Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harbor Village North Health And Rehabilitation Cen during CMS and state inspections, most recent first.
A resident with COPD, seizures, bradycardia, visual impairment, weakness, and a cognitive communication deficit, who required substantial assistance for transfers and used a wheelchair, experienced an unresponsive episode while seated on a bench in the supervised smoking area. After a NA reported the resident might not be breathing, an RN assessed the resident as breathing but nonverbal with abnormal skin color, then left the resident with two NAs and instructed them not to move the resident while she went inside to call a code and EMS, leaving no licensed nurse at the scene. During her absence, an LPN arrived, found the resident leaning forward and responsive, and, without RN direction, assisted with transferring the resident to a wheelchair and transporting the resident inside, before the RN’s assessment was completed. EMS later documented that staff could not provide a clear, consistent account of the incident, including whether a fall or head strike occurred, reflecting that the resident was moved and the event was not fully or accurately assessed and documented in accordance with facility policies for change in condition and accidents.
A resident with COPD, seizures, visual impairment, weakness, and documented dependence on a wheelchair for mobility was allowed by staff to walk with a rollator to a supervised smoking activity, despite physician orders limiting ambulation to therapy and a care plan requiring wheelchair use and assist for transfers. A CNA did not check the resident care card and relied on an RN, who did not verify orders or the care plan, before permitting the resident to walk without a wheelchair following. During the smoking session, two CNAs were supervising about twelve residents when the resident, seated on a bench, became slumped and unresponsive to verbal cues. One CNA, aware that two staff were required to remain outside, panicked and ran inside to get the RN instead of using required communication devices, leaving only one staff member with the group. A wheelchair was not readily available at the smoking area, requiring staff to search for one after the resident became unresponsive, and the resident was later transported to the hospital for acute hypoxemic respiratory failure.
Pressure ulcers were not properly prevented, assessed, or monitored for two residents. One resident with diabetes, CKD, severe cognitive impairment, and major mobility dependence developed a new deep tissue injury to the heel and a worsening sacral/coccyx ulcer after delayed assessment, missing measurements, and inconsistent heel offloading. Another resident with malnutrition, diabetes neuropathy, and an indwelling catheter developed a device-associated stage 3 penile pressure injury, while heel boots were not consistently in place despite an existing stage 4 heel ulcer and the catheter was not anchored as ordered.
Failure to timely address significant weight loss. A resident with dementia, DM, CKD, and CHF had severe cognitive impairment, poor intake, and progressive weight loss despite ONS orders and nutrition monitoring. Surveyors observed the resident in bed at lunch refusing food and declining sandwiches, while meal tickets did not clearly direct regular provision of preferred sandwiches or finger foods. RD notes and physician orders showed ongoing supplementation, but the resident’s weight continued to decline and the record reflected delayed and incomplete nutrition interventions.
The facility failed to prevent physical abuse when two residents with dementia and documented behavioral issues, including prior aggression and a history of anger and yelling, were placed together as roommates despite known personality incompatibilities. During a disagreement over room temperature, one resident reported that the other grabbed their neck, and the alleged aggressor admitted to putting hands on the peer and justified the action based on the peer’s language. A roommate witness confirmed seeing hands placed on the victim’s shoulders and an altercation occurring. This incident occurred in the context of existing care plans and staff knowledge that both residents had behavioral and mood-related risks, contrary to the facility’s zero-tolerance abuse policy.
Expired food items were found in kitchen storage, including canned pulled chicken, orange juice, and beef stew. The Food Service Director said checking expiration dates was his responsibility and that reviews should occur monthly or when new stock arrived, but he had not checked the emergency food supply because he was told it was good to go. A food storage policy was not provided.
The facility failed to ensure a qualified infection preventionist directly oversaw the infection prevention program. An Infection Prevention LPN had a Nursing Home Preventionist certificate, but the DON who oversaw her role was on extended leave. A Regional Clinical RN stated she oversaw the program, but she did not directly oversee the LPN, and the DON had to re-complete the infection preventionist training course.
A resident with dementia, cognitive impairment, and Parkinson’s disease with dyskinesia, who required extensive assistance with ADLs and mechanical-lift transfers, was found seated at the nurse’s station with an unwitnessed hematoma on the forehead. Staff assumed the resident had struck their head on the bed’s headboard due to dyskinesia, but no one observed the event and the cause was not confirmed. The ADNS interviewed only two NAs from the prior shift and did not interview the unit nurse who had recently interacted with the resident, despite facility policy requiring a broader 72-hour inquiry for injuries of unknown source. After the ADNS relayed an assumed explanation to a regional RN, the event was not reported to the State Agency as an injury of unknown origin, contrary to the facility’s abuse and reporting policy.
A resident with dementia, cognitive deficits, and Parkinson's disease with dyskinesia, who was dependent on staff for most ADLs and required two-person mechanical lift transfers, was found with an unwitnessed hematoma on the forehead while seated at the nurse’s station. No staff witnessed the incident, and only two NAs from the prior shift were interviewed, whose statements were inconclusive and based on an assumption that the resident hit their head on the bed’s headboard due to dyskinesia. The ADNS did not follow policy requiring a 72-hour look-back and broader staff interviews, did not interview the unit nurse who had interacted with the resident minutes before the injury was noted, and, after discussing with a regional RN, did not report the event to the State Agency as an injury of unknown origin based on the unverified assumption of cause.
Failure to honor a resident's smoking choice: A resident with COPD, HLD, and ASHD, and intact cognition, stated he/she smoked cigars but had not been allowed to smoke since admission because of oxygen use. The resident was upset about being denied the opportunity, while RN stated the resident had not been asked or evaluated for smoking on admission and the smoking assessment was completed only later. The facility policy required smoking education, acknowledgement, and smoking assessments on admission, including assistance with oxygen equipment for residents who smoke.
Failure to Notify Provider of Significant Weight Loss: A resident with dementia, DM, and other chronic conditions had severe cognitive impairment and a documented 15 lb. weight loss over 6 months, with intake declining to mostly fluids. Although the RD tracked the loss and the care plan identified nutritional risk, staff did not notify the APRN/provider of the significant weight loss as required by policy.
Missed smoking and elopement assessments. The facility failed to complete required smoking and wander/elopement assessments for multiple residents. One resident with cognitive impairment was a current smoker, but several required smoking evaluations were missing despite a policy for admission, quarterly, readmission, and change-in-condition assessments. Another resident with severe cognitive impairment and daily wandering had multiple missed elopement assessments even though the care plan identified elopement risk and a wander guard was in place. A newly admitted resident with COPD and heart disease also was not assessed for smoking on admission and was not identified as a smoker until much later, despite stating he smoked cigars and wanted to smoke.
Oxygen Administered Without Order and Set Incorrectly: Two residents with COPD were observed receiving oxygen in bed with the HOB elevated. One resident had no physician order for oxygen at the time of observation, and another resident’s oxygen was set above the ordered range. Nursing staff confirmed oxygen should be administered according to the physician’s order, and the facility policy required verification of an order before oxygen use.
A resident with ESRD and dependence on hemodialysis had an ordered fluid restriction, but staff did not document or monitor fluid intake on the MAR, TAR, meal records, or nutrition notes. Interviews confirmed the RN supervisor, ADNS, dietitians, and corporate nurse could not explain why the restriction was not tracked or reflected in the clinical record, despite the resident’s dialysis-related care plan and physician orders.
Unattended Medication Cart and Improper Controlled Substance Storage: A medication cart with a singly locked narcotic box was observed in a hallway across from the front lobby without being locked and without a nurse in view. Multiple residents, staff, and visitors passed by the cart while it was unattended. The assigned LPN stated she was responsible for locking the cart when walking away but got busy and went on break, and the RN supervisor confirmed the cart should have been locked when unattended.
Failure to Follow Up on Requested Upper Dentures: A resident with COPD, anxiety, and HTN had broken and missing teeth and requested replacement of lost upper dentures. Although dental consultation was arranged and the resident again requested a full maxillary denture, the facility did not follow up on the request. The dental office did not submit the denture request because the resident was incorrectly listed as uninsured, despite facility paperwork showing Medicaid coverage, and the ADON stated the resident did not receive a new set of upper dentures because the facility failed to follow up.
Hand hygiene was not performed during resident care and equipment cleaning. An ADNS changed a dressing for a resident with a Foley catheter and multiple pressure injuries, but removed gloves and put on new gloves without sanitizing hands. In a separate observation, an LPN cleaned a glucometer and reapplied gloves without hand hygiene. Facility policy required hand hygiene before and after glove use and after handling contaminated equipment.
