Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crestwood Manor - 104 during CMS and state inspections, most recent first.
Two residents with known psychiatric and behavioral issues were not adequately monitored or supervised, resulting in separate resident-to-resident physical altercations. In one case, a resident with a documented history of assaultive behavior and prior need for frequent checks struck a roommate on the head with a belt after a dispute over television volume, causing a skin tear, at a time when enhanced observation had been discontinued. In another case, a resident entered another resident’s room and bathroom without permission because her own bathroom was occupied, then hit the resident in the face, causing a fall and facial swelling and discoloration. Staff later confirmed that rooms and bathrooms are considered residents’ personal space and that residents needing a bathroom when theirs is in use should be assisted to alternative bathrooms, but these practices were not followed, and staff did not intervene before the behaviors escalated.
A resident with schizoaffective disorder and parkinsonism was assaulted by another resident, resulting in facial injuries and fear of the assailant. On the day of the incident, the SSD documented that the resident would receive weekly psychosocial monitoring for 90 days, and the care plan specified Social Services follow-up once a week to observe for psychosocial decline. Review of records showed no documented weekly follow-up by Social Services during the 90-day period, and a nurse confirmed the intervention was not implemented. The SSD, lead Social Services staff, and DON all acknowledged that this follow-up was expected under facility policies addressing abuse, assaultive behavior, and care planning, which require Social Services to provide psychosocial support and address mental and psychosocial needs.
A resident with schizoaffective disorder, violent behavior, and a documented history of intrusive, assaultive, and socially inappropriate behaviors was on 1:1 supervision due to escalating sexually inappropriate behavior. Despite continuous restlessness, agitation, pacing, and ineffective redirection by a CNA, PRN Ativan ordered for behavior management was not successfully administered before the resident used the bathroom, exited, and crossed into a roommate’s personal space to smear feces on the sleeping roommate’s face. Multiple nurses later confirmed that 1:1 supervision required staff to remain within arm’s length, anticipate escalation, and prevent entry into other residents’ space, and that PRN medication should be given promptly when nonpharmacological interventions fail. The facility’s own policies on assaultive behavior management and elder/dependent adult abuse, which guarantee freedom from physical abuse by anyone, were not effectively implemented, resulting in a failure to protect a resident from physical abuse by another resident.
A resident with a history of falls and a self-care deficit developed a fear of falling and refused to walk, but the facility did not update the care plan to address these issues. Despite PT recommendations for staff assistance and documentation of declining ambulation, staff confirmed that the resident's fear and refusal were not incorporated into the care plan, contrary to facility policy.
A resident experienced a decline in ambulation ability after staff failed to consistently document walking attempts or refusals, did not always provide recommended supervision, and did not update the care plan to address the resident's fear of falling. Despite a history of falls and a physical therapy recommendation for supervised ambulation, the care plan lacked interventions for the resident's behavioral barriers, and ambulation assistance was inconsistently provided and recorded.
Surveyors identified multiple deficiencies in food storage, preparation, and equipment sanitation, including moldy produce, improperly labeled and undated food items, ice buildup in the walk-in freezer, wet-stacked dishes, a dirty and damaged can opener, stained serving ware, deeply grooved cutting boards, and missing air gaps in plumbing for the ice machine and produce sink. These issues were confirmed by dietary and maintenance staff during interviews.
The facility did not ensure that four residents' rights regarding advance directives and code status were properly documented and protected. In several cases, signed Advance Directives or documentation of discussions were missing from both electronic and physical charts, and staff were unable to locate or verify these critical documents. For one resident, code status was not documented in either the EHR or physical chart, leading staff to rely on chart label color to determine status. These failures were confirmed by interviews with staff and residents.
Two residents experienced deficiencies in nutritional care: one resident with significant weight loss and swallowing difficulties did not receive a speech therapy referral despite ongoing meal refusals and poor intake, while another resident with diabetes was not offered a timely replacement meal after refusing and discarding her lunch, contrary to facility policy. These actions resulted in inadequate nutrition for both residents.
The facility did not provide appropriate vegetarian meals for four residents with documented vegetarian diet orders or preferences. Instead, staff substituted fruit and cottage cheese plates for main entrees containing meat, resulting in meals with significantly less protein and calories than the regular menu. Dietary staff and the RD confirmed that these substitutions did not meet residents' nutritional needs, despite facility policy and state law requiring balanced vegetarian options.
The facility failed to maintain proper infection control by storing clean supplies next to hoppers used for waste disposal in utility rooms, allowing a nurse to bring a supply bucket for insulin administration into multiple resident rooms without cleaning, and not cleaning medication carts and pill cutters after use. Additionally, kitchen vent covers above food prep areas had rust, peeling paint, and debris, with maintenance and dietary staff confirming these unsanitary conditions.
Nursing staff did not have access to drug information resources, such as reference books or online guides, when administering medications. An LPN was unaware of specific administration instructions for Linzess, and staff confirmed that neither the medication cart nor the medication room contained drug reference materials. The DON acknowledged that drug information resources were not available for staff use, contrary to facility policy.
A resident with a history of convulsions did not receive accurate fall risk assessments, as multiple assessments failed to document seizures as a predisposing factor and did not reflect the resident's use of antiseizure medication. These inaccuracies were confirmed by an LPN and acknowledged by the DON, with the facility's policy requiring accurate assessment and documentation to guide fall prevention interventions.
