Average — CMS composite of the measures below.
A standard survey is most likely before 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 Wellsprings Care Center during CMS and state inspections, most recent first.
The facility failed to protect several residents from repeated physical abuse by other residents with known behavioral issues and cognitive impairments. In common areas, a cognitively intact resident in a wheelchair was struck twice by another resident with schizophrenia and a history of peer-to-peer aggression, once on the back and once on the head, causing a bump. In a separate room incident, a resident with bipolar disorder, upset over a perceived clothing issue, attempted to remove a shirt from a roommate who required assistance with dressing, then threw juice in the roommate’s face; the roommate reported also being hit on the chin. Another altercation occurred when a resident in a wheelchair accidentally bumped into another resident, who responded by hitting the wheelchair user in the head, followed by a retaliatory hit. One victim reported feeling nervous around the aggressor, and another reported that staff did not separate the residents and laughed when she was hit. Staff interviews revealed inconsistent understanding of what constitutes abuse and reliance on de-escalation and monitoring, while care plans already identified aggression risks and prior altercations.
A resident with cognitive impairment, muscle weakness, reduced mobility, and a history of a recent community fall with fracture and ongoing pain was identified as a high fall risk, yet no fall-related focus or interventions were added to the care plan and no further fall risk assessments were completed. Therapy notes documented fall risk precautions, and the resident reported going out alone daily and using a walker due to fear of falling again, but the record lacked any assessment of the resident’s ability to leave independently or education on community safety. Observation showed the resident ambulating with a front-wheeled walker while using one hand to hold up his pants, secured with a makeshift glove belt, and interviews revealed that nursing staff did not recognize any current fall-risk residents, the DON stated they only care planned for controllable in-facility factors, while the physician and PT both considered the resident a fall risk.
A facility employee exploited a resident by convincing the resident to transfer a vehicle title, provide money for insurance and registration, and share credit card information, resulting in unauthorized charges and loss of property. The employee's actions went undetected by management for several months despite the resident's history of financial exploitation and existing support measures.
Food Storage and Date Marking Deficiency: Surveyors found multiple perishable foods in the walk-in refrigerator past their discard dates, including brown romaine lettuce, parsley, and watermelon, along with several unlabeled or undated items such as sausage-like patties, hard boiled eggs, beans, and sliced cheese. A dietary aide and the DS stated that refrigerated foods should be labeled and dated, and that expired items should have been discarded.
A facility failed to ensure residents were not responsible for purchasing routine hygiene items covered under Medicaid/Medicare, including soap for room bathrooms. Observations found multiple resident bathrooms without bar soap or liquid hand soap, and residents reported being told they had to buy their own toiletries or use activity points to obtain items such as soap, deodorant, and mouthwash. Staff gave conflicting accounts about who stocked soap dispensers, while the NHA stated hygiene items were provided free of charge.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: A resident with schizophrenia, TBI, severe cognitive impairment, and a history of aggression physically assaulted two other residents in separate incidents. One resident was pushed and scratched on the smoking patio, and another was struck when the assailant threw a step stool, causing a skin tear above the eyebrow. The assailant’s record did not show the incidents were added to the behavior care plan or that specific behavior triggers and interventions were documented.
The facility failed to promptly notify the state mental health agency after a resident with schizoaffective disorder and a PASRR II had significant psychiatric changes, including behavioral decompensation, psychiatric hospitalizations, suicidal ideation, and new antipsychotic orders. The EMR contained no social services documentation or evidence that the OBRA coordinator was notified of the resident’s change in mental status or psychiatric admissions.
Medication storage and labeling were not properly maintained in two med carts. An albuterol inhaler for a resident was unlabeled and expired, two other inhalers were missing resident names, and one inhaler was missing the open date and expiration date. An expired OTC vitamin B-12 bottle was also found in a cart, and an LPN acknowledged it did not belong there.
A resident with traumatic brain injury and multiple fractures was admitted with orders for PT, OT, and ST, but the facility did not enter the therapy referral orders into the EMR on admission. The resident reported not being seen by PT, OT, or ST, not receiving a walker, and remaining limited to a wheelchair. Staff later confirmed the admitting nurse missed the orders, and the therapy order was not entered until several days after admission.
