Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Murray Woods Of Journey Llc during CMS and state inspections, most recent first.
The facility failed to prevent sexual abuse when a cognitively impaired resident with dementia and behavioral disturbances repeatedly wandered into other residents’ rooms and got into their beds, often lying on top of them, despite ongoing documentation and staff awareness of these behaviors. Nursing notes and staff interviews described this pattern as common, with redirection attempts by CNAs and LPNs noted as unsuccessful. Another cognitively impaired resident was later found in bed with this resident on top of her, his pants down and attempting to kiss her while she screamed, and prior concerns had been raised by her family about unexplained blood on her lip and changes in her condition. These events occurred even after environmental changes to a previously locked dementia unit, while staff continued to regard the behavior as typical for the resident.
Insufficient staffing led to delayed ADL care, incontinence care, meal transport, and activities. A cognitively intact resident waited more than 2 hours to be changed and remained in a saturated brief, while a family member and RN confirmed residents were eating meals in their rooms because there were not enough CNAs to bring them to the dining room. Staff also reported weekend staffing was not doable, residents needing mechanical lifts had to wait for 2 staff, and the Resident Council President said activities and socialization were limited because of staffing shortages.
Improper Food Labeling and Dishware Storage in Kitchen: Surveyors found unlabeled and undated leftover foods in the walk-in cooler, including items that appeared to be salad and soups, and observed dishware stored on a drying rack under an AC vent without proper covering or inversion. The dietary aide, Dietary Mgr, and District Dietary Mgr acknowledged the storage and labeling issues.
Administration failed to keep two halls clean, in good repair, and homelike, and failed to protect residents from abuse, including sexual abuse and physical abuse by another resident. The facility also did not timely report or thoroughly investigate abuse allegations, did not develop or provide adequate activity care plans and programs for several residents, had insufficient staffing to meet resident needs, and left the ice machine and primary oven out of service for months.
Kitchen Equipment Not Kept in Working Order. The facility’s ice machine was not producing ice needed for residents, so staff or family members sometimes bought bagged ice, and the primary range oven was out of service and could not be used. A Dietary Aide reported both problems had been ongoing for months, and the Dietary Manager and District Dietary Manager acknowledged awareness of the broken equipment but could not provide documentation showing repair or replacement.
Failure to provide resident activities: The facility did not provide an ongoing activities program based on resident assessments, care plans, and preferences. A cognitively intact resident said staff never invited her to activities or brought supplies to her room, and observations showed no in-room activities. On the secure unit, residents with diagnoses including dementia, schizophrenia, bipolar disorder, stroke-related deficits, COPD, and chronic pain had limited documented activity involvement, scheduled activities were not observed as planned, and the activity calendar showed many days with no activities marked as provided. Staff said activities were not offered daily and were often limited to snacks, nail painting, or occasional simple group events.
A resident who was cognitively intact and dependent on staff for toileting was left soiled for over two hours after repeated call light requests, including while her mother was visiting. Another cognitively intact resident, who needed staff help to have her roommate changed before her daughter arrived, waited without assistance and left her room to meet her daughter elsewhere because of the odor from her roommate’s incontinence. The Administrator confirmed that ignoring residents’ timely incontinence care needs was not treating them with dignity and respect.
Unsafe and Unsanitary Environmental Conditions: The facility failed to maintain a safe, clean, comfortable, and homelike environment on two halls. Observations found a missing baseboard in a resident room, stained and missing floor tiles in a bathroom, a blanket placed under an AC unit to catch leaking liquid, and a buildup of brown/black substance around door jams and wall corners, especially in the day room. The MD said rounds were made to monitor needed repairs, and the Administrator said remodeling would address many of the issues after the facility sale was finalized.
Failure to Protect Residents from Abuse: Staff found one resident in another resident’s room with the female resident crying and undressed, and she stated he touched her breasts and peri-area and that they had almost had sex. The facility did not substantiate the sexual abuse because neither resident remembered it. In a separate incident, one cognitively impaired resident slapped another resident on the buttock after a verbal argument; the administrator said it was not abuse because the resident was cognitively impaired.
Failure to Timely Report Resident-to-Resident Abuse Allegations: The facility failed to report two resident-to-resident abuse allegations to SSA within 2 hours after becoming aware of them. One resident had dementia, agitation, and mobility issues, and another incident involved a severely cognitively impaired resident found with a roommate's hand down the resident's pants. In both cases, the Administrator confirmed the reports were submitted as 5-day follow-up reports days after the incidents, and there was no evidence the required 2-hour reporting timeframe was met.