A resident with chronic pain related to embolism and thrombosis experienced ongoing, inadequately managed pain despite frequent requests and increased use of PRN acetaminophen. Staff did not notify the physician about the ineffective pain regimen, and no individualized care plan for pain was developed or implemented, contrary to facility policy. These failures resulted in the resident experiencing unnecessary pain and reduced participation in daily activities.
Three residents experienced deficiencies in medication management, including the long-term use of a PPI without reassessment and the absence of clear monitoring parameters for insulin and blood sugar levels in two diabetic residents. The consultant pharmacist and DON did not identify or address these issues, and medication orders lacked specific guidance for nursing staff on when to intervene for abnormal blood sugar readings.
The facility had a medication error rate of 9%, with errors including improper eye drop administration, giving Linzess after a meal instead of on an empty stomach, and inaccurate MAR documentation for a held blood pressure medication. Staff failed to follow standard practices, manufacturer instructions, and facility policies during medication administration and documentation.
Surveyors found that medications were improperly labeled and stored, with discontinued and unlabeled drugs kept in active storage areas, hazardous medication spills present in a medication cart, and sticky residues in pre-pour bins. Supplies and discontinued medications were stored under sinks, and medication refrigerators were not maintained within the required temperature range. Staff interviews revealed uncertainty about proper procedures, and facility policies were not consistently followed.
A resident with schizophrenia and anxiety was transferred to an acute care hospital for stabilization but was not permitted to return to the LTC facility. Despite being stable for discharge, the facility refused readmission, did not provide required bed-hold or discharge notices, and failed to re-evaluate the resident's return. The resident remained at the hospital for five days, awaiting placement elsewhere.
The facility failed to provide dental services for two residents, resulting in unmet dental needs and potential health complications. One resident had not seen a dentist since admission despite having missing teeth and cavities, while another resident waited seven months for recommended dental treatment.
A CNA failed to ensure a resident's dignity and safety by standing over her while assisting with a meal, contrary to the facility's policy and the resident's care plan, which required close supervision due to dementia, a left-hand contracture, and schizophrenia.
A facility failed to ensure a resident's call light was accessible, as it was found on the floor and not within reach. The resident, who had ataxia and a high fall risk, was dependent on staff for basic care. Staff acknowledged that the call light should have been accessible at all times, and the facility's policy was not followed.
A facility failed to document an evaluation or assessment for a resident's use of a lap buddy after multiple falls. The resident was observed with the lap buddy secured, and staff confirmed its use without proper medical documentation or periodic assessments, leading to a deficiency in ensuring the resident was free from physical restraints without proper evaluation.
A resident admitted with dental issues did not receive timely dental care due to inaccurate MDS assessment documentation. The resident reported missing and broken teeth, but the facility failed to arrange a dental consultation, leading to potential health complications.
The facility failed to provide necessary oral hygiene supplies and care to a resident, resulting in poor oral hygiene and potential health complications. Despite claims of refusal, there was no documentation to support this, and the resident's personal hygiene basket was missing.
The facility failed to ensure that two residents were free from potential accidents and injury. One resident's fall mat was not laid out as per the care plan, and another resident's bed side rails were found in an unsafe position, creating a tripping hazard. The facility's policies and procedures for safety were not followed.
The facility failed to protect a resident from physical abuse by another resident, resulting in emotional distress and a physical injury. The incident occurred when one resident, with a history of assaultive behavior, punched another resident in the nose during an altercation in their shared bathroom. Staff intervened and moved the aggressive resident to a different room.
Failure to Prevent Resident-to-Resident Physical Abuse and Protect Personal Space
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse and to prevent resident-to-resident altercations. One incident occurred between two roommates with schizophrenia and other psychiatric diagnoses. One resident, who had a documented history of assaultive behavior, delusions, paranoia, hallucinations, and inappropriate sexual behavior, had previously kicked a roommate and was placed on every 15-minute checks during morning and evening shifts and line-of-sight monitoring on nights. According to the record and Licensed Nurse (LN) 1, these enhanced observations were discontinued on 9/1/25. Approximately five days later, this resident struck his roommate on the head with a belt after a disagreement about the television volume, causing a skin tear to the top of the roommate’s head. The roommate then kicked him in response. The Administrator acknowledged that at the time of this altercation, neither every 15-minute checks nor line-of-sight monitoring was in place. A second incident involved two residents with schizoaffective disorder, one of whom also had parkinsonism and presbyopia. The resident with parkinsonism shared a room and bathroom with two roommates and did not want anyone other than her roommates using that bathroom. On the day of the incident, staff heard her screaming and found her on her left side near the bathroom door with swelling and discoloration to her left upper eyebrow; she later reported that another resident, who was not her roommate, had entered her room, used her bathroom without permission, hit her in the face, and caused her to fall. The aggressor resident stated that her own bathroom was full, so she went to the other bathroom, and when the first resident raised a closed fist, she hit her first with a closed fist to the face, causing the fall and sustaining discoloration and swelling to her own right middle finger. Staff interviews and facility policies further clarified the context of these events. LN 1 confirmed the first resident’s history of assaultive behavior and the prior use of frequent checks and line-of-sight monitoring to manage his aggression, as well as the fact that these checks had been discontinued shortly before the belt-hitting incident. Certified Nurse Assistant (CNA) 1 stated that residents whose own bathrooms were occupied should be assisted to use the shower room toilet, and CNA 2 stated that residents’ rooms and bathrooms were considered their personal space. The Administrator stated that staff were expected to ensure resident safety, to use line-of-sight monitoring to prevent altercations when needed, and to knock and obtain permission before entering a resident’s room. The Administrator acknowledged that the lack of monitoring for the first resident and the unsupervised entry of the second aggressor resident into another resident’s room and bathroom without permission placed residents at risk for physical harm, contrary to facility policies on abuse prevention, resident rights, and management/prevention of assaultive behavior.
