Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Rock Creek Care Center during CMS and state inspections, most recent first.
A resident with a history of stroke sequelae and anxiety, and mild memory impairment, was transferred by non-emergent transport to a hospital ED for reported behavioral symptoms without accompanying paperwork, prior physician or family notification, or a documented assessment supporting the need for transfer. Hospital case management documented that the resident was calm, cooperative, and agreeable to return, yet the facility’s Admission Coordinator repeatedly refused readmission, citing rooming concerns, despite multiple open beds. The facility completed a discharge notice indicating the resident was not expected to return, but the notice and required information on appeal rights and bed-hold policy were not provided at the time of transfer, and the LTC Ombudsman was notified only later. The DON and ADON confirmed there was no documentation of a bed-hold offer, no transfer packet, no required transfer/discharge notices, and no assessment of the resident’s status and needs at the time of proposed return, contrary to the facility’s own transfer/discharge policy.
Improper Storage of Cookware and Utensils: Kitchen staff stored 2 steam table pans, 2 spatulas, and 1 whisk while still wet in the dry storage area, and 1 steam table lid, 1 gray scoop, and 1 green serving spoon were found with dried food debris in the ready-to-use storage area. The CDM confirmed the items were wet or soiled, and the RD stated that cookware and utensils must be fully cleaned and completely air dried before storage.
A resident with no cognitive impairment and care plan needs for mod A bathing was not provided a shower for a week despite repeated requests for help. Staff documented a shower that did not occur, and the CNA later admitted he charted the shower as completed without actually assisting the resident. The DON/ADON expectations were that residents be offered showers twice weekly to support hygiene and skin monitoring.
Insufficient room space per resident was identified in multiple rooms after review of facility records and direct observation. Double-occupancy rooms provided only 71.4-78.65 sq ft per resident and triple-occupancy rooms provided only 70.4-76.5 sq ft per resident, below the required minimum. Staff stated there was enough space to provide care, and several rooms were observed uncluttered with adequate room for personal effects, equipment movement, and bathroom access.
Surveyors found that kitchen and storage areas contained multiple expired and unlabeled food items, including cooked tomato sauce, raw meats, vegetables, and bread. The Dietary Services Supervisor and other staff confirmed these items were not properly labeled or discarded according to facility policy, and that some foods had been stored beyond recommended timeframes.
The facility failed to follow prescribed dietary menus, affecting residents on modified texture, NCS/CCHO, and 60g Protein Renal diets. Errors included incorrect bread and dessert items, and a lack of menu-specified vegetables and garnishes. The Dietary Supervisor and Registered Dietitian acknowledged these issues, citing kitchen errors and lack of communication with residents.
The facility failed to meet food safety standards, with issues including wet and dirty sheet pans, improperly stored and labeled food, an unclean ice machine, incorrect hot food cooling practices, and dietary aides lacking knowledge of dishwashing and sanitizer procedures. Additionally, the microwave for residents' food was found dirty.
The facility failed to ensure that two dietary aides were adequately trained in food safety procedures. The aides were unable to correctly verbalize the process of manual dishwashing and the correct concentration range for sanitizer solutions, as required by facility policy. This lack of knowledge was confirmed by the Dietary Supervisor and acknowledged by the Registered Dietitian, highlighting a deficiency in staff training and competency verification.
The facility failed to ensure call lights were within reach for two residents, both with severely impaired cognition and requiring assistance with daily activities. Observations showed that call lights were not accessible, despite care plans and facility policy indicating they should be. Staff confirmed the deficiency during interviews.
A resident admitted with diagnoses of adult failure to thrive and malnutrition was inaccurately assessed in their MDS, which failed to mark them as edentulous despite having no teeth. Observations and interviews confirmed the resident's edentulous status, and the MDS LVN admitted the error. The facility could not provide policies on assessment accuracy.
A CNA transferred a resident alone using a Hoyer lift, contrary to the facility's policy requiring two staff members for such transfers. The resident, who was non-weight bearing and required assistance from two or more staff for transfers, was at risk due to this action. The Director of Staff Development confirmed that two-person transfers are standard for safety.