Incomplete Abuse Investigations: The facility failed to thoroughly investigate allegations of sexual abuse involving two residents and physical abuse involving another resident. The abuse policy required immediate investigation and interviews with all involved persons and anyone with knowledge of the allegations, but the investigative files lacked interviews with the residents involved, staff, and other residents who may have witnessed the events. One resident was found naked after a male resident entered her room and she reported he touched her breasts and peri area; another resident slapped a cognitively intact resident on the buttock, but the file did not document who reported the incident or when the Administrator was notified.
Missing Transfer, Bed Hold, and Ombudsman Notifications: The facility failed to provide written transfer notices and bed hold notices with required details for two residents who were sent to the ER/hospital, and it did not notify the LTC Ombudsman of the transfers. One resident was transferred for hip surgery and later readmitted, while another had SOB, rapid respirations, pale skin, and wheezing before EMS transported the resident to the ER.
MDS assessments failed to accurately reflect a resident’s PASSR II status and another resident’s upper-extremity contracture. One resident with bipolar disorder, depression, and PTSD had an annual MDS that did not show PASSR II even though facility records indicated it was required and completed. Another resident with hemiplegia/hemiparesis had a quarterly MDS showing no upper-extremity ROM limitation despite observation and staff confirmation of a contracted right hand.
A facility failed to develop comprehensive care plans for four residents. One resident's care plan did not address activity preferences despite a cognitively intact MDS showing favorite activities were very important, another resident with hemiplegia, hemiparesis, and a right-hand contracture was not care planned for the contracture or a hand device, and two residents involved in resident-to-resident abuse incidents were not care planned for diversional activities identified in the investigation reports. The Activity Director said she only attended care plan meetings to answer questions and was not educated on revising care plans as needs were identified.
Delayed incontinence care and unanswered call lights were observed for two residents who required staff assistance with toileting and personal hygiene. One resident was cognitively intact but dependent on staff for toileting after fractures and operative repair from a fall, and she reported repeated unanswered call light requests for incontinent care. Another resident with dementia, psychotic disorder, and ESRD was completely dependent for ADLs, wore incontinent briefs, and had a colostomy; her roommate reported the need for a brief change while a strong urine odor was present and the call light remained unanswered.
Failure to address a resident’s right-hand contracture: A resident admitted with hemiplegia and hemiparesis on the right side was observed with a contracted right hand and no device in the palm. The resident confirmed staff did not place a device in the hand, and record review showed no care plan for the contracture. Staff, including the CNA, LPN, DON, and MDSC, confirmed the resident should have had a device in the hand to keep it open and that the contracture was not addressed in the care plan.
The facility failed to ensure adequate nursing staff to meet the needs of its 116 residents, resulting in excessively low weekend staffing and a one-star staffing rating for Quarter 1 of 2024. Despite efforts to use agency staff, the facility's staffing levels were insufficient.
The facility failed to serve the meal listed on the cycled menu, affecting 115 residents. Instead of the listed ham and California vegetable blend, residents received a sloppy joe. Interviews and a photo confirmed the deviation, and the Administrator acknowledged the issue, noting sufficient ingredients were available.
The facility failed to provide a safe, clean, and homelike environment in nine resident rooms and the lobby media common area. Observations revealed pests, damaged fixtures, dirty walls, and crowded furniture. Interviews confirmed these issues, and the Administrator acknowledged the unacceptable conditions, requesting immediate action.
The facility failed to enforce its smoking policy, allowing a resident with serious health conditions to vape unsupervised in his room. Despite the policy requiring supervision and designated smoking areas, the resident was observed vaping multiple times without staff intervention.
The facility failed to ensure residents were free of medication administration errors exceeding 5 percent. One nurse did not have a resident rinse their mouth after using an inhaler, and another nurse did not properly disinfect a PICC line lumen, both actions contrary to facility policies.
A facility failed to follow proper infection control practices when flushing a PICC line for a resident. An LPN was observed wiping the needleless connector only once instead of the required five seconds. The resident had multiple diagnoses, including osteomyelitis and cellulitis, and there was no physician's order for the PICC line flushes. The DON confirmed the expectation to disinfect the connector for at least five seconds.
