Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Crescent Health Care during CMS and state inspections, most recent first.
A resident with Alzheimer’s dementia, anxiety disorder, osteoarthritis, impaired cognition, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift while a wedge-shaped bed bolster remained in place along the bed edge. The care plan addressed bed placement against the wall for fall prevention but did not include the bolster, and there was no physician order, assessment, care plan entry, or representative consent for its use. During the two-person lift transfer, the sling was already attached when staff raised the resident with the bed at working height; the sling became affected by the bolster, the lower sling loop came off the lift hook, and the resident slid from the sling onto the floor, partially onto the lift leg. The resident sustained a forehead laceration, left ankle injury with fracture, bruising, and pain. Staff later stated the bolster should have been removed or taken down and that the bed height was too high, and leadership acknowledged there were no written policies, documented training, or guidelines for mechanical lift use with bed bolsters.
Failure to supervise and assess after an unwitnessed fall: A resident with dementia, a prior fall history, and a high fall-risk assessment had no specific fall care plan or interventions in place. The resident was found face down on the floor by an NA, had multiple lacerations and significant pain, and an LPN did not complete a full assessment until after moving the resident into a wheelchair. The resident was later sent to the hospital and diagnosed with multiple complex fractures requiring surgery.
The facility failed to ensure residents were informed about how to file grievances, including written or anonymous complaints, and failed to make grievance forms, policy information, and hotline/Ombudsman details readily accessible. Several residents reported missing money or belongings with no clear follow-up, and staff stated grievances were typically handled through SSD, with forms hidden or difficult to locate and residents unable to complete them independently.
Failure to thoroughly investigate resident incidents: A resident with multiple medical conditions had a choking episode that was not investigated because no Heimlich maneuver was performed, another resident with severe cognitive impairment had a spill with skin discoloration but no incident report or investigation was documented, and a third resident reported unwanted touching by staff without a nursing investigation, alert charting, or staff statement. The DON stated the event should have been thoroughly investigated to rule out abuse and neglect.
Shower Rooms Not Maintained in Clean, Safe Condition: The facility failed to keep 2 shower rooms clean and in good repair. In the East Hall shower room, surveyors observed loose, cracked, chipped, and stained tiles, missing tile exposing debris, sharp cracked tile edges, and a shower chair with wheels coated in thick debris. In the North Hall shower room, surveyors observed stained grout, soap scum, and a broken drain guard exposing an open drain. Staff and the DON/Administrator stated they were unaware of the conditions, and the maintenance logbook had no entries for repairs.
Failure to protect resident dignity and rights: A resident with cognitive impairment reported that an employee touched inside the resident’s shirt in the hallway without permission to check for a bra, and the DON acknowledged the resident’s rights were not honored. In addition, residents were served meals on trays during breakfast and lunch instead of having the trays removed, and another resident stated staff did not ask permission or explain before moving them or getting them dressed, which the POA said left the resident sad.
A resident with dementia and a prior subdural hemorrhage was started on Seroquel for reported worsening behaviors despite limited behavior documentation and no documented non-pharmacological interventions before initiation. The dose was later increased and Zoloft was added for sundowning, hallucinations, delusions, and exit seeking even though the chart showed little to no supporting behavior documentation. The resident later fell and sustained multiple fractures. Staff and pharmacy interviews confirmed the record lacked sufficient documentation to justify the psychotropic medications.
A facility failed to report an allegation of improper touching involving a resident with moderately impaired cognition and ADL assistance needs. The resident said a staff member placed a hand down the resident’s shirt in the hallway without permission to check for a bra, and the concern was reported internally to Social Services and the floor nurse, but the DON later stated it should have been investigated and reported to the SA.
A resident with ESRD on hemodialysis and diabetes did not have dialysis orders, a dialysis-specific care plan, or documented post-dialysis assessments or vital signs in the record. Staff reported they only checked blood sugar and gave insulin and a meal after return, assumed the dialysis center had already obtained vital signs, and had no standardized communication process with the dialysis center. The DON and Administrator acknowledged the resident’s dialysis care was not being managed with the expected monitoring and coordination.
Failure to honor diet preferences and texture needs for two residents. One resident with Lewy bodies dementia and dysphagia was served chicken nuggets on a mechanical soft diet and said they were too hard to chew, with no alternate meal offered. Another resident with heart disease, kidney disease, and arthritis was served chicken nuggets despite documented dislikes for chicken and pork; the POA reported the resident did not like those foods, and the diet record lacked the dislike documentation.
Food was not stored and maintained in a clean, dry, sanitary manner in several areas of the facility. Surveyors observed dirt buildup on kitchen ceiling pipes and the ventilation fan, residue and slimy buildup inside the hallway ice machine while ice was present, and dry goods such as muffin mix, coffee, and hashbrowns stored in a staff office on the carpeted floor. The Dietary Manager and Maintenance Director identified maintenance responsibility for cleaning the kitchen ventilation components and the ice machine, and the Dietary Manager acknowledged the dry goods were stored outside the kitchen due to limited space.
A resident developed avoidable pressure injuries due to the facility's failure to consistently assess and implement interventions. Despite being at risk, the resident's skin condition was not adequately monitored, leading to pressure injuries on the heels and calf. Observations showed the resident often without prescribed heel protectors, and staff interviews revealed a lack of awareness and communication regarding necessary interventions. The DON acknowledged that required assessments were not completed, contributing to the resident's decreased quality of life.
Two residents experienced a decline in ROM and mobility due to the facility's failure to implement timely restorative therapy services, including the use of braces and splints. One resident developed hand contractures due to delayed therapy initiation, while another did not receive consistent splint application. Staff interviews revealed a lack of awareness and training, as well as staffing issues, contributing to the deficiency.
The facility failed to provide quarterly personal fund statements to three residents, each with varying cognitive and physical impairments. Despite the requirement to send these statements, the facility's administrator admitted that they had not been sent for almost a year, placing residents at risk of not having an accurate accounting of their personal funds.
