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 Hill Haven Nursing Home during CMS and state inspections, most recent first.
A resident with Parkinson's disease and limited mobility was not protected from another resident with dementia and a history of physical and verbal aggression. The roommate threw food and a tray at her, threatened to kill her, and staff interviews confirmed prior aggressive behavior and threats toward other residents. The resident stated she felt unsafe and feared being attacked, while staff acknowledged the roommate's behavior and the impact on the resident.
The facility failed to timely report an allegation of resident-to-resident verbal and physical abuse to the SSA. A resident with intact cognition reported that another resident threw a tray at her, got food on her, got in her face, and threatened to kill her; the resident said she did not feel safe. The other resident had documented physical and verbal behaviors toward others. The Administrator stated the incident was not reported because it was determined not to meet the definition of abuse, and only a verbal investigation was conducted with no documentation available.
The facility failed to ensure proper labeling and storage of food items in the kitchen, as required by their policy. Observations revealed undated waffles, an open bag of onion rings, an unsealed box of fish sticks, and open containers of sausage and eggs. The Dietary Kitchen Manager confirmed that staff were expected to label and date food items, but this was not consistently done, potentially affecting 55 out of 59 residents receiving an oral diet.
The facility did not establish a water management program as part of its infection prevention and control program, despite it being a requirement in their policy. The absence of this plan was confirmed by the Administrator, who had recently started working at the facility and planned to address the issue in an upcoming QAPI meeting. The facility had 59 residents at the time.
A facility failed to report a sexual abuse allegation involving a resident with severe cognitive impairment within the required time frame. The incident involved a CNA allegedly engaging in inappropriate conduct with the resident. The DON did not complete necessary notifications or documentation, and the Medical Director was not properly informed. The accused CNA was sent home, and the reporting CNA was moved to a different hall. The Administrator expected immediate reporting, but the previous Administrator had not enforced contacting law enforcement.
A facility failed to thoroughly investigate a sexual abuse allegation involving a resident with severe cognitive impairment. The investigation lacked proper documentation, with missing witness statements and no confirmation of notification to the Medical Director. The Director of Nursing did not complete a required skin assessment, and local police were not contacted. The accused CNA was suspended, but the Human Resource Director confirmed no findings were documented in employee files. The Administrator noted previous failures in reporting procedures.
The facility failed to develop comprehensive care plans for two residents receiving respiratory care. One resident with pneumonia and respiratory failure had physician orders for nebulizer treatments, but these were not included in the care plan. Another resident with anemia, coronary artery disease, and heart failure had orders for nebulizer therapy, but the care plan only included oxygen therapy. Interviews confirmed the absence of these care plans.
The facility failed to maintain safe water temperatures in resident rooms, with temperatures exceeding the policy limit of 120 degrees Fahrenheit in five rooms. Despite monthly checks showing acceptable ranges previously, recent observations revealed dangerously high temperatures, though no residents were injured.
A facility failed to properly store a nebulizer mouthpiece for a resident with severe cognitive impairment and respiratory issues, leaving it unbagged and exposed, which could lead to infections. Staff interviews confirmed awareness of proper storage procedures, but the equipment was found uncovered multiple times. The DON noted a lack of a logging system for maintenance tasks.