Failure to Implement Care-Planned Psychosocial Follow-Up After Resident Assault
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement a care-planned psychosocial intervention following a resident-on-resident assault. Resident 3, who had diagnoses including schizoaffective disorder, parkinsonism, and presbyopia, was admitted to the facility and on 9/3/25 was found on the floor near her bathroom after screaming was heard. She reported that another resident entered her room, pulled her off the toilet, hit her, and pushed her down, resulting in swelling and discoloration to her left eyebrow and left side of her lip. A progress note on 9/3/25 documented that the Social Services Designee (SSD) followed up that day and wrote that Resident 3 would be monitored once a week for 90 days to observe for any psychosocial decline. The resident’s care plan, initiated on 9/3/25 under “WELLNESS CONSIDERATION,” identified that the resident had been hit in the face by a peer and included an intervention directing Social Services to follow up with the resident once weekly for 90 days to observe for signs and symptoms of psychosocial decline. Review of progress notes from 9/3/25 through 12/2/25 with a licensed nurse showed no documented weekly follow-up by Social Services, and the licensed nurse confirmed the care-planned intervention was not implemented. During an interview, Resident 3 stated she remained scared of the other resident who had assaulted her. The SSD acknowledged that Social Services failed to continue follow-up after the assault, and the Lead Social Services staff and DON stated that it was expected practice and policy for Social Services to meet with residents involved in altercations and provide psychosocial support. Facility policies on abuse, management/prevention of assaultive behavior, and care planning all indicated that Social Services staff are responsible for providing psychosocial care and support, meeting with involved residents, and addressing mental and psychosocial needs through the care plan.
Failure to Prevent Resident-to-Resident Physical Abuse During 1:1 Supervision
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident with a known history of intrusive, assaultive, and socially inappropriate behaviors. Resident 1 was admitted with schizoaffective disorder bipolar type, cataract, presbyopia, and anemia. Resident 2 was admitted with schizoaffective disorder bipolar type, violent behavior, and mild neurocognitive disorder with behavioral disturbance. Resident 2 had documented care plans for intrusive behavior, assaultive behavior, combative behavior, and socially inappropriate behavior, including a history of pacing, entering other residents’ rooms, becoming aggressive with redirection, and attempting to strike staff during oral medication administration. On the night of the incident, Resident 2 was on 1:1 supervision due to sexually and socially inappropriate behavior. CNA 1, who was assigned to provide 1:1 supervision, reported that Resident 2 was restless, agitated, pacing, and repeatedly leaving the room, and described these behaviors as acting weird. CNA 1 attempted redirection, advised Resident 2 to calm down, and encouraged Resident 2 to go back to sleep, but these nonpharmacological interventions were ineffective. CNA 1 stated she asked the nurse to give medication to help with Resident 2’s behavior, but Resident 2 initially refused. Despite ongoing uncontrolled behaviors that did not respond to redirection, medication to manage behavior was not successfully administered before the incident. At approximately 4 AM, Resident 2 used the bathroom and, upon exiting, walked toward Resident 1’s bed. Resident 2 approached the head of Resident 1’s bed, where Resident 1 was sleeping, and smeared feces on Resident 1’s face. The CNA yelled for help, and nursing staff responded. Progress notes and MAR review confirmed that Ativan by mouth was offered and refused, and Ativan by injection was administered to Resident 2 only after the incident. Multiple licensed nurses and the DON stated that 1:1 supervision required staff to remain within arm’s length or very close proximity to the resident, closely monitor for escalating behaviors, and intervene to prevent the resident from entering another resident’s personal space, and that when nonpharmacological interventions were ineffective, prescribed PRN medication should be administered promptly to prevent escalation. The facility’s policies on management/prevention of assaultive behavior and elder and dependent adult abuse stated that residents have the right to be free from physical abuse and that PRN medication may be offered when nonpharmacological interventions are ineffective, but Resident 1 nonetheless experienced unwanted physical contact with feces from Resident 2. The physical layout of the room placed Resident 1’s bed (Bed C) near the window and bathroom, with the head of the bed against the wall and the foot of the bed visible from the bathroom exit. Resident 2’s bed was in the middle (Bed B). On the date of the incident, Resident 2 had also been reported to have left paper towels with feces at the nurse’s station on two occasions and had previously sprayed CNAs with a shower hose. Staff interviews confirmed that Resident 2’s behaviors were escalating and that 1:1 supervision was in place for safety and behavior concerns. Despite this, Resident 2 was able to exit the bathroom, cross into Resident 1’s personal space, and smear feces on Resident 1’s face while Resident 1 slept, constituting physical abuse by another resident and a failure to protect Resident 1 from abuse as required by facility policy and regulation. Staff, including LN 1, LN 2, LN 3, and LN 4, acknowledged that Resident 2’s history of intrusive, anxious, pacing, aggressive, assaultive, and combative behaviors placed Resident 2 at risk for resident-to-resident altercations and that delays in administering ordered behavior-management medications could allow behaviors to escalate and increase safety risks. They also stated that 1:1 supervision required close proximity, continuous observation, and prevention of entry into other residents’ personal space. Nonetheless, during the period of escalating restlessness and agitation, Resident 2’s behavior was not effectively controlled, and the required level of supervision and timely pharmacologic intervention was not achieved before Resident 2 smeared feces on Resident 1’s face. This sequence of events led to the deficiency for failure to protect a resident from physical abuse by another resident. The facility’s Elder and Dependent Adult Abuse/Suspicion of a Crime policy stated that every resident has the right to be free from physical abuse with resulting physical harm, pain, or mental suffering, and that residents must not be subjected to abuse by anyone, including other residents. The Management/Prevention of Assaultive Behavior policy stated that when licensed staff assess that an individual is not responding to nonpharmacological interventions, PRN medication may be offered per physician order. Despite these policies and the known behavioral history and active 1:1 supervision status of Resident 2, the facility did not prevent Resident 2 from entering Resident 1’s personal space and smearing feces on Resident 1’s face while Resident 1 was sleeping, resulting in the cited deficiency for failure to protect residents from abuse.
