Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Ark Healthcare & Rehabilitation At St. Camillus during CMS and state inspections, most recent first.
Failure to Provide or Document Showers: A resident with depression, schizophrenia, and moderately impaired cognition required assistance with bathing and was scheduled for showers twice weekly, but the record showed bathing documented only three times and did not specify whether it was a shower or sponge bath. The resident reported mostly receiving sponge baths and only one shower in several weeks, with no refusals documented. Staff could not verify when the last shower occurred, and the DON stated the bathing documentation did not distinguish between showers and sponge baths.
Dietary staff failed to consistently complete required food safety logs for food temperatures, refrigeration/freezer temperatures, dishwasher temperatures, and sanitizer PPM levels, and a staff member was observed preparing and serving breakfast with visible facial hair and no beard guard. The FSD said 2025 log sheets were unavailable, and the ADM acknowledged the logs were not consistently completed. The staff member later returned wearing a beard guard after the surveyor’s inquiry.
COVID-19 vaccine education and documentation were deficient. Staff education specific to the vaccine was not located, and an RN stated training covered infection control generally but did not offer the vaccine to staff. For residents, documentation was incomplete for vaccine education, verbal consent, and eligibility screening, including missing consent pages and no recorded screening process for a resident whose conservator gave verbal consent.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with dementia and ESRD was fed breakfast while seated in a wheelchair, but an NA stood over the resident during the meal instead of sitting. The NA said she stood because no chair was available and the resident needed to eat before leaving for several hours. An LPN later brought a chair and directed the NA to sit, and the DON stated aides must sit, maintain eye contact, and converse to support a dignified dining experience; the facility feeding policy also says staff are not to stand while feeding a resident.
A cognitively intact resident with ulcerative colitis had a personal funds account with the facility, but the BOM could not show that quarterly account statements had been consistently provided. The BOM stated residents responsible for themselves should receive statements in person and sign for them, yet prior documentation of receipt was unavailable until the resident was given the current quarterly statement and signed it.
The facility failed to update PASRR when two residents developed new psychiatric diagnoses after their initial screens. One resident with dementia later had anxiety, depression, and bipolar disorder documented, with psychotropic meds ordered, but the state agency was not notified. Another resident with dementia, seizure disorder, anxiety, depression, and bipolar disorder also had new mental health diagnoses and psychotropic treatment documented without a PASRR update. The SW acknowledged the missed updates during chart review.
A resident admitted with pneumonia and already at risk for pressure ulcers developed a boggy left heel with intact skin. Although the APRN was notified and wound/MD orders directed heel offloading and skin prep, the care plan and care card were not updated for 22 days to reflect the new heel issue or the offloading interventions. Staff stated the care card flows from the care plan and that LNs would need to tell nurse aides about heel offloading, but the resident’s plan of care still only reflected an existing buttock DTI from admission.
Inconsistent sacral wound treatment occurred for a resident with dementia and DM who had an order for daily cleansing, Medi honey gel, and a dry dressing. During an observed dressing change, no old dressing was found on the resident, and staff reported there was no PRN order for dressing changes if the dressing fell off. An NA had already assisted the resident with morning care and did not see a dressing in place, and the wound care MD stated the dressing was intended to provide moisture, support, and antibacterial protection.
Therapeutic diet orders were not followed for a resident with ulcerative colitis and diverticulitis. The resident had a low fiber diet order with double portions/double protein, but the lunch tray was missing items listed on the meal ticket, and dietary staff were unsure which foods were appropriate for the diet. The Dietitian said low fiber is a therapeutic diet, while the facility diet manual listed broccoli as not allowed on that diet.
Incomplete Vaccine Consent and Education Documentation: The facility failed to consistently document vaccine eligibility screening and failed to show that residents or responsible parties received flu and pneumococcal education materials before consent. Records for three residents showed blank or incomplete screening sections, missing dates, missing staff signatures, and no clear evidence of signed acknowledgment that vaccine fact sheets or education on risks and benefits were provided before administration.
A resident with severe cognitive and physical impairments, requiring two-person assistance for bed mobility, was left unattended by a single nurse aide during incontinent care. The aide attempted to turn the resident alone, resulting in the resident falling from bed and sustaining a displaced spiral femur fracture that required surgical intervention. This occurred despite clear physician orders and care plan directives for two-person assistance and use of bed rails.
The facility failed to provide accessible contact information for the State Long-Term Ombudsman Program. Residents were unaware of the Ombudsman and where to find contact details. The information was posted high on elevator walls, inaccessible to wheelchair users and not visible to those facing forward. It was also absent from bulletin boards outside elevators and on units, violating facility policy.
The facility did not inform residents about the grievance process or ensure that grievance forms were accessible. Residents were unaware of how to complete a grievance or where to find the forms. A social worker could not locate the forms in the designated area and acknowledged they were not easily accessible. Despite a request, a copy of the grievance policy was not provided.
