Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Center during CMS and state inspections, most recent first.
A resident with poor cognition and a fall history had ordered bed rails for turning, repositioning, and safer bed exit, but after a room change the rails and floor mats were not moved with him. He later had an unwitnessed fall from bed, was found on the floor beside the bed, and was sent to the ER after the HCS requested further evaluation. Hospital imaging showed an intracranial hemorrhage and a small occipital hemorrhage, and the ER documented fall from bed with head trauma.
Unsanitary and cluttered common areas were observed throughout the facility, including a dirty cabinet with trash, crumbs, and a soiled brief in the 3rd floor dining room, broken items and medical supplies left on the floor in a 2nd floor lounge, and a plate with leftover food plus a dirty refrigerator in the Homestead unit. The Administrator, DON, and Homestead Program Director confirmed the conditions.
Failure to provide feeding assistance to dependent residents. A resident was observed with a cold breakfast tray and no feeding help despite a tray ticket showing assist needed, an LPN confirmed another resident had not been assisted and believed the order was old, and a third resident was found with a full lunch tray at bedside with no help provided. The resident’s daughter reported repeated instances of breakfast trays left untouched and cold, and the care plan called for partial/moderate assist with eating.
A resident with no decision-making capacity, an ostomy, a catheter, and wounds was discharged without sufficient documented preparation and caregiver orientation. The facility’s NOMNC contact attempts were limited, the daughter was not reached until after the appeal deadline, the discharge plan listed the resident as going home alone despite needing assistance, and the family reported receiving no education on wound, ostomy, or catheter care.
A facility failed to correctly enter a physician order for CBC/CMP monitoring for one resident, and failed to administer ordered Admelog insulin as written for another resident. The insulin was repeatedly withheld despite blood glucose values below 150, even though the order only directed notification for blood sugar less than 70 or greater than 400; the DON acknowledged there were no hold parameters in the order and that refusals should have been documented.
Medication administration and controlled drug documentation did not match for two residents receiving gabapentin for neuropathy. For one resident, the MAR showed a dose as given even though the controlled drug log did not show removal of the medication. For another resident, the controlled drug log showed gabapentin removed on several occasions when the MAR was blank, and the medication was also signed out after the order had ended and before it was reordered. An RN confirmed the discrepancies.
The facility failed to ensure monthly pharmacist MRRs were completed and failed to ensure the MD acted on pharmacist-identified medication irregularities. One resident had no MRR found for a month despite multiple psychotropic meds, and two other residents had pharmacist recommendations for GDR review or medication clarification that were not reviewed, acknowledged, or acted upon by the MD.
A multi-use vial of Tubersol in the Transitional Care Unit was found in the refrigerator with an opening date that exceeded the 30-day discard timeframe printed on the box. The DON acknowledged the vial should have been discarded, and the FDA package insert stated that a vial of Tubersol entered and in use for 30 days should be discarded.
Failure to use PPE during EBP was observed when an LPN gave a resident medications and had direct contact without gown, gloves, or mask, despite an EBP sign on the door. In a separate observation, a nurse and an aide provided ADLs and cleaned up two residents on EBP without proper PPE, even though a stocked PPE cart was outside the room.
Failure to provide and document scheduled showers for a dependent resident. A resident with limited mobility and a CVA was care planned for showers twice weekly, but the resident said showers were only occurring every three or four weeks. The shower schedule listed twice-weekly showers, yet the bathing task reports showed no showers documented for the period reviewed, and the handwritten shower book showed only one shower with no other showers documented. The DON confirmed there was no documentation that the resident had received or been offered the ordered shower frequency.
Delayed assessment and treatment of pressure injuries were identified for a resident with DTPI to the sacrum and right heel on admission. The skin check noted pressure areas, but the wound evaluations and treatment orders were not completed right away; the right heel injury was later measured at 8.2 cm by 3.3 cm by 0.1 cm, while the sacral injury had no measurements recorded. The DON acknowledged the wounds were not fully assessed or treated upon admission.
Clean dishware and serving items were left in a hallway outside the dining area to finish drying after being washed and sanitized. The hallway was a main first-floor intersection with heavy foot traffic and was under a vent that could allow dust to fall on the items. Kitchen staff stated the room was too small to dry them inside and said they had not thought about them getting dirty while left there.
Failure to obtain informed consent for psychotropic medications. Two residents had active orders for psychotropic drugs, including antidepressants, anxiolytics, and an antipsychotic, but the chart lacked documented consent showing the resident or representative had been informed in advance of the risks, benefits, and alternatives. When asked by the surveyor, the DON acknowledged the facility had missed or failed to initiate the consents.
A facility failed to provide a written Notice of Transfer/Discharge and a Bed Hold notice when a resident was sent to the hospital. Record review showed no evidence that the resident or the resident's representative was notified in writing of the transfer, the reasons for it, or any bed-hold period, and the RCO confirmed the facility could not produce documentation that either notice had been given.
A facility failed to carry out person-centered care plan interventions for skin breakdown prevention for two residents. One resident with impaired mobility, frail skin, cognitive impairment, and a facility-acquired Stage 3 PU and chronic foot ulcer had ordered T&P every 2 to 3 hours, but documentation showed it was often completed on only one shift or not at all. Another resident with left-sided impairment, bilateral Stage 2 buttock PUs, and multiple contractures also had T&P interventions in the care plan, but records showed the intervention was only documented on one shift on multiple dates.
Failure to obtain ordered lab work for a resident. The resident had an active order for HGA1C, CMP, and CBC every 4 months, including July, but the EMR contained no evidence that the blood work was completed. The DON confirmed the facility could not produce proof that the ordered labs were done.
A resident’s medical record contained multiple encounter notes that listed the wrong room number after room transfers. The DON acknowledged that the notes were documented with incorrect room information.
A resident with prior PCV13 documentation was not fully vaccinated for pneumococcal disease, and the record showed no additional pneumococcal vaccine had been given. The consent form listed the resident as “up to date” without naming a vaccine, and the IP later confirmed the resident should have been offered Prevnar 20; the resident then refused when it was offered after surveyor intervention.
A resident with a history of sexually inappropriate behavior engaged in unwanted sexual touching of another resident, highlighting the facility's failure to implement adequate protective measures. Despite the resident's known history and cognitive impairment, interventions were insufficient, leading to an immediate jeopardy situation.