Failure to Prevent Ongoing Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent sexual abuse between residents and to protect residents from non-consensual sexual contact as required by its Abuse, Neglect, and Exploitation policy. The policy states the facility will prohibit and prevent abuse, neglect, and exploitation, including non-consensual sexual contact of any type with a resident. Despite this, one resident (R1), who had significant cognitive impairment with a BIMS score of 08 and diagnoses including vascular dementia, bipolar disorder, anxiety disorder, and dementia with behavioral disturbances, repeatedly entered other residents’ rooms and beds. Nursing notes over several months documented R1 attempting to go into other residents’ rooms, climbing into their beds, wandering hallways, and being found lying on top of other residents, both male and female, with staff redirection attempts noted as unsuccessful. Multiple nursing notes described specific incidents where R1 was found in bed with other residents. On one occasion, a nurse documented that R1 was found in another patient’s room lying asleep on top of another patient and was assisted off. Another note the same date documented that another patient was in R2’s room and laid down on top of her and went to sleep, and that the other patient was removed and returned to their room. Subsequent notes indicated that R1 continued to try to get into bed with residents and that he was wandering up and down hallways and going in and out of other residents’ rooms, with continued attempts to enter a specific female resident’s room despite redirection. Staff interviews confirmed that it was common and “normal” for R1 to get in and out of bed with other residents and to lie on top of them, and that CNAs routinely reported these behaviors to nursing staff. R2 was a resident who could not complete the BIMS, indicating significant cognitive impairment. A nurse note documented that R2’s daughter was concerned after finding blood on R2’s bottom lip and that R2 was not herself. Later, a nurse note recorded that R2’s responsible party was notified that another resident had been found in bed with R2, with his pants down and his lips on hers. The facility’s investigation included a CNA’s written statement that R1 was found in R2’s bed with his pants and underwear off, on top of R2, holding her by both arms and attempting to kiss her while R2 screamed. Another CNA interview described finding R1 on top of R2 with her arms pinned down, his face very close to hers, and his pants pulled down. Staff, including the Social Services Assistant and LPNs, acknowledged that R1’s behaviors of getting into bed with other residents were ongoing, that redirection was ineffective, and that these behaviors occurred both when R1 was on a locked dementia unit and after the unit doors were removed, yet R1 continued to have access to other residents and their rooms.
Insufficient Staffing Delayed Resident Care and Limited Meals and Activities
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs timely, including assistance with ADLs, dressing, transport to the dining room for meals, incontinence care, activities, and services to prevent further decrease in range of motion for a resident with a contracture. During the initial tour, no residents were in the dining room, and a family member stated residents had been eating all three meals in their rooms on Saturday and again that morning because the facility was short staffed. An RN confirmed the family member’s concerns, and the Administrator acknowledged the facility had reported excessively low weekend staffing and had a one-star staffing rating. The staffing assignment for that day showed one CNA and one nurse on each of four halls for 111 residents, and the RN stated that this was not doable on weekends and that residents needing mechanical lifts had to wait for two staff members. A cognitively intact resident stated she had been waiting more than two hours to be changed, her brief was saturated with urine, and she wanted help using her bedside commode. She reported that a CNA had said staff were short and would return after trays were passed, but the CNA did not return and the resident remained soiled for another hour. CNAs stated they did not stay on the same halls because there were not enough staff, and there were days they could not keep up. The interim Resident Council President stated staffing problems negatively impacted residents’ lives, that the facility did not do many activities because there was not enough staff, and that residents often ate in their rooms because they were not dressed and brought to the dining room for socialization.
Improper Food Labeling and Dishware Storage in Kitchen
Penalty
Summary
The facility failed to ensure refrigerated foods in the walk-in cooler were stored and labeled correctly and that dishware stored under an air conditioner vent was covered and properly inverted. During a kitchen tour, the walk-in cooler contained a large bowl that appeared to be lettuce salad with no label or date, an open container that appeared to be cream of chicken soup with no label or date, and large containers that appeared to be leftover vegetable soup and leftover tomato soup with no label or date. The dietary aide stated the food items should have been labeled or removed from the cooler. The same observation found a four-level rack for drying kitchen dishware located under an overhead air conditioner vent. The rack contained bowls that were not covered but were inverted, and saucers that were not covered and were not inverted. During interview, the Dietary Manager stated dietary employees were to properly label stored foods in the cooler. The District Dietary Manager stated he knew leftover food must be labeled and dated and that dishware needed to be inverted or covered while standing under the air conditioning vent.
