Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Noble Horizons during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and dependence for ADLs, including transfers, was care planned as a fall risk requiring contact guard assist of two and close monitoring. While seated in a wheelchair near the nurse’s station due to fidgeting and repeatedly leaning forward, the resident fell to the floor when a NA attempted to reposition the resident alone without calling for help, despite feeling the resident was too large to manage alone. According to facility documentation and staff interviews, an RN heard the NA tell the resident that if the resident kept leaning forward she would let the resident fall, then heard a loud noise and found the resident on the floor while the NA was reclined with feet elevated. Multiple staff reported that the NA laughed after the fall and made comments such as hoping the resident had learned a lesson, and other NAs told her the situation was not funny. These actions conflicted with the facility’s Resident Rights policy requiring residents be treated with respect and dignity.
Staff failed to immediately report an allegation of verbal mistreatment involving a resident with dementia, severe cognitive impairment, and dependence for ADLs who required assist for transfers and had an indwelling catheter. One NA told the resident that if the resident kept leaning forward the NA would let the resident fall, after which a loud noise was heard and the resident was found on the floor while the NA laughed. Other NAs observed the NA laughing and informed the RN supervisor, who did not promptly notify the DON and instead sent an email that was not seen until many hours later, contrary to the facility’s abuse policy requiring immediate reporting of alleged abuse.
A resident with dementia, severe cognitive impairment, dependence in ADLs, and a Foley catheter was care planned as needing two-person assistance for transfers and repositioning when leaning forward in a wheelchair. While the resident was seated at the nurse’s station and repeatedly leaning and sliding forward, a NA attempted to verbally redirect the resident but then tried to reposition the resident alone from behind without requesting help, despite the resident’s size and assessed need for two staff. The resident fell forward from the wheelchair, striking their head on a door, while an RN and other NAs reported hearing the NA make comments about letting the resident fall and observed the NA laughing and sitting in a reclined position with feet elevated after the fall, demonstrating a failure to provide safe repositioning and adequate supervision.
A resident with dementia, severe cognitive impairment, and dependence for ADLs, who required two-person assistance for transfers, was seated at the nurse’s station with an NA due to fidgeting and repeatedly sliding forward in a wheelchair. The NA stated, “If you keep leaning forward, I am going to let you fall,” then attempted to reposition the resident alone, contrary to the required two-person assist, and the resident fell forward, striking a door. An RN reportedly assessed the resident after the fall and found no injuries, but the assessment was not documented in the clinical record, resulting in an incomplete and inaccurate medical record in violation of facility documentation policy.
Nurses were found to lack up-to-date competencies in IV therapy, with the last review conducted several months ago. The Staff Educator, who is responsible for annual IV competency assessments, was unaware of the outdated status until mid-year and had not received the necessary training. The DON acknowledged the issue.
The facility failed to discard expired food in the kitchen, including cans of beets, corn, and boxes of chickpea rotini. The Director of Dining Services, responsible for monthly checks, could not explain the oversight, despite facility policy requiring proper dating and rotation of food.
The facility failed to ensure that therapeutic and resident pets were up to date with vaccinations and veterinary visits as per facility policy. One of the facility cats had outdated vaccinations and wellness exams, and a resident's pet cat lacked evidence of a distemper vaccine. The facility's policies on pets and support animals were inconsistent with actual practices, leading to deficiencies in pet care and documentation.
The facility failed to ensure a dignified dining experience for eight residents by serving meals on dietary trays instead of placing food and drink items on the dining table. A nurse aide cited mess containment as the reason, while the ADNS confirmed this practice was against facility policy.
A facility failed to ensure an updated code status form was signed by both a resident and physician, reflecting a change from full code to DNR. The resident's consent was not documented, violating the facility's policy and the resident's rights.
A resident with type II diabetes mellitus and heart failure refused the prescribed dose of insulin, opting for a lower dose without notifying the physician. The incident was not reported to the evening/night shift supervisor or the physician, leading to delayed medical intervention and fluctuating blood sugar levels.
The facility failed to assess and obtain consent for the use of full siderails for a resident, which were considered a physical restraint. The resident, who had cognitive impairments and was readmitted after hip surgery, had siderails in place at night per family request. The facility did not conduct an assessment to determine if the siderails were a restraint and did not obtain the necessary consent for their use.
The facility failed to complete timely comprehensive assessments for two residents who experienced significant changes in condition, including the development of pressure ulcers and substantial weight loss. The MDS Coordinator did not perform the required significant change MDS assessments, leading to a deficiency in care.