Failure to Develop and Implement Care Plan for Resident's Fear of Falling and Refusal to Walk
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan addressing a resident's fear of falling and subsequent refusal to walk following multiple unwitnessed falls. The resident, who had a documented self-care performance deficit and was at risk for falls, experienced several unwitnessed falls in the bathroom and near her bed. Despite a physical therapy consult indicating the resident was unsafe to ambulate independently and required staff assistance at all times, documentation showed a decline in the resident's walking activity over several months. Staff provided some encouragement and supervision, but the resident continued to refuse to walk due to fear of falling. Interviews with facility staff, including a CNA and the DON, confirmed that the resident's fear of falling and refusal to walk were not addressed in the care plan. The Director of Staff Development also stated that such refusals and fears should be communicated and incorporated into the care plan to guide staff interventions. Review of the facility's care planning policy indicated that care plans should include measurable objectives, timeframes, and address resident refusals and psychosocial needs, but these elements were missing in this case.
Failure to Maintain Resident Ambulation Due to Inadequate Documentation and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained the ability to perform activities of daily living, specifically ambulation, without a documented medical reason for decline. Staff did not consistently document attempts to walk the resident or record refusals, and there was a lack of consistent supervision during ambulation as recommended by physical therapy. The care plan did not address the resident's fear of falling, despite this being identified as a barrier to participation in walking activities. The resident had a history of falls and was previously able to ambulate independently for short distances, as documented in the Minimum Data Set (MDS). Over time, the resident's ability to walk declined, and she began using a wheelchair. Interviews with staff revealed that the resident stopped walking due to fear of falling, and staff confirmed that there was no walker in her room. Documentation showed sporadic and inconsistent ambulation attempts, with staff sometimes providing assistance but not always following the recommended supervision or documenting refusals. The physical therapist noted that the resident was too fearful to participate in walking during evaluation and recommended psychiatric assessment before starting a rehabilitation program. However, the psychiatric evaluation did not address the resident's fear of falling, and the care plan was not updated to include interventions for this issue. Facility policies required documentation of ambulation and assistance as needed, but these were not consistently followed, contributing to the resident's decline in mobility.
Multiple Food Safety and Sanitation Deficiencies Identified in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards, as evidenced by multiple observations during a kitchen tour and interviews with dietary staff. Mold was found on red onions in the walk-in refrigerator, and other onions were cracked, bruised, and discolored. The Dietary Assistant Supervisor confirmed that storing molded food with non-molded food was unacceptable. Additionally, several food items in the kitchen and refrigerator lacked proper labeling, open dates, or expiration dates, and some labels were incomplete or missing the year. The Registered Dietician and Dietary Supervisor both stated that proper dating is necessary to ensure food safety and prevent the use of expired items. Further deficiencies were observed in the storage and maintenance of kitchen equipment and utensils. The walk-in freezer had significant ice buildup, preventing the door from closing and latching properly, which the Plant Maintenance Supervisor attributed to faulty hinges. Clean kitchen items were stacked while still wet, and a dirty plate was placed among clean dishes, which staff acknowledged could lead to bacterial growth. The fixed can opener was found with food particles, missing metal, and visible metal shavings, raising concerns about food contamination. Additionally, coffee mugs and pitchers were stained and deglazed, and cutting boards had deep grooves, all of which were confirmed by the Dietary Supervisor as not meeting expectations for cleanliness and safety. Plumbing issues were also identified, with the ice machine and fruit/vegetable preparation sink lacking required air gaps to prevent backflow contamination. Both the Plant Maintenance Supervisor and Plant Maintenance Assistant were unaware of the air gap requirement and confirmed the improper plumbing setup. These findings were supported by references to the facility's policies and the US FDA Food Code, which outline standards for food storage, equipment maintenance, and plumbing to ensure food safety for residents.
Failure to Document and Honor Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that four residents had their rights related to treatment choices, advance directives, and code status properly documented and protected. For one resident, the signed Advance Directive was not found in the chart, despite documentation in the EHR that the resident had been given copies and had signed the forms. The Social Services staff and Unit Clerk were unable to locate the paperwork in either the current or archived charts, and the resident herself was unsure if she had an Advance Directive in place. The Director of Nursing confirmed that the documentation should have been present in the chart as per facility policy. Another resident expressed a desire to formulate an Advance Directive, and the Social Services note indicated that the conservator was contacted. However, there was no follow-up documentation or acknowledgement form found in the chart, and the resident did not recall being offered the Advance Directive. The Social Services staff and Director of Medical Records both verified that the documentation was missing and should have been included in the resident's record. A third resident's chart did not contain documentation regarding an Advance Directive discussion, and the resident had refused the initial assessment due to anxiety. The Social Services staff acknowledged that no follow-up or documentation was completed. For a fourth resident, neither the electronic health record nor the physical chart contained documentation of the resident's code status, and staff relied on the color of the chart label to determine code status in the absence of formal documentation. The Director of Nursing and other staff confirmed that the code status should have been clearly documented in both the EHR and physical chart.
