Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Ridge Center during CMS and state inspections, most recent first.
Unsafe and Unclean Resident Rooms and Missing Bed Linens: A walk-through with the DON found multiple resident rooms with cracked and missing caulking, debris buildup, cobwebs, stained surfaces, torn flooring, damaged walls, and other cosmetic defects. Two residents were also found without sheets on their bariatric beds; one resident said the facility often ran out of sheets large enough for the bed, and the DON found only one sheet on the linen cart while additional sheets were available in laundry.
Infection control deficiencies were identified involving damaged resident mobility equipment and missing TB screening documentation. A resident’s wheelchair, another resident’s rollator/walker, and a third resident’s geri-chair were observed with tears exposing inner padding, and the DON confirmed the damaged wheelchair. In addition, three residents had no documentation of TB Two Step skin testing on admission, and the DON confirmed that no TB Two Step PPD tests were administered per facility policy.
Care plans were not kept current for multiple residents, and interdisciplinary care planning was not ensured for one resident. One resident’s care plan still listed an e-cigarette even though the resident said he no longer used one and only used smokeless tobacco, and the DON confirmed the smoking list reflected smokeless tobacco use. Another resident had prior MD orders for a left eye shield after cataract surgery, but was observed without the shield and the care plan had not been revised to match current orders.
Failure to follow physician orders for a resident with a right ankle contracture related to positioning and Medex boots. The resident was observed without the ordered BLE boots on multiple occasions, despite TAR entries showing removal and skin checks and task documentation for heel/elbow protectors. During an observation with the NHA, the boots could not be found, and an employee’s statement that they had been applied was not consistent with what was observed.
A resident was observed accessing an unlocked courtyard storage bench and removing pruning shears, and the bench also contained a pointed metal shovel, a rounded shovel, and a small rake. Another resident’s wheelchair had rips and tears in the seat pad and a screw protruding through the left arm pad; the resident reported the screw scratched her arms and the metal wheels bumped her knuckles, and the DON confirmed the issue.
Food was not temped for always available menu items before leaving the kitchen, and temperature logs showed only main and alternate meal items were recorded. A dietary manager could not confirm when hot always available items were served, and residents reported the food was often burnt or overcooked; a test tray item was also found to be flavorless and overcooked.
Failure to Honor Meal Preferences and Provide Alternate Choices: Residents reported that ordered meals and preferred items were not being provided, including repeated receipt of unwanted items and missed requests for alternate selections. The kitchen phone used for meal preference orders was not answered, messages were left without response, and the Administrator later found the line disconnected from the wall, preventing residents from obtaining requested meal choices.
The facility failed to store, prepare, distribute, and serve food according to professional food safety standards and did not follow proper kitchen sanitation practices. Surveyors found missing dish machine temperature log entries, debris in the handwashing sink, a package of shredded cheese not tightly sealed in the walk-in refrigerator, and a Dietary Aide working in the kitchen without proper facial hair restraint.
Improper Trash Storage and Disposal: The kitchen trash can near the handwashing sink was observed multiple times with the lid unsecured and overflowing, with coffee grounds spilling into the sink. In a separate observation, a clear bag of trash was left on the sidewalk outside the service entrance for about 20 minutes before being removed, and the Facility Administrator acknowledged the bag had been left there.
Incomplete and inaccurate resident records were found for four residents. Two residents had house supplements documented as 100% consumed even though the drinks were still sitting on the bedside table, an LPN acknowledged the documentation did not match what was observed, one resident had no left arm trough present despite shift-by-shift documentation, and another resident had Medex boots documented as in place and removed for skin checks even though the boots were not on the resident and could not be located.
Failure to provide appropriate foot care was identified for two residents. One resident stated he needed to see a podiatrist and that his feet looked bad; the DON later agreed the facility was not following the MD orders or care plan for ADL foot care. Another resident was found to have foot care needs not being followed per MD orders or the care plan, and the DON stated the resident’s toenails would be clipped.
A resident with significant wt loss was served lunch without the ordered extra sandwich and fruit. Her tray did not include the physician-ordered items intended to support her nutritional needs, and kitchen staff said they were unaware of the order. A recent nutritional assessment documented that she was underweight and had ongoing significant wt loss.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
The facility failed to ensure food was consistently served at safe and appetizing temperatures, as required by the FDA Food Code and its own policy. Temperature logs for a two-week period showed missing entries and multiple cold items documented above 41°F before leaving the kitchen. During the survey, several residents reported that their food was not hot when served. Direct temperature checks of a delivered tray showed one hot item at 120.7°F, another hot item at 112.1°F, and ice cream at 23.5°F, confirming that hot foods were not always hot and cold foods were not always cold at point of service.
A resident receiving scheduled morphine for pain also had PRN morphine ordered and was supposed to have pain level and non-pharmacological interventions documented each shift. The MAR showed the PRN opioid was given multiple times, but the resident’s pain level was not documented before administration, even though the medication was recorded as effective afterward. The DON confirmed the missing documentation.
Kitchen sanitation and food storage deficiencies were observed throughout the food service area. Surveyors found sludge in the ice machine, a soiled hand sink, leftover food on the floor, unlabeled chemicals on a cart, cleaning cloths left on counters, soiled equipment and vents, food items that were not labeled or dated, and improper storage of clean items and equipment. The dish machine log was incomplete, food temp logs were missing entries, the cleaning schedule was not filled out, and the menu posting and substitution log did not match the approved menu changes.
The facility failed to keep accurate resident records for several residents. Transfer forms for two residents listed incorrect acute care transfer dates, a PEG tube feeding order and MAR entries for one resident did not match the ordered volume, and an activities assessment for another resident was signed by an AD before that staff member was qualified.
The facility posted inaccurate daily nurse staffing information for one of the reviewed days, displaying incorrect Hours Per Patient Day (HPPD) and census figures compared to the verified staffing and census records. The posting showed lower HPPD and a higher census than actually documented, and the administrator later confirmed that the displayed staffing and census information for that day was incorrect.
The facility failed to follow a resident’s diet order for double vegetable portions and large breakfast portions, despite a policy requiring menus and meals to meet residents’ nutritional needs and be served as written. A resident with a consistent carbohydrate diet order did not have the double vegetable portion instruction printed on tray tickets, and was observed receiving the same number of potato wedges as other residents. The Dietary Manager confirmed that extra portion orders should appear on tray tickets and acknowledged that this resident’s tickets previously included, but no longer showed, the extra portion instructions.
Missed Quarterly Restraint Assessment: A resident with cerebral palsy and involuntary trunk movements had a wheelchair positioning belt order, but the required restraint re-evaluation was not completed on a quarterly basis. Surveyors reviewed the record, confirmed the last restraint evaluation/reduction had been done months earlier, and the ADM acknowledged the lapse. The facility policy required monthly reassessment for three months, then quarterly.
A resident with documented PTSD and exposure to disaster, war, and other hostilities was not care planned for PTSD until the care plan focus was added later. Corporate nursing confirmed the resident had not been care planned for PTSD before that point.
