Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Complete Care At Kimberly Hall North during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, paralysis, diabetes, and dependence for care developed posterior scalp pressure wounds after staff failed to consistently monitor skin, inspect the back of the head, provide adequate hair care, and follow the repositioning plan. Weekly skin checks and routine care did not identify severely matted hair or early scalp changes, and camera review showed a prolonged gap in turning and repositioning despite the care plan. When the resident’s head was shaved by the RP, multiple scalp lesions with necrotic tissue were discovered, and the wound physician later determined the wounds were pressure-related and likely present for at least 1 to 2 weeks before discovery.
Failure to Report Alleged Neglect Involving Missed Repositioning: A dependent resident with severe cognitive and physical impairments developed posterior scalp pressure wounds after staff did not consistently turn and reposition the resident as required by the care plan. The RP raised concern about missed repositioning, documentation showed an overnight shift with uncompleted care tasks, and camera footage later showed the resident went nearly 4 hours without being turned. The allegation of neglect was not reported to the SA within the required timeframe.
Incomplete investigation of scalp pressure injuries: A dependent resident with severe cognitive impairment and multiple chronic conditions was found to have a cluster of pressure injuries on the back of the head after the RP raised concern about scalp skin changes related to severely matted hair. Although the event was treated as possible neglect, the facility did not obtain statements from several RN, LPN, and NA staff who had worked with the resident or on the unit during the prior 72 hours, and the DON confirmed the investigation was incomplete.
Failure to turn and reposition a high-risk resident led to posterior scalp pressure injuries. The resident had severe cognitive impairment, paralysis, diabetes, and dependence for bed mobility, and the care plan directed repositioning four times per shift with regular skin checks. Documentation and camera review showed missed repositioning for hours at a time, and the resident later developed a cluster of wounds on the back of the head with devitalized tissue. The resident’s call bell was also found out of reach during observation.
Call Bell Not Kept Within Reach of Dependent Resident: A resident with severe cognitive impairment, limited verbal communication, and total dependence for ADLs was found twice with the touch pad call bell out of reach while in bed. Staff observed the call system hanging on the wall or oxygen concentrator instead of being accessible, and an NA reported forgetting to return it after care while another NA ignored a request to place it within reach and remained in the hallway. An LPN later placed the call bell by the resident’s hand, and the DON stated staff should ensure the call bell is within reach before leaving the room.
Two cognitively impaired residents on a locked dementia unit, both with severely impaired BIMS scores and care plans noting dementia-related cognitive decline, were left unsupervised for about 15–20 minutes after breakfast while staff assisted other residents. During this interval, staff discovered the two residents in a bed, prone and partially unclothed, with one on top of the other and lower garments removed or unfastened. Both residents were documented as not responsible for themselves, had no prior sexual disinhibition behaviors, and later demonstrated lack of recall or misperception of the event. The facility’s sexual expression policy applied only to residents with intact decision-making capacity, and there was no prior consent from responsible parties for sexual activity, resulting in a failure to protect these residents from sexual abuse through adequate supervision and interventions.
A resident with seizure disorder, dementia, and multiple comorbidities experienced repeated failures in timely medication administration and documentation. Required scheduled doses of gabapentin and acetaminophen were not documented as given at the ordered time, despite an RN later stating they had been administered. On another day, an RN documented a set of 9:00 AM medications, including anticonvulsants, antihypertensives, anticoagulant, antidepressant, and laxative, more than four hours late, while another RN administered evening anticonvulsant, analgesic, muscle relaxant, anticoagulant, sleep aid, antidepressant, and neuropathy medications more than two to three hours earlier than scheduled. One RN reported routinely delaying electronic documentation until after completing the full med pass due to EMR issues and workload, contrary to the facility’s one-hour administration window and immediate documentation standard.
A resident with dementia and dysphagia, fully dependent on staff for feeding, was not fed in a dignified manner. Video evidence showed a nursing assistant feeding the resident rapidly with large spoonfuls of food, not allowing time to swallow between bites, and letting food drip onto the resident's chin. Staff interviews confirmed the feeding did not follow the care plan or facility policy, which required slow, attentive feeding and ensuring swallowing between bites.
A nurse aide failed to follow proper feeding techniques for a resident with dementia and dysphagia, providing large spoonfuls of food too quickly and not ensuring the resident had swallowed before offering more, despite documented competency and clear care plan instructions. Video evidence and staff interviews confirmed the feeding was too rapid and did not adhere to protocols for safe feeding of residents with swallowing difficulties.
A resident with severe cognitive and physical impairments was subjected to abuse when a nursing assistant forcefully fed them despite clear signs of resistance, contrary to the care plan that required redirection and postponement of care. The incident was captured on video and confirmed through facility documentation and interviews.
A resident with dementia, dysphagia, and severe cognitive impairment, who was dependent on staff for eating, did not receive appropriate feeding interventions as outlined in their care plan. Video evidence showed a nursing assistant disregarding the resident's attempts to block feeding, continuing to feed, and failing to use redirection or re-approach techniques, resulting in improper care.
