Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Crescent Health Care during CMS and state inspections, most recent first.
A resident with Alzheimer’s dementia, anxiety disorder, osteoarthritis, impaired cognition, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift while a wedge-shaped bed bolster remained in place along the bed edge. The care plan addressed bed placement against the wall for fall prevention but did not include the bolster, and there was no physician order, assessment, care plan entry, or representative consent for its use. During the two-person lift transfer, the sling was already attached when staff raised the resident with the bed at working height; the sling became affected by the bolster, the lower sling loop came off the lift hook, and the resident slid from the sling onto the floor, partially onto the lift leg. The resident sustained a forehead laceration, left ankle injury with fracture, bruising, and pain. Staff later stated the bolster should have been removed or taken down and that the bed height was too high, and leadership acknowledged there were no written policies, documented training, or guidelines for mechanical lift use with bed bolsters.
A resident developed avoidable pressure injuries due to the facility's failure to consistently assess and implement interventions. Despite being at risk, the resident's skin condition was not adequately monitored, leading to pressure injuries on the heels and calf. Observations showed the resident often without prescribed heel protectors, and staff interviews revealed a lack of awareness and communication regarding necessary interventions. The DON acknowledged that required assessments were not completed, contributing to the resident's decreased quality of life.
Two residents experienced a decline in ROM and mobility due to the facility's failure to implement timely restorative therapy services, including the use of braces and splints. One resident developed hand contractures due to delayed therapy initiation, while another did not receive consistent splint application. Staff interviews revealed a lack of awareness and training, as well as staffing issues, contributing to the deficiency.
The facility failed to provide quarterly personal fund statements to three residents, each with varying cognitive and physical impairments. Despite the requirement to send these statements, the facility's administrator admitted that they had not been sent for almost a year, placing residents at risk of not having an accurate accounting of their personal funds.
The facility failed to resolve grievances voiced in Resident Council meetings and did not inform residents about the grievance process. A resident reported broken bathroom equipment, but the issue was not documented or addressed. Additionally, residents were unaware of how to file grievances or who the Grievance Officer was. The facility's informal process relied on department heads to address concerns without proper documentation or follow-up.
The facility failed to conduct accurate PASARR assessments for two residents, leading to a deficiency in care. One resident with depression and severe cognitive impairment and another with anxiety and moderately impaired cognition did not receive required level two evaluations. Staff were unaware of updated regulations and had not received training, contributing to the oversight.
The facility failed to provide trauma-informed care for three residents, including one with PTSD and another with significant personal losses. Care plans lacked trauma assessments and interventions, leaving residents' mental health needs unaddressed. Staff were unaware of recent traumas and did not document or manage triggers effectively.
The facility's kitchen had several maintenance deficiencies, including a broken floor under the oven, dusty appliances, leaking faucets, and improper storage of dry goods under a steam table. Additionally, dirty vents with exposed insulation were observed. Staff interviews revealed a lack of maintenance personnel and communication issues, with the Administrator unaware of these problems.
A resident with significant health issues was not provided adequate care to maintain bowel continence and personal hygiene, leading to multiple incontinent episodes and insufficient showering opportunities. The resident expressed dissatisfaction with the care, citing delays in assistance and a lack of a scheduled toileting program. Staff acknowledged the challenges in providing timely care due to resource constraints.
The facility failed to assess and monitor the use of physical restraints for two residents, leading to the use of roll bolsters without proper orders or consents. One resident with mood disorder and heart failure was immobilized in bed due to staffing issues, while another with stroke and dementia had limited movement. No assessments or consents were documented, placing residents at risk.
The facility failed to complete significant change assessments (SCAs) for two residents who experienced changes in their health status related to hospice and palliative care. One resident was discharged from hospice services without an SCA, and another experienced a decline in ADLs and was diagnosed with palliative care without an SCA. Staff interviews revealed confusion and lack of responsibility regarding the completion of MDS assessments, contributing to the deficiency.