A CNA failed to wear the required N95 mask when entering a COVID-19 positive resident's room, despite signage indicating droplet precautions. The resident was under isolation due to COVID-19, and the facility's policy required an N95 mask, which was not followed, leading to a deficiency in infection control.
The facility failed to provide the required 80 square feet per resident in 28 multiple-resident rooms, with space ranging from 70.47 to 78.93 square feet. While some residents reported no issues, one resident experienced difficulties with space when using a Hoyer lift, affecting care provision.
The facility failed to serve food at a palatable and safe temperature, affecting three residents who reported receiving cold meals. Incomplete temperature recordings and lack of a test tray temperature log were noted. The Dietary Manager was unaware of the need for temperature checks at the point of service, and the facility's policies for meal service and food transport were not effectively implemented.
A resident with osteoarthritis and muscle weakness was unable to reach her call light, as it was wrapped around the bed's side rail. Her roommate reported having to assist with the call light, and a CNA confirmed the inaccessibility. The facility's policy requires call lights to be within easy reach, which was not followed, potentially compromising the resident's safety.
A resident's surgical staples were not removed within the physician-ordered timeframe, leading to a deficiency in maintaining professional standards of quality. The staples, located on the resident's forehead, were ordered to be removed within 10-14 days but were removed late, increasing the risk of infection. Interviews with staff confirmed the oversight and the importance of adhering to physician orders.
A resident admitted with alcohol abuse did not receive chlordiazepoxide as ordered for three days, leading to uncomfortable symptoms during detoxification. The facility's Infection Preventionist confirmed the delay was unacceptable, and records showed the medication was awaiting pharmacy delivery.
The facility failed to maintain food service safety standards when dirty and uncleanable dishware was found in use and storage. Observations revealed mugs with residue in the dining room and unclean dishware in the kitchen. Staff acknowledged the need for cleanliness checks and disposal of unsanitary items, as per facility policy, to prevent potential food-borne illnesses.
Two residents in a facility did not receive the RNA program services as ordered, which were intended to maintain or improve their range of motion and strength. Despite being referred to the RNA program after completing physical therapy, documentation showed inconsistencies in the provision of services. The Director of Rehabilitation confirmed the referrals, and the Director of Nursing and Director of Staff Development were responsible for oversight. However, the RNA program was not implemented per physician's orders, with significant gaps in documented sessions, leading to potential declines in residents' range of motion and strength.
Failure to Provide Required Notices and Readmit a Hospitalized Resident After Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure an appropriate transfer and discharge for a resident and to provide required discharge notices and bed-hold information. The resident was admitted with sequelae of cerebral infarction and an anxiety disorder, had mild memory impairment, and no documented physical behavioral symptoms directed toward others on the MDS. The baseline care plan documented psychosocial goals related to recognition and management of depression, anxiety, fear, disability, pain, and limitations in daily living. On the morning following admission, the Social Services Director documented that the resident would be sent out for further evaluation. Shortly thereafter, a SNF-to-hospital transfer form indicated the resident was being transferred to the hospital for behavioral symptoms such as agitation and psychosis, with noted restlessness, irritability, verbal/combative behavior, and refusal of care. Nurse’s notes documented that the resident was transferred to the hospital ED for further evaluation and treatment. Case management documentation from the hospital later that evening indicated the resident arrived at the ED by non-emergent transportation without paperwork or notification of the direct transfer, and the facility’s Admission Coordinator reported the transfer was due to the resident being aggressive and combative. The case manager documented that the resident was agreeable to return to the facility, but the Admission Coordinator stated the facility was at capacity and could not place the resident in a single room, despite facility census records showing multiple empty beds on that date and subsequent days. Over the next several days, hospital case management notes documented repeated notifications to the facility that the resident was ready to return, while the