Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Bloomfield Center For Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with a neurogenic bladder, recurrent UTIs, and atrial fibrillation was scheduled for a suprapubic tube placement and had preoperative instructions from Interventional Radiology that included holding Eliquis for 48 hours before the procedure. An RN received these instructions verbally, verified them with the provider, and entered an order to hold the anticoagulant for two days, but did not confirm the electronic start and end dates or restart time. As a result, Eliquis doses were held only on the first day, while both doses on the second day and the morning dose before the procedure were administered, contrary to the intended 48-hour hold. The consultation report documented that the procedure was cancelled because Eliquis had not been held for the required time, and the DON later noted that the RN did not document the verbal pre-op orders in a nurse’s note, so a second licensed nurse did not perform a follow-up check of the transcription.
A resident with bladder dysfunction, recurrent UTIs, and atrial fibrillation was scheduled for a suprapubic catheter procedure while receiving Eliquis. Interventional Radiology provided detailed pre-op instructions, including required labs, NPO status, and specific directions to hold Eliquis starting two days before the procedure and to restart it afterward. Although the RN verified these instructions with the provider and entered related orders, she did not fully document the pre-op instructions in the clinical record. The record contained only a note about faxing lab results, and the MAR showed Eliquis was held on one day but still administered on subsequent doses contrary to the intended pre-op plan. The facility’s own documentation policy and the DON’s statements confirmed that all provider communications and pertinent care details should have been accurately and completely recorded, leading to the cited deficiency.
A resident who was totally dependent on staff for care was observed being wheeled down the hallway after a shower with their buttocks exposed, wearing only a hospital gown and no additional covering. Staff, other residents, and a surveyor were able to see the exposed area. The DON confirmed the resident should have been fully covered, and the responsible NA admitted she was aware of the policy but was in a hurry.
A resident with significant medical needs was placed on isolation precautions after a roommate tested positive for Covid, despite testing negative and showing no symptoms. The resident was not allowed to leave the room, was not evaluated for mask use, and was denied access to activities, resulting in missed religious services and social engagement. Facility staff were unclear on CDC guidelines and did not provide physician orders for isolation, leading to the resident's unnecessary confinement.
Two residents did not have comprehensive care plans reflecting their specific needs: one with quadriplegia and communication barriers lacked a documented 24-hour positioning plan and interpreter services, while another with dental pain did not have dental issues included in their care plan, despite clinical documentation and staff awareness.
The facility did not update care plans for two residents after significant changes in condition—one after a decline in mobility leading to pressure injuries, and another after multiple unwitnessed falls. Staff interviews confirmed that required care plan revisions and new interventions were not implemented as per facility policy.
A resident with COPD and other respiratory conditions was found with a portable oxygen cylinder stored sideways on a wheelchair in their room. An unqualified social worker reported administering oxygen to the resident, contrary to facility policy and without proper training, while the DON confirmed only nursing staff should perform this task.
A resident with quadriplegia and intact cognition was not provided with recreation activities suitable for their physical limitations. Although the care plan called for involvement in cognitive and social activities, the resident reported a lack of options due to hand paralysis, and the recreation director confirmed that no specialized programs were offered for residents with physical impairments, contrary to facility policy.
Two residents did not receive weekly skin checks, Braden Scale risk assessments, or timely nutritional evaluations after developing or being admitted with pressure ulcers. The dietician was not informed to assess nutritional needs, and care plans were not updated to reflect changes in condition, contrary to facility policy.
Surveyors found that a portable oxygen cylinder was improperly stored unsecured on a wheelchair, a dependent resident had a nasal foreign body removed by staff instead of being sent to the ED as ordered, and another resident sustained a hand injury from a bed side rail that was used without a required assessment or documentation. These deficiencies involved failure to follow safety protocols, physician orders, and facility policies.
A resident with CHF and other comorbidities was not weighed daily as ordered by the physician, with weights documented only sporadically over several months. Staff interviews confirmed the daily weight order was current and should have been followed, but no explanation was provided for the missed weights, and there was no documentation of refusals or reasons for not weighing the resident.
A resident with multiple medical conditions was administered the wrong IV solution after a provider order was changed, due to staff not verifying the updated order and using an available but incorrect fluid. The error was not detected during shift change or by supervisory staff, and facility protocols for IV verification and monitoring were not followed, resulting in the resident receiving inappropriate IV fluids until a change in condition was noted.
A resident receiving hemolytic treatment with a physician-ordered 1000 cc fluid restriction did not have daily fluid intake tracked or documented, as required. Staff interviews revealed confusion about responsibility for monitoring intake, and the fluid restriction order was not visible on the MAR. The resident was unaware of the restriction, and the facility could not show how total fluid intake was maintained, despite policy requiring such documentation.
A resident with multiple chronic conditions was found with several prescribed medications left unattended at the bedside by an LPN, who did not remain to ensure administration. The resident had not been assessed or approved for self-administration, and facility policy prohibits leaving medications at the bedside without observation.
A resident with COPD, heart failure, and quadriplegia was on isolation precautions for Covid, requiring staff to wear gloves, a gown, and an N-95 mask as posted on the room signage. During care, a nurse aide was observed wearing a surgical mask instead of the required N-95 mask, despite being aware of the correct PPE protocol. The facility's infection preventionist and policy confirmed that staff must follow posted PPE requirements.
