Below average — CMS composite of the measures below.
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 Mountain View Care Center during CMS and state inspections, most recent first.
Disrepair was observed in two resident rooms and the main dining room. In one room, an outlet cover was missing, a TV cable was lying on the floor, and ceiling damage was noted near a sprinkler; in another room, the bathroom had a missing vanity strip, cracked paint, holes in the wall, and areas needing drywall and paint repair. Both dining room doors also had chipping paint.
A resident missed scheduled follow-up appointments because the facility did not show transportation was provided, another resident had BP taken in the wrong arm despite an active order, a third resident’s CT findings after a fall were not promptly reported to the physician and a follow-up ortho visit was missed, and a dialysis resident did not receive multiple ordered morning meds on dialysis days. DON and corporate nursing staff confirmed several of these documentation and care failures.
Food temperature monitoring was deficient when the kitchen only recorded temps for main menu items and did not record alternate or always available items before serving them. Surveyors and the DDS confirmed the issue during a kitchen walkthrough, and residents reported hard bread, cold food, and poor meal quality. The facility policy required hot foods above 135 degrees F and cold foods below 41 degrees F, with temps taken before, during, and after service.
Food items were found improperly labeled or dated, and multiple kitchen surfaces and equipment were soiled, including refrigerators, ovens, microwaves, can openers, handwashing sinks, and a drip pan. The dish machine also had missing temperature logs, and the three-compartment sink water temperatures were not being recorded, showing failures in food safety and sanitation practices.
Improper Garbage and Refuse Storage: The facility failed to keep trash can lids on in the kitchen and dish room during survey observations. A trash can beside the handwashing sink had no lid, and the DDS said the lid could not be found. The dish room trash can was also observed without a lid more than once, despite being replaced after the issue was pointed out.
Grievance Process Not Readily Available and Missing-Item Grievances Not Adequately Resolved: Residents stated they did not know how to file grievances, including anonymously, and grievance forms were not readily accessible, with staff needing time to locate them. The facility also documented multiple missing-item grievances for several residents, but could not provide evidence that the listed clothing and personal items were actually replaced, and a resident continued to report missing belongings.
Abuse investigations were not correctly interpreted, and residents were not protected while the investigations were pending. One resident was observed inappropriately with another resident, but the ordered 1:1 supervision did not begin until later that evening. Other incidents involved a resident reporting verbal abuse, another resident alleging a unit manager hit her while separating residents, and investigations that were incorrectly labeled inconclusive or unsubstantiated despite staff-witnessed contact and a resident kicking and attempting to punch another resident.
Failure to Provide Transfer Notices and Ombudsman Notification: The facility did not document written transfer notices with appeal rights and LTC Ombudsman contact information for residents transferred to the hospital due to abnormal vital signs. The DON stated the notices were not provided to the resident or resident representative, and there was no documentation that the Ombudsman was notified for multiple hospital transfers.
Care plans were not fully developed or implemented for three residents. One resident’s feelings of abandonment and related anxiety/depression were not addressed in the care plan, another resident’s pressure-reduction wheelchair cushion was not in place despite a care plan requiring it at all times, and a third resident’s discharge plan did not reflect his stated goal to transfer to another SNF closer to family.
A facility failed to keep care plans accurate and to involve an incapacitated resident in care planning. One resident’s care plan listed conflicting transfer methods, another resident’s G-tube care plan did not match the physician’s order for pH checks, and a third resident said she had not attended a care plan meeting or been told what was happening while records showed she was incapacitated and the MPOA signed by phone instead of the resident.
Dialysis Meal Service Not Provided as Scheduled: A resident who received dialysis three times weekly reported that dinner was not always saved when returning from evening treatments, and the DON confirmed the meal documentation showed multiple missed or unrecorded dinners that matched the resident’s dialysis schedule. The resident had an order for transport to a local dialysis center with facility transport arranged, but meal records showed many Monday and Friday suppers were not documented or marked as unavailable.
The facility failed to provide medically related social services by mishandling resident grievances, sending medical record excerpts without permission, and not honoring advance directives or care plan participation rights. Staff also failed to report and interpret abuse allegations correctly, delayed discharge planning, and did not ensure timely vision and dental follow-up. In addition, social service assessments and trauma screens contained inaccurate information, and grievance forms were not readily available to residents.
Controlled substance counts were not consistently signed by both the off-going and on-coming nurses, and an LPN confirmed the missing signatures on multiple count sheets. In addition, a resident’s oxycodone was signed out on the controlled substance log on several occasions without being documented as administered on the MAR, and a nurse consultant agreed this should have been identified as possible drug diversion.
Residents were served lunch without items listed on their trays, including fortified pudding, mandarin oranges, and key lime pie, and staff had to obtain the missing foods after the omissions were identified. Another resident stated she continued to receive mixed vegetables despite telling staff she did not like them, even though she had a BIMS of 15.
Medical records were incomplete and inaccurate for multiple residents. Documentation errors included an incorrect medication indication, a TB consent form completed incorrectly, a PPD test not signed off in the MAR, missing surrogate paperwork, incorrect demographic and functional entries, and assessment forms that did not match the residents’ actual status or needs.
A resident’s medical record was sent to an out-of-state facility without the MPOA’s permission. Social services documented that notes were provided to the outside facility per its request, and a nurse consultant confirmed there was no evidence of MPOA authorization in the record.
The facility failed to ensure an RN was on duty for 8 consecutive hours daily. Record review showed only 4.33 hours of RN coverage on the cited date, and the NHA confirmed the facility did not meet the 8-hour RN requirement. The facility census was 109.
Failure to Honor Resident Food Preferences A resident stated she was a vegetarian and reported she had told staff for years that she does not eat meat. Her dietary profile did not document her dislikes, and it had not been completed quarterly as required. During meal observations, she was served meat-containing items, including spaghetti with meat sauce and sausage, while staff acknowledged she did not eat meat and that the profile was overdue.
A facility failed to treat two residents with dignity by not recognizing their individuality. An agency CNA entered residents’ rooms during the overnight hours to label personal items, waking one resident and interrupting another, and the DON stated this should not have been done at that time of the morning.
A resident's call light was found behind her pillow and was not within her reach when a surveyor interviewed her. The resident said she could not find it earlier, and a CNA later confirmed the call light was not within the resident's reach.
Advance directive wishes were not consistently honored for two residents. One resident had regained capacity, but the most recent POST form in the chart was signed by someone other than the resident, and the SW confirmed the resident should have been given the chance to complete a new POST. Another resident had a signed POST indicating DNR and comfort-focused care, but the physician order in the chart listed full code/full treatments, which the Nurse Consultant and NHA confirmed did not match the resident’s expressed wishes.
Failure to protect a resident from verbal abuse occurred when another resident yelled at and called her names over a man, leaving her feeling degraded. Records showed the other resident was supposed to be on 1:1 observation but was not placed on it until hours later, and the incident was documented as unverified even though both residents admitted it happened.
Failure to timely report alleged sexual abuse. A resident was involved in an incident in which another resident reached between her legs and she struck his hands away before a CNA redirected them. The facility identified the event as sexual abuse, but the report was not faxed to the state agency within the required 2-hour timeframe, and the Corporate Nurse and NHA confirmed the delay.
Delayed Reporting of Alleged Abuse: A resident-to-resident abuse allegation was documented after one resident reached between another resident’s legs and was redirected by a CNA, but the incident was not faxed to the state agency until more than 4 hours later. An interview with the Corporate Nurse and NHA confirmed the report was not made within the required 2-hour timeframe.
