Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wonder City Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Unsecured hazardous chemicals were found accessible to residents when multiple janitor carts were observed unlocked or left with keys in the locks, and a housekeeping storage room was found unlocked with additional carts inside. The carts contained chemicals such as foam cleaner, Clorox urine cleaner, bleach-containing cleaner, disinfectant spray, and neutral floor cleaner, and one cart also had an unlabeled liquid in a water bottle. Staff interviews and MSDS information confirmed the products were hazardous and that unsecured access could expose residents to injury or poisoning.
Insufficient CNA staffing on two units led to delayed med administration after CNAs walked out during a shift because they were frustrated with chronic short staffing. Staff reported the facility often had only two or three CNAs per unit, and admin staff had to assist residents while the CNAs were out. As a result, one resident’s insulin and two other residents’ scheduled meds were given hours late.
Sufficient dietary support personnel were not provided, and breakfast was served late on two units. A resident repeatedly asked where breakfast was while trays did not arrive until nearly 10:00 AM, and staff said the delay was due to kitchen callouts and only two staff being available to prepare meals. The Dietary Manager also stated dinner had been served between 4:45 PM and 5:15 PM, and resident council minutes had already noted concerns about late meal times related to staffing shortages.
The facility failed to provide meals that were palatable, attractive, and served at a safe, appetizing temperature on two units. A resident reported food was terrible and sometimes cold, especially breakfast. The ADM said meals were being served in Styrofoam because the dishwasher had been broken for months, and resident council minutes noted that this made it difficult to keep food hot and contributed to late trays and ongoing concerns about meal prep, appearance, and temperature.
Kitchen Not Maintained in Clean and Sanitary Condition: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. During a kitchen tour with the dietary manager, the surveyor observed dead bugs in the food service area and storage areas, plus food crumbs, debris, and grime throughout the kitchen. The prep area also had damaged walls, missing tile, and gaps where walls were pulling away. The dietary manager said the kitchen needed a lot of attention, while the administrator said he mainly checked temp logs, storage, and the tray line and had not noticed concerns.
A facility with more than 120 beds failed to have a full-time, qualified social services worker. Record review showed the social worker had a BS degree, but the file lacked evidence of a social work degree or one year of supervised social work experience under a qualified social worker. The Administrator stated the individual had a human services degree with a criminal justice major and could not provide documentation of the required supervised experience; the training documents presented did not show supervised training.
A facility failed to keep its dish machine functional, and residents were served meals on Styrofoam/disposable plates, cups, and utensils for months. Staff said the dishwasher stopped working, replacement equipment was delayed by ordering and installation problems, and the dish room was blocked off during repairs. Resident council minutes also noted complaints that disposable service made food harder to keep hot and that meals were often cold.
Pest Control Program Not Maintained in Kitchen: Surveyors observed dead bugs that appeared to be cockroaches under the 3-compartment sink, in the dry storage room, and near the walk-in freezer doorway while food service activities were occurring. The kitchen and storage areas had damaged walls, missing baseboards, cracks, crevices, a gap around a drainage pipe, and a gap between back doors that could allow pest entry. Pest control records showed the same issues had been identified for over a year, while the dietary manager, maintenance director, and administrator each described limited awareness or follow-through regarding the ongoing pest concerns.
Unclean and Damaged Resident Rooms and Bathrooms: Unit One had multiple rooms and bathrooms with scuffed and discolored walls, cracked and stained tiles, peeling finishes, and floors covered with dirt, debris, food crumbs, and trash. A resident stated the floors were filthy and scratched up, and observations also noted a disheveled room with an unmade bed, a quarter full urinal, and damaged drywall and vanity surfaces.
Failure to Follow Care Plan Interventions: Surveyors found that a resident’s food preferences were not consistently honored and enhanced barrier precautions were not in place for a chronic wound, another resident received oxygen at a higher flow rate than ordered, and two residents had only one fall mat despite care plans calling for bilateral mats. The findings were based on direct observation, meal review, and record review, and staff confirmed the care plan interventions were not being followed as written.
Failure to Update Care Plans for Current Needs and Events: The facility did not keep 2 residents' care plans current with their changing needs, preferences, and events. One resident's plan still listed a respiratory infection that was no longer present, contained conflicting smoking instructions, and did not reflect current orders or personal preferences such as no vitals and helping a roommate. Another resident's fall-risk plan was revised several times after falls, but it did not include the documented intervention of close monitoring after a fall, despite the resident's repeated falls and cognitive impairment.
