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 Three Oaks Health Services during CMS and state inspections, most recent first.
Improper disposal of garbage and refuse was observed around the dumpster area. The surveyor found cigarette butts scattered outside the back door, an open grease dumpster lid, and a cardboard box with plastic and other debris behind the dumpster. The DM said the box was frozen to the ground, and the NHA later acknowledged that garbage should not be on the ground and the dumpsters should be closed.
Infection prevention and control deficiencies were observed when residents were not offered hand hygiene before meals, kitchen staff had face masks down while working, and an RN provided wound care to a resident with PVD and foot wounds without proper PPE. The RN was observed touching the resident’s bandaged feet and wound care items without gloves, leaving the room to retrieve scissors, and reentering without gloves or a gown while the wound was exposed; the DON stated staff were expected to wear gowns and gloves for wound care and for residents on EBP.
Incomplete Pre- and Post-Dialysis Assessments: A resident who required dialysis did not receive current pre- and post-dialysis assessments. Staff repeatedly documented prior weights and vital signs instead of current assessments, and on one occasion no pre-dialysis assessment was documented before the resident went to dialysis. The DON and RNs stated the forms were completed by staff, but the records reviewed showed the assessments were not current.
A resident with significant physical and cognitive impairments was unable to reach their call light due to improper placement, despite multiple staff interactions in the room. The call light was only repositioned after a surveyor raised the concern, highlighting a failure to provide care in accordance with professional standards for a resident requiring assistance.
Staff did not follow facility protocols for feeding tube care for a resident with complex medical needs. A nurse failed to check tube placement before administering medications, used auscultation to verify placement despite policy advising against it, and did not maintain the required head-of-bed elevation during tube feeding. The correct bed elevation was only achieved after surveyor intervention, and the DON confirmed these actions were not in line with facility expectations.
A resident with a history of throat cancer and dysphagia was left unsupervised during meals, leading to a choking incident. Despite care plan instructions for supervised eating, the resident was found alone with food, resulting in immediate jeopardy. Staff interviews revealed a lack of awareness and adherence to the resident's swallowing guidelines.
The facility was cited for unsanitary conditions in food preparation, storage, and distribution. Observations revealed dirty floors in the kitchen and dish room, unsanitary refrigerators in the ACU and East dining room, and dirty carts used for food transport. The Dietary Manager acknowledged the issues and noted a lack of adherence to cleaning schedules, with missing logs and inadequate accountability for staff.
A resident's POA was not informed when Tramadol was prescribed and later scheduled, contrary to the facility's pain management policy. The DON confirmed the oversight, and no process improvement plan was implemented.
A resident continued to receive duloxetine, a psychotropic medication, despite it being deemed unnecessary by their psychiatry provider. The resident, who had not experienced hallucinations for several years, was supposed to have the medication discontinued in agreement with their power of attorney. However, due to the DON's failure to act on the provider's recommendation, the medication was not stopped until over a month later, resulting in unnecessary administration.
The facility failed to properly store foods in two refrigerators, leading to potential contamination risk for 47 residents. Water was observed pooling and dripping from freezers over snacks and beverages due to high freezer temperatures. The Account Manager was unaware of any repairs, and foods continued to be stored despite the risk.
The facility inaccurately reported staffing data to CMS due to agency staff and nurse managers not clocking in on weekends, leading to excessively low weekend staffing data. The issue was identified when the PBJ system flagged the data for two fiscal quarters in 2024. The facility schedules the same number of RNs, LPNs, and CNAs on weekends as weekdays, but the absence of clock-in records resulted in underreporting.
The facility failed to provide written transfer notices to residents and their representatives, as well as notifications to the State Ombudsman, affecting five residents. Despite the facility's policy requiring documentation of transfers, no written notices were found in the records of residents transferred to the hospital for various medical conditions. Interviews revealed that residents were not aware of their rights regarding transfers, and staff acknowledged the issue, indicating inconsistent adherence to the process.
The facility failed to provide written bedhold notifications to four residents during hospital transfers, as required by policy. Despite multiple transfers for various health issues, there was no documentation of bedhold notices for these residents. Interviews revealed that floor nurses were responsible for these notifications, but the facility acknowledged ongoing issues with compliance.