The facility failed to complete quarterly MDS assessments for four residents in a timely manner. The MDS Coordinator, an LPN, cited being the sole staff member in the MDS office as the reason for the delays, which ranged from 28 to 57 days past due.
The facility failed to submit MDS assessments timely for four residents. An LPN responsible for the assessments was unable to meet the required timeframes due to being the only staff member in the MDS office.
The facility failed to ensure a comprehensive and individualized care plan for a resident with type II diabetes and heart failure. Despite the care plan indicating the use of alarms for fall risk, observations and staff interviews confirmed that no alarms were ever in place.
The facility failed to revise care plans for two residents after multiple falls and for another resident who frequently refused a daily treatment. Despite several incidents and refusals, the care plans were not updated with new interventions to prevent further falls or address treatment refusals. Interviews with staff confirmed that the care plans should have been updated but were not.
A resident with a history of falls experienced multiple unwitnessed falls, and the facility failed to complete the required neurological checks as per policy. The DNS confirmed that staff did not document any refusals for the missed checks, indicating a lapse in adherence to the neuro-check policy.
The facility failed to document the turning and repositioning of a resident at risk for pressure ulcers, leading to the development and progression of multiple pressure ulcers. The resident's care plan included interventions for pressure ulcer prevention, but the clinical record lacked documentation of these actions. Interviews confirmed the absence of documentation and identified issues with the facility's software.
The facility failed to ensure safety checks for a resident's alarm and did not complete fall assessments after multiple falls for another resident, contrary to their policies. This led to unaddressed safety risks and potential harm.
The facility failed to respond to pharmacy recommendations for a resident receiving psychotropic medications. The resident, diagnosed with anxiety disorder and depression, was prescribed Trazadone 50 mg every 8 hours PRN for agitation without a discontinuation date. A pharmacy consult recommended a 'stop' date, but there was no documented provider response until after surveyor inquiry, contrary to facility policy.
A resident's medications were administered 30 minutes late, exceeding the facility's allowed time frame. The LPN responsible cited the difficulty of safely administering medications to 30 residents within the given time.
A resident with type II diabetes mellitus refused the prescribed dose of insulin and was administered a reduced dose by an LPN without notifying the supervisor or physician, leading to a significant medication error. Subsequent elevated blood sugar readings were recorded, and the facility's policy on reporting medication errors was not followed.
The facility failed to ensure clinical records were complete and accurate for a resident with dementia, anxiety, and depressive episodes. A pharmacy review recommendation was missing, and there was no evidence it had been addressed by the physician, contrary to the facility's policy.
The facility failed to ensure the Medical Director attended QAPI meetings quarterly. Despite being listed as a required member, there was no evidence of the Medical Director's attendance at any QAPI meetings from January 2023 through March 2024. The DNS acknowledged the requirement but noted the Medical Director might not have been able to attend. Attempts to contact the Medical Director were unsuccessful.
The facility failed to ensure infection control policies and procedures were reviewed annually. A review of the Infection Control Program revealed no documented evidence of an annual review, and the DON confirmed that such a review was never required. The facility was also unable to provide a policy for the review of policies and procedures when requested.
The facility failed to ensure the daily census was written on the 24-hour nurse staffing sheet posted in the lobby. Observations noted the missing census, and interviews revealed confusion between the receptionist and the scheduler regarding responsibility for filling in the census. The DNS and the scheduler were working on revising the procedure.