The facility failed to resolve grievances voiced in Resident Council meetings and did not inform residents about the grievance process. A resident reported broken bathroom equipment, but the issue was not documented or addressed. Additionally, residents were unaware of how to file grievances or who the Grievance Officer was. The facility's informal process relied on department heads to address concerns without proper documentation or follow-up.
The facility failed to conduct accurate PASARR assessments for two residents, leading to a deficiency in care. One resident with depression and severe cognitive impairment and another with anxiety and moderately impaired cognition did not receive required level two evaluations. Staff were unaware of updated regulations and had not received training, contributing to the oversight.
The facility failed to provide trauma-informed care for three residents, including one with PTSD and another with significant personal losses. Care plans lacked trauma assessments and interventions, leaving residents' mental health needs unaddressed. Staff were unaware of recent traumas and did not document or manage triggers effectively.
The facility's kitchen had several maintenance deficiencies, including a broken floor under the oven, dusty appliances, leaking faucets, and improper storage of dry goods under a steam table. Additionally, dirty vents with exposed insulation were observed. Staff interviews revealed a lack of maintenance personnel and communication issues, with the Administrator unaware of these problems.
A resident with significant health issues was not provided adequate care to maintain bowel continence and personal hygiene, leading to multiple incontinent episodes and insufficient showering opportunities. The resident expressed dissatisfaction with the care, citing delays in assistance and a lack of a scheduled toileting program. Staff acknowledged the challenges in providing timely care due to resource constraints.
The facility failed to assess and monitor the use of physical restraints for two residents, leading to the use of roll bolsters without proper orders or consents. One resident with mood disorder and heart failure was immobilized in bed due to staffing issues, while another with stroke and dementia had limited movement. No assessments or consents were documented, placing residents at risk.
The facility failed to complete significant change assessments (SCAs) for two residents who experienced changes in their health status related to hospice and palliative care. One resident was discharged from hospice services without an SCA, and another experienced a decline in ADLs and was diagnosed with palliative care without an SCA. Staff interviews revealed confusion and lack of responsibility regarding the completion of MDS assessments, contributing to the deficiency.
A facility failed to update the PASARR Level I form for a resident newly diagnosed with mental health concerns, including anxiety and delusions. The resident was prescribed Ativan for agitation, but the PASARR assessment was not revised to reflect these changes. Staff interviews revealed a lack of awareness about the requirement to update PASARR forms for new mental health diagnoses.
The facility failed to update care plans for two residents, leading to inaccuracies in their documented care needs. One resident's care plan did not reflect their interest in activities or worsening vision, while another's inaccurately stated they could feed themselves. Staff confirmed these discrepancies, and the DON acknowledged the need for review.
The facility failed to provide consistent Restorative Aide (RA) programs for three residents, leading to a risk of functional decline. A resident with dementia and diabetes was not participating in RA programs due to fatigue and fear, while another with a history of stroke was not encouraged to self-feed or transfer. A third resident with ankylosing spondylitis did not receive prescribed exercises. Staffing issues and lack of training contributed to these deficiencies.
A resident with visual and hearing impairments felt isolated due to the lack of meaningful activities at the facility. Despite their interest in political science and news, they were unable to engage in these activities effectively. Staff interviews revealed no planned one-on-one activities, and the activities director was unsure how to meet the resident's needs.
The facility failed to conduct proper skin assessments and provide timely specialized services for residents. A resident with a urostomy did not have their skin condition properly documented or communicated to a physician. Another resident with Alzheimer's disease did not receive weekly skin and wound documentation as ordered. Additionally, two residents did not receive timely specialized services, including therapy and Botox injections, due to administrative oversights and lack of proper documentation.
A resident with lower back pain and anxiety experienced issues with unsafe bathroom equipment, including an unsecured toilet seat riser and broken handrails, leading to falls. Despite reporting these issues, staff failed to document or address them, resulting in a deficiency in ensuring a safe environment.
The facility failed to ensure residents were free from unnecessary psychotropic medications, as two residents were prescribed such medications without proper monitoring or documentation. One resident received Ativan without a stop date, and behavior monitoring was inconsistent. Another resident's antidepressant dosage was increased without complete behavior monitoring, and there was no signed consent for medication use. Staff interviews revealed a lack of adherence to protocols for informed consent and behavior monitoring.
A resident with complete hearing loss experienced miscommunications and unmet care needs due to the facility's failure to provide adequate communication support. Despite using a whiteboard and iPad, the resident expressed frustration over staff's inability to communicate effectively, particularly regarding medication information and personal care. The facility had not provided an interpreter, even three months after admission, leading to further communication issues.
A resident with multiple health issues experienced unmanaged pain and a delayed response to a change in condition, including an allergic reaction to an antibiotic. The resident's complaints of pain were not promptly addressed, leading to a delay in emergency care. Additionally, there was a lack of proper assessment and communication regarding the resident's allergic reaction, resulting in further complications.
The facility failed to maintain a cleanable and sanitary environment in three resident rooms, where worn and discolored tiles with black sticky substances were observed. A resident reported that their room was dirty and uncleanable. The Environmental Manager confirmed the uncleanable condition, attributing it to old and worn surfaces with glue seeping through the tiles.
Failure to Manage Bed Bolster Hazard During Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to identify and prevent an avoidable accident hazard related to the combined use of bed bolsters and mechanical lift transfers for a resident. The resident had Alzheimer’s dementia, anxiety disorder, osteoarthritis, moderately impaired cognition, was dependent on staff for grooming, bed mobility, and transfers, and was assessed as being at risk for falls. The resident’s fall care plan specified that the left side of the bed was to be placed against the wall to prevent falls or rolls out of bed, but there were no care plan interventions addressing the use of a bed bolster. The facility also lacked a physician order, assessment, care plan entry, or representative consent for the bolster that had reportedly been in use on the resident’s bed for a couple of years. On the day of the incident, staff used a mechanical lift to transfer the resident from bed to wheelchair while a wedge-shaped bolster remained along the right side of the bed, with the bed at working height. Nursing assistants involved in the transfer reported that the sling was already hooked to the lift and that, during the lift, the lower left sling loop came off the lift hook as the resident was moved over the side of the bed. Staff later acknowledged that the bolster wedge should have been removed or taken down before performing the mechanical lift transfer and that if the bolster is not moved, the sling can get caught on it. One NA stated they had not been told to remove bolsters for mechanical lifts, and another stated that looking back, the bed had been too high and the bolster should have been removed. As a result of the sling loop disconnecting from the lift hook, the resident slid out of the sling and fell to the floor, landing partially on the mechanical lift leg. The resident sustained a forehead laceration, bruising to the left arm and elbow, skin shearing, bruising, and swelling to the left ankle, and was transported to the hospital. The resident was diagnosed with a left ankle fracture, treated with a leg splint, and had a shallow scalp laceration. Upon return, the resident was observed yelling out and later groaning in pain, with visible bruising on the forehead. The DON, restorative nurse, and administrator acknowledged there were no written policies, documented training, or guidelines specific to mechanical lift transfers in conjunction with bed bolsters, and the administrator stated they were not aware that bolsters could be a hazard.
