Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Claridge House Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Improper refrigerator temperatures were observed in two unit pantry refrigerators, each containing resident-labeled food items, while the temperature logs documented acceptable readings. In addition, an employee with facial hair was observed preparing lunch tray line items without a beard net, despite the facility policy requiring beard restraints for staff with facial hair.
Refrigerators in two unit pantries were observed at 50 degrees F while storing resident-labeled food items, even though the logs documented 40 degrees F. An LPN and an RN supervisor both confirmed the higher temperatures, and the facility’s policy required refrigerator temperatures to remain between 36 degrees F and 41 degrees F.
Unsafe items and incomplete side rail padding were found in resident rooms. Surveyors observed unsecured hygiene products and medications in several rooms, along with scissors and insect spray in one resident’s room. Another resident was observed in bed with bilateral side rails up, but only one rail was padded, despite an order for bilateral padded side rails for seizure precautions. Staff and the DON described room safety and item-control practices, and the facility policy stated it would maintain an environment free from accident hazards.
Oxygen therapy was not delivered as ordered for two residents with tracheostomies. One resident with respiratory diagnoses including pneumonia and acute pulmonary edema was observed with O2 running below and then at the ordered 4 lpm via trach, and another resident with chronic respiratory failure was observed with O2 running below and then at the ordered 5 lpm via trach. Staff stated oxygen concentrator settings should match the physician's order during rounds, and care plans included oxygen, suctioning, and trach care as ordered.
QAA/QAPI oversight failed to show an effective plan of action for repeated deficiencies involving F812, F867, and F908. Survey history showed prior citations for unsanitary food preparation and for a convection oven and stove that were not clean and not in good repair, and the facility also had repeated deficiencies involving care planning and drug storage. The DON and NHA stated the QAA committee meets monthly and reviews data, but the record did not show an effective response to the repeated issues.
A resident with severe cognitive impairment and a history of dementia left the facility undetected, likely by following visitors, and was missing for several hours before being found by law enforcement miles away. The resident did not have a wander alert system bracelet at the time, and staff only noticed the absence when delivering lunch, indicating a lapse in supervision and monitoring protocols.
A resident with severe dementia and total dependence for ADLs was able to leave the facility undetected during a busy visitor period, despite not showing prior exit-seeking behavior. The absence of effective monitoring and security measures allowed the resident to exit unnoticed, resulting in the individual being missing for several hours before being found by law enforcement.
Two residents in an LTC facility experienced delays in receiving appropriate respiratory care during emergencies. One resident was in distress with gurgling sounds and drooling, but the attending RN did not perform necessary assessments before administering medication and suctioning. Another resident's respiratory distress was not immediately addressed by an LPN, leading to a delay in suctioning. The facility's failure to follow established protocols for respiratory care was acknowledged by the DON and staff.
A resident at high risk for aspiration was observed vomiting and showing signs of respiratory distress, but the facility staff failed to notify the family and physician of the change in condition. Despite the resident's symptoms, staff did not perform a thorough assessment or document the incident, violating the facility's policy on changes in condition.
The facility failed to prevent aspiration and secure PEG tubes for residents at risk. A resident was observed with vomit draining from her mouth, and nurses did not implement timely interventions. Two other residents had unsecured PEG tubes, increasing the risk of dislodgement. Staff interviews revealed a lack of understanding and implementation of necessary interventions to secure PEG tubes.
A facility failed to secure medications and ensure a resident received the full dosage during administration. An RN left medications unattended and did not ensure the resident received the full amount via PEG tube. The resident had a tracheostomy and was prescribed medications like Levetiracetam, Eliquis, and Tylenol. The RN acknowledged leaving the medications unattended, stating the resident could not access them.
The facility was cited for repeated deficiencies in drug and biological storage, tube feeding management, and QAPI-QAA improvement activities during both a recertification and a complaint survey. These deficiencies suggest systemic issues in the facility's processes, potentially affecting all residents.
The facility failed to implement infection prevention and control precautions during tracheostomy care for residents. Staff did not follow Enhanced Barrier Precautions, such as wearing gowns and masks, while providing care to residents with tracheostomies. Additionally, shared medical equipment was not properly cleaned, and staff acknowledged not adhering to the facility's infection control policies.
The facility failed to maintain kitchen equipment in a sanitary condition, with brown stains observed on the convection oven and stove cooktop. Despite policies requiring daily cleaning, the Dietary Supervisor confirmed the stains, indicating a discrepancy in cleaning practices. This deficiency potentially affects 189 residents who eat orally.
The facility failed to ensure a convection oven and stove were clean and in good repair, potentially affecting 189 residents. Observations revealed brown stains on the oven and stove, despite policies requiring regular cleaning. The Dietary Supervisor confirmed the presence of stains, indicating a lapse in adherence to cleaning procedures.
A resident's food preferences were not honored, despite being cognitively intact and having communicated her dislikes to the dietary staff. The resident, on a NCS/NAS diet, repeatedly received meals with chicken and fish, contrary to her preferences for rice and beans. The facility's failure to adhere to its care plan and policies on resident rights led to dissatisfaction and a violation of the resident's right to self-determination.