The facility failed to revise care plans for three residents, leading to deficiencies in managing physical limitations, skin integrity, and fall risk. A resident with hand deformities did not have a care plan update to manage the condition. Another resident with a stage 3 pressure ulcer lacked a care plan for offloading boots, despite recommendations. A third resident's care plan was not updated after a fall, missing necessary interventions.
A resident at risk for pressure ulcers developed a new DTI on the left heel due to the facility's failure to consistently document turning and repositioning. Despite recommendations from a wound physician, the facility did not obtain physician's orders for offloading boots, contributing to the ulcer's progression to stage 3. Interviews revealed a lack of communication and documentation regarding pressure-relieving interventions, indicating non-compliance with the facility's skin care management policies.
The facility failed to ensure timely evaluation and treatment for residents with limited mobility and contractures. A resident developed bilateral hand deformities without proper evaluation or treatment, while another experienced contractures post-stroke with delayed intervention. Additionally, a resident prescribed splints for contracture management did not receive them as ordered, with staff unaware of the requirements.
The facility's kitchen was found to be unsanitary, with issues such as dirty ceiling tiles, a broken dishwasher cover, and unlabeled food items. Temperature logs were incomplete, and a cook was not wearing a beard guard. The Dietary Manager acknowledged these deficiencies.
The facility failed to properly dispose of garbage and refuse, with numerous debris items found alongside the dumpsters, including mattresses, televisions, and broken furniture. The Dietary Director had informed the Maintenance Director about the need for cleanup two weeks prior, and the Maintenance Director confirmed the situation, stating that a company was scheduled to pick up the items.
The facility failed to investigate a missing item report for a resident, resulting in confusion about the item's recovery. Additionally, the facility environment was unsanitary, with a rusted medicine cabinet, dusty fan, and poorly maintained shower rooms. Maintenance staff were unaware of repair needs, and there was no documentation of maintenance rounds or cleaning policies.
A facility failed to ensure the accuracy of the MDS assessment for a resident with a serious mental illness. The resident, diagnosed with dementia and schizoaffective disorder, was incorrectly coded on the MDS as not having a PASRR related condition. An RN responsible for MDS coding admitted to the oversight, despite the RAI instrument directing that such conditions be coded under Section A 1500 PASRR related condition.
A resident with Type 2 diabetes and incontinence was given Lactulose syrup borrowed from another resident's supply due to a depletion of their own medication. The LPN admitted to routinely borrowing medications, contrary to facility policy, which states that medications should not be shared and the pharmacy should be contacted if a medication is unavailable.
A resident with heart failure, diabetes, and neuropathy was found with long, dirty fingernails despite being dependent on staff for personal hygiene. The resident had requested nail care but did not receive it, and there was no documentation of nail care being offered or refused. Staff interviews revealed no specific schedule for nail care, and the DNS stated that staff should proactively offer nail care. The facility's policy required daily cleaning and regular filing of nails.
A resident with Alzheimer's and wandering behavior was inadequately supervised, leading to unsupervised wandering and access to potentially hazardous items. Despite being on 15-minute checks, the resident was observed without supervision, entering another resident's room, and handling personal items, highlighting a failure in implementing the care plan and facility policy.
A facility failed to maintain a complete communication log for a resident receiving dialysis, missing critical information such as nurse names, access site conditions, vital signs, and meal times. Staff interviews revealed inconsistencies in understanding documentation requirements, leading to incomplete records despite the facility's policy for comprehensive communication with the treatment center.
A facility failed to ensure staff was knowledgeable about using electronic care cards, leading to a resident experiencing pressure on their feet and legs due to improper use of offloading booties. The RN supervisor could not find a physician order or care plan for the booties, and a nurse aide was unaware of their necessity due to a lack of available care cards and reliance on verbal reports. The process for reviewing assignments and documenting care on electronic tablets was not followed, and there was no documentation of the booties' implementation or effectiveness.
A resident's prescribed Lactulose medication was unavailable, leading an LPN to use another resident's medication, contrary to facility policy. The facility's policy prohibits borrowing medications and emphasizes timely reordering to ensure availability.
The facility's PBJ data for Quarter 3 of 2023 was found to be incomplete and inaccurate, with excessively low weekend staffing levels. Despite meeting state staffing requirements on certain dates, the HR Director could not explain the low weekend staffing trigger. Staffing data was compiled from payroll and agency invoices and submitted to CMS by an outside consultant.