The facility failed to maintain an effective infection prevention and control program, lacking necessary documentation for infection surveillance. The DON and ADON could not locate the required records and were trying to contact the former Infection Control Preventionist. This deficiency potentially affected all 150 residents.
The facility did not implement its antibiotic use protocol or monitor antibiotic use as part of its stewardship program. During a review, the facility could not provide documentation for infection control practices, including infection surveillance and antibiotic stewardship. The DON and ADON were unable to locate the documentation and were trying to contact the former Infection Control Preventionist for assistance.
The facility did not have a designated certified Infection Preventionist (IP) after the previous IP resigned, affecting all 150 residents. The ADON, who holds a certificate for Nursing Home Infection Preventionist, and the DON have been managing infection control without a dedicated IP. The facility lacked required infection surveillance and antibiotic stewardship documentation.
The facility failed to conduct Level II PASRR evaluations for residents with new diagnoses of serious mental disorders. Several residents, including those with major depressive disorder and schizoaffective disorder, were not referred for necessary evaluations, despite policy requirements. This oversight affected seven out of eight residents reviewed during the survey.
The facility failed to offer RSV immunization to residents, coordinate hospice care for a resident, and ensure proper monitoring of a resident's pacemaker. Additionally, there were inconsistencies in monitoring blood glucose and blood pressure for a resident, and inadequate management of dialysis-related care for another resident.
The facility failed to maintain accurate and current Daily Staffing Posting information by incorrectly including administrative staff hours as direct care hours and not reflecting staff absences. Additionally, the facility did not retain the staffing records for the required 18 months, as the responsible staff was unaware of this requirement.
The facility failed to maintain safe and sanitary food preparation and storage practices. Sliced ham in the walk-in refrigerator was not dated, contrary to facility policy requiring labeling with the product name and 'use by' date. Additionally, the flat top stove was found to be dirty with black build-up, and the Dietary Manager noted difficulty in cleaning due to the stove burning very hot. These issues had the potential to affect a significant number of residents.
The facility failed to provide residents and their families with access to grievance forms and the ability to file grievances anonymously. A family member was unaware of the grievance process, and staff, including the GSD, were not informed about anonymous filing procedures. Grievance forms were not prominently displayed, and postings were missing on the second and third floors, limiting residents' access due to elevator restrictions.
The facility failed to ensure that NAs completed essential competencies such as hand hygiene, PPE use, and equipment handling, affecting resident safety and well-being. Three NAs had incomplete records, and the Corporate Administrator acknowledged the issue without providing further information.
The facility failed to maintain complete and accurate medical records, particularly with POST forms lacking required witness signatures and missing representative signatures, rendering them invalid. Additionally, meal intake documentation was incomplete for a resident refusing tube feeding.
The facility's call system was found to be inaudible on both the 2nd floor and the transitional care unit, affecting all 150 residents. Staff confirmed the system was turned down to a low volume, relying on visual cues instead. The Maintenance Director and Helper acknowledged the issue, stating it was adjusted to staff preferences.
A resident who is non-verbal and uses an alphabet board to communicate was not provided with a readily accessible wheelchair, as observed during a survey. The resident expressed that they were not being assisted to get up due to the lack of a wheelchair. The Assistant Nursing Director confirmed the absence of extra wheelchairs on the floor, and it took 24 minutes for the Occupational Therapy-Assistant Director of Rehab to locate a suitable Geri chair from another floor. The resident's care plan indicated the need for a Geri-chair when out of bed, but the facility failed to ensure its availability.
A resident was unable to exercise his choice regarding daily routine due to the facility's failure to provide a readily accessible wheelchair. The resident, who is non-verbal and uses an alphabet board to communicate, expressed that staff would not get him up due to the unavailability of a wheelchair. It took 24 minutes to locate a suitable Geri chair, which was found in another resident's room, indicating a lack of proper equipment management to support resident choice.
The facility inaccurately transmitted MDS data for two residents' discharge statuses. One resident's discharge to a hospital for congestive heart failure was incorrectly coded as 'Home/Community,' while another resident's departure against medical advice was wrongly coded as 'Short-Term General Hospital.' The MDS Coordinator cited being overburdened and short-staffed as reasons for these errors.
A facility failed to conduct a complete and accurate PASRR evaluation for a resident with a history of schizophrenia and grand mal seizures. The resident was admitted without a Level II PASRR evaluation, which is required for individuals with mental illness or intellectual disability to assess the need for specialized services. The PASRR did not reflect the resident's diagnoses, as confirmed by the Corporate Administrator.
The facility failed to update care plans for two residents, leading to deficiencies. One resident's care plan inaccurately restricted smoking on the property, despite a current assessment allowing it. Another resident, with a history of throwing items, was served meals on Styrofoam dishes, but this intervention was not documented in the care plan.
The facility failed to provide an adequate activity program for two residents. One resident, who is non-verbal, was not given a wheelchair to attend group activities, despite expressing interest. Another resident was not offered scheduled one-on-one social interactions as outlined in her care plan. The Guest Services Director, new to the role, acknowledged these deficiencies.
The facility failed to ensure a safe environment and adequate supervision for residents. A resident's telephone was dangerously placed above their head, and another resident with moderate cognitive impairment was left to take medication unsupervised, contrary to facility policy. The Nurse Manager acknowledged the error in medication administration.
A facility failed to follow professional standards for urinary catheter care, as a resident's urine collection bag was repeatedly observed lying on the floor, contrary to the facility's procedure. An LPN confirmed the improper placement and planned to use a basin to prevent direct contact with the floor.
The facility failed to store oxygen tanks safely, as an empty tank was found in a wheelchair seat. The Corporate Administrator confirmed this was improper storage, contrary to the facility's policy requiring tanks to be secured in approved holders or brackets.
A resident expressed a desire to receive his dentures, noting that an impression had been made over three months prior. A review of the medical records revealed no follow-up notes regarding the resident's dental care after the initial dentist visit. The facility's Administrator acknowledged that a return appointment was not scheduled due to issues with obtaining payment from the insurance company.