Several residents who experienced falls were assessed by LPNs, but required follow-up assessments by an RN were either not documented or not completed in a timely manner. In some cases, RNs performed assessments but did not record them if their findings matched those of the LPNs, and in other cases, documentation was delayed. This resulted in incomplete medical records and a failure to ensure that care was provided by qualified personnel as outlined in the residents' care plans.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, with strong odors, stained linens, broken fixtures, and unclean common areas observed throughout multiple hallways and resident rooms. Residents reported inadequate cleaning of their rooms and bathrooms, while staff interviews revealed inconsistencies in cleaning routines and uncertainty about the frequency of privacy curtain laundering.
Two residents with chronic medical conditions were not properly supported by the facility in ensuring their representatives were notified of significant changes in their condition, such as hospitalizations. The facility failed to keep representative contact information updated in the EMR and did not make or document multiple notification attempts when initial contact was unsuccessful. Staff interviews revealed inconsistent practices and a lack of clear procedures for updating and verifying representative information.
Three residents were not protected from physical abuse, as evidenced by two separate altercations involving physical aggression between residents. In one case, two residents engaged in a fight on the patio, resulting in punches and minor injuries, while in another, a resident pulled another's hair in the dining room after a verbal provocation. Both incidents were witnessed by staff and other residents, and the individuals involved had documented histories of behavioral and cognitive challenges. Staff were aware of these risks, but existing interventions and monitoring failed to prevent the abuse.
The facility failed to provide a clean and homelike environment, with strong odors and unsanitary conditions observed throughout. Residents reported infrequent linen changes and inadequate room cleaning. Staff interviews revealed challenges in maintaining cleanliness, contributing to the deficiencies noted.
A resident with a known history of aggression abused three other residents in a facility. The facility failed to implement timely and effective interventions, resulting in sexual and physical abuse incidents. Staff were not adequately informed about the resident's behaviors, and investigations were incomplete, lacking key witness statements and proper documentation.
A resident, who was cognitively intact and had a history of stroke and diabetes, was exploited by a staff member who took $5,060 from them. The resident received a large sum of money and gave cash tips to staff, but a housekeeper accepted a significant amount and continued to request more. The facility's investigation revealed money transfers to the housekeeper's account, leading to their termination and police involvement.
The facility failed to maintain a safe and sanitary environment, with debris cluttering the smoking patio and refuse area, and long-standing stains in a resident's room. Staff interviews revealed a lack of communication and understanding regarding cleaning processes, contributing to the deficiencies.
A resident who required substantial assistance with showering did not receive her scheduled showers, receiving only five out of 16 opportunities over two months. Despite being cognitively intact and dependent on staff for bathing, there were no documented refusals or interventions for missed showers. Staff interviews revealed inadequate documentation and follow-up, and the DON acknowledged the need for process improvement.
A resident with heart failure was not weighed weekly as ordered, resulting in unmonitored weight gain. The facility also failed to update the resident's care plan to include new weight monitoring interventions after hospital readmission. Staff interviews confirmed these oversights.
The facility failed to maintain a clean and sanitary environment, with surveyors observing unclean living spaces and mouse droppings in multiple units. Residents reported dissatisfaction with housekeeping services, noting the presence of mice and inadequate cleaning. Staff interviews revealed that housekeeping was responsible for daily cleaning, but issues persisted despite pest control efforts.
