Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Manor during CMS and state inspections, most recent first.
A resident with impaired mobility and cognitive impairment developed a worsening PI to the left ischial tuberosity while staff failed to ensure a Roho cushion was properly inflated and functioning as intended and did not consistently complete required weekly skin assessments. Survey observations found a Hoyer sling left under the resident in a Broda chair, and staff gave conflicting accounts of repositioning and skin-check responsibilities while the wound progressed from slough and redness to stage 3 and then unstageable with undermining and purulent drainage.
Unsafe food storage, sanitizing, and meal service practices were observed in the kitchen and during tray delivery. Staff found unmarked and improperly stored food items, damaged and unusable sanitizer test strips, uncovered trash cans in food prep areas, and a dietary staff member reused a thermometer probe between foods without proper cleaning and drying. A tray with uncovered food was also observed being carried down the hall to a resident's room.
Medication administration errors exceeded the acceptable rate, with surveyors finding multiple errors during a medication pass. An RN administered IV Daptomycin through a PICC without aspirating for blood return and set the pump using the wrong volume, a medication tech gave eye drops without holding the resident’s eyelids open and underdosed an intranasal spray, and an LPN gave eight scheduled medications outside the allowed time window. The DON confirmed the expected administration practices and timing requirements.
A resident with CHF and CAD had oxygen ordered to keep SPO2 at or above 90%, but EMAR documented repeated low SPO2 readings over consecutive days with no progress note of symptoms and no documentation that the provider was notified. RN, DON, and the family medicine physician all stated the provider should have been updated when the resident’s SPO2 fell below the ordered range.
A resident with CVA-related weakness and a contracted hand did not receive needed nail care assistance even though her fingernails were observed to be long and digging into her palm. The resident said staff kept telling her they would get to it when they had time, while a CNA said a nurse usually trims the nails and the DON confirmed staff should be assisting with the resident’s nail care.
Failure to Implement Fall Interventions for a High-Risk Resident: A resident with dementia, chronic pain, and a strong hx of falls was admitted with a high Morse fall score, but the initial care plan did not include key fall precautions such as a bed alarm or low bed. The resident later attempted to get out of bed, fell, and was sent to the ER, where x-rays showed a distal fibular fx and a splint was applied. The DON stated the resident had been considered immobile and staff were surprised she got out of bed on her own.
PICC Medication Administration Not Performed per Order: An RN administered Daptomycin through a resident’s PICC without aspirating for blood return and programmed the pump for 50 mL even though the IV bag contained 70 mL, leaving part of the dose outside the ordered 30-minute infusion time. The resident was cognitively intact and receiving IV therapy via central access for infection-related diagnoses. The DON confirmed staff should aspirate for blood return and administer meds according to the physician order.
Food Served at Unsafe Temperatures: A resident reported that meals often were not served hot and that dining room meals tasted terrible, with meals lately being served very late. During a test tray observation, multiple items were measured outside the facility’s stated safe serving temperatures, including hot items that were too cool and cold items that were too warm. The DM agreed the tray temperatures were not what she would expect for safe and palatable service.
Failure to use a barrier during perineal and catheter care: A resident with an indwelling catheter and a history of MRSA in the urine received care when a CNA placed a basin of soapy water directly on the bedside table next to open drinks and used it to complete perineal care without a barrier. The resident had severe cognitive impairment, and both the IC nurse and DON stated a barrier should have been used for infection control purposes.
A resident with Parkinson's disease, dementia, dysphagia, and essential tremor, who was care planned for feeding assistance and direct supervision, was observed eating alone in the dining room without staff seated at the table to assist or supervise. Staff present were either assisting others or unaware of the resident's specific needs, and there was no clear documentation accessible to CNAs regarding required meal assistance. The facility lacked a separate dining supervision policy, resulting in inadequate supervision during meals.
A resident with severe dementia, mood disturbance, anxiety, atrial fibrillation, and muscle weakness was not seen by a physician at the required 60-day interval after admission, as confirmed by record review and staff interviews. Facility policy requires physician visits every 30 days for the first 90 days, but the April visit and corresponding orders were missed.
Two residents' grievances, including concerns about rushed meals, improper positioning, and late meal service, were not documented or investigated according to facility policy. Staff interviews revealed a lack of understanding and adherence to the grievance process, resulting in these concerns not being tracked or resolved as required.