facility refused readmission. The Admission Coordinator refused readmission, and a Notice of Proposed Transfer/Discharge was completed indicating the resident was discharged and not expected to return. The notice to the Long Term Care Ombudsman was faxed the day after the notice was dated, and the Ombudsman later stated the notice should have been provided at the time of transfer or discharge and that the facility should have accepted the resident back. The DON and ADON confirmed there was no documentation that the resident’s family, emergency contacts, or physician were contacted prior to the ER transfer, no documentation that a bed hold was offered, no transfer packet or required transfer/discharge notices were provided, and no assessment of the resident’s status and needs was completed at the time the resident was ready to return. The DON also acknowledged that the documentation in the record did not support the transfer to the ER and that the facility did not readmit the resident due to concerns over behaviors, contrary to the facility’s own transfer/discharge policy requirements for documentation, notice, and appeal rights. Additional interviews corroborated the lack of appropriate transfer documentation and notice. The hospital case manager stated the resident sat in the ED waiting room without paperwork or information from the facility regarding the reason for the direct transfer, and that the facility refused readmission because they were not comfortable with the resident returning to a three-person room. The transportation company manager reported that, unlike typical practice where facilities provide a transfer packet or paperwork for ER transfers or medical appointments, this facility did not provide any transfer documents or instructions for this resident. Review of the facility’s transfer/discharge policy showed that residents have the right to remain in the facility, that transfers and discharges must meet specific criteria, and that the facility must document the basis for transfer/discharge, provide appropriate notice, communicate necessary information to the receiving provider, and inform the resident of appeal rights and the bed-hold policy. These policy requirements were not met in this case, as confirmed by the DON, ADON, and documentary evidence.
Improper Storage of Cookware and Utensils
Penalty
Summary
The facility failed to store cookware pans and utensils in accordance with professional standards for food service safety. During a concurrent initial tour observation and interview in the kitchen with the Certified Dietary Manager, 2 steam table pans were found wet in the dry storage area, along with 2 spatulas and 1 whisk that were also wet while stored away. In the same area, 1 steam table lid was observed with dried food debris, and 1 gray scoop and 1 green serving spoon were found with dry food particles in the ready-to-use storage area. The Certified Dietary Manager confirmed that the 2 steam table pans, 2 spatulas, and 1 whisk were wet, and confirmed that the steam table lid, scoop, and serving spoon had dried food particles and were stored in the ready-to-use storage area. The CDM stated that the steam table pans, spatulas, and whisk must be fully dried before storage, and that the lid, scoop, and serving spoon must be fully cleaned without any food particles before being stored. The Registered Dietician stated that all cookware and utensils must be fully cleaned and completely air dried before storage. The facility policy titled Dishwashing stated that gross food particles shall be removed by careful scraping and pre-rinsing in running water, and that dishes are to be air dried in racks before stacking and storing.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
Facility staff failed to ensure ADLs were provided to Resident 82 when she did not receive a shower for a week. Resident 82 was a female admitted in January 2026 with diagnoses including radiculopathy, difficulty walking, and muscle weakness. Her MDS indicated no cognitive impairment. Her care plan identified her as at risk for skin breakdown related to activity intolerance and impaired ADL ability, and noted she required moderate assistance with bathing and that her needs should be anticipated and met by staff. During observation and interview, Resident 82 was lying in bed and stated she had some skin breakdown on her thighs and needed staff assistance with ADLs. She reported that she had not received a shower for a week despite asking multiple staff for help. Record review showed she received a shower on 1/20/26 at 1:18 p.m., and the DSD confirmed CNA 2 was scheduled to shower her on 1/21/26. The DSD stated CNAs were expected to offer showers twice weekly to all residents. During interview, CNA 2 admitted he charted that a shower had been provided for Resident 82, but he did not actually assist her with a shower. The ADON stated residents were expected to be offered showers two times a week to maintain hygiene and monitor for skin breakdown.