A facility failed to implement a care plan for a resident with End Stage Renal Disease by not completing a required dialysis communication form. Despite a verbal report being given, the absence of the form was noted during the resident's dialysis session. Staff interviews revealed confusion over responsibility for the form, and the Director of Nursing confirmed the procedure was not followed.
The facility failed to follow protocols for enteral feeding for four residents, as observed in incorrect dating and missing start times on feeding equipment. These residents, who are dependent on tube feeding due to various medical conditions, were not managed according to the facility's policies, potentially impacting their nutritional status.
The facility failed to properly store and label medications in three out of four sampled medication carts. An expired eye drop was found on one cart, a refrigerated medication was left unrefrigerated on another, and a narcotic sheet with a different prescription number was used for reconciliation on a third cart. Staff acknowledged the errors, and the DON emphasized the importance of following labeling instructions and ensuring proper storage.
The facility failed to implement effective corrective actions for repeated deficiencies in developing comprehensive care plans, labeling/storing drugs, and food sanitation. These issues, identified during a recertification survey, have the potential to affect all 217 residents. Despite having a QAPI program, the facility did not demonstrate successful resolution of these deficiencies.
The facility failed to maintain the laundry room in a sanitary condition, with soiled washing machines, disrepair in the utility room, and wasp nests on the ceiling. Additionally, a Biohazard room door was left open, allowing unauthorized access, contrary to the facility's infection control policy.
A resident with severe cognitive impairment and a sacral pressure ulcer had a wound care consult ordered, but the facility failed to document follow-up care. Despite an LPN evaluating the resident, no documentation was made because no skin opening was observed, leading to a deficiency in medical record accuracy.
Improper Refrigerator Temperatures and Missing Beard Restraint
Penalty
Summary
The facility failed to ensure proper temperatures of food stored in the 2 South Unit Floor Pantry Refrigerator and the 1 North Unit Floor Pantry Refrigerator. On 3/16/2026 at 8:08 AM, the 2 South Unit refrigerator was observed at 50 degrees F while it contained resident food items labeled with resident names, room numbers, and dates placed in the refrigerator. Staff K, an LPN, confirmed the temperature was 50 degrees F and stated she would call maintenance because the refrigerator was not working properly. However, the refrigerator log for that same date documented the temperature as 40 degrees F. On 3/16/2026 at 8:16 AM, the 1 North Unit refrigerator was also observed at 50 degrees F with resident food items inside, and Staff L, an RN Supervisor, confirmed the temperature. The refrigerator log for that date documented the temperature as 40 degrees F. The facility also failed to ensure kitchen staff were wearing a beard restraint. The Hair Restraint Policy and Procedure stated that employees with facial hair must wear a beard net and that hair restraints must always be worn in food preparation, service, and dishwashing areas. During a second kitchen observation on 3/16/2026 at 11:07 AM, Staff M, who had a beard, was observed preparing items for the lunch tray line without a beard guard. Staff M confirmed at 11:08 AM that he was not wearing a beard guard and stated that he was supposed to have one on.
Refrigerators in Two Unit Pantries Were Not Maintaining Proper Temperatures
Penalty
Summary
The facility failed to ensure the refrigerators in the 2 South Unit Floor Pantry and the 1 North Unit Floor Pantry used to store residents’ food were working properly. Record review of the Refrigerator and Freezer Temperature Monitoring Policy and Procedure stated that the dietary department would maintain proper temperature control for all refrigerators and freezers used for food storage, that temperatures would be checked and recorded daily on the refrigerator temperature log, and that acceptable refrigerator temperatures were 36 degrees Fahrenheit to 41 degrees Fahrenheit. The policy also stated that if the temperature fell outside the acceptable range, staff would notify the supervisor and maintenance department for review and corrective action. During observation, the 2 South Unit Floor Pantry refrigerator was found at 50 degrees Fahrenheit and contained resident food items labeled with residents’ names, room numbers, and the dates the items were placed in the refrigerator. An LPN confirmed the temperature was 50 degrees Fahrenheit and stated she would call maintenance because the refrigerator was not working properly. The refrigerator log for that unit documented 40 degrees Fahrenheit. In the 1 North Unit Floor Pantry, the refrigerator was also observed at 50 degrees Fahrenheit with resident food items inside labeled with residents’ names, room numbers, and dates placed in the refrigerator. An RN supervisor confirmed the temperature was 50 degrees Fahrenheit, while the refrigerator log for that unit documented 40 degrees Fahrenheit.
