Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Boulevard Post Acute during CMS and state inspections, most recent first.
A resident with cognitive and physical impairments fell during incontinent care when staff turned the resident and the resident struck a dresser, causing head bleeding and sutures after hospital transfer. Another resident’s bed had a family-installed mesh barrier/rail in use without an assessment, MD order, or care plan for that device, and the RN UM and DON stated it was not allowed.
Staff failed to follow physician orders for several residents, including ordered weights and compression stockings, and failed to provide proper wound care for a resident with a skin tear. An LPN did not maintain clean technique during dressing change, and ordered monitoring such as weekly and daily weights was not consistently obtained or documented. One resident was also observed without prescribed compression stockings, and the TAR contained documentation that did not match what was observed.
Food storage and handling practices were not followed in the main kitchen and on the Cardinal unit nourishment room. Surveyors found expired opened dry goods and refrigerated items still available for use, staff without proper hair restraints, improper glove use and hand hygiene during food prep, and a cold turkey salad item held above the required temperature and plated for service. On the unit, multiple refrigerator and freezer items were unlabeled or beyond date, including electrolyte solution, frozen fruit juice, butter packets, and freezer-burnt ice cream.
Surveyors found that multiple rooms on one unit had heavy dirt and debris on floors, including food items, medical waste, and a bug, and that a bathroom floor was also dirty. A cognitively intact resident reported that housekeeping came about once a week, often left debris on the floor, and that the resident had to clean up spills. The Environmental Services Director stated that one housekeeper is assigned per unit to complete daily cleaning by midday, with no further housekeeping cleaning afterward and light cleaning left to unit staff, despite a written policy requiring daily trash removal, disinfection of high-touch surfaces, full bathroom cleaning, dusting, sweeping, mopping, and supply replenishment.
Resident rights notices were not posted in accessible locations on three nursing units or in the lobby, and repeated tours found no postings. Several residents said they had never seen the notices, and the DON could not locate them during the survey. The administrator later stated the notices had been removed during unit construction and were never put back.
Required notices and contact information for the state survey agency, APS, and the ombudsman were not posted in accessible areas on three of three units. During tours of the units and lobby, no postings were observed, and several residents stated they had never seen them. The DON could not locate the notices, and the administrator later stated they had been removed during construction and were never replaced.
Failure to Provide Privacy During ADL Care: A resident receiving ADL care was observed without the privacy curtain being pulled, leaving the resident's buttocks exposed and visible from the hallway. The CNA acknowledged the curtain should have been used, and the DON stated staff were expected to provide comfort and privacy during care. Facility policy reviewed addressed privacy and confidentiality, but the ADL policy was not provided.
Failure to develop comprehensive care plans for two residents. One resident’s care plan did not address turning, repositioning, or incontinent care before a fall, despite diagnoses including encephalopathy, cognitive communication disorder, and hemiplegia. Another resident with CVA, dementia, dysphagia, and a gastrostomy tube had no care plan for feeding tube insertion site care, even though staff stated it should have been included in the comprehensive care plan.
Incomplete Wound Assessment and Treatment Documentation: A resident with multiple chronic conditions and a cognitively intact status developed a skin tear on the right lower leg, but the nursing record lacked descriptive initial and ongoing wound assessments, including size, appearance, skin color, and drainage/bleeding status. An observed wound care and dressing change by an LPN showed irregular wound edges, scabbed tissue, red tinted drainage, and pink/red surrounding skin with a purplish tone, yet the treatment and wound status were not documented in the clinical record.
Pressure ulcer care interventions were not implemented as ordered for two residents. One resident with a stage 4 pressure ulcer had an air mattress and wound vac set incorrectly, and an RN confirmed the settings were not right. Another resident had an order and care plan for an alternating pressure mattress, but the mattress was not in place for 18 days even though staff documented it as present; an LPN stated signing the record means the treatment or device was in use, and the ADON confirmed the mattress was not actually in place.
A resident with a Foley catheter reported feeling urine leakage while the drainage bag stayed empty, and staff did not address the concern until family intervened. The catheter tubing had been capped off for most of the day during a bag change, and once the cap was removed urine flowed again. Nursing notes showed the Foley was patent but did not record urine output after the initial drainage, and the DON confirmed there was no documented bladder scan, assessment, or intervention related to the incident.
