Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Peterson Park Health Care Ctr during CMS and state inspections, most recent first.
Two cognitively intact residents with multiple chronic conditions, including nicotine dependence, became involved in a physical altercation while accessing the smoking patio via a ramp and vestibule with a blind spot. One resident stopped in the walkway to light a cigarette, partially blocking the path, and when another resident attempted to pass, physical contact and an argument escalated into the second resident being grabbed, knocked to the ground, and punched in the face. Witnesses and staff provided differing accounts of who initiated the contact, but consistently confirmed that one resident struck the other in the facial area. The injured resident was observed with facial redness, later developing a black eye and maroon discoloration of the upper right cheek, and was admitted to the hospital with a facial contusion and other diagnoses before being readmitted. The facility’s abuse policy defines physical abuse as non-accidental infliction of injury requiring medical attention, and surveyors determined the facility failed to protect residents from such abuse.
Failure to Maintain Effective Pest Control Program: Surveyors observed live roach activity in a resident bathroom, a resident dresser, and a conference room table, and residents reported seeing roaches in bathrooms, dressers, and nightstands. One resident described stepping on a roach and having housekeeping clean it up, while another stated he had not seen an exterminator come to spray for roaches. The MDS stated the exterminator comes twice per month and he reports where roach activity was last seen.
A resident with a history of TIA, cerebral infarction, adult failure to thrive, and documented weakness in all four extremities was inaccurately coded on the MDS for functional limitation in range of motion. Hospital records and therapy notes described significant limitations in both upper and lower extremities, including inability to move the left hand or lower extremities and marked weakness requiring arm and leg exercises. However, the Restorative Nurse coded no limitations in bilateral upper and lower extremities on Section GG0115, stating that no limitations were noticed during the physical assessment, contrary to the medical documentation and the RAI manual definition of functional limitation.
A resident with COPD and other comorbidities, who had a PRN order for Ipratropium-Albuterol nebulizer treatments, had a nebulizer machine, tubing, and mask left on the nightstand while not in use, with the tubing and mask dated beyond the facility’s 7-day use policy and not stored in a dated clear plastic bag as required. The ADON confirmed that facility policy requires nebulizer equipment to be changed weekly, dated, and stored in a dated clear plastic bag when not in use, which was not followed in this case.
A resident with a history of stroke and dysphagia, on a physician-ordered mechanical soft diet with honey-thick liquids, was observed during an activity and meal period with an unthickened can of soda placed in front of her, in addition to her prescribed honey-thick beverages. Despite staff acknowledging that all of the resident’s liquids must be honey-thick and that nursing holds the thickening agent, the resident was seen drinking the unthickened soda, which had been provided and opened by staff after a family donated pizza and soda following a religious service. The resident confirmed that all liquids must be thickened and that no one offered to thicken the soda, while the RN and SLP verified the honey-thick liquid order, the availability of thickener, and that non-thickened liquids place the resident at risk for coughing, choking, and aspiration pneumonia, demonstrating a failure to follow the ordered therapeutic diet consistency.
A resident was slapped by another resident during a conversation, leading to a report of physical abuse. The incident was witnessed by another resident and assessed by an LPN and a Family Nurse Practitioner, who confirmed tenderness on the affected resident's face. The aggressor admitted to the action, citing sleep deprivation and frustration, but the investigation did not substantiate the abuse allegation.
The facility failed to properly clean and sanitize kitchen utensils and did not discard food by the use-by date. A cook used a sponge from a soap and water bucket to wash tongs and pitchers, which were then used to handle food without proper sanitization. Additionally, food in the prep refrigerator was incorrectly labeled with a past date. The Dietary Manager confirmed that utensils should be washed in a three-compartment sink and that food should be dated and used within 3-5 days.
A facility failed to ensure proper PPE use and linen handling, affecting infection control. A hospice CNA did not wear a gown while caring for a resident on Enhanced Barrier Precautions, unaware of the required precautions. Additionally, clean linens were improperly stored, with uncovered bins and a fan blowing air from dirty to clean linens, risking contamination. The facility's policies on linen protection were not followed, and the laundry chute was found overflowing.
