Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Touchpoints At Chestnut during CMS and state inspections, most recent first.
Two residents at high risk for skin breakdown did not have weekly skin assessments documented as required by facility policy. Despite care plans and risk assessments indicating the need for regular monitoring, there were significant gaps in the documentation of skin checks, which was confirmed by the DON during record review.
Multiple resident rooms were observed to have temperatures above 81°F, and several residents reported ongoing discomfort due to excessive heat over a period of weeks. Requests for portable air conditioners were not fulfilled in a timely manner, and the facility was unable to provide temperature logs for several days during a period of high outdoor temperatures. The Maintenance Director confirmed ongoing issues with the air conditioning system.
A resident with severe cognitive impairment and total dependence for care did not receive incontinence care or repositioning every two hours as required by the care plan and facility policy. Documentation and staff interviews confirmed that the resident was left saturated with urine for several hours, and care was not provided until a family member intervened. Facility policy mandates two-hour checks and care for incontinent residents unable to request assistance, which was not followed in this case.
Surveyors identified deficiencies in kitchen sanitation, food labeling, and monitoring practices, including unclean dry storage areas with debris and dead insects, improperly labeled and dated refrigerated food items, inadequate sanitizing solution levels, and dish machine rinse cycles not consistently reaching required temperatures. Documentation and verification of daily cleaning and temperature logs were frequently incomplete or missing, and staff could not provide clear explanations for these lapses.
The facility did not ensure nurse aides received or were properly tracked for the required 12 hours of annual education, including dementia care and abuse prevention. Education was delivered through self-directed poster boards and post tests, often completed in less time than credited, with answer keys available and no instructor present. There was no formal tracking of actual hours completed, and some nurse aides did not complete all required modules or have their competencies verified.
A resident with severe cognitive impairment was admitted without timely review and documentation of required admission paperwork, including resident rights, consent for treatment, and advance directives. The resident's representative did not review or sign these documents until about a month after admission, and the advance directive/code status consent was not signed until six months later, contrary to facility policy.
The facility did not consistently notify physicians or resident representatives when residents experienced significant changes, such as elevated blood glucose levels, returning from leave smelling of marijuana, or being found with smoking materials. In several cases, staff failed to follow physician orders and facility policy regarding notification and documentation, even when incidents were reported among staff or discussed in meetings. This lack of communication and documentation occurred despite clear expectations from the medical director and facility policies.
Two residents experienced failures in the timely reporting and investigation of abuse and neglect allegations. In one case, a resident alleged verbal abuse, including profanity and a racial slur, by a staff member during a smoking break, but the incident was not promptly reported to the state agency as required. In another case, a resident reported neglect after waiting several hours for incontinence care, but the concern was not properly documented or investigated, and key staff were unaware of the allegation. Facility policy requiring immediate reporting and investigation of such incidents was not followed.
A resident with significant care needs reported not receiving incontinence care for several hours after multiple requests for assistance. The facility did not conduct a thorough investigation, failed to document findings, and did not interview or remove involved staff as required by policy. Key staff were unaware of the incident, and the required investigative steps were not followed.
A resident with a new diagnosis of schizoaffective disorder did not receive a required PASARR rescreen after this change in mental health status. The facility's records and care plan reflected the updated diagnosis and use of psychotropic medications, but staff confirmed that only the original PASARR was on file and no new screening was completed as required.
A resident with significant care needs reported waiting five hours for incontinent care after a bowel movement, repeatedly calling for assistance without timely response. Despite the grievance being reported, no RN assessment was performed to check for injuries or complications, and key nursing staff were unaware of the incident. Required facility policy for assessment after a change in condition was not provided.
The facility failed to ensure appropriate care and documentation for multiple residents, including not completing RN assessments after a feeding tube dislodgement, not obtaining or recording weights as ordered, not documenting or following up on refusals of care, and not assessing or notifying providers when a resident repeatedly returned from leave smelling of marijuana. Facility policies and physician orders were not followed, and required documentation was missing.
