Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marcella Post Acute during CMS and state inspections, most recent first.
Failure to Provide Ordered Pain Medication: A resident prescribed scheduled MS Contin for pain did not receive the medication for 48 hours because it was unavailable from the pharmacy, and staff substituted one-time oxycodone doses. The resident reported inadequate pain relief and withdrawal symptoms, and the NP documented an acute opioid withdrawal episode with diaphoresis when the scheduled opioid supply was interrupted.
A resident was assaulted by another resident who entered the room and struck him in the chest, and the resident later reported being hit in the hand during the altercation. The incident resulted in a left thumb fracture confirmed by x-ray. The other resident had a history of aggressive behavior and prior monitoring, but was still able to access the room and cause harm.
Laundry Lint Trap Not Maintained as Required: The facility failed to keep dryer lint traps cleaned at the required interval. During a laundry room fire event, smoke was seen coming from dryer #3, and the Maintenance Director found embers of lint in the lint trap. Interviews showed the lint trap had not been emptied as required, and the cleaning log had been completed for an entire shift before the shift was over.
Pest control failed to prevent insects throughout resident care areas. Surveyors observed live and dead insects near a resident’s bed, in a resident’s bed, under an ice machine, and on a snack cart, while residents and a family member reported cockroaches, water bugs, ants, gnats, flies, and insects in rooms, beds, windowsills, meal trays, and vents. Pest logs and invoices showed repeated extermination services and ongoing reports of roaches, ants, spiders, and water bugs, but insect activity continued to be documented by staff, residents, family, and surveyors.
Failure to Administer Ordered Medications and Follow Prescriber Parameters Multiple residents had provider-ordered meds, treatments, or monitoring not carried out as documented in the MAR/TAR. An LPN and other nursing staff recorded missed doses or nonadministration even when meds were available in OTC stock or the Med Bank, including pain, thyroid, vitamin, seizure, COPD, and antibiotic therapies. One resident’s ER antibiotic order was not addressed in a timely manner, and another resident received a beta blocker despite BP being below the hold parameter. A PRN antihypertensive order was also reviewed in relation to BP readings.
Inadequate staffing led to delayed resident care, missed routine tasks, and poor call light response. Residents and staff reported late meals, delayed brief changes, missed showers, and inconsistent ice and water service, while one resident experienced a delayed pain medication request when only one nurse was covering the hallway for part of the night shift. PBJ data showed one-star staffing and excessively low weekend staffing, and no staff were observed passing ice or water during the survey.
Ordered medications were not available for administration for multiple residents. MARs documented code 22 for several prescribed drugs, including a mouth rinse, probiotic, fiber supplement, alfuzosin, insulin, Januvia, oxcarbazepine, glargine, buspirone, and calcium citrate with D3. Notes indicated some medications were missing from the cart or Pixis, awaiting pharmacy delivery, or not listed on the OTC/Med Bank records, despite care plans calling for medications to be given as ordered.
Insufficient dietary staffing delayed meal service and disrupted resident care. Dietary staff were still on the tray line during breakfast service, the last breakfast cart left the kitchen late, and lunch tray line preparation was repeatedly delayed with trays not ready until well after the scheduled time. Residents on the unit were still eating breakfast late in the morning, lunch trays were not delivered to the 400 hall until mid-afternoon, and CNAs reported meals were often so late that it affected when they could provide showers and other care.
Meal service was not provided at regular times, with tray line preparation and delivery repeatedly running late. Staff reported the goal was to have the last breakfast cart out by 9:00 AM and lunch trays delivered by 1:10 PM, but breakfast, lunch, and dinner were often delayed; residents were still eating breakfast late in the morning, lunch trays were not ready at scheduled times, and some dinner trays reportedly arrived as late as 9:00 PM. Staff attributed the delays to short staffing in dietary services.
Food storage and sanitation practices were not followed in the kitchen and two nutrition rooms. Surveyors found unlabeled and undated food, expired items, open or improperly sealed packages, and a ripped-open bag of bread in the kitchen, along with dirty resident refrigerators containing sticky residue and multiple resident food items that were unlabeled, undated, or past the facility’s 3-day limit. Staff interviews showed nursing and food service staff were unclear or inconsistent about responsibility for checking, dating, and discarding items.
Surveyors found expired influenza vaccines in a medication refrigerator, an unattended and unlocked treatment cart with scissors on top, and an unattended and unlocked medication cart left with drawers facing outward. Surveyors also found a resident’s medications on an overbed table with no locked box in the room, despite the resident stating he had not been provided one and the DON stating staff believed one was already there.
Incomplete clinical records were identified for multiple residents. A resident with Parkinson’s disease, DM, and dementia had no documentation of showers or bed baths despite being dependent on staff for bathing, and a CNA reported staffing shortages at times. Another resident’s MAR had numerous unsigned entries or holes, a third resident’s record lacked meal intake documentation on multiple dates, and a cognitively intact resident’s medication orders listed “Monitoring” instead of a diagnosis for several meds, which the DON acknowledged needed clarification.
A resident was found double briefed, with one soiled brief against the skin and another outer brief over it. A CNA denied applying two briefs, while an LPN said she found the resident in that condition and removed only the outer brief before reporting the issue and directing the CNA to provide incontinent care. The record also included a note that the resident's daughter was upset about the two briefs, and the facility's ADL guidance stated residents should receive care needed to maintain personal hygiene.
The facility failed to maintain a clean, homelike environment for two residents. One resident with schizophrenia, PTSD, panic disorder, and insomnia had a broken overbed light that stayed on after the pull cord detached, and the resident said it made sleep difficult. Another cognitively intact resident with diabetes, respiratory failure, PVD, and hemiplegia had an unclean room with food debris, wrappers, stains, and a powder substance on the floor and overbed table; the resident reported inconsistent housekeeping and said the table had not been cleaned in months.
Incomplete investigation documentation for an alleged neglect incident. A resident with severe dementia and other serious diagnoses was found on the floor with head and extremity lacerations after falling from an elevated bed during ADL care, later sustaining a femoral neck fracture and requiring surgery. The facility could not produce witness statements or a complete investigation file, and key staff involved were unavailable for interview.
A resident with severe cognitive impairment and multiple diagnoses, including pneumonitis, AFib, AKI, diabetes, and malnutrition, was transferred to a hospital-level of care. The record did not show written notice of the reason for transfer/discharge was provided to the resident or representative, and there was no evidence that a bed-hold offer was made; the Regional Nurse stated there was no discharge paperwork available.
