Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rocky Knoll Health Care during CMS and state inspections, most recent first.
Unsafe Food Cooling, Dishwashing, and Reheating Practices: Surveyors found multiple cooked foods in the cooler that were not documented as cooled per FDA Food Code time/temperature requirements, including an item not listed on the cooling log. They also observed and reviewed logs showing the dishwasher repeatedly failed to reach required wash and rinse temps, and that 33 pureed meals were reheated below the required 165 degrees F before service. The DM confirmed the temperature failures and incomplete documentation.
The facility did not revise care plans for two residents. One resident started Hospice care and had moderately impaired cognition, but the care plan did not include Hospice-related focus, goals, or interventions. Another resident returned from the hospital with a catheter, but the care plan did not address catheter use. The DON confirmed the missing catheter care plan.
A resident with a history of falls, orthostatic hypotension, and syncopal episodes was admitted after a fall with injury and later fell multiple times in the facility, including while toileting and in PT. The admission fall risk assessment and post-fall assessments were inaccurate, including incorrect statements that the resident had no recent falls and no orthostatic BP drop, despite documented falls and a subsequent femur fracture.
A resident on EBP for an indwelling catheter had the catheter bag observed on the floor multiple times, including while seated in a wheelchair and in bed. An LPN and a CNA adjusted the bag without wearing the required gown and gloves, despite the facility’s EBP policy and the DON’s statement that gown and gloves should be used during catheter care and that catheter bags should not be on the floor without a barrier.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to maintain sanitary conditions in food storage, preparation, and service, affecting all residents. Numerous food items lacked proper labeling and use-by dates, cooling logs were incomplete, and sanitizing procedures were not consistently followed. Staff also neglected proper microwave reheating, hair restraint usage, and hand hygiene practices.
The facility failed to maintain the dignity of residents requiring dining assistance by allowing staff to stand while feeding them, rather than sitting at eye level. This practice was observed during multiple meals, involving residents with various medical conditions such as dementia and functional quadriplegia. Staff interviews revealed that standing while feeding was common, despite the facility's expectation for staff to sit, as confirmed by the DON.
The facility failed to notify the Long-Term Care Ombudsman of ER or hospital transfers for six residents, as required. The residents were transferred multiple times due to changes in their conditions, but the facility's records did not include notifications to the Ombudsman. Interviews with staff revealed a lack of clarity and procedure regarding the notification process, indicating a systemic issue.
The facility failed to ensure proper labeling and storage of medications for two residents. Unsecured medications were found in a resident's room without proper self-administration orders, and an LPN left a tray of medications unattended on a cart. The Director of Nursing acknowledged these practices violated facility policies, posing potential safety risks.
A LTC facility failed to maintain an effective infection control program, with staff not adhering to protocols. An LPN administered a dropped pill to a resident, and staff did not use proper PPE during high-contact care for residents requiring Enhanced Barrier Precautions. Additionally, a CNA neglected hand hygiene after glove removal, and wound care for a resident with pressure ulcers was conducted without necessary precautions. These actions indicate systemic non-compliance with infection control measures.
A resident with a history of respiratory failure and heart disease experienced a low blood pressure reading, but the facility failed to notify the physician as required by the resident's medical order. The resident was cognitively intact and had a court-appointed guardian for healthcare decisions. Despite the facility's policy and the specific order, there was no documentation of physician notification.
An LPN at a facility administered a lidocaine patch to a resident in a dining room and insulin to another resident in a hallway, both in the presence of others, breaching privacy protocols. The DON acknowledged these actions as inappropriate, emphasizing the need for privacy during such procedures.
The facility failed to comply with PASRR requirements for three residents. One resident was prescribed Abilify without an updated Level II Screen. Another resident, initially on a short-term stay, remained beyond 30 days without a timely Level II Screen. A third resident, diagnosed with anxiety and dementia, received new medications without a Level II Screen. These oversights were confirmed by the facility's social worker.