Insufficient Room Space Per Resident
Penalty
Summary
The facility failed to provide at least 80 square feet of space per resident in rooms 1-8, 11, 12, 17, 18, 19, 21, and 23-36 for a census of 77. Facility document review showed that the double occupancy rooms provided 142.8-157.3 square feet of living space, which equaled 71.4-78.65 square feet per resident, and the triple occupancy rooms provided 211.4-229.6 square feet of living space, which equaled 70.4-76.5 square feet per resident. A facility letter to the Department also noted that these rooms did not meet the minimum space requirements and that the Administrator requested a continuance of the room size waiver for the specified rooms. During concurrent observations and interviews, rooms 1, 2, 3, 4, 5, 6, 12, and 24 were observed to be uncluttered with sufficient space for residents' personal effects, entrance and egress, maneuvering of equipment, and access to bathrooms. Residents in those rooms did not verbalize any validated issues or safety concerns related to lack of space for care delivery. CNA 1 stated there was enough space in the facility rooms to perform resident care, maneuver, and transfer residents, and the MD stated that no alterations had been made to any room in the facility. LN 1 also stated there were no problems performing resident care in the rooms while transferring a resident from bed to wheelchair.
Failure to Properly Store and Label Food Items in Kitchen and Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to properly store food in accordance with professional standards and its own policies. During an inspection of the kitchen's walk-in refrigerator and freezer, multiple food items were found to be either expired, unlabeled, or both. These included cooked tomato sauce, fresh parsley, raw chicken pieces, meat packages of raw hamburger, shredded red cabbage, and fresh spinach in the refrigerator, as well as an opened, unsealed, unlabeled, and undated package of veggie burgers in the freezer. The Dietary Services Supervisor (DSS) confirmed uncertainty regarding how long some of the meat products had been thawing and acknowledged that expired and unlabeled food should not be served. In the dry goods storage area, additional items such as hamburger buns and cinnamon bread were found to be unlabeled or past their recommended storage time, with both the DSS and another staff member confirming these items should have been labeled and were inedible. Interviews with the DSS and the Administrator confirmed that kitchen staff were not following facility procedures, which require all food items to be labeled, dated, and used or discarded within specified timeframes. Facility policies reviewed by surveyors outlined clear guidelines for the storage and labeling of refrigerated, frozen, and dry goods, including maximum storage times and the requirement to discard food past expiration dates. The failure to adhere to these procedures resulted in the storage of expired and unlabeled food items, creating the potential for foodborne illness among the facility's residents.
Failure to Follow Prescribed Dietary Menus
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents during a lunch meal service. Specifically, three residents on modified texture diets did not receive the appropriate wheat roll preparations as indicated on the menu. Additionally, two residents on a No Concentrated Sweets/Consistent Carbohydrate diet received wheat rolls contrary to their dietary restrictions. Furthermore, two residents on a 60-gram Protein Renal diet were served vanilla wafers instead of the specified cookies, and three residents received mashed potatoes and green beans instead of the planned rice and carrots. The dietary supervisor acknowledged these discrepancies, noting that some items were not prepared due to kitchen errors, such as not preparing enough rice and carrots and substituting vanilla wafers for cookies. The Registered Dietitian confirmed these issues, stating that the kitchen staff did not follow the standardized recipes, leading to insufficient preparation of certain menu items. The RD also mentioned that any substitutions should have been approved and communicated to the residents, which did not occur. Additionally, all meals were served without the parsley garnish as indicated on the menu. The facility's policy and procedure documents emphasize the importance of following prepared menus and portion control guides, as well as the necessity of adhering to standardized recipes. The failure to follow these guidelines resulted in the potential compromise of the medical and nutritional status of the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several metal sheet pans in the clean and ready-to-use storage areas were found stacked while still wet and contained food debris. This was confirmed by the Dietary Supervisor (DS) and Registered Dietician (RD), who acknowledged that dishes, pans, and pots should be completely air-dried and clean before being stored to prevent mold and bacteria growth. The facility's policy and procedure (P&P) on dishwashing indicated that dishes are to be air-dried before stacking and storing. Additionally, the facility did not properly manage opened food items in storage. Opened bags of elbow noodles and croutons were not tightly closed or labeled with open or use-by dates, and a package of hamburger meat patties was similarly unlabeled. The DS confirmed these findings and stated that opened packages should be wrapped tightly and labeled with dates. The facility's P&P on food storage and labeling required that opened food items be tightly closed, labeled, and dated. The facility also failed to maintain cleanliness and proper procedures in other areas. The ice machine had an orange slimy substance on the ice chute, which was dripping onto the ice, and the DS confirmed that the machine had not been cleaned as frequently as required. The hot food cool down process was not practiced correctly, with logs showing improper cooling times and temperatures. Dietary aides were unable to correctly verbalize the manual dishwashing process and the concentration of the sanitizer solution. Furthermore, the microwave used for residents' food was found to be dirty, with black dry food splashes inside.