Failure to Treat a Resident With Dignity Following a Fall
Penalty
Summary
A resident with dementia, severe cognitive impairment (BIMS score of 4), dependence for personal hygiene, bed mobility, and transfers, and an indwelling urinary catheter was care planned as being at risk for falls and requiring contact guard assist of two for transfers, with staff directed to anticipate the resident’s needs. On the evening in question, the resident was seated in a wheelchair near the nurse’s station due to fidgeting and repeatedly leaning forward. Nursing assistant (NA) #1, who was assigned to the resident, reported that the resident continued to lean forward despite her directions. NA #1 stated she went behind the resident to attempt to reposition the resident in the wheelchair without calling for assistance, even though she felt the resident was too big for her to reposition alone. The resident then leaned too far forward and fell from the wheelchair onto the floor. Multiple staff accounts and facility documentation indicated that NA #1 made disrespectful comments and laughed in connection with the fall. According to a reportable event and the DON’s interview, RN #1 heard NA #1 say to the resident, "If you keep leaning forward, I'm going to let you fall," followed by a loud noise, after which RN #1 observed the resident on the floor and NA #1 in a reclined position with her feet elevated, not appearing to have attempted to prevent the fall. RN #1 further reported that NA #1 laughed after the incident and told the resident, "I hope you learned your lesson," while another NA responded that it was not funny. NA #2 and NA #3 each reported observing the resident on the floor and NA #1 laughing, and both stated they told NA #1 that laughing or making fun of the situation did not help. The DON stated that the comments and laughing at the resident after the fall were disrespectful and not an appropriate way to respond, in contrast to the facility’s Resident Rights policy, which states that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Failure to Timely Report Allegation of Verbal Mistreatment After Resident Fall
Penalty
Summary
Staff failed to timely report an allegation of mistreatment involving a cognitively impaired resident with dementia who was dependent for ADLs, including personal hygiene, bed mobility, transfers, and had an indwelling urinary catheter. The resident’s care plan identified a risk for falls and the need for contact guard assist of two for transfers, with interventions to anticipate the resident’s needs. On the evening in question, the 3–11 PM RN supervisor heard a nursing assistant tell the resident, "If you keep leaning forward, I am going to let you fall," followed by a loud noise. The RN then observed the resident on the floor and the nursing assistant laughing. Other nursing assistants also observed the same nursing assistant laughing at the resident after the fall and reported their concerns to the RN supervisor. The resident later had no recollection of the events leading up to the fall or the interaction with staff after the fall. The deficiency centers on the failure to immediately report this allegation of verbal mistreatment and potential abuse to facility leadership as required by policy. The RN supervisor did not notify the DON at the time of the incident and instead sent an email that was not received by the DON until approximately 11.5 hours later the following morning. The facility’s abuse policy required that reports of alleged abuse be immediately reported to the DON, ADON, Administrator, and/or supervisor, and defined verbal abuse as oral, written, or gestured language that willfully includes disparaging or derogatory terms, including threats of harm or statements intended to frighten a resident. The DON confirmed that the allegation should have been reported immediately and that she did not know why the RN supervisor failed to do so.
Failure to Provide Safe Two-Person Repositioning and Supervision Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe repositioning and adequate supervision to prevent a fall for a resident with dementia and severe cognitive impairment. The resident’s care plan identified a risk for falls, dependence in ADLs, and the need for contact guard assist of two staff for transfers. A subsequent MDS confirmed the resident was dependent for bed mobility, transfers, and personal hygiene, and had a Foley catheter in place. The resident was of substantial size and required two staff for safe repositioning when leaning forward in a wheelchair. On the evening of the incident, the resident was seated in a wheelchair at the nurse’s station due to fidgeting and repeated leaning forward and sliding in the chair, reportedly focusing on the Foley catheter. NA #1, who was assigned to the resident, was seated next to the resident and repeatedly attempted verbal redirection, instructing the resident to sit back and sit up. Despite knowing the resident required two-person assistance for repositioning when leaning too far forward and not responding to directions, NA #1 did not request help from other staff before attempting to reposition the resident alone. NA #1 moved behind the resident and tried to pull the resident back in the wheelchair while attempting to hold the resident up, but the resident was too heavy to manage alone and fell forward and to the left, striking their head on a door. RN #1, who was nearby, reported hearing NA #1 say to the resident, "If you keep leaning forward, I'm going to let you fall," followed by a loud noise and then observing the resident on the floor. RN #1 and other NAs reported that NA #1 laughed after the fall and made a comment to the resident, and that NA #1 had been in a reclined position with feet elevated after the fall. Facility staff interviews and documentation confirmed that NA #1 did not seek assistance prior to attempting to reposition the resident, despite the resident’s assessed need for two-person assistance and the facility’s fall prevention policy to provide a safe environment by addressing fall risk factors.