Unsafe items and incomplete side rail padding found in resident rooms
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for four rooms on the second floor and for two sampled residents. During initial screening, surveyors observed unsecured items in resident rooms, including a bottle of bacterial mouthwash on an overbed table, three full vials of medication next to a nebulizer machine on a bedside cupboard, another bottle of bacterial mouthwash on a bedside cupboard, and a bottle of lotion and a can of spray deodorant on a windowsill. Staff interviews stated that medications found in resident rooms should be disposed of or stored in the medication cart or medication room, and personal hygiene products should be stored in the resident’s bedside drawer for safety. Resident #153 was observed lying in bed with bilateral side rails upright, but only the left side rail was padded. The resident had diagnoses including encephalopathy, was admitted with a history that included seizures, and had a BIMS score of 06 out of 15 indicating cognitive impairment. The physician order dated 03/10/2026 called for bilateral 1/4 padded side rails while in bed for seizure precautions and bed mobility/enabler, and the care plan identified the resident as at risk for falls related to altered mental status, encephalopathy, aggressive behavior, progressive dementia, hypertension, seizures, and polyneuropathy. Staff stated that both rails should be up and padded when the resident was in bed. Resident #10 was observed with a pair of scissors on the overbed table near the bed and a can of insect spray on the shelf behind the bed; the resident later stated the spray had been brought in by her daughter. The resident’s diagnoses included seizures, traumatic amputation of the left foot, major depressive disorder, type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis, and the MDS showed a BIMS score of 15 out of 15. The DON stated that family members were supposed to route items brought into the facility through the nursing station for inventory, but items were sometimes brought directly to residents’ rooms. The facility policy stated that it would provide an environment free from accident hazards over which it has control and would identify hazards, implement interventions, and monitor effectiveness.
Oxygen Therapy Not Delivered as Ordered for Two Residents With Tracheostomies
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to ensure oxygen therapy was delivered as prescribed for two residents with tracheostomies. Resident #5 was observed with oxygen running at 3 lpm via tracheostomy on one occasion and at 4 lpm on later observations, while the physician's order directed oxygen continuous at 4 liters via tracheostomy every shift. Resident #5's record also documented diagnoses including malfunction of tracheostomy stoma, pneumonia due to other specified bacteria, and acute pulmonary edema, and the resident was dependent for care with shortness of breath when lying flat, sitting at rest, and with exertion. Resident #211 was observed with oxygen running at 3.5 lpm via tracheostomy on one occasion and at 5 lpm on later observations, while the physician's order directed oxygen via tracheostomy at 5 lpm every shift. Resident #211's record documented diagnoses including encounter for attention to tracheostomy, chronic respiratory failure, and respiratory failure with hypoxia. Both residents' care plans included tracheostomy-related interventions such as administering oxygen as ordered, suctioning, and tracheostomy care. Staff interviews stated that oxygen concentrator settings should match the prescribed orders during rounds, and the facility policy stated oxygen should be administered only under physician orders.
QAA Committee Failed to Correct Repeated Food Safety and Equipment Deficiencies
Penalty
Summary
The facility's QAA committee failed to demonstrate that an effective plan of action was implemented to correct repeated quality deficiencies related to F812, Food Procurement, Store/Prepare/Serve Sanitary, F867, QAPI/QAA Improvement Activities, and F908, Essential Equipment, Safe Operating Condition. These repeated deficient practices were identified as having the potential to affect any of the 225 residents in the facility at the time of the survey. Record review showed that during a recertification survey conducted in August 2024, the facility had already been cited for F812 because food was not prepared under sanitary conditions and for F908 because a convection oven and stove used to prepare food for residents were not clean and not in good repair. The survey record also showed that F867 had been cited for repeated deficiencies involving F656, Develop/Implement Comprehensive Care Plan, F761, Label/Store Drugs & Biologicals, and F812, Food Procurement, Store/Prepare/Serve Sanitary. During interview, the DON and NHA stated that the QAA committee meets monthly and reviews the prior month's data, with department heads reporting on assigned tasks and new issues. The facility policy titled Quality Assurance Performance Improvement Plan stated that the purpose of the QAPI plan is to use a data-driven, proactive approach to improve quality of life, care, and services, and that the Quality Improvement Program systematically monitors, analyzes, and improves performance to advance resident outcomes.
Resident Elopement Due to Inadequate Supervision and Lapse in Monitoring
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including unspecified dementia and acute respiratory failure, was able to leave the facility undetected. The resident required assistance with all activities of daily living and was incontinent of bladder. On the day of the incident, the resident was last seen in his room after receiving a shower in the morning. Staff noted his absence when his lunch tray was delivered and he was not present in his room. Upon realizing the resident was missing, staff initiated a search of the facility and its grounds, and a code for a missing resident was called. Law enforcement, the resident's guardian, and the medical doctor were notified. The resident was eventually found by law enforcement approximately 5.2 miles away from the facility after boarding a city bus and being missing for about eight hours. The area where the resident was found was described as a high-traffic location with cross streets, increasing the risk of harm due to the resident's vulnerability and cognitive impairment. Interviews with staff revealed that the facility had a high volume of visitors on the day of the incident, and it was suggested that the resident may have followed a visitor out of the building. At the time, the resident did not have a wander alert system bracelet in place, and staff were unaware of his exit until the lunch tray was delivered. The facility's protocols for monitoring and supervising residents at risk for elopement were not effectively implemented, resulting in the resident's undetected departure.
