Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jennings Terrace during CMS and state inspections, most recent first.
Failure to assess and address a resident's limited ROM and hand contracture. A resident with RA, Alzheimer's disease, stiffness, and reduced mobility was observed with a contracted left hand, with four fingers bent toward the palm and no splint or device in use. Staff reported the hand could not be opened, the MDS coordinator said there were no contractures on the prior assessment and no orders or care plan for splints, and the Therapy Aide had not seen the resident for ROM work in a long time. A CNA stated ROM was not done to the left hand because it does not open, while the physician said a splint had been ordered but was unsure when.
Kitchen sanitation and food storage deficiencies were identified when expired test strips were used to check sanitizer levels, the 3-compartment sink and sanitizer buckets tested out of range, and the dishwasher chlorine level was above the facility’s stated PPM target. Surveyors also observed dirty equipment, expired and improperly stored food, dented cans, open unlabeled food in the freezer, missed log entries, and a staff member preparing food without a beard covering.
A facility failed to obtain and record pacemaker device information for a resident with a cardiac pacemaker, failed to promptly report and document a new skin issue under a resident’s breast, and failed to complete ordered blood glucose checks for two residents with diabetes. Staff observed a pacemaker monitor but could not find pacemaker details in the EMR, a CNA reported a skin concern that was later treated with Nystatin without a corresponding order on the POS, and ordered pre-meal or scheduled glucose checks were not completed or recorded as required.
A mechanical lift used for resident transfers was kept in circulation even though its remote cord had a stripped outer layer with exposed electrical wires. CNAs used the lift to transfer a resident without performing a safety check, then returned it to the unit for further use. Staff reported the issue had been known for more than a month, and the DON and Maintenance Director said the lift was unsafe for transfer use.
A facility failed to promptly address a billing grievance raised by a resident's family member, resulting in a deficiency. The family member contacted the facility about billing discrepancies for a period when they were paying out of pocket despite the resident being approved for public aid. Despite involving the Ombudsman, the facility did not provide a timely resolution, violating its grievance policy.
The facility did not perform an assessment to identify potential growth areas for Legionella and other waterborne pathogens, affecting all 46 residents. The Maintenance Director confirmed no assessment or testing had been done in the past three years, despite the facility's policy requiring such measures.
The facility failed to label and date medications properly, leading to expired medications not being discarded. Narcotic medications had broken seals, and suppositories were stored unsanitarily. The DON and a pharmacist confirmed that narcotics should be destroyed if not administered, with a witness present, to prevent diversion. The facility's policy requires medication storage areas to be clean, safe, and sanitary.
The facility failed to prepare green peas to the appropriate pureed consistency for residents on pureed diets. A cook did not test the consistency of the pureed peas, which contained fibrous casings, posing a risk of choking. The Dietary Manager confirmed the inconsistency, and the Registered Dietitian emphasized the need for a smooth, pudding-like consistency. The facility's policy required food to be pureed to meet individual needs.
The facility did not use the McGeer Criteria for monitoring antibiotic use from March to November 2024, affecting nine residents. The Infection Preventionist/ADON stopped using the criteria due to multiple responsibilities, leading to a lack of documentation to assess if residents met standards for antibiotic use.
The facility failed to provide dementia training for CNAs responsible for caring for residents with dementia, affecting 26 residents. The CNA Supervisor and Director of Nursing confirmed the absence of such training, and several CNAs reported not receiving dementia training during their orientation or employment. Despite caring for residents with dementia, CNAs were not equipped with the necessary training to address their specific needs.
A resident with multiple diagnoses, including diabetes and heart failure, had a sacral wound that was not properly assessed or documented by the facility. Despite having a wound care order, the care plan was not updated, and the DON was unaware of the wound. The wound care doctor was not involved, and the facility's policies for skin assessment and documentation were not followed, resulting in a deficiency.
The facility's arbitration agreement was found deficient as it lacked required language stating that residents or their representatives are not required to sign the agreement as a condition for admission or continued care. Additionally, it did not inform them of their right to rescind the agreement within 30 days. The Community Relations Coordinator confirmed the omission, affecting all 46 residents.
A resident was injured while being transported in a wheelchair without foot pedals, resulting in a fall and head laceration. Staff interviews confirmed that it is the transporter's responsibility to ensure residents' feet are either held up or placed on foot pedals. The facility's policy lacked specific safety measures for wheelchair transportation.