Failure to Supervise and Assess After an Unwitnessed Fall
Penalty
Summary
The facility failed to provide adequate supervision and failed to immediately assess a resident after an unwitnessed fall. Resident 54 was admitted with traumatic subdural hemorrhage, dementia, and a history of falls prior to admission. The comprehensive assessment showed moderately impaired cognition and the resident required assistance from one staff member for activities of daily living. The admission fall-risk assessment identified the resident as high risk for falls, but the comprehensive care plan dated 08/08/2025 showed no specific fall care plan and no interventions were in place to address the resident's high fall risk. During the early morning hours of 09/11/2025, Resident 54 was found face down on the floor in their room by an NA. An LPN entered the room and assisted in lifting the resident into a wheelchair using a gait belt. The resident had lacerations on the left hand, left forearm, left elbow, left shoulder, and left temporal area, and stated, "It hurts so much." The LPN stated a complete physical assessment was not performed until after the resident was transferred into the wheelchair, and the resident later required transfer to the hospital for pain and was diagnosed with multiple complex fractures of the left humerus, hip, and left tibia requiring surgical intervention. Staff interviews also confirmed there were no fall risk interventions in place and that the resident's care plan lacked the necessary required information and interventions.
Grievance Process and Missing Item Complaints Not Properly Communicated
Penalty
Summary
The facility failed to provide residents and their representatives with information on how to report concerns, incidents, and grievances for four of six residents reviewed for grievances. The grievance process was not clearly available to residents, and the facility did not establish a grievance policy that included prominent postings throughout the facility, the right to file a grievance in writing or anonymously, the right to review the complaint in writing, or a reasonable time frame for review and resolution. The report identified residents 35, 19, 33, and 18 as affected by these issues. During the resident council meeting, Resident 35 stated the facility did not respond to a missing money complaint from six months earlier and there was no follow-up. Resident 19 reported missing money to social services but had not received information about the conclusion of the investigation, though a drawer lock was provided. Resident 33 reported missing blankets to social services but also had no follow-up. The residents stated they were unaware that grievance forms were available, that grievances could be filed anonymously, or that other facility staff could assist them with the grievance process. They also stated they were unaware of the grievance policy, the policy for lost money, the state hotline number, and Ombudsman contact information. Resident 18 stated that if items were missing and staff were told, there was no follow-up, and the resident was unaware of how to file a concern or grievance. Staff interviews showed complaints were generally routed to social services, and staff stated residents did not complete grievance forms themselves because social services filled them out. Staff also stated grievance forms were difficult to locate, with one RN finding them hidden, high on a wall, behind other paperwork, and unlabeled. The administrator stated the personal property and missing items policy did not make sense and would need reworking, and acknowledged the policy language regarding inventory and reimbursement was not correct.
Failure to Thoroughly Investigate Resident Incidents
Penalty
Summary
The facility failed to ensure investigations were completed and/or thorough for three residents reviewed for incident investigations. The report states that all incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated, including the who, what, when, why, and how of the event and a reasonable cause established within 24 hours. For Resident 40, who had diagnoses including osteomyelitis, respiratory failure, GERD, and a right below-the-knee amputation, the record showed a choking episode when the resident ate corn chips at dinner and was able to cough and clear the throat, but staff stated the event was not investigated because a Heimlich maneuver was not performed. The Administrator initially stated that if the facility could identify how the incident happened, an investigation was not needed, then later stated the incidents should have been investigated. For Resident 14, who had Alzheimer's disease, severely impaired cognition, and required extensive assistance with ADLs and eating, the nursing note documented that the resident spilled cocoa on the left thigh and developed a small, light red area of skin discoloration, but the incident reporting log had no documentation of an investigation or report for that event. For Resident 35, who had heart disease, diabetes, depression, and moderately impaired cognition, the record showed the resident reported being upset that a staff member touched them without permission while looking for a bra. Staff stated the incident was handled by Social Services, but no investigation was completed by nursing, no alert charting was initiated, and no staff statement was obtained. The DON stated the incident should have been thoroughly investigated to rule out abuse and neglect.
Shower Rooms Not Maintained in Clean, Safe Condition
Penalty
Summary
The facility failed to maintain a safe, sanitary, comfortable environment in 2 of 3 shower rooms reviewed, including the East Hall and North Hall shower rooms. Review of the maintenance logbook for November and December 2025 showed no entries for repair of either shower room. In the East Hall shower room, observation showed a 3-foot by 4-foot divider wall with multiple loose, cracked, chipped, and black/brown stained tiles on the shower floor where it connected to the base of the divider wall. A 12-inch by 10-inch corner section of the divider wall had no tile, exposing a black/brown substance and yellow and white flaky wall debris that crumbled when touched. A 2-inch tile on the top edge of the divider wall was cracked in half with sharp edges. During observation and interview, the Maintenance Director stated staff were to report needed repairs in the maintenance logbook and said they were unaware of the East Hall shower room concerns. The Maintenance Director stated the broken and missing shower tiles should be repaired and/or replaced and the shower chair wheels needed to be replaced. The Administrator also stated they were unaware of the condition of the East Hall shower room, said the shower tiles were uncleanable and needed repair, and stated the resident shower chair should not be in use and needed to be disposed of. In the North Hall shower room, observation showed pink and dark brown substance in the tile grout, pink and yellow soap scum on the tile floor, and a broken drain guard exposing an open drain. A Nursing Assistant stated the facility did not have a shower team, NAs were assigned showers for their shift, and they used sanitizing spray after showers, but were unsure who was responsible for deep cleaning. The Maintenance Director later stated they were not aware of the North Hall issues and said staff used a maintenance log at the South Hall nurses' station to communicate facility issues.