Failure to Protect Resident from Roommate Abuse
Penalty
Summary
The facility failed to protect one resident from physical and verbal abuse by another resident. The cited resident had Parkinson's disease, anxiety, depression, suicidal ideations, intact cognition on MDS, and limited physical mobility related to neurological deficits, poor balance, coordination, and weakness. The other resident had diagnoses including dementia with behavioral disturbance, severe dementia with psychotic disturbance, depression, psychosis, and mood disorder, and her care plan identified a potential for physical and verbal aggression due to dementia, anger, and poor impulse control. On the day of the incident, the resident reported that her roommate threw a tray at her, food got all over her, and the roommate got in her face and stated that she would kill her. The resident stated she did not feel safe and requested that the roommate be moved to another room. The social worker documented the report and notified leadership, and the decision was made to move the roommate. The resident later stated that she had repeatedly asked staff to provide the roommate's meals in the dining room under supervision, but trays continued to be delivered to the room. Staff interviews confirmed the roommate's aggressive behavior. A CNA stated food was on the floor and between the resident's legs in her wheelchair, the tray was on her bed, and the resident was upset. Another CNA stated the roommate threw food, the resident was frightened because of her Parkinson's disease and inability to protect herself due to balance problems, and that the roommate had previously thrown dessert at her and had hit her before. The social service director and medical director both stated they were aware of the roommate's verbal and physical aggression and threatening statements toward residents, and the medical director confirmed the resident feared she would be attacked.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident verbal and physical abuse to the State Survey Agency within the required time frame for one of 36 sampled residents. Review of the facility policy stated that all reports of resident abuse, neglect, exploitation, or misappropriation are to be reported to local, state, and federal agencies as required, and that allegations involving abuse or bodily injury are to be reported immediately, defined as within two hours. The deficiency involved two residents: one resident with a BIMS score of 15, indicating intact cognition, and another resident whose MDS documented that the interview was not completed or unsuccessful and who exhibited physical and verbal behaviors toward others for one to three days. Progress notes documented that the cognitively intact resident reported that the other resident threw a tray at her, got food all over her, got in her face, and stated that she would kill her. The resident stated she did not feel safe and requested that the other resident be moved to another room. The other resident’s progress note documented aggressive behavior toward the roommate and that the incident had been reported. A facility investigation summary stated the incident was not reportable to the state because it did not meet the definition of abuse, citing no willful intent to inflict harm and no physical or mental harm. During interview, the Administrator stated the incident was not reported to the State because it was determined not to meet abuse criteria, and that only a verbal investigation was conducted with several staff members, with no documentation available for review.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure that food items stored in the main kitchen were labeled, dated, and properly stored, as required by their policy titled 'Food Receiving and Storage.' During a tour of the kitchen, several issues were identified, including a sleeve of waffles in the walk-in freezer that was undated, a half bag of onion rings left open in a box without a label or date, a five-pound box of frozen fish sticks that had been opened and not resealed, and two open containers containing sausage and frozen eggs. These observations indicate a lack of adherence to the facility's policy, which mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated. The Dietary Kitchen Manager (DKM) confirmed during an interview that kitchen staff were expected to label and date each food item received for the facility and properly store food items after opening them. The DKM acknowledged the deficiency and stated that it was her expectation for each staff member to comply with these requirements. The failure to follow these procedures had the potential to affect 55 out of 59 residents receiving an oral diet, as the improperly stored food items could compromise food safety.
Failure to Establish Water Management Program
Penalty
Summary
The facility failed to establish a water management program as part of its overall infection prevention and control program, which is a requirement according to their policy titled 'Infection Prevention and Control Program' revised on 10/28/2022. The policy explicitly states that a water management program should be in place, but upon review, it was found that the facility did not have an established Water Management Plan. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of the plan. The Administrator, who had started working at the facility two weeks prior, identified this issue and planned to address it in the upcoming Quality Assurance Performance Improvement (QAPI) meeting. The facility had a census of 59 residents at the time of the survey.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident, identified as R59, to the State Agency and other officials within the required time frame. The facility's policy mandates immediate reporting, defined as within two hours for allegations involving abuse or serious bodily injury. The incident involved a note received by a CNA, suggesting inappropriate sexual conduct by another CNA with R59, a resident with severe cognitive impairment and multiple diagnoses including cerebral palsy and epilepsy. Despite the policy, the Director of Nursing (DON) did not complete the necessary notifications or documentation, and the Medical Director was not properly informed. Interviews revealed that the accused CNA was sent home, and the reporting CNA was moved to a different hall. The DON did not conduct a skin assessment as documented and failed to notify local law enforcement. The Medical Director was not aware of the incident, and the Human Resource Director confirmed that no investigation findings were placed in the employee files. The Administrator expected immediate reporting of such incidents, but the previous Administrator had not enforced contacting law enforcement, leading to a deficiency in the facility's response to the allegation.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of sexual abuse involving a resident, identified as R59, who has severe cognitive impairment and multiple medical conditions including cerebral palsy and epilepsy. The facility's policy requires all allegations to be thoroughly investigated, with witness statements obtained in writing, signed, and dated. However, nine out of 20 staff interviews lacked names and/or dates, and the investigation was not properly documented. The Director of Nursing (DON) did not complete a skin assessment as noted in the nurse's notes, and there was no confirmation of notification to the Medical Director. Additionally, the local police were not contacted, and the DON believed the allegations were merely rumors. The incident report indicated that a Certified Nursing Assistant (CNA) was accused of inappropriate behavior with R59, leading to the suspension of the accused CNA. The Human Resource Director confirmed that no investigation findings were placed in the employee files. The Administrator expected immediate reporting of abuse allegations, but the previous Administrator did not ensure law enforcement was contacted. The DON and Administrator's interviews revealed inconsistencies in the investigation process, and the facility did not adhere to its policy for handling such allegations.