Failure to Follow Insulin Hold Parameters: A resident with DM2 and multiple comorbidities had an insulin glargine order with a hold parameter for blood glucose less than 200 mg/dL, but nursing documentation showed insulin was given on several occasions when the resident’s blood glucose was below that threshold. The physician and NP continued to document the same hold parameter, yet the MAR later reflected a different instruction to call the provider only if blood sugar was less than 60 or greater than 400, and the DON stated nurses are expected to read and follow the full prescriber order.
A resident receiving hospice for CHF had no credible hospice plan of care, hospice visit notes, or hospice agreement in the chart. Facility notes showed the resident was on comfort care with PRN meds and no vitals, labs, or weights, and staff said hospice was being notified of changes in condition, but the DON later stated the hospice binder could not be located and the hospice paperwork had not been scanned into the EMR.
Failure to Preserve Resident Dignity During Feeding and Grooming: A cognitively intact resident who required staff feeding was observed being fed while a CNA stood over her throughout breakfast, and she was also observed with facial hair on her mouth and chin that she said she did not want. The resident had multiple medical diagnoses, including adult failure to thrive, malnutrition, and respiratory failure, and her care plan directed staff assistance with feeding.
The facility failed to notify the provider of two falls for a resident with multiple chronic conditions, including DM2, muscle weakness, malnutrition, HTN, anemia, UTI, and Parkinson's disease. The resident had moderate cognitive impairment, and the record lacked evidence that the MD/provider was informed of either fall; the UM also could not provide documentation showing notification of the provider or responsible party.
Failure to remove alleged perpetrators during a sexual abuse investigation. A resident alleged that two housekeeping employees made sexual comments and attempted to expose themselves, but both employees were allowed to continue working full shifts after the allegation was reported. The facility’s abuse policy required immediate protection of residents, including removal of alleged perpetrators pending the investigation, but the Administrator stated they were not suspended because the facility was still determining whether the allegation was credible.
A resident alleged that two housekeeping employees attempted to expose themselves and made sexual comments toward her, but the facility did not remove the alleged perpetrators from resident contact while the abuse investigation was pending. Records showed both employees continued working full shifts after the allegation was reported, and the investigation file did not document increased supervision, separation measures, or a rationale for allowing continued access to residents.
Failure to restrict alleged perpetrators during a sexual abuse investigation. A resident alleged that two housekeeping employees made sexual comments and exposed themselves to her, but both employees were allowed to continue working their full shifts while the allegation was being investigated. The facility’s abuse prevention policy required immediate protective interventions, yet the record lacked documentation of resident separation, increased supervision, or other interim safeguards; the resident was later noted to be guarded and worried about her safety.
A resident with COPD, chronic respiratory failure with hypoxia, and moderate cognitive impairment was observed with the oxygen concentrator set at 6 L/min via NC, exceeding the physician-ordered 4 L/min. The Unit 2 Nurse Manager confirmed the incorrect setting and adjusted it. The record also contained NP notes for 2 L/min, while the care plan directed staff to administer oxygen as ordered and facility policy required verification and documentation of continuous oxygen therapy each shift and as needed.
Failure to Provide Required RN Coverage: The facility did not ensure RN services were provided for at least 8 consecutive hours per day as required. Review of nursing schedules, staffing records, daily assignment sheets, and payroll documentation showed no RN coverage during the required period on two dates, and the DON acknowledged the lack of RN coverage and the absence of supplemental staffing or alternate RN records.
A resident with DM type 2, GERD, anemia, AFib, HTN, asthma, and post-stroke hemiparesis/hemiplegia was found to have her food preferences ignored at breakfast and lunch. She stated her oatmeal was covered in butter and that she did not eat sausage or bread; her tray included toast, sausage, and buttered oatmeal. At lunch, she received tomato soup and other items that did not match her stated dislikes, and the RD said staff had been trying to honor her preferences but that they changed frequently.
