Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Atlantic Specialty Care during CMS and state inspections, most recent first.
Failure to provide written transfer, ombudsman, and bed-hold notifications: The facility did not give the resident representative written notice of a hospital transfer or notify the state ombudsman for one resident, and it did not document bed-hold and reserve bed payment information for two residents. One resident had severe cognitive impairment and was transferred after a fall, while another resident with cancer, HF, and respiratory failure was transferred for breathing difficulty and later diagnosed with PNA. Staff stated the transfers were emergent and could not locate the required written documentation.
Late Admission MDS Submission: A resident with a BIMS score of 15/15 had an admission MDS that remained in progress past the required timeframe. The MDS Coordinator said she had been working on the floor and needed help from other facilities and an RN travel MDS staff member to complete submissions, while the DON and Regional Nurse Consultant acknowledged the facility was using a hybrid MDS process and that MDSs needed to be submitted timely per the RAI Manual.
Care plan failed to address a resident’s high-risk medication needs and wandering risk. The resident had moderately impaired cognition, vascular dementia with agitation and restlessness, required assistance with mobility, received Lorazepam for restlessness and agitation, and had repeated high wandering risk scores. Review of the care plan showed no documentation of the antianxiety medication, related side effects or monitoring needs, and no interventions for wandering; the DON acknowledged these omissions.
Incontinence care was not provided according to facility policy for a resident who was dependent for all ADLs, had severely impaired cognition, and was always incontinent of bowel and bladder. During observation, two CNAs cleaned the resident with only one wipe per area and did not complete the full pericare process described by staff, including separate wipes for different areas and cleaning the penis tip. The CNA acknowledged missing steps, and the DON stated staff should have followed the policy.
Wheelchair Not Locked During Mechanical Lift Transfer: A resident with severely impaired cognition, dementia, stroke, MS, hemiplegia, and total dependence for ADLs was transferred from bed to a wheelchair using a mechanical lift by two CNAs. The wheelchair was left unlocked while the resident was lowered onto it, and the brakes were not applied until after the resident was seated. Both CNAs stated the wheelchair should have been locked, and one said she forgot to lock it; the DON later confirmed the brakes should have been locked.
Failure to administer ordered vaccinations: one resident with intact cognition and diagnoses including Parkinsonism, HTN, and respiratory failure did not receive the annual flu vaccine despite a physician order and signed consent, with no order entered in the EHR and no documentation of administration. Another resident with severe cognitive impairment and diagnoses including a hip fracture and dementia did not receive the pneumococcal vaccine despite a physician order and signed consent, and the EHR also lacked an order and administration record. The DON stated the residents had consented but the facility had not given the vaccines yet.
Staff did not consistently monitor or document food temperatures at the steam table before and after meal service, resulting in food being served below required temperatures. Two residents reported that food was often cold, both in the dining room and on room trays. Review of temperature logs showed incomplete documentation, and staff acknowledged that temperature checks and logging were expected but not performed as required.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including undated and improperly stored food items, incomplete temperature and sanitizing logs, inconsistent hand hygiene, and failure to follow facility policies for food safety. Staff were observed using improper glove techniques, not dating food products, and failing to maintain cleanliness and temperature records as required.
A resident with CHF and related diagnoses did not receive consistent monitoring of weights and vital signs as required by the care plan and physician orders. Staff failed to administer PRN diuretic medication despite documented symptoms of edema and shortness of breath, and there were gaps in documentation of daily weights and skilled assessments. Nurses were unaware of the PRN order and lacked clear parameters for its use, and the facility did not have policies for CHF-related monitoring.
A resident with severe cognitive impairment and a history of pressure ulcers was repeatedly found without required protective boots and wound dressings, despite care plans and physician orders directing their use. Staff did not consistently follow protocols for reapplying dressings or ensuring protective devices were in place, and the resident was observed with exposed feet and missing treatments on multiple occasions. The DON confirmed expectations for prompt replacement of dressings, but these were not reliably met.
An unlocked and unattended medication cart was found in a hallway near resident rooms after a CMA left it unsecured while administering medications and then walked away to speak with a nurse. The DON confirmed that staff are expected to keep medication carts locked when not in view, in accordance with facility policy.
A resident did not receive a full serving of pureed baked beans as required for their modified diet, after the food dried up during preparation and was still served in an incomplete portion. The facility's policy did not specifically address portion sizes for mechanically altered diets, and staff did not prepare additional food to meet the serving requirement.
A resident with a history of CHF, acute respiratory failure, and recent heart surgery did not have vital signs documented on multiple occasions, even though nursing notes indicated the task was completed. The DON confirmed that daily skilled assessments, including vital signs, were expected, and facility policy required complete and accurate documentation.
A CNA failed to change gloves after adjusting a soiled brief for a resident with an indwelling catheter and colostomy, then touched other surfaces with the same gloved hand. Facility policy required glove changes and hand hygiene, but these practices were not followed during care.
Two residents with normal cognitive function and adequate hearing reported hearing staff swearing in the hallways, which was upsetting to them. The facility's policies emphasize treating residents with dignity, but the Regional Nurse Consultant acknowledged that such language would be distressing, indicating a failure to adhere to these standards.
Two residents experienced falls resulting in injuries, but the facility failed to complete required neurological assessments. One resident had a hematoma after an unwitnessed fall, and another had a hematoma and skin tears after a scooter accident. Incomplete assessments and delayed physician notifications were noted, contrary to facility policy.
A facility failed to provide adequate nursing staff, resulting in delayed call light responses for several residents. One resident experienced incontinence and falls due to long waits, while others reported delays of up to an hour. Staff acknowledged response times could exceed 15 minutes, especially during peak hours. Facility grievances and Resident Council Minutes highlighted concerns about untimely responses and staff inattentiveness.