A resident with dementia and abnormal gait, who was independent with ambulation, tripped over an electrical cord stretched across a hallway while housekeeping was cleaning. Despite caution signs being present, the resident fell and sustained a laceration to the lip requiring sutures. Facility policy prohibited cords from crossing open areas, but this was not followed, resulting in the incident.
A resident with severe cognitive impairment and total care needs did not receive the required two-person assistance for bed mobility, as specified in their care plan and aide Kardex. Instead, a nurse aide provided care alone during an overnight shift, despite being aware of the two-person requirement. The resident was later found to have a right shoulder dislocation, and facility documentation confirmed the care plan was not followed.
The facility failed to protect residents from physical mistreatment, as evidenced by incidents involving two residents who were physically abused by other residents. One resident, diagnosed with Alzheimer's and anxiety disorder, was hit by another resident with a history of aggressive behavior. Another resident, diagnosed with dementia and anxiety, was bitten and knocked down by a resident with impulse disorder. The facility's policies and procedures were insufficient in preventing these incidents, highlighting a failure to ensure a safe environment.
A resident with severe cognitive impairment was admitted with a stage 3 pressure ulcer, which deteriorated to stage 4 after admission. The facility failed to update the care plan to reflect this change, incorrectly indicating the ulcer was present on admission. Staff interviews confirmed the ulcer was facility-acquired, highlighting a deficiency in care planning.
A resident with dementia and Alzheimer's was not provided with a Kennedy cup as required by their care plan during mealtime. Despite the care plan and meal ticket indicating the need for adaptive equipment, the resident was observed using a regular cup. Interviews revealed that the kitchen was responsible for providing the equipment, but it was not included on the tray until after surveyor inquiry.
A facility failed to monitor behaviors for a resident on psychotropic medications, leading to undocumented administration. Another resident with a knee brace order was not wearing it due to improper documentation and lack of care planning for refusal. Additionally, a resident with edema did not receive prescribed Ace wraps due to oversight and lack of supplies, with no documentation of refusals.
A facility failed to provide adequate supervision during dining for six residents with cognitive impairments, leaving them unsupervised while eating. Observations and staff interviews confirmed that an LPN left the dining area to administer medications, resulting in residents being unattended. The ADNS acknowledged the lapse in supervision, which was contrary to the residents' care plans requiring assistance.
The facility failed to ensure staff competencies for IV therapy and the use of Low Air Loss (LAL) mattresses. Seventeen licensed staff lacked documented IV therapy competencies, and a resident's LAL mattress was incorrectly set due to inadequate staff training. The ADNS confirmed the absence of in-service training or facility policy on the specific LAL mattress used, leading to confusion among staff.
A resident with dysphagia was served a dinner roll despite being on a chopped diet, contrary to dietary guidelines. Staff interviews revealed a lack of understanding and communication about dietary restrictions, and the facility's policy to inspect food trays was not effectively implemented.
A resident with dementia and other health issues was served a meal that did not match their dietary preferences as indicated on their lunch ticket. Staff interviews revealed that dietary trays were served without verifying the meal against the ticket, contrary to facility policy. The Director of Dietary confirmed that a staff member is supposed to ensure meals meet dietary restrictions and preferences, but this was not done.
A facility failed to follow infection control procedures during wound care for a resident with a stage 4 pressure ulcer. An LPN handled wound supplies with dirty gloves and placed a trash bag on a nonsterile surface. Enhanced barrier precautions were not followed, as staff did not wear gowns and were unaware of the requirement, despite a sign outside the resident's door. PPE carts were located in the hall, shared among residents, but not immediately available near the resident's room.
The facility did not provide a homelike dining environment for memory unit residents, serving meals on dietary trays to prevent food sharing, as observed and confirmed by the Administrator.
A resident with severe cognitive impairment experienced a breach of dignity when a medical doctor made an inappropriate comment about a disciplinary sign in the resident's room. The comment, although not directed at the resident, was overheard by staff and considered unprofessional. The facility's policy on resident rights was not upheld, leading to a deficiency in maintaining the resident's dignity.
A resident with anxiety and depression was verbally abused by a nursing assistant (NA) who accused them of being a troublemaker and lying. The incident was confirmed by a facility investigation, which found that the NA's actions constituted verbal abuse as per the facility's policy. The NA's employment was subsequently terminated.