Failure to provide ADL care including nail care, showers, and shaving. Three residents were observed with long, jagged, or dirty nails and poor grooming, and one resident had oily hair, flaking, and had not been shaved or showered as required. Records showed impaired cognition or dependence for personal hygiene, and staff interviews confirmed missed care and lack of timely assistance with grooming and showers.
Failure to Offer/Document Pneumococcal Vaccine for a Resident: The facility did not ensure a resident with multiple chronic conditions, including stroke, ESRD, COPD, diabetes, and chronic respiratory failure, was offered the appropriate pneumococcal immunization after admission. The record showed prior PPSV23 only, no documentation that PCV20 or PCV21 was offered, and the IP confirmed the resident was not up to date and needed additional pneumococcal vaccination.
Inaccurate MDS assessments were completed for two residents. One resident was incorrectly coded as having a limb restraint despite no restraint use, no restraint order, and no restraint observed, while another resident’s MDS did not reflect that he was edentulous and had difficulty chewing some foods, with dental status items left blank despite resident interviews indicating no natural teeth and dentures at home.
Incomplete PASRR Screening: Facility staff failed to fully complete a Level I PASRR for a resident with dysphagia, DM, depression, and vascular dementia. The resident had severe cognitive impairment with a BIMS score of 3, and section 5 of the PASRR recommendation was left blank. An alternate PASRR copy with an earlier timestamp was later provided, but it predated the PASRR under review.
The facility failed to develop comprehensive, person-centered care plans for several residents. One resident had no care plan interventions for CPAP use or room hoarding, another had no care plan for being edentulous and having chewing difficulty, a third had a dialysis care plan that was not specific to the access site or type of access, and a fourth had no care plan for enhanced precautions related to dialysis and a pressure ulcer. Staff observations, resident statements, and record reviews showed the care plans were missing or not individualized.
Failure to revise the CPCCP after foley catheter discontinuation. A resident with a history of urinary retention and intact cognition had a provider order to remove the foley and begin a void trial with bladder scans, but the care plan still listed an active indwelling urinary catheter focus with related goals and interventions. The MDS Nurse stated the error occurred during an electronic system transition, and facility policy required care plans to be revised as resident conditions change.
Failure to Provide Ongoing Person-Centered Activities: A resident with moderate cognitive impairment and a history of CVA, hemiplegia, epilepsy, altered mental status, cognitive communication deficit, and adult failure to thrive had documented preferences for music, news, group activities, favorite activities, outdoor time, and religious services. Although the care plan called for meaningful activities and regular participation, the only documented activity support was a small number of 1:1 room visits, and the AD confirmed there was no documentation of refusals, independent pursuits, or social visits.
Failure to Apply Ordered Bilateral Palm Guards: A resident with severe cognitive impairment, vascular dementia, and bilateral UE ROM limitation was ordered bilateral palm guards during AM ADLs and removal during PM ADLs, with skin checks before and after use. Staff observed the resident wearing only the left palm guard on two occasions, while the right-hand palm guard was not in place, and the SDC was unsure whether the bilateral order existed.
A resident with diabetes, CHF, chronic pain, and ESRD on dialysis did not have pressure dressing supplies kept at the bedside as ordered for the dialysis access port. An LPN searched the room and could not find the supplies, and the DON stated new orders are sometimes missed because they are entered electronically versus on paper.
Therapeutic diet order not followed for a resident on a CCD, 2-gram Na, mechanical soft, thin consistency diet. During a meal observation, the resident was served a tray with a salt packet, and the meal ticket did not reflect the 2-gram sodium restriction. The dietary manager and RD both confirmed the resident should not have received salt.
The facility failed to maintain infection control practices on two nursing units and for one resident. A clean linen cart was stored in a resident’s bathroom beside an unflushed toilet with feces, an in-use shower mat was torn and the shower gurney underneath was soiled with matter and hair, and a resident’s nebulizer mask was left improperly stored on the bedside table instead of being kept in a sanitary manner.
Facility staff failed to document COVID-19 vaccine education for two residents whose immunization records showed vaccine refusal and Education Provided marked No. One resident had severe cognitive impairment with diagnoses including stroke, ESRD, vascular dementia, and COPD, while the other had intact cognition and diagnoses including diabetes, asthma, chronic respiratory failure, ESRD, and CHF. The IP stated she used the VIS for education but had missed documenting it, and no progress note entries showed the vaccine was discussed.
A resident with a broken and painful tooth did not receive timely emergency dental services due to the facility's failure to arrange necessary transport and appointment scheduling. Despite the resident's moderate cognitive impairment and severe pain, the responsibility to schedule a dental appointment was inappropriately deferred to the resident's niece. The facility's staff were aware of the issue but did not take adequate action until after the surveyor's findings.
Two residents experienced environmental deficiencies in their rooms. One resident, with cardiogenic shock and COPD, reported a non-functioning air conditioning unit since admission, causing discomfort. Another resident, with quadriplegia, faced a leaking roof and water-stained ceiling tile, with requests for repairs going unanswered for months. These issues highlight the facility's failure to maintain a clean, comfortable, and homelike environment.
Two residents in an LTC facility were not provided timely toileting assistance, leading to deficiencies in care. One resident, with dementia, was not changed despite multiple requests during supper, as the CNA prioritized her break. Another resident, requiring maximal assistance, waited over an hour for toileting help during breakfast, forcing her to eat while needing a bowel movement. The DON confirmed a CNA is designated for toileting during meals, but this protocol was not followed.
A resident with a broken tooth experienced severe pain and the facility failed to have an agreement with a dentist for emergency services. The resident required stretcher transport, but no local dentist was available. Attempts to schedule an appointment at a dental school's clinic were deferred to the resident's niece. The facility's Administrator was researching a new dental provider.
Failure to Provide Ordered Pain Medication
Penalty
Summary
The facility failed to provide effective pain management for one resident who was prescribed MS Contin 15 mg twice daily for pain. The resident stated that his morphine was not available, that oxycodone was ordered one time in place of the morphine, and that the oxycodone did not relieve his pain like the morphine did. He also stated that he experienced withdrawal symptoms because he went without the morphine. Clinical record review showed the resident’s care plan directed staff to administer analgesia as ordered and to observe for effectiveness and signs and symptoms of side effects. Progress notes documented that the resident’s morphine extended release medication was interrupted when the supply was not available, and that he was given oxycodone as a substitute. A nurse practitioner note later stated that the resident experienced an acute opioid withdrawal episode when his MS Contin supply was interrupted and he went without medication for 44 hours, with diaphoresis and withdrawal symptoms, and that he was bridged with oxycodone until the refill arrived. The medication administration record showed the resident was not administered MS Contin on two consecutive days and missed four doses, leaving him without the medication for 48 hours. During that time, the NP issued a one-time order for oxycodone 10 mg for pain. The DON stated the morphine extended release was on back order and that there was a gap when the medication could not be obtained. The NP stated she expected residents on scheduled pain medication not to go without it and that staff should ensure medications were available.