A resident with CHF experienced a significant weight gain, but the facility failed to notify the Heart Failure Clinic or the primary physician as required by physician orders. Despite the resident's weight increasing by 5.2 lbs over five days, staff interviews confirmed the lack of documentation or notification. The Nursing Home Administrator noted that following physician orders is a standard practice, although no specific policy exists.
A medication error rate of 6.67% was observed in a facility, exceeding the acceptable 5% threshold. An LPN nearly administered eye drops prescribed for one resident to another, failing to verify the medication label against the MAR. The error was identified by a surveyor, and the LPN acknowledged the oversight, highlighting a lapse in following medication administration procedures.
A facility failed to maintain proper infection control practices, as observed in two separate incidents involving improper hand hygiene and glove use. An LPN did not perform hand hygiene between glove changes while providing wound care to a resident on Enhanced Barrier Precautions, and a CNA failed to remove gloves and perform hand hygiene after providing incontinence care. Both staff members acknowledged the lapses in protocol when questioned.
A facility failed to report a physical abuse incident to law enforcement as required by their policy. An LPN witnessed a resident hitting another resident on the head during a wheelchair maneuvering issue. The LPN intervened, assessed the victim, and notified relevant parties, but law enforcement was not informed. The Nursing Home Administrator later admitted the incident should have been reported.
Improper Disposal of Garbage and Refuse Around Dumpster Area
Penalty
Summary
Proper disposal of garbage and refuse was not maintained around the exterior dumpster area. During the initial kitchen tour with the Dietary Manager, the surveyor observed a large amount of cigarette butts scattered on the ground outside the back door, the grease dumpster door on top was open and was closed by the Dietary Manager, and a large cardboard box containing plastic and other debris was behind the dumpster. The Dietary Manager stated the box was frozen to the ground and could not be picked up immediately, and also stated that if staff had concerns with pests or rodents, there were people that come and take care of it. On the following day, the cigarette butts were still present on the ground and the box remained frozen to the ground. The Nursing Home Administrator later acknowledged that garbage should not be on the ground and around the dumpster and that the dumpsters should be closed.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility did not provide a safe, sanitary, and comfortable environment or help prevent the development and transmission of communicable diseases and infections. Surveyors observed residents entering the dining room for breakfast and being served meals without being offered hand hygiene, and a CNA stated she usually washes residents’ hands before bringing them out of their rooms but was unsure about residents who go to the dining room independently after touching walkers and wheelchair wheels. The facility policy titled Hand Hygiene stated that hand hygiene is indicated before and after eating, before invasive procedures, and before and after performing care to residents in isolation. Surveyors also observed improper PPE use by kitchen staff when a dietary employee and the Dietary Manager had their face masks down in the kitchen during temping, and the Dietary Manager acknowledged the masks should have been on properly. In addition, during wound care for a resident admitted with peripheral vascular disease and wounds to the left second toe and right bunion, a nurse was observed providing care without gloves before touching the resident’s bandaged feet, removing gloves and leaving the room to retrieve scissors, handling wound care supplies without gloves, and later reentering the room without gloves or a gown while the resident’s wound remained exposed. The nurse stated she should have worn a gown and gloves for direct care such as dressing the resident and repositioning the resident’s legs, and the DON stated staff were expected to wear gowns and gloves when performing wound care and when dressing a resident on EBP.
