Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Touchpoints At Bloomfield during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction, intact cognition, and dependence with ADLs used an electric wheelchair and fell while attempting to enter a wheelchair van without assistance, striking the back of the head and later being found to have an L2 transverse process fracture. After the fall, an RN supervisor assessed the resident and then used a personal, non‑encrypted cell phone to text an APRN, including the resident’s full name and specific clinical details about the fall, head injury, neurological status, and care provided. The RN acknowledged that the device was not encrypted and that he could not confirm the security of the text, and the facility lacked a policy governing the use of personal cell phones for transmitting resident information, resulting in a breach of privacy and confidentiality requirements for protected health information.
A resident with Alzheimer's disease, abnormal posture, and chronic pain syndrome was totally dependent on staff for ADLs, but was observed with a sock on the right hand without a corresponding care plan intervention or physician order. Staff said the sock was used for self-scratching behaviors, while the DON/DNS could not identify documentation directing the practice. The resident's rights policy stated the resident has the right to be treated with consideration, respect, and full recognition of dignity.
A resident with CHF, HTN, and a stage 3 pressure ulcer had a 14-pound weight gain in one month, but weekly weights were missing on multiple occasions and the physician was not notified despite an order to report a gain greater than 5 pounds in one week. An LPN said nursing did not trend weight increases unless residents were on fluid restrictions, while the ADNS said the dietician was expected to notify nursing of significant weight changes. The physician stated he had not been informed and would have ordered a CXR, labs, and possibly changed meds and treatment.
A resident with cerebral infarction, anxiety, and depression alleged that an NA stole money and a bank card during an outside medical trip. Interviews and record review showed the NA accompanied the resident, later reported the resident accused her after a dispute over confiscated smoking materials, and the facility could not identify when the NA was removed from the schedule despite its abuse policy requiring removal during the investigation.
Incomplete investigation of alleged misappropriation involving a resident with cerebral infarction, anxiety, and depression. The resident, who had a BIMS score of 15 and required substantial assistance with transfers, alleged that an NA stole money and a bank card during an outside medical trip. Interviews showed conflicting accounts about the outing and the resident’s accusation, but the facility had no resident statement, no clear timeline, no clinical record documentation, and no documented police input, despite policy requiring prompt investigation, staff/witness statements, and law enforcement consultation.
Failure to notify the State Ombudsman’s office of a resident discharge. A resident with right knee replacement, difficulty walking, and OA had intact cognition and was independent with basic ADLs, and the care plan anticipated discharge home. The record showed the resident was discharged home, but SW and the regional Behavioral Health Director confirmed the facility did not submit the required discharge notification to the Ombudsman because staff were unaware of the reporting requirement.
Care plans were not updated for residents with a pressure ulcer, a diabetic foot ulcer, and a pelvic positioning device. The care plans did not reflect EBP for the wounds, even though the IP stated EBP was used for residents with chronic wounds and diabetic foot ulcers. A resident observed with a pelvic belt in a wheelchair also had no care plan entry or physician order for the device, despite staff stating it was used to prevent falls and for positioning.
Duplicate tube feeding orders were not clarified for a resident with dysphagia, aphasia, hemiplegia, and stroke. The resident’s care plan called for tube feedings and flushes as ordered, but the MAR showed both orders were signed off as completed. Staff interviews showed one LPN followed the newer order, another LPN had previously reported the conflicting orders, and an RN stated the earlier order should have been discontinued when the new order was written.
A resident with severe cognitive impairment and elopement risk was found to have a Wanderguard device in use without a physician's order or documentation of placement and function checks. Staff and leadership confirmed the absence of required orders and documentation, despite the care plan indicating the need for monitoring.
A resident with severe cognitive impairment and elopement risk was found to have a Wanderguard device in place without a physician's order or documentation of monitoring. Staff were aware of the resident's risk but did not have orders or records to verify the device's placement or function, and facility leadership confirmed that such orders should have been present.
A resident with impaired cognition and no LOA order left the facility unnoticed, walking several miles in cold weather before being found by family. Staff failed to initiate the missing resident protocol, did not call a missing person code, and did not conduct a coordinated search, resulting in delayed discovery and return of the resident.
A resident with multiple mental health diagnoses became physically aggressive towards their roommate, who was diagnosed with depression and chronic pain, in a LTC facility. Despite no prior history of aggression, the resident attacked their roommate, leading to a substantiated case of abuse. The facility's policy to protect residents from abuse was not effectively implemented, resulting in this incident.
The facility failed to complete the MDS cognitive assessments for six residents due to the unexpected departure of the social worker responsible for Section C. The DNS confirmed that these assessments, crucial for care planning, were not conducted as required by the RAI manual.
The facility was found deficient in maintaining kitchen sanitation and ensuring food was served at appropriate temperatures. Observations revealed a sticky kitchen floor with debris, a dietary aide without a hair restraint, and food temperatures below the required 135 degrees Fahrenheit. The Food Service Manager noted that food likely cooled due to delays in distribution.
