Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Marigold Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
The facility failed to protect residents from verbal and physical abuse by staff and other residents. A CNA verbally abused a resident in her room and was described by another resident as rude, rough, aggressive, and loud during care, while an LPN noted the CNA appeared overwhelmed, anxious, and short-tempered. A cognitively impaired resident with hallucinations and a history of unprovoked hitting repeatedly engaged in physical altercations, including pinning a roommate to the bed and causing facial bruising and an ear laceration, and later grabbing another resident’s arm and not letting go. On the dementia unit, another CNA/PTA was observed yelling and speaking in a concerning raised tone to cognitively impaired residents who could not report how they felt, with staff describing this CNA as overwhelmed and stressed. These incidents show multiple failures to prevent and manage abusive interactions involving vulnerable residents with dementia.
A resident with prostate cancer and metastatic disease was admitted with hospital discharge orders for daily Abiraterone 250 mg (four tablets on an empty stomach) without a stop date. Facility policy required accurate documentation of all medication orders and changes, but an LPN transcribed the Abiraterone order onto the MAR with an unwarranted stop date, and another LPN later only adjusted the administration time. The MAR showed that the medication was not given for three consecutive days, and the resident and family reported that staff repeatedly stated there was no order or that the drug was unavailable, despite the resident having brought in a supply from home. The former DON confirmed the order had been improperly stopped, which led to the missed doses.
A resident with complex cardiac and respiratory conditions was admitted with multiple physician‑ordered medications, including diuretics, bronchodilators, steroids, and other maintenance drugs, which were to begin shortly after arrival. Over the next two days, an LPN documented numerous doses as unavailable and did not administer key medications such as diuretics, nebulizer treatments, and prednisone, despite the facility having a STAT safe stocked with several of these drugs and pharmacy deliveries arriving overnight. The LPN did not notify the physician or nursing administration about the missed doses, and no alternative interventions or treatment plan changes were implemented. The resident was later found without respirations or pulse and was pronounced deceased, and the survey determined that the failure to administer ordered medications and to notify the provider constituted neglect and resulted in actual harm and death, rising to Immediate Jeopardy.
A resident with complex cardiac and respiratory conditions was admitted after a prolonged hospitalization with multiple physician‑ordered medications, including diuretics, bronchodilators, steroids, and maintenance drugs. Over the first two days, the MAR shows that numerous scheduled doses were not given and were marked as unavailable, even though many of these medications were stocked in the facility’s STAT Safe and later documented as delivered by pharmacy. The LPN did not obtain medications from the STAT Safe, did not notify the physician or DON about the missed doses, and did not escalate the issue despite the resident’s need for breathing treatments and heart failure medications. The resident, previously documented as alert with intermittent SOB and requiring BiPAP and nebs with O2, was later found without respirations or pulse when the LPN went to administer medications, and the death certificate lists acute on chronic CHF and diastolic heart failure with COPD as contributing conditions. The failure to follow physician orders, secure and administer available medications, and communicate missed doses resulted in actual harm and death and was cited at the Immediate Jeopardy level.
The facility failed to maintain accurate medical records by not obtaining signed physician orders to support nursing documentation that medications were placed on hold for three newly admitted residents when their medications were unavailable. Nursing notes indicated that an APN or physician had been notified and had given orders to hold various medications, including Abilify, Trelegy, Jardiance, and that some PRN Ultram and Lasix were obtained from backup, but the corresponding physician order sheets contained no signed orders authorizing these holds. The interim DON verified the absence of signed orders and acknowledged that, under the facility’s standard of practice, telephone or verbal orders without a physician’s signature are insufficient and void.
A resident with dementia and multiple chronic conditions was pushed by another resident, resulting in a fall, after repeatedly entering the other's personal space despite staff redirection. Staff confirmed that the resident who pushed is known to become aggressive when his space is invaded, and that the incident occurred while the LPN was not present in the immediate area.
The facility did not reasonably accommodate the needs and preferences of residents, as identified during the survey. The report does not specify the particular circumstances or individuals involved.
A resident who was cognitively intact requested a care plan meeting with the ombudsman present to address concerns about inconsistent bathing and hair care. Despite repeated requests and involvement of the ombudsman, facility staff did not schedule or document the meeting, and the resident's concerns remained unaddressed.
The facility failed to prevent and respond to resident-to-resident sexual and physical abuse, including incidents where a cognitively impaired resident was sexually assaulted by another resident and another resident was physically struck by her roommate. Care plans and medical records did not reflect the abuse incidents or necessary interventions, despite staff awareness and direct observation of the events.
The facility did not post grievance procedures in prominent locations and failed to promptly address a resident's grievance regarding care concerns, resulting in residents being unaware of how to file grievances and reports of grievances not being followed up on in a timely manner.
The facility did not promptly report allegations of sexual and physical abuse between residents to the State Agency and local law enforcement as required. In one case, an LPN observed inappropriate sexual contact between two residents, but the incident was reported to the State Agency several days late and not at all to law enforcement. In another case, a resident was struck by another during care, and the incident was not reported within the mandated two-hour window. These reporting failures involved four residents.
A resident with severe dementia was not properly assessed or documented after being found on the floor following a fall. CNAs notified an LPN, who did not assess the resident at the time and instructed staff to return her to bed. The resident was later sent to the ED and diagnosed with rib fractures. There was no documentation of the fall, assessment, or notifications in the nursing notes, contrary to facility policy.
The facility did not ensure that Medicaid residents received their Personal Needs Allowance, failed to assist residents in applying for SSI or disability benefits, and improperly deducted room and board payments from a resident's trust account. Staff interviews revealed a lack of knowledge and action regarding financial assistance processes, resulting in residents not receiving funds for personal expenses.
Several residents did not receive their monthly personal needs allowance (PNA) or assistance with obtaining state-funded payments due to the facility's failure to update payee information, assist with SSI or disability applications, and ensure proper financial arrangements. Staff were unclear about their responsibilities, and there was no documentation of efforts to help residents access entitled benefits.
A resident's personal trust account was improperly charged for room and board, a service covered by Medicaid and social security, resulting in the depletion of her personal funds. The resident did not receive her monthly Personal Needs Allowance due to issues with social security payments, leaving her without money for personal expenses.
