Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Timber Point Healthcare Center during CMS and state inspections, most recent first.
A cognitively impaired male resident with significant psychiatric and behavioral diagnoses was not effectively assessed or supervised for abuse risk, despite facility policy requiring identification of residents with behaviors that might lead to conflict. One night, staff responded to yelling and found the male resident leaving a female resident’s room; the female resident reported he had climbed onto her bed and punched her, and another resident corroborated seeing him on top of her in bed. The female resident, who had a history of anxiety, later described prior unwanted advances and an attempted breast touching by the same resident, as well as ongoing fear, anxiety, and restlessness after the incident, requiring psychiatric follow-up and medication changes. Her care plan did not address the abuse allegations or include protective interventions, and an abuse risk review inaccurately stated she had no abuse allegations, resulting in no care plan updates.
The facility failed to conduct a thorough investigation of an alleged resident-to-resident physical abuse incident. An RN heard yelling, found a male resident leaving a female resident’s room, and documented that the female resident reported he had crawled on top of her in bed and punched her in the face three times, after which she punched him back and pushed him off; the male resident was later sent to the ED for psychiatric evaluation, and EMS reported he had allegedly hit another resident. The female resident’s assessment showed no visible injuries. Despite this, the Administrator’s abuse investigation only included two statements and did not document that one resident had been on top of the other or that both residents had hit each other, and the Administrator acknowledged not interviewing additional staff or residents and not being aware of the mutual hitting that the RN stated she had reported.
Three residents developed or experienced worsening of facility-acquired pressure ulcers due to the facility's failure to update care plans with pressure-relieving interventions, implement those interventions, conduct routine skin checks, and perform Braden Scale assessments as required. In each case, staff did not consistently apply or use appropriate pressure-relieving devices, and care plans were not followed or updated, resulting in painful and worsening pressure injuries.
Surveyors found that staff failed to monitor and record cool down temperatures for prepared meats, did not label opened food items in refrigerators and dry storage, and used incorrect test strips for dish machine sanitization. The Dietary Manager confirmed these lapses, and kitchen staff were not using a cool down log for meals prepared in advance. These failures were observed to potentially affect all residents in the facility.
The facility did not maintain any system for tracking infections among residents or employees, as confirmed by the DON, despite having a policy requiring such surveillance. This deficiency was identified through interviews and record review, affecting all individuals in the facility.
The facility did not have a full-time, qualified infection preventionist as required, following the termination of the previous IP. The individual currently assigned to the role had not completed the necessary training, leaving all residents without a designated, trained IP.
The facility did not ensure that all CNAs received the required 12 hours of annual in-service training, as confirmed by the DON and a review of training records. This deficiency has the potential to affect all 69 residents in the facility.
Multiple residents reported ongoing issues with missing clothing, filing repeated grievances that were not resolved by the facility. Despite the facility's grievance policy requiring investigation and written decisions, the missing clothing concerns persisted, and the administrator confirmed the problem was ongoing.
Surveyors found that the facility did not consistently change or date oxygen tubing weekly for several residents receiving oxygen therapy, as required by physician orders and facility policy. Observations and interviews confirmed that tubing was often not labeled or was overdue for replacement, and documentation did not reflect that changes were completed as scheduled.
A resident with a completed POLST form indicating DNR and comfort-focused treatment did not have a corresponding plan of care addressing these advanced directives. Facility guidelines require such directives to be documented and included in the care plan, but this was not done, as confirmed by the Care Plan Coordinator.
A registered nurse administered an IV bag of normal saline labeled for a former resident to a current resident, using medication from the storage room without proper authorization. The bag, which was clearly marked with another individual's name and an outdated date, was infused and later found in the resident's room. The DON was informed after the fact and was unaware of the details regarding the bag's origin and labeling.
Two residents who were transferred to the hospital did not receive the required bed hold notices as documented in facility policy. One resident was sent for chest pain and another for constipation, but in both cases, there was no evidence in the medical records that the bed hold policy was communicated at the time of transfer, as confirmed by staff and administrative interviews.
A resident with a physician's order for hospice admission was not accurately coded as receiving hospice services in the MDS assessment. The MDS Coordinator acknowledged the error, noting that the assessment should have indicated the resident's hospice status, as required by facility policy.
A resident diagnosed with Bipolar II Disorder and prescribed antipsychotic medication was not referred for a Level II PASRR assessment as required. Facility records and staff confirmed that the necessary referral was not made following the mental illness diagnosis, in violation of policy.