The facility failed to provide adequate supervision during smoking breaks, with staff not remaining on the patio and lacking training for fire incidents. Additionally, utility rooms containing sharps and infectious waste were unsecured, allowing resident access. These deficiencies posed safety risks to residents, particularly smokers and ambulatory individuals.
The facility failed to prevent complications from enteral feeding for two residents by not ensuring proper bed positioning to avoid aspiration and by not removing expired feeding products. Despite care plans requiring elevated head positions during feeding, residents were observed inappropriately positioned. Additionally, expired enteral feeding products were found in the medication room, posing potential harm to residents.
Expired medications were found in a medication cart, potentially affecting all residents receiving medications from it. Staff interviews confirmed that expired medications should not be present, as they could harm residents. The facility's policy requires medications to be labeled with expiration information and to expire based on manufacturer's guidelines.
The facility did not follow the prescribed menu for residents on a pureed diet, affecting 19 residents. Pureed bread was omitted from the meal, and mashed potatoes were served instead without the required approval from the dietician. This oversight could have impacted the residents' caloric intake.
A resident with hemiplegia and hemiparesis was not provided with a hand splint for contracture management as per their care plan. Despite documentation indicating the splint was applied, observations revealed it was not in place, and the resident confirmed it was not applied on the observed day. The facility was short-staffed, impacting the ability to provide necessary restorative services.
A resident with a complex medical history, including hypertension and diabetes, had an intravenous catheter dressing that was not changed for 12 days, contrary to the facility's policy of changing it every 7 days. This oversight was confirmed by a registered nurse and the Director of Nursing, who acknowledged the potential risk for infection due to the delay in changing the dressing.
A resident's refrigerator contained undated sandwiches and cookies, despite the facility's policy requiring food items to be labeled and dated. The resident, with Type 2 Diabetes Mellitus, had a care plan to monitor diet compliance. An LPN and the DON provided conflicting information on who is responsible for checking and discarding undated items, leading to the deficiency.
A resident's call light system was found non-functional during a survey, as it failed to illuminate or produce an audible sound when used. Both an LPN and a CNA confirmed the malfunction, which prevented staff from being alerted to the resident's needs. The resident's care plan encouraged the use of the call light, but a documentation error initially misrepresented the resident's ability to use it. Facility policy required daily checks and immediate reporting of defective call lights, which was not followed.
The facility failed to schedule service plan meetings for the [NAME] Consent Decree Program, which aims to transition residents back into the community. Despite ongoing communication with the program representatives, the facility did not facilitate these meetings, affecting 28 residents. The Social Services Director cited delays in assigning case managers and deemed certain residents as not good candidates for the program.