Improper medication labeling and storage were observed on the Dogwood unit. A tuberculin multi-dose vial had been opened but was not dated, lorazepam vials were not stored in a double-locked area, and the medication area door was unlocked. The RN unit manager confirmed proper labeling and secure storage procedures were not consistently followed, and facility policy required the storage area to be locked when not in use and all meds to be properly labeled.
Failure to arrange dental services for denture replacement affected a resident whose lower dentures were lost after being placed in a cup while waiting for cleaning tablets. The resident reported the loss to staff, but the dentures were not found, and the DON was unaware of the issue. The resident was admitted with lower dentures documented on the inventory sheet, and the RDCS confirmed staff had been notified of the missing dentures, but the matter was not addressed until surveyor inquiry.
The facility had inaccurate and incomplete charting for three residents. One resident’s Foley catheter tubing was capped for hours, but the nurse’s note did not document the incident, assessment, or interventions, and a bladder scan was referenced without supporting order or documentation. Another resident’s wound care was charted as completed even though the dressing observed showed it had not been changed as recorded. A third resident’s record incorrectly showed contact precautions as active long after they had been discontinued, and staff continued signing the TAR despite no signage or PPE use.
Infection control practices were not followed during wound care for a resident with a right shin skin tear. An LPN touched the room light switch, moved personal items, placed clean wound supplies on an unclean overbed table, handled the trash can, and continued wound care without proper hand hygiene or glove changes between dirty and clean tasks. The RN unit manager, infection preventionist, and DON stated that hand hygiene and glove changes were expected during wound care, and the facility policy required a disinfected overbed table, a clean field, and hand hygiene throughout the procedure.
Failure to Supervise Incontinent Care and Unsafe Bed Rail Use
Penalty
Summary
Facility staff failed to provide adequate supervision during incontinent care for a resident with metabolic encephalopathy, cognitive communication disorder, left-sided hemiplegia, and urinary tract infection, resulting in a fall that caused harm. The resident’s MDS coded a BIMS score of 9, indicating moderate cognitive impairment, and the functional assessment showed substantial to maximal assistance was needed for bed mobility and transfers. The clinical record documented a fall risk score of 11 and noted a history of falls, chairbound status, incontinence, and balance problems. On the morning of the fall, staff were providing incontinent care when the resident was turned on her side and asked whether she had a bowel movement. At that moment, she fell from the bed to the floor and struck her head on a dresser, with bleeding noted to the head. Emergency services were called, and the resident was transported by ambulance to the hospital. Post-fall documentation described a left eye bruise and a forehead skin tear requiring two sutures, with intermittent scant bleeding and pressure dressing applied. The resident was later discharged to an acute care facility and did not return. The resident’s care plan initially did not include guidance for supervision, turning, repositioning, or incontinent care. It was updated after the fall to include incontinent care and turning/repositioning by two staff. During interview, a CNA stated the resident was known to be difficult to manage during incontinent care and that staff did not attempt to turn, reposition, provide incontinent care, or get the resident up alone because she was a fighter and a large, tall woman. The DON stated the care plan did not provide care parameters regarding turning, positioning, and incontinent care prior to the fall. Facility staff also failed to provide a safe bed environment for another resident. That resident had diagnoses including humerus fracture, vertigo, major depressive disorder, and cognitive communication deficit, and was documented as alert and oriented to person, place, and time on admission. The resident’s bed was observed with 1/4 length grab rails and an additional mesh barrier/rail installed along the middle portion of the bed. The resident stated the mesh rail was used at home to prevent rolling or falling out of bed and that a family member insisted it be used in the facility. The clinical record showed the family requested bed rails, a baseline care plan and consent were completed for 1/4 length grab rails, and a physician order was written for side rails/grab bars for bed mobility. However, there was no assessment, physician order, or plan of care for the mesh-covered barrier/rail that was observed in use. The RN unit manager stated the family brought and installed the mesh barrier and that it should not be in use on the resident’s bed. The DON stated the family had been told the mesh barrier/rail was not allowed.