Failure to Monitor Skin, Hair, and Repositioning Led to Posterior Scalp Pressure Wounds
Penalty
Summary
The facility failed to ensure a severely cognitively impaired resident who was dependent on staff for hygiene, bed mobility, transfers, and toileting received ongoing skin monitoring, hair care, thorough head-to-toe skin assessments, and repositioning needed to prevent pressure-related skin breakdown. The resident had diagnoses including bilateral paralytic syndrome following cerebral infarction, type II diabetes mellitus with diabetic neuropathy, chronic pain syndrome, muscle weakness, and anxiety disorder. The resident was identified as being at risk for pressure injuries, had a history of healed pressure injuries, and the care plan directed use of a low air loss mattress, turning and repositioning, daily skin observation with care, and weekly skin checks by a licensed nurse. Weekly skin checks completed in March and early April documented no skin injury, and a shower note documented the skin observation as not applicable. The resident’s care plan and Kardex directed staff to monitor skin redness or irritation, observe skin condition daily with ADL care, and continue every two-hour repositioning. However, the resident’s hair at the back of the head was not identified as severely matted until the resident representative shaved the head because of odor and concern about hair hygiene. When the scalp was exposed, multiple lesions were found on the posterior scalp, including areas with adherent fibrinous tissue and a pink wound bed, with the cluster measuring 6 cm by 5 cm. After the wounds were discovered, the resident was assessed and the posterior scalp lesions were described as a full-thickness clustered wound with necrotic tissue. The wound physician later determined the wounds were caused by pressure due to the back of the head location and stated they likely would not have developed if the area had been consistently offloaded. The physician also stated the wounds appeared to have been present for at least one to two weeks or longer before discovery. Interviews and camera review showed staff did not consistently inspect the back of the head, did not identify the matted hair during routine care or weekly skin checks, and there was a documented period when the resident was not turned and repositioned for almost four hours despite the care plan directing repositioning four times per shift.
Failure to Report Alleged Neglect Involving Missed Repositioning
Penalty
Summary
The facility failed to notify the State Agency of an allegation of neglect within 2 hours after the allegation was made. The allegation involved a dependent resident with bilateral paralytic syndrome following cerebral infarction, type II diabetes mellitus with diabetic neuropathy, chronic pain syndrome, muscle weakness, anxiety disorder, severely impaired cognition, and dependence on staff for bed mobility, transfers, and personal care. The resident had been identified as at risk for pressure injuries and had a care plan requiring turning and repositioning four times per shift, skin checks, and daily observation for skin abnormalities. The resident developed a cluster of wounds on the posterior scalp after the responsible party shaved the resident’s head because of severely matted hair. A nurse assessed the wounds and documented a cluster of five lesions on the back of the head, with some areas covered by adherent fibrinous tissue and one pink wound bed. The provider was notified, wound treatment was started, and later the wound physician documented the posterior scalp wound as a full-thickness cluster wound with devitalized necrotic tissue. The wound physician initially listed the etiology as undetermined, but later determined the wounds were caused by pressure due to the back of the head location. The responsible party reported concern about the resident’s turning and repositioning, and facility documentation showed assigned tasks on an overnight shift were not documented, including turning and repositioning. A disciplinary form identified a nursing assistant failed to complete assigned tasks and documentation. The responsible party later reviewed camera footage showing the resident was not turned and repositioned for almost 4 hours despite the care plan requiring repositioning at least four times per shift. The DON confirmed the footage showed the resident had not been turned or repositioned during that period, and subsequent review of the state portal showed the allegation of neglect was not reported to the State Agency as required.
Incomplete Investigation of Scalp Pressure Injuries
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect after a dependent resident was found to have a cluster of five pressure injuries on the posterior scalp. The resident had significant medical complexity, including bilateral paralytic syndrome following cerebral infarction, type II diabetes mellitus with diabetic neuropathy, chronic pain syndrome, muscle weakness, and anxiety disorder. The resident also had severely impaired cognition, required substantial assistance for bed mobility, was dependent on staff for personal hygiene and transfers, and was at risk for pressure injuries. Prior assessments and skin checks documented intact skin and no open areas, including a nursing readmission assessment, weekly skin checks, and a care plan identifying the resident as high risk for skin breakdown with interventions such as a low air loss mattress, turning and repositioning, daily skin observation, and weekly licensed nurse skin checks. When the scalp wounds were discovered after the responsible party reported concern about the resident’s hair hygiene and a change in scalp skin integrity following shaving of severely matted hair, the nurse documented a cluster of lesions on the back of the head, including wounds with adherent fibrinous tissue and one pink wound bed. The resident denied pain, and the provider was notified. The facility initiated a reportable event and identified the concern as possible neglect, but the investigation was incomplete. Review of the accident and investigation documents showed that statements were not obtained from several staff members who had worked with the resident or on the resident’s unit during the prior 72 hours, including RN #2, RN #4, LPN #4, NA #4, and NA #10. The DON stated the wounds should have been investigated as an injury of unknown origin and that statements should have been obtained from all staff who worked with the resident, but she was unable to produce the missing statements.