The facility failed to review its infection prevention control program policies annually and did not conduct required quarterly environmental rounds. The Infection Control Program manual was not reviewed in 2022, and documentation for environmental rounds was missing for two quarters in 2023. The current Infection Preventionist and Administrator, both not employed during the lapses, confirmed the deficiencies.
The facility failed to ensure that the antibiotic stewardship program, including antibiotic usage, was reviewed at quarterly medical staff meetings. Documentation for several months in 2022 and 2023 was missing, and interviews revealed a lack of formal review and documentation of antibiotic usage, contrary to the facility's policy.
The facility failed to document the required 12 hours of in-service training for nurse aides, including abuse prevention and dementia care, for 2022 and 2023. Interviews and reviews revealed a lack of documentation and absence of a staffing education policy, despite claims of annual training practices.
A resident with dementia and schizophrenia was injured in an altercation with a roommate over television access, highlighting a lack of supervision. The incident resulted in a skin tear and bruising, and both residents were hospitalized. The facility's abuse policy was not effectively enforced to prevent this incident.
A resident admitted with shoulder conditions was not assessed by an RN upon arrival, as required by facility policy. The resident's clinical record lacked documentation of a comprehensive assessment, and the resident requested discharge the following day. The facility's policy mandates an accurate history and assessment upon admission, which was not completed.
A resident with multiple health conditions, including diabetes and renal disease, developed a pressure ulcer on the left heel. The facility failed to ensure a timely assessment and treatment by a registered nurse, as the wound was noted on one day but not assessed or treated until the next. The wound progressed from a deep tissue injury to an unstageable pressure injury. Facility policy required immediate RN assessment and treatment, which was not followed.
A facility failed to ensure clear and complete physician's orders for a resident with a gastrojejunostomy tube, leading to inconsistencies in the administration of enteral nutrition and medications. The resident, with a history of Huntington's disease and dementia, experienced a clogged j-tube, and staff did not promptly notify the physician or resolve the issue, resulting in missed medications and nutrition. Interviews revealed communication gaps and unclear instructions regarding the use of feeding tubes.
Two residents experienced inadequate pain management due to incomplete assessments and poor documentation. One resident faced delays and inconsistencies in receiving Oxycodone, while another did not receive proper pain assessments or medication. The facility's pain management policy was not consistently followed, leading to deficiencies in care.
A facility failed to monitor fluid intake for a resident with end-stage renal disease on a 1500 ml fluid restriction. Despite physician orders, staff interviews revealed confusion and lack of documentation regarding fluid monitoring responsibilities. The facility's Hemodialysis policy was not followed, leading to inadequate monitoring of the resident's fluid intake.
The facility failed to ensure proper medication storage and labeling, leading to expired insulin being used for a resident with diabetes, unlabeled insulin vials for two other residents, and improper storage of Morphine Sulfate for a resident with cancer. LPNs acknowledged the responsibility for checking expiration dates and proper storage, but inconsistencies were found in practice.
The facility did not complete annual performance evaluations for several nurse aides in 2022. Personnel files lacked documentation of evaluations, and interviews revealed that the responsibility lay with the shift supervisor and DNS, but none were conducted. The facility's practice was to perform these evaluations annually, but this was not done for 2022, although 2023 evaluations were completed. A policy for Annual Performance Evaluation was not provided.
The facility failed to maintain proper accountability records for controlled substances, with missing documentation for three prescriptions. Interviews revealed that the white copy of the Control Substance Disposition Record was used for scanning to the pharmacy system and should have been returned for record-keeping, but the ADNS could not locate the necessary copies. This lapse violates the facility's policy requiring records to be kept for at least five years.
Failure to Protect Resident Health Information During Text Communication
Penalty
Summary
The deficiency involves the facility’s failure to maintain the privacy and confidentiality of a resident’s personal and medical information when communicating about a fall event. Resident #1 had a diagnosis of cerebral infarction, a BIMS score of 15/15 indicating no cognitive impairment, and was dependent with ADLs and transfers while using an electric wheelchair independently. The resident had an identified risk for falls and alteration in mobility, with care plan interventions including assistance with ADLs, ensuring the call bell was in reach, determining causative factors of falls, and monitoring and administering pain medication as ordered. On the morning of 1/7/2026, Resident #1 was being transported for a scheduled medical appointment in a wheelchair-accessible van. The nurse aide reported that the resident refused assistance during transfer into the van and fell backwards out of the wheelchair, landing supine on the pavement and striking the back of the head. Facility documentation and a reportable event form indicated that the wheelchair became caught on an object while the resident was seated, causing it to tilt and tip over. An RN assessment was completed, the resident initially denied pain or discomfort and insisted on proceeding to the scheduled appointment, and later hospital imaging identified an acute displaced L2 transverse process fracture. Following notification of the fall, RN #2, the night shift supervisor, used his personal, non‑encrypted cell phone to text the facility APRN about the incident, including the resident’s full name and clinical information such as the head injury, neurological status, refusal to stay for monitoring, vital signs, and initiation of the facility fall protocol. RN #2 acknowledged that his phone was not encrypted and that he could not verify whether the text was secure. Although the APRN reportedly had an encrypted messaging application, there was no confirmation that RN #2’s device or method of communication was secure, and the facility did not provide a policy regarding the use of personal cellular devices to communicate resident information. This resulted in a failure to safeguard the confidentiality of the resident’s personal and medical records from unauthorized disclosure.