Two residents with cognitive and physical impairments were repeatedly observed using smoking materials, including vaping and marijuana, inside the facility. Staff failed to consistently report these incidents, and management did not ensure care plans were updated or that appropriate supervision and interventions were implemented. The facility did not follow its own policies for smoking assessments, care plan revisions, or notification of responsible parties and medical providers, resulting in ongoing safety hazards.
A resident with a history of epilepsy, gastrostomy, and dysphagia experienced significant, unaddressed weight loss after admission. Despite documented weight declines and recommendations for supplements, the facility failed to consistently monitor the resident's weight, update the care plan, or provide timely nutritional assessments. Inconsistent dietitian coverage and lack of follow-up contributed to the deficiency.
A resident with a history of alcohol dependence and anxiety disorder was admitted following hospitalization for alcohol withdrawal. The facility failed to assess the resident's smoking status upon admission and did not provide the substance abuse support services recommended by the Level II PASARR, such as group therapy and recovery support groups. During the stay, the resident was repeatedly found with marijuana and smoking paraphernalia, and staff confirmed that no substance abuse support programs were available.
The facility did not ensure timely action on pharmacy consultant recommendations for three residents, resulting in missed or delayed medication management interventions such as stop dates for anticoagulants, appropriate medication forms for tube administration, monitoring for side effects of antipsychotics, and completion of recommended laboratory tests. Staff interviews and record reviews confirmed that pharmacy recommendations were not consistently reviewed, signed, or acted upon by providers as required by facility policy.
Two residents with significant dental needs were not scheduled for recommended outside dental consultations and extractions due to unclear staff responsibilities and lack of training in the referral process, resulting in delays in receiving necessary dental care.
A resident with quadriplegia and full dependence on staff was not assisted out of bed for lunch as ordered by a physician. When the resident requested help, a nurse aide refused, responded disrespectfully, and instructed the resident to get out of bed independently, despite the resident's inability to do so. The incident was documented in the aide's personnel file and confirmed through staff interviews, highlighting a failure to treat the resident with dignity and respect.
A resident with dementia and behavioral disturbances was physically struck in the nose by another resident with a history of behavioral issues after a verbal exchange and accidental contact in a hallway. Despite care plans and staff presence, the altercation was not prevented, resulting in pain and distress for the affected resident.
Failure to Document Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The facility failed to ensure that weekly skin assessments were documented for two residents who were at risk for skin integrity issues. For one resident with a history of stroke, hemiplegia, incontinence, diabetes, and impaired mobility, the care plan required weekly skin checks and other interventions to prevent skin breakdown. However, there was no documentation of weekly skin observation tool assessments for this resident between February and late June, despite the resident being identified as very high risk for pressure sores on the Braden scale. The only documented skin assessments during this period were at the beginning and end of the timeframe, with a gap of several months in between. Similarly, another resident with chronic ulcer, osteomyelitis, and a history of stroke was also identified as at risk for skin breakdown, with care plan interventions including regular Braden/Norton assessments. For this resident, there was no documentation of weekly skin assessments between late April and mid-July, except for assessments at the start and end of the period. The Director of Nursing confirmed that she could not provide documentation of the required weekly skin assessments for either resident during the specified periods, despite facility policy directing that weekly head-to-toe skin checks be completed and documented.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels for residents, as evidenced by observations of three resident rooms with temperatures exceeding 81 degrees Fahrenheit. Specifically, rooms were recorded at 82 and 83 degrees, and multiple residents reported that their rooms had been uncomfortably hot for two to three weeks. Residents expressed dissatisfaction with the temperature, with one resident stating they had requested a portable air conditioner from the Maintenance Director but had not yet received one. The Director of Maintenance confirmed ongoing issues with the air conditioning and chiller systems and acknowledged that requests for portable air conditioners were being prioritized. Additionally, the facility was unable to provide temperature logs for a four-day period during which outdoor temperatures ranged from 86 to 91 degrees Fahrenheit. Interviews with several residents confirmed persistent discomfort due to the heat, and the Maintenance Director verified that the temperature control issues had been ongoing. The lack of temperature documentation and unresolved maintenance concerns contributed to the deficiency in providing a safe, comfortable, and homelike environment for residents.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