Failure to Protect Resident Dignity and Rights
Penalty
Summary
The facility failed to promote and protect residents’ rights to a dignified existence and respectful treatment. Review of the facility policy showed residents were to be able to exercise their rights without interference, coercion, discrimination, or reprisal, and were entitled to dignity and respect. The deficiency involved two residents reviewed for dignity concerns and two dining observations in which residents were not treated in a dignified manner during meals. Resident 35, who had diagnoses including heart disease, diabetes, and depression and whose cognition was moderately impaired, reported that a staff member placed a hand down the resident’s shirt while the resident was sitting in the hallway to check whether the resident was wearing a bra, without asking permission. The resident stated the contact was embarrassing and upsetting. Staff from Social Services and the DON acknowledged the incident and stated it had been reported through the grievance process, and the DON acknowledged the resident’s rights were not honored when the unwanted touch occurred. During dining observations, residents were served and ate breakfast and lunch with their meals left on pale-yellow serving trays in the south dining room. Staff observed and interviewed stated that resident meals should not be left on serving trays during mealtime and that trays should be removed when residents are served. Resident 35 stated eating from the tray was uncomfortable and made it easy to spill food and drinks. Resident 51, who had diagnoses including heart disease, kidney disease, and arthritis and was hard of hearing but able to understand and make needs known, stated staff did not treat them with dignity by not asking if they wanted to get up and dressed and by moving them without explanation or permission into bed. The resident’s POA also stated the resident was sad about the way staff treated them.
Unnecessary Psychotropic Medication Use Without Documented Behavior Monitoring
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication use when it did not monitor resident-specific behaviors or consistently document non-pharmacological interventions before starting and increasing psychotropic medications. Resident 54 was admitted with dementia without behavioral disturbance and a traumatic subdural hemorrhage, had moderately impaired cognition, and required assistance from one staff member for ADLs. The assessment showed no wandering or refusal of care behaviors during the assessment period, and nursing notes later documented that the resident preferred to walk the halls independently and was sometimes exit seeking but could be easily redirected. The record showed no behavior monitoring orders were initiated until 08/19/2025, and the medical record did not show non-pharmacological interventions had been implemented or documented before Seroquel was ordered on 08/20/2025 for worsening behaviors. Seroquel 12.5 mg at bedtime was started on 08/22/2025 for cognitive decline and sundown with dementia. After that, progress notes from 08/22/2025 through 08/28/2025 documented no behaviors, and a later note on 08/29/2025 documented the resident exited the front door and was immediately redirected by a visitor. Despite limited documented behaviors, the physician increased Seroquel to 25 mg at bedtime and started Zoloft for unspecified dementia sundown with hallucinations, delusions, and exit seeking, even though the record did not show documented behaviors supporting those diagnoses. The resident then had a fall on 09/11/2025 that resulted in multiple fractures, eight days after the medication increase and start of the antidepressant. Interviews with staff and pharmacy personnel confirmed expectations for clear behavior charting, attempted non-pharmacological interventions, and sufficient documentation before psychotropic medication initiation or dose increases, and staff acknowledged the record lacked enough documentation to support the medications.
Failure to Report Allegation of Improper Touching to State Agency
Penalty
Summary
The facility failed to ensure allegations of abuse or neglect involving an unwitnessed event with a substantial injury were reported to the State Agency as required. The report states that immediate reporting is required when there is reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal or financial exploitation, or misappropriation of resident property has occurred, and that substantial injuries of unknown source must be reported within 24 hours if they are not reasonably related to a disease process or known sequence of events after a thorough investigation. Resident 35 had diagnoses including heart disease, diabetes, and depression, and the comprehensive assessment showed moderately impaired cognition and a need for supervision or touching assistance with ADLs. The resident stated that a staff member placed a hand down the resident’s shirt in the hallway to check for a bra without asking permission, which the resident found embarrassing and reported to administration. Progress notes documented that the resident and the Activities Director reported the resident was upset that a staff member had touched them without permission, and the Activities Director stated the incident was reported to Social Services and the floor nurse the same day. The DON later stated the incident should have been investigated and reported to the SA.
Dialysis Monitoring and Communication Deficiencies
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care and services for a resident with end-stage renal disease requiring hemodialysis and diabetes. The resident’s comprehensive assessment showed intact cognition and a need for assistance with activities of daily living. Although the resident was receiving dialysis on Monday, Wednesday, and Friday, the December physician orders contained no dialysis orders, the care plan contained no dialysis information or interventions, and the record from 06/01/2025 through 12/05/2025 showed no follow-up assessments to monitor for complications after the resident returned from dialysis. The vital sign record also showed no documented post-dialysis vital signs between 11/01/2025 and 12/01/2025. Interviews confirmed there was no standardized communication process with the offsite dialysis center and that communication generally occurred only when there was a specific concern. The clinical case manager stated staff were checking blood sugar, administering insulin as ordered, and providing a meal after return, but were not routinely obtaining post-dialysis vital signs because they assumed the dialysis center had already done so. The dialysis center contact stated the nursing facility was expected to send communication forms, conduct post-treatment monitoring, obtain post-dialysis vital signs, and assess the access site for bleeding, infection, and bruit, but did not recall receiving a communication form for the resident. The DON and Administrator both stated they expected dialysis-specific orders, monitoring, and a dialysis care plan, and acknowledged the correct process was not followed for the resident.