Failure to Maintain Resident Dignity With Unordered Hand Sock
Penalty
Summary
The facility failed to ensure Resident #42 was dressed in a dignified manner. Resident #42 had diagnoses including Alzheimer's disease, abnormal posture, and chronic pain syndrome, and the quarterly MDS indicated the resident was totally dependent on staff for eating, bathing, hygiene, and dressing. The resident's care plan identified the need for assistance with all ADLs and included positioning the resident in a custom wheelchair with a pelvic positioning belt, but it did not identify the use of a sock on the resident's hand. The physician's orders for November 2025 also did not direct placement of a sock on the right hand. Observations on 11/17/25 and 11/18/25 showed Resident #42 with a sock on the right hand. An LPN stated the sock was used because the resident scratched him/herself and that staff placed socks on residents' right hands, but was unsure whether there were physician orders or care plan interventions directing this practice. The DNS stated that any resident with self-scratching behaviors should have a care plan and physician order for the intervention. Nursing notes from 3/1/24 through 11/18/25 documented only one instance of scratching on 7/10/24, and later an SBAR form dated 11/18/25 described itching behaviors. On 11/19/25, the DNS was unable to identify a physician order or care plan directing the sock to the resident's right hand. The facility's Resident's Rights policy stated the resident has the right to be treated with consideration, respect, and full recognition of dignity.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant weight gain for Resident #10 despite a physician order to obtain weekly weights and notify the physician for a greater than 5 pound weight gain in one week. Resident #10 had diagnoses including a stage 3 pressure ulcer, congestive heart failure, and hypertension. The quarterly MDS showed severely impaired cognition, moderate assistance needed for transfers and rolling, and set-up assistance for eating. The care plan addressed nutritional problems related to diabetes, congestive heart failure, coronary artery disease, and hypertension, with interventions to obtain weights as ordered and monitor, record, and report signs and symptoms of significant weight loss; no care plan for congestive heart failure was identified. The clinical record showed Resident #10 weighed 172 pounds on 10/6/25 and 186 pounds on 11/3/25, a 14 pound, 8.4% gain in one month. Weekly weights were missing on 9/29/25, 10/13/25, and 11/21/25. An LPN stated the dietician was responsible for monitoring significant weight changes and nursing did not trend weight increases unless residents were on fluid restrictions. The ADNS stated nursing had not been notified by the dietician of the weight gain and that she would have wanted to be notified so the resident could be assessed for fluid overload and the physician notified. The physician stated he had not been notified of the significant weight gain and would have wanted to be; he said he would have ordered a chest X-ray, laboratory work, and potentially changed medications and treatment.
Failure to Remove Staff Member From Schedule During Abuse Investigation
Penalty
Summary
The facility failed to follow its abuse policy for removing a staff member from the schedule after an allegation of misappropriation involving Resident #31. Resident #31 had diagnoses of cerebral infarction, anxiety, and depression, and the annual MDS indicated no cognitive impairment with substantial/maximal assistance needed for transfers and independence with wheelchair mobility. The care plan noted the resident may make statements that are not real or true but believed to be true, with interventions including listening for any truth in statements, offering 1:1 social work visits, and providing 2 staff members at all times with care. A Reportable Event form identified an allegation that money and a bank card were stolen from the resident’s bag by NA #4 during an outside physician visit. Interviews and record review showed NA #4 accompanied the resident to the appointment, remained outside a gift shop while the resident went in to make a purchase, later left the resident alone to buy a sandwich, and the resident was later found outside returning to the building smelling of smoke. The DNS and RN #1 stated NA #4 reported that the resident later accused her of stealing money after she said the resident owed her $15 for confiscated smoking materials. Although the DNS stated NA #4 was taken off the schedule, the time and date could not be identified, and review of the facility’s abuse policy indicated the staff member would be taken off the schedule during the investigation.