A facility failed to update the PASARR Level I form for a resident newly diagnosed with mental health concerns, including anxiety and delusions. The resident was prescribed Ativan for agitation, but the PASARR assessment was not revised to reflect these changes. Staff interviews revealed a lack of awareness about the requirement to update PASARR forms for new mental health diagnoses.
The facility failed to update care plans for two residents, leading to inaccuracies in their documented care needs. One resident's care plan did not reflect their interest in activities or worsening vision, while another's inaccurately stated they could feed themselves. Staff confirmed these discrepancies, and the DON acknowledged the need for review.
The facility failed to provide consistent Restorative Aide (RA) programs for three residents, leading to a risk of functional decline. A resident with dementia and diabetes was not participating in RA programs due to fatigue and fear, while another with a history of stroke was not encouraged to self-feed or transfer. A third resident with ankylosing spondylitis did not receive prescribed exercises. Staffing issues and lack of training contributed to these deficiencies.
A resident with visual and hearing impairments felt isolated due to the lack of meaningful activities at the facility. Despite their interest in political science and news, they were unable to engage in these activities effectively. Staff interviews revealed no planned one-on-one activities, and the activities director was unsure how to meet the resident's needs.
The facility failed to conduct proper skin assessments and provide timely specialized services for residents. A resident with a urostomy did not have their skin condition properly documented or communicated to a physician. Another resident with Alzheimer's disease did not receive weekly skin and wound documentation as ordered. Additionally, two residents did not receive timely specialized services, including therapy and Botox injections, due to administrative oversights and lack of proper documentation.
A resident with lower back pain and anxiety experienced issues with unsafe bathroom equipment, including an unsecured toilet seat riser and broken handrails, leading to falls. Despite reporting these issues, staff failed to document or address them, resulting in a deficiency in ensuring a safe environment.
The facility failed to ensure residents were free from unnecessary psychotropic medications, as two residents were prescribed such medications without proper monitoring or documentation. One resident received Ativan without a stop date, and behavior monitoring was inconsistent. Another resident's antidepressant dosage was increased without complete behavior monitoring, and there was no signed consent for medication use. Staff interviews revealed a lack of adherence to protocols for informed consent and behavior monitoring.
A resident with complete hearing loss experienced miscommunications and unmet care needs due to the facility's failure to provide adequate communication support. Despite using a whiteboard and iPad, the resident expressed frustration over staff's inability to communicate effectively, particularly regarding medication information and personal care. The facility had not provided an interpreter, even three months after admission, leading to further communication issues.
A resident with multiple health issues experienced unmanaged pain and a delayed response to a change in condition, including an allergic reaction to an antibiotic. The resident's complaints of pain were not promptly addressed, leading to a delay in emergency care. Additionally, there was a lack of proper assessment and communication regarding the resident's allergic reaction, resulting in further complications.
The facility failed to maintain a cleanable and sanitary environment in three resident rooms, where worn and discolored tiles with black sticky substances were observed. A resident reported that their room was dirty and uncleanable. The Environmental Manager confirmed the uncleanable condition, attributing it to old and worn surfaces with glue seeping through the tiles.