Surveyors found dirty trays, fruit flies in a resident's room, and stained carpets in multiple areas. The Housekeeping Supervisor confirmed ongoing pest issues and persistent carpet stains despite recent cleaning efforts, with no documentation available to verify cleaning or carpet replacement plans.
A resident with severe cognitive impairment and multiple health issues experienced a decline in functional abilities, requiring increased assistance with bed mobility, transfers, and ambulation. Although the care plan was updated to reflect these changes, staff failed to complete a significant change MDS assessment within the required timeframe. The decline was not promptly communicated to the DON or identified by the MDS Coordinator until after the resident developed a new pressure ulcer.
Surveyors identified that the facility failed to accurately code MDS assessments for two residents. One resident with a Level II PASRR was incorrectly coded as not having one on the annual MDS, and another resident with significant eating deficits was coded as independent despite documentation and observations showing total dependence on staff for eating. These deficiencies were confirmed through record review, staff interviews, and direct observation.
Two residents with multiple mental health diagnoses did not have accurate or complete Level 1 PASRR screenings, and the facility failed to submit required Level 2 PASRR evaluations after changes in diagnosis. Care plans lacked PASRR information, and staff interviews revealed gaps in PASRR documentation and oversight.
Three residents, including individuals with cognitive impairments, experienced unauthorized withdrawals from their personal funds accounts. In each case, funds were withdrawn in amounts or under circumstances not consistent with the residents' usual patterns, and required documentation such as vendor receipts or proper signatures was missing. Investigation identified a former receptionist as responsible for these unauthorized transactions, which were not in accordance with facility policy or procedures.
A resident with a history of bipolar disorder and dementia, who was alert and independent, was involved in an altercation with a nurse aide over a spilled lunch tray. During the incident, the nurse aide threatened to retaliate if the resident hit her, a statement witnessed by another staff member. This threat caused the resident distress and violated facility policies prohibiting abuse and intimidation.
A witnessed verbal abuse allegation involving a resident with bipolar disorder and dementia was not reported within the required timeframe. The incident, in which a nurse aide threatened to retaliate if struck, was observed by an Administrative Assistant who did not immediately notify the DON as required by policy, resulting in a delayed report.
A resident with a brain tumor, seizure disorder, and behavioral care plan requiring two caregivers was left alone with an LPN who became frustrated, handled the resident roughly, and engaged in a loud verbal altercation. The incident was not properly reported or investigated, and facility documentation was incomplete, failing to ensure the resident was free from abuse as required by policy.
Two residents experienced incidents involving delayed care and alleged mistreatment, which were reported to the DON but not to the State Agency as required. In both cases, the facility did not complete formal investigations or document findings, and failed to follow its policy for immediate reporting and investigation of abuse or neglect allegations.
The facility did not thoroughly investigate or document allegations of abuse and neglect involving two residents. In one case, a resident was reportedly left in soiled incontinence products for extended periods, and in another, a resident alleged emotional abuse by an LPN. The DON was notified but failed to ensure investigations or proper documentation were completed, as required by facility policy.
A resident with a brain tumor, seizure disorder, and behavioral concerns had a care plan requiring two caregivers at all times. An LPN, unaware of this requirement, entered the room alone to provide pain medication and assistance, leading to a distressing interaction where the resident felt emotionally mistreated. The incident was reported to the nursing supervisor and DNS, but the care plan directive was not followed, resulting in a deficiency.
A resident with multiple medical conditions and documented urinary incontinence was not provided with a bladder evaluation upon admission, despite facility policy requiring such an assessment within three days for incontinent individuals. Staff documentation and care plans noted the incontinence, but the necessary evaluation to guide interventions was not completed.
Two residents did not receive timely social services support after reporting incidents of neglect and emotional abuse. In both cases, required follow-up and documentation by social services did not occur, as the responsible social workers were either not notified or did not document any intervention, despite facility policy requiring such actions.
A resident with dementia and a history of aggression physically assaulted three other residents with cognitive and psychiatric conditions on separate occasions, resulting in injuries such as bruising and a bloody nose. Despite care plans and interventions like one-to-one supervision and medication management, the facility did not prevent repeated incidents of physical abuse between residents.
Incorrect Transcription of Preoperative Anticoagulant Hold Order Leading to Procedure Cancellation
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and implement preoperative orders to hold an anticoagulant, resulting in the medication being administered too close to a scheduled procedure and the procedure being cancelled. The resident involved had diagnoses including neuromuscular dysfunction of the bladder, recurrent UTIs, and atrial fibrillation, and was alert and oriented with a BIMS score of 15. The resident’s care plan documented an indwelling catheter for neurogenic bladder with monitoring for UTI symptoms. Interventional Radiology staff called the facility with preoperative instructions for a suprapubic tube placement, including required lab work, NPO status after midnight except medications with sips of water, and directions to hold Eliquis starting on a specified morning and to restart it after the procedure. The nurse receiving the call verified the instructions with the provider and entered the orders the same day. A physician’s order was created directing Eliquis to be held for two days as preparation for the suprapubic tube procedure. However, review of the MAR showed that while the morning and evening doses of Eliquis were held on the first designated day, both doses on the second day and the morning dose prior to the procedure were administered. A consultation report documented that the suprapubic catheter replacement was cancelled because Eliquis had not been held for the required 48 hours, and the nurse reported that the medication was held only on the first day. The 3–11 PM RN supervisor later stated she had selected a start date and duration for the hold order but did not confirm the end date or restart time were correct. The DON stated that, although there was no specific policy for licensed nurses to verify order transcription accuracy after entering verbal orders, nursing standards required the RN to ensure the orders were complete and accurate, and that because the preoperative orders were received verbally and not documented in a nurse’s note, a second licensed nurse check on the next shift did not occur. The facility’s Transcription of Orders policy described who may accept and transcribe orders but no separate physician orders policy was provided.