Incomplete investigation of alleged misappropriation
Penalty
Summary
The facility failed to follow its abuse policy when it did not complete a thorough investigation of an allegation of misappropriation involving Resident #31 and NA #4. Resident #31’s diagnoses included cerebral infarction, anxiety, and depression. The annual MDS identified the resident as having a BIMS score of 15, indicating no cognitive impairment, and requiring substantial to maximal assistance for bed mobility and transfers while being independent in a wheelchair. The care plan noted the resident may make statements that are not real or believed to be true and directed staff to listen for any truth in what was said, offer 1:1 social work visits, and provide two staff members during care. A reportable event form documented an allegation that money and a bank card were stolen from the resident’s bag by NA #4 during an outside physician visit. Interviews and record review showed NA #4 accompanied the resident to the appointment, remained outside a gift shop while the resident made a purchase, later left the resident alone to buy a sandwich, and then found the resident missing before the resident was later found outside returning to the building and smelling of smoke. NA #4 reported that the resident had purchased cigarettes and a lighter in the gift shop and later told her that she owed $15 for the confiscated smoking materials. When NA #4 refused, the resident said he/she would report that NA #4 had stolen money from him/her. The facility’s investigation was incomplete. The corporate RN and DNS stated there was no resident statement, no timeline of events, no documentation of the event in the resident’s clinical record, and no indication of what police said or did. NA #4 stated she reported the allegation to the nursing supervisor and wrote a statement, then was later asked to rewrite it, but she had not been contacted by police. The facility summary of findings stated the employee stayed with the resident throughout the appointment and that the resident had his/her pocketbook at all times, while the employee denied the allegation. The abuse policy required the investigation to begin within 24 hours, staff to be taken off the schedule, statements from staff and witnesses, and consultation with local law enforcement.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State Ombudsman’s office of Resident #138’s discharge. Resident #138 had diagnoses including right knee replacement, difficulty walking, and osteoarthritis. The discharge MDS assessment identified a BIMS score of 15, indicating intact cognition, and the resident was independent with personal hygiene, upper and lower body dressing, and putting on/taking off footwear. The care plan dated 8/25/25 anticipated discharge to home and included nursing and social work coordination for follow-up and future care needs. The clinical record documented that the resident was discharged home on 9/5/25, but interviews with the Social Worker and regional Behavioral Health Director confirmed the facility had not notified the State Ombudsman’s office of the planned discharge and had not done so for residents discharged before 9/23/25 because staff were unaware of the requirement until informed by the Ombudsman.
Care plans not updated for wound precautions and pelvic positioning device
Penalty
Summary
The facility failed to update the Resident Care Plan for a resident with a stage 3 pressure ulcer, left femur fracture, and dementia. The Resident Care Plan dated 6/26/2025 identified the resident as having a stage 2 pressure ulcer on the left heel and included interventions for ordered treatments and monitoring effectiveness, but it did not indicate that the resident was on enhanced barrier precautions (EBP) for the pressure ulcer. The quarterly MDS showed a BIMS score of 7, moderate assistance with rolling and chair/bed-to-chair transfers, and that the resident had developed a stage 2 pressure ulcer while at the facility. The facility also failed to update the Resident Care Plan for a resident with a diabetic foot ulcer, CHF, and type 2 diabetes. The Resident Care Plan dated 10/31/2025 identified the resident as having a diabetic foot ulcer on the left heel and included interventions for ordered treatments and identifying and resolving causative factors, but it did not indicate that the resident was on EBP for the diabetic foot ulcer. The significant change MDS showed a BIMS score of 15, dependence with rolling and chair/bed-to-chair transfers, and a diabetic foot ulcer. The Infection Preventionist stated the facility used EBP for residents with portals of entry including chronic wounds and diabetic foot ulcers, and identified that EBP should have been included in the care plans for both residents. The facility failed to update the Resident Care Plan for a resident with mild dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was observed with a pelvic positioning device in use. The quarterly MDS indicated the resident was severely cognitively impaired, had no behavioral symptoms, and was totally dependent for eating, personal care, and chair-to-bed transfers. The care plan in effect on 11/17/25 did not identify the use of a pelvic positioning belt, and there was no physician order directing its use. Staff observed the belt in place while the resident was in a wheelchair, and staff interviews indicated it was applied as a precaution to prevent the resident from falling. The Director of Rehabilitation stated the resident had been assessed for wheelchair alignment and that a pelvic positioning belt was appropriate, while the DNS stated the care plan should have been updated immediately after screenings were completed.
Duplicate tube feeding orders were not clarified
Penalty
Summary
The nursing facility failed to clarify a duplicate physician order for tube feeding for a resident with dysphagia, aphasia, hemiplegia and hemiparesis, and stroke. The quarterly MDS identified the resident as cognitively impaired and dependent on oral care, personal hygiene, and chair-to-bed transfers. The care plan identified tube feeding related to dysphagia, stroke, and traumatic brain injury, with interventions including tube feedings and flushes as ordered. A physician order dated 9/22/25 directed Jevity 1.5 at 85 cc per hour with the tube feeding turned off at 4:00 AM for 6 hours once daily. A second physician order dated 10/10/25 directed Jevity 1.5 at 85 cc per hour twice daily, with the tube feeding turned off at 1:00 AM for 6 hours and restarted at 7:00 AM. The MAR showed both orders were signed off as completed for the month of November. During observation, the resident’s tube feeding was off per the physician orders. Staff interviews showed one LPN was following the most recent order and communicating with the overnight nurse about the stop time, another LPN reported previously raising the conflicting orders but could not recall to whom, and an RN stated the earlier order should have been discontinued when the new order was written. The ADNS stated staff should have brought concerns about physician orders to the RN Supervisor immediately and should not have signed off on an order that was not in use. The physician order dated 9/22/25 was discontinued after surveyor inquiry.