Two residents who required staff assistance for personal hygiene did not receive routine fingernail care, resulting in long, jagged nails that extended past their fingertips. Both residents expressed a desire to have their nails trimmed, and facility documentation confirmed that nail care had not been provided for several months, despite facility guidelines requiring regular cleaning and trimming.
A resident with a documented DNAR order and multiple serious health conditions was found unresponsive, and staff initiated CPR before confirming code status, contrary to the resident's advance directive. The CNA performing compressions was unaware of the need to check code status, and the facility's process for communicating advance directives was not followed, resulting in the resident receiving CPR against her wishes.
A resident with an indwelling urinary catheter for urinary retention was observed with the catheter drainage bag resting on the floor next to the bed, contrary to facility policy requiring catheter bags to be kept off the floor. An LPN confirmed that catheter bags should be secured to the bed and never placed on the floor.
A resident did not receive their prescribed enteral nutrition formula via gastrostomy tube for several days, and the facility failed to notify the physician or seek an alternative. The DON confirmed that the nurses did not inform the physician about the unavailability of the ordered formula.
A facility did not complete an inventory of a resident's personal belongings upon admission, as required by their Admission's Contract. The resident, who is cognitively intact, reported that their belongings were taken for cleaning, but no inventory list was provided or completed. The facility's administrator confirmed this oversight.
A resident with severe malnutrition and a gastrostomy did not receive the prescribed enteral nutrition due to the facility receiving the wrong formula and nursing staff failing to notify the DON or administer any g-tube feeding. The resident was admitted with a prescription for Osmolite 1.5 at 45 ml/hr, but did not receive it for several days due to these oversights.
The facility did not provide readily available grievance forms or post grievance procedures in prominent locations, affecting all residents. Residents were unaware of how to file grievances, and an inspection confirmed the absence of official forms and posted procedures.
The facility did not provide written notices of transfer to residents or their representatives when transferring them to a hospital. This issue was confirmed by the DON and the Social Service Director, who both acknowledged a lack of awareness about the requirement for such notifications.
The facility failed to provide food items from the Always Available Menu to residents requesting meal substitutions. Residents reported only receiving limited options like peanut butter and jelly sandwiches or fruit plates, despite the menu listing various other items. They also expressed fear of requesting substitutions due to potential delays and cold meals. This deficiency affected all 70 residents in the facility.
The facility failed to document cool down temperatures for potentially hazardous foods, as required by their Two Stage Cool Down Process and HACCP Cooling Log. The Dietary Manager admitted to recently learning about the requirement and had instructed cooks to use the form, but it was not being utilized. This oversight could affect all 70 residents.
A resident with venous insufficiency and other medical conditions had a physician's order to wear compression stockings daily, but this was not documented in the care plan. The resident reported swelling in her legs and the need for compression stockings. The DON confirmed the absence of a care plan for this requirement, and the ADON/Wound Nurse added it after the deficiency was noted.
A resident with a history of skin integrity issues did not receive a physician-ordered Ketoconazole cream for 17 days due to a lack of order clarification and processing delays. The resident, at risk for skin issues due to multiple health conditions, expressed concerns about the facility's failure to complete medication orders timely. The DON confirmed the delay but was unsure of the reasons behind it.
A resident with End Stage Renal Disease did not receive comprehensive dialysis care, including physician-ordered yogurt with meals, daily weights, and lunch meals during dialysis sessions. The facility failed to communicate with the dialysis center and did not monitor the resident's central venous catheter port. Staff confirmed the lack of communication and documentation related to the resident's dialysis care.
A facility failed to monitor targeted behaviors for a resident on Abilify, an antipsychotic medication, and did not attempt a gradual dose reduction (GDR) in the past year. The resident's care plan lacked specific behaviors to monitor, and records showed no behaviors despite documentation of inappropriate comments and manipulative behaviors. The DON confirmed no GDR was conducted or recommended, citing a concurrent reduction in Buspirone as a reason.
A facility failed to implement Enhanced Barrier Precautions for a resident with a central venous catheter for dialysis. The facility's policy requires such precautions for residents with indwelling medical devices, but the resident's room lacked signage and personal protective equipment. The resident confirmed having the catheter since January, and the LPN/Infection Control Preventionist acknowledged the absence of precautions and documentation.