Delayed discharge planning for a resident wanting to return to the community. A resident told staff he wanted to go home, but the record showed Section Q was completed using family input and indicated he did not wish to return to the community and that active discharge planning was not underway. The care plan already listed a short-term discharge plan, and a SW note stated the resident could live alone with some assistance and wanted to find a place, yet the SW said she had only just learned he wanted to go home and had not started discharge planning.
A resident’s PASARR failed to include bipolar disorder even though the diagnosis was present on admission. Social Services confirmed the diagnosis was known at admission but was not listed on the PASARR.
A resident who could not complete ADLs independently did not receive scheduled bathing assistance as ordered. Her record showed she preferred bed baths, but the bathing log reflected multiple missed bath intervals, and an RN consultant confirmed that a bath or documented refusal was not recorded.
Failure to ensure timely access to eyeglasses for two residents. One resident reported he had seen the eye doctor but never received his glasses, and the DON and Social Services were unaware of the status while the eye clinic still had prescriptions waiting. Another resident said she had waited weeks for glasses because the invoice had not been paid; email records showed the clinic would not order the glasses until payment was received, and the NHA confirmed payment was delayed until after the surveyor asked about it.
A resident with pressure ulcers reported that a trapeze bar base caused a left foot sore during transfers, and records documented a pressure area related to weight-bearing on the trapeze device. Staff notes stated the resident agreed to discontinue the trapeze because it was causing injury, yet the trapeze bar remained in the room for days after it was identified as a contributing factor, and the DON later confirmed it had been left in place for 13 days.
Failure to provide appropriate foot care for two residents. One resident had black spots on the toes and was supposed to follow up with podiatry, but the consult was not in the record and the appointment had been cancelled without being rescheduled at the time. Another resident with DM had long, thick toenails that were observed above the tips of the toes, despite a care plan calling for diabetic foot care and checks; no podiatry consult was found in the record.
A resident receiving continuous O2 via NC had a physician order for 2 LPM, but staff observed the flow meter set at 5 LPM on two occasions. A corporate nurse confirmed the setting did not match the ordered rate, and the resident stated he did not adjust the O2 and usually used 2 liters.
A multi-use vial of tuberculin PPD was found in the side 2 med room refrigerator after it had been in use longer than the manufacturer’s 30-day limit. An LPN confirmed the vial should have been discarded, and the facility’s policy required opened multi-dose vials to follow the manufacturer’s recommended expiration date.
The facility failed to ensure dental services were provided for two residents. One resident had ongoing mouth pain and a dental referral order, but the most recent dental visit in the record was much earlier and no newer appointment had been made. Another resident missed a denture evaluation because the wheelchair would not fit through the door, and there was no evidence the visit was rescheduled or any dental follow-up completed.
Failure to Offer Recommended Pneumococcal Vaccination: A resident with prior PPSV23 vaccination had no documentation that the facility offered or administered a recommended follow-up pneumococcal vaccine per CDC/ACIP guidance. The record also contained an undated consent form for PPSV23 after admission, but no evidence of an additional PCV20, PCV21, or PCV15 vaccine being offered or given.
The facility failed to offer COVID-19 vaccination to two residents within accepted standards of practice. Records showed no documentation that either resident was offered the COVID-19 2025-2026 vaccine until staff later documented education and refusal, and the IP nurse confirmed the offers were not made until after the surveyor requested evidence.
Surveyors found that the facility did not follow menus, failed to provide consistent portion sizes, and made unapproved food substitutions without Registered Dietician input. Residents reported ongoing dissatisfaction with food quality, portion sizes, and lack of communication about menu changes, while posted menus often did not match meals served.
Multiple failures in food service were observed, including a resident being served a meal that had been left uncovered and was cold, with food temperatures measured in the danger zone. Additional concerns were reported about food quality, temperature, and contamination, such as a hair found in a dessert. Residents also voiced ongoing dissatisfaction with food temperature, portion size, and texture.
Staff failed to check the internal temperature of hamburger patties before serving, resulting in undercooked meat being placed on trays for residents. A surveyor intervened to prevent the undercooked food from being served, highlighting a lapse in food safety protocols.
A resident's room was found to have HVAC filters covered in gray dust bunnies, with both the Maintenance Director and Director of Housekeeping confirming the filters had not been cleaned as required.
A resident with significant weight loss was not properly assessed or monitored, as the facility failed to obtain weekly weights per RD and risk management recommendations. The DON confirmed that weights were not completed, and there was no evidence that the physician or responsible party was notified of the resident's ongoing weight loss.
A resident who was ordered a Mechanical Soft texture diet with nectar thickened liquids was instead served a pureed meal, contrary to the physician's order and care plan. Staff confirmed the incorrect meal consistency was delivered without adjustment.
A resident with an order for nectar thickened liquids was served honey thickened liquids during a meal, contrary to their care plan and physician's order. This failure was observed and reported by staff, and confirmed through review of the resident's records and care plan.
Multiple residents requiring mechanical soft or pureed diets were served food items such as whole meatballs, whole pasta, deep-fried French fries, and coleslaw, which did not meet prescribed texture modifications. Some residents also received liquids that were either not thickened or were too thick, contrary to their orders. Staff interviews and observations revealed inconsistent adherence to dietary policies and improper use of thickening agents, resulting in immediate risk to residents.
Several residents experienced significant delays in receiving their meals, with some waiting up to thirty-three minutes after their tablemates had been served, and others repeatedly asking for their food while staff continued to serve other tables. Staff confirmed that meals should have been served together. Additionally, all residents were served on styrofoam bowls and plates because the kitchen ran out of standard dining ware, as verified by dietary staff. These actions resulted in a failure to provide a dignified dining experience.
The facility did not promptly or effectively address repeated Resident Council concerns about meal service, including issues with drink timing, menu substitutions, and unfulfilled food preferences. Observations confirmed that drinks were served too early, meals did not match the posted menu, and food meetings with kitchen management were inconsistently held. Staff acknowledged the ongoing nature of these problems.
The facility did not ensure that survey results were posted in a location easily accessible to residents. During interviews, residents reported not knowing they could access the survey findings, and staff confirmed the results book was kept behind the front desk rather than in a public area.
A resident's wheelchair was repeatedly observed to be dirty with dried food and liquids over several days, and staff confirmed it had not been cleaned. Additionally, the kitchen ceiling, exhaust fan, and shower room ceiling with peeling paint were not cleaned. The administrator stated there was no policy or schedule for cleaning wheelchairs or facility areas.
A treatment cart was left unlocked and unattended in a hallway with residents nearby, and a resident at risk for elopement was present while the wanderguard exit system was not functioning properly. Both deficiencies were confirmed by staff and documentation.
The facility did not maintain adequate nursing staff levels, resulting in prolonged call light response times and residents being left in bed due to lack of assistance. Multiple residents and staff reported frequent understaffing, especially on weekends and night shifts, which led to unmet care needs and incomplete tasks.
The facility did not consistently provide residents with the correct food portions, types, and consistencies as ordered, including failing to serve double portions to a resident with a history of weight loss and not following posted menus. Staff and residents reported frequent menu substitutions, insufficient food, and missing items, with dietary staff confirming errors in meal preparation and serving sizes.
Disrepair in Resident Rooms and Dining Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in two resident rooms and the main dining room. In one room occupied by two residents, a blank electrical outlet cover was noted needing to be moved to cover a hole in the wall, the TV cable for one resident’s television was lying on the floor away from the wall, and the resident stated that the other resident’s wheelchair had gotten tangled in the cable before and required assistance to get unstuck. The same room also had ceiling damage near a fire sprinkler measuring approximately 12 inches by 12 inches. In another room occupied by two residents, the bathroom had multiple areas of disrepair, including a missing laminate strip on the vanity that prevented it from being easily cleanable, a crack in the paint above the toilet, three small holes above the glove holder near the bathroom door, and two areas beside the bathroom mirror needing drywall and paint repair. In the main dining room, both doors leading into the room had paint chipping and falling off, and the Corporate RN agreed that both doors needed sanding and painting.