The facility failed to implement proper hand hygiene and infection control during medication administration. A CMA did not consistently perform hand hygiene between residents, and another CMA failed to use appropriate PPE and hand hygiene when administering medications to residents with enhanced barrier precautions. These actions violated the facility's policies on hand hygiene, medication administration, and catheter care.
The facility failed to ensure wheelchair safety for two residents by not using foot pedals while pushing them, contrary to the facility's guidelines. One resident with normal cognitive function was pushed without foot pedals, and another with moderate cognitive impairment was pushed without a leg rest. Staff confirmed the requirement for foot pedals to prevent injury.
The facility inaccurately submitted staffing data for the CMS PBJ report, indicating excessively low weekend staffing. Review of daily assignment sheets showed similar staffing levels for weekdays and weekends, with three CNAs frequently on overnight shifts. The Administrator confirmed the incorrect submission, citing a lack of weekend management as the cause, an issue also affecting other corporate facilities.
The facility failed to serve food at appetizing temperatures to several residents, with reports of cold and overcooked meals. Observations showed food temperatures below safe levels, and staff interviews suggested issues with the delivery system. Residents expressed dissatisfaction, and the facility's policy emphasized maintaining proper food temperatures to prevent pathogen growth.
The facility failed to follow infection control protocols during resident care and medication administration. A CNA improperly wore a gown during catheter care, and two staff members did not don gowns for a resident with a catheter. A CMA neglected hand hygiene during medication rounds. Additionally, a resident with MASD reported discomfort due to prolonged bedpan use, and a CNA did not change gloves or perform hand hygiene while searching for cream. These actions reflect deficiencies in the facility's infection prevention practices.
The facility failed to provide timely assessments and interventions for residents, leading to significant deficiencies in care. A resident with severe cognitive deficits and multiple health conditions was not monitored for vital signs after a hospital stay, resulting in her passing away. Another resident experienced significant weight loss due to refusal of a nutritional supplement, with no notification to the physician or dietician. Additionally, a resident at risk for dehydration was not monitored for urinary output, and another resident did not receive required neurological assessments after a fall.
The facility failed to respond to call lights in a timely manner for 11 residents, leading to significant delays in care. A resident was left on a bedpan for over 50 minutes, while another had to transfer himself to the bathroom due to delays. Residents reported call light response times of 30-60 minutes, particularly at night, and the grievance log revealed multiple complaints about delayed responses. The DON acknowledged call light audits but denied reports of incontinence due to delays.
The facility failed to accurately document MDS information for two residents. One resident's MDS incorrectly noted anticoagulant use, conflicting with physician orders for antiplatelet medication. Another resident's MDS inaccurately recorded bed rails as restraints, while orders specified assist bars for repositioning. The DON and MDS Coordinator acknowledged the errors.
A resident with severe cognitive impairment did not have a comprehensive care plan addressing activities, as required by facility policy. Observations showed the resident was not engaged in activities, and staff confirmed the absence of a care plan. The DON acknowledged the resident's interests but noted the lack of personalized activity planning.
The facility failed to update care plans for two residents after changes in their medication orders. One resident's insulin was discontinued, but the care plan was not updated. Another resident's care plan inaccurately classified an antiplatelet medication as an anticoagulant. These actions were contrary to the facility's policy requiring care plan revisions following changes in condition or medication.
A resident with chronic skin damage did not receive prescribed treatments, leading to discomfort and pain. The resident, dependent on staff for care, reported that barrier cream was not applied as ordered, particularly after dialysis sessions. A CNA found the resident with a raw area lacking treatment, prompting an RN to apply the necessary cream and padding.
A facility failed to provide resident-centered activities for a cognitively impaired resident, lacking a care plan that incorporated the resident's known interests such as coffee and movies. Observations showed the resident was often unengaged during activities, and staff interviews confirmed the absence of a structured activity plan, despite the facility's policy to support residents' well-being.
A facility failed to provide restorative therapy for a resident with hemiplegia following a cerebral infarction. The resident's care plan included therapy sessions three times weekly, but no documentation was found for May, and the facility lacked a restorative staff member. Interviews revealed the resident was discharged from therapy after reaching maximum potential, and the Director of Nursing confirmed the absence of a restorative aide, contrary to facility policy.
A facility failed to follow physician orders and policies for a resident with a PEG tube. The resident's feeding was set at 70 mL/hr instead of the ordered 60 mL/hr, and medications were administered via a piston syringe rather than by gravity flow. The DON confirmed that the orders were not followed, resulting in insufficient formula and water administration.
A facility failed to conduct post-dialysis assessments for a resident with chronic kidney disease and other health issues. The resident, who had intact cognitive ability, was admitted after a hospital stay and received hemodialysis treatments. The care plan required monitoring for renal insufficiency, but post-dialysis assessments were not completed on multiple occasions. The ADON acknowledged the missing assessments, which were required on dialysis days.
A resident with severe cognitive deficits experienced an unwitnessed fall, resulting in a laceration. Although the facility's policy required vital signs to be documented during neurological assessments, the resident's records lacked this information on several occasions. The DON confirmed that staff were expected to record new vital signs with each assessment.
Two residents reported being treated without dignity and respect in the facility. One resident was left on a bedpan for over 50 minutes, causing distress due to a sore, while another was scolded for drinking water and found without bedding. Staff were reported to have withheld water and responded sarcastically to requests for assistance. Additionally, a grievance highlighted rude behavior from a staff member during a resident's hospital transfer.
Failure to Provide Written Transfer, Ombudsman, and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written notification to the resident's representative and the state ombudsman when Resident #8 was transferred to the hospital. Resident #8 had a BIMS score of 03 out of 15 indicating severely impaired cognition, with diagnoses including a right hip fracture and non-Alzheimer's dementia. After a fall with a fracture and later a hospital transfer, the incident documentation noted the family was made aware, but the record did not include the required ombudsman notification for the hospitalization and did not contain written notification to the resident's representative explaining the reason for the transfer. The facility also failed to provide bed-hold and reserve bed payment information for Resident #6 and Resident #8. Resident #6 had diagnoses including cancer, heart failure, and respiratory failure, and was transferred to the hospital for breathing difficulty and later diagnosed with pneumonia. Resident #8 was transferred to the hospital after a fall. For both residents, the EHR Standard Evaluations section did not include documented bed-hold authorization with reserve payment information, and staff could not locate written notification to the resident's representative about the bed hold or the reason for the hospital transfer. Staff interviews confirmed the facility had not been notifying resident representatives in writing because the transfers were emergent, and the DON stated the nurse should have called the family about the bed hold and transfer and that the transfer should have been reported to the Ombudsman.