Failure to Assess Abuse Risk and Supervise Residents, Leading to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess a resident’s risk of abuse and to adequately supervise residents to prevent resident-to-resident physical abuse, resulting in one resident physically assaulting another. The facility’s Abuse and Retaliation Prevention Program Policy states that residents have the right to be free from abuse, neglect, exploitation, and mistreatment, and that staff will identify residents with increased vulnerability for abuse or behaviors that might lead to conflict through admission assessments, care plans, and MDS assessments. Despite this policy, a male resident with severe cognitive impairment and diagnoses including vascular dementia with behavioral disturbance, schizoaffective disorder, and delusional disorder was not effectively assessed or managed for behaviors that could lead to conflict or abuse. On the night of the incident, an RN heard yelling from the middle hall and found the cognitively impaired male resident wheeling out of a female resident’s room. The female resident reported that the male resident had crawled on top of her in bed and punched her on the right side of her face three times, after which she punched him back and pushed him off. Another resident in the room reported being awakened by the female resident yelling for help and observed the male resident crawling on top of the female resident in bed, with the female resident trying to get him off and striking him until he got back into his wheelchair. The RN documented that the male resident was showing signs of increased mania that night and was capable of transferring himself from his wheelchair into the female resident’s bed. The male resident was subsequently sent to the emergency department, where records noted he had allegedly hit another resident earlier that day. The female resident, who was cognitively intact with documented anxiety and insomnia, later described that the male resident had repeatedly pursued her for a relationship, followed her in the hallways, and on one occasion attempted to touch her breasts, which she blocked and reported to staff. She stated that on the night of the incident she awoke to the male resident rubbing her stomach while kneeling on her bed, and that when she yelled at him to get off, he began punching her in the head, causing pain and leaving her feeling stunned and traumatized. She reported ongoing fear of men, changes in how she dressed at night, and the need for therapy to cope with what occurred. Her psychiatric APN documented that this event triggered increased anxiety, fear, restlessness, and self-blame, leading to medication adjustments for anxiety. Despite these allegations and documented anxiety, her care plan did not address the abuse allegations or include interventions to protect her from the male resident or to address her increased anxiety and fear. Additionally, an Abuse Risk Review completed by the Social Service Director inaccurately documented that she had not experienced or made allegations of any type of abuse since the prior review, and therefore no further care plan recommendations were made, reflecting a failure to recognize and incorporate the abuse incident into her assessment and care planning.
Failure to Thoroughly Investigate Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident physical abuse as required by its Abuse and Retaliation Policy Prevention Program. The policy dated 1/2026 states that any incident or allegation involving abuse, neglect, exploitation, retaliation, mistreatment, or misappropriation of resident property will result in an investigation, and that the appointed investigator will at a minimum attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if interviewable, as well as review written statements and pertinent records. On 1/2/26, an RN documented hearing yelling from the middle hall and then observing one resident wheeling out of another resident’s room. The second resident reported that the first resident allegedly crawled on top of her in bed and punched her on the right side of the face three times, after which she punched him back and pushed him off. The RN’s note also documented that the first resident was sent to the ED for psychiatric treatment due to increased agitation, and ED records indicated EMS reported that this resident had allegedly hit another resident earlier that day. The second resident’s progress note from the same date documented her report that a male resident allegedly crawled on top of her and punched her three times on the right side of her face, with an assessment showing no visible injuries or redness and no complaints of pain or distress. However, the abuse investigations and witness statements for both residents, dated 1/2/26 through 1/6/26 and signed by the Administrator, only included two statements from the RN and the roommate of the second resident and did not document that the first resident crawled on top of the second resident, hit her, or that she hit him back. In interview, the Administrator stated she did not know that the residents had hit each other, acknowledged she only had interviews from the RN and the roommate, and confirmed she did not interview other staff or residents who might have knowledge of the incident. The RN stated she had immediately reported to the Administrator that the second resident said the first resident was on top of her in bed and hit her in the head, and that she had hit him back. The investigation therefore did not capture or reflect the full allegation of mutual hitting and did not meet the facility’s own minimum investigative procedures.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for three residents, resulting in the development and worsening of facility-acquired pressure ulcers. For one resident with a history of diabetes, impaired mobility, and cognitive impairment, the care plan was not updated with pressure-relieving interventions prior to the development of a right heel pressure ulcer. The resident did not receive routine skin checks, and Braden Scale assessments were not completed quarterly as required by facility policy. The resident's pressure-relieving boots were not consistently applied, and when used, did not have a heel off-loading cavity, failing to relieve pressure. This led to the development of a painful, unstageable pressure ulcer that required surgical debridement. Another resident, who was dependent on staff for mobility and transfers and at risk for pressure ulcers due to decreased mobility, incontinence, and morbid obesity, developed two stage two pressure ulcers on the buttocks. The resident was observed on a standard foam mattress rather than a pressure-relieving mattress as ordered in the care plan and physician orders. Staff were unaware of the open areas, and there was no documentation of the pressure areas in the medical chart until the ulcers were identified by the Director of Nursing. A third resident, severely cognitively impaired and dependent on staff for all activities of daily living, developed an unstageable deep tissue pressure injury to the right heel that continued to worsen. The care plan did not include pressure-relieving interventions, and although orders were in place for heel protectors and regular repositioning, these interventions were not consistently implemented. The resident was observed without heel protectors in both bed and wheelchair, and staff failed to ensure pressure was relieved as directed, contributing to the progression of the pressure ulcer.
