncovered on a nightstand. The ADON stated that linens should not be left on the floor and respiratory equipment should be bagged when not in use.
Dietary staff were observed working in the kitchen without required hair restraints or beard nets, and one staff member stated he had never been educated on hair nets or beard restraints. The cook was also observed handling food with gloves and oven mitts, then changing gloves without hand hygiene. The ADM stated the dietary manager had quit, several dietary staff left soon after, and the RDDS was in the process of establishing training for new dietary employees.
Facility staff did not employ a qualified infection preventionist with the required training, resulting in residents needing EBP or TBP not having proper notification, signage, or PPE available. Interim leadership confirmed they were acting as IPs without certification, and although an LPN had IP certification, she was not performing the IP role. Documentation showed staff education and a job description requiring only the ability to obtain certification, but no further details were provided.
A resident with multiple medical conditions and intact cognition experienced significant delays in call bell response, with the call light remaining unanswered for at least 20 minutes despite staff presence nearby. The facility's policy allowed any staff to respond, but several staff members walked by without addressing the call, and expectations for response times varied among leadership.
Facility staff did not administer a prescribed dose of Cyclobenzaprine, a muscle relaxant, to a resident with multiple medical conditions, despite a clear provider order and the resident being cognitively intact. The omission was confirmed through MAR review and staff interview, with no further explanation provided.
Staff did not follow established infection control protocols for three residents requiring Enhanced Barrier Precautions or Transmission-Based Precautions. In multiple cases, required PPE such as gowns was not worn during care, signage and visual indicators were missing, and PPE supplies were not available as per facility policy. Staff interviews revealed a lack of awareness about precaution requirements, and observations confirmed that infection control measures were not consistently implemented.
Dietary Services Failed to Match Ordered Diets and Maintain Food Service Coverage
Penalty
Summary
The facility staff failed to meet the daily nutritional and dietary needs of residents receiving nutrition by mouth and failed to maintain an overall system to manage and execute food and nutritional services during a lapse in food service management. During tray line observation, the menu included Swedish meatballs, egg noodles, and pacific blend vegetables, but no special diets were called out other than regular, ground, and puree consistencies. When asked why no carbohydrate-controlled diets were announced, staff stated there was only one resident on a carb-controlled diet and that the resident’s spouse called the kitchen to determine the meal choice for that service. Staff also reported that the evening meal was being prepared by the administrator or the human resource director because the dietary manager and other dietary staff had quit. The registered dietician stated that a resident’s tray ticket showed a carbohydrate-controlled diet even though the medical provider order was for a regular diet, and the dietician said they would audit and provide corrections. The administrator later stated that the human resource director had ServSafe certification and that a fill-in cook from within the company would prepare dinner; the certification for that cook was provided later that day. The diet audit identified 34 residents with medical provider orders for consistent carbohydrate diets and one resident with a renal diet, and the tray ticket system had 2 errors.
Food Storage, Labeling, and Hand Hygiene Failures
Penalty
Summary
The facility failed to prepare, store, distribute, and serve food in accordance with professional standards in the kitchen and in all 4 unit nutrition rooms. During an initial tour of the kitchen, surveyors observed multiple out-of-date and improperly stored food items in the dry storage area, including expired boxes and bags of food, open containers and bags that were not sealed, and an open container of coffee without an open date. The registered dietician was made aware of these items and removed them. In the walk-in refrigerator, surveyors observed prepared foods stored on the floor, food items without labels or dates, uncovered trays, and multiple containers of food with visible contamination or dried residue. Items included ham, chef salads, coleslaw, shredded cheese, sandwiches, Jell-O cups, pudding cups, ground beef with use or freeze-by dates past due, and turkey meat stored on top of fresh apples. The registered dietician was made aware of these items and removed them. A staff member reported that cooks were trained on first in-first out stock rotation, but that items had been getting missed for about 2 weeks since most of the staff were lost. Surveyors also observed dietary staff entering the kitchen without hair restraints, and one staff member with visible facial hair did not have a beard net visible. Staff stated there were no hair restraints outside the kitchen door and that they had been entering the kitchen this way; another staff member stated he had not been educated on hair nets or beard restraints. During meal preparation, a cook was observed using oven mitts over gloves, changing gloves without hand hygiene, and then continuing food service activities until reminded by the RDDS or asked to wash hands. In the D-, B-, C-, and A-wing nutrition rooms, surveyors found numerous unlabeled or undated food items, expired food products, dirty storage containers, and refrigerators with dried spills and improper storage conditions, including food items in styrofoam bowls, sandwiches in baggies, puddings, peanut butter, juice, mustard, coffee, and a freezer item with a resident's name and an expired date.