Failure to Manage Bed Bolster Hazard During Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to identify and prevent an avoidable accident hazard related to the combined use of bed bolsters and mechanical lift transfers for a resident. The resident had Alzheimer’s dementia, anxiety disorder, osteoarthritis, moderately impaired cognition, was dependent on staff for grooming, bed mobility, and transfers, and was assessed as being at risk for falls. The resident’s fall care plan specified that the left side of the bed was to be placed against the wall to prevent falls or rolls out of bed, but there were no care plan interventions addressing the use of a bed bolster. The facility also lacked a physician order, assessment, care plan entry, or representative consent for the bolster that had reportedly been in use on the resident’s bed for a couple of years. On the day of the incident, staff used a mechanical lift to transfer the resident from bed to wheelchair while a wedge-shaped bolster remained along the right side of the bed, with the bed at working height. Nursing assistants involved in the transfer reported that the sling was already hooked to the lift and that, during the lift, the lower left sling loop came off the lift hook as the resident was moved over the side of the bed. Staff later acknowledged that the bolster wedge should have been removed or taken down before performing the mechanical lift transfer and that if the bolster is not moved, the sling can get caught on it. One NA stated they had not been told to remove bolsters for mechanical lifts, and another stated that looking back, the bed had been too high and the bolster should have been removed. As a result of the sling loop disconnecting from the lift hook, the resident slid out of the sling and fell to the floor, landing partially on the mechanical lift leg. The resident sustained a forehead laceration, bruising to the left arm and elbow, skin shearing, bruising, and swelling to the left ankle, and was transported to the hospital. The resident was diagnosed with a left ankle fracture, treated with a leg splint, and had a shallow scalp laceration. Upon return, the resident was observed yelling out and later groaning in pain, with visible bruising on the forehead. The DON, restorative nurse, and administrator acknowledged there were no written policies, documented training, or guidelines specific to mechanical lift transfers in conjunction with bed bolsters, and the administrator stated they were not aware that bolsters could be a hazard.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to consistently assess and implement interventions to prevent and manage pressure injuries (PIs) for Resident 30, who developed three avoidable PIs after admission. Resident 30 was admitted with diagnoses including kidney and heart failure, and was at risk for developing PIs. Despite this, the facility did not adequately monitor or document the condition of Resident 30's skin, leading to the development of PIs on the right heel, left heel, and left calf, which were not present upon admission. Observations revealed that Resident 30 was often found lying in bed without the use of prescribed heel protectors, which were intended to prevent pressure on the heels. The facility's Treatment Administration Record (TAR) showed orders to monitor and float the heels, but these interventions were not consistently implemented. Staff failed to document weekly heel assessments, and there were no treatment orders for the Stage 1 PI on the right heel. Additionally, the care plan did not include interventions for the left outer calf PI or the use of the air mattress overlay and heel protectors. Interviews with staff indicated a lack of awareness and communication regarding Resident 30's condition and the necessary interventions. Nursing assistants reported observing abnormalities but did not have a place to document these findings, and there was confusion about the use of heel protectors. The Director of Nursing Services acknowledged that weekly skin assessments and wound assessments were not being completed as required, and the Resident Care Managers were not updating care plans promptly due to their workload. This lack of consistent assessment and intervention contributed to the worsening of Resident 30's PIs and their decreased quality of life due to pain.
Failure to Implement Timely Restorative Therapy Services
Penalty
Summary
The facility failed to implement timely restorative therapy services, including the consistent use of braces and splints, to prevent avoidable reduction of range of motion (ROM) and mobility for two residents. Resident 27 developed right and left-hand contractures, which were not present upon admission and were not documented in subsequent assessments until much later. Despite a physician's diagnosis of a right-hand contracture, there was a significant delay in initiating a ROM restorative program, and no documentation indicated that such a program was in place for the resident's upper extremities. Observations confirmed the absence of necessary devices like dowels to aid in reducing contractures. Resident 20, who had a known contracture to the left hand, was supposed to be on a nursing restorative program that included the use of a splint. However, observations revealed that the splint was not consistently applied, and staff interviews indicated a lack of awareness and training regarding the resident's restorative program. Staff members reported being too busy or not trained to perform the necessary ROM exercises, leading to the program not being followed as required. Interviews with staff, including the Rehab Director and nursing assistants, highlighted systemic issues such as inadequate communication and training, as well as staffing shortages that contributed to the failure in providing necessary restorative care. The facility's administrator acknowledged the expectation for braces and splints to be applied as ordered and for residents showing a decline to be evaluated and treated promptly, which was not the case for these residents.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents and/or their representatives, as required. This deficiency was identified for three residents, each with varying degrees of cognitive and physical impairments. Resident 20, diagnosed with Parkinson's disease and requiring extensive assistance for activities of daily living (ADLs), had severely impaired cognition. The resident's representative reported not receiving any statements regarding the resident's personal funds. Similarly, Resident 23, who has cerebral palsy and intact cognition, also did not receive any personal fund statements. Resident 27, with scoliosis and moderately impaired cognition, required extensive assistance for ADLs, and their representative assumed the funds were used for care, as they had not received any statements. During an interview, the facility's administrator, Staff A, acknowledged the failure to send out personal fund statements, admitting that the facility was behind schedule and had not sent any statements for almost a year. This lapse in procedure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility, as required by regulations.