The facility failed to ensure proper kitchen sanitization and correct storage and disposal of food items, leading to potential risks of foodborne illnesses. Sanitizing buckets and the three-compartment sink tested at zero ppm for sanitizer concentration, and multiple food items were improperly labeled, stored, or expired.
The facility failed to ensure lint was removed from the dryers, posing a fire hazard. Significant lint accumulation was observed in three dryers, with one dryer having a one-inch layer of lint and the other two having piles of lint about 10 inches high and wide. The laundry staff cleans the dryers once a day without keeping a log, and the facility lacks a policy on lint removal. The Maintenance Director acknowledged the fire hazard and the absence of maintenance logs.
A facility failed to investigate and report a potential abuse allegation involving a resident with Alzheimer's disease and dementia. Another resident reported observing an agency CNA pushing the affected resident into a dining room table. The administrator did not conduct a thorough investigation or report the incident to the State Survey Agency, only requesting the CNA not return to the facility.
A resident with moderately impaired cognition and a need for moderate assistance with personal hygiene was observed with unwanted facial hair, which was not addressed by staff despite the resident's request. The ADON confirmed that CNAs were responsible for such care, and the facility's policy required assistance for residents unable to perform ADLs independently.
The facility failed to secure hazardous chemicals, leaving a bleach bottle and an odor eliminator in shared bathrooms of residents with impaired mental status. Housekeeping staff admitted to the oversight, and the DON confirmed the chemicals should have been locked away for safety.
The facility failed to ensure sanitary storage and containment of respiratory equipment for a resident with COPD. The resident's oxygen tubing and nasal cannula were observed on the floor on two occasions, contrary to the facility's policy requiring storage in a plastic bag when not in use.
A facility failed to administer the correct dose of insulin to a resident with Type 2 Diabetes Mellitus. An agency RN left 2 units of insulin in the pen, resulting in the resident not receiving the full prescribed dose of 50 units. The ADON confirmed that the nurse should have administered the full dose as per the doctor's order.
The facility failed to isolate a COVID-positive resident from her COVID-negative roommate, despite having available beds for relocation. The COVID-negative resident later tested positive and was on antiviral medication. The facility's policy and CDC guidelines were not followed, leading to a deficiency in infection control practices.
A resident was found repeatedly yelling for help because his call light was not functioning. Upon testing, the call light only worked intermittently and then failed to turn off. The DON confirmed the call light was sticky and not functioning properly, despite the facility's policy requiring timely response and maintenance of call lights.
Failure to Assess and Address Resident Hand Contracture
Penalty
Summary
The facility failed to assess a resident for limited ROM and implement interventions to prevent a decline in ROM. The deficiency involved one resident, R45, who had diagnoses including rheumatoid arthritis, Alzheimer's disease, stiffness of an unspecified joint, and reduced mobility. Her 11/24/2025 contracture risk evaluation stated she did not have contractures, required staff assistance to turn and reposition, and had diagnoses that predisposed her to contractures minimally to moderately. Her current physician orders did not include a splint or other contracture-preventing device, and her care plan included daily ROM exercises and monitoring for complications related to arthritis and impaired mobility. On 01/20/2026, R45 was observed sitting in the dining/activity area with her left hand contracted, with four fingers bent toward her palm. She could move the thumb of her left hand with her right hand but could not extend the four fingers, and she did not have any device in use for the contracted hand. A CNA stated she was unable to open her hand and did not have a splint or any device in place. The next day, another CNA stated R45 could open her left hand only a little and also agreed she did not use any splint or device for the hand. The MDS Coordinator stated she last completed R45's contracture risk assessment on 11/24/25 and that R45 did not have any hand contractures at that time. She also stated there were no physician orders for splint use or other devices and nothing care planned regarding contractures or splints. At bedside re-evaluation, she verified the left hand did not open and stated she did not know when the hand became contracted. The DON stated no one was specifically assigned as restorative nurse, while the Therapy Aide stated he had not seen R45 since early 2025 and did not remember which hand had slight contractures. A CNA later stated he did not perform ROM exercises to the left hand because it does not open, and the physician stated a splint had been ordered but he was unsure when and did not know when the contracture developed.