Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Nortonville Health Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities developed a worsening left heel pressure ulcer after staff failed to implement a physician's order for suspension boots and did not document or apply the intervention. The order was not entered into the EMR, and the care plan did not address the required preventative measures. The wound deteriorated, and there was no evidence of timely physician notification or communication with the resident's representative, despite facility policies requiring these actions.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
The facility did not ensure RN coverage for eight consecutive hours daily, as required, with schedule reviews revealing multiple days without an RN on duty. Staff could only verify RN coverage through a staffing program, and the facility was unable to provide an RN coverage policy when asked.
The facility did not complete annual performance reviews for five staff members, including LNs, CMAs, and CNAs, who had been employed for over a year. Personnel records lacked documentation of these evaluations, and the administrative nurse could not verify their completion. The facility also failed to provide a policy for employee annual performance reviews when requested.
The facility did not maintain a system to accurately account for controlled medications in its emergency kit, with the kit being stored in an office that was found unlocked and unattended on several occasions. The emergency kit was received with one drawer unlocked and lacking an inventory list, containing Schedule 2 narcotics such as fentanyl, morphine, and tramadol. The facility also lacked a policy for narcotic storage and did not require receipts for kit deliveries, resulting in an inability to reconcile and safeguard controlled substances.
The facility did not ensure a licensed pharmacist performed required monthly drug regimen reviews for all residents, with missing documentation and reports for several months. A resident with multiple complex conditions and at risk for medication side effects did not have their medication regimen reviewed as required by policy.
Surveyors identified multiple sanitation and food safety issues in the kitchen, including unverified use of pasteurized eggs, dirty equipment and surfaces, expired chemical testing strips, dead insects above food prep areas, and structural problems such as missing baseboards and a back door gap. Dietary staff confirmed the need for cleaning and repair, and the facility's policies for cleaning and sanitizing were not followed.
The facility did not prioritize quality improvement, failed to develop and implement action plans, and did not conduct or document any Performance Improvement Projects (PIPs) for two consecutive years. Administrative staff confirmed the absence of PIPs and noted frequent changes in facility leadership. The facility also did not provide evidence of QAPI committee activities or regular data review as required by policy.
The facility did not maintain a QAA committee with the required members or meet at least quarterly, as sign-in sheets lacked key personnel and there was no documentation for meetings in the previous year. No Performance Improvement Projects were started or documented, contrary to the facility's QAPI policy.
The facility did not implement a water management program for Legionella prevention, despite staff training and an existing policy requiring routine cleaning and disinfection of potable water systems. Both maintenance and administrative staff confirmed that a surveillance system for Legionella was not in place.
The facility did not have a certified Infection Preventionist (IP) responsible for the infection prevention and control program, and could not provide documentation of a current certified IP. An administrative nurse confirmed the absence of a certified IP and was unsure if an infection tracking system had been in place previously, despite facility policy requiring the IP to oversee infection control activities and reporting.
A review of CNA records showed that several aides employed for over a year did not complete the required 12-hour in-service training, and facility leadership could not provide documentation to verify compliance.
Surveyors found that expired medications, including multivitamins, zinc tablets, Milk of Magnesia, and nicotine patches, were not removed from the medication room. An LN confirmed the medications were expired and should have been removed, and the facility could not provide a policy for medication storage or expired medications.
A facility serving 30 residents did not employ a full-time Certified Dietary Manager to oversee its food and nutrition services. The staff member acting as manager was not certified and had not begun certification training. The facility also could not provide a policy for employing a Certified Dietary Manager, relying instead on monthly visits and phone consultations from a Registered Dietitian.
Two residents were not assessed for eligibility to receive the pneumococcal PCV20 vaccine, and there was no documentation of the vaccine being offered, declined, or contraindicated. Medical records lacked evidence of consent or informed declination, and staff confirmed there was no system in place to check vaccine eligibility.