Failure to Prevent Resident-to-Resident Physical Abuse During Smoking Patio Access
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse between two cognitively intact residents, R1 and R2, during access to the smoking patio. Both residents have multiple medical diagnoses, including nicotine dependence and other chronic conditions, and both have BIMS scores of 15, indicating intact cognition. On the date of the incident, R1 and R2 were proceeding to the smoking area via a ramp and vestibule with a noted blind spot. R2 stopped in the walkway to light a cigarette, which partially blocked the path. R1 attempted to pass and there was physical contact between them, after which a physical altercation occurred resulting in R2 being struck and falling to the ground. Multiple interviews and notes describe differing accounts of who initiated the physical contact, but consistently confirm that R1 hit R2 in the face. R1 reported that while attempting to pass R2 on the ramp, he felt a blow to the left side of his own face, then grabbed R2’s jacket collar, pulled him down, and punched him in the face multiple times before another resident intervened. R2 stated that he was attacked in the vestibule on the way to the smoking tent, reporting that R1 rammed him from behind with a wheelchair, hit him in the right temple area, and threatened to beat him into a coma, and that he did not feel safe. Witnesses, including residents and staff, gave varying accounts: some stated R2 hit or pushed R1 first and R1 hit back, while others stated R2 put his hand in R1’s face and R1 then struck R2, or that R1 grabbed R2, threw him to the ground, and hit him in the face. Clinical documentation and staff observations confirm that R2 sustained visible injury as a result of the altercation. An abuse report noted redness on R2’s upper cheek immediately after the incident, and subsequent nursing and wound care notes described a bruise, black eye, and maroon discoloration on the upper right cheek and around the right eye. R2 was sent to the hospital and admitted with diagnoses including hypotension, facial contusion, dehydration, and lactic acidosis, and later readmitted to the facility with a documented black eye. The facility’s abuse and neglect policy states that physical abuse includes infliction of injury that occurs other than by accidental means and requires medical attention. The survey finding concludes that the facility failed to protect residents from physical abuse, resulting in R2 sustaining an injury near the right eye and requiring hospital evaluation, and that a reasonable person would have experienced psychosocial harm from being injured in this manner.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to provide and maintain an effective pest control program. During observation and interview, a resident stated he had seen roaches in his bathroom, dresser, and nightstand, and when the dresser was opened, surveyors observed live roaches of three different sizes scattering away. Another resident stated she had seen roaches in her bathroom and described stepping on one and calling the nurse, after which housekeeping cleaned up the dead roach. A third resident stated he had seen roaches in the bathroom and that he had not seen an exterminator come in to spray medication to get rid of them. Surveyors also observed a small roach in a bathroom and a small roach on a conference room table. The Maintenance Director stated he had seen roaches in the past, typically in the hallways, and had seen improvement since the facility hired an exterminator. He stated the exterminator comes to the facility two times per month and that he tells the exterminator where he last saw roach activity. The facility policy titled Pest Control states it is the facility's policy to ensure there is an effective pest control process in the building and that if there is a suspicion or actual problem with pests, the facility will contact a pest control company to inspect for a pest control problem and treat it if identified.
Inaccurate MDS Coding of Functional Range of Motion
Penalty
Summary
The facility failed to ensure an accurate MDS assessment by not following the RAI manual for one resident’s functional limitation in range of motion (Section GG0115). The resident, an older adult with diagnoses including personal history of TIA and cerebral infarction, gastrostomy status, adult failure to thrive, essential hypertension, type 2 diabetes mellitus, developmental disorder of scholastic skills, and unspecified asthma, was readmitted with adult failure to thrive and generalized weakness. Hospital discharge records dated 6/26/24 documented limitations in all four extremities, and hospital physician notes from 6/20/24 stated the resident was barely able to move the right arm and was unable to move the left hand or lower extremities. Therapy staff reported providing exercises for the resident’s arms and legs due to weakness and noted more limitation in the left arm and hand. Despite these documented and observed limitations, the Restorative Nurse, who was responsible for completing the functional limitation in range of motion section of the MDS on 6/30/24, coded the resident as having no limitation in bilateral upper and lower extremities. The Restorative Nurse stated this coding was based on not noticing any limitation during the physical assessment, even though the hospital discharge records reviewed with the surveyor showed limitations in all four extremities. The Clinical Care Coordinator stated it was her expectation that all MDS sections be coded accurately, and the Restorative Nurse job description requires completion of assigned MDS portions accurately and on time. The CMS RAI Manual defines functional limitation in range of motion as limited ability to move a joint that interferes with daily functioning, particularly with ADLs, which was inconsistent with how the resident was coded.