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents food borne illness for all 44 residents receiving dietary services. During a kitchen tour, the three-compartment sink and red sanitizing buckets were tested using strips that had expired on 10/15/25, and the dietary aide/dishwasher stated she did not check the expiration date before using them. The three-compartment sink tested at 400 PPM, the red sanitizing buckets tested at 200 PPM, 400 PPM, and 0 PPM, and the dietary manager tested the low temperature dishwasher at 100 PPM even though the facility policy stated the chlorine level should be 50 PPM. The kitchen and food storage areas were observed with multiple sanitation and storage issues. The walk-in cooler had dirty floors, five heads of iceberg lettuce were wilted and had a brown substance, and two 5 lb tubs of cottage cheese were expired. In dry storage, two dented cans of yams were present in an unlabeled dented can shelf. In the walk-in freezer, a large plastic bag of bread sticks was open to air and had no labels or dates. In the general kitchen area, the tomato slicer, covered meat slicer, and plastic covering on the meat slicer were dirty, a drawer with cooking utensils had crumbs, and a personal insulated cup was on a food counter. Food handling practices were also observed to be out of compliance with facility policy. A staff member preparing food did not have any covering on his full-face beard. The dietary manager stated that test strips should not be expired, that the dishwasher chlorine level should be 50 PPM per facility policy, that dented cans should be labeled and separated, that food should be labeled, dated, and sealed, and that kitchen equipment and utensils should be kept clean. Facility logs showed missed entries for sanitizer buckets, the three-compartment sink, the dishwasher, the freezer, and the cooler across November 2025, December 2025, and January 2026, and no sink-testing log was provided for November 2025.
Failure to document pacemaker information, report skin concerns, and follow glucose monitoring orders
Penalty
Summary
The facility failed to obtain and record pacemaker device information for a resident with chronic atrial fibrillation, presence of a cardiac pacemaker, and occlusion and stenosis of bilateral carotid arteries. A pacemaker monitor was observed on the resident’s nightstand, but nursing staff and the DON stated they could not locate the resident’s medical identification card or any pacemaker information in the EMR. The resident’s EMR and care plan did not contain the required pacemaker details, and the facility policy required the medical record to include the pacemaker identification information upon admission. The facility also failed to promptly report and document a new skin concern for a resident with type II diabetes mellitus, osteoarthritis, rheumatoid arthritis, osteoporosis, hypertension, anemia, depressive disorder, fibromyalgia, anxiety, and moderate cognitive impairment. During a bed bath, redness under the resident’s left breast was observed, and a CNA stated the area had been present for more than a week and that a nurse had been informed and had given powder to apply. The RN later assessed the area, described it as appearing like a fungal infection, stated he would inform the physician and obtain an order, and applied Nystatin powder; however, the physician order sheet reviewed afterward did not show an order for Nystatin powder. The facility further failed to follow physician orders for glucose monitoring for two residents with diabetes. For one resident, the ordered 8 AM blood glucose check before breakfast was not completed, and the LPN later checked the blood glucose after the resident said he had not eaten breakfast and was hungry. For another resident, the ordered 6 AM blood glucose check was not completed, and the LPN stated she was unsure whether the prior shift had checked it because it was not recorded in the EMAR or reported during nursing report. Both residents’ care plans and order summaries required scheduled blood glucose monitoring, and the facility policy stated staff would follow physician glucose orders and obtain, record, and monitor glucose levels.
Mechanical Lift Kept in Service With Exposed Wiring
Penalty
Summary
The facility failed to keep a mechanical lift in operating condition and failed to prevent its use while the lift had a stripped remote wire with exposed electrical wiring. On 1/20/2026, two CNAs transferred R30 from a wheelchair to bed using the lift labeled South, with one CNA operating the hand control remote and the other assisting the resident. The remote cord was described as having its protective layer entirely stripped off for about four feet, with exposed multi-colored electrical wires, and neither CNA performed a safety check before or after the transfer. The lift was then placed back into circulation in the unit's clean utility room for further use. On 1/21/2026, staff reported that the North unit had multiple residents who required mechanical lift transfers, including R30, R27, R11, R5, and R41. A CNA said the stripped wire had been reported more than a month earlier and that the lift remained in circulation even though she felt unsafe using it. The CNA supervisor said she had notified the Maintenance Director about the issue more than a month earlier, and the Maintenance Director said the lift was unsafe for transfer use because of the battery voltage connection and electrical hazard. The DON stated the lift should have been removed from circulation and that staff should assess transfer lift equipment prior to use and routinely to ensure it is safe to operate. Records showed the lift had exposed wires and was to be removed from circulation, but it remained available for use.