Incomplete Documentation of Preoperative Instructions and Anticoagulant Management
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident undergoing coordination with a community provider for a suprapubic catheter procedure. The resident had diagnoses including neuromuscular dysfunction of the bladder, recurrent urinary tract infections, and atrial fibrillation, and was receiving Eliquis 5 mg twice daily per monthly physician orders. A quarterly MDS showed the resident was alert and oriented with a BIMS score of 15/15. On 12/4/25, the 3–11 PM nursing supervisor received a call from the hospital’s Interventional Radiology department with preoperative instructions for a suprapubic tube placement scheduled for 12/11/25. These instructions included required blood work to be obtained and faxed, NPO status after midnight except medications with sips of water, and specific directions to hold Eliquis starting on the morning of 12/9/25 and to restart it after the resident’s return from the procedure. Although the nurse verified these instructions with the provider and entered related orders, she did not document the full preoperative instructions in a narrative note in the clinical record. Subsequent review of the clinical record from 12/4/25 through 12/11/25 showed no documentation of the complete preoperative instructions received on 12/4/25, aside from a 12/5/25 nurse’s note indicating that INR, CBC, and CMP results were faxed to the hospital. A physician’s order dated 12/4/25 directed that Eliquis be held on 12/9/25 and 12/10/25 for procedure preparation. However, the December MAR showed that while both doses of Eliquis were held on 12/9/25, the morning and evening doses on 12/10/25 and the morning dose on 12/11/25 were administered. A consultation report on 12/11/25 documented that the suprapubic catheter replacement was cancelled because Eliquis had been held on 12/9/25 but not on 12/10/25, and that Eliquis needed to be held for 48 hours. The DON stated that licensed nurses are responsible for documenting all communication with community providers, and the facility’s Charting and Documentation policy requires accurate, relevant, and complete documentation of assessments, observations, and services, including communication used to develop the plan of care and measure quality of care. The lack of complete documentation of the preoperative instructions and related communication led to the cited deficiency.
Resident Dignity Compromised During Post-Shower Transfer
Penalty
Summary
A resident with quadriplegia, diabetes, and feeding difficulties, who was totally dependent on staff for mobility, transfers, eating, and bathing, was observed being wheeled down the hallway in a shower chair after a shower with their buttocks exposed. The resident was wearing only a hospital gown with no additional covering, and staff, other residents, and the surveyor were able to view the exposed area. The resident's care plan indicated total dependence on staff for bathing and transfers, and the facility's policy required residents to be treated with dignity and to have privacy during personal care. The Director of Nursing (DNS) witnessed the incident and confirmed that the resident should have been fully covered during the transfer. The nursing assistant responsible for the transfer acknowledged awareness of the policy but stated she was in a hurry at the time. The facility's resident rights policy emphasized the right to dignity, respect, and privacy during care, which was not upheld in this instance.
Failure to Prevent Involuntary Seclusion During Covid Exposure Precautions
Penalty
Summary
A resident with quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease was placed on isolation precautions after their roommate tested positive for Covid. Despite testing negative and showing no symptoms, the resident was not allowed to leave their room, even when wearing appropriate PPE, and was not evaluated for mask use or compliance. The facility's infection preventionist and nursing staff were unable to correctly identify CDC recommendations for cohorting or the appropriate use of source control, and there were no physician orders directing isolation or specific precautions for the resident. The resident was observed alone in their room, behind a privacy curtain, without a mask or access to engaging activities, and expressed distress over missing religious services. Staff interviews revealed a lack of clarity regarding when the resident could leave the room, and the infection preventionist stated that no activities could be offered during the isolation period. The director of recreation confirmed the resident had not participated in or been offered any activities since the exposure. The director of nursing services stated it was unsafe for the resident to leave the room, despite staff being able to enter and exit with masks, and acknowledged the resident had not been trialed for mask use. The administrator was not aware of the resident's request to leave the room and recognized that restricting the resident could be considered involuntary seclusion. The facility's operational guide indicated exposed residents should be monitored, tested, and wear masks, but did not support the level of restriction imposed.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident with quadriplegia, diabetes, and feeding difficulties, the care plan did not include a 24-hour positioning plan as ordered by the physician, nor did it address the resident's communication barriers, despite the resident being Spanish-speaking and requiring an interpreter. Documentation such as the nurse aide care card and the resident care plan lacked information about the positioning plan and the need for specialized communication services, even though occupational therapy notes and physician orders specified these requirements. Interviews confirmed that staff were unaware of these omissions in the care plan. For another resident with a history of malignant neoplasm, malnutrition, and dysphagia, the care plan did not reflect ongoing dental issues, despite dental and hygienist notes documenting tooth pain and the need for further evaluation. The resident's dental discomfort was known to nursing staff, and previous assessments had recommended referral for treatment, but the care plan was not updated to include these dental concerns. Review of facility policy indicated that care plans should be revised to reflect current status and new problems, but this was not done for the resident's dental issues.