Inadequate Training of Dietary Aides in Food Safety Procedures
Penalty
Summary
The facility failed to ensure that two dietary aides were adequately trained to safely and effectively carry out the functions of the food and nutrition services. Dietary Aides 1 and 2 were unable to correctly verbalize the process of manual dishwashing using three-compartment sinks. Specifically, DA 1 could not state the correct immersion time for the sanitizing step, while DA 2 incorrectly stated the immersion time as 20 seconds instead of the required 60 seconds. This discrepancy was confirmed by the Dietary Supervisor and was contrary to the facility's policy, which mandates a 60-second immersion time. Additionally, DA 1's competency audit indicated she was competent in the procedure, despite her inability to verbalize it correctly during the interview. Furthermore, DA 2 was unable to verbalize the correct concentration range for the sanitizer solution used in the sanitation bucket, which should be between 200-400 ppm. This lack of knowledge was confirmed by the Dietary Supervisor and acknowledged by the Registered Dietitian, who emphasized the importance of staff knowing the correct procedures to prevent food-borne illness. DA 2's employee file showed no completed competency audit or evidence of attending any in-service training for sanitation, which is a requirement according to the facility's job description for dietary aides.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident 17, who was admitted with Parkinson's disease and muscle weakness, had severely impaired cognition and required assistance with activities of daily living. During an observation, it was noted that the call light was not within reach, and a licensed nurse confirmed that the resident would use the call light if it were available. The resident's care plan specifically indicated that the call light should be within reach and answered timely. Similarly, Resident 25, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, also had severely impaired cognition and required substantial assistance with daily activities. Observations revealed that the call light was not within reach on two separate occasions, once when the resident was in bed and once when sitting in a reclining seat. Both the Director of Staff Development and a licensed nurse confirmed the call light was not accessible. The resident's fall risk care plan also indicated that the call light should be kept within reach. The facility's policy on answering call lights emphasized the importance of ensuring the call light is within easy reach of residents.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, identified as Resident 22, who was admitted with multiple diagnoses including adult failure to thrive and malnutrition. The Minimum Data Set (MDS) for Resident 22, dated shortly after admission, inaccurately indicated that the resident had no memory problems and did not mark the resident as edentulous, despite the resident having all teeth missing. Observations and interviews confirmed that Resident 22 had no teeth and required dentures, information that was also communicated by the resident's responsible party during admission. The MDS Licensed Vocational Nurse acknowledged the inaccuracy in the MDS, attributing it to a mistake. The facility was unable to provide policies on the accuracy of assessments.
Inadequate Staffing for Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skill sets to meet the care and services for a resident when a Certified Nursing Assistant (CNA) transferred the resident by herself using a Hoyer lift. The resident, who was admitted with diagnoses including a fracture of the upper end of the right leg, muscle weakness, abnormalities in gait and mobility, and hemiplegia and hemiparesis following a cerebral infarction, required the assistance of two or more staff for chair/bed-to-chair transfers. The resident was also non-weight bearing on the right lower extremity, as indicated in the Minimum Data Set and Physical Therapy Evaluation. During an observation, the CNA was seen transferring the resident alone using the Hoyer lift, despite the facility's policy and procedure requiring at least two nursing assistants for such transfers. The CNA confirmed that she performed the transfer without additional staff assistance, acknowledging that Hoyer lift transfers should be done by two persons. The Director of Staff Development also stated that Hoyer lift transfers were always done by two persons for the safety of the residents, as part of training and education.