Removal Plan
- Nurses completed a head count using the facility's census to ensure no other residents were missing, verified by the nursing supervisor.
- Resident was reevaluated by the psychiatrist and new orders were received.
- Reeducation regarding the prevention of elopement was initiated for the staff by the Director of Nurses (DON).
- All nursing staff on all shifts received education regarding residents who exhibit exit-seeking behavior, the risk of elopement, and the need for adequate supervision to ensure resident safety.
- Unit Managers, supervisors, and/or designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for elopement by completing a new elopement risk screening form.
- MDS Coordinator and/or designee reviewed and updated the care plans of the residents at risk for elopement to reflect the current elopement risk.
- Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
- A Root Cause analysis was completed using the Five Whys to develop new approaches to prevent reoccurrence.
- Facility conducted an AdHoc Quality Assurance Meeting to review the Performance Improvement Plan ensuring proper interventions are put in place.
- The facility conducted an elopement drill on every shift.
- Staff were re-educated on the Elopement and wandering, exit seeking resident policy.
- DON, ADON, and designee completed elopement risk screening on active residents and reviewed their plan of care to ensure appropriate interventions are in place, and the plan of care was updated.
- Facility wide audit of the elopement screenings identified new residents that triggered for elopement risk.
- Residents triggered for at risk for elopement have orders for a wander alert system to be put in place.
- Orders were obtained from the physician for psych reevaluation for residents triggered for elopement risk.
- The elopement book was updated with new pictures of residents triggered for elopement risk.
- Elevator keypads installed on the elevators by the Elevator Company.
- A keypad/alarm installed at the door leading to the lobby by the alarm company.
- Elopement drills are done on every shift.
- The Maintenance Director or designee to conduct Safety rounds Log to check exit door, screamer alarms and outside gates.
- Residents with new behaviors of exit seeking and wandering will be added to the elopement risk book that is kept at the nursing station and is accessible to all staff. The behaviors will be added to the resident's care plan and the Kardex.
- Nursing staff will communicate during the shift to shift report any resident who exhibits behaviors to leave the facility, and the safety measures put into place.
- The nurses and nursing supervisors will use the facility census to conduct the headcount of the residents in their respective unit during shift change and they will sign the census to validate that the count is correct, and all residents are accounted for.
- The CNAs will conduct rounds every two hours to ensure the residents are safe and accounted for. CNAs will report to the nurse immediately if unable to locate a resident. Facility protocols for missing residents will be used immediately to locate the residents.
- New admissions elopement evaluations will be reviewed during clinical meetings to ensure elopement interventions are in place for residents that are at risk and the facility guidelines are followed. Nursing Supervisors will review the new admissions elopement evaluation for compliance.
- The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place.
- Residents with new behaviors of wandering, exit seeking will be reassessed by the ADON, Unit Managers, Supervisors or designee for a risk for elopement.
- The DON, Administrator, ADON and/or designee will enforce disciplinary action for facility staff who fail to follow the elopement policy and procedures.
- New hires will receive education on wandering, elopement, and resident safety by the DON, ADON or designee(s).
- Education Target goal is 100%.
- DON and ADON reeducated employees on the facility's policy & procedures as it is related to elopement and residents' safety.
- Staff members participated in the elopement drills.
- Facility compliance with elopement drills was tracked and increased.
- All elopement elements put into place were verified and the facility is in compliance.
- After the facility wide audit of the elopement screening, the facility identified new residents who triggered for elopement.
- A QAPI (Quality Assurance and Performance Improvement) review for follow-up was done and all elements were verified.
- The facility will conduct an elopement drill.
- The DON, ADON, and administrator will review the clinical record of any residents with behaviors of exit seeking and wandering to ensure the facility policy and procedures are implemented and followed, and residents have remained safe at the facility.
- Review the findings during the QAPI meeting.
- The DON, ADON/designee will conduct a quality review of residents on each unit.
- The findings of these reviews will be reported in the next Risk Management/QA Committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their quality systems review.
- The committee reviewed the plan and determined the removal plan has been implemented effectively.
Failure to Prevent Elopement of Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure effective systems were in place to provide adequate supervision for a resident with severe cognitive impairment. On the day of the incident, the resident, who had a diagnosis of unspecified dementia and required assistance with all activities of daily living, was found to be missing when a CNA noticed his lunch tray was untouched and he was not in his room. The nurse was alerted, and a search of the facility and grounds was initiated. Despite these efforts, the resident had already left the facility undetected. The resident was able to exit the building, reportedly during a time when there were many visitors entering and leaving, possibly by following a visitor out. The facility's entry and exit procedures at the time required guests to sign in and out, but there was no mention of a system in place to prevent residents from leaving alongside visitors. Staff interviews confirmed that the resident was not exhibiting exit-seeking behaviors prior to the incident, and it was not immediately clear how he managed to leave the premises. The absence of effective monitoring and security measures allowed the resident to leave unnoticed. The resident was missing for approximately eight hours before being located by law enforcement over five miles away from the facility. During this period, staff followed internal protocols for missing residents, including notifying law enforcement, the resident's guardian, and conducting searches of the facility and surrounding areas. The incident exposed a failure in the facility's supervision and security systems, particularly for residents at risk of elopement due to cognitive impairment.