The facility did not identify specific competencies required for CNAs in the Facility Assessment, affecting care for residents. Despite stating that staffing and training were evaluated, the assessment lacked details on CNA competencies. The Corporate Administrator could not specify required competencies, even with a document outlining skills validation.
The facility failed to review Resident Council minutes and address resident grievances, as evidenced by unsigned minutes and unresolved food quality issues raised in meetings. The Guest Services Director confirmed the lack of documentation and follow-up, indicating a deficiency in addressing resident concerns.
Bed safety devices not maintained after room change
Penalty
Summary
The facility failed to keep Resident #157’s environment as free of accident hazards as possible by not ensuring his ordered bed safety devices remained in place after a room change. The resident had an order dated 12/19/25 for 1/2 bed rails as an enabler for turning and repositioning in bed, and a bed safety evaluation noted rails at the top of the bed to aid in turning, repositioning, and being more safe when exiting the bed. The resident was moved to another room on 12/24/25, and the side rails did not go with him. On 12/26/25, Resident #157 had an unwitnessed fall from bed and was found on the floor beside his bed. Staff reported the bed was in the lowest position with the call light in reach, and the resident could not recall what happened due to poor cognition consistent with baseline. He had no complaints of pain or visible injuries noted at the time, and he was assisted back to bed by staff using a mechanical lift. The facility notified the provider, started neuro checks, and later sent him to the ER at the request of his health care surrogate. Hospital records showed imaging findings including an intracranial hemorrhage and a small left occipital hemorrhage without significant mass effect or shift. The ER report documented a fall from bed with head trauma, and EMS reported the resident had fallen from his bed, struck his head, and landed on his left shoulder. The health care surrogate stated the family had requested side rails and floor mats because of the resident’s fall history, and that after the room change the side rails and floor mats did not follow him to the new bed.
Unsanitary and Cluttered Common Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment based on multiple observations of unsanitary and cluttered areas. In the 3rd floor dining room, a cabinet was found with trash such as wrappers and napkins, lots of food crumbs, and a dirty brief stuffed in a drawer. In the 2nd floor lounge area, broken pictures, a bed headboard, several leg rests, two tubes of Zinc oxide paste, and wheelchair cushions were observed on the floor beside the pop machine. In the Homestead Alzheimer's Unit dining room, a plate containing chewed up meat, peas, and a half-eaten roll was left in the sink accessible to residents, and the unit refrigerator was covered in a brown-red substance on the bottom with dirty paper towels stuck to it. The Administrator, DON, and Homestead Program Director each confirmed the conditions observed.
Failure to Provide Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living, specifically feeding. Resident #20 was observed in the third floor dining room with a breakfast tray in front of him, and the tray ticket indicated he required assistance with feeding; the food was cold and the oatmeal was congealed, and the DON confirmed he had not been assisted with eating. Resident #102 was observed with an uneaten breakfast tray at bedside, and the tray ticket also indicated she required assistance with feeding; an LPN confirmed she had not been assisted and stated she thought the order was old and that the resident no longer required assistance. Resident #112’s daughter reported that family members came daily to assist with feeding because the resident had not been fed, and that they had found breakfast trays with cold food on the bedside table on multiple occasions; the resident was later observed with a full lunch tray on the bedside table with no assistance being provided, and a nurse confirmed no assistance was provided. The care plan for Resident #112 included an intervention to provide partial/moderate assist for eating.
Discharge Preparation and Family Education Deficiencies
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation to Resident #158 and the resident’s caregiver to ensure a safe and orderly discharge. Resident #158 had a physician determination of capacity dated 03/06/26 stating he did not have capacity to understand or make medical decisions. The discharge transition plan listed the discharge destination as home alone and stated the resident was responsible for self and made own decisions, while also noting he needed assistance with toileting, household tasks, and transfers from bed to chair. A progress note on 04/07/26 stated the resident was educated on current wounds and treatments and was able to verbal repeat back the treatment orders and express understanding regarding wound status and treatments. During interview, the resident’s daughter stated the facility notified her of discharge plans after the appeal deadline and reported that the facility said they did not yet have the admission paperwork signed. She also stated she was unhappy that she was not given contact information for complaints and reported that her father had an ostomy, a catheter, and wounds, but the family received no education on managing these conditions. The record showed the facility attempted to call the resident’s son four times regarding the NOMNC, but could not provide proof of mailing or evidence that the daughter was contacted that day. The Durable Power of Attorney identified the son as primary POA and the daughter as alternate health care agent, and a non-completion affidavit showed the admission packet had not been signed. The social services specialist stated the family was not educated on wound care or ostomy/catheter care, and a post-discharge follow-up form showed the resident was admitted to the VA hospital the day after discharge.
Incorrect Order Entry and Insulin Administration Issues
Penalty
Summary
The facility failed to ensure a physician order was correctly entered into the medical record for Resident #122. During record review on 09/30/2025, the resident’s electronic medical record showed an order for CBC and CMP every four months, with the months listed as February, May, and August. In interview, the DON acknowledged that those months reflected three-month intervals and did not accurately represent a four-month timespan. The facility also failed to ensure insulin was administered in accordance with professional standards of care for Resident #99. The resident had an order for Admelog insulin 25 units subcutaneously before meals and at bedtime for DM2, with instructions to notify the provider if blood sugar was less than 70 or greater than 400. Review of the September 2025 MAR showed multiple instances where the insulin was not given when blood glucose values ranged from 97 to 148, and the MAR documented WR on those dates and times. The DON stated WR meant no coverage and acknowledged there were no blood glucose parameters associated with the order. She also stated that refusals should have been documented. A corporate RN stated a nurse had held the insulin because he was used to an order to hold it for blood sugar less than 150, and that the physician had been notified and the order was going to be modified.