Failure to Turn and Reposition a High-Risk Resident
Penalty
Summary
The facility failed to ensure a resident at risk for pressure injuries was turned and repositioned according to the plan of care, and the resident developed several pressure injuries to the posterior scalp. The resident had diagnoses including bilateral paralytic syndrome following cerebral infarction, type II diabetes mellitus with diabetic neuropathy, chronic pain syndrome, muscle weakness, and an anxiety disorder. The quarterly MDS identified severe cognitive impairment, short- and long-term memory problems, substantial assistance needed for bed mobility, dependence for personal hygiene and transfers, and risk for pressure injuries with no current skin abnormalities at that time. The resident’s care plan identified risk for skin breakdown related to quadriplegia with contractures, decreased activity, impaired cognition, bowel and bladder incontinence, dependence on staff for bed mobility, transfers, and toileting, and a history of healed pressure injuries. Interventions included a low air loss mattress, turning and/or repositioning, skin checks four times per shift as determined by tissue tolerance, daily skin observation with care, and weekly skin checks by a licensed nurse. Despite these directions, documentation showed missed or incomplete turning and repositioning. The April documentation survey report identified that all assigned tasks on the 11:00 PM to 7:00 AM shift on 4/11/26 were not documented, including turning and repositioning. The resident’s responsible party reported concerns about hair hygiene and believed the resident had been neglected because the hair at the base of the scalp was knotted and irritating the scalp and back of the head. When the head was shaved, multiple pink areas and scabbed areas were observed on the back of the head, and a nurse later documented a cluster of five lesions on the posterior scalp, including areas with adherent fibrinous tissue and a pink wound bed. The wound physician later described the posterior scalp wound as a full thickness cluster with devitalized tissue and determined the wounds were caused by pressure due to the back of the head location. In-room camera footage reviewed with the responsible party showed the resident was last repositioned at 5:18 AM and was not turned again until 9:08 AM, despite the plan of care directing repositioning four times per shift. During observation, the resident’s call bell was also found hanging out of reach, and staff did not immediately enter the room to replace it or reposition the resident.
Call Bell Not Kept Within Reach of Dependent Resident
Penalty
Summary
The facility failed to ensure a working call system was consistently accessible and within reach for a resident who was dependent for all ADLs, had severely impaired cognition, limited verbal communication, and required substantial assistance with bed mobility, transfers, and personal hygiene. The resident’s care plan directed staff to anticipate and meet needs, keep the call light within reach, encourage use of the call light for assistance, and provide prompt response to requests for help. The resident also had diagnoses including bilateral paralytic syndrome following cerebral infarction, type II diabetes mellitus with diabetic neuropathy, chronic pain syndrome, muscle weakness, anxiety disorder, COPD, chronic respiratory failure, and a tracheostomy with increased respiratory secretions. On one observation, the resident was found in bed with tears running down the face, unable to verbally communicate, with pink secretions noted under the tracheostomy gauze. The touch pad call bell was hanging on the oxygen concentrator against the back wall about three feet away from the head of the bed and was not within reach. An LPN observed that the call bell was not within reach and later placed it next to the resident’s right hand and clipped it to the bed. The LPN stated she was unsure why the call bell was not in place and within reach, noting the resident had recently received personal care from an NA and had use of the right hand to operate the call bell. On a later observation, the resident was again in bed with the touch pad call bell hanging on the back wall and not within reach. An NA reported she had not yet been in the room since the start of her shift because there was no help and ignored the request to place the call bell within reach. She continued passing drinks for breakfast in the hallway and did not go into the resident’s room to replace the call bell or reposition the resident. The DON stated that after providing care, NAs and licensed nurses should ensure the call bell is within reach before leaving the room, and that if the NA was not providing care to another resident when notified, she should have responded immediately and placed the call bell within reach.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to protect two cognitively impaired residents from sexual abuse by not ensuring adequate supervision and interventions on a locked dementia unit. One resident had Alzheimer’s dementia with behavioral disturbance, was oriented only to self, and had a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. This resident’s care plan identified impaired cognitive function and thought processes related to dementia, with interventions focused on assisting with decision-making, using cues, and redirecting as needed. The other resident had frontotemporal neurocognitive disorder and dementia, a conservator of person, and a BIMS score of 6, also indicating severely impaired cognition. This second resident’s care plan identified risk for elopement and wandering, as well as impaired cognitive function, with interventions including engagement in tailored activities, redirection when wandering or intrusive, and communication strategies adapted to cognitive deficits. On the day of the incident, both residents were on a locked dementia unit and were described as not responsible for themselves. Breakfast was served on the unit, and one resident ate in the dining room while the other ate in their room. After breakfast trays were picked up, there was an interval of approximately 15–20 minutes between the last observation of the residents and the discovery of the incident. During this time, staff were engaged in feeding and assisting other residents. A nursing assistant entered one resident’s room to feed that resident and found the two residents lying prone in bed, partially clothed, with one resident on top of the other. Clothing for both residents was displaced or removed from the lower body. Staff statements and clinical evaluations documented that both residents had severe cognitive impairments and limited orientation, with no prior documented sexual disinhibition behaviors. The assistant and a certified occupational therapy assistant both described finding one resident on top of the other, with pants and undergarments removed or unfastened. Subsequent interviews with clinical staff indicated that one resident did not recall the incident, and the other misidentified the peer as someone from their past and believed they were rekindling a relationship. The facility’s policy on sexual expression specified that it applied to individuals with intact cognitive decision-making capacity, and there was no indication that either resident had such capacity or that consent for sexual activity with other residents had been obtained from their responsible parties prior to the incident. The combination of severe cognitive impairment, lack of capacity to consent, and the lapse in supervision on the locked dementia unit led to the failure to protect these residents from sexual abuse.
