Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Candlewood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, vascular dementia, restlessness, and agitation, and severely impaired cognition had a care plan identifying combative behaviors with an intervention to stop care and reapproach later if the resident became aggressive or resistive. On one shift, during incontinent care, the resident became combative while two NAs attempted to provide care, and a family member assisted by holding the resident to prevent hitting staff so care could be completed. Staff interviews, including with an RN, confirmed that care was continued instead of stopping and reapproaching as directed by the care plan, resulting in a failure to provide care in accordance with the individualized plan.
A resident with COPD and severely impaired cognition was observed self-applying Vaseline petroleum jelly while on continuous O2 by nasal cannula, with the jelly kept within reach on the bedside/overbed table. Staff said the resident had no order for Vaseline and was using it throughout the day while oxygen was running. In a separate incident, a resident with Parkinson’s disease, dementia, and dependence for toileting fell while seated on the toilet after staff left the resident in the bathroom with a spouse present; staff later confirmed the resident should not have been left unattended.
Failure to inform residents of rights and facility rules: Residents reported that staff had not reviewed Resident Rights or discussed rules and responsibilities with them, and that the posted rights notice was too high and too small to read from a wheelchair. Resident Council minutes did not document resident education on rights or rules, and the ADM acknowledged management had not taken the initiative to attend council meetings to review these topics.
Survey Results Not Readily Accessible or Posted: The facility failed to make the most recent survey results readily accessible to residents, family members, and legal reps, and failed to post a visible notice showing where the reports were located. Residents in council said they did not know they could review the survey results or where to find them. In the lobby, signs were hidden behind a credenza, no clear notice was visible, and the State Inspection Report book was found bent in half inside a drawer obstructed by a hand sanitizer stand; the Administrator stated the book should have been on top of the credenza.
Failure to Use Beard Restraint During Food Service: A Dietary Aide was observed plating breakfast items for resident meal delivery without a beard guard despite visible facial hair extending below the chin. The DON confirmed dietary staff are required to wear hair restraints, including beard covers, when handling food, and the facility policy required beard restraints for anyone with more than stubble or two days' growth.
Advanced Directive forms were not properly completed or signed for multiple residents. For two residents, the forms documented verbal telephone consent and code status choices, but the resident representatives never signed the forms despite the residents having dementia and impaired cognition. For another resident with intact cognition, the form only checked Do Not Hospitalize and did not reflect the resident’s DNR wishes or match the physician order.
Failure to Timely Report Injury of Unknown Origin: A resident with dementia, severe cognitive impairment, and combative behaviors developed an unexplained bruise and swelling to the hand with no known trauma or witnesses. Staff documented the injury, and a visitor later reported the bruise was not present the day before and that the facility did not notify them about it. The DON stated he was unaware of the injury and that bruises of unknown origin must be reported to the State Agency, while facility policy required immediate reporting of such injuries.
Incomplete Investigation of Unexplained Hand Bruise: A resident with dementia, severe cognitive impairment, incontinence, and total dependence for care developed a large bruise and swelling to the hand with no known trauma or witnesses. Staff documented the injury, but the charge nurse and RN did not notify the DON/DNS when first identified, did not complete a thorough look-back or full staff interview process, and did not determine how the injury occurred. The resident also had combative behaviors and required a mechanical lift for transfers.
Failure to provide bed-hold notice at hospital transfer: A resident with Alzheimer’s disease, CHF, Afib, CKD, and agitation was transferred to the hospital after developing AMS, hypoxia, hypotension, and bradycardia while being treated for diverticulitis. The record did not show that the resident or representative received written bed-hold information explaining the duration of the policy, and staff interviews showed confusion about who was responsible for providing the notice.
Two residents with dementia and behavioral or mood concerns were newly diagnosed with psychotic disorders, but the SWs did not notify the PASRR contracted agency for a Level II review. One resident also had paranoia, delusions, agitation, and a psychiatric transfer, while the other had a care plan for behavioral risk and a later psychotic dx. The record showed the agency was not updated after the new psychiatric information was added.
A resident with cerebral infarction, HTN, and GERD received IV Ceftriaxone for an elevated WBC count, but the IV flush orders were not aligned with the antibiotic administration times. An LPN and the ADNS reviewed the record and could not explain the SAS order, while the MAR showed the flushes were signed off at times separate from the IV antibiotic, despite facility policy requiring flushing before and after intermittent medication administration.
A resident with COPD, dementia, and HTN was receiving continuous oxygen via nasal cannula and oxygen concentrator, but no oxygen cautionary or safety sign was posted at the doorway. An LPN said nursing was responsible for posting the sign but could not find one, an RN said she was unaware the doorway lacked signage and had recognized the need to order more oxygen signs earlier, and the DNS said staff are responsible for ensuring oxygen signage is posted when oxygen is in use. The facility policy required an oxygen in use sign on the resident's door.
A resident with dementia, anxiety, agitation, and disruptive behaviors did not receive timely follow-up on community psych recommendations. The APRN and consultant noted ongoing yelling and combative behavior, and the psychiatrist recommended med changes including stopping Trazodone and starting Seroquel. Staff waited for faxed orders, did not contact the psychiatrist to obtain the recommendations, and the new orders were not received for 25 days.
An LPN changed a resident’s tube feeding set-up without wearing the gown required under EBP, despite knowing the resident had a feeding tube and was on EBP. In a separate wound care observation, an APRN handled two thigh wounds without changing gloves or performing hand hygiene between wounds, placed supplies on the resident’s bed without a barrier, and used the same tape measure for both wounds. The APRN acknowledged the wounds should have been treated separately and that glove changes and hand hygiene were required between steps.
Missed Neurological Checks After Unwitnessed Fall: A resident with impaired cognition, fall risk, and anticoagulant use had an unwitnessed fall while self-transferring from the bathroom and sustained a facial laceration and finger injury. Nursing documentation showed neuro checks were started but several ordered assessments were not completed, and the DON stated the missed checks occurred because the MD order was not transcribed correctly.
