Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Wadsworth Glen Health Care And Rehabilitation Cent during CMS and state inspections, most recent first.
Menus Not Reviewed or Signed by Dietician and Missing Portion Sizes: The facility failed to ensure the dietician reviewed and approved posted menus and failed to include serving sizes on menus posted in multiple dining areas. The Dietary Director stated he posted menus as received and that portion sizes were not included, while a Regional Dietician said menus came from an agency and were reviewed but not signed before being emailed to the facility. Another dietician stated she did not receive the facility menu and did not sign or print menus for posting.
A facility failed to serve meals at safe and appetizing temperatures and failed to ensure food was palatable. Multiple residents reported cold meals, poor taste, and limited meal choices, including residents on therapeutic and mechanically altered diets. During observation, steam table items and a test tray were measured below expected hot-holding and palatability temperatures, and the DON/Dietary Director acknowledged prior complaints about low food temperatures and that no effective change had been made to food service delivery.
Unsanitary food handling and storage practices were observed throughout the kitchen and during meal service. The kitchen had dirty equipment, soiled surfaces, opened and undated food items, incomplete cleaning and temp logs, and food left out on counters for extended periods, including items that were no longer frozen solid. Staff also failed to follow hand hygiene expectations during meal service, as an NA touched her hair and served residents without sanitizing her hands, and uncovered food was transported for service.
Advance directive consent forms and physician orders were not in place for two residents. One resident with intact cognition and diagnoses including muscular dystrophy and chronic pain had a care plan stating a wish for CPR, but the chart lacked a completed code status form and the physician order did not direct code status. Another resident with mild cognitive impairment had no code status addressed in the care plan or physician orders, and staff did not readdress the undecided status or provide documented education despite the responsible party visiting daily.
Grievance for Damaged Clothing Not Resolved: A resident with CHF, mild cognitive impairment, and intellectual disabilities reported that laundry returned clothing discolored, including a sweatshirt that changed from blue to purple and sweatpants that changed from black to gray. A concern form noted bleach issues with clothing, but it was not fully signed or shown as resolved, the care plan did not address the concern, and staff did not complete the grievance process per policy.
Failure to Protect Residents from Physical Abuse: Two residents were involved in a resident-to-resident altercation when one resident became agitated and backhanded the other resident on the cheek and grabbed both wrists. Staff heard yelling and intervened, and witnesses confirmed the physical contact. One resident had dementia and severe cognitive impairment, while the other had moderate cognitive impairment and was receiving psychotropic meds for depression.
A resident with CHF had ordered daily weights tied to bumetanide dosing, but staff did not obtain weights as directed and were unaware the monitoring had been missed. Another resident with dementia and nutrition concerns had a weekly weight order that was not followed, with staff describing a breakdown in how the weight task was communicated and scheduled. A third resident with COPD had a prescribed inhaler unavailable during med pass, and the MAR showed doses signed as given despite the medication not being on hand.
A resident with broken eyeglasses reported difficulty seeing, but the care plan did not identify a need for glasses and ancillary optometry consent had not been obtained. Another resident with dementia and cataracts had eye consults recommending ophthalmology evaluation for cataract surgery, but the consult was not scheduled and the care plan did not reflect the change in visual needs.
Failure to apply an ordered hand splint: A resident with muscular dystrophy, polyarthritis, and chronic pain syndrome was found in bed without the left-hand splint on multiple observations. The care plan, MD order, and care card all directed staff to apply the splint during scheduled wearing times, but the resident said staff did not apply it consistently, and an NA stated it had not been applied since surgery because of arm swelling, even though the splint was not on hold.
The facility failed to ensure nutritional support and weight monitoring for two residents. One resident with significant weight loss had a dietician-recommended calorie/protein supplement that was not documented as implemented, missed weight checks, and an unchanged care plan despite a notable loss and a physician order for monthly weights. Another resident developed a stage 3 pressure ulcer, but the record did not show timely nutritional assessment or supplement orders tied to wound healing, even though the wound APRN repeatedly requested dietician consultation.