Baseline care plans not provided, reviewed, or completed for newly admitted residents
Penalty
Summary
The facility failed to provide, review, or complete baseline care plans for multiple newly admitted residents, and failed to ensure that the resident and/or resident representative received a summary or copy of the baseline care plan when required. The report identified deficiencies involving Residents #6, #2, #13, #126, #134, and #84. Facility policy stated that the resident and their representative would be provided with a summary of the baseline care plan, and for one resident the policy also stated that a baseline care plan would be developed within 48 hours of admission to meet immediate care needs. For Resident #6, who was listed as their own responsible party and had diagnoses including sepsis and chronic pulmonary edema, the clinical record did not show that a copy of the baseline care plan was provided. The resident’s BIMS score was 8, indicating moderate cognitive impairment. An LPN stated the baseline care plan had been initiated but there was no proof anyone received a copy, and the resident stated they were not aware of receiving one. For Resident #2, who had diagnoses including acute on chronic respiratory failure with hypoxia, atrial fibrillation, CHF, anxiety disorder, depression, and COPD, the admission Nursing Collection Tool showed the section indicating that a copy of the baseline care plan and medications had been given was left blank. The resident, who had a BIMS score of 15, did not recall receiving a copy. For Residents #13, #126, and #134, the admission records also showed the baseline care plan review and copy sections were blank, and interviews with the residents and/or family members indicated they had not received or reviewed a copy. Resident #13 had diagnoses including psoas muscle abscess, sepsis due to streptococcus, CKD stage 3, and malnutrition, with a BIMS score of 8. Resident #126 had diagnoses including surgical aftercare following circulatory system surgery, infection and inflammatory reaction due to a cardiac valve prosthesis, diabetes with hyperglycemia, CKD, gastroparesis, and pleural effusion, with a BIMS score of 12. Resident #134 had diagnoses including lumbar compression fracture, displaced intertrochanteric fracture of the right femur, CHF, CKD stage 3, atrial fibrillation, osteoarthritis, and muscle weakness, with a BIMS score of 15. For Resident #84, who had diagnoses including chronic respiratory failure with hypoxia, atherosclerotic heart disease, history of TIA, CHF, COPD, morbid obesity, bilateral hip osteoarthritis, shortness of breath, and muscle weakness, the clinical record did not contain evidence of an admission Nursing Collection Tool or any baseline care plan. The resident had a BIMS score of 6, indicating severe cognitive impairment. The survey findings documented that the facility did not complete the required baseline care plan process for this resident.
Incomplete Comprehensive Care Planning and Resident Participation
Penalty
Summary
The facility staff failed to include Resident #50 and/or the resident representative in reviews and/or revisions of the comprehensive person-centered care plan. Resident #50 had diagnoses including depression, obstructive and reflux uropathy, COPD, cardiomegaly, tachycardia, metabolic encephalopathy, weakness, and chronic respiratory failure with hypoxia. The resident’s most recent MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness, and during interview the resident could not recall being invited to care plan meetings. The clinical record did not show evidence that the resident and/or representative had been invited to participate in care plan reviews, and social work staff stated the last documented invitation was in May 2025. The facility also failed to develop and implement a care plan for self-administration of medications for Resident #116. The resident’s record included diagnoses related to respiratory conditions and a physician order allowing Flonase and Chloroseptic to be kept at bedside. The resident’s MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. The comprehensive care plan did not contain a self-administration of medications focus, and the resident stated that Flonase and Chloroseptic were kept in the top drawer of the nightstand. For Resident #11, the facility failed to develop a comprehensive care plan for PTSD. The resident’s diagnoses included PTSD, anxiety disorder, and depression, and the quarterly MDS showed a BIMS score of 14, indicating cognitive intactness. Review of the comprehensive care plan showed no focus area for PTSD. For Resident #32, the facility failed to develop a comprehensive care plan for self-administration of medications. The resident had diagnoses including acute and chronic respiratory failure, chronic diastolic CHF, and diabetes, and the quarterly MDS showed a BIMS score of 12, indicating moderate impairment in cognitive skills for daily decision making. During observation, a bottle of Systane eye drops was seen on the over-bed table, and the record included an order allowing the eye drops to be kept at bedside, but there was no evidence the resident had been assessed for self-administration or that this had been included in the comprehensive care plan.