Failure to Honor Diet Preferences and Texture Needs
Penalty
Summary
The facility failed to provide food that accommodated the preferences and diet needs of 2 of 4 sampled residents reviewed for preferences. Resident 9 had diagnoses including Lewy bodies dementia and heart disease, was able to make needs known, and required assistance with utensils and monitoring swallowing once a meal was served. During observation, the resident was served chicken nuggets and French fries, stated the chicken nuggets were too hard to chew, and was not offered another meal selection. The resident’s food card showed a Mechanical Soft diet, and the Dietary Manager stated the resident should have been served softer mechanical soft food and was unaware the resident required a dysphagia diet. Resident 51 had diagnoses including heart disease, kidney disease, and arthritis, was hard of hearing but could understand others, made needs known, and required setup assistance for meals. During observation, the resident was served breaded chicken nuggets and French fries and stated the chicken nuggets were too tough to bite into. The resident’s POA stated the resident did not like chicken or pork, but there was no documented dislike of pork or chicken on the diet card. The Dietary Manager stated the resident was on a mechanical soft diet and that pork chops were the second entrée choice, so chicken nuggets were served instead. The resident’s diet report listed a mechanical soft textured diet with chopped meats and additional directions including no chicken or pork, no fortified juices, extra gravy/sauces, soft foods, and nothing crunchy.
Food Storage and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored in a clean, dry, and sanitary manner in accordance with professional standards for the kitchen, the ice machine, and the dry storage area. During an initial kitchen tour, the ceiling pipes and ventilation fan had black dirt buildup, and the top of the stove hood had a vent pipe with gray, fuzzy dust and dirt buildup. On interview, the Dietary Manager stated maintenance was scheduled to clean the kitchen ventilation fan and pipes. The ice machine in the east hallway had a white residue on the inside of the top lid and a pink slimy residue on the back and side walls during multiple observations, while ice remained inside and the scoop was stored in a lidded plastic container mounted nearby. The Dietary Manager stated this was the only ice machine in the facility and that maintenance was responsible for cleaning and maintaining it. In addition, dry goods and food items, including muffin mix, decaffeinated coffee, and hashbrowns, were stored in Staff C's office on the carpeted floor because the kitchen storage area did not have enough space, and the Dietary Manager acknowledged the boxes were not kept off the floor in that location.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to consistently assess and implement interventions to prevent and manage pressure injuries (PIs) for Resident 30, who developed three avoidable PIs after admission. Resident 30 was admitted with diagnoses including kidney and heart failure, and was at risk for developing PIs. Despite this, the facility did not adequately monitor or document the condition of Resident 30's skin, leading to the development of PIs on the right heel, left heel, and left calf, which were not present upon admission. Observations revealed that Resident 30 was often found lying in bed without the use of prescribed heel protectors, which were intended to prevent pressure on the heels. The facility's Treatment Administration Record (TAR) showed orders to monitor and float the heels, but these interventions were not consistently implemented. Staff failed to document weekly heel assessments, and there were no treatment orders for the Stage 1 PI on the right heel. Additionally, the care plan did not include interventions for the left outer calf PI or the use of the air mattress overlay and heel protectors. Interviews with staff indicated a lack of awareness and communication regarding Resident 30's condition and the necessary interventions. Nursing assistants reported observing abnormalities but did not have a place to document these findings, and there was confusion about the use of heel protectors. The Director of Nursing Services acknowledged that weekly skin assessments and wound assessments were not being completed as required, and the Resident Care Managers were not updating care plans promptly due to their workload. This lack of consistent assessment and intervention contributed to the worsening of Resident 30's PIs and their decreased quality of life due to pain.
Failure to Implement Timely Restorative Therapy Services
Penalty
Summary
The facility failed to implement timely restorative therapy services, including the consistent use of braces and splints, to prevent avoidable reduction of range of motion (ROM) and mobility for two residents. Resident 27 developed right and left-hand contractures, which were not present upon admission and were not documented in subsequent assessments until much later. Despite a physician's diagnosis of a right-hand contracture, there was a significant delay in initiating a ROM restorative program, and no documentation indicated that such a program was in place for the resident's upper extremities. Observations confirmed the absence of necessary devices like dowels to aid in reducing contractures. Resident 20, who had a known contracture to the left hand, was supposed to be on a nursing restorative program that included the use of a splint. However, observations revealed that the splint was not consistently applied, and staff interviews indicated a lack of awareness and training regarding the resident's restorative program. Staff members reported being too busy or not trained to perform the necessary ROM exercises, leading to the program not being followed as required. Interviews with staff, including the Rehab Director and nursing assistants, highlighted systemic issues such as inadequate communication and training, as well as staffing shortages that contributed to the failure in providing necessary restorative care. The facility's administrator acknowledged the expectation for braces and splints to be applied as ordered and for residents showing a decline to be evaluated and treated promptly, which was not the case for these residents.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents and/or their representatives, as required. This deficiency was identified for three residents, each with varying degrees of cognitive and physical impairments. Resident 20, diagnosed with Parkinson's disease and requiring extensive assistance for activities of daily living (ADLs), had severely impaired cognition. The resident's representative reported not receiving any statements regarding the resident's personal funds. Similarly, Resident 23, who has cerebral palsy and intact cognition, also did not receive any personal fund statements. Resident 27, with scoliosis and moderately impaired cognition, required extensive assistance for ADLs, and their representative assumed the funds were used for care, as they had not received any statements. During an interview, the facility's administrator, Staff A, acknowledged the failure to send out personal fund statements, admitting that the facility was behind schedule and had not sent any statements for almost a year. This lapse in procedure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility, as required by regulations.
Failure to Resolve Grievances and Inform Residents of Grievance Process
Penalty
Summary
The facility failed to establish an effective system for promptly resolving grievances voiced during Resident Council meetings. Resident 9, who had moderately impaired cognition and was receiving hospice services, reported broken bathroom equipment during a Resident Council meeting. Despite this, the issue was not documented in the meeting minutes or the maintenance book, and no action was taken to resolve the concern. Staff V, the Activities Director, assumed that concerns raised in the meetings were addressed by individual departments but did not follow up to ensure resolution. Additionally, four residents who regularly attended Resident Council meetings were unaware of how to file a grievance or who the facility's Grievance Officer was. The facility's grievance policy stated that grievances should be investigated by the Director of Nursing or the Administrator, with results communicated to the resident or their representative. However, the process for handling concerns raised in Resident Council meetings was informal, with no formal documentation or follow-up to ensure grievances were addressed. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. Staff A, the Administrator, and Staff H, the Grievance Officer, acknowledged that concerns from Resident Council meetings were not treated as formal grievances. The process relied on department heads to address issues based on meeting minutes, but there was no documentation or follow-up to confirm resolution. This lack of a structured grievance process placed residents at risk for unresolved concerns and dissatisfaction.