Missed appointments, improper BP monitoring, delayed notification of imaging results, and omitted dialysis-day medications
Penalty
Summary
The facility failed to provide treatment and care in accordance with orders and professional standards for multiple residents. For one resident, hospital discharge instructions included follow-up appointments with the CHF Clinic and Nephrology, and the facility policy stated it would help arrange transportation as needed. The transportation schedule for July 2025 did not show either appointment, and the facility could not produce evidence that transportation was provided or that the resident attended the appointments. A corporate RN confirmed the resident was not provided transportation and did not attend the follow-up visits. For another resident with a dialysis-related order stating that a full set of vital signs and weight were to be obtained after dialysis and that no BP was to be taken in the left arm, the electronic record showed repeated BP measurements taken in the left arm on numerous dates in May and June 2026. The DON reviewed the vital signs record and confirmed that staff documented taking BP in the left arm on multiple occasions despite the active order prohibiting it. A third resident had a fall with major injury and subsequent imaging that suggested a coronoid fracture and later a traumatic radial head fracture with dorsal soft tissue edema. The physician was not notified of the CT findings until weeks later, and an orthopedic referral was then ordered. The resident attended one orthopedic appointment, where non-weight-bearing status to the right upper extremity and a six-week follow-up were ordered, but the resident did not make the follow-up appointment. For another resident on dialysis, the MAR showed multiple dialysis-day mornings when ordered medications, including docusate sodium, Eliquis, nateglinide, and multivitamins, were not administered; the same pattern also occurred for a prescribed antibiotic on certain mornings. A corporate consultant nurse confirmed the resident did not receive all ordered morning medications on dialysis days during the months reviewed.
Food Temperature Monitoring and Meal Quality Deficiency
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures. During record review, resident interviews, and staff interviews, surveyors found that food temperatures were not being taken for all food items before they left the kitchen. The facility was only recording temperatures for items on the main menu and was not recording temperatures for alternate or always available food items before serving them to residents. The Director of Dining Services confirmed these findings during the kitchen walkthrough and stated that temperatures for those items would start being recorded. The facility’s policy stated that all foods shall be cooked, held, and served at safe temperatures, with hot foods above 135 degrees F and cold foods below 41 degrees F, and that temperatures would be taken once cooked, before, during, and after service. Resident Council members stated the bread was always hard. Residents reported that food was cold at times, breadsticks were hard as a rock, hot food was cold at times, and the food was not good. One meal tray was tested throughout the survey process, and the failed practice was identified as affecting one of one meal tray tested, with the potential to affect more than a limited number of residents.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional food safety standards, and kitchen sanitation practices were not followed. During an initial walkthrough of the kitchen, the Director of Dining Services verified multiple sanitation and food storage issues, including a soiled walk-in refrigerator floor, beverage spills in the reach-in refrigerator, a soiled drip pan under the stove, a soiled microwave interior, a soiled toaster, soiled fronts of both conventional ovens, soiled handwashing sinks, soiled can openers, and a heavily soiled microwave in the side pantry. The dish machine also had missing temperature documentation for multiple dates in May 2026 and for breakfast service on June 1, 2026. The surveyor also observed multiple food items that were not properly labeled or dated, including juice cups in the walk-in and reach-in refrigerators, two containers of honey thickened juice, an opened and undated package of flour, a foam cup of sugar that was not sealed, labeled, or dated, and a container of coffee that was not dated. On follow-up observation, one can opener remained soiled, the dish machine temperature had not been taken and recorded before washing breakfast dishes, the three-compartment sink water temperatures were not being recorded, and a soiled pair of gloves was found on the countertop near the coffee maker.
Improper Garbage and Refuse Storage
Penalty
Summary
The facility failed to store and dispose of garbage and refuse properly in the kitchen and dish room. During the initial walkthrough of the kitchen, the Director of Dining Services accompanied the surveyor and verified the findings. A trash can located beside the handwashing sink had no lid, and the Director of Dining Services stated that a lid was available somewhere but could not be found and that she would remove the trash can from the kitchen. Later, the trash can in the dish room was observed without a lid at 11:20 AM, and after the surveyor brought it to the Director of Dining Services’ attention, the lid was placed on it. At 11:46 AM, the same trash can in the dish room was again observed without its lid, and the Director of Dining Services stated she would speak to staff about leaving the lids on the trash cans when not in use.
Grievance Process Not Readily Available and Missing-Item Grievances Not Adequately Resolved
Penalty
Summary
The facility failed to ensure residents knew how to file a grievance, including anonymously if desired, and failed to adequately resolve resident grievances. During the Resident Council Meeting, residents stated they did not know how to file a grievance in writing or anonymously. One resident pointed to a box on the wall and said it had been put up that day, but there were no forms in it. The LSW stated the grievance forms were kept behind the nurses’ station and that most residents would need help completing them, while an LPN and the DON had difficulty locating the forms, taking about 10 minutes to find a binder in a cabinet. The DON confirmed the grievance forms were not readily available for residents and family members. The facility also failed to adequately resolve grievances related to missing personal items. A resident reported missing multiple clothing items and said she no longer sent her clothes to laundry because items were not always returned. Her grievance documented several missing items, and although the facility recorded some items as located and others as replaced, the resident was still reporting missing belongings when surveyed. The facility did not provide evidence that the remaining items had actually been replaced until after the surveyor requested proof, and the Nurse Consultant confirmed the items were not replaced until after the surveyor asked about them. A review of the grievance log identified additional missing-item grievances for several residents, including missing clothing, shoes, jackets, sweaters, socks, and a robe. In each case, the investigation found the items were not located and the grievance record stated the items would be replaced, but the facility was unable to provide evidence that the items were replaced. The Corporate Nursing Home Administrator confirmed that receipts could not be located for these residents’ replaced items and stated the facility would follow up to get the items replaced.
Abuse investigations were misinterpreted and residents were not protected during pending investigations
Penalty
Summary
The facility failed to correctly interpret abuse allegation investigations and did not prevent further potential abuse while investigations were still in progress. The report states this involved five of six residents sampled for abuse during the survey process. Facility policy required that, when abuse was alleged or observed, the resident be immediately assessed, the physician and responsible party be notified, and the resident and others be protected from further harm or incident. For Resident #21 and Resident #8, a nurse note documented that one resident was found sitting in the hallway holding hands with the other resident, with the other resident’s hands between the first resident’s legs. The residents were separated and Resident #8 was placed on 1:1 and q15 minute checks, with the PCP and responsible party notified. Witness statements indicated the incident occurred earlier in the day, but Social Services confirmed Resident #8 was not on 1:1 at the time of the incidents. Corporate RN review confirmed the 1:1 observation was supposed to begin after the first incident, but the MAR showed the 1:1 did not start until later that evening. The same resident was also involved in another incident in which Resident #49 reported being yelled at and called names over a man, and in a separate event Resident #8 alleged that a unit manager hit her while separating residents. For Resident #74, the incident report described another resident reaching between Resident #74’s legs while she was sitting by the nurses station, and the resident smacked the hands away. The five-day follow-up concluded the incident was verified because it was witnessed by staff, but it was still labeled inconclusive for abuse due to no physical or psychosocial harm, uncertainty about intent, and lack of recollection by the residents. For Resident #70, the investigation documented that Resident #63, who had dementia and a low BIMS score, came out of Resident #70’s room, became irate, kicked Resident #70 in the lower legs, and attempted to punch him again. The facility concluded the abuse was unsubstantiated because of the resident’s diagnosis and low BIMS score related to intent, even though the NHA later agreed the resident had kicked the other resident voluntarily and that it was done on purpose.