Failure to Protect Resident from Assault
Penalty
Summary
The facility failed to protect one resident from a resident-to-resident altercation that occurred when another resident entered the resident’s room and struck him in the chest. Staff heard yelling and a thud, responded to the room, and found the resident had been assaulted. The incident resulted in harm to the resident, who later reported that he had put his hand up and was hit in the hand during the altercation. After the incident, the resident was evaluated and an x-ray of the left hand was obtained because of pain. The x-ray showed a nondisplaced vertical fracture involving the proximal radial corner of the first distal phalanx of the left thumb. A physician’s note later documented that the resident was being treated for a left thumb fracture following a reported physical assault in the facility and that he was wearing a splint and receiving pain medication. The record also showed that the other resident had a history of aggressive behavior before the assault. The DON stated that the resident had been on frequent monitoring and hourly behavior watch, had previously punched a roommate’s television, and had been moved to a private room after that behavior so he would not have a roommate. Despite those prior behaviors, the resident was able to enter the injured resident’s room and assault him, and the facility did not identify or implement interventions, supervision, or monitoring that prevented the altercation.
Laundry Lint Trap Not Maintained as Required
Penalty
Summary
The facility failed to maintain laundry equipment in safe operating condition when lint traps on the dryers were not cleaned as required. The facility policy for Personal Laundry Handling and Processing stated lint traps should be checked, brushed, and cleaned at least every hour unless more frequent attention was required, and that cleanings should be documented on the Lint Trap Cleaning Log. During the incident review, the facility stated that on Thursday, January 22, 2026, the fire alarm activated at about 9:22 AM and smoke was seen coming from dryer #3 in the laundry room. The Maintenance Director reported opening the lint trap doors and seeing embers of lint, which were extinguished, and the facility later determined there had been excess lint buildup. Facility interviews showed the lint trap had not been cleaned as required. The Maintenance Director stated the lint trap had not been cleaned like it was supposed to and that laundry staff were supposed to empty it every hour. The Director of Environmental Services stated the lint trap was supposed to be emptied every hour, but the staff member working that morning did not do it, and the log had been filled out for the entire shift even though it was only 9:40 AM. The District Manager stated new employees were educated on checking lint traps during orientation and that, after the fire, laundry staff received corrective actions. The survey team reviewed the concern with facility leadership, and no further information was provided before exit.
Pest Control Program Failed to Prevent Insects in Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to address and prevent the presence of insects throughout resident care areas. During observation and interviews, surveyors found live and dead insects in multiple locations, including a brown insect near a resident’s bed, a second insect crossing the floor, a live water bug in a resident’s bed, and a live brown insect resembling a cockroach under an ice machine. Residents reported ongoing problems with cockroaches, gnats, flies, ants, and water bugs, including insects in rooms, beds, windowsills, meal trays, ice machines, and vents. A family member also pointed out a dead brown insect in an air conditioning unit and behind a bed and reported concerns about ants and room cleanliness. Facility documentation and staff interviews showed repeated pest activity despite ongoing extermination services. The exterminator stated the facility received weekly services with additional treatment as needed and identified the insect found under the ice machine as an American cockroach. Pest control logs documented reports of ants, spiders, water bugs, roaches above curtains, on ceilings and walls, and ants on dressers, inside dressers, on walls, and behind baseboards. Invoices showed the facility had been treated multiple times for roaches and ants with various insecticides and baits, yet insects continued to be observed by residents, staff, family, and surveyors.
Failure to Administer Ordered Medications and Follow Prescriber Parameters
Penalty
Summary
The facility failed to ensure medications and treatments were provided according to provider orders for multiple residents. For Resident #29, who had quadriplegia, anxiety disorder, paralytic ileus, neuromuscular dysfunction of the bladder, and cervical disc disorder, nursing staff documented code 22 on the MAR for ordered medications that were available in OTC stock or the Med Bank. Resident #55, who had dysphagia, diabetes, depression, and vascular dementia with severe cognitive impairment, also had provider-ordered medications documented as not administered even though they were available in the facility’s OTC supply or Med Bank. For Resident #165, who had convulsions, diabetes, and spondylolisthesis and was cognitively intact, nursing staff documented code 22 for ordered weights and blood sugar monitoring without supporting documentation for why the tasks were not completed. For Resident #15, who had Alzheimer’s disease, adult failure to thrive, and pain, staff failed to apply an ordered Lidocaine 4% patch to the right knee on two occasions; the chart stated the patch was not applied because the facility ran out or it was not available, although the DON stated the patch was part of house stock and was available in OTC inventory. For Resident #3, who had COPD, insomnia, vitamin D deficiency, hypomagnesemia, chronic kidney disease, atherosclerotic heart disease, and type 2 diabetes, staff did not timely address an ER order for Keflex after a UTI diagnosis and also missed multiple ordered medications in March and April. The record showed several medications were not administered even though they were available in the Med Bank or OTC stock, with notes indicating the facility was waiting on pharmacy delivery or needed a new script. For Resident #4, staff administered Metoprolol Tartrate on occasions when the resident’s systolic BP was below the ordered hold parameter, and for Resident #72, the record showed an order for PRN Hydralazine for elevated BP, with the MAR documenting BP readings as part of the medication record review.
Inadequate Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and to maintain a licensed nurse in charge on each shift. Review of PBJ staffing data for quarter one 2026 showed the facility triggered for one-star staffing and excessively low weekend staffing. During the survey, cognitively intact residents and resident representatives reported concerns about staffing and delayed responses to call lights. Resident council minutes from 03/2026-05/2026 documented concerns about staff using personal phones while providing care, unprofessional staff behavior, daily care interactions with aides, and one resident being asked to make their own bed. Interviews with staff and residents described missed or delayed care during periods of limited staffing. A CNA stated ice and water were expected twice per shift but could not always be completed because there was not enough help. Residents reported difficulty getting briefs changed at night, that staff would say "give me a minute" and not return, and that residents needing Hoyer transfers were often last to be put to bed. One resident reported a delay in receiving pain medication and that the call light was not answered in a timely manner during a night shift when only one nurse was available on the hallway for a three-hour period because another nurse called out. Staff also reported delayed showers and late meals, including dinner trays arriving as late as 9:00 PM, which left no time for showers before the shift ended. Throughout the survey, no staff member was observed passing ice or water to residents, despite the DON stating that water and ice are passed every shift.