A resident with significant cognitive and physical impairments was discharged and transferred to another facility without prior notification to their court-appointed guardian. Although the guardian was involved in discussions about referrals and equipment, staff did not inform the guardian of the resident's acceptance and transfer to a new facility until after the discharge had occurred, contrary to facility policy.
A resident with a history of repeated falls and multiple risk factors experienced multiple falls due to the facility's failure to update and implement appropriate fall prevention interventions in the care plan. Despite documented incidents and staff awareness of the resident's needs, new interventions were not consistently added to the care plan, and required safety measures such as non-skid strips were not in place. The facility also could not provide a fall management program policy when requested.
A resident with dementia, anxiety, and major depressive disorder exhibited ongoing aggressive and inappropriate behaviors, including verbal outbursts, threats, and refusal of care. Despite a care plan outlining interventions such as redirection, paired care, and activity engagement, staff were unable to consistently manage the resident's behaviors, and the facility could not provide a dementia behavior management policy when requested.
A resident with multiple medical conditions did not receive seven physician-ordered medications, including an anticoagulant, antibiotic, antipsychotic, and others, for three consecutive days after admission. The resident, who was cognitively intact and independent, reported the missed doses, and a nurse confirmed the omission. Facility policy required timely administration of medications by licensed staff, but this was not followed.
The facility failed to provide timely delivery of physician-ordered medications for two residents, leading to missed doses of critical medications such as Eliquis, montelukast, ropinirole, tamsulosin, and tramadol. Despite attempts to contact the pharmacy, the medications were not delivered on time, and there was no evidence that providers were notified of the supply issues. Staff interviews indicated frequent delays in pharmacy deliveries and a lack of a local pharmacy for emergencies.
A resident with a history of heart failure and hemiplegia experienced a fall and subsequent critical health changes, including low blood pressure and a critical creatinine level. The facility failed to notify the physician or act on the resident's representative's request for hospital transfer, leading to the resident's admission to the ICU with acute kidney injury and dehydration.
A resident with a PICC line for IV antibiotics did not have their dressing changed for 38 days, leading to possible sepsis. The facility failed to monitor the dressing status and lacked orders for dressing changes, placing the resident in immediate jeopardy. Staff interviews revealed a lack of education and competency checks related to PICC line care.
A resident with a stage four pressure ulcer experienced wound deterioration due to the facility's failure to consistently assess wound characteristics and notify the physician of changes. Despite having a care plan that included a wound vac, the facility did not document changes or involve the physician in treatment decisions, leading to the resident's condition worsening and eventual transfer to the emergency room.
A resident with a history of amputation, heart failure, and hemiplegia fell during a Hoyer lift transfer when staff failed to widen the lift legs and did not use the backup loop on the sling. The resident sustained abrasions and skin tears and expressed fear of future lift use.
The facility did not provide quarterly statements for resident trust fund accounts, as required by policy. A resident's representative reported never receiving a statement, and Administrative Staff confirmed no statements had been sent due to lack of training. This oversight risked uninformed decisions and potential misappropriation of funds.
The facility failed to convey personal funds within 30 days for several residents after discharge or death, as required by policy. This deficiency involved significant balances in resident trust accounts and was compounded by staff's lack of understanding of procedures for handling these funds. Interviews revealed that families were not informed about the status of these accounts, highlighting a communication gap.
A resident with severely impaired cognition had unauthorized transactions from their trust fund, including a $300 debit card purchase. The facility failed to obtain necessary authorization from the resident's DPOA, violating their policy and risking misappropriation of funds.