Survey Results Not Easily Accessible to Residents: A resident council meeting showed residents did not know where the prior state survey results were located or that they had the right to review them. Observation of the lobby found the results were not visible, and the Administrator confirmed they were placed in a wall file holder behind an artificial tree, making them inaccessible to residents and visitors. The Administrator also stated she was unaware residents were allowed access to the survey results, while the facility’s Resident Rights policy stated residents have the right to examine survey results.
A resident council identified that residents were not consistently receiving mail on Saturdays and were unaware they were supposed to receive it that day. The Recreation Director said he personally delivered mail when working Saturdays, but there was no formal complaint reported to him. Facility mail policy required delivery within 24 hours, including Saturday deliveries.
Incorrect PASRR Coding on MDS Assessments: The facility failed to code the MDS PASRR section accurately for multiple residents with PASRR Level 2 determinations and serious mental health diagnoses. Several residents had PASRR forms showing approved LTC placement and identified mental health needs, yet Section A1500 was coded as no serious mental illness; staff interviews confirmed the PASRR coding responsibility and that incorrect coding had been identified.
PASRR Level 2 Review Not Completed After Expiration: A resident with schizophrenia, depression, and moderate cognitive impairment had a PASRR level 2 approval that expired after 180 days, but the facility did not complete a new level of care review before expiration. The SW stated the missed review was an oversight. Facility policy required PASRRs to be reviewed, maintained in the chart, and level 2 recommendations to be incorporated into the care plan.
Failure to Implement Fall Risk Care Plan Intervention: A resident with difficulty walking, muscle weakness, extrapyramidal movement disorder, and severe cognitive impairment was identified as a moderate fall risk with a care plan intervention for a floor mat on the right side of the bed. Staff observed the resident in bed without the mat, and the unit nurse, LPN, and ADNS could not identify why the intervention was not implemented; the NA care card also did not include the floor mat intervention.
The facility failed to conduct thorough investigations into multiple resident-to-resident abuse incidents. In one case, a resident with schizophrenia struck another with dementia, but staff statements were missing. Another incident involved a resident with intellectual disabilities threatening their roommate, yet staff documentation was incomplete. A third case saw a resident with schizoaffective disorder being punched, but again, staff statements were not obtained. The DNS acknowledged the investigations were incomplete, contrary to facility policy.
The facility failed to provide timely social services support to residents involved in abuse incidents. A resident with paranoid schizophrenia was not met by social services until a day after an incident, with follow-ups lacking. Another resident with vascular dementia had no documented social worker interaction regarding the incident. Similar deficiencies were noted for other residents, with social workers failing to meet within 24 hours and not following up daily for 72 hours.
The facility failed to maintain a clean kitchen environment and did not discard expired foods. Observations included dust-covered fans, dirty walls, and expired food items in storage. The Food Service Manager, new to the position, had not yet updated the cleaning schedule or checked expiration dates. The Administrator was aware of the issues and had made some improvements.
The facility failed to resolve cleanliness issues in the kitchen identified during environmental rounds from January to June 2024. The ICN noted these issues, but there was no evidence of resolution within the required 10-day period. Additionally, significant lint debris was observed in the laundry area, with no documentation of recent cleaning. The Laundry Manager, temporarily covering the position, could not provide cleaning records, indicating a failure to maintain cleanliness as per policy.
The facility failed to notify the physician of significant changes in the conditions of two residents. One resident with multiple co-morbidities experienced worsening symptoms, including abdominal pain and labored breathing, without timely assessment or physician notification, leading to hospitalization and eventual death. Another resident with congestive heart failure gained 35.1 pounds over two weeks without re-weighing or physician notification, potentially contributing to lower leg edema. Staff interviews revealed gaps in monitoring and documentation, highlighting deficiencies in care processes.
The facility failed to assess, care plan, and obtain consents for residents on a secured dementia unit. Observations showed restricted access requiring a code, with no criteria for placement or physician's orders. Clinical records lacked consent and documentation of the least restrictive setting, and care plans did not reflect secured unit placement.
A resident with paraplegia experienced pain due to long, thickened, and brittle toenails, despite regular podiatrist visits. The facility failed to provide specific foot care beyond shower care, and the podiatrist did not prescribe anti-fungal treatment due to the resident's age and co-morbidities. The facility's foot care policy and healthcare service agreement required appropriate care, but the resident's toenail condition persisted, indicating a deficiency.
Two residents reported dissatisfaction with the food quality and preparation at the facility. One resident, with dementia and other conditions, noted a lack of variety and flavor, while another resident with spinal cord injury and paraplegia expressed similar concerns. Observations confirmed issues such as undercooked pork, mushy zucchini, and raw quiche crust. The food service manager attributed some problems to the use of frozen vegetables and a late delivery. The facility's policy on cooking temperatures did not ensure food safety during plating and transport.
The facility failed to maintain a pest-free environment, with fruit flies observed in resident rooms and the hallway of the Northeast wing, and rodent droppings found in the kitchen's emergency food storage area. Despite previous pest control treatments, the issues persisted, indicating inadequate pest management and sanitation practices. Interviews with staff revealed a lack of awareness and documentation regarding pest control efforts.
A resident with cognitive impairments was exposed to the hallway during morning care due to an open door, and was spoken to disrespectfully by a nursing assistant. The incident was witnessed by a surveyor, and staff interviews confirmed the failure to maintain privacy and dignity, contrary to facility policy.
A resident with dementia and other conditions was not provided privacy during morning hygiene care, as observed by a surveyor. The resident was exposed to the hallway with the door open, and the care plan's privacy interventions were not followed. Staff interviews confirmed the expectation of privacy, aligning with the facility's policy on resident dignity.
The facility failed to monitor and assess two residents for changes in their health conditions. A resident with multiple co-morbidities experienced worsening symptoms without proper assessment or physician notification, leading to an emergency hospital transfer and subsequent death. Another resident with CHF had a significant weight gain, indicating potential fluid overload, but was not reassessed or reported to a physician in a timely manner. Staff interviews revealed communication lapses and protocol failures.
The facility failed to implement pharmacy recommendations for two residents, leading to deficiencies in medication management. One resident's PRN Miralax order lacked frequency clarification despite agreement from the APRN, while another resident's Seroquel prescription required orthostatic BP monitoring, which was not conducted. Communication lapses between the pharmacy consultant, DNS, ADNS, and APRN contributed to these oversights.
A medication error occurred when an LPN crushed and administered medications to a resident, despite instructions not to crush enteric coated and extended-release medications. The resident, who was severely cognitively impaired, received Aspirin EC, Bupropion HCl ER, and Metoprolol Succinate ER in crushed form, leading to a facility medication error rate of 12%. The LPN admitted to not fully reading the medication instructions, and the RN Supervisor confirmed the error.
A facility failed to maintain complete medical records for a resident with GERD, bipolar disorder, and COPD. Signed pharmacist recommendations from several months were missing from the resident's chart, contrary to facility policy. Interviews revealed inconsistencies in the handling and filing of these documents, leading to incomplete records.
A facility failed to prevent altercations between two residents, one with dementia and behavioral disorders and another with moderate cognitive impairment. Despite known risks and previous incidents, interventions such as a Velcro cloth stop sign were not consistently implemented, leading to physical altercations. The oversight resulted in a deficiency related to abuse prevention.