Incomplete Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility did not ensure safe, appropriate dialysis care for one sampled resident who required dialysis services. For resident R52, the facility failed to provide ongoing assessments of the resident’s condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility, as required by the facility’s Hemodialysis policy. The policy stated that the licensed nurse would complete ongoing assessment of the resident’s condition and monitor for complications before and after dialysis treatment, and would communicate physician/treatment orders, laboratory values, and vital signs to the dialysis facility using the Pre-dialysis Communication UDA. Record review showed multiple instances in which pre- and post-dialysis documentation did not reflect current assessments. On 02/21/26, the post-dialysis assessment documented only the weight obtained before dialysis, and no weight was obtained when R52 returned. On 02/24/26, the post-dialysis assessment documented blood pressure, pulse, and respirations from before dialysis, with no return assessment completed. On 02/26/26, the post-dialysis assessment again documented only the pre-dialysis weight, and no weight was obtained after dialysis. On 02/28/26, the pre-dialysis assessment sent to the dialysis center used vital signs from 02/26/26, oxygen saturation from 02/26/26, and weight from 02/27/26, rather than a current assessment. On 02/28/26, the post-dialysis assessment documented blood pressure, temperature, pulse, and respirations from the prior day. On 03/03/26, no pre-dialysis assessment was documented before R52 went to dialysis, and the post-dialysis assessment documented a weight from 03/01/26. When interviewed, the DON stated assessments are completed and entered on the pre- and post-dialysis forms, but the documented assessments did not have completed current assessments. RN O and RN P stated that when R52 leaves before 6 AM, the prior shift completes the pre-dialysis form, and when R52 returns staff obtain vitals and enter them in the computer and on the post-dialysis form.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including Parkinson's disease, dementia, stroke, larynx cancer, and gastrostomy, was found unable to reach their call light while lying in bed. The resident, who is on palliative care and has significant self-care deficits due to impaired vision, physical limitations, and weakness, requires assistance for toileting, transfers, and bed mobility. During the surveyor's observation, the call light was attached to the bed but positioned approximately four inches from the resident's right upper arm, out of their reach. When asked, the resident attempted but was unable to locate or reach the call light. Despite the presence of staff in the room, including a CNA who checked the resident's blood pressure and an RN who administered medications and performed a tube feeding dressing change, neither ensured the call light was within the resident's reach before leaving. The issue was only addressed after the surveyor brought it to the attention of an LPN, who then repositioned the call light onto the resident's lap and adjusted the bed to a more appropriate angle for tube feeding. The deficiency was confirmed through observation and staff interviews, with acknowledgment from the DON after being informed of the findings.
Failure to Follow Feeding Tube Protocols and Positioning Requirements
Penalty
Summary
Staff failed to follow facility protocols and professional standards regarding feeding tube care for a resident with multiple complex medical conditions, including Parkinson's disease, stroke, pneumonia due to aspiration, dysphagia, malnutrition, larynx cancer, reflux, and gastrostomy. The resident required full staff assistance for all tube feeding management and care. During observation, a registered nurse administered medications via the gastrostomy tube without first checking tube placement, as required by facility policy. When asked about placement verification, the nurse stated that placement is usually checked by auscultating air injected into the tube, but admitted to not performing this check prior to medication administration that morning. Further observations revealed that the nurse used auscultation to check tube placement before administering tube feeding, despite current guidelines and facility policy stating that auscultation is no longer recommended for this purpose. Additionally, the resident's head-of-bed was observed to be at a 20-degree angle during tube feeding administration, which is below the facility's required minimum of 30 degrees to prevent aspiration. The head-of-bed was only elevated to the appropriate angle after the surveyor intervened. The Director of Nursing confirmed that the facility's expectation is to maintain a minimum 30-degree elevation and to verify tube placement prior to any administration through the tube, without using air injection for placement verification.
Lack of Supervision Leads to Choking Incident
Penalty
Summary
The facility failed to provide necessary supervision and assistance to a resident, identified as R1, during meals, which led to a choking incident. R1, who has a history of throat cancer, dysphagia, and aspiration pneumonia, was not given the required supervision during mealtime as per speech therapy recommendations. On the day of the incident, R1 was left unsupervised in the activity area with her meal, and subsequently choked on sweet potatoes. R1's Power of Attorney (POA) found her red in the face and performed the Heimlich maneuver to dislodge the food, as no staff were present to assist. The facility's policy mandates that residents receive adequate supervision to prevent accidents, including during meals for those with swallowing difficulties. Despite this, R1's care plan, which included specific instructions for supervised eating, was not followed. The care plan outlined that R1 should have small bites and sips, a slow eating rate, and supervision while eating. However, observations during the survey revealed that R1 was left alone with food and beverages on multiple occasions, indicating a lack of adherence to the care plan. Interviews with staff, including the Director of Nursing (DON) and Certified Nursing Assistants (CNAs), confirmed that R1's swallowing guidelines were not consistently implemented. Staff were unaware of the need for supervision, and no reeducation or audits were conducted post-incident to ensure compliance with R1's care plan. This oversight resulted in a finding of immediate jeopardy due to the potential for serious harm to R1.