Failure to Resolve Grievances and Inform Residents of Grievance Process
Penalty
Summary
The facility failed to establish an effective system for promptly resolving grievances voiced during Resident Council meetings. Resident 9, who had moderately impaired cognition and was receiving hospice services, reported broken bathroom equipment during a Resident Council meeting. Despite this, the issue was not documented in the meeting minutes or the maintenance book, and no action was taken to resolve the concern. Staff V, the Activities Director, assumed that concerns raised in the meetings were addressed by individual departments but did not follow up to ensure resolution. Additionally, four residents who regularly attended Resident Council meetings were unaware of how to file a grievance or who the facility's Grievance Officer was. The facility's grievance policy stated that grievances should be investigated by the Director of Nursing or the Administrator, with results communicated to the resident or their representative. However, the process for handling concerns raised in Resident Council meetings was informal, with no formal documentation or follow-up to ensure grievances were addressed. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. Staff A, the Administrator, and Staff H, the Grievance Officer, acknowledged that concerns from Resident Council meetings were not treated as formal grievances. The process relied on department heads to address issues based on meeting minutes, but there was no documentation or follow-up to confirm resolution. This lack of a structured grievance process placed residents at risk for unresolved concerns and dissatisfaction.
Failure to Conduct Accurate PASARR Assessments
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) assessments accurately reflected the mental health conditions of two residents, leading to a deficiency in the care provided. Resident 16 was admitted with diagnoses including a stroke and depression, and their comprehensive assessment indicated severe cognitive impairment and symptoms of depression. However, the PASARR assessment, completed by the Resident Care Manager upon admission, incorrectly indicated that a level two evaluation was not required, despite the presence of a mood disorder. Similarly, Resident 8, who was admitted with an anxiety disorder and had moderately impaired cognition, also did not receive the necessary level two evaluation as indicated by their PASARR assessment. The staff responsible for completing the PASARRs, Staff C and Staff D, were unaware of the updated regulations requiring these evaluations to be completed prior to admission, and they had not received training on the changes. The facility administrator, Staff A, was also unaware of the regulatory changes and the need for training, contributing to the oversight.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for three residents who were trauma survivors. Resident 12, who had experienced significant personal losses including the death of their spouse and multiple amputations, expressed feelings of sadness and loss of manhood. Despite these clear indicators of trauma, the resident's care plan did not address their trauma concerns or identify any triggers or interventions to manage their mental health well-being. Staff H, the Social Services Director, was unaware of the recent nature of the resident's losses and did not conduct a thorough assessment to understand the impact on the resident's mental health. Resident 38, who had a history of cataracts, dementia, and multiple falls, expressed feelings of isolation and guilt over the death of their child from alcoholism. Despite these expressed concerns, the psychosocial history did not reflect these issues, and no trauma-based care plan was initiated. Staff DD, the Social Services Assistant, was aware of the resident's regrets but did not ensure that these were documented or addressed in the care plan. Resident 27, diagnosed with PTSD, anxiety, and depression, had specific triggers related to their past experiences of being yelled at by their parents. However, their care plan did not include any trauma-informed interventions or assessments to address these triggers. Staff H acknowledged that the process for trauma-informed care was not followed, and there was no trauma assessment tool available in the electronic health record. The Director of Nursing Services confirmed that no trauma assessments had been completed for the residents.