Improper Dating and Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not properly dating, labeling, and storing nebulizer equipment for one resident. During observation, the resident was resting in bed and not using the nebulizer machine, which was sitting on the nightstand with the nebulizer tubing and mask placed on top of the machine. The tubing and mask were labeled with a date of 10/22/25, and they were not stored inside a clear plastic bag when not in use. The Assistant Director of Nursing stated that nebulizer tubing and masks are to be changed weekly, dated when last changed, and stored in a clear plastic bag that is also dated when the equipment is not in use. The resident’s clinical record showed an admission date of 1/4/23 and diagnoses including COPD, end-stage renal disease, and hypertensive heart disease with heart failure. The resident had an active PRN order for Ipratropium-Albuterol inhalation solution every six hours as needed for shortness of breath or congestion, ordered on 10/22/25. The facility’s Respiratory Therapy Equipment Use policy dated 7/3/25 stated that nebulizer masks will not be reused beyond seven days after opening and must be dated and discarded after seven days of use, whether used continuously or on a PRN basis. The Assistant Director of Nursing confirmed during the room observation that the nebulizer tubing and mask were dated 10/22/25, should have been inside a clear bag when not in use, and that the bag should also have been dated, which was not the case at the time of the surveyor’s observation.
Failure to Provide Ordered Honey-Thick Liquids During Activity and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide liquids in the physician-ordered honey-thick consistency for a resident with dysphagia during an activity and meal period. A resident on a mechanical soft diet with honey-thick liquids was observed seated at a table with mechanical soft food items, a closed container of honey-thick milk, an opened container of honey-thick juice, and an opened can of soda. The resident’s meal ticket and electronic health record documented a diet order of mechanical soft/mechanical altered with honey-thick liquids due to swallowing difficulties and a history of stroke and dysphagia. The speech therapy evaluation and plan of treatment also recommended honey-thick liquids. During observation, the activity aide stated that the resident could only drink honey-thickened liquids and acknowledged that the soda in front of the resident was not thickened, explaining that the soda had been requested by the resident but was supposedly not being consumed. Shortly thereafter, the resident was observed picking up the soda can and taking several sips, which was confirmed by both the activity aide and the social worker, who stated the resident should only be drinking honey-thick liquids. The social worker later explained that a family member had donated pizza and soda after a religious service and that a staff member must have provided and opened the soda for the resident, as the resident could not have opened it independently. In interviews, the resident confirmed that all liquids, including water, must be thickened to prevent coughing and stated that a staff member had given and opened the soda without offering to thicken it, adding that she would have accepted thickened soda and believed staff had forgotten to thicken it. The RN verified that the resident was on a mechanical soft diet with honey-thick liquids and at high risk for aspiration, and that thickener was available on the medication cart, but he had not been informed that the resident had been given soda. The activity aide stated she knew the resident required honey-thick liquids and that nursing staff are responsible for thickening beverages, but described the environment as very busy after the religious service and acknowledged placing the soda in front of the resident and that it should not have been opened or consumed unthickened. The speech language pathologist confirmed the need for honey-thick liquids for this resident and stated that all liquids, including soda, can be thickened and that non-honey-thick liquids would place the resident at risk for increased coughing, choking, and aspiration pneumonia. Facility diet lists, meal tickets, and kitchen policies further documented the requirement for thickened liquids and adherence to therapeutic diet orders.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. This incident involved a resident, R2, who reported feeling in terrible danger after being slapped on the face by another resident, R5. The altercation occurred while R2 and another resident, R8, were having a conversation, and R5 became upset, leading to the physical assault. R8 confirmed witnessing the incident, stating that R5 hit R2 on the face with an open hand because R5 was upset about the conversation taking place in his room. A Licensed Practical Nurse (LPN), V22, was present in the vicinity when the incident occurred and intervened by separating the residents and assessing R2, who showed signs of distress and tenderness on the face. The Family Nurse Practitioner, V18, was also called to assess R2, confirming tenderness on the left side of the face but no discoloration. The Social Service Director, V11, acknowledged that the incident constituted physical abuse and emphasized that such behavior is not expected in a safe, home-like environment. The facility's administrator, V1, interviewed R5, who admitted to slapping R2 due to sleep deprivation and frustration. R5's care plan indicated a history of criminal behavior, including aggravated battery, highlighting the need for careful management of his behavior. Despite the acknowledgment of the incident as physical abuse, the investigation concluded that the allegation could not be substantiated, as R5 claimed the action was a means to achieve peace and quiet. The facility's policy emphasizes a commitment to preventing abuse and maintaining a safe environment for all residents.