Ordered Medications Not Available for Administration
Penalty
Summary
The facility failed to ensure provider-ordered medications were available for administration for multiple residents. For Resident #29, who had diagnoses including quadriplegia, anxiety disorder, paralytic ileus, neuromuscular dysfunction of the bladder, and cervical disc disorder, the MAR documented code 22 for Peridex mouth/throat solution, Saccharomyces probiotic, and Benefiber on multiple occasions. Review of the OTC medication list and Med Bank list showed these medications were not listed as available for administration, despite the resident being cognitively intact with a BIMS score of 15 and having a care plan intervention to administer medications as ordered. For Resident #50, who had Parkinson’s disease and benign prostatic hyperplasia and a BIMS score of 3, the MAR documented code 22 for alfuzosin extended-release tablet because it was not available in the Pixis back-up supply and was awaiting pharmacy supply. For Resident #55, who had diabetes and vascular dementia and a BIMS score of 3, the MAR documented code 22 for Lantus insulin and Januvia, with a nursing note stating Januvia was not on the medication cart and had been reordered. The OTC medication list and Med Bank list did not show these medications as available for administration. For Resident #165, who had convulsions and diabetes and a BIMS score of 15, the MAR documented code 22 for oxcarbazepine on two dates. For Resident #3, provider-ordered Glargine YFGN, Buspirone, and Calcium Citrate plus D3 were not administered on multiple occasions, with nursing notes stating the medication was reordered, was waiting on arrival from the pharmacy, or was unavailable for administration. Facility policies stated medications are to be administered in accordance with prescriber orders and that the facility would make every effort to ensure ordered medications were available, but no additional information was provided to the survey team prior to exit.
Insufficient Dietary Staffing Caused Delayed Meal Service
Penalty
Summary
The facility failed to employ sufficient staff to safely and effectively carry out the functions of food and nutrition services. During the initial kitchen tour on 5/17/2026 at 9:05 AM, dietary staff were still on the tray line, and the dietary aide stated they were prepping cart #7 of 9 carts. At 9:25 AM, the aide said they were prepping the last cart, and the last tray cart did not leave the kitchen until 9:50 AM, although the aide stated the goal was to have the last cart out by 9:00 AM. The aide reported the normal staffing was three aides and one cook, and that this was the daily staffing pattern. The cook directed the surveyor to return at 11:30 AM to observe lunch tray line preparation. At 11:25 AM on 5/17/2026, three residents on the [NAME] unit were still eating breakfast and several others still had breakfast trays in their rooms. At 11:30 AM, four additional staff members were in the kitchen, but the tray line was not ready; the District Manager stated they needed 15 more minutes. At 12:05 PM, the tray line was still not ready, and it was not ready until 12:40 PM. The last cart was finished and loaded at 2:00 PM. On 5/18/2026 at 2:38 PM, residents on the 400 hall still did not have lunch trays, and the Administrator stated the trays were on a cart outside the kitchen door and had not been pushed up because staff were busy doing something else. The last tray on that cart was passed at 2:48 PM, leaving many residents on the unit still eating lunch after 3:00 PM. The Dining Services District Manager stated the goal was four aides and one cook per shift, but that this was rarely happening because there were not enough people, and the department had been short staffed since March. CNA #12 and CNA #8 also reported that meal service was often very late and interfered with showering and other care tasks.
Late Meal Delivery and Irregular Meal Times
Penalty
Summary
The facility failed to ensure residents received meals and snacks at times in accordance with their needs, preferences, and requests, and failed to provide three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. During the kitchen tour on 5/17/2026, dietary staff were still on the tray line at 9:05 AM while prepping cart #7 of 9, and at 9:25 AM they were still preparing the last cart. The dietary aide stated the goal was to have the last cart out by 9:00 AM, but that it did not always happen. The last tray cart left the kitchen at 9:50 AM for the 400 hall. The cook later stated the lunch tray line should start at 11:30 AM, but at that time the tray line was not ready and the District Manager said they needed 15 more minutes; at 12:05 PM it was still not ready, and the tray line did not become ready until 12:40 PM. The last cart was finished and loaded at 2:00 PM. On 5/17/2026 at 11:25 AM, three residents on the [NAME] unit were still eating breakfast and several others still had breakfast trays in their rooms. Two of those residents stated it was fairly normal for breakfast to be that late and that when breakfast was late, each consecutive meal would be late as well, with supper likely not until 8:00 PM or later. On 5/18/2026 at 2:38 PM, residents on the 400 hall still did not have lunch trays, and the Administrator stated the trays were on a cart outside the kitchen door and no one had pushed them up. The last tray on that cart was passed at 2:48 PM, leaving many residents on the unit still eating lunch after 3:00 PM. The District Manager stated the department had been short staffed since taking over the building in March and that the goal of four aides and one cook on each shift was rarely happening. On 5/19/2026, lunch trays arrived on the 400 hall at 1:36 PM. A CNA also stated that dinner trays had once not been served until 9:00 PM, and another CNA stated meals were often really late and that dinner trays had sometimes arrived around 7:00 to 7:30 PM.
Food Storage and Refrigerator Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen and in two nutrition rooms. During the kitchen tour, surveyors observed multiple food items that were not properly labeled, dated, sealed, or stored as required by facility policy, including a cut raw onion in an unlabeled bag, sandwich cheese with no label or date, an open bag of chopped lettuce that was not sealed and was wilted and brown, an unopened cole slaw kit past its best-by date, fresh parsley with a use-by date that had passed, sausage patties with a use-by date that had passed, and a ripped-open bag of sandwich bread that was exposed to the air and had no label. The cook stated they were in charge, agreed the onion and cheese should have been labeled, acknowledged the other items were out of date, and said the bread should not have been ripped open and would be discarded. Surveyors also found poor food storage and sanitation practices in the resident refrigerators in two nutrition rooms. One refrigerator had brown and purple sticky substances on the top shelf that had leaked down the back and settled under the drawers, along with resident-labeled food items including a birthday cake dated 5/13, a brown bag dated 5/9/26, and a white food box with illegible writing. In the other refrigerator, surveyors found a sealed Subway bag with no name or date, an Olive Garden bag with a receipt dated 5/12/26, a freezer bag containing what appeared to be cheesecake with no name or date, and a tied grocery bag dated 5/4-5/7. Staff interviews showed CNA #2 and LPN #13 stated nursing was responsible for checking the refrigerators, keeping them clean, and discarding food after three days, while LPN #5 stated nursing was responsible for ensuring items were dated and discarded after three days. The questionable items were discarded during the survey, and the refrigerator contents and cleanliness concerns were discussed with facility leadership.