Failure to Maintain Adequate Nutrition and Timely Meal Replacement for Two Residents
Penalty
Summary
The facility failed to maintain adequate nutritional status for two residents. For one resident with a history of poor intake, meal refusals, and food pocketing, there was an 8-pound (5.8%) weight loss over one month. Despite the resident's ongoing issues with swallowing and refusal of pureed foods, no referral was made to a speech therapist, and interventions were limited to offering supplemental nutrition drinks, an appetite stimulant, and a pureed diet. Observations showed that the resident continued to refuse meals and consumed only a partial amount of a supplemental drink, resulting in insufficient caloric and protein intake. The resident's medical record indicated diagnoses including hypothyroidism, anxiety, depression, pain, and recent pneumonia. Nursing notes documented persistent meal refusals, pocketing, and spitting out food, with the resident expressing dislike for pureed foods. The Registered Dietitian had recommended an appetite stimulant and supplemental nutrition, but no further assessment or intervention for swallowing difficulties was initiated, as the facility lacked a therapy department and no physician order for a speech therapy consult was made. For another resident with diabetes, staff failed to offer a replacement lunch meal in a timely manner after the resident refused to eat and spilled her lunch tray during a behavioral episode. Although facility policy required staff to offer meal replacements at least twice following a refusal, the resident was only asked once and then not again. The DON confirmed that the resident should have been offered a replacement meal at least twice, but this did not occur, resulting in the resident not receiving adequate nutrition during that meal period.
Failure to Provide Adequate Vegetarian Diets
Penalty
Summary
The facility failed to provide a vegetarian menu for four residents who had physician orders or documented preferences for vegetarian diets. Observations and interviews revealed that the facility did not offer a dedicated vegetarian menu and instead substituted fruit and cottage cheese plates for residents avoiding animal products. Review of meal tickets and medical records confirmed that these residents had ongoing orders or preferences for vegetarian diets, some dating back several months or years. During multiple meal observations, residents on vegetarian diets were served meals that lacked adequate protein and calories compared to the regular menu, with one resident receiving only pureed vegetables and another receiving only fruit, cottage cheese, crackers, and a cookie bar. Staff interviews indicated a lack of understanding and implementation of vegetarian diet requirements, with dietary staff and CNAs confirming that fruit and cottage cheese were routinely substituted for main entrees containing meat. The Registered Dietitian acknowledged that these substitutions did not meet the nutritional needs provided by the regular menu and noted that a vegetarian option was available through the menu company but was not being utilized. Facility policy documents and state law require the provision of balanced vegetarian or plant-based meals, but these were not being followed, resulting in residents receiving nutritionally inadequate meals.
Infection Control Failures in Utility Rooms, Medication Handling, and Kitchen Ventilation
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices in several key areas. In three utility rooms, clean supplies such as gloves, N95 masks, blood pressure apparatus, wound care supplies, and residents' personal items were stored in close proximity to hoppers used for disposal of blood or body fluids, without any clear separation between clean and dirty areas. The Infection Preventionist confirmed that this arrangement could lead to contamination of clean supplies, which could then be used for resident care. During medication administration, a nurse was observed bringing a bucket containing clean supplies for insulin administration and blood glucose testing into a resident's room. After use, the bucket was returned to the medication cart without any cleaning or sanitizing, despite being used in multiple resident rooms. Both nursing staff and the Director of Nursing acknowledged that this practice could result in contamination of supplies shared among residents. Additionally, the medication cart was found to have brownish residues and sticky spills in the pre-pour medication bins, and a pill cutter stored in the cart had white powder-like residue inside the lid, both of which were not cleaned after use. In the kitchen, three ceiling vent covers above food preparation areas were observed to have rust, flaking, peeling, and missing paint, with visible dust and debris. The Plant Maintenance Supervisor and Dietary Supervisor confirmed these conditions and acknowledged that the vents were not maintained in a manner that would prevent contamination of food. The facility's own policies and federal guidelines require that such areas be kept clean and in good repair to prevent the risk of contamination.
Lack of Drug Information Resources for Nursing Staff
Penalty
Summary
The facility failed to provide drug information resources, such as a drug reference book or online access, for nursing staff to consult when administering medications. During interviews and record reviews, multiple nursing staff members, including a licensed nurse, a licensed psychiatric technician, and a registered nurse supervisor, confirmed that they did not have access to drug information resources in the medication cart, medication room, or via the internet. One nurse was unaware of the specific administration instructions for Linzess, a medication used to treat complicated constipation, and did not know it should be given on an empty stomach 30 minutes before meals. Staff also indicated that the Medication Administration Record (MAR) did not provide this information. The Director of Nursing confirmed that the facility did not have printed or online drug resources available for nursing staff. Review of the facility's policy on medication reference sources indicated that such resources should be maintained and accessible at each nursing station, but this was not being followed at the time of the survey.