Failure to Follow Physician Orders and Provide Proper Wound Care
Penalty
Summary
Facility staff failed to follow physician orders for four residents and failed to provide wound care for one resident in a manner to promote healing. Resident #11, who was cognitively intact and had diagnoses including atrial fibrillation, end stage renal disease with hemodialysis, anemia, hypertension, and congestive heart failure, had a right lower leg skin tear with an order for cleansing and dressing changes three times weekly. On 4/6/26, the dressing was observed dated 4/2, and staff acknowledged the dressing change ordered for 4/4/26 had not been completed. The wound was later observed as irregular shaped with scabbed edges, red tinted drainage on the removed dressing, and pink/red surrounding skin with a purplish tone. During the observed wound care for Resident #11, the LPN placed clean supplies on an overbed table without first disinfecting it or creating a clean field, touched room items such as the light switch and trash can, and did not perform hand hygiene or change gloves between dirty and clean tasks. The LPN removed the soiled dressing, cleansed the wound, and applied the new dressing while not following the facility’s wound care steps as written in policy. Staff interviews confirmed the dressing should have been changed as ordered and that infection control practices were expected during wound care. Resident #41, who had diagnoses including stroke, vascular Parkinson’s, dementia, dysphagia with gastrostomy, and protein-calorie malnutrition, had a physician order for weekly weights and a care plan directing weights at ordered intervals. The record showed only one documented weight and multiple scheduled weekly weights were marked not obtained, with no explanation documented. Resident #38, who was cognitively intact and had diagnoses including dementia, atrial fibrillation, anxiety, and depression, had an order for compression stockings every day and evening shift, but was observed without stockings on two occasions; the TAR documented stockings as applied on one day and later showed a refusal entry after the issue was raised, while an unopened pair of stockings was found in the room. Resident #72 also had a physician order for daily weights, but the record showed no documented evidence that the daily weights had been initiated or consistently obtained as ordered.
Food Storage, Labeling, and Food Handling Deficiencies
Penalty
Summary
Food was not stored, labeled, prepared, and served in accordance with professional standards in the main kitchen and on the Cardinal unit nourishment room. In the main kitchen, staff failed to discard opened dry goods and refrigerated items that were beyond their use-by dates, including rice, dry cereal, Texas barbeque sauce, ricotta, chipotle cream, garlic aioli, and deli turkey and ham packets. The executive chef identified that opened items should have open and use-by dates, and the expired items were found available for use during the kitchen tour. During the follow-up kitchen observation, staff were seen putting on hair and beard nets only after hearing surveyors enter the area. A cold turkey salad croissant on the tray line had a temperature of 46.8 degrees and was plated and placed on the food cart for service even though the executive chef stated cold turkey salad should be held at 41 degrees or less. A dietary staff member was also observed wearing gloves while using a meat slicer, leaving the slicer multiple times to handle other objects and touching the face and nose without removing gloves or washing hands before returning to food preparation. On the Cardinal unit nourishment room, refrigerator and freezer items were found without proper labeling or dating, including an opened bottle of electrolyte solution and two opened bottles of frozen fruit juice. The refrigerator also contained butter packets inside a container with an expiration date of 3/20/26, and the freezer contained an unopened container of freezer-burnt ice cream. Nursing staff acknowledged the findings and discarded the items. Facility policies reviewed by surveyors required hair restraints, hand hygiene after contact with hair or face, and labeling and disposal of expired food items.
Failure to Maintain Clean and Sanitary Resident Rooms on One Unit
Penalty
Summary
Surveyors identified a failure to maintain a clean, safe, and comfortable room environment on one of three units (Dogwood Unit). During an initial tour, multiple rooms on this unit were observed with heavy accumulations of dirt and debris on the floors, including food items and medical waste. One room had a bug observed on the floor, and another had dirt and debris on the bathroom floor. These observations showed that several resident rooms and bathrooms were not being kept clean in accordance with expected standards for a safe and homelike environment. A cognitively intact resident, as evidenced by a BIMs score of 15/15 on the MDS, reported that housekeeping services occurred once a week, sometimes more depending on staffing, and stated that housekeeping left debris on the floor. The resident further reported that if something spilled, the resident had to clean it up and commented that staff could do a better job. The Environmental Services Director stated that one housekeeper is assigned per unit, starting at 8:00 AM, and is expected to clean shower rooms first and have occupied rooms cleaned by noon, with no additional housekeeping cleaning of resident rooms after the initial cleaning; other unit staff are responsible for light cleaning. The facility’s housekeeping policy and daily room cleaning checklist included tasks such as emptying trash, disinfecting high-touch surfaces, cleaning and disinfecting bathrooms, dusting, sweeping and mopping floors, and replenishing supplies, which contrasted with the observed conditions and resident report.