Expired Medications and Unsecured Medication Storage
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles. During a medication storage room check, surveyors found expired influenza vaccines in the refrigerator, including a box of Flublok Influenza vaccine with ten single-dose prefilled syringes and an unopened box of Flucelvax 2025-2026 Formula. The LPN who was present acknowledged the expiration dates and stated the items would be disposed of according to facility policy. The facility also failed to ensure medications and biologicals were kept in secure storage on a treatment cart and a medication cart. Surveyors observed a treatment cart unattended and unlocked in the hallway with its drawers not facing the wall and scissors lying on top of it. An LPN stated she was not using the cart, while another LPN stated he was using it. Surveyors also observed a medication cart unattended and unlocked in front of the nurses’ station with the drawers and doors facing outward, and the LPN identified it as her cart and agreed she had left it unlocked. In addition, the facility failed to provide a locked storage box for a resident’s self-administered medications. The DON stated the resident did not self-administer medications and that nurses administered them, but surveyors observed medications on the resident’s overbed table and no lock box in the room. The resident stated he was in his right mind and had not been offered a locked box, and later stated he had never been provided one. Facility staff later stated they thought the resident had a lock box in his room, but none was observed during the survey.
Incomplete clinical documentation for care, medications, meals, and medication orders
Penalty
Summary
Resident #50’s clinical record did not include documentation showing that the resident received showers or bed baths after admission to the facility in April 2026. The resident had diagnoses of Parkinson’s disease, diabetes, and dementia, and the admission MDS showed a BIMS score of 3, indicating severe impairment in cognitive skills for daily decision making. The MDS also coded the resident as dependent on staff assistance for showers. A family member raised concerns about whether the resident was receiving showers or baths, and survey review of the record found no documentation of any showers or baths since admission. During record review, the Staff Development Coordinator and Assistant DON were unable to locate documentation confirming that the resident had received a shower or bath. During interview, CNA #7 stated there were times when there were not enough staff to provide residents with showers or baths. The resident stated he had a shower about once or twice and reported receiving a few bed baths. The facility policy titled Charting and Documentation stated that all services provided to the resident shall be documented in the medical record. Resident #55’s March 2026 MAR contained numerous unsigned entries or holes, showing that nursing staff did not document administration of prescribed medications and/or treatments. Resident #175’s clinical record lacked documentation of meal intake on multiple dates for breakfast, lunch, and dinner. Resident #8’s physician medication orders listed the reason for several medications as “Monitoring” rather than a diagnosis, including mirtazapine, pregabalin, prazosin, and Ranexa. Resident #8 had diagnoses including diabetes, CHF, chronic pain, PTSD, and ESRD on dialysis, and the DON acknowledged that a diagnosis should be attached to each medication order.
Failure to Provide Individualized Incontinence Care
Penalty
Summary
The facility failed to treat one resident with respect and dignity by not ensuring individualized incontinence care for Resident #181. Survey findings indicated that the resident was found with multiple briefs on at one time, including a brief against his skin that was soiled and an outer brief over it. A CNA stated she did not apply two briefs and said she had never seen the resident's daughter provide incontinent care, while also reporting that the daughter would sometimes ask only for a towel to wipe the resident's face. An LPN stated she found the resident double briefed, removed the outer brief, and left the soiled brief in place so it would not be tampered with, then told the aide the resident needed to be changed. The clinical record included a progress note written by the LPN stating the resident's daughter was upset that the resident had two briefs on and that the LPN assisted the daughter in removing the outer brief before directing the CNA to provide incontinence care. The facility's ADL supporting document stated residents are to receive care and services as appropriate to maintain or improve ADLs, including personal and oral hygiene. During the end of day meeting, the administrator, DON, vice president of operations, vice president of clinical services, and regional director of clinical services were informed of the concern, and no additional information was provided before exit conference.
Failure to Maintain Clean Room and Repair Broken Overbed Light
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for two sampled residents. For Resident #3, who was admitted with diagnoses including schizophrenia, PTSD, panic disorder, and insomnia, the overbed light remained on after the pull cord broke off and the switch was pulled out. Resident #3, who had intact cognition, stated the light had been on for a couple of days and that it was hard to sleep with the light on at night. A work order was created for the missing light string, but the light was still on during observation and the cord remained detached on the overbed table. For Resident #111, who had diagnoses including diabetes, respiratory failure, peripheral vascular disease, and hemiplegia and was assessed as cognitively intact, the room was observed to be unclean. Surveyors noted food wrappers and crumbs on the floor, a sticky dried liquid substance on the floor, a white powder substance behind the bed, and food debris and dried liquid stains on the overbed table. Resident #111 stated housekeeping did not consistently clean the room, that some housekeepers barely mopped, and that the overbed table had not been cleaned in months. The room remained unclean on repeated observation, and the care plan reviewed did not document refusals to clean the room or interventions related to that issue.
Incomplete Investigation Documentation for Alleged Neglect
Penalty
Summary
The facility failed to maintain documentation showing that an alleged incident of neglect involving a severely cognitively impaired resident was thoroughly investigated. Resident #63 had diagnoses including adult failure to thrive, severe dementia with mood disturbance, Parkinson’s disease, and major depressive disorder, and the most recent MDS documented a BIMS score of 5 out of 15, indicating severe cognitive impairment. A nursing fall progress note documented that a CNA notified the nurse the resident was found on the floor lying face down, with lacerations to the forehead, right knee, and right hand. Facility documents later stated the resident fell out of bed during ADL care and was sent to the ER for further evaluation. A medical provider fall investigation summary stated the resident fell from bed with injury to the forehead and femur fracture, and described staff providing care, rolling the resident to the side, positioning the resident in the middle of the bed, and then the resident shaking and rolling out of bed. A hospital discharge summary stated the bed had been elevated while the resident was being changed, the resident fell from an elevated position, hit the head, required suturing, suffered a right femoral neck fracture, and required hemiarthroplasty. During the investigation, the facility could not locate witness statement forms and only produced the fall investigation and incident/accident summary. The summary referenced attached staff statements and interviews with the roommate and a resident across the hall, but those witness statements were not available for review. CNA #10 stated she assisted after the fall and recalled the resident was a one-person assist and the bed was approximately stomach height when she entered the room. The assigned CNA could not be reached for interview, and the LPN assigned at the time was no longer employed. The facility therefore lacked complete investigation documentation for the alleged neglect incident involving Resident #63.