A resident with multiple medical conditions was found with unexplained bruising after being cared for by a CNA, and the facility did not follow its policy to interview other residents cared for by the same CNA as part of the abuse investigation. The DON confirmed that required interviews with like-residents were not conducted, resulting in an incomplete investigation.
A facility failed to provide adequate supervision and safety measures, resulting in harm to two residents and potential harm to another. One resident experienced multiple falls from a lift chair, leading to fractures and lacerations, without effective interventions being implemented. Another resident with severe cognitive impairment had 26 falls in a year, with inadequate root cause analyses and care plan interventions. A third resident was served inappropriate food for his diet level after losing his denture, posing a choking hazard. Staff were not adequately informed about interventions, and care plans were not robust enough to prevent further incidents.
The facility failed to provide meals at safe and appetizing temperatures, affecting all 52 residents. Multiple residents reported receiving cold meals, and test trays confirmed food was served in the temperature danger zone. The Associate Director of Food and Nutrition acknowledged the issue, noting that trays often sat on carts for extended periods, leading to cold food being served.
The facility failed to adhere to food safety and hand hygiene standards, affecting all 52 residents. Surveyors observed opened and undated items in refrigerators, unsealed items in freezers, and improper storage of food on the freezer floor. The meat slicer and mixer were found uncovered and unclean. Additionally, a CNA and a Dietary Aide were observed not performing hand hygiene before handling food, despite facility policies.
The facility inaccurately reported staffing data to CMS, showing no RN hours and insufficient licensed nursing coverage, despite schedules indicating otherwise. The issue was due to invalid data files, and the exact cause remains unknown.
The facility failed to maintain dignity for three residents with indwelling catheters by not covering their catheter drainage bags, as required by policy. Observations revealed uncovered bags in various settings, and interviews with staff indicated a lack of awareness and availability of dignity bags. The Director of Nursing confirmed the policy requirement for covering bags when residents are out of their rooms.
A resident with multiple diagnoses, including chronic pain and anxiety, did not have a comprehensive care plan addressing these issues. Despite being prescribed medications like fentanyl and lorazepam, the care plan lacked specific goals and interventions. The facility's policies require such plans to be developed with an interdisciplinary team, but this was not done, as confirmed by the DON during a survey.
A facility failed to ensure a licensed pharmacist conducted a monthly drug regimen review for a resident, as required by their policy. The last documented review was in September, with no review for October. The DON confirmed the absence of documentation and acknowledged the expectation for monthly completion.
A facility failed to monitor side effects for a resident on psychotropic medications, as staff were unaware of specific side effects to watch for. The resident, with a history of mood disorders, was prescribed Sertraline and Seroquel, but the care plan and records lacked documentation of side effect monitoring. Interviews with staff, including CNAs and a Med Tech, confirmed their lack of knowledge, and the DON acknowledged the expectation for monitoring, leading to a deficiency.
A resident received their medications two hours late, resulting in a 32% medication error rate. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not followed. The RN did not notify the provider of the late administration or document the actual time in the MAR.
The facility failed to properly label and store medications, as observed in two medication carts. One cart contained an expired bottle of Atropine 1% eye drops, while another had an unlabeled Combivent Respimat inhaler. The RNs acknowledged the deficiencies, and the DON confirmed the facility's policy on medication labeling and expiration.
A resident with specific dietary needs and preferences was not provided with food that accommodated their preferences, nor were they offered appealing options of similar nutritive value. Despite the facility's policy to respect patient food preferences, the resident was only offered limited options, and the staff failed to provide the always available menu for additional choices.
A resident with a history of falls experienced an unwitnessed fall, resulting in a head laceration and shoulder soreness. Despite ongoing complaints of shoulder pain, the facility's nursing staff failed to immediately consult with the on-call physician over the weekend, delaying the diagnosis of a probable distal clavicle fracture. The DON confirmed that the staff should have contacted the physician when the resident's pain increased.