Failure to Provide Nail Care and Bathing Assistance
Penalty
Summary
The facility failed to provide activities of daily living care, specifically nail care and, for some residents, shower/bathing care, for multiple residents identified during survey. The report states that staff failed to provide ADL care for 7 of 25 residents: Resident #6, #84, #42, #51, #62, #67, and #116. The findings were based on observation, resident interviews, staff interviews, clinical record review, and facility document review. Resident #6 was observed with long, jagged fingernails with debris under the nails. The resident, who had diagnoses including sepsis and chronic pulmonary edema and was assessed as moderately impaired in cognition with substantial/maximal assistance needed for personal hygiene, stated the nails were too long and that staff had said they would cut them but had not done so. Resident #6’s care plan included reminders to use the call light for assistance with ADLs, and the facility policy stated nail care includes daily cleaning and regular trimming. Resident #84, who had multiple chronic diagnoses including chronic respiratory failure with hypoxia, CHF, COPD, morbid obesity, and severe cognitive impairment, stated they missed a shower due to a room change and wanted one. Shower/bathing records showed only two showers during the reviewed period and no documentation of refusals, bed baths, or partial bed baths. An email from a CNA stated baths were not documented on certain days and that when the resident did not feel up to a shower, the CNA would wipe the resident down with a wet soapy rag. The facility policy required at least two full baths or showers per week and documentation of refusals or alternative bathing care. Resident #42 reported not getting showers on time and sometimes going a week without one, and toenails were observed curling over the ends of the toes. Resident #51 had long toenails and stated podiatry had not been in since June 2025, with toenails sometimes cutting into the adjacent toe. Resident #62 was asking for toenail trimming because the nails were long and hurting, and the nails were observed to be long, thick, and ragged; the resident stated the toenails had not been cut in close to a year. Resident #67 was observed with extremely long, ragged toenails and long, ragged fingernails with dark debris under and around the nail bed, and stated the toenails needed to be cut. Resident #116 also had long toenails and stated they usually went to podiatry but missed the last appointment because they were in the hospital. For these residents, the DON stated nail care was the responsibility of the ADON, CNA, shower team, or nurses depending on the task, and the facility policy stated routine nail care may be performed by nursing staff and/or qualified activity team members and includes daily cleaning and regular trimming.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess 2 of 25 residents for self-administration of medications, including Resident #32 and Resident #116. The facility policy stated that staff and the practitioner would assess each resident’s mental and physical abilities and choice to determine whether self-administering medications and/or treatments was clinically appropriate, and that a more specific skill assessment would be performed for residents who self-administered medications. For Resident #32, the clinical record included an order for Systane eye drops to be kept at bedside, and the resident had diagnoses including acute and chronic respiratory failure, chronic diastolic congestive heart failure, and diabetes. The quarterly MDS showed a BIMS score of 12, indicating moderate impairment in cognitive skills for daily decision making. During observation and interview, Systane eye drops, Voltaren cream, and Neosporin ointment were seen on the resident’s over-the-bed table, and the resident stated she had to order the medications herself and that the Voltaren was for her hip. The record did not include orders for Voltaren or Neosporin ointment, and no evidence of a self-administration assessment was found in the record. For Resident #116, the record included orders to keep Flonase nasal spray and Chloraseptic throat spray at bedside, and the resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. The eMAR for February 2026 contained no documentation related to Flonase or Chloraseptic, and no self-administration assessment was located in the record when reviewed. When interviewed, the resident stated that she kept her Flonase and Chloraseptic in the top drawer of her nightstand. A self-administration assessment was later provided by the DON and was dated after the review period.