Failure to Implement Physician-Ordered Wound Interventions and Notify Provider
Penalty
Summary
The facility failed to follow physician orders and implement preventative wound interventions for a resident with a left heel ulcer. After a consultant assessed the resident and ordered suspension boots and daily wound cleaning, the facility did not enter the order for suspension boots into the electronic medical record (EMR), nor did they apply the boots as directed. The resident's care plan and EMR lacked documentation of the suspension boots order, and there was no evidence that the intervention was implemented. Additionally, the facility did not notify the physician when the resident's left heel wound opened, as required by the order. The resident had multiple diagnoses, including congestive heart failure, diabetes mellitus, and dementia with agitation, and was at risk for skin issues due to impaired mobility and incontinence. Over time, the resident's wound worsened, progressing from a deep tissue injury to an unstageable pressure ulcer, and eventually required advanced wound care interventions such as a wound vac. The EMR showed gaps in documentation of wound assessments, notifications to the physician and the resident's representative, and implementation of ordered interventions. The care plan also failed to address the physician's order for heel protectors and did not include all necessary interventions related to the resident's left heel wound. Interviews with staff revealed confusion and lack of clarity regarding the implementation and documentation of physician orders for wound care and preventative devices. Staff were unsure if the suspension boots were ever ordered or applied, and the EMR did not reflect the order or its implementation. The facility's policies required prompt transcription and implementation of physician orders, as well as systematic pressure injury prevention and management, but these were not followed in this case, resulting in a decline in the resident's wound status and the development of additional complications.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility, with a census of 30 residents, failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. Review of nursing schedules for June 2024 and March 2025 showed that no RN was on duty on three specific dates. Consulting staff confirmed RN coverage could only be verified through a staffing program, which had recently changed companies. Additionally, when requested, the facility was unable to provide a policy regarding RN coverage.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete the required annual performance reviews for five staff members, including licensed nurses, certified medication aides, and certified nurse aides, all of whom had been employed for over a year. A review of personnel records showed that these employees did not have documented annual evaluations. When asked, the administrative nurse was unable to locate or verify the existence of these performance reviews. Additionally, the facility could not provide an Employee Annual Performance Review policy upon request.
Failure to Account for and Secure Controlled Medications in Emergency Kit
Penalty
Summary
The facility failed to maintain a system for accounting for controlled medications, specifically regarding the receipt and disposition of narcotics in the emergency kit. On multiple occasions, the door to the Administrative Nurse's office, where the emergency kit was stored, was found unlocked and unattended. The emergency kit itself was received with one of its drawers unlocked, containing Schedule 2 controlled substances such as fentanyl patches, morphine, and tramadol, among others. The kit did not include an inventory list of the narcotic medications, and staff were unable to access two of the three drawers. The facility did not have a policy related to the storage of narcotic medications and did not require a receipt upon delivery of the emergency kit. The pharmacy was notified of the issue with the emergency kit, but did not promptly resolve the problem. When a replacement kit was brought, it also lacked an inventory and contact information for unlocking, leading the facility to refuse it and return the damaged kit. The consultant pharmacist confirmed that the emergency kit should not have been accepted if it was damaged or unlocked, and that proper documentation and inventory should have been provided. The lack of a detailed system for tracking controlled substances and the absence of a storage policy contributed to the facility's inability to accurately reconcile and safeguard narcotic medications.
Failure to Provide Monthly Consultant Pharmacist Drug Regimen Review
Penalty
Summary
The facility failed to provide the services of a Consultant Pharmacist to review and identify irregularities in the drug regimens of all 30 residents during December 2024. Record review showed that monthly medication regimen reviews (MRRs) were documented for August, September, October, and November 2024, but there was no documentation of an MRR for December 2024. Additionally, when requested, the facility was unable to provide the Consultant Pharmacist reports for August through December 2024. Administrative staff reported a change in pharmacy providers in November 2024 and were unable to locate the pharmacist's recommendations for the relevant months. One resident in the sample, who had multiple diagnoses including major depressive disorder, anxiety, pain, diabetes, muscle spasms, repeated falls, and intervertebral disc degeneration, was identified as being at risk for adverse side effects from medications with black box warnings. The resident's care plan required regular pharmacy review and recommendations, but the lack of a December 2024 MRR and missing reports indicated that this oversight did not occur as required by facility policy. Facility policies stated that the consultant pharmacist would review each resident's medication regimen at least monthly to identify any irregularities.
