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 Lafayette Manor during CMS and state inspections, most recent first.
Failure to Investigate Falls and Maintain Effective Fall Prevention Measures: The facility did not adequately investigate or monitor falls for three residents with cognitive impairment and fall risk. One resident with dementia and prior falls reported an unwitnessed fall that was not treated as an actual fall, with no fall report, neuro checks, or new interventions, and later sustained a rib fracture after another fall. A second resident’s fall had limited neuro documentation and no ongoing monitoring. A third resident’s unwitnessed fall in the dining room resulted in a head injury, but the fall was not thoroughly investigated and no new interventions were put in place.
Infection surveillance did not track specific symptoms on staff line lists. Record review showed staff call-ins documented only vague complaints such as sick, not feeling well, don't feel well, and flu-like symptoms, rather than specific signs and symptoms. The IP and NHA both agreed that specific symptoms were needed to identify illness and determine return-to-work dates.
Bed rails and grab bars were used for multiple residents without the required assessment, informed consent, physician orders, risk-versus-benefit review, or care planning. Surveyors observed residents with side rails or grab bars in place, including a resident with severe cognitive impairment and an air mattress, and staff interviews confirmed missing documentation, lack of entrapment measurements, and no evidence that alternatives had been tried before installation.
A resident with Type 2 DM and epilepsy, and moderate cognitive impairment per BIMS, was transferred to the ER twice for confusion and swallowing-related symptoms. The facility did not provide the required written bed hold notice to the resident or representative at either transfer, and the NHA confirmed the notices were not in the record and were not given.
A resident with Huntington's Disease, severe cognitive impairment, and total ADL dependence was assessed as a fall risk, but the comprehensive care plan did not include a fall-risk focus, goal, or interventions. A nursing note documented the resident was restless and found with both legs over the edge of the bed, and staff interviews confirmed that fall risk should be included in the care plan with person-centered interventions.
A resident with PTSD had a documented trauma history and identified triggers, but the facility did not complete a trauma-informed care assessment or include PTSD, triggers, or resident-specific interventions on the care plan or CNA Kardex. CNAs, an LPN, and the SW were unaware of the resident’s PTSD and triggers, and the SW stated the facility typically does not complete trauma-informed care assessments.
The facility did not have an effective antibiotic stewardship program with protocols and monitoring for antibiotic use. One resident received Cephalexin for UTI prophylaxis without documented stewardship discussion with the provider, another was treated for a UTI without a completed sensitivity, and a third was given Ciprofloxacin even though the culture sensitivities did not show it was appropriate.
Care plans were not accurately reviewed and revised for multiple residents. A resident with dementia had outdated fall interventions listed, did not have current wheelchair safety measures reflected, and had fall care plans that were not updated after falls. Another resident had abuse-related safety interventions in place, but they were not added to the care plan, and his fall care plan was also not revised after a fall. A third resident’s care plan omitted an order for Prevalon boots at all times and listed ambulation assistance even though therapy and the DON stated he did not ambulate.
Two CMAs were found to have access to keys for the locked narcotic box and medication storage room, contrary to facility policy and their job descriptions, which prohibit them from handling or administering narcotics. Both CMAs confirmed they held the keys and participated in narcotic count verifications, while nursing staff and administration confirmed that only nurses are authorized to access and dispense narcotic medications.
Staff failed to immediately report two resident-to-resident altercations, including verbal threats and aggressive behavior, to both the administrator and the State Survey Agency as required by policy. An LPN documented the incidents but only reported one to the administrator, and neither was reported to the State Agency. Both the LPN and administrator later acknowledged that these events should have been reported as allegations of abuse.
Staff failed to investigate documented resident-to-resident altercations involving two residents, despite facility policy requiring immediate investigation of suspected abuse. An LPN recorded incidents where a resident yelled, threw an object, and made threats toward others, but no follow-up investigation was performed.
A resident with a high risk for pressure ulcers did not receive necessary treatment and services, leading to a deficiency in care. The facility failed to implement and document interventions, such as pressure-relieving devices and consistent wound care, resulting in the resident's pressure injury worsening. The lack of communication and coordination among staff, along with an environmental emergency, further contributed to the deficiency.
A resident in hospice care, suffering from serious medical conditions, was subjected to abuse by a CNA who ignored the resident's requests to stop care, causing pain and distress. Despite the presence of other staff, no intervention occurred. The facility's policies on abuse prevention were not effectively implemented, and the incident was not reported to the state agency in a timely manner.
The facility did not adhere to professional standards for food service safety, affecting all residents. Observations included improperly dated food items, a staff member without a hairnet in the kitchen, and a scoop stored inside a sugar container, raising concerns about cross-contamination and infection control.