Failure to Update Care Plans After Resident Decline and Falls
Penalty
Summary
The facility failed to update the Resident Care Plan (RCP) with appropriate interventions following significant changes in residents' conditions. For one resident with severe protein calorie malnutrition, vascular dementia, and difficulty walking, a decline in bed mobility, transfers, and ambulation was documented in a physical therapy discharge summary. Despite this decline, the RCP was not updated to include new preventative measures for pressure ulcer development. The resident subsequently developed a deep tissue injury and a stage 2 pressure ulcer, with the RCP only being updated after these injuries were identified. Another resident, admitted with hypertension, generalized body weakness, and dementia, experienced two unwitnessed falls within a short period. The RCP for this resident identified a risk for falls and included some interventions, but after the falls occurred, no new interventions were added to the care plan to prevent further incidents. The responsible nurse acknowledged that the RCP should have been updated post-fall but could not explain the omission. Interviews with facility staff, including the Director of Nursing Services (DNS) and the MDS Coordinator, confirmed that the care plans were not reviewed or revised in response to significant changes in the residents' conditions or after adverse events. Facility policies required ongoing updates to care plans when new problems arose, but these were not followed in the cases reviewed.
Improper Storage and Administration of Portable Oxygen Cylinder
Penalty
Summary
A deficiency was identified when a portable oxygen cylinder was observed stored improperly, lying sideways on the seat of a manual wheelchair at the base of a resident's bed. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, and congestive heart failure, had been provided with an extra oxygen tank to facilitate movement and socialization within the facility. The resident was cognitively intact and required varying levels of assistance with mobility and dressing. The care plan included monitoring for respiratory symptoms and administering oxygen as ordered. During interviews, a social worker reported that she had provided oxygen to the resident in the past and knew how to operate the oxygen tank, despite not being professionally trained or qualified to do so. The Director of Nursing confirmed that only nursing staff should administer oxygen and that the social worker did not have the necessary competency or qualifications. Facility policy required staff to identify hazards related to oxygen therapy, particularly for residents with COPD, but this was not followed in this instance.
Failure to Provide Activities for Resident with Physical Impairment
Penalty
Summary
The facility failed to provide activities that met the needs of a resident with significant physical impairments. The resident, who had diagnoses including quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease, was cognitively intact but dependent on others for personal hygiene and mobility, using a motorized wheelchair. The resident's care plan specified involvement in cognitive and social activities, with interventions such as invitations to scheduled activities and provision of an activity calendar. However, interviews revealed that the resident was not offered recreation activities suitable for someone with paralyzed hands, and the Director of Recreation confirmed that no specialized recreation programs were provided for residents with physical limitations, despite the facility's policy requiring resident-centered activities based on physical and cognitive limitations.
Failure to Perform Required Pressure Ulcer Assessments and Care Planning
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two of three sampled residents. For one resident with multiple comorbidities including diabetes, chronic kidney disease, dementia, and congestive heart failure, the facility did not perform weekly skin checks as ordered, nor did they complete weekly Braden Scale risk assessments after the initial admission assessment. The resident developed a reddened heel, a sacral pressure injury, and a deep tissue injury to the left big toe during their stay. Additionally, the dietician did not conduct a nutritional assessment after the development of pressure ulcers, despite facility policy and physician orders requiring such evaluations. For another resident with diabetes, chronic kidney disease, and intellectual disability, the facility also failed to perform weekly skin assessments as required, with missed documentation for two weeks. The Braden Scale risk assessment was not repeated after the initial assessment, and the dietician did not evaluate the resident's nutritional status following the identification of a pressure ulcer present on readmission. Furthermore, the resident's care plan and nurse aide care card were not updated to reflect necessary interventions for pressure ulcer prevention and care after the resident was readmitted with an unstageable pressure ulcer. Interviews with facility staff confirmed that weekly skin and wound assessments, Braden Scale evaluations, and timely nutritional assessments by the dietician were expected per facility policy but were not completed. The Director of Nursing and the dietician both acknowledged lapses in communication and adherence to protocols, resulting in the deficiencies identified. Review of facility policies confirmed the requirements for regular assessments and care plan updates, which were not followed for the affected residents.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
A deficiency was identified when a portable oxygen cylinder was observed unsecured and lying sideways on the seat of a wheelchair in a resident's room. The resident, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and congestive heart failure, required oxygen therapy. Facility policy and OSHA regulations require that oxygen cylinders be stored upright and secured, but the cylinder was not in a holder or chained area as required. Another deficiency occurred when a resident with quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease had a Q-tip lodged in their nostril. The resident was dependent on staff for care and unable to independently grasp objects. Despite a provider order to send the resident to the Emergency Department for Q-tip removal, facility staff removed the Q-tip themselves with tweezers and did not immediately send the resident to the hospital as ordered. Additionally, the facility did not complete an accident or reportable incident form for this occurrence. A further deficiency was found when a resident with dementia and generalized weakness sustained a skin tear after their hand became caught in a bed side rail. The resident was alert but confused and required maximum assistance for mobility and hygiene. The care plan did not indicate side rail use, and interviews and record review confirmed that a side rail assessment was not completed prior to the use of side rails, contrary to facility policy. The facility also failed to obtain informed consent or document side rail use in the resident's plan of care.