Failure to Conduct Accurate PASARR Assessments
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) assessments accurately reflected the mental health conditions of two residents, leading to a deficiency in the care provided. Resident 16 was admitted with diagnoses including a stroke and depression, and their comprehensive assessment indicated severe cognitive impairment and symptoms of depression. However, the PASARR assessment, completed by the Resident Care Manager upon admission, incorrectly indicated that a level two evaluation was not required, despite the presence of a mood disorder. Similarly, Resident 8, who was admitted with an anxiety disorder and had moderately impaired cognition, also did not receive the necessary level two evaluation as indicated by their PASARR assessment. The staff responsible for completing the PASARRs, Staff C and Staff D, were unaware of the updated regulations requiring these evaluations to be completed prior to admission, and they had not received training on the changes. The facility administrator, Staff A, was also unaware of the regulatory changes and the need for training, contributing to the oversight.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for three residents who were trauma survivors. Resident 12, who had experienced significant personal losses including the death of their spouse and multiple amputations, expressed feelings of sadness and loss of manhood. Despite these clear indicators of trauma, the resident's care plan did not address their trauma concerns or identify any triggers or interventions to manage their mental health well-being. Staff H, the Social Services Director, was unaware of the recent nature of the resident's losses and did not conduct a thorough assessment to understand the impact on the resident's mental health. Resident 38, who had a history of cataracts, dementia, and multiple falls, expressed feelings of isolation and guilt over the death of their child from alcoholism. Despite these expressed concerns, the psychosocial history did not reflect these issues, and no trauma-based care plan was initiated. Staff DD, the Social Services Assistant, was aware of the resident's regrets but did not ensure that these were documented or addressed in the care plan. Resident 27, diagnosed with PTSD, anxiety, and depression, had specific triggers related to their past experiences of being yelled at by their parents. However, their care plan did not include any trauma-informed interventions or assessments to address these triggers. Staff H acknowledged that the process for trauma-informed care was not followed, and there was no trauma assessment tool available in the electronic health record. The Director of Nursing Services confirmed that no trauma assessments had been completed for the residents.
Kitchen Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen, which placed residents at risk for infection. Observations revealed several issues, including a broken and missing area of rubberized concrete under the oven's right leg support, making it uncleanable. Additionally, the top of the oven was covered with dusty stainless steel appliances and inserts used for the steam table. The clean sink area had a leaking water faucet, which worsened over time, affecting a second faucet. Despite the Dietary Manager reporting the issue to the Maintenance Director, the problem persisted. Further observations showed that white plastic barrels containing powdered milk, flour, and other dried goods were stored under a steam table, exposing them to constant high temperatures and moisture, potentially affecting their quality. The kitchen also had two dirty vents with black fuzzy dust, and one vent had exposed yellow insulation due to splits in the ceiling. Interviews with staff revealed a lack of maintenance personnel and communication issues, as the Administrator was unaware of the kitchen repair issues until informed by the surveyors.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 12, by not providing adequate care to support their bowel continence and personal hygiene needs. Resident 12, who was readmitted with a fracture of the right lower leg and other significant health issues, required assistance with a mechanical lift for transfers and was continent of bowel. However, the resident was not on a scheduled bowel toileting program, leading to multiple incontinent bowel episodes. The resident expressed dissatisfaction with the care received, particularly the lack of timely assistance to use the bathroom, resulting in accidents. Additionally, the facility did not provide Resident 12 with sufficient opportunities for personal hygiene, as they were only scheduled for one shower per week. The resident expressed a preference for more frequent showers, especially before appointments and family visits, but staff indicated they lacked the time to accommodate this request. The care plan for Resident 12 did not include a specific toileting schedule, and staff acknowledged the difficulty in using the mechanical lift quickly due to the need for two staff members. The Director of Nursing Services recognized the need for reassessment to determine the resident's toileting and showering needs.
Failure to Assess and Monitor Physical Restraints
Penalty
Summary
The facility failed to comprehensively assess and monitor the need for physical restraints for two residents, identified as Resident 30 and Resident 39. Resident 30, who was admitted with a mood disorder and heart failure, had severely impaired cognition and required substantial assistance for bed mobility. Observations revealed that roll bolsters were used to immobilize Resident 30 in bed without a physician's order or proper assessment. Staff interviews indicated that the roll bolsters were used due to insufficient staffing to assist the resident in getting up, and there was no ongoing reassessment or consent obtained for their use. Similarly, Resident 39, who had a history of stroke, dementia, and depression, was observed with roll bolsters that limited their freedom of movement. There were no physician orders or assessments justifying the use of these restraints. Staff interviews revealed that the roll bolsters were used to prevent the resident from turning around in bed, but there was no documentation of an assessment, order, or consent for their use. The facility's failure to assess, document, and obtain necessary consents for the use of physical restraints placed residents at risk for diminished quality of life and other complications.
Failure to Complete Significant Change Assessments for Residents
Penalty
Summary
The facility failed to complete a significant change assessment (SCA) for two residents, Resident 9 and Resident 30, who were reviewed for hospice and end-of-life care. According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, an SCA is required when a resident experiences a major decline or improvement in health status, such as when hospice benefits are selected or discontinued. Resident 9 was admitted with hospice care and later discharged from hospice services, but no SCA was completed following this change. Similarly, Resident 30 experienced a significant decline in activities of daily living (ADLs) and was diagnosed with palliative care, yet no SCA was conducted to address these changes. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of MDS assessments. Staff C and Staff D, who shared the task with Staff Y, the MDS Coordinator, were uncertain about who was responsible for completing the SCAs for Residents 9 and 30. Staff B, the Director of Nursing Services, admitted to not being knowledgeable about the timing and frequency of SCAs. This lack of coordination and understanding among staff members contributed to the failure to complete the necessary assessments, placing the residents at risk for unmet care needs.