Failure to Provide Transfer Notices and Ombudsman Notification
Penalty
Summary
The facility failed to notify residents in writing of the reason for transfer to the hospital and failed to send a copy of the notice to the ombudsman. Record review showed that Resident #2 was transferred to the hospital due to abnormal vital signs, but there was no documentation of a transfer notice that included appeal rights or the contact information for the long-term care Ombudsman. The Director of Nursing stated the facility did not provide such a notice to the resident or resident representative and that there was no documentation the Ombudsman had been notified of the transfer. A similar finding was identified for Resident #11, who was also transferred to the hospital due to abnormal vital signs, with no documentation of a transfer notice containing appeal rights and Ombudsman contact information. The DON stated the facility did not provide the notice and had no documentation that the Ombudsman was notified. For Resident #9, the facility was unable to produce Ombudsman notification for hospital transfers in April, and the Administrator confirmed there was no proof of Ombudsman notification for two hospital transfers.
Care Plans Not Developed or Implemented for Resident Emotional Needs, Wheelchair Cushion Use, and Discharge Preferences
Penalty
Summary
The facility failed to develop and/or implement care plans for three residents based on information identified during resident interviews, record review, observation, and staff interviews. One resident stated that his family, especially his fiancée, had abandoned him and that this contributed to his anxiety and depression, but his care plan did not address those feelings. The social worker confirmed awareness that the resident’s relationship had ended and that his feelings of abandonment were known on admission, and agreed the issue was not addressed in the care plan. Another resident returned from dialysis and stated that the wheelchair cushion had not been placed in her wheelchair that morning and that the chair hurt without it; the cushion was observed on the floor in her room while she remained seated in the wheelchair. Her care plan included an intervention for a pressure reduction cushion to be in the wheelchair at all times, with placement observed each shift and replaced as indicated, but it was not in place at the time of observation. A third resident stated he was waiting for a bed at another SNF closer to his family and had planned this since admission, yet his care plan stated he was expected to remain in the facility long term with no plans to discharge. The social worker confirmed a referral had been sent to the other SNF, and the nurse consultant agreed the care plan should have been updated to reflect the resident’s desire to transfer.
Inaccurate care plans and failure to involve incapacitated residents in care planning
Penalty
Summary
The facility failed to complete and maintain accurate care plans for residents reviewed during the survey. For Resident #6, the care plan listed two transfer interventions at the same time: a Hoyer lift for all transfers with 2 staff and a wheeled device for ambulation and transfers. During interview, the Nurse Consultant confirmed both interventions could not be correct and stated that the resident needed a Hoyer lift, so the other intervention should have been removed from the care plan. For Resident #4, the physician’s order required G-tube placement checks five times a day by confirming the pH of aspirate, but the comprehensive care plan still directed staff to check G-tube placement two times a day, and the DON confirmed the care plan was incorrect regarding the frequency of pH testing. For Resident #11, the resident stated she had not been to a care plan meeting and had not been told what was going on. Record review showed the resident was deemed incapacitated from admission until 03/24/26, and the care plan signature page during that period was completed with the MPOA by telephone, with the resident’s signature absent. The LSW stated that the resident would not have received notice before because she had recently regained capacity and also stated that if residents do not have capacity, they are not involved in the care plan meeting. The facility policy stated that the resident, family, or legal representative/guardian or surrogate are encouraged to participate in care plan development and revisions, and that every effort will be made to schedule the meeting at the best time for the resident and family.
Dialysis Meal Service Not Provided as Scheduled
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when the facility failed to provide dialysis-related services in accordance with professional standards of practice. Resident #1 stated that they go to dialysis three times a week, with two evening treatments, and reported that dinner meals were not always saved for them when they returned. The resident said they sometimes had to eat food kept in their room and did not know why meals could not be refrigerated and reheated. Record review showed an order for dialysis at a local dialysis center every Monday and Friday, with the resident to be ready for transport by 3:00 PM for a 3:30 PM chair time and facility transport arranged. Review of meal documentation from 03/03/26 to the present showed 24 possible Monday and Friday dinners, with 15 not recorded or documented as the resident not available. The DON confirmed that the documentation appeared to show Resident #1 did not receive dinner meals on the dates that correlated with the dialysis schedule.
Failures in social services, grievance handling, privacy, and resident rights
Penalty
Summary
The facility failed to provide medically related social services in several areas, including privacy of medical records, resident grievances, advance directives, abuse reporting and investigation, discharge planning, care plan participation, vision and dental services, and completion of accurate social service assessments and trauma screens. Surveyors reviewed records, interviewed residents and staff, and observed that the facility sent excerpts of one resident’s medical record to an out-of-state facility without permission from the resident’s MPOA. The MPOA stated this had occurred previously, and a nurse consultant confirmed the records were sent without evidence of permission. Residents and staff also reported problems with the grievance process. During a resident council meeting, residents stated they did not know how to file a grievance in writing or anonymously. Staff interviews showed grievance forms were not readily available and had to be located in a binder in a cabinet at the nurses’ station. Multiple grievances involving missing clothing and personal items were documented as resolved with replacement items, but the facility could not produce evidence that the items had actually been replaced for several residents. One resident continued to report missing clothing after the grievance was marked resolved, and a nurse consultant confirmed the items were not replaced until after the surveyor asked about them. The facility also failed to honor resident rights related to advance directives and care planning. One resident had capacity to make medical decisions, but the most recent POST form in the record was signed by someone other than the resident, and staff confirmed the resident should have been given the opportunity to complete a new POST form after regaining capacity. Another resident had a POST form indicating comfort-focused treatment and no CPR, but the physician order entered into the chart listed full code and full treatment. A short-term resident who stated he wanted to go home had a care plan focused on discharge to the community, but the social worker stated discharge planning had not yet been started. In addition, one resident stated she had never been to a care plan meeting and was not told what was going on, while staff stated residents without capacity were not involved in care plan meetings. The report also documented failures involving abuse allegations, vision and dental services, and inaccurate social service documentation. One abuse allegation was reported to the state agency more than four hours after the incident, and staff confirmed it was not reported within the required two hours. In other abuse investigations, staff and leadership agreed the incidents should have been verified as abuse, but the investigations were instead labeled inconclusive or unsubstantiated based on the residents’ diagnoses and BIMS scores. Residents also experienced delays in receiving glasses and dental follow-up; one resident’s glasses had not been obtained after an eye appointment, another’s glasses were not paid for until after surveyor inquiry, and two residents had unresolved dental needs with no evidence of timely follow-up. Finally, social service assessments and trauma screens contained inaccurate information, including an incorrect gender entry, a trauma screen listing a resident as not interviewable despite being cognitively intact, and an assessment incorrectly stating a resident needed an interpreter.
Controlled Substance Count and Medication Documentation Deficiencies
Penalty
Summary
The facility failed to ensure an account of all controlled drugs was maintained and periodically reconciled. The facility’s policy stated that an accurate inventory of all controlled medications would be maintained at all times, but the policy did not provide specific instructions for counting the medications. During inspection of the B hallway medication cart with an LPN present, the controlled substance count forms showed that the count was recorded, but the forms were not consistently signed by both the off-going and on-coming nurses. The LPN confirmed that the controlled substance counts had not been signed by both nurses as required on multiple dates. The facility also failed to identify and investigate a possible drug diversion involving Resident #98. The resident had an order for oxycodone IR 10 mg every 8 hours. Review of the Controlled Substance Log and MAR showed that on four occasions, an LPN signed out the resident’s oxycodone on the controlled substance log but did not document the medication as administered on the MAR. A nurse consultant later confirmed these findings and agreed that the discrepancy should have been identified as possible drug diversion.