Failure to Prevent and Monitor Pressure Injury Progression
Penalty
Summary
The facility did not implement professional standards of practice to prevent pressure injuries from developing or worsening and to promote healing for one resident with multiple risk factors, including hemiplegia/hemiparesis following a cerebral infarction, chronic kidney disease, atherosclerotic heart disease, impaired mobility, and moderate cognitive impairment. The resident’s care plan included use of a Roho cushion in the wheelchair and recliner, but staff did not ensure the cushion was properly inflated or functioning according to the manufacturer’s recommendations. The resident also had a history of impaired skin integrity and later developed a pressure injury to the left ischial tuberosity that progressed over time. The resident’s records showed inconsistent and incomplete skin monitoring after the wound developed. The facility policy required weekly skin assessments, but the record review showed the wound was not consistently tracked with the required detail, and the assessment documentation did not always include staging when the wound first appeared. The initial skin assessment on the left ischial tuberosity identified two small areas with slough and surrounding redness, with pressure/shearing listed as the possible cause, but no stage was documented. Subsequent assessments showed the wound enlarging and changing in depth and tissue characteristics, including progression to stage 3, then unstageable, with undermining and purulent drainage documented later in the course. Survey observations and interviews also identified problems with pressure relief practices. The resident was observed sitting in a Broda chair with a Hoyer sling left underneath him, and multiple staff members stated that slings were left in place under residents in Broda chairs. Staff gave differing explanations about who completed weekly skin checks, with some stating nurses did them and others stating CNAs completed them during showers. The surveyor also found that the Roho cushion was low and leaking air before being replaced by OT. The resident’s repositioning documentation showed variable frequency, and the wound continued to worsen despite the documented interventions and ongoing assessments.
Unsafe Food Storage, Sanitizing, and Meal Service Practices
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During the kitchen tour, the surveyor observed dried food drips on the outside of the oven doors, personal unmarked food in the beverage cooler, a half loaf of bread that was undated and showed visible freezer burn, burger patties that were not properly sealed in the freezer, dessert bars that were not dated or marked and were not properly closed in the bakery freezer, and trash cans in the food prep area without lids. The surveyor also observed that the test strips used to check sanitizer parts per million for the sanitizing buckets and three-compartment sink were damaged and unusable, and the Dietary Manager stated there were no other test strips in the facility at that time. During meal service, a dietary staff member tested garlic bread and then set the thermometer probe on the counter before using the same probe to test tomato sauce. When asked about cleaning the probe, the staff member stated that he normally cleaned it before inserting it into a new food but had forgotten a couple of times during meal service. He described cleaning the probe with an alcohol wipe for 3 seconds and letting it dry for 3 seconds before using it again. The surveyor noted that the probe should be allowed to dry at least 10 seconds before being reinserted into the next food item. The surveyor also observed a tray with uncovered food being taken down the hall and delivered to a resident's room. The Infection Control nurse stated that fruit and dessert cups are uncovered on trays when received from the kitchen and acknowledged that there could be a risk of airborne contamination if trays are carried down the hallway uncovered. The Dietary Manager later confirmed that she expected food to be prepared, stored, and transferred in a safe and sanitary manner.
Medication administration errors exceeded acceptable rate
Penalty
Summary
The facility did not ensure that medication error rates remained below 5 percent. Surveyors identified 11 errors out of 37 medication administration opportunities, affecting 4 of 6 residents observed during the medication pass task, for an overall error rate of 29.73%. The cited errors involved IV antibiotic administration through a PICC line, incorrect administration of an intranasal medication, improper administration of eye drops, and late administration of multiple scheduled medications. For one resident receiving Daptomycin 100 mg via PICC line, RN N administered the medication without aspirating for blood return and programmed the pump using 50 mL instead of the bag’s total volume of 70 mL. The medication was ordered to run over 30 minutes, but the pump setting did not account for the full volume in the bag. During interview, RN N stated she did not aspirate for blood return because labs had been drawn from the PICC line earlier, and she acknowledged setting the pump to the bag volume rather than the total volume. The DON stated staff should aspirate for blood return and that the pump should be set so the medication is administered according to the ordered timeframe. For another resident, MT O administered Artificial Tears without holding the resident’s eyelids open or asking the resident to do so, even though the resident’s eyes were observed to be almost completely closed. MT O stated she should hold the eyelids open unless the resident can keep the eye open independently, and the DON stated staff should hold residents’ eyelids open when administering eye drops. MT O also administered ipratropium bromide nasal spray incorrectly by giving only 1 spray in each nostril when the order required 2 sprays in each nostril. In addition, LPN I administered eight scheduled medications to another resident outside the facility’s 1-hour before/after medication window, resulting in eight timing errors. The DON confirmed that medications ordered for 8:00 AM should be given within the 1-hour window and that administration at 9:30 AM would be considered a medication error.