A resident with a history of stroke, left-sided hemiplegia, dysphagia, epilepsy, diabetes, and severe cognitive impairment was admitted with total dependence for activities of daily living and was always incontinent of bowel and bladder. The care plan and physician's orders required incontinence care and repositioning every two hours to maintain skin integrity and assist with wound healing. On the date in question, documentation and interviews revealed that the resident was not provided incontinence care or repositioned as required between 4:00 PM and 7:00 PM. The resident's family member discovered the resident saturated with urine at 7:00 PM, and facility records failed to show incontinence care provided between 12:21 PM and 10:19 PM that day. Staff interviews confirmed that the resident was checked at 4:00 PM and not again until the family member raised concerns at 7:00 PM. The nurse aide responsible did not return to the resident's room after the initial check, and the nurse confirmed the resident was wet when assessed. Facility policy and the Director of Nursing Services both indicated that incontinent residents unable to request care should be checked and changed every two hours, which was not done in this instance. The lack of timely incontinence care and repositioning was not in accordance with the resident's care plan and facility policy.
Deficiencies in Kitchen Sanitation, Food Labeling, and Monitoring Practices
Penalty
Summary
The facility failed to maintain the kitchen's dry storage areas in a clean and sanitary condition, as evidenced by observations of debris, dead insects, dried pasta, and powdery substances scattered throughout the storage rooms and under shelving. Multiple mouse and insect glue traps were present, and cleaning schedules did not specifically assign or document regular cleaning of these areas. The Dietary Director and staff were unable to provide documentation or clear explanations regarding the cleaning assignments or verification of completed cleaning tasks for these areas. Additionally, the facility did not ensure that previously opened refrigerated items were properly labeled and dated. Packages of meat and bags of what appeared to be raw chicken were found in the walk-in refrigerator without clear identification or date markings. The Dietary Director was unable to confirm the contents or the dates when the items were prepared or opened, and there was confusion regarding the labeling system in use. This lack of proper labeling and dating of perishable food items is contrary to facility policy and food safety standards. The facility also failed to maintain appropriate sanitizing solution levels and dish machine rinse temperatures. Testing of the sanitizing solution in the pot sink and sanitizing bucket revealed levels below the required 200 PPM, and the test strips used were found to be expired. The high temperature dish machine did not consistently reach the required rinse temperature of 180°F, with multiple documented instances of substandard temperatures and missing temperature logs. Daily monitoring sheets for sanitizer levels, dish machine temperatures, and food temperatures were frequently incomplete or missing, and staff did not consistently initial or verify these logs as required by facility policy.
Failure to Provide and Track Required Annual Nurse Aide Education
Penalty
Summary
The facility failed to provide and accurately track the required 12 hours of annual education for nurse aides, including essential topics such as dementia care and abuse prevention. Interviews with the ADNS and RN responsible for staff education revealed that the annual mandatory education was delivered primarily through poster boards and post tests in the staff break room, with no formal tracking system for the actual hours completed by each nurse aide. The staff development nurse and the corporate regional educator both acknowledged that they did not monitor the actual time spent on education modules, instead assigning predetermined credit hours regardless of the time staff actually spent on the material. Multiple nurse aides reported that the mandatory education and dementia training took significantly less time than the hours credited, often completing the material in 15 to 60 minutes. The education was self-directed, with answer keys available for copying, and there was no instructor present to answer questions or verify understanding. Some nurse aides did not complete all required modules, and there was no observation or verification of competency for skills, as staff simply signed off on forms themselves. The corporate COO confirmed awareness of issues with the staff education and competency process during the year in question. A review of the facility assessment indicated that the facility's staffing plan required nurse aide competency in areas such as dementia management and abuse prevention, with training to be completed during orientation and annually. However, the facility was unable to provide a policy for mandatory staff education or documentation verifying that nurse aides received the full 12 hours of required education. The lack of a structured, monitored education program and insufficient documentation led to the deficiency.
