Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Park Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Dishwasher sanitizer monitoring and hand hygiene lapses were observed during food service. A Dietary Aide reloaded dirty dishes into the dishwasher while wet dishes were still in the clean area, and the Dietary Manager’s repeated sanitizer tests showed levels below the expected range. The dish machine log also had multiple missing entries for meal periods. During meal service, the Dietary Manager licked his fingers to handle tickets, touched his eyeglasses, and served food and handled trays without hand hygiene. The DON stated all 82 residents were served food prepared in the facility kitchen.
Missed Documentation of Ordered Wound Care and Medications: The facility failed to follow physician orders for wound care and scheduled meds for multiple residents. Ordered treatments for wounds on the foot, calf, and knee were not documented as completed on several occasions, and one resident also missed scheduled doses of baclofen, dantrolene, gabapentin, and hydrocodone-acetaminophen. The DON stated that treatments should be signed after completion and that blank MAR spaces should not be left without a documented reason.
A facility failed to accurately identify fall risk for two residents and failed to store hazardous chemicals securely in a resident room. One resident with multiple diagnoses and high-risk meds had a fall and was later scored as not at risk, while another resident with dementia, wheelchair use, and a history of falls had assessments that did not reflect the documented incidents. In a separate observation, bleach, cleaning products, ant spray, and buckets of liquid were left in a resident’s room, and the ESD stated such chemicals should be stored in secured areas and kept inaccessible to residents.
Failure to Administer Oxygen as Ordered: A resident with COPD and chronic respiratory failure with hypoxia was observed without oxygen despite a physician order for continuous O2 at 4 L/min via NC. The resident’s chart lacked documentation of refusal in the progress notes, care plan, or treatment record, while staff gave conflicting accounts that the resident used oxygen only off and on or only at night and managed it himself.
The facility did not ensure that an RN was on duty for 8 consecutive hours each day, as required. Review of the nursing schedule and time clock records showed that on several days, the only RN present worked less than 8 hours, and there was no documentation to confirm that the DON or ADON provided the remaining required coverage.
Surveyors found that food items in the kitchen and unit refrigerators were not consistently labeled, dated, or properly stored, with some leftovers left uncovered and undated. Staff were observed not following hygiene protocols, including a CNA entering the kitchen without a hairnet. Facility policies requiring labeling, dating, and separation of resident and staff food were not followed, affecting all residents served by the kitchen.
The facility did not maintain ongoing QAPI oversight for previously identified deficiencies involving labeling and dating food items in the kitchen and proper maintenance of facility waste in the dumpster. After a period of review, these issues were closed without continued monitoring or inclusion in the QAPI program, despite being cited in a prior survey.
Surveyors observed that air vents and return air ducts in multiple units were covered with numerous grey dust clumps, with dust falling onto surfaces when covers were opened. The Maintenance Director and Administrator confirmed that filters and vent covers were cleaned monthly, but high-traffic areas near the residents' smoking area accumulated significant dust. Facility policy required monthly cleaning and dust removal from vents.
The facility did not ensure accurate and consistent weight monitoring for two residents, resulting in significant discrepancies in recorded weights. One resident with failure to thrive and diabetes had fluctuating weights without documentation of refusals, and reweights requested by the dietician were not always obtained. Another resident with chronic conditions also had large variations in weight records, despite facility policy requiring accuracy. Staff interviews and documentation revealed inconsistent weighing practices.
A resident with cognitive impairment and a history of substance abuse repeatedly exhibited behaviors such as yelling, refusal of medications, and emotional distress. The care plan did not address these specific behaviors or triggers, and staff were not consistently aware of or addressing the resident's needs as required by facility policy.
Medications and biologicals were found to be improperly stored and labeled in two medication storage areas. Expired Pulmicort was present in the medication room, open vials of insulin lacked opened dates, and an expired bottle of Konvomep was not refrigerated as required. Interviews with an LPN and the DON confirmed these practices were not in line with facility policy.
A resident with diabetes and other health conditions had two blood glucose readings above 500 mg/dL, but the physician was not notified as required by facility policy. An LPN confirmed that such notification was expected, and the facility's policy supported this requirement.
The facility did not ensure snacks were consistently available to all residents during nighttime hours. A resident reported that snacks were often gone in the evening and not suitable for those with diabetes or dental issues, while others noted that snacks were sometimes taken by a few individuals, leaving none for others. Staff confirmed that snacks were only available when delivered by dietary staff, and when they ran out, there was no way to provide more, as staff could not access the kitchen.
Garbage and refuse were observed improperly contained, with dumpster lids and doors left open and trash bags hanging out, leading to scattered refuse in the lawn, parking lot, and sidewalks. Staff interviews confirmed that dumpsters should be kept closed and trash should not be present in outdoor areas, but facility policy was not consistently followed.