Late Admission MDS Submission
Penalty
Summary
The facility failed to complete and submit the admission MDS within the required time frame for one resident. Resident #83’s MDS assessment showed a BIMS score of 15/15, indicating normal cognition. The electronic clinical record showed the admission MDS, dated 3/30/26, was still in progress on 4/8/26, with an ARD of 4/6/26, making the admission MDS 2 days overdue. On 4/9/26, the MDS page showed the admission MDS as export ready. The resident’s clinical census record showed admission to the facility on [DATE], and the resident stated on 4/6/36 at 1:34 PM that she had been in the facility for 2 weeks. On 4/8/26, the MDS Coordinator acknowledged the admission MDS had not been submitted and was late, stating she had been working on the floor and needed assistance from other facilities and Staff A, RN/Travel MDS. Staff A stated she was assisting with MDS submission because staff from other facilities may not be an RN, which is required for MDS submission. The DON stated the MDS Coordinator had been working as a Charge Nurse due to increased census and staffing needs, and the Regional Nurse Consultant stated the facility had been using a Hybrid MDS to help complete and submit MDSs. Staff concurred the MDSs needed to be submitted timely according to the RAI Manual, which states the admission assessment can be no more than 14 days from the date of admission.
Care Plan Did Not Address High-Risk Medication or Wandering Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #54 that addressed identified risk factors and interventions. The resident’s MDS dated 1/30/26 showed a BIMS score of 03, indicating moderately impaired cognition, and documented diagnoses of vascular dementia with agitation and restlessness. The MDS also showed the resident required supervision/touching assistance with transfers and ambulation and received antianxiety medication during the last 7 days. A physician order dated 2/5/26 directed Lorazepam 0.5 mg by mouth twice a day for restlessness and agitation. Resident #54’s wandering evaluations documented high wandering risk scores of 16 on 11/21/25, 17 on 12/4/25, and 13 on 1/20/26. Review of the care plan with target date 5/10/26 showed the antianxiety medication, its potential side effects, and what to monitor for while taking the high-risk medication were not addressed on the comprehensive care plan. The care plan also did not address the resident’s wandering risk or interventions for wandering. The DON acknowledged on 4/8/26 that the antianxiety medication and wandering had not been addressed on the care plan and stated the care plan was updated on 4/7/26 and 4/8/26, respectively.
Incontinence Care Not Completed Per Facility Policy
Penalty
Summary
Appropriate incontinence care was not provided for a resident who was dependent for all ADLs and mobility and always incontinent of bowel and bladder. The resident’s MDS identified severely impaired cognition, diagnoses of non-Alzheimer’s dementia, stroke, multiple sclerosis, and hemiplegia, and the care plan directed staff to clean the peri-area with each incontinence episode. The care plan also indicated the resident was dependent with toileting and required 2-person staff assistance. During observation of incontinence care, two CNAs provided peri-care after an incontinent episode, but the care was not completed according to the facility’s described process. One CNA wiped the resident’s entire perineal area once and discarded the wipe, then removed gloves and sanitized hands before putting on a new pair of gloves. The other CNA removed the remainder of the brief, wiped the anal area once, and discarded the wipe. Staff later stated that pericare should include removing the brief and using separate periwipes for different areas, including cleaning the penis tip and retracting the foreskin if applicable. The CNA involved acknowledged forgetting to use separate wipes and to clean the penis tip. The facility’s perineal care policy directed staff to retract the foreskin of an uncircumcised male and wash and rinse the urethral area using a circular motion, and the DON stated staff should have followed the policy.
Wheelchair Not Locked During Mechanical Lift Transfer
Penalty
Summary
The facility failed to lock the wheelchair for a resident who was dependent on mechanical lift transfers. Resident #49 had a BIMS score of 07 out of 15, indicating severely impaired cognition, and diagnoses included non-Alzheimer's dementia, a stroke, multiple sclerosis, and hemiplegia. The resident was dependent with all ADLs and mobility, required supervision with eating, and was always incontinent of bowel and bladder. The care plan also identified bladder incontinence and directed staff to clean the peri-area with each incontinence episode, and noted the resident was dependent with toileting and required 2-person staff assistance. During a continuous observation, two CNAs transferred the resident from bed to a wheelchair using a mechanical lift. Both staff positioned the sling under the resident, connected it to the lift, and raised the resident off the bed. One CNA positioned the resident in front of the wheelchair while standing behind the unlocked wheelchair, grabbed the sling, and used it to position the resident over the wheelchair cushion. The other CNA lowered the resident onto the wheelchair cushion, and the wheelchair brakes were not locked until after the resident was seated. Both CNAs stated a wheelchair should be locked when lowering a resident onto it, and one stated she forgot to lock the wheelchair during the transfer. The DON later stated staff should have locked the wheelchair brakes.