Environmental, Abuse, Activity, Staffing, and Kitchen Equipment Deficiencies
Penalty
Summary
Administration failed to ensure residents' environment on two halls, 200 and 400, was clean, in good repair, and homelike. Survey observations and interviews found the facility was still in the middle of remodeling, and the Administrator stated that many of the issues would be resolved once the remodeling was completed and the sale of the facility was finalized by the end of October 2025. Administration failed to ensure residents R33 and R14 were free from abuse. The facility did not identify that R33 was sexually abused by another resident, R57, and did not ensure R14 was protected from physical abuse by another resident. The Administrator stated that the sexual abuse allegation for R33 was not substantiated because neither resident remembered the incident. Administration also failed to timely report allegations of resident-to-resident abuse involving R14 and R12 to the State Survey Agency within two hours, and failed to thoroughly investigate the allegations involving R33 and R14. The investigation did not include interviews with R14, other residents, or staff members. In addition, the facility failed to develop comprehensive activity care plans for R53, R59, R12, and R2, and failed to provide activities for R53, R60, R74, and R97 that matched their needs and preferences. The facility also failed to provide sufficient staff to meet resident needs, and failed to maintain the ice machine and primary oven in working order; the Dietary Manager reported both had been out of service for about six months, and family members had to buy ice for residents.
Kitchen Equipment Not Kept in Working Order
Penalty
Summary
Keep all essential equipment working safely. The facility’s policy titled Equipment stated that all foodservice equipment would be clean, sanitary, and in proper working order, but the ice machine was not providing ice needed for residents and family members had to buy ice for residents. The primary range oven in the kitchen was also not working and could not be used. During a kitchen tour, a Dietary Aide reported that the ice machine had been broken and that staff or family members often purchased bagged ice for residents, and also stated that the primary range oven had not worked for several months and that she did not know when or if it would be repaired. The Dietary Manager stated he had reported the broken ice machine and oven to the Administrator but was not informed when or if the equipment would be repaired. The District Dietary Manager stated he was aware both pieces of equipment had not worked for the past six months and could not provide an order or invoice showing the equipment was being repaired or replaced.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide a program of activities to support residents in their choice of activities for four residents and failed to provide an ongoing activities program designed to support residents’ physical, mental, and psychosocial well-being. The facility policy stated that activities were to be based on each resident’s comprehensive assessment, care plan, and preferences, and were to include group, individual, independent, indoor, outdoor, religious, exercise, social, in-room, individualized, and educational activities. The report identified that the facility did not consistently provide or document activities for residents on the secure unit, and that scheduled activities were not marked as provided on multiple days in September 2025. One resident was cognitively intact with a BIMS score of 14 out of 15 and had MDS-documented preferences indicating that customary routine and favorite activities were very important. The resident stated staff never asked her to attend activities and never came to her room to provide activities or supplies. Observations on two separate occasions showed no activities occurring in the resident’s room, and the September 2025 activity interaction/attendance record showed no activities highlighted on the calendar as being provided. Another resident had diagnoses including idiopathic peripheral autonomic neuropathy, COPD, schizophrenia, bipolar disorder, dementia, anxiety disorder, heart failure, and chronic pain syndrome, resided on the secure unit, and had a BIMS score of 15 out of 15 with independent ambulation. A third resident had diagnoses including hemiparesis and hemiplegia following cerebral infarction, cognitive communication deficit, heart failure, heart disease, COPD, seizures, vascular dementia, bipolar disorder, psychotic disorder, major depressive disorder, and aphasia, resided on the secure unit, and had a BIMS score of 9 out of 15 with moderate cognitive impairment and moderate assist needed for ambulation. A fourth resident had diagnoses including Alzheimer’s disease, COPD, dementia, falls, and chronic pain, resided on the secure unit, and had a severely impaired BIMS score with supervision needed for ambulation. Care plans for some residents noted little activity involvement or limited activity participation, but one resident had no activity-related care plan entry. During observation, the October activity schedule posted on the secure unit listed church at 2:30 p.m., but no church activity was observed during the scheduled time, and the activities aide arrived later with snacks and juice. The activity calendar for the secure unit showed activities were not marked as provided on 25 days in September 2025. Staff interviews indicated activities were not offered daily, and that when activities staff came to the unit they might paint nails or hand out snacks before leaving.