Medication Administration Timing and Documentation Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered within acceptable time frames and documented at the time of administration for a resident with seizure disorder, anxiety, and dementia. The resident was identified as severely cognitively impaired and required assistance with activities of daily living. The resident’s care plan noted risk for seizure activity with interventions to medicate as ordered and monitor for effectiveness and side effects. Physician orders included gabapentin every eight hours for neuropathy and acetaminophen every eight hours for pain. On one date in March, the Medication Administration Record showed that the resident’s scheduled 2:00 PM doses of gabapentin and acetaminophen were not documented as given. The nurse supervisor for that shift stated in interview that these medications were administered at 2:00 PM but acknowledged failing to document the administration, despite facility policy requiring documentation at the time medications are given. Additional deficiencies were identified when review of the March Medication Administration Record showed that multiple scheduled medications were administered significantly outside the facility’s standard one-hour before to one-hour after window. On one date, a nurse documented a group of 9:00 AM medications, including brivaracetam, ferrous sulfate, baclofen, carvedilol, losartan, apixaban, amlodipine, duloxetine, senna, and lorazepam, as administered at 1:32 PM, more than four and a half hours late. On the same date, another nurse administered 9:00 PM medications, including brivaracetam, diclofenac gel, baclofen, melatonin, apixaban, mirtazapine, lorazepam, and acetaminophen, between 6:32 PM and 6:33 PM, over two hours early, and a 10:00 PM gabapentin dose at 6:34 PM, more than three hours early. One nurse reported documenting medications only after all assigned residents had received their medications, citing electronic record issues and workload, which conflicted with the facility’s standard of practice and policy requiring immediate documentation and adherence to the one-hour administration window.
Failure to Feed Dependent Resident in a Dignified Manner
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including eating, was not fed in a dignified manner. The resident had significant medical conditions, including dementia, dysphagia, mood disorder, and lack of coordination, and was on a dysphagia puree diet with nectar thick liquids. Care plans and physician orders specified that the resident should be fed slowly, with small bites and sips, and that staff should ensure the resident swallowed each mouthful before offering more food. However, video evidence showed that a nursing assistant fed the resident rapidly, placing multiple heaping spoonfuls of oatmeal into the resident's mouth without waiting for the resident to swallow, and allowed food to drip onto the resident's chin before using the spoon to remove it. Interviews with facility staff confirmed that the feeding was not performed according to the resident's care plan or facility policy, which emphasized slow feeding and ensuring swallowing between bites. The nursing assistant acknowledged not realizing how quickly she was feeding the resident and recognized that she should have paused between spoonfuls. The Director of Nursing Services also confirmed that the feeding was too fast and did not meet the required standards for dignified care. Facility documentation and policies reviewed supported the expectation for dignified, slow, and attentive feeding practices for residents with similar needs.
Improper Feeding Technique for Dependent Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a nurse aide failed to use the proper feeding technique for a resident who was dependent on staff for feeding and had significant medical conditions, including dementia, dysphagia, and impaired cognitive and physical abilities. The resident was on a dysphagia puree diet with nectar thick liquids and required slow feeding with small bites, alternating solids and liquids, and monitoring for signs of aspiration. Despite documented competency validation and clear care plan instructions, video evidence showed the nurse aide feeding the resident too quickly, providing large spoonfuls of food without ensuring the resident had swallowed before offering more, and not pausing between bites as required. Interviews with facility staff, including the nurse aide, speech and language pathologist, and director of nursing, confirmed that the feeding was performed too rapidly and did not follow the established protocols for safe feeding of residents with swallowing difficulties. The facility's competency validation form also specified the need to ensure the resident's mouth was empty before the next bite, which was not followed in this instance. The facility was unable to provide a specific policy for feeding residents when requested.
Failure to Protect Resident from Abuse During Feeding
Penalty
Summary
A deficiency occurred when a resident with dementia, dysphagia, mood disorder, and severe cognitive and physical impairments was not protected from abuse during mealtime assistance. The resident required total assistance with eating and was to be fed slowly, with cues and redirection if resistive. During a breakfast meal, video footage showed a nursing assistant (NA) attempting to feed the resident, who raised their hands to block their face. Instead of stopping or redirecting as care plans directed, the NA moved the resident's hands away and forcefully placed a spoonful of oatmeal into the resident's mouth, causing the resident's head to jerk. The NA then verbally accused the resident of kicking, despite no evidence of such behavior, and abruptly ended the feeding by throwing the spoon and leaving the room. Facility documentation and interviews confirmed that the NA did not follow the resident's care plan, which required postponing and reapproaching care if the resident became resistive. The actions observed in the video were identified by facility leadership as mistreatment and not in accordance with established policies to prevent abuse. The incident was substantiated through direct observation and review of the resident's care requirements and staff responsibilities.