Nebulizer tubing for three residents with respiratory orders was repeatedly found undated, unlabeled, and stored open to the environment without a cover. Two residents had care plans that addressed COPD and nebulizer use, while one resident's care plan did not identify respiratory status or nebulizer treatments. Staff interviews confirmed the expectation to date, label, and bag the tubing, but the observed supplies were not maintained that way.
Delayed Dental Consent for Resident with Broken and Decaying Teeth: A resident with protein calorie malnutrition, DM2, and GERD had multiple missing, broken, and decaying teeth, mouth discomfort, and difficulty chewing. The resident’s diet was downgraded, speech therapy noted follow-up dental work was still needed, and the care plan did not identify dental issues. The unit secretary stated the dental consent was not offered on admission and she was unaware the resident needed to be seen by a dentist.
A resident with diabetes, bipolar disorder, and oral mucosa lesions reported a loose tooth, a missing crown, and a dark spot on the tongue, but the facility did not ensure an outside dental appt was scheduled and the care plan did not include the loose tooth or missing crown. Notes from the RN/APRN and physician ordered dental evals, yet the unit secretary could not locate a referral to an outside dental provider and the Administrator was unaware the appt was needed until surveyor inquiry.
A resident with dementia and high risk for pressure ulcers was admitted without a comprehensive skin assessment, despite facility policy requiring one. Two days later, an LPN identified three deep tissue injuries on the resident's foot that were present on admission, but no RN assessment was completed for these findings.
The facility failed to treat residents with dignity and respect, as evidenced by incidents involving inappropriate staff behavior. A resident was called a liar by an LPN, another was upset by a nurse aide's yelling, and a third was yelled at for using the bathroom independently. Additionally, a resident with dementia experienced a fall and was subjected to profanity during a staff argument.
A resident with multiple fractures and specific weight-bearing restrictions was not transferred with the required assistance of two staff members, as per the care plan and physician's orders. Despite directives for non-weight bearing on the left lower extremity and toe touch weight bearing on the right, the resident was observed being transferred by only one staff member, leading to a deficiency finding.
A facility failed to implement a hospital discharge order for a resident requiring pain management. The resident, with multiple fractures and arthritis, was discharged with instructions to apply ice to the lower extremities five times a day, which was not included in the physician orders or care plan. The Director of Nursing confirmed the oversight, indicating a failure to adhere to the facility's pain management policy.
Menus Not Reviewed or Signed by Dietician and Missing Portion Sizes
Penalty
Summary
The facility failed to ensure that the dietician reviewed and approved menus and failed to ensure portion sizes were included on posted menus. Observation of the kitchen menu on 8/4/2025 showed breakfast, lunch, and dinner entrees posted in the kitchen area, but no serving sizes were listed for any of the meals. The posted menu in the second floor dining room also did not include serving sizes for any of the listed meals, and a later observation of the third floor dining room showed the same omission. During interview, Regional Dietician #2 stated that menus came from an agency and were reviewed by all on-site dieticians, but she had not signed the menus before emailing them to the facility. She also stated it was the Dietary Director's expectation to include portion sizes on posted menus and that she had previously shown him how to print the menus with portion sizes. The Dietary Director stated the kitchen menus were not signed by the on-site dietician because there may be changes during the week, and that he printed the menus as sent to him by dietary, with portion sizes not included. Dietician #3 stated she had not received any emails from Regional Dietician #2 with a facility menu and did not sign or print menus for the facility. Facility policy identified that menus are posted in designated areas, but did not state that portion sizes should be included on posted menus, and the Food and Dining Service Policy did not include that the facility's dietician should review the menus and maintain a signed and reviewed copy.