Failure to Provide Transfer/Discharge Notice and Bed-Hold Offer
Penalty
Summary
The facility failed to provide written notification of the reason(s) for transfer and/or discharge to Resident #175 and/or the resident’s representative, and it also failed to offer a bed hold for this resident. Resident #175 was transferred to a higher level of care from the facility on 06/24/2024, and the clinical record review did not show documentation that the required written notice was given or that a bed hold was offered. Resident #175 had diagnoses including pneumonitis, atrial fibrillation, acute kidney failure, alcohol dependence, clostridium difficile, gastro-esophageal reflux disease, benign prostatic hyperplasia, hypotension, gout, diabetes, and protein-calorie malnutrition. The admission MDS assessment dated 06/13/2024 showed a BIMS score of 3, indicating severe impairment in cognitive skills for daily decision making. The record included a progress note stating the resident had been transferred to a local hospital, and during interview the Regional Nurse stated they did not have any paperwork for this individual’s discharge.
Failure to Provide ADL Care Including Nail Care, Showers, and Shaving
Penalty
Summary
The facility failed to provide activities of daily living care for three residents, including nail care, showers, shaving, and personal hygiene. Resident #55 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, diabetes, and a contracture of the left hand, and was severely cognitively impaired with a BIMS score of 3. The resident was observed with fingernails on both hands that were excessively long and jagged, and the Staff Development Coordinator confirmed the nails needed trimming. The resident’s care plan identified an ADL self-care performance deficit, and the facility policy stated that residents unable to perform ADLs independently are to receive services necessary to maintain grooming and personal hygiene. Resident #149 had diagnoses including end stage renal disease, diabetes, and depressive disorder, and was moderately cognitively impaired with a BIMS score of 8. The resident required supervision or touching assistance with personal hygiene and had a care plan identifying an ADL self-care performance deficit. The resident was observed with fingernails that were long, jagged, and contained visible debris, and stated he did not have nail clippers available. On a later observation, the fingernails remained long and jagged before the resident later reported that staff had cut his nails and given him a shave. Resident #36 was dependent with showers and personal hygiene per the MDS. The resident was observed with oily-looking hair, white flake-like material in the hair, long and dirty nails, and was not shaved; he stated he had not gotten a shower in a long time and that a CNA would not give him a shower. The CNA stated he did not have time to give a shower because dinner trays came out too late and said he did not work that side of the unit often. A clinical record review showed that for two weeks no shower was documented for the resident, and the facility policy stated residents unable to carry out ADLs independently are to receive services necessary to maintain grooming and personal and oral hygiene.
Failure to Document and Offer Pneumococcal Immunization
Penalty
Summary
The facility failed to ensure that each resident was offered a pneumococcal immunization unless medically contraindicated or already immunized for 1 of 5 residents sampled, including resident #134. The facility policy, revised August 2025, stated that residents are to be assessed for pneumococcal vaccine eligibility prior to or upon admission and, when indicated, offered the vaccine series within 30 days unless contraindicated or the current recommended series had already been completed. Resident #134 was admitted on 10/30/25 with diagnoses including stroke, end stage renal disease, COPD, diabetes, and chronic respiratory failure. The vaccination record showed PPSV23 was given on 12/26/2016, but there was no documentation that any pneumococcal vaccine had been offered since admission. CDC guidance reviewed by surveyors indicated that a resident over [AGE] years old who previously received only PPSV23 should have been offered 1 dose of PCV15, PCV20, or PCV21 at least 1 year after the last PPSV23 dose. During interview, the Infection Preventionist stated the resident was not up to date and needed PCV20 or PCV21, and also stated the resident may have refused it when offered with the COVID vaccine, but this was not documented in the immunization record.
Inaccurate MDS Assessments for Restraint Use and Dental Status
Penalty
Summary
Facility staff failed to ensure accurate MDS assessments for two residents. For one resident, the 03/21/2026 quarterly MDS coded a limb restraint in Section P even though the resident stated they did not have any type of restraints, no restraints were observed, and there was no medical provider order for a limb restraint. The resident’s BIMS score was 15 out of 15, indicating intact cognition, and the MDS coordinator later stated the restraint entry was made in error because the resident did not have restraints and the facility did not use restraints. For another resident, the quarterly MDS dated 03/26/2026 did not accurately reflect oral/dental status. The resident was observed and interviewed as edentulous, stated he had no natural teeth, and reported difficulty chewing meat when it was not chopped up. The MDS coordinator reviewed the assessment and stated the resident was not coded for broken or loose-fitting dentures and was not aware the resident had no natural teeth, despite the resident reporting dentures at home and difficulty chewing some foods. The MDS section for dental status was left blank for broken or loose-fitting dentures and for mouth or facial pain, discomfort, or difficulty with chewing.
Incomplete PASRR Screening
Penalty
Summary
Facility staff failed to fully complete a Level I PASRR for Resident #55, leaving section 5, titled RECOMMENDATION, blank. Resident #55 had diagnoses of dysphagia, diabetes, depression, and vascular dementia, and the quarterly MDS assessment with an ARD of 02/16/2026 showed a BIMS score of 3, indicating severe impairment in cognitive skills for daily decision making. The resident was admitted on 01/24/2022, and the clinical record contained a Level I PASRR dated 01/24/2022 that was incomplete because section 5 had not been checked. On 05/18/2026, the DON was informed that the PASRR was incomplete, and later that day the incomplete PASRR was reviewed during an end-of-day meeting with the Administrator, DON, Regional President of Operations, Regional Nurse, Staff Development Coordinator, and ADON. Before the exit conference, staff provided a different PASRR copy with a timestamp of 12/23/2021, which predated the PASRR under review.