Failure to Provide Timely Incontinence Care and Respectful Visitation Conditions
Penalty
Summary
The facility failed to ensure two residents were treated with dignity and respect. One resident, admitted for short-term rehabilitation after a traumatic fall with fractures and operative repair of the right elbow, wrist, and right knee, had an MDS showing a BIMS score of 15 and was dependent on staff for toileting assistance. During observation, the resident’s call light was on while her mother was visiting, and both stated they had been waiting more than two hours for incontinent care. The resident said she was embarrassed to remain soiled in front of visitors, described pressing the call light twice, and reported that a CNA had silenced the alarm and left without providing care or explaining why she was not being helped. A second resident, who had diagnoses including bipolar disorder and chronic kidney disease and was cognitively intact with a BIMS score of 15, was ambulatory with a rollator and required stand-by and set-up assistance. She was observed standing in the doorway of her shared room with her call light on and stated she needed staff to change her roommate before her daughter arrived because of the odor from the roommate’s incontinence. After waiting without assistance, she left the room and went toward the lobby to meet her daughter there instead of in her room because of the odor. The Administrator stated the facility was short staffed on weekends and confirmed that ignoring residents’ needs for timely incontinence care was not treating them with dignity and respect.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on two of four halls, 200 and 400, based on observations, interviews, and review of the facility policy titled Resident Environmental Quality. The policy stated the facility is to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents. During a tour of the facility, a bedroom in one room had a missing baseboard on the wall holding the sink, leaving an open space between the floor and the sheetrock. In another room, the bathroom floor tile around the base of the toilet was stained black and some floor tiles were missing. On the secure unit on 200 Hall, a blanket was placed under the air conditioning unit to absorb liquid draining from it, and there was a buildup of a brown/black substance around the door jams and in the corners of the walls throughout the unit, especially in the day room. The Maintenance Director stated that rounds were made throughout the facility to monitor items needing repair and said the stained, cracked floor tiles were being replaced as needed. The Administrator stated that once remodeling was completed, many of these issues would be resolved after the sale of the facility was finalized by the end of October 2025.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to ensure two residents were free from abuse: one resident was not protected from sexual abuse by another resident, and another resident was not protected from physical abuse by a different resident. The facility policy defined abuse to include physical, mental, or sexual abuse, including sexual abuse involving a resident who does not have the capacity to decline participation. The report states that the facility did not substantiate the sexual abuse incident because neither resident remembered it, despite the documented observations and resident statements made at the time of the event. For the sexual abuse incident, staff found a male resident standing beside a female resident’s bed while he was trying to button his pants, and the female resident was crying and undressed. Staff separated the residents and dressed the female resident. The female resident stated that the male resident thought she was his wife, that he touched her breasts and peri-area, and that they had “almost” had sex. She also asked whether she would have to leave the facility so he would leave her alone. The female resident had diagnoses including dementia with behavioral disturbance, cognitive communication deficits, and psychotic disorder, and her BIMS score was 3, indicating severe cognitive impairment. The male resident also had dementia with behaviors, visual hallucinations, cognitive communication deficits, and a BIMS score of 3. For the physical abuse incident, one resident slapped another resident on the left buttock after a brief verbal argument at the nurses’ station. The resident who was slapped had no redness noted and was returned to her room. The resident who slapped her had dementia with severe cognitive impairment and a history of anger and difficulty being redirected. The administrator stated there was no resident-to-resident abuse because the resident who slapped the other was cognitively impaired, and the injured resident confirmed that she was not harmed beyond mild sensitivity and no redness.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse to the State Survey Agency within 2 hours after becoming aware of the allegations for two residents. The facility policy titled, Abuse, Neglect and Exploitation, revised 3/5/2024, stated that the facility would notify the appropriate agencies immediately, as soon as possible, but no later than 2 hours after discovery or forming suspicion. For one incident, R2, who had diagnoses including cognitive communication deficit, dementia with agitation, early onset Alzheimer's disease, and mobility abnormalities, had an incident on 8/23/2025 at 5:21 PM that was reported to the DON, but there was no documentation showing when the Administrator was notified. The Administrator later confirmed the investigation report was submitted to the SSA as a 5-day follow-up report on 9/1/2025, nine days after the incident. For a second incident, R55, who had diagnoses including COPD, early onset Alzheimer's disease, dementia with agitation, dysphagia, major depressive disorder with psychotic features, and moderate intellectual disabilities, was found in bed when roommate R12 was observed with his hand down R55's pants and had to be removed by staff. R55 was severely cognitively impaired based on the MDS, and R12 was also severely cognitively impaired with a BIMS score of 3 out of 15 and diagnoses including dementia with psychotic disturbance and neurocognitive disorder with Lewy bodies. The progress notes documented that the responsible party, physician, and Administrator were notified, and the Administrator confirmed the SSA report was submitted as a 5-day follow-up report on 2/17/2025, six days after the incident. He could not provide evidence that the allegation of sexual abuse was reported within 2 hours.