Deficiencies in Food Storage, Labeling, and Dish Sanitization Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including failure to monitor and record cool down temperatures for prepared meats, lack of labeling on opened food items in both refrigerators and dry storage, and improper use of dish machine sanitizing test strips. Observations revealed that opened hot dog buns were left undated and unsealed on a kitchen counter, and several opened, undated food items such as liquid eggs, onion, shredded cheese, and a bottle of soda not belonging to a resident were found in the refrigerator. The Dietary Manager confirmed these items should have been dated and that the soda should not have been stored there. Further, the kitchen staff were not using a cool down log for meals cooked ahead of time, as confirmed by the Dietary Manager when a pork loin was being prepared for a future meal. Additionally, the Dietary Manager was observed using incorrect quaternary test strips instead of the required 160 EF sanitizer test strips to check the dish machine, and admitted to not knowing which test strips to use or having the correct ones available. These failures were found to be contrary to the facility's own policies and have the potential to affect all 69 residents residing in the facility.
Failure to Track Infections per CMS Requirements
Penalty
Summary
The facility failed to track infections among individuals who enter or reside in the facility, as required by CMS regulations. According to the facility's own Infection Prevention and Control Manual, there should be a system in place for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and contracted service providers. However, during an interview, the Director of Nursing confirmed that there was no current or past tracking of infections for residents or employees. This deficiency was identified through interview and record review, and it was noted that 69 residents were residing in the facility at the time.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate or hire a full-time infection preventionist (IP) as required by CMS, which affected all 69 residents currently residing in the facility. According to the facility's own Infection Prevention and Control Manual, an IP should be designated who is qualified by education, training, experience, or certification, and who has completed specialized training in infection prevention and control. The manual also requires the IP to work at least part-time and participate in the facility's quarterly assessment and assurance committee. Interview with the Administrator confirmed that the previous IP was terminated and the individual currently assigned to the role has not completed the required training, resulting in the facility being without a full-time, qualified IP since the termination.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training. A review of CNA training records from January 1, 2024, through June 2, 2025, showed that none of the CNAs had completed the mandated annual training hours. This was confirmed by the Director of Nursing, who acknowledged that all currently employed CNAs had not met the annual in-service training requirement. The deficiency has the potential to affect all 69 residents residing in the facility, as documented on the CMS Form 671 signed by the Administrator. No information was provided regarding the medical history or condition of individual residents at the time of the deficiency.
Failure to Resolve Repeated Resident Grievances Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve multiple repeated grievances related to missing clothing items for eight residents, as documented through interviews and record reviews. Grievance forms for these residents, spanning several months, consistently reported missing clothing, and the facility's own Resident Council Grievance form indicated that this was an ongoing issue. During a resident council meeting, all eight affected residents confirmed that they had filed numerous grievances regarding their missing clothes, but the issue remained unresolved and their clothing was never found. The facility's grievance policy requires a written decision for each grievance, including investigation steps, findings, and any corrective actions, but the records reviewed did not show resolution of the grievances. The administrator acknowledged that missing laundry is a persistent problem in the facility. There is no mention in the report of any corrective actions taken or resolution provided to the residents regarding their missing clothing.
Failure to Change and Date Oxygen Tubing Weekly for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that oxygen tubing was changed weekly and properly dated for five residents who required oxygen therapy. Observations, interviews, and record reviews revealed that oxygen tubing and cannulas were not changed as ordered by physicians and facility policy, which required weekly changes and labeling with the date. In several cases, the tubing was not labeled at all, and in one instance, the tubing was found to be dirty and had not been changed for several weeks. Documentation on treatment administration records and flowsheets also showed missed or unsigned entries for required tubing changes. Residents affected included individuals with diagnoses such as emphysema, acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. At the time of observation, these residents were using oxygen via nasal cannula or concentrator, but their equipment was either not dated or had outdated labels. Staff interviews confirmed that all oxygen tubing should be dated and changed weekly, but this was not consistently done according to both facility policy and physician orders.