The facility failed to update care plans for two residents. One resident’s plan did not include the one-on-one activities that were being provided and documented by the AD, and another resident’s plan still listed an old PEG tube measurement even though the current baseline length had changed to 26 cm per the physician order and the DON’s confirmation.
Failure to follow ordered oxygen settings. A resident was observed receiving oxygen via nasal cannula at 4 L/min even though the active MD order directed 2 L/min. An LPN confirmed the oxygen was set above the ordered rate, and the DON stated that any increase would require documentation of a change in condition and updated MD orders, which were not present in the record.
A facility failed to ensure that nine residents on renal and/or 2 gram sodium diets received the ordered low sodium marinara meat sauce at lunch. The tray tickets and the facility’s recipe and diet guide indicated the sauce should have been served, but the dietary manager and HCSG DO stated the low sodium sauce was not available, and the facility did not follow its therapeutic diet policy.
A resident with a history of Alzheimer's disease and resistance to care began frequently refusing multiple prescribed medications shortly after admission. The care plan documented the resident's resistance but failed to include measurable goals or interventions to address the medication refusals. The DON confirmed the care plan was not completed in a timely manner.
A resident's psychiatric telemedicine notes contained incorrect information in the history of present illness section, including age, admission date, first name, and health care surrogate's name, due to details being copied from another resident with the same surname. The DON confirmed the error during the investigation.
A medicine cup containing a half tablet of Senokot was found left on the bedside table of a resident during a medication pass performed by an employee. The DON verified the incident, and a review of other residents showed this was an isolated occurrence. Facility leadership acknowledged the deficiency after it was observed and reported.
Multiple incidents of missing controlled medications occurred, including discrepancies in narcotic counts, missing doses, and absent documentation. In one case, a resident's Hydrocodone was short by thirty tablets, while another resident was missing twenty-six doses of Oxycodone with missing logs. Several other residents' medications intended for destruction were also unaccounted for, and an LPN was found responsible for a separate Hydrocodone diversion. Required shift-to-shift counts and secure storage procedures were not consistently followed, resulting in substantiated misappropriation and drug diversion.
A resident did not receive multiple physician-ordered wound treatments as documented in the Treatment Administration Records over a three-month period. Orders for cleaning and treating various wounds, including a DTI, venous ulcers, abrasions, a diabetic wound, and stage 2 pressure ulcers, were not completed on several dates. This deficiency was confirmed by facility leadership after review of records and staff interviews.
Surveyors found that several beds had excessive gaps at the foot without gap fillers, creating entrapment hazards. One resident with severe cognitive impairment and a history of falls suffered an arterial tear after his arm became trapped between the mattress and bed rail. Critical steps in the bed safety evaluation were not completed or documented, and the hazards were confirmed by staff interviews.
A resident with severe cognitive impairment and a history of falls suffered a serious arm injury after being left unsupervised for over two hours, due to a nurse aide leaving without notifying a supervisor and a delayed shift change. The resident was found on the floor with his arm entrapped between the bed and bed rail, and a bed safety evaluation had not been fully completed.
Surveyors identified Immediate Jeopardy when a hand washing sink in a main dining area was found to have dangerously high hot water temperatures, with readings as high as 139.2°F. The maintenance director had not been routinely monitoring this sink, and it was discovered that the water supply was linked to the kitchen, which required higher temperatures. Multiple residents were able to access this sink independently, placing them at risk for serious burns.
A resident with a tracheostomy did not have the required spare trach tube and ambu bag at bedside as ordered, and staff took over 15 minutes to locate the correct supplies, with confusion over trach sizing and staff responsibilities. Additionally, another resident ordered for continuous oxygen was found without oxygen in place, and the LPN had to correct the oxygen delivery after it was identified.
Two residents experienced failures in pain management, including lack of timely assessment, incorrect dosing, and failure to implement nonpharmacological interventions as ordered. One resident was left unassessed for pain despite clear signs of distress, and both residents had discrepancies in medication administration and documentation, resulting in unmet pain management needs.
Multiple residents reported prolonged wait times for assistance with ADLs, including incontinence care and bathing, due to insufficient staffing. Observations confirmed unanswered call lights and missed care tasks, while staff interviews revealed frequent call-ins and difficulty covering shifts. Family members and resident council meetings echoed concerns about inadequate staffing and unmet resident needs.
The facility did not ensure that residents received their mail on Saturdays as required by policy. Residents reported missed Saturday mail delivery during a council meeting, and the Administrator confirmed that mail delivery was expected on weekends but had not occurred due to staffing shortages in the activities department.
Five residents on dialysis did not receive their prescribed phosphate binder medications with meals as ordered. Instead, these medications were given during routine med passes or after residents had left for dialysis, rather than at meal times. Staff interviews and MAR reviews confirmed that the medications were not administered as prescribed, affecting residents with complex medical conditions requiring strict adherence to medication timing.
A staff member served pork using tongs instead of a 2 oz scoop, resulting in residents not receiving the correct portion size as required by the menu. The error was identified after two halls had already been served, and the issue was observed during a kitchen pathway review.
A meal service was delayed for 19 residents when the facility ran out of prepared food, causing lunch to be served 45 minutes late. Staff had to prepare additional food under the direction of the Corporate Director of Operations, resulting in the final resident being served nearly an hour after the shortage was identified.
Five bottles of unlabeled shampoo were observed in a male shower room during an inspection, with an LPN confirming the lack of resident identification on the bottles. This failure to label personal care items was identified as a breach of infection control procedures in one of two shower rooms inspected.
A resident who was cognitively intact was left in a soiled brief for approximately 40 to 45 minutes after activating the call light and repeatedly calling for assistance. Despite staff being present in the hallway, the resident's needs were not promptly addressed, and care was only provided after multiple delays and staff handoffs. The resident reported feeling undignified and distressed by the prolonged wait.
A resident reported waiting over two hours in pain for bladder care from an LPN, who responded with attitude and delayed assistance. The resident also experienced rude behavior from a CNA during care. Multiple residents expressed concerns about staff retaliation when voicing grievances, indicating the facility did not ensure residents could voice complaints without fear of reprisal.
Two residents experienced neglect when one did not receive multiple doses of prescribed medications, despite their availability, and another waited over 30 minutes for a snack, was given food not appropriate for her pureed diet, and had it taken away, causing distress. Staff present did not respond promptly to the residents' needs, resulting in unmet care requirements.
A required discharge MDS assessment was not completed for a resident who had been admitted and later discharged. The omission was identified during a record review and confirmed by the MDS Coordinator, who acknowledged the oversight.
Surveyors found that two residents did not receive care as outlined in their care plans: one resident experiencing pain did not receive timely assessment or nonpharmacological interventions, and another resident with a tracheostomy did not have the required spare trach kit at the bedside. Staff failed to follow established interventions, and documentation was incomplete or inconsistent, as confirmed by the DON and other staff.