Resident Rights Notices Not Posted
Penalty
Summary
The facility failed to ensure that notices of resident rights were posted in accessible locations for residents, families, and visitors on three nursing units and in the lobby areas. During a tour of the facility on 4/6/26, no resident rights postings were observed in any of the three units or lobby areas. At a resident council meeting on 4/7/26, three residents stated they had never seen any postings of resident rights in the facility. During an interview on 4/7/26, the DON stated the resident rights should be posted in the lobby and at the nurses stations, but the postings could not be found during the walk-through of the nurses station and dining room. A second tour later that day again found no resident rights postings on the nursing units or in the lobby. On 4/8/26, the administrator stated the resident rights poster had been put up and was in place, and also stated the notices had been taken down during construction of the units and were never placed back. Facility documentation reviewed on 4/8/26 included the Resident Rights policy, which stated residents are to be informed about their rights and responsibilities.
Required Resident Rights Notices Not Posted
Penalty
Summary
The facility failed to ensure that required notices and contact information for the state survey agency and other entities, including adult protective services and the ombudsman, were posted in accessible areas for residents, families, and visitors on three of three units. During a tour of the facility's nursing units and lobby areas, the required postings were not observed anywhere in the facility. In a resident council meeting with six residents present, three residents stated they had never seen any required notices posted in the facility with contact information for state agencies or other entities. The DON stated the required notices should be posted in the lobby and at the nurses stations, but during the interview the DON was unable to locate the postings on one unit and in the dining room area. A second tour later that day again found no postings on the nursing units or in the lobby areas. The administrator later stated the notices had been taken down during construction of the units and were never placed back. Facility documentation reviewed included the Resident Rights policy, which referenced the resident's right to communicate with outside agencies, including state and federal surveyors, the state long term care ombudsman, and protection or advocacy organizations.
Failure to Provide Privacy During ADL Care
Penalty
Summary
Facility staff failed to ensure privacy during ADL care for Resident #18. During observation on 4/6/26 at 4:55 pm, R18 was receiving ADL care without the privacy curtain being pulled, and the resident's buttocks were exposed and visible from the hallway. At 5:04 pm, the CNA providing the care acknowledged that the privacy curtain should have been pulled to provide more privacy and demonstrated how it should be used, apologizing for not providing privacy. At 5:25 pm, the DON stated that staff were expected to provide comfort and privacy for residents during care. Facility documentation reviewed on 4/7/26 included the Resident Rights policy, which addressed privacy and confidentiality, but the ADL policy was requested and not provided.
Failure to Develop Comprehensive Care Plans for Turning, Repositioning, Incontinent Care, and Feeding Tube Site Care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #96 related to care and safety during turning, repositioning, and incontinent care. Resident #96 was admitted with diagnoses including metabolic encephalopathy, cognitive communication disorder, hemiplegia affecting the left nondominant side, and urinary tract infection. The resident’s plan of care was initiated on 07/24/24, but it did not include problems, goals, or interventions addressing turning, repositioning, or incontinent care before the fall on 09/30/24. During interview, the DON stated the care plan did not provide care parameters for turning, positioning, and incontinent care prior to the fall, and the care plan was updated on 09/30/24 to include incontinent care and turning and repositioning by 2 staff. The facility also failed to develop a care plan for Resident #41 regarding care of the feeding tube insertion site. Resident #41 had diagnoses including CVA, vascular Parkinson’s, dementia, aphasia, dysphagia with gastrostomy use, protein-calorie malnutrition, vertebral compression fracture, seizures, and spondylosis. The resident’s MDS assessed short- and long-term memory problems and moderately impaired cognitive skills. The clinical record showed an order for NPO status with nutrition and hydration provided via gastrostomy, and the care plan addressed malnutrition and altered hydration through tube feeding, but it did not include any problems, goals, or interventions for feeding tube insertion site care. RN #3, the DON, and the MDS coordinator each stated that care of the tube insertion site should have been included in the comprehensive care plan.