Incomplete and Non-Specific Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents. For one resident, staff did not create care plan interventions for the use of a CPAP machine or for hoarding behaviors in the room. During observation, the resident’s room contained personal items packed in bags and boxes stacked at the end and sides of the bed, metal racks filled with belongings, and an overbed table covered with items that made it difficult to see the resident in bed. Staff stated the resident declined room cleaning and that the piled towels and sheets were his special linen, while the care plan contained no intervention for CPAP use. For another resident, staff did not develop a care plan addressing the resident’s lack of natural teeth. The resident stated he was diabetic, had no teeth, sometimes could not chew meat when it was not chopped up, and reported coughing and choking on food when not sitting upright enough. The record review showed no care plan for edentulous status, dentures kept at home, or chewing difficulty. The quarterly MDS did not code dentures or chewing difficulty, and the nutritional assessment was incomplete because the edentulous section was left unmarked. The facility also failed to develop resident-centered care plans for dialysis-related needs and enhanced barrier precautions. One resident with diabetes, CHF, chronic pain, and ESRD on dialysis had a dialysis care plan that was not specific to the resident’s access site or type of access. Another resident with CKD, diabetes, and a stage III sacral pressure ulcer had signage outside the room for enhanced precautions, but the record review found no care plan for enhanced precautions related to dialysis and wound care. Staff confirmed the missing care plan, and the resident’s care plan was later updated to include enhanced precautions.
Failure to Revise Care Plan After Foley Catheter Discontinuation
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for one resident after the resident’s foley catheter was discontinued. The resident was admitted with a history that included heart failure, unspecified, and retention of urine, unspecified. The quarterly MDS with an ARD of 4/9/2026 showed a BIMS score of 14 out of 15, indicating intact cognition. The resident’s provider orders included an order dated 1/06/2026 to remove the foley catheter, perform a void trial, and complete bladder scans every 8 hours and as clinically indicated. On 5/19/2026, the resident’s comprehensive care plan still contained an active focus area dated 12/17/2025 stating the resident had an indwelling urinary catheter, with the related goals and interventions remaining active. During interview, the MDS Nurse stated the error occurred during a transition with the electronic computer system and that the foley should have been removed from the care plan. Facility policy stated that assessments are ongoing and care plans are revised as resident information and conditions change. The facility administrative staff, including the Administrator and DON, were informed of the failure to revise the care plan during the survey meeting.
Failure to Provide Ongoing Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing, person-centered activity program to support resident choice, interests, and physical, mental, and psychosocial well-being for one resident. The resident was admitted with a history that included cerebral infarction, hemiplegia and hemiparesis, epilepsy, altered mental status, cognitive communication deficit, and adult failure to thrive. A quarterly MDS assessment showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment. The resident’s Life Enrichment Activities assessment stated it was very important to listen to music, keep up with the news, do things with groups of people, do favorite activities, go outside in nice weather, and participate in religious services or practices, and the resident was coded as dependent on staff for activities, cognitive stimulation, and social interaction. The resident’s care plan identified a need for meaningful activities, sensory and tactile stimulation, and assistance to and from programs appropriate for social stimulation and enjoyment at least 1-2 times per week, with attendance or participation in activities of choice 3-5 times weekly. However, the activity participation records for March, April, and May showed only six documented 1:1 in-room activity visits. The Activity Director stated these records were the only evidence of 1:1 activities provided and acknowledged there was no documentation of refusals to group activity invitations and no documentation of the resident’s independent activity pursuits or social visits by activity staff.
Failure to Apply Ordered Bilateral Palm Guards
Penalty
Summary
Facility staff failed to provide appropriate services and/or treatment to prevent further decrease in range of motion for Resident #55. The resident had diagnoses including dysphagia, diabetes, depression, and vascular dementia, and the quarterly MDS showed a BIMS score of 3, indicating severe impairment in cognitive skills for daily decision making. The resident’s care plan identified an ADL performance deficit and directed staff to apply bilateral palm guards during AM ADLs and remove them during PM ADLs; the resident was also noted to be resistive to care. A provider order dated 04/06/2026 directed staff to wear bilateral palm guards and check skin pre/post application. During observation, Resident #55 was seen with a palm guard on the left hand but no palm guard on the right hand. This was observed on 05/17/2026 during the initial tour and again on 05/18/2026 at 9:05 AM with the SDC and CNA #1 present. The SDC stated she was unsure whether the resident had an order for bilateral palm guards and said she would verify the order. The treatment administration records showed documentation for application and removal of the palm guards on 05/17/2026 and 05/18/2026, but the resident was still observed without the right-hand palm guard. At the end-of-day meeting on 05/18/2026, the issue with the provider-ordered palm guard not being in place was reviewed.
Missing Dialysis Access Pressure Dressing Supplies
Penalty
Summary
The facility failed to follow a physician order for Resident #8, who had diagnoses including diabetes, congestive heart failure, chronic pain, and end stage renal disease on dialysis. The resident’s most current MDS showed a cognitive score of 15, indicating the resident was cognitively intact. The physician order dated 5/19/26 directed staff to keep pressure dressing supplies at the bedside for the dialysis access port. On 5/20/26 at 10:32 a.m., the resident’s room was observed and the LPN searched the closet, drawers, under the bed, the window ledge, and behind furniture but could not find the pressure dressing kit/supplies. The LPN stated the supplies would be put in place. Later that day, the DON reviewed the order and stated the supplies would be put in place and that new orders are sometimes missed because they are entered electronically versus on paper. At 11:58 a.m., the LPN stated the resident’s pressure dressing had been placed.
Therapeutic Diet Not Followed for Resident
Penalty
Summary
Facility staff failed to follow a physician-ordered therapeutic diet for one resident, who had an order dated 3/11/26 for a consistent carbohydrate, 2-gram sodium diet with mechanical soft texture and thin consistency. During a lunchtime observation on 5/19/26, the resident was served a mechanical soft meal tray that included a salt packet. The meal ticket for the tray listed the mechanical soft meal items, but did not reflect the 2-gram sodium restriction. During record review and interviews, the dietary manager stated the resident should have received a pepper packet, a sugar packet, and a salt-free packet, and that a salt packet should not have been on the tray. She also stated the resident’s meal ticket should have been corrected when the physician order was sent to dietary. The RD reviewed the order and confirmed the 2-gram sodium diet, stating the resident should not have received a salt packet and that something had confused the system. The facility’s Therapeutic Diets document stated therapeutic diets are prescribed by the attending physician and include low sodium and altered consistency diets.