Failure to Provide Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide appropriate beneficiary notices to 2 of 3 residents reviewed, Residents #36 and #42, regarding Medicare coverage and potential liability for services not covered. Resident #36 had diagnoses of sepsis and acute respiratory failure, and the admission MDS with an ARD of 01/19/26 showed a BIMS score of 15, indicating the resident was cognitively intact. Resident #42 had diagnoses of chronic systolic congestive heart failure and diabetes, and the quarterly MDS with an ARD of 02/03/26 showed a BIMS score of 15, also indicating cognitive intactness. On 02/25/26, the surveyor requested notices provided to both residents regarding discharge from Medicare Part A. During an interview on 02/26/26, the Social Worker stated that Residents #36 and #42 were not given the appropriate notices, that Resident #36 should have received an ABN, and that Resident #42 should have received a NOMNC. The Social Worker also stated that Resident #36 was provided an ABN on 02/26/26.
Failure to Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
Facility staff failed to notify the office of the state long-term care ombudsman of a resident transfer/discharge for Resident #13, who was transferred/discharged to a higher level of care. Resident #13 had diagnoses including psoas muscle abscess, sepsis due to streptococcus, atrial fibrillation, chronic kidney disease-stage 3, infrarenal abdominal aortic aneurysm, muscle weakness, and malnutrition. The most recent MDS showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment. An order progress note documented that the resident may be sent to the ER for evaluation and treatment related to Hgb 7 and severe left-sided abdominal pain. On interview, SW#2 provided a January 2026 transfer/discharge list and stated it was printed that day, and Resident #13 was listed. SW#2 stated the fax confirmation form was not kept and agreed there was no evidence the list was sent to the state long-term care ombudsman. The facility did not provide evidence of notification or a transfer/discharge policy before exit.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up on pharmacist recommendations for 2 of 25 residents, Resident #5 and Resident #72. For Resident #5, the clinical record showed diagnoses including personal history of traumatic brain injury, major depressive disorder, and metabolic encephalopathy. The most recent MDS dated 12/14/25 coded the resident with a BIMS score of 3 out of 15, indicating severe cognitive impairment, and showed use of an antipsychotic, antidepressant, and antibiotic. Resident #5's record contained a Pharmacy/Pharmacy Consultant Note dated 09/23/25 stating that a medication regimen review was completed and recommendations were written to the provider, but the related pharmacy report could not be located. The DON was informed of the missing pharmacy report but could not locate it. The facility policy entitled Medication Regimen Review stated that the consultant pharmacist will perform an MRR for every resident, report irregularities to the attending physician, medical director, and DON, and provide a written report with the resident's name, relevant drug, and identified irregularity. For Resident #72, the clinical record listed diagnoses including unspecified dementia, delusional disorders, psychotic disorder, and major depressive disorder. The most recent MDS dated 11/25/25 coded the resident with a BIMS score of 3 out of 15, indicating severe cognitive impairment, and showed use of antipsychotics, antianxiety medications, antidepressants, opioids, and anticonvulsants. The resident's care plan included a psychoactive medication plan related to anxiety disorder, depression, and insomnia. The record contained a Pharmacy/Pharmacy Consultant Note dated 09/22/25 stating that a medication regimen review was completed and recommendations were written to the provider, but the related pharmacy report could not be located. The DON was informed of the missing pharmacy report but could not locate it.
Unsecured Medications Left in Residents' Rooms
Penalty
Summary
Drugs and biologicals were not safely stored in a locked and secure manner for 2 residents. For Resident #4, who had diagnoses including Parkinson's disease, respiratory failure, and epilepsy, the quarterly MDS showed a BIMS score of 10, indicating moderate impairment in cognitive skills for daily decision making. During the initial tour, survey staff observed a white cream in a clear plastic medicine cup sitting on top of an extended outlet box in the resident's room. An LPN stated the cream was hydrocortisone and that she had placed it there. The resident's record included an order for hydrocortisone cream to be applied to the right lower leg twice daily for 5 days, and the DON later stated the hydrocortisone should not have been left in the room. For Resident #32, who had diagnoses including acute and chronic respiratory failure, chronic diastolic CHF, and diabetes, the quarterly MDS showed a BIMS score of 12 out of 15, indicating moderate impairment in cognitive skills for daily decision making. Survey staff observed Systane eye drops, Voltaren cream, and Neosporin ointment on the resident's over-the-bed table unattended. The resident stated she had to order the medications herself and that the Voltaren was for her hip. The clinical record included an order for Systane eye drops twice daily with permission to leave at bedside, but there were no orders for Voltaren or Neosporin ointment at the time of the observation; the order for Diclofenac (Voltaren) Sodium External Gel 1% was entered later that day.