Failure to Document RN Assessment Following Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and accurate clinical record by not documenting an RN assessment after a resident fall. The resident had dementia and was care planned as being at risk for falls, requiring assistance with ADLs and contact guard assist of two staff for transfers. A significant change MDS showed severe cognitive impairment (BIMS score of 4), dependence for personal hygiene, bed mobility, transfers, and the presence of a Foley catheter, with a height of 67 inches and weight of 199 pounds. On the date of the incident, the resident was seated at the nurse’s station with a nursing assistant (NA) due to fidgeting behaviors and was observed sliding forward and leaning in the wheelchair. According to the facility’s reportable event documentation and interviews, the NA told the resident, “If you keep leaning forward, I am going to let you fall,” and then attempted to reposition the resident without obtaining the required additional staff assistance, during which the resident fell forward and to the left, striking a door headfirst. The RN heard the NA’s comment, then a loud noise, and found the resident on the floor. Facility documentation indicated that an RN assessment was completed and no injuries were identified, but the Director of Nursing confirmed that although the RN performed the assessment, it was not documented in the medical record. This failure to document occurred despite a facility nursing documentation policy directing that nursing documentation must reflect the resident’s assessment.
Outdated IV Competencies Identified Among Nursing Staff
Penalty
Summary
The facility failed to ensure nurses were competent in intravenous (IV) therapy, as evidenced by outdated IV competencies last reviewed on 12/23/22. The Staff Educator, responsible for annual IV competency assessments, only became aware of the outdated competencies after July 2023 and had not received the necessary training herself. The Director of Nursing Services acknowledged the need for addressing the issue.
Expired Food Not Discarded
Penalty
Summary
The facility failed to ensure that expired food was discarded, as identified during a tour of the kitchen. In the dry storage room and the overflow dry storage room, 12 cans of beets, several cans of corn, and 3 boxes of chickpea rotini were found to be expired. The Director of Dining Services, who is responsible for checking food storage monthly for expiration dates, could not explain why the expired foods were not discarded. The facility's Dietary Services policy mandates that all food must be dated when opened and stored, with the most recent dates utilized first to prevent expiration.
Deficiency in Pet Care and Documentation
Penalty
Summary
The facility failed to ensure that the facility assessment included therapeutic facility pets and individualized resident pets to meet the needs of the residents. Specifically, the facility did not ensure that therapy pets were up to date with vaccinations and veterinary visits as per facility policy. During an interview and document review with the Director of Recreation, it was found that one of the two facility cats had outdated vaccinations and wellness exams. Cat #2 was overdue for its rabies vaccine and had not had a wellness exam since 2019. Additionally, there was no evidence of a distemper vaccine for Cat #2. The Director of Recreation indicated that an appointment had been scheduled for Cat #2 with the veterinarian on the day of the interview. Furthermore, Resident #58 had a pet cat (Cat #3) whose veterinary care was managed by the resident's family. Upon request, documentation for Cat #3 was provided, showing up-to-date rabies vaccination and wellness exam but no evidence of a distemper vaccine. The facility's policies on pets and support animals were reviewed and found to be inconsistent with the actual practices observed during the survey. The facility's Pet Policy and Agreement required that pet cats have current veterinary health records, including distemper and rabies shots. However, the facility's Service and Support Animal Policy indicated that support animals are not subject to the Pet Policy and Agreement but must have an annual clean bill of health and be immunized against common diseases. The Recreation policy indicated that the Recreation Director was responsible for the wellbeing, shots, and licenses of resident cats. The facility assessment did not mention services and care offered based on resident needs concerning support animals, despite providing care for residents with psychiatric/mood disorders. This lack of documentation and adherence to policies led to the identified deficiencies in the care and management of therapeutic and resident pets.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for eight residents during the noon meal service. Observations on 3/13/24 at 12:15 PM revealed that these residents were served their meals on dietary trays, with food and drink items remaining on the trays rather than being placed on the dining table. An interview with a nurse aide indicated that the trays were used to contain messes caused by residents spilling their food and drinks. However, the Assistant Director of Nursing Services (ADNS) confirmed that the facility's policy required food and drink items to be removed from the trays and set in front of the residents. The ADNS was unsure why the policy was not followed and planned to investigate the issue. The Dietary Services Policy dated 7/28/21 emphasized the importance of resident rights, choice, and quality of life in meal service.