Kitchen Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen, which placed residents at risk for infection. Observations revealed several issues, including a broken and missing area of rubberized concrete under the oven's right leg support, making it uncleanable. Additionally, the top of the oven was covered with dusty stainless steel appliances and inserts used for the steam table. The clean sink area had a leaking water faucet, which worsened over time, affecting a second faucet. Despite the Dietary Manager reporting the issue to the Maintenance Director, the problem persisted. Further observations showed that white plastic barrels containing powdered milk, flour, and other dried goods were stored under a steam table, exposing them to constant high temperatures and moisture, potentially affecting their quality. The kitchen also had two dirty vents with black fuzzy dust, and one vent had exposed yellow insulation due to splits in the ceiling. Interviews with staff revealed a lack of maintenance personnel and communication issues, as the Administrator was unaware of the kitchen repair issues until informed by the surveyors.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 12, by not providing adequate care to support their bowel continence and personal hygiene needs. Resident 12, who was readmitted with a fracture of the right lower leg and other significant health issues, required assistance with a mechanical lift for transfers and was continent of bowel. However, the resident was not on a scheduled bowel toileting program, leading to multiple incontinent bowel episodes. The resident expressed dissatisfaction with the care received, particularly the lack of timely assistance to use the bathroom, resulting in accidents. Additionally, the facility did not provide Resident 12 with sufficient opportunities for personal hygiene, as they were only scheduled for one shower per week. The resident expressed a preference for more frequent showers, especially before appointments and family visits, but staff indicated they lacked the time to accommodate this request. The care plan for Resident 12 did not include a specific toileting schedule, and staff acknowledged the difficulty in using the mechanical lift quickly due to the need for two staff members. The Director of Nursing Services recognized the need for reassessment to determine the resident's toileting and showering needs.
Failure to Assess and Monitor Physical Restraints
Penalty
Summary
The facility failed to comprehensively assess and monitor the need for physical restraints for two residents, identified as Resident 30 and Resident 39. Resident 30, who was admitted with a mood disorder and heart failure, had severely impaired cognition and required substantial assistance for bed mobility. Observations revealed that roll bolsters were used to immobilize Resident 30 in bed without a physician's order or proper assessment. Staff interviews indicated that the roll bolsters were used due to insufficient staffing to assist the resident in getting up, and there was no ongoing reassessment or consent obtained for their use. Similarly, Resident 39, who had a history of stroke, dementia, and depression, was observed with roll bolsters that limited their freedom of movement. There were no physician orders or assessments justifying the use of these restraints. Staff interviews revealed that the roll bolsters were used to prevent the resident from turning around in bed, but there was no documentation of an assessment, order, or consent for their use. The facility's failure to assess, document, and obtain necessary consents for the use of physical restraints placed residents at risk for diminished quality of life and other complications.
Failure to Complete Significant Change Assessments for Residents
Penalty
Summary
The facility failed to complete a significant change assessment (SCA) for two residents, Resident 9 and Resident 30, who were reviewed for hospice and end-of-life care. According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, an SCA is required when a resident experiences a major decline or improvement in health status, such as when hospice benefits are selected or discontinued. Resident 9 was admitted with hospice care and later discharged from hospice services, but no SCA was completed following this change. Similarly, Resident 30 experienced a significant decline in activities of daily living (ADLs) and was diagnosed with palliative care, yet no SCA was conducted to address these changes. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of MDS assessments. Staff C and Staff D, who shared the task with Staff Y, the MDS Coordinator, were uncertain about who was responsible for completing the SCAs for Residents 9 and 30. Staff B, the Director of Nursing Services, admitted to not being knowledgeable about the timing and frequency of SCAs. This lack of coordination and understanding among staff members contributed to the failure to complete the necessary assessments, placing the residents at risk for unmet care needs.