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) system, as required by their policy, to identify and address quality deficiencies. The Nursing Home Administrator admitted to conducting only one QAPI meeting since October and confirmed that no Performance Improvement Projects (PIPs) were in place, citing leadership changes as a barrier. This deficiency potentially affects all 39 residents.
The facility's QAA Committee did not include the required members, specifically the Infection Preventionist (IP), in any of the quarterly meetings over the past year. The Nursing Home Administrator was unaware of the IP's required attendance, despite the facility's policy stating otherwise. This deficiency could potentially impact all 39 residents in the facility.
The facility failed to establish an effective infection prevention and control program, with surveyors observing water dripping near residents during meals and a lack of tracking for MDROs. The facility's infection rates were not segregated by type, hindering trend identification. Additionally, the facility lacked a comprehensive water management program, missing key documentation on the building's water system and control measures.
The facility failed to properly label and store medications, as observed in two medication carts and storage rooms. An undated insulin pen, expired morphine tablets, and improperly dated cough syrup were found. Staff interviews revealed inconsistencies in understanding medication expiration protocols, with the DON and NHA acknowledging the responsibility of nurses and pharmacy audits in checking expiration dates.
Two residents experienced issues with weight monitoring and physician notification. One resident had weights recorded using different methods, leading to unclear accuracy, and the physician was not updated on weight changes. Another resident experienced a significant weight loss without physician notification, and there was no documentation of nutritional supplement trials. Interviews revealed inconsistencies in weighing methods and a lack of clear guidelines for notifying physicians about weight changes.
A resident with eczema did not receive a scheduled dose of Dupilumab due to a failure in the facility's pharmaceutical services. The medication was not administered on the scheduled date, and the oversight was not reported or addressed by the staff. The resident's condition worsened, and the issue was not resolved despite being raised by the resident's POAHC.
The facility failed to ensure appropriate use and monitoring of psychotropic medications for two residents. One resident was given Quetiapine without proper diagnosis or monitoring for agitation or aggression, while another resident's care plan lacked documentation on side effects to monitor for their medications. Staff interviews revealed a lack of knowledge about specific side effects, and the facility's policy on psychotropic medication use was not followed.
A resident under hospice care, diagnosed with malignant neoplasm and intracranial hemorrhage, reported pain during care by a CNA who continued despite the resident's request to stop. The facility failed to report the abuse allegation to the State Agency within the required two-hour timeframe, as the report was made several hours later. The Nursing Home Administrator confirmed the delay, acknowledging the breach of the facility's policy on immediate reporting.
A facility failed to thoroughly investigate an abuse allegation involving a resident under hospice care, who reported pain during care by a CNA. The investigation was incomplete, lacking necessary steps such as skin assessments for nonverbal residents and staff education on abuse. Interviews revealed other residents felt unsafe with the CNA, but the facility did not document all conversations or ensure adequate resident protection.
Three residents experienced multiple falls due to inadequate supervision and lack of individualized interventions. A resident with severe cognitive impairment fell without a root cause analysis or new interventions. Another resident with brain cancer and seizures had multiple falls without documented interventions or analysis. A third resident with dementia fell due to a slippery fall mat, with no documented interventions or analysis.
The facility failed to report allegations of abuse and neglect involving three residents. One resident's sexual abuse allegation was not reported to law enforcement, while another's report of rough handling by a CNA was not communicated to the State Agency or law enforcement. Additionally, a resident left unsupervised in the tub was not reported as neglect. Interviews with the Social Service Director and Director of Nursing confirmed these incidents should have been reported.
The facility failed to investigate allegations of abuse and neglect involving two residents. One resident reported rough handling by a CNA, and another reported inattentive supervision during bathing, posing a risk of slipping. Despite these reports, the facility did not conduct necessary investigations or interviews with staff and residents, as acknowledged by the SSD and DON.
Failure to Investigate Falls and Maintain Effective Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for three residents reviewed for falls. The deficiency was based on observation, interview, and record review showing that fall events were not thoroughly investigated, root causes were not identified, and interventions were not consistently implemented or monitored after the falls. The facility policy required hazard identification, evaluation and analysis of risks, implementation of interventions, and monitoring for effectiveness, and its fall procedure required immediate assessment, neuro checks for unwitnessed falls or head injuries, notification of the charge nurse, DON, NHA, provider, and documentation of the fall and follow-up care. R8 had dementia, moderate cognitive impairment, and a history of falls with a fall risk score of 24. His care plan included interventions such as keeping the bed in the lowest position, using a call light, and using alarms and a floor mat while in bed. A nurse progress note documented that R8 reported he had missed sitting back down in his wheelchair after going to the bathroom and sat on the floor during the night, but the medical record did not contain a fall report for that event, neuro checks were not completed, and no root cause analysis or new intervention was put in place. Later, R8 was found on the floor in his room and was noted to have right rib pain and abrasions; he was sent to the ER and was diagnosed with a right rib fracture. Observation showed his bed was not in the lowest position and there was no floor mat or alarm in place, despite those interventions being listed on his CNA Kardex. R42 had dementia, mild cognitive impairment, muscle weakness, and a fall risk score of 15. After he was found sitting on the floor propped against the bed, the record showed one set of neuro checks and a note that he was educated on call light use, but continued monitoring after the fall was not documented. The DON stated the fall was not thoroughly investigated, no root cause was completed, no new interventions were put into place, and continued monitoring was not completed. R44 had severe cognitive impairment, dementia, anxiety, and a history of bilateral femur fractures with a fall risk score of 10. After an unwitnessed fall in the dining room, she was found on the floor holding her head with an egg-sized knot to the left upper forehead, and EMS and the ER were notified. The record did not show a thorough root cause investigation or new interventions after the fall, and the DON stated that no root cause was completed and no new interventions were put into place.