Failure to Update Code Status Form with Required Signatures
Penalty
Summary
The facility failed to ensure that an updated code status form was signed by both the resident and the physician to reflect the resident's wishes and the physician's orders. Resident #57, who was admitted with diagnoses including venous insufficiency, urinary tract infection, and anxiety, had a signed Advanced Directive form indicating full code status. However, a subsequent physician's order directed Do Not Resuscitate (DNR) without evidence of the resident's consent to this change. The clinical record did not provide documentation that the resident agreed to the DNR status, which is a violation of the resident's rights to participate in their care decisions. During an interview, both a Registered Nurse and a Licensed Practical Nurse confirmed that the updated code status form was not signed by the resident or the physician to reflect the change from full code to DNR. The facility's policy requires that such decisions be consensually reached between the resident and the attending physician, and the nurse managers are responsible for ensuring the accuracy of these forms. The deficiency was identified when the surveyor inquired about the documentation, leading to the discovery that the required signatures were missing.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to ensure the physician was notified of a medication refusal by Resident #52, who has diagnoses including type II diabetes mellitus and heart failure. The resident, who is cognitively intact and requires supervision for certain activities, refused the prescribed 6 units of Humalog insulin and insisted on receiving only 4 units. Despite patient teaching and encouragement to take the full dose, the resident's request was honored without notifying the physician or the evening/night shift supervisor. The incident was only reported to the day shift nurse manager the following morning, and no immediate action was taken to inform the physician or adjust the care plan accordingly. Interviews with the involved staff, including the LPN, RN, and APRN, revealed that the proper protocol for medication refusal was not followed. The Director of Nursing was unaware of the incident until the survey, and the facility's policy clearly states that changes in a resident's condition or medication should be reported timely to the physician or nurse practitioner. The failure to notify the physician of the medication refusal led to a delay in appropriate medical intervention, as evidenced by the resident's fluctuating blood sugar levels and the eventual administration of a higher insulin dose without prior notification to the on-call provider.
Failure to Assess and Obtain Consent for Use of Siderails as Restraints
Penalty
Summary
The facility failed to properly assess and obtain consent for the use of full siderails for a resident, which were considered a physical restraint. Resident #40, who was readmitted after hip surgery and had cognitive impairments, was found to have full siderails in place at night per family request. However, the facility did not conduct an assessment to determine if the siderails were a restraint and did not obtain the necessary consent for their use. The care plan indicated the use of siderails but did not classify them as a restraint, and there was no evidence of ongoing monitoring or evaluation of the siderails' use. Interviews with staff revealed that the resident was unable to remove or adjust the siderails independently, confirming their status as a restraint. The facility's policy required a specific consent form for the use of restraints, but this form was not provided. Additionally, the facility's Side Rail Policy was requested but not supplied. The lack of proper assessment, consent, and documentation led to the deficiency identified by the surveyors.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to ensure a comprehensive resident assessment was completed timely after a significant change in condition was identified for two residents. Resident #47, who had a diagnosis including a fracture of the right femur and pressure ulcers, was found to have developed multiple new pressure ulcers and experienced a decline in the condition of an existing ulcer. Despite these significant changes, the MDS Coordinator did not complete a significant change MDS assessment as required by the Resident Assessment Instrument guidelines. The resident's condition, including the development of three pressure ulcers and likely weight loss, was not adequately monitored or reassessed in a timely manner. Similarly, Resident #38, who had diagnoses including dysphagia, dementia, and nutritional deficiency, experienced a significant weight loss over a short period. Despite a care plan that included monitoring weights and dietary interventions, the resident's weight continued to decline significantly. The MDS Coordinator acknowledged that a significant change MDS assessment should have been completed due to the resident's substantial weight loss, but it was not done. The facility's failure to complete these assessments in a timely manner represents a deficiency in their care processes.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly assessments for four residents were completed in a timely manner. Resident #12's quarterly MDS assessment was 33 days late, Resident #32's was 57 days late, Resident #53's was 28 days late, and Resident #56's was 33 days late. The MDS Coordinator, an LPN, acknowledged the delays and attributed them to being the only staff member in the MDS office, which hindered their ability to keep up with the workload. The facility's policy requires quarterly assessments to be completed every 92 days from admission to allow for necessary revisions to the care plan.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely submission of Minimum Data Set (MDS) assessments for four residents. Resident #12's quarterly MDS with an Assessment Reference Date (ARD) of 2/1/24 was due on 2/15/24 and required submission by 2/29/24, but it was not submitted as of 3/19/24, making it 19 days late. Similarly, Resident #32's quarterly MDS with an ARD of 1/8/24 was due on 1/22/24 and required submission by 2/5/24, but it was not submitted as of 3/19/24, making it 43 days late. Resident #53's quarterly MDS with an ARD of 2/6/24 was due on 2/20/24 and required submission by 3/5/24, but it was not submitted as of 3/19/24, making it 14 days late. Lastly, Resident #56's annual MDS with an ARD of 2/1/24 was due on 2/15/24 and required submission by 2/29/24, but it was not submitted as of 3/19/24, making it 19 days late. An interview with the LPN responsible for completing and submitting the MDS assessments revealed that she was the only one in the MDS office and was unable to keep up with the required timeframes. The LPN acknowledged the delays and attributed them to her being the sole person handling the MDS assessments. The Resident Assessment Instrument 3.0 user manual from October 2023 specifies that quarterly assessments must be completed within 14 days of the ARD and submitted within 14 days after completion, which was not adhered to in these cases.