Failure to Provide or Document Showers
Penalty
Summary
The facility failed to ensure Resident #23 was provided and/or offered showers. Resident #23 was admitted with diagnoses including depression and schizophrenia, had moderately impaired cognition, had not exhibited refusal of care, and required moderate assistance with bathing. The resident’s care plan and nurse aide care card identified the need for supervision with bathing and dressing, and the facility’s bathing/shower policy stated each resident would be offered a full bath or shower at least weekly. Bathing flowsheets from admission through 4/21/2026 showed bathing was documented only three times, and the documentation did not specify whether the care provided was a shower or a sponge bath. Nursing progress notes did not identify any refusal of care or refusal of showers. The resident stated he/she had been receiving sponge baths and had only received one shower approximately three weeks earlier, with none since, and said he/she preferred showers and would accept them if offered. Staff interviews confirmed the resident was scheduled for showers twice weekly, but the LPN and NA could not verify when the last shower occurred, and the DON stated the flowsheets did not distinguish between showers and sponge baths, making it impossible to determine what type of bathing was provided.
Incomplete Dietary Logs and Missing Beard Guard During Meal Service
Penalty
Summary
The dietary department failed to consistently document required food safety checks before meals were served. During a tour of the department, surveyors found that the 2025 log sheets for breakfast, lunch, and dinner food temperatures were not completed, and the 2025 refrigerator, freezer, dishwasher temperature, and sanitizer PPM log sheets were also not completed. The Food Service Director stated on interview that he did not have any log sheets for 2025 and said the only daily logs available were from 1/1/2026 through 4/20/2026. The Administrator later acknowledged that the daily log sheets for food temperatures, refrigerator/freezer temperatures, dishwasher temperatures, and sanitizer PPM levels were not consistently completed during 2025. Surveyors also observed a dietary staff member preparing and serving breakfast foods at the steam table with visible facial hair and no beard guard. The foods on the steam table included scrambled eggs, bacon, sausage, toast, and bread. The Admissions Director stated that dietary staff are required to wear hair restraints, including beard guards, while preparing or serving food, and said the staff member must have removed his beard guard and forgotten to put on a new one. After the surveyor’s inquiry, the staff member left the kitchenette and returned wearing a beard guard.
COVID-19 Vaccine Education and Documentation Deficiencies
Penalty
Summary
The facility failed to educate residents and staff on the COVID-19 vaccine, offer the vaccine to eligible residents and staff after education, and properly document vaccination status. During an interview and document review, the Assistant Director of Nursing Services/Infection Preventionist was unable to locate specific staff education about the COVID-19 vaccine, could not identify that staff were offered the vaccine, and could not indicate where staff could obtain vaccination. The Staff Development Nurse stated that staff training covered COVID infection and staff roles in infection control, but was not specific to the COVID-19 vaccine and did not include offering the vaccine to staff. For residents, the Assistant Director of Nursing Services/Infection Preventionist could not provide evidence of what educational materials were given or who obtained verbal consent for a resident who refused vaccination, despite a form indicating receipt and review of the CDC vaccination statement. Another resident’s record showed verbal consent from the conservator for influenza and COVID-19 vaccination, but the consent form lacked the second page with the conservator’s signature attesting to receipt of the vaccination information sheet, and there was no documentation of the screening process used to determine eligibility for the vaccine. The Assistant Director of Nursing Services/Infection Preventionist stated that residents are screened before receiving the COVID-19 vaccine but that the screening is not documented, and that education and verbal consent are obtained by phone without documentation of the educational source provided to residents or responsible parties.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Dignified Dining Not Maintained During Assisted Feeding
Penalty
Summary
The facility failed to ensure a dignified dining experience for Resident #3, who had diagnoses including dementia and end-stage renal disease. The physician ordered a regular renal diet with thin liquids, and the annual MDS identified the resident as having severely impaired cognition and requiring setup or cleanup assistance for eating. The resident care plan identified risk for further decline in ADL self-care related to increased weakness, fatigue, and continuous deconditioning, with interventions including adaptive equipment, a scoop plate, a double-handled sippy cup, and assistance of one with eating. During breakfast observation, Resident #3 was seated in a wheelchair at a round table in the lounge while an NA fed the resident. The NA stood to the left side of the wheelchair and fed the resident scrambled eggs and fortified cereal, periodically offering liquids from a two-handled cup, and no chair was available for the NA to sit. The NA stated she stood because the resident needed to eat before going out for several hours and because no chairs were available. An LPN later retrieved a wheeled chair and directed the NA to sit while feeding the resident, and the LPN stated nurse aides should sit while feeding a resident to promote dignity. The DON also stated nurse aides must sit while feeding residents, maintain eye contact, and engage in conversation to promote a dignified dining experience. The facility feeding policy stated staff are not to stand while feeding a resident.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
Properly hold, secure, and manage each resident's personal money deposited with the nursing home was not maintained for one cognitively intact resident with ulcerative colitis. The quarterly MDS assessment identified the resident as cognitively intact, and the Business Office Manager confirmed the resident had a personal account with the facility and was responsible for himself/herself. The BOM also stated that residents who are responsible for themselves are expected to receive quarterly account statements in person and sign to acknowledge receipt. During the review, the BOM was unable to provide documentation showing that the resident had received prior quarterly account statements. The BOM stated she was unaware of the prior process used by previous Business Office Managers and would contact the regional BOM to determine whether documentation existed. Because the resident reported not having received prior quarterly statements, the BOM provided the January 2026 through March 2026 quarterly statement and obtained the resident's signature to acknowledge receipt at that time.