Inadequate PPE Usage for COVID-19 Positive Resident
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for a resident diagnosed with COVID-19. The resident, who was admitted with diagnoses including COVID-19, moderate protein-calorie malnutrition, and muscle weakness, was placed under droplet precautions. Despite the presence of signage indicating the need for droplet precautions, a Certified Nursing Assistant (CNA) entered the resident's room wearing only a yellow surgical mask, instead of the required N95 mask, along with a gown and gloves. During an observation, the CNA acknowledged the mistake upon being reminded of the proper protocol. The facility's policy on transmission-based precautions required masks to be worn when entering rooms under droplet precautions. The Infection Preventionist confirmed that the signage indicated the need for an N95 mask, which was not adhered to by the CNA, leading to a deficiency in infection control practices.
Inadequate Room Size in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that 28 multiple-resident rooms met the required 80 square feet per resident. Measurements of these rooms revealed that the space per resident ranged from 70.47 to 78.93 square feet, which is below the regulatory requirement. This deficiency was identified through observations, interviews, and record reviews conducted during the survey. Despite the inadequate space, some residents reported having enough room for their belongings and did not express concerns about the room size. However, one resident reported difficulties due to the limited space, particularly when using a Hoyer lift for transfers. The resident mentioned that CNAs had to maneuver furniture, such as the bedside table, to accommodate the lift, which sometimes encroached on the roommate's space. This situation indicates that the limited room size could potentially hinder the provision of care, especially for residents requiring assistive devices. The Department recommended the continuation of a waiver for the affected rooms.
Deficiency in Serving Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide palatable food at a safe and appetizing temperature for three of seven sampled residents, leading to dissatisfaction with meals. Residents reported that their meals were served cold, and this was confirmed through interviews and record reviews. Resident 3, who was admitted with multiple diagnoses including hemiparesis and moderate protein calorie malnutrition, reported that her breakfast was cold and could not be reheated. Resident 4, admitted with osteoarthritis and moderate protein calorie malnutrition, stated that her food was always cold, particularly the vegetables, and she was not eating well. Resident 7, with hemiparesis and diabetes, expressed that her meals were consistently cold, leading to weight loss. The facility's dietary management practices were inadequate, as evidenced by incomplete temperature recordings on the menus and the absence of a test tray temperature log. The Dietary Manager, who recently started working at the facility, acknowledged that she was not aware of the need to maintain a test tray temperature log and was only managing temperatures in the kitchen, not at the point of service to residents. The Director of Nursing and the Administrator confirmed that temperature monitoring was incomplete and that the previous cook had not documented food temperatures. The facility's policy and procedure for meal service required that food temperatures be taken prior to service and recorded on the daily therapeutic menu. However, this was not consistently done, as shown by missing temperature entries on multiple dates. Additionally, the policy for covering food during transport to maintain proper temperature was not effectively implemented, contributing to the issue of cold food being served to residents.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 3, by not ensuring that her call light was within reach. Resident 3, who was admitted with multiple diagnoses including osteoarthritis and muscle weakness, had moderately impaired cognition as per the Minimum Data Set assessment. During an interview, Resident 2, who shared a room with Resident 3, reported that Resident 3 was unable to push the call light and often had to call out for help. Resident 2 also mentioned that she had to assist by pushing the call light for Resident 3 on multiple occasions. An observation confirmed that Resident 3 was lying in bed on her right side, facing the wall, with the call light wrapped around the left side rail, making it inaccessible. Certified Nursing Assistant 1 acknowledged that Resident 3 could not reach her call light, which could lead to potential risks such as falls if the resident attempted to move without assistance. The facility's policy on answering call lights and accommodating resident needs emphasized the importance of ensuring call lights are within easy reach and adapting the environment to meet individual needs, which was not adhered to in this case.