Failure to Update PASARR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-Admission Screening and Resident Review (PASARR) Level I form for a resident who was newly diagnosed with mental health concerns. This oversight involved a resident who was admitted with diagnoses including depression and blindness. The resident's medication records indicated that they were prescribed Ativan, a psychotropic medication, for agitation and comfort care without a stop date. The medication was initially ordered in July 2024 and continued into August 2024. Despite these changes in the resident's mental health status and medication regimen, the PASARR assessment from January 2023 was not updated to reflect the new behavioral diagnoses of anxiety, agitation, or delusions. Interviews with facility staff revealed a lack of awareness regarding the requirement to update PASARR forms when a resident is newly diagnosed with mental health issues. The contracted pharmacist noted that the resident was receiving Ativan due to agitation from delusions, yet the resident case managers admitted they were unaware of the need to update the PASARR assessments under such circumstances. This failure to update the PASARR form potentially placed the resident at risk for health and emotional decline due to the absence of a professional evaluation to determine if further mental health interventions were necessary.
Inaccurate and Outdated Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans for two residents were reviewed, revised, and accurately reflected their current care needs. Resident 38, who had been at the facility for over a year, had a care plan that was outdated and did not reflect their current condition. Despite having cognitive impairment, the resident was able to express their needs clearly. The care plan did not account for the resident's interest in activities such as reading newspapers and going on outings, nor did it reflect their worsening vision due to cataracts. Additionally, the care plan did not update the resident's restorative program after a fall that resulted in a clavicle fracture, and there were no new restorative assessments or interventions documented. Resident 39, who was severely cognitively impaired and required substantial assistance for self-care, had a care plan that inaccurately stated they could feed themselves 50% of their meals. Observations showed that the resident was fed 100% of their meals by staff and preferred to remain in bed rather than use a wheelchair, contrary to what was documented in the care plan. Interviews with staff and the resident's representative confirmed that the resident no longer fed themselves due to their dementia. The Director of Nursing Services acknowledged that the care plans did not reflect the current conditions and concerns of the residents.
Failure to Implement Restorative Aide Programs
Penalty
Summary
The facility failed to consistently provide necessary care and services to ensure that Restorative Aide (RA) Nursing programs were implemented for three residents, leading to a risk of avoidable decline in their functional abilities. Resident 21, who had dementia and diabetes, was observed multiple times remaining in bed without participating in their RA programs for dressing/grooming and bed mobility. Staff interviews revealed that the resident was not encouraged to participate due to fatigue and fear of transferring, and the Restorative Assistant responsible for these programs was working as a regular Nursing Assistant (NA) instead. Resident 39, with a history of stroke, dysphagia, and dementia, was also not participating in their RA programs for eating/swallowing and transfer training. Observations showed the resident being fed by staff without any attempt to encourage self-feeding, contrary to their care plan. Interviews with staff and the resident's representative indicated a lack of awareness and implementation of the RA programs, with staff routinely providing total assistance for meals and not facilitating transfer training. Resident 9, diagnosed with ankylosing spondylitis, was not receiving exercises or participating in RA programs for bed mobility, dressing, and walking as outlined in their care plan. Observations and interviews highlighted that the resident struggled with reaching their call light due to stiffness and had not been engaged in the prescribed exercises. The Restorative Director acknowledged the staffing issues, with only one RA available who was also assigned to work as a NA, leading to the delegation of RA program responsibilities to floor NAs without proper training or documentation processes in place.
Failure to Provide Meaningful Activities for a Resident
Penalty
Summary
The facility failed to provide meaningful and engaging activities for a resident who did not participate in group activities due to visual and hearing impairments. The resident, who had a history of cataracts, dementia, and multiple falls, expressed feelings of isolation and dissatisfaction with the facility due to the lack of suitable activities. Despite the resident's interest in political science and news, they were unable to read newspapers or watch television effectively, and their voting ballot remained uncompleted due to a lack of assistance from staff. Interviews with staff revealed that there were no planned or routine one-on-one activities for the resident, and the activities director was unsure how to address the resident's needs. Documentation showed minimal engagement with the resident, with one-on-one activities being limited to brief interactions such as assisting with bedding. The activities staff acknowledged the need for follow-up assessments to better understand and meet the resident's activity preferences, but no specific actions were taken to address the deficiency at the time of the report.
Deficiencies in Skin Assessments and Specialized Services
Penalty
Summary
The facility failed to ensure residents received care and services in accordance with professional standards of practice, particularly regarding ongoing skin assessments and specialized services. For Resident 37, the facility did not conduct proper skin assessments or document the condition of the skin around the urostomy stoma. Despite having a physician's order to change the urostomy bag and monitor for leakage, there was no care plan addressing the potential for skin impairment or the presence of an additional opening on the resident's abdomen that drained fluid. Staff interviews revealed a lack of awareness and documentation regarding the resident's skin condition, which was not communicated to the physician. Resident 8, who had Alzheimer's disease and open wounds on their head, was also not properly monitored. The facility failed to follow a physician's order to document the resident's skin and wound condition weekly. Despite having a chronic skin condition, there was only one documented observation over a 12-week period. The Director of Nursing Services acknowledged that the nurses were responsible for skin and wound treatments but did not follow the physician's orders for Resident 8. The facility also failed to provide timely specialized services for Residents 9 and 20. Resident 9, who had a history of falls and was at risk due to leg weakness, did not receive the ordered physical and occupational therapy services. The facility did not consult the resident, who was capable of making decisions, and instead relied on the family's previous decision to decline therapy. For Resident 20, the facility did not ensure the continuation of Botox injections for hand contractures due to missing power of attorney documentation, resulting in a significant delay in treatment.