Failure to Ensure Comprehensive and Individualized Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for Resident #52 was comprehensive and individualized. Resident #52, who has diagnoses including type II diabetes mellitus and heart failure, was identified as cognitively intact and requiring partial assistance with transfers and ambulation. The care plan dated 8/25/23 indicated that the resident was at risk for falls and included interventions such as the use of alarms to notify staff of the resident's needs. However, observations on 3/18/24 revealed that no safety devices were in use in the resident's room, and interviews with staff confirmed that the resident never had any alarms in place. LPN #7 acknowledged that nursing staff were responsible for initial care planning and that she should have removed the incorrect information regarding the use of alarms during her review. RN #1 admitted to placing interventions regarding alarms in the care plan as a precaution, even though the resident never had any motion detection alarms and would require an order and consent for their use. The Director of Nursing confirmed that the care plan should accurately reflect the individualized needs of the resident. The facility's policy mandates that the Resident Care Plan should ensure high-quality, individualized care and be developed within 21 days of admission.
Failure to Revise Care Plans After Falls and Treatment Refusals
Penalty
Summary
The facility failed to revise the care plan for Resident #11 after multiple falls. Despite several incidents where the resident was found on the floor, the care plan was not updated with new interventions to prevent further falls. The resident's care plan was last reviewed on 6/28/23, and subsequent falls on 8/13/23, 9/24/23, 9/26/23, 10/1/23, 10/16/23, 11/1/23, 12/8/23, 1/12/24, 1/18/24, 2/1/24, 2/26/24, 3/5/24, and 3/13/24 did not result in any new interventions being added to the care plan. Interviews with the DNS and MDS Coordinator revealed that the care plan should have been updated with each fall and personalized to the resident's needs, but this was not done. Resident #38 also experienced multiple falls without appropriate updates to the care plan. Despite being identified as at risk for falls due to moderate dementia, behaviors, and poor safety awareness, the care plan was not revised after falls on 2/11/24, 2/13/24, and 2/21/24. Although some revisions were made on 2/27/24, 3/6/24, and 3/8/24, these did not directly address the falls. The DNS indicated that the care plan is only updated if there is a change to be made, and interventions are not always added to the care plan. Resident #57 frequently refused a daily treatment of ACE wraps for bilateral lower extremities edema, but the care plan was not revised to reflect this. Observations on 3/13/24 and 3/18/24 showed the resident out of bed without the ACE wraps, and the MAR indicated refusals on 33 occasions. Interviews with LPN #2 and the DNS confirmed that the staff was aware of the refusals, but the care plan was not updated to include interventions to address this issue. The facility policy directed that the care plan should be reviewed and revised as needed, but this was not followed in the case of Resident #57.
Failure to Complete Neurological Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neurological checks were completed to professional standards after Resident #11 experienced multiple unwitnessed falls. Resident #11, who was admitted with diagnoses including heart failure, generalized muscle weakness, and repeated falls, had a care plan identifying them as at risk for falls. Despite this, the facility did not consistently complete the required neurological checks following the resident's falls. Specifically, on five separate occasions, the neurological checks were either partially completed or not done at all, and there was no documentation of the resident refusing these checks as per facility policy. The DNS confirmed that staff should have attempted the checks and documented any refusals, but this was not done in the cases reviewed. The incidents occurred on 8/13/23, 9/24/23, 9/26/23, 1/18/24, and 2/26/24, with the resident found on the floor each time. The facility's policy required neurological assessments to be documented on a 24-hour flowsheet, with specific intervals for checks. However, the flowsheets for these dates showed missing entries, and in one instance, the flowsheet was not completed at all. The DNS could not provide an explanation for these lapses, indicating a failure to adhere to the facility's neuro-check policy designed to monitor residents following a head injury or suspected head injury.