Failure to Administer Ordered Vaccinations
Penalty
Summary
The facility failed to provide the recommended influenza vaccine for one eligible resident and the recommended pneumococcal vaccine for one eligible resident. Resident #2 had intact cognition with a BIMS score of 13, diagnoses including Parkinsonism, high blood pressure, and respiratory failure, and was admitted without having received the seasonal influenza vaccine. Although a physician order allowed the annual flu vaccine and the admission documents included a signed vaccination consent form, the EHR medication list showed the influenza vaccine was never ordered, the vaccination tab did not document administration, and the care plan did not include a vaccination focus category. An encounter progress note later documented the resident’s most recent influenza vaccine as having been given on 10/06/23. Resident #8 had severely impaired cognition with a BIMS score of 03, diagnoses including right hip fracture and non-Alzheimer’s dementia, and was admitted after receiving the influenza vaccine but without having received the pneumococcal vaccine. A physician order allowed the pneumococcal vaccine if applicable, and the consent form indicated the resident consented to receive it; however, the EHR medication list showed the pneumococcal vaccine was never ordered, the vaccination tab did not document administration, and the care plan did not include a vaccination focus category. A progress note later entered pneumococcal vaccine as declined/historical with complete consent form, and the DON stated the residents had consented to the vaccinations but the facility had not administered them yet.
Failure to Monitor and Document Food Temperatures During Meal Service
Penalty
Summary
The facility failed to prepare, serve, and distribute food in accordance with professional standards, specifically by not consistently taking and documenting food temperatures at the steam table before and after meal service. Observations showed that food items were placed on the steam table an hour before service began, and meal service lasted over an hour, yet staff did not take temperatures at the steam table prior to or at the completion of meal service. Additionally, a sample tray returned to the kitchen after meal service revealed food temperatures below required serving standards. Review of food temperature logs for three months showed incomplete documentation, with 33% of required entries missing. Resident interviews indicated dissatisfaction with food temperatures, with one resident stating that food was not served at appropriate temperatures in both the dining room and in-room trays, and another resident reporting that food was often cold in the dining room. Staff interviews confirmed expectations that temperatures should be taken and logged before and after meal service, and the facility's policy required monitoring of food temperatures throughout the meal. The FDA Food Code was also referenced, indicating the need for daily oversight of cooking temperatures.
Deficiencies in Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's kitchen. The walk-in cooler lacked an interior thermometer and contained opened, undated food items, including cake, canned fruit, and a jug of Half and Half with an expired date and improper covering. The walk-in freezer had an unsealed, undated bag of ravioli, and the milk cooler exhibited thick, darkened frost. Additional issues included undated opened milk and a yellow substance in the reach-in refrigerator, as well as undated, opened packages of cookies and pasta in the pantry. The food preparation area was found to be dirty, with food remnants and crumbs present. Temperature logs for refrigeration units and sanitizing equipment were incomplete or missing for several days across multiple months. During meal preparation and service, staff were observed failing to consistently follow hand hygiene protocols, including donning gloves without handwashing and touching both food and packaging with the same gloves. Staff also failed to date and properly store food items, with several opened and undated products used in meal preparation. There were inconsistencies in checking and recording food temperatures before and after processing, and some food items were left uncovered in the steamer. The Registered Dietitian and Certified Dietary Manager both acknowledged these lapses, confirming that food should be dated, covered, and stored in airtight containers, and that hand hygiene should be performed between tasks and before and after glove use. Policy reviews revealed that the facility's own procedures required all food to be dated upon receipt and opening, stored in sealed containers, and for temperature logs to be maintained for all refrigeration and sanitizing equipment. Staff interviews confirmed a lack of awareness or adherence to these policies, with the new Certified Dietary Manager unsure if logs were kept for certain appliances. The Administrator and Registered Dietitian both expected compliance with these standards, but observations and record reviews demonstrated ongoing deficiencies in food safety and sanitation practices.
Failure to Monitor and Intervene for CHF Resident per Care Plan and Physician Orders
Penalty
Summary
The facility failed to implement care and treatment consistent with the care plan and physician orders for a resident with congestive heart failure (CHF), coronary artery disease, renal insufficiency, and pneumonia. The resident required special monitoring of weights and vital signs due to her CHF diagnosis and was admitted with orders for diuretic therapy to manage edema and fluid retention. Despite these orders, staff did not consistently monitor the resident's weight or conduct daily vital signs as required. The Medication Administration Record showed that the PRN furosemide was not administered, even though the resident exhibited symptoms such as shortness of breath and edema, which were documented multiple times in the progress notes. The care plan directed staff to administer diuretic medications as ordered and to monitor for side effects and effectiveness every shift. However, there was a lack of documentation of daily weights and skilled assessments on several dates, and staff interviews revealed that nurses were unaware of the PRN furosemide order and lacked clear parameters for its use. The resident experienced significant weight gain and worsening edema over the course of her stay, with documentation showing a weight increase from 149.1 lbs to 168.4 lbs and progression of edema from +1 to +3 pitting in the lower extremities before scheduled diuretic therapy was initiated. Additionally, the facility did not have policies in place for documentation of skilled assessments, edema monitoring related to CHF, or weight monitoring, relying instead on nursing judgment and physician orders. The facility assessment indicated that early identification and management of heart failure and related conditions were expected, but the lack of consistent monitoring and intervention placed the resident at risk.
Failure to Implement Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
Staff failed to implement prescribed interventions for the prevention and care of pressure ulcers for a resident identified as high risk. The resident, who had severe cognitive impairment and was totally dependent on staff for all activities of daily living, had a history of pressure ulcers, including a Stage III ulcer and an unstageable sore with eschar. The care plan directed staff to float the resident's heels, ensure sheepskin boots were worn at all times, and complete weekly treatments. Orders were in place for specific wound dressings to be applied and changed on designated days and as needed if dressings fell off. Multiple observations revealed that the resident was frequently found without the required protective boots and wound dressings. On several occasions, she was seen in bed or in a wheelchair with only socks on her feet, and the protective boots were either missing or on the floor. During a treatment session, an LPN discovered that neither foot had the prescribed adhesive dressings, and the resident's feet appeared dry and scaly. The LPN acknowledged that the dressings were not in place and was unsure about the protocol for reapplying them if they fell off. The resident was also observed to have peeling skin and a red spot on her foot, though no open or reddened areas were noted at that time. The Director of Nursing confirmed that she expected staff to notify nursing when dressings fell off so they could be replaced promptly. However, the observations and staff interviews indicated that this process was not consistently followed, resulting in the resident being left without necessary protective measures and wound care. Facility policy required regular skin assessments and adherence to physician-ordered treatments, but these were not reliably implemented for this resident.