Unsafe and Unclean Resident Rooms and Missing Bed Linens
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment after a walk-through with the administrator identified multiple environmental deficiencies in resident rooms #15, #16, #24, #28, #32, #33, #35, #36, #37, #39, and #42. Observations included cracked and missing caulking around sinks and countertops with dark, discolored debris buildup, blackish toilet bases with missing pieces, dirty buildup and cobwebs in bathroom corners, missing paint chips on bathroom walls and around doors, peeling baseboard, cracked and broken floor tiles, torn linoleum flooring, rips and tears in wallpaper, a hole in a bathroom door, black stains in a sink, and brownish stains on the sink, floor, and outside of a bathroom door. One room also had a resident wheelchair cushion with heavy food crumb and dirt buildup underneath, and another had stained privacy curtain and bed sheet. During a tour with the DON, two residents, #76 and #130, were found without sheets on their bariatric bed. Resident #76 stated they often run out of sheets big enough for the bed and said staff told her, "Your just going to wet them anyway." Resident #130 stated he did not know why he did not have a sheet that day but said they never put one on the bed. The DON checked the linen cart and found only one sheet available, while several sheets were present in laundry but had not been placed on the unit for use.
Infection Control Deficiencies in Resident Equipment and TB Screening
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program related to resident ambulatory equipment and tuberculosis screening. During observation and interviews, Resident #102’s wheelchair was found to have rips and tears across the front edges of the seat exposing the inner padding, and the DON confirmed the exposed padding and removed the chair. During a facility walk-through, Resident #36’s rollator/walker seat was observed with exposed inner padding due to a tear in the right side of the plastic seat covering, and Resident #98’s geri-chair was observed with tears down both sides of the back rest exposing the inner padding. The report stated these porous surfaces could not be cleaned effectively. The facility also failed to document TB Two Step skin testing for Resident #126, Resident #37, and Resident #110 after admission. Review of the immunization tab for each resident showed no documentation of the TB Two Step skin test, and the DON confirmed that no TB Two Step PPD skin tests were administered at the time of admission per the facility TB policy. The facility policy stated that all patients will be screened for TB on admission according to CDC and local/state health department regulations and recommendations, and CDC guidance noted that skin tests should be administered to all new residents and employees as soon as residency or employment begins unless there is documentation of a previous positive reaction.
Care Plans Not Revised to Match Current Resident Needs
Penalty
Summary
The facility failed to develop, review, and revise care plans within 7 days of the comprehensive assessment and failed to ensure an interdisciplinary approach to care planning for Resident #91, Resident #115, and Resident #11. Resident #11’s care plan dated 05/05/25 indicated that an e-cigarette was to be kept and charged at the nursing station, but during an interview on 06/16/26 the resident stated he no longer used an e-cigarette and only used smokeless tobacco; the DON later verified that the resident was only using smokeless tobacco as shown on the facility smoking list. Resident #115 had a cataract procedure with MD orders dated 04/07/25 to wear an eye shield to the left eye, but during observations on 06/16/26 and 06/18/26 the resident was not wearing the eye shield, and the DON confirmed there were no current MD orders for the left eye shield even though the care plan had not been revised. The report also identifies Resident #91 as part of the deficiency involving lack of interdisciplinary care planning.
Failure to Follow Orders for Medex Boots
Penalty
Summary
The facility failed to follow physician orders for Resident #10, who had a diagnosis of contracture of the right ankle, related to positioning and wearing Medex boots to both lower extremities. The resident had an order for Medex boots to BLE with the licensed nurse to remove and assess skin integrity every shift, but on 06/18/2026 at 12:05 PM the resident was observed without the boots in place. The Treatment Administration Record for June 2026 showed the boots were removed and skin assessed at 01:17, 10:40, and 19:05, with these entries signed by Employee #67. The resident’s tasks for 06/18/26 documented preventative skin care for heel/elbow protectors at 10:40 AM and 7:05 PM by Employee #102, yet at the 10:40 AM observation the resident was not wearing anything on either foot. On 06/22/26 at 10:30 AM, the resident was again observed without Medex boots on either lower extremity, and this was confirmed during an observation with the NHA at 11:45 AM. The NHA stated the boots could not be found, and Employee #114 noted the boots were applied at 11:04 AM, although this was observed not to be true. The DON stated she would discuss discontinuing the order with the Medical Director because the resident was noncompliant, but the tasks and TAR did not show that.
Accident Hazards in Courtyard and Wheelchair
Penalty
Summary
The facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. In the courtyard, which was not locked and was accessible to residents, a resident was observed opening a storage bench and removing pruning shears to clear weeds away from the gazebo. When the surveyor inspected the bench, it contained pruning shears, a hand held metal shovel with a pointed end, a hand held shovel with a rounded end, and a small rake. The DON and the NHA were brought to the courtyard and agreed the items did not need to be in the storage bench, and the DON confirmed several residents would be able to get into the courtyard without staff assistance. The facility also failed to address a wheelchair hazard for another resident. The resident’s wheelchair was observed with rips and tears across the seat pad and a screw protruding through the left arm pad. The resident stated the screw scratched her arms and that the metal wheels inside the circle bumped her knuckles. The DON confirmed the screw was protruding through the left arm pad and stated she would get the resident another wheelchair.
Food not temped and meals often overcooked
Penalty
Summary
The facility failed to ensure that all food was temped before leaving the kitchen and failed to ensure safe and appetizing temperatures for food items, including always available menu items. A review of HCSG policy #6 stated that food will be prepared to conserve nutritive value, flavor, and appearance, and will be palatable, attractive, and served at proper safe and appetizing temperatures. HCSG policy #16 stated that all foods are prepared in accordance with the FDA Food Code. On 06/17/26, the surveyor reviewed the June 2026 food temperature logs with the Dietary Account Manager and found that only the main meal and alternate meal items were being temped, while the always available items were not recorded. The same issue was found when the May 2026 logs were reviewed, with no recorded temperatures for always available menu items. When asked about resident orders from the always available menu, the Dietary Account Manager stated he did not take the orders and was not aware of any residents ordering those items in June 2026. He stated that only cold sandwiches were ordered in May 2026 and that they were not temped. When asked about hot always available menu items ordered during 2026, he stated that hot items had been made this year but he did not remember when. Resident #14 stated that the food was bad and often burnt. During a test tray on 06/18/26, the fiesta corn was described by three surveyors as flavorless and overcooked. Resident #63 also told surveyors that the food was often overcooked.
Failure to Honor Meal Preferences and Provide Alternate Choices
Penalty
Summary
The facility failed to provide food that accommodated resident preferences and appealing options of similar nutritive value for residents who chose not to eat the food initially served or who requested a different meal choice. The deficiency was identified through record review, resident interviews, and staff interviews, and involved residents #32, #40, and #9 in a facility with a census of 115. The dining and food preferences policy stated that residents who refused food or beverages would be offered an alternative selection of comparable nutrition value and that the alternative meal or beverage would be provided in a timely manner. Resident #32 stated she liked boiled eggs but kept receiving scrambled eggs and said she was not getting the food she ordered because kitchen staff never answered the phone, despite placing orders before the cut-off time. Resident #40 reported that the food was terrible, that too much fish and chicken were served, and that he left a voicemail on the kitchen phone requesting a fried bologna sandwich for lunch but received the regular tray instead. Resident #9 also reported having trouble getting meal orders fulfilled because no one answered the kitchen phone and messages left for meal requests were not resulting in the ordered food being provided. The Administrator later stated he found the kitchen phone line used by residents for meal preference orders was disconnected from the wall.