Infection Surveillance Did Not Track Specific Symptoms
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The deficiency was identified through interview and record review and was based on the facility’s infection surveillance policy, which states that surveillance is a core activity of the infection prevention and control program and that the facility will collect data to identify possible communicable diseases or infections by tracking signs and symptoms. Record review showed that the facility’s staff surveillance line lists for January, February, and March 2026 documented vague symptoms rather than specific signs and symptoms. The January line list included four staff call-ins with symptoms recorded as not feeling well, sick, and not feeling good. The February line list showed three staff call-ins with symptoms recorded as not feeling well and sick. The March line list showed three staff call-ins with symptoms recorded as feeling sick, sick, don't feel well, and flu-like symptoms. During interview, the Infection Preventionist stated that the facility should be tracking specific symptoms on the staff and resident surveillance lists and agreed that vague symptoms were not specific enough to determine illness or return-to-work dates. The Nursing Home Administrator also agreed that specific symptoms were needed to track illnesses and determine return-to-work dates for staff.
Bed Rails and Grab Bars Used Without Required Assessment, Consent, or Care Planning
Penalty
Summary
The facility failed to ensure proper assessment, consent, physician orders, care planning, and installation/monitoring of bed rails or grab bars for multiple residents. The report states that the facility did not ensure alternatives were tried before bed rails were installed or used, did not accurately assess entrapment risk, did not obtain informed consent, did not obtain physician orders, did not care plan the use of the bed rails, did not document risk-versus-benefit discussions, did not measure gaps between the mattress and bed rails, and did not ensure bed dimensions were appropriate for the resident's size and weight for 9 of 14 residents reviewed for bed rails. For R30, who had Huntington's Disease, severe cognitive impairment, total dependence for ADLs, and a fall risk assessment, the record lacked physician orders, entrapment assessment, risk-versus-benefit documentation, evidence of alternatives tried, ongoing monitoring, manufacturer guideline adherence, and care plan inclusion for the bed rails. Surveyor observation found R30 in bed with side rails and an air mattress, and staff interviews confirmed the gap between the mattress and rail measured 2 1/4 inches on one side. Staff stated the gap was large enough for an arm to fit between the mattress and rail, and multiple staff acknowledged the possibility of entrapment. The legal guardian stated he thought verbal consent had been given to hospice, but there was nothing in writing and he had not been educated on risks and benefits. Similar deficiencies were identified for R2 and R27, both of whom had bed rails in use without physician orders, entrapment measurements, risk-versus-benefit documentation, evidence of alternatives, manufacturer guideline adherence, ongoing monitoring, or care plan inclusion. R2 had diagnoses including stroke-related hemiplegia/hemiparesis, dysphagia, COPD, diabetes, morbid obesity, schizoaffective disorder, anxiety, epilepsy, muscle spasm, and insomnia, with moderate cognitive impairment and total dependence for ADLs. R27 was cognitively intact but had a bed rail assessment noting a history of falls and poor bed mobility; however, the record still lacked physician orders, consent, risk-versus-benefit documentation, and care planning, and R27 stated she never signed consent or received education on the risks and benefits of side rails. The report also identified grab bars on the beds of R6, R8, R42, R44, R17, and R5 without the required assessment, alternatives, risk-versus-benefit review, consent, or care planning. R6 had diagnoses including metabolic encephalopathy, abnormal posture, and dementia, with recent falls documented in progress notes. R17 had hemiparesis, hemiplegia, and blindness, and the facility had a signed risks-and-benefits form from 2022 but could not find an assessment or care plan. R5 was on hospice with colon cancer, and the facility could not find an assessment or risk-and-benefit documentation for the grab bars. Staff interviews showed the facility's process relied on nursing or therapy requests and maintenance installation, but staff could not consistently produce documentation showing the required assessments, consent, or monitoring had been completed.