Improper Cleaning and Food Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of kitchen utensils and did not discard food from the prep refrigerator by the use-by date. During an inspection, a surveyor observed red rice and chicken in the prep refrigerator with a date label indicating it was prepared in July, although the current month was September. The Dietary Manager acknowledged the incorrect labeling. Additionally, the cook was observed using a sponge from a green bucket containing soap and water to wash kitchen tongs and measurement pitchers, which were then used to handle food without proper sanitization. The cook used the same unsanitized tongs to place steak burgers on buns and the measurement pitcher to handle Italian parmesan sauce and ravioli. The Dietary Manager later confirmed that the tongs and pitchers should have been washed in a three-compartment sink, which includes a sanitizing step, and that clean utensils should be used each time. The facility's policy requires that potentially hazardous food be dated and used within 3-5 days and that utensils be properly washed, rinsed, and sanitized, which was not adhered to in this instance.
Inadequate PPE Use and Linen Handling in LTC Facility
Penalty
Summary
The facility failed to ensure that contracted staff wore appropriate Personal Protective Equipment (PPE) while caring for a resident on Enhanced Barrier Precautions (EBP). A hospice Certified Nurse Aide (CNA) was observed bagging dirty linen in a resident's room while wearing gloves but no gown, despite the EBP sign outside the room indicating the need for both gloves and a gown during high-contact resident care activities. The CNA was unaware of the precautions required for the resident and had not been informed by the facility. The Infection Preventionist confirmed that EBP is necessary for residents with certain medical devices, such as gastrostomy tubes, and requires the use of gloves and gowns to prevent the transmission of multi-drug resistant organisms (MDROs). Additionally, the facility failed to ensure proper linen storage and handling. Observations in the laundry area revealed uncovered bins of clean linens and a fan blowing air from dirty to clean linens, which could lead to contamination. The laundry chute was also found to be overflowing with bags of linen and resident clothing. The facility's policies require that clean linens be covered to protect them from contamination, but these procedures were not followed. The Infection Preventionist and Assistant Director of Nursing acknowledged that linens should be covered, and the laundry chute should be checked regularly to prevent overflow.
Inadequate Supervision and Security in Smoking and Utility Areas
Penalty
Summary
The facility failed to provide adequate supervision and safety measures for residents during smoking breaks on the smoking patio. Observations revealed that staff, including activity aides, did not remain on the patio for the entire duration of the smoking breaks, instead checking periodically. Staff members were not trained on what to do if a resident's clothing caught fire, and there was no documentation of fire drills or training specific to the smoking patio. The facility's smoking policy lacked specific safety measures for such incidents, and the staff's lack of knowledge and presence posed a risk to residents who smoke. Additionally, the facility did not secure soiled utility rooms on the first and second floors, which contained sharps and infectious waste containers. A resident was observed accessing a utility room without authorization, using a keypad entry code, and the door was found to be unlocked multiple times. The room contained hazardous materials, including sharps containers, biohazard waste, and a specimen refrigerator. Staff acknowledged that the room should be locked and that residents should not have access due to the risk of infection and injury. The facility's policy on hazards stated that residents should not have access to hazardous items such as medications, sharps, and chemicals. However, the failure to secure the utility rooms and provide adequate supervision on the smoking patio demonstrated a lack of adherence to this policy, potentially affecting the safety of all residents, particularly those who are ambulatory or identified as smokers.