Failure to Obtain and Document Daily Weights for Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document daily weights for a resident with Congestive Heart Failure (CHF) as ordered by the physician. The resident, who had a history of hypertension, CHF, and diabetes, was admitted in July 2024 and had a care plan that included daily weight monitoring due to the risk of fluid overload associated with CHF. Despite a physician's order to weigh the resident every day and notify the physician of significant weight changes, the clinical record showed that weights were only recorded sporadically over several months, with significant gaps in documentation. There was no evidence in the record of the resident refusing to be weighed, nor were refusals or reasons for missed weights documented. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the daily weight order was current and should have been followed, and that any refusals should have been documented. However, staff were unable to explain why the resident was not weighed as directed. Additionally, the facility's weight policy required documentation of refusals or circumstances preventing weighing, but this was not done. The facility was unable to provide a specific CHF policy when requested.
Failure to Administer Correct IV Solution per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, acute kidney failure, and malnutrition was administered the incorrect intravenous (IV) solution, contrary to the physician's order. The resident was at risk for dehydration and had an order for Sodium Chloride 0.45% IV at 75 ml/hr, which was later changed to Dextrose 5% (D5W) at 65 ml/hr due to hypernatremia and tachycardia. Despite this change, the resident was given D5 ½ NS (Dextrose 5% in 0.45% Sodium Chloride) instead of the ordered D5W, as the correct solution was not available in stock. The LPN who administered the IV solution believed it was correct after confirming with an RN, but did not verify the updated order or contact the provider for clarification when the correct solution was unavailable. The error was not identified during the shift change, as the incoming LPN did not verify the IV solution due to arriving late and only received a verbal report. The oncoming nurse checked the IV site but not the fluid, and did not take vital signs upon assuming care. The incorrect IV solution continued to be administered until the resident was found to be lethargic and tachycardic, prompting further assessment and eventual transfer to the emergency department. Multiple staff interviews revealed that the facility's protocol for verifying IV solutions during shift change and monitoring IV sites every two hours was not followed. Facility documentation and staff interviews confirmed that the wrong IV fluid was administered and that there was a failure to verify the correct solution at multiple points, including by the supervising RN and the Director of Nursing. The policies required staff to follow physician orders for IV fluids and to monitor IV sites regularly, but these procedures were not adhered to, resulting in the administration of an incorrect IV solution to a resident with significant medical needs.
Failure to Monitor and Document Fluid Restriction for Resident on Hemolytic Treatment
Penalty
Summary
A resident with end stage renal disease, congestive heart failure, and anemia was admitted to the facility and required hemolytic treatment. The resident had a physician's order for hemolytic treatment three times per week and a fluid restriction of 1000 cc per 24 hours, as recommended by a nephrologist due to episodes of hypotension during treatment. The care plan and dietary instructions reflected this restriction, with specific fluid amounts allocated for meals and medication administration. Despite these orders, a review of the clinical records, including nursing notes, MAR, and TAR, revealed that there was no documentation or tally of the resident's daily fluid intake from the time the fluid restriction order was implemented. Interviews with nursing staff showed confusion regarding responsibility for tracking fluid intake, with some staff believing it was the responsibility of licensed nurses and others indicating it was a shared responsibility. The fluid restriction order was not visible on the MAR, and staff acknowledged that the order had not been properly activated to prompt documentation. The resident was not aware of the fluid restriction until two days prior to the survey, and reported consuming both facility-provided and outside food and fluids without tracking intake. The dietician confirmed that nursing staff were expected to maintain intake records for residents on fluid restriction, but the order may not have been activated in the system. The facility's policy required nursing personnel to document fluid intake, but this was not done for the resident in question. The facility was unable to demonstrate how the total fluid intake was tracked or maintained for the resident as required by the physician's order.
Medications Left Unattended at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including hypertension, congestive heart failure, and diabetes, was found with five pills in a medication cup left on the bedside table. The resident, who was cognitively intact and required varying levels of assistance for activities of daily living, reported that an LPN had left the medications at the bedside for self-administration. Observation and interview confirmed that the LPN left the room before ensuring the resident had taken the medications, despite the resident not being assessed or approved for self-administration. Further review of the clinical record and facility policy revealed that there was no completed self-administration assessment or evaluation for the resident. The facility's medication pass policy requires staff to observe residents until all medications are swallowed and prohibits leaving medications at the bedside. The LPN identified the medications left as trazodone, carvedilol, Ativan, and torsemide, and acknowledged that leaving them at the bedside was not in accordance with facility policy.
Failure to Use Required PPE for Resident on Covid Isolation Precautions
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control program by not wearing the required Personal Protective Equipment (PPE) when providing care to a resident on isolation precautions for Covid. Specifically, a nurse aide was observed wearing a gown, gloves, and a surgical mask instead of the required N-95 mask, as indicated by the signage posted outside the resident's room. The signage clearly stated that gloves, a gown, and an N-95 mask were required for entry due to airborne precautions. The resident involved had a history of chronic obstructive pulmonary disease (COPD), heart failure, and quadriplegia, and was dependent on staff for personal hygiene and mobility. The resident was on isolation precautions for Covid, as documented in the care plan and nurse progress notes. During the observation, the nurse aide acknowledged awareness of the requirement to wear an N-95 mask but stated she had forgotten to use the correct mask. The facility's policy and the infection preventionist both confirmed that staff are expected to follow the posted PPE requirements for residents on precautions.