Widespread Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen during meal preparation and service for all residents. Dietary staff reported cooking eggs to order, including over-easy and sunny-side-up, but could not verify that the eggs used were pasteurized as required. The kitchen's back door had a gap allowing outside light to enter, and the window above the microwave, where bread was stored, had a layer of brown dust. The handwashing sink and eyewash station were dirty, and two wheeled carts had greasy, linty material on the wheels and shelves. Additional observations included brown stains on ceiling tiles, food debris on oven surfaces, dried food remnants in stove drip pans, and lint on shelving used for cutting boards. Dead insects were found in a fluorescent light above food prep areas, and a container holding thermometers and chemical testing strips was covered in brown dust, with the strips found to be expired. Further issues included an ice machine floor drain lacking the required two-inch air gap and baseboards throughout the kitchen that were missing or coming unattached from the walls. Dietary staff confirmed the need for cleaning and repair in these areas and acknowledged that undercooked eggs should be pasteurized. The facility's own Nutritional Service policy requires adherence to federal and state food codes for cleaning and sanitizing equipment, but these standards were not met as evidenced by the observations.
Failure to Implement and Document QAPI Activities
Penalty
Summary
The facility failed to prioritize quality improvement, develop and implement action plans, conduct at least one Performance Improvement Project (PIP) annually, and regularly review, analyze, and act on collected data. During the survey, the facility was unable to provide documentation of any PIPs for the years 2024 and 2025. Administrative staff confirmed that no PIPs had been started or documented in the previous year, and noted that the facility had experienced turnover with seven administrators in the past two years. The facility's QAPI policy required the development and maintenance of a comprehensive, data-driven QAPI program, including systematic identification, reporting, investigation, analysis, and prevention of adverse events. The policy also specified the composition of the QAPI committee and the frequency of meetings. Despite these requirements, the facility did not provide evidence of QAPI committee activities or action plans addressing quality deficiencies, placing all 30 residents at risk for a lack of quality improvement activities.
Failure to Maintain Required QAA Committee Membership and Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required membership and meeting frequency. Specifically, the QAA committee did not have documented attendance from the medical director or their representative, the administrator or governance leadership, or the consultant pharmacist. Sign-in sheets were only available for two meetings in 2025, with no documentation for meetings in 2024. Administrative staff confirmed the absence of these records and were unable to locate them within the facility. Additionally, the facility did not initiate any Performance Improvement Projects (PIPs) during the current year and had no documentation of PIPs from the previous year. The facility's QAPI policy required a comprehensive, data-driven program with systematic identification and prevention of adverse events, and specified the required committee members and quarterly meetings. The lack of proper QAA committee function and documentation placed all 30 residents at risk for impaired care and services.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement a water management program for Legionella disease prevention, as required by its own policy. Maintenance staff reported attending training on Legionella prevention but had not yet developed a surveillance system. Administrative staff confirmed the absence of a surveillance system for Legionella prevention. The facility's policy stated that potable water systems should be routinely cleaned and disinfected, but this was not being carried out. This deficiency was identified during a review of records and staff interviews, with a facility census of 30 residents at the time.
Lack of Certified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist (IP), who was responsible for the Infection Prevention and Control Program, had completed the required specialized training in infection prevention and control. Upon request, the facility was unable to provide documentation of a current certified IP employed at the facility. An administrative nurse confirmed that there was no current certified IP and stated she had only been employed for four weeks, expressing uncertainty about the existence of an infection tracking system prior to her employment. The facility's policy indicated that the IP was responsible for oversight of the infection prevention and control program, including surveillance activities, documentation, and reporting to the Quality Assessment and Assurance committee.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to maintain an appropriate and effective in-service training program for nurse aides, as required by regulations. Specifically, a review of the records for three randomly selected Certified Nurse Aides (CNAs) who had been employed for more than a year revealed that they did not complete the required 12-hour in-service training. When asked, the Administrative Nurse was unable to verify that these CNAs had received the mandated training, and the facility could not provide documentation of the required in-service hours. This deficiency was identified through observation, record review, and staff interview, and affected a facility with a census of 30 residents.