Missed Meal Items and Unmet Food Preferences
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs and preferences during dining observations. Resident #13 received lunch without the nutritious pudding listed on the tray ticket; the Business Office Manager stated the pudding was not available and went to get it. Resident #23 received lunch without mandarin oranges, and a CNA confirmed the resident should have received them and said she would ask for them. Resident #68 received lunch without key lime pie, and facility staff in the dining room obtained a serving after the omission was identified. Resident #89 stated that despite telling staff she does not like mixed vegetables, she continued to receive them; the resident had decision-making capacity with a BIMS score of 15.
Incomplete and inaccurate resident medical records
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for multiple residents. The report identified errors in physician order documentation, TB screening consent and administration records, capacity and surrogate decision-making paperwork, and resident assessment documentation. These issues were found during record review and staff interviews for residents including those with cognitive impairment, residents receiving TB screening, and residents whose records contained incorrect demographic or functional information. For one resident, a gabapentin order listed an incorrect indication of neurocognitive disorder with Lewy bodies even though staff confirmed it had been prescribed for pain. Another resident signed a TB questionnaire and consent form that was completed incorrectly, and the resident later received TB skin tests despite the form reflecting no authorization for a TB skin test. A separate resident had a PPD order documented in the physician orders, but the MAR was not signed to show the test had been administered, even though the infection prevention nurse had handwritten notes indicating it was given. Additional record inaccuracies included a resident whose chart lacked the surrogate decision-making paperwork after a physician determination found no capacity, a social service evaluation that incorrectly identified a male resident as female, documentation showing a resident as dependent for walking even though staff confirmed the resident could not stand or walk at all, oral assessments that failed to record the number of teeth despite the resident having six natural teeth, a trauma screen that incorrectly stated a cognitively intact resident was not interviewable, and a social service assessment that incorrectly indicated a resident needed an interpreter when staff confirmed no interpreter was needed.
Failure to Protect Resident Medical Record Privacy
Penalty
Summary
The facility failed to ensure Resident #63’s medical record remained private and confidential when excerpts from the resident’s medical record were sent to an out-of-state facility without permission from the healthcare decision maker. During an interview, the resident’s MPOA stated that the facility had sent the records without permission. The medical record included social service progress notes documenting that the out-of-state facility contacted social services requesting additional notes, that 7 days of notes were sent, and that 60 days of notes were submitted to the out-of-state nursing facility per their request. A nurse consultant later confirmed that excerpts of Resident #63’s medical record were sent to the out-of-state facility and that there was no evidence in the record that the MPOA gave permission for the records to be sent.
Insufficient RN Coverage
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours daily. Record review showed the facility had 4.33 hours of RN coverage on 03/22/26, which was below the required eight-hour level. An interview with the Nursing Home Administrator on 06/03/26 at 1:30 PM confirmed the facility did not meet the eight-hour RN requirement on that date. The facility census was 109.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure Resident #20’s food preferences were identified and honored. During interview, the resident stated she was a vegetarian and said she had told the facility for years that she does not eat meat. The most recent quarterly dietary profile in the record, dated 05/15/25, did not identify that the resident did not like meat, and the dislikes section was left blank. The resident’s medical record also showed that the dietary profile had not been completed quarterly as required. During meal observations, the resident was served spaghetti with meat sauce at lunch, and the assigned nurse aide stated she had told staff that morning not to send that tray because the resident does not eat meat. At breakfast, the resident was served sausage, oatmeal, eggs, and a pureed blueberry muffin bake, and the nurse aide feeding the resident stated she was not a fan of meat so she did not eat the sausage. The resident stated, “I am a vegetarian.” The CDM and Corporate Nutritional Consultant later stated the resident had told them the only meat she likes is chicken in chicken noodle soup, and that she did not want pork or beef, but the dietary profile had not been updated and was overdue.
Failure to Respect Resident Dignity During Overnight Labeling
Penalty
Summary
The facility failed to treat each resident with respect and dignity by not recognizing their individuality for 2 of 3 residents reviewed for dignity. Resident #88, who had a BIMS score of 15, stated that an agency CNA came into the room at 1:00 in the morning and woke the resident up to put the resident's name on personal belongings, and the resident told the CNA no and to get out. Resident #88 also stated the CNA may have gone into other rooms and done the same thing. Resident #101, who had a BIMS score of 12, stated that a CNA came into the room about 2:00 in the morning and wanted to put the resident's name on some items, said she had to go get something, and then did not return. The DON stated she was not sure whether the items were being labeled or whether the direction came from the nurse, but agreed that this should not have been done at that time of the morning.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure a resident's call light was within reach. During a surveyor interview, Resident #52 stated that she could not find her call light and had tried to find it earlier. The surveyor located the call light behind the resident's pillow and pressed the button. Shortly afterward, a CNA entered the room and was told that the call light had been activated; when asked whether the call light was within the resident's reach, the CNA stated that it was not within her reach and that she would fix it. The facility policy titled "Answering the Call Light" states that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Advance directive wishes were not consistently honored
Penalty
Summary
The facility failed to ensure that all residents were afforded the opportunity to formulate their own advance directive and that their expressed wishes were honored after an advance directive was completed. This deficiency involved two of seven residents reviewed for advance directives during the survey process, including Resident #11 and Resident #124. For Resident #11, the medical record showed a physician determination of capacity completed by the attending physician indicating the resident had capacity to make medical decisions. The most recent Physician Order for Scope of Treatment (POST) form in the record was dated after admission and indicated full code status, but it was signed by someone other than Resident #11. The Social Worker confirmed that the POST form was not signed by Resident #11 and stated that the resident should have been given the opportunity to complete a new POST form when capacity was regained. For Resident #124, the record contained a POST form signed by the resident indicating a preference not to receive CPR and to receive comfort-focused treatments, but a physician order entered into the chart later listed the resident as full code/full treatments and noted no artificial means of nutrition desired with capacity. The Nurse Consultant and Nursing Home Administrator confirmed that the physician order did not match the resident's expressed wishes and needed correction.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
Resident #49 was not protected from abuse when another resident yelled at her and called her names over a man, which she said made her feel degraded. The facility’s policy defined abuse to include verbal abuse and mental abuse, and Resident #49 reported the incident during interview on 06/03/26. A nursing note dated 02/17/26 documented that it was reported to the nurse that one resident verbally threatened to kick another resident’s butt, and the threatened resident stated she did not want the other resident to kick her butt. The record review showed the resident who yelled at Resident #49 was supposed to be placed on 1:1 observation at 2:30 PM on 02/17/26, but the MAR showed the resident was not placed on 1:1 until 7:00 PM that evening. The facility reported incident indicated the event was unverified even though both residents admitted it happened. Social Services confirmed the offending resident was not on 1:1 at the time of the incident, and Corporate RN confirmed that Resident #49 was yelled at by another resident who was supposed to be on 1:1 observations.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to implement its Abuse Investigation and Reporting policy for an alleged sexual abuse incident involving Resident #74 and Resident #97. The policy stated that allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, would be reported immediately, but no later than two hours if the allegation involved abuse or resulted in serious bodily injury. A reportable incident dated 01/19/26 documented that Resident #97 rolled by Resident #74, reached between her legs, and Resident #74 smacked his hands away before a CNA redirected the residents. The facility identified the event as sexual abuse, but the report was faxed to the state agency at 5:49 PM, which was 4 hours and 37 minutes after the 1:12 PM incident time. Corporate Nurse #131 and the NHA confirmed in interview that the incident was not reported within the required two-hour timeframe.