Failure to Maintain Clean, Sanitary, and Pest-Free Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment, as well as an environment free of pests. During a tour, dirty trays were found on a counter and fruit flies were present in a resident's room on the A Wing. Additionally, on the C Wing, carpets in front of the nurse's station were noted to be stained brown, yellow, and red. These observations were made over a period of approximately 30 minutes. The Housekeeping Supervisor confirmed that although pest control had recently treated another resident's room for fruit flies, fruit flies remained in the affected resident's room. The supervisor also stated that spot and steam cleaning of the carpet had been performed the previous week, but stains persisted, and no documentation could be provided to verify the cleaning. The facility had received a quote for carpet replacement, but this was not provided to the surveyor as requested. Facility policies required daily spot checks and semiannual wet extraction of carpets, but the observed conditions indicated these procedures were not effectively implemented.
Failure to Complete Significant Change MDS Assessment After Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to identify and complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a decline in condition. The resident, who had diagnoses including severe protein calorie malnutrition, vascular dementia, and difficulty walking, was initially assessed as requiring only supervision for bed mobility, transfers, and ambulation, and was at risk for skin breakdown but had no current pressure ulcers. However, subsequent documentation from physical therapy indicated a decline in the resident's functional abilities, with increased assistance needed for bed mobility, transfers, and ambulation. The resident care plan was updated to reflect these changes, but a significant change MDS assessment was not completed as required. Further review revealed that the Advanced Practice Nurse Practitioner documented a recent decline in the resident's function, including increased time spent in bed, decreased interaction, and the development of a new pressure ulcer. The DON was not made aware of the resident's decline until after the pressure ulcer developed, and the MDS Coordinator did not recognize the need for a significant change assessment until after meeting with rehabilitation staff. The MDS Coordinator acknowledged that the assessment should have been completed within 14 days of the decline, but this was not done due to oversight.
Inaccurate MDS Coding for Resident Assessment and ADL Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to resident assessment accuracy. For one resident with diagnoses including schizophrenia, encephalopathy, and morbid obesity, the clinical record showed a Level II PASRR outcome document was on file. The admission MDS assessment correctly indicated a positive Level II PASRR, but the subsequent annual MDS assessment was incorrectly coded as negative for Level II PASRR, despite no change in the resident's status. The Director of Social Work confirmed the inconsistency and was unable to explain the miscoding. For another resident with a history of malignant neoplasm of the left breast, moderate protein calorie malnutrition, and dysphagia, the annual MDS assessment indicated the resident was independent with eating. However, the care plan, nurse aide documentation, and direct observations showed the resident required extensive or total assistance with eating, including the use of adaptive equipment and staff feeding. The Director of Nursing Services acknowledged the conflicting documentation and could not explain the incorrect MDS coding. These findings were based on observations, record reviews, and staff interviews.
Failure to Ensure Accurate PASRR Screening and Timely Level 2 Referrals
Penalty
Summary
The facility failed to ensure the accuracy and completeness of Level 1 PASRR screenings and did not submit required Level 2 PASRR evaluations for two residents with mental health diagnoses. For one resident admitted with anxiety disorder, major depressive disorder, and PTSD, the Level 1 PASRR did not accurately reflect the resident's history of suicidal ideation or prior psychiatric hospitalizations, and did not trigger a Level 2 PASRR evaluation. Additionally, after a new diagnosis of anxiety was made, the facility did not submit a new PASRR as required for a change in condition. For another resident admitted with multiple mental health diagnoses, including anxiety, dependent personality disorder, major depressive disorder, and bipolar disorder, the Level 1 PASRR failed to include all relevant diagnoses and did not prompt a Level 2 PASRR evaluation. The facility also did not submit a status change to the PASRR vendor after the resident was later diagnosed with unspecified dementia, as required by PASRR protocols. Interviews with facility staff revealed that the Level 1 PASRR forms were not coded correctly and that there was a lack of understanding or oversight regarding the need to update PASRR documentation following changes in residents' mental health diagnoses. The facility did not have a policy in place for PASRR, and the care plans for both residents did not include information related to PASRR requirements.
Failure to Protect Residents from Misappropriation of Personal Funds
Penalty
Summary
The facility failed to protect residents from the wrongful use and misappropriation of their personal funds, as evidenced by incidents involving three residents. One resident, diagnosed with schizophrenia and major depressive disorder and noted to be alert and oriented, discovered a significant discrepancy in their account balance after attempting to withdraw funds. Upon review, it was found that several withdrawals had been made in amounts inconsistent with the resident's usual withdrawal pattern, and the resident denied authorizing these transactions or signing the receipts. Investigation revealed that a former receptionist, whose signature appeared on the questionable receipts, was present at the facility during at least one of the unauthorized transactions, despite having called out sick that day. For another resident with schizophrenia, metabolic encephalopathy, and dementia, an audit of personal funds uncovered several handwritten receipts for food purchases without corresponding receipts from the restaurant, raising concerns about the legitimacy of these transactions. Similarly, a third resident with depression, anxiety, and dementia was found to have a withdrawal noted for food, but again, no vendor receipt was available to verify the transaction. Both residents had memory recall deficits, making them particularly vulnerable to financial misappropriation. Interviews with facility staff confirmed the standard process for resident fund withdrawals, which requires a receipt signed by the resident and the distributing staff member, with additional management signatures if the resident is unable to sign. However, the investigation determined that the former receptionist did not follow these procedures and was responsible for the misappropriation of funds from the residents' accounts. Facility policy explicitly prohibits misappropriation and exploitation of resident property, but these incidents demonstrated a failure to adhere to established protocols, resulting in unauthorized withdrawals from resident accounts.