Failure to Incorporate Advanced Directives into Care Plan
Penalty
Summary
The facility failed to develop a plan of care addressing advanced directives for one resident reviewed for advanced directives. According to the facility's own guidelines, staff are required to identify, clarify, and review existing care instructions during the quarterly Resident Assessment Instrument (RAI) process and with any significant changes in condition. These guidelines also require that any changes to a resident's advanced directives be documented, included in the resident's care plan, and communicated to staff. However, for one resident, although a completed and signed POLST form indicated a Do Not Resuscitate (DNR) order and a preference for comfort-focused treatment, there was no corresponding plan of care addressing these advanced directives in the resident's current care plan. During an interview, the Care Plan Coordinator confirmed that the resident did not have a current care plan addressing advanced directives. This omission was identified through record review and staff interview, demonstrating that the facility did not follow its own procedures for ensuring that residents' advanced directives are incorporated into their care plans and communicated to staff.
Misappropriation of IV Medication Administered to Wrong Resident
Penalty
Summary
A deficiency occurred when a registered nurse (RN) administered an intravenous (IV) bag of normal saline labeled for a former resident to a current resident. The RN obtained the IV bag from the medication storage room, where it was stored with other extra bags of fluids. The bag was clearly labeled with the former resident's name and a date from several months prior. The RN infused the entire bag into the current resident and later notified the Director of Nursing (DON) about using the bag intended for a different resident. The DON instructed the RN to remove the former resident's name from the bag but was not aware of the date on the bag or that it remained in the resident's room. The facility's Abuse Prevention Policy prohibits the misappropriation of resident property, including the wrongful use of a resident's belongings or medications without consent. In this incident, the RN knowingly used IV fluids prescribed for a former resident and administered them to another resident without proper authorization or consent. The event was confirmed through observation of the labeled empty IV bag in the resident's room, interviews with the resident, RN, and DON, and review of the facility's documentation.
Failure to Provide Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide required bed hold notices to two residents who were transferred to the hospital. According to the facility's Bed Hold and Readmission Policy, residents or their representatives must be informed of the bed hold policy at admission and at the time of transfer to a hospital, with written notification provided at the time of transfer. In cases of emergency hospitalization, notification by telephone or in person is required within 24 hours, with documentation in the medical record. However, for both residents reviewed, there was no evidence in their electronic health records that a bed hold notice was given upon their transfer to the hospital. One resident, who had a history of chest pain, was sent to the hospital for observation and reported not receiving a bed hold notice at the time of transfer. The administrator confirmed that the medical record did not contain evidence of the notice being provided. Another resident, with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy, Dementia, Chronic Kidney Disease (Stage 3), and Malignant Neoplasm of the Uterus, was sent to the emergency room for constipation, and similarly, there was no documentation of a bed hold notice being issued. Staff interviews confirmed that the required notifications were not completed for these hospital transfers.
Inaccurate Coding of MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for one of 17 residents reviewed for MDS accuracy. According to the facility's policy, all assigned disciplines are required to participate in the completion of the MDS assessment and verify the accuracy of their respective sections. In this case, a resident had a physician's order for hospice admission, but the corresponding MDS assessment did not indicate that the resident was receiving hospice services in Section O, which covers special treatments, procedures, and programs. The MDS Coordinator confirmed that the assessment was inaccurately coded and should have reflected the resident's hospice status. This deficiency was identified through record review and staff interview, specifically noting the discrepancy between the physician's order and the information documented in the MDS assessment.
Failure to Refer Resident for Level II PASRR After Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) after the resident was diagnosed with Bipolar II Disorder. According to the facility's PASRR policy, the facility is required to comply with federal and state standards by requesting and maintaining complete PASRR materials, including Level II assessments, for residents with qualifying mental health diagnoses. Record review showed that the resident was admitted with a diagnosis of Depression Disorder and later diagnosed with Bipolar II Disorder, for which antipsychotic medication was prescribed. Despite this, there was no evidence in the medical record that a Level II PASRR was obtained following the new diagnosis. The Social Service Director confirmed that the PASRR II was never requested after the diagnosis of Bipolar II Disorder, as required by policy.