Expired Medications Not Removed from Medication Room
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from the medication room, as evidenced by the presence of multiple expired stock medications including multivitamins with iron, zinc tablets, Milk of Magnesia, and nicotine patches. These medications were found to have expiration dates ranging from 04/2024 to 03/2025. A licensed nurse confirmed that these medications were expired and should have been removed from possible use. Additionally, when requested, the facility was unable to provide a policy regarding medication storage or the handling of expired medications. The facility had a census of 30 residents, with a sample of 12 residents included in the review. The failure to remove expired medications was identified through observation, interview, and record review during the survey.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility, with a census of 30 residents, failed to employ a full-time Certified Dietary Manager to oversee the food and nutrition service. During an observation, kitchen staff were seen completing the morning meal and preparing for the midday meal. The staff member identified as the manager confirmed she was not a Certified Dietary Manager and had not enrolled in a certification course. She also stated that a Registered Dietitian visited monthly and was available by phone for consultation. When requested, the facility was unable to provide a policy regarding the employment of a Certified Dietary Manager.
Failure to Assess and Document Pneumococcal Vaccination Eligibility and Consent
Penalty
Summary
The facility failed to assess two residents for eligibility to receive the pneumococcal PCV20 vaccination and did not offer, obtain informed declination, or secure a physician-documented contraindication for the vaccine as required by CDC guidelines. Review of the clinical medical records for these residents showed no evidence that the facility, the residents, or their representatives received or signed a consent to receive or an informed declination for the pneumococcal vaccine. The records also indicated that no pneumococcal vaccination had been given historically, offered, or declined. An administrative nurse confirmed that there was no system in place to check residents' eligibility status for pneumococcal vaccines at the time of the survey.
Failure to Notify Guardian Prior to Resident Discharge and Transfer
Penalty
Summary
The facility failed to notify a resident's guardian prior to the resident's discharge and transfer to another facility. The resident in question had a history of anxiety, traumatic brain injury, aphagia, dysphagia, and convulsions, and was documented as having moderately impaired cognition, requiring supervision for eating and total assistance for all other activities of daily living. The resident had an active court-appointed guardian, and the facility's records showed ongoing communication with the guardian regarding therapy services, equipment needs, and the search for alternative placement due to the facility's VA contract expiring. However, although the guardian was involved in discussions about referrals and equipment, documentation revealed that the guardian was not notified of the resident's actual discharge and transfer until after it had occurred. Staff interviews confirmed that the social services staff did not notify the guardian of the resident's acceptance and transfer to a new facility until the day of discharge, despite having received acceptance from the new facility several days prior. The facility's own discharge planning policy required that residents and their representatives be assisted in choosing appropriate care providers and be provided with accessible information about care options. Administrative staff verified that notification of a resident's representative or guardian prior to transfers or discharges was required, but this did not occur in this instance.
Failure to Update Fall Prevention Interventions and Care Plan
Penalty
Summary
The facility failed to identify and implement appropriate interventions to prevent falls for a resident with a history of repeated falls and multiple risk factors, including impaired mobility, moderately impaired cognition, and use of medications such as antianxiety agents, antidepressants, diuretics, and opioids. The resident's care plan documented the risk for falls and included interventions such as reminding the resident to notify staff when not feeling well, applying non-skid strips at the bedside, answering the call light promptly, and ensuring the resident wore nonskid socks and footwear during transfers and walking. However, after documented falls, the care plan and electronic medical record were not updated with new interventions to address the ongoing risk. The resident experienced multiple falls, including one incident where the resident slid off the bed while reaching for a television remote and another where the resident slid down in the bathroom while wearing shoes with no tread. Observations revealed the absence of non-skid strips at the bedside, and staff interviews indicated that interventions following falls were not consistently documented or updated in the care plan. Additionally, the facility was unable to provide a fall management program policy upon request.