Failure to Provide Timely Notice of Rights and Secure Admission Consents
Penalty
Summary
The facility failed to ensure that a resident and their representative were informed of their rights, rules, and responsibilities upon admission. Specifically, the clinical record did not show that the required admission paperwork—including the bed hold policy, contraband policy, consent for treatment, advance directive/code status consent, smoking policy, resident rights, influenza vaccination consent and education, and the facility admission agreement—was reviewed with the resident representative at the time of admission. Additionally, there was no documentation of a signed advance directives/code status consent form at admission. The resident in question was admitted with diagnoses including alcohol dependence, repeated falls, and anxiety disorder, and had severely impaired cognition, requiring moderate assistance with activities of daily living. The resident was hospitalized for alcohol withdrawal prior to admission and was initially identified as full code regarding resuscitation status. However, the care plan and physician orders regarding code status were inconsistent and not supported by timely, signed documentation from the resident or their representative. Interviews with facility staff revealed that the social worker was responsible for reviewing administrative paperwork, while the RN supervisor was responsible for clinical paperwork. The social worker acknowledged that, due to the resident's cognitive impairment, paperwork was reviewed with the resident's representative, but this did not occur until approximately one month after admission. Furthermore, the signed documents were not placed in the resident's paper chart or uploaded to the electronic record. The advance directive/code status consent form was not signed until six months after admission, contrary to facility policy requiring this to be completed upon admission.
Failure to Notify Physician and Resident Representatives of Significant Changes and Incidents
Penalty
Summary
The facility failed to notify physicians and resident representatives of significant changes in resident status and incidents as required by policy and physician orders. For one resident with diabetes, there were multiple documented instances where blood glucose readings exceeded the threshold set by the physician's order, which required immediate physician notification. Despite this, nursing staff did not notify the physician or document such notifications in the clinical record, even though the physician expected to be informed to provide additional insulin coverage. Interviews with nursing staff confirmed that notifications were not made, and the Director of Nursing Services (DNS) stated that her expectation was for staff to follow the physician's order and document all notifications. For another resident with chronic kidney disease who frequently left the facility for dialysis and with family, staff repeatedly noted the resident returned smelling of marijuana. Although this was reported among staff and discussed in meetings, there was no documentation of physician notification, assessment, or notification to the dialysis center, as required by facility policy. The physician was not made aware of these ongoing issues, despite his expectation to be notified due to potential drug interactions with prescribed medications. The facility also lacked documentation of smoking assessments, education, or agreements for this resident, contrary to its own smoking policy. A third resident with a history of substance use and impaired cognition was involved in multiple incidents of suspected smoking and possession of smoking paraphernalia within the facility. Documentation showed that room searches were conducted and smoking materials were found, but there was a lack of evidence that the physician or the resident's representative was notified in most cases. The facility's own policies required such notifications and documentation, but interviews with staff and review of records confirmed these steps were not consistently followed. The only documented notification to the resident's representative occurred after a policy violation that led to discussions of discharge planning.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse involving a resident with a history of hemiplegia, hemiparesis, and depression. During a supervised smoking break, the resident alleged that a nurse aide used profanity and a racial slur towards them. The resident reported the incident to the administrator, but the administrator did not immediately recognize or act upon the allegation of verbal abuse. The charge nurse was informed by the resident that the aide had used a racial slur, but did not escalate the report to the RN Supervisor as required, choosing instead to wait for the resident to calm down before seeking further details. The administrator only became fully aware of the specific allegation the following day, at which point the state agency was notified and an investigation was initiated, outside the required reporting timeframe. In a separate incident, another resident with chronic osteomyelitis and a diaphragmatic hernia reported a concern of neglect after waiting several hours for incontinence care. The resident filed a grievance stating that they called for assistance multiple times over a five-hour period before receiving care. The social worker documented the grievance and reported it to nursing and administration, but the Director of Nursing Services (DNS) was unaware of the concern and could not locate documentation of an investigation. The administrator, upon learning of the allegation, spoke with the resident and the assigned aide, but determined that the information did not require reporting to the state agency, despite facility policy requiring immediate reporting of all allegations of mistreatment. Both incidents demonstrate failures in the facility's process for reporting and investigating allegations of abuse and neglect. The facility's own policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported to the state agency immediately, but in both cases, the required notifications and investigations were either delayed or not completed according to policy. Documentation was incomplete or missing, and key staff members were not always aware of the allegations or the required procedures for handling them.