Failure to Provide Routine Fingernail Care for Dependent Residents
Penalty
Summary
The facility failed to provide proper fingernail care for two residents who required assistance with activities of daily living. One resident, who required substantial to maximal staff assistance for personal hygiene, had not had her fingernails trimmed for several months, as documented in her shower sheets. Upon observation, her fingernails were found to be long, jagged, and extended past her fingertips, and she could not recall the last time they were clipped, expressing a desire for them to be trimmed. Another resident, who was severely cognitively impaired and required staff assistance for personal hygiene, also had not had his fingernails trimmed during a similar timeframe. His fingernails were observed to be long, jagged, and extended past his fingertips, and he also expressed a desire for them to be cleaned and trimmed. The facility's own guidelines require routine cleaning and regular trimming of nails, and the DON confirmed that all residents should have their nails cleaned and trimmed as needed with all showers.
Failure to Honor Advance Directive Resulting in Unwanted CPR
Penalty
Summary
The facility failed to follow the advance directive for one resident who had a documented Do Not Attempt Resuscitation (DNAR) order. The resident, who had multiple serious diagnoses including end stage renal disease, heart failure, and cancer, was found unresponsive with no pulse or respiration. Despite the presence of a completed POLST form indicating no CPR, staff initiated cardiopulmonary resuscitation (CPR) before confirming the resident's code status. The nurse directed a CNA to call 911 and began CPR while checking the resident's DNR status, and the CNA also performed compressions until being told to stop when the DNR was confirmed. The CNA involved stated she was unaware of the need to verify code status before starting CPR and expressed concern about the lack of a clear system to identify residents' code status. Documentation in the medical record and the CPR checklist confirmed that CPR was performed on the resident in contradiction to her advance directive. The facility's policy required staff to review and communicate advance directives, but this was not followed in this instance, resulting in the resident receiving unwanted resuscitative efforts.
Catheter Bag Not Properly Secured and Left on Floor
Penalty
Summary
The facility failed to ensure proper care and management of an indwelling urinary catheter for one resident who was admitted with a 16 French indwelling catheter for urinary retention. During observation, the resident was found lying in bed with the catheter drainage bag resting on the floor next to the bed. According to the facility's Urinary Catheter Care policy, catheter tubing and drainage bags are required to be kept off the floor to prevent infection. Interview with a Licensed Practical Nurse confirmed that catheter bags should be secured to the side of the bed and never placed on the floor. This deficiency was identified through observation, interview, and record review.
Failure to Notify Physician of Missed Enteral Nutrition
Penalty
Summary
The facility failed to notify the physician about a resident not receiving a physician-ordered enteral nutrition formula via gastrostomy tube. The resident, who was discharged from the hospital with orders for Osmolite 1.5 at a goal rate of 45 ml per hour, did not receive the prescribed nutritional tube feeding from the date of admission through several days. The medical record lacked documentation of any physician notification regarding the failure to administer the ordered nutrition. The Director of Nursing confirmed that the nurses did not inform the physician or gastroenterology specialist about the unavailability of Osmolite, nor did they seek an order for a substitute formula.
Failure to Complete Inventory of Resident's Belongings
Penalty
Summary
The facility failed to adhere to its Admission's Contract by not performing an inventory of a resident's personal belongings upon admission. The contract specified that an inventory sheet should be provided to the resident or their family to document all belongings, with assistance available if needed. However, for one resident, identified as R3, this process was not followed. R3, who is cognitively intact according to their Minimum Data Set (MDS) assessment, reported that upon admission, their belongings were taken by staff for cleaning to prevent bugs, but no inventory list was completed or provided. The facility's administrator confirmed that the inventory sheet was not completed for this resident.
Failure to Administer Prescribed Enteral Nutrition
Penalty
Summary
The facility failed to administer a physician-ordered enteral nutrition formula via gastrostomy tube for a resident who was admitted with several medical conditions, including alcoholic cirrhosis of the liver, severe protein-calorie malnutrition, and a gastrostomy. The resident was prescribed Osmolite 1.5 at a rate of 45 ml per hour, but did not receive this feeding from the time of admission on November 21 through November 25. The facility's Gastric Tube Feeding policy requires compliance with physician orders, including product volume and infusion rate, but this was not adhered to in this case. The deficiency occurred because the pharmacy sent the wrong formula, Jevity, and the nursing staff failed to notify the Director of Nursing or take action to ensure the correct formula was provided. Interviews with the Director of Nursing and nursing staff revealed that the facility did not have the prescribed Osmolite in-house, and the nurses did not administer any g-tube feeding to the resident during this period. The lack of communication and failure to follow up on the physician's order resulted in the resident not receiving the necessary enteral nutrition as prescribed.