Failure to Obtain Physician's Order and Document Wanderguard Use
Penalty
Summary
A deficiency was identified when a resident with diagnoses including cerebral infarction, dementia, and mild cognitive impairment, who was assessed as having severely impaired cognition and being at risk for elopement, did not have a physician's order for the use of a Wanderguard device. The resident's care plan indicated the use of a Wanderguard and directed staff to observe and monitor its placement and function according to facility policy. However, a review of the clinical record, physician's orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed no documentation or orders for the Wanderguard, nor any record of staff checking its placement or function. During observation, the resident was found with a Wanderguard in place, but an LPN confirmed there was no physician's order or documentation task for the device, and she could not recall checking it previously. Interviews with facility leadership confirmed that there was no policy in place for Wanderguards, but acknowledged that a physician's order and regular checks should have been present. The lack of a physician's order and absence of documentation for the Wanderguard's placement and function constituted the deficiency.
Failure to Obtain Physician's Order and Document Monitoring of Wanderguard Device
Penalty
Summary
A deficiency was identified when a resident with diagnoses including cerebral infarction, dementia without behavioral disturbances, and mild cognitive impairment was found to have a Wanderguard device in place without a corresponding physician's order. The resident was assessed as having severely impaired cognition and was at risk for elopement, with care plans indicating the use of a wander/elopement alarm and interventions to monitor the Wanderguard's placement and function per facility policy. However, a review of the clinical record, including physician's orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR), revealed no documentation or orders for the Wanderguard or instructions to check its placement and function. During observation, the resident was noted to have the Wanderguard intact, but staff interviews confirmed the absence of a physician's order and lack of documentation regarding the device's monitoring. An LPN acknowledged awareness of the resident's flight risk but could not recall checking the device or explain the lack of an order. Facility leadership confirmed that, despite not having a formal policy, there should have been a physician's order for the Wanderguard to be checked regularly.
Failure to Initiate Missing Resident Protocol After Unauthorized Leave
Penalty
Summary
A deficiency occurred when staff failed to initiate the missing person protocol after a resident with schizophrenia, alcohol abuse, and moderately impaired cognition was discovered missing. The resident, who was assessed as unable to meet minimal basic needs in the community and had no prior history of seeking unescorted exit, left the facility without a Leave of Absence (LOA) order. The resident exited the building by walking past the Receptionist, who was distracted by a vendor, and was not noticed leaving. Staff did not realize the resident was missing until after 1:00 PM, despite the last known sighting being around 11:30 AM. Multiple nurse aides and an LPN discussed the resident's absence but did not escalate the situation or initiate a facility-wide search as required by policy. The facility's policies required that if a resident could not be located, the missing resident protocol should be immediately initiated, including announcing a missing person code over the intercom and conducting a thorough search. However, interviews with staff revealed that the missing person code was not called, and no coordinated search was conducted. The Assistant Director of Nursing Services (ADNS) and Administrator were not notified of the resident's absence until a family member called the facility after finding the resident at a restaurant 3.6 miles away. The resident had walked this distance in cold weather, crossing major intersections, and was only returned to the facility several hours later by family. Documentation and interviews confirmed that the resident did not have an LOA order, did not sign out, and staff failed to follow the facility's missing resident and LOA policies. The Receptionist, responsible for monitoring residents exiting the building, did not observe the resident leaving due to an obstructed view. Staff members involved could not recall a missing person code being called or participating in a search. The Administrator and Director of Nursing Services confirmed that the required protocols were not followed, and the incident was not properly investigated or documented at the time.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents who were roommates. One resident, diagnosed with depression and chronic pain, was alert and oriented, while the other resident had multiple diagnoses including Parkinson's, bipolar disorder, borderline personality disorder, paranoid schizophrenia, and depression, and was moderately cognitively impaired. Despite having no prior history of aggressive behavior, the second resident became physically aggressive, grabbing the first resident by the neck and hitting them. This incident occurred after a nursing assistant had just left the room and heard the first resident calling for help. The nursing assistant intervened and separated the residents, and the aggressive resident was subsequently sent to the hospital for evaluation. The facility's documentation and interviews revealed that the incident was substantiated as abuse, and it was noted that there had been no previous altercations between the roommates. The facility's abuse policy clearly states that residents should not be subjected to abuse by anyone, including other residents. However, the incident demonstrated a failure to ensure the safety and protection of the resident from abuse, as the aggressive behavior was not anticipated or prevented, despite the facility's policy and the residents' care plans.