Failure to Update PASARR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-Admission Screening and Resident Review (PASARR) Level I form for a resident who was newly diagnosed with mental health concerns. This oversight involved a resident who was admitted with diagnoses including depression and blindness. The resident's medication records indicated that they were prescribed Ativan, a psychotropic medication, for agitation and comfort care without a stop date. The medication was initially ordered in July 2024 and continued into August 2024. Despite these changes in the resident's mental health status and medication regimen, the PASARR assessment from January 2023 was not updated to reflect the new behavioral diagnoses of anxiety, agitation, or delusions. Interviews with facility staff revealed a lack of awareness regarding the requirement to update PASARR forms when a resident is newly diagnosed with mental health issues. The contracted pharmacist noted that the resident was receiving Ativan due to agitation from delusions, yet the resident case managers admitted they were unaware of the need to update the PASARR assessments under such circumstances. This failure to update the PASARR form potentially placed the resident at risk for health and emotional decline due to the absence of a professional evaluation to determine if further mental health interventions were necessary.
Inaccurate and Outdated Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans for two residents were reviewed, revised, and accurately reflected their current care needs. Resident 38, who had been at the facility for over a year, had a care plan that was outdated and did not reflect their current condition. Despite having cognitive impairment, the resident was able to express their needs clearly. The care plan did not account for the resident's interest in activities such as reading newspapers and going on outings, nor did it reflect their worsening vision due to cataracts. Additionally, the care plan did not update the resident's restorative program after a fall that resulted in a clavicle fracture, and there were no new restorative assessments or interventions documented. Resident 39, who was severely cognitively impaired and required substantial assistance for self-care, had a care plan that inaccurately stated they could feed themselves 50% of their meals. Observations showed that the resident was fed 100% of their meals by staff and preferred to remain in bed rather than use a wheelchair, contrary to what was documented in the care plan. Interviews with staff and the resident's representative confirmed that the resident no longer fed themselves due to their dementia. The Director of Nursing Services acknowledged that the care plans did not reflect the current conditions and concerns of the residents.
Failure to Implement Restorative Aide Programs
Penalty
Summary
The facility failed to consistently provide necessary care and services to ensure that Restorative Aide (RA) Nursing programs were implemented for three residents, leading to a risk of avoidable decline in their functional abilities. Resident 21, who had dementia and diabetes, was observed multiple times remaining in bed without participating in their RA programs for dressing/grooming and bed mobility. Staff interviews revealed that the resident was not encouraged to participate due to fatigue and fear of transferring, and the Restorative Assistant responsible for these programs was working as a regular Nursing Assistant (NA) instead. Resident 39, with a history of stroke, dysphagia, and dementia, was also not participating in their RA programs for eating/swallowing and transfer training. Observations showed the resident being fed by staff without any attempt to encourage self-feeding, contrary to their care plan. Interviews with staff and the resident's representative indicated a lack of awareness and implementation of the RA programs, with staff routinely providing total assistance for meals and not facilitating transfer training. Resident 9, diagnosed with ankylosing spondylitis, was not receiving exercises or participating in RA programs for bed mobility, dressing, and walking as outlined in their care plan. Observations and interviews highlighted that the resident struggled with reaching their call light due to stiffness and had not been engaged in the prescribed exercises. The Restorative Director acknowledged the staffing issues, with only one RA available who was also assigned to work as a NA, leading to the delegation of RA program responsibilities to floor NAs without proper training or documentation processes in place.
Failure to Provide Meaningful Activities for a Resident
Penalty
Summary
The facility failed to provide meaningful and engaging activities for a resident who did not participate in group activities due to visual and hearing impairments. The resident, who had a history of cataracts, dementia, and multiple falls, expressed feelings of isolation and dissatisfaction with the facility due to the lack of suitable activities. Despite the resident's interest in political science and news, they were unable to read newspapers or watch television effectively, and their voting ballot remained uncompleted due to a lack of assistance from staff. Interviews with staff revealed that there were no planned or routine one-on-one activities for the resident, and the activities director was unsure how to address the resident's needs. Documentation showed minimal engagement with the resident, with one-on-one activities being limited to brief interactions such as assisting with bedding. The activities staff acknowledged the need for follow-up assessments to better understand and meet the resident's activity preferences, but no specific actions were taken to address the deficiency at the time of the report.