Food Service Complaints Not Adequately Addressed
Penalty
Summary
The facility failed to adequately address resident complaints about food services, including concerns about taste, temperature, condiments, and the availability of snacks. During resident interviews, multiple residents reported that the food was cold, the eggs and vegetables were watery, trays lacked condiments, and snacks were not available at night. Resident Council Minutes documented repeated complaints that voicing concerns to dietary was a waste of time, that snacks were still not being provided, and that residents were waiting for alternate meal calls to be answered and for soda to be returned. Surveyors also observed that a requested test tray on 2/25/26 was the last tray off the cart at 1:10 PM and was described as palatable and at a temperature that would have been enjoyed. However, on 2/26/26 the four unit pantries were observed to contain several out-of-date items with limited snacks available or safe for resident consumption. An LPN stated kitchen staff were supposed to stock snack carts but did not do so often, forcing CNAs to go to the kitchen for snacks, and that nursing staff kept some snacks in the office and had even brought in their own food items at one point to make sandwiches for residents. The administrator acknowledged that food concerns had been raised in Resident Council but did not have notes or documentation from the prior dietary manager regarding the complaints.
Infection Control Practices Not Followed During Medication Pass and Resident Care
Penalty
Summary
The facility failed to follow established infection control procedures during medication administration and resident care observations. During a medication pass and pour, RN #2 was observed dispensing medication from a medication card into her bare hand and placing the medication into a cup. The nurse also removed a capsule from the medication cup with her bare hand, opened it, and poured the contents into a cup of pudding. The facility provided a medication administration policy stating that if tablets must be broken, hands are to be washed with soap and water and gloves applied prior to handling tablets. Additional infection control concerns were observed with linens and respiratory equipment. Linens were seen on the floor in room B-6, and a wet washcloth was observed on the floor in room A-6. An incentive spirometer was observed under the head of Resident #42's bed on multiple observations. Resident #92's CPAP mask was observed lying uncovered on the nightstand on multiple observations. The ADON stated that linens should not be left on the floor and that respiratory equipment should be bagged when not in use. Facility policies provided for linen handling required soiled linen to be placed directly into a covered laundry hamper, and the respiratory care policy stated that respiratory equipment not in use should be stored in a safe manner and that CPAP/BiPAP equipment should be cleaned, disinfected, and stored in a clean environment.
Dietary Staff Lacked Training and Proper Food Safety Practices
Penalty
Summary
The facility failed to provide adequate training and skill sets for dietary staff to safely and effectively carry out food and nutrition services. During observation of the lunch tray line in the kitchen, other staff #3 was preparing resident trays with visible facial hair and was not wearing a beard net. When asked about it, the regional director of dining services requested a beard net, and OS#3 then placed one over his facial hair. Later, other staff #4, #5, and #6 entered the kitchen to begin their shift and went to the hand-washing sink without hair restraints; OS#6 also had visible facial hair and no beard net was visible. Staff stated there were no hair restraints outside the kitchen door, that this was how they had been entering the kitchen, and that OS#6 had never been educated on hair nets or beard restraints since starting in February 2026. Additional observations showed the cook, OS#2, handling food while wearing gloves covered by oven mitts, then removing the mitts and changing gloves without performing hand hygiene. The regional director of dining services reminded OS#2 to change gloves, and later asked OS#2 to wash hands after a break for water because hand hygiene had not been performed before putting on new gloves. OS#2 was again observed using oven mitts over gloves while adding egg noodles to the serving station and then changing gloves without hand hygiene. The administrator stated the dietary manager had quit on 2/6/26, several other dietary staff quit soon afterward, and the facility had hired new dietary staff, including a new cook and dietary aide. The administrator also stated an offer to a new dietary manager was about to be made and that the regional director of dining services was in the process of establishing training for dietary employees.