Unsecured Hazardous Chemicals Left Accessible to Residents
Penalty
Summary
The facility failed to store hazardous chemicals in a manner that prevented resident access on two units. During a tour of the facility, four unsecured and unlocked janitor carts were observed outside the activity room and therapy gym in an area with direct resident access. Two of the carts had faulty locks that could be freely pulled up and down without a key, and the other two had keys left in the locks, allowing access to the cabinets. Each cart contained multiple chemicals, including foam cleaner, Clorox urine cleaner, Clorox cleaner with bleach, disinfectant spray, and neutral floor cleaner. One cart also contained an unlabeled yellowish green liquid in a small transparent water bottle, which the EVS Director identified as neutral floor cleaner. Additional observations in the housekeeping storage room showed the door unlocked and ajar, with six janitor carts inside. Four of the six carts were unlocked, and each of those carts had accessible compartments containing multiple chemicals that were unsecured and accessible to residents. The cleaning items observed included foam cleaner, Clorox urine cleaner, Clorox cleaner with bleach, disinfectant spray, and neutral floor cleaner. A housekeeper stated the housekeeping storage room should be locked at all times and that the carts are supposed to be locked. The facility’s MSDS information identified one of the bleach-containing cleaning solutions as hazardous under the OSHA Hazard Communication Standard and stated that if ingested, poison control or a doctor should be called. Staff interviews confirmed awareness that unsecured chemicals could be dangerous, with responses including chemical exposure, poisoning, burns, slipping, and death. The report also states that the facility’s failure to ensure hazardous chemicals were stored securely resulted in immediate jeopardy and substandard quality of care.
Insufficient CNA Staffing Led to Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs on two of two units. Staff interviews described chronic staffing shortages, with unit managers stating there were usually only two or three CNAs on duty and that the facility was often staff challenged. On 04/06/2026, CNAs walked out of the building during the day shift because they were frustrated with working short staffed, including having only two CNAs for 60 residents and only three CNAs for the entire facility. Administrative staff then assisted residents while the CNAs were out, and the CNAs returned a little after an hour later. Interviews also showed that agency staffing had been requested because of the shortages, but corporate did not approve it, and daily staffing meetings were being held with administrative leadership. Resident records showed that the staffing disruption affected medication administration. Resident #2 was scheduled to receive insulin at 7:30 AM but did not receive it until 9:55 AM. Resident #1 was scheduled for ferrous sulfate at 8:00 AM and multiple medications at 9:00 AM; two were given at 10:26 AM and the remaining eight at 10:28 AM. Resident #5 was scheduled for metoprolol at 8:00 AM and additional medications at 9:00 AM; six were administered at 12:53 PM and the other two at 12:55 PM. Facility staff, including the DON, MDS coordinator, scheduler, and unit managers, acknowledged that staffing had been short for an extended period and that the facility had been operating with two to three CNAs per unit per shift.
Late Meal Service Due to Dietary Staffing Shortages
Penalty
Summary
Sufficient dietary support personnel were not provided to safely and effectively carry out food and nutrition services, resulting in meals being served late on two units. The facility’s mealtime schedule listed breakfast at 7:30 AM, but during the morning tour of unit one, breakfast had not yet been served. A resident asked where breakfast was at 9:05 AM, and the nurse assigned to that resident said it should be coming soon. The Administrator stated at 9:23 AM that trays should have come around eight-ish, but the first tray cart did not arrive on unit one until 9:23 AM, the second at 9:41 AM, and the third at 9:55 AM. The resident continued asking when food was coming and did not receive the tray until 10:00 AM. Staff interviews identified staffing shortages in the kitchen as the reason for the delay. The nurse on the hall stated there was only the Dietary Manager and one other person in the kitchen because of callouts. The Registered Dietitian later stated breakfast was delayed because there were two callouts and only two staff available to prepare meals. The Dietary Manager said it was only her and the cook in the kitchen that morning, and also stated dinner on Monday was served between 4:45 PM and 5:15 PM, leaving nearly 17 hours between meals. Resident council meeting minutes from January 2026 also documented prior concerns about late meal times, with the Dietary Manager responding that late meals could be caused by staff shortages that slowed meal preparation and tray assembly.