A resident's right to privacy in receiving mail was violated when the Business Office Manager opened two envelopes containing life insurance checks addressed solely to the resident. The mail was delivered to the resident already opened, despite facility policy requiring mail to be delivered sealed and only opened at the resident's request. Staff interviews confirmed the breach, and the incident was corroborated by the resident and a family member.
The facility failed to ensure sanitary handling of food during mealtimes, affecting all 75 residents. A CNA was observed preparing food trays without using gloves or washing hands, handling bread with bare hands, and placing it back on the tray. This was against the facility's policy, as confirmed by the CNA and other staff members, including an Activities staff member and an LPN.
The facility failed to respond to call lights in a timely manner for 11 residents, with some waiting over two hours for assistance. Despite the administrator's expectation of a 30-minute response time, there was no formal policy, leading to significant delays and unmet resident needs.
The facility did not provide bedtime snacks to 11 residents, despite a policy requiring snacks to be offered at 8:00 PM. A CNA confirmed that only some residents receive snacks, and the Regional Director of Operations stated that all residents should be offered snacks. Several affected residents have Type II Diabetes Mellitus, which may require regular nutritional intake.
The facility did not implement Enhanced Barrier Precautions for residents with wounds and indwelling medical devices, as required by their infection control policy. Observations showed a lack of personal protective equipment and signage in residents' rooms, and staff confirmed they had not received training on these precautions. The Infection Preventionist acknowledged the oversight, highlighting a gap in adherence to infection control measures.
A facility failed to provide a resident and/or their representative with a written notice of hospital transfer, as required. The resident's Census Profile documented hospital unpaid leave, but there was no evidence of a written notice of transfer or discharge in the resident's chart. This was confirmed by a Social Service Assistant during an interview.
A facility failed to provide a Bed Hold Policy to a resident or their representative during a hospital transfer. The resident, diagnosed with Dementia with Agitation, was admitted to a hospital after attempting self-harm. The facility's policy requires notification of the Bed Hold Policy, but no documentation was found to confirm this was done.
A facility failed to obtain a Level II PASRR screening for a resident newly diagnosed with Disorganized Schizophrenia. Initially, the resident's PASRR Level I indicated no need for further screening. However, after a nurse practitioner documented the new diagnosis, the facility did not conduct the required Level II PASRR. The Regional Director of Operations acknowledged this oversight.
A facility failed to document PTSD triggers and interventions for a resident with PTSD, as required by their Trauma Informed Care Policy. The resident's care plan and Trauma Informed Care form lacked necessary documentation, despite the resident's diagnosis being noted in their Physician Order Sheet and PASRR. The Regional Director of Operations acknowledged the oversight, attributing it to updates made during a receivership transition.
The facility failed to document behaviors justifying the use of antipsychotic medications, obtain consent prior to their use, and perform an annual gradual dose reduction for two residents. One resident was prescribed ABH gel for dementia and anxiety without documented behaviors or consent, while another was given Haldol Decanoate IM monthly without justification or consent. Staff confirmed the absence of behaviors warranting these medications.
A facility failed to prevent multiple incidents of resident-to-resident abuse, involving a resident with severe cognitive impairment who physically assaulted several other residents and was also sexually assaulted by another resident. The facility did not adequately address the aggressive behaviors in the care plans or provide sufficient supervision, leading to Immediate Jeopardy.
A bariatric resident in a LTC facility was unable to be safely transferred due to malfunctioning mechanical lifts. Despite being dependent on staff for transfers, the facility's lifts either failed to lift the resident high enough or stopped working mid-transfer. Staff and the resident reported these issues to the administration, but the problems persisted, leaving the resident feeling unsafe and neglected.
The facility failed to investigate two resident-to-resident altercations involving physical abuse. A resident with severe cognitive impairment and aggressive behavior assaulted another resident, and in a separate incident, threw water on a different resident. Despite these events, the facility did not conduct investigations or report the incidents to the state agency, as required by their policy.
A resident with depression and type 2 diabetes did not receive their prescribed medications, Venlafaxine HCl ER and Victoza, for several days due to unavailability. The nursing staff failed to notify the resident's physician or document any interventions to address the medication shortage. The facility's protocol for handling such situations was not followed, leading to adverse effects for the resident.
Failure to Prevent Staff Verbal Abuse and Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and physical abuse, including resident-to-resident altercations and staff-to-resident verbal abuse, for five residents reviewed for abuse. The facility’s own Abuse, Prevention, and Prohibition Policy states that each resident has the right to be free from abuse by anyone, including staff and other residents, and defines resident-to-resident abuse as willful, deliberate actions regardless of intent to harm. Despite this, one CNA (V10) was reported by a resident (R4) to have verbally abused another resident (R5) in R5’s room, with R5 unable to state if she felt abused due to cognitive impairment. R4 reported that V10 was rude, rough, aggressive, and loud when providing care to him and rude to other residents. An LPN (V14) and the prior administrator (V19) were made aware of the incident, and V14 described V10 as overwhelmed, anxious, agitated, and short-tempered while on duty. The facility also failed to prevent multiple episodes of resident-to-resident physical abuse involving a cognitively impaired resident (R2) with hallucinations and a history of running into doors and hitting unprovoked. On one night, nursing notes document that R2 was found in his roommate R1’s bed, physically restraining R1 by the wrists, pinning him to the bed, and screaming in his face while insisting R1 had a gun and was going to hurt him and staff. Staff reported R2 was not redirectable, and police and EMS were involved. Subsequent documentation shows R1 developed new in-house injuries, including bruising under the right eye and a wound to the right ear, while R2 had a cut lip and a scratch near his left eye; both residents had redness where they had come into physical contact. Later observation noted R1 with significant bruising around both eyes and R2 as confused, hard to redirect, and very active, with staff confirming that the two residents had been “going at it fighting.” Additional failures to prevent abuse occurred on the Alzheimer’s/dementia care unit, where residents were generally unable to state if they felt verbally abused due to cognitive status. An RN ADON (V12) reported that a CNA/PTA (V13) spoke to residents in a concerning raised tone, and other staff (V20, V17) described V13 as overwhelmed and stressed by workload while she was yelling in the presence of R2 and multiple other residents. In a separate incident on the same unit, R2 grabbed another resident’s (R6’s) left arm and would not let go, as documented by an RN (V16) and confirmed by two CNAs (V17, V18). These events, combined with staff reports that R2 has hallucinations, is hard to redirect, sometimes “freaks out,” runs for the door, and pounds on it, demonstrate that the facility did not effectively prevent or manage abusive interactions and behaviors, resulting in repeated episodes of physical and verbal abuse among vulnerable, cognitively impaired residents.