The facility failed to maintain a secure environment in a memory care unit, as several doors, including 'Soiled Utility,' 'Supply Room,' and 'Clean Utility,' were not fully closed, latched, or locked. The 'Shower' door was also unlocked. Interviews revealed that moisture prevented proper door closure, and the Director of Maintenance was unaware of the locking requirement. No facility policy for a safe environment was provided.
The facility failed to properly store and label medications, as observed in four medication carts. A resident's medication was not refrigerated as required, and two residents' medications were not labeled correctly on the Apple Blossom Unit. Additionally, an expired medication was found in the Dogwood unit. Staff interviews revealed a lack of adherence to facility policy, which mandates proper storage, labeling, and expiration checks.
The facility failed to maintain cleanliness in the laundry room, with vents and a smoke detector covered in debris. The Laundry Supervisor was unsure of the last cleaning date, and cleaning logs were not readily available. The IP/LPN confirmed that vents should be cleaned weekly, but the policy was not followed. A review of logs showed specific cleaning dates in May, but the June log lacked a specific date, only stating cleaning occurred on the surveyor's inquiry day.
Two residents experienced a lack of dignity and respect from a nurse aide (NA) who delayed assistance with toileting and raised her voice when addressed. One resident, with COPD and respiratory failure, reported the incident, but the facility failed to document a thorough investigation. The other resident, requiring total assistance due to hemiplegia, was left waiting for help, contrary to facility policy.
A resident with acute kidney failure and duodenitis experienced recurring diarrhea after admission to a facility. Despite the symptoms, the nursing staff failed to notify the physician in a timely manner. Interviews revealed communication lapses, with an LPN assuming the condition was documented and not reporting it to a supervisor or physician. The Medical Director was not informed of the recurrent episodes until later, contrary to facility policy.
A resident with Alzheimer's disease and severe cognitive impairment was struck in the chest by another resident with similar conditions in an unprovoked altercation. The incident was witnessed by an LPN, who confirmed no prior signs of agitation. The facility's policy requires intent to harm for abuse classification, but the incident was reported, and the involved resident was placed under observation and sent for evaluation.
A resident with Alzheimer's and insomnia was not administered medications as prescribed, as pills were found in their nightstand drawer. Despite no swallowing disorders, the resident was at risk for aspiration and required a ground diet. Staff interviews revealed that oral checks to confirm medication ingestion were not consistently performed, although it was a standard practice learned during nursing education.
A resident with acute kidney failure and duodenitis experienced diarrhea and gastric upset after eating shrimp, but the nursing staff did not report the change of condition to a supervisor or physician. Additionally, the resident had a nosebleed that was not followed by a documented nursing assessment. The facility lacked a policy for RN assessments, leading to a deficiency in care.
A resident with multiple health conditions, including diabetes and cancer, developed new pressure wounds, but the facility failed to reassess their nutritional status. Despite weekly discussions with the interdisciplinary team, the Dietitian was unaware of the new wounds and did not conduct a reassessment, contrary to the facility's policy on pressure injury management.
Two residents experienced deficiencies in respiratory care due to improper storage of equipment. A resident with COPD had a nebulizing mouthpiece left uncovered, while another with sleep apnea had a CPAP mask and oxygen tubing improperly stored. Staff interviews confirmed the equipment should have been stored in bags, but the facility's policy was not provided.
A facility failed to re-evaluate the use of PRN Lorazepam for a resident with anxiety disorder, Major Depressive Disorder, and vascular dementia. Despite the resident's behavioral records showing no change, the medication was administered without documented review or justification. Staff interviews revealed inconsistencies in managing PRN psychotropic medications, and the facility's policy did not address medication use requirements.
The facility failed to honor the food preferences of two residents, leading to deficiencies in care. One resident, with diverticulitis and atherosclerosis, wanted eggs and hash browns more often than provided, but the facility did not consistently accommodate this preference. Another resident, with macular degeneration and heart failure, repeatedly received sandwiches with mayonnaise despite indicating a dislike for it. The facility's dietary policy and Residents' Rights emphasize accommodating preferences, yet these were not consistently followed.
A facility failed to provide a resident's medical records within 48 hours as required. The resident, who had cognitive impairment and required assistance with daily activities, had a family member request discharge paperwork. The social worker miscommunicated the process, directing the family to the acute care facility for records. Additionally, the medical records staff could not recall or find documentation of the request, violating the facility's policy for timely access to records.
A resident's family member was overcharged for copies of medical records, with inconsistencies in the rates quoted by facility staff. The facility's administrator was unaware of the overcharge, which exceeded the state statute and facility policy limits.
Failure to Follow Care Plan Interventions for Combative Resident During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care in accordance with an existing care plan and to follow care plan interventions when a resident became combative and resistive to care. Resident #1 had diagnoses including Alzheimer’s disease, vascular dementia, restlessness, and agitation, and a quarterly MDS showed a BIMS score of 1, indicating severely impaired cognition, dependence for ADLs, and no documented behaviors in the prior seven days. The resident’s care plan, dated 2/2/26, identified combative behaviors and directed staff that if the resident became aggressive or resistive to care, they were to leave the resident if safe to do so and reapproach later. Facility policy on care planning directed development of an appropriate and individualized plan of care for residents. On 4/4/26, a nursing note documented that Resident #1 was combative with incontinent care at the start of the shift. During surveyor interviews, NA #1 reported that around 3–4 PM that day, Resident #1 was combative while NA #1 and NA #3 attempted to provide incontinent care, and that a family member assisted by helping to hold the resident to prevent the resident from hitting staff so that care could be completed. Interview with RN #1 confirmed that the resident was combative during care around 4 PM and that staff should have stopped care and reapproached later when the resident became combative. The DON and Administrator acknowledged the resident had a history of being combative during care and stated that if the resident was combative, staff should ensure the resident’s safety, leave, and attempt to reapproach later. These accounts show that staff did not follow the care plan intervention to stop and reapproach when the resident became combative.