Failure to Provide Appropriate Dementia Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate supervision, treatment, and services to a resident diagnosed with dementia, anxiety, and major depressive disorder, who also exhibited aggressive behaviors. The resident's medical record documented moderately impaired cognition, inattention, disorganized thinking, and fluctuating levels of consciousness, as well as frequent pain and total incontinence. The care plan identified risks for outbursts, yelling, spitting, and refusal of care, and directed staff to use redirection, paired care, and activity engagement as interventions. Despite these documented interventions, multiple progress notes and staff interviews revealed ongoing incidents of verbal aggression, refusal of care, and inappropriate interactions with other residents, including the use of profanity, threats, and physical actions such as throwing objects. Staff reported that the resident was not easily redirected and required separation from another resident due to behavioral issues. The care plan also included consulting mental health services and medication management, but the facility was unable to provide a dementia behavior management policy when requested. Observations and interviews confirmed that the resident continued to display aggressive and inappropriate behaviors toward staff and other residents, indicating that the facility did not consistently implement or document effective behavioral management strategies as outlined in the care plan.
Failure to Administer Physician-Ordered Medications for Three Days
Penalty
Summary
Staff failed to administer seven physician-ordered medications to a resident for three consecutive days following admission. The medications included an anticoagulant, antibiotic, anti-inflammatory, anticonvulsant, diuretic, antipsychotic, and a vitamin for anemia. The resident's electronic medical record documented multiple diagnoses, including cellulitis, anemia, bipolar disorder, hypertension, acute embolism, thrombosis, osteomyelitis, and an open wound. The resident was cognitively intact, used a walker, and was independent with activities of daily living. The medication administration record confirmed that none of the prescribed medications were given on the specified three days. The resident reported to surveyors that several of his medications, including psychoactive drugs, were not administered for a few days after admission. A licensed nurse verified that the medications were not given as ordered. Facility policy required medications to be administered by licensed staff as ordered by the physician and in accordance with professional standards, but this was not followed in this instance.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure the availability of physician-ordered medications for two residents, R1 and R2, which posed a risk for physical complications and less than desired therapeutic effects. R1, who was admitted with diagnoses including acute kidney injury, atrial fibrillation, and hyperlipidemia, did not receive her prescribed medications, including Eliquis, montelukast, and ropinirole, on multiple occasions due to delays in delivery from the pharmacy. The facility's records showed repeated instances where R1's medications were marked as 'Hold/See Progress Notes' or 'Other/See Progress Notes,' indicating they were not administered as ordered. Despite the facility's attempts to contact the pharmacy, there was no evidence that R1's provider was notified about the medication supply issues. Similarly, R2, who had diagnoses of chronic obstructive pulmonary disease and major depressive disorder, experienced delays in receiving his prescribed medications, including tamsulosin and tramadol. The facility's records documented several instances where R2's medications were not available, and the facility was waiting for delivery from the pharmacy. Although the facility made R2's provider and pharmacy aware of the situation, the medications were still not delivered in a timely manner, leading to gaps in R2's medication regimen. Interviews with facility staff, including a Certified Medication Aide and a Licensed Nurse, revealed that the pharmacy frequently failed to deliver medications on time, and the facility did not have a local pharmacy for emergencies. The facility's policy on administering oral medications did not address the process for ordering medications or ensuring timely pharmacy services. This lack of a clear protocol contributed to the failure to provide necessary medications to R1 and R2, highlighting a significant deficiency in the facility's pharmaceutical services.