Failure to Maintain Licensed Nurse Presence and Prevent Movement After Unresponsive Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing services met professional standards of quality during and after an unresponsive episode of unknown origin involving Resident #1. Resident #1 had multiple diagnoses, including COPD, myoclonus, seizures, bradycardia, macular degeneration, weakness, and a cognitive communication deficit, and required substantial assistance for transfers, used a wheelchair for locomotion, and was a supervised smoker per the care plan. On the morning in question, a nurse documented that the resident went to the smoking area using a rolling walker with assistance, instead of the usual wheelchair. Shortly thereafter, the nursing supervisor (RN #3) was notified by a nursing assistant (NA #1) that the resident was outside, possibly not breathing, and unresponsive. When RN #3 went to the smoking area, she observed the resident hunched over on a bench, breathing but nonverbal, not moving, with pale/abnormal skin color and eyes closed, and she assessed vital signs and neurological signs as normal. RN #3 instructed NA #1 and NA #2 to stay with the resident and not to move the resident while she returned inside to call a code, notify the charge nurse (RN #4), and contact EMS. During this time, no licensed nurse remained with the resident. When RN #3 finished the calls and returned her attention to the situation, she observed that LPN #1 was already pushing the resident in a wheelchair down the hallway toward the resident’s room, indicating the resident had been moved from the bench before RN #3 completed her assessment and without her direction. LPN #1 later reported that when she responded to the code in the smoking area, the resident was on a bench leaning forward, breathing, and answering questions appropriately, and that no RNs were present at that time. LPN #1 stated she sat the resident up, obtained a wheelchair, and, with the assistance of NA #1 and NA #2, transferred the resident to the wheelchair and transported the resident inside to the room. EMS documentation indicated they were notified that the resident had sustained a fall, was unconscious, not breathing, and possibly in cardiac arrest, but upon arrival found the resident in bed, conscious but in an altered state, and staff were unable to provide an accurate, consistent description of the incident or confirm whether a head strike occurred. The facility’s policies on change in condition and accidents required licensed nurses to complete and document assessments of changes in condition and to provide supervision and a safe environment, but there was no specific policy for unresponsive episodes provided, and RN #3 acknowledged she did not remain with the resident or document staff reports about the resident leaning forward and falling back on the bench.
Failure to Follow Mobility Orders and Emergency Procedures During Supervised Smoking
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and appropriate use of assistive devices to prevent accidents during a supervised smoking activity. The resident involved had multiple diagnoses, including COPD, myoclonus, seizures, bradycardia, macular degeneration, weakness, and a cognitive communication deficit. A physician’s order directed assist of one for all transfers with a rollator and specified that the resident was to ambulate with therapy only. The admission MDS documented that the resident required substantial assistance for transfers, did not ambulate, used a wheelchair, and was dependent on staff for mobility. The resident’s care plan identified the resident as a current smoker with ADL self-care, mobility, and performance deficits due to failure to initiate, weakness, and impaired vision, and required supervision for smoking at all times, assist of two for transfers, wheelchair use for locomotion, and monitoring for altered respiratory status. On the day of the incident, a nurse’s note documented that the resident went to the smoking activity using a rolling walker with staff assist because the resident wanted to walk rather than use the wheelchair. NA #6 reported that she had initially assisted the resident into a wheelchair for the smoking activity, but when the resident requested to walk with a rolling walker, she did not reference the resident care card and instead asked RN #4 if the resident could walk. RN #4 told her it was fine and that the resident could use the exercise, without checking physician’s orders or the care plan. NA #6 then walked alongside the resident, without a wheelchair following, as the resident used the rolling walker down the hallway to the dining room, where the resident was seated to wait for the outside smoking activity. NA #6 then left the resident and returned to the unit. During the supervised smoking activity, NA #1 and NA #2 were responsible for supervising approximately twelve residents, including the resident involved. NA #1 stated that the resident walked outside independently with a rolling walker and sat on a bench. About fifteen minutes into the activity, NA #1 observed the resident slumped forward and to the right, appearing faint and unresponsive to verbal cues. NA #1 reported that she panicked and ran inside to locate RN #3, leaving NA #2 alone with the resident and the other residents, despite knowing that two staff were required to remain outside during the smoking activity. The facility’s smoking policy required that walkie-talkies or electronic devices be brought out with the smoking cart and used to contact the supervisor in case of emergency, but NA #1 reported that walkie-talkies were not utilized and she did not think to call the facility main line. RN #3 documented that she was notified in person by NA #1 that the resident might not be breathing, and upon going outside, she observed the resident hunched over on a bench, breathing but nonverbal, not communicating, and with pale/abnormal skin color. RN #4 documented that when informed by the nursing supervisor that the resident was slumped over in the smoking area, she went to check and found the resident unresponsive with abnormal skin color and initiated a sternal rub. She then went back into the building to obtain oxygen, and when she returned, the resident was responsive and in a wheelchair being brought toward the room by another nurse. Oxygen was applied in the hallway, and the resident had one episode of vomiting as EMS arrived to transport the resident. Interviews with the Director of Rehab and the DON confirmed that the resident was unsafe to ambulate with nursing staff, required a wheelchair within reach at all times due to unpredictable weakness and balance, and that NA #6 and RN #4 failed to verify and follow the resident’s ambulation and transfer orders. The DON also stated that staff supervising smoking were responsible for having a cell phone to contact the nursing supervisor and that NA #1 should not have left the smoking area with only one staff member present. The facility’s accident and incidents policy required the provision of appropriate assistive devices and supervision to prevent avoidable accidents, but staff did not follow these requirements, and a facility policy for following physician’s orders was not provided when requested.
Pressure Ulcers Not Timely Assessed or Offloaded
Penalty
Summary
The facility failed to prevent, identify, assess, and treat pressure ulcers and pressure injuries for two residents. One resident had chronic kidney disease, muscle weakness, diabetes, severe cognitive impairment, dependence for toileting and transfers, and required substantial to maximal assistance with bed mobility. The resident was identified as at risk for pressure ulcers, but the care plan and physician orders did not include turning and positioning interventions or heel offloading at the outset. When redness was first noted on both heels, the heels were described as red and blanchable, yet the record did not show ongoing measurement or monitoring of the heels after that finding, and weekly skin checks did not identify a right heel alteration until a later wound evaluation documented a new in-house deep tissue pressure injury to the right heel. The same resident also developed a sacrum/coccyx wound that was first described as purple discoloration and later as nonblanchable, but the record lacked a completed assessment or measurements until several days after the onset date recorded by the facility. The wound was then documented as a stage 2 pressure injury with exposed dermis and drainage, and later measured larger on the wound physician visit. The record did not show timely implementation of new interventions after the wound was identified. The resident was also documented as having severe weight loss, and the dietitian noted additional nutritional interventions should have been initiated for wound healing. Observations and interviews showed the resident was sometimes in bed without heel boots, and staff stated the resident regularly kicked the boots off. The second resident had severe protein calorie malnutrition, diabetes with neuropathy, urinary retention, total dependence for care, an indwelling urinary catheter, and existing pressure ulcers including a stage 4 heel ulcer. The care plan did not include anchoring the catheter to prevent pulling. Nursing notes documented excoriation, tearing, and later laceration with pus at the tip of the penis, and the wound physician later identified a stage 3 device-associated pressure injury of the penis related to the indwelling catheter. The record also showed that heel boots were ordered and that the resident was supposed to have heels offloaded while in bed, but observations found the heels resting on the mattress and the boots placed away from the bed. Staff stated the resident kicked the boots off or refused them, but the record did not show refusal documentation or alternate offloading measures.
Failure to timely address significant weight loss
Penalty
Summary
The facility failed to initiate timely interventions to prevent ongoing significant weight loss for a resident with muscle weakness, diabetes, and dementia. The resident had severe cognitive impairment on MDS assessments, required set-up help for eating, and later became totally dependent on staff for personal hygiene, toileting, and transfers. The resident’s weight declined from 113.8 lbs. to 96 lbs. over the course of the record reviewed, including a 15 lb. loss in 6 months and a 13.5 lb. loss in 6 months on later weight review. The resident’s care plan identified nutritional risk related to dementia, diabetes, chronic kidney disease, congestive heart failure, and poor intake, with interventions including RD consultation, OT screening as needed, and supplements as ordered. Dietitian assessments documented poor intake, fair intake at times, and continued use of Boost Glucose, fortified cereal, and fortified pudding, but several later nutrition notes failed to accurately reflect all supplements the resident was receiving. Physician orders showed Boost Glucose twice daily for most of the period reviewed, later increased to three times daily, while the resident’s weight continued to fall. The record also showed that the resident was placed on a CCHO diet despite an earlier dietitian note stating a therapeutic diet was not indicated at that time related to quality of life. Survey observation showed the resident in bed at lunch, not attempting to eat independently, and refusing to eat when staff tried to assist. The resident also declined multiple offers for a sandwich. Meal ticket review showed preferences for ham and cheese sandwiches and finger foods, but the ticket did not direct that these be provided regularly or as a replacement or addition to meals on a daily basis. The RD stated she first identified significant weight loss after the resident had already lost weight and that the only intervention put in place was an increase in Boost Glucose to three times daily, while the record also showed that sandwiches and finger foods had already been in place since earlier orders. The facility weight policy required a reweigh within 24 hours for significant weight change and reporting of weight variance to the provider, and the nutritional assessment policy required a systematic, multidisciplinary process to define meaningful interventions for residents at risk for impaired nutrition.