Unsafe Oxygen Use and Inadequate Toileting Supervision
Penalty
Summary
The facility failed to ensure a safe environment when a resident with COPD, chronic respiratory failure with hypoxia, obstructive sleep apnea, and severely impaired cognition was observed using a 13-ounce tub of Vaseline petroleum-based jelly while receiving continuous oxygen by nasal cannula. The resident’s physician order directed oxygen at 0-4 liters per minute continuously to maintain oxygen saturation above 90%, and the care plan identified the resident as at risk for respiratory distress and noted the resident had previously removed oxygen. During observation, the resident was found in bed and later in a recliner with the petroleum-based jelly on the bedside or overbed table within reach while oxygen was running at 2 liters per minute. The resident told the surveyor that a family member had brought in the Vaseline and that the resident had been self-administering it to the lips when they felt dry and also applying it to the nose while oxygen was in use. The RN stated the resident did not have a physician order for Vaseline and did not know who provided it. The NA stated she was aware the resident had the tub of Vaseline on the overbed table and was self-administering it while on continuous oxygen. The DON stated he was not aware the resident was applying Vaseline throughout the day while wearing oxygen continuously and said the resident should not be using Vaseline while utilizing oxygen. The facility also failed to provide adequate supervision during toileting for a resident with Parkinson’s disease, generalized muscle weakness, uncoordinated gait, dementia, severely impaired cognition, and dependence on staff for transfers, toileting, and wheelchair mobility. The resident had a history of falls and an order for extensive assistance with toileting. The resident fell in the shower room while seated on the toilet after staff left the resident with a spouse in the bathroom; the spouse briefly left to ask the nurse a question, and staff later found the resident sitting on the floor. Facility documentation stated the resident was dependent on staff at the time of the fall and that staff were directed to remain with the resident while in the bathroom. Staff interviews confirmed the resident should not have been left alone in the bathroom and that the presence of a family member did not remove the need for staff supervision.
Failure to Inform Residents of Rights and Facility Rules
Penalty
Summary
The facility failed to ensure residents were informed of their rights and of all the rules and regulations governing resident conduct and responsibilities during their stay. During a Resident Council meeting on 03/24/2026, residents in attendance stated that facility staff had not reviewed or discussed Resident Rights with them and that they had not received education regarding facility rules or policies governing resident conduct and responsibilities. Residents also reported that the Resident Rights posting was positioned too high for individuals using wheelchairs and was too small to read. Review of Resident Council meeting minutes from 1/29/2025 through 2/24/2026 did not show documentation that residents were informed of their rights or educated on the rules and regulations governing resident conduct and responsibilities. The Administrator stated on 3/30/26 that he was aware Resident Rights were not being reviewed during Resident Council meetings and acknowledged that facility management waited to be invited by the Resident Council to attend meetings rather than taking the initiative to attend and review Resident Rights and facility rules and regulations.
Survey Results Not Readily Accessible or Posted
Penalty
Summary
The facility failed to ensure that the most recent Federal or State survey results were posted in a place readily accessible to residents, family members, and legal representatives, and failed to post notice of where those reports could be found in prominent, accessible areas. During a Resident Council meeting, residents stated they were not aware they could review the most recent survey results or where the surveys were located. Review of Resident Council meeting minutes from 1/29/2025 through 2/24/2026 did not show that residents were informed of this right or the location of the reports. Observation in the main lobby showed several signs placed on a windowsill behind a credenza, but no visible sign identified the location of the State Inspection Report book, and the posted materials were not accessible at wheelchair level because of their placement behind the credenza. The Receptionist believed the report book was in a drawer in the lobby table and said there had previously been a sign identifying its location. Further observation found the report book bent in half inside a drawer that was obstructed by a free-standing hand sanitizer dispenser. The Administrator stated the report book should have been kept on top of the credenza and revealed a sign behind another sign that read, "Survey Results in Desk," while also stating he did not know why the sign had been moved or how long the report book had been stored in the drawer.
Failure to Use Beard Restraint During Food Service
Penalty
Summary
The facility failed to ensure dietary staff wore a beard guard while assembling and serving food. During observation of the meal service, a Dietary Aide was seen at the steam table plating scrambled eggs, oatmeal, and toast for resident meal delivery while having visible facial hair extending below the chin and not wearing a beard restraint. The Dietary Director stated that dietary staff are required to wear appropriate hair coverings, including beard restraints, when working in the kitchen and handling food, and confirmed that beard covers are always available and that the aide should have been wearing one. Review of the facility Hair Restraint policy stated that kitchen staff, anyone inside the kitchen, or anyone handling food must wear hair restraints, including a beard guard if applicable, and defined a beard as anything beyond stubble, scruff, or two days' growth.