Failure to Complete MDS Cognitive Assessments
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for six residents, specifically in Section C, which pertains to cognitive patterns. The assessments for these residents were either not completed or marked as not assessed. This deficiency was identified during a clinical record review and interviews, revealing that the social worker responsible for completing Section C had recently left the facility unexpectedly. As a result, the assessments for cognitive patterns were not conducted as required by the Resident Assessment Instrument (RAI) manual. The Director of Nursing Services (DNS) confirmed that the social worker was responsible for completing Section C of the MDS, which should have been done for annual, significant change, and quarterly assessments. The facility's policy required the social worker to conduct a Brief Interview for Mental Status (BIMS) or a Staff Assessment for Mental Status if the resident could not be interviewed. However, due to the social worker's sudden departure, these assessments were not completed, leading to the deficiency in accurately assessing the residents' cognitive patterns.
Deficiencies in Kitchen Sanitation and Food Temperature Control
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, as observed during a survey. The kitchen floor was found to be sticky with visible debris, and there was no sign-off procedure for cleaning tasks, despite a policy indicating the floor should be mopped twice daily. Additionally, a dietary aide was observed portioning cake without a hair restraint, contrary to the facility's Hair Restraint policy, which requires all kitchen staff to wear appropriate hair coverings. Food temperature issues were also identified, with chicken, mashed potatoes, and stuffed shells initially not meeting the required temperature of 135 degrees Fahrenheit or higher. Although the food was reheated, a test tray later revealed that the food served to residents was below the recommended temperature, with chicken at 128 degrees, vegetables at 120 degrees, and mashed potatoes at 140 degrees. The Food Service Manager acknowledged that the food likely cooled due to prolonged sitting before distribution, which is against the facility's palatability policy requiring hot foods to be held at 135 degrees or higher.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to review its infection prevention control program policies and procedures annually, as required. The Infection Control Program Policies and Procedure manual was reviewed in January 2023, but there was no review conducted in 2022. The Infection Preventionist Nurse, who was not employed at the facility during the time the review was due, confirmed the oversight. The facility was unable to provide a policy for the review and renewal of the infection control program policies and procedures. The Administrator, who also was not working at the facility during the time of the missed review, acknowledged the lapse and stated it was the facility's practice to review and renew policies annually. Additionally, the facility did not conduct quarterly environmental rounds as required. Documentation for environmental rounds was missing for January 2023 and October 2023. The current Infection Preventionist, who began working at the facility in November 2023, could not locate the environmental rounds survey worksheets for these months. The Corporate Director of Education and Infection Preventionist also confirmed the absence of documentation for the specified months. The facility's policy mandates that the Professional Development Coordinator and other department heads complete environmental rounds quarterly, with survey worksheets retained for review and quality improvement purposes.
Failure to Review Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that a review of the antibiotic stewardship program, including antibiotic usage, was presented at the quarterly medical staff meetings. This deficiency was identified through a review of facility documentation, policies, and interviews. The infection control program documentation for the past two years lacked records of monthly reviews of the antibiotic stewardship program for several months in 2022 and 2023. Additionally, the facility did not provide documentation of quarterly reviews of antibiotic usage for 2022 and 2023. Interviews with the Infection Preventionist Nurse and the former Director of Nursing Services revealed that while infections were reviewed weekly and quarterly, there was no formal documentation of antibiotic usage being discussed at these meetings. The facility's Antibiotic Stewardship policy required that all infections be tracked and reviewed for trends, with findings presented quarterly at medical staff meetings. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation and formal review of antibiotic usage. The Infection Preventionist Nurse, who was new to the role, was unaware of any formal documentation regarding the antibiotic stewardship program for the medical staff meetings. The former DNS also could not provide documentation of the antibiotic stewardship program review, despite acknowledging that APRNs reviewed antibiotic use and documented notes in residents' charts.