Infection Control Lapses With Linen Storage, Shower Equipment, and Nebulizer Mask
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of diseases and infections for two nursing units and one sampled resident. On one nursing unit, a stocked clean linen cart was observed stored inside Resident #170’s bathroom beside an unflushed toilet containing feces, with a strong odor of fecal matter present. A CNA was notified and removed the cart from the bathroom and placed it in the hallway for staff use, and the Infection Preventionist later stated the cart should never have been in the bathroom and needed to be cleaned, including everything on it. On another nursing unit, an in-use shower bed mat used for Resident #15 was observed with multiple tears exposing the inner foam, and the shower gurney underneath was soiled with dark green/brown matter and body hair. The DON was notified and instructed staff to take the shower bed mat out of service. In addition, Resident #36’s nebulizer mask was observed sitting on the bedside table with the tubing wrapped around the nebulizer machine and the mask portion lying on the machine rather than being stored in a sanitary manner. The DON later stated the nebulizer mask should be stored properly in a plastic bag when not in use.
Failure to Document COVID-19 Vaccine Education for Two Residents
Penalty
Summary
Facility staff failed to implement policies and procedures to ensure residents or their representatives received education regarding the risks, benefits, and potential side effects of the COVID-19 vaccine for two residents in the immunization review sample. A facility policy stated that before the COVID-19 vaccine is offered, the resident is to be provided education regarding the benefits, risks, and potential side effects, and the resident or representative is to receive the current VIS prior to vaccine administration. For one resident, the admission record showed diagnoses including stroke, end stage renal disease, vascular dementia, and COPD, and the quarterly MDS showed a BIMS score of 5 indicating severe cognitive impairment. The immunization record showed the resident refused the COVID-19 vaccine, but the section labeled Education Provided was marked No, and the nurse progress notes contained no notation that education was provided or that the vaccine was discussed. For the second resident, the admission record showed diagnoses including diabetes, asthma, chronic respiratory failure, shortness of breath, end stage renal disease, and CHF. The quarterly MDS showed a BIMS score of 15 indicating intact cognition. The immunization record also showed refusal of the COVID-19 vaccine, with Education Provided marked No, and the nurse progress notes contained no notation that education was provided or that the vaccine was discussed. The Infection Preventionist stated she used the VIS to do the education with residents and guessed she had missed documenting it. The concern was discussed with the Administrator, DON, ADON, Regional President of Operations, and Regional Director of Clinical Services, and no further information was provided before exit.
Failure to Provide Emergency Dental Services
Penalty
Summary
The facility failed to obtain emergency dental services for a resident who presented with a broken and severely painful tooth. The resident, who had a history of diabetes, high blood pressure, and heart failure, reported the issue to a nurse and was provided with Anbesol and other pain medications, but the pain persisted. Despite the resident's moderate cognitive impairment, she was aware of the need for a dental evaluation. The facility's staff, including a Licensed Practical Nurse and a Social Worker, were aware of the situation but did not have specific details about the dental appointment. The resident's oral cavity was observed to have many carious teeth and poor hygiene, and she experienced significant pain that affected her ability to eat. The Social Worker stated that the resident required stretcher transport and an escort to a dentist, but there was no local dentist available for such needs. An attempt was made to schedule an appointment at a dental school's clinic, but the task was deferred to the resident's niece, who was unfamiliar with the process. The Medical Assistant provided the niece with necessary information to schedule the appointment, but the niece felt obligated to take on this responsibility. The Nurse Practitioner ordered pain management and antibiotics, believing these actions were sufficient. The facility's administrative staff acknowledged the lack of a dental contract and eventually scheduled an appointment for the resident, but this was after the surveyor's findings.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility staff failed to maintain a clean, comfortable, and homelike environment for two residents. One resident, admitted after an acute care hospital stay with diagnoses including cardiogenic shock and chronic obstructive pulmonary disease, reported that the air conditioning unit in their room was not functioning since their admission. Despite repeated requests for repair, the issue remained unresolved until a portable air conditioning unit was eventually provided. The resident expressed significant discomfort due to the lack of air conditioning, indicating a failure in addressing the resident's environmental needs promptly. Another resident, with diagnoses including quadriplegia and anxiety disorder, experienced a persistent issue with a leaking roof, resulting in a water-stained and dirty ceiling tile in their room. The resident reported that the roof had been leaking for months and that their requests for repairs had gone unanswered by the facility's management team. The ceiling tile was only replaced after the surveyor's observation, and the facility acknowledged the ongoing roof leak, indicating a delay in addressing the environmental concerns raised by the resident.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility staff failed to provide appropriate toileting hygiene and assistance to two residents, leading to deficiencies in care. Resident #6, who has dementia and requires assistance for toileting hygiene, requested to be changed before and during the supper meal on 5/29/24. Despite pressing the call bell multiple times, the resident was not assisted by CNA #1, who assessed the resident's incontinence product and deemed it unnecessary to change at that time. CNA #1 also failed to inform the assigned CNA of the resident's request, prioritizing her break instead. The Director of Nursing confirmed that a CNA is designated to assist with toileting during meals, but this protocol was not followed. Similarly, Resident #5, who requires maximal assistance for toileting hygiene, was not provided timely assistance on 5/30/24 during the breakfast meal. The resident, who has atrial fibrillation and renal insufficiency, waited over an hour for her call bell to be answered after requesting assistance to toilet. Despite informing the staff of her need, she was served breakfast without being toileted, forcing her to eat while needing to have a bowel movement. CNA #2, who was responsible for toileting during meals, was not informed of the resident's request, indicating a breakdown in communication among staff. The Director of Nursing acknowledged the protocol for meal-time toileting assistance but did not address the failure in this instance.
Lack of Emergency Dental Services for Resident
Penalty
Summary
The facility failed to have an agreement with a dentist to provide emergency dental services for a resident who experienced severe pain due to a broken tooth. The resident reported the issue to a nurse, but details of a dental appointment were not provided. The Social Worker (SW) indicated that the resident required stretcher transport and an escort to a dentist, but there was no local dentist available for such needs. An attempt was made by the Medical Assistant (MA) to schedule an appointment at a dental school's clinic in another city, but the task was deferred to the resident's niece due to scheduling constraints. The facility's Administrator acknowledged the lack of a current contract with a dental practice and was in the process of researching a new provider to accept the resident.
What surveyors are citing around you — mapped
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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 238 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hampton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hampton Health & Rehab Center, Llc | 0.9 mi | ★★★★★ | 0 | 0 |
| Langley Post Acute | 2 mi | ★★★★★ | 0 | 0 |
| Waterview Health & Rehab Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Atlantic View Post Acute | 3.5 mi | ★★★★★ | 2 | 0 |
| The Chesapeake | 4.1 mi | ★★★★★ | 14 | 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 October 2026) and official state health department websites.