Failure to Notify Physician of Low Oxygen Saturation
Penalty
Summary
The facility failed to immediately notify the resident’s physician when R61 had a significant change in physical status, specifically decreased peripheral oxygen saturation on two consecutive days. R61 was admitted with chronic diastolic heart failure and atherosclerotic heart disease of the native coronary artery, and the most recent MDS showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact. On 2/13/26, R61 had an order for oxygen via concentrator at 1L-2L/min continuous to keep O2 saturation at or above 90% or for signs and symptoms of shortness of breath or dyspnea. On 2/18/26, EMAR documentation showed SPO2 readings of 83% on 3L in the morning and 87% on 3L in the evening, with no progress note documenting signs or symptoms and no documentation that the physician was notified. On 2/19/26, EMAR again documented SPO2 of 87% on 2L in both the morning and evening, with no additional charting regarding signs or symptoms or physician notification. Surveyor interviews with RN G, the DON, and the family medicine physician confirmed that the provider should have been updated when the SPO2 was below the ordered range, and RN G stated it did not appear that the provider had been notified.
Failure to Provide Needed Nail Care Assistance
Penalty
Summary
The facility failed to provide nail care assistance for one dependent resident who was unable to perform the task independently. The resident had diagnoses including anxiety disorder, depression, ischemic stroke, and contracture of the right forearm, and the most recent MDS documented a BIMS score of 15, indicating cognitive intactness. The resident’s care plan included weekly nail care on Wednesday mornings and assistance with ADLs due to impaired physical mobility and right-sided weakness related to a previous CVA. During observation, the surveyor noted moderately long fingernails on the resident’s contracted right hand, with the thumb nail poking up between the forefinger and middle finger and the nails digging into the resident’s palm. The resident stated staff needed to assist with clipping her fingernails and that staff said they would get to it when they had time, but it never seemed to happen. A CNA stated a day shift nurse normally trims the resident’s nails, while the DON stated the resident’s nails were trimmed weekly on bath day or as needed and that staff should be assisting with nail care. Despite the resident’s request and the surveyor’s observation that the nails were digging into the palm, the nails had not been trimmed at the time of the surveyor’s follow-up interview.
Failure to Implement Fall Interventions for a High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate fall interventions were in place for a resident with a known history of falls, and the resident later sustained a fall with a distal fibular fracture. The resident was admitted with diagnoses including vascular dementia with anxiety, adult failure to thrive, chronic pain, depression, and other Alzheimer’s disease. The resident’s admission Morse Fall Scale score was 90, indicating high fall risk, and the care plan identified impaired physical mobility due to dementia and a history of falls, with interventions focused on PT, pain medication, and praise for progress. At the time of admission, the resident’s care plan did not include fall interventions such as a bed alarm or low bed. The comprehensive care plan included turning schedules, and the facility later stated that the resident had last-round toileting and turn/repositioning checks. However, the resident was found on the floor after attempting to get up from bed, with the pillow at her back making her feel stuck. The resident was assisted off the floor with a Medi-lift and three people, and she complained of left hip pain, with limited assessment due to her non-specific responses and existing limitations. After the fall, the resident was sent to the ER, where imaging showed a distal fibular fracture and a splint was applied. The resident’s re-admission Morse score remained high at 75. The facility’s documentation later added a Posey alarm, low bed, two-assist Medi-lift transfers, last-round toileting, and left ankle splint and weight-bearing restrictions, but these interventions were not in place before the fall. During interview, the DON stated that the resident had a history of falls at home and weakness, but the facility had not placed an alarm or low bed on admission because staff believed the resident did not get out of bed by herself.
PICC Medication Administration Not Performed per Order
Penalty
Summary
RN N failed to follow facility policy and standard practice when administering Daptomycin through R3’s PICC line. During observation, RN N did not aspirate for blood return before starting the IV medication, and she programmed the pump to deliver 100 mg in 50 mL at 100 mL/hour rather than setting it to infuse the full 70 mL total volume in the bag over the ordered 30 minutes. The surveyor observed the infusion and reviewed the medication label, which showed the bag contained 70 mL total, leaving 20 mL not infused within the ordered timeframe. R3 was admitted with diagnoses including infection and inflammatory reaction due to an internal right knee prosthesis, urinary tract infection, and prostate cancer. His MDS showed a BIMS score of 15 out of 15, indicating he was cognitively intact, and he was receiving IV medication through central access. The physician ordered Daptomycin 100 mg to run over 30 minutes via PICC line at 0800. During interview, RN N stated she primed the line, checked the MAR, reviewed the 5 rights, set up the pump, flushed the PICC, and then administered the medication. She stated she did not aspirate for blood return because she had drawn labs from the PICC 30 minutes to 1 hour earlier, and she said she set the pump to 50 mL even though she knew the bag contained 70 mL. The DON stated staff should aspirate for blood return and that medications should be administered according to physician order. The facility’s PICC competency document also stated to aspirate for blood flow/catheter patency and reposition the arm if no blood flow was obtained.