Incomplete Abuse Investigations
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving one resident and an allegation of physical abuse involving another resident. The facility policy titled, Abuse, Neglect and Exploitation, required an immediate investigation of any report or allegation of abuse and included identifying and interviewing all involved persons, including the alleged victim, the alleged perpetrator, and any staff or residents who may have knowledge of the allegations. For the sexual abuse allegation, the investigation documented that a male resident entered a female resident’s room and was found trying to put his pants back on while the female resident was lying naked on her bed and stated he touched her breasts and peri area and that they had sex "almost." However, the investigative file did not include interviews with staff, the two residents involved, or other residents on the secure unit. For the physical abuse allegation, documentation showed one resident slapped another resident on the buttock, but the investigative file lacked documentation of who reported the allegation, when the Administrator was notified, and statements from staff or residents who may have witnessed the incident. The Administrator confirmed the investigation did not include interviews with the resident who was slapped, other residents, or staff members.
Missing Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide written transfer notices and written bed hold notices with all required information for two residents, and it also failed to notify the Long-Term Care Ombudsman of their hospital transfers. The facility policy titled Transfer and Discharge stated that transfer/discharge notices must be given to the resident and resident representative in a language and manner they can understand and must include the specific reason and basis for transfer or discharge, the specific location of transfer, appeal rights, the state entity receiving appeal requests, and the name, address, and phone number of the Office of the State Long-Term Ombudsman. The Bed Hold Policy stated that the resident and a family member or legal representative would be notified of the bed hold policy at admission and upon transfer from the center. For one resident, progress notes showed transport to the ER for a hospital transfer followed by readmission after hip surgery, but the EMR contained no documentation that the resident or resident representative received the transfer notice or bed hold policy for that transfer. For the second resident, progress notes showed the resident had shortness of breath, rapid respirations, pale skin, and wheezing, and EMS was called to send the resident to the ER; later notes showed return from the hospital via EMS. The Administrator confirmed the facility did not send the bed hold policy or notice to the resident representative and also confirmed the facility did not notify the Ombudsman of the residents' hospital transfers.
MDS assessments failed to accurately reflect PASSR II status and contracture
Penalty
Summary
The facility failed to ensure the comprehensive assessment accurately reflected PASSR level II status for one resident. The resident was admitted with diagnoses of bipolar disorder, depression, and PTSD. Review of the annual MDS with an ARD of 1/8/2025 showed the resident did not require PASSR level II, even though the facility’s PASSR level I documentation indicated the resident required PASSR level II and that level II had been completed by the facility. The MDSC confirmed that the PASSR II was not correctly documented on the resident’s MDS. The facility also failed to ensure the comprehensive assessment accurately reflected contractures for another resident. The resident was admitted with complete paralysis and partial weakness or paralysis on the right dominant side. Review of the quarterly MDS with an ARD of 8/19/2025 showed no functional limitation in range of motion in the upper extremities, but observation of the resident showed the right hand was contracted. LPNs confirmed the resident could not open the right hand and that it was contracted, and the DON confirmed the resident could not open the hand due to contracture. The MDSC confirmed the resident’s MDS should indicate an impairment to the upper extremity.
Incomplete Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for four of 31 residents, including R53, R59, R12, and R2, as identified through interview, record review, and review of the facility policy titled "Comprehensive Care Plans." The policy stated that the facility was to develop and implement a comprehensive person-centered care plan for each resident, address all services identified in the comprehensive assessment, and review and revise the care plan after each comprehensive and quarterly MDS assessment. The deficiency was based on the absence of care plan content for identified resident needs and preferences. R53's care plan dated 2/5/2024 did not address her activity preference, even though her quarterly MDS with an ARD of 1/21/2025 showed a BIMS score of 14 out of 15 and indicated it was very important for her to do her favorite activities. R53 stated staff never asked her to attend activities and did not provide activity supplies for her in her room, and observations on 9/28/2025 and 9/29/2025 found no activities occurring with her in her room. R59's care plan dated 4/24/2023 did not address his right-hand contracture, despite his admission record showing hemiplegia and hemiparesis on the right dominant side and his quarterly MDS with an ARD of 11/26/2024 showing a functional limitation in range of motion with upper extremities; observations showed his right hand contracted without a device, and staff confirmed no device was present. R12 and R2 were both involved in resident-to-resident abuse incidents, and each investigation report identified diversional activities as an immediate intervention, but their care plans did not identify diversional activities or specify what activities were to be provided. The Activity Director stated she attended care plan meetings only to answer questions and was not educated on the purpose of the care plan or revising it as resident care needs were identified, and the Administrator stated he assumed the Activity Director was completing or updating activity care plans.