Failure to Provide Bed Hold Notices at Hospital Transfer
Penalty
Summary
The facility did not provide the required written bed hold notice information for one resident, R4, when the resident was transferred to the emergency room on 10/28/25 and again on 11/19/25. Survey review found no evidence in the medical record that R4 or the resident representative received the bed hold notice at the time of either hospitalization transfer, and the Nursing Home Administrator confirmed the facility did not have the bed hold notice for either event. R4 was admitted to the facility with diagnoses including Type 2 Diabetes Mellitus and epilepsy. The quarterly MDS dated 1/10/26 showed a BIMS score of 12, indicating moderate cognitive impairment. Hospital discharge documentation showed that R4 was sent to the ER with confusion and difficulty swallowing on one occasion, and with confusion, slurred speech, and difficulty swallowing on the other occasion. During interview on 3/25/26, the Nursing Home Administrator stated that nurses on the floor were responsible for providing bed hold notices at the time of transfers and confirmed the notices were not provided to R4 at either transfer.
Comprehensive Care Plan Missing Fall Risk Focus
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for one resident, R30, to address fall risk and include measurable objectives, timeframes, goals, or interventions. R30 was admitted with diagnoses including Huntington's Disease, Major Depressive Disorder, Anxiety Disorder, and Insomnia, had a BIMS score of 2 out of 15 indicating severe cognitive impairment, and was totally dependent on staff for all ADLs, including eating, toileting hygiene, bathing, dressing, transferring, and rolling in bed. R30 was assessed on 2/4/25 to be at risk for falls, and a nursing progress note on 7/15/25 documented that the resident was very restless and was found with both legs over the edge of the bed while the torso remained on the bed, after which the resident was repositioned and staff were told to monitor for safety. Review of the comprehensive care plan showed no focus, goal, or interventions for fall risk. During interviews, CNA E, CNA K, the Infection Prevention Nurse, and the Nursing Home Administrator each stated that a resident assessed as a fall risk should have fall-related care plan interventions and that care plans should reflect resident needs, goals, preferences, and person-centered interventions.
Missing Trauma-Informed Care Assessment and Care Planning for Resident with PTSD
Penalty
Summary
The facility did not ensure that 1 of 1 resident with PTSD, R7, received culturally competent, trauma-informed care in accordance with professional standards of practice and the resident’s experiences and preferences. R7 was admitted with diagnoses including PTSD and had a social history documenting significant traumatic events, including a fall from a second-story banister with multiple surgeries and a later seizure that revealed a large brain tumor, followed by several brain operations, chemotherapy, and radiation. The social history also identified bright and blinking lights as a potential trigger because they can set off seizures. Survey review found no trauma-informed care assessment in the medical record. Survey review also found no care plan focus areas or CNA Kardex entries addressing PTSD, R7’s triggers, or resident-specific interventions. During interviews, CNA L, CNA M, and LPN N each stated they were not aware of R7’s PTSD or PTSD triggers. The SW stated she was not aware of the PTSD diagnosis, had not completed a Trauma Informed Care Assessment on admission, and indicated the facility typically does not complete such assessments. The SW also confirmed that PTSD and triggers were not on R7’s care plan or CNA Kardex.
Failure to Monitor Antibiotic Use and Review Appropriateness
Penalty
Summary
The facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 3 of 5 residents reviewed for antibiotic stewardship. The facility policy stated that antibiotic use protocols should include laboratory testing in accordance with current standards of practice and that antibiotic orders from consulting, specialty, or emergency providers should be reviewed for appropriateness. During interview, the Infection Preventionist stated that prophylactic antibiotic treatment was not appropriate and that there was no documentation of a conversation with the physician regarding antibiotic stewardship for a resident who was receiving Cephalexin 250 mg twice daily for UTI prophylaxis. The resident’s records showed Cephalexin was ordered for prevention of UTI and administered across multiple months. A second resident had a positive urinalysis and urine culture showing Aerococcus urinae greater than 100,000 CFU/mL, but no sensitivity was completed to identify which antibiotics would be effective. The resident received Nitrofurantoin and then Levaquin, and the Infection Preventionist stated the resident should not have been treated with those antibiotics without a sensitivity. A third resident’s urine culture showed Enterococcus faecium, vancomycin-resistant, and Aerococcus urinae greater than 100,000 CFU/mL, with sensitivities showing susceptibility to Daptomycin, Linezolid, Nitrofurantoin, and Tigecycline. The resident was treated with Ciprofloxacin for UTI even though Ciprofloxacin was not listed as susceptible, and the Infection Preventionist stated Ciprofloxacin should not have been used.