Failure to Accurately Transcribe Cancer Medication Order Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and maintain a continuous physician order for an anti-neoplastic medication, resulting in a resident not receiving the drug for three days. The facility’s medication administration policy requires that all medication orders and any changes be accurately documented in the medical record, and that errors or omissions be recorded and reported. The resident was admitted with multiple diagnoses including malignant neoplasm of the prostate, malignant pleural effusion, and secondary malignant neoplasm of bone. Hospital discharge orders dated 2/9/26 directed Abiraterone 250 mg, four tablets orally once daily on an empty stomach, with no stop date. However, the facility’s MAR for the month showed the Abiraterone order entered with a stop date of 2/24/26, and the MAR documented that the resident did not receive the medication on 2/25, 2/26, and 2/27. The resident and family reported that the resident had missed several doses of his cancer medication because nurses told him there was no order for it or that it was not available. The resident stated he had brought a four-day supply from home and had it renewed after admission, and that he was told he could not miss taking it because his prostate cancer had spread to his bones. The LPN who transcribed the admission orders confirmed she entered the Abiraterone order and acknowledged that the hospital discharge orders did not contain a stop date, and she did not know where the 2/24/26 stop date came from. Another LPN stated she only changed the administration time based on the resident’s usual home schedule and that the stop date was already present on the order. The former DON reported that the resident had voiced concerns that a nurse would not administer his cancer medication because there was no order for it, and that the order had been incorrectly stopped, leading to the documented missed doses.
Failure to Provide Ordered Medications and Notify Physician Resulting in Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not providing ordered medications and necessary services to prevent physical harm. A resident with complex cardiopulmonary conditions, including acute on chronic respiratory failure with hypercapnia, COPD, pulmonary hypertension, and acute on chronic diastolic congestive heart failure, was admitted from a hospital with detailed physician orders for multiple medications and treatments. These included oxygen at 5 L via nasal cannula, diuretics (such as spironolactone and torsemide), bronchodilators and nebulizer treatments (including arformoterol, Breztri, ipratropium‑albuterol, and albuterol), steroids (prednisone), and several other maintenance medications and supplements. The facility’s own policies required that physician orders be entered within one hour of admission, that medications be available upon admission using the emergency drug kit or STAT safe if needed, and that pharmacy be contacted for STAT delivery when medications were not on hand. Despite these requirements and the resident’s high‑risk medical status, the Medication Administration Record shows that on multiple days following admission, the resident did not receive numerous ordered medications at scheduled times. Missed medications included aspirin, cyanocobalamin, docusate sodium, ferrous sulfate, fluoxetine, fluticasone, folic acid, prednisone, spironolactone, vitamin D3, acetazolamide, Budeson‑Glycopyrrolate‑Formoterol (Breztri), clonazepam, hydroxychloroquine, torsemide, and ipratropium‑albuterol at various 8:00 a.m., 12:00 p.m., and 4:00 p.m. doses. These omissions were documented by the LPN as “unavailable.” The facility had an electronic STAT safe/automated dispensing cabinet stocked with several of these medications, including albuterol, fluoxetine, prednisone, simvastatin, spironolactone, torsemide, and ipratropium, but the LPN acknowledged that she did not obtain medications for the resident from this machine on the days in question. The LPN further stated that the resident’s medications had not arrived from the pharmacy and that the resident did not receive medications on those days, but she did not notify the physician or nursing management that ordered medications, including breathing treatments, diuretics, heart failure medications, and prednisone, were not being administered. Pharmacy records later showed that many of the resident’s medications were in fact delivered to the facility overnight and early morning, yet the LPN could not explain why certain medications, such as acetazolamide and Breztri, were still not administered after delivery. The primary physician and advanced practice nurse both stated they were not notified that the resident’s medications were unavailable or not being given and indicated that they would have modified the treatment plan or sent the resident back to the hospital if they had been informed. On the day of death, staff last spoke with the resident shortly before noon, and when the LPN went to administer medications late that morning, the resident was found without respirations or pulse and was pronounced expired. The facility and surveyors determined that the failure to administer prescribed medications as ordered, to use available medication resources, and to notify the physician and nursing administration of missed doses constituted neglect and resulted in actual harm and death, rising to the level of Immediate Jeopardy. The facility’s own documentation and staff interviews confirmed that there was no timely escalation when medications were marked as unavailable, no documented physician notification regarding missed doses over multiple days, and no implementation of alternative interventions despite the resident’s complex cardiac and respiratory diagnoses. The DON verified that the resident did not receive multiple ordered medications on the identified days. The death certificate listed acute on chronic congestive heart failure and acute on chronic diastolic heart failure as the cause of death, with COPD as a significant contributing condition. The survey findings concluded that the deprivation of necessary medications and services, in violation of the facility’s abuse prevention and medication availability policies, constituted neglect and led to actual harm and death, resulting in an Immediate Jeopardy determination.
Removal Plan
- Director of Nursing reviewed all residents receiving prescribed medications as ordered.
- Director of Nursing reviewed all residents and identified no residents as having missed any doses of prescribed medications.
- All licensed nurses were educated by the Director of Nursing and provided access and instructions on how to obtain unavailable medications from the facility emergency medication kit (STAT Safe).
- Regional Nurse Consultant educated the Director of Nursing on medication administration and availability.
- Weekly match-back audits are completed for medication availability.
- All new admissions are reviewed to ensure medications are available and orders are in place using a checklist, which is reviewed daily during the clinical QA meeting.