Failure to Prevent and Manage Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite known behavioral histories and prior altercations. Facility policy dated 5/3/23 states that residents have the right to be free from abuse, neglect, and all forms of physical and mental mistreatment. In two separate incidents on 12/12/25 and 12/14/25, a cognitively intact resident with COPD and peripheral vascular disease was physically struck by another resident with schizophrenia, nicotine dependence, and a history of head injury and severe cognitive impairment. In both incidents, the victim was backing through a doorway in a wheelchair while another resident guided the chair, and the assailant resident hit her—first on the upper back and then on the head, resulting in a small bump. The facility’s own investigation documented that the assailant had five other documented instances of physical aggression in the past year and a care plan noting a history of peer-to-peer altercations and potential for physical aggression. Another deficiency event involved a resident with heart failure, opioid abuse, and bipolar disorder physically abusing her roommate, a resident with a brain tumor, obesity, repeated falls, and moderate cognitive impairment who required assistance with dressing. The facility investigation documented that the aggressor resident became upset after believing the roommate was wearing her shirt, attempted to remove the shirt, and then threw juice in the roommate’s face. The roommate reported that she was accused of wearing the shirt, was hit on the chin, and had juice poured on her. The investigation also noted that the victim was incapable of dressing herself and would not have been able to put on the shirt without assistance, and that the aggressor had a prior history of verbally aggressive behavior toward the same roommate, including hostile and profane remarks and a statement that she hoped the roommate would choke on her own blood. The aggressor’s care plan already identified potential for verbally aggressive behaviors, often involving cigarettes and money, and included interventions such as monitoring interactions with the roommate and separating them if altercations arose. A further incident of physical abuse occurred between two residents when one resident, while going to bed and wheeling backwards in a wheelchair, accidentally bumped into another resident, who then hit the wheelchair user in the head. The investigation documented that the bumped resident then hit back in retaliation, although one of the residents later denied retaliating and reported feeling that staff did not separate the residents and laughed when she was hit, leaving her feeling helpless and unable to prevent future incidents. Staff interviews showed inconsistent understanding of what constitutes abuse, with one LPN stating she was unsure exactly what line needed to be crossed for an event to constitute abuse, while others described any hitting or nonconsensual touching as abuse. The nursing home administrator acknowledged ongoing behavioral issues with one of the aggressive residents and referenced other residents bumping into him, as well as a clothing mix-up contributing to the roommate altercation. Across these events, the facility’s failure to prevent repeated peer-to-peer physical aggression, despite known behavioral risks and prior incidents, resulted in multiple residents being subjected to physical abuse. Staff interviews further highlighted the environment in which these incidents occurred. One CNA reported working often with two of the aggressive residents and stated she tried to de-escalate them by talking and giving them space when they became agitated, and believed these strategies generally prevented incidents. Another LPN stated that if a resident was getting agitated, she would try to calm and de-escalate them and monitor them frequently, and another LPN described separating residents and reporting abuse to administration if witnessed. The maintenance director, who is also a CNA, stated that the facility generally responded to physical abuse by keeping residents separated and moving them to separate floors, and noted that clothing was labeled and should be double-checked by CNAs when assisting residents with dressing. Despite these stated practices and care plan interventions, the documented events show that residents with known behavioral risks and cognitive impairments engaged in repeated physical aggression toward other residents, and victims reported ongoing fear and nervousness when in the same room as their aggressors.
Failure to Assess and Care Plan for High Fall-Risk Resident After Community Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess, educate, and implement care plan interventions for a resident identified as being at high risk for falls, despite having a fall management policy requiring such actions. The facility’s Fall Management policy stated that all residents would be assessed for fall risk, that individualized care plans would be implemented for residents at high risk, and that interventions would be re-evaluated after a fall. The policy also required review of incidents, IDT risk management, and care plan initiation or revision after falls, with all falls reviewed during QAPI meetings. Training records showed that all staff had completed in-service trainings on fall prevention on two occasions. The resident involved was an older adult with diagnoses including bipolar disorder, underweight, muscle weakness, fatigue, and reduced mobility, and was not cognitively intact, with a BIMS score of 6/15. The MDS documented that the resident required set-up assistance with ADLs and had sustained a fall. Nursing progress notes showed that the resident fell in the community and was sent to the hospital, where he was found to have a left radial fracture, abrasions on knees and palms, bodily pain, and left knee pain, with significant difficulty ambulating afterward. An IDT risk management note documented that the resident lost balance and fell while out in the community, and a nursing fall risk assessment completed shortly after the fall identified the resident as a high fall risk. Occupational therapy notes indicated the resident was on fall risk precautions. Despite these findings, the comprehensive care plan contained no fall-related focus or interventions, and no further nursing fall risk assessments were completed after the initial high-risk assessment. The EMR did not show any assessment of the resident’s ability to safely leave the facility independently or any education provided on community safety, even though the resident reported going out alone daily and using a walker due to fear of falling again. Observations showed the resident ambulating in the hallway using a front-wheeled walker with one hand while using the other hand to hold up his pants, which he secured with a rubber glove tied through belt loops. Staff interviews revealed that the LPNs on duty did not identify any current residents as fall risks, the DON stated that a fall risk care plan was not developed because the facility only care planned for factors controllable within the facility, and the physician and PT both considered the resident a fall risk based on his diagnoses, prior fall, and mobility issues, with the PT noting that a four-wheeled walker would provide more stability for the resident in the community.