Care plans were not updated to reflect current safety and fall interventions
Penalty
Summary
The facility did not ensure that comprehensive care plans were reviewed and revised for 3 of 14 residents identified in the report. The facility policy required comprehensive, person-centered care plans with resident-specific interventions, and the accident/supervision policy required monitoring, evaluation, and modification of interventions when needed. Survey findings showed that the care plans for R8, R42, and R1 did not accurately reflect current interventions or resident needs as documented in records and interviews. R8, who had dementia and moderate cognitive impairment, had care plan interventions for a low bed, floor mat, tab and/or pressure alarms, and assistive devices, but the care plan did not reflect antiroll back brakes on the wheelchair or the fact that the listed interventions were no longer appropriate. CNA H stated R8 did not use those interventions and that the floor mat and low bed could increase fall risk. R8 had falls on 9/4/25 and 9/9/25, but the fall care plan was not revised after those events. DON B acknowledged the care plan was not accurate and was not revised as it should have been. R42, who had muscle weakness, dementia, and mild cognitive impairment, had safety interventions implemented after an abuse investigation, including a motion sensor at the bedroom door and staff education not to place him next to female residents when out of his room. CNA F and RN G confirmed those interventions were in use, but they were not included in the comprehensive care plan. R42 also had a fall on 12/2/25, and the fall care plan was not revised after the fall. For R1, who had central spinal cord syndrome and muscle weakness, the admission orders included Prevalon boots at all times for pressure relief, but the order was not added to the care plan or CNA Kardex. R1’s care plan also stated he required assistance with ambulation, although therapy and the DON stated he did not ambulate and therapy had never recommended ambulation.
Unauthorized Access to Narcotic Keys by Medication Aides
Penalty
Summary
The facility failed to ensure that only authorized staff had access to the keys for the locked narcotic box and medication storage room. Observations showed that two Certified Medication Aides (CMAs) were in possession of the keys to the medication cart and the locked narcotic box, despite facility policy and their job descriptions explicitly stating that CMAs are not permitted to pass or access narcotic medications. Both CMAs confirmed during interviews that they held the keys during their shifts and participated in verifying narcotic counts with the narcotic binder, although they stated they did not administer narcotics to residents. Interviews with nursing staff, including an LPN and an RN, confirmed that only nurses are allowed to dispense narcotic medications. Review of facility policies indicated that the responsibility for the keys to Schedule II medication storage areas lies solely with nurses, and access to these keys should be limited to those who require them. The Administrator and Director of Nursing acknowledged that the CMAs should not have had access to the narcotic box keys, confirming this was contrary to facility policy. No information was provided regarding any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency as required by facility policy and state law. Specifically, staff documented two resident-to-resident altercations involving two residents, but these incidents were not reported to the State Agency, and one was not reported to the administrator. The facility's abuse prohibition policy requires immediate reporting of such allegations, but this procedure was not followed in these cases. Documentation showed that after supper, one resident exhibited aggressive behaviors, including yelling at another resident and throwing an object in their direction. The same resident also threatened another by slamming her walker into a chair and making a verbal threat. The LPN who documented the events reported only one of the incidents to the administrator and was uncertain about reporting the other. During interviews, both the LPN and the administrator acknowledged that these events should have been reported as allegations of abuse to both the administrator and the State Agency, but this did not occur.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for two of five residents reviewed. Staff documented observations of resident-to-resident altercations involving two residents on the same date, but there was no indication that these incidents were investigated by the facility as required by their abuse prohibition policy. The policy mandates immediate investigation when there is suspicion or report of abuse, neglect, or exploitation. Surveyors reviewed a progress note authored by an LPN, which described an incident where one resident yelled profanities at another, threw a wander guard in the direction of a resident, and later slammed a walker into a chair while making a threatening statement to a different resident. During an interview, the Nursing Home Administrator confirmed that these events should have been investigated as allegations of abuse, but no investigation was conducted.
Deficiency in Pressure Ulcer Care for a Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, leading to a deficiency in care. The resident, who was admitted with a stage 2 pressure injury on her left elbow and had a high risk for pressure ulcer development, did not receive appropriate interventions to manage and heal her pressure injuries. The facility's policy required a care plan with measurable goals and interventions, but these were not effectively implemented or communicated to the staff. The resident's care plan included interventions such as evaluating skin for redness, monitoring ulcer characteristics, and providing wound care per treatment order. However, the facility did not transcribe or carry out orders effectively, and there was no guidance for CNAs on managing the resident's pressure injuries. The resident's nutritional orders included protein supplements for wound healing, but there was no documentation of consistent application of these interventions. Additionally, the facility did not provide a specialty pressure-relieving mattress or any pressure-relieving devices, and the resident's foot was observed directly on the mattress during treatment. The facility's failure to implement and document necessary interventions resulted in the resident's pressure injury worsening, with signs of infection and tunneling. The facility did not document the application of border foam dressing or the Santyl treatment consistently, and there was a lack of communication and coordination among staff regarding the resident's care. The deficiency was further compounded by an environmental emergency that required the transfer of residents to other facilities, during which time the resident's treatments were not documented. The facility's inaction and lack of proper documentation and communication led to the deficiency in pressure ulcer care.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was in pain and discomfort during care provided by CNA D. Despite the resident's repeated requests to stop, CNA D continued with the care, causing the resident to scream in pain. Other staff members, including CNAs and an LPN, were present and overheard the resident's distress but did not intervene to stop the abuse. The resident, who had been admitted to the facility with serious medical conditions including a malignant neoplasm and nontraumatic intracranial hemorrhage, was under hospice care at the time of the incident. The resident had expressed a preference for a male caregiver and had refused care from female staff members, including the administration of medications and changes to his brief. Despite this, CNA D proceeded with the care against the resident's wishes, using dismissive language and ignoring the resident's cries of pain. Interviews with other residents revealed that CNA D had a history of disregarding residents' wishes and making them feel unsafe. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the lack of intervention from other staff members and the failure to educate all staff on abuse prevention following the incident. The facility's response to the incident, including the timing of the report to the state agency, was also inadequate.