Failure to Ensure Safe and Functional Bathroom Equipment
Penalty
Summary
The facility failed to ensure that a resident's bathroom had safe and functional Durable Medical Equipment (DME), which placed the resident at risk for falls and injuries. Resident 9, who was admitted with diagnoses including lower back pain and anxiety, was observed using a wheelchair and self-propelling in their room. The bathroom equipment, specifically a toilet seat riser with handles and portable handrails, was not secured properly. The handrails were unstable, with the right-side handrail being broken, causing it to push outwards when pressure was applied. Resident 9 reported these issues during a group meeting but was informed that nothing could be done. Staff interviews revealed a lack of communication and documentation regarding the broken equipment. Staff M, a Nursing Assistant, did not report the issues to maintenance or document them in the maintenance book. Staff V, the Activities Director, recalled the resident's report but did not ensure it was recorded. The Maintenance Director, Staff I, confirmed no reports were received about the equipment. The Restorative Director, Staff E, was unaware of the equipment issues and had not assessed the bathroom, as the resident attributed their falls to leg weakness. The maintenance book showed no entries for the equipment issues, and the resident experienced two non-injury falls in the bathroom, attributed to leg weakness and deconditioning.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by the cases of two residents. Resident 7 was prescribed Ativan on a PRN basis without a stop date, and the medication was continued for 43 days before being discontinued and reordered without a stop date. Despite a pharmacist's recommendation to add a stop date, the medication was extended for three months without documented rationale. Additionally, behavior monitoring for Resident 7 was inconsistent, with numerous shifts lacking documentation of interventions or outcomes. Resident 16 was prescribed Desvenlafaxine and Remeron for depression, but there were no orders for monitoring targeted behaviors. The Desvenlafaxine dosage was increased without complete documentation of behavior monitoring, and there was no care plan for the resident's depression or use of psychotropic medications. Furthermore, there was no signed consent or education provided for the use of Remeron, and staff reported increased sadness without documentation to support these claims. Interviews with staff revealed a lack of adherence to protocols for obtaining informed consent and monitoring targeted behaviors. The Director of Nursing Services acknowledged the need for consent and documentation of behavior changes to justify medication adjustments. The facility's failure to develop, monitor, and implement individualized care plans and obtain informed consent placed residents at risk for medication-related adverse effects and compromised their ability to make informed decisions.
Failure to Provide Adequate Communication Support for Deaf Resident
Penalty
Summary
The facility failed to provide adequate communication support for a resident who is deaf, resulting in miscommunications and unmet care needs. The resident, who has complete hearing loss and other medical conditions such as heart disease, diabetes, and kidney disease, was observed using a whiteboard and an iPad for communication. Despite these tools, the resident expressed frustration over the staff's inability to communicate effectively, particularly regarding medication information and during personal care activities. The resident's care plan only mentioned the use of a whiteboard for communication, with no additional instructions or interventions. Interviews and observations revealed that staff members did not consistently use the whiteboard to communicate with the resident, and some staff members did not understand sign language. The resident's representative had requested an interpreter due to poor communication, but the facility had not yet provided one, even three months after the resident's admission. During medication administration, a nurse failed to inform the resident about the medications being given, despite the resident's request. Additionally, an incident occurred where a staff member startled the resident by changing their sheets without prior communication. The facility's administrator acknowledged the ongoing search for an interpreter but had not yet secured one.
Failure to Timely Assess Change in Condition and Manage Medication Reaction
Penalty
Summary
The facility failed to assess a change in condition in a timely manner for a resident who complained of abdominal pain and experienced an allergic reaction to a prescribed antibiotic. The resident, who had multiple diagnoses including deaf-nonspeaking, urinary retention with a catheter, chronic UTIs, and heart and kidney failure, communicated their pain through sign language and writing. On the morning of the incident, the resident pointed to their urinary catheter and complained of back pain to a nursing assistant, who did not report the complaint to a nurse. Despite the resident's communication of pain and the need to go to the emergency room, there was a delay in response, with the emergency ambulance arriving three hours after the initial complaint. The resident's medical record indicated a previous urologist visit where excessive sediment was noted in the urine, and an order was given to flush the catheter with acetic acid. However, there was no order to flush the catheter until 12 days later, and staff used normal saline instead. The resident's urinary catheter was leaking, and the resident experienced unmanaged pain due to the delay in assessment and treatment. Additionally, the resident was prescribed Cefdinir for a UTI, which led to a suspected allergic reaction causing throat pain and swelling. The staff failed to assess the resident's mouth or throat and did not notify the resident representative or provider promptly. The resident received a one-time dose of Benadryl for the side effects of Cefdinir, but there was no further direction documented. The staff did not assess the resident's condition, and the resident was not sent to the emergency room despite the suspected allergic reaction. The resident later developed a secondary fungal infection in the mouth, which was attributed to the antibiotic. The facility lacked a written policy for flushing urinary catheters, and staff relied on online resources for guidance, indicating a gap in proper procedural knowledge and communication among staff members.
Unsanitary Flooring Conditions in Resident Rooms
Penalty
Summary
The facility failed to maintain a cleanable and sanitary environment in three of ten resident rooms, as observed during a survey. In room [ROOM NUMBER], a five by four feet area of white tile was discolored to a blackish-brown color, with a black sticky substance between the tiles and multiple indentations that were uncleanable. Resident 1 reported that their room was dirty and the floor could not be cleaned properly. In room [ROOM NUMBER], a three by three feet area of worn tiles with several indentation marks and black sticky substance between the tiles was observed. Similarly, room [ROOM NUMBER] had a four by four feet area of worn, discolored tiles with several indentation marks and black sticky substance between the tiles. During an interview, the Environmental Manager, Staff H, acknowledged that the rooms were not cleanable and that the black sticky substance was glue coming up from the under flooring where the tiles were glued. Staff H admitted awareness of the uncleanable surfaces, which were old and worn. This situation placed staff and residents at an increased risk for infectious diseases and a non-functional resident environment due to the uncleanable flooring surfaces.
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Illustrative
What surveyors actually found near you
We read the 131 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Yakima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Care And Rehabilitation | 0.3 mi | ★★★★★ | 2 | 0 |
| Summitview Rehab And Health Center | 0.4 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Health Care Ctr | 1.5 mi | ★★★★★ | 17 | 0 |
| Garden Village | 2 mi | ★★★★★ | 34 | 0 |
| Willow Springs Care And Rehabilitation | 2.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.