Removal Plan
- Nurses completed a head count using the facility's census to ensure no other residents were missing, verified by the nursing supervisor.
- Resident was reevaluated by the psychiatrist and new orders were received.
- Reeducation regarding the prevention of elopement was initiated for the staff by the Director of Nurses (DON).
- All nursing staff on all shifts received education regarding residents who exhibit exit-seeking behavior, the risk of elopement, and the need for adequate supervision to ensure resident safety.
- Unit Managers, supervisors, and/or designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for elopement by completing a new elopement risk screening form.
- MDS Coordinator and/or designee reviewed and updated the care plans of the residents at risk for elopement to reflect the current elopement risk.
- Nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
- A Root Cause analysis was completed using the Five Whys to develop new approaches to prevent reoccurrence.
- The Facility conducted an AdHoc Quality Assurance Meeting to review the Performance Improvement Plan ensuring proper interventions are put in place.
- The facility conducted an elopement drill on every shift.
- Staff were re-educated on the Elopement and wandering, residents' exit seeking policy.
- The DON, ADON, and designee completed elopement risk screening on active residents and reviewed their plan of care to ensure appropriate interventions are in place, and the plan of care was updated.
- Facility wide audit of the elopement screenings identified new residents that triggered for elopement risk.
- Residents triggered for at risk for elopement have orders for a wander alert system to be put in place.
- Orders were obtained from the physician for psych reevaluation for residents triggered for elopement risk.
- The elopement book was updated with new pictures of residents triggered for elopement risk.
- Elevator keypads installed on the elevators by the Elevator Company.
- A keypad/alarm installed at the door leading to the lobby by the alarm company.
- Elopement drills are done on every shift.
- The Maintenance Director or designee to conduct Safety rounds Log to check exit door, screamer alarms and outside gates.
- Residents with new behaviors of exit seeking and wandering will be added to the elopement risk book that is kept at the nursing station and is accessible to all staff. The behaviors will be added to the resident's care plan and the Kardex.
- Nursing staff will communicate during the shift to shift report any resident who exhibits behaviors to leave the facility, and the safety measures put into place.
- The nurses and nursing supervisors will use the facility census to conduct the headcount of the residents in their respective unit during shift change and they will sign the census to validate that the count is correct, and all residents are accounted for.
- The CNAs will conduct rounds every two hours to ensure the residents are safe and accounted for. CNAs will report to the nurse immediately if unable to locate a resident. Facility protocols for missing residents will be used immediately to locate the residents.
- New admissions elopement evaluations will be reviewed during clinical meetings to ensure elopement interventions are in place for residents that are at risk and the facility guidelines are followed. Nursing Supervisors will review the new admissions elopement evaluation for compliance.
- The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place.
- Residents with new behaviors of wandering, exit seeking will be reassessed by the ADON, Unit Managers, Supervisors or designee for a risk for elopement.
- The DON, Administrator, ADON and/or designee will enforce disciplinary action for facility staff who fail to follow the elopement policy and procedures.
- New hires will receive education on wandering, elopement, and resident safety by the DON, ADON or designee(s).
- The DON and ADON reeducated employees on the facility's policy & procedures as it is related to elopement and residents' safety.
- Elopement drills were conducted with staff participation tracked and compliance rates monitored, with ongoing drills for staff who have not yet participated.
- All elopement elements put into place were verified and the facility is 100% compliance.
- After the facility wide audit of the elopement screening, the facility identified new residents who triggered for elopement.
- A QAPI (Quality Assurance and Performance Improvement) review for follow-up was done, all the elements were verified, and facility was 100% compliance.
- The facility will conduct an elopement drill.
- The DON, ADON, and administrator will review the clinical record of any residents with behaviors of exit seeking and wandering to ensure the facility policy and procedures are implemented and followed, and residents have remained safe at the facility.
- Review the findings during the QAPI meeting.
- The DON, ADON/designee will conduct a quality review of residents on each unit.
- The findings of these reviews will be reported in the next Risk Management/QA Committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their quality systems review.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility's staff failed to address respiratory emergencies in a timely manner for two residents, leading to a deficiency in providing safe and appropriate respiratory care. Resident #6 was observed in respiratory distress, with loud gurgling sounds, coughing, and drooling. Despite these signs, the attending nurse, Staff A, RN, did not perform necessary assessments such as auscultating lung sounds or checking vital signs before administering medication and suctioning. Additionally, the drainage collection bag for the resident's tracheostomy was missing, and Staff B, RN, failed to check the oxygen level or clean the suction machine before use. Resident #5 also experienced a delay in receiving appropriate respiratory care. Staff F, LPN, left the resident's room after administering medication without addressing the resident's respiratory distress, characterized by facial grimacing and gurgling sounds. It took twelve minutes for Staff F, LPN, to return with another nurse, Staff E, RN, to perform suctioning. During this time, the resident's feeding was not stopped, and the head of the bed was not elevated, contrary to the care plan's aspiration precautions. The facility's failure to adhere to established protocols for respiratory care, including timely suctioning and proper assessment of residents in distress, was acknowledged by the Director of Nursing and other staff members. The report highlights the lack of immediacy and proper procedure in handling respiratory emergencies, which is critical for residents with conditions such as chronic respiratory failure and tracheostomy status.