Failure to Address Billing Grievance Promptly
Penalty
Summary
The facility failed to address a billing grievance raised by a resident's family member, resulting in a deficiency. The resident, identified as R1, was admitted and later discharged from the facility. R1's family member, V5, raised concerns about billing discrepancies for the period when the family was paying out of pocket despite R1 being approved for public aid. V5 contacted the facility's Administrator and Business Office Manager (BOM) on September 20, 2024, regarding the credit due to R1's family. However, V5 felt that the facility did not respond promptly to the grievance, leading him to seek assistance from the Ombudsman, V3. The Ombudsman, V3, attempted to mediate the issue by contacting the facility on December 13, 2024, but was unsuccessful in obtaining a resolution. The facility stopped responding to V3 on December 26, 2024. The BOM, V2, acknowledged that V5 had contacted her in October 2024 but admitted to ceasing communication after V3's involvement. The facility confirmed the amount due to R1's family on January 1, 2025, but failed to communicate this to V5 and V3. The facility's grievance policy mandates prompt resolution of grievances, which was not adhered to in this case, as evidenced by the 130-day delay in addressing V5's billing grievance.
Failure to Conduct Legionella Assessment
Penalty
Summary
The facility failed to conduct an assessment to identify potential growth areas for Legionella and other opportunistic waterborne pathogens, affecting all 46 residents. The Maintenance Director, who has been with the facility for three years, confirmed that no such assessment had been performed during his tenure. He also stated that the facility had not engaged a company to conduct the necessary assessment, nor had any testing for Legionella been carried out. The facility's policy on Infection Prevention & Control for Legionnaires Disease, dated November 1, 2018, outlines the procedure for maintaining a water management program. This includes identifying building water systems that require Legionella control measures and assessing the risk posed by hazardous conditions in those systems. However, the facility did not have an assessment or a building flow diagram as recommended by the CDC toolkit, indicating a lapse in following their own policy and procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and date medications once opened, which is crucial for determining their expiration dates. This deficiency was observed in several instances, including Latanoprost ophthalmic solutions for two residents that were opened but not discarded after their expiration dates. Additionally, two inhalers were found opened without being dated, contrary to pharmacy recommendations that require discarding them six weeks after opening. Furthermore, expired medications were not removed, as evidenced by a vial of Tuberculin Purified Protein that was kept beyond its recommended disposal date. The facility also failed to maintain the integrity of narcotic medications, as several blister packs had broken seals that were taped over, which is against the facility's controlled medication policy. Suppository medications were stored in unsanitary conditions, with boxes drenched in water from a leaking refrigerator. The Director of Nursing and a Registered Pharmacist confirmed that narcotic medications should be destroyed if not administered, with a witness present, to prevent potential diversion. The facility's policy mandates that medication storage areas be kept clean, safe, and sanitary, which was not adhered to in these instances.
Failure to Ensure Proper Pureed Food Consistency
Penalty
Summary
The facility failed to prepare green peas to the appropriate pureed consistency for residents on pureed diets, affecting five residents in the sample. During an observation in the facility kitchen, a cook, identified as V5, was seen preparing pureed green peas for these residents. V5 used a food processor to puree the peas but did not test the consistency of the final product. Upon tasting, it was found that the mixture contained fibrous casings from the pea pods, which were not chewable and posed a risk of getting stuck in the throat when swallowed. The Dietary Manager, V4, confirmed the inconsistency of the pureed peas, agreeing that the product should have been smooth and pudding-like without fibrous casings. The facility's diet list confirmed that the affected residents were on pureed diets, and the Registered Dietitian, V7, reiterated that the expected consistency should be smooth and free of chunks or fibrous material. The facility's policy and procedure for pureed diets, dated 2010, stated that food should be provided in a form designed to meet individual needs, with pureed diets served as ordered by the physician. The policy also specified that whole food should be pureed to a semi-solid, pudding-like consistency.
Failure to Utilize McGeer Criteria for Antibiotic Stewardship
Penalty
Summary
The facility failed to utilize the McGeer Criteria for monitoring antibiotic use from March 2024 through November 19, 2024, as per their policy. This deficiency affected nine residents who were reviewed for antibiotic stewardship. The Infection Preventionist/Assistant Director of Nursing (V3) admitted to ceasing the use of the McGeer Criteria in March 2024, despite the facility's protocol requiring its use to evaluate and communicate clinical signs and symptoms when a resident is suspected of having an infection. The facility's infection tracking binder showed documentation of the McGeer Criteria for January and February 2024, but none for the subsequent months. V3 acknowledged that due to multiple responsibilities, infection control had been neglected, resulting in the absence of necessary documentation to determine if residents met the standards for antibiotic utilization.