A resident with an unstageable pressure injury on the spine did not receive proper assessment or treatment according to facility policy. The care plan lacked goals or interventions for the injury, and dressing changes were inconsistently documented. Interviews revealed that wound care was not performed daily as required, highlighting a deficiency in care.
A resident with a history of respiratory issues was observed without oxygen, and their care plan lacked details on continuous oxygen use. The facility's policies required updated care plans, but the resident's plan and Kardex did not reflect their oxygen needs. Staff interviews confirmed the oversight, highlighting a deficiency in managing the resident's oxygen therapy.
A facility failed to monitor and document the antibiotic use for a resident prescribed prophylactic vancomycin. The resident, with a history of Clostridium difficile, was not routinely assessed for continued antibiotic use, and the infection surveillance log contained inaccuracies. Despite being seen by an infectious disease physician, there was no documented follow-up after January 2025. Additionally, the resident was prescribed Bactrim for a UTI, although the facility's log indicated the resident did not meet the criteria for a UTI.
A facility failed to report an alleged sexual abuse incident involving two residents with impaired cognition to the State Agency. One resident kissed another, who then touched the first resident's breast. Despite the incident meeting the federal definition of sexual abuse, the facility did not report it, citing no harm occurred. The facility's decision was based on a skin assessment and a decision tree, but they did not complete official capacity to consent assessments for the residents involved.
The facility did not thoroughly investigate an alleged sexual abuse incident involving two residents with impaired cognition. The investigation lacked interviews with the involved residents, other residents, and staff present during the incident, contrary to the facility's policy. The facility ruled out abuse, citing the incident as a singular event and noting that many residents had dementia and memory deficits.
A facility failed to follow a care plan intervention for a resident with impaired cognition, resulting in an inappropriate interaction with another resident. The resident was supposed to be escorted and kept separate from female residents but was left unsupervised, leading to the incident. Staff were aware of the care plan but were occupied with other duties, contributing to the lapse in supervision.
Unsafe Food Cooling, Dishwashing, and Reheating Practices
Penalty
Summary
The facility did not ensure food was stored and prepared in a safe and sanitary manner. During an initial kitchen tour, surveyors and the Dietary Manager (DM-F) observed multiple containers of cooked food in the reach-in cooler, including vegetables, mashed potatoes, lasagna, beef, ham, grilled chicken, egg bake, and peppers and sausage, with dates ranging from 6/4/26 to 6/7/26. DM-F stated the facility used a cooling log for staff to document temperatures of food placed in the cooler for future resident consumption and indicated temperatures were obtained every two hours until food reached 41 degrees F or below. DM-F also verified that the container labeled peppers and sausage was not on the cooling log. During review of the cooling logs, surveyors found that the observed cooked and cooled foods were not documented as reaching a safe cooled temperature within six hours. The report states that the items in the cooler were not documented as having cooled according to the facility's process and the FDA Food Code requirements. The surveyor and DM-F reviewed the logs during a continuous kitchen observation and identified that the foods observed in the cooler had not been documented as reaching the required cooled temperature in the required time frame. Surveyors also observed and reviewed dishwashing temperature logs and found the dishwasher did not consistently reach required temperatures. During observation, wash cycle temperatures were recorded at 166, 159, and 158 degrees F, while rinse cycle temperatures were 177, 181, and 186 degrees F. The June 2026 log showed the dishwasher failed to reach the minimum wash temperature on 7 occasions and the minimum rinse temperature on 3 occasions, and the May 2026 log showed 21 wash temperature failures, 4 rinse temperature failures, and multiple failures to reach the required internal temperature. In addition, surveyors reviewed cooked, pureed, and reheated food logs and found 33 pureed meals were not reheated to 165 degrees F before service, with documented temperatures ranging from 115 degrees F to 155 degrees F. DM-F confirmed the dishwasher and reheated food temperatures did not consistently meet the required minimums.