Cold and Unpalatable Food Served to Residents
Penalty
Summary
The facility failed to ensure that food was palatable and served at a safe and appetizing temperature for sampled residents receiving dietary services. Multiple residents interviewed reported that meals were cold and, in some cases, did not taste good. Resident #1, who had diagnoses including a left patella fracture, left femur fracture, and Type 2 diabetes mellitus, stated the food quality was terrible and the food was served cold. Resident #2, with chronic kidney disease, chronic systolic and diastolic heart failure, and GERD, said the food was always cold. Resident #38, who had chronic heart failure, mixed lipidemia, and GERD, reported that substitute meals were often not received and that the food was always cold. Resident #45, with osteoarthritis, hyperparathyroidism, and GERD, stated the food was always cold and did not taste good. Additional residents gave similar accounts. Resident #66, diagnosed with Type 2 diabetes, Stage 3 chronic kidney disease, and hyperlipidemia, stated the food was delivered cold at all meals. Resident #70, with Type 2 diabetes, chronic diastolic heart failure, and hyperlipidemia, reported that the food did not taste good and there was not a variety of meal options. Resident #76, diagnosed with Type 2 diabetes, hypertension, and hyperlipidemia, stated that many times the food was cold and did not taste good. The residents reviewed had varying cognitive status and dietary needs, including mechanically altered diets, therapeutic diets, and assistance or set-up with eating. On observation and temperature testing, the lunch steam table contained breaded fish, chicken, mixed carrots and peas, mashed potatoes, and baked potatoes. The fish temperature was 122.0 F, while the chicken, mashed potatoes, and vegetables were recorded at higher temperatures. Kitchen Worker #1 stated food should be maintained between 150.0 and 160.0 F for safety and palatability and could not explain why the fish was below that range. A test tray left the third-floor steam table at 12:31 PM and, by the time the last tray was delivered at 12:50 PM, the chicken, vegetables, and mashed potatoes on the test tray were measured below the temperatures identified by the Dietary Director as safe and palatable. The Dietary Director stated he had previously notified the Administrator about low food temperatures, but no changes had been made to food service delivery. The Administrator stated she was aware of complaints of cold food and had directed food service to move the steam table into the hallway, but that directive had not been followed because there was no accessible outlet, resulting in cold food. The facility policy stated hot cooked foods would be held above 140 F and steam tables would keep food at proper temperature.
Unsanitary food storage, preparation, and serving practices
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served under sanitary conditions. During a kitchen tour, the Director of Dietary was observed with incomplete cleaning and temperature logs for the day, including missing signatures and missing freezer temperatures. Multiple areas in the kitchen were visibly soiled, including the inside bottom of a reach-in cooler, the dishwashing area fan over clean dishes, the wall behind the clean dish storage area, the air compressor area, the counter next to the coffee pot, the windowsill behind the coffeepot, and the inside of the microwave. Clean serving utensils were also observed placed directly on a soiled windowsill. Opened spice containers and other food items were stored under the stove on trays that had debris on and under them, and several of those items were not dated with open dates. The Director of Dietary acknowledged that dishes washed in the dishwasher did not always come out clean and identified the brown substance on the wall as leftover debris from cleaned dishes. He also stated that the air handling unit for the kitchen air compressor was not his responsibility because an outside vendor handled it, and that maintenance was aware of it. He further stated that he did not clean the cabinet under the stove because the spices were on trays and that he replaced the trays when they became dirty, but he could not identify when the trays had last been removed for cleaning. The Kitchen Manager later stated she had signed staff initials on the weekly cleaning schedules for the previous two months because she did not want blank spots on the logs to be presented to the State Agency, and the Administrator stated she knew the kitchen was not clean and had previously directed the Director of Dietary to perform a thorough cleaning. The facility also failed to ensure safe thawing and proper temperature control of food. Frozen hamburgers were observed thawing in a dish of water at the three-bay sink with no cold running water. Frozen eggs and single-serve vanilla milkshakes labeled refrigerate were left on the kitchen prep counter for several hours after delivery, and on later observation the eggs were slushy and the milkshakes were no longer solid. In addition, several prepared food items, including soup, pureed peas, rice pilaf, gravy, pureed chicken, ground chicken, and ground ham, were left on the counter since about 9:30 AM, and temperatures taken on some items showed them well above the stated danger zone. During food service, a Nurse Aide with long painted nails repeatedly touched her hair and did not sanitize her hands before serving residents, and her nails contacted multiple residents’ plated food. Staff also transported uncovered plates of food to residents while the facility policy required handwashing prior to serving and distributing food.