Delayed Incontinence Care and Unanswered Call Lights
Penalty
Summary
The facility failed to provide timely incontinence care for two residents reviewed for ADL assistance. The facility policy titled Activities of Daily Living (ADL) stated that residents who are unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. Review of one resident’s record showed she was admitted for short-term rehabilitation after a traumatic fall at home with fractures and operative repair of her right elbow, wrist, and right knee. Her MDS indicated she was cognitively intact with a BIMS score of 15 out of 15, but dependent on staff for toileting and required one staff member to assist her with use of her bedside commode. During observation, she reported that she had activated her call light twice over a two-and-a-half-hour period requesting incontinent care, including one request that had gone unanswered for about two hours and another call light activation that remained unanswered while staff entered, silenced the alarm, and left without explaining why. A second resident’s record showed diagnoses including dementia, psychotic disorder, and ESRD. Her quarterly MDS indicated a BIMS score of 4 out of 15, severe cognitive impairment, complete dependence on staff for all ADL care, use of incontinent briefs, and a colostomy, with incontinence care planned as needed. During observation, the roommate stood in the doorway with the call light on and stated she needed someone to change the resident before her daughter arrived. There was a strong urine odor in the room and hallway, and about 20 minutes later the call light was still engaged with no staff response. The DON stated she would be addressing staffing concerns first to improve residents’ overall care and their perception of wellbeing.
Failure to Address Resident’s Right-Hand Contracture
Penalty
Summary
The facility failed to ensure a resident admitted with hemiplegia and hemiparesis on the right dominant side received services to maintain or improve range of motion for a contracted right hand. During observations, the resident’s right hand was contracted and there was no device in the palm of the hand. The resident confirmed that staff did not place a device in the contracted right hand. Record review showed the resident was admitted with complete paralysis and partial weakness or paralysis on the right side, and the quarterly MDS indicated a functional limitation in range of motion with the upper extremities. The care plan dated 4/24/2023 did not include a care plan for the resident’s right-hand contracture. Staff interviews confirmed the resident could not open the right hand, had no device in the hand, and should have a device placed in the palm to keep the hand open and prevent the contracture from worsening; the DON and MDSC also confirmed the absence of a device and the lack of a care plan for the contracture.
Inadequate Nursing Staff
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of its 116 residents. The Facility Assessment Tool (FAT) for 2024 indicated that the average daily census was 112 residents, requiring 84 hours of licensed nurses and 233 hours for nurses' aides per day. However, the Payroll-Based Journal (PBJ) Staffing Data Report for Quarter 1 of 2024 revealed that the facility had excessively low weekend staffing and received a one-star staffing rating. This rating was due to several factors, including failure to submit PBJ data by the deadline, more than four days in the quarter without RN staffing hours, and failure to respond to or pass a CMS audit for PBJ data discrepancies. Interviews with the Director of Nursing (DON) and the Human Resources Director/Nursing Scheduler (NS) revealed that they were unaware of the one-star staffing rating and excessively low weekend staffing. The DON mentioned that extra staff were scheduled for weekends to cover call-offs, and the NS stated that agency staff were used to meet staffing numbers. However, the Administrator acknowledged awareness of the staffing issues and mentioned efforts to subsidize with agency staff. Despite these efforts, the facility's staffing levels were insufficient to meet the residents' needs, leading to the identified deficiency.
Failure to Serve Menu-Listed Meal
Penalty
Summary
The facility failed to serve the meal listed on the cycled menu for residents who received an oral diet from the kitchen. Specifically, the cycled menu stated ham and California vegetable blend was to be served for dinner, but instead, a sloppy joe was served. This deficiency affected 115 of 116 residents who received an oral diet from the kitchen. The facility policy titled 'Menus' updated in February 2017, mandates that all residents receive the meal stated on the weekly menu, which was not followed in this instance. The weekly menu cycle for the week of Sunday, 5/26/2024, indicated that residents were to receive glazed baked ham, pinto beans, broccoli, and cornbread, but this was not adhered to. Interviews with residents and staff revealed dissatisfaction with the meal served. Residents reported receiving a bag of potato chips and a spoon of watered-down sloppy joe chili on a slice of white bread instead of the listed menu items. A photo taken by a resident confirmed this. During a Resident Council meeting, several alert and oriented residents confirmed they received sloppy joe on a slice of bread instead of glazed ham. The Corporate Registered Nutritionist and the Administrator acknowledged receiving complaints and confirmed that there was sufficient ham and hamburger buns available in the kitchen. The Cook responsible for serving the meal did not provide an explanation for the deviation from the menu. The Administrator expressed shock and disappointment in the Cook's behavior, noting that she is a seasoned kitchen cook.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in nine of 53 resident rooms on two of four halls, and in the lobby media common area. Observations revealed multiple deficiencies including the presence of pests (flies), damaged floor fall strips, dirty wall sheetrock, dirty privacy curtains with missing hanging hooks, stained and damaged floor tiles, damaged bathroom toilet commodes, damaged baseboards, dirty and broken PTAC unit vent covers, damaged soap dispensers, and crowded furniture in the lobby media common area. Specific rooms were noted to have flies on residents' pillows and floors, dirty walls, damaged floor fall strips, unattached soap dispensers, dirty PTAC units, missing paint on bedroom sinks, big holes in walls, and damaged bathroom fixtures. Additionally, the lobby media common area was observed to have crank beds pushed against the wall, creating a crowded environment for residents watching television. Interviews with the Administrator, Assistant Maintenance Director (AMD), and Housekeeping/Laundry Director (HLD) confirmed the presence of pests, damaged and dirty fixtures, and crowded furniture. The HLD mentioned that a cleaning audit of privacy curtains was in progress, and the AMD stated that pest control services had been conducted but was unsure of the specific measures taken for flies. The Administrator acknowledged the unacceptable conditions and requested immediate action to address the issues. The AMD also confirmed and fixed the missing back of the commode top in one of the rooms during the walk-through.