Deficiencies in Enteral Feeding Management and Expired Product Handling
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications from enteral feeding for two residents. Resident R35, who has multiple diagnoses including dysphagia and severe protein-calorie malnutrition, was observed receiving enteral feeding with the head of the bed not adequately elevated, posing a risk of aspiration. The care plan for R35 indicated the need for the head of the bed to be elevated during feeding, but this was not consistently followed, as noted by the surveyor and confirmed by the Licensed Practical Nurse. Similarly, Resident R132, with severe cognitive impairment and a history of cerebral infarction, was also observed receiving enteral feeding in a low Fowler's position, contrary to the care plan's requirement for the head of the bed to be elevated to prevent aspiration. The Director of Nursing acknowledged the risk of aspiration if residents are not properly positioned during enteral feeding. Despite the care plan's interventions, the facility did not ensure the correct positioning of R132 during feeding. Additionally, the facility failed to remove expired enteral feeding products from the medication room, which could potentially affect residents receiving enteral nutritional feedings. Expired products, including Osmolite and TwoCal, were found in the medication room, and staff acknowledged that expired products should not be present as they could harm residents. The facility's policy required checking expiration dates, but this was not adhered to, leading to the presence of expired feeding products in the facility.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure that expired medications were removed and unavailable for administration to residents, as observed during a review of the 2 North Front medication cart. On September 17, 2024, the Director of Nursing (V2) and a surveyor found Gas Relief Simethicone 80mg chewable tablets with an expiration date of August 2024 still present in the cart. This oversight has the potential to affect all residents receiving medications from this cart. Interviews with staff members, including a Registered Nurse (V27) and the Infection Control Nurse (V8), confirmed that expired medications should not be present in medication carts or rooms, as administering them could harm residents. The Director of Nursing (V2) also acknowledged that expired medications or enteral feedings should not be in the carts or rooms, as they could cause adverse reactions in residents. The facility's policy on medication storage, labeling, and disposal, dated August 16, 2024, states that house stocks should be labeled with expiration information, and medications automatically expire based on the manufacturer's guidelines.
Failure to Follow Prescribed Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on a pureed diet, which potentially affected 19 residents. On a specific date, the kitchen staff was observed serving pureed ravioli, pureed mixed vegetables, and mashed potatoes, but failed to include pureed bread as specified in the menu. The absence of pureed bread was not communicated to the registered dietician, who confirmed that the menu should have included pureed bread and that any substitution, such as mashed potatoes, should have been documented and approved in advance. The dietary manager confirmed that the menu was not followed and acknowledged that the cook forgot to include the pureed bread. This oversight could have resulted in residents not receiving the intended caloric intake. The facility's policy requires that any changes to the menu be approved by the dietician to ensure nutritional adequacy, which was not done in this instance.
Failure to Apply Hand Splint for Contracture Management
Penalty
Summary
The facility failed to apply a hand splint to the left hand of a resident, identified as R145, for contracture management. R145 has a medical history that includes hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side, among other conditions. The resident's care plan included the application of a resting hand splint and elbow on the left hand for 4 hours daily, as well as a pressure relief ankle foot orthosis on bilateral lower extremities. However, during an observation on 09/17/24, the resident was found without the splint on the left upper extremity, despite documentation indicating it had been applied. The resident confirmed that the splint was not applied on that day. The Restorative Nurse, V21, acknowledged that the splint should be applied daily and that there was no proof of its application other than the documentation by a Certified Nurse Assistant, V22, who stated they did not apply the splints themselves. The facility was short-staffed on the day in question, with only two restorative aides available instead of the usual four, which impacted the ability to cover the entire building. The facility's policy requires comprehensive nursing and restorative services to be provided according to the resident's functional needs, including contracture prevention and management, which was not adhered to in this instance.
Failure to Timely Change IV Catheter Dressing
Penalty
Summary
The facility failed to change an intravenous catheter dressing in a timely manner for a resident, identified as R33, who was under review for intravenous catheter care. R33 had a complex medical history, including conditions such as hypertension, diabetes, obesity, and vascular dementia, among others. The care plan for R33 noted a potential for infection due to the presence of a midline catheter in the right upper arm, with specific interventions to follow facility policy for infection prevention. Despite this, the midline catheter dressing, which was supposed to be changed every 7 days according to facility policy, was observed to be dated 09/05/24 during a survey conducted on 09/17/24, indicating that it had not been changed for 12 days. During the survey, a registered nurse (V16) confirmed the date on the dressing and acknowledged that the facility's policy required dressing changes every 7 days. The Director of Nursing (V2) also stated that the dressing should be changed weekly and as needed, emphasizing the importance of checking the site for signs of infection during dressing changes. The facility's policy on intravenous therapy, revised in August 2024, mandates that all midline catheter dressings be changed every 7 days, with the dressing labeled with the change date and time. The failure to adhere to this policy presents a potential risk for infection, as noted by the Director of Nursing.