Meals Served at Improper Temperature and Poor Appearance
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature on two of two units. A resident reported that the food was terrible and not good, and said it was sometimes cold, especially breakfast. During an interview, the Administrator stated meals were being served in Styrofoam because the dishwasher was broken, and could not provide a definite timeframe other than that it had been broken for months. Resident council minutes from April 2026 documented that the Dietary Manager stated the use of Styrofoam made it difficult to keep food hot because hot plates/pellets could not be used, and that late trays/carts were sometimes unavoidable because preparation equipment was not in service, causing longer meal preparation times. Facility resident council minutes also documented concerns about meal preparation and appearance in January, and concerns about meal temperature in February, March, and April, with no additional information provided.
Kitchen Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. During a tour of the kitchen and food storage areas with the dietary manager, the surveyor observed the kitchen was not maintained in a clean and sanitary manner. There were multiple dead bugs in the food service area under the three-compartment sink, outside the walk-in freezer, and in the dry storage area, along with food crumbs, debris, and a build-up of grime throughout the kitchen and food storage areas. The food preparation area was also observed to be in poor condition, with significant damage to walls and baseboards, missing tile, and walls pulling away leaving gaps. The dietary manager stated the kitchen needed a lot of attention and provided cleaning logs titled Cooks daily cleaning assignments and Monthly Cleaning Assignments, which included tasks such as cleaning equipment, baseboards, vents, and storage areas. The administrator stated he visited the kitchen a couple of times a week, mainly to check temperature logs, storage, and the tray line, and reported he had not identified any concerns and that the kitchen was usually pretty clean when he went.
Unqualified Social Worker in Facility Over 120 Beds
Penalty
Summary
The facility failed to provide a full-time, qualified social services worker in a building with more than 120 beds, as required by S483.70(p). Record review for SW#1, identified by the Administrator as the facility social worker, showed a Bachelor of Science degree, but the personnel file did not contain evidence of a bachelor's degree in social work or documentation showing one year of supervised social work experience under the supervision of a qualified bachelor's degree-level social worker. During interview, the Administrator stated SW#1 had a degree in human services with a major in criminal justice and said the individual met the required qualifications because she had been in other buildings. The Administrator was unable to provide additional documentation supporting supervised social work training or experience. Later, the Administrator presented a Social Workers Department New Hire Orientation Training document and several Central Weekly SWDCP Meeting documents, but these documents did not show supervised training. The Administrator, DON, and Regional Nurse were informed of the concern, and no additional information was provided before exit.
Broken Dishwasher Led to Disposable Meal Service
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a functional manner when the main dish machine was out of service for several months. During observations, residents were being served meals on Styrofoam/disposable containers with disposable cups and utensils. The administrator confirmed the dishwasher was broken, and resident council minutes documented complaints that the use of Styrofoam made it difficult to keep food hot and that meals were cold, especially breakfast. The kitchen tour showed the dish room blocked off with plastic sheeting and no dish machine in place. In the storage area, two dish machines were still packaged in wooden shipping crates. The dietary manager stated the facility had been using disposable dishes for several months because the dishwasher had to be replaced after it stopped getting dishes clean and would not reach temperature. The service technician reported that on February 5, 2026, the vacuum breaker was leaking badly and the machine could not be repaired, so replacement was needed. He also stated the facility had been on paper for some time and that installation had been postponed multiple times. Interviews with facility leadership and maintenance staff showed delays related to ordering the replacement machine, receiving the wrong unit, removing the existing machine, and postponing installation because the dish room floor needed repair and drying time. The maintenance director also reported the two-compartment sink could not be used, leaving the three-compartment sink as the only means to wash dishes, cooking pans, and utensils. The administrator acknowledged the dishwasher had completely stopped working in February and that the facility had been using disposable dishes while the replacement process and related repairs remained unresolved.
Pest Control Program Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the main kitchen and food storage areas. During a surveyor tour of the kitchen with the dietary manager, a dead bug that appeared to be a cockroach was observed underneath the three-compartment sink where staff were actively washing meal service pans and dishes. Additional dead bugs, also appearing to be cockroaches, were observed in the dry storage room floor and along the outer wall/doorway of the walk-in freezer. Staff also observed dietary staff cleaning the door in the hallway where the walk-in freezer was located. The kitchen and food storage areas had visible long-standing structural issues, including damaged walls, missing baseboards, cracks, large crevices, a large access gap around a drainage pipe under the three-compartment sink, and a gap between the kitchen back doors that could allow pests entry. Facility interviews showed the dietary manager believed the kitchen needed a lot of attention, while the cook reported the pest problem had improved. Review of pest control records showed the contracted pest control company had identified many of the same issues in monthly reports dating back to January 2025, with several noted as high priority and stating they were allowing pest access. The maintenance director stated he had not reviewed the recent reports closely and had only recently learned how significant the pest control issues were. The administrator reported he had not identified concerns during kitchen rounds and was not aware of the contractor's recommendations, despite the ongoing issues and evidence of active pest activity in the kitchen during the survey.