Incomplete Wound Assessment and Treatment Documentation
Penalty
Summary
The facility failed to follow professional standards of care for wound assessment and documentation for one resident with a skin tear on the right lower leg. The resident was admitted with diagnoses including atrial fibrillation, depression, end stage renal disease with hemodialysis, anemia, osteoarthritis, respiratory failure, polyneuropathy, hypertension, and congestive heart failure, and was assessed by MDS as cognitively intact. After the skin tear was identified, the nursing record included a nursing note, skin assessment form, and change of condition form, but these documents did not describe the wound’s size, appearance, skin color, or whether there was bleeding or drainage. Ongoing skin assessments also identified the skin tear but continued to lack descriptive details about the wound’s status, surrounding skin, or drainage/exudate. During an observed wound care and dressing change, an LPN performed cleansing and dressing treatment to the right lower leg skin tear, and the wound was noted to be irregular shaped with scabbed edges, red tinted drainage on the removed dressing, Xeroform stuck to the wound, and pink/red surrounding skin with a purplish tone. However, this dressing change and the wound’s condition at the time were not documented in the clinical record. The RN unit manager stated the wound should have been assessed and documented with appearance, size, and condition, and the DON stated the initial and ongoing assessments should have included description, color, size, and any bleeding or drainage, with weekly monitoring at minimum. The DON also stated the LPN reported not documenting the dressing change because it was not the scheduled treatment day and there was no space on the TAR, but the DON stated the wound care should still have been documented in the clinical record.
Pressure ulcer care interventions were not implemented as ordered
Penalty
Summary
Facility staff failed to implement ordered pressure ulcer interventions for two residents. One resident had diagnoses including a chronic stage four pressure ulcer of the right buttock, macular degeneration, malignant neoplasm, and anemia, and was assessed as moderately cognitively intact. The resident had physician orders for a wound vac set continuously at 125 mm negative pressure and an air mattress set by body weight at 118.9, but the air mattress was observed set at 350 pounds and the wound vac at 116 negative pressure. An RN reviewed the settings with the surveyor, acknowledged they were not correct, and stated the concern would be addressed. For another resident, a physician order dated 3/20/26 directed use of an alternating pressure mattress to promote wound healing, and the care plan also listed an alternating pressure mattress at all times. Clinical record review found no evidence the mattress had been put in place as ordered for 18 days. Although nursing documentation showed signatures indicating the mattress was in place, observation and interview confirmed it had not been implemented when those entries were made. An LPN stated that signing the treatment record indicates the treatment was completed and that signing off on an assistive device indicates the device is present and being used. The ADON later observed that the resident did not have an alternating pressure mattress in place and stated staff were expected to notify maintenance when one is ordered.
Foley Catheter Tubing Left Capped, Blocking Urine Flow
Penalty
Summary
Appropriate catheter care was not provided for one resident with a Foley catheter when the catheter tubing was capped off and urine flow was obstructed. The resident reported that he repeatedly told staff he could feel himself urinating while his drainage bag remained empty, and he stated that staff did not address his concerns until his wife intervened. He also reported that his daughter later discovered the catheter tubing was capped off. Once the cap was removed, urine began to flow and approximately 600 cc was obtained. The resident also reported some pain and later was treated for a UTI, with his urologist changing the antibiotic after an appointment. The DON stated that 300 cc of urine had been obtained earlier in the day before the drainage bag was capped to switch from an overnight bag to a leg bag, and that the bag remained capped for about 11.5 hours. Nursing documentation showed the Foley was patent and draining yellow urine, but no urine output was recorded after the initial 300 cc. The DON acknowledged concern about the lack of output documentation and stated the catheter should have been assessed and the lack of urine output identified and reported. The record contained no documentation of a bladder scan, no physician order for one, and no nursing documentation describing the incident, assessment findings, or interventions related to the capped catheter tubing.
Improper Medication Labeling and Storage on Dogwood Unit
Penalty
Summary
Medication storage on the Dogwood unit was not maintained in accordance with accepted labeling and locking requirements. During observation and medication storage review, a tuberculin multi-dose vial was found opened but not dated with the date it was opened, and lorazepam vials were not secured in a double-locked storage area as required for controlled substances. The door to the medication area was also observed to be unlocked. In interview, the RN unit manager for Dogwood confirmed that proper labeling and secure storage procedures were not consistently followed and stated she was not sure why the main door was not locked. Facility policy titled Medication Storage stated that the storage area will be kept locked when not in use and that all medications will be kept in original containers and properly labeled and identified.