Failure to Provide Grievance Forms and Procedures
Penalty
Summary
The facility failed to provide readily available grievance forms and did not post grievance/complaint procedures in prominent locations throughout the building, potentially affecting all 70 residents. The facility's grievance policy, dated November 2016, requires that grievance procedures be posted prominently and include contact information for the grievance official. During a resident council meeting, several residents expressed that they were unaware of how to file a grievance. An inspection revealed a wooden box near the activity director's office with a note indicating that grievances could be placed there, but no official grievance forms were available. Additionally, a tour with the Administrator confirmed that there were no posted grievance procedures in any prominent locations within the facility.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide residents and their representatives with a written notice of transfer, which is a requirement when transferring or discharging residents. This deficiency was identified through interviews and record reviews, revealing that two residents, R43 and R56, were transferred to a local hospital without receiving the necessary written notification. The Director of Nursing (DON) confirmed the absence of such notifications and admitted to being unaware of the requirement for a written notice of transfer form. Additionally, the Social Service Director also stated a lack of awareness regarding the form, indicating a systemic issue within the facility's procedures for handling resident transfers.
Failure to Provide Always Available Menu Options
Penalty
Summary
The facility failed to provide food items listed on the Always Available Menu to residents who requested substitutions for their meals. This deficiency was identified during a Resident Council Meeting where several residents reported that they could only receive a peanut butter and jelly sandwich or a fruit plate as substitutes, despite the menu listing a variety of other options such as grilled cheese, cheeseburgers, and salads. The residents expressed that when they requested other items from the Always Available Menu, the cook refused to prepare them, and they were not aware of the menu's existence or its offerings beyond the limited options they received. Additionally, residents reported feeling hesitant to request menu substitutions due to fear of receiving their meals late and cold. This indicates a lack of communication and transparency regarding the Always Available Menu, as well as a failure to honor residents' dietary preferences and needs. The facility's documentation confirmed that 70 residents were residing in the facility at the time of the survey, highlighting the potential widespread impact of this deficiency on the resident population.
Failure to Document Cool Down Temperatures for Hazardous Foods
Penalty
Summary
The facility failed to utilize Cool Down Temperature Logs for potentially hazardous foods, which could affect all 70 residents. The facility's Two Stage Cool Down Process, dated 2015, requires potentially hazardous foods to be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two hours, and then from 70 degrees Fahrenheit to 41 degrees Fahrenheit within four hours. Additionally, the Hazard Analysis Critical Control Point (HACCP) Cooling Log, dated 2024, mandates recording temperatures every hour during the cooling cycle. However, during an observation on July 8, 2024, the HACCP Cooling Log was found to be blank for the month of July, and there were no Cool Down Temperature Logs for previous months. The Dietary Manager acknowledged that potentially hazardous foods are sometimes prepared a day in advance and admitted to recently learning about the requirement to record cool down temperatures. Although the manager had instructed the cooks to start using the HACCP form, it was not being utilized. The meals for the day of the observation were prepared on the same day, but the lack of documentation for previous days indicates a failure to adhere to the established cooling procedures, potentially compromising food safety for the residents.
Failure to Document Compression Stockings in Care Plan
Penalty
Summary
The facility failed to develop a personalized care plan for a resident with multiple medical conditions, including venous insufficiency, sciatica, major depressive disorder, anxiety disorder, hypertensive heart disease without heart failure, and localized edema. The resident, who was admitted with these diagnoses, had a physician's order to wear vascular compression stockings daily from 6:00 AM to 6:00 PM. However, the care plan did not document this requirement. During an interview, the resident expressed that her legs had been swelling and she needed to wear compression stockings daily. The Director of Nursing confirmed the absence of a care plan for the compression stockings, and the Assistant Director of Nursing/Wound Nurse acknowledged the oversight and added the requirement to the care plan after the deficiency was identified.
Delay in Administration of Antifungal Cream
Penalty
Summary
The facility failed to provide timely administration of a physician-ordered Ketoconazole cream for a resident with a known topical yeast growth. The resident, who has a history of diabetes mellitus, heart failure, weakness, obesity, and COPD, was at risk for skin integrity issues and had a previous pressure ulcer and yeast growth. Despite a physician's order for the antifungal cream on June 11, 2024, the medication was not administered until 17 days later, on June 28, 2024. The delay was due to a lack of clarification on the order's specifics, such as the percentage, application site, and dosage, which were not documented in the resident's electronic medical record until the follow-up. The resident expressed concerns about the facility's failure to process and complete medication orders as required. The Director of Nursing confirmed the delay but was unsure of the reasons behind the confusion or delay in starting the treatment. The facility's Drug Order Policy mandates timely processing of medication orders, but this was not adhered to in this case, resulting in a significant delay in the resident receiving the necessary treatment for their condition.