Failure to Label and Date Food in Resident's Refrigerator
Penalty
Summary
The facility failed to ensure that food items in a resident's personal refrigerator were labeled and dated, as observed during a survey. The resident, who has multiple diagnoses including Type 2 Diabetes Mellitus, had two undated sandwiches and two undated chocolate chip cookies in their refrigerator. The care plan for this resident includes monitoring compliance with their diet, which is crucial given their medical conditions. During the survey, a Licensed Practical Nurse (LPN) acknowledged that any nurse could check the resident's refrigerator and that items should be dated, discarding those that are not. However, the Director of Nursing (DON) stated that housekeeping is responsible for checking the refrigerators and notifying nurses of any unlabeled items, with social services discussing the issue with the resident. This discrepancy in responsibility and procedure led to the deficiency, as the food items remained undated and unaddressed.
Non-Functioning Call Light System for Resident
Penalty
Summary
The facility failed to ensure a functioning call light system for a resident, identified as R14, during a survey. On the specified date, a surveyor observed that when R14 attempted to use her call light for assistance, the system did not illuminate or produce an audible sound, indicating it was not functioning. Despite being plugged into the wall, the call light did not alert staff, which was confirmed by both a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) responsible for R14's care. Both staff members acknowledged the malfunction and stated that the call light should have been operational to alert staff visually or audibly. The resident's care plan indicated that R14 had an Activities of Daily Living (ADL) self-care performance deficit and was encouraged to use the call light for assistance. However, a discrepancy was noted in the call light assessment documentation by a Restorative Nurse, who initially recorded that R14 was unable to use the call light due to cognitive issues. Upon review, the nurse admitted to a documentation error, confirming that R14 could use the call light, although she experienced cognitive confusion at times. The facility's policy required daily checks of call lights and immediate reporting of any defects, which was not adhered to in this instance.
Failure to Schedule Service Plan Meetings for Transition Program
Penalty
Summary
The facility failed to comply with applicable federal, state, and local laws, regulations, and codes by not scheduling service plan meetings for the [NAME] Consent Decree Program, which aims to transition residents back into the community. The Social Services Director (SSD), who has been in her role since February 2023, stated that the facility provides residents with the [NAME] Program fact sheet upon admission. However, there have been significant delays in assigning case managers from the [NAME] Program to residents, and the facility has had to contact residents' insurance company case managers to assist with transitions. Despite recent efforts by the [NAME] Program to schedule care plan meetings, the SSD indicated that the facility was unable to facilitate these meetings, citing that certain residents were not good candidates for the program. Email correspondences between the SSD and [NAME] Program representatives revealed ongoing communication issues and a lack of response from the facility regarding scheduling care plan meetings for residents in the program. The facility does not have a policy for the [NAME] Program, and documentation provided by the facility outlines the process for transitioning residents into the community, which includes assessments and service plans created by care managers. The failure to schedule these meetings has the potential to affect 28 residents currently participating in the [NAME] Program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Lincolnwood Place | 0.9 mi | ★★★★★ | 2 | 0 |
| Harmony Healthcare & Rehab Ctr | 1.2 mi | ★★★★★ | 2 | 0 |
| Alta Rehab At Fairmont | 1.3 mi | ★★★★★ | 27 | 0 |
| Astoria Place Living & Rehab | 1.5 mi | ★★★★★ | 4 | 0 |
| Ambassador Nursing & Rehab Center | 1.7 mi | ★★★★★ | 5 | 0 |
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