Food Served at Unsafe Temperatures
Penalty
Summary
The facility did not ensure that each resident received food and drink that was palatable and at a safe and appetizing temperature for one sampled resident, R19. R19 told the surveyor that meals tasted terrible, that food served in the dining room was not hot, and that this had been happening a lot of the time, with meals lately being served very late. During a test tray observation, the surveyor measured several items that were not at the facility’s stated safe serving temperatures. The pork loin was 118.9 degrees Fahrenheit, peas were 128.5 degrees Fahrenheit, coffee was 119.5 degrees Fahrenheit, mixed fruit cup was 52 degrees Fahrenheit, peach cobbler was 53.8 degrees Fahrenheit, and milk was 52 degrees Fahrenheit. The rice with tomatoes and spinach measured 148.8 degrees Fahrenheit. The Dietary Manager stated that pork should be served at least 145 degrees Fahrenheit and agreed that the tray temperatures should be safe and palatable.
Failure to Use Barrier During Catheter Care
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when CNA M performed perineal and catheter care for a resident with an indwelling catheter and a history of MRSA in the urine without using a barrier on the bedside table. The resident, R41, had diagnoses including other specified disorders of the bladder, unspecified dementia, major depressive disorder, anxiety disorder, and repeated falls, and the most recent MDS documented a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident’s care plan included catheter care with morning and evening care and a history of MRSA in the urine with Enhanced Barrier Precautions intended to reduce transmission of resistant organisms to others. During observation, CNA M and CNA L performed perineal and catheter care while a basin of soapy water was placed directly on the resident’s bedside table next to several open drinks with straws. CNA M used the basin on the bedside table to complete the resident’s perineal care. In interview, CNA M stated she sometimes places a paper towel on the bedside table under the water basin to prevent splashing and agreed that it could help prevent contamination from microorganisms in the environment. The Infection Control Nurse and the DON both stated that a barrier should have been placed on the bedside table for infection control purposes.
Failure to Provide Required Dining Supervision and Assistance
Penalty
Summary
A deficiency occurred when a resident with significant medical needs, including Parkinson's disease with dyskinesia, dementia, dysphagia, and essential tremor, was not provided with the required level of supervision and assistance during mealtime. The resident's care plan specified the need for feeding assistance, direct supervision, and cuing due to worsening tremors and difficulty feeding independently. Despite these documented needs, the resident was observed eating alone in the dining room without staff seated at the table to provide supervision or assistance. Staff present in the dining area were either assisting other residents or unaware of the specific supervision requirements for this resident. Interviews with CNAs revealed a lack of clarity regarding which residents required meal assistance, with one CNA stating that such information would be found in computer charting, but not specifically in the CNA charting for this resident. The Assistant Director of Nursing confirmed that direct supervision meant a staff member should be seated at the table with the resident to assist with eating. The facility did not have a separate dining supervision policy and relied on care plans and general regulatory guidance, which led to inadequate supervision for the resident during meals.
Missed Physician Visit for Newly Admitted Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was seen by a physician at the required intervals following admission, as outlined in the facility's Physician Visits Policy. The policy mandates that newly admitted residents must be seen by a physician at least once every 30 days for the first 90 days, and then at least every 60 days thereafter. Record review and staff interviews confirmed that a resident with severe, unspecified dementia with mood disturbance and anxiety, as well as other medical conditions including persistent atrial fibrillation and generalized muscle weakness, was not seen by a physician in the month of April, resulting in a missed 60-day visit after admission. Both the Assistant Director of Nursing and the Interim Nursing Home Administrator acknowledged that the required physician visit and corresponding signed orders for that period were missed.
Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for two residents, as required by its own grievance policy and federal regulations. In the first instance, a resident's representative voiced concerns regarding the resident being rushed during meals and not being allowed to finish eating, as well as improper positioning on a shower chair. These concerns were communicated to facility staff but were not entered into the facility's grievance log, nor was there evidence of follow-up or investigation according to the facility's grievance process. Interviews with staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed that these concerns were not documented or tracked as grievances. In the second instance, another resident's representatives raised concerns during a meeting, which were documented in the resident's medical record and hospice notes. The concerns included late meal service, the need for assistance with menus, and the use of a different lift. Despite being documented, these concerns were not entered into the facility's grievance log, and there was no evidence that the facility's grievance process was followed. Multiple staff members, including hospice staff and registered nurses, indicated unfamiliarity with the grievance process or stated that they had never filled out a grievance form, further contributing to the lack of proper documentation and follow-up. The facility's policy requires that all grievances, whether verbal or written, be promptly recorded, investigated, and tracked through to resolution, with documentation retained for at least 18 months. However, interviews and record reviews revealed that staff were unclear about their responsibilities in reporting and documenting grievances, and that concerns voiced by residents or their representatives were not consistently handled according to policy. This resulted in grievances not being tracked, trended, or resolved in a timely manner, as required.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation in response to a potential allegation of abuse involving a resident with significant medical conditions, including osteoporosis, hemiplegia, and vascular dementia. The incident involved the discovery of discolored (yellow) areas on the resident's right knee and left ankle, which were reported by the resident's representative. The representative expressed concerns that improper positioning by a CNA during a shower may have caused the bruising and noted discomfort and unusual positioning of the resident after the bath. Despite facility policy requiring a comprehensive investigation of injuries of unknown origin, including interviews with other residents cared for by the implicated staff member, the facility did not interview other residents who had been under the care of the same CNA. The Director of Nursing confirmed that such interviews were not conducted, even though it was acknowledged that this step should have been part of the investigation process. The deficiency was identified through interviews and record review, which showed that the investigation was incomplete according to facility policy.
Inadequate Supervision and Safety Measures Lead to Resident Harm
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for three residents, resulting in actual harm for two residents and potential harm for another. Resident 37, who has a history of multiple falls, experienced several falls from her lift chair, leading to significant injuries, including fractures and lacerations. Despite the resident's cognitive intactness, the facility did not implement effective fall interventions, and the resident continued to have control over the recliner remote, which was a known risk factor. The facility's documentation revealed repeated incidents of falls without new interventions being implemented, and staff were not adequately informed about the interventions in place. Resident 12, with severe cognitive impairment, experienced 26 falls in the past year, one of which resulted in a fracture and laceration. The facility did not conduct thorough root cause analyses for several falls and failed to ensure appropriate interventions were included in the resident's care plan. Despite the resident's repeated self-transfer attempts and poor safety awareness, the facility's interventions were ineffective, and the care plan was not robust enough to prevent further falls. The staff were not adequately informed about the interventions, and the resident's desire for independence was not effectively managed. Resident 36, who is edentulous and wears an upper denture, was served inappropriate food for his prescribed diet level after his upper denture went missing. The facility did not update the resident's diet order to reflect the new dietary needs, leading to a choking hazard when the resident was observed eating a whole banana. The dietary department was not informed of the updated diet recommendation, and the resident's meal ticket was not updated, resulting in a failure to provide the correct diet texture to prevent health and safety hazards.
Deficiency in Serving Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and at a safe and appetizing temperature. This deficiency was identified through observations, interviews, and record reviews, affecting the entire census of 52 residents. Multiple residents reported that their meals were not served at desirable temperatures, with some meals being practically cold. For instance, one resident with moderate cognitive impairment expressed that her breakfast was cold, while another resident with intact cognition stated that his food often needed to be reheated by staff. Additionally, a resident in the dining room reported that her breakfast items were cold and difficult to eat. Test trays further confirmed the deficiency, as they were observed to be served at inappropriate temperatures. During one test, a breakfast tray contained items such as a poached egg, ham slice, and hashbrowns, all of which were in the temperature danger zone. Another test tray, served later, included items like rice with tomatoes and spinach, peas, and roast pork with gravy, which were also not at the appropriate temperatures. The Associate Director of Food and Nutrition acknowledged the issue, noting that trays often sat on carts for extended periods, leading to cold food being served. Despite the expectation for food to be served at desired temperatures, this was not consistently achieved, resulting in unpalatable meals for residents.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, potentially affecting all 52 residents. During an initial tour of the kitchen, surveyors observed several deficiencies, including opened and undated items in refrigerators and coolers, such as lettuce, breadcrumbs, grapes, cucumbers, blueberries, and milk cartons. The Associate Director of Food and Nutrition (ADFN E) was unsure if these items would be used within the next 24 hours and incorrectly believed milk was good until the expiration date on the carton. Additionally, items in the freezer, such as cakes, vegetables, and meats, were found unsealed and unmarked, which ADFN E acknowledged should be properly sealed to prevent freezer burn. Boxes of food were also improperly stored on the freezer floor, and the meat slicer and mixer were found uncovered and unclean, respectively. The facility's hand hygiene practices were also found lacking. Surveyors observed a Certified Nursing Assistant (CNA T) feeding a resident without performing hand hygiene or wearing gloves. When interviewed, CNA T admitted she should have used the wipes provided on the table before assisting the resident. A Dietary Aide (DA P) was seen picking up dirty trays and dishes and then touching bread to make toast for a resident without washing hands or performing hand hygiene. Despite DA P's claim of always performing hand hygiene, two surveyors observed otherwise. These observations indicate a failure to adhere to the facility's hand hygiene policy, which aims to prevent the transmission of microorganisms via contaminated hands of healthcare workers.