Removal Plan
- Care Plan for R40 updated to address pain management: Breathing, Stress Balls during Care, Medications for Pain scheduled instead of PRN
- Discussion between CNA D and Interim NHA A related to resident rights and customer service
- Inservice for all staff on Resident rights/self-determination
- Continue touch bases with R40 to determine if needs are being met
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all 39 residents. During an inspection, several deficiencies were observed in the kitchen's dry storage and main refrigerator. Unopened pasta bags and canned goods lacked use-by dates, while a container of sunflower seeds was past its use-by date. Additionally, thawed nutritional supplements had no thaw dates, contrary to manufacturer guidelines. Furthermore, a staff member entered the kitchen without a hairnet, and a scoop was improperly stored inside a sugar container, raising concerns about cross-contamination and infection control.
Lack of QAPI System and PIPs in Facility
Penalty
Summary
The facility failed to establish and maintain a Quality Assurance and Performance Improvement (QAPI) system, which is necessary for identifying and addressing quality deficiencies. The facility's policy, dated 1/1/24, mandates the development and implementation of a comprehensive, data-driven QAPI program that focuses on care outcomes and quality of life. However, upon review, there was no evidence of a Performance Improvement Project (PIP) in place to enhance the quality of care for the residents. This deficiency has the potential to affect all 39 residents in the facility. During an interview, the Nursing Home Administrator (NHA) admitted to having conducted only one QAPI meeting since assuming the role in October and acknowledged that the facility was not currently working on any PIPs. The NHA recognized the necessity of having at least one PIP annually to ensure quality care but cited leadership changes as a barrier to prioritizing the QAPI plan and initiatives. The lack of a structured QAPI process and the absence of ongoing PIPs indicate a failure to follow the facility's QAPI plan, which is crucial for identifying and addressing problem areas to ensure resident care quality.
Deficiency in QAA Committee Composition and Meeting Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required members and did not meet the quarterly meeting requirements. The QAA Committee was supposed to include the Director of Nursing Services, the Medical Director or their designee, at least three other staff members including the Administrator, Owner, or a Board Member, and the Infection Preventionist (IP). However, the review of the QAPI Committee meeting sign-in sheets revealed that the IP was absent from all meetings in the past year, and the Administrator was absent from one meeting. During an interview, the Nursing Home Administrator (NHA) was unaware that the IP needed to attend the QAPI meetings, as infection control topics were presented by the Director of Nursing (DON). The facility's policy, however, clearly stated the requirement for the IP's attendance. This oversight in the composition of the QAA Committee has the potential to affect all 39 residents residing within the facility.
Inadequate Infection Control and Water Management Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by several deficiencies identified during the survey. Surveyors observed missing ceiling tiles with water actively dripping from a pipe into a container near residents during the lunch meal, which posed a potential infection control issue. The Nursing Home Administrator (NHA) acknowledged the situation and agreed that residents should have been seated elsewhere to avoid exposure to the dripping water. Additionally, the facility lacked a mechanism for tracking Multi-Drug Resistant Organisms (MDROs). Although the NHA and the Infection Preventionist (IP) were aware of which residents had MDROs, they did not have a formal tracking system accessible to others. Furthermore, the facility's monthly infection control rates were not segregated by specific infection types, making it difficult to identify trends or increases in certain infections. The NHA admitted that without segregated rates, they could not ascertain increases in specific infection types. The facility also failed to provide evidence of a comprehensive water management program. The surveyor was unable to locate descriptions of the building water system, identification of areas where Legionella and other pathogens could grow, or descriptions of control measures and monitoring processes. The NHA acknowledged that these elements should have been included in the water management program and indicated that they would check with maintenance to locate the necessary documentation.