Medication Documentation and Order Tracking Errors
Penalty
Summary
Pharmaceutical services were not provided in a way that matched medication administration records and controlled drug records for two residents. For Resident #34, the physician ordered gabapentin 100 mg twice daily for neuropathy on 07/25/25. The MAR documented that the scheduled 9:00 AM dose was given on 07/28/25, but the Controlled Drug Record did not show that gabapentin was removed from the resident’s supply. Staff noted the resident occasionally refused gabapentin, and an RN stated she could not explain why the MAR showed the dose as given when the controlled drug record did not document removal of the medication. For Resident #51, gabapentin 100 mg twice daily was ordered for neuropathy for 8 days beginning 08/14/25. On multiple occasions during that order period, the Controlled Drug Record showed gabapentin was removed from the resident’s supply, but the MAR was left blank and did not document administration. After the 8-day order ended on 08/21/25, gabapentin continued to be signed out on the Controlled Drug Record on dates when there was no active order, while the MAR was marked with an X because the medication was not ordered for those dates. An RN confirmed the discrepancies between the MAR and the Controlled Drug Record and confirmed gabapentin had been signed out when no order was in place.
Failure to Complete Monthly Pharmacist Reviews and Act on Medication Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly drug regimen review, including review of the medical chart, and failed to ensure that irregularities identified by the pharmacist were acted upon in accordance with facility policy. The facility’s policy stated that the consultant pharmacist reviews each resident’s medication regimen and medical chart at least monthly, and that recommendations requiring physician intervention are to be accepted and acted upon or rejected with rationale documented in the resident’s medical record. This deficiency was identified for three residents reviewed during survey. For Resident #100, the record showed multiple psychotropic medication orders, but there was no consultant pharmacist MRR for April 2025 in the chart. The DON stated she could not locate one. The record also contained a pharmacist recommendation dated 08/01/25 reminding the physician of the need for a gradual dose reduction review of psychotropic medications, but the Medical Director did not review, sign, or acknowledge the recommendation. For Resident #10, the pharmacist completed monthly MRRs, but an 08/01/25 irregularity report recommended considering a gradual dose reduction for psychotropic medications; this recommendation was never reviewed, acknowledged, or acted upon by the Medical Director. For Resident #1, the pharmacist’s new admission MRR dated 07/05/25 requested clarification of the bupropion SR order and asked to clarify the indication for use, but the Medical Director did not acknowledge, review, or act upon the recommendation.
Expired Multi-Use Tubersol Vial Kept in Use
Penalty
Summary
The facility failed to store medications within accepted standards of care when a multi-use vial of Tubersol injection remained in use beyond the labeled discard date. During an inspection of the medication storage room in the Transitional Care Unit with the DON present, surveyors found a multi-use vial of Tubersol in the refrigerator with an opening date of 08/19/25, and the box stated it should be discarded 30 days after opening. The DON acknowledged that the vial should have been discarded after 30 days. The Tubersol package insert available on the FDA website stated that a vial of Tubersol that has been entered and in use for 30 days should be discarded.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to use proper infection control practices during care in rooms marked for Enhanced Barrier Precautions (EBP). During medication pass, an LPN gave a resident medications without wearing PPE, despite the EBP sign posted on the door; the LPN sanitized hands but did not apply PPE, and had direct contact with the resident, including adjusting the resident in bed and hugging the resident before leaving the room. The resident was on EBP and the sign identified who the precautions applied to. In another observation, a nurse and an aide were in a room providing morning ADLs and cleaning up two residents without proper PPE, with no gown, gloves, or mask observed. Both residents in the room were on EBP precautions, one due to having a chest port for dialysis and the other due to abnormal blood chemistry. A PPE cart stocked with appropriate PPE was observed outside the room, and the administrator stated the two staff members should have been in proper PPE when in direct contact with a resident.
Failure to Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to provide activities of daily living assistance, specifically showers, to a dependent resident. Resident #34 required assistance with ADLs due to limited mobility and a cerebrovascular accident, and the care plan indicated the resident was to receive showers twice weekly. The resident stated she was supposed to get a shower twice a week but was only receiving one every three or four weeks. The facility’s shower schedule showed the resident was scheduled for showers on Mondays and Thursdays each week, but bathing task reports for 09/01/25 through 09/23/25 showed no showers documented during that period. An RN stated the bathing task reports were inaccurate and that showers were also documented in a handwritten shower book, which showed one shower on 09/22/25 and no other showers for the period. The DON confirmed there was no documentation that the resident had received or been offered twice weekly showers.
Delayed Assessment and Treatment of Pressure Injuries
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for Resident #164. On admission, the resident’s skin check documented pressure to the sacrum and right heel, along with abrasions to both outer forearms, a surgical non-removable dressing to the right hip, healed surgical incision to the chest and bilateral inner thighs, and an ostomy to the left lower quadrant. A late-entry progress note stated the wound nurse was notified, but the skin and wound evaluations for the pressure injuries were not completed until 03/31/25. The right heel deep tissue pressure injury was then assessed as 8.2 cm by 3.3 cm by 0.1 cm, with surrounding tissue described as denuded, discolored black or blue, dry/flaky, and fragile. The sacral deep tissue pressure injury was also evaluated, but no measurements were recorded. Treatment orders for the right heel and sacrum were not initiated until 03/31/25. The DON acknowledged that the resident’s deep tissue pressure injuries had not been fully assessed upon admission and that treatment had not been initiated upon admission, stating it was the facility’s standard of care to assess and initiate treatment for pressure ulcer injuries upon admission.
Clean Dishware Stored in Hallway to Dry
Penalty
Summary
The facility failed to ensure that dishware and serving items were kept in a clean and sanitary area after washing and sanitizing. On 09/29/25 at 9:03 PM, an observation showed dishes, cups, tray tops, and glasses left in the hallway outside the dining area to finish drying. The items were exposed in a main first-floor intersection with heavy foot traffic and people moving through it, and the area was also under a vent that could allow dust to fall onto the clean dishes. During interview, Kitchen Staff #3 stated that the items were washed and sanitized but had to be left in the hallway to dry because the room was too small, and said they had not thought about the items getting dirty while being out there.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents or their representatives in advance of the risks and benefits of proposed psychotropic medications, treatment alternatives, or treatment options, and failed to document informed consent for those medications. For Resident #10, the record showed active orders for Xanax 1 mg three times daily for anxiety disorder, Quetiapine ER 150 mg at bedtime for bipolar disorder with psychosis, and Citalopram 30 mg daily for depression. When the surveyor reviewed the chart, informed consents for Xanax, Celexa, and Seroquel were not found, and the requested consents were still not provided later that day. The DON then presented consents dated 09/24/25 that documented the resident or representative had not been informed in advance of the risks and benefits or given other treatment options, and stated the facility had apparently missed getting the consent. For Resident #1, the medical record showed active orders for Bupropion HCl ER 300 mg daily for MDD and Buspirone 7.5 mg twice daily for anxiety. The surveyor could not locate informed consents for Wellbutrin or Buspar in the record and requested them from the facility. When asked again later, the DON stated the facility had failed to initiate the informed consents and said, "We will get this completed immediately."