Failure to Respond to Critical Health Changes
Penalty
Summary
The facility failed to respond promptly to a critical change in a resident's health status, which included a critical lab result and abnormally low blood pressure. The resident, who had a history of heart failure, hemiplegia, and an above-knee amputation, experienced a fall from a Hoyer lift, resulting in back pain and shakiness. Despite these symptoms and a critical creatinine level indicating potential kidney issues, the facility did not notify the physician or take immediate action to address the resident's declining condition. On the day following the fall, the resident's blood pressure readings were significantly below the physician-ordered parameters, yet the facility staff failed to notify the physician. The resident's representative requested that the resident be sent to the hospital, but the staff hesitated, citing potential difficulties in returning the resident if not admitted. It was only after the Program of All-Inclusive Care for the Elderly (PACE) intervened that the resident was sent to the hospital, where they were diagnosed with acute kidney injury and dehydration, and admitted to the ICU. The facility's inaction and failure to communicate the resident's critical condition to the physician placed the resident in immediate jeopardy. The resident's medical records and staff interviews revealed a lack of timely response to the resident's low blood pressure and critical lab results, as well as a failure to honor the resident's representative's request for hospital transfer. This deficiency resulted in the resident's admission to the ICU with severe health complications.
Failure to Provide Appropriate PICC Line Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident's peripherally inserted central catheter (PICC) line, including monitoring for complications and performing sterile dressing changes as per the standards of care. The resident, who was admitted with a PICC line for intravenous antibiotics, did not have their PICC dressing changed for 38 days, which was discovered when the resident was sent to an acute care hospital for possible sepsis. The hospital staff identified the outdated dressing, which had not been changed since the resident's admission, potentially contributing to the resident's sepsis. The resident's electronic medical record lacked evidence of any PICC dressing changes during their stay at the facility. Despite having orders to flush the PICC line, there were no orders or documentation regarding dressing changes. The facility's staff failed to monitor the dressing status and did not identify the absence of dressing change orders. This oversight placed the resident in immediate jeopardy, as the lack of proper PICC line care increased the risk of infection. Interviews with facility staff revealed a lack of education and competency checks related to PICC line care. A licensed nurse admitted to not receiving any training on PICC line care at the facility, despite having prior experience. The facility's administrative nurse confirmed that staff had not received PICC line care education before a recent skills fair and that there were no skills checks to ensure staff competency. The facility did not provide a policy related to PICC line care, further highlighting the deficiency in staff training and protocol adherence.
Failure in Wound Care Management
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with a stage four pressure ulcer on the sacrum, leading to the deterioration of the wound and worsening of the infection. The resident, who had a history of cerebral infarction, pressure-induced deep tissue damage, and other medical conditions, was admitted with a sacral wound and was on IV antibiotics. The care plan included the use of a wound vac, with specific instructions for wound assessment and physician notification in case of changes. However, the facility did not consistently assess the wound characteristics or notify the physician of changes, such as bleeding and skin breakdown around the wound. Throughout the resident's stay, there were multiple instances where the wound assessments were incomplete or lacked documentation of changes in the wound's condition. Despite the presence of a wound vac, the facility did not have a contingency plan for when the wound vac could not be placed due to skin breakdown. The resident's wound showed signs of deterioration, including increased redness, skin breakdown, and necrotic tissue, but these changes were not communicated to the physician in a timely manner. The facility's records also lacked evidence of physician involvement in the decision-making process for wound care adjustments. The situation escalated when the resident's condition worsened, leading to a decline in alertness and vital signs, and the wound developed a strong foul odor. The resident was eventually sent to the emergency room, where the wound was found to be necrotic with significant tunneling. Interviews with facility staff revealed a lack of communication and documentation regarding the wound's condition and the absence of a clear protocol for handling wound care complications. The facility's failure to adhere to wound care standards and ensure physician involvement contributed to the resident's deteriorating condition.