Inaccurate Staffing Data Reporting to CMS
Penalty
Summary
The facility failed to ensure accurate reporting of staffing information to the Centers for Medicare & Medicaid Services (CMS) based on payroll data, which affected the facility's staffing rating and compliance. The facility's Payroll Based Journal (PBJ) reporting for fiscal year quarter 3 of 2024 showed no Registered Nurse (RN) hours and a lack of licensed nursing coverage for 24 hours a day on multiple dates. This discrepancy was noted despite the facility's staffing postings and nursing schedules indicating that there was at least 8 hours of RN coverage and 24-hour licensed nursing coverage each day. The Nurse Scheduler (NS L) and the Director of Nursing (DON B) were interviewed, revealing that the process for gathering and transmitting data had not changed for the months in question. NS L indicated that CMS was contacted when the error was noted, and it was discovered that the data file received by CMS was invalid. DON B suggested that the data might have been encrypted or sent in the wrong file type, but the exact cause of the issue was still unknown. The facility was working on processes to ensure proper reporting in the future.
Failure to Maintain Dignity for Residents with Catheters
Penalty
Summary
The facility failed to ensure that three residents with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and maintain their dignity. Residents were observed with their catheter drainage bags uncovered, which is against the facility's policy that promotes dignity and respect. Resident 16, who has multiple diagnoses including Parkinson's Disease and type 2 diabetes, was observed multiple times with an uncovered catheter bag, both in his room and in the hallway. Despite expressing a preference for the bag to be covered, it was often left uncovered. Interviews with CNAs revealed a lack of awareness and availability of dignity bags, contributing to the deficiency. Resident 26, admitted with a Foley catheter for wound healing, was observed with an uncovered urinary drainage bag visible from the hallway. Similarly, Resident 41, admitted with a Foley catheter for urinary retention, was observed with an uncovered drainage bag, although it was later covered during a subsequent observation. The Director of Nursing confirmed that the facility's policy requires catheter bags to be covered when residents are out of their rooms, indicating a failure to adhere to this policy consistently.
Failure to Develop Comprehensive Care Plan for Pain and Anxiety
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident, identified as R26, who was reviewed for care plans. R26's care plan did not include a problem, goal, and interventions for managing pain or anxiety, despite the resident having multiple diagnoses that necessitate such considerations. These diagnoses included major depressive disorder, chronic pain, and osteoarthritis, among others. The resident was prescribed several medications for pain management, including hydrocodone-acetaminophen and fentanyl, as well as lorazepam for anxiety. However, the care plan lacked specific and individualized instructions for staff to follow regarding these issues. The facility's policies on Psychotropic Medication Use/Chemical Restraints and Comprehensive Person-Centered Care Planning emphasize the need for care plans to be developed with the assistance of an interdisciplinary team and to include specific goals and interventions. During an interview, the Director of Nursing (DON) confirmed that residents receiving medications like fentanyl and lorazepam should have corresponding care plans addressing pain and anxiety, which R26 did not have. This oversight was identified during a survey, highlighting a deficiency in the facility's adherence to its own care planning policies.