Failure to Employ Qualified Infection Preventionist and Ensure Proper Precautions
Penalty
Summary
Facility staff failed to employ a qualified infection preventionist (IP) with the required training prior to assuming the role, as evidenced by staff interviews and document review. On multiple occasions, surveyors observed residents requiring enhanced barrier precautions (EBP) and/or transmission-based precautions (TBP) without proper notification, signage, or personal protective equipment (PPE) available to staff, residents, or visitors. During an interview, the interim administrator and interim director of nursing confirmed that the previous IP left employment and that they were acting as IPs without the necessary certification. Although an LPN on staff held an IP certification from 2022, she did not perform the IP role at the facility. The facility provided evidence of staff education on infection control procedures and a job description for the IP position, which only required the ability to obtain certification, but no further information was provided.
Failure to Respond Timely to Resident Call Bell
Penalty
Summary
Facility staff failed to provide a reasonable accommodation of needs for one resident by not responding to the resident's call bell in a timely manner. The resident, who had diagnoses including chronic obstructive pulmonary disease, dysphagia, and major depressive disorder, was cognitively intact according to the most recent assessment. The resident reported to the surveyor that call bell response times had been an ongoing issue, discussed at resident council meetings without improvement, and stated they had waited up to an hour for assistance in the past. During the surveyor's visit, the resident's call bell had been on for about five minutes, and the surveyor observed the call light active over the resident's door. Multiple staff were present at the nurse's station and walked by the resident's room without acknowledging the call bell, which remained unanswered for at least 20 minutes. Facility leadership, including the ADON and DON, provided differing expectations for call bell response times, with the ADON stating approximately five minutes and the DON stating 20 minutes or less. The facility's policy on answering call lights did not define a specific response time but emphasized that any staff member could answer a call light and that response should be appropriate to the situation. Despite these guidelines, staff failed to respond to the resident's call bell in a timely manner, as observed by the surveyor and confirmed through staff and resident interviews.
Failure to Administer Ordered Medication
Penalty
Summary
Facility staff failed to administer Cyclobenzaprine, an oral muscle relaxant, as ordered by the medical provider for one resident. The resident had multiple diagnoses, including encephalopathy, hemiplegia, hemiparesis, congestive heart failure, epilepsy, and several fractures, and was assessed as cognitively intact. The clinical record included a provider order for Cyclobenzaprine 10 mg by mouth three times daily for muscle spasms. Review of the September 2024 Medication Administration Record (MAR) showed an omission of the medication on a specific date and time, with no documentation that it was given. When interviewed, the Interim Administrator confirmed the medication was not signed off and assumed it was not administered. No additional information regarding the omission was provided to the survey team before the exit conference.
Failure to Implement Infection Control Precautions and PPE Use
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols for three residents requiring either Enhanced Barrier Precautions (EBP) or Transmission-Based Precautions (TBP). For one resident with a history of urinary tract infections and colonization with a multidrug-resistant organism (MDRO), staff did not don required personal protective equipment (PPE), specifically gowns, during incontinence care. The resident’s care plan and physician orders specified EBP, but staff were unaware of the precautions, and appropriate signage and PPE were not consistently available in the resident’s area. Interviews with the involved certified nurse aides revealed a lack of knowledge regarding the resident’s EBP status and the need for gowns, and the resident confirmed that staff did not wear gowns during care. Another resident with a urinary tract infection and a Foley catheter had orders and a care plan indicating the need for EBP. However, there was no visual indicator, such as a colored sticker or signage, in the resident’s room to alert staff to the required precautions. Additionally, PPE was not available on the linen carts as outlined in facility policy. The absence of these measures was confirmed by both observation and staff interviews, indicating a failure to implement the facility’s EBP process for this resident. A third resident with an active Acinetobacter infection in the urine and a provider order for contact isolation did not have appropriate TBP signage or PPE available outside the room. Staff, including CNAs and LPNs, entered and exited the room without donning PPE, and there was confusion among staff regarding the type of precautions required. The facility’s policy required signage and PPE availability for residents on TBP, but these were not in place at the time of surveyor observation. The deficiencies were discussed with facility leadership, but no additional information was provided prior to the survey exit.
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 14 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 Dublin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pulaski Hlth & Rehab Cntr | 5.2 mi | ★★★★★ | 2 | 0 |
| Radford Health And Rehab Center | 6.4 mi | ★★★★★ | 0 | 0 |
| The Wybe And Marietje Kroontje Health Care Center | 15.6 mi | ★★★★★ | 0 | 0 |
| Heritage Hall Blacksburg | 16 mi | ★★★★★ | 1 | 0 |
| Heritage Hall-rich Creek | 20.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.