Advanced Directive Forms Not Properly Completed or Signed
Penalty
Summary
The facility failed to ensure Advanced Directive forms were signed by resident representatives for Resident #1 and Resident #5. Resident #1 had diagnoses including dementia with behaviors, stroke, anxiety, and depression, and had a physician order for DNR after admission from the hospital. The Advanced Directive/Medical Treatment Decision Form documented verbal telephone consent from the responsible party and identified the resident as DNR, but the form was not signed by the representative 85 days after admission. Resident #1’s admission MDS showed a BIMS score of 3, indicating severely impaired cognition, and a care plan meeting note documented that neither the resident nor the representative was present while the code status remained DNR. Resident #5 had dementia and a BIMS score of 9, indicating moderately impaired cognition. The Advanced Directive/Medical Treatment Decision Form documented verbal telephone consent from the responsible party and identified the resident as full code, but the form was not signed by the representative 500 days after admission. The resident also had a physician order for full code, and care plan documentation identified the resident as full code with advanced directives. In addition, Resident #94, who had diagnoses including high blood pressure, difficulty swallowing, and malnutrition and had intact cognition on the admission MDS, had an Advanced Directive/Medical Treatment Decision Form that only checked the Do Not Hospitalize box and did not identify the resident’s code status wishes, despite a physician order for DNR, RN may pronounce, and anticipated death due to illness, infirmity, and/or disease.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency in a timely manner for Resident #14, a resident with dementia with behavioral disturbances, severely impaired cognition, incontinence, total dependence for personal hygiene, dressing, and transfers, and behaviors that included hitting, screaming, and disruptive sounds. The resident’s care plan addressed sundowning and agitation with redirection, removal from public areas when behavior was unacceptable, psychiatric evaluation as needed, and medications as ordered. On 3/23/26, the resident was evaluated for new right-hand swelling and discoloration of unclear origin with no known history of trauma. The facility incident report documented a bruise to the right hand measuring 8.5 cm by 3.7 cm with mild swelling and no witnesses. RN #5’s investigation noted the resident was confused, that NA #3 used a mechanical lift during the morning shift, and that the resident had behaviors including hitting and grabbing at staff. Written statements from multiple nursing assistants indicated they did not observe a bruise on the resident’s hand during their care or were not assigned to the resident. Additional documentation showed the bruise was observed by staff and a visitor, with the resident’s right hand later noted to have bruising and swelling involving the hand, wrist, index finger, and thumb. The visitor stated the bruise and swelling were not present the prior day and reported that no one from the facility notified them about the bruise or its circumstances. The DNS stated he was not notified and was not aware of the bruising, and that bruises of unknown origin must be reported to the State Agency; he further stated that had he been notified, he would have reported the injury of unknown origin. The facility policy required injuries of unknown origin to be reported immediately, but no later than 2 hours, and to be thoroughly investigated and reported to the appropriate authorities.
Incomplete Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a complete and thorough investigation for a resident with an injury of unknown origin. Resident #14 had dementia with behavioral disturbances, severely impaired cognition, was incontinent of bowel and bladder, and was totally dependent on staff for personal hygiene, dressing, and transfers. The resident also had behaviors directed toward others, including hitting, screaming, and disruptive sounds, and the care plan addressed sundowning and agitation with redirection, removal from public areas when behavior was unacceptable, psychiatric evaluation as needed, and medications as ordered. On 3/23/26, the resident was evaluated for new right-hand swelling and discoloration with no known history of trauma. The facility incident report identified a bruise to the right hand measuring 8.5 cm by 3.7 cm with mild swelling and no witnesses. RN #5 documented that the resident was confused, that NA #3 used a mechanical lift during the 7:00 AM to 3:00 PM shift, and that the resident had behaviors including hitting and grabbing at staff. Staff statements obtained that day indicated several aides did not observe a bruise, while one aide stated she was not assigned to the resident and did not observe any bruise. The investigation was incomplete because the charge nurse and RN #5 did not notify the DNS when the bruise was first identified, and the DNS stated he would have investigated if notified. RN #5 left the reportable event form and staff statements for review the next day and did not determine how the injury occurred. RN #4 stated she assessed the resident but did not ask whether the resident had been put back in bed for incontinent care or whether the mechanical lift had been used. The DNS stated his expectation for an injury of unknown origin was a complete investigation, including a 72-hour look back, interviews with all staff who cared for the resident, and written statements. The facility policy required unexplained injuries to be promptly and thoroughly investigated by the DNS, with documentation of relevant risk factors and conditions, but the investigation did not include those elements.
Failure to Provide Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to ensure that Resident #142 and/or the resident representative were provided written information about the bed-hold policy when the resident was transferred to the hospital. Resident #142 had diagnoses including Alzheimer's disease, chronic systolic congestive heart failure, chronic atrial fibrillation, chronic kidney disease, and restlessness and agitation, and the quarterly MDS identified the resident as having intact cognition. On 3/4/26, RN #2 documented that the resident was being treated for diverticulitis and presented with altered mental status, hypoxia, hypotension, and bradycardia. The PA was notified, orders were obtained to transfer the resident to the hospital, and the resident was transported by EMS. Review of the clinical record did not show that written notice specifying the duration of the bed-hold policy had been provided to the resident or resident representative at the time of transfer. A social worker note dated 3/5/26 documented that the resident was admitted to the hospital. During interviews, RN #2 stated she did not provide a bed-hold notice when the resident was transferred and was unsure who was responsible for doing so. SW #1 and SW #2 stated they were not responsible and believed Admissions handled bed-hold notices. The Administrator stated the notice was not provided and that bed-hold notices were not being consistently provided, while the DNS stated a copy should be given to the resident at transfer, kept in the chart, and mailed to the resident representative, but it was not completed for this transfer.