Care plans not revised for hospice and catheter needs
Penalty
Summary
The facility did not ensure the comprehensive care plan was revised for 2 of 28 sampled residents. R9, who had diagnoses including Alzheimer's disease, dementia, and urine retention, started Hospice care on 11/5/25. R9's MDS assessment dated 5/6/26 showed a BIMS score of 11 out of 15, indicating moderately impaired cognition, and R9 had an activated POAHC. On 6/8/26, surveyor review of the medical record found an order for Hospice care, but R9's care plan did not include a focus, goals, or interventions related to Hospice care. R11, who had diagnoses including Parkinson's disease, dementia, and urinary retention, returned to the facility on 3/5/26 from a hospitalization where a catheter was inserted. R11's MDS assessment dated 3/26/26 included a staff assessment indicating cognitive impairment. Between 6/8/26 and 6/10/26, surveyor review of the medical record showed R11 had a catheter, but the care plan did not address catheter use. The facility's DON confirmed on 6/10/26 that R11 did not have a care plan that addressed catheter use.
Inaccurate fall risk assessments for a resident with repeated syncopal falls
Penalty
Summary
The facility did not ensure the resident environment was as free of accident hazards as possible for one resident with a history of falls. The resident was admitted following a syncopal episode that resulted in a fall with injury and had diagnoses including multiple rib fractures, history of falling, atrial fibrillation, hypertension, and orthostatic hypotension. The resident’s care plan identified bowel continence, bladder incontinence, and the need for one staff member for toileting, then was revised to require two staff with a gait belt and walker for transfers. An admission fall risk assessment scored the resident as high risk for falls, but it incorrectly stated the resident had not had a fall resulting in fracture within six months prior to admission and had no noted orthostatic blood pressure drop, despite the admission for a fall with rib fractures and a diagnosis of orthostatic hypotension. After admission, the resident fell during a syncopal episode while toileting, then fell again during physical therapy, and later was found on the bathroom floor with the wheelchair tipped back after attempting to use the bathroom. The resident sustained a compound fracture of the right femur and was transferred to the hospital. The post-fall risk assessments completed after the falls were not accurate: one scored the resident as low risk and stated there was no information about falls since admission, and another scored the resident as moderate risk while also stating there had been no falls since admission or the prior assessment. A unit manager RN verified the admission fall assessment and post-fall assessments were not accurately completed and stated assessments should accurately reflect a resident’s needs so appropriate interventions and assistance can be provided.
Infection Control Lapses During Catheter Care
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for one resident, R9, who was on enhanced barrier precautions (EBP) related to an indwelling catheter. The facility’s EBP policy stated that EBP apply to residents with an indwelling medical device and require anyone providing or assisting with high-contact care to wear a gown and gloves. R9 was admitted with diagnoses including Alzheimer’s disease, dementia, and urine retention, and the MDS dated 5/6/26 showed a BIMS score of 11 out of 15, indicating moderately impaired cognition. Surveyors observed R9’s catheter bag on the floor on multiple occasions. On 6/8/26, the bag was hooked to the wheelchair frame and resting on the floor. On 6/9/26, the bag was again observed touching the floor while R9 was in a wheelchair in the dining room. LPN-C confirmed the bag was touching the floor and, without donning a gown or gloves, adjusted it; LPN-C stated a gown and gloves should have been worn. Later that morning, the catheter bag was again resting on the floor, and CNA-D, also without gown or gloves, adjusted the bag and placed a pad underneath it. The DON stated staff should wear a gown and gloves during all catheter care and verified catheter bags should not be on the floor without a barrier.