Deficiency in Nurse Aide Training Documentation
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training, including education on abuse prevention and dementia care, for the years 2022 and 2023. This deficiency was identified through a review of facility documentation and interviews with staff, which revealed that the facility could not provide documentation confirming the completion of the mandatory training for five sampled nurse aides. The Staff Development Nurse, who began working at the facility in November 2023, acknowledged the lack of documentation and indicated that the previous Staff Development Nurse was responsible for ensuring the completion of the required training hours. Interviews with the Corporate Director of Education and the Administrator further confirmed the absence of documentation for the in-service training. The Administrator mentioned that the facility's practice was to conduct annual training to meet requirements, and that staff also completed online in-service training through Medline University. However, no records of completion for the nurse aides were found. Additionally, the facility did not have a policy for staffing education, and the facility assessment indicated that nurse aide competencies, including dementia management and abuse prevention, were part of the annual mandatory in-services.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide necessary supervision to prevent a resident-to-resident altercation involving Resident #112, who has diagnoses of unspecified dementia, schizophrenia, and post-traumatic stress disorder. Resident #112 was cognitively intact and required assistance for various activities of daily living. An incident occurred where Resident #112 was hit in the nose by another resident over a disagreement regarding the community television, resulting in a skin tear and bruising. The residents were separated, and emergency services were called, leading to both residents being transported to the hospital. Interviews revealed that the altercation stemmed from a disagreement over television access. The aggressor, who shared a room with Resident #112, did not have a television and was upset when Resident #112 changed the channel on the community television. A nursing assistant had attempted to mediate by suggesting Resident #112 watch television in their room, but left the area for rounds, during which the altercation occurred. The facility's abuse policy mandates that residents should not be subjected to abuse by anyone, including other residents, but the supervision provided was insufficient to prevent the incident.
Failure to Conduct Admission Assessment by RN
Penalty
Summary
The facility failed to ensure that a registered nurse assessed a newly admitted resident upon arrival, as required by the facility's policy and professional standards of care. The resident, who was admitted from an acute care hospital, had diagnoses including osteoarthritis, bicipital tendinitis, and status post arthroplasty to the left shoulder. Upon admission, a late entry nurse's note by RN #6 documented the resident's arrival and initial condition, including complaints of pain and a change in medication order. However, the clinical record lacked documentation of a comprehensive assessment by a registered nurse. During an interview and clinical record review with RN #6, it was confirmed that the admission assessment form did not reflect a comprehensive assessment of the resident's clinical condition. The resident was admitted in the evening and requested to be discharged against medical advice the following day, which contributed to the lack of a completed admission assessment. The facility's Admission Process policy requires an accurate resident history and assessment of clinical condition upon admission, which was not fulfilled in this case.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure timely and appropriate pressure ulcer care for a resident with a facility-acquired pressure ulcer. The resident, who had diagnoses including end-stage renal disease, type 2 diabetes mellitus, and left foot drop, was identified as being at mild risk for pressure ulcer development. Despite this, a pressure ulcer was noted on the resident's left heel on December 3rd, but the initial assessment by a registered nurse was delayed until the following day. The wound nurse, who was also the nursing supervisor at the time, did not document the assessment until December 4th and could not recall if treatment was initiated on the day the wound was discovered. The facility's treatment administration record showed no treatment was provided to the resident's left heel pressure injury on the day it was noted. The wound progressed from a deep tissue injury to an unstageable pressure injury by December 11th. Interviews with staff revealed that the nursing supervisor did not assess the wound promptly, and the treatment order was not documented until the day after the wound was identified. The facility's policy required immediate RN assessment and treatment for new wounds, which was not adhered to in this case.
Deficiency in Feeding Tube Order Clarity and Administration
Penalty
Summary
The facility failed to ensure that physician's orders for a resident with a gastrojejunostomy tube were clearly and completely written and transcribed onto the medication administration record (MAR). This deficiency was identified through a clinical record review and interviews concerning a resident with a history of gastrojejunostomy placement, Huntington's disease, and unspecified dementia. The resident required enteral nutrition and medications to be administered via feeding tubes, but the orders lacked clarity regarding the specific tube to be used, leading to inconsistencies in care. The resident's care plan indicated the use of a feeding tube due to the unsafe nature of oral intake. However, the MAR for various months showed discrepancies in the administration of nutritional formulas and medications, with some orders not specifying whether the g-tube or j-tube should be used. This lack of specificity resulted in the resident not receiving necessary medications and nutrition when the j-tube became clogged, as the staff did not notify the physician promptly or attempt to resolve the issue immediately. Interviews with nursing staff revealed a lack of communication and understanding regarding the resident's feeding tube orders. An LPN reported using the j-tube for all medications and nutrition based on initial instructions, but when the tube clogged, she informed a supervisor who did not take immediate action. The supervisor later acknowledged not being aware of the issue until the following day, which delayed the necessary medical intervention. The facility's failure to provide clear and complete orders contributed to the resident's care disruption.