Failure to Prevent Resident-to-Resident Physical Abuse Between Roommates
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by allowing two residents with known behavioral issues to be placed together as roommates, which led to a physical altercation. Resident #15 had diagnoses including vascular dementia with behaviors, schizophrenia, and paranoid personality disorder, with a care plan noting potential for behaviors related to dementia, paranoia, delusions, a history of physical aggression, and a prior resident-to-resident altercation. Resident #40 had diagnoses including unspecified dementia, bipolar II disorder, and anxiety, with a care plan identifying risk for mood and behavioral issues such as rummaging, anger, yelling at staff, increased delusions, and confusion. Despite these documented behavioral risks, the residents were roomed together. Prior documentation showed that Resident #15 had a past reportable event involving an alleged altercation with a roommate, where words were exchanged and there was an allegation that Resident #15 grabbed the roommate’s arm, though both residents later denied physical contact and no injuries were found. Nursing and psychiatry notes following that earlier event did not identify ongoing resident-to-resident altercations, and subsequent notes up to the time of the later incident did not document further altercations. However, the care plan for Resident #15 continued to reflect a history of physical aggression and a prior resident-to-resident altercation. On the date of the cited incident, Resident #40 reported to a nurse aide that Resident #15 grabbed them around the neck after Resident #40 adjusted the room thermostat. Resident #15 admitted to putting hands on Resident #40 and justified the action by stating that the other resident had a foul mouth and deserved it. A roommate witness reported seeing Resident #15 place hands on Resident #40’s shoulders and confirmed that an altercation occurred. Staff interviews described Resident #40 as someone who could get mad, loud, and unpleasant with others and as having a feisty personality, and Resident #15, usually quiet, was identified as the aggressor who grabbed Resident #40’s neck during a disagreement over room temperature. The facility’s abuse prohibition policy required a zero-tolerance environment free from abuse, but the placement of these two residents together, despite known behavioral histories and personality incompatibility, led to a physical abuse incident in which Resident #15 grabbed Resident #40 around the neck.
Expired Food Stored in Kitchen
Penalty
Summary
The facility failed to ensure expired food items were identified and discarded in the kitchen food storage area. During observation, interview, and document review with the Food Service Director, surveyors found multiple expired items, including Deluxe pulled chicken with broth 48 oz cans, Ocean Spray Orange Juice 32 oz bottles, and Beef stew 48 oz cans. The Food Service Director stated that checking expiration dates was his responsibility and that checks should occur monthly or when new stock arrived, but he was newly hired and had not checked the emergency food supply for expiration dates because he had been told it was good to go. The facility did not provide a food storage policy when requested.
Infection Prevention Program Lacked Qualified Oversight
Penalty
Summary
The facility failed to ensure a qualified infection preventionist was responsible for the infection prevention and control program. During interview and document review, the Infection Prevention LPN stated she was serving as the Infection Control Nurse and had a Nursing Home Preventionist certificate dated 4/17/22, but the DON who oversaw her infection control role was out of the facility on an extended leave. A Regional Clinical RN later stated she was certified as a Nursing Home Infection Preventionist as of 12/17/21 and oversaw the facility infection prevention program, but she did not directly oversee the current Infection Prevention LPN. The RN also stated the DON could not locate her certificate and had re-completed the Nursing Home Infection Preventionist training course, with a certificate dated 3/1/26, but she was still not overseeing the LPN.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by policy and regulation. One resident with dementia with agitation, cognitive communication deficit, and Parkinson’s disease with dyskinesia had significant ADL and mobility deficits and required extensive staff assistance, including two-person assist and a mechanical lift for transfers. The resident’s care plan reflected these needs. On the morning of 2/18/26, while the resident was seated in a wheelchair at the nurse’s station, an LPN observed a hematoma on the left side of the resident’s forehead. No one had witnessed how the injury occurred, and the cause was unknown at the time it was discovered. Staff concluded that the resident had likely hit their head on the bed’s headboard earlier in the morning due to intermittent dyskinesia. The Assistant Director of Nursing (ADNS) consulted with the Regional Director of Clinical Services (RN #3) and reported that the injury could be explained by dyskinesia, leading RN #3 to determine that the event did not need to be reported as an injury of unknown origin within the 24-hour reporting window. The ADNS did not follow the facility’s abuse policy requirement to conduct a complete investigation by interviewing all staff with access to the resident in the prior 72 hours; instead, only the two NAs from the previous shift were interviewed, and the unit nurse who had interacted with the resident minutes before the hematoma was noted was not interviewed. The facility’s policy defined an injury of unknown source as one not observed or not explainable by the resident and suspicious due to its extent or location, and directed reporting of such events to the State Agency within specified time frames. Because the investigation was incomplete and the source of the injury remained unwitnessed and unexplained, the injury met the facility’s definition of an injury of unknown origin, but it was not reported to the State Agency.
Failure to Thoroughly Investigate Resident Head Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for Resident #47, who had dementia with agitation, cognitive communication deficit, and Parkinson's disease with dyskinesia. The resident had moderate cognitive impairment and required extensive assistance, including two-person assist with a mechanical lift for all transfers and dependence for most ADLs. On the morning of 2/18/26, staff observed an unwitnessed hematoma on the left side of the resident’s forehead while the resident was seated in a wheelchair at the nurse’s station. No one had witnessed how the injury occurred, and the two NA statements were inconclusive, only assuming the resident had hit his/her head on the bed’s headboard earlier in the morning due to dyskinesia. The ADNS reported that, after conferring with the Regional Clinical Director (RN #3) and indicating the cause was believed to be related to dyskinesia, it was determined the injury did not need to be reported to the State Agency as an injury of unknown origin within the 24-hour reporting window. The ADNS acknowledged not following the facility’s abuse policy requirement to conduct a thorough investigation, including going back 72 hours and interviewing all staff with access to the resident; instead, only the two NAs from the prior shift were interviewed, and the unit nurse who had interacted with the resident minutes before the hematoma was noted was not interviewed. RN #3 stated she believed a complete and thorough investigation had been done and that the cause was known, and that she would have had the injury reported as an injury of unknown origin had she known the investigation was incomplete. The facility’s abuse policy required a thorough investigation of alleged abuse or neglect by the Administrator and/or DON to determine if conduct violated standards of care, which was not carried out in this case.
Failure to Honor Resident Smoking Choice
Penalty
Summary
The facility failed to provide access to the smoking activity per the resident's choice for one sampled resident with chronic obstructive pulmonary disease, hyperlipidemia, and atherosclerotic heart disease. The quarterly MDS identified the resident had a BIMS score of 13, indicating intact cognition, and required substantial to maximal assistance with lower body dressing and transfers. The resident's care plan in effect from 1/7/26 through 3/3/26 did not identify a preference for smoking. During interview, the resident stated he/she smoked cigars and had not been able to smoke since admission to the facility on 1/7/26, explaining that smoking was not allowed because of oxygen use. The resident stated he/she wanted to have a cigar and was upset about being denied the opportunity to smoke. RN #1 stated the facility's process was to ask on admission whether a resident was a smoker or wanted to smoke, complete a smoking evaluation, and determine whether adaptive equipment or staff assistance was needed. RN #1 also stated the resident had never been identified as a smoker because he/she was not evaluated or asked on admission, and that the smoking assessment had only been completed the previous day. The facility smoking policy required smoking education and acknowledgement on admission, smoking assessments upon admission and at other specified times, and assistance with removal and reapplication of oxygen equipment for residents receiving oxygen.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
The facility failed to notify the provider of a significant weight loss for Resident #3, who had diagnoses including muscle weakness, diabetes, and dementia. The resident’s quarterly MDS assessments showed severe cognitive impairment, with a BIMS score of 4 and later 5, and the resident required assistance with eating and was dependent on staff for personal hygiene, toileting, and transfers. The MDS also documented a weight of 121 lbs. with no significant weight loss, followed later by a weight of 99 lbs. with a significant loss of 5% or more in the last month or 10% or more in the last 6 months and no physician-prescribed weight loss regimen. The care plan identified the resident as at risk for malnutrition due to dementia, diabetes, chronic kidney disease, congestive heart failure, and poor intake, with interventions including RD consultation, OT screening as needed, and supplements as ordered. A nutrition note documented recent weight loss after hospitalization and a decline in intake with a decrease of 15 lbs. since 7/14/25, representing a 15.18% loss in 6 months, and noted the resident mostly consumed fluids with varied intakes. Interviews confirmed the provider was not notified of the significant weight loss despite facility policy requiring communication of resident changes and reporting weight variance to the provider; the APRN stated she had not been notified and would have monitored weights more closely, recommended protein shakes, and discussed the decline with the family if informed.