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a sanitary manner, potentially affecting all 134 residents. During an inspection, numerous food items in the cooler, freezer, and dry storage were found without proper labeling or use-by dates, contrary to the facility's Food Storage Policy and the FDA Food Code. The Director of Dining Services (DDS) admitted to not knowing the use-by dates for many items and acknowledged that staff should use stickers for labeling. Additionally, the facility's cooling logs were either blank or missing, indicating a lack of documentation for cooling temperatures of cooked food, which is a requirement under the FDA Food Code. The facility also failed to adhere to proper sanitizing procedures. The sanitizing solution was not consistently tested for temperature, and the logs showed inadequate entries, with some days missing entirely. Staff admitted to not always testing the sanitizing solution and sometimes only documenting the first test of the day. Furthermore, the dishwashing process was compromised as staff did not use temperature test strips correctly, and there were missing entries in the dishwashing temperature logs. Staff were observed handling clean dishes without performing hand hygiene after processing dirty dishes. Additional deficiencies were noted in microwave reheating procedures, hair restraint usage, and hand hygiene practices. Staff were observed reheating food in the microwave without stirring, letting it stand, or checking the temperature, as required by the FDA Food Code. Hair restraints were not properly used, with staff's hair and beards not fully covered while preparing and serving food. Hand hygiene was also neglected, with staff failing to wash hands before and after glove use and between different tasks, which is against the facility's Personal Adherence to Sanitary Procedures policy.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to maintain the dignity of seven residents who required dining assistance. During meal observations, staff members were noted to stand while feeding residents, rather than sitting at eye level, which is considered a more dignified approach. This practice was observed during both lunch and breakfast meals over two consecutive days. The residents involved had various medical conditions, including dementia, anxiety, functional quadriplegia, Parkinson's disease, and cognitive impairments, which necessitated assistance with dining. Despite the presence of chairs, staff members, including CNAs and a Registered Nurse Manager, were observed standing while feeding residents, sometimes attending to multiple residents simultaneously. Interviews with staff revealed that standing while feeding residents was a common practice in the facility, as it was perceived to be easier than sitting and standing repeatedly. The Director of Nursing later confirmed that staff should sit and be at eye level with residents during feeding, indicating a deviation from the facility's expectations. The report highlights that the facility did not uphold the residents' right to a dignified existence by failing to ensure that staff adhered to proper feeding protocols, thereby compromising the residents' dignity during meals.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of emergency room (ER) or hospital transfers for six residents, as required. The residents involved were transferred multiple times due to changes in their conditions, but the facility's records did not include notifications to the Ombudsman for these transfers. Specifically, residents were transferred on various dates between September 2024 and January 2025, yet the facility's Ombudsman Notification records for these months did not reflect these transfers. The deficiency was further compounded by the absence of a process to ensure Ombudsman notification for ER or hospital transfers. Interviews with the Director of Nursing and the Health Information Director revealed a lack of clarity and procedure regarding the notification process. The Health Information Director confirmed that the monthly report sent to the Ombudsman did not include ER and hospital transfers, indicating a systemic issue in the facility's notification process.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for two residents, R43 and R228, which was observed during a survey. For resident R43, two bags of unidentified and unsecured medications were found in their room. The facility's policy requires that medications be stored securely and that residents have a self-administration order and assessment before being allowed to self-administer medications. Although R43 had orders for self-administration of certain medications, the medications found in the room were not secured, and there was no order for all the medications observed. The Director of Nursing acknowledged that the medications should be locked and that R43 was not adhering to the protocol. Additionally, during medication administration, a Licensed Practical Nurse (LPN) was observed leaving a tray of medications unattended on top of a medication cart in the hallway. The