Advance directive consent and physician orders were missing for two residents
Penalty
Summary
The facility failed to ensure advance directive consent forms and physician orders were in place for 2 of 2 residents reviewed for advance directives. Resident #98 had diagnoses including muscular dystrophy, polyarthritis, and chronic pain syndrome, and the MDS identified intact cognition with a BIMS score of 14. The care plan stated the resident had an established advance directive and wished to receive CPR, but the physician's orders did not direct a code status. The advance directive declaration forms in the paper chart were incomplete, as they did not include the resident's wishes for code status and lacked resident/responsible party and physician signatures. During interview and record review, an LPN stated the facility's process was to review code status choices on admission or readmission and obtain a signature within 24 hours, and that in an emergency staff would check the physician orders or the advance directive form in the chart. Review of Resident #98's electronic record and paper chart did not identify a code status choice, and the LPN noted there should have been an updated form because the resident had been hospitalized multiple times since the prior form. The DON also stated the admitting nurse was responsible for obtaining a signature and physician's order the same day or within 24 hours, but the record still did not show a code status review on readmission. Resident #99 had diagnoses including acute cystitis, mild cognitive impairment, and depression, and the admission assessment identified mild cognitive impairment and need for assistance with activities of daily living. The care plan did not address code status or advance directives, and physician orders did not direct the resident's choice. A nursing note documented that the resident and responsible party had not decided on advance directive status and had not signed the consent form, but subsequent nursing, social services, and practitioner documentation did not show that the issue was readdressed over the following days. Observations showed the responsible party was visiting daily, and staff interviews indicated advance directives should have been addressed on admission and readdressed if undecided, but no written education was provided and the code status remained unresolved until after surveyor inquiry.
Grievance for Damaged Clothing Not Resolved
Penalty
Summary
The facility failed to follow its grievance policy to ensure a grievance was resolved for a resident with congestive heart failure, mild cognitive impairment, and intellectual disabilities. A concern form dated 3/19/2025 documented bleach issues with the resident’s clothing, and the Department Head Resolution section stated that when the resident’s clothing became soiled, laundry washed the items in a soil program using bleach, which caused the clothing to become discolored or bleach stained. Although the form was signed by the Laundry Department Head on 3/20/2025, it was not signed by the Resident Council President, the Administrator, or the Director of Recreation, and it did not indicate that the issue had been resolved. The resident’s care plan did not address clothing concerns. The resident stated that after complaining about a state college insignia sweatshirt that had been returned from laundry changed from blue to purple, he/she was told nothing could be done, and said this concern had been communicated to the head of laundry. Observation later showed the purple sweatshirt and another item of clothing, sweatpants that had been black and were now gray. The Director of Housekeeping/Laundry stated that damaged clothing would be brought to administration for replacement, but she did not fill out a grievance form for the damaged items and said she could not replace all items all of the time when they came into laundry soiled with fecal matter. The Administrator stated the process for damaged clothing was to complete a grievance form for Social Services review and then to her for replacement, but could not explain why a grievance was not filed for the resident’s bleached clothing items.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure freedom from physical abuse for two residents involved in a resident-to-resident altercation. Resident #14 had diagnoses of Alzheimer's disease, dementia, and major depressive disorder, was severely cognitively impaired, and required substantial to maximal assistance for transfers. Resident #26 had diagnoses of major depressive disorder, essential hypertension, and chronic obstructive pulmonary disease, was moderately cognitively impaired, and was receiving psychotropic medication for depression with monitoring for side effects and target behaviors. The incident occurred when the two residents were sitting together in the hallway and Resident #26 became agitated and struck Resident #14 on the cheek with a backhanded punch and grabbed both of Resident #14's wrists. Staff intervened and separated the residents, and Resident #26 was placed on 1:1 observation and sent to the Emergency Department after being assessed as a danger to self or others. Interviews confirmed that staff heard yelling and responded, and one witness observed Resident #26 holding Resident #14's wrists while another witness observed the backhand strike and wrist grabbing. Resident #14 had no recollection of the incident, and the facility policy stated that residents would be protected from physical and psychosocial harm during and after an abuse investigation.