Food Safety and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, and it also failed to follow proper sanitation practices in the kitchen. During a follow-up kitchen observation, the dish machine temperature log did not contain recorded temperatures for the breakfast dishes washed that day, and the HCSG District Manager verified that the temperatures had not been recorded. The handwashing sink contained a substance that appeared to be coffee grounds, which the Dietary Account Manager stated had likely fallen out of the trash can. The observation also identified one package of shredded mild cheddar cheese in the walk-in refrigerator that was not sealed tightly. In addition, a Dietary Aide was observed working in the kitchen without a hair restraint covering his facial hair, and the HCSG Dietary Manager directed him to put on a beard net. The report states that these findings involved the kitchen and food service practices for a census of 115 residents.
Improper Trash Storage and Disposal
Penalty
Summary
The facility failed to store and dispose of garbage and refuse properly. During survey observations, the trash can located in the kitchen near the handwashing sink was observed full of garbage with the lid not secured on three separate occasions. On the first observation, the trash can was full and unsecured, and the Dietary Account Manager closed the lid; coffee grounds from the overflowing trash had spilled into the handwashing sink. The same condition was observed again shortly afterward, with the lid still not secured, and the Dietary Account Manager closed it again. On a third observation, the kitchen trash can near the handwashing sink was again full of garbage with the lid not secured, and the Dietary Account Manager closed the lid and moved the container out of the kitchen into the service hallway. In a separate observation, a clear bag of trash was found on the sidewalk outside the service entrance door and remained there for about 20 minutes before being removed and placed into the dumpster. Two staff members confirmed the bag was on the ground outside the service entrance door, and the Facility Administrator acknowledged that the bag of trash had been left outside the service entrance door.
Incomplete and Inaccurate Resident Records and Care Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for four sampled residents. For two residents, house supplements were observed sitting on the bedside table while the Medication Administration Record later showed 100 percent consumed, even though the supplements had not been drunk at the time of observation. When questioned, the assigned LPN stated she thought one cup may have been left over from breakfast and said she would go back later and change the documentation if needed. The facility also failed to ensure accurate documentation and care related to ordered equipment and treatments. One resident had an order for a left arm support cushion/trough to be monitored each shift, yet observation showed no left arm trough present on the wheelchair while the treatment record had been signed every shift. Another resident had an order for Medex boots to both lower extremities with skin checks every shift, but the boots were not on the resident during observation and could not be found when staff attempted to locate them; the TAR and task records had been signed as if the care had been completed.
Failure to Provide Appropriate Foot Care
Penalty
Summary
Provide appropriate foot care was not ensured for two residents reviewed for foot health. Resident #27 stated he needed to see a podiatrist and that his feet looked bad. During an interview with the DON, after she looked at Resident #27’s feet, she agreed the facility was not following the physician’s orders or the care plan for his ADL foot care and stated she would schedule a podiatry appointment. Resident #27 had a physician order for podiatry consult as needed/indicated and treatment for health and comfort, and his care plan included assistance with ADL care, daily skin observation with ADL care, offloading heels in bed, and wound treatment as ordered. Resident #22 was also reviewed for foot care concerns. After the DON spoke with Resident #22 and looked at her feet, she agreed the facility was not following the physician’s orders or the care plan for ADL foot care and stated she would get the resident’s toenails clipped. The report states the DON later said the toenails would be clipped that day.
Missed Ordered Meal Items for Resident With Significant Weight Loss
Penalty
Summary
Failure to provide Resident #22 with a nourishing, palatable, well-balanced diet that met her daily nutritional and special dietary needs occurred when her lunch tray was served without the additional sandwich and additional serving of fruit ordered by the physician on 05/19/26. The order had been put in place because of significant weight loss. Resident #22 was admitted at 106 pounds and her most recent documented weight on 06/10/26 was 86.2 pounds, reflecting a loss of 19.8 pounds, or 18.7% of her body weight since admission. The quarterly nutritional assessment completed on 06/16/26 at 11:50 AM documented that she was underweight, had current significant weight loss, and had an order for an assorted sandwich and assorted fruit with every lunch and dinner meal. When the missing items were brought to nursing staff's attention, the Unit Manager went to the kitchen, where staff stated they were unaware of the order.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure food and beverages were palatable, attractive, and maintained at safe and appetizing temperatures in accordance with the FDA Food Code and the facility’s own policy. The facility’s policy required cold foods to be held at 41°F or below and hot foods at 135°F or above before leaving the kitchen, and hot foods to be 120°F or above at point of service. Review of the service line checklists for 02/01/2026–02/15/2026 showed missing temperature documentation for prepared food items and eleven cold food items recorded at 42°F before leaving the kitchen, which exceeded the FDA Food Code limit. The facility was not consistently taking and documenting all food temperatures prior to sending food to residents. During the complaint survey, multiple residents reported that their food was not hot when served, with one resident stating the food was not always hot, another stating the food was not hot when received, and another stating that the food “sucks.” At 12:58 PM on the survey date, the dietary manager took temperatures of a meal tray for a specific room, finding spaghetti with meat sauce at 120.7°F, green beans at 112.1°F, and vanilla ice cream at 23.5°F. While the spaghetti met the 120°F point-of-service expectation, the green beans were below 120°F, and prior documentation showed cold foods leaving the kitchen above 41°F. These observations and interviews demonstrated that hot foods were not consistently served hot and cold foods were not consistently served cold, resulting in failure to follow the FDA Food Code and the facility’s policy and procedure.