Failure to Prevent Misappropriation of Property and Exploitation by Facility Employee
Penalty
Summary
The facility failed to protect a resident from misappropriation of property and exploitation by a facility employee. The incident involved an activity assistant who developed a personal relationship with a resident and convinced him to have his van's title and registration transferred to her name. The resident also provided the employee with money for vehicle insurance, registration, and future caregiving services, as well as access to his credit card, which was subsequently used for unauthorized charges. The employee's actions were not known to the facility's management until the social services director overheard a phone conversation between the resident and the employee discussing the vehicle title transfer. The resident involved was under 65 years old, cognitively intact according to his most recent assessment, but had a history of disorganized thinking and anxiety disorder. He was dependent on renal dialysis and required varying levels of assistance with daily activities. The resident had previously been a victim of financial exploitation and had support from attorneys, a banker, and a private helper for financial matters. Despite these interventions, the employee was able to exploit the resident financially over several months, obtaining both money and property without the knowledge or consent of facility management. Staff interviews revealed that employees were aware of policies prohibiting acceptance of gifts or money from residents and had received abuse prevention training. However, the employee in question circumvented these policies, and the facility's management team was unaware of the ongoing exploitation until it was discovered incidentally. The employee was subsequently terminated, and the incident was reported to appropriate authorities, but the deficiency centers on the facility's failure to prevent the misappropriation and exploitation from occurring.
Food Storage and Date Marking Deficiency
Penalty
Summary
Food in the main kitchen was not stored, prepared, and served under sanitary conditions because perishable items were found past their discard dates and several refrigerated foods were not labeled or dated. During the initial kitchen tour, surveyors observed a bag of romaine lettuce that was brown with a discard date of 8/25/25, a bag of parsley with a discard date of 8/1/25, and a pan labeled watermelon with a discard date of 8/26/25 in the walk-in refrigerator. Surveyors also observed an uncovered, unlabeled pan with three patties resembling sausage, an unlabeled pan dated 9/6/25 with five hard boiled eggs, an unlabeled pan dated 8/2/25 with what resembled beans, another unlabeled pan with a black substance that resembled beans, and a pan with five wrapped, unlabeled blocks of sliced cheese. During interviews, a dietary aide stated that all items in the walk-in refrigerator should be dated as soon as opened and that food in manufacturer bags should use the discard date printed on the package. She said all food items should be labeled and identified the romaine lettuce, parsley, and watermelon as items that should have been discarded. She was unable to identify the unlabeled pans with food resembling beans. The dietary supervisor stated that kitchen staff were expected to check the walk-in refrigerator every evening before leaving and again when opening staff arrived in the morning to ensure food was discarded timely, and he said all food items needed to be labeled and dated.
Resident Hygiene Items Improperly Charged
Penalty
Summary
The facility failed to ensure residents were not charged for items or services covered under Medicare or Medicaid, specifically routine personal hygiene items such as soap for resident bathrooms. The admission agreement stated that services covered under Medicaid/Medicare included routine personal hygiene items and services, including hygiene supplies, comb, brush, soap, and disinfecting soaps or specialized cleansing agents when indicated to treat special skin. During observations, seven resident rooms were checked and several bathrooms had no bar soap or liquid hand soap, and one room had bar soap but no liquid hand soap. In interviews, residents said they were told they had to purchase their own toiletries, including soap, razors, mouthwash, and deodorant, and that some soap in a bathroom belonged to a roommate who bought it himself. One resident said staff told him he could buy soap from the store or activities department, and another said residents could use activity points to purchase personal hygiene items. Staff interviews showed conflicting information about who was responsible for filling soap dispensers, with one LPN and one CNA saying housekeepers or maintenance were responsible, while a housekeeper was unsure. The NHA stated the facility provided liquid soap and other standard hygiene items free of charge, but the observations and resident interviews showed residents were being told to obtain or purchase their own soap.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to keep two residents free from physical abuse by another resident. Record review and interviews showed that Resident #48, who had schizophrenia, a traumatic brain injury, severe cognitive impairment, and documented behaviors of physical and verbal aggression, was involved in separate physical altercations with Resident #27 and Resident #43. The facility investigation for the first incident documented that Resident #48 pushed Resident #27 and scratched her arm during an encounter on the smoking patio after another resident had thrown a partially smoked cigarette on the ground. Resident #48’s record showed a history of aggressive behaviors, including attempts to strike another resident, throwing coffee in a nurse’s face, kicking, pulling hair, punching a nurse, and attempting to swing at staff. His behavior care plan identified a potential for physical aggression, but the record did not show that the episodes involving Resident #27 and Resident #43 were added to the care plan or that specific interventions and precipitating factors were documented to prevent recurrence. The record also failed to show specific documentation of the physical altercation with Resident #27 in the behavior progress notes. The second incident involved Resident #43, who was cognitively intact and had diagnoses including discitis, chronic respiratory failure, end stage renal disease, and dialysis dependence. The facility investigation documented that Resident #43 was yelling at and calling Resident #48 names when Resident #48 picked up a step stool and threw it at Resident #43, causing a skin tear above the eyebrow. The investigation substantiated the allegation, and the record again failed to show specific documentation of the altercation in Resident #48’s behavior notes or analysis of what triggered the behavior.