Missed Weights and Unavailable Inhaler
Penalty
Summary
The facility failed to ensure daily weights were obtained for a resident with chronic diastolic CHF, CAD, and atrial fibrillation who had a physician order for bumetanide with daily weight monitoring and extra dosing parameters based on weight gain. The resident’s care plan identified CHF and directed monitoring of weights and signs of fluid retention, but the clinical record did not show daily weights were obtained from 7/9/2025 through 8/6/2025, with 24 missed weights out of 28 opportunities. The APRN stated she was not aware the daily weights had not been obtained and identified that the nurse was responsible for ensuring weights were obtained and documented as ordered. The nurse stated she was not aware the resident had been placed on daily weights with bumetanide parameters in place. The facility also failed to obtain weekly weights for a resident with dementia, GERD, and depressive disorder who had a physician order for weekly weight monitoring on Mondays during the day shift. The resident’s care plan identified a potential for impaired nutrition/malnutrition related to dementia, dysphagia, cachexia, sub-optimal meal intake, and weight loss, with interventions to monitor meal intake and weights as needed. Review of the weight record showed only one documented weight after the order was implemented, with missed weights on multiple scheduled weeks. Staff interviews showed the NA obtained weights only when communicated by the nurse, and the LPN stated the nurse was supposed to review the order, highlight the resident on the daily weight sheet, and coordinate the weight with the shower schedule, but the ordered weekly weights were not obtained as directed. The facility also failed to ensure a prescribed inhaler was available for administration to a resident with COPD and CHF. During medication administration observation, the Trelegy Ellipta inhaler was unavailable, and the resident stated it had not been received for a couple of days and needed to be reordered. The LPN contacted the supervisor, pharmacy, and APRN, and a new order was obtained to administer the inhaler when received. The MAR showed the inhaler had been signed as given on several prior days, but the resident reported it had not been administered, and the pharmacy manager stated the delivery history did not support enough medication being available for the time period unless it had come from another source. The DNS stated that if a medication was unavailable it should not have been signed as given and that the facility had not received a medication error report for the resident.
Failure to Arrange Vision Services and Update Care Plan for Residents with Visual Needs
Penalty
Summary
The facility failed to assist a resident in gaining access to vision services when a resident reported broken eyeglasses and difficulty seeing. The resident, admitted with diagnoses including type 2 diabetes, anxiety disorder, and depression, told the surveyor that the lens was loose and the hinge on the glasses was broken, causing the temple to come off. The resident stated it was difficult to see and that he or she could not even watch television across from the bed, and also reported having told a nurse aide about the problem. The clinical record identified the resident as near sighted with adequate vision with glasses on admission assessments, and a physician order was in place for Lutein. However, the resident care plan did not identify a need for glasses, and a progress note later documented poor vision secondary to broken glasses. The unit secretary stated she was responsible for obtaining consents for ancillary services on admission and that the resident had not signed consent for optometry services since admission, which she said was an oversight on her part. She also stated she was not aware the eyeglasses needed repair. The facility also failed to revise the care plan and address ophthalmology follow-up for another resident with dementia, diabetes, and bipolar disorder. Eye care consultation notes documented moderate nuclear cataracts in both eyes and recommended ophthalmology consultation for cataract surgery evaluation, with follow-up in 4 to 5 months. The resident care plan noted glasses and ability to see small print, but nurse notes did not show that an ophthalmology consultation had been scheduled. The resident stated he or she needed cataract surgery and that the facility would not arrange transportation, while the unit secretary, RN supervisor, and Administrator were unable to identify that the ophthalmology recommendation had been addressed.