Failure to Notify PASRR Agency After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to submit a request for a PASRR Level II screen after two residents developed new psychiatric diagnoses. Resident #1 was admitted with diagnoses including dementia with behaviors, stroke, anxiety, and depression, and later had a significant change in condition with moderately impaired cognition, verbal and physical behaviors several days a week, and use of antianxiety and antidepressant medications. A psychiatric APRN later documented a new diagnosis of psychotic disorder not due to substance or known physiological condition, with paranoia, persecutory delusions, mood dysregulation, agitation, and a plan to start Zyprexa. Resident #1 was also transferred to an inpatient psychiatric facility and later readmitted, and a new diagnosis of PTSD was added later in the record. The clinical record did not identify that the PASRR contracted agency was notified of Resident #1’s new psychiatric diagnoses from the time the psychotic disorder was added through the survey review period in order to conduct a Level II screen. Interviews with social work staff showed they were responsible for updating the PASRR contracted agency when there was a new psychiatric diagnosis, but one social worker stated she may or may not update the agency when a resident has a change in condition or new mental health diagnosis and that she decides when she believes she should update the agency. She acknowledged awareness of Resident #1’s new psychiatric diagnoses and stated she did not update the PASRR contracted agency. Resident #5 was admitted with diagnoses including depression and dementia, and the initial PASRR Level I screen found a Level II was not required unless there were changes or new information. The resident care plan identified behavioral risk and included interventions such as redirection, removing the resident from public areas when behavior was unacceptable, medications as ordered, and psychiatric consultation as needed. A psychiatric APRN later documented that Resident #5 was newly diagnosed with a psychotic disorder not due to substance or known physiological condition, and the diagnosis was added to the record. The clinical record did not identify that the PASRR contracted agency was notified of this new psychiatric diagnosis to determine whether a Level II screen was needed, and a social worker stated she did not feel she needed to update the agency at that time.
IV Flush Orders Did Not Align With Intermittent Antibiotic Administration
Penalty
Summary
The facility failed to provide safe, appropriate administration of IV fluids for Resident #101, who had diagnoses including cerebral infarction, hypertension, and gastroesophageal reflux disease. The quarterly MDS identified the resident as cognitively intact with a BIMS score of 14 and dependent on staff for dressing, toileting, and transfers. The resident’s care plan required IV therapy related to an elevated white blood count, with interventions for IV therapy per physician’s order and IV-line management per facility protocol. A physician ordered Ceftriaxone 1 gram IV once daily at 5:30 PM for 3 days and also ordered the peripheral IV catheter flushed using the SAS technique every 12 hours at 8:30 AM and 8:30 PM with 10 ml of normal saline. During interviews and record review, an LPN and the ADNS identified that the facility policy required IV catheters to be flushed before and after intermittent medication administration, but neither could explain the SAS order or determine whether the flushing order was appropriate. The MAR showed the SAS flushing order was signed off at times that did not align with the Ceftriaxone administration times, and the ADNS stated the times should have aligned but could not explain why the flush orders were scheduled separately from the antibiotic administration.
Missing oxygen cautionary signage at resident doorway
Penalty
Summary
The facility failed to ensure cautionary and safety signage was posted outside the room of a resident receiving oxygen therapy. Resident #76 had diagnoses including COPD, dementia, and hypertension, and the physician ordered oxygen at 0 to 4 L/min to keep SpO2 above 90%. The quarterly MDS identified the resident as severely cognitively impaired with a BIMS score of 5 and noted that the resident was receiving oxygen therapy. The resident care plan identified the resident as at risk for respiratory distress due to COPD and included interventions for oxygen administration as ordered, maintaining oxygen saturation as ordered, and monitoring for signs and symptoms of respiratory deficiency. Observations on 3/23/2026 showed Resident #76 in bed and later seated in a recliner receiving continuous oxygen at 2 L/min via nasal cannula connected to an oxygen concentrator, and there was no oxygen cautionary and safety signage posted at the doorway during either observation. An LPN stated nursing was responsible for placing oxygen signage but did not place it because she could not locate any cautionary oxygen safety signage. An RN stated she was unaware the doorway lacked signage and said she had recognized the need to order additional oxygen signs a few weeks earlier while switching out concentrators. The DNS stated staff are responsible for ensuring oxygen cautionary and safety signage is posted when oxygen is in use, and said audits and rounds were conducted but could not provide dates because the audit sheets did not include dates. The facility oxygen concentrator policy stated that residents utilizing an oxygen concentrator will have an oxygen in use sign posted on the resident's door.
Delayed follow-up on psychiatric recommendations for resident with behavioral symptoms
Penalty
Summary
The facility failed to ensure that necessary behavioral health care and services were provided for a resident with dementia, anxiety, agitation, and behavioral symptoms. The resident’s quarterly MDS identified severely impaired cognition, dependence for personal care and transfers, incontinence, and behaviors occurring one to three days a week, including hitting, screaming, and disruptive sounds. The resident’s care plan addressed sundowning and agitation with interventions to redirect the resident, remove the resident from public areas when behaviors were unacceptable, obtain a psychiatric evaluation as needed, and administer medications as ordered. The clinical record showed that a neurology consultant recommended follow-up with the community psychiatrist for medication management and consideration of reducing Trazodone after the resident had multiple medication changes following a recent hospitalization. The APRN documented that the resident continued to have intermittent yelling and striking at staff and deferred medication changes pending psychiatric follow-up. Later, the community psychiatrist recommended Seroquel 12.5 mg twice daily for 14 days, and the resident continued to have yelling and combative behaviors during the period reviewed. Facility documentation and interviews showed that the psychiatrist’s recommendations were not obtained and implemented in a timely manner. A nurse documented that the psychiatrist had not provided new orders and that the facility was waiting for faxed recommendations, while the resident’s representative reported that the psychiatrist had seen the resident and recommended discontinuing Trazodone and starting Seroquel, but the changes had not been implemented. The DNS stated supervisors were responsible for following up on consultation recommendations the same day, yet from the psychiatrist visit through the end of the review period, staff did not obtain the new orders, and the facility did not receive the psychiatrist’s fax until 25 days after the visit.