PASRR Updates Not Submitted After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure the state agency was updated when two residents received new psychiatric diagnoses after their initial PASRR determinations. For Resident #21, a PASRR Level 1 screen dated 11/27/24 identified dementia with no mental health diagnosis and granted a dementia exemption. After that screen, the resident was documented with new psychiatric diagnoses including anxiety, depression, and later bipolar disorder, with psychiatric APRN notes and physician orders reflecting treatment with psychotropic medications such as Seroquel, Depakote, Trazodone, and Valproic Acid. The clinical record did not show that the PASSR contracted agency was notified of these new diagnoses from 2/26/25 through 4/22/26 so that an additional Level 1 and Level 2 screen could be completed. For Resident #117, a PASRR Level 1 screen dated 11/18/22 identified no mental health diagnosis known or suspected and stated that Level 2 was not required unless changes occurred or new information refuted the findings. After that screen, the resident was documented with new psychiatric diagnoses, including major depression disorder, anxiety, and bipolar disorder, along with dementia and seizure disorder. The record included psychiatric APRN notes and physician orders for psychotropic treatment, including Depakote, but did not show that the state agency was notified of the new psychiatric diagnoses after they were added. During interview, the Social Worker stated she was responsible for reviewing PASRRs for new admissions and for submitting updates when a resident received a new mental health diagnosis. She acknowledged that both residents' most recent PASRRs did not include the later psychiatric diagnoses and stated she had missed the discrepancy during her audit for Resident #21 and could not identify why Resident #117's PASRR had not been updated. After surveyor inquiry, PASRR Level I screen submission requests were made for both residents to report the new diagnoses.
Failure to Update Care Plan for New Heel Pressure Injury
Penalty
Summary
The facility failed to revise Resident #1’s plan of care after the resident developed a left heel pressure injury. Resident #1 was admitted with pneumonia, was cognitively intact, and the admission MDS indicated the resident was at risk for pressure ulcers and had an unstageable deep tissue injury. The care plan documented a pressure ulcer on the right buttock present on admission and included weekly skin checks, good nutrition, and incontinent care, but it did not reflect the later change in skin status involving the left heel. A Health Status Note documented that the left heel was boggy with intact skin and that bilateral heel boots were applied, and the APRN was notified with no new orders. The wound consultant and physician orders directed heel offloading and skin prep to the heels, and later orders addressed checking the air mattress each shift. On observation, the resident was in bed with blue booties on both feet. During interview and record review, the RN supervisor stated the care cards flow from the care plan and that licensed nurses would need to inform nurse aides about heel offloading, but the care plan had not been updated for 22 days to include the left heel issue or heel offloading interventions. The facility policy stated care cards are to be updated as needed with changes to the resident plan of care.
Inconsistent Sacral Wound Treatment Due to Missing PRN Order
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Resident #59 was admitted with diagnoses of dementia and diabetes mellitus and was assessed as severely cognitively impaired, requiring substantial to maximal assistance with toileting and supervision or touching assistance with bathing. A physician’s order dated 4/17/2026 directed staff to cleanse the sacral wound with vashe, apply Medi honey gel, and cover it with a dry dressing daily. The treatment administration record from 4/17/2026 through 4/23/2026 showed the sacral dressing was changed as ordered on the day shift. On 4/24/2026 at 1:23 PM, an observation of the sacral dressing change found no old dressing over the resident’s sacral wound. The resident was in bed wearing underwear, pants, and a shirt, and the LPN could not locate the dressing in the resident’s clothes or bed. Review of the physician’s orders did not identify a PRN order for dressing changes. The LPN stated that if a dressing fell off, he would notify the nursing supervisor to obtain a PRN order, and he was not aware the resident did not have a sacral dressing on or that it had fallen off. At 1:30 PM, an NA stated she assisted the resident with washing and dressing before breakfast and did not see a dressing on the resident. At 1:46 PM, the wound care provider stated the Medi honey was intended to provide autolytic debridement, moisture, and antibacterial protection, and the foam dressing would provide moisture, support, and protection from bacteria; the provider also stated that without the dressing in place, the wound would be at higher risk for infection and delayed healing.