Failure to Apply Ordered Hand Splint
Penalty
Summary
The facility failed to ensure a left hand splint for contractures was applied according to the physician's order for a resident with muscular dystrophy, polyarthritis, chronic pain syndrome, and dependence on staff for dressing, personal hygiene, and transfers. The resident's care plan directed that the left hand splint be applied with morning care and removed with evening care, and the physician's order specified daily application with AM care and removal with PM care. The Resident Care Card also directed staff to place the splint on before lunch and remove it after dinner. Observations on multiple occasions found the resident in bed without the left-hand splint in place. During interview, the resident stated the splint helped the hand feel better, did not refuse to wear it, and said staff did not apply it consistently. A nurse aide stated the splint was in the room but had not been applied since surgery because of arm swelling, while the Director of Rehabilitation stated the splint was not on hold and that failure to use it could cause loss of ROM, decreased skin integrity, and increased contractures. The facility policy required nursing staff to apply and remove the designated splint during wearing times.
Failure to Provide Nutritional Support and Weight Monitoring
Penalty
Summary
The facility failed to provide enough food and fluids to maintain residents’ health for two sampled residents. For one resident with hemiplegia, hemiparesis, hypertension, and hyperlipidemia, the record showed a dietician recommendation for a calorie and protein supplement after reduced appetite and weight loss, but the recommendation was not documented as implemented. The resident’s care plan identified risk for malnutrition, yet it was not updated to reflect the significant weight loss, the supplement recommendation, or the weekly weight monitoring that was later indicated. The record also showed missed weight monitoring, including gaps in the months after the weight loss was identified, and no documentation that the supplement had been given. For the same resident, a physician order directed monthly weights during the first 10 days of each month, but the record did not show a July weight and did not show that the resident had refused weighing. The resident had a documented 7.2 lb. loss in one month, which met the facility’s definition of significant weight loss, yet nursing notes, physician/APRN notes, and dietician documentation did not show that the weight loss had been addressed or that the physician, dietician, or family had been notified as required by policy. The regional DNS stated the resident should have been placed on weekly weights for 4 weeks after the unanticipated weight loss, but that did not occur. For the second resident, who had peripheral autonomic neuropathy, atherosclerosis of both lower extremities, and chronic pain, the hospital wound consult identified a need to optimize nutrition due to heel skin changes, but the readmission order did not direct nutritional supplementation. After the resident developed a stage 3 pressure ulcer on the right foot, the wound APRN documented repeated wound visits and requested dietician consultation for supplementation to aid wound healing, but the dietician record did not show a nutritional evaluation for pressure ulcer prevention or a supplement assessment tied to the wound. The dietician stated she had not been notified of the pressure ulcer or the supplement request, and the regional DNS confirmed the record did not show that a supplement had been implemented when first requested.
Nebulizer Tubing Not Labeled, Dated, or Properly Stored
Penalty
Summary
The facility failed to ensure that nebulizer tubing and masks were labeled, dated, and stored appropriately for three residents receiving respiratory care. Resident #1 had COPD and CHF and had an order for Albuterol inhalation treatment as needed for wheezing and shortness of breath. Resident #2 had CHF and CAD and had an order for Albuterol inhalation as needed for shortness of breath and wheezing, while Resident #49 had COPD and atrial fibrillation and had an order for Albuterol inhalation solution as needed. Their care plans identified respiratory needs for Residents #1 and #49, but Resident #2's care plan did not identify respiratory status or nebulizer use. Observations for all three residents identified nebulizer tubing that was undated and unlabeled. The tubing was also stored inappropriately, without a cover and open to the environment. The same condition was observed repeatedly across multiple dates for each resident. Interviews with central supply staff, an LPN, and the DNS confirmed that the facility expected nebulizer tubing to be dated, labeled, and stored in a bag, and that tubing should be changed weekly, but the items observed were not maintained in that manner. A policy for nebulizer treatments and tubing was requested but not provided; only an oxygen administration policy was available, which directed that oxygen tubing be changed weekly and when visibly soiled.