PPE and Hand Hygiene Failures During Tube Feeding and Wound Care
Penalty
Summary
The facility failed to wear appropriate PPE during tube feeding care for a resident with cancer of the upper throat, difficulty swallowing, malnutrition, and a feeding tube. The resident’s care plan and physician’s order directed continuous tube feeding, daily changes of tube feeding supplies, and Enhanced Barrier Precautions (EBP) related to the feeding tube. During observation, an LPN performed hand hygiene and donned gloves before entering the resident’s room, then changed the resident’s tube feeding set-up without wearing a gown. The LPN removed the used tube feeding set-up, discarded the supplies, and placed the new labeled and dated tube feeding set-up while wearing only gloves. The LPN stated she knew the resident was on EBP and acknowledged that a gown was required for high-contact care activities, but said she forgot to wear one. The facility also failed to maintain proper infection control and hand hygiene during wound care for a resident with dementia, osteoarthritis, severe cognitive impairment, bowel and bladder incontinence, and impaired skin integrity involving blisters and rash on both inner thighs. The resident’s record included orders for cleansing and treating the affected areas, and later orders for open inner thigh wounds. During observed wound care, the APRN assessed the wounds, left the room, returned with a treatment cart, and placed supplies on the resident’s bed without a barrier. The APRN performed hand hygiene, donned gloves, removed soiled dressings from both thighs, and discarded them on the bed. She then cleansed both wounds using gauze and wound cleanser, again discarding used gauze on the bed, and later picked up the soiled items and discarded them in the bathroom trash can. The APRN removed her gloves, performed hand hygiene, and donned a new pair of gloves, but then measured both wounds with the same tape measure and applied dressings to both wounds without changing gloves or performing hand hygiene between wounds. The APRN stated she should treat every wound separately and acknowledged she should have changed gloves and performed hand hygiene when moving from one wound to another, including between cleaning, measuring, removing, and applying dressings. The facility’s dry clean dressing policy required a clean field, hand hygiene, glove changes, and cleaning each wound from the least contaminated area to the most contaminated area, and the hand hygiene policy stated that hand hygiene is required between glove changes and that gloves do not replace hand hygiene.
Missed Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure neurological assessments were completed after an unwitnessed fall for a resident with pneumonia, C. difficile, atrial fibrillation, depression, and lung cancer with brain metastasis who was also at risk for falls and bleeding while receiving Eliquis. The resident’s care plan identified fall and bleeding risk, and a physician’s order on admission directed Eliquis twice daily with monitoring every 30 minutes for 24 hours due to fall risk and documentation of interventions in the nursing progress notes. The resident’s admission MDS identified moderately impaired cognition, frequent bowel incontinence, occasional bladder incontinence, and need for maximum assistance with toileting hygiene, lower body dressing, and personal hygiene. Facility documentation showed the resident was found sitting on the floor in the room after self-transferring from the bathroom. A nursing note documented a laceration above the right eyebrow and a superficial laceration to the left index finger, with cleansing of both areas, Steri-Strips applied to the eyebrow laceration, and a band-aid applied to the finger. The nurse documented that neurological assessments were initiated and within normal limits, the resident denied pain or discomfort, and the resident reported losing balance while moving the walker out of the bathroom. The physician ordered neurological checks every 15 minutes for one hour, every 30 minutes for 2 hours, every 4 hours for 20 hours, and every 8 hours for six shifts. Review of the MAR showed neurological assessments were documented at 7:45 PM, 8:00 PM, and 8:15 PM, but were not completed at 9:15 PM, 9:45 PM, and 10:15 PM on the day of the fall. The MAR also showed a missed neurological assessment at 9:15 PM on 8/22/24. The next day, the resident’s neurological assessment and vital signs were documented as within normal limits, and the resident was transferred to the emergency department after the representative requested a CT scan of the head. The DNS stated the neurological assessments were not completed on 8/20/24 and 8/22/24 per physician’s order because the order was not transcribed correctly.
Failure to Secure Doors in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe and secure environment on a locked memory care unit for residents with special needs. During an observation, it was found that several doors, including those labeled 'Soiled Utility,' 'Supply Room,' and 'Clean Utility,' were unable to be fully closed, latched, and locked. Additionally, the 'Shower' door was not locked. Although there were no accessible sharps or hazardous materials in these rooms and no residents were in the immediate area, the doors were expected to remain securely locked. Interviews with the Director of Nursing Services confirmed that the doors should have been locked, and the Director of Maintenance identified moisture as the reason for the doors not closing properly. The Director of Maintenance was not previously aware of the requirement for the doors to be locked. The facility did not provide a policy for ensuring a safe and secure environment when requested.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications according to professional standards and facility policy, as observed in four out of seven medication carts. On the Elm Tree unit, a medication prescribed to a resident was not stored in the refrigerator as required after opening, and the Licensed Practical Nurse (LPN) was unsure of when it was opened. The medication was last administered the previous evening, and the LPN acknowledged that medications should be stored according to directions, with the last nurse responsible for proper storage. On the Apple Blossom Unit, two residents' medications were not labeled correctly. One resident's inhaler was not labeled at all, and another resident's medication lacked a date indicating when it was opened. The Registered Nurse (RN) interviewed was unable to explain the labeling issue and stated that the pharmacy is responsible for labeling, while staff should check orders before administration. Additionally, in the Dogwood unit's medication room, a resident's medication was found to be expired. The LPN interviewed confirmed that expired medications should be reviewed and discarded, and nurses are responsible for checking expiration dates. The facility's policy requires medications to be stored in pharmacy-labeled containers, with opened medications dated and refrigerated if necessary.
Laundry Room Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the laundry room, as observed during a tour on June 5, 2024. Two vents and a smoke detector were found covered in gray debris, with one vent located in the dirty laundry area and the other in the clean laundry area near a folding table. The smoke detector was also in the clean laundry area. During an interview, the Laundry Supervisor admitted uncertainty about the last cleaning date and mentioned that cleaning logs were not readily available in the laundry area. The Infection Preventionist (IP)/LPN confirmed that the vents should be cleaned weekly by the laundry aide and that cleaning logs exist, but was unsure why the policy was not followed. A review of the cleaning logs for May and June 2024 revealed that the vents were cleaned on specific dates in May, but the June log lacked a specific date, only stating that the vents were cleaned on the day of the surveyor's inquiry. The facility's policy, dated February 20, 2024, directed that vents be cleaned weekly, which was not adhered to.