Lack of Dementia Training for CNAs
Penalty
Summary
The facility failed to provide dementia training for Certified Nurse Assistants (CNAs) responsible for caring for residents with dementia. This deficiency affected 26 residents identified by the facility as having a dementia diagnosis. Interviews and record reviews revealed that the CNA Supervisor, who is responsible for conducting annual evaluations and in-services for CNAs, did not provide dementia training and could not recall attending such training. The Director of Nursing, who started working at the facility in April 2024, confirmed that no dementia training had been conducted since her tenure began. An in-service binder review failed to produce any documentation of dementia training, and the Community Relations Coordinator, who was believed to conduct such training, stated that she did not provide dementia training for the staff. Several CNAs, including those who had been working at the facility for varying lengths of time, reported that they had not received dementia training during their orientation or at any point during their employment. Despite caring for residents with dementia, these CNAs were not equipped with the necessary training to address the specific needs of these residents. The lack of dementia training was a significant oversight, as the facility had a substantial number of residents diagnosed with dementia, yet there was no evidence of structured training to ensure CNAs were adequately prepared to provide appropriate care.
Deficiency in Wound Care Assessment and Documentation
Penalty
Summary
The facility failed to properly assess and document a resident's wound care, specifically for a resident identified as R5. R5, a cognitively intact female with multiple diagnoses including osteoarthritis, congestive heart failure, and type 2 diabetes, was admitted to the facility with a sacral wound. Despite the presence of a wound care order dated October 23, 2024, which included specific instructions for cleansing and dressing the wound, the facility did not update R5's care plan to reflect the wound. The care plan had not been revised since August 23, 2023, and did not include interventions for the sacral wound. Observations and interviews revealed that R5 had been experiencing pain and had an open wound on her sacrum for several months. The Director of Nursing (DON) was unaware of the wound and could not provide any assessment or documentation for it. The wound care doctor had not been informed or involved in R5's care, and R5's name was not listed in the wound care system for October or November 2024. The facility's policies required comprehensive skin assessments and documentation, which were not followed in this case, leading to a deficiency in wound care management.
Deficient Arbitration Agreement Lacks Required Language
Penalty
Summary
The facility's arbitration agreement was found to be deficient as it lacked the required language indicating that residents or their representatives are not obligated to sign the arbitration agreement as a condition for admission or continued care. Additionally, the agreement did not inform residents or their representatives of their right to rescind the agreement within 30 calendar days of signing. This deficiency was identified during a review of the facility's admission packet, which included the arbitration agreement under the section titled 'Miscellaneous Provisions N. Mediation/Arbitration.' The Community Relations Coordinator, identified as V8, confirmed during an interview that the arbitration agreement did not contain the necessary language. V8 explained that she typically reviews the contract with residents or their representatives, either in person or over the phone, but acknowledged the omission upon re-reading the agreement. The facility's failure to include this critical information affects all 46 residents residing at the facility, as indicated by the facility's application for Medicare and Medicaid.
Failure to Safely Transfer Resident Using Wheelchair
Penalty
Summary
The facility failed to safely transfer a resident using a wheelchair, resulting in an accident. On 5/13/24, a resident was being transported from her room to the dining room by an Activity Aide. The resident's wheelchair did not have foot pedals, and the Activity Aide instructed the resident to hold her feet up. However, the resident's foot got caught in the front wheel of the wheelchair, causing her to topple over and fall to the ground, hitting her head and sustaining a laceration. The Maintenance Director confirmed that there was no issue with the wheelchair's wheels or brakes. The resident was sent to the emergency room and returned to the facility the same day without needing sutures or having any fractures. The resident's fall risk assessment indicated she was at high risk for falls, and her MDS showed no cognitive impairment. Interviews with various staff members, including a CNA, LPN, and the Director of Nursing, revealed that it is the responsibility of the transporter to ensure that residents' feet are either held up or placed on foot pedals to prevent accidents. The facility's policy on assistive devices and equipment, revised in July 2017, did not include specific safety measures for transporting residents in wheelchairs. The Administrator confirmed that the resident was bleeding from her forehead when she arrived at the scene, and 911 was called to transport the resident to the hospital. The incident highlights a gap in the facility's policy and staff training regarding the safe transportation of residents in wheelchairs.