Delayed Dental Consent for Resident with Broken and Decaying Teeth
Penalty
Summary
The facility failed to ensure a consent to treat was signed in a timely manner so dental services could be provided to a resident with known dental issues. Resident #1 was admitted with diagnoses including protein calorie malnutrition, type 2 diabetes, and GERD. Nursing oral health assessments identified more than 4 missing and decaying teeth, and the admission MDS showed a BIMS score of 14, independence with eating and oral hygiene after setup, and mouth or facial pain, discomfort, or difficulty chewing. The care plan in effect during June and July 2025 did not identify any dental issues for the resident. Resident #1 had a physician order for a small bite size diet with thin liquids and later a mechanical soft, ground texture diet. APRN documentation noted significant weight loss since admission and poor intake. During interview and observation, the resident stated that extractions and dentures had been planned before admission, reported many missing and broken teeth causing difficulty eating, and said no facility staff had provided information about dental services. Speech therapy later documented that the resident was not appropriate for a diet upgrade because follow-up dental work was still needed, and noted 8 remaining teeth that were broken and/or decaying. The unit secretary stated she was responsible for obtaining ancillary service consents on admission, that it was an oversight that this resident was not offered a dental consent, and that she was not aware the resident needed to be seen by a dentist.
Failure to Arrange Outside Dental Care and Update Care Plan
Penalty
Summary
The facility failed to ensure that Resident #70 received an outside dental provider appointment and failed to update the Resident Care Plan for dental issues. Resident #70 had diagnoses including diabetes, bipolar disorder, and lesions of the oral mucosa. A dental note dated 1/2/2025 documented crowns and bridges throughout the mouth and a follow-up visit scheduled for 6/20/2025, but it did not identify a missing crown or a lesion on the resident’s tongue. The quarterly MDS assessments identified the resident as cognitively intact with a BIMS score of 14 or 15 and needing set-up assistance for oral hygiene, but did not indicate dental issues. On 4/23/2025, Resident #70 told an LPN that a top right tooth was very loose and requested to be seen by a dentist; the note stated the request was placed in the appointment book and the supervisor was informed. On 5/19/2025, the APRN documented the resident requested evaluation for a dark spot on the right lateral tongue, and a physician order directed the resident to be seen by a dentist as soon as possible for the painless dark spot. A later APRN note on 6/16/2025 again directed a follow-up dental evaluation for the tongue lesion. The care plan dated 7/25/2025 addressed the dark area on the tongue and daily observation, but did not identify the missing crown or loose tooth. During interview and observation on 8/4/2025, the resident stated the front tooth crown had fallen off in April and that an outside dentist was needed because the facility dentist could not repair a crown in house. On 8/7/2025, the unit secretary could not locate a referral to an outside state dental provider, and the Administrator stated she was unaware the resident needed an outside dental appointment until surveyor inquiry.