Failure to Notify Mental Health Agency After Psychiatric Status Change
Penalty
Summary
The facility failed to notify the state mental health agency promptly after a significant change in the mental condition of Resident #7, who had diagnoses including schizoaffective disorder, demoralization and apathy, delusional disorder, and unspecified mood disorder. The resident had a PASRR level II related to schizoaffective disorder, bipolar type, and a history of probable neurocognitive disorder due to traumatic brain injury with past behavior disturbances. The record showed multiple psychiatric events, including an episode in which the resident smashed computers at the nurses’ station and was escorted out by police, a later psychiatric hospitalization, refusal of medications, another hospitalization after being found intoxicated and admitted for psychosis, and a readmission from a behavioral health transition of care hospital with decompensation and suicidal ideations with a plan. The record also documented that after the resident returned from hospitalization, new psychotropic medications were ordered, including clozapine and haloperidol, and the resident later stated that he wanted to die. Review of the electronic medical record from June through early September showed no social services documentation related to the psychiatric hospitalizations, the new psychotropic medications, or the suicidal ideations, and no documentation that the OBRA coordinator was notified of the resident’s decline in behavior, medication changes, or psychiatric hospitalizations. The social services director stated that a status change PASRR level I should be submitted when there is a change in diagnosis or a significant change in mood or behavior, and that the facility should notify the mental health agency when a resident is decompensating.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently stored, secured, and labeled according to accepted professional principles in two medication carts. During observation of medication cart #1, an albuterol sulfate 90 mcg inhaler for Resident #2 was stored in a labeled medication box but was not labeled with the resident’s name, and the inhaler’s expiration date had already passed. In the same cart, a Breo Ellipta 50/25 mcg inhaler for Resident #31 was stored in a labeled medication box but was not labeled with the resident’s name. A [NAME] 160-4.5 mcg inhaler for Resident #52 was also stored in a labeled medication box but was not labeled with the resident’s name, the date it was opened, or the expiration date. On the south medication cart on the second floor, an OTC vitamin B-12 100 mcg tablet bottle with an expired date was found in the OTC drawer. An LPN acknowledged the expired OTC medication did not belong in the cart. The regional clinical resource stated the usual process was to label the individual medication bottles inside their medication boxes with the resident’s name and medication expiration date, and said she was not sure how to best label inhalers.
Failure to Initiate Ordered Therapy Services
Penalty
Summary
The facility failed to ensure Resident #74 received the specialized rehabilitative services ordered by the physician on admission. The resident, who was under 65 and admitted after traumatic subarachnoid hemorrhage and multiple fractures of the foot, ankle, tibia, fibula, and heel, had a September 2025 MDS showing cognitive intactness with a BIMS score of 15. The resident told the surveyor she had been admitted to continue therapy services, but she had not yet been seen by PT, OT, or ST, had not received a walker at the facility, and had remained limited to a wheelchair after previously using a walker at the prior facility. Record review showed the admission physician's orders dated 8/22/25 indicated discharge to LTC for PT, OT, and ST, but the September 2025 CPO contained no referral orders for PT, OT, or ST to evaluate and treat the resident. The ADL care plan documented the resident needed assistance with bed mobility, dressing, and transfers, and the mobility care plan noted limited physical mobility related to recent polytrauma with multiple fractures and included PT and OT referrals as ordered and PRN. The regional clinical resource stated the admitting nurse was responsible for entering and reconciling physician orders in the EMR and was not aware the therapy orders were missing; she said the orders had been missed by the admitting nurse on 9/3/25. A physician order for PT, OT, and ST evaluation and treatment was not entered into the EMR until seven days after admission.