Unclean and Damaged Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on Unit One. During an initial tour, multiple rooms and bathrooms were observed with scuffed, discolored, or damaged walls; cracked, dark, and discolored bathroom tiles; stained toilet sills; peeling finish on a bed footboard; and floors with black footprints, heavy dirt, and debris, including plasticware wrappers, toilet paper, napkins, a plastic lid, and a straw. One room also had a large hole in the drywall by the window, a sink vanity with finish coming off, a backsplash that had come off exposing damaged drywall, and a bathroom with discolored cracked tiles and a dark, discolored toilet sill. A resident stated that the floors were filthy, scratched up, and had dirt all over them, and said they did not want their feet to touch the ground because of how dirty the floor was. Additional observations found a disheveled room with an unmade bed, food crumbs on the bed, heel boots, balled up napkins, a plastic lid, dirt on the floor, a quarter full urinal, and food item trash on the overbed table. Another room had dirt and egg on the floor, and the wall by the door was scraped and discolored with patching that did not match the wall paint color. No additional information was provided.
Failure to Follow Care Plan Interventions
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for four residents. The report identified failures related to enhanced barrier precautions, honoring food preferences, administering oxygen as ordered, and placing bilateral fall mats as documented in the residents’ care plans. Surveyors observed these issues during room rounds, meal observations, and record review, and facility staff confirmed several of the care plan interventions were not being followed as written. For one resident with diagnoses including diabetes, GERD, anemia, atrial fibrillation, hypertension, asthma, hemiparesis and hemiplegia following cerebral infarction, and memory deficit following stroke, the resident was cognitively intact with a BIMS of 15. During breakfast and lunch observations, the resident expressed dissatisfaction that meal preferences were not honored, stating that oatmeal was covered with butter and that she did not eat sausage or bread because it affected her reflux and body. Meal tickets listed dislikes such as bread, sausage, grits, potatoes, orange juice, scrambled eggs, fried eggs, and tomato sauce, yet the tray included items the resident said she did not eat. The resident’s care plan included honoring diet-compliant food preferences and enhanced barrier precautions for a chronic sacral wound, but surveyors observed no signage or PPE bin for enhanced barrier precautions at the resident’s room. For another resident with COPD, chronic respiratory failure with hypoxia, diabetes, CKD stage 3, convulsions, hypertensive heart disease, and heart failure, the resident was observed receiving oxygen at 6 liters per minute via nasal cannula even though the physician order was for continuous oxygen at 4 liters per minute. The nurse manager confirmed the oxygen concentrator was set above the ordered rate and stated that exceeding the flow rate could be toxic to the resident. The resident’s care plan included administering oxygen as ordered. Two additional residents with diagnoses including diabetes, muscle wasting, weakness, malnutrition, difficulty walking, MI type 2, history of falls, Parkinson’s disease, anxiety disorder, hypotension, and right femur fracture had care plan interventions for bilateral fall mats. Surveyors observed that each resident had a fall mat only on the right side of the bed during multiple observations. The unit manager confirmed that fall mats should have been on both sides of the beds and stated that the housekeeper had taken them the prior week and did not return them.