Delayed Reporting of Alleged Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the required state agency within two hours of the alleged incident. For Resident #74, a reportable incident dated 01/19/26 involved an allegation that Resident #97 rolled by the resident, reached between the resident’s legs, and was smacked away by the resident before a CNA redirected the residents. The incident was documented as occurring at 1:12 PM, but the report was faxed to the state agency at 5:49 PM the same day, which was 4 hours and 37 minutes after the incident. An interview with Corporate Nurse #131 and the NHA on 06/04/26 confirmed the incident was not reported within the required two-hour timeframe.
Delayed discharge planning for a resident wanting to return to the community
Penalty
Summary
The facility failed to ensure Resident #77 received timely and adequate discharge planning after he indicated to staff that he wanted to return to the community. During an interview on 06/01/26, the resident stated that he wanted to go home, but he had lived with his fiance and she did not want him there, so he did not know what he would do. The record showed one capacity statement dated 04/07/26 indicating the resident had capacity to make medical decisions. The Minimum Data Set with an ARD of 03/02/26 showed Section Q was completed by interviewing the resident's family and was coded to indicate the resident did not wish to return to the community and that active discharge planning was not underway. The care plan included a short-term discharge plan initiated on 03/04/26 stating the resident was expected to return to the community, with interventions to coordinate with the physician, make DME referrals, refer for community resources, refer to the local contact agency if indicated, and review and update discharge plans with the resident when needed. A Social Service Quarterly Note dated 05/22/26 stated the resident could live alone with some assistance and had voiced that he would like to find a place. During an interview on 06/09/26, the social worker stated she was aware the resident wanted to go home and said she had just found that out and was going to start working on discharge planning that week, but had not had the chance.
PASARR did not include bipolar disorder for a resident
Penalty
Summary
The facility failed to identify all mental disorders for Resident #99 on the PASARR. The resident’s diagnosis list included bipolar disorder on admission, but bipolar disorder was not included on the PASARR. During an interview, Social Services #100 confirmed that Resident #99 had bipolar disorder on admission and that it was not included on the PASARR.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure Resident #20, who was unable to perform her own activities of daily living, received assistance with bathing as scheduled. Her record showed she was to receive a shower or bed bath on Mondays and Thursdays on day shift, and she stated a preference for bed baths instead of showers. Review of the bathing report from 03/09/26 through 06/09/26 showed multiple missed bathing intervals, including a seven-day gap between baths from 04/15/26 to 04/22/26 and a nine-day gap from 05/01/26 to 05/10/26. During interview on 06/09/26, Nurse Consultant #134 confirmed the findings and agreed the resident should have received a bath or a documented refusal, but neither was documented.
Failure to Ensure Timely Access to Eyeglasses
Penalty
Summary
The facility failed to ensure Resident #7 received glasses to maintain vision ability. Resident #7 stated he had gone to the eye doctor about a month earlier but never received his glasses. Social Services stated they did not know anything about the glasses and thought they could still be at the doctor’s office. The DON also stated she did not know anything about new glasses and would check into it. The facility produced only one page of the eye doctor visit note from 03/06/26, which did not include follow-up information. When the surveyor contacted Virginia Eye Consultants, the receptionist stated there were two prescriptions for glasses waiting at the office, and it was confirmed that Resident #7 had not received his glasses after the eye appointment and the facility had made no effort to obtain further notes or the glasses. The facility also failed to make timely payment for Resident #6’s glasses. Resident #6 stated she had seen the eye doctor eight weeks earlier and still had not received her glasses, and she had asked the social worker about them after learning they had not been paid for. The medical record showed she was seen by the in-house eye doctor on 04/16/26 and that the invoice was sent to the facility. Email correspondence showed Social Worker #100 asked the eye doctor about residents still waiting for glasses, and the eye doctor replied that invoices had to be paid in full before glasses would be ordered. The NHA later confirmed the glasses were not paid until after the surveyor asked about them, and a copy of the check for Resident #6’s glasses was then provided.
Failure to Remove Trapeze Bar Contributing to Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with pressure ulcers. Resident #12 stated he had sores on his left foot and buttocks and reported that the left foot sore came from the base of a trapeze bar used during transfers. The resident said the trapeze bar was supposed to be removed but had not been taken out. Observation showed the trapeze bar remained in the room on 06/01/26 and again on 06/02/26. Record review showed the resident had a change-in-condition assessment describing a pressure area caused by the way he transferred and put weight on the trapeze mobility device when moving from bed to wheelchair. A skin and wound note documented a stage II area on the left outer foot above a stage III area on the left lateral foot, and noted the resident demonstrated how his foot rested on the base of the trapeze bar during transfer and stated that this was how he injured his foot. A nursing note recorded that the resident agreed to discontinue the trapeze because it was causing injury to his foot. Staff interviews confirmed the trapeze bar was still present in the room after it had been identified as a contributing factor, and the DON confirmed the facility left it in the room for 13 days after identifying it as the cause of the pressure ulcer.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to ensure proper foot care and treatment for two residents. One resident had a hospital discharge summary indicating follow-up with a podiatrist in two to four weeks for black spots on the toes, but the consult could not be located in the medical record and a nurse consultant confirmed the resident had not been seen by a podiatrist because a previously scheduled appointment had been cancelled and not rescheduled at that time. The record later showed the facility called to reschedule the appointment and it was set for a later date. A second resident with diabetes stated that the toenails were very long and that the resident did not think a podiatrist had ever been seen. Observation showed both feet with toenails about 1/2 inch long, above the tips of the toes, and the nails appeared thick. The care plan directed staff to provide diabetic foot care and checks as needed, but no podiatry consultations were found in the record. A later observation showed the toenails remained long and thick, and the DON confirmed the toenails were long and said the resident would be placed on the podiatrist list and the RN would cut them.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to provide oxygen services within accepted standards of practice for Resident #69 by not following the physician’s ordered supplemental oxygen flow rate. The resident had an order written on 05/19/26 for oxygen at 2 LPM via nasal cannula continuously, and the facility policy instructed staff to turn on oxygen at the number of liters per minute ordered by the physician or practitioner. During observation on 06/01/2026 at 12:36 PM and again on 06/02/2026 at 11:31 AM, Resident #69 was sitting in a chair in his room and receiving oxygen via nasal cannula, but the oxygen flow rate was set at 5 liters per minute on both occasions. Corporate Nurse #131 confirmed the oxygen flow rate was not set to the prescribed rate and asked the resident whether he had adjusted it; the resident stated he had not and said he usually used 2 liters of oxygen.
Expired Multi-Use PPD Vial Kept in Use
Penalty
Summary
The facility failed to follow accepted standards of practice for medication labeling and storage when a multi-use vial of tuberculin purified protein derivative (PPD) remained in use beyond the manufacturer’s recommended time period. The facility’s policy stated that opened multi-dose vials may be used until the manufacturer’s recommended expiration date and that the expiration date triggered by opening the vial should be available on the medication label or packaging insert. During inspection of the side 2 medication room, a refrigerated multi-use vial of tuberculin PPD was found dated 04/30/26 to show when it was first accessed, and the box instructions stated that once entered, the vial should be discarded after 30 days. An LPN confirmed that the vial had been in use for more than 30 days and should have been discarded.