- Licensed nursing staff were educated by the Director of Nursing on adherence to physician orders, timely resident assessment and documentation, physician notification when an ordered dose is missed, immediate notification and escalation to facility nursing administration for medication administration issues, and the facility Abuse and Neglect Policy related to administering prescribed medications to avoid physical harm.
- Director of Nursing created an audit tool to ensure compliance with medication administration and availability, assessment and documentation, physician notification and escalation to nursing administration, and staff knowledge of facility medication administration standards to avoid physical harm to residents.
- Director of Nursing or designee will audit licensed nurses to ensure compliance with medication administration standards.
- Administrator or designee will audit licensed nurses to ensure compliance with medication administration standards to avoid physical harm to residents.
Failure to Administer Ordered Medications and Notify Providers Resulting in Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received prescribed medications in accordance with physician orders. The resident was admitted from a local hospital after a prolonged hospitalization for acute on chronic respiratory failure with hypercapnia, acute respiratory distress, COPD, pulmonary hypertension, and acute on chronic diastolic congestive heart failure, among other diagnoses. Hospital discharge instructions and the facility’s October physician order sheet show that the resident was to receive multiple routine medications, including oxygen at 5 L via nasal cannula, diuretics (torsemide, spironolactone, acetazolamide), bronchodilators and nebulizer treatments (albuterol, ipratropium‑albuterol, arformoterol, Breztri), steroids (prednisone, fluticasone), psychotropic medication (clonazepam), and several other maintenance medications and supplements. Facility policy required that physician orders be entered within one hour of admission, that pharmacy be contacted after 4:00 p.m. for new admissions, and that medications be obtained from the emergency drug kit or STAT Safe if not yet delivered. Despite these orders and policies, the resident’s Medication Administration Record shows that on two consecutive days after admission, the resident did not receive a wide range of ordered medications at scheduled times (8:00 a.m., 12:00 p.m., and 4:00 p.m.). Missed medications included aspirin, cyanocobalamin, docusate sodium, ferrous sulfate, fluoxetine, fluticasone, folic acid, prednisone, spironolactone, vitamin D3, acetazolamide, Budeson‑Glycopyrrolate‑Formoterol, clonazepam, hydroxychloroquine, torsemide, and ipratropium‑albuterol. These doses were documented by the LPN as “unavailable,” yet there is no documentation in the medical record that the physician was notified of the missed doses or that nursing management was informed. The facility had an electronic STAT Safe with several of the resident’s ordered medications stocked, including albuterol nebulizer solution, fluoxetine, prednisone, simvastatin, spironolactone, torsemide, and ipratropium, but the LPN later stated she did not obtain medications for the resident from this machine on the days in question. Interviews confirmed that required escalation and communication did not occur. The LPN reported that when new admissions arrive, other staff typically enter orders and that medications are usually delivered between 8:00 p.m. and 10:00 p.m., but she stated the resident’s medications had not arrived and that the resident did not receive medications on the two days prior to death. She acknowledged she did not notify the physician or nursing management that the resident had not received any medications, including breathing treatments, diuretics, heart failure medications, or prednisone, and could not explain why she did not administer certain medications that had been delivered by pharmacy before the resident’s death. The attending physician and an advanced practice nurse both stated they were not notified that the resident’s medications were unavailable or not administered; the physician stated the medications, including multiple diuretics, nebulizer treatments, and steroids, should never have been placed on hold and that he expected medications to be available on the evening of admission or to be notified to modify the treatment plan. Pharmacy records showed that many of the resident’s medications were delivered late in the evening and early morning following admission, but the resident still did not receive them as ordered. The resident was last noted as alert with shortness of breath at times and requiring BiPAP and nebulizer treatments with oxygen; later, staff found the resident without respirations or pulse when attempting to administer medications, and the death certificate lists acute on chronic congestive heart failure and acute on chronic diastolic heart failure with COPD as contributing conditions. The facility’s failure to follow physician orders, obtain and administer available medications, and provide appropriate monitoring and response resulted in actual harm and death and was cited at the Immediate Jeopardy level. The facility’s own policies and available resources underscore the inactions that led to the deficiency. The Medication Availability policy directed staff to enter orders promptly, contact pharmacy after 4:00 p.m. for new admissions, use the emergency drug kit or STAT Safe for needed medications, and obtain STAT or backup pharmacy delivery when medications were not in stock, with all administrations documented in the EMAR. The pharmacy’s posted hours and cutoff times, along with the STAT Safe inventory list, showed that many of the resident’s ordered medications were accessible through the automated dispensing cabinet. Nonetheless, the LPN did not use the STAT Safe to obtain medications, did not document any attempts to secure medications beyond marking them as unavailable, and did not escalate the issue to the DON or physician. The DON later verified that the resident did not receive multiple ordered medications on the days prior to death and that she had not been informed of the unavailability or non‑administration of these medications. These documented failures in medication procurement, administration, and communication formed the basis of the cited deficiency and Immediate Jeopardy determination.
Removal Plan
- Director of Nursing reviewed all residents to confirm they are receiving prescribed medications as ordered.
- All licensed nurses were educated by the Director of Nursing and provided access/instructions on how to obtain unavailable medications from the facility emergency medication kit (STAT Safe).
- Regional Nurse Consultant educated the Director of Nursing on medication administration and medication availability processes.
- As part of QA activities, match-back audits are completed for medication availability.
- All new admissions are reviewed using a checklist to ensure medications are available and orders are in place; this checklist is reviewed during the clinical QA meeting.
- Licensed nursing staff were educated by the Director of Nursing on adherence to physician orders, timely resident assessment and documentation, physician notification when an ordered medication dose is missed, and immediate notification/escalation to facility nursing administration for any medication administration issue.
- An audit tool/process was created by the Director of Nursing to ensure compliance with medication administration and availability, assessment and documentation, physician notification, and escalation to nursing administration.
- Director of Nursing or designee will audit licensed nurses to ensure compliance with medication administration standards.