Removal Plan
- Reeducation with nursing staff (CNAs and Licensed Nurses) on following physician orders or Speech Therapy recommendations to include level of required supervision or cueing needed, and ensuring those residents requiring supervision while eating or drinking snacks or meals, have nursing staff at the dining table or bedside table when food/fluids are in front of the resident.
- DON/designees completed an audit of current residents to validate: Speech therapy recommendations pertaining to swallowing precautions are reflected in the care plan and Kardex.
- DON/designees completed an audit of current residents to validate: Physician orders pertaining to swallowing precautions are reflected in the care plan and Kardex.
- DON/designees completed an audit of current residents to validate: Level of supervision during meals and snacks for residents with swallowing precautions are reflected in the care plan and Kardex.
- DON/designee completed random observations (audits) of dining room service or snack pass to verify that residents in need of supervision related to swallowing precautions receive assistance as per plan of care.
- DON/designee will continue these observations on varying meals or snacks.
- Results of audits will be presented to facility QAPI (Quality Assurance Performance Improvement) committee for review and any recommendations.
- Ad hoc QAPI meeting held to review this plan.
Unsanitary Food Handling and Storage Conditions
Penalty
Summary
The facility was found to have deficiencies in food preparation, storage, and distribution, which were not conducted under sanitary conditions. During an initial tour of the kitchen, the surveyor observed dirt, debris, and food particles on the floors of the kitchen, dish room, and walk-in refrigerator/freezer. The Dietary Manager (DM) acknowledged the unsanitary conditions and noted that the floors were supposed to be swept and mopped daily according to the dietary staff's daily cleaning logs. However, the logs were either missing or not initialed for 24 days, indicating a lack of adherence to the cleaning schedule. Additionally, the surveyor noted unsanitary conditions in the refrigerators located in the Alzheimer's Care Unit (ACU) and East dining room, where resident foods are stored. The refrigerators contained discolored ice and dried beverages, which posed a risk of cross-contamination. The DM confirmed that the refrigerators were not clean and were supposed to be cleaned daily. However, the daily cleaning logs did not include the cleaning of the refrigerators, and the task list only mentioned cleaning the fridge if it was dirty. Furthermore, the surveyor observed that the carts used to transport food and beverages to residents were dirty, discolored, and contained dried food matter. The DM acknowledged the carts were not clean and attempted to clean one with a wet rag, which became visibly dirty. The DM expressed that the current cleaning system was failing, as it did not hold staff accountable for maintaining cleanliness, and noted that a new checklist for cleaning would be developed to address these issues.
Failure to Inform POA of Medication Changes
Penalty
Summary
The facility failed to inform the power of attorney (POA) for health care of a resident when medication was initiated and dosage was changed. The resident was started on Tramadol as needed, and later, a scheduled Tramadol was added without notifying the POA of the risks and benefits of the medication. The facility's policy on pain management requires collaboration with the resident or their representative to develop and monitor interventions for pain management, but this was not adhered to in this case. The resident's records showed frequent pain and the use of Tramadol, both as needed and scheduled, but there was no evidence that the POA was informed of these prescriptions. The Director of Nursing confirmed that the nurse responsible for entering new orders should have notified the POA, but this did not occur. The oversight was not recognized by the facility, and no process improvement plan was implemented to address the issue.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
The facility continued the administration of a psychotropic medication, duloxetine, to a resident, R2, despite it being deemed unnecessary by the resident's psychiatry provider. R2, who had diagnoses including dementia and depressive disorder, had not experienced hallucinations for several years, which was the initial reason for the prescription of duloxetine. The psychiatry provider recommended discontinuing the medication during visits in October and November, and the resident's power of attorney agreed with this plan. However, the medication was not discontinued until December, resulting in the resident receiving unnecessary medication for over a month. The deficiency occurred due to the Director of Nursing (DON) B's failure to act on the psychiatry provider's recommendation to discontinue duloxetine. Despite receiving the provider's notes via email, DON B admitted to not reading the notes and failing to catch the recommendation for discontinuation. This oversight led to the continued administration of the medication, which was no longer necessary, as confirmed by the absence of hallucinations in the resident's documentation from February through October. The resident's power of attorney expressed concern over this missed medication change, highlighting the lapse in medication management by the facility.