Failure to Ensure Dental Services Were Provided
Penalty
Summary
The facility failed to ensure dental services were provided to meet residents’ needs for two residents reviewed. One resident had an order for a dental referral due to mouth pain after continued complaints of pain in the upper teeth, and Tylenol was given and documented as effective, but the resident’s record showed the most recent dental appointment had been on 12/04/24 for a toothache with no more recent dental report found; an RN stated the resident was on the list for a dental appointment, but one had not yet been made. Another resident reported that a prior appointment for dentures was missed because the wheelchair would not fit through the door. The record showed a denture evaluation appointment with a note written across the top asking to use a smaller wheelchair, and the facility could not produce evidence that the appointment had been rescheduled; the DON confirmed there had been no dental follow-up since that appointment.
Failure to Offer Recommended Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer pneumococcal vaccination to a resident within accepted standards of practice. The facility policy titled, Pneumococcal Vaccine, stated that residents would be assessed for eligibility upon admission and offered pneumococcal vaccination within 30 days unless contraindicated or already vaccinated, based on CDC or ACIP guidelines. Resident #76 had received a PPSV23 vaccination before admission to the facility and had an undated consent form in the medical record indicating consent for PPSV23 vaccination after admission. The resident was [AGE] years old and admitted in July 2025. CDC/ACIP guidance for adults over [AGE] years old states that adults vaccinated only with PPSV23 should be offered PCV20, PCV21, or PCV15 at least one year after the PPSV23 vaccine. Review of the resident’s record showed no documentation that an additional pneumococcal vaccine was offered or given. On 06/09/2026, the Infection Prevention nurse confirmed there was no documentation that the resident had been offered or had received the additional pneumococcal vaccination recommended by CDC guidelines.
Failure to Offer COVID-19 Vaccination to Two Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to residents within accepted standards of practice. The facility policy stated COVID-19 vaccinations would be administered according to CDC, ACIP, FDA, and manufacturer guidelines, and the CDC guidance cited in the report stated the COVID-19 2025-2026 vaccine was recommended for people ages 6 months and older. Based on record review, two of five residents reviewed for vaccinations were affected: Resident #11, admitted in January 2026, and Resident #24, admitted in 2024. Resident #11's record contained no documentation that the resident had been offered the COVID-19 2025-2026 vaccination until 06/04/26, when a nursing note documented that staff spoke with the resident, provided education using a VIS dated 1/31/2025, and the resident declined the vaccine, with verification by two nurses. Resident #24's record also contained no documentation that the resident had been offered the COVID-19 2025-2026 vaccination until 06/04/26, when a nursing note documented that staff spoke with the resident, educated him using a VIS sheet, and the resident stated he did not want it, witnessed by two nurses. On 06/09/2026, the Infection Prevention Nurse confirmed both residents were not offered the vaccine until 06/04/26, after the surveyor had asked for evidence that the vaccine had been offered.
Failure to Follow Menus and Ensure Consistent Meal Service
Penalty
Summary
The facility failed to ensure that menus met residents' nutritional needs, were prepared in advance, and were followed as required. Staff interviews and observations revealed that food service staff did not use proper serving sizes or utensils, with cooks admitting to guessing portion sizes and serving inconsistent amounts of food. Production sheets and serving size documentation were not available when requested by surveyors, and serving scoops were not filled completely. During meal service, some residents received less than the intended portion of chicken, and the kitchen ran out of key menu items such as chicken and broccoli, leading to unapproved substitutions without Registered Dietician consultation. Additionally, the current menu was not posted, and residents were not informed of menu changes, with posted menus often not matching what was served. Resident Council meeting minutes over several months documented ongoing concerns about food quality, portion sizes, menu substitutions, and lack of communication regarding menu changes. Residents reported not receiving meals as listed on the menu, dissatisfaction with food temperature and toughness, and unfulfilled scheduled events such as cookouts. The facility's own policies required that all substitutions be noted and menus be updated, but these procedures were not followed, as evidenced by both staff and resident reports and direct surveyor observation.
Failure to Provide Palatable and Safe-Temperature Food
Penalty
Summary
The facility failed to ensure that food and drink served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. One resident received a meal tray that had been left uncovered in the main dining room for approximately 40 minutes before consumption. The food was not reheated or cut up by staff, and the resident reported that it was cold and difficult to chew. Temperature checks of the meal items revealed that all were within the danger zone, as defined by the facility's own policy, with none of the items meeting safe serving temperatures. Additionally, an anonymous interview indicated that food was frequently overcooked, of poor quality, and often served cold, including coffee that was not hot enough to dissolve creamer. Further observations included a tray provided for surveyors, where the garlic bread was found to be dry and crunchy, and a hair was discovered baked into the chocolate cake. The Regional Dietary Manager confirmed the presence of the hair. Resident Council Meeting minutes also documented ongoing concerns from residents regarding food temperature, portion size, and the toughness of food. These findings demonstrate multiple failures in food service practices, affecting the quality and safety of meals provided to residents.
Failure to Ensure Safe Food Preparation and Service
Penalty
Summary
The facility failed to ensure that food was prepared and served in a manner that prevents foodborne illness. On the day in question, after running out of chicken, hamburger patties were substituted and cooked by staff. The cook and another staff member did not check the internal temperature of the hamburger patties before placing them on buns and preparing them for service to residents. A state surveyor intervened and requested that the temperatures of two patties be checked; the readings were 149 and 151 degrees Fahrenheit, both below the recommended safe temperature for ground beef. Despite this, a staff member instructed that the undercooked hamburgers be placed on trays to be served to residents, but the surveyor intervened again and the hamburgers were removed from service. These actions demonstrate a failure to follow proper food safety protocols, specifically regarding the cooking and serving of ground beef at safe temperatures, and the lack of temperature monitoring prior to serving food to residents.
Failure to Maintain Clean HVAC Filters
Penalty
Summary
The facility failed to ensure that the heating, ventilation, and air conditioning (HVAC) filter in one of six units observed on A Hall was free of debris. During an observation in room 126-2, both HVAC filters were found to be covered in gray dust bunnies. The Maintenance Director confirmed the presence of debris on the filters and stated that the Housekeeping Department was responsible for cleaning them on a weekly basis. The Director of Housekeeping also confirmed that both filters needed cleaning due to the accumulation of gray dust bunnies.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to assess and review significant weight loss for a resident, as well as to obtain weekly weights as recommended by the Registered Dietician (RD) and risk management. The resident experienced notable weight loss over several months, with documented losses of 8 pounds (5.6%) in one month, 12.6 pounds (8.5%) over three months, and 26 pounds (16%) over six months. Despite the RD's recommendation for double portions and regular weight checks every four weeks, the facility did not complete the required weekly weights. The Director of Nursing (DON) confirmed that the weights were not performed, stating that weekly weights are discontinued when a resident is considered stable. Additionally, there was no evidence that the physician or responsible party was notified of the significant weight loss.
Failure to Provide Physician-Ordered Diet Consistency
Penalty
Summary
The facility failed to provide food in the form ordered by the physician for a resident who required a Mechanical Soft texture diet with nectar thickened liquids. Instead, the resident was served a pureed lunch meal, which did not match the prescribed diet. The resident's care plan also indicated the need for a Regular Diet, Mechanical Soft texture, and Nectar-like fluids. Staff confirmed that the meal provided was of pureed consistency and that it was delivered to the dining room without any changes, despite the dietary order specifying otherwise.
Failure to Provide Prescribed Liquid Consistency
Penalty
Summary
A deficiency occurred when a resident with a physician's order for a puree diet and nectar consistency liquids was provided with honey thickened liquids instead of the ordered nectar consistency. The resident's care plan specified a regular diet with puree texture and nectar thickened liquids, and the facility's policy required that dietary cards and care plans accurately reflect the required liquid consistency. Despite these orders and policies, the resident was served honey thickened liquids during a lunch meal, as observed and reported by staff. The discrepancy was confirmed through record review and discussion with the Director of Nursing, indicating a failure to provide drinks consistent with the resident's needs and prescribed diet order.