Missed smoking and elopement assessments
Penalty
Summary
The facility failed to complete required smoking assessments for a resident with unspecified dementia, Bipolar II Disorder, and anxiety who was identified as a current smoker. The resident’s MDS showed a BIMS of 8, indicating moderate cognitive impairment, and the care plan included smoking safety observation and use of a smoking apron. Although a physician’s order allowed participation in the supervised smoking program per facility policy, the resident’s record showed smoking assessments were completed only on 7/4/24, 11/4/25, and 2/2/26, with four required evaluations missing during that period. The ADNS confirmed the facility policy required smoking evaluations on admission, readmission, quarterly, and with a change in condition, but could not explain why the assessments were not completed. The facility also failed to complete required elopement assessments for a resident with dementia with psychotic disturbances, delusional disorders, and frontotemporal neurocognitive disorder. The resident’s MDS assessments showed severe cognitive impairment, and the later assessment identified daily wandering behaviors that were the same as the prior assessment. The care plan identified the resident as at risk for elopement and included interventions such as checking the elopement device, monitoring for tailgating, and using verbal cues to minimize exit seeking. A physician’s order directed staff to check the elopement device placement to the left wrist every shift, and observation confirmed a wander guard was in place on the left wrist. Record review showed elopement assessments were completed on 7/8/24, 10/14/25, and 1/13/26, but four additional assessments should have been completed between 7/2024 and 10/2025. RN #3 stated the facility policy required wander/elopement assessments on admission, quarterly, annually, and with a change in condition, but could not identify why the assessments were not completed for a resident who was exhibiting wandering behaviors. The facility also failed to complete a smoking assessment for a newly admitted resident with COPD, hyperlipidemia, and atherosclerotic heart disease who told staff he smoked cigars and wanted to smoke but had not been allowed to do so because of oxygen use. The resident’s admission MDS identified him as a non-smoker, the care plan did not identify him as currently smoking or desiring to smoke, and RN #1 stated the resident had never been asked on admission or identified as a smoker because no smoking assessment had been completed until 55 days after admission.
Oxygen Administered Without Order and Set Incorrectly
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents receiving oxygen. Resident #8 had diagnoses including COPD, acute pulmonary edema, and anxiety disorder, and was observed lying in bed with the head of the bed elevated and wearing a nasal cannula while receiving oxygen at 2 liters per minute. Review of the physician’s orders did not identify an order for oxygen at the time of the observation, although a physician order was later obtained after surveyor inquiry directing oxygen via nasal cannula at 1 to 4 liters per minute. The resident’s care plan identified COPD and included interventions for monitoring breathing difficulty and elevating the head of the bed during episodes of difficulty breathing. Resident #93 had diagnoses including COPD and muscle weakness and was observed on two occasions lying in bed with the head of the bed elevated and wearing a nasal cannula while receiving oxygen at 5 liters per minute. The resident had a physician’s order directing continuous oxygen at 2 to 4 liters per minute via nasal cannula to keep oxygen saturation greater than 92%, but the oxygen was set above the ordered range. An LPN stated oxygen should be set according to the physician’s order and adjusted Resident #93’s oxygen to 3 liters per minute after identifying it was set incorrectly. Interviews with nursing staff and the ADNS confirmed that oxygen should be set according to the physician’s order, and the facility’s oxygen policy directed staff to verify that a physician’s order existed and to set oxygen at 2 to 3 liters per minute unless otherwise ordered.
Failure to Monitor Ordered Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to provide safe, appropriate dialysis-related care for a resident with end stage renal disease, diabetes, and dependence on renal hemodialysis by not maintaining a physician-ordered fluid restriction. The resident’s care plan identified hemodialysis treatment and fluid restriction as ordered, and a physician order dated 1/29/26 directed a 1500 mL per day fluid restriction. However, review of meal intake documentation, MARs, and TARs for January through March 2026 did not identify fluid intakes recorded for meals, amounts to be given, or any indication that the resident was to maintain a fluid restriction. The quarterly nutrition assessment identified the 1500 mL fluid restriction but did not document compliance, non-compliance, or fluid intake. The hemodialysis treatment communication forms available in the binder did not identify concerns or inability to follow the restriction. During interview and record review, the RN supervisor stated the resident’s fluid restriction was not and had not been monitored according to the physician order, and the ADNS confirmed there should have been written direction on the MAR and TAR to maintain the restriction and document intake amounts, but could not explain why this was not done. Dietitian review and interviews showed the restriction was discussed among staff, including a later change to 1000 mL daily, but the clinical record did not reflect documentation breaking down the restriction into amounts per meal or shift, nor did nutrition notes show monitoring of the restriction. The corporate nurse stated she would expect documentation of conversations with the hemodialysis dietitian and changes in fluid restriction, intake, and communication with the treatment center, but the record did not contain this information. The APRN stated that if a fluid restriction was ordered, intake should be monitored and she would expect to be notified if the facility could not monitor it, but she was not notified.
Unattended Medication Cart and Improper Controlled Substance Storage
Penalty
Summary
The facility failed to ensure medications were stored according to professional standards and that controlled substance narcotic medications were double locked. On observation, the South-Central medication cart was found in the hallway parallel to the front door, across the front lobby, with a singly locked narcotic box and the cart itself not locked. The cart was unattended and there was no nurse in view of it while multiple people passed by, including the ADNS, residents, housekeeping staff, the receptionist, the Dietary Director, rehabilitation staff, an APRN, a visitor, the scheduler, an LPN, the psychiatric APRN, and nurse aides. During interview, the LPN assigned to the South-Central medication unit and cart stated the facility policy directed medication carts be locked when unattended, and she acknowledged she was responsible for locking the cart when walking away but got busy and went on break. The RN supervisor stated the policy was to lock medication carts when unattended, or in an emergency another nurse could keep watch if right next to the cart, and said no one had been asked to watch the cart and it should have been locked. Review of the Storage of Medications Policy stated drugs and biologicals are to be stored in a safe, secure, and orderly manner, with compartments locked when not in use and unlocked medication carts not left unattended. The Controlled Substances Policy stated the facility complies with requirements related to handling, storage, disposal, and documentation of controlled substances.
Failure to Follow Up on Requested Upper Dentures
Penalty
Summary
The facility failed to provide or obtain dental services for a resident who had requested replacement of missing upper dentures. Resident #10 had diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and hypertension, and the admission MDS identified moderate cognitive impairment, independence with oral hygiene, and need for supervision/touching assistance with transfers. The care plan identified dental concerns related to broken and missing teeth, with interventions for dental consultation and treatment. A nurse progress note documented that the resident had lost upper dentures at a previous facility and wanted the missing upper dentures replaced. A dental examination note documented that the resident wanted a full maxillary denture made, but the facility did not follow up on the request. The Central Supply/Medical Records Manager stated she scheduled dental appointments but did not review the appointment notes and was unaware of the request for new upper dentures. The dental provider representative stated the dentures were not requested because the resident was listed as not insured, and after reviewing the paperwork sent by the facility, identified that this was a data entry error because the paperwork showed Medicaid insurance. The Assistant DON stated the resident had requested new upper dentures on admission and at the dental appointment, and that the facility failed to follow up on the request, resulting in the resident not receiving a new set of upper dentures.
Hand Hygiene Not Performed During Dressing Change and Glucometer Cleaning
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to perform hand hygiene during resident care and equipment cleaning. During an observed dressing change for a resident with severe protein calorie malnutrition, diabetes with neuropathy, urinary retention, a Foley catheter, a stage 4 pressure injury, and two unstageable pressure injuries, the ADNS applied gloves to cleanse the penis area with normal saline, removed the gloves, and put on new gloves without cleansing or sanitizing her hands. The ADNS later removed gloves after handling the left heel dressing and was stopped before putting on new gloves because hand hygiene had not been performed. The ADNS stated that hand sanitizing should occur with each glove removal and before putting on new gloves. During a separate observation, an LPN cleaned a glucose testing device while wearing gloves and then reapplied gloves without performing hand hygiene. The LPN stated she had been distracted with another resident and did not perform hand hygiene, but should have. The facility policy reviewed stated that hand hygiene is required before handling clean or soiled dressings, during resident care, after handling contaminated equipment, and after removing gloves, and that glove use does not replace handwashing or hand hygiene.