Failure to Provide Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide a Notice of Transfer/Discharge and a written Bed Hold notice to a resident and/or the resident's legal representative when Resident #177 was transferred to the hospital. Record review showed the resident was sent to the hospital on [DATE] at 2:06 PM, but there was no evidence in the electronic medical record that the facility notified the resident or the resident's representative in writing of the transfer/discharge and the reasons for the transfer. There was also no evidence that the facility provided a written notice specifying the duration of any bed-hold period during which the resident would be permitted to return to the nursing home. During interview, the Regulatory Compliance Officer confirmed the facility was unable to produce evidence that either notice had been given for the resident's discharge to the hospital.
Care Plan Interventions Not Carried Out for Skin Breakdown Prevention
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan that met residents’ preferences, goals, and medical, physical, mental, and psychosocial needs for two residents reviewed. For Resident #8, the care plan identified a risk for skin breakdown related to decreased activity, frail fragile skin, impaired cognitive function, and impaired mobility, and included an intervention to turn and position the resident every 2 to 3 hours. The resident also had a facility-acquired Stage 3 pressure ulcer and a non-pressure chronic ulcer of the right foot acquired during the stay. Review of the medical record showed turning and positioning were documented on only one shift on multiple dates, and not documented on any shift on 07/05/25 and 07/13/25. The DON reviewed the documentation and acknowledged the intervention was not carried out as planned. For Resident #100, the resident had impairment of the left upper and lower extremities, bilateral Stage 2 pressure ulcers to both buttocks, and was dependent on staff for dressing, toileting, bathing, and personal hygiene, with set-up assistance needed for eating. The resident also had diagnoses of contractures of the left wrist, left elbow, and left hand, and orders related to PT, OT, and use of a left palm protector or wash cloth when the splint was off. The care plan included interventions to assist with turning and repositioning every 1 to 2 hours in bed and/or chair and every 2 to 3 hours, but review of July, August, and September 2025 documentation showed turning and positioning were completed on only one shift on multiple dates.
Failure to Obtain Ordered Lab Work
Penalty
Summary
Timely laboratory services were not provided for Resident #6 when the facility failed to obtain blood work in July 2025 as ordered. During record review, there was no evidence in the resident’s electronic medical record that the ordered HGA1C, CMP, and CBC had been completed for the month of July 2025. The DON confirmed that there was an active physician order for HGA1C, CMP, and CBC every 4 months in March, July, and November, and stated the facility was unable to produce evidence that the lab work had been completed as ordered.
Inaccurate Resident Location Documentation in Medical Record
Penalty
Summary
The facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices because Resident #6’s encounter notes were inaccurately documented with incorrect room numbers. A record review showed that Resident #6 transferred to room [ROOM NUMBER]-B on 04/09/25 and again on 06/26/25, yet multiple encounter notes on 04/20/25, 05/15/25, 05/17/25, 08/14/25, and two notes on 08/16/25 documented the resident in the wrong room. During interview, the DON acknowledged that the encounter notes listed the incorrect room number for Resident #6.
Pneumococcal Vaccine Not Offered per Guidance
Penalty
Summary
The facility failed to provide pneumococcal vaccinations in accordance with professional standards of practice for one resident reviewed for vaccinations. The facility policy stated pneumococcal vaccinations were to follow current ACIP recommendations, and CDC guidance indicated adults 50 years or older who had only received PCV13 should receive a single dose of PCV21 or PCV20 at least one year after the PCV13 dose. Resident #34 was over [AGE] years old and had documentation showing PCV13 was received on 03/18/16, with no further pneumococcal vaccines documented in the record. The resident’s medical record included a pneumococcal vaccine informed consent signed on 06/01/25, but the line for the vaccine type was left blank and the words “Up to date - does not need” were handwritten on the form. Review of the electronic vaccination record showed no additional pneumococcal vaccination after PCV13. On 09/24/25, the Infection Preventionist confirmed the resident was not fully vaccinated for pneumococcal disease and agreed the resident should have been offered Prevnar 20. She stated she offered the resident a Prevnar 20 injection that morning after surveyor intervention, and the resident refused.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving Resident #208 and Resident #15. Resident #208, who had a history of sexually inappropriate behavior, entered Resident #15's room and engaged in unwanted sexual touching. Despite Resident #208's known history and cognitive impairment, the facility did not implement adequate measures to prevent such incidents, leading to Resident #15 experiencing sadness, depression, and requiring evaluation for physical injury. Resident #208 had a documented history of sexually inappropriate behavior, including incidents with other residents. Despite this, the facility's interventions, such as one-on-one supervision and medication adjustments, were inconsistently applied or insufficient to prevent further incidents. The facility's failure to maintain consistent supervision and effective behavioral interventions allowed Resident #208 to continue exhibiting inappropriate behaviors, culminating in the incident with Resident #15. The facility's processes and response to the incident were inadequate, as evidenced by the delayed and insufficient investigation and reporting of the incident. The facility's inability to substantiate the sexual inappropriate behavior between residents and the lack of immediate and effective protective measures placed all residents at risk, leading to the determination of an immediate jeopardy situation by the State Agency.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which is crucial for preventing the development and transmission of communicable diseases and infections. Specifically, the facility did not provide the necessary documentation for infection surveillance of communicable illnesses. During an interview, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) admitted they could not locate the infection control surveillance documentation. They mentioned that they were attempting to contact the Infection Control Preventionist, who was no longer employed at the facility, to retrieve the missing documentation. This deficiency had the potential to affect all 150 residents currently residing in the facility.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for antibiotic use and did not monitor actual antibiotic use as part of its antibiotic stewardship program. This deficiency was identified during a record review and interview process. The facility was unable to provide the necessary documentation for infection control practices, including infection surveillance and antibiotic stewardship. During an interview, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) admitted they could not locate the required documentation and were attempting to contact the former Infection Control Preventionist to retrieve it. No additional information was provided before the survey concluded.