Deficiencies in Dialysis Care Coordination and Documentation
Penalty
Summary
The facility failed to provide comprehensive and coordinated dialysis care for a resident with End Stage Renal Disease, as evidenced by multiple deficiencies in the care and services provided. The resident, who required hemodialysis three times a week, did not receive physician-ordered yogurt with all meals, and daily weights were not obtained as prescribed. Additionally, the facility did not provide lunch meals when the resident was out of the facility for scheduled hemodialysis sessions, and there was a lack of communication with the dialysis center before and after treatments. The resident's care plan was inadequate, lacking detailed documentation of dialysis care and required services. The care plan did not include emergency central venous catheter care, complications to watch for at the site, protocols and procedures for venous catheter dressing changes, or a specific plan of care for the resident's individualized renal dialysis treatment. Observations revealed that the resident's central venous catheter port was not being monitored or documented in the medical record, and there was no evidence of communication between the facility and the dialysis center regarding the resident's treatments. Interviews with facility staff, including the Licensed Practical Nurse/Infection Control Preventionist, Dietary Manager, Cook, Assistant Director of Nursing, and Director of Nursing, confirmed the lack of communication and documentation related to the resident's dialysis care. The staff acknowledged that there was no documented communication plan with the dialysis center, and the resident's dialysis catheter port was not being assessed or cared for as required. The dietary staff also failed to consistently provide the resident with the prescribed yogurt and sack lunches for dialysis appointments.
Failure to Monitor and Reduce Antipsychotic Medication
Penalty
Summary
The facility failed to identify and monitor targeted psychotic behaviors to justify the use of the antipsychotic medication Abilify for a resident diagnosed with bipolar disorder, current episode depressed, severe, with psychotic features. The resident's care plan, dated March 2024, did not specify the behaviors to be monitored for the use of the antipsychotic medication, despite documenting behaviors such as inappropriate comments, manipulative behaviors, and manic behaviors like trouble sleeping. The Behavior/Intervention Monthly Flow Record and Medication Flowsheet for June and July 2024 indicated monitoring for verbalized sadness, anxiety, and irritability, but noted no behaviors. Observations of the resident during this period also showed no behaviors. The facility's Antipsychotic Medication Use policy requires the attending physician and staff to gather and document information on a resident's behavior and symptoms to determine the necessity of antipsychotic medications. However, the resident's electronic medical record lacked evidence of a gradual dose reduction (GDR) for Abilify or a pharmacy recommendation for a GDR in the past twelve months. The Director of Nursing confirmed that a GDR had not been conducted or recommended, despite acknowledging that a GDR should occur at least annually. The Director also mentioned an attempt to reduce the Abilify dosage was hindered by a concurrent reduction in the resident's Buspirone medication.
Failure to Implement Enhanced Barrier Precautions for Dialysis Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for a resident with a Central Venous Catheter dialysis port. The facility's policy requires Enhanced Barrier Precautions, in addition to Standard and Contact Precautions, during high-contact resident care activities for residents with an increased risk of acquiring a multi-drug-resistant organism (MDRO). This includes residents with wounds, indwelling medical devices, or those with infection or colonization with an MDRO. The policy specifies that signage should be posted outside the resident's room, and an isolation cart with personal protective equipment should be provided immediately outside the room. The deficiency was identified for a resident who required dialysis three times a week and had a central venous catheter in his upper left chest. During an observation, it was noted that the resident's room did not contain any signage or personal protective equipment to indicate that Enhanced Barrier Precautions were in place. The resident confirmed having the central venous catheter since January, and the Licensed Practical Nurse/Infection Control Preventionist acknowledged that the resident was not on enhanced barrier precautions, despite having the catheter line since January. The nurse also mentioned that the central venous catheter was not charted anywhere, and the resident had not been on any recent isolation.
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 26 citations issued within 25 miles in the last 12 months — including the 3 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 Camp Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Good Shepherd Home | 5.1 mi | ★★★★★ | 10 | 0 |
| Mount Sterling Health And Rehab Center | 15.9 mi | ★★★★★ | 4 | 1 |
| Blessing Hospital Snu | 18.3 mi | ★★★★★ | 0 | 0 |
| Quincy Healthcare & Sr Living | 18.8 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Home | 18.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.