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 and two medication storage rooms. On the 2nd floor, an undated open insulin pen for a resident and expired morphine tablets for another resident were found. The 3rd floor medication cart contained a cough syrup with no open or expiration date. Additionally, both the 2nd and 3rd floor medication storage rooms contained expired stock medications, such as Thiamin Vitamin B1, Super View Healthy Eyes vitamins, Paxlovid, and acetaminophen suppositories. Interviews with staff revealed inconsistencies in the understanding of medication expiration and labeling protocols. LPN I indicated that medications were considered good for 30 days after opening, while RN H stated they were good for 28 days. The Director of Nursing acknowledged that insulin pens should be dated upon first use, and the Nursing Home Administrator confirmed that nurses were responsible for checking expiration dates, with the pharmacy conducting audits every three months. However, discrepancies in labeling and storage practices were evident, leading to the observed deficiencies.
Inconsistent Weight Monitoring and Lack of Physician Notification
Penalty
Summary
The facility failed to ensure that two residents, R35 and R17, maintained acceptable parameters of nutritional status. For R35, weights were obtained using different methods, leading to unclear accuracy. The facility did not update R35's physician on weight gain or loss based on these weights. The facility's policy on weight monitoring was not consistently followed, as there was no documentation of re-weights or provider notifications for significant weight changes. Interviews with staff revealed inconsistencies in weighing methods and a lack of clear guidelines for notifying physicians about weight changes. R17 experienced a significant weight loss of 21 pounds, yet the physician was not informed, and there was no documentation of trialing supplements with R17. The facility's dietician noted changes in R17's nutritional supplements, but there was no tracking of supplement consumption or documentation of a trial of Magic Cup supplements. Interviews with the Dietary Manager and Nursing Home Administrator indicated a lack of communication and documentation regarding R17's nutritional interventions and weight changes. The facility's failure to maintain consistent weighing methods and notify physicians of significant weight changes contributed to the deficiency. The lack of documentation and communication regarding nutritional interventions and weight monitoring for both residents highlights a systemic issue in the facility's approach to managing residents' nutritional status. The interim Nursing Home Administrator acknowledged the discrepancies and the need for consistent weighing methods and documentation.
Missed Dupilumab Dose for Resident with Eczema
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R142, by not administering a scheduled dose of Dupilumab, a medication for eczema. The medication was due on 12/6/24, but it was not given, as indicated by the Medication Administration Record (MAR) which showed a circled 'M' and 'N/A' for the administration time. This omission occurred despite the physician's order dated 11/22/24, with a start date of 12/6/24. The resident's Power of Attorney for Health Care (POAHC) reported that the resident's skin condition was worsening due to the missed medication, and the facility had not provided a definitive answer regarding the issue. The facility experienced an environmental emergency, leading to the relocation of residents, including R142, to other local facilities from 11/27/24 to 12/6/24. During this period, medications were sent with the residents to the other facilities. Upon return, the facility staff did not review the MARs to identify missed medications, and the missed dose of Dupilumab was not reported to the Nursing Home Administrator (NHA). The interim NHA, who was previously the Director of Nursing, acknowledged the oversight and confirmed that the missed medication was not documented or addressed appropriately.
Inadequate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for two residents, R17 and R30, during a survey. R17 was administered Quetiapine, an antipsychotic medication, without appropriate diagnoses or indications for its use. The facility's documentation indicated that R17 was taking Quetiapine for depression, but there was no evidence of harmful behavior or appropriate diagnosis to justify the use of this medication. Additionally, the facility was unable to provide documentation that R17 was being monitored for agitation or aggression, which were later added as diagnoses by the physician. R30's care plan and documentation did not specify what side effects of antipsychotic, benzodiazepine, or antidepressive medications should be monitored for, nor was there any documentation indicating that R30's side effects were being monitored by staff. Interviews with various staff members, including CNAs and a Med Tech, revealed a lack of knowledge regarding the specific side effects to monitor for R30's medications. The facility's Nursing Home Administrator acknowledged that specific side effects were not listed in the Medication Administration Record and that staff relied on drug books for reference. The facility's policy on the use of psychotropic medications emphasizes the need for assessing the resident's condition, identifying underlying causes, and evaluating the effects of medications on an ongoing basis. However, the facility did not adhere to these guidelines, as evidenced by the lack of appropriate diagnoses for R17's medication use and the absence of documented monitoring for R30's medication side effects. This failure to follow policy and ensure proper documentation and monitoring contributed to the identified deficiencies.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, identified as R40, to the State Agency within the required timeframe. The incident occurred at 6:15 AM, and the facility became aware of it shortly thereafter. However, the report to the State Agency was not made until 11:14 AM, exceeding the mandated two-hour reporting window for incidents involving abuse or serious bodily injury. The facility's policy requires immediate reporting of such allegations to the administrator and relevant authorities, but this protocol was not followed in this case. R40, who was admitted to the facility with a diagnosis of malignant neoplasm of the left bronchus or lung and nontraumatic intracranial hemorrhage, was under hospice care at the time of the incident. The alleged abuse involved a CNA who continued to provide care despite the resident's request to stop due to pain. The Nursing Home Administrator acknowledged the delay in reporting to the State Agency and confirmed that the incident should have been reported within two hours, as per the facility's policy.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an accusation of physical abuse involving a resident, identified as R40, who was under hospice care and had a diagnosis of malignant neoplasm of the left bronchus or lung and nontraumatic intracranial hemorrhage. The incident involved a Certified Nursing Assistant (CNA D) who allegedly continued to provide care despite the resident's request to stop, causing the resident to report pain during the care. The facility became aware of the allegation but did not complete a thorough investigation as required by their policy. The facility's policy on abuse, neglect, and exploitation mandates an immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, interviewing all involved parties, and documenting the investigation thoroughly. However, the investigation was incomplete as it did not include all necessary steps, such as conducting skin assessments on nonverbal residents and providing staff education on abuse. The Nursing Home Administrator (NHA A) acknowledged that the investigation was not complete and should have included these additional measures. Interviews conducted by the Social Worker (SW G) revealed that several residents felt their rights were not respected by CNA D, with some expressing that they did not feel safe when CNA D was working. Despite these findings, the facility did not document all conversations with residents, and the measures taken to ensure resident safety were insufficient. The facility's failure to conduct a comprehensive investigation and adequately protect residents from potential abuse constitutes a deficiency in their care practices.