Failure to Ensure Timely and Documented RN Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that post-fall assessments for several residents were completed timely by a qualified person, specifically a registered nurse (RN), and that these assessments were properly documented in the residents' medical records. In multiple instances, after residents experienced falls—either unwitnessed or witnessed—initial assessments were conducted by licensed practical nurses (LPNs), but there was no documentation of follow-up assessments by an RN as required by facility policy. For example, one resident with hepatic encephalopathy, schizophrenia, and other complex conditions reported an unwitnessed fall and was assessed by an LPN, but there was no record of an RN assessment in the electronic medical record (EMR). Another resident, dependent on staff for all activities of daily living and with diagnoses including encephalopathy and severe vision impairment, experienced a fall while attempting to self-transfer. The director of nursing (DON) stated she assessed the resident after the fall but did not document her assessment until three days later. Similarly, a resident with multiple sclerosis and a history of falls was found on the floor by a CNA and assessed by an LPN, with no documentation of an RN assessment in the EMR. In another case, a resident with neurofibromatosis and muscle weakness slipped off the toilet and was assessed by an LPN, but again, there was no timely RN assessment documented. Staff interviews revealed that RNs sometimes performed assessments but did not document them if their findings matched those of the LPNs, and that documentation was sometimes delayed or omitted entirely. The facility's policy required that all post-fall assessments be completed by an RN and documented in the medical record, but this was not consistently followed, leading to incomplete records and a lack of evidence that qualified personnel provided care according to each resident's plan of care.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, sanitary, and comfortable homelike environment throughout three out of four hallways, as evidenced by strong odors of urine, cigarettes, and body odor in multiple areas, including hallways, resident rooms, and common spaces. Observations revealed that the dining room and common areas were not properly cleaned, with food, cigarette butts, hair ties, and dust present on the floors and under heating units. Tables in the dining area were stained with paint and food, and lacked tablecloths. Window blinds and heating units were covered in dust and dirt, with some blinds broken and left unrepaired for at least a week, resulting in a lack of privacy for residents. Resident rooms were found with broken closet doors, stained privacy curtains, and strong odors of urine and body odor. Some rooms had brown-stained sheets and blankets, and in one instance, a urinal filled with urine was left uncovered and soiled on a bedside table. Bathrooms were not consistently cleaned, with dried sticky substances and stains observed on floors and around toilets. Window curtains in some rooms were broken and hanging off the rods, further contributing to the unkempt environment. Residents reported that their rooms and bathrooms were not cleaned daily, and one resident stated that she had to clean her own bathroom due to inadequate housekeeping. Interviews with staff indicated that daily cleaning routines were in place, but there was inconsistency in the frequency and thoroughness of cleaning, particularly regarding privacy curtains and deep cleaning schedules. Housekeeping staff were unsure how often privacy curtains were cleaned, and maintenance staff acknowledged ongoing issues with room repairs and decluttering. Bed linens were reportedly changed twice a week on shower days, but observations contradicted this, as stained linens were found in several rooms. Staff also indicated that refusals by residents to have their rooms or linens cleaned were documented, but there was no evidence that these refusals accounted for the widespread lack of cleanliness and sanitation observed.
Failure to Notify Representatives of Significant Change in Condition
Penalty
Summary
The facility failed to notify residents' representatives of significant changes in condition for two out of three residents reviewed, as required by both facility policy and federal regulations. In both cases, the facility did not ensure that the residents' current designated representatives' names and contact information were updated in the electronic medical record (EMR). Additionally, when representatives were unreachable, staff did not make additional attempts or try alternative methods to contact them, nor did they document multiple attempts as expected. For one resident, who was cognitively intact and had multiple chronic conditions including COPD, atrial fibrillation, and diabetes, the facility made only a single attempt to contact the representative when the resident was hospitalized. No message was left, and there was no documentation of further attempts to notify the representative. The resident confirmed that the contact information in the EMR was correct and expressed distress that his representative was not informed of his hospitalization, only learning of it when the resident himself called. Another resident, also cognitively intact and with chronic heart failure, COPD, and bipolar disorder, reported that her representative was not notified of her hospitalizations on multiple occasions. The EMR contained outdated information, listing a deceased individual as her representative. The resident stated that the facility did not verify or update her representative's information during her stay or at care conferences, and she was unsure how to ensure the information was current. Staff interviews revealed inconsistent practices regarding updating and verifying representative contact information, and there was no official procedure in place to ensure accuracy or follow-up when notification attempts were unsuccessful.