Deficiencies in Skin Assessments and Specialized Services
Penalty
Summary
The facility failed to ensure residents received care and services in accordance with professional standards of practice, particularly regarding ongoing skin assessments and specialized services. For Resident 37, the facility did not conduct proper skin assessments or document the condition of the skin around the urostomy stoma. Despite having a physician's order to change the urostomy bag and monitor for leakage, there was no care plan addressing the potential for skin impairment or the presence of an additional opening on the resident's abdomen that drained fluid. Staff interviews revealed a lack of awareness and documentation regarding the resident's skin condition, which was not communicated to the physician. Resident 8, who had Alzheimer's disease and open wounds on their head, was also not properly monitored. The facility failed to follow a physician's order to document the resident's skin and wound condition weekly. Despite having a chronic skin condition, there was only one documented observation over a 12-week period. The Director of Nursing Services acknowledged that the nurses were responsible for skin and wound treatments but did not follow the physician's orders for Resident 8. The facility also failed to provide timely specialized services for Residents 9 and 20. Resident 9, who had a history of falls and was at risk due to leg weakness, did not receive the ordered physical and occupational therapy services. The facility did not consult the resident, who was capable of making decisions, and instead relied on the family's previous decision to decline therapy. For Resident 20, the facility did not ensure the continuation of Botox injections for hand contractures due to missing power of attorney documentation, resulting in a significant delay in treatment.
Failure to Ensure Safe and Functional Bathroom Equipment
Penalty
Summary
The facility failed to ensure that a resident's bathroom had safe and functional Durable Medical Equipment (DME), which placed the resident at risk for falls and injuries. Resident 9, who was admitted with diagnoses including lower back pain and anxiety, was observed using a wheelchair and self-propelling in their room. The bathroom equipment, specifically a toilet seat riser with handles and portable handrails, was not secured properly. The handrails were unstable, with the right-side handrail being broken, causing it to push outwards when pressure was applied. Resident 9 reported these issues during a group meeting but was informed that nothing could be done. Staff interviews revealed a lack of communication and documentation regarding the broken equipment. Staff M, a Nursing Assistant, did not report the issues to maintenance or document them in the maintenance book. Staff V, the Activities Director, recalled the resident's report but did not ensure it was recorded. The Maintenance Director, Staff I, confirmed no reports were received about the equipment. The Restorative Director, Staff E, was unaware of the equipment issues and had not assessed the bathroom, as the resident attributed their falls to leg weakness. The maintenance book showed no entries for the equipment issues, and the resident experienced two non-injury falls in the bathroom, attributed to leg weakness and deconditioning.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by the cases of two residents. Resident 7 was prescribed Ativan on a PRN basis without a stop date, and the medication was continued for 43 days before being discontinued and reordered without a stop date. Despite a pharmacist's recommendation to add a stop date, the medication was extended for three months without documented rationale. Additionally, behavior monitoring for Resident 7 was inconsistent, with numerous shifts lacking documentation of interventions or outcomes. Resident 16 was prescribed Desvenlafaxine and Remeron for depression, but there were no orders for monitoring targeted behaviors. The Desvenlafaxine dosage was increased without complete documentation of behavior monitoring, and there was no care plan for the resident's depression or use of psychotropic medications. Furthermore, there was no signed consent or education provided for the use of Remeron, and staff reported increased sadness without documentation to support these claims. Interviews with staff revealed a lack of adherence to protocols for obtaining informed consent and monitoring targeted behaviors. The Director of Nursing Services acknowledged the need for consent and documentation of behavior changes to justify medication adjustments. The facility's failure to develop, monitor, and implement individualized care plans and obtain informed consent placed residents at risk for medication-related adverse effects and compromised their ability to make informed decisions.