Survey Results Not Easily Accessible to Residents
Penalty
Summary
The facility failed to ensure residents could easily view the previous state survey results. During a Resident Council meeting, residents stated they did not know where the prior survey results were located or that they had the right to review them, and they said they would have reviewed the results if they had known where to find them. Observation of the facility entrance lobby did not identify the previous state survey results, and the Administrator later confirmed that the survey results were in the main lobby in a wall file holder about 4 feet off the ground and behind an artificial tree, making them not visible to residents or visitors. During interview, the Administrator acknowledged that the artificial tree was obscuring the survey results binder and stated she was unaware residents were allowed access to the state survey results. She said she would ensure the results were in an area easily accessible to residents and visitors and would inform residents and staff of the location. On a later observation, the artificial tree was again blocking the area, and the Administrator stated she did not know why it had been placed back there and that she would move the survey results to a more accessible location. The facility’s Resident Rights policy dated 10/26/22 stated that residents have the right to examine survey results.
Failure to Consistently Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to consistently provide residents their mail on Saturdays, as identified during a Resident Council meeting and a review of the facility's mail policy. During the Resident Council meeting on 2/27/26, residents reported that they were not consistently receiving mail on Saturdays and stated they were unaware that they were supposed to receive mail each Saturday. The Recreation Director stated in an interview on 2/27/26 that he personally delivered mail to residents when he worked on Saturdays, but he had not formally received a complaint from residents about Saturday mail delivery. The facility policy for mail stated that residents' mail and packages were to be delivered within 24 hours of delivery on premises or to the facility's post office box, including Saturday deliveries.
Incorrect PASRR Coding on MDS Assessments
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to code the MDS PASRR section correctly for 5 of 5 sampled residents reviewed. Resident #8 had diagnoses including paranoid schizophrenia, major depressive disorder, and anxiety, and an Ascend PASRR Level 2 form indicated schizophrenia, major depression, and anxiety disorder with long-term approval and no specialized mental health services needed, yet the annual MDS coded Section A1500 as no serious mental illness. Resident #16 had schizophrenia, anxiety disorder, and auditory hallucinations, and a PASRR Level 2 form identified schizoaffective disorder and anxiety disorder with long-term approval and no specialized mental health services needed, yet the significant change MDS also coded Section A1500 as no serious mental illness. Resident #23 had schizophrenia disorder, bipolar type, anxiety disorder, and EPS, and a Maximus PASRR Level 2 form identified schizoaffective disorder, anxiety disorder, and dementia with long-term nursing facility care approved and mental health needs identified, yet the admission MDS coded Section A1500 as no serious mental illness. Resident #30 had paranoid personality disorder, depression, and schizophrenia, and the annual MDS coded Section A1500 as no serious mental illness despite a Maximus PASRR Level 2 form identifying paranoid schizophrenia and depression with 180-day approval and a subsequent PASRR Level 2.5 not completed. Resident #62 had bipolar disorder, anxiety disorders, and adjustment disorder with mixed anxiety and depressed mood, and a Maximus PASRR Level 2 form identified bipolar disorder and dementia with long-term nursing facility care approved, yet the annual MDS coded Section A1500 as no serious mental illness. Interviews showed the MDS coordinator stated social services was responsible for coding Section A1500, and the social worker stated she was responsible for coding the PASRR section and that staff had identified incorrect PASRR coding. The facility policy stated PASRR Level 2 residents should be reviewed and kept on the chart, and social services should maintain a current list of Level 2 residents and review them with quarterly, annual, and significant change assessments.
PASRR Level 2 Review Not Completed After Expiration
Penalty
Summary
The facility failed to complete a PASRR level 2 review after the resident’s 180-day exemption had expired. Resident #30 had diagnoses including paranoid personality disorder, depression, and schizophrenia. The annual MDS identified a BIMS score of 11, indicating moderate cognitive impairment, and showed the resident required set-up assistance with hygiene while remaining independent with dressing, bed mobility, and transfers. The care plan identified a psychosocial wellbeing problem related to recent admission and a positive PASRR, with interventions focused on allowing time to answer questions, verbalize feelings, support assistance with realistic goals, and discuss expectations in realistic terms. The Maximus PASRR level 2 form identified paranoid schizophrenia and depression and approved 180 days of nursing facility services, with the approval later expiring. At the time of interview, the Social Worker stated she was responsible for ensuring a level of care was completed before expiration and could not explain why another level of care was not requested, other than that it was an oversight. The facility policy required PASRRs to be reviewed, maintained in the chart, and for level 2 recommendations to be reviewed and incorporated into the care plan, with social services maintaining a current list of level 2 PASRR residents and reviewing them with quarterly, annual, and significant change assessments.
Failure to Implement Fall Risk Care Plan Intervention
Penalty
Summary
The facility failed to implement a fall risk care plan intervention for Resident #7, whose diagnoses included difficulty walking, muscle weakness, and extrapyramidal movement disorder. The quarterly MDS identified severe cognitive impairment with a BIMS score of 6, and the resident was dependent on staff for putting on and taking off footwear, sitting to standing, and transfers. The active care plan identified the resident as a moderate fall risk and included an intervention for a floor mat to be applied on the right side when the resident was in bed. Observations on 2/24/26 at 10:01 AM and 3/2/26 at 9:31 AM showed Resident #7 lying in bed without the floor mat on the right side of the bed. RN #1 stated that implementation of care plan interventions was the responsibility of the unit nurse and did not know why the mat was not present. LPN #2 also observed the resident in bed without the mat and stated that the unit nurse was responsible for ensuring implementation; she noted that the NA care card did not include the floor mat intervention even though NAs usually implemented floor mats for fall risk residents. The ADNS stated that the unit nurse was responsible for ensuring care plan interventions were implemented according to facility policy and could not identify why the intervention was not in place.
Incomplete Investigations into Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into multiple incidents of resident-to-resident abuse involving five residents. In one incident, a resident with paranoid schizophrenia and antisocial personality disorder struck another resident with vascular dementia and behavioral disturbances. The facility's reportable event documentation lacked statements from staff who witnessed the incident, and the acting Director of Nursing Services (DNS) was unable to explain why these statements were not obtained. The nursing supervisor on duty did not have a clear list of caregivers assigned to the involved residents, which contributed to the incomplete investigation. Another incident involved a resident with severe intellectual disabilities threatening to harm their roommate, who had dementia and schizophrenia. Although the residents were separated and emergency services were notified, the facility's documentation did not include statements from the staff responsible for the residents' care during the incident. The DNS acknowledged the lack of complete documentation and was unsure why the necessary statements were not collected. A third incident involved a resident with schizoaffective disorder being punched by another resident. The nursing supervisor documented the physical injuries sustained by the victim but failed to obtain statements from staff present during the altercation. The DNS admitted that the investigations into these incidents were incomplete due to missing staff statements and a lack of documentation regarding the residents' status before the incidents. The facility's policy required a thorough investigation by the DNS or Social Services department, which was not fulfilled in these cases.
Failure to Provide Timely Social Services Support After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide timely social services support to residents involved in resident-to-resident abuse incidents. Five residents were reviewed for such incidents, and it was found that the facility did not ensure that social services met with the residents within the required timeframe. For instance, Resident #1, diagnosed with paranoid schizophrenia and other disorders, was involved in an incident on 8/7/24 but was not met by social services until the following day. Subsequent follow-ups were also lacking, as there were no social service notes from 8/9/24 through 8/11/24 and from 8/13/24 through 8/20/24. Resident #2, who has vascular dementia and other behavioral issues, was also involved in the same incident on 8/7/24. However, there was no documentation of any social worker interaction with this resident regarding the incident throughout the entire month of August. Social Worker #1 admitted to not remembering meeting with the resident, which resulted in the absence of documentation. This lack of timely intervention and documentation was a recurring issue for other residents involved in similar incidents. Residents #3, #4, and #5 also experienced deficiencies in social services follow-up after incidents of resident-to-resident abuse. For example, Resident #3 was involved in an incident on 8/30/24, but follow-up documentation was missing from 9/1/24 through 9/8/24. Similarly, Resident #4, involved in the same incident, had no further social service documentation after the initial meeting on 8/30/24. The facility's social workers failed to consistently meet with residents within 24 hours of incidents and did not follow up daily for the required 72 hours, as confirmed by interviews with the social workers and the facility administrator.