Unattended, Unlocked Medication Cart Found in Hallway
Penalty
Summary
A deficiency was identified when an unlocked and unattended medication cart was observed in a hallway near resident rooms. The incident occurred when a Certified Medication Aide (CMA) left the cart unsecured while administering medications in a resident's room and then proceeded down the hallway to speak with a nurse, leaving the cart out of her line of sight. The CMA acknowledged that she failed to lock the drawers before leaving the cart unattended. The Director of Nursing (DON) confirmed that facility policy requires medication carts to be locked at all times when not within the staff member's view. The facility had a reported census of 61 residents at the time of the observation. The facility's policy, titled 'Security of Medication Cart,' dated April 2007, specifies that medication carts must be securely locked whenever they are out of the nurse's view, which was not followed in this instance.
Failure to Provide Full Serving of Pureed Diet to Resident
Penalty
Summary
The facility failed to provide a well-balanced diet that met the nutritional and special dietary needs of a resident by serving an incorrect portion size of pureed baked beans during a meal. Observation showed that the cook prepared modified barbeque pork and pureed baked beans for residents requiring mechanically altered diets. During preparation, the cook processed and measured the food, but when serving the final pureed meal, it was noted that there was an incomplete serving of pureed baked beans due to the food drying up in the steamer. Despite this, the incomplete serving was placed on the room service tray and delivered to the resident, resulting in the resident not receiving a full serving as required. Interviews with the Registered Dietitian and the Administrator confirmed that the expectation was for residents to receive full servings according to the facility's guidelines. The Registered Dietitian stated that if there was a shortage, additional food should be prepared to ensure a complete serving. The facility's Therapeutic Diets Policy did not specifically address the preparation and portion sizes for mechanically altered diets, contributing to the deficiency.
Failure to Maintain Accurate Medical Records for Resident with Cardiac History
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident with significant cardiac and respiratory diagnoses, including congestive heart failure, acute respiratory failure, and a history of atrial fibrillation with rapid ventricular response. The resident's care plan required close monitoring, including daily skilled assessments and documentation of vital signs. However, on three separate occasions, the clinical record lacked documentation of vital signs, despite nursing notes indicating that obtaining new vital signs had been completed on those dates. During an interview, the Director of Nursing confirmed the expectation that skilled assessments, including vital signs, should be documented daily. The facility's policy on charting and documentation required that all medical record entries be objective, complete, and accurate, including care-specific details such as assessment data. The absence of vital sign documentation on the specified dates constituted a failure to maintain accurate medical records in accordance with accepted professional standards.
Failure to Change Gloves and Perform Hand Hygiene During Resident Care
Penalty
Summary
Staff failed to follow appropriate infection control practices when providing care to a resident with complex medical needs, including an indwelling catheter and colostomy. During care, a CNA, while wearing gloves, adjusted a soiled brief and then touched the arm of a mechanical lift and the resident's shoulder without changing gloves. The resident was noted to have a copious amount of blood around the catheter site and under the abdominal fold. Facility policy required staff to change gloves after they became soiled and to perform hand hygiene before donning clean gloves. The Director of Nursing confirmed that staff were expected to adhere to these practices.
Staff Swearing in Hallways Violates Resident Dignity
Penalty
Summary
The facility failed to uphold the residents' right to a dignified existence by allowing staff to use inappropriate language in the hallways, which was audible to residents. This deficiency was identified through interviews, clinical record reviews, and facility policy reviews. Two residents, both with intact cognitive function and adequate hearing, reported hearing staff swearing during conversations in the hallways. Resident #2 confirmed that the language was bothersome, while Resident #5 expressed that the swearing was very upsetting, although she could not identify specific staff members responsible. The facility's policies on abuse prevention and resident rights emphasize the importance of treating residents with kindness, respect, and dignity. The policies also highlight the need to maintain a culture of compassion and prevent stressful working conditions that could lead to such behavior. Despite these policies, the Regional Nurse Consultant acknowledged that swearing in the hallways would indeed be upsetting to residents, indicating a lapse in adherence to the established standards of resident care and dignity.
Incomplete Neurological Assessments After Falls
Penalty
Summary
The facility failed to provide necessary neurological assessments following falls for two residents, leading to a deficiency in care. Resident #1, who had a moderate cognitive impairment and used a wheelchair for mobility, experienced an unwitnessed fall from bed, resulting in a hematoma on the forehead. Despite the fall being reported, the neurological evaluations were incomplete, with only 7 out of 18 required assessments documented. The resident's Power of Attorney was notified of the fall a day later and observed a noticeable injury during a visit weeks after the incident. Resident #5, who had intact cognition and used a wheelchair, experienced a witnessed fall involving a motorized scooter, resulting in a hematoma and skin tears. The neurological assessments for this resident were also incomplete, with 14 out of 18 required assessments documented. The resident declined hospital transfer, and the physician was notified via fax, with orders to continue monitoring. Staff interviews revealed inconsistencies in the completion of neurological assessments and communication with physicians. The facility's policy required comprehensive neurological assessments following falls, including frequent vital sign checks and immediate physician notification of any changes. However, the assessments for both residents were incomplete, lacking full documentation of vital signs and other required evaluations. The Director of Nursing acknowledged the deficiencies in the assessments, which did not meet the facility's standards for post-fall care.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure resident safety by not responding to call lights in a timely manner for four residents. Resident #2, with normal cognitive functioning and requiring assistance with transfers and toileting, reported waiting over 30 minutes for call lights to be answered, leading to incontinence episodes and self-transfers that resulted in falls. Resident #3, also with normal cognitive functioning and requiring total assistance for transfers and toileting, experienced call light delays of up to 30 minutes, attributing it to low staffing levels. Resident #5, with intact cognition and independent mobility, reported waiting over an hour for call lights to be answered and having to seek staff assistance actively. Resident #6, with intact cognition and requiring moderate assistance for ambulation, experienced call light delays exceeding 20 minutes, leading to self-initiated actions like leaving the room. Staff interviews corroborated the residents' experiences, with staff acknowledging that call light response times could exceed 15 minutes, particularly during peak hours when multiple lights were activated. The Director of Nursing confirmed that call lights were expected to be answered within 15 minutes. Facility grievances and Resident Council Minutes since June 2024 documented concerns about untimely call light responses and staff inattentiveness, including instances of staff being distracted by personal activities at the nurses' station. The facility's policy on answering call lights, revised in March 2021, aimed to ensure timely responses to residents' needs, but the reported incidents indicate a failure to adhere to this policy.