Failure to Maintain Signed Physician Orders for Held Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and physician orders related to holding medications for three residents. For one resident, the nursing progress note documented that an advanced practice nurse was notified that the resident was a new admission and that medications were not available, and that the practitioner gave an order to hold the unavailable medications. However, a review of the resident’s physician order sheet for that month did not show any signed physician order to hold those medications. For a second resident, nursing progress notes documented receipt of a physician’s order to hold Abilify, Trelegy, and Jardiance until the pharmacy could verify delivery and fill all orders for drop-off that evening, but the corresponding physician order sheet contained no signed physician order to hold these medications. For a third resident, nursing progress notes stated that the resident’s medications were on hold until available, that PRN Ultram and Lasix were obtained from backup, and that the primary care physician was aware that medications were on hold; however, there was no signed physician order in the medical record to support holding the medications. The interim DON confirmed that the electronic medical records for all three residents lacked signed physician orders to hold medications and stated that, per facility standard of practice, telephone or verbal orders must be backed up by a signed physician order and that without such a signature, those orders are insufficient and void.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in one resident pushing another, causing the latter to lose balance and fall to the floor. The incident involved two residents on a locked dementia unit, both of whom were not cognitively intact. The resident who was pushed had a history of dementia with psychotic disturbance and other chronic conditions, and was ambulatory without assistance. The resident who pushed used a wheelchair and had diagnoses including dementia with anxiety and other chronic illnesses. According to staff interviews and documentation, the resident who was pushed had repeatedly entered the personal space of the other resident, requiring redirection on multiple occasions. On the day of the incident, staff observed the ambulatory resident approach the wheelchair-bound resident twice—first in the hallway and then in the day room. After being redirected the first time, the resident again entered the other's personal space, at which point the wheelchair-bound resident pushed, causing a fall. Staff confirmed that the resident who pushed is known to become aggressive when his personal space is invaded, and that the other resident frequently needs redirection for similar behaviors. The incident occurred while the LPN was down the hall, and staff confirmed the sequence of events as described.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of each resident. This deficiency was identified during the survey process, but the report does not provide specific details regarding the actions or inactions that led to the failure, nor does it mention any particular residents or their conditions at the time of the incident.
Failure to Honor Resident's Request for Care Plan Meeting with Ombudsman
Penalty
Summary
The facility failed to honor a cognitively intact resident's request to participate in a care plan meeting with the ombudsman present. The resident had submitted a grievance regarding inconsistent bathing and hair care after a change in CNA assignments and specifically requested a care plan meeting with the ombudsman to discuss these concerns. Despite the resident's repeated verbal and written requests, and the ombudsman's direct communication with the prior administrator and DON about scheduling the meeting, no care plan meeting was arranged or documented in the resident's electronic health record during the review period. Interviews confirmed that the resident continued to express frustration about not being heard and not having the requested meeting, and the ombudsman reported never receiving follow-up from facility leadership after the initial discussion. The Social Service Director, responsible for scheduling care plan meetings, stated they were never informed of the resident's request. At the time of observation, the resident's hair appeared oily and stringy, and the resident expressed ongoing dissatisfaction with care and communication from staff.
Failure to Protect Residents from Abuse and Inadequate Documentation
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident sexual and physical abuse, as evidenced by multiple incidents involving four residents. One cognitively intact resident entered the room of a severely cognitively impaired resident on more than one occasion and engaged in inappropriate sexual contact, including groping and exposing the resident. Staff members witnessed these incidents, and there was evidence that the cognitively impaired resident was unable to recall or report the events due to her condition. Despite these occurrences, the care plan for the cognitively impaired resident did not address her risk for abuse or include interventions to protect her from further harm. Additionally, the facility failed to document the incidents and necessary interventions in the medical records of both the perpetrator and the victim. The cognitively intact resident's record did not reflect the sexual abuse allegations or the rationale for increased supervision, and the cognitively impaired resident's records lacked documentation of the abuse incidents and protective measures. Staff interviews confirmed that the administration was aware of the incidents, but appropriate documentation and care plan updates were not completed at the time of the events. A separate incident involved a resident with a history of physical aggression due to dementia and mood disorders physically striking her roommate during care. The aggressive resident's care plan noted her behavioral issues and triggers, but the incident still occurred, resulting in the roommate being hit on the shoulder. Staff and the roommate confirmed the aggressive behavior, and the facility's records corroborated the event. These failures to prevent and appropriately respond to abuse led to the finding of Immediate Jeopardy.
Failure to Post and Address Grievance Procedures
Penalty
Summary
The facility failed to post grievance and complaint procedures in prominent locations throughout the building and did not promptly address resident grievances, as required by policy. The facility's grievance policy states that forms should be available at all nurse's stations and front desks, and that grievances should be addressed and resolved within five days. However, during a tour, the Administrator confirmed that grievance procedures were not posted in any prominent locations. Additionally, during a resident council meeting, multiple residents stated they did not know where or how to file a grievance, and some reported that grievances were not followed up on promptly or at all. A specific incident involved a resident who filed a grievance with the assistance of the Ombudsman regarding issues with bathing, call light response times, and supply availability. The grievance requested a care plan meeting with the Ombudsman present. The Ombudsman submitted the grievance to the Administrator, but the Administrator did not document any investigation or resolution, and the Activities Director, who received the grievance weeks later, had not started addressing it. The lack of investigation and response to this grievance, along with the absence of posted procedures and resident awareness, demonstrates the facility's failure to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual and physical abuse to the appropriate authorities in a timely manner, as required by its own Abuse, Prevention, and Prohibition Policy. In one incident, a Licensed Practical Nurse observed a resident groping another resident, exposing her breasts and abdomen. The initial report of this sexual abuse was sent to the State Agency five days after the incident, and the final report was sent eleven days after the allegation was made. There was no documentation that local law enforcement was notified of the alleged sexual abuse, despite policy requirements. The Administrator confirmed the delay in reporting and the lack of notification to law enforcement. In a separate incident, a resident was hit on the shoulder by another resident during incontinence care, resulting in a complaint of shoulder pain rated as 3/10, though no visible injury was noted. The incident was not reported to the State Agency within the required two-hour window; instead, it was reported the following day. The Administrator acknowledged the delay and stated unawareness of the two-hour reporting requirement. These failures affected four residents reviewed for abuse in the sample of 38.