tray contained a bottle of Florajen and several insulin medications for resident R228. This practice was against the facility's policy, which requires medications to be stored securely and not left unattended to ensure resident safety. The Director of Nursing confirmed that medications should not be left on top of the medication cart. The facility's failure to adhere to its medication storage policies posed a potential safety risk to residents, as unsecured medications could be accessed by other residents. The Director of Nursing indicated that the facility's self-administration of medication policy needed adjustments regarding securing and locking medications, highlighting a gap in the facility's adherence to its own protocols.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple incidents involving staff not adhering to established protocols. One incident involved an LPN who dropped a pill on the floor and then administered it to a resident with severe cognitive impairment, despite knowing that the medication should have been discarded and replaced. This action was contrary to the facility's medication pass and infection control procedures, as confirmed by the Director of Nursing. Another deficiency was observed with a resident requiring Enhanced Barrier Precautions (EBP) due to medical conditions such as bladder and kidney issues. The Occupational Therapist and a CNA failed to wear appropriate personal protective equipment, such as gowns and gloves, during high-contact care activities. The resident's care plan did not include EBP, and there was a lack of proper signage to indicate the need for such precautions. Interviews with staff revealed a misunderstanding of when EBP should be applied, leading to non-compliance with infection control measures. Additionally, a CNA did not perform hand hygiene after removing soiled gloves during the care of another resident, which is a critical step in preventing the spread of infection. Furthermore, a resident with pressure ulcers was not placed on EBP, and wound care was conducted without the necessary precautions. The Infection Preventionist and RN involved in the care were unsure of the healing timeline for the wounds, which should have been classified as chronic, necessitating EBP. These incidents highlight a systemic failure in adhering to infection control policies, putting residents at risk of infection.
Failure to Notify Physician of Resident's Low Blood Pressure
Penalty
Summary
The facility failed to notify a physician of a significant change in condition for a resident, identified as R93, who experienced a low blood pressure reading of 84/43 mmHg on January 1, 2025. According to the facility's Notification of Change policy, the resident's physician should have been informed immediately of such a significant change. However, there was no documentation to indicate that the physician was notified as required by the resident's medical order, which specified contacting the primary care provider for systolic blood pressure readings less than 85 or greater than 175. R93 had a history of acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and hypertensive heart disease with heart failure. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15, and had a court-appointed guardian responsible for healthcare decisions. Despite the resident's medical history and the specific order to notify the physician for low blood pressure, the Director of Nursing was unable to provide documentation that the physician was updated on the resident's condition on the specified date.
Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to maintain privacy during medication administration for two residents, R17 and R228, as observed by a surveyor. On March 4, 2025, an LPN administered a lidocaine patch to R17 in the dining room, lifting the resident's shirt and lowering their pants in the presence of 22 other residents and staff. R17, who had a severely impaired cognition with a BIMS score of 5 out of 15, was exposed in a public area, which was acknowledged by the LPN and the Director of Nursing (DON) as inappropriate. The DON indicated that such procedures should be conducted in the privacy of the resident's room. Similarly, the same LPN administered insulin to R228 in the hallway, lifting the resident's shirt to inject Basaglar and Humulin insulin into the abdomen. This action was also witnessed by other residents and staff. The DON confirmed that this was not an appropriate setting for administering insulin, emphasizing that it should have been done in the privacy of the resident's room. These incidents highlight a breach in maintaining the residents' dignity and privacy during medical care.