Inadequate Hand Hygiene and Infection Control During Medication Administration
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during medication administration, as observed on multiple occasions. Staff A, a Certified Medication Aide (CMA), did not consistently perform hand hygiene between administering medications to four residents. Similarly, Staff B, another CMA, failed to complete consistent hand hygiene between administering medications to sixteen residents. These lapses in hand hygiene were observed during medication administration rounds, indicating a systemic issue in adhering to infection control protocols. Specific incidents further highlighted the deficiency in infection control practices. Staff B placed eye drops in her pocket along with gloves and a tissue, then proceeded to administer oral medication to a resident without proper hand hygiene. Additionally, Staff B handled a basin used by a resident for toileting without following appropriate hand hygiene and PPE protocols. Another incident involved Staff B providing eye drops to a resident with enhanced barrier precautions (EBP) without using the required PPE, such as gowns, and failing to maintain catheter care standards by allowing a catheter bag to touch the floor. These actions were contrary to the facility's policies on hand hygiene, medication administration, and catheter care, as well as the guidelines for EBP.
Failure to Ensure Wheelchair Safety for Residents
Penalty
Summary
The facility failed to protect residents from potential accidents and injuries by not adhering to proper wheelchair safety protocols. Resident #3, who has normal cognitive function and uses a manual wheelchair for mobility, was observed being pushed by a Certified Medication Aide without the use of foot pedals. This action contradicts the resident's care plan, which indicates that the resident normally self-propels the wheelchair. The absence of foot pedals while being pushed poses a risk of injury to the resident. Similarly, Resident #9, who has moderate cognitive impairment and also uses a wheelchair for mobility, was observed being pushed by the Assistant Director of Nursing without a leg rest on the right side. Despite the resident's ability to self-propel, the lack of proper foot support while being pushed is against the facility's guidelines. Multiple staff members, including CNAs, CMAs, and the Director of Nursing, confirmed that foot pedals must be used when pushing residents in wheelchairs to prevent injury. The facility's guidelines clearly state that footrests should be used when pushing residents, yet this protocol was not followed in these instances.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of October 1 to December 31. The PBJ Staffing Data Report, run on May 31, 2024, indicated excessively low weekend staffing. Upon reviewing the Facility Daily Assignment Sheets for October, November, and December 2023, it was found that staffing for nurses and CNAs was scheduled similarly for weekdays and weekends, with three CNAs frequently on the overnight shift during both periods in December. On June 5, 2024, the Administrator confirmed that the data submission for the PBJ was incorrect and mentioned that the issue was due to the absence of management on weekends, a problem also present in other facilities managed by the corporate entity.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to four residents, as observed during a survey. Resident #7, with moderate cognitive impairment, reported that the food was cold and overcooked. Similarly, Resident #60, also with moderate cognitive impairment, expressed dissatisfaction with the cold food, stating it was unfit even for a pet. Observations on June 5 revealed that the food temperatures were below the required safe levels, with breaded shrimp and carrots measuring 113.5 and 113 degrees, respectively. Staff interviews indicated awareness of the issue, with one staff member suggesting that the delivery system might be contributing to the problem. Residents #9 and #38, both without cognitive impairment, also reported receiving cold food. Resident #9 mentioned that this had occurred several times over the past two weeks, while Resident #38 noted frequent occurrences of cold food. The Resident Council Minutes from June 5 documented complaints about cold food, and the facility's policy on food preparation and service emphasized the importance of maintaining food temperatures to prevent the growth of harmful pathogens. The policy stated that potentially hazardous food must be kept below 41 F or above 135 F, highlighting the facility's failure to adhere to these guidelines.