Failure to Assess and Document Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident was properly assessed following an alleged fall. The resident, who had severe dementia, anxiety, and depression, was found sitting on the floor in her room and reported she had fallen but could not recall the details. Certified Nursing Assistants notified an LPN of the incident, but the LPN did not immediately assess the resident and instructed staff to return her to bed. The resident was later sent to the emergency department, where she was diagnosed with closed fractures of the 8th and 9th ribs on the right side. There was no documentation in the nursing progress notes regarding the fall, assessment, notifications, or the time the resident was sent to the emergency department. Further interviews revealed that the LPN who received the resident back from the emergency department was not informed of the fall and found no documentation in the notes. The Assistant Director of Nursing confirmed that the facility's policy requires immediate assessment and documentation after a fall, including a detailed progress note and notifications. The facility's post-fall procedure was not followed, as there was no evidence of a fall risk evaluation, assessment, or proper documentation in the resident's record.
Failure to Provide Personal Needs Allowance and Financial Assistance for Medicaid Residents
Penalty
Summary
The facility failed to provide effective administrative oversight to ensure that residents on Medicaid received their Personal Needs Allowance (PNA), assistance with supplemental income financial applications, and proper management of personal funds. The administrator and business office manager did not ensure that residents were receiving their entitled PNA, nor did they assist residents in applying for Supplemental Security Income (SSI) or disability benefits when appropriate. The facility also failed to prevent the use of residents' personal funds for Medicaid-covered services, as evidenced by the deduction of room and board payments from a resident's trust account. One resident, who had been in the facility for nearly a year, reported not receiving her social security or the $60 monthly PNA, leaving her without money for personal expenses such as haircuts or shoes. The resident's trust account showed a significant deduction for room and board, and no deposits had been made since her admission. The business office manager confirmed that the resident was owed the PNA for the past year and that her trust funds had been depleted due to improper deductions. Additionally, the facility did not ensure that residents without income were assisted in applying for SSI or disability benefits, resulting in several residents not receiving any monthly PNA. Interviews with staff revealed a lack of knowledge and action regarding the application process for SSI or disability benefits. The social services staff and business office manager both stated they had not assisted any residents with these applications. The administrator was unaware of the issues with residents' income and PNA, and there was no documentation to show that residents had been informed or assisted regarding their financial entitlements. This lack of oversight and failure to follow established procedures affected all Medicaid residents in the facility.
Failure to Provide Personal Needs Allowance and Financial Assistance
Penalty
Summary
The facility failed to provide medically-related social services and financial assistance to ensure that residents received their entitled state-funded payments and personal needs allowances (PNA). One resident, who had been in the facility for nearly a year, was not receiving her monthly PNA despite being on Medicaid. Her trust account showed a balance of only $0.01 for several months, with no deposits or transactions, and she reported having no money for personal expenses such as haircuts or shoes. The Business Office Manager confirmed that the resident's Social Security payments were not being received by the facility due to the payee not being updated, resulting in the resident not receiving her monthly allowance. Additionally, three other residents, all under the age of 65 and with Medicaid as their payer source, were not receiving a monthly PNA because they had no income. Staff interviews revealed that neither the Business Office Manager nor Social Services had assisted these residents in applying for Supplemental Security Income (SSI) or disability benefits, which would have enabled them to receive a PNA. The staff were unclear about the process and responsibilities for initiating SSI or disability applications, and there was no documentation to show that these residents had been assessed or assisted in obtaining financial benefits. Job descriptions for the Social Services Assistant, Admissions Coordinator, and Business Office Coordinator outlined responsibilities for ensuring residents' financial arrangements and facilitating access to benefits. However, the facility did not follow through with these duties for the affected residents. The lack of action resulted in multiple residents not receiving funds for personal needs, and there was no evidence that the facility had made appropriate referrals or provided necessary assistance to secure these benefits.
Improper Use of Resident Personal Funds for Medicaid-Covered Services
Penalty
Summary
The facility failed to ensure that a resident's personal funds were not used to pay for items or services covered by Medicaid. According to the facility's Financial Responsibility Agreement and Medicaid guidelines, residents eligible for Medicaid should not be charged for medical or personal supplies routinely supplied to all residents, and their Personal Needs Allowance (PNA) should not be used for items or services paid for by Medicaid. Despite this, a resident who had been on Medicaid since admission had $1,086.20 deducted from her personal trust account for room and board, which should have been covered by Medicaid and her social security income. The resident's trust account was subsequently depleted, with no deposits made since her admission, and she did not receive her monthly PNA due to issues with social security checks not being delivered to the facility or the facility not being set as her payee. The business office manager confirmed that the resident's Medicaid and social security should have covered her room and board, and that the resident had not received her $60 monthly PNA for the past year. The deduction from the resident's trust account for room and board was made at the direction of her financial power of attorney, but this action was inconsistent with Medicaid regulations. The resident reported having no money for personal expenses, relying only on occasional bingo winnings or gifts from friends, and her trust account balance was reduced to one cent.
Failure to Ensure Privacy of Resident Mail Delivery
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened and without being read, as required by resident rights policies. Specifically, the Business Office Manager (V4) admitted to opening two envelopes addressed solely to the resident, which contained life insurance checks related to the resident's late spouse. The envelopes were not addressed to the facility, and the resident reported receiving both envelopes already opened. The Business Office Manager stated that the mail was opened by accident, but both envelopes were opened before being delivered to the resident. The resident's family member confirmed that all banking is managed by the family and not the facility, and that the envelopes were clearly marked as life insurance correspondence addressed only to the resident. Interviews with staff confirmed that resident mail should be delivered sealed and only opened at the resident's request. The Activity Director (V7) stated that mail is typically received from the Business Office Manager and delivered to residents unopened, except in cases where the recipient is unclear. In this instance, however, the mail was clearly addressed to the resident, and the facility's own policy affirms the right to privacy in sending and receiving mail. The incident was corroborated by both the resident and a family member, as well as the staff member responsible for sorting and delivering mail.