Therapeutic Diet Not Followed for Resident with Low Fiber Order
Penalty
Summary
The facility failed to ensure that a resident with a therapeutic diet was provided food items consistent with the prescribed diet. Resident #52 had diagnoses of ulcerative colitis and diverticulitis, and the physician ordered a regular diet with regular texture, thin consistency, low fiber, and double portions/double protein with all meals. The quarterly MDS identified the resident as cognitively intact and not on a therapeutic diet despite the low fiber order, while the care plan identified the resident as at risk for malnutrition related to multiple chronic diseases and exacerbation of ulcerative colitis, with interventions including supplements, preferred foods, and the prescribed low fiber diet with double portions. During observation of lunch, Resident #52’s tray included a meal ticket noting a protein shake and assorted sandwiches, but those items were not present on the tray. The Dietary Manager stated staff prepared trays based on the meal ticket but was unsure which foods were appropriate for a low fiber diet and relied on the menu rather than specific dietary guidance. The Dietitian identified low fiber as a therapeutic diet and stated broccoli could be served, but the facility’s diet manual identified broccoli as not allowed on a low fiber diet. The Dietitian also stated the electronic diet order system did not include a selectable low fiber option and required entry in the comment section.
Incomplete Vaccine Consent and Education Documentation
Penalty
Summary
The facility failed to consistently document the vaccination screening process and failed to provide evidence that residents or responsible parties received copies of educational materials before deciding to accept or decline influenza and pneumococcal vaccines. For Resident #22, who had diabetes mellitus, the Universal Vaccine Consent and Administration Record dated 10/23/2024 showed verbal consent from the Conservator of Person for the flu vaccine, but the screening section for eligibility was left blank, page 2 was missing another consent form without a date, and the attorney-supplied flu consent form had no staff signature and left the screening area blank. The page 2 section indicating receipt of a copy and understanding of the educational material was also not signed by the attorney. For Resident #49, who had pyelonephritis, the Universal Vaccine Consent and Administration Record dated 10/9/2024 showed verbal consent from the resident for flu vaccine, but the screening area was incomplete and page 2 did not show evidence that educational materials were received or that the resident understood the forms. Another undated consent form with the resident's name was present, with the same printed name appearing in the signature section on both pages without a date. For Resident #63, who had Parkinson's disease, the consent record was not dated, verbal consent was noted from a family member, but the staff member obtaining consent was not identified, the screening area on page 2 was incomplete, and the form did not show receipt of educational materials prior to vaccination. The ADNS/Infection Preventionist stated that residents are screened before flu vaccination but the screening is not documented, verbal consent and education are obtained by phone, and the facility could not provide educational resources that were given to residents or responsible parties; the facility policy stated that residents or responsible parties would receive vaccine fact sheets and education on risks and benefits before administration.
Failure to Provide Required Assistance with Bed Mobility Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to provide the required assistance with bed mobility for a resident with significant cognitive and physical impairments. The resident had diagnoses including Parkinson's disease, dementia, abnormal gait, and generalized muscle weakness, and was assessed as severely cognitively impaired and fully dependent for bed mobility and ADLs. Physician orders and the care plan specified that two staff members were required to assist with bed mobility, and that 1/4 bed rails should be used as an enabler during repositioning. Despite these directives, a nurse aide provided incontinent care to the resident alone, without seeking assistance, because other aides were busy and she believed she could manage by herself. During the process of turning the resident, the aide turned the resident onto their right side, at which point the resident's foot slid off the mattress and the resident fell out of bed onto the floor. Initial assessment did not reveal injuries, but swelling and deformity of the left leg were noted the following morning, and subsequent hospital evaluation confirmed a displaced spiral fracture of the left femur requiring surgical intervention. The Director of Nursing confirmed that the nurse aide did not follow physician orders, which were in place to prevent such falls, and the facility's fall prevention policy required individualized interventions to prevent falls.