Failure to Enforce Smoking Policy
Penalty
Summary
The facility failed to enforce its smoking policy adequately for one resident, allowing him to vape unsupervised in his room. The facility's policy required that electronic cigarettes be used only in designated smoking areas under supervision. Despite this, the resident was observed multiple times vaping in his room without supervision. The resident's medical record indicated several serious health conditions, including cerebral infarction and psychotic disorder, and his care plan included specific interventions to ensure safety during smoking times. However, these interventions were not followed, as evidenced by the repeated observations of the resident vaping in his room. During the survey, the resident was seen vaping in his room on several occasions, and staff members did not notice or address the vaping device on the bedside table. The Director of Nursing and the Administrator confirmed that vaping in rooms was against the facility's policy and that staff were required to confiscate vaping devices and ensure residents only vaped under supervision. Despite this, the resident continued to vape unsupervised, indicating a failure in policy enforcement and staff supervision.
Medication Administration Errors Exceeding 5 Percent
Penalty
Summary
The facility failed to ensure that residents were free of medication administration errors of more than 5 percent. Specifically, one nurse did not have a resident rinse their mouth after administering a Breo inhaler, which is required per manufacturer recommendations. The resident, who had moderate cognitive impairment and was diagnosed with Parkinson's disease and chronic obstructive pulmonary disease (COPD), did not rinse their mouth after the inhaler was administered. The nurse acknowledged forgetting this step when questioned immediately after the administration. Another nurse failed to properly disinfect the lumen of a peripherally inserted central catheter (PICC) line for a resident with osteomyelitis of the vertebra, obstructive and reflux uropathy, and cellulitis of both lower legs. The nurse only wiped the needleless connector once with an alcohol wipe instead of performing a vigorous mechanical scrub for five seconds as required by the facility's policy. When asked about the proper procedure, the nurse admitted to not knowing the correct duration for disinfecting the PICC line port.
Improper Infection Control Practices for PICC Line Flushing
Penalty
Summary
The facility failed to use proper infection control practices when flushing a needleless connector of a peripherally inserted central catheter (PICC) for a resident (R111). The facility's policy required disinfecting the needleless connector with an antiseptic solution using a vigorous mechanical scrub for five seconds and allowing it to dry completely. However, during an observation of medication administration, an LPN was seen wiping the alcohol wipe across the needleless connector just once before flushing the catheter and again wiping it once before applying the cap. This practice did not comply with the facility's policy and had the potential to cause infection for the resident. The resident, R111, was admitted with diagnoses including osteomyelitis of the vertebra, obstructive and reflux uropathy, and cellulitis of the right and left lower legs. The resident's care plan included administering IV antibiotic medications as per the medical doctor's order. However, there was no physician's order for the PICC line flushes in the electronic medical record. When interviewed, the LPN could not specify the required time for disinfecting the PICC line port, and the Director of Nursing confirmed that nurses should disinfect the needleless connector for at least five seconds, as per the facility's policy.
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.
Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — 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 Chatsworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Park Health And Rehabilitation | 11.5 mi | ★★★★★ | 6 | 0 |
| Quinton Mem Hc & Rehab Center | 11.5 mi | ★★★★★ | 0 | 0 |
| Ridgewood Manor Health And Rehabilitation | 11.6 mi | ★★★★★ | 2 | 0 |
| Parkside Center For Nursing And Rehab At Ellijay | 18 mi | ★★★★★ | 8 | 0 |
| Calhoun Crossing Of Journey Llc | 18.7 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.