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from physical abuse, resulting in multiple incidents of resident-to-resident altercations. In one incident, two residents were involved in a physical altercation on the patio, where one resident punched another in the face twice, and the other retaliated by striking back. Witnesses confirmed the sequence of events, and both residents had documented histories of behavioral issues, including aggression and impaired cognitive function. The care plans for these residents noted their tendencies toward verbal and physical aggression, but the interventions in place did not prevent the altercation from occurring. In a separate incident, another resident made a derogatory comment to a peer in the dining room, prompting the peer to grab and pull the resident's hair. This event was witnessed by staff and another resident, and the staff member intervened to stop the physical contact. The resident who initiated the hair-pulling had a documented history of poor impulse control and aggression, and the victim was also known to use derogatory language and display verbally aggressive behavior. Despite these known risks, the care plan for the aggressor was not revised until several days after the incident. Staff interviews revealed that employees were aware of the behavioral challenges and triggers among the residents involved. Staff described expectations to monitor residents closely and intervene when agitation or altercations were observed. However, the facility's actions and existing interventions were insufficient to prevent the physical abuse incidents, as evidenced by the repeated altercations and the lack of timely updates to care plans following the events.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. During a tour of the facility, surveyors noted strong odors of urine, body odor, and smoked cigarettes throughout the building, particularly on the first and second floors. Several resident rooms were found with heavily soiled and stained flooring, dingy and stained bed sheets, and a lack of hand towels. Common areas, such as the first-floor resident shower rooms, were also found to be unsanitary, with soiled linens and trash, including soiled adult incontinent briefs, contributing to the strong odors. Interviews with residents revealed dissatisfaction with the cleanliness of their rooms and the frequency of linen changes. One resident reported that their bed sheets were rarely changed despite frequent requests, and another resident mentioned that their room was only cleaned once a week since the hiring of a new housekeeper. Staff interviews indicated that the housekeeper was unable to keep up with the daily cleaning routine, and there were issues with the timely removal of trash and soiled items, which contributed to the persistent odors. The facility's maintenance director acknowledged the need for repairs and improvements, such as replacing baseboards and stripping and rewaxing floors. However, the current state of the facility, as observed by surveyors, did not meet the standards outlined in the facility's Safe and Homelike Environment policy. The policy emphasized the importance of maintaining a clean, sanitary, and odor-free environment, which the facility failed to uphold, leading to the identified deficiencies.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect three residents from abuse by another resident, who had a known history of violent aggression and inappropriate behaviors. Resident #12 reported being sexually abused by Resident #13, who entered her room and touched her inappropriately. Despite the initial report, the facility's investigation was incomplete, lacking statements from key witnesses and failing to document the incident properly in Resident #12's electronic medical record. The care plan for Resident #13 was not updated promptly to address his inappropriate behavior, even though the facility had information about his history of aggression at the time of admission. Resident #14 was physically assaulted by Resident #13, who hit him on the ear. The incident was not observed by staff, and the investigation did not include an interview with Resident #14. Additionally, there was no documentation in Resident #13's electronic medical record regarding this incident. Resident #14 reported the assault to the police, and although the facility moved Resident #13 to a different room, the care plan was not adequately adjusted to prevent further incidents. Resident #23 was also physically assaulted by Resident #13 in a common area, an event witnessed by staff and other residents. This incident, along with the previous ones, highlighted the facility's failure to implement effective monitoring and intervention strategies for Resident #13, despite his known history of aggression. The facility's staff, including CNAs and LPNs, were not adequately informed about Resident #13's behaviors, contributing to the repeated incidents of abuse.