Failure to Document Pain Level Before PRN Morphine Administration
Penalty
Summary
Resident #14 was receiving scheduled morphine sulfate extended release for pain and also had an order for morphine sulfate 30 mg every 6 hours as needed for pain. The resident was additionally ordered to have pain level and non-pharmaceutical interventions documented every shift, with pain assessed on a 0-10 scale. The facility policy stated that reasons for PRN pain medications would be documented. Review of the MAR for February 2026 showed the resident received PRN morphine sulfate six times, but there was no documentation of the resident’s pain level before the medication was given. The medication was documented as effective in relieving pain. On 02/18/2026, the DON confirmed the pain level had not been documented before administration of PRN pain medications and stated the MAR had been revised to include a place for pain level and non-pharmacological interventions to be recorded before medication administration.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, and failed to follow proper sanitation practices for the kitchen and food preparation equipment. During an initial walkthrough of the kitchen, surveyors observed pink-colored sludge inside the ice machine, a mildew smell around the outside of the ice machine, a soiled hand washing sink in the dining room, two containers of leftover food on the dish room floor, an unlabeled chemical bottle without a lid on a push cart, cleaning cloths left on countertops instead of in sanitized water, and multiple pieces of soiled or improperly stored equipment and surfaces, including a soiled can opener, microwave, toaster crumb tray, convection ovens, vents, knife rack, trash can lid, ice scoop holder, and pantry refrigerator. Additional observations included bread that was not dated, red gelatin and cut yellow squash that were not labeled or dated, clean stock pots not stored upside down, an oven rack on the floor, mop equipment beside the bread rack, and heavy ice buildup in the walk-in freezer. The dish machine had not been working the previous evening, and the three-compartment sink log was missing water temperature and sanitizer PPM entries until employee #48 filled them in when asked. Surveyors also reviewed the service line checklist and found missing temperatures for food items, with eleven cold food items documented at 42 degrees Fahrenheit before leaving the kitchen. The cleaning schedule posted for the kitchen was not filled out, and no current weekly cleaning schedule was posted. On follow-up visits, the same cart in the dish room still had soiled and clean items together, one oven rack was again on the floor, the menu posting did not match the menu week at a glance, and the menu substitution log did not reflect the menu change that the RD was supposed to approve per facility policy. Later observations showed the outside of the ice scoop holder was still dusty and the container holding bread crumbs was open to the air with the lid off.
Inaccurate resident records and assessments
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents reviewed in the survey sample. For two residents, transfer assessments contained incorrect transfer dates: one resident was transferred to an acute care facility on 12/26/25, but the transfer form listed 10/31/25, and another resident had two acute care transfers documented with incorrect dates on the transfer forms. A Corporate RN confirmed the dates on the transfer forms were incorrect. The facility also had inaccurate documentation related to tube feeding and resident assessments. For one resident with a PEG tube feeding order, the physician's order initially stated Jevity at 82 ml per hour for 20 hours to total 1400 ml in 24 hours, but the DON confirmed that 82 ml per hour for 20 hours equals 1640 ml and the order was rewritten to reflect 1640 ml. The MAR also documented 1400 ml on day shift and 1400 cc on night shift, which the DON stated was a documentation error. In addition, an activities assessment for another resident was signed by an Activity Director before that staff member had completed or was enrolled in the required class to be a qualified AD, and the Administrator and Activity staff confirmed the assessment was completed before the staff member was qualified.
Inaccurate Posting of Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to ensure the accuracy of its posted daily nurse staffing information for one of 20 reviewed days. Review of the nurse staffing posting dated 07/06/25, as viewed on 02/18/26, showed the posted Hours Per Patient Day (HPPD) as 2.19 and the posted facility census as 109 residents, while the actual verified staffing documentation and census reports provided by the administrator showed an HPPD of 2.58 and an actual census of 105 residents for that date. During an interview on 02/19/26 at 11:00 AM, the administrator confirmed that the posted staffing information contained incorrect HPPD and census data, resulting in inaccurate staffing and census information being displayed for that day. No specific residents, medical histories, or clinical conditions were identified in the report as being directly involved in or affected by this deficiency.
Failure to Provide Ordered Double Vegetable Portions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with proper portion sizes as ordered, in accordance with its own menu and nutrition policies. The facility’s Healthcare Services Group policy titled “Menus” states that menus will be planned in advance to meet residents’ nutritional needs, will use standardized recipes and nutrient analysis, and will be served as written unless substitutions are made and logged. Despite this, surveyors found that residents were not consistently receiving the ordered portions, specifically related to extra vegetable servings. Resident #91 had a diet order written for a consistent carbohydrate diet with regular texture, thin liquids, double vegetable portions, and large portions for breakfast. On review of the resident’s diet tray ticket on one observation date, the ticket did not specify double vegetable portions, and the resident had already finished the meal, so the actual portions could not be verified. On another observation date, the tray ticket again did not specify double vegetable portions, and the resident was observed receiving three potato wedges, the same amount as other residents, rather than an increased portion. The Dietary Manager acknowledged that orders for extra portions should appear on tray tickets so dietary staff are aware, and stated that this resident’s tray tickets previously included instructions for extra portions but no longer did, without knowing why this change occurred.
Missed Quarterly Restraint Assessment
Penalty
Summary
The facility failed to complete the required quarterly restraint assessments for Resident #6, who had a physician’s order dated 04/22/25 for a positioning device/belt to the wheelchair while up in the wheelchair due to cerebral palsy and involuntary movements of the core/trunk area. The record review showed that the last restraint evaluation/reduction was completed on 05/29/25, even though the evaluation was required to be completed quarterly. During the survey, the Administrator was notified and confirmed on 02/18/26 that the quarterly evaluation had not been completed. The facility policy reviewed during the survey stated that patients with a restraint are to be re-assessed monthly for three months, then quarterly, and with any significant change in condition or in accordance with state regulations.
Failure to Develop a Comprehensive Care Plan for PTSD
Penalty
Summary
Resident #3 had diagnoses of PTSD and exposure to disaster, war and other hostilities documented on 01/20/26. Review of the comprehensive care plan showed that a focus for the resident’s past trauma, described as feeling upset when reminded of a stressful experience from the past related to PTSD, was not initiated until 02/17/26. On 02/18/26 at 11:27 AM, Corporate Nurse #156 confirmed that Resident #3 had not been care planned for PTSD until 02/17/26.
Care Plans Not Updated for One-on-One Activities and PEG Tube Length
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents based on changes in their care needs. For Resident #50, the activity participation record showed that most activities provided were one-on-one activities, and the Activity Director confirmed the resident was on the one-on-one program list. However, the resident’s care plan did not include one-on-one activities. For Resident #47, the physician ordered PEG tube placement checks before each feeding, flush, or medication administration by measuring the tube length, with a baseline length of 26 cm. The resident’s comprehensive care plan still listed the PEG tube as 22 cm at the base, which the DON confirmed was an old measurement. The DON stated the care plan had not been updated when the PEG tube was replaced and the length changed.
Failure to Follow Ordered Oxygen Settings
Penalty
Summary
The facility failed to follow a physician's order for oxygen administration for Resident #20. On 02/18/26 at 9:19 a.m., observation showed the resident receiving oxygen via nasal cannula at 4 liters per minute, while the active physician order in the record directed oxygen at 2 liters per minute via nasal cannula. During the same observation, Nurse #111 confirmed the oxygen was set at 4 liters per minute and verified that the current order was for 2 liters per minute. The DON stated that any increase in oxygen flow rate would require documentation of a change in condition and updated physician orders, but by 9:40 a.m. on 02/18/26 the medical record did not show documentation of a change in condition or updated physician orders to support the higher oxygen setting.