Failure to Update Care Plans for Current Needs and Events
Penalty
Summary
The facility failed to revise and update the person-centered care plans for 2 of 13 residents reviewed. For Resident #5, who was admitted with diagnoses including CHF, pulmonary embolism, HTN, COPD, anxiety, and MI, the most recent MDS coded the resident as cognitively intact and independent. On 5/7/26, the care plan still included a focus for a respiratory infection even though the resident did not currently have one, and it also contained conflicting smoking interventions stating both that the resident may smoke independently and that the resident requires supervision with smoking. Resident #5's care plan also did not reflect several current preferences and orders documented in the record. The record showed an order from the hospice provider for no vitals, labs, or weights, yet the care plan still included an intervention to obtain vitals as needed. The record also showed an order related to CPAP/BiPAP tubing change, but no care plan focus or intervention reflected that order. In addition, Resident #5 stated she likes to make her roommate's bed to help her friend, which was confirmed by the roommate, the roommate's granddaughter, and the Unit 2 Nurse Manager, but this preference was not included in the care plan. During the 5/7/26 meeting, the DON acknowledged the care plan should have been updated to reflect the resident's current smoking supervision status, preference to store her nasal cannula on her rollator handle, and desire to make her roommate's bed. For Resident #2, who was admitted with diagnoses including DM2, muscle wasting and weakness, moderate protein calorie malnutrition, difficulty walking, MI type 2, history of falls, HTN, BPH, anemia, UTI, and Parkinson's disease, the most recent MDS coded the resident with a BIMS score of 8 out of 15. The care plan identified the resident as at risk for falls, and the record showed falls on 1/20/26, 1/21/26, 1/24/26, and 2/20/26. Although the care plan was revised several times with interventions such as bilateral floor mats, therapy assessment of wheelchair cushion, encouraging chair activities, scoop mattress, and offering preferred clothing, it was not revised after a fall to include the documented intervention of close monitoring. The Unit Manager for First Floor confirmed on 5/6/26 that the care plan should have been revised to include close monitoring.
Failure to Follow Insulin Hold Parameters
Penalty
Summary
The facility failed to follow physician orders for insulin administration for one resident with diabetes mellitus type 2. The resident was admitted and later re-admitted after a hospitalization for a GI bleed and had additional diagnoses including GERD, anemia, atrial fibrillation, hypertension, asthma, hemiparesis and hemiplegia following a cerebral infarction, and memory deficit following stroke. The resident’s most recent MDS coded diabetes mellitus, insulin injections, and a high-risk drug class for insulin, and the resident was documented as cognitively intact with a BIMS score of 15 out of 15. On 4/6/26, the NP documented that the resident’s blood glucose had improved and added a hold parameter to the Lantus regimen: hold insulin for blood glucose less than 200 mg/dL. The order was transcribed to the MAR, and the MAR showed blood glucose readings of 184, 197, 189, 158, and 165 mg/dL on multiple dates in April 2026, with nursing documentation that insulin was administered despite the hold parameter. The record also showed that on 4/16/26 and 4/17/26, the physician and NP continued to document the hold parameter for blood glucose less than 200 mg/dL. On 4/18/26, the MAR order was changed to a different instruction to call the provider if blood sugar was less than 60 or greater than 400, and the MAR from 4/18/26 through 4/26/26 did not contain the hold instruction for blood glucose less than 200 mg/dL. During interview and record review, the DON stated nurses are to read the entire order and follow physician orders or notify the provider for additional instructions. The facility policy stated medications are to be administered in accordance with written orders of the prescriber.
Missing Hospice Plan of Care and Visit Documentation
Penalty
Summary
The facility failed to have credible evidence of a hospice plan of care, hospice services provided, or documentation of hospice provider visits for one resident receiving hospice care. The resident was admitted to the facility with diagnoses including CHF, pulmonary embolism, HTN, COPD, anxiety, and MI, and was admitted to hospice services for CHF. The resident’s MDS coded the resident as cognitively intact and indicated hospice services were being received. The clinical record contained an order stating the resident was admitted to hospice with instructions including no 911, do not transport, continue scheduled and PRN medications, and no vital signs, labs, or weights, but the record did not contain hospice visit notes, hospice provider documentation, or a hospice plan of care or agreement. Facility progress notes documented that the resident was receiving hospice services for CHF, had PRN medications for pain and anxiety, and that hospice providers were being notified of changes in condition such as falls and nausea by facility staff. The resident confirmed she had been receiving hospice services for a few months. During interview, the DON stated hospice documentation was kept in a purple binder at the nurse’s station, but later said the facility was waiting for hospice to fax visit notes and other paperwork because the purple binder could not be located and the documents had not been scanned into the EMR. The Administrator stated all requested documents had been provided except for the pending fax from hospice. No hospice policy was provided.