Failure to Follow Physician Orders for Staple Removal
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in a deficiency in maintaining professional standards of quality. The resident, who was admitted with multiple diagnoses including a fracture of the right lower leg and rhabdomyolysis, had surgical staples on the right side of the forehead. The physician's order specified that these staples should be removed within 10-14 days, between April 24 and April 28. However, the staples were not removed until May 3, which was beyond the ordered timeframe. Interviews with the Infection Preventionist and the Treatment Nurse confirmed the oversight. The Infection Preventionist stated that the treatment nurse is responsible for removing staples and emphasized the importance of following physician orders. The Treatment Nurse acknowledged the delay in removing the staples and recognized the associated risk of infection. The facility's policy mandates that licensed staff carry out physician orders as prescribed, which was not followed in this instance.
Delayed Medication Administration for Alcohol Withdrawal
Penalty
Summary
The facility failed to ensure timely pharmacy services for a resident who was admitted with multiple diagnoses, including alcohol abuse. Upon admission, the resident had a physician's order for chlordiazepoxide, a medication used to treat alcohol withdrawal symptoms. However, the resident did not receive the medication until three days after the order was placed. This delay was confirmed during an interview with the resident, who expressed concern about not receiving the medication needed for detoxification. The facility's Infection Preventionist acknowledged that a three-day delay in receiving medications is unacceptable and could lead to side effects. A review of the resident's records showed that the medication was not available in the emergency kit and was awaiting delivery from the pharmacy. The facility's policy requires licensed staff to carry out physician orders as prescribed, but this was not adhered to in this case, resulting in the resident experiencing uncomfortable symptoms during alcohol detoxification.
Failure to Maintain Food Service Safety Standards
Penalty
Summary
The facility failed to maintain professional standards for food service safety, as observed during a survey. During an observation in the main dining room, it was noted that three mugs available for resident use had brown and white residue stuck inside. The Activities Assistant confirmed the mugs were not clean and should not be used for residents, indicating a lapse in cleanliness standards. Additionally, in the kitchen, the Certified Dietary Manager identified a plastic cup with yellow residue and a bowl with white residue on the rack of ready-to-use dishware, confirming they were not clean and needed to be rewashed. Furthermore, a plastic cup with brown residue and two bowls with rough surfaces were deemed uncleanable and required disposal. The Dietary Aide, responsible for putting away dishware, acknowledged the expectation to check for cleanliness and stated that uncleanable dishware should be discarded, while dirty but cleanable items should be sent back for washing. The facility's policy on sanitation, dated 2023, mandates that unsightly, unsanitary, or hazardous dishware should be discarded. These observations and interviews highlight the facility's failure to adhere to its own sanitation policies, potentially exposing residents to food-borne illnesses due to the use of dirty dishware.
Failure to Implement RNA Program as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents as part of the Restorative Nursing Assistant (RNA) program, which was intended to help maintain or improve their range of motion and strength. Resident 1, who was admitted with muscular dystrophy and multiple sclerosis, reported inconsistencies in receiving RNA program assistance, which was supposed to occur three times a week. Similarly, Resident 2, admitted with generalized muscle weakness and gait abnormalities, expressed uncertainty about the frequency of RNA sessions and noted infrequent assistance. Interviews and record reviews revealed that both residents were referred to the RNA program after completing physical therapy, as indicated in their PT discharge summaries. The Director of Rehabilitation confirmed the referrals, and the Director of Nursing (DON) and Director of Staff Development (DSD) were responsible for overseeing the RNA program. However, documentation showed that neither resident received RNA assistance as ordered, with significant gaps between documented sessions. The DSD confirmed the lack of documentation for refusals and acknowledged that undocumented sessions were not conducted. The facility's policy required certified and trained RNA staff to provide treatments per physician's orders, but this was not adhered to. The RNA 1 confirmed that if RNA assistance was not documented, it was not performed. The failure to implement the RNA program as ordered had the potential to result in declines in range of motion and strength for the affected residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Auburn Ravine Healthcare Center | 1.6 mi | ★★★★★ | 19 | 0 |
| Auburn Oaks Care Center | 3.9 mi | ★★★★★ | 9 | 0 |
| Siena Skilled Nursing & Rehabilitation Center | 4.1 mi | ★★★★★ | 15 | 0 |
| Westview Healthcare Center | 4.5 mi | ★★★★★ | 12 | 0 |
| Lincoln Meadows Care Center | 12.4 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.