Infection Control Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during personal care and medication administration for several residents. In one instance, a Certified Nursing Assistant (CNA) provided catheter care to a resident without properly wearing a gown, as the sleeves were pushed up over the elbows. The Director of Nursing (DON) confirmed that the expectation was for the gown to be worn correctly during such procedures. Another incident involved two staff members who did not don gowns while providing catheter care to a resident with a neurogenic bladder, despite the facility's policy requiring enhanced barrier precautions for residents with indwelling medical devices. Additionally, a Certified Medication Assistant (CMA) failed to perform hand hygiene during multiple medication administrations. The CMA was observed removing medication from the cart, administering it to residents, and returning to the cart without washing hands before or after these tasks. The DON stated that the facility's policy required hand hygiene before and after direct contact with residents and when handling medications, which was not followed in this case. Furthermore, a resident with Moisture Associated Skin Damage (MASD) reported that staff often left him on a bedpan for extended periods, causing discomfort and irritation to the affected area. During an observation, a CNA changed the resident's brief and searched for a cream without changing gloves or performing hand hygiene, despite the resident's complaint of pain and request for salve. These actions indicate a lack of adherence to infection control protocols, contributing to the deficiencies noted in the facility's infection prevention and control program.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to provide accurate and timely assessments and interventions for several residents, leading to significant deficiencies in care. Resident #120, who had severe cognitive deficits and multiple health conditions, experienced a lack of vital sign monitoring after returning from a hospital stay for influenza A and aspiration pneumonia. Despite being lethargic and having difficulty swallowing, vital signs were not documented for an extended period, and the resident was eventually found unresponsive with a subdural hematoma, leading to her passing away. Resident #57, who had intact cognitive ability but multiple health issues including diabetes and chronic kidney disease, experienced significant weight loss. The resident frequently refused a prescribed nutritional supplement, and there was no documentation that the physician or dietician was notified of these refusals. The resident expressed dissatisfaction with the taste of the supplement and mentioned a preferred alternative available during dialysis, which was not pursued by the facility. Resident #59, who had profound intellectual disabilities and was dependent on tube feedings and a urinary catheter, was at risk for dehydration. The facility failed to monitor his urinary output as recommended by the dietician. Additionally, Resident #119, who had severe cognitive deficits and was at risk for falls, did not receive the required neurological assessments after an unwitnessed fall, as vital signs were not consistently documented. These failures highlight significant lapses in the facility's monitoring and response to changes in residents' conditions.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for 11 out of 21 residents reviewed, leading to significant delays in care. Resident #57, who had intact cognitive ability and was dependent on staff for toileting and transfers, reported being left on a bedpan for over 50 minutes after returning from dialysis. Despite using the call light, it took an additional 15 minutes for staff to assist him, resulting in a sore on his bottom. Resident #49, also with intact cognitive ability, expressed that he often had to transfer himself to the bathroom due to call light delays exceeding 30 minutes, risking falls and further injury. Resident #6, with moderate cognitive deficits, required substantial assistance for transfers and reported call light response times of 30-60 minutes, particularly at night. Resident #9, with no cognitive impairment, experienced a two-hour delay in call light response, leading to incontinence of urine and bowel. Resident #31, also cognitively intact, noted that call light response times often exceeded 15 minutes, with staff citing understaffing as a reason for delays. The resident council minutes from several months documented ongoing complaints about prolonged call light response times. The facility's grievance log revealed multiple complaints over the past six months about delayed responses to call lights, including instances where residents had to resort to banging on walls or having family members call the facility for assistance. The Director of Nursing acknowledged that call light audits had been conducted, with one instance of a call light delay exceeding 15 minutes noted. However, the DON stated that no resident had reported being incontinent due to prolonged call light delays, despite evidence to the contrary from resident interviews and grievances.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessment information was entered in the Minimum Data Set (MDS) for two residents. For one resident, the MDS inaccurately documented the use of anticoagulant medication, while the clinical physician orders indicated the resident was on an antiplatelet medication, clopidogrel. The resident had a moderate cognitive deficit and was independent in daily activities, with diagnoses including hypertension, Alzheimer's Disease, anxiety, and muscle weakness. The care plan was inconsistent with the MDS, as it noted anticoagulant use related to a left anterior fascicular block. For another resident, the MDS inaccurately documented the use of bed rails as a restraint, while the electronic health record and clinical physician orders indicated the use of assist bars for repositioning due to muscle weakness. The resident had intact cognition. The Director of Nursing and the MDS Coordinator acknowledged the error, with the coordinator admitting to possibly marking the MDS incorrectly. The facility's policy requires individuals completing any portion of the MDS to certify the accuracy of their entries.
Lack of Comprehensive Care Plan for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident with severe cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 0. The care plan lacked focus, goals, or interventions for activities, and incorrectly documented insulin for a resident who was not on insulin. Observations revealed that the resident was often not engaged in activities, such as sitting alone at bingo without participating, sleeping in the dayroom, and not being present during outdoor activities. Staff interviews confirmed that there was no care plan for activities, and the resident's interests were limited to movies and coffee, with no encouragement to participate in other activities. The facility's policy on care plans, which requires goals and objectives to be resident-oriented, behaviorally stated, measurable, and timely, was not followed. The Director of Nursing acknowledged the absence of a care plan for activities and stated that the resident enjoyed coffee and socializing outside. Despite this, the resident was primarily observed attending exercise sessions without participating, indicating a lack of personalized activity planning to promote the resident's well-being.
Failure to Update Care Plans Following Medication Changes
Penalty
Summary
The facility failed to update the care plans of two residents following changes in their medication orders, leading to deficiencies in care planning. Resident #57, who was admitted with a diagnosis of diabetes mellitus among other conditions, had an insulin order discontinued due to lack of use. However, the care plan was not updated to reflect this change, despite the facility's policy requiring care plans to be reviewed or revised when there is a change in condition or when a desired outcome has been achieved. Similarly, Resident #36, who had a moderate cognitive deficit and was on an antiplatelet medication, had their care plan inaccurately reflect the medication as an anticoagulant/blood thinner. The care plan was not updated to correctly classify the medication, which was clopidogrel (Plavix), an antiplatelet. This oversight occurred despite the facility's policy that care plans should be revised to reflect accurate medication classifications.
Failure to Follow Physician's Orders for Skin Treatment
Penalty
Summary
The facility failed to follow physician's orders for a resident with chronic skin damage on the gluteal area related to moisture and positioning. The resident, who had intact cognitive ability, was totally dependent for toileting, transfers, and lower body dressing, and used a wheelchair for mobility. Despite having an order for Desitin and Mepilex to be applied to the affected area on specific days, the treatment was not documented as completed on one occasion. The resident reported discomfort and pain due to the lack of treatment, particularly after dialysis sessions when he was left sitting for extended periods. During an observation, a CNA discovered that the resident had a reddened, raw area on the right gluteal without any cream or Mepilex padding. The resident expressed that the area hurt and requested the salve. The CNA was unable to find the cream and sought assistance from an RN, who then applied the necessary treatment. The Director of Nursing later stated that the sore was caused by moisture and had healed, indicating that the issue was not a pressure injury but rather a result of moisture-associated skin damage.