Failure to Preserve Resident Dignity During Feeding and Grooming
Penalty
Summary
The facility failed to ensure Resident #3 was treated with respect and dignity. Resident #3 was admitted with diagnoses including anxiety disorder, adult failure to thrive, hypotension, fracture of the neck of the right femur, moderate protein calorie malnutrition, essential hypertension, acute respiratory failure with hypoxia, and insomnia. Her most recent MDS coded her as BIMS 14 out of 15, indicating she was cognitively intact for daily decision making. Her physician orders included a regular diet with dysphagia pureed texture and thin liquids, and her care plan stated that she received an altered diet and required staff feeding, with an intervention to encourage oral intake and assist with feeding as needed. During observation, the Executive Director brought the resident’s tray to her room and a nurse stated not to take the tray in because she was a feeder. A CNA then brought the tray into the room, set the resident up for breakfast, remained standing over her, and fed her while continuing to stand throughout the meal. In addition, the resident was observed with facial hair around her mouth and covering her chin, and when asked if she wanted the facial hair, she stated, “No, I don’t.”
Failure to Notify Provider of Resident Falls
Penalty
Summary
The facility failed to notify a provider of two falls for Resident #2. Resident #2 was admitted with diagnoses including diabetes mellitus type 2, muscle wasting and atrophy, muscle weakness, moderate protein calorie malnutrition, difficulty walking, myocardial infarction type 2, history of falling, essential hypertension, benign prostatic hyperplasia, anemia, urinary tract infection, and Parkinson's Disease without dyskinesia. The resident's most recent MDS coded a BIMS score of 8 out of 15, indicating moderate cognitive impairment for daily decision making. On review of the clinical record, there was no evidence that the doctor/provider was notified of falls that occurred on 01/21/2026 and 02/20/2026. During interview, the Unit Manager stated she did not see a progress note about the first fall and did not see documentation in the progress notes or risk management showing that the provider or responsible party was notified, and she could not provide evidence that the provider was notified of the second fall.
Failure to Remove Alleged Perpetrators During Sexual Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse prevention policy by not immediately removing two identified housekeeping employees from resident contact after a resident alleged sexual abuse. The facility policy titled Responding to Abuse/Neglect/Misappropriation/Crime stated that residents would be immediately protected from further potential abuse, including removal of alleged perpetrators pending the outcome of the investigation. An incident summary documented that the resident reported on 12/16/25 that the two employees attempted to reveal themselves and made sexual comments toward her, and the allegation was reported to facility administration that same day. Review of resident and staff statements showed the time of the incident was redacted or left blank. Staffing schedules, payroll records, and assignment sheets showed the two employees continued to work full shifts on 12/16/25 after the allegation was reported. The Administrator stated on 5/7/26 that both employees were allowed to continue working during the initial investigation because the facility was still trying to determine whether the allegation was credible.
Failure to Protect Resident During Sexual Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate and prevent further potential abuse after a resident alleged that two identified housekeeping employees attempted to expose themselves and made sexual comments toward her. The allegation was reported to administration, and the facility investigation included statements from the resident and staff, but the times of the incident were redacted or left blank in the documentation. Review of the facility policy titled Abuse Prevention and Investigation stated that the facility would immediately implement interventions to protect residents from further potential abuse during investigations, including removal of alleged perpetrators from resident contact pending investigative findings. Despite the allegation being reported, the facility did not implement interim protective measures during the initial investigation. Staffing schedules and assignment sheets showed both identified employees continued working their full shifts after the allegation had been made to administration. The incident summary did not document a rationale for allowing continued resident access by the employees, and it did not show increased supervision, resident separation measures, or other interventions to protect residents while the investigation was pending. The Administrator stated the employees were not suspended initially because the facility was still trying to determine whether the allegation was credible.
Failure to Restrict Alleged Perpetrators During Sexual Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse prevention policy during an allegation of sexual abuse involving Resident #9. The policy required immediate interventions to protect residents from further potential abuse during investigations, including removal of alleged perpetrators from resident contact pending investigative findings. Resident #9 alleged on 12/16/25 that two identified housekeeping employees attempted to reveal themselves and made sexual comments toward her, and the allegation was reported to administration that same day. Statements from the resident and staff had the time of incident redacted or left blank. The facility did not put interim protective measures in place after the allegation was reported. Staffing schedules and assignment sheets showed both identified employees continued working on 12/16/25 after the allegation had been made to administration, with one employee working 8.16 hours and the other working 10.04 hours. The incident summary did not document a rationale for continued access, increased supervision, resident separation measures, or other interventions to protect residents while the investigation was pending. The Administrator stated on 5/7/26 that both employees were allowed to continue working the full shift during the initial investigation because the facility was still trying to determine whether the allegation was credible. Clinical records noted the resident was guarded and worried about her safety after the investigative report.