Inaccurate Fall Risk Assessments for Resident with Seizure History
Penalty
Summary
The facility failed to ensure that a resident with a history of convulsions received accurate post-fall and comprehensive fall risk assessments. Multiple fall risk assessments for the resident incorrectly indicated that there were no predisposing factors such as seizures, despite the resident's admission record documenting a history of seizures and ongoing use of antiseizure medication (Keppra). Additionally, the assessments did not accurately reflect the resident's medication regimen, which included both antiseizure and psychotropic medications. These inaccuracies were confirmed by a licensed nurse during a review of the resident's clinical record. The Director of Nursing acknowledged that the fall risk assessments were not completed accurately and emphasized the importance of these assessments in determining fall risk and developing appropriate interventions. The facility's policy requires that fall risk assessments be completed upon admission and that relevant findings and interventions be documented and updated in the care plan. The failure to accurately complete these assessments potentially resulted in a subsequent fall for the resident 14 days later, as the resident's fall risk was not properly identified or addressed.
Failure to Provide Adequate Pain Management and Develop a Person-Centered Pain Care Plan
Penalty
Summary
A resident with a history of chronic embolism and thrombosis of the lower extremities experienced ongoing pain, fluctuating between 5 and 8 out of 10 on the pain scale, primarily in the bilateral anterior thigh radiating to the lower extremities. The resident reported that the prescribed pain medication, acetaminophen, was not effective in relieving the pain, which impacted daily activities and participation in group and social events. Staff interviews confirmed that the resident frequently requested pain medication, particularly in the mornings, and that the frequency of PRN acetaminophen administration had increased significantly from 4 doses in February to 28 doses in April. Record reviews and staff interviews revealed that despite the increased use of PRN pain medication and the resident's ongoing complaints of pain, there was no evidence that the effectiveness of the pain management regimen was evaluated or that the physician was notified about the lack of pain control, as required by facility policy. Both the licensed nurse and the DON acknowledged that the increase in PRN medication indicated ineffective pain management, and that the physician should have been notified to consider alternative or routine pain management strategies. The facility's pain management policy specifically required physician notification and reassessment when pain control was inadequate. Additionally, the resident did not have a comprehensive, person-centered care plan addressing pain management, despite being prescribed pain medication and having active pain symptoms. Staff confirmed that the absence of a care plan for pain meant that measures to manage the resident's pain and discomfort were not identified or implemented. The DON acknowledged that this failure was not in accordance with facility policy, which required individualized care plans for residents experiencing pain, including specific interventions and measurable objectives.
Failure to Reassess Long-Term Medication and Lack of Safe Monitoring Parameters for Diabetic Medications
Penalty
Summary
The facility failed to ensure safe medication use practices for three residents by not reassessing the continued need for long-term medication and by not providing clear monitoring parameters for diabetic medications. One resident had been receiving Protonix, a proton pump inhibitor (PPI), daily for several years to treat GERD, but there was no documented reassessment of the ongoing need for this medication. The resident's care plan and physician progress notes did not address the continued use of Protonix, and the consultant pharmacist did not make recommendations regarding the long-term use despite being aware of FDA warnings about risks associated with prolonged PPI use. The physician stated he was not prompted to review the medication and acknowledged there were no active issues requiring its continuation. Two other residents were receiving multiple medications for diabetes, including insulin, but their medication orders lacked specific parameters for nursing staff to follow in response to abnormal blood sugar readings. Orders included instructions for blood sugar monitoring and the use of a reversal agent for hypoglycemia, but did not specify what constituted high or low blood sugar levels that would require intervention before the resident became unresponsive. The consultant pharmacist did not identify the lack of parameters, and the DON agreed that having such parameters would be a safe practice, especially given the use of other medications that could affect blood sugar levels. During medication administration observations, it was noted that nurses administered insulin without clear guidance on when to hold the medication or notify a physician based on blood sugar results. The facility's policy referenced notifying a physician for abnormal blood sugar results, but the actual orders for these residents did not provide the necessary parameters. Both the physician and nursing staff acknowledged the absence of these safety measures and indicated that parameters would be beneficial for safe medication administration.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 9%, which exceeds the acceptable threshold of 5%. During medication administration observations, three errors were identified out of 32 opportunities. These errors involved three residents and included improper administration techniques, failure to follow manufacturer instructions, and inaccurate documentation in the Medication Administration Record (MAR). One resident received ophthalmic medication, but immediately after administration, used a tissue to squeeze and wipe the eyes, contrary to standard practice. The staff member present acknowledged that the resident should not have wiped the eye drops from the eyes in this manner. Another resident was administered Linzess, a medication intended to be given on an empty stomach, after breakfast. The nurse administering the medication was unaware of the specific administration requirements, and the MAR did not include instructions to give the medication before meals or on an empty stomach. A third resident had a blood pressure medication, metoprolol, held due to low systolic blood pressure as per physician orders. However, the MAR was inaccurately documented, indicating the medication was given when it was actually held. The nurse confirmed that there was no documentation to reflect that the medication was withheld, and the Director of Nursing agreed that the documentation should have accurately indicated when a medication was held. Facility policies reviewed required proper administration techniques, adherence to manufacturer instructions, and accurate documentation when medications are held.