Inaccessible Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure that residents were provided access to the contact information for the Office of the State Long-Term Ombudsman Program in a manner that was accessible and understandable. During a meeting with eight residents, it was identified that they were unaware of who the State Ombudsman was and where to locate the contact information. An interview with a social worker revealed that the contact information was posted on bulletin boards located on each elevator. However, observations showed that the information was posted high on the back wall of the elevator, making it inaccessible to individuals in wheelchairs and not visible to residents facing the front of the elevator. Additionally, the information was not posted on bulletin boards outside the elevator doors or on the units, contrary to the facility's policy requiring such postings to be accessible and understandable to residents and their representatives.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to inform residents about the grievance process and ensure that grievance forms were accessible and available to residents and visitors. During a meeting with eight residents, it was revealed that they were unaware of how to complete a grievance or where to find the forms. An interview with a social worker indicated that the grievance forms were supposed to be located in the nursing office behind the nursing station on both floors. However, during an observation, the social worker was unable to locate the forms in the designated area and could not provide any other location for them. The grievance policy, which was reviewed, stated that forms should be easily accessible, especially for those wishing to remain anonymous. The social worker acknowledged that the forms were not easily accessible and mentioned that the location would be changed to better meet the residents' needs. Despite a request, a copy of the facility's grievance policy was not provided.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #13, who was identified with physical limitations of the hands. Despite the resident's left-hand deformity being noted in an interdisciplinary rehabilitation screen and bilateral hand contractures being documented in progress notes, the care plan did not include any interventions for managing these deformities to prevent progression. The Director of Nursing acknowledged that the care plan should have been revised once the physical limitation was identified. For Resident #98, the facility did not develop a care plan to address the resident's skin integrity to prevent further skin breakdown. The resident, who had a stage 3 pressure ulcer on the left heel, was recommended to use offloading boots by a wound physician. However, there was no physician's order for the boots, and the care plan was not updated to reflect this recommendation. The wound care nurse confirmed that the recommendation for offloading boots was overlooked, and the care plan did not include this intervention until after surveyor inquiry. Resident #54 experienced a fall, but the facility failed to revise the resident's care plan timely post-fall. Although the care plan indicated the resident was at risk for falls, it did not show updated interventions after the fall occurred. The Director of Nursing stated that staff are expected to update the care plan with new interventions to prevent injuries after a fall, but the care plan reviewed was the most updated version available, lacking any new interventions post-fall.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to consistently provide evidence of turning and repositioning a resident, leading to the development of a pressure ulcer. The resident, who was at risk for pressure ulcers due to paraplegia, diabetes mellitus, and incontinence, developed a new Deep Tissue Injury (DTI) on the left heel. Despite having a care plan that included interventions to prevent pressure ulcers, there were multiple instances of missing documentation for turning and repositioning the resident, which is a fundamental practice to prevent pressure ulcers. Additionally, the facility did not obtain physician's orders for recommendations made by a consulting wound physician, which contributed to the further decline of the pressure ulcer. The wound physician recommended the use of offloading boots to prevent further injury, but there was no physician's order for their use, and the care plan did not reflect this intervention. The resident's pressure ulcer progressed from a DTI to a stage 3 pressure ulcer, indicating a lack of timely and appropriate intervention. Interviews with staff revealed that there was a lack of communication and documentation regarding the use of offloading boots and other pressure-relieving interventions. The facility's policies on skin care management and prevention of pressure injuries were not adequately followed, as evidenced by the missing documentation and lack of physician's orders for recommended treatments. This deficiency highlights the need for consistent documentation and adherence to care plans to prevent the development and worsening of pressure ulcers.
Failure to Address Mobility and Contracture Needs
Penalty
Summary
The facility failed to ensure timely evaluation and treatment for residents with newly identified limited mobility and contractures. Resident #13, who was admitted with mild cognitive impairment and other conditions, developed bilateral hand deformities over time. Despite multiple screenings and observations indicating the presence of contractures, a full evaluation to determine the extent of the limitations and appropriate treatment was not conducted until after surveyor inquiry. The lack of timely intervention and preventative measures potentially contributed to the progression of the contractures. Resident #97, diagnosed with cerebral infarction and hemiplegia, also experienced a lack of timely evaluation and intervention for contractures. Initial therapy sessions identified impairments and recommended services to increase functional activity tolerance. However, after discharge from therapy, no further recommendations were made to prevent further loss of mobility. Subsequent screenings noted increased tone and contractures, but no evaluations or interventions were conducted until prompted by surveyor inquiry. The absence of a documented physician's order for a recommended splint further delayed necessary treatment. Resident #86, with a history of hemiplegia and cerebral infarction, was prescribed splints for contracture management. However, the facility failed to ensure the application of these splints as per physician's orders. Observations revealed that the resident was not wearing the prescribed splints, and staff interviews indicated a lack of awareness and communication regarding the splint application. The facility's failure to adhere to its own policies and procedures for splint application and staff training contributed to the deficiency.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour of the Dietary Department. Several issues were identified, including ceiling tiles with a brown substance, a broken and discolored dishwasher cover, and black substances around the dishwasher edges and on the tiles in the kitchen and dishwasher room. The floor throughout the kitchen was dirty with debris and food, and the second-floor nourishment refrigerator had a red substance inside. Additionally, the baking oven and cooktop were covered with a brown substance, and the ceiling vent in the main kitchen had a brown substance around it. The facility also failed to ensure proper food labeling and storage, with numerous items in the dry goods storage area and freezer found unlabeled or undated. The temperature logs for the freezer and refrigerator were missing several evening readings, and the day cook was not wearing a beard guard as required by policy. Interviews with the Dietary Manager revealed that staff were responsible for labeling and dating items, and that hair coverings, including beard guards, were to be worn around food. The Dietary Manager acknowledged the issues and identified that the facility had hired a company to steam clean the kitchen, but it was not as clean as expected.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed by surveyors. During an inspection with the Dietary Director, numerous debris items were found alongside the dumpsters and facility, including discarded mattresses, old televisions, a nightstand, a tire, broken pieces of wood, and chairs. The Dietary Director acknowledged that the area was not well-kept or cleaned and mentioned that these items were from maintenance, not dietary-related. He had informed the Maintenance Director about the need for cleanup two weeks prior, and noted that the dumpsters are emptied twice a week. The Maintenance Director confirmed that the Dietary Director had spoken to him about the debris on June 29, 2024. He identified the items beside the dumpsters and stated that a company was scheduled to pick them up on the day of the inspection. He also acknowledged his responsibility for maintaining the cleanliness of the dumpsters and surrounding area, and stated that the area had only been in that condition since June 29, 2024.