Improper Kitchen Sanitization and Food Storage
Penalty
Summary
The facility failed to ensure proper sanitization of the kitchen and correct storage and disposal of food items, which could prevent the transmission of foodborne illnesses. During a quality assurance check, it was observed that the sanitizing buckets and the three-compartment sink tested at zero parts per million (ppm) for sanitizer concentration. The Dietary Manager acknowledged that staff were not regularly checking or documenting the sanitizer levels, which should be done several times during meal preparation and at least three times a day for the sink. This lapse in procedure could lead to ineffective sanitization and potential cross-contamination and foodborne illnesses among residents. During a kitchen tour, several issues were noted with food storage. Multiple opened food items in the dry storage area lacked proper labeling, including open dates and use-by dates. Some items were expired, and others were not stored according to manufacturer instructions, such as lime juice that should have been refrigerated. In the walk-in cooler, moldy green peppers and improperly stored Canadian bacon were found. The reach-in cooler contained opened mayonnaise and cream cheese without proper labeling. The walk-in freezer had a large bag of garlic bread with illegible writing, and the reach-in freezer contained expired apple muffin batter. The facility's policies on food storage and sanitization were not followed. The policies required that foods stored in bins be labeled with the item and date unpacked, and that open products be tightly covered to protect against contamination. The sanitizing solution policy required testing each time the sanitization buckets were changed. The Dietary Manager admitted that these procedures were not being followed, leading to potential risks of foodborne illnesses due to improper food handling and storage practices.
Failure to Remove Lint from Dryers Poses Fire Hazard
Penalty
Summary
The facility failed to ensure lint was removed from the facility's dryers, posing a fire hazard. On 01/17/24 at 3:48 PM, it was observed that the facility's three dryers had significant lint accumulation. Dryer 1 had approximately a one-inch layer of lint on the bottom and on all four sides of the lint basket, while dryers 2 and 3 had lint approximately one inch thick on the top of the lint screens and a pile under both screens about 10 inches high and 10 inches wide. Both dryers 2 and 3 were running with clothes in them at the time of observation. The laundry staff member (V16) stated that she cleans the dryers once a day at the end of her shift and does not keep a log of when the lint is cleaned. She mentioned that she handles about 20 to 30 loads a day. The Maintenance Director (V12) acknowledged that running the dryers with such lint accumulation would be a fire hazard and admitted that the facility does not have a policy on removing lint from the dryers. Additionally, the facility does not maintain a log for dryer maintenance. The dryer manuals provided by the facility emphasized the importance of keeping lint screens clean to prevent fire hazards, suggesting cleaning every third or fourth load.
Failure to Investigate and Report Potential Abuse
Penalty
Summary
The facility failed to respond appropriately to a potential abuse allegation involving a resident with multiple diagnoses, including Alzheimer's disease and dementia. The incident was reported by another resident who observed an agency CNA pushing the affected resident into a dining room table. Despite being informed of the concern, the facility's administrator did not conduct a thorough investigation or report the allegation to the State Survey Agency. Instead, the administrator only contacted the staffing agency to request that the CNA not return to the facility. The facility's documentation showed that the grievance was not resolved and was still in process at the time of the survey. The facility's policy on abuse and neglect requires the identification and investigation of possible incidents or allegations, but this protocol was not followed. The administrator admitted to only performing a quick verbal follow-up and did not consider the concern as abuse, which led to the failure in addressing the potential abuse allegation properly.