Failure to Maintain Resident Dignity and Rights
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by the actions of a nurse aide (NA #1) towards two residents. Resident #23, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), emphysema, and chronic respiratory failure, required supervision and assistance with activities of daily living (ADL). Despite being cognitively intact and able to make needs known, Resident #23 reported that NA #1 raised her voice when asked to assist another resident, Resident #30, who needed to use the bathroom. This incident was reported to the nursing supervisor (RN #2), but there was no documented investigation attached to the grievance report. Resident #30, diagnosed with weakness, hemiplegia, and hemiparesis, required total assistance with toileting and was non-ambulatory. On the day of the incident, Resident #30 requested assistance from NA #1 to use the bathroom. NA #1, who was busy clearing trays, told Resident #30 to wait and did not inform another staff member to assist. It was only after Resident #23 intervened that NA #1 assisted Resident #30, approximately 15 minutes after the initial request. This delay in assistance and the manner in which NA #1 responded to the residents were not in line with the facility's policy to treat residents with care, courtesy, and respect. The facility's grievance policy requires a prompt and thorough investigation of all grievances, which was not adhered to in this case. The nursing supervisor acknowledged the incident as a customer service issue but failed to document the investigation properly. The lack of documentation and the failure to prioritize resident needs, such as toileting assistance, contributed to the deficiency in maintaining resident dignity and rights.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in status for Resident #427, who was exhibiting recurring symptoms of diarrhea. Resident #427, who had been diagnosed with acute kidney failure and duodenitis, was discharged from the hospital with a stable condition. However, upon admission to the facility, the resident began experiencing loose stools and requested medication for relief. Despite these symptoms, there was no documentation of how the change in condition was addressed, and the physician was not notified in a timely manner. Interviews with various nursing staff revealed a lack of communication and reporting regarding the resident's condition. LPN #6, who was on duty during the episodes of diarrhea, did not report the change of condition to a nursing supervisor or physician, believing it was already documented in the APRN communication book. The Medical Director was not informed of the recurrent episodes until later, and the Director of Nursing Services expected that any change of condition should be reported. The facility's policy directed that significant changes in status should be reported to the Nursing Supervisor, which was not followed in this case.
Resident-to-Resident Altercation in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse during a resident-to-resident altercation. Resident #48, who has Alzheimer's disease and severe cognitive impairment, was struck in the chest by another resident, Resident #75, who also has Alzheimer's disease and severe cognitive impairment. The incident occurred while Resident #48 was walking in the hallway with another person. Resident #75, who had no prior history of aggression, unexpectedly hit Resident #48 and yelled profanities. The altercation was witnessed by LPN #4, who confirmed that there was no provocation or signs of agitation from either resident prior to the incident. The facility's policy defines resident-to-resident altercation as a physical or verbal act between two residents, regardless of injury. The policy also states that cognitively impaired residents must possess intent to harm for an act to be considered abuse. Despite this, the incident was reported, and the supervisor, physician, and police were notified. Resident #75 was placed on 1:1 observation and sent to the hospital for evaluation following the altercation.
Failure to Ensure Proper Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #48, was administered medications as prescribed by the physician and in accordance with professional practice standards. Resident #48, who had diagnoses including Alzheimer's disease and insomnia, was found to have severe cognitive impairment and required assistance with personal hygiene and dressing. Despite having no swallowing disorders, the resident was at risk for aspiration and was on a ground diet consistency. The care plan included administering psychotropic medications as ordered and monitoring the resident's behaviors and sleep. However, an internal investigation revealed that pills, which were supposed to be administered to the resident at bedtime, were found in the resident's nightstand drawer. These pills included Melatonin, paroxetine, donepezil, quetiapine, and memantine. Interviews with staff indicated that the pills were identified by their appearance and imprints, and it was suspected that the resident may have had the pills in their mouth and spit them out. The facility acknowledged that ensuring cognitively impaired residents take their medications completely is part of the standard of practice. Despite this, it was noted that oral checks to confirm medication ingestion were not consistently performed. An LPN confirmed that checking if a resident swallowed their medications properly was a standard practice learned during nursing education. Observations during a medication pass showed that oral checks were performed, but not all staff had participated in the in-service training on oral checks, highlighting a gap in consistent practice across the facility.
Failure to Conduct Nursing Assessment for Change of Condition
Penalty
Summary
The facility failed to ensure a nursing assessment was completed for a resident experiencing a change of condition. Resident #427, who had diagnoses including acute kidney failure and duodenitis, was discharged from the hospital with a stable condition. However, upon admission to the facility, the resident began experiencing symptoms of diarrhea and gastric upset after consuming shrimp. Despite the resident's request for medication to address these symptoms and documentation in the APRN communication book, the nursing staff did not report the change of condition to a nursing supervisor or physician. Interviews revealed that the nursing staff believed the symptoms were food-related and did not require further reporting or assessment. Additionally, the resident experienced an episode of epistaxis, which was noted in the shift report but not followed by a documented nursing assessment. The Director of Nursing Services indicated that any change of condition should be reported and assessed, but this protocol was not followed. The lack of a policy for RN assessments was noted, and interviews with nursing staff confirmed that the change of condition was not communicated to the appropriate personnel, leading to a deficiency in care.