Deficiencies in Resident Safety and Facility Maintenance
Penalty
Summary
The facility failed to thoroughly investigate a report of a missing item for a resident diagnosed with morbid obesity, heart failure, and an above-the-knee amputation. The resident, who was cognitively intact, reported a missing Apple watch, which was initially documented as recovered by a social worker. However, subsequent interviews revealed that the watch had not been located, and there was confusion about whether the resident actually possessed the watch. The facility's policy for missing items was not followed, as there was no detailed investigation or conclusion documented regarding the missing watch. The facility environment was found to be unsanitary and not homelike, with a rusted medicine cabinet without doors and disconnected light bulb sockets in a bathroom. Maintenance staff were unaware of how long the cabinet had been in disrepair, and there was no documentation of repair requests or maintenance rounds. Additionally, a resident with chronic obstructive pulmonary disease had a fan in their room that was covered in dust, which had not been cleaned for at least six months. The facility lacked a policy for cleaning fans, and the housekeeping/maintenance director was unsure of the cleaning procedures. The facility's shower rooms were observed to be in poor condition, with chipped and cracked paint, black substances on floors and walls, torn wallpaper, and rusty shower curtain rods. The director of housekeeping/maintenance acknowledged the need for repairs but failed to document any concerns in the environmental rounds logs. The facility did not provide a maintenance policy or documentation of maintenance rounds, indicating a lack of oversight and attention to maintaining a safe and sanitary environment for residents.
Inaccurate MDS Assessment for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident identified with a serious mental illness. This deficiency was identified during a review of clinical records, facility policy, and interviews. Specifically, for one of the sampled residents, the facility did not accurately code the Preadmission Screening and Resident Review (PASRR) related condition on the MDS. The resident in question was admitted with diagnoses including dementia and schizoaffective disorder, and a PASRR level II outcome had previously identified the resident as meeting criteria for a serious mental illness. However, the Annual MDS assessment incorrectly indicated that the resident did not have a PASRR related condition for serious mental illness or intellectual disability. An interview with a Registered Nurse (RN) revealed that she was responsible for MDS coding and acknowledged that the PASRR should be coded on the MDS upon admission, annually, and with significant changes. Despite this, the RN entered incorrect information on the MDS due to an oversight, even though social services were responsible for coding the MDS for residents with serious mental illness. The Resident Assessment Instrument (RAI) used for MDS coding directs that all conditions related to serious mental illness or intellectual disability be coded under Section A 1500 PASRR related condition.
Medication Borrowing Leads to Deficiency
Penalty
Summary
The facility failed to meet professional standards of quality during medication administration for a resident diagnosed with Type 2 diabetes mellitus and incontinence. The resident had a physician's order for Lactulose Oral Solution to be administered daily for constipation. However, during an observation, it was noted that the Lactulose syrup administered to the resident was borrowed from another resident's supply because the resident's own supply was depleted. The LPN involved admitted that it was their usual practice to use other residents' medications when a resident's supply was unavailable. The facility's policy clearly states that medications prescribed for one resident should never be administered to another resident, and if a medication cannot be located, the pharmacy should be contacted. Despite this policy, the LPN did not adhere to the guidelines, leading to the deficiency. The RN Unit Manager confirmed that the facility's practice is not to borrow medications and emphasized the importance of reordering medications to ensure availability for residents.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that a resident's fingernails were clean and cut, as observed in the case of a resident with diagnoses including heart failure, diabetes mellitus, and neuropathy. The resident was cognitively intact and required substantial assistance for personal hygiene. Despite being dependent on staff for bathing and personal hygiene, the resident's fingernails were observed to be long with a black and brown substance underneath. The resident reported having requested nail care about a week prior but could not recall the staff member they spoke to. The medical records from the relevant period did not document any offer or refusal of nail care. Interviews with staff revealed that there was no specific schedule for cutting residents' fingernails, although nurse aides were expected to notice and address long or dirty nails during routine care. The Director of Nursing Services (DNS) indicated that staff should proactively ask residents if they would like their nails cut, rather than waiting for residents to request it. The facility's policy on fingernail care emphasized daily cleaning and regular filing to prevent infection, but this was not adhered to in the case of the resident in question.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with Alzheimer's disease, disorientation, wandering, unspecified dementia, and unspecified psychosis. The resident was identified as cognitively impaired and at risk for elopement, with a care plan that included frequent safety checks and supervision when off the unit. Despite these interventions, the resident was observed wandering without supervision, entering another resident's room, and handling personal items, which posed a safety concern. On the morning of the incident, the resident was seen walking in the hallway without undergarments and later wandering in socks without shoes. The resident was redirected by staff but continued to wander unsupervised, eventually obtaining a bowl of applesauce from a medication cart and entering another resident's private room. The resident handled items such as shaving cream and a bottle of sterile water and attempted to drink from a used coffee mug before being assisted by a nurse aide. The facility's policy on wandering and elopements aimed to prevent harm while maintaining a least restrictive environment. However, the resident's frequent checks were not adequately documented or executed, as evidenced by the resident's unsupervised wandering and access to potentially hazardous items. The Director of Nursing Services acknowledged the safety concerns and indicated that the resident was on 15-minute checks, but the checks were not effectively implemented, leading to the observed deficiencies.