Staff Member Threatens Retaliation Against Resident
Penalty
Summary
A deficiency occurred when a staff member failed to protect a resident from intimidation and the threat of retaliation. The incident involved a resident with bipolar disorder and vascular dementia, who was alert and oriented with a BIMS score of 15, and generally independent in activities of daily living. The resident reported an altercation with a nurse aide following a spilled lunch tray, during which the nurse aide stated that if the resident hit her, she would hit the resident back. This statement was made in the presence of another staff member and was confirmed during the facility's investigation. The facility's abuse policy prohibits any form of abuse, including intimidation or threats that result in mental anguish. The nurse aide's comment was witnessed by the Administrative Assistant, who intervened to calm the resident and advised the nurse aide against making such statements. The incident was reported to the Director of Nursing, who confirmed that the statement upset the resident. The facility's policies and the resident's rights were not upheld in this instance, as the resident was subjected to a threat of retaliation by a staff member.
Failure to Timely Report Witnessed Verbal Abuse Allegation
Penalty
Summary
A witnessed allegation of verbal abuse involving a resident with bipolar disorder and vascular dementia was not reported to the Administrator or designee within the required two-hour timeframe. The resident, who was alert, oriented, and independent with most activities of daily living, reported that a nurse aide stated, during an altercation over a spilled lunch tray, that if the resident hit her, she would hit the resident back. This statement was witnessed by the Administrative Assistant, who intervened to calm the resident but did not report the incident to the Director of Nursing (DON) as required by facility policy. The incident was only brought to the attention of the DON when the resident reported it to social services approximately two weeks later. The Administrative Assistant acknowledged being aware of the policy to immediately report allegations of abuse but failed to do so, focusing instead on de-escalating the situation. Facility documentation and interviews confirmed that the delay in reporting was not in accordance with the facility's abuse policy, which mandates immediate notification of the administrator or nursing supervisor upon witnessing or learning of abuse.
Failure to Protect Resident from Verbal and Emotional Abuse and Inadequate Reporting
Penalty
Summary
A deficiency occurred when a resident with a history of malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD was not protected from verbal and emotional abuse. The resident, who was cognitively intact and required moderate assistance with mobility and transfers, had a care plan specifying that two caregivers should be present at all times due to behavioral concerns. Despite this, an LPN entered the resident's room alone to administer pain medication and became visibly annoyed when the resident requested additional assistance. The LPN handled the resident's bedding roughly, caused medication to spill, and engaged in a loud verbal exchange with the resident, which was overheard by a supervising RN. The resident reported feeling demeaned and emotionally abused by the LPN's actions and words. The incident was not properly reported or investigated according to facility policy. The supervising RN, who heard the altercation, did not collect a statement from the LPN at the time, did not report the incident to the Director of Nursing Services (DNS), the Administrator, or the oncoming nurse supervisor, and did not ensure the grievance form was collected from the resident. The DNS later confirmed that no formal investigation was conducted, and the incident was handled as a customer service issue rather than an abuse allegation, despite the resident's report of mental and emotional abuse. Facility documentation revealed further lapses, including an incomplete grievance form with no documented actions taken or follow-up provided to the resident. The abuse policy required immediate reporting and investigation of all abuse allegations, but these procedures were not followed. The LPN was unaware of the care plan requirement for two caregivers, and staff failed to ensure the resident's safety and dignity as outlined in facility policy.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or mistreatment to the State Agency for two residents. In the first case, a resident with a history of right fibula fracture, congestive heart failure, and muscle weakness required maximal assistance with bed mobility and was dependent on staff for toileting hygiene. There were two incidents where incontinent care was not provided for over three hours, despite requests. The responsible party reported these incidents to the Director of Nursing Services (DNS), but did not receive follow-up. The facility did not report these allegations to the State Agency, and there was no documentation of completed investigations or Accident & Investigations (A&Is) for either incident. In the second case, a resident with diagnoses including malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD, who required moderate assistance with bed mobility and was dependent on staff for transfers, reported an incident involving an LPN. The resident described being treated roughly and spoken to in a loud, unprofessional manner, which caused emotional distress. The incident was reported to the DNS, but no formal investigation was conducted, and the event was not reported to the State Agency. The DNS handled the matter as a customer service issue and did not document a formal investigation or reporting. Facility policy requires that all allegations of abuse, neglect, or mistreatment be reported immediately to the Administrator and DNS, with a two-hour requirement to notify the Department of Public Health and local law enforcement. In both cases, the facility did not follow its own policy or regulatory requirements for reporting and investigating allegations of abuse or neglect, as evidenced by the lack of timely notification to authorities and incomplete documentation of investigations.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that allegations of abuse and/or neglect were thoroughly investigated in accordance with facility policy for two residents. For one resident with a history of right fibula fracture, congestive heart failure, and muscle weakness, there were multiple reports from a family member that the resident was left in a soiled diaper for extended periods despite requests for care. The Director of Nursing Services (DNS) was notified of these incidents via phone and email, but did not provide follow-up to the family member and was unable to produce documentation of any completed investigations or staff re-education, as required by facility policy. For another resident with diagnoses including a malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD, an incident occurred in which the resident alleged emotional abuse by an LPN who entered the room alone, acted in an unprofessional and rough manner, and yelled at the resident. The resident reported the incident to the DNS and believed a grievance was filed, but there was no evidence of a formal investigation, grievance documentation, or follow-up in the clinical record. The DNS acknowledged that no formal investigation was conducted and that required documentation was missing. Interviews with staff confirmed that allegations were either not reported to the appropriate personnel or not investigated according to policy. The facility's abuse policy requires thorough investigation and reporting of all allegations of abuse, mistreatment, or neglect, but the facility was unable to provide documentation that these procedures were followed for the incidents involving both residents.