Improper Food Storage in Refrigerators Poses Contamination Risk
Penalty
Summary
The facility failed to store foods brought in for residents and snacks in a manner that prevents contamination, affecting two refrigerators with the potential to impact 47 of 66 residents. During an initial tour, a surveyor observed water pooled at the bottom of the refrigerators in the east and west kitchenettes, which was dripping from the freezers over snacks and beverages. The Account Manager responsible for food service operations indicated that the west kitchenette's freezer had been dripping for several weeks, while the east refrigerator had been dripping for 1-2 weeks. Despite this, foods and beverages continued to be stored in these units, posing a risk for contamination. The Account Manager was unaware of any repairs being made to the freezers/refrigerators. It was later discovered that the dripping was due to the freezer temperatures being set too high, causing them to defrost and drip water over the stored items. The Director of Nursing confirmed that 47 of 66 residents had the potential to be affected by the improper storage of foods in these refrigerators/freezers.
Inaccurate Staffing Data Reporting Due to Clock-In Issues
Penalty
Summary
The facility failed to ensure accurate reporting of mandatory staffing information to the Centers for Medicare and Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. This deficiency was identified when the facility's submitted weekend staffing data was flagged as excessively low for two fiscal quarters in 2024. The issue arose because agency staff and nurse managers working on weekends were not clocking in, leading to underreporting of hours. The facility's time clock system was used to report PBJ data, and the absence of clock-in records for these staff members resulted in inaccurate staffing data being submitted. The Nursing Home Administrator (NHA) and Scheduler reported that the facility schedules the same number of RNs, LPNs, and CNAs on weekends as on weekdays, and agency staff also work on weekends. However, the NHA discovered that agency staff were not punching in on the facility's time clock, and nurse managers covering the floor on weekends were not clocking in either. This problem was identified in mid-September, and changes were implemented to ensure all agency staff and nurse managers' hours are now clocked into the system. Despite these changes, the facility did not provide evidence of a root cause analysis or systemic changes following the identification of excessively low weekend staffing after March 2024.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to residents and their representatives, as well as to the State Long-Term Care Ombudsman, affecting five residents. The facility's policy requires that a transfer form documenting the resident's status, diagnosis, and other pertinent information be completed and sent with the resident or provided as soon as practicable. However, in the cases reviewed, this procedure was not followed, and no written notices were found in the residents' records. Resident 49 was transferred to the hospital following an unwitnessed fall and subsequent medical complications, but did not receive a written notice of transfer. Similarly, Resident 52, who requested to go to the emergency room due to feeling unwell, was transferred without receiving a written notice or notification to the State Ombudsman. Resident 6, who was transferred twice to the hospital, also did not receive written notices of transfer or notifications to the Ombudsman. Residents 3 and 22 experienced multiple hospital transfers due to various medical conditions, including abnormal labs, fever, chills, and increased weakness. In each instance, there was no documentation of written notices of transfer or notifications to the State Ombudsman. Interviews with the residents revealed that they were not aware of their rights regarding transfers, and the facility's staff acknowledged the issue, indicating that floor nurses were responsible for completing the notices, but the process was not consistently followed.
Failure to Provide Bedhold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of bedhold policies, including the right to appeal, to four out of five residents or their representatives during hospital transfers. This deficiency was identified through interviews and record reviews conducted by the surveyor. The facility's policy, revised on 7/15/22, mandates that residents and their representatives be informed of the bedhold policy at the time of transfer, or within 24 hours. However, this procedure was not followed for residents R52, R6, R3, and R22, as no documentation of such notifications was found in their records. Resident R52 was transferred to the hospital on 1/17/24 due to health concerns, including nausea and a urinary tract infection. Despite returning to the facility on 1/25/24, there was no record of a bedhold notice being provided. Similarly, resident R6, who was transferred to the hospital on 9/22/24 for myoclonic jerking movements, did not receive a bedhold notice for this or a previous transfer. Resident R3, with multiple hospital transfers for various health issues, also lacked documentation of bedhold notifications for each instance. Resident R22 experienced several hospital transfers due to conditions such as left-sided weakness, facial drooping, and increased fluid retention. Despite these multiple transfers, there was no evidence of bedhold notifications being provided. Interviews with the Nursing Home Administrator and Director of Nursing revealed that floor nurses were responsible for completing these notices, but the facility acknowledged ongoing issues with incomplete transfer information. A Process Improvement Plan was developed to address these deficiencies, but compliance concerns persisted.