Incomplete Dialysis Communication Log for Resident
Penalty
Summary
The facility failed to consistently maintain a communication log for a resident receiving specialized dialysis treatment. The resident, diagnosed with end-stage kidney disease, dementia, and Parkinson's disease, required dialysis three times a week. The care plan highlighted the risk of dehydration and fluid deficit, necessitating close monitoring of intake, output, and vital signs. However, the communication log, which was supposed to document the resident's status and treatment details, was found to be incomplete on several occasions. Missing information included the nurse's name, the condition of the specialized access site, the resident's last vital signs, and the time of the last meal. Interviews with facility staff revealed discrepancies in understanding the documentation requirements. The nurse unit manager expected the log to include vital signs, weight, and access site status, while an LPN believed only vital signs were necessary. The facility's policy required comprehensive communication between the long-term care facility and the specialized treatment center, but this was not consistently followed. The specialized treatment center did not have access to the resident's electronic medical record, relying instead on the communication log and telephone updates, which were not adequately maintained.
Failure to Ensure Staff Knowledge on Electronic Care Card Use
Penalty
Summary
The facility failed to ensure that staff was knowledgeable about using the electronic care card to provide resident care according to the plan of care. During an observation and interview, it was found that a resident was experiencing pressure on various parts of their feet and legs while seated in a wheelchair. Although there was an indication that offloading booties were ordered for the resident, the RN supervisor could not find a physician order or care plan for their use. The RN supervisor also could not explain how licensed nurses were supposed to monitor for pressure on the resident's feet and heels while out of bed. Additionally, a nurse aide who had not worked on the resident's unit for some time was unaware of the need for pressure-relieving booties, as there were no care cards available in the resident's room or at the nurse's station. The nurse aide relied on verbal reports from the outgoing aide and the resident's own instructions for care. The RN supervisor identified that the process for reviewing assignments and documenting care on electronic tablets was not followed, as the nurse aide did not review the assignment at the beginning of the shift. Furthermore, there was no documentation of the implementation, consistent use, or evaluation of the effectiveness of the booties, and the nurse aide had not received prior education on using the electronic documentation system.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's supply of Lactulose medication was available for administration as per the physician's orders. Resident #45, who has a diagnosis of Type 2 diabetes mellitus and incontinence, was prescribed Lactulose Oral Solution to be administered daily for constipation. During a medication administration observation, it was found that the Lactulose syrup intended for Resident #45 was depleted, and the Licensed Practical Nurse (LPN) used medication prescribed for another resident instead. This action was contrary to the facility's policy, which prohibits borrowing medications from other residents. The incident was observed during a medication administration session, where the LPN admitted to using another resident's medication due to the unavailability of Resident #45's supply. The LPN stated that an order had been sent to the pharmacy the previous day. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed, using the Five Rights, and explicitly states that medication for one resident should never be administered to another. The RN Unit Manager confirmed that the facility's practice is to ensure medications are reordered in a timely manner to prevent such occurrences.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to ensure that its Payroll-Based Journal (PBJ) data for Quarter 3 of 2023 was complete and accurate. A review of the facility's PBJ submissions for this period revealed excessively low weekend staffing levels. Despite meeting minimum state staffing requirements on specific dates, such as May 21 and June 10, 2023, the overall data indicated inconsistencies. The Human Resource (HR) Director explained that staffing data was compiled from the facility's payroll provider and agency staffing invoices, which were then sent to an outside consultant for submission to the Centers for Medicare and Medicaid Services (CMS). However, the HR Director could not account for the low weekend staffing trigger in the PBJ data, suggesting fluctuations in staffing levels that were not accurately reflected in the submissions.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 724 citations issued within 25 miles in the last 12 months — including the 11 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stamford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stamford Care Center | 1 mi | ★★★★★ | 18 | 0 |
| Edgehill Health Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Civita Care Center At Long Ridge | 3.5 mi | ★★★★★ | 1 | 0 |
| Nathaniel Witherell, The | 5.2 mi | ★★★★★ | 3 | 0 |
| Waveny Care Center | 5.7 mi | ★★★★★ | 12 | 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.