Therapeutic Diets Not Followed for Residents on Renal and 2 Gram Sodium Diets
Penalty
Summary
The facility failed to ensure that residents on therapeutic diets received the ordered renal diet and 2 gram sodium diet. A review of Healthcare Services Group policy 008 on Therapeutic Diets showed that therapeutic diets are physician-ordered or delegated to a registered or licensed dietitian as part of treatment for a disease or clinical condition. During survey observation, record review, resident interview, and staff interview, it was found that nine residents identified as #42, #56, #80, #78, #132, #90, #98, #105, and #117, who were on renal and/or 2 gram sodium diets, did not receive low sodium marinara meat sauce for the lunch meal. The facility’s recipe and diet guide indicated that the sauce should have been provided, and the tray ticket also showed that the residents should have received low sodium sauce. The dietary manager and the HCSG DO stated that the low sodium sauce was not available for these residents, and the facility did not follow its therapeutic diet policy for the nine residents on that meal date.
Incomplete Care Plan for Medication Refusals
Penalty
Summary
The facility failed to ensure a complete and accurate comprehensive care plan addressing medication refusals for a resident who began refusing multiple prescribed medications, including those for hyperlipidemia, diabetes, depression, gastroesophageal reflux disease, hypertension, and sleeplessness, starting the day after admission. Documentation showed that the resident's medication refusals were frequent, yet the care plan only included a focus statement regarding the resident's resistance to care and medication refusal, without any corresponding goals or interventions. The Director of Nursing acknowledged that the care plan for medication refusals was not completed in a timely manner, and no further information was provided during the complaint investigation.
Inaccurate Psychiatric Telemedicine Documentation
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident, as evidenced by incorrect information documented in the psychiatric telemedicine notes. Specifically, the history of present illness (HPI) section in multiple psychiatric notes contained inaccurate details regarding the resident's age, admission date, first name, and health care surrogate's name. These inaccuracies were attributed to the HPI information being copied from another resident with the same surname. The remainder of the notes appeared correct for the resident in question. The Director of Nursing acknowledged the error during the investigation.
Medication Left Unattended at Bedside
Penalty
Summary
A deficiency was identified when a medicine cup containing a half tablet of Senokot was found left on the bedside table of one resident during an observation at approximately 11:07 p.m. The Director of Nursing (DON) was notified and verified the presence of the medication cup. A subsequent check of 26 residents in rooms 1-16 revealed that only one resident had medication left at the bedside. The DON confirmed that the medication pass for this resident was performed by a specific employee, who had left the medication cup on the bedside table. The incident was further verified and acknowledged by both the DON and the Administrator during the exit interview. This event demonstrates a failure to maintain an environment free of accident hazards by not ensuring that medications were properly administered and not left unattended at the bedside, as observed and confirmed by facility leadership.
Failure to Safely Manage and Control Narcotics Resulting in Drug Diversion and Misappropriation
Penalty
Summary
The facility failed to manage and control narcotics in a safe manner, resulting in multiple incidents of missing controlled medications for all residents reviewed during the survey. In one instance, a discrepancy was identified when a staff member attempted to reorder Hydrocodone for a resident and discovered that thirty tablets were missing from the medication cart, despite pharmacy records indicating that sixty tablets had been delivered and signed for. The staff member who received the medication reported only receiving thirty tablets, while another staff member documented receipt of sixty tablets on the manifest. The facility was unable to confirm misappropriation at that time, but the missing medication was not located. Another incident involved a resident missing twenty-six doses of Oxycodone, with both the sign-out log and shift-to-shift count report also missing. The investigation substantiated misappropriation, but the responsible nursing staff could not be determined. Additional review revealed that controlled medications intended for destruction for eight other residents were missing from the lock box when the pharmacist arrived to destroy them, despite being logged for destruction. The facility could not determine how or when these medications were taken or by whom, but the misappropriation was substantiated. A further incident involved a discrepancy in the medication count for seven Hydrocodone tablets. Investigation determined that an LPN who had access to the medication cart during a shift was responsible for the missing medication. The resident involved was interviewed and denied any previous missing doses, and had full cognitive capacity as documented by a BIMS score of 15 and physician determination. The facility's policy required shift-to-shift counts and double-locked storage for controlled substances, but these procedures were not effectively followed, leading to the deficiencies.
Failure to Complete Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to complete all physician-ordered wound treatments for one of three residents reviewed during the investigation. Record review and staff interviews revealed that, over a three-month period, multiple wound care orders were not documented as completed on several specific dates. These orders included cleaning and treating various wounds such as a deep tissue injury to the left buttocks, wounds at an amputation site, venous ulcers on the feet and digits, abrasions, a diabetic wound, and stage 2 pressure ulcers to the sacrum. The prescribed treatments involved wound cleansing, application of skin prep, Betadine, sureprep, silicone barrier cream, and appropriate dressings, all to be performed during the day shift. The missing documentation and lack of completion of these wound care orders were confirmed by both the Corporate Resource Nurse and the Administrator. The findings were based on a thorough review of physician orders and Treatment Administration Records (TARs) for the period from August through October, and the facility leadership agreed that the wound treatments were not completed as ordered by the physician.
Failure to Prevent Bed Entrapment Hazards and Ensure Resident Safety
Penalty
Summary
Surveyors observed that several resident beds in the facility had excessive gaps, specifically at the foot of the beds, with no gap fillers in place. These gaps were greater than approximately 5 inches and were identified as potential entrapment hazards for multiple residents. During the inspection, one resident was found with his arm entrapped between the mattress and side rail, confirming the risk posed by these gaps. The maintenance assistant verified the presence of these hazards during an interview. One resident, who had severe cognitive impairment and a history of falls, experienced a significant injury as a result of these hazards. This resident was found on the floor with his left arm stuck between the bed and bed rail, resulting in an arterial tear that required surgical intervention. Witness statements indicated that the bed was at an unusually high position, both bed rails were up, and the resident's call light and bed remote were on the floor. The resident was unable to squeeze with his left hand after the incident, and a knot was observed in his left armpit. A review of the resident's bed safety evaluation revealed that critical steps, including risk factor evaluation and checking for zones of entrapment, were not completed or documented. The lack of proper assessment and failure to address the identified hazards led to the entrapment and injury. The survey team confirmed that, at the time of their investigation, no further potential entrapment areas were observed between mattresses and side rails.
Resident Harm Due to Lapse in Supervision and Incomplete Bed Safety Assessment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not provided an environment free from neglect and physical harm. The resident, who was at high risk for falls and had multiple medical conditions including dementia and diabetes, was found on the floor with his left arm entrapped between the bed and bed rail. The incident resulted in a significant injury, specifically an arterial tear to the left arm, which required surgical intervention. The sequence of events leading to the deficiency involved a lapse in supervision and failure to follow established protocols for resident checks and shift handoff. The nurse aide assigned to the resident left the facility without notifying the supervising nurse, and the oncoming aide was delayed and did not arrive as scheduled. As a result, the resident was not checked for over two hours, contrary to the facility's expectation of checks at least every two hours. When the resident was eventually found, his bed was observed to be higher than normal, both bed rails were up, and his call light and bed remote were on the floor, further contributing to the risk of harm. Additionally, documentation revealed that a bed safety evaluation had not been fully completed, with specific steps regarding risk factor evaluation and checking for zones of entrapment left blank. Although the resident had been assessed as a fall risk and care planned accordingly, these lapses in supervision, incomplete safety assessments, and failure to ensure proper shift-to-shift communication directly contributed to the resident's injury.