Failure to Notify Physician of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to consult with a physician as required by ordered parameters for a resident with a significant weight increase. The resident, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, hypertensive heart, and chronic kidney disease with congestive heart failure (CHF), experienced a weight gain of 5.2 lbs over a five-day period. According to the resident's physician orders, the Heart Failure Clinic (HFC) should be contacted if the resident gains 3 lbs in one day or 5 lbs in a week. Despite this, there was no documentation indicating that the HFC or the primary physician was informed of the weight gain. Interviews with facility staff, including a Registered Nurse (RN), Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed the oversight. The RN acknowledged the weight gain and the requirement to notify the HFC, but no such notification was found in the resident's progress notes. The LPN and DON also confirmed the absence of any assessments or notifications related to the resident's weight gain and CHF status. The Nursing Home Administrator stated that while there is no specific policy for following physician orders, it is a standard practice expected of the staff.
Medication Administration Error Observed
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 6.67% error rate observed during a medication administration task. The surveyor observed two errors out of 30 medication opportunities. One significant error involved an LPN who almost administered eye drops prescribed for one resident to another resident. The LPN was observed preparing two ophthalmologic solutions and incorrectly identified them as belonging to the resident intended for administration. Upon further inspection by the surveyor, it was revealed that the eye drops were labeled for a different resident. The LPN acknowledged the mistake after being prompted by the surveyor to verify the medication label against the MAR. The LPN admitted to focusing on the medication match rather than the resident's name on the label. The Director of Nursing confirmed that the facility's policy requires nurses to verify the correct medication with the order in the MAR before administration. This incident highlights a lapse in following the established medication administration procedures, which could have led to administering the wrong medication to a resident.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during wound care and incontinence care. A resident on Enhanced Barrier Precautions (EBP) for a pressure injury on the left ear was observed receiving wound care from an LPN who did not perform hand hygiene between glove changes. The LPN donned a gown and gloves before entering the resident's room, but after removing the dressing and cleansing the area, the LPN changed gloves without washing hands. The LPN continued to handle the wound and supplies without proper hand hygiene, and at one point, touched the resident's ear and head without gloves. The LPN acknowledged the lapse in protocol when questioned by the surveyor. Additionally, a CNA was observed providing incontinence care to another resident without removing gloves or performing hand hygiene after cleaning the resident's perineal area. The CNA continued to dress the resident and handle clean clothing with contaminated gloves. When interviewed, the CNA confirmed that gloves should have been removed and hand hygiene performed after completing perineal care. The Director of Nursing expressed disappointment in these observations, noting that staff are regularly educated on EBP and hand hygiene practices.
Failure to Report Physical Abuse Incident to Law Enforcement
Penalty
Summary
The facility failed to adhere to its policy for reporting a reasonable suspicion of a crime, as required by Section 1150B of the Social Security Act. An incident occurred where a resident, while attempting to maneuver his wheelchair, became angry and hit another resident on the back of the head. This incident was witnessed by an LPN who intervened immediately, separated the residents, and assessed the victim, finding no physical injury or pain. The LPN notified the hospice provider, the victim's Activated Power of Attorney, and the Director of Nursing, but law enforcement was not informed. The Nursing Home Administrator later acknowledged that the incident should have been reported to local law enforcement, as the facility's policy includes physical abuse as a reportable crime. The failure to report the incident to law enforcement was a deviation from the established procedures, which require immediate reporting of such incidents, but not later than two hours after the allegation is made. This oversight affected one of the three residents reviewed during the survey.
What surveyors are citing around you — mapped
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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 11 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marshfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norwood Health Ctr-central | 1 mi | ★★★★★ | 2 | 0 |
| North Shore Healthcare At Marshfield | 3.3 mi | ★★★★★ | 0 | 0 |
| Colonial Health Services | 17.4 mi | ★★★★★ | 2 | 2 |
| Abbotsford Health Care Center | 18.9 mi | ★★★★★ | 7 | 0 |
| Clark County Rehabilitation & Living Center | 25.6 mi | ★★★★★ | 18 | 0 |
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