Deficiencies in Kitchen Cleanliness and Food Expiration Management
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not discard expired foods, as observed during a tour of the Dietary Department. The inspection revealed a ceiling fan covered with dust blowing over washed silverware and mugs, walls in the dishwashing area coated with dust, and a foul odor emanating from the sink area due to grime and dirt accumulation. Additionally, the vent above the stove was dusty while food was being prepared, and the cleaning schedule did not include fans, walls, or ceiling tiles. The Food Service Manager, who had been in the position for four weeks, acknowledged the need for steam cleaning the kitchen and had reported the cleanliness issues in meetings. However, the cleaning schedule did not cover all necessary areas, and the responsibility for cleaning certain areas was unclear between the kitchen staff and the maintenance department. The Sanitarian had previously identified cleanliness issues during an inspection and noted that staff were cleaning the kitchen during a follow-up visit. Expired food items were found in the emergency food supply and the walk-in freezer, including cereal, pudding, canned fruits, and meats. The Food Service Manager admitted to not checking expiration dates yet and stated that it was the responsibility of the staff stocking the freezer. The Dietician noted that serving expired food could make residents ill. The Administrator was aware of the cleanliness issues and had made some improvements but acknowledged that the cleaning schedule needed updates.
Failure to Address Cleanliness Issues in Kitchen and Laundry Areas
Penalty
Summary
The facility failed to address cleanliness issues identified during monthly environmental rounds from January 2024 to June 2024. The Infection Control Nurse (ICN) and other staff were responsible for conducting these rounds, and they noted cleanliness issues in the kitchen. However, there was no evidence that these issues were resolved within the 10-day timeframe as required by the facility's policy. The ICN confirmed that the cleanliness of the kitchen remained an issue throughout this period, indicating a lack of follow-through on identified problems. Additionally, during an observation in the laundry area, significant lint debris was found on the back wall, ceiling wall, metal pipe, and floor where the washing machines were located. The Laundry Manager, who was temporarily covering the position, could not provide documentation of when these areas were last cleaned. This indicates a failure to maintain a clean laundry area, as required by the facility's Environmental Rounds Best Practice policy, which mandates that problem areas be resolved and documented within 10 days.
Failure to Notify Physician of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the physician of significant changes in the condition of two residents, leading to deficiencies in care. Resident #16, who had multiple co-morbidities including chronic anemia, cirrhosis, and heart failure, experienced a significant change in condition with symptoms such as abdominal pain, vomiting, and labored breathing. Despite these symptoms, there was a lack of timely and thorough assessment by the nursing staff, and the physician was not notified of the resident's worsening condition. This oversight resulted in the resident being sent to the hospital in a critical state, where they later expired. Resident #43, diagnosed with congestive heart failure, diabetes, and dementia, experienced a significant weight gain of 35.1 pounds over two weeks. The facility failed to re-weigh the resident or notify the physician of this significant change, as required by their weight policy. The oversight in monitoring and reporting the resident's weight gain potentially contributed to the resident's lower leg edema, which was noted in the clinical record. The lack of communication and follow-up on the resident's condition highlights a deficiency in the facility's care processes. Interviews with facility staff, including the ADNS, LPNs, and the dietician, revealed gaps in the monitoring and documentation of the residents' conditions. The staff acknowledged the failure to conduct thorough assessments and notify the physician of significant changes. The facility's policy on changes in a resident's condition or status was not adhered to, resulting in a lack of timely intervention and appropriate care for the affected residents.
Failure to Assess and Obtain Consent for Secured Unit Placement
Penalty
Summary
The facility failed to properly assess, care plan, and obtain necessary consents for residents residing on a secured dementia unit. Observations during the survey period revealed that the secured unit required a code for entry and exit, and only staff were observed using the code. The facility assessment did not include criteria or specific functions for the unit, and interviews with facility staff confirmed that there were no established criteria for placing residents on the secured unit. The decision to place residents was based on diagnoses or family requests, without a formal assessment process or physician's orders. The clinical records of thirty-eight residents on the secured unit did not show evidence of consent from responsible parties, physician's orders, or documentation that the secured unit was the least restrictive setting. Care plans did not reflect the residents' placement on the secured unit or agreement from residents or their responsible parties. Interviews with the facility's administration and staff confirmed the lack of criteria for placement and the absence of reassessments to ensure the appropriateness of the secured unit for residents.
Deficiency in Toenail Care for Resident with Paraplegia
Penalty
Summary
The facility failed to provide necessary services for maintaining good grooming and personal care for a resident with paraplegia, specifically related to toenail care. The resident, who had intact cognition and used a wheelchair, experienced pain due to long toenails. Observations revealed that the toenails were thickened, yellowed, brittle, and had grown over the ends of the toes. Despite regular visits from a podiatrist, the resident's toenails remained problematic, and the facility did not provide specific foot care beyond shower care. The podiatrist's notes indicated that the resident had fungal nails that were debrided, but anti-fungal treatment was not prescribed due to the resident's age and co-morbidities. The facility's foot care policy stated that residents should receive appropriate care to maintain foot health, and those with foot disorders should be referred to qualified professionals. However, the resident continued to experience issues with toenail care, as the podiatrist did not recall the resident and did not make a referral for oral anti-fungal medication. The facility's healthcare service agreement with the podiatry group required care and treatment in accordance with professional standards, yet the resident's toenail condition persisted, indicating a deficiency in the facility's adherence to its own policies and agreements.
Deficiency in Food Preparation and Serving Standards
Penalty
Summary
The facility failed to provide food that was prepared in a manner to conserve nutritive value and in a palatable manner for two residents. Resident #20, who has diagnoses including unspecified dementia, major depressive disorder, and diabetes insipidus, reported that the food lacked variety and flavor, with an overuse of pasta. The menu review showed frequent repetition of pasta dishes over several weeks. An observation and taste test of a lunch meal revealed issues such as undercooked pork, mushy zucchini, and a raw quiche crust. The food service manager confirmed the issues with the quiche and zucchini, attributing the latter to the use of frozen vegetables and a late delivery truck. Resident #39, with diagnoses including unspecified injury to the lumbar spinal cord and paraplegia, expressed dissatisfaction with the food choices and preparation, noting that the food was sometimes overcooked or undercooked. During an observation, Resident #39 was seen pushing away his lunch tray, indicating he did not consume the meal. A test tray observation confirmed the issues with the meal, including overcooked zucchini and undercooked quiche. The food service manager acknowledged the substitution of zucchini for broccoli due to a late delivery and confirmed the quiche was undercooked. The facility's policy on proper cooking temperatures was reviewed, highlighting the importance of maintaining food outside the danger zone to prevent bacterial growth. However, the policy did not account for maintaining the appropriate temperature during plating and transport. The dietician noted that consuming undercooked or raw foods could cause gastrointestinal symptoms and that overcooking could lead to a loss of nutritional value. The facility's failure to adhere to proper food preparation and serving standards resulted in unpalatable and potentially unsafe meals for the residents.