Failure to Implement Feeding Interventions for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to implement appropriate interventions for a resident who was dependent on staff for eating and had multiple diagnoses, including dementia, dysphagia, mood disorder, lack of coordination, and difficulty waking. The resident's care plan and Kardex directed staff to assist or feed as needed, use a slow approach with cues, encourage fluid intake, and, if the resident became resistive, to postpone care and re-approach after allowing time to regain composure. Physician orders specified a dysphagia puree diet with nectar thick liquids, and the resident was documented as having severely impaired cognitive skills, being dependent for all ADLs, and being non-ambulatory. On the date in question, video footage showed a nursing assistant feeding the resident and, when the resident attempted to block their face, the assistant moved the resident's hands away and continued feeding, ultimately pushing a spoon further into the resident's mouth and causing the resident's head to jerk. The assistant then abruptly ended the feeding and left the room. The Director of Nursing confirmed that the assistant should have stopped feeding, attempted redirection, and re-approached the resident as per the care plan. This failure to follow the established interventions and care plan led to the deficiency.
Resident Fall Due to Electrical Cord Hazard in Hallway
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and abnormal gait, who was independent with ambulation but had poor memory recall, tripped over an electrical cord that was stretched across a hallway. The resident was identified as being at risk for falls due to dementia, and the care plan included interventions to keep areas clutter-free and provide handheld assistance when redirecting. On the day of the incident, the resident was observed ambulating independently in the hallway, where four wet floor caution signs were present, and an electrical cord was running across the hall as housekeeping staff were buffing rooms. Despite the caution signs, the resident tripped over the cord and fell, sustaining a laceration to the inner lower lip that required sutures and hospital evaluation. Facility policy for floor care specifically directed staff not to stretch equipment cords across open common areas to prevent trip hazards. Interviews with staff confirmed that the cord was running across the hallway at the time of the fall, and the housekeeper acknowledged plugging the machine into a hallway outlet, causing the cord to cross the hall. The Director of Housekeeping confirmed that staff had previously been in-serviced on this policy, and the housekeeper involved had attended the training. The failure to follow facility policy and ensure the hallway was free from environmental hazards directly led to the resident's fall and injury.
Failure to Provide Required Two-Person Assistance for Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, osteoarthritis, and osteoporosis, who required total assistance for activities of daily living (ADLs), did not receive care in accordance with their established care plan. The resident's care plan and aide care card/Kardex both specified that two staff members were required to assist with bed mobility. Despite this directive, a nurse aide provided care and repositioned the resident alone during an overnight shift, as there was only one aide assigned to the unit at that time. The nurse aide was aware of the two-person assist requirement but proceeded without additional help. Subsequently, the resident was observed with facial grimacing and later diagnosed with a right shoulder dislocation. Facility documentation and interviews confirmed that the required two-person assistance was not provided during the relevant shift, and the LPN on duty did not assist or receive reports of pain from the aide. The facility's policy required the care plan to describe the services to be furnished, but the care plan was not followed, resulting in the resident not receiving the level of assistance specified.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical mistreatment, as evidenced by incidents involving Resident #76 and Resident #122. Resident #76, who was severely cognitively impaired and diagnosed with Alzheimer's disease and anxiety disorder, was hit in the back by Resident #139 while both were ambulating in the hallway. Resident #139, who had a history of aggressive behavior and was diagnosed with Alzheimer's disease, depression, and aphasia, was observed to be agitated and throwing objects prior to the incident. Despite being redirected by staff, Resident #139 managed to hit Resident #76, indicating a lapse in supervision and intervention. In another incident, Resident #122, who was severely cognitively impaired and diagnosed with dementia, anxiety, and depression, was physically abused by Resident #10. Resident #122 was bitten on the forearm by Resident #10 after holding onto Resident #10's wheelchair. Later, Resident #122 was knocked down by Resident #10, resulting in a bruise. Resident #10, diagnosed with dementia, schizoaffective disorder, and impulse disorder, was known to express frustration with other residents and had previously bitten Resident #122. The facility's failure to effectively supervise and redirect Resident #122, who exhibited wandering behaviors, contributed to these altercations. The facility's policies and procedures were insufficient in preventing these incidents of resident-to-resident abuse. Staff interviews revealed that Resident #139 and Resident #10 had histories of aggressive behavior, yet interventions to manage their behaviors were inadequate. The Director of Nursing Services acknowledged the challenges in redirecting Resident #139 and the ineffectiveness of stop signs in preventing Resident #122 from entering other residents' rooms. These deficiencies highlight the facility's failure to ensure a safe environment for its residents, free from abuse and mistreatment.
Failure to Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan for a resident with a pressure ulcer when there was a change in the wound's status. The resident, who was severely cognitively impaired, was admitted with a stage 3 pressure ulcer on the sacral region. The wound was initially assessed as unstageable due to necrosis and was debrided by a consulting wound physician. Subsequent evaluations revealed that the wound deteriorated to a stage 4 pressure ulcer. Despite these changes, the care plan was not updated to reflect the new status of the wound. The care plan, initiated after the wound was confirmed as stage 4, incorrectly indicated that the pressure ulcer was present on admission. Interviews with facility staff, including the ADNS and RN responsible for MDS assessments, confirmed that the wound had deteriorated from stage 3 to stage 4 after admission, making it a facility-acquired pressure ulcer. The failure to update the care plan to reflect the accurate status of the wound represents a deficiency in the facility's care planning process.