Failure to Comply with PASRR Requirements for Residents
Penalty
Summary
The facility failed to ensure compliance with the Pre-Admission Screening and Resident Review (PASRR) requirements for three residents, leading to deficiencies in their care. Resident 13, who had a history of bipolar disorder, chronic generalized disorder, major depressive disorder, and post-traumatic stress disorder, was prescribed Abilify, an antipsychotic medication, on January 5, 2023. However, the facility did not complete an updated PASRR Level II Screen following this prescription, despite the requirement to do so when significant changes occur, such as the introduction of new medications. Resident 36 was admitted with a positive PASRR Level I Screen and was initially expected to have a short-term stay. However, when it became clear that the resident would remain in the facility beyond the 30-day exemption period, the facility failed to conduct a PASRR Level II Screen in a timely manner. The Level II Screen was only completed on March 4, 2025, despite the facility being aware of the resident's long-term stay since April or May of 2024. Resident 38, who was initially not suspected of having a mental illness, later received diagnoses of anxiety and dementia with severe anxiety. The resident was prescribed medications for these conditions, including buspirone and lorazepam. Despite these significant changes in diagnosis and medication, the facility did not complete a PASRR Level II Screen to reassess the resident's needs. This oversight was confirmed by the social worker, who acknowledged the failure to conduct the necessary screening following the resident's new diagnoses and prescriptions.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent and treat pressure injuries for a resident, identified as R376. The resident had an unstageable pressure injury on the middle spine, which was not assessed or treated according to the facility's policy. The facility's Wound and Treatment policy requires skin integrity assessments upon admission and weekly thereafter, with interventions to be implemented and care planned. However, R376's care plan did not include goals or interventions for the treatment of the pressure injury. R376 was admitted to the facility following hospitalization for chronic compression fractures and had diagnoses including diabetes mellitus with kidney complications and atrial fibrillation. The resident's Minimum Data Set (MDS) assessment indicated an unhealed unstageable pressure injury, but the care plan did not reflect this condition. A skin assessment noted the presence of the pressure injury, but there was no wound assessment or care order upon readmission from the hospital. The treatment administration record showed inconsistencies in the completion of dressing changes as ordered. Interviews with the resident and staff revealed that the wound dressing was not changed daily as required. The Director of Nursing indicated that hospital orders should be transcribed and implemented immediately upon admission, with skin assessments and wound care completed on the day of admission. However, the facility failed to ensure that R376's wound treatment was completed as ordered, and the care plan did not include necessary interventions to alleviate pressure, contributing to the deficiency in care.
Deficiency in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide necessary care and services for a resident requiring oxygen therapy. The resident, who had a history of pulmonary fibrosis, interstitial pulmonary disease, eosinophilic asthma, and dependence on supplemental oxygen, was observed without oxygen in the hallway. The resident's oxygen order did not specify the flow rate, and the care plan did not indicate the need for continuous oxygen use. The resident reported having to request assistance to connect the oxygen, indicating this was not the first occurrence. The facility's policies required that a resident's care plan be comprehensive and updated to reflect their needs, including oxygen therapy specifications. However, the resident's care plan and Kardex lacked details about continuous oxygen use, and the oxygen order only specified maintaining saturation above 90% without indicating the flow rate. Staff confirmed that the resident's care plan and Kardex should have included these details to ensure proper care. Interviews with staff, including the LPN and DON, revealed that the resident's care plan and Kardex were not updated to reflect the resident's oxygen needs. The DON acknowledged that the care plan should be up-to-date with the resident's requirements, including the oxygen flow rate. The Nursing Home Administrator also confirmed that care plans should be updated within 24 hours of new diagnoses or treatment orders, which was not done in this case.