Failure to Document Turning and Repositioning
Penalty
Summary
The facility failed to consistently document the turning and repositioning of Resident #47, who was at risk for pressure ulcers. The resident's diagnoses included a fracture of the right femur, pressure ulcer of the sacrum, and deep tissue damage of the left hip and right heel. The care plan dated 3/8/2024 indicated that the resident was at risk for pressure ulcers due to poor nutrition, immobility, and incontinence, and included interventions such as stage-appropriate wound care, pain management, and pressure reduction measures. However, a review of the clinical record from 2/27/24 through 3/7/24 showed no documentation of turning and repositioning per facility practice. Interviews with the DNS and MDS Coordinator confirmed the lack of documentation and identified that the facility software did not include a section for Nurse Aides to document these actions. The resident's condition deteriorated over time, with the development of new pressure ulcers and the progression of existing ones. On 3/1/2024, the resident was found to have a right heel deep tissue injury, and by 3/8/2024, new deep tissue injuries on the left hip and a stage 1 pressure ulcer on the coccyx were noted. By 3/15/2024, the coccyx wound had progressed to a stage 2 pressure ulcer. The MDS Coordinator indicated that the resident likely experienced weight loss, contributing to the development of the pressure ulcers. The facility's failure to document turning and repositioning as per their practice contributed to the resident's declining condition and the development of multiple pressure ulcers.
Failure to Conduct Safety Checks and Fall Assessments
Penalty
Summary
The facility failed to ensure that staff conducted safety checks as directed by the manufacturer to ensure the alarm was functional for Resident #10. The resident, who had diagnoses including dementia, abnormalities of gait, and rheumatoid arthritis, was found lying on the floor with a complaint of right hip pain. The Tab alarm, which was supposed to be used for safety, did not sound at the time of the fall. Interviews with staff revealed that safety checks were not logged, and there was uncertainty about whether the checks were completed the night of the fall. The facility's policy required safety checks every shift, but documentation of these checks was inconsistent or missing. For Resident #11, the facility failed to ensure fall assessments were completed after each fall as per facility policy. The resident, who had a history of multiple falls and was identified as at risk for falls, experienced several unwitnessed falls. Despite the facility's policy requiring a new fall risk assessment after each fall, reviews of clinical records and facility documentation showed that these assessments were not completed. Interviews with the DNS revealed a misunderstanding of the policy, with the DNS indicating that fall risk assessments were not necessary after every fall, contrary to the written policy. The facility's current Fall Prevention Policy, revised in 2019, indicated that a fall risk assessment should be completed quarterly, annually, and whenever a resident experiences a fall. However, this policy was not followed, leading to multiple instances where Resident #11 did not receive the required assessments after falls. This failure to adhere to the policy potentially compromised the resident's safety and well-being.
Failure to Respond to Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to respond to pharmacy recommendations for a resident receiving psychotropic medications. Resident #38, who had diagnoses including anxiety disorder and depression, was identified as moderately cognitively impaired and dependent with ADL assistance. The resident's care plan included the use of psychotropic drugs and directed attempts for gradual dose reductions and psychiatric consults. A physician's order prescribed Trazadone 50 mg every 8 hours PRN for agitation without a discontinuation date. A pharmacy consult recommended including a 'stop' date for the PRN use of Trazadone, but there was no documented provider response until after surveyor inquiry. The facility policy required monthly pharmacy consults to be reviewed by the practitioner, but this was not adhered to in this case.
Medication Administration Timeliness Deficiency
Penalty
Summary
The facility failed to ensure medications were administered timely and that medication errors did not exceed 5% for one of the residents reviewed. Resident #57, who had diagnoses including localized swelling and edema, vitamin deficiency, and left knee effusion, had specific physician orders for the administration of Vitamin C, Vitamin D3, and Hydrochlorothiazide at 8:00 AM daily. However, during an observation on 3/19/2024 at 9:30 AM, it was noted that these medications were administered 30 minutes late by an LPN. The facility policy allows for medications to be administered within one hour before or after the scheduled time, which was not adhered to in this instance. An interview with the Director of Nursing Services (DNS) and a review of the medication administration history confirmed the late administration. The DNS acknowledged that the medications were administered outside the allotted time frame and indicated that an interview with the LPN would be necessary to determine the reason. The LPN explained that the delay was due to the challenge of safely administering medications to 30 residents within the given time. The DNS mentioned the possibility of adjusting medication administration times to make them more manageable for the nursing staff.