Failure to Deliver Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to deliver the prescribed oxygen flow rate for one resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, diabetes mellitus type 2, chronic kidney disease stage 3, convulsions, hypertensive heart disease, and heart failure. The resident’s most recent MDS coded a BIMS score of 09 out of 15, indicating moderate cognitive impairment, and the resident was coded for oxygen use in Section O. During observation, the resident was found in bed with the head of the bed elevated and the oxygen concentrator set at 6 liters per minute via nasal cannula. The Unit 2 Nurse Manager confirmed the concentrator was set above the physician-ordered 4 liters per minute and adjusted the flow rate. The clinical record included nurse practitioner progress notes stating to continue supplemental oxygen at 2 liters per minute via nasal cannula, while the physician order specified continuous oxygen at 4 liters per minute via nasal cannula. The resident’s care plan identified respiratory risk related to COPD and chronic respiratory failure with hypoxia and included an intervention to administer oxygen as ordered. The facility policy required staff to follow the physician’s ordered flow rate and verify and document continuous oxygen therapy each shift and as needed.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that the services of a registered nurse were provided for at least 8 consecutive hours a day, 7 days a week, as required by S483.35(b), for a census of 123 residents. Review of nursing schedules, staffing records, daily assignment sheets, and payroll documentation showed that no RN was scheduled or documented as working during the required 8 consecutive-hour period on 4/4/26 and 4/5/26, and posted staffing records did not show RN presence for the required duration. During an interview on 4/7/26 at 3:45 pm, the DON acknowledged the facility did not have RN coverage on the identified dates and stated the facility was experiencing staffing challenges. The DON also confirmed that no supplemental staffing documentation or alternate RN coverage records were available.
Food Preferences Not Honored
Penalty
Summary
The facility failed to honor one resident’s food preferences for 1 of 13 residents reviewed. Resident #8 was admitted to the facility on 11/25/25 and later re-admitted after a hospitalization from 4/26/26 to 5/1/26 for a GI bleed. Her diagnoses included DM type 2, GERD, anemia, atrial fibrillation, hypertension, asthma, hemiparesis and hemiplegia following a cerebral infarction, and memory deficit following stroke. Her most recent MDS, with an ARD of 3/3/26, coded her as BIMS 15 out of 15, indicating she was cognitively intact for daily decision making. On 5/5/26 at breakfast, Resident #8 stated that her oatmeal was smothered in butter, that she could not eat it because it affected her reflux, and that she did not eat sausage or bread because it went against her body. Her meal ticket listed oatmeal, hard-boiled egg, hot cereal, egg patty, and alternate breakfast items, with dislikes including bread, sausage, grits, potatoes, orange juice, scrambled eggs, and fried eggs. Her tray contained hard-boiled eggs, toast, sausage patty, and oatmeal with butter. At lunch the same day, she received sliced ham, broccoli and tomato soup, magic cup, and lemonade; the meal ticket listed an alternate entree, broccoli, brownie, apple juice, and magic cup, with dislikes including bread, potatoes, tomato sauce, fried foods, mayonnaise, and orange juice. During the meal, the Unit 2 Nurse Manager brought chicken noodle soup and removed the tomato soup. The RD stated that resident preferences should be honored, but staff had been trying to honor her preferences and it had been a challenge because they changed frequently. The RD also stated a care plan meeting had been held with the resident, her granddaughter, dietary, nursing, and social services, and that the meal ticket was being updated as preferences changed. The care plan included an intervention to honor diet-compliant food preferences as made known by the resident.
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What surveyors actually found near you
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hopewell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River View On The Appomattox Health & Rehab Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Colonial Heights Rehabilitation And Nursing Center | 4 mi | ★★★★★ | 5 | 0 |
| Petersburg Healthcare Center | 5 mi | ★★★★★ | 20 | 1 |
| Battlefield Park Healthcare Center | 6 mi | ★★★★★ | 2 | 0 |
| Hiram W Davis Medical Ctr | 7.4 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.