Deficient Medication Storage, Labeling, and Temperature Control
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices across several medication rooms and carts. Unlabeled and discontinued medications, including Linzess and Gavilyte-G, were found stored in active medication storage areas in two medication rooms. Some medication bottles lacked full pharmacy labels, displaying only small labels on the caps, and staff were unable to explain the absence of proper labeling. Discontinued or one-time use medications were not removed from active storage, contrary to facility expectations, and staff interviews confirmed uncertainty about proper storage procedures. In one medication cart, a hazardous liquid medication, Valproic Acid, was found with visible spills on the outer surface of the bottle. Staff acknowledged that while gloves are typically used to administer this medication, there was a risk of inadvertent skin contact when searching for other medications in the cart. Additionally, another medication cart contained pre-pour medication bins with sticky, brownish spills and broken sections, and staff were unsure of the origin of the residue or the last time the bins were cleaned or replaced. Further deficiencies were observed in the storage of supplies and discontinued medications under sinks in two medication rooms, where staff could not provide a rationale for this practice. Medication refrigerators were also found to be outside the recommended temperature range, with one refrigerator above and another below the accepted range. Staff interviews confirmed awareness that improper storage temperatures could affect medication efficacy, and facility policies required medications to be stored at appropriate temperatures and for discontinued or expired medications to be separated and destroyed or returned according to guidelines.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after being transferred to an acute care hospital for stabilization. The resident, who had been at the facility for nearly nine months, was diagnosed with schizophrenia and an anxiety disorder. On the day of the incident, the resident exhibited aggression and was administered lorazepam intramuscularly. Subsequently, the resident was transferred to an acute care hospital, where she was deemed stable for discharge. However, the facility refused to readmit her, resulting in the resident remaining at the hospital for five days. The facility did not provide the resident or her conservator with a 7-day bed hold notice or a 30-day discharge or transfer notice, as required by their policy. Interviews with the Director of Nursing (DON) and the Social Services Designee (SSD) revealed that the facility did not anticipate the resident's return and had not communicated the necessary notices. Despite having 12 empty beds, the facility did not re-evaluate the resident's ability to return, nor did they maintain adequate communication with the acute care hospital. The facility's policy on bed-hold and return to the facility, as well as their transfer and discharge notice policy, were not followed. The resident's conservator confirmed that the resident remained at the acute care hospital awaiting placement at another facility. The failure to adhere to these policies resulted in the resident being held at the hospital without proper notice or evaluation for return to the facility.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to ensure residents received dental services for two residents, Resident 166 and Resident 75. Resident 166 was admitted to the facility in September 2023 with multiple diagnoses, including disturbances of salivary secretions. Despite having missing teeth, cavities, and a loose tooth, Resident 166 had not been seen by a dentist since admission. Multiple staff members, including CNAs and LNs, confirmed the poor condition of Resident 166's teeth and the lack of dental records in his chart. The facility's process for scheduling dental appointments was not followed, and there was no record of any attempts to obtain dental services for Resident 166 within the first 90 days of admission, as required by the facility's policy. The DON and other staff members acknowledged the oversight and the potential health complications that could arise from not receiving timely dental care. Resident 75 also did not receive timely dental services. Despite having a dental care plan initiated in May 2015 and a dental note from September 2023 indicating the need for further dental treatment, Resident 75 had not seen a dentist for seven months. The Consultant Coordinator confirmed that the company performing dental care visited the facility monthly, but Resident 75's recommended dental treatment had not been scheduled. During an interview, Resident 75 reported tooth pain, and the facility's policy on dental services, which required licensed nursing staff to notify social services of a resident's need for dental services, was not followed. The facility's failure to provide dental services for Resident 166 and Resident 75 resulted in both residents not obtaining necessary dental care. This lack of action had the potential to cause health complications, including pain, infection, and difficulty eating. The facility's processes for scheduling and tracking dental appointments were not adequately followed, leading to these deficiencies in care.
Failure to Ensure Resident Dignity and Safety During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when a CNA stood over the resident while assisting her with her lunch meal. During an observation and interview, the CNA admitted that she should have been sitting next to the resident to properly assist her with eating and to monitor for any potential choking hazards. The CNA acknowledged that she had forgotten to follow the correct procedure. The resident's care plan indicated that she required assistance with meals due to dementia, a left-hand contracture, and schizophrenia, which necessitated close supervision during meals. The Assistant Director of Staff and Development confirmed that staff should sit next to residents while assisting them with meals to ensure safety and create a home-like environment. A review of the facility's dining program policy also indicated that staff should sit while feeding residents and observe them for safety issues and functional difficulties. The policy emphasized the importance of creating a positive dining experience by smiling and providing words of encouragement to promote and increase food intake.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's needs were met when the call light was found on the floor and not within reach. This deficiency was observed during a concurrent observation and interview with a CNA, who acknowledged that the call light was not accessible to the resident. The resident, identified as having ataxia and a high fall risk, was dependent on staff for basic care and required the use of a wheelchair. The resident's clinical records indicated a high fall risk due to factors such as low blood pressure, unstable gait, and the use of medications that increased the risk for falls. The resident's care plan included interventions to anticipate and meet the resident's needs and encourage the use of the call light if assistance was needed. Further interviews with LN 1 and LN 2 confirmed that the call light should have been accessible to the resident at all times. The Director of Nursing and the Administrator both acknowledged that the facility's policy and procedure regarding call lights, which required the call light to be within reach of the resident upon leaving the room, was not followed. The failure to adhere to this policy could have resulted in the resident being unable to alert staff in case of an emergency or if assistance was needed.
Failure to Document Evaluation for Use of Lap Buddy
Penalty
Summary
The facility failed to ensure an evaluation or assessment was documented in the medical record for a resident when the use of a lap buddy was initiated after multiple falls. The resident was observed multiple times with the lap buddy secured across her lap, and staff confirmed its use every time she was in her wheelchair. The resident indicated that staff would secure the lap buddy back in place if she tried to remove it. Despite the use of the lap buddy, there was no documented initial evaluation or periodic assessments for its continued use in the resident's medical record. The resident's care plan and interdisciplinary team (IDT) notes indicated a history of falls and the use of the lap buddy for safety, but lacked documented evaluations or assessments for its use. Interviews with staff confirmed the absence of a medical diagnosis from a physician for the lap buddy and the lack of documented assessments. The facility's policy required regular nursing assessments, but these were not conducted for the lap buddy, leading to the deficiency in ensuring the resident was free from the use of physical restraints without proper medical evaluation and documentation.