Failure to Provide Properly Prepared Modified Diets and Liquids
Penalty
Summary
The facility failed to provide food and beverages in the appropriate form and consistency as ordered for residents requiring mechanical soft or pureed diets. Multiple residents with physician-ordered mechanical soft diets were observed being served whole meatballs, whole penne pasta, and deep-fried French fries, all of which did not meet the required texture modifications. Residents were seen having difficulty cutting their food due to the use of plastic utensils, and some consumed food items that were not properly chopped or ground as per facility policy and menu extensions. Additionally, residents were served ground meat without the required gravy, resulting in food that was not moist as specified in the dietary guidelines. Further deficiencies were observed in the preparation and serving of thickened liquids. Residents with orders for nectar-thickened liquids were given non-thickened or overly thickened beverages, with staff acknowledging errors in the use of thickening agents and measuring techniques. The facility's dietary and nursing staff demonstrated inconsistent knowledge and application of proper food and liquid modifications, as evidenced by staff interviews and direct observations during meal service. The use of incorrect thickening products and improper preparation of thickened liquids contributed to residents receiving beverages that did not match their prescribed consistency. Additional incidents included a resident on a pureed diet being served a mechanical soft meal with coleslaw, and other residents on mechanical soft diets being served coleslaw instead of the appropriate vegetable. These errors were confirmed by staff and were not in accordance with the facility's menu extensions and dietary policies. The cumulative effect of these failures created an immediate risk of choking and adverse outcomes for residents requiring modified diets.
Failure to Provide Dignified Dining Experience Due to Meal Delays and Inadequate Dining Ware
Penalty
Summary
The facility failed to ensure a dignified dining experience for multiple residents, as evidenced by significant delays in meal service and the use of inappropriate dining ware. One resident was left waiting for their meal while others at the same table were served and assisted, only receiving their tray after the delay was brought to the attention of the Director of Activities. Another resident experienced a delay of thirty-three minutes before being served, after all other residents had already left the dining room. Additionally, a third resident waited eighteen minutes after their tablemate was served, repeatedly asking about their food while staff continued to serve other tables first. These delays were confirmed by staff interviews, including the Director of Activities and an LPN Unit Manager, who acknowledged that the residents should have received their meals in a timely manner alongside their tablemates. Further observations revealed that residents were served meals on styrofoam bowls and plates due to the kitchen running out of standard dining ware. This was confirmed by both a dietary aide and a dietary manager, who stated that the kitchen had run out of plates and bowls for the meal service. The use of disposable dining ware and the delays in meal service contributed to a lack of dignity in the dining experience for the affected residents.
Failure to Address Resident Council Meal Service Concerns
Penalty
Summary
The facility failed to act promptly and effectively upon grievances and concerns raised by the Resident Council regarding meal service. Resident Council meeting minutes and concern forms documented repeated issues, including drinks being served before meal trays arrived, meals being repeated too frequently, meal tickets not reflecting residents' preferences, and discrepancies between the posted menu and the food served. An ad-hoc Quality Assurance meeting was held in response, but the actions taken did not directly address the specific concerns raised by the Resident Council. Observations during meal service confirmed that drinks were distributed well before meals, resulting in residents having empty drinks by the time their food arrived. Additionally, there were instances where the kitchen ran out of menu items, and residents did not receive the food listed on the menu. Further interviews and observations revealed ongoing dissatisfaction among residents, with repeated complaints about cold drinks, lack of menu alternatives, and insufficient food quantities. The Resident Council also noted that scheduled food meetings with kitchen management were not consistently held as promised. Staff interviews confirmed awareness of the ongoing issues and acknowledged that the problems persisted despite attempts to address them. The failure to resolve these concerns demonstrates a lack of prompt and effective response to resident grievances, as required by regulations.
Survey Results Not Easily Accessible to Residents
Penalty
Summary
The facility failed to make the results of the last standard survey easily accessible to residents. During a Resident Council meeting, residents collectively stated they were unaware that they had access to the findings from the last standard survey. Upon observation and interview, the survey results book was found behind the front desk rather than in a location easily accessible to residents. The Administrator acknowledged that the book was not in its intended place and instructed that it should remain on the desk. The Receptionist confirmed that the book had always been kept behind the desk during their three months of employment.
Failure to Maintain Clean and Sanitary Resident Equipment and Facility Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment by not cleaning and sanitizing a resident's wheelchair, as well as neglecting to clean the kitchen ceiling, exhaust fan, and the shower room's ceiling and peeling paint. The resident's wheelchair was observed multiple times over several days with a dirty footboard containing dried food-like substances and liquids. Staff, including an LPN, confirmed that the wheelchair remained uncleaned during this period. Additionally, the facility administrator acknowledged that there was no policy, procedure, or cleaning schedule in place for wheelchairs or for the facility overall. These deficiencies were identified through direct observation and staff interviews, and the lack of cleaning and sanitation practices had the potential to affect more than a limited number of residents in the facility.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents. An unattended and unlocked treatment cart was observed in the hallway near the conference room, with no staff present and residents nearby, creating an accident hazard. Additionally, a resident assessed as an elopement risk and lacking capacity, with a BIMS score of 3 and a wanderguard bracelet in place, experienced a malfunction of the wanderguard system on the exit door in the A Hallway. The system was not functioning properly during the observation period, despite the resident's documented risk for elopement. These deficiencies were confirmed by staff interviews and record reviews.
Insufficient Nursing Staff Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by record review, resident interviews, and staff interviews. Payroll Based Journal (PBJ) data indicated excessively low weekend staffing over a three-month period. Multiple residents reported significant delays in call light response, with some waiting from 30 minutes to several hours for assistance. Residents also described instances where they were left in bed due to lack of available staff, particularly on weekends and during meal times. The Resident Council collectively expressed concerns about prolonged wait times and insufficient help, especially during busy periods. Staff interviews corroborated these concerns, with nursing aides and other employees reporting frequent understaffing, especially on weekends and night shifts. Staff described being left alone on units for extended periods, being unable to complete assigned tasks, and having to leave residents in bed due to insufficient staff to safely operate lifts. Employees also noted that call-ins were not consistently covered, leading to ongoing staffing shortages and unmet resident care needs.
Failure to Provide Prescribed Diets and Follow Menus
Penalty
Summary
The facility failed to ensure that residents received food in the correct amount, type, and consistency as ordered, resulting in multiple instances where dietary needs were not met. One resident with a history of significant weight loss and a care plan specifying double portions of pureed, nectar-thick meals was observed receiving only a single portion, despite both staff and dietary manager confirming the error. The resident's care plan and diet order clearly indicated the need for double portions at all meals, but this was not followed. Additionally, pureed diets did not receive the appropriate vegetables as listed on the menu, with substitutions such as V-8 juice being provided instead of spinach, and inconsistencies in serving sizes were noted by both dietary staff and the registered dietician. Further observations and interviews revealed that menus were not consistently followed, with frequent substitutions and omissions of menu items, such as vegetables and pureed fruits, and reports of insufficient food being served. Residents and family members reported repeated issues with meal portions, menu discrepancies, and the use of plasticware. Staff confirmed running out of food, leading to improvised meals and sandwiches being served. These failures were confirmed through staff interviews, resident council concerns, and direct observation, affecting more than a limited number of residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ripley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ravenswood Village | 9.1 mi | ★★★★★ | 3 | 1 |
| Roane General Hospital | 19.1 mi | ★★★★★ | 0 | 0 |
| Miletree Center | 19.2 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Lakin | 21.4 mi | ★★★★★ | 8 | 0 |
| Overbrook Center | 21.5 mi | ★★★★★ | 11 | 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.