Failure to Complete Timely Admission Skin Assessment
Penalty
Summary
A deficiency occurred when a comprehensive skin assessment was not completed in a timely manner upon admission for a resident with dementia, frontotemporal neurocognitive disorder, and significant immobility. The resident was admitted for a respite stay, was nonverbal, had contractures, and was dependent on staff for activities of daily living. The admission assessment identified the resident as being at very high risk for pressure ulcer development, but did not include a head-to-toe skin assessment as required by facility policy. Two days after admission, a wound nurse identified three non-facility acquired deep tissue injuries (DTIs) on the resident's left foot, which were determined to have been present on admission. Further review showed that no RN assessment was completed for the newly identified skin alterations when they were discovered. Interviews with staff confirmed that the facility's policy requires a comprehensive skin assessment upon admission, but this was not performed or documented. The reason for the omission was not identified during interviews, and there was also no documentation of an RN assessment when the pressure injuries were first noted.
Inappropriate Staff Behavior and Lack of Respect for Residents
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by several incidents involving inappropriate staff behavior. Resident #8, who was cognitively intact and required assistance for daily activities, reported that a charge nurse used insensitive language, calling the resident a liar and turning off the call bell without providing toileting assistance. This incident caused emotional distress to the resident, and the investigation confirmed the nurse's undignified conduct. Resident #9, also cognitively intact, became visibly upset when a nurse aide yelled at other staff members in the hallway about the resident's grievance. The resident was seen crying and shaking due to the disturbance. The investigation confirmed the nurse aide's inappropriate behavior, which was not respectful of the resident's rights. Resident #10, who required assistance with personal care, reported being yelled at by a nurse aide after using the bathroom independently. The aide questioned the resident's need for assistance and made dismissive comments. Additionally, Resident #12, who had dementia and was at risk for falls, experienced a fall and was subjected to profanity by a nurse aide during an argument with another staff member. The resident apologized for being an inconvenience, highlighting the distress caused by the staff's conduct.
Failure to Follow Transfer Assistance Protocols
Penalty
Summary
The facility failed to ensure that a resident, who had multiple fractures and specific weight-bearing restrictions, was transferred with the assistance of two staff members as required. The resident's diagnoses included a fracture of the lateral condyle of the right tibia, a fracture of the left calcaneus, an unspecified head injury, and arthritis. The nursing admission assessment indicated that the resident was alert and oriented and required assistance from two staff members for toileting, transferring, and ambulation with a walker, with partial weight-bearing restrictions. The care plan and physician's orders specified non-weight bearing on the left lower extremity and toe touch weight bearing on the right lower extremity, with assistance from two staff members for transfers. Despite these directives, an interview and picture review revealed that the resident was observed being transferred by only one staff member. The Director of Nursing confirmed that the physician's orders required two staff members for transfers, and there was no policy provided on weight-bearing status. This discrepancy between the care plan, physician's orders, and the actual practice led to the deficiency identified in the report.
Failure to Implement Pain Management Orders
Penalty
Summary
The facility failed to implement a hospital discharge order for a resident requiring pain management. The resident, who had a fracture of the lateral condyle of the right tibia, a fracture of the left calcaneus, an unspecified head injury, and arthritis, was discharged with instructions to apply ice to the lower extremities five times a day for twenty-minute intervals. However, this order was not included in the physician orders or the resident's care plan, leading to a deficiency in the resident's pain management. The resident's care plan identified several interventions, including keeping the call bell within reach, encouraging elevation of the fracture site, and monitoring circulatory motor sensation. Despite these interventions, the specific order to apply ice was overlooked. The Director of Nursing confirmed that the hospital discharge summary included the ice application order, but it was not reflected in the facility's documentation. This oversight indicates a failure to adhere to the facility's pain management policy, which requires the development and implementation of both pharmacological and non-pharmacological pain management interventions.
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 915 citations issued within 25 miles in the last 12 months — including the 11 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 Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Water's Edge Center For Health & Rehab | 1.3 mi | ★★★★★ | 15 | 0 |
| Apple Rehab Middletown | 1.6 mi | ★★★★★ | 5 | 0 |
| Portland Care & Rehab Centre, Inc | 2.7 mi | ★★★★★ | 19 | 0 |
| Pilgrim Manor | 3.4 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Cromwell | 3.6 mi | ★★★★★ | 0 | 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.