Failure to Designate a Certified Infection Preventionist
Penalty
Summary
The facility failed to designate a certified Infection Preventionist (IP) responsible for the infection prevention and control program, affecting all 150 residents. The facility's documentation review revealed a lack of required infection surveillance and antibiotic stewardship documentation. Although the Assistant Director of Nursing (ADON) held a certificate for Nursing Home Infection Preventionist, the facility had not dedicated an IP since the previous IP resigned in October or November 2023. The Corporate Administrator confirmed the absence of a dedicated IP, with the ADON and Director of Nursing (DON) attempting to manage infection control. The ADON, who also serves as the third-floor unit manager, acknowledged the lack of a dedicated IP role during an interview.
Failure to Conduct Level II PASRR Evaluations for New Diagnoses
Penalty
Summary
The facility failed to ensure that residents with newly evident or possible serious mental disorders were referred for Level II resident review, as required by the Preadmission Screening and Resident Review (PASRR) program. This deficiency was identified during a survey, which reviewed the records of eight residents, seven of whom were affected by this oversight. The PASRR process is crucial for determining whether residents with mental illness or intellectual disabilities require specialized services, and the lack of appropriate referrals could impact the care provided to these residents. Resident #23 was admitted without a Level II PASRR requirement, but after receiving a new diagnosis of major depressive disorder, recurrent, the resident was not referred for a Level II evaluation. Similarly, Resident #15, who had a PASRR indicating no Level II review was needed, was diagnosed with major depressive disorder, recurrent, mild, but was not referred for further evaluation. Resident #74 had a Level II PASRR completed initially, but after a new diagnosis of schizoaffective disorder bipolar type, no additional evaluation was conducted. Other residents, including Resident #29, Resident #66, Resident #17, and Resident #33, also had new diagnoses that warranted a Level II PASRR evaluation, but these were not completed. The facility's policy states that social services should coordinate evaluations when there is a significant change in a resident's mental health status, but this was not adhered to, leading to the deficiency noted in the survey.
Deficiencies in Resident Care and Immunization Practices
Penalty
Summary
The facility failed to provide residents with information and offer the Respiratory Syncytial Virus (RSV) immunization as recommended by the Centers for Disease Control and Prevention (CDC). The Assistant Director of Nursing confirmed that the RSV vaccine was not offered to residents, and they would have to request it themselves. This oversight affected all 150 residents, as none had been provided educational information about the RSV vaccination, which is crucial for older adults who are at higher risk of severe RSV. Resident #73, who was receiving hospice services, did not have a coordinated plan of care with the hospice provider. The facility failed to identify the provider responsible for specific services and functions, leaving the resident without an active hospice care plan. This lack of coordination was confirmed by the Homestead Unit Facilitator, who acknowledged the absence of a current plan of care. Resident #19 expressed concern about not having a pacemaker check since admission to the facility. Despite a physician's note and order to contact the cardiologist for a pacemaker check, there was no follow-up or documentation indicating that the pacemaker had been checked. The Director of Nursing admitted that the facility was unaware of the resident's pacemaker. Additionally, Resident #79's blood glucose and blood pressure were not consistently monitored or documented as per physician's orders, and Resident #23's dialysis-related care was not properly managed, with conflicting orders regarding blood pressure measurements and missing smooth clamps for the Permacath.
Inaccurate Staffing Records and Incomplete Record Maintenance
Penalty
Summary
The facility failed to ensure the accuracy and currency of the Daily Staffing Posting information, which had the potential to affect all residents. During a review on March 25, 2024, it was found that nursing administrative staff hours were incorrectly included in the Nursing Direct Care hours on several dates. The Corporate Administrator acknowledged that the facility was using administrative staffing hours as direct care hours, based on the misunderstanding that staff helping out with others throughout the day could be counted as direct care. This misunderstanding was clarified during the review of the Centers for Medicare & Medicaid Services policy manual, which specifies that hours should be reported based on the employee's primary role. Additionally, the facility did not maintain the Daily Nurse Staffing Posting Forms for the required minimum of 18 months. It was discovered that the forms did not accurately reflect staff absences due to call-outs and illness, as required by regulatory guidance. The Corporate Administrator admitted that the staff responsible for posting the forms was unaware of the requirement to keep the original forms for 18 months, resulting in the loss of these records. This oversight in maintaining accurate and complete staffing records was acknowledged by the facility's administration.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe and sanitary manner, as observed during a survey. During an initial tour of the kitchen, it was found that sliced ham in the walk-in refrigerator was stored in a clear container without a date label. The Dietary Manager confirmed that all items in the walk-in should be dated, as per the facility's policy, which requires all foods to be labeled with the name of the product, the date received, and a 'use by' date once opened. Additionally, the flat top stove in the kitchen was observed to be covered in black build-up and was dirty, including the splash guard around and behind it. The Dietary Manager mentioned that the stove burns very hot, making it difficult to clean. The facility's policy mandates that equipment should be cleaned as soon after use as possible. These deficiencies had the potential to affect more than a limited number of residents, given the facility's census of 150.
Failure to Provide Access to Grievance Forms and Anonymous Filing
Penalty
Summary
The facility failed to honor the residents' right to file grievances anonymously, as residents and their families did not have access to grievance forms. During an interview, a family member of a resident expressed that they were unaware of the process to file a grievance themselves and had never seen a grievance form. The Guest Services Director (GSD) admitted that she was not aware of how families could file grievances anonymously and acknowledged that the grievance forms were not prominently displayed. The forms were located in a manila file folder on the ground floor, but there was no posting explaining the grievance procedure or the right to file grievances anonymously. Further investigation revealed that the facility's policy required grievance procedures to be posted in prominent locations on each unit, which was not the case. The information was only posted on the ground floor, and residents on the second and third floors could not freely access this area due to elevator restrictions. Staff members, including the Unit Clerk, CNA, and LPN, were unaware of how to file anonymous grievances and did not know the location of grievance forms on their respective floors. The Administrator confirmed the lack of postings on the second and third floors and was uncertain about the procedure for filing anonymous complaints.