Immediate Jeopardy Due to Unsafe Hot Water Temperatures at Accessible Hand Sink
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment under its control was free from accident hazards, specifically regarding unsafe hot water temperatures accessible to residents. The hand washing sink in the main dining room was found to have hot water temperatures significantly above safe levels, with one measurement reaching 139.2 degrees Fahrenheit and another at 125 degrees Fahrenheit. These temperatures were discovered after a surveyor noticed the water was uncomfortably hot to the touch and could not keep her hand under the stream without risk of burns. The maintenance director confirmed these readings using facility equipment. The maintenance director stated that he did not routinely check the water temperature at the hand sink in the dining room, focusing instead on shower rooms and resident rooms, which were found to have much lower water temperatures. Upon further investigation, it was determined that the hot water tank supplying the dining room sink was connected to the kitchen, which required higher water temperatures, explaining the elevated readings at the dining room sink. The facility identified a large number of residents who could potentially access the hand sink in the main dining room without staff assistance. The state agency determined that the unsafe water temperatures at the accessible hand sink placed residents at immediate risk for serious injury or death, constituting an Immediate Jeopardy situation. The risk was particularly acute given the number of residents who could independently use the sink, and the fact that water temperatures at these levels can cause severe burns in a very short period of time, as referenced in the CMS State Operations Manual.
Failure to Provide Required Respiratory Care and Supplies at Bedside
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy, as required by physician orders and the resident's care plan. Specifically, the resident was to have a spare tracheostomy tube and ambu bag at bedside, but during observation, these supplies were not present. When staff were asked to locate the correct size trach kit, it took over 15 minutes to find it in a supply closet rather than at the bedside, as required. The respiratory therapist acknowledged the error in ordering the wrong size trach and confirmed the supplies were not readily available as directed. Further review revealed discrepancies in the documentation and understanding of the trach size, with the respiratory therapist admitting to confusion over the sizing and the care plan reflecting incorrect information. Interviews with staff indicated a lack of clarity regarding who was authorized to replace the trach tube, and the facility's own procedures required verification of the correct size and availability of two replacement trachs at bedside. The DON confirmed the delay in locating the correct supplies and agreed that the spare trach should have been at bedside. Additionally, another resident with an order for continuous oxygen was observed without oxygen in place, and the oxygen concentrator was turned off. The LPN confirmed the resident was not receiving oxygen as ordered and adjusted the settings after the deficiency was identified. These findings demonstrate failures in adhering to physician orders and care plans for respiratory care for both residents.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to the administration and monitoring of pain interventions. One resident, who was receiving hospice care for end-stage illness following a cerebrovascular accident, had physician orders for morphine sulfate to be administered every two hours as needed for pain or dyspnea, along with nonpharmacological interventions. Despite exhibiting clear indicators of pain such as yelling out, restlessness, and tenseness, the resident was left unattended and unassessed for approximately 50 minutes while audibly calling for help. Staff, including nurse aides and an LPN, did not enter the room to assess the resident until prompted by a surveyor. Upon assessment, the resident confirmed pain and was administered medication, which led to a reduction in distress. Review of records revealed that nonpharmacological interventions were not documented or implemented, and the resident did not receive the correct dose of morphine on multiple occasions, with discrepancies noted between the medication administration record and the narcotic log. Additionally, the resident's care plan included specific interventions for pain management, such as observing for pain, attempting nonpharmacological interventions, administering medication as ordered, and documenting effectiveness. These interventions were not followed, as evidenced by the lack of documentation and implementation of nonpharmacological approaches and the failure to administer the correct medication dose. The DON confirmed that the care plan was not being implemented as required, and the resident's pain management needs were not met according to physician orders and care plan directives. A second resident with an order for hydrocodone every six hours for pain also experienced deficiencies in pain management. Review of the medication administration record and controlled substance log showed that on two occasions, the medication was documented as administered but was not signed out on the controlled substance log, indicating it was likely not given. This was confirmed by a corporate RN, further demonstrating a failure to ensure that pain medications were administered as ordered and properly documented.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of its resident population, as evidenced by multiple resident and staff interviews, observations, and documentation review. Residents reported extended wait times for assistance, with some call lights going unanswered for up to 40-45 minutes or longer, particularly during night shifts and weekends. One cognitively intact resident described waiting over 40 minutes to be changed, despite repeated requests and staff being present in the hallway. Another resident reported waiting up to two hours for assistance with basic needs such as water or catheterization, and noted that staff often cited understaffing as the reason for delays. Additional residents described similar experiences, including missed or delayed assistance with activities of daily living (ADLs) such as bathing, with documentation confirming multiple missed scheduled bed baths and showers over a 90-day period. Family members also observed issues, such as strong urine odors and soiled briefs left in rooms, indicating delays in incontinence care. During a resident council meeting, concerns were raised about frequent staffing shortages, with reports of only one staff member per hall and wait times for call lights ranging from one to three hours. Staff interviews corroborated these findings, with nurse aides acknowledging frequent call-ins, difficulty covering shifts, and the resulting impact on resident care. Observations during the survey showed multiple call lights going unanswered while some staff were not actively responding to resident needs. The Director of Nursing confirmed gaps in care documentation, and no additional evidence was provided to refute the reported deficiencies.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to honor residents' rights to receive mail on Saturdays, as required by its own policy and procedure. The policy specified that mail should be delivered to residents unopened within 24 hours, including Saturdays. During a Resident Council Meeting, residents reported that mail was not being delivered on Saturdays. This was confirmed by the Administrator, who acknowledged that mail was supposed to be delivered on Saturdays and that there were staffing shortages in the activities department due to recent departures.
Failure to Administer Phosphate Binders with Meals for Dialysis Residents
Penalty
Summary
The facility failed to administer phosphate binder medications as prescribed for five residents receiving dialysis. These medications, including Renvela, Velphoro, Calcium Acetate, and Auryxia, are required to be given with meals to effectively control phosphorus levels in patients with end-stage renal disease or chronic kidney disease. Medication Administration Records (MARs) and staff interviews revealed that these medications were routinely administered during scheduled med passes rather than with meals, and in several cases, after residents had already left the facility for dialysis appointments, resulting in missed or improperly timed doses. For example, one resident with end-stage renal disease on hemodialysis had orders for Renvela to be given before meals, but the MAR showed administration times that did not coincide with meal times and occurred after the resident had departed for dialysis. Similar patterns were observed for other residents, including those prescribed Velphoro, Calcium Acetate, and Auryxia, with MAR entries indicating administration at times not aligned with meals or the residents' presence in the facility. Staff interviews, including those with the Unit Manager and DON, confirmed that medications were not being administered as prescribed with food, but rather during routine medication passes. The residents affected had complex medical histories, including chronic heart failure, diabetes, hypertension, anemia, and other comorbidities, and were all dependent on hemodialysis. The failure to administer phosphate binders as ordered was consistent across all five residents reviewed, regardless of their individual dialysis schedules or dietary accommodations. The deficiency was identified through observation, record review, and staff interviews, all of which confirmed the deviation from prescribed medication administration protocols.