Resident Exploited by Staff Member for Financial Gain
Penalty
Summary
The facility failed to protect a resident from exploitation and misappropriation of property, specifically involving a staff member taking $5,060 from the resident. The resident, who was cognitively intact and had a history of stroke, hemiplegia, aphasia, and diabetes, received a large influx of money and decided to give cash tips to some facility staff. While most staff declined, a housekeeper accepted a significant amount of money, totaling $3,000, and continued to request more. The resident, wanting to help the housekeeper with financial struggles, transferred money directly to the housekeeper's bank account. The facility's investigation revealed that the housekeeper received money transfers on 11 occasions, as evidenced by the resident's bank statements. The nursing home administrator discovered these transactions while assisting the resident with insurance recertification. The housekeeper initially denied receiving money until confronted with the bank statement evidence. The facility's policy prohibits staff from accepting gifts or money from residents, and the staff involved were reminded of this policy. The housekeeper was terminated, and the police were notified of the incident.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed that the second-floor smoking patio was cluttered with debris, including a wooden pallet and a flattened cardboard box, which obscured the visibility of a fire blanket. Additionally, the outdoor refuse area was cluttered with approximately 20 wooden pallets and two shopping carts, creating an unorganized and potentially hazardous environment. In a resident's room, a long-standing pink stain from a spilled red drink was observed on the floor, along with scuff marks and brown crumbs. The resident reported that the stain had been present for approximately two months and that housekeeping had not taken significant action beyond regular mopping to remove it. A subsequent spill of a chocolate drink resulted in a brown liquid stain that was not cleaned despite multiple staff members entering the room. Interviews with staff revealed a lack of communication and understanding regarding the cleaning process for stains. Housekeeper #1 acknowledged the presence of the pink stain but had not reported it for further action. The housekeeping supervisor indicated that certain chemicals were needed for stain removal and that unremovable stains should be reported for additional intervention. The maintenance supervisor explained that the debris on the smoking patio was due to ongoing facility maintenance, and the wooden pallets near the dumpsters were left by contracted vendors and had not been removed as expected.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for bathing received her scheduled showers. The resident, who was cognitively intact and required substantial assistance with showering, reported receiving only three showers over a two-month period, despite being scheduled for showers twice a week. Observations confirmed the resident's hair was disheveled, and there was a noticeable body odor in her room. The resident's care plan indicated she required partial assistance with personal hygiene, but it did not specify the assistance needed for showering. The facility's documentation was inconsistent, with records showing the resident received only five showers out of 16 opportunities. There were no documented refusals or interventions to address missed showers. Staff interviews revealed a lack of proper documentation and follow-up when the resident was unavailable for scheduled showers. The Director of Nursing acknowledged the need for process improvement in documenting showers, but no such improvements had been implemented at the time of the report.
Failure to Monitor Weight and Update Care Plan for Resident with Heart Failure
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident diagnosed with chronic obstructive pulmonary disease, depression, atrial fibrillation, high blood pressure, and heart failure. The resident was supposed to be weighed weekly as per physician orders, but the facility did not obtain the resident's weight between specified periods, and there was no documentation of any refusal by the resident to be weighed. The resident experienced a significant weight gain, which was not monitored as required, indicating a lapse in following the physician's orders for weight monitoring. Additionally, the facility did not update the resident's care plan to include new weight monitoring interventions after the resident was readmitted from the hospital with a diagnosis of acute respiratory failure and volume overload. The care plan was supposed to include daily weight monitoring and reporting any significant weight gain to the provider, but this was not done. Interviews with facility staff revealed that the missing weight should have been identified and that the care plan should have been updated to reflect the resident's condition and physician's orders.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary homelike environment for residents on three of four units, as observed and reported by surveyors. The deficiencies included unclean living spaces with odors, dirt, debris, and soiled areas, as well as the presence of mouse droppings that were not removed, leading to unsanitary conditions. Observations revealed soiled hallway walls, rooms with strong odors of body odor and urine, heavily soiled bedding, and torn mattresses. Additionally, there were mouse droppings scattered in various rooms, closets, and common areas, contributing to the unsanitary environment. Interviews with residents indicated dissatisfaction with the cleanliness of their rooms and the presence of mice. One resident reported seeing mice on several occasions and noted a decline in the quality of housekeeping services, mentioning that rooms were only being swept and not mopped. Another resident confirmed the presence of mouse droppings in their room and expressed dissatisfaction with the cleaning services. These resident accounts were corroborated by observations of dirty rooms with evidence of mouse droppings. Staff interviews revealed that housekeeping staff were responsible for cleaning resident rooms daily, including high-touch areas, trash removal, sweeping, mopping, and bathroom cleaning. However, it was noted that the nursing staff was responsible for changing soiled linens. The maintenance director acknowledged the ongoing issue with mice infestation and the need for better housekeeping practices to address the unsanitary conditions. Despite monthly pest control visits and efforts to remove mice, the facility failed to ensure that mouse droppings were cleaned up and that surfaces were properly sanitized.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 494 citations issued within 25 miles in the last 12 months — including the 8 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 Englewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Englewood Post Acute And Rehabilitation | 0.1 mi | ★★★★★ | 0 | 0 |
| Julia Temple Healthcare Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Cherrelyn Healthcare Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Suites At Clermont Park Care Center, The | 2.6 mi | ★★★★★ | 8 | 0 |
| Heights Care & Rehabilitation Llc | 2.7 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.