Failure to Notify Family and Physician of Change in Resident's Condition
Penalty
Summary
The facility's staff failed to notify a resident's family and physician of a change in condition, which was identified during a survey. The resident, who was at high risk for aspiration, was observed vomiting and displaying signs of respiratory distress. Despite these symptoms, the facility staff did not notify the physician and the family of the changes in her condition. The resident was observed with audible gurgling breathing sounds, vomit draining from her mouth, and a PEG feeding formula infusing at 65 ml/hr. Staff A, a registered nurse, did not perform an assessment or implement any interventions when initially alerted to the situation. Further observations revealed that the resident continued to exhibit gurgling sounds and vomit drainage, and a Scopolamine patch was noted behind her ear. Staff C, a certified nursing assistant, cleaned the vomit but did not ensure that the nurse was informed of the resident's condition. When Staff A, RN, was questioned about the interventions, he mentioned administering Ondansetron but did not perform a thorough assessment, such as checking vital signs or auscultating lung sounds. Staff B, RN Supervisor, also failed to perform a comprehensive assessment upon entering the room. A review of the resident's clinical records showed no documentation indicating that the resident's family and doctor were notified of the change in condition. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition. The facility's policy on changes in condition requires notifying the physician and family, which was not adhered to in this case. The 24-hour log also lacked documentation related to the resident's change in condition, highlighting a deficiency in the facility's adherence to its policies and procedures.
Failure to Prevent Aspiration and Secure PEG Tubes
Penalty
Summary
The facility failed to implement measures to prevent aspiration and dislodgement of PEG tubes for residents at risk. One resident was observed with vomit draining from her mouth, and the registered nurses did not implement timely interventions. Despite the presence of gurgling sounds and vomit, the nurse did not check vital signs, bowel sounds, or lung sounds, nor did they hold the PEG feeding. The resident had a history of COPD, dysphagia following cerebral infarction, and seizures, which increased her risk for aspiration. Additionally, the facility did not secure PEG tubes for two other residents, increasing the risk of dislodgement. One resident's PEG tube was observed resting above his hand, and he guarded the site, indicating discomfort or potential dislodgement. Another resident's feeding line was wrapped around a privacy curtain and a metal pole, posing a risk for dislodgement. Both residents had clinical diagnoses that included seizures and dysphagia, further complicating their care needs. Interviews with staff revealed a lack of understanding and implementation of necessary interventions to secure PEG tubes. The Director of Nursing confirmed that no special anchoring or adhesive was used to secure the tubes, and staff members expressed that they did not believe securing the tubes was necessary. This lack of appropriate measures and understanding contributed to the deficiencies observed in the care of residents with PEG tubes.
Medication Administration Deficiency
Penalty
Summary
The facility failed to secure medications and ensure a resident received the full dosage of their medications during a medication administration observation. A Registered Nurse (RN), identified as Staff A, was observed administering medications to a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The RN left the resident's medications unattended on the overbed table and walked out of the room. Upon returning, the RN attempted to discard the medication cups and extra water, but the surveyor intervened and found that approximately 75% of the Tylenol and Eliquis were still in the cups. The resident involved had a clinical history that included a tracheostomy status and was prescribed medications such as Levetiracetam, Eliquis, and Tylenol to be administered via PEG tube. During an interview, Staff A acknowledged leaving the medications unattended, justifying the action by stating that the resident was not able to access the medications. This incident highlights a failure in medication administration procedures, specifically in ensuring that medications are not left unattended and that residents receive the full dosage of their prescribed medications.
Repeated Deficiencies in Drug Storage, Tube Feeding, and QAPI Activities
Penalty
Summary
The facility failed to implement effective plans of action to correct identified quality deficiencies in the areas of drug and biological storage, tube feeding management, and QAPI-QAA improvement activities. These deficiencies were observed during both a recertification survey and a subsequent complaint survey. The repeated nature of these deficiencies suggests a systemic issue within the facility's processes, as the same areas were cited in both surveys. The facility's policy and procedures indicate a commitment to a comprehensive, data-driven QAPI program, yet the repeated citations suggest that the facility did not effectively follow through with these plans. The deficiencies have the potential to affect all residents residing in the facility, indicating a widespread impact on the quality of care and life for the residents.