Failure to Implement Resident-Centered Activities for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement resident-centered activities for a resident with severe cognitive impairment, as evidenced by a lack of a care plan for activities tailored to the resident's interests and needs. Observations revealed that the resident was often left unengaged during activities, such as sitting alone at bingo without participation or sleeping in the dayroom. Despite staff knowledge of the resident's preferences for coffee, movies with a specific actress, and sitting outside, these interests were not incorporated into a structured activity plan. Interviews with staff and the Director of Nursing confirmed the absence of a care plan for activities, with staff acknowledging the resident's limited participation in exercise activities and a lack of engagement in other interests. The facility's policy on activity programs emphasizes the need to meet the interests and support the well-being of each resident, yet this was not reflected in the care provided to the resident in question. The deficiency highlights a gap between the facility's policy and its implementation, particularly in addressing the psychosocial needs of residents with cognitive impairments.
Failure to Provide Restorative Therapy for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide services to maintain or improve the range of motion for a resident diagnosed with hemiplegia following a cerebral infarction. The resident, who had intact cognition, was supposed to receive restorative therapy using an omni cycle or nu step for 10-15 minutes three times weekly, as per the care plan. However, there was no documentation of the therapy being provided in May, and the resident reported that the facility lacked a restorative staff member at the time. Interviews with the resident and staff revealed that the resident was discharged from therapy at the beginning of May after reaching maximum potential, according to the physical therapist. The Director of Nursing confirmed that the facility's full-time restorative aide had recently left, and the expectation was for restorative therapy to be completed as ordered. The facility's policy stated that residents should receive restorative nursing care to promote optimal safety and independence, which was not adhered to in this case.
Failure to Follow Feeding Tube Protocols
Penalty
Summary
The facility failed to adhere to policies and procedures regarding the administration of feeding tubes for Resident #59, who has a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. The resident's physician orders specified a continuous feed of Osmolite 1.5 Cal at 60 mL/hr over 12 hours, with a tap water flush every hour. However, an observation revealed that the feeding was set at 70 mL/hr, contrary to the physician's orders. This discrepancy was acknowledged by Staff U, a Registered Nurse, who had set up the resident's feedings multiple times. The Director of Nursing confirmed that the physician's orders should have been followed, indicating that 720 mL of formula and water should have been administered, but only 414 mL of formula was given. Additionally, the facility did not follow the policy for administering medications through an enteral tube. Staff L, another Registered Nurse, was observed crushing medications, mixing them with water, and administering them via a piston syringe instead of by gravity flow, as per the facility's policy. The feeding pump history showed no hourly flush set for water, and the total water administered was not in accordance with the physician's orders. These actions demonstrate a failure to implement the technical aspects of feeding tube care as per the established policies and physician's directives.
Failure to Conduct Post-Dialysis Assessments
Penalty
Summary
The facility failed to conduct post-dialysis assessments for a resident who required such services. Resident #57, who had intact cognitive ability, was admitted to the facility after an acute hospital stay and had a diagnosis that included diabetes mellitus, anxiety, depression, chronic kidney disease, nutritional deficiency, acute pain, gangrene, and necrosis of the lung. The resident received hemodialysis treatments at the facility. The care plan indicated that the resident was at increased nutritional risk due to chronic kidney disease and diabetes, and staff were directed to monitor and report any signs or symptoms of renal insufficiency. However, post-dialysis assessments were not completed on several occasions, specifically on 5/16, 5/23, 5/30, and 6/1. The Assistant Director of Nursing acknowledged the absence of post-dialysis assessments on these dates, despite the requirement for both pre and post-dialysis assessments on dialysis days.
Failure to Document Vital Signs After Resident Fall
Penalty
Summary
The facility failed to document accurate information in the electronic medical records of a resident who experienced an unwitnessed fall. The resident, who had severe cognitive deficits and required assistance with daily activities, was found on the floor with a laceration on her eyebrow. Although the incident report indicated that vital signs were taken and a neurological assessment was completed, the clinical records lacked documentation of the vital signs on multiple occasions following the fall. The facility's policy required that vital signs be taken and documented during neurological assessments after an unwitnessed fall. However, the records for the resident did not include the necessary vital signs on several dates, despite the expectation that staff would obtain and record new vital signs with each assessment. This discrepancy was confirmed by the Director of Nursing and Corporate Nurse, who noted that the vital signs should have been documented in the resident's file.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by the experiences of two residents. Resident #57, who had intact cognitive ability and was dependent on staff for toileting and transfers, reported being left on a bedpan for over 50 minutes, which caused him distress due to a sore on his bottom. Despite his request for assistance, a registered nurse responded sarcastically and did not provide the needed help. This incident occurred after the resident returned from dialysis and was not promptly attended to by the staff. Resident #35, also with intact cognitive ability, reported being scolded by staff for drinking too much water and urinating in bed. The resident's care plan lacked interventions for her water-seeking behavior, and staff were instructed to provide her with water and ice. However, a certified nurse aide reportedly withheld water from the resident overnight, and the resident was found without bedding on multiple occasions. The resident's friend corroborated these claims, noting the staff's rude behavior and neglect in providing basic care. Additionally, a grievance form documented an incident involving an Emergency Medical Technician who reported rude behavior from a male staff member when a resident was in distress. The staff member made sarcastic remarks about the resident's belongings during a hospital transfer. This staff member, identified as Staff S, was temporarily suspended pending investigation. The facility's policy emphasizes the residents' right to be free from abuse and neglect, yet these incidents indicate a failure to uphold these standards.
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Illustrative
What surveyors actually found near you
We read the 104 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Atlantic
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage House | 0.5 mi | ★★★★★ | 8 | 0 |
| Caring Acres Nursing And Rehab Center | 12.2 mi | ★★★★★ | 20 | 0 |
| Griswold Rehabilitation & Health Care Center | 12.9 mi | — | 0 | 0 |
| Salem Lutheran Home | 14.3 mi | ★★★★★ | 10 | 0 |
| Exira Care Center | 14.8 mi | ★★★★★ | 7 | 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.