Failure to Arrange Replacement for Lost Dentures
Penalty
Summary
The facility failed to arrange dental services for denture replacement for Resident #86, whose lower dentures were lost while he was a resident of the facility. During an interview, the resident stated that his lower dentures were placed in a cup while he waited for his wife to bring denture cleaning tablets, and when the tablets were brought in, both the cup and dentures were missing. He reported the loss to staff and was told they would try to locate the dentures, but they were not found. Observation during the interview confirmed that he was missing his lower dentures. The clinical record showed the resident was admitted with a full set of lower dentures, as documented on the admission inventory sheet. The DON stated she was not aware of the missing dentures and confirmed there had been no grievance filed. The RDCS stated the resident had reported a sore in his mouth and had not worn his dentures for a few days before placing them in a white cup, and that the issue was discussed during a care plan/discharge meeting with staff notified of the missing dentures. The regional director of operations and the administrator later confirmed the dentures had not been located and that the facility planned to replace them, but this issue was not addressed until it was brought to the facility’s attention by the surveyor.
Inaccurate and incomplete resident clinical documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents. One resident had a Foley catheter issue in which the drainage tubing was capped for an extended period, yet the nursing record did not document the incident, assessment findings, interventions, or the lack of urine output after the initial drainage was recorded. The resident reported telling staff that he could feel himself urinating while the bag remained empty, and he stated that his wife and daughter had to intervene before the tubing cap was discovered and corrected, after which urine began to flow and approximately 600 cc was obtained. The DON confirmed that the catheter bag had been capped from about 7:00 a.m. until about 6:30 p.m., and the record contained no physician order or documented evidence supporting a bladder scan that was later referenced. A second resident had a documented skin tear on the right shin with an order for wound care three times weekly, but the treatment record showed a dressing change as completed when the dressing observed on the resident did not match the documented date. The resident was observed with a dressing dated 4/2, while the TAR reflected that the dressing change had been completed on 4/4. Staff interviews confirmed that the dressing should have been changed on the ordered schedule and that the treatment was not actually provided on the date documented. The DON stated the documentation was inaccurate because the wound care was not provided as recorded. A third resident’s record inaccurately showed contact precautions in place for eleven days even though precautions had been discontinued after less than a day. The resident had been placed on contact precautions after several loose stools and a stool culture was ordered, but the nurse practitioner later documented no further stools and discontinued the precautions and stool culture. Despite this, nursing continued to sign the TAR indicating precautions were in use. The resident was observed without signage or PPE use, and staff interviews confirmed that the precautions should have been discontinued in the record on the following day and were not actually in effect.
Infection Control Not Followed During Wound Care
Penalty
Summary
Infection control practices were not followed during wound care for a resident with a skin tear on the right shin. The resident was cognitively intact and had diagnoses including atrial fibrillation, depression, end stage renal disease with hemodialysis, anemia, osteoarthritis, respiratory failure, polyneuropathy, hypertension, and congestive heart failure. A nursing note documented that the resident had bumped her leg against a wheelchair and that an order was in place to cleanse the skin tear, pat it dry, apply Xeroform, and cover it with a dry dressing three times weekly. During observed dressing change care, an LPN entered the room with wound care supplies after using hand sanitizer and putting on a gown and clean gloves. The LPN touched the light switch and moved the resident’s personal items from the overbed table, then placed clean wound care supplies on the table without disinfecting it or using a clean barrier. The LPN also touched the trash can with gloved hands, opened gauze packages, and placed gauze on top of the packaging without hand hygiene or changing gloves. The soiled dressing was removed, the wound was cleansed, and the same gloves were used through multiple steps involving dirty and clean items before the LPN removed gloves, put on clean gloves, and applied the new dressing. Interviews after the observation confirmed that the expected infection control practices were not followed. The LPN stated the overbed table should have been cleaned before supplies were placed on it and said she changed gloves during care and used alcohol wipes between glove changes. The RN unit manager, infection preventionist, and DON each stated that hand hygiene and glove changes were expected between contact with dirty and clean items and that wound care should follow infection control protocols. The facility policy for wound treatment required disinfecting the overbed table, performing hand hygiene, using a clean field, removing soiled dressings, changing gloves, and performing hand hygiene between dirty and clean tasks.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,006 citations issued within 25 miles in the last 12 months — including the 13 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairfax
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| August Healthcare At Iliff | 2.9 mi | ★★★★★ | 4 | 0 |
| Fairfax Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 2 | 0 |
| Annandale Healthcare Center | 5.1 mi | ★★★★★ | 0 | 0 |
| August Healthcare At Leewood | 5.4 mi | ★★★★★ | 3 | 1 |
| Burke Health & Rehabilitation Center | 5.6 mi | ★★★★★ | 0 | 0 |
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