Failure to Follow Sanitary Food Handling Procedures
Penalty
Summary
The facility failed to adhere to its policy on sanitary handling of food items during mealtimes, which has the potential to affect all 75 residents. The facility's Hand Washing and Glove Usage Policy requires employees to use proper hand washing procedures and gloves in accordance with State and Federal Sanitation Guidelines. On a specific date, a Certified Nursing Assistant (CNA) was observed preparing food trays for residents without using gloves or washing hands. The CNA handled bread with bare hands, buttered it, and placed it back on the meal tray. This action was contrary to the facility's policy, as confirmed by the CNA and other staff members, including an Activities staff member and a Licensed Practical Nurse (LPN), who stated that staff should wear gloves when touching residents' food.
Failure to Timely Respond to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for 11 residents, as revealed through record review and interviews. During a resident council meeting, multiple residents reported significant delays in call light responses, with some residents waiting over two hours for assistance. One resident mentioned having to fix their own oxygen supply due to the lack of timely response, while another reported that staff would turn off the call light without returning to provide help. These delays were reported to occur across all shifts, with some residents experiencing these issues multiple times a week. The facility's Regional Director of Operations admitted that there was no specific policy on answering call lights, although the expectation was that residents' needs should be met whenever a call light is activated. The facility administrator stated that call lights should be answered within 30 minutes, but this standard was not being met, as evidenced by the residents' testimonies. The lack of a formal policy and the failure to adhere to the 30-minute response expectation contributed to the deficiency in providing timely assistance to residents.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide bedtime snacks to 11 residents, all of whom were reviewed for bedtime snacks in a sample of 33. The facility's Dining Service Mealtimes policy requires that an HS (Hour of Sleep) snack be offered to all residents at 8:00 PM. However, during a resident council meeting, all 11 residents reported not receiving bedtime snacks. Additionally, a Certified Nursing Assistant (CNA) confirmed that only some residents are offered bedtime snacks, indicating a deviation from the facility's policy. Among the affected residents, several have Type II Diabetes Mellitus, which may necessitate regular nutritional intake. The Regional Director of Operations acknowledged that all residents should be offered bedtime snacks, yet the practice was not consistently followed. The CNA, who has been working at the facility since February, stated that not all residents are offered a bedtime snack, further corroborating the residents' claims. This inconsistency in providing snacks highlights a failure to adhere to the established policy, impacting the nutritional care of the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling medical devices, as observed in four out of twelve residents reviewed for EBP. The policy outlined in the Infection Prevention and Control Manual requires the use of gowns and gloves during high-contact resident care activities for those at increased risk for multidrug-resistant organism (MDRO) acquisition. However, observations revealed that residents with conditions such as an arteriovenous fistula, wounds, and indwelling urinary catheters did not have the necessary personal protective equipment (PPE) available in their rooms, nor were there any signs indicating the need for EBP. Additionally, staff members, including licensed practical nurses, registered nurses, and certified nursing assistants, confirmed they had not received training or in-service on Enhanced Barrier Precautions. The Infection Preventionist acknowledged the oversight and communicated the need for EBP to the facility administrator. The lack of training and awareness among staff, coupled with the absence of PPE and signage, contributed to the facility's failure to adhere to the infection control policy, thereby increasing the risk of MDRO transmission among residents.
Failure to Provide Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a resident and/or their representative with a written notice of hospital transfer, which is a requirement for ensuring proper communication and rights awareness. The deficiency was identified for one resident in a sample of 33. The resident had a hospital unpaid leave documented on their Census Profile, covering specific dates. However, there was no evidence in the resident's chart of a written notice of transfer or discharge being provided. This was confirmed during an interview with the Social Service Assistant, who acknowledged the absence of documentation or evidence of such notification.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to a resident or their representative when the resident was transferred to a hospital. The facility's policy, revised in February 2024, requires that a Bed Hold Agreement be obtained for each occurrence of hospital or therapeutic leave, and that the resident or their representative be notified of this policy. However, in the case of the resident reviewed, there was no documentation indicating that the Bed Hold Policy was provided. The resident, who had a diagnosis of Dementia with Agitation, was admitted to a local hospital after an incident where they attempted to harm themselves with broken glass. Despite the facility's procedure, the Social Service Assistant confirmed that there was no record of the Bed Hold Policy being given to the resident or their representative.
Failure to Obtain Level II PASRR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to obtain a Level II PASRR (Pre-Admission Screening and Resident Review) screening for a resident who was newly diagnosed with a mental illness. The resident, identified as R67, was admitted to the facility with a PASRR Level I determination indicating no need for a Level II screening, as there was no severe mental illness, intellectual disability, or related condition noted at that time. However, on July 6, 2023, a nurse practitioner documented a new evaluation diagnosing the resident with Disorganized Schizophrenia, noting that the resident was delusional and prone to outbursts or attempts to elope when upset. Despite this new diagnosis, the resident's medical record did not show evidence of a Level II PASRR screening being conducted. The Regional Director of Operations confirmed that the facility did not request a Level II PASRR after the diagnosis of Disorganized Schizophrenia was made.
Failure to Document PTSD Triggers and Interventions
Penalty
Summary
The facility failed to assess and identify potential triggers and provide specific personalized interventions for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's Trauma Informed Care Policy, dated October 2022, outlines the importance of considering residents' past traumatic experiences to develop person-centered care plans that avoid re-traumatization. However, the resident's Trauma Informed Care form, effective August 2024, did not document any PTSD triggers or interventions. Additionally, the resident's care plan, which was initiated in August 2023 and revised in June 2024, also lacked documentation of identified triggers or interventions for PTSD. The deficiency was identified during a review of the resident's records and an interview with the Regional Director of Operations. The resident's Physician Order Sheet and Preadmission Screening and Resident Review (PASRR) both documented a diagnosis of PTSD. Despite this, the facility did not have any documented triggers or interventions for the resident's PTSD. The Regional Director of Operations acknowledged the oversight, stating that updates to the facility's computer forms during a receivership transition might have contributed to the lack of documentation. The care plan was updated on the day of the interview to identify the triggers.