Resident Falls During Hoyer Lift Transfer Due to Staff Error
Penalty
Summary
The facility failed to ensure a resident remained free from preventable accidents during a Hoyer lift transfer. The resident, who had a history of amputation, heart failure, and hemiplegia, required total assistance for transfers. During a transfer to a shower chair, the resident fell from the Hoyer lift when the sling loops became unattached, resulting in the resident hitting their back on the lift leg and sustaining abrasions and skin tears. The incident occurred when two staff members, a Certified Nurse Aide (CNA) and a Certified Medication Aide (CMA), were performing the transfer. They did not widen the Hoyer lift legs after clearing the bed, as per the manufacturer's instructions, which caused the lift to become unsteady. Additionally, the staff did not use the backup loop on the sling, contributing to the resident's fall. The resident expressed fear of using the Hoyer lift in the future and experienced pain following the incident. The facility's investigation revealed that the staff involved did not follow proper procedures for using the Hoyer lift, including ensuring the correct sling size and placement, and using the appropriate sling lift loops.
Failure to Distribute Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to distribute quarterly statements to residents with trust fund accounts, as required by their policy. The facility had 30 active resident trust fund accounts with a total balance of $63,621.38. A sample review included nine residents, and it was found that a resident's representative had never received a quarterly statement regarding the resident's trust account, despite making inquiries after the resident's discharge. Administrative Staff C confirmed that no quarterly statements had been sent out for any trust accounts, citing a lack of training on the matter. The facility's policy mandates that quarterly statements be provided in writing to residents or their representatives within 30 days after the end of the quarter and upon request. This failure placed residents at risk for uninformed decisions regarding their trust funds and potential misappropriation.
Failure to Convey Resident Trust Funds Timely
Penalty
Summary
The facility failed to ensure the timely conveyance of personal funds for several residents following their discharge or death, as required by their policy. The report identifies that the facility had 30 active resident trust fund accounts, with a sample review of nine residents. Specifically, the facility did not convey the personal funds within 30 days for five residents, placing them at risk for impaired rights and misappropriation. The trial balance revealed significant balances in the trust accounts of these residents, including one resident who was discharged and four who had died in the facility. Interviews with facility staff revealed a lack of understanding and adherence to the policy regarding the handling of resident trust funds. Administrative Staff C admitted uncertainty about the procedures for managing trust funds upon a resident's death and indicated that she typically contacted the family to arrange for funeral expenses. She also acknowledged that she was scheduled for training on how to handle older accounts. Furthermore, there was a lack of communication with the families regarding the status of these accounts, as evidenced by a representative of one resident who had not received any account statements or responses to inquiries about the trust fund balance.
Failure to Obtain Authorization for Resident's Trust Fund Transactions
Penalty
Summary
The facility failed to properly manage a resident's trust fund by not obtaining the necessary authorization for transactions. The resident, identified as having severely impaired cognition, had two debits from their trust account: one for $124.61 and another for $300.00. The first transaction was for personal needs items, which was authorized by the resident's durable power of attorney (DPOA) due to the resident's inability to sign. However, the second transaction for a debit card purchase was not authorized by the DPOA, despite a receipt indicating the resident's signature and a note about buying a debit card for online orders. The DPOA was unaware of the $300.00 debit card purchase and expressed concern about the resident's vulnerability due to dementia. Administrative staff acknowledged that authorization from the DPOA should have been obtained for expenditures from the resident's trust fund, especially given the resident's cognitive impairment. The facility's policy requires written authorization for managing residents' funds, but this was not followed, leading to a risk of impaired rights and potential misappropriation of the resident's funds.
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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.
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What surveyors actually found near you
We read the 67 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nortonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| F W Huston Medical Center | 6.8 mi | — | 8 | 0 |
| Valley Health Care Center | 9.1 mi | — | 0 | 0 |
| Easton Health Care Center | 11.6 mi | — | 14 | 0 |
| Heritage Gardens Health And Rehabilitation Center | 14 mi | — | 0 | 0 |
| Dooley Center | 14.1 mi | — | 9 | 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.