Failure to Reassess Nutritional Needs for Resident with New Pressure Wounds
Penalty
Summary
The facility failed to reassess the nutritional status and needs of a resident with newly identified pressure wounds. Resident #103, who had diagnoses including type II diabetes mellitus, obstructive sleep apnea, and malignant neoplasm of the urethra/bladder, was identified as being at risk for pressure ulcers. Despite the presence of unhealed pressure ulcers and the development of new wounds on the left ankle, sacrum, right hip, and right knee, there was no documented reassessment of the resident's nutritional status following these developments. The resident was receiving palliative care, and while some nutritional interventions were noted, such as the addition of liquid protein, the lack of a formal reassessment was a significant oversight. Interviews with the Dietitian and the Director of Nursing Services (DNS) revealed that wounds were discussed weekly with the interdisciplinary team, including the Dietitian. However, the Dietitian was unaware of the new wounds and had not conducted a reassessment of the resident's nutritional needs. The facility's policy for Pressure Injury Prevention and Management required that residents at high risk for pressure injuries or with existing pressure injuries receive appropriate interventions, and that the plan of care be revised as necessary. The failure to reassess the nutritional needs of Resident #103 following the identification of new wounds was a deviation from this policy.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and maintenance of respiratory equipment for two residents, leading to deficiencies in respiratory care. Resident #71, diagnosed with chronic obstructive pulmonary disease and essential hypertension, was observed with a nebulizing mouthpiece left uncovered on top of the nebulizing equipment. Despite having a care plan that included nebulizer treatments, the mouthpiece was not stored in a bag after use, as confirmed by a registered nurse who admitted to the oversight. The Director of Nursing Services and the registered nurse both acknowledged that all respiratory equipment should be stored in a bag when not in use. Resident #103, who has obstructive sleep apnea, was found with a CPAP mask placed on top of the machine without a cover and oxygen tubing labeled with an outdated date. The resident used the CPAP during the night and oxygen during the day, but the equipment was not stored properly when not in use. Interviews with a nurse aide and the Director of Nursing Services confirmed that the CPAP mask and oxygen tubing should have been stored in a bag and changed weekly, respectively. The facility's policy for storage guidelines was not provided, contributing to the deficiency.
Failure to Re-evaluate PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the re-evaluation of a psychotropic medication for a resident diagnosed with anxiety disorder, Major Depressive Disorder, and vascular dementia. The resident, who was cognitively impaired and required maximal assistance with daily activities, had a physician's order for Lorazepam to be administered every four hours as needed for restlessness and agitation. Despite the medication being prescribed on a PRN basis, the facility did not provide documentation or rationale for the continued use of this medication. The resident's behavioral flow records indicated no change in behaviors, yet the PRN Lorazepam was administered without a documented review or justification. Interviews with facility staff revealed inconsistencies in the management and documentation of PRN psychotropic medications. An RN indicated that PRN orders should be reevaluated every 14 days, while an LPN noted that targeted behaviors and interventions should be documented when psychotropic medications are used. However, the facility's policy on psychotropic medication did not address the requirements for medication use, and there was no rationale provided for the continued PRN order for Lorazepam. The facility's DNS mentioned that psychotropic medications are not usually prescribed as PRN, highlighting a lack of adherence to the facility's usual practices.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to deficiencies in their care. Resident #121, who has diagnoses including diverticulitis and atherosclerosis, expressed a preference for eggs and hash browns more frequently than the once-weekly offering. Despite communicating this preference to the dietary staff, the Food Service Director stated that eggs could not be provided more often due to preparation constraints, and hash browns were not consistently set aside for the resident. The Director of Nursing Services acknowledged the resident's numerous preferences and expected reasonable accommodations, but the facility did not ensure these preferences were consistently met. Resident #52, with diagnoses including macular degeneration and heart failure, repeatedly received sandwiches with mayonnaise despite expressing a dislike for it and indicating this preference on meal tickets. The Kitchen Supervisor acknowledged the issue, attributing it to confusion among new staff, which led to the resident receiving incorrect meals. The facility's dietary notice policy and the Residents' Rights emphasize the importance of accommodating individual preferences, yet these were not adhered to, resulting in the residents' preferences being overlooked.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide copies of a resident's medical record within the required 48-hour timeframe. This deficiency was identified during a review of the clinical records, facility policy, and staff interviews for a resident who was admitted with multiple diagnoses, including metabolic encephalopathy and cognitive impairment. The resident required substantial assistance with daily activities, as noted in their care plan. A family member, identified as the resident's emergency contact, requested a copy of the resident's discharge paperwork. However, the social worker informed the family member that they could not provide the paperwork and directed them to the acute care facility for the records. Further investigation revealed inconsistencies in the facility's handling of the request. The social worker later clarified that the request was for medical records from the acute care facility, not the discharge paperwork from the facility, and stated that the facility's policy required the family to obtain records from the outside facility. Additionally, a staff member from the medical records department could not recall receiving any request for copies of the resident's medical record and found no documentation of such a request. The facility's policy allows residents or their legal representatives to access and purchase copies of their records within two working days of the request, which was not adhered to in this case.
Inappropriate Charges for Medical Record Copies
Penalty
Summary
The facility failed to charge the appropriate amount for copies of a resident's medical records, leading to a deficiency in compliance with applicable laws and regulations. Resident #432, who was admitted with diagnoses including metabolic encephalopathy, essential hypertension, muscle weakness, hypothyroidism, and dysphagia, was identified as cognitively impaired and required substantial assistance with activities of daily living. The resident's family member, who was the emergency contact, requested copies of the medical records and was charged 75 cents per page and an additional 30 dollars for document retrieval. Interviews with facility staff revealed inconsistencies in the charges for medical record copies, with different staff members quoting different rates per page, none of which aligned with the Connecticut general state statute. The facility's administrator acknowledged that residents or family should not be charged more than 65 cents per page and was unaware of the reason for the overcharge. The facility's policy stated that the cost for copies should not exceed prevailing community rates, indicating a failure to adhere to their own policy and state regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 145 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Milford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Crest Center For Health & Rehabilitation | 1 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At Pawling | 9.8 mi | ★★★★★ | 0 | 0 |
| Springs At East Hill, The | 11.3 mi | — | 0 | 0 |
| Lutheran Home Of Southbury Inc | 11.8 mi | ★★★★★ | 5 | 0 |
| Pomperaug Woods Health Center | 11.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.