Failure to Follow Care Plan Requiring Two Caregivers for Resident with Behavioral Needs
Penalty
Summary
The facility failed to follow the established care plan for a resident with a malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD, who required the presence of two caregivers at all times due to behavioral concerns. The resident's care plan, dated 10/23/24, specifically directed that two caregivers be present at all times, along with other interventions to address accusatory behaviors and ensure the resident's safety and well-being. Despite this directive, an LPN entered the resident's room alone to administer pain medication and assist with repositioning and other requests. During the interaction, the LPN appeared rushed and agitated, resulting in a rough handling of the resident's bedding and an incident where the medication was dropped. The resident reported feeling emotionally mistreated, describing the LPN as yelling, slamming doors, and acting unprofessionally. The incident was witnessed in part by the nursing supervisor, who acknowledged hearing the LPN yelling and provided the resident with a grievance form. The resident reported the incident to the Director of Nursing Services (DNS) the following day, expressing feelings of mental and emotional abuse, but did not receive follow-up regarding the grievance. Interviews with the LPN revealed she was unaware of the requirement for two caregivers to be present with the resident at all times, indicating a lack of communication or training regarding the resident's care plan. The DNS confirmed that staff are expected to review and be aware of care plans prior to providing care and was unable to explain why the LPN was unaware of the two-caregiver requirement. Facility policy requires the interdisciplinary team to develop and implement person-centered care plans, but in this case, the plan was not followed, resulting in a deficiency.
Failure to Complete Bladder Evaluation on Admission for Incontinent Resident
Penalty
Summary
A resident admitted with diagnoses including a right fibula fracture, congestive heart failure, and muscle weakness was identified as frequently incontinent of bowel and bladder upon admission. The admission MDS assessment indicated the resident had intact cognition, required maximal assistance with bed mobility, and was dependent on staff for toileting hygiene. The resident care plan and nurse aide documentation reflected ongoing urinary incontinence, with interventions directing staff to check and clean the resident every two to three hours. Despite these findings, a review of the clinical record revealed that a bladder evaluation was not completed for the resident upon admission, as required by facility policy. The policy mandates that all residents with incontinence be evaluated within three days of admission to guide care interventions. The DNS confirmed awareness of the resident's incontinence but was unable to explain why the evaluation was missed, acknowledging that it should have been completed according to policy.
Failure to Provide Timely Social Services Support After Allegations of Abuse/Neglect
Penalty
Summary
The facility failed to provide timely social services support to two residents following allegations of abuse or neglect. For the first resident, who had diagnoses including a right fibula fracture, congestive heart failure, and muscle weakness, there were two incidents where incontinent care was not provided for over three hours. Despite these incidents being reported to the Director of Nursing Services (DNS), there was no documented follow-up or social services intervention, and the social worker responsible for follow-up was not made aware of the allegations. Review of social service notes for the relevant period showed no documentation regarding these incidents. For the second resident, who had a malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD, an incident occurred involving an LPN who was reportedly rough and verbally aggressive while providing care. The resident reported feeling emotionally abused and reported the incident to the DNS, expecting social services support. However, there was no documentation in the social service notes indicating that support or follow-up was provided by social services after the incident. Interviews with facility staff confirmed that the social workers were either not notified of the allegations or did not document any follow-up or support provided to the residents. Facility policy required social services to meet with residents following allegations of abuse or neglect and to document these interactions, but this did not occur in either case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by another resident with a known history of aggression and cognitive impairment. One resident, diagnosed with Alzheimer's disease, anxiety, and psychotic disorder, had a care plan identifying a risk for physical aggression due to dementia and a history of aggressive behavior. Despite interventions such as one-to-one support during agitation and medication management, this resident was able to physically strike three other residents on separate occasions. In each incident, the resident entered another resident's room and engaged in physical altercations, resulting in injuries such as bruising, a black eye, and a bloody nose. The affected residents had varying degrees of cognitive impairment and psychiatric diagnoses, including dementia, schizoaffective disorder, schizophrenia, and depression. Their care plans included interventions for behavioral monitoring, medication administration, and psychiatric services. However, these interventions did not prevent the resident with a history of aggression from accessing other residents' rooms and causing harm. Documentation shows that the resident was able to strike another resident in the face after an argument, hit a roommate with slippers, and punch a resident multiple times, causing visible injuries. Interviews and facility documentation revealed that after each incident, the aggressive resident was placed on one-to-one supervision, but this was discontinued following psychiatric evaluation without implementing more frequent checks or additional safeguards. The facility's abuse policy states that residents have the right to be free from abuse and neglect, but the actions taken were insufficient to prevent repeated physical contact and harm between residents.
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What surveyors actually found near you
We read the 772 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Touchpoints At Bloomfield | 0.5 mi | ★★★★★ | 19 | 0 |
| Seabury | 0.8 mi | ★★★★★ | 0 | 0 |
| Caleb Hitchcock Health Center | 2.3 mi | ★★★★★ | 11 | 0 |
| Saint Mary Home | 2.6 mi | ★★★★★ | 3 | 0 |
| Complete Care At Kimberly Hall-south | 2.6 mi | ★★★★★ | 0 | 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.