Inadequate Pain Management and Documentation
Penalty
Summary
The facility failed to ensure proper pain management for two residents, Resident #107 and Resident #241, as evidenced by incomplete pain assessments and inadequate documentation of pain medication administration. Resident #107, who had a history of a left leg fracture, anxiety, and a suicide attempt, reported difficulties in receiving pain medication on time. Despite having a physician's order for Oxycodone to be administered as needed for pain, Resident #107 experienced delays and inconsistencies in receiving the medication. Interviews revealed that the resident had to wait for extended periods and was sometimes given fewer tablets than requested due to medication shortages. Additionally, the nursing staff failed to document the effectiveness of the pain medication on the Medication Administration Record (MAR). Resident #241, admitted with osteoarthritis and post-arthroplasty to the left shoulder, also experienced inadequate pain management. Upon admission, the resident's pain medication, Dilaudid, was deemed ineffective, and a new order was obtained to increase the dosage. However, the clinical record lacked documentation of pain assessments for several shifts, and there was no evidence that the resident received the prescribed pain medication. The resident eventually chose to discharge against medical advice, citing incorrect information about medications provided by the hospital. The facility's pain management policy required initial pain evaluations and regular reassessments, but these were not consistently followed for the residents in question. Interviews with nursing staff and supervisors highlighted gaps in knowledge and practice regarding pain assessment and medication administration. The facility's failure to adhere to its pain management policy and ensure timely and effective pain relief for residents resulted in deficiencies in care.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper monitoring of fluid intake for a resident with a fluid restriction. Resident #34, who has diagnoses including end-stage renal disease and dependence on renal dialysis, was ordered by a physician to have a fluid restriction of 1500 milliliters per day. Despite this order, there was a lack of documentation and monitoring of the resident's fluid intake. Interviews with various staff members, including an LPN, NA, RN, and the DNS, revealed that there was confusion and lack of clarity regarding who was responsible for monitoring the fluid intake. The LPN admitted to not documenting the fluid given during medication administration due to the absence of an input and output paper, and the NA was unaware of the specific fluid amounts to be given during meals. The nursing supervisor and DNS both acknowledged the resident's fluid restriction but could not identify who was responsible for monitoring the intake. The facility's Hemodialysis policy requires maintaining fluid intake and output as ordered by the physician, yet this was not adhered to in practice. The lack of a clear protocol and communication among staff members led to the failure in monitoring the resident's fluid intake, which is critical for a resident with end-stage renal disease undergoing dialysis.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that expired medications were not in use and were removed from the medication cart, as well as failed to date insulin when opened and store medications according to the manufacturer's recommendations. For Resident #36, who has type 2 diabetes mellitus, hyperlipidemia, and anxiety disorder, an opened vial of Lantus insulin was found to be 17 days past its expiration date. Another vial was opened without proper labeling. The charge nurse acknowledged the responsibility of checking expiration dates before administering medications. For Residents #61 and #62, both diagnosed with type 2 diabetes mellitus, insulin vials were found without labels indicating the opening or expiration dates. The facility's practice was to label insulin with the date opened, but this was not consistently followed. The facility's policy required that the original seal of the manufacturer's container or vial be dated when initially broken. Additionally, for Resident #242, who has type 2 diabetes mellitus, muscle weakness, and laryngeal cancer, Morphine Sulfate Oral Concentrate was improperly stored in a refrigerator, contrary to the manufacturer's instructions to store it at room temperature. This error was identified during an observation of the medication room refrigerator. The charge nurse responsible for receiving the medication admitted to storing medications based on memory and not consistently checking the label for storage instructions.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for four out of five sampled nurse aides for the year 2022. Specifically, the personnel files of nurse aides hired in 2017, 2007, and 2019 did not contain documentation of performance evaluations for 2022. Interviews with the Director of Nursing Services (DNS) and the Former DNS revealed that it was the responsibility of the shift supervisor to conduct these evaluations, with assistance from the DNS, but none were completed for 2022. The facility's practice was to conduct these evaluations annually between August and October, as notified by the corporate office, but this was not done for 2022, although evaluations were completed for 2023. Additionally, the facility was unable to provide a policy for Annual Performance Evaluation upon request.
Failure to Maintain Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain proper accountability records for controlled substances, as evidenced by missing documentation for three prescription numbers. During a review of the facility's controlled substance medication reconciliation and disposition records, it was found that the Control Substance Disposition Record white copy sheet for the unit and the yellow copy for the office were not available for Prescription Numbers 1882731, 1394477, and 2028718. These records are crucial for tracking the usage and disposal of controlled substances, and their absence indicates a lapse in the facility's record-keeping procedures. Interviews with the Director of Nursing Services (DNS), the former DNS, and the Assistant Director of Nursing Services (ADNS) revealed that the white copy of the Control Substance Disposition Record was used to scan information to the pharmacy electronic system and was supposed to be returned to the ADNS for record-keeping. However, the ADNS was unable to locate the white and yellow copies for the specified prescription numbers, despite searching for them. The facility's Controlled Substance Handling policy requires that all controlled substance accountability records be kept on file for at least five years, highlighting the importance of maintaining these records.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 755 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bloomfield Center For Nursing & Rehabilitation | 0.5 mi | ★★★★★ | 2 | 0 |
| Seabury | 0.8 mi | ★★★★★ | 0 | 0 |
| Complete Care At Kimberly Hall-south | 2.2 mi | ★★★★★ | 0 | 0 |
| Complete Care At Kimberly Hall North | 2.2 mi | ★★★★★ | 7 | 0 |
| Saint Mary Home | 2.8 mi | ★★★★★ | 3 | 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.