Failure to Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of neglect involving a resident with chronic osteomyelitis and a diaphragmatic hernia. The resident, who required assistance with activities of daily living and was incontinent, reported calling for help after a bowel movement and not receiving assistance for five hours, despite multiple requests. The resident's grievance was documented, but the investigation process was incomplete. Key facility staff, including the Director of Nursing Services (DNS), social worker, and administrator, were responsible for investigating such allegations. However, the DNS was unaware of the incident, and the administrator could not provide documentation of a completed investigation, including staff or resident statements or a summary of findings. The administrator also could not identify the staff involved or explain why the DNS was not included in the investigation. Staff members who worked during the incident were not interviewed as part of the investigation, nor were they removed from the schedule pending the outcome, as required by facility policy. Interviews with staff assigned to the resident on the day of the incident revealed that they were not informed of the allegation, were not asked to provide statements, and did not receive any education related to the event. The facility's policy required immediate reporting and thorough investigation of all allegations of neglect, including removal of the alleged abuser from resident care, but these steps were not followed. Attempts to interview additional staff involved were unsuccessful.
Failure to Complete PASARR Rescreen After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASARR) rescreen was completed for a resident following a new diagnosis of schizoaffective disorder. The resident had an initial Level 2 PASARR evaluation that determined they met the criteria for nursing home level-of-care but did not require specialized mental health services, and no further evaluations were required unless there was a change in condition related to mental illness. Despite the resident later being diagnosed with schizoaffective disorder, this significant change in mental health status was not reported or followed up with a new PASARR screening as required by facility policy and federal/state procedures. Review of the clinical record showed that the resident's primary diagnosis was updated to schizoaffective disorder, and the care plan included interventions for multiple mental health conditions, including the use of psychotropic medications. However, the annual MDS did not identify a serious mental illness or intellectual disability as a Level II PASARR condition. Interviews with facility staff confirmed that the only PASARR on file was the original one, and that a new Level 1 and potentially Level 2 PASARR should have been completed after the new diagnosis. The lack of timely PASARR rescreening following the change in mental health diagnosis constituted the deficiency.
Failure to Conduct RN Assessment After Reported Delay in Incontinent Care
Penalty
Summary
A resident with chronic osteomyelitis, a diaphragmatic hernia, and urinary incontinence reported waiting five hours for incontinent care after a bowel movement. The resident, who required assistance with transfers and perineal care, called for help multiple times over a five-hour period, but staff did not respond until much later. The incident was documented in a grievance report, and the resident was cognitively intact at the time. The baseline care plan and physician's orders indicated the resident's need for significant assistance with mobility and toileting. Despite the resident's report of delayed care, there was no evidence that an RN assessment was conducted to evaluate for potential injuries or complications resulting from the delay. The Director of Nursing Services (DNS) was not aware of the allegation, and the LPN on duty was not informed of the untimely care concern. Facility policy for assessment following a change of condition was requested but not provided. The failure to conduct an RN assessment after the reported delay in care constituted a lapse in meeting professional standards of quality.