Incomplete Competencies for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) completed the necessary competencies and skill sets required for resident care, which is essential for maintaining the residents' safety and well-being. This deficiency was identified during a survey process where three out of five staff competency records reviewed showed incomplete competencies. Specifically, NA #92, NA #129, and NA #164 had not completed essential competencies such as hand hygiene, donning/doffing personal protective equipment (PPE), lift/transfer equipment, and weights/heights. These competencies are crucial for ensuring the safety and rights of the residents, as well as their physical, mental, and psychosocial well-being. During an interview, the Corporate Administrator (CA) acknowledged that the competencies were not completed and provided a list of required skills validation for upon hire and annual competencies. Despite this acknowledgment, no further information was provided to address the incomplete competencies. The facility census at the time was 150, indicating that the deficiency had the potential to affect a limited number of residents residing in the facility.
Incomplete Medical Records and POST Form Deficiencies
Penalty
Summary
The facility failed to ensure complete and accurate medical records for several residents, particularly concerning the Physician's Orders for Scope and Treatment (POST) forms. For Resident #14, the POST form indicated verbal consent was obtained from the resident's representative for CPR, full treatments, and tube feeding if needed. However, the form lacked the required two witness signatures to confirm the verbal consent, as per the 2021 POST form guidance. The Corporate Administrator acknowledged this deficiency during the survey. Similarly, Resident #23's POST form also lacked the necessary witness signatures for the verbal consent obtained from the representative, who had opted for no CPR, selective treatments, and no artificial means of nutrition. The Corporate Administrator confirmed the absence of witness signatures, indicating a recurring issue with the facility's handling of POST forms. Additionally, Resident #15's POST form was incomplete as it was not signed by the resident's representative, despite the representative frequently visiting the resident. This omission rendered the form invalid according to the 2020 POST form guidance. Furthermore, the facility failed to document meal intake accurately for Resident #15, who had an order for tube feeding but had been refusing it. The resident's meal intake percentages for the evening meal were not recorded on three specific dates. Resident #141's POST form also had deficiencies, including the absence of two witness signatures and the date for the verbal consent obtained from the MPOA. These issues were confirmed by the Corporate Administrator and the Corporate Registered Nurse during the survey.
Inaudible Call System in Facility
Penalty
Summary
The facility failed to maintain a functioning call system, which had the potential to affect all 150 residents. During an observation tour on the 2nd floor, the call light system was found to be turned down to a volume too low to be heard throughout the unit. A nurse aide confirmed that he was unable to hear the call system and relied on visual cues from lights above residents' doors. The Maintenance Director acknowledged that the call system was both visual and audible but stated that it was turned down because the staff preferred it that way. A similar issue was observed on the transitional care unit, where the call light system was again turned down to an inaudible level. The Maintenance Helper confirmed this finding.
Failure to Provide Accessible Wheelchair for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs by not ensuring the availability of a readily accessible wheelchair. The resident, who is non-verbal and communicates using an alphabet board, expressed that they were not being assisted to get up due to the unavailability of a wheelchair. During the survey, it was observed that the resident was in a Geri chair, and the Assistant Nursing Director (AND) confirmed that there were no extra wheelchairs available on the floor. The AND mentioned that in case of an emergency, they would resort to a sheet drag to move the resident. Further investigation revealed that the Occupational Therapy-Assistant Director of Rehab (OT-ADOR) acknowledged that wheelchairs were sometimes stored in various locations, and it took 24 minutes to locate a suitable Geri chair for the resident. The chair was found in another resident's room on a different floor, and it was noted that if the previous user of the chair had not been discharged, there would not have been a wheelchair available for the resident at that moment. The resident's care plan indicated that they may be up to a Geri-chair when out of bed, highlighting the facility's failure to provide necessary equipment for the resident's mobility needs.
Failure to Provide Wheelchair for Resident's Choice
Penalty
Summary
The facility failed to provide Resident #17 with a choice regarding his daily routine by not ensuring the availability of a wheelchair, which is necessary for him to get up when he chooses. Resident #17 is non-verbal and communicates using an alphabet board. During an observation, he communicated that the staff would not get him up because they claimed there was no wheelchair available for him. The Assistant Nursing Director (AND) confirmed that Resident #17 was in a Geri chair and mentioned that wheelchairs were stored in the Therapy department on the first floor, but none were available on the third floor where Resident #17 resided. Further investigation revealed that it took 24 minutes to locate a suitable Geri chair for Resident #17, which was found in another resident's room on the second floor. The Occupational Therapy-Assistant Director of Rehab (OT-ADOR) noted that the chair belonged to a resident who had been discharged a week prior, indicating that if the previous resident were still present, there would not have been a wheelchair available for Resident #17. The care plan for Resident #17 indicated that he may be up to a Geri-chair when out of bed, highlighting the facility's failure to provide the necessary equipment to support his choice and mobility needs.
Inaccurate MDS Data Transmission for Discharge Statuses
Penalty
Summary
The facility failed to electronically transmit accurate Minimum Data Set (MDS) data for two residents, leading to deficiencies in the documentation of discharge statuses. For one resident, the medical record indicated an admission to a hospital telemetry unit for congestive heart failure, but the MDS data inaccurately coded the discharge status as 'Home/Community.' For another resident, the medical record showed the resident left the facility against medical advice, yet the MDS data incorrectly coded the discharge status as 'Short-Term General Hospital.' The MDS Coordinator acknowledged the errors, attributing them to being overburdened with tasks and short-staffed.
Incomplete PASRR Evaluation for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure complete and accurate pre-admission screening for a resident with serious mental disorders prior to admission. The resident, who had a history of schizophrenia and grand mal seizures, was admitted without a Level II PASRR evaluation, which is necessary for residents with mental illness or intellectual disability to determine if specialized services are required. The PASRR completed did not document the resident's diagnoses of seizure disorder or schizophrenic disorder, despite these being present in the medical records. The Corporate Administrator confirmed the inaccuracies in the PASRR evaluation.