Failure to Conduct Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for a resident, identified as R26, as required by their policy. The facility's policy mandates that a consultant pharmacist must analyze each resident's medical chart, medication administration record, and pharmacy software monthly to prevent and resolve medication-related issues. However, for the month of October 2024, there was no documentation to confirm that R26's medication regimen was reviewed by a pharmacist, despite the policy's requirement for such reviews to be completed by the end of each calendar month. During an interview, the Director of Nursing (DON B) confirmed that the reviews are typically documented in the resident's hard chart on the Medication Regimen Review form. Upon being informed of the missing documentation for October 2024, DON B acknowledged the absence of the review and stated that she would have expected it to be completed. This oversight was identified during a survey, which revealed that the last documented review for R26 occurred on September 26, 2024, with no subsequent review for the following month.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was free from unnecessary medications, as evidenced by the lack of monitoring for side effects of antidepressant and antipsychotic medications. The resident, who was cognitively intact and had a history of mood disorders, was prescribed Sertraline and Seroquel for depression and psychosis, respectively. However, the facility did not document any monitoring of side effects in the resident's care plan, medication administration record, or mood and behavior monitoring records. Interviews with facility staff, including CNAs and a Med Tech, revealed that they were unaware of the specific side effects to monitor for the resident's medications. The Director of Nursing acknowledged that staff were expected to monitor for side effects, but the care plan and documentation did not specify what side effects to monitor. This lack of documentation and staff awareness led to the deficiency in ensuring the resident was free from unnecessary medications.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 32% error rate during a survey. This was observed when a resident received their scheduled 8:00 AM medications at 10:02 AM, which included Systane eye drops, Senna, Vitamin C, Miralax, Calcium + Vitamin D, and Eliquis. The facility's policy requires medications to be administered within one hour before or after the scheduled time, which was not adhered to in this instance. During interviews, both the RN involved and the Director of Nursing confirmed the policy of administering medications within the specified time frame. However, the RN did not notify the resident's provider about the late administration, nor was the actual administration time documented in the Medication Administration Record (MAR), as required by the facility's policy. This oversight contributed to the high medication error rate identified during the survey.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as observed in two medication carts. On Swan hall, a medication cart contained an expired bottle of Atropine 1% eye drops for a resident, with an expiration date of 11/3/24. During an interview, the RN acknowledged that expired medications should not remain on the cart and subsequently removed the expired eye drops. On Monarch hall, a medication cart was found to contain a Combivent Respimat inhaler that was neither labeled nor dated, lacking a resident name or room number. The RN present during the observation was unable to identify the resident to whom the inhaler belonged, acknowledging that it should have been labeled. The Director of Nursing confirmed that medications should be dated when opened, labeled with a resident's name, and removed once expired.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodates a resident's preferences and did not offer appealing options of similar nutritive value. The resident, who has a history of dysphagia, cerebral infarction, diabetes mellitus type 2, and vascular dementia, was on a Level 6 diet according to the International Dysphagia Diet Standardization Initiative (IDDSI). Despite the resident's dietary needs and preferences, the facility did not adhere to its policy of respecting patient food preferences and making appropriate dietary substitutions. On a specific occasion, the resident was not served the menu items of their preference and was not offered appealing alternatives. The resident was only offered mashed potatoes and gravy, which they accepted, but declined shepherd's pie and was not provided with any other main meal or protein options. The Director of Nursing confirmed that staff should have offered the always available menu for additional options, which was not done in this case.
Failure to Notify Physician of Resident's Increased Pain After Fall
Penalty
Summary
The facility failed to immediately consult with a physician when there was a need to alter treatment for a resident who experienced an unwitnessed fall. The resident, who had a history of falls and was cognitively intact, fell while attempting to stand from a recliner. The fall resulted in a large laceration to the right side of the head and soreness in the right shoulder. Although the resident was transported to the emergency room for evaluation, the shoulder was not x-rayed, and the resident continued to experience pain in the shoulder in the days following the fall. Despite the resident's ongoing complaints of shoulder pain, the facility's nursing staff did not contact the on-call physician over the weekend following the fall. Instead, they sent faxes to the nurse practitioner, which did not result in immediate action. It was not until several days later that an x-ray was ordered, revealing a probable distal clavicle fracture. The Director of Nursing confirmed that the nursing staff should have called the on-call physician when the resident experienced increased pain over the weekend after the fall.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 129 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beaver Dam
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaver Dam Health Care Center | 0.2 mi | ★★★★★ | 23 | 2 |
| Clearview | 8.1 mi | ★★★★★ | 0 | 0 |
| Clearview Brain Injury Center | 8.1 mi | ★★★★★ | 4 | 0 |
| Randolph Health Services | 10.8 mi | ★★★★★ | 11 | 0 |
| Columbus Health And Rehab | 12.9 mi | ★★★★★ | 11 | 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.