Failure to Develop Comprehensive Care Plans for Respiratory Therapy
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents receiving respiratory care, specifically for nebulizer therapy for one resident and oxygen therapy for another. Resident R10, who had diagnoses of pneumonia and respiratory failure, had physician orders for nebulizer treatments, but these were not included in the care plan. The care plan only addressed potential impaired gas exchange related to congestive heart failure and oxygen therapy as needed for shortness of breath, omitting the necessary nebulizer therapy. Similarly, Resident R13, diagnosed with anemia, coronary artery disease, and heart failure, had physician orders for nebulizer therapy, but the care plan only included oxygen therapy as needed for shortness of breath, without addressing the nebulizer therapy. Interviews with the unit nurse and the Director of Nursing confirmed the absence of these care plans, acknowledging that all care areas, including medications, diagnoses, and treatments, should be included in the care plans.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain safe water temperatures in resident rooms, leading to potential accident hazards. During an inspection, water temperatures in five resident rooms were found to be significantly above the facility's policy limit of 120 degrees Fahrenheit, with measurements reaching as high as 137 degrees Fahrenheit. This discrepancy was observed despite the facility's policy requiring maintenance staff to regularly check and log water temperatures to ensure they remain within safe limits. The maintenance director confirmed that water temperature checks were conducted monthly, and the facility's logs indicated that previous checks showed temperatures within the acceptable range. However, the recent observations revealed a failure to maintain these standards, as several rooms had dangerously high water temperatures. Fortunately, no residents sustained burn injuries due to the elevated water temperatures at the time of the inspection.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident receiving respiratory care. Specifically, the facility did not properly store the nebulizer mouthpiece for a resident with severe cognitive impairment, pneumonia, and respiratory failure. The resident's treatment plan included the use of a nebulizer for shortness of breath and wheezing. However, observations revealed that the nebulizer jar and mouthpiece were left unbagged and exposed to the environment on the resident's bed and bedside, which could potentially lead to respiratory infections. Interviews with facility staff, including a CNA and the DON, confirmed awareness of the proper storage procedures for respiratory equipment, which involves storing the equipment in a clear plastic bag when not in use to prevent infections. Despite this knowledge, the nebulizer mouthpiece was found uncovered on multiple occasions. The DON acknowledged that the night shift staff were responsible for ensuring proper storage and maintenance of respiratory equipment, but there was no logging system in place to track these tasks, contributing to the oversight.
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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.
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Nursing homes near Commerce
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northridge Health And Rehabilitation | 0.3 mi | ★★★★★ | 0 | 0 |
| Oaks - Athens Skilled Nursing, The | 16.4 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Grandview | 17.3 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Athens Heritage | 17.6 mi | ★★★★★ | 6 | 0 |
| Presbyterian Village - Athens | 18.8 mi | ★★★★★ | 1 | 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.