Failure to Provide Care and Documentation per Orders and Standards
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and professional standards for multiple residents. For one resident with a history of epilepsy, gastrostomy, and dysphagia, the facility did not complete or document an RN assessment after the dislodgement of a feeding tube, nor did they notify the provider on the day of the incident. There was also a lack of documentation regarding the resident’s removal or self-discontinuation of the G-tube, and weights were not consistently obtained or recorded as ordered by the physician. The clinical record showed significant gaps in weight monitoring, and weights provided by therapy staff were not entered into the resident’s clinical record. Interviews confirmed that staff did not document or communicate key events, and the facility’s own policies on weight monitoring and documentation were not followed. Another resident with congestive heart failure and severe protein calorie malnutrition had a physician’s order for daily weights, which were not consistently obtained or documented on numerous days over several months. When the resident refused weights, there was no documentation of education, re-approach, or notification to the physician or APRN, despite repeated refusals. The care plan did not address refusals of care, and interviews with staff and leadership confirmed that documentation and follow-up were inconsistent or absent. The facility’s policies and guidelines for inotrope therapy, which emphasize the importance of daily weights, were not adhered to in this case. A third resident, with chronic kidney disease and a history of returning from leave of absence or dialysis smelling of marijuana, did not receive care in accordance with professional standards. There was no documentation of assessments upon return, notification to the physician or dialysis center, or education provided to the resident regarding the impact of drug use. The facility also failed to maintain required documentation such as a smoking agreement or smoking assessment, and did not document room searches or the retrieval of smoking materials. Interviews revealed that staff were aware of the issue but did not consistently document or communicate it, and the facility’s smoking policy requirements were not met.
Failure to Prevent and Address Unauthorized Smoking and Substance Use
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with a history of tobacco and substance use. One resident, with hemiplegia, hemiparesis, and depression, was repeatedly observed by staff vaping in their room and bathroom, in violation of the facility's smoking policy. Despite these observations, there was a lack of consistent reporting to management, and the Director of Nursing Services (DNS) was not made aware of the incidents. The care plan for this resident did not initially address the ongoing unauthorized use of smoking materials, and staff interviews revealed that management was aware of the behavior but did not take effective action. Another resident, with diagnoses including alcohol dependence, repeated falls, and anxiety disorder, was involved in multiple incidents of smoking and possession of smoking paraphernalia within the facility. Documentation showed that this resident was found with marijuana, a lighter, and a smoking pipe on several occasions, and was observed smoking in both their room and a facility bathroom. The facility failed to notify the resident's physician or conservator after these incidents, did not revise the care plan to address the repeated policy violations, and did not consistently document or implement increased supervision or other interventions. Staff interviews indicated that the issue of residents smoking, including marijuana use, was ongoing and that reporting and follow-up were inconsistent or lacking. Facility policy required smoking assessments upon admission and after significant changes, as well as care plan updates and supervision for residents with smoking risks. However, the facility did not adhere to these requirements, as evidenced by the lack of smoking assessments, care plan revisions, and documentation of interventions following repeated incidents. The facility also failed to consistently notify responsible parties and medical providers, and did not maintain adequate records of investigations or actions taken in response to the observed hazards, resulting in a failure to protect residents from accident hazards related to unauthorized smoking and substance use.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and address the nutritional status and weight of a resident with a history of epilepsy, gastrostomy, and dysphagia, who was dependent on staff for care and had a G-tube for enteral nutrition. Upon admission, the resident weighed 173.6 lbs, but within a week, a significant weight loss of 9.4 lbs (5.4%) was documented. The dietitian recommended nutritional supplements and an appetite stimulant, but there was no evidence that the stimulant was started, and no follow-up weights or nutritional assessments were performed in the subsequent weeks. After a hospitalization and readmission, the resident's weight continued to decline, with a further loss of 21 lbs (12.1%) since admission. Despite this, there were no documented weights or nutritional assessments for the entire month following readmission, and the care plan was not revised to address the ongoing weight loss. Interviews revealed that the facility lacked consistent, in-person dietitian coverage, with periods of only remote coverage and uncertainty among staff about who was responsible for nutritional oversight. Staff also reported that diet slips and diet change forms were not being signed off by a dietitian for newly admitted residents. Facility policy required weights to be obtained on admission and monthly, with additional monitoring and interventions for significant weight changes. However, the resident did not receive the required monitoring or timely interventions after multiple episodes of significant weight loss. Interviews with staff and the resident confirmed that weight monitoring was inconsistent, and the lack of dietitian presence contributed to the failure to reassess and update the nutritional care plan as required.