Inadequate Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for three residents reviewed for falls. Resident R142, who has severe cognitive impairment and a history of falls, sustained a fall on 11/27/24. The facility did not conduct a root cause analysis or implement new interventions within 72 hours of the fall, as required by their policy. Observations and interviews revealed that the interventions listed in the resident's care plan were not updated following the fall, and staff were unable to locate specific fall interventions in the resident's records. Resident R16, diagnosed with malignant neoplasm of the brain and seizures, experienced multiple falls without significant injuries. Despite being at high risk for falls, the facility did not document any interventions or conduct a root cause analysis for these incidents. The care plan mentioned fall risk precautions, but these were not detailed, and there was no record of Interdisciplinary Team meetings to address the resident's continued falls. Resident R31, who has dementia, also experienced several falls, including one that resulted in a hematoma. The facility did not document any interventions or root cause analysis for these falls. Interviews revealed that the resident tripped over a fall mat, which was noted to be slippery. The facility's failure to document and analyze these incidents, as well as to implement individualized interventions, contributed to the ongoing risk of falls for these residents.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting suspected abuse, neglect, or theft in accordance with section 1150B of the Act. This deficiency was identified in three separate incidents involving residents. In the first case, a resident reported a sexual abuse allegation involving their significant other, which was communicated to the facility by Adult Protective Services (APS). However, the facility did not report this allegation to law enforcement, as required. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) revealed that both acknowledged the need to report such allegations to law enforcement, but it was not done in this instance. In the second incident, a resident reported that a Certified Nursing Assistant (CNA) was rough with her, but the facility did not report this allegation of abuse to the State Agency or law enforcement. The Social Service Director and the Director of Nursing both recognized that the incident could be considered abuse and should have been reported. In the third case, a resident reported being left unsupervised in the tub by a CNA, which was not reported as neglect to the State Agency. The Social Service Director and the Director of Nursing acknowledged that the lack of supervision could be considered neglect and should have been reported. These failures indicate a lack of adherence to the facility's policy on reporting alleged violations to the appropriate authorities.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to investigate alleged violations of abuse and neglect for two residents. For the first resident, an allegation was made on February 6, 2024, that a CNA was rough with the resident. Despite the resident being unable to identify the specific staff member involved, the facility did not conduct interviews with staff on duty at the time to narrow down the potential perpetrator. Both the Social Services Director (SSD) and the Director of Nursing (DON) acknowledged that the situation should have been investigated as a potential abuse case, and staff should have been interviewed to rule out abuse. For the second resident, an allegation of neglect was made on May 31, 2024, when the resident reported that a CNA was inattentive during bathing, leading to a potential risk of slipping. The CNA admitted to being distracted and not supervising the resident properly. The facility did not conduct an investigation into this incident, despite the acknowledgment from both the SSD and DON that the situation could be considered neglect and warranted an investigation. The failure to interview staff and other residents further contributed to the lack of a thorough investigation.
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 25 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 Darlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mineral Point Health Services | 17.1 mi | ★★★★★ | 2 | 1 |
| Edenbrook Of Platteville | 17.4 mi | ★★★★★ | 0 | 0 |
| Galena Stauss Nursing Home | 19.2 mi | ★★★★★ | 2 | 0 |
| St Dominic Villa | 19.7 mi | ★★★★★ | 9 | 1 |
| Allure Of Stockton | 20.1 mi | ★★★★★ | 0 | 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.