Failure to Implement Infection Control Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to implement infection prevention and control precautions during tracheostomy care for residents with tracheostomies. On January 22, 2025, a resident was observed in bed with gurgling sounds and vomit draining from the mouth while receiving tube feeding. A registered nurse supervisor entered the room, performed hand hygiene, and wore gloves but did not don a gown as required by Enhanced Barrier Precautions. The nurse checked the resident's mouth, removed gloves, and exited the room without following proper infection control protocols. On January 23, 2025, another resident was observed in distress with loud gurgling sounds, coughing, and drooling. The resident was receiving oxygen via tracheostomy and tube feeding. A nurse and a supervisor entered the room to assist the resident, but the supervisor was not wearing a mask and spoke closely to the resident. Additionally, the supervisor did not clean his stethoscope after use, and neither staff member wore a gown while checking the resident's PEG tube. Both staff members acknowledged not following the facility's infection prevention and control policy and procedures for Enhanced Barrier Precautions.
Sanitation Deficiency in Kitchen Equipment
Penalty
Summary
The facility failed to ensure that food was prepared under sanitary conditions, as evidenced by the lack of cleanliness in the kitchen equipment. During an initial kitchen tour, surveyors observed brown stains on various parts of the convection oven, including the outside, inside, and doors, as well as on the stove cooktop and the sides of the oven. These observations were made despite the facility's policy, which mandates that all equipment used in food handling be cleaned and sanitized to prevent contamination. The facility's cleaning policies for ovens and ranges/griddles require that spills and food particles be removed after each use and that the equipment be cleaned daily. The Dietary Supervisor confirmed the presence of the brown stains and stated that the oven undergoes a deep clean once a week and is cleaned daily. However, the cleaning logs for August 2024 indicated that the ovens and convection ovens were cleaned daily, suggesting a discrepancy between the cleaning practices and the observed condition of the equipment. This deficiency has the potential to affect 189 out of 217 residents who consume food orally at the facility.
Failure to Maintain Cleanliness of Kitchen Equipment
Penalty
Summary
The facility failed to maintain a convection oven and stove in good repair and cleanliness, which could potentially affect 189 out of 217 residents who consume food orally. During an initial kitchen tour, surveyors observed brown stains on various parts of the convection oven and stove, including the outside, inside, and doors of the oven, as well as the stove cooktop. These observations were made in the presence of the Dietary Supervisor, who confirmed the presence of the stains. The facility's policies on food safety and equipment cleaning require that all food handling equipment be cleaned and sanitized to prevent contamination. The policies specify that ovens should be cleaned as needed and according to a cleaning schedule, with spills and food particles removed after each use. Despite these policies, the cleaning logs for August 2024 indicated that the ovens were cleaned daily, yet the observed stains suggest a failure to adhere to the cleaning procedures outlined in the facility's policies.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, violating the resident's right to self-determination and choice. Resident number 63, who was cognitively intact with a BIMS score of 15, expressed dissatisfaction with the meals provided, specifically noting a preference against chicken and fish, and a desire for rice and beans instead of mashed potatoes. Despite having communicated these preferences to the dietitian and dietary staff, the resident continued to receive meals that did not align with her stated preferences, as observed during a survey on 8/19/24. The resident's care plan, which included honoring food preferences and substituting for dislikes, was not adhered to, as evidenced by the repeated provision of unwanted meals. The resident's dietary needs were documented as a No Concentrated Sweets (NCS), No Added Salt (NAS) diet with regular texture and thin consistency liquids, and her food preferences were updated multiple times in the facility's records. However, these updates were not reflected in the meals served to her, leading to dissatisfaction and a failure to respect her autonomy and choices. Interviews with the Registered Dietitian and a staff member eligible to be a dietitian confirmed the oversight in honoring the resident's food preferences. The staff acknowledged the resident's right to have her preferences respected and noted that the dietary department was informed of these preferences, yet the issue persisted until the surveyor's intervention. This deficiency highlights a lapse in the facility's adherence to its policies on resident rights and care planning, specifically regarding the accommodation of personal and cultural preferences in meal planning.
Failure to Implement Dialysis Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident undergoing dialysis, as evidenced by the absence of a completed communication form by the nursing staff prior to the resident's dialysis session. On the specified date, the resident was observed in the dialysis room, and it was noted that the floor nurse had not filled out the required dialysis communication form, although a verbal report was given to the Dialysis Patient Care Technician. The resident, who has a diagnosis of End Stage Renal Disease and is dependent on renal dialysis, had a care plan in place that required coordination with the dialysis center, including communication regarding medication, diet, and lab results. The care plan for the resident, which was initiated and revised on specific dates, included interventions to prevent complications related to hemodialysis. However, the review of the resident's progress notes revealed no documentation prior to the dialysis session on the specified date. Interviews with staff members indicated a lack of clarity and responsibility regarding the completion of the communication form, with one nurse stating that the form was usually filled out by another nurse, and the supervisor indicating that no report was given to the dialysis staff as there was nothing to report. The Director of Nursing confirmed the procedure for assessing residents before dialysis and completing the communication form, which was not followed in this instance.