Failure to Implement PASARR Recommendations for Substance Abuse Support
Penalty
Summary
A deficiency occurred when the facility failed to implement Level II PASARR recommendations for a resident with a diagnosed substance abuse disorder. The resident was admitted with a history of alcohol dependence, anxiety disorder, and repeated falls, and had recently been hospitalized for alcohol withdrawal. Upon admission, the resident's smoking status was not assessed, and subsequent clinical records did not document any smoking assessments. Despite a physician's order for supervised smoking and care plan interventions for safety risk evaluations, the admission MDS did not identify current tobacco use, and there was no evidence that the recommended substance abuse support services were provided. The Level II PASARR identified that the resident required specific services, including participation in a support group for substance abuse recovery (such as Alcoholics Anonymous), group therapy with a trained therapist, and the appointment of a guardian conservator for health and safety decisions. While the care plan acknowledged these recommendations, the facility did not offer group counseling or substance abuse support programs. Interviews with facility staff confirmed that the recommended services were not available, and there was no documentation of the resident receiving these supports. During the resident's stay, multiple incidents occurred involving the possession and use of marijuana and smoking paraphernalia, as well as violations of the facility's smoking and safety policies. Room searches revealed marijuana, a smoking pipe, and a pocketknife in the resident's possession. Despite these findings and the clear recommendations from the PASARR, the facility did not provide the required substance abuse support services, contributing to ongoing behavioral and safety concerns.
Failure to Act on Pharmacy Consultant Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure that physicians or advanced practice registered nurses (APRNs) acted upon pharmacy consultant recommendations in a timely manner for three residents reviewed for unnecessary medications. For one resident with multiple complex diagnoses, including diabetes, stroke, epilepsy, and gastrostomy, the pharmacy consultant made several recommendations over multiple months regarding medication management, such as adding stop dates for anticoagulants, switching medication forms for easier administration via feeding tube, and monitoring for side effects. Despite these recommendations, there was no documentation that the physician or APRN responded to or acted upon them within the expected timeframe, as required by facility policy. Interviews with facility staff confirmed that the process for following up on pharmacy recommendations was inconsistent, with forms not always being reviewed, signed, or returned by the responsible providers. Another resident with a history of stroke, diabetes, and heart failure was started on an antipsychotic medication, and the pharmacy consultant recommended baseline and ongoing monitoring for side effects, as well as laboratory testing for lipid profiles. The clinical record review revealed that these recommendations were not completed, and the forms were not signed or dated by the provider. Interviews with nursing and pharmacy staff confirmed that the recommendations were not reviewed or acted upon, and the required monitoring and laboratory tests were not documented in the resident's record. A third resident with bipolar disorder and hyperlipidemia was receiving an antipsychotic medication, and the pharmacy consultant recommended ordering a lipid profile and HbA1C due to the risk of diabetes and dyslipidemia. Although the prescriber agreed with the recommendations, only the HbA1C was completed, and there was no documentation that the lipid profile was ordered or completed. Facility staff interviews indicated that the process for ensuring completion of pharmacy recommendations was not consistently followed, resulting in missed or delayed actions on important medication management recommendations.