Failure to Ensure Accurate Dental Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's dental condition, leading to a delay in dental care services. Resident 166, admitted in September 2023 with multiple diagnoses including disturbances of salivary secretions, reported not being seen by a dentist while in the facility. Observations revealed that Resident 166 had two missing teeth, a black and broken tooth, and a loose tooth, which he had informed the staff about, but no action was taken. The resident's admission note indicated missing teeth and cavities, but there was no record of a dental consultation being arranged within the first 90 days of admission. The MDS assessment for Resident 166 did not accurately reflect his dental condition, as it failed to document cavities or broken teeth. The MDS nurse confirmed that the assessment was inaccurate and acknowledged that proper documentation would have led to a referral for dental services. The inaccurate assessment resulted in Resident 166 not receiving necessary dental care, which could affect his ability to chew food and potentially lead to further dental issues. The Director of Nursing (DON) stated that nurses are expected to assess residents' dental health upon admission and refer them for dental consultations if needed. The DON emphasized the importance of accurate assessments for creating appropriate care plans. The facility's policy on the Minimum Data Set (MDS) requires comprehensive assessments, including dental status, to be completed accurately to ensure residents receive the necessary care. The failure to accurately assess and document Resident 166's dental condition led to a lack of timely dental care, which could result in health complications.
Failure to Provide Oral Hygiene Supplies and Care
Penalty
Summary
The facility failed to ensure necessary care and services were provided to Resident 166, who did not have oral hygiene supplies and did not receive oral hygiene from staff. Resident 166, admitted in September 2023 with multiple diagnoses including disturbances of salivary secretions, was observed to have poor oral hygiene, including missing and broken teeth, and buildup on his teeth. The resident reported difficulty chewing food and indicated that his teeth were not being properly cared for by the staff. Certified Nursing Assistants (CNAs) verified that Resident 166's teeth were in poor condition and needed cleaning. They also confirmed that the resident did not have a personal hygiene basket with oral care supplies in the utility room, which was supposed to be provided. Despite claims that the resident refused to brush his teeth, there was no documentation in the behavior monitoring log to support this. The CNAs admitted that they might have documented the oral hygiene tasks incorrectly in the electronic record. The Director of Nursing (DON) stated that staff were expected to provide oral hygiene to residents twice a day and document any refusals of care. The DON confirmed that residents' oral hygiene supplies were kept in labeled baskets in the utility room to prevent infection control issues. The facility's policy on oral care indicated that residents should receive adequate oral care to maintain dignity, comfort, and oral hygiene, which was not adhered to in the case of Resident 166.
Failure to Prevent Potential Accidents and Injuries
Penalty
Summary
The facility failed to ensure that two residents were free from potential accidents and injury. Resident 75 was observed lying in bed without the fall mat laid out on the floor as per the care plan. The fall mat was found folded up and positioned next to the nightstand. Licensed Nurse 4 confirmed that the fall mat was not implemented, which posed a risk of falls and injury. Resident 75's care plan indicated a high risk for falls due to various medical conditions and a history of multiple falls. The fall mat was added as an intervention to prevent injury from falls, but it was not in place during the observation. Resident 141's bed side rails were found in an unsafe position, with the right-side rail angled away from the bed and touching the floor. This positioning created a tripping hazard. Certified Nursing Assistant 1 and Licensed Nurse 1 both confirmed the unsafe positioning of the side rail and acknowledged the risk it posed for Resident 141, who had a high fall risk due to ataxia and other medical conditions. The Maintenance Director was not informed of the issue, and the Director of Nursing acknowledged that the facility's policies and procedures for side rails and safety were not followed. The facility's policies and procedures required regular checks for bed rail safety and prompt reporting of any environmental concerns. However, these protocols were not adhered to, leading to the unsafe conditions observed for both residents. The Administrator also confirmed that the policies were not followed, acknowledging the risk for injury due to the improper positioning of the bed side rail for Resident 141.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical abuse by Resident 2, resulting in Resident 1 experiencing emotional distress and a physical injury. Resident 1, diagnosed with schizoaffective disorder, bipolar type, was punched in the nose by Resident 2, who has dementia with psychotic disturbance, during an altercation in their shared bathroom. The incident occurred when Resident 1 demanded that Resident 2 get off the toilet, leading to Resident 2 becoming upset and punching Resident 1, causing a nosebleed. Staff intervened, applied an ice pack to Resident 1's nose, and moved Resident 2 to a different room for safety. Resident 2 had a documented history of assaultive behavior, including previous incidents of yelling at others and spitting in a staff member's face. Despite this history, the facility did not adequately prevent the altercation between the two residents. The facility's policy on elder and dependent adult abuse emphasizes the right of residents to be free from physical abuse, yet this incident demonstrates a failure to uphold that policy. Interviews with staff and residents confirmed the details of the altercation and the emotional impact on Resident 1.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 505 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookside Care Center | 0.1 mi | ★★★★★ | 22 | 0 |
| Oak Grove Post Acute | 1.1 mi | ★★★★★ | 61 | 0 |
| Fulton Gardens Post Acute, Llc | 1.7 mi | ★★★★★ | 20 | 0 |
| Delta Oaks Post Acute | 1.7 mi | ★★★★★ | 34 | 0 |
| Noble Care Center | 1.8 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.