Deficiencies in Enteral Feeding Protocols
Penalty
Summary
The facility failed to adhere to its protocols and procedures for enteral feeding for four residents, as observed during a survey. The deficiencies were noted in the incorrect dating and missing start times on enteral supplements, water bag flushes, and enteral feeding syringes. These discrepancies were observed in the cases of four residents who were receiving tube feedings, indicating a systemic issue in the facility's management of enteral nutrition. Resident #37 was observed with an enteral feeding supplement dated incorrectly and lacking a start time. The resident, who is cognitively impaired and dependent on care, had specific physician orders for enteral feeding and water flushes that were not followed accurately. Similarly, Resident #89, who is dependent on enteral feeding due to multiple medical conditions, was found with an enteral feeding syringe dated incorrectly. This resident also experienced weight loss, which could be related to the improper management of their nutritional needs. Resident #157 and Resident #194 also exhibited similar issues with incorrect dating and missing start times on their enteral feeding equipment. Both residents have significant medical conditions requiring precise nutritional management, and the facility's failure to follow its own protocols could potentially impact their health. The facility's policy mandates accurate administration and documentation of enteral nutrition, which was not adhered to, as confirmed by staff interviews and record reviews.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label medications in three out of four sampled medication carts, leading to deficiencies in medication management. On the first-floor south front medication cart, an expired eye drop labeled Cosopt was found with an opened date but no expiration date written on it. The medication was supposed to expire 15 days after opening, but it was not discarded as required. Staff D, an LPN, acknowledged the oversight, stating that expired medications should be reordered and discarded to prevent harm to residents. On the second-floor south back medication cart, a box of sublingual Lorazepam meant for refrigeration was found unrefrigerated. Staff B, an RN, admitted to seeing the medication but failing to place it in the refrigerator. Additionally, on the first-floor north back medication cart, a narcotic sheet with a different prescription number was used to reconcile an Oxycodone bingo card, although the count was correct. Staff E, an LPN, was unaware of how the error occurred. The Director of Nursing emphasized the importance of following labeling instructions and ensuring proper storage and reconciliation of medications.
Repeated Deficiencies in Care Plan, Drug Storage, and Food Sanitation
Penalty
Summary
The facility failed to effectively implement corrective actions to address repeated deficiencies in three key areas: F 656 Develop/Implement Comprehensive Care Plan, F 761 Label/Store Drugs and Biologicals, and F 812 Food Procurement, Store/Prepare/Serve-Sanitary. These deficiencies were identified during a recertification survey with an exit date of April 20, 2023, and have the potential to impact all 217 residents residing in the facility at the time of the survey. The facility's survey history indicates that these issues have been persistent, suggesting that previous corrective measures were not successful in resolving the underlying problems. The facility's policy and procedures emphasize the development and maintenance of a comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. However, the facility did not demonstrate that effective plans of action were implemented to correct the identified deficiencies. The facility's Quality Assessment and Assurance (QAA) committee is responsible for monitoring performance improvement activities, but the repeated citations indicate a lack of effective oversight and follow-through in addressing these critical areas of care and service delivery.
Deficiencies in Laundry Room Maintenance and Biohazard Room Security
Penalty
Summary
The facility failed to maintain the laundry room in a safe and sanitary condition. During an observational tour, it was noted that the washing machines were soiled with rust-like stains and dust, and the floors in the soiled utility room were in disrepair. Additionally, wasp nests were observed on the ceiling, and the exhaust fans were rusted and in disrepair. Despite these conditions, the cleaning schedule document indicated that staff had signed off daily to confirm the machines were cleaned. The Housekeeping Director and Maintenance Staff acknowledged these findings, but the Maintenance Director did not comment on the issues. The facility also failed to follow safety and infection control protocols for one of its Biohazard rooms. An observation revealed that the door to the first floor North nursing station Biohazard room was open, allowing unauthorized access. A Floor tech entered the room without a code, stating that the door should be kept locked with a code. The Director of Nursing confirmed that the Biohazard room doors are supposed to be locked to ensure resident safety. The facility's Infection Prevention and Control Program policy requires that any breach in infection prevention and control practices be reported to the Director of Nursing.
Incomplete Medical Records for Wound Care Consult
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident with a pressure ulcer. The resident, who had severe cognitive impairment and was dependent for toileting and transfer, was admitted with a pressure ulcer in the sacral region. A wound care consult was ordered after a nurse identified a reopened area on the sacral region, but there was no follow-up documentation in the medical records regarding the wound care consult or evaluation by the wound care nurse. Despite the order for a wound care consult, there was no documentation of an evaluation by the wound care nurse after the wound was identified. The LPN involved stated that they did not remember why there was no documentation, and the Director of Nursing confirmed that the LPN evaluated the resident but did not document the findings because no opening of the skin was observed at the time. This lack of documentation led to the deficiency noted in the survey.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 317 citations issued within 25 miles in the last 12 months — including the 4 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 North Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinecrest Center For Rehabilitation And Healing | 0.2 mi | ★★★★★ | 0 | 0 |
| Fountain Manor Health & Rehabilitation Center | 0.3 mi | ★★★★★ | 1 | 0 |
| North Dade Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 9 | 0 |
| Pines Nursing Home | 1.2 mi | ★★★★★ | 0 | 0 |
| Villa Maria Nursing Center | 1.3 mi | ★★★★★ | 4 | 2 |
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.