Failure to Schedule and Follow Up on Dental Referrals
Penalty
Summary
The facility failed to follow through on recommendations for outside dental consultations for two residents who required specialized dental care. One resident, with a history of multiple sclerosis, paraplegia, and cardiomegaly, was fully dependent on staff for oral hygiene and had documented dental issues including tooth decay and mobile teeth. Despite a dental provider's note indicating the need for an outside dental appointment for specific teeth, the resident was not scheduled for the recommended consultation for several months. Interviews revealed that the staff responsible for scheduling such appointments was unclear about their responsibilities and had not received adequate training on the referral process, resulting in the delay. Another resident, diagnosed with type 2 diabetes, reduced mobility, and requiring a mechanically altered diet, was identified as having significant dental issues, including cavities and broken teeth. The dental provider recommended referral to an oral surgeon for extractions prior to denture fabrication. However, the resident was not scheduled for the necessary dental extractions, and staff interviews indicated confusion and lack of clarity regarding the process for scheduling follow-up appointments. The staff member responsible for appointments had only recently taken on this role and had not been fully trained, contributing to the oversight. Facility policy required assistance with making appointments and arranging transportation for medical and professional services, including dental care. Despite this, the lack of clear procedures and staff training led to failures in ensuring timely dental services for the residents, as recommended by consulting dental providers.
Failure to Honor Resident Dignity and Physician Orders During Transfer Request
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, contracture of the left hand, and chronic pain syndrome, who was fully dependent on staff for all activities of daily living and required transfer via a Hoyer lift, was not assisted out of bed for lunch as per physician's orders. The resident requested assistance from a nurse aide to be transferred to a wheelchair before lunch, but the aide refused, stating she was busy and instructed the resident to get out of bed independently, despite the resident's inability to do so due to their medical condition. The resident reported this interaction to a registered nurse supervisor, and documentation confirmed that the aide responded in a rude and disrespectful manner, failed to follow the physician's order, and was insubordinate to the supervising nurse. The clinical record did not document the negative interaction, but the aide's personnel file included a corrective action record for the incident, noting the refusal to assist the resident and the disrespectful communication. The aide had a history of multiple disciplinary actions related to care issues. Interviews with facility staff confirmed awareness of the incident and the expectation that all residents be treated with dignity and respect. The facility's policy directs that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with dementia, epilepsy, anxiety disorder, and depressive disorder was involved in a physical altercation with another resident who had a history of behavioral problems, including being inconsiderate to roommates and intentionally disturbing others. The incident occurred when the first resident was waiting at the nurse's medication cart and accidentally touched the second resident, who was attempting to pass by in a wheelchair. The second resident responded by shouting and then physically striking the first resident in the nose. The facility's documentation indicated that both residents had care plans addressing their behavioral issues, with interventions such as monitoring behaviors, documenting observed incidents, and intervening to protect the rights and safety of others. Despite these interventions, the altercation occurred, resulting in the first resident experiencing pain and discomfort, though no visible trauma was noted upon assessment. Staff present at the scene attempted to intervene but were unable to prevent the physical contact, and one staff member was injured while separating the residents. Interviews with the involved resident and staff confirmed the sequence of events, with the resident expressing feelings of embarrassment and fear following the incident. The facility's abuse policy prohibits abuse, neglect, and mistreatment by anyone, including other residents. The report documents that the facility failed to protect the resident from physical abuse by another resident with a known history of altercations.
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 677 citations issued within 25 miles in the last 12 months — including the 7 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 East Windsor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bickford Health Care Center | 0.5 mi | ★★★★★ | 51 | 2 |
| Fresh River Healthcare | 0.6 mi | ★★★★★ | 1 | 0 |
| St Joseph's Residence | 3.5 mi | ★★★★★ | 0 | 0 |
| Suffield House Rehabilitation And Healthcare Cente | 4.2 mi | ★★★★★ | 2 | 0 |
| Autumn Lake Healthcare At Windsor | 4.3 mi | ★★★★★ | 48 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.