Failure to Monitor Antibiotic Use for a Resident
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by the lack of monitoring and documentation for a resident, R115, who was prescribed a prophylactic antibiotic. R115's medical record did not show routine assessment of the prophylactic antibiotic use, and the facility's infection surveillance log contained inaccurate documentation regarding the continued appropriate use of antibiotics for R115. The facility's policy required that residents on antibiotics be reviewed by the Infection Control Preventionist, Director of Nursing, or a designee, but this was not adhered to in R115's case. R115, who had a history of Clostridium difficile and other infections, was prescribed vancomycin prophylactically upon readmission to the facility. Despite being seen by an infectious disease physician, there was no documented follow-up or communication with the physician regarding the risks and benefits of continued antibiotic use after January 2025. Additionally, R115 was diagnosed with a UTI and prescribed Bactrim, although the facility's infection surveillance log indicated that R115 did not meet the criteria for a UTI. The Infection Preventionist and nursing staff failed to track and document the long-term use of antibiotics for R115, leading to a deficiency in the facility's antibiotic stewardship program.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the State Agency (SA) as required by their policy. On April 21, 2024, one resident with severely impaired cognition due to Alzheimer's disease and other conditions, approached another resident with moderately impaired cognition due to vascular dementia and other conditions, in the lobby. The first resident kissed the second resident on the mouth, and the second resident responded by touching the first resident's breast. Despite the incident meeting the federal definition of sexual abuse, the facility did not report it to the SA within the required 24-hour timeframe. The facility's policy on Freedom From Abuse, Neglect, and Exploitation mandates reporting allegations of sexual abuse, including non-consensual intimate touching, to the SA. The policy specifies that incidents involving residents who lack the cognitive ability to consent should be reported. However, the facility determined that the incident did not constitute abuse and that no harm occurred, based on a skin assessment of the first resident. The facility used a decision tree and concluded that the incident did not need to be reported because they believed no psychological or emotional harm occurred. The facility's decision not to report was further questioned by the surveyor, who noted that the facility did not complete official capacity to consent assessments for either resident involved. The facility provided a Social Services Assessment for the first resident, completed more than 24 hours after the incident, which indicated severely impaired decision-making abilities. The assessment also noted that the resident was not interested in pursuing a relationship at the facility. Despite these findings, the facility did not report the incident to the SA, leading to a deficiency in their handling of the situation.
Incomplete Investigation of Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, R2 and R5. On April 21, 2024, R5 approached R2 in the lobby, kissed R2 on the mouth, and R2 touched R5's breast. The facility's investigation was incomplete as it did not include interviews with R5 and R2, other residents, or staff who were present during the incident. The facility's policy requires a thorough investigation, including interviews with the alleged victims, witnesses, and staff, as well as an analysis of the situation to determine risk factors and the need for systemic action. R2 had moderately impaired cognition with a BIMS score of 8 out of 15, while R5 had severely impaired cognition with a BIMS score of 4 out of 15. Both residents had activated Powers of Attorney for Healthcare. The facility's risk management report indicated that R5 and R2 were immediately separated and supervised, and their care plans were updated. However, the facility did not conduct interviews with other residents or staff, as they believed the incident was a singular event and abuse was ruled out. The Nursing Home Administrator stated that many residents on the unit had dementia and memory deficits, making them not interviewable.
Failure to Follow Care Plan Leads to Resident Interaction
Penalty
Summary
The facility failed to ensure that care plan interventions were consistently followed, resulting in an inappropriate interaction between two residents. Resident R2, who had moderately impaired cognition due to vascular dementia and other mental health conditions, was supposed to be escorted to and from their room and kept separate from female residents. However, on the day of the incident, R2 was not escorted as required, leading to an interaction with Resident R5, who also had severely impaired cognition due to Alzheimer's disease and other mental health conditions. On the day of the incident, R2 was self-propelling their wheelchair back from the dining room when R5 approached and kissed R2 on the mouth. R2 responded by touching R5's breast. The care plan for R2, which included direct supervision and separation from female residents, was not adhered to at the time of the incident. Staff members, including CNAs and an RN, were aware of R2's care plan requirements but were occupied with other duties, leading to a lapse in supervision. Interviews with staff revealed that R2 was often impatient and did not always wait for staff assistance, which contributed to the failure to follow the care plan. The incident was witnessed by RN-E, who noted that R2 was not being escorted at the time, and CNA-D, who intervened after the incident occurred. The facility's administration acknowledged the expectation for staff to escort R2 as per the care plan, but this was not consistently implemented, leading to the deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plymouth Health Services | 3.9 mi | ★★★★★ | 1 | 0 |
| Sheboygan Senior Community Inc | 10 mi | ★★★★★ | 16 | 0 |
| Willowdale Health Services | 11.2 mi | ★★★★★ | 10 | 0 |
| Homestead Health Services | 11.8 mi | ★★★★★ | 14 | 0 |
| Sheboygan Health Services | 11.9 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.