Failure to Assist Resident with Grooming and Hygiene
Penalty
Summary
The facility failed to ensure residents receive assistance for grooming and hygiene care, specifically for one resident who was observed with several white hairs on her upper lip and chin. The resident expressed dissatisfaction with the hair and mentioned that someone was supposed to remove it but never did. The resident's MDS indicated moderately impaired cognition and a need for moderate assistance with personal hygiene, while her care plan required extensive assistance from one staff member for personal hygiene. The Assistant Director of Nursing confirmed that CNAs were responsible for assisting residents with ADL care and acknowledged that the resident should not have hair on her chin or upper lip. The facility's policy stated that residents unable to carry out ADLs independently should receive necessary services to maintain good grooming and personal hygiene.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to secure hazardous chemicals, which were found in shared bathrooms of residents with impaired mental status. Specifically, a 32 oz spray bottle of bleach was found in the shared bathroom of two residents, one of whom had a severely impaired mental status and the other with diagnoses including dementia, schizoaffective disorder bipolar type, neurocognitive disorder, and major depressive disorder. The housekeeping staff admitted to leaving the bleach bottle in the bathroom after cleaning it. Additionally, a 32 oz spray bottle of odor eliminator was found in another shared bathroom of two residents, one with schizoaffective disorder, major depressive disorder, and far-sightedness, and the other with dementia with agitation, mild cognitive impairment, and age-related cognitive decline. The housekeeping staff acknowledged that the bottle should have been locked away for safety reasons. The Director of Nurses confirmed that the chemicals should not have been left in the residents' rooms due to safety concerns, especially for residents with altered mental status who could potentially harm themselves or others. The facility's Chemical Use Policy mandates that all chemicals must be under the control of housekeeping staff, either in a locked housekeeping cart or behind locked doors. The failure to adhere to this policy resulted in hazardous chemicals being accessible to residents, posing a significant safety risk.
Failure to Ensure Sanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure sanitary storage and containment of respiratory equipment for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). On two separate occasions, the resident's oxygen tubing and nasal cannula were observed on the floor when not in use. The resident confirmed that he uses the oxygen. The facility's policy, updated earlier in the month, mandates that oxygen tubing should be stored in a plastic bag when not in use for infection control reasons. The Assistant Director of Nursing confirmed that the equipment should not be on the floor.
Failure to Administer Correct Insulin Dose
Penalty
Summary
The facility failed to administer the correct dose of insulin medication to a resident. During a medication pass, an agency RN administered 50 units of Lantus insulin to a resident with Type 2 Diabetes Mellitus. However, after the administration, it was observed that 2 units of insulin remained in the pen, indicating that the resident did not receive the full prescribed dose. The resident's electronic medical records confirmed the diagnosis and the physician's order for 50 units of insulin. The Assistant Director of Nursing acknowledged that the nurse should have administered the full dose as per the doctor's order. The facility's policy on administering medications states that medications must be administered in accordance with the orders.
Failure to Isolate COVID-Positive Resident from COVID-Negative Roommate
Penalty
Summary
The facility failed to isolate a COVID-positive resident from her COVID-negative roommate, leading to a deficiency in infection control. On 01/17/24, the Director of Nursing (DON) stated that one resident was positive for COVID and another was under observation, both sharing the same room. Despite the facility's policy to isolate COVID-positive residents and relocate their COVID-negative roommates, the two residents were kept together based on the physician's instructions. The Assistant Director of Nursing (ADON) confirmed that there were seven open beds available to relocate the COVID-negative resident, but this was not done. The COVID-negative resident expressed concerns about not being offered another room and not knowing how she was being protected from COVID. Nurse documentation later indicated that the COVID-negative resident tested positive and was on antiviral medication, although initial tests were negative. The facility's policy, dated 4/27/20, mandates that any resident suspected or confirmed to have COVID-19 should be moved to a private room, and only residents of the same gender and infection status may be cohorted. The ADON/IC Nurse stated that no facility-wide testing was conducted because the two residents did not leave their room, and there were no exposure risks. However, the facility policy and CDC guidelines recommend isolating symptomatic or exposed residents from confirmed COVID-positive residents until testing confirms their status. The failure to follow these guidelines and policies led to the deficiency in infection control practices at the facility.
Non-Functional Call Light
Penalty
Summary
The facility failed to ensure a resident had a functional call light available. A male resident was observed repeatedly yelling for help from his room, stating that no one was answering his call light. Upon testing, it was found that the call light was not activated and only worked intermittently after being re-plugged by a CNA. The call light then failed to turn off. The Director of Nurses confirmed that the call light was sticky and not functioning properly, and stated that staff are expected to check call lights at the beginning of every shift. The facility's call light policy mandates that call lights be answered in a timely manner and maintained by the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 616 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Bella Of Aurora | 1.4 mi | ★★★★★ | 3 | 0 |
| Alden Courts Of Waterford | 2.6 mi | ★★★★★ | 2 | 1 |
| Avantara Aurora | 2.6 mi | ★★★★★ | 11 | 0 |
| Alden Of Waterford | 2.6 mi | ★★★★★ | 4 | 0 |
| Pearl Of Orchard Valley | 3.1 mi | ★★★★★ | 26 | 1 |
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 October 2026) and official state health department websites.