Failure to Provide Adequate Communication Support for Deaf Resident
Penalty
Summary
The facility failed to provide adequate communication support for a resident who is deaf, resulting in miscommunications and unmet care needs. The resident, who has complete hearing loss and other medical conditions such as heart disease, diabetes, and kidney disease, was observed using a whiteboard and an iPad for communication. Despite these tools, the resident expressed frustration over the staff's inability to communicate effectively, particularly regarding medication information and during personal care activities. The resident's care plan only mentioned the use of a whiteboard for communication, with no additional instructions or interventions. Interviews and observations revealed that staff members did not consistently use the whiteboard to communicate with the resident, and some staff members did not understand sign language. The resident's representative had requested an interpreter due to poor communication, but the facility had not yet provided one, even three months after the resident's admission. During medication administration, a nurse failed to inform the resident about the medications being given, despite the resident's request. Additionally, an incident occurred where a staff member startled the resident by changing their sheets without prior communication. The facility's administrator acknowledged the ongoing search for an interpreter but had not yet secured one.
Failure to Timely Assess Change in Condition and Manage Medication Reaction
Penalty
Summary
The facility failed to assess a change in condition in a timely manner for a resident who complained of abdominal pain and experienced an allergic reaction to a prescribed antibiotic. The resident, who had multiple diagnoses including deaf-nonspeaking, urinary retention with a catheter, chronic UTIs, and heart and kidney failure, communicated their pain through sign language and writing. On the morning of the incident, the resident pointed to their urinary catheter and complained of back pain to a nursing assistant, who did not report the complaint to a nurse. Despite the resident's communication of pain and the need to go to the emergency room, there was a delay in response, with the emergency ambulance arriving three hours after the initial complaint. The resident's medical record indicated a previous urologist visit where excessive sediment was noted in the urine, and an order was given to flush the catheter with acetic acid. However, there was no order to flush the catheter until 12 days later, and staff used normal saline instead. The resident's urinary catheter was leaking, and the resident experienced unmanaged pain due to the delay in assessment and treatment. Additionally, the resident was prescribed Cefdinir for a UTI, which led to a suspected allergic reaction causing throat pain and swelling. The staff failed to assess the resident's mouth or throat and did not notify the resident representative or provider promptly. The resident received a one-time dose of Benadryl for the side effects of Cefdinir, but there was no further direction documented. The staff did not assess the resident's condition, and the resident was not sent to the emergency room despite the suspected allergic reaction. The resident later developed a secondary fungal infection in the mouth, which was attributed to the antibiotic. The facility lacked a written policy for flushing urinary catheters, and staff relied on online resources for guidance, indicating a gap in proper procedural knowledge and communication among staff members.
Unsanitary Flooring Conditions in Resident Rooms
Penalty
Summary
The facility failed to maintain a cleanable and sanitary environment in three of ten resident rooms, as observed during a survey. In room [ROOM NUMBER], a five by four feet area of white tile was discolored to a blackish-brown color, with a black sticky substance between the tiles and multiple indentations that were uncleanable. Resident 1 reported that their room was dirty and the floor could not be cleaned properly. In room [ROOM NUMBER], a three by three feet area of worn tiles with several indentation marks and black sticky substance between the tiles was observed. Similarly, room [ROOM NUMBER] had a four by four feet area of worn, discolored tiles with several indentation marks and black sticky substance between the tiles. During an interview, the Environmental Manager, Staff H, acknowledged that the rooms were not cleanable and that the black sticky substance was glue coming up from the under flooring where the tiles were glued. Staff H admitted awareness of the uncleanable surfaces, which were old and worn. This situation placed staff and residents at an increased risk for infectious diseases and a non-functional resident environment due to the uncleanable flooring surfaces.
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What surveyors actually found near you
We read the 109 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.
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 Yakima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Care And Rehabilitation | 0.3 mi | — | 1 | 0 |
| Summitview Rehab And Health Center | 0.4 mi | — | 1 | 0 |
| Good Samaritan Health Care Ctr | 1.5 mi | — | 17 | 0 |
| Garden Village | 2 mi | — | 24 | 0 |
| Willow Springs Care And Rehabilitation | 2.5 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.