Pest Infestation in Resident Rooms and Kitchen Storage
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of fruit flies in several resident rooms and the hallway of the Northeast wing. Observations revealed fruit flies in rooms 15, 18, and 20, with significant infestations noted on overbed tables, side tables, and beds. The presence of food items, such as cups of orange juice and sandwiches, contributed to the infestation. Despite previous pest control treatments, the issue persisted, indicating inadequate pest management and sanitation practices. In addition to the fruit fly issue, the facility's kitchen food storage area showed signs of rodent infestation. Observations identified chewed markings and fecal droppings on emergency food supplies, including cans of diced peaches, carrots, and corned beef hash. The flooring beneath the storage racks was also coated with fecal droppings. Interviews with the Food Service Manager and review of pest control invoices revealed that the facility had a history of rodent issues, with treatments conducted twice monthly. However, the presence of droppings indicated that these measures were insufficient. Interviews with facility staff, including the Administrator and DNS, highlighted a lack of awareness and documentation regarding pest control efforts. The Administrator admitted to changing pest control companies due to unsatisfactory results, while the DNS mentioned that treatments for fruit flies were conducted outside, as the chemicals could not be used indoors. The facility's failure to effectively address pest issues in both resident areas and food storage environments demonstrates a significant deficiency in maintaining a sanitary and safe environment for residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident #33, during morning hygiene care. Resident #33, who has diagnoses including unspecified dementia, a history of traumatic brain injury, and Asperger's syndrome, was observed in a vulnerable state with the door to their room open, exposing their naked body to the hallway. The resident, who has moderately impaired cognition and requires assistance with daily activities, was subjected to undignified treatment by a nursing assistant (NA#1). NA#1 responded to the resident's repeated comments about a smell with a disrespectful and inappropriate remark, which was repeated multiple times. This interaction was witnessed by a surveyor, prompting NA#1 to close the door belatedly. Interviews with staff, including NA#1, LPN#1, and RN#1, confirmed that the resident's privacy should have been maintained by closing the door or drawing the curtain during care. NA#1 acknowledged the failure to provide privacy and admitted that the comment made to the resident was inappropriate. LPN#1 identified the incident as verbal abuse and emphasized the importance of reporting such behavior immediately. The facility's policy on dignity, which mandates respectful communication and the protection of resident privacy, was not adhered to in this instance.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy for Resident #33 during personal care, as observed by a surveyor. Resident #33, who has diagnoses including unspecified dementia, a history of traumatic brain injury, and Asperger's syndrome, was observed receiving morning hygiene care with the door open, exposing the resident's naked body to the hallway. The care plan for Resident #33, which includes interventions for privacy during care, was not followed. NA#1, who was providing the care, responded inappropriately to the resident's repeated comments about a smell, using the resident's first name in a frustrated manner. It was only after noticing the surveyor that NA#1 closed the door. Interviews with NA#1, LPN#1, and RN#1 confirmed that privacy should have been maintained by closing the door or drawing the curtain during care. The facility's policy on Quality of Life Dignity, revised in 2009, directs staff to promote and protect resident privacy during personal care and treatment procedures. The failure to adhere to these policies and procedures resulted in a deficiency related to the privacy and dignity of Resident #33.
Failure to Monitor and Assess Changes in Residents' Conditions
Penalty
Summary
The facility failed to consistently monitor and assess two residents for changes in their health conditions, leading to deficiencies in care. Resident #16, who had multiple co-morbidities including chronic anemia, cirrhosis of the liver, and heart failure, experienced an acute onset of nausea and vomiting. Despite orders for close monitoring and assessments, the facility's nursing staff did not document complete assessments or notify the attending physician of significant changes in the resident's condition, such as altered mental status, shortness of breath, and labored breathing. The resident's condition worsened, leading to an emergency transfer to the hospital, where the resident later expired. Resident #43, diagnosed with congestive heart failure, diabetes, and dementia, experienced a significant weight gain of 35.1 pounds over a short period. The facility failed to reassess the resident or notify the physician of this significant change, which could indicate fluid overload due to CHF. The weight gain was not addressed until much later, despite the potential for contributing to the resident's lower leg edema. Interviews with facility staff, including LPNs, RNs, and the APRN, revealed a lack of communication and failure to follow protocols for monitoring and reporting changes in residents' conditions. The facility's policy required prompt notification of changes to the attending physician and detailed assessments by nursing staff, which were not adhered to in these cases. The deficiencies highlight a failure in the facility's processes for managing residents' health changes effectively.
Failure to Implement Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to implement pharmacy review recommendations for two residents, leading to deficiencies in medication management. For one resident with diagnoses including GERD, bipolar disorder, and COPD, the pharmacist recommended clarifying the frequency of a PRN Miralax order on multiple occasions. Despite the APRN agreeing to the recommendation, the order was not updated in the resident's medical record, and the facility's policy requiring action within 30 days was not followed. Interviews revealed communication issues between the pharmacy consultant, DNS, ADNS, and APRN, contributing to the oversight. Another resident with diagnoses of unspecified dementia, psychosis, and Asperger's syndrome was prescribed Seroquel, which can cause orthostatic hypotension. The pharmacist recommended monitoring orthostatic blood pressures, and the physician agreed to this recommendation. However, the facility failed to implement the order, as no orthostatic blood pressures were recorded in the resident's medical record. Similar communication lapses were noted, with the APRN and DNS not ensuring the recommendation was acted upon. The facility's policy on Medication Regimen Review and Reporting requires that recommendations be communicated to the DNS or designee and acted upon within 30 days. However, the facility did not adhere to this policy, resulting in unaddressed pharmacy recommendations for both residents. The lack of follow-through on these recommendations highlights a breakdown in the facility's processes for managing medication regimens and ensuring resident safety.
Medication Administration Error Due to Crushing of Medications
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by an incident involving a resident with diagnoses including hypertension, depression, repeated falls, and anxiety. The resident was severely cognitively impaired and required assistance with personal hygiene, bed mobility, transfers, and supervision with eating. On a specific date, an LPN prepared and administered medications to the resident by crushing and mixing them in applesauce, despite pharmacy directions indicating that the medications should not be crushed. The medications included Aspirin enteric coated (EC), Bupropion Hydrochloride (HCl) extended release (ER), and Metoprolol Succinate ER, all of which have specific release mechanisms that are compromised when crushed. The LPN, who was not the regular nurse for the unit, admitted to not fully reading the medication administration record and instructions, leading to the error. The RN Nursing Supervisor confirmed that the administration orders should have been followed. The Pharmacy Consultant explained the potential effects of crushing these medications, such as faster release and potential irritation. The facility's total medication error rate was reported to be 12%, and the facility's policy required medications to be administered according to orders, with staff verifying the right resident, medication, dose, time, and method before administration.
Incomplete Medical Records for Resident
Penalty
Summary
The facility failed to ensure that medical records for a resident were readily accessible and complete, as required by professional standards. The resident in question had diagnoses including gastro-esophageal reflux disease (GERD), bipolar disorder, and chronic obstructive pulmonary disease (COPD). The facility's deficiency was identified during a clinical record review, which revealed that signed copies of pharmacist recommendations from December 2023 to February 2024 were missing from the resident's medical records. These recommendations were supposed to be part of the resident's medical chart, but they were not filed appropriately, as confirmed by interviews with the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS). The facility's policy on medication monitoring and regimen review required that findings be communicated to the director of nursing or designee and documented in the resident's chart. However, the process was not followed correctly, as the recommendations were found outside the medical chart and not filed under the pharmacy tab as expected. Interviews with the former DNS and medical records personnel revealed a lack of clarity and consistency in the handling and filing of these documents, contributing to the incomplete medical records for the resident.
Failure to Prevent Resident Altercations
Penalty
Summary
The facility failed to protect two residents from mistreatment, resulting in a deficiency related to abuse prevention. Resident #1, who had diagnoses including dementia and behavioral disorders, was known to exhibit behaviors such as wandering and intruding into others' spaces. Despite being identified as an elopement risk and having a history of altercations, the facility did not effectively prevent Resident #1 from entering Resident #2's room, leading to a confrontation. Resident #2, who had moderate cognitive impairment and a potential for mood disorders, was found in a physical altercation with Resident #1, which was not prevented by the facility's interventions. On two separate occasions, Resident #1 entered Resident #2's room, leading to incidents of yelling and physical altercations. The first incident occurred when Resident #1 was found next to Resident #2's bed, causing Resident #2 to yell for Resident #1 to leave. Although a Velcro cloth stop sign was placed across Resident #2's doorway as a deterrent, it was not documented as being in place during a subsequent incident. During the second incident, both residents were observed punching each other, resulting in red marks on their faces, indicating a failure to maintain a safe environment. The facility's documentation and interviews revealed that the interventions to prevent Resident #1 from entering Resident #2's room were not consistently implemented. Despite the known behaviors of Resident #1 and the previous altercations, the Velcro cloth stop sign was not in place during the second incident, allowing Resident #1 to enter the room and engage in a physical altercation with Resident #2. This oversight contributed to the deficiency in ensuring residents were free from mistreatment and abuse.
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 176 citations issued within 25 miles in the last 12 months — including the 6 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 London
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beechwood Health & Rehabilitation Center | 0.7 mi | ★★★★★ | 3 | 0 |
| New London Sub-acute And Nursing | 1.1 mi | ★★★★★ | 22 | 3 |
| Fairview | 2 mi | ★★★★★ | 3 | 0 |
| Civita Care Bayview | 3.4 mi | ★★★★★ | 52 | 1 |
| Complete Care At Groton Regency | 3.4 mi | ★★★★★ | 13 | 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.