Failure to Provide Adaptive Equipment at Mealtime
Penalty
Summary
The facility failed to provide adaptive equipment at mealtime for a resident diagnosed with dementia, muscle weakness, and Alzheimer's disease. The resident was identified as severely cognitively impaired and required supervision with transfers and bed mobility but was independent with eating when provided with adaptive equipment. The care plan specified the use of a Kennedy cup to assist the resident in feeding themselves, which was also noted in the dietician's assessment and the meal ticket. On a specific observation date, the resident was found drinking from a regular cup instead of the prescribed Kennedy cup. Interviews with the nursing assistant and the Director of Dietary revealed that the kitchen was responsible for providing adaptive equipment, but the Kennedy cup was not included on the resident's tray. The following day, after inquiry by the surveyor, the resident was provided with the Kennedy cup. The facility's policy directed nursing staff to ensure assistive devices were available as needed, which was not adhered to in this instance.
Deficiencies in Medication Monitoring, Assistive Device Application, and Edema Management
Penalty
Summary
The facility failed to monitor the behaviors associated with psychotropic medications for a resident diagnosed with major depressive disorder, history of suicidal ideation, and cerebral vascular disease. The care plan required behavior monitoring, but there were omissions in documentation on specific shifts, and psychotropic medications were administered without documented behaviors. Interviews revealed that the nursing staff did not document behaviors prior to administering medications, contrary to the facility's policy. Another deficiency involved a resident with polyosteoarthritis and dementia, who had a physician's order for a knee brace. Observations showed the resident was not wearing the knee brace on multiple occasions, and interviews indicated the resident frequently removed it. The care plan did not reflect the resident's refusal to wear the brace, and the order was not properly documented in the facility's system, leading to a lack of application. The facility also failed to manage edema for a resident with localized edema and hypertension. The resident was observed without Ace wraps on multiple occasions, despite physician orders to apply them daily. Nursing staff did not apply the wraps due to a lack of supplies and assistance, and there was no documentation of refusals or rationale for not applying the wraps. The Director of Nursing Services expected the staff to follow physician orders, but the task was not completed.
Inadequate Supervision During Dining
Penalty
Summary
The facility failed to provide adequate supervision during dining for six residents, all of whom had varying degrees of cognitive impairment and required assistance with eating. Observations revealed that these residents were left unsupervised in the dining room while still eating, contrary to their care plans which specified the need for supervision and assistance. For instance, Resident #9, who was severely cognitively impaired and required supervision for eating, was left alone with food items on the table. Similarly, Resident #116, who needed extensive assistance for eating, was observed holding a bowl of food without staff presence. The lack of supervision was confirmed by staff interviews, where an LPN assigned to supervise the dining room admitted to leaving the area to administer medications, leaving residents unattended. The ADNS acknowledged that residents should not have been left alone and mentioned a rotating schedule for supervising the dining room, which was not adhered to in this instance. The absence of staff during dining posed a risk to residents who required assistance, as evidenced by Resident #116's statement about needing to yell for help in an emergency.
Deficiencies in Staff Competencies for IV Therapy and LAL Mattress Use
Penalty
Summary
The facility failed to ensure that nursing staff had current competencies for the provision of Intravenous Therapy (IV) and the use of Low Air Loss (LAL) mattresses. A review of staff competencies revealed that 17 out of 47 licensed staff members did not have documented competencies for IV therapy. The Assistant Director of Nursing Services (ADNS) confirmed that competencies for IV therapy were reviewed with staff only when a resident was prescribed IV therapy, despite the facility's policy requiring these competencies to be completed upon hire and annually. Additionally, the facility did not ensure that staff were trained in the use, settings, and maintenance of LAL mattresses, as evidenced by the case of a resident with a stage 4 pressure ulcer. The resident's care plan required the LAL mattress to be set according to the resident's weight, which was 80 pounds. However, observations showed the mattress was incorrectly set at 260 pounds. Interviews with staff revealed confusion regarding the correct settings, and the ADNS admitted there was no in-service training or facility policy on the specific LAL mattress used. Manufacturer guidelines contradicted the care plan instructions, leading to further confusion among staff.