Improper Portioning of Pork During Meal Service
Penalty
Summary
During an observation of meal service, a staff member was seen serving pork to residents using tongs instead of the required 2-ounce scoop. This method did not ensure that each resident received the proper portion size as specified by the menu, which required a 2-ounce serving of pork. The Director of Operations confirmed that the correct utensil was not used and that the North Short Hall and South Short Hall had already been served before the error was identified. The deficiency was discovered during the kitchen pathway review as part of the survey process.
Delayed Meal Service Due to Insufficient Food Preparation
Penalty
Summary
The facility failed to ensure that all residents received meals at regular times comparable to normal mealtimes in the community. On the observed lunch meal, the facility ran out of prepared food, resulting in a delay of 45 minutes for 19 residents who did not receive their meals at the scheduled time. Staff reported running out of food and needing to prepare additional servings, with the Corporate Director of Operations stepping in to direct meal preparation. The last resident was served nearly an hour after the facility initially ran out of food. This deficiency affected a total of 19 identified residents out of a facility census of 101.
Unlabeled Shampoo Bottles Found in Shower Room
Penalty
Summary
During an inspection of the facility's male shower room, five bottles of shampoo were found to be unlabeled and not identified with any resident names. This observation was made in the presence of an LPN, who confirmed that the bottles were not labeled. The issue was identified as a failure to adhere to infection control procedures, as the lack of labeling could lead to improper use of personal care items among residents. The deficiency was noted in one of two shower rooms inspected during the survey, with a facility census of 111 residents at the time. The Director of Nursing later confirmed the presence of the unlabeled bottles in the shower room.
Resident Left in Soiled Brief for Extended Period Due to Delayed Staff Response
Penalty
Summary
A resident with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitive intactness, was left in a soiled brief for an extended period of time. The resident's call light was observed ringing at approximately 9:05 PM, and he was heard calling out for assistance multiple times without receiving a response. During this period, staff including an LPN and multiple nurse aides were present in the hallway but did not respond to the resident's needs. The LPN eventually entered the resident's room at 9:25 PM, acknowledged the request for assistance, and informed the resident that she would notify the appropriate aide. However, the resident's call light was turned off without care being provided at that time. Subsequent interactions among staff indicated a lack of immediate response, as the aides either did not address the resident or prioritized other tasks. The resident ultimately received care at approximately 9:45 PM, resulting in a wait time of about 40 to 45 minutes while remaining in a soiled brief. During an interview, the resident expressed awareness of staffing challenges but described the experience as undignified and distressing. The facility census at the time was 111.
Failure to Protect Resident's Right to Voice Grievances Without Reprisal
Penalty
Summary
The facility failed to ensure that a resident could voice grievances without fear of reprisal, as required by policy. During a Resident Council Meeting, several residents expressed concerns that voicing complaints could lead to staff retaliation, with some reporting that staff would argue with them depending on which staff member was involved. One resident described a specific incident where she waited over two hours in pain for her bladder to be drained by an LPN. When she sought assistance, the LPN responded with an attitude and told her, 'I'll get to you when I get to you.' The LPN later entered the resident's room and confronted her, claiming she had not been informed by the CNA, though the resident stated otherwise. Later that night, the same resident reported that the CNA was rude and snapped at her during care, ending the interaction abruptly. The resident admitted to being rude due to her pain but stated she tried to be understanding. The resident gave verbal permission to the state surveyor to investigate the incident. The facility's policy clearly states that residents have the right to voice grievances without discrimination or reprisal, but the events described indicate that this right was not upheld for the resident involved.
Failure to Prevent Resident Neglect in Medication Administration and Dietary Needs
Penalty
Summary
The facility failed to prevent neglect for two residents. One resident reported that LPNs often let him run out of medication, resulting in missed doses of Gabapentin, Ropinirole, and Synthroid, despite these medications being available in the pyxis system. Review of the medication administration record confirmed that several doses were not documented as administered, and a registered nurse verified that the medications were accessible but not given by the on-duty nurse. The resident experienced discomfort due to missing his medication for restless leg syndrome. Another resident requested a snack for over 30 minutes, specifically asking for a peanut butter sandwich. Multiple staff were present and could have responded, but the resident was not provided with a snack until much later. When a sandwich was finally given, it was not the correct consistency for her prescribed pureed diet. The sandwich was then taken away by a nurse aide, which upset the resident. The resident declined alternative snacks and expressed unhappiness about not receiving the requested food. The correct snack was not provided until nearly an hour after the initial request.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a required Minimum Data Set (MDS) assessment for a resident upon discharge. The resident was admitted and stayed at the facility for a specified period, during which several MDS assessments were completed, including Entry, Medicare 5-Day, and Admission assessments. However, during a record review, it was found that the discharge MDS was missing for this resident. This omission was confirmed by the MDS Coordinator during an interview, who acknowledged that the discharge MDS had not been completed.
Failure to Implement Care Plans for Pain Management and Tracheostomy Care
Penalty
Summary
The facility failed to implement care plans for two residents regarding pain management and tracheostomy care. One resident, who was receiving hospice services for end-stage cerebrovascular accident, had a physician's order for morphine sulfate to be administered as needed for pain or dyspnea. Despite exhibiting clear indicators of pain such as yelling out, restlessness, and tenseness, the resident was repeatedly observed calling out for help over several hours without staff intervention. Staff, including nurse aides and an LPN, walked by the resident's room without checking on him, and it was only after a surveyor intervened that the LPN assessed and administered pain medication. The resident's Medication Administration Record showed no documentation of nonpharmacological pain interventions for the month, and there were inconsistencies between the narcotic log and progress notes regarding the dosage of morphine administered. The resident's care plan included multiple interventions for pain management, such as observing for pain, attempting non-pharmacologic interventions, administering medication as ordered, and documenting effectiveness. However, these interventions were not consistently implemented, as evidenced by the lack of nonpharmacological interventions and delayed response to the resident's pain indicators. The Director of Nursing confirmed that the care plan was not being followed in this case. For another resident with a tracheostomy, the care plan required a specific size trach and ambu bag to be kept at the bedside. Upon observation, the required trach size was not present at the bedside, and staff were initially unable to locate the correct size in the facility. It was later determined that the resident had a different size trach in place, and the appropriate spare trach kit was not readily available at the bedside as directed by the care plan. This failure to implement the care plan was confirmed by the Director of Nursing and the respiratory therapist.
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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.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sissonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arthur B Hodges Center, The | 9.2 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Acres | 10.1 mi | ★★★★★ | 5 | 0 |
| Dunbar Center | 10.4 mi | ★★★★★ | 38 | 1 |
| Complete Care At Oak Ridge Llc | 10.8 mi | ★★★★★ | 0 | 0 |
| Thomas Hospitals Skilled Nursing Unit | 10.8 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.