Failure to Revise Care Plans for Smoking and Meal Interventions
Penalty
Summary
The facility failed to revise care plans in a timely manner for two residents, leading to deficiencies identified during the Long-Term Care Survey Process. For one resident, the care plan inaccurately stated that the resident was not allowed to smoke on the property due to not following facility smoking rules. However, observations revealed the resident was smoking in the designated smoking area on the facility property, and the Corporate Administrator confirmed that the resident was safe to smoke according to a current smoking assessment. The outdated care plan had not been updated to reflect this change. Another resident was observed being served meals on Styrofoam dishes, which was not documented as an intervention in the resident's care plan. The resident had a history of behaviors related to an anoxic brain injury, including throwing items, and had a physician's order for meals to be served on paper products. The Director of Nursing confirmed that the intervention of using paper products for meals was not included in the resident's care plan, despite the resident's behavior of sweeping dishes off the table when finished eating.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program to meet the interests and support the well-being of its residents, specifically affecting two residents. Resident #17, who is non-verbal and communicates using an alphabet board, was not provided with a wheelchair, which prevented him from attending group activities of his choice. Despite his Minimum Data Set indicating the importance of participating in group activities, his records only showed participation in independent and individual engagements, with no group or one-on-one activities recorded. The Guest Services Director, who was new to the position and undergoing training, acknowledged that Resident #17 had not attended activities for some time, attributing it to his refusal to get up. Resident #29 expressed a desire to participate in activities but reported not being offered the opportunity. Her care plan included an intervention for two to three one-on-one social interactions weekly with recreation staff, but a review of her activity participation records from February to March 2024 showed no evidence of these interactions taking place. The Guest Services Director confirmed the absence of documented one-on-one social interventions, indicating a failure to adhere to the resident's care plan.
Failure to Ensure Safe Environment and Supervised Medication Administration
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for its residents. In one instance, a resident's landline telephone was precariously placed directly above their head on the edge of an over-the-bed light fixture. The resident was unaware of how the telephone ended up in that position, and a Licensed Practical Nurse (LPN) acknowledged the danger of the situation but did not know who was responsible for placing it there. In another instance, a resident was observed taking medication from a medicine cup without any staff supervision. The facility's policy requires staff to observe residents during medication administration, but the medication nurse had left the pills for the resident to take independently. The resident, who had moderate cognitive impairment and a diagnosis of dementia, was scheduled to receive Norco and midodrine at specific times. The Nurse Manager confirmed that medications should not have been left at the bedside, indicating a lapse in adherence to the facility's medication administration policy.
Improper Care of Urinary Catheter Collection Bag
Penalty
Summary
The facility failed to adhere to professional standards of care for residents with urinary catheters. Specifically, the urine collection bag for a resident with a urostomy was observed lying on the floor, contrary to the facility's procedure which mandates that the drainage bag be kept below the level of the patient's bladder and off the floor. This deficiency was noted during multiple observations over several days, with the urine collection bag consistently found on the floor under the resident's bed. A Licensed Practical Nurse confirmed the improper placement of the urine collection bag and indicated an intention to obtain a basin to prevent it from being directly on the floor.
Improper Storage of Oxygen Tanks
Penalty
Summary
The facility failed to store oxygen tanks in a safe manner consistent with professional standards of practice. During an observation in the facility's courtyard, an empty oxygen tank was found improperly stored in the seat of a wheelchair. This was confirmed during an interview with the Corporate Administrator, who acknowledged that this was not the proper way to store oxygen tanks, whether full or empty. A review of the facility's policy on compressed gases indicated that cylinders must be stored in an approved cabinet, holder, or secured by cylinder brackets or chains, with the restraining mechanism positioned above the midpoint of the cylinder.
Failure to Assist Resident in Obtaining Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental care. A resident expressed a desire to receive his dentures, noting that an impression had been made over three months prior. A review of the medical records revealed no follow-up notes regarding the resident's dental care after the initial dentist visit in November 2023. During an interview, the facility's Administrator acknowledged that a return appointment was not scheduled due to issues with obtaining payment from the insurance company.
Failure to Identify CNA Competencies in Facility Assessment
Penalty
Summary
The facility failed to identify the specific competencies required for Certified Nursing Assistants (CNAs) to provide the necessary level and types of care for the resident population, as outlined in the Facility Assessment. During a review of the Facility Assessment, it was noted that the competencies for CNAs were not clearly identified, despite the assessment stating that staffing, training, and services were evaluated for various categories such as activities of daily living, bed mobility, and hygiene. This lack of identification of specific CNA competencies had the potential to affect more than a limited number of residents in the facility, which had a census of 150. In an interview with the Corporate Administrator (CA) #182, it was revealed that she was unable to identify any specific competencies required for CNAs as per the Technical Skills Matrix/Facility Assessment. Although a document was provided that outlined required skills validation for CNAs upon hire and annually, it did not specify the competencies needed according to the Facility Assessment. The CA acknowledged that the list referred to skills per the Technical Skills Matrix/Facility Assessment but was unable to provide further details on the competencies required for CNAs.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that Resident Council minutes were reviewed and that resident concerns and grievances were addressed. This deficiency was identified through Resident Council meeting responses and staff interviews. The minutes from several meetings, spanning from October 2023 to February 2024, were reviewed and found to lack signatures from the President, Recording Secretary, or facility Administrator. Additionally, there was no evidence that residents received written responses to the concerns they voiced during these meetings. During a Resident Council meeting in March 2024, residents expressed ongoing issues with food quality, including it being burnt, cold, served in small portions, and not receiving requested substitutes. These issues had reportedly been raised in previous meetings, but there was no documentation in the minutes to confirm this. The Guest Services Director (GSD), responsible for the Resident Council, acknowledged during an interview that the facility was in transition and confirmed that they did not maintain a roster of meeting attendees. The GSD also confirmed that none of the minutes from the meetings were signed. This lack of documentation and follow-up on resident concerns indicates a failure in the facility's process for addressing and resolving grievances raised by the Resident Council, potentially affecting a limited number of residents in the facility with a census of 150.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 67 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huntington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Huntington Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 19 | 0 |
| Madison Park Healthcare | 1.8 mi | ★★★★★ | 4 | 0 |
| St. Mary's Hospital | 2.7 mi | ★★★★★ | 2 | 0 |
| Riverview Post Acute | 5.2 mi | ★★★★★ | 5 | 0 |
| Wayne Healthcare Center | 11.3 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.