Failure to Administer Prescribed Insulin Dose
Penalty
Summary
The facility failed to ensure that Resident #52 was free from significant medication errors following the administration of an unprescribed reduced dose of insulin. Resident #52, who had diagnoses including type II diabetes mellitus and heart failure, was cognitively intact and had specific physician orders for Humalog insulin to be administered based on a sliding scale. On 3/11/24, the resident's blood sugar was 300 mg/dl, requiring 6 units of insulin. However, the resident refused the prescribed dose and requested only 4 units, which was administered by LPN #4 without notifying the supervisor or the physician. This deviation from the prescribed dosage was not reported to the evening/night shift supervisor or the physician, contrary to the facility's policy on medication errors. The incident was only reported to the day shift nurse manager the following morning, who also did not notify the physician immediately. The Director of Nursing Services and the Advanced Practice Registered Nurse (APRN) were unaware of the medication error until later interviews. Subsequent blood sugar readings for Resident #52 showed elevated levels, including a reading of 432 mg/dl early the next morning, which required 12 units of insulin per APRN orders. The facility's policy mandates that all medication errors, including wrong doses, be reported to the supervisor, Director of Nursing, and the attending physician. However, this protocol was not followed, leading to a significant medication error. Interviews with the involved staff confirmed the failure to adhere to the policy and the lack of timely communication with the medical provider regarding the resident's refusal and the administration of a reduced insulin dose.
Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for a resident diagnosed with dementia with psychotic disturbance, anxiety, and depressive episodes. The quarterly Minimum Data Set (MDS) indicated the resident was cognitively impaired and received antipsychotic and antidepressant medications. The care plan included interventions such as monitoring mood and response to medications, consulting with the psychiatric APRN, conducting an Abnormal Involuntary Movement Scale (AIMS) assessment every six months, and assessing and recording the effectiveness and side effects of the medication. However, during an interview and record review with the Director of Nursing Services (DNS), it was revealed that a monthly pharmacy review recommendation made on 12/4/2024 could not be found, nor was there evidence that the recommendation had been addressed by the physician. The facility's policy on Medication Regimen, dated 1/2024, required that within 24 hours of the medication regimen review, the consultant pharmacist provides a written report to the physicians for each resident reviewed, including the resident's name, the name of the medication, the identified irregularity, and the pharmacist's recommendation. The policy further indicated that copies of medication regimen review reports, including the physicians' responses, are to be maintained as part of the permanent medical record. The failure to adhere to this policy resulted in incomplete and inaccurate clinical records for the resident in question.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director attended Quality Assurance Performance Improvement (QAPI) meetings quarterly. A review of facility documentation and interviews revealed that although the Medical Director was listed as a required member of the QAPI committee, there was no evidence of their attendance at any QAPI meetings from January 2023 through March 2024. The Director of Nursing Services (DNS) acknowledged that the Medical Director was aware of the requirement but may not have been able to attend the meetings. The Medical Director was reportedly updated during medical staff meetings, but no evidence of these meetings was provided. Attempts to contact the Medical Director for further clarification were unsuccessful.
Failure to Review Infection Control Policies Annually
Penalty
Summary
The facility failed to ensure infection control policies and procedures were reviewed annually. During the survey, a review of the facility's Infection Control Program and policies revealed no documented evidence of an annual review. An interview with the Director of Nursing Services confirmed that the facility had never required a documented review of current policies and procedures. Additionally, the facility was unable to provide a policy for the review of policies and procedures when requested.
Failure to Post Daily Census on Nurse Staffing Sheet
Penalty
Summary
The facility failed to ensure the daily census was written on the 24-hour nurse staffing sheet posted in the lobby for the view of the residents and the public. Observations on two separate occasions noted that the resident census was missing from the designated space on the form. Interviews with the receptionist and the scheduler revealed confusion and miscommunication regarding the responsibility for filling in the census. The receptionist believed it was the scheduler's responsibility, while the scheduler initially indicated it was the receptionist's duty before acknowledging it was their own responsibility. The Director of Nursing Services (DNS) and the scheduler were working on revising the procedure for completion and posting of the 24-hour nurse staffing sheet.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 38 citations issued within 25 miles in the last 12 months — including the 1 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Geer Nursing And Rehabilitation | 4.7 mi | — | 0 | 0 |
| Sharon Center For Health & Rehabilitation | 8.3 mi | — | 1 | 1 |
| Timberlyn Heights Nursing And Rehabilitation | 13.4 mi | — | 1 | 0 |
| Fairview Commons Nursing & Rehabilitation Center | 15.7 mi | — | 0 | 0 |
| Berkshire Rehabilitation & Skilled Care Center | 17.1 mi | — | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.