Failure to Serve Correct Diet to Resident
Penalty
Summary
The facility failed to ensure that food was served in the correct form for a resident on a mechanically altered diet. The resident, who had diagnoses including Alzheimer's disease, dysphagia, and hypertension, was prescribed a regular diet with chopped texture and thin consistency. Despite this, during a lunch meal observation, the resident was served a dinner roll, which was not allowed on a chopped diet. The resident's care plan and dietary guidelines clearly indicated the need for a chopped diet, yet the dietary staff did not adhere to these requirements. Interviews with staff revealed a lack of understanding and communication regarding dietary restrictions. A nursing assistant admitted to not knowing which foods were allowed on a chopped diet and assumed the food on the tray was correct. The Food Service Director acknowledged that a dinner roll was not appropriate for a chopped diet and was unsure why the resident received incorrect food items. The Speech Language Pathologist confirmed that a dinner roll should not have been served and expected staff to be aware of dietary needs. The facility's policy required food trays to be inspected to ensure correct meals were provided, but this was not effectively implemented.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preference, as observed during a dining review. Resident #90, who has diagnoses including dementia, hypertension, and muscle weakness, was identified as severely cognitively impaired but independent with eating. The resident's care plan included providing food and beverage choices, and a physician's order specified a regular diet with regular texture. However, during an observation, the resident was served an egg salad sandwich and macaroni salad instead of the assorted cold cereals indicated on their lunch ticket. Interviews with staff revealed that Nurse Aides served dietary trays as they were received from the kitchen without verifying the meal against the ticket. The Director of Dietary stated that a staff member is responsible for ensuring meals meet dietary restrictions and preferences before being placed on meal trucks. Despite this, the facility's Food and Nutrition Services policy, which requires inspection of food trays to ensure correct meals are provided, was not followed. The Nutrition Assessments policy also mandates interviews with residents or families to assess food preferences, which was not adhered to in this instance.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control procedures during wound care for a resident with a stage 4 pressure ulcer on the sacral region. The resident, who was severely cognitively impaired, was observed receiving wound care where the charge nurse, an LPN, placed the old dressing on the resident's top sheet before discarding it into a trash bag. The LPN then handled the resident's wound supply bag with dirty gloves, prompting the unit manager, an RN, to instruct the LPN to wash hands and apply new gloves. Despite this intervention, the LPN placed the trash bag on a television stand on top of an open nonsterile package of 4x4 dressings before washing hands. Additionally, the facility did not follow enhanced barrier precautions as required for the resident. The ADNS/IP/wound nurse noted that a gown should have been worn during the procedure, but the staff did not see the sign indicating enhanced barrier precautions outside the resident's door. The PPE carts were located in the hall, shared among residents requiring PPE, but no cart was outside the room. The facility's policy on hand hygiene and enhanced barrier precautions was not followed, as gowns and gloves were not immediately available near the resident's room, and the staff was unaware of the need for a gown during the procedure.
Failure to Provide Homelike Dining Environment in Memory Unit
Penalty
Summary
The facility failed to provide a homelike environment for residents in the memory unit during meal times. Observations on multiple occasions revealed that 30 residents were served their lunch meals on dietary trays. This practice was intended to act as a barrier to prevent residents from taking food from others, as confirmed by an interview with the Administrator.
Failure to Maintain Resident Dignity Due to Unprofessional Staff Comments
Penalty
Summary
The facility failed to ensure that staff comments within the hearing of a resident were respectful, which led to a deficiency in honoring the resident's right to a dignified existence. The incident involved a resident with severe cognitive impairment and dementia, who was admitted with diagnoses including loss of movement on both sides of the body after a stroke. The resident's care plan included interventions to explain procedures clearly and slowly, using short phrases that required yes or no answers. However, a grievance was filed by the resident's conservator after observing a video where a medical doctor (MD) made an inappropriate comment in the resident's room. The comment was related to a sign about camera usage and potential staff discipline, and although it was not directed at the resident, it was deemed unprofessional. The incident occurred when the MD noticed a sign in the resident's room that mentioned disciplinary actions for staff if the camera was obstructed. The MD found the sign offensive and made a comment to a vendor outside the room, questioning whether the discipline would involve a thrashing or spanking. This comment was overheard by staff who laughed, and although the MD provided care to the resident afterward without any noted unusual behaviors, the comment was considered unprofessional and inappropriate for the setting. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, which was not upheld in this instance.
Verbal Abuse Incident Involving Resident
Penalty
Summary
The facility failed to protect Resident #2 from verbal abuse by a nursing assistant (NA #1). Resident #2, who was admitted with anxiety and major depression, reported an incident where NA #1 accused them of being a troublemaker and making up stories. This incident occurred after a disagreement about a linen hamper and was witnessed by another staff member, LPN #1. The facility's investigation confirmed that NA #1 made disparaging remarks to Resident #2, which constituted verbal abuse as defined by the facility's policy. The facility's investigation revealed that NA #1 had a confrontation with Resident #2, during which NA #1 accused the resident of lying and causing trouble. This interaction was distressing for Resident #2, who was already identified as at risk for mood disturbances due to their mental health conditions. The facility's policy on abuse, neglect, and misappropriation clearly defines verbal abuse as the use of language that includes disparaging and derogatory terms, which NA #1's actions met. As a result of the investigation, NA #1's employment was terminated.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Windsor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Kimberly Hall-south | 0 mi | ★★★★★ | 0 | 0 |
| Seabury | 2.1 mi | ★★★★★ | 0 | 0 |
| Touchpoints At Bloomfield | 2.2 mi | ★★★★★ | 19 | 0 |
| Autumn Lake Healthcare At Windsor | 2.2 mi | ★★★★★ | 48 | 0 |
| Bloomfield Center For Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.