Failure to Document Justification and Obtain Consent for Antipsychotic Use
Penalty
Summary
The facility failed to document behaviors justifying the use of antipsychotic medications, obtain consent prior to their use, and perform an annual gradual dose reduction for two residents. Resident R10, who is severely cognitively impaired, was prescribed ABH gel for unspecified dementia and anxiety disorder without documented behaviors that would justify its use. The medical record lacked a consent form and a care plan for the use of this medication. Observations and staff interviews indicated that R10 did not exhibit behaviors that posed a risk or disrupted care, and could be easily redirected. Resident R67, diagnosed with disorganized schizophrenia, was prescribed Haldol Decanoate IM monthly without documented behaviors to justify its use. The medical record did not include a consent form, a care plan, or evidence of a gradual dose reduction attempt since the medication's initiation. Staff interviews confirmed that R67 did not exhibit behaviors warranting the medication and primarily wanted to rest, receiving hospice services. The facility's failure to comply with its policies on psychotropic medication use and gradual dose reduction was evident in these cases.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse for several residents, resulting in multiple incidents of resident-to-resident physical and sexual abuse. Resident R3, who was severely cognitively impaired and had a history of aggressive behavior, was involved in several altercations. R3 physically assaulted R11 by hitting and shaking her arm, shoved R10 to the ground causing a head injury, punched R9 in the face, and threw water on R12. Additionally, R4 sexually assaulted R3 by placing his hand down R3's pants when R3 wandered into R4's room. These incidents highlight the facility's failure to implement effective interventions and supervision to prevent such occurrences. R3's care plan did not adequately address her aggressive behaviors or provide interventions to prevent further incidents. Despite R3's known history of physical aggression and cognitive impairment, the facility did not update her care plan to include strategies for managing her behavior or preventing her from entering other residents' rooms. Similarly, R4's care plan lacked interventions to address inappropriate sexual behavior, which contributed to the incident involving R3. The facility's staff also failed to provide adequate supervision and intervention during these incidents. Staff members were unable to redirect R3 effectively, and there were instances where staff left residents unsupervised, allowing altercations to occur. The facility's policies on abuse prevention and intervention were not properly implemented, leading to a situation of Immediate Jeopardy for the residents involved.
Failure to Provide Functional Mechanical Lift for Bariatric Resident
Penalty
Summary
The facility failed to ensure that a mechanical lift was available and in working order for a bariatric resident who was dependent on transfers. The resident, a female with a history of chronic atrial fibrillation, depression, morbid obesity, hypertension, type 2 diabetes, and chronic sinusitis, was admitted to the facility and required assistance for activities of daily living and transfers. Her care plan specified the use of a mechanical lift with two staff members for transfers. However, the facility's mechanical lifts were either not functioning properly or were inadequate for the resident's weight, leading to difficulties in transferring her safely. The facility's staff reported multiple issues with the mechanical lifts. The new lift, which had a maximum weight capacity of 750 pounds, failed to lift the resident high enough for a transfer, even when the bed was lowered to its lowest position. The older blue lift, with a capacity of 500 pounds, was unreliable and often stopped working mid-transfer, requiring an ambulance to assist in returning the resident to bed. Despite attempts to address the issue by ordering a new sling and lift, the problems persisted, and the resident expressed dissatisfaction and concern for her safety during transfers. Interviews with staff and the resident revealed that the facility's administration, including the Director of Nursing and the Administrator, were aware of the ongoing issues but had not effectively resolved them. The resident felt neglected and unsafe, as the lifts had previously tipped and failed to function properly. Staff confirmed that the mechanical lifts had not been reliable since April, and despite reporting these issues to the administration, the problems remained unresolved, impacting the resident's ability to get out of bed as desired.
Failure to Investigate Resident-to-Resident Altercations
Penalty
Summary
The facility failed to conduct a thorough investigation of two resident-to-resident altercations involving physical abuse. The incidents involved three residents, R3, R11, and R12, and were not properly investigated as required by the facility's Abuse, Prevention, and Prohibition Policy. The policy mandates immediate reporting and thorough investigation of any alleged abuse, which was not adhered to in these cases. In the first incident, R3, who has a history of severe cognitive impairment and aggressive behavior, physically assaulted R11 by punching and shaking her arm. This altercation was witnessed by a CNA, who reported that R3 was swinging her arms aggressively and had a history of such behavior. Despite the severity of the incident, the facility did not conduct an investigation or report the incident to the state agency as required. In the second incident, R3 threw a glass of water on R12, another resident with moderate cognitive impairment. This incident was reported to the facility administrator, who dismissed it as a behavior issue rather than abuse, and no investigation was conducted. The administrator later admitted to not being aware of the incidents or failing to investigate them, which resulted in a lack of documentation and reporting to the state agency.
Medication Unavailability for Resident with Depression and Diabetes
Penalty
Summary
The facility failed to ensure the availability of essential medications for a resident, identified as R1, who was diagnosed with depression and type 2 diabetes mellitus. The resident did not receive their prescribed antidepressant, Venlafaxine HCl ER, for three consecutive days, and their diabetes medication, Victoza, for approximately a week. This lapse in medication administration was due to the medications being on order or back order, and there was no evidence of alternative measures being taken to address the unavailability. Interviews with the nursing staff revealed a lack of communication with the resident's physician regarding the unavailability of the medications. The LPNs responsible for R1's care did not notify the doctor or seek alternative prescriptions during the period when the medications were unavailable. Additionally, there were no documented interventions or progress notes in R1's medical record indicating that the facility took steps to mitigate the impact of the missed doses. The Director of Nursing confirmed that the facility's protocol for handling medication shortages was not followed. The protocol requires nurses to check the emergency medication box, contact the pharmacy, and notify the resident's doctor to obtain further orders. However, these steps were not documented or executed, resulting in R1 experiencing adverse effects such as severe headaches, depression, and fatigue due to the missed medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 46 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Galesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seminary Manor | 0.1 mi | — | 5 | 0 |
| Allure Of Lake Storey | 1.4 mi | — | 1 | 0 |
| Allure Of Knox County | 1.5 mi | — | 2 | 1 |
| Allure Of Galesburg | 1.6 mi | — | 13 | 5 |
| Knox County Nursing Home | 5.9 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.