An LPN failed to follow infection control protocols by not disinfecting equipment after use on a resident, not performing hand hygiene after glove removal and before handling medication carts, and by handling a water pitcher and ice scoop without hand hygiene. These actions were not consistent with facility policies as confirmed by nursing leadership.
A resident with multiple chronic conditions experienced a fall and later showed an acute change in mental status, including confusion and unclear speech. The facility failed to notify the physician of these changes in a timely manner, as required. The Administrator acknowledged the need for physician notification, but no policy was provided by the facility regarding this process.
A facility failed to accurately code a quarterly MDS assessment for a resident with a history of chronic conditions and pressure ulcers. Upon readmission after hospitalization, the resident had pressure wounds, but the initial MDS assessment inaccurately reported no unhealed pressure ulcers. A subsequent assessment corrected this error, indicating an unhealed pressure ulcer. The facility's staff acknowledged the need to follow RAI guidance for accurate assessments.
A facility failed to monitor and assess a resident with a history of substance use disorder and multiple falls. The resident was hospitalized after several falls and tested positive for illegal drugs, despite not using drugs or alcohol in the past year. The facility lacked a care plan for relapse or positive drug tests, and staff were unaware of the positive test results. The facility did not have a policy for monitoring residents with substance use diagnoses who tested positive for drugs.
A facility failed to ensure an effective behavior care plan and proper documentation for a resident with mental disorders, including schizophrenia and bipolar disorder. The resident, with a history of UTIs, reported inappropriate touching by staff, leading to hospitalization. Despite ongoing delusions and hallucinations attributed to a UTI, these behaviors were not documented as required. Staff interviews revealed a lack of documentation and monitoring, contributing to the deficiency.
The facility's kitchen was found to be unsanitary, with issues such as open and undated food items, an open back door near dumpsters, and inadequate handwashing by staff. The kitchen floor was dirty, and there was a lack of housekeeping staff to clean it. These deficiencies indicate a failure to maintain food safety and hygiene standards.
The facility failed to ensure proper labeling and dating of food products, as identified during an annual survey. Despite having a policy requiring foods needing temperature control to be labeled and dated, these procedures were not followed. The QAPI committee, responsible for reviewing dietary services, did not include a Performance Improvement Plan for dietary in their reviewed plan, indicating a lack of effective communication and documentation.
The facility failed to maintain a clean environment in four resident rooms, with issues such as urine odors, dirty floors, and uncleaned mattresses. Observations showed inadequate cleaning practices, and interviews revealed challenges in maintaining cleanliness due to resident behavior. The facility's cleaning schedules and policies were not effectively implemented in the affected areas.
A resident with right-sided weakness and a history of falls was observed leaning to the right in their wheelchair, indicating a failure by the facility to maintain correct posture. The care plan lacked specific interventions and assistive devices to address the resident's postural issues, despite therapy evaluations and staff awareness of the problem.
A resident with a history of traumatic brain injury and vascular dementia was observed leaning dangerously in their wheelchair, increasing their fall risk. Despite multiple falls and a high fall risk score, the care plan did not address the resident's tendency to lean to the right. Facility staff were unaware of the need for specific interventions to mitigate this risk, leading to inadequate supervision and fall prevention measures.
A facility failed to maintain respiratory equipment properly for a resident, leading to potential contamination. A face mask was found unbagged and undated on a nebulizer machine, and a suction machine with a full container and open tube was observed without dates. The resident required tracheostomy care and had a history of cerebral infarction and acute respiratory failure. Facility policies required weekly replacement and labeling of equipment, but these were not followed.
The facility failed to identify and address trauma triggers and mental health needs for two residents with PTSD, anxiety, and depression. Care plans lacked specific focuses on these conditions and did not include resident-specific behaviors or stressors. Staff interviews revealed a lack of awareness regarding the residents' triggers and mental health diagnoses, contributing to deficiencies in care.
The facility failed to secure medications for two residents, leading to deficiencies in medication management. One resident had unsecured Tylenol pills left on the bedside table, with no assessment for self-administration. Another resident had a bottle of povidone iodine left unsecured on the dresser, with no orders for self-administration. Facility policy required medications to be secured and ingested under supervision.
The facility failed to properly contain and dispose of garbage and refuse, as observed during a survey. The kitchen door was propped open, and the dumpster lids were open with trash bags inside. Trash and food debris were scattered around the dumpster and parking lot, with numerous cigarette butts on the pavement. Staff interviews confirmed that the dumpster lids should be closed and the area kept clean, as per facility policy.
Dishwasher Sanitizer Monitoring and Hand Hygiene Lapses During Food Service
Penalty
Summary
The facility failed to ensure adequate hypochlorite sanitizer use in the dishwasher and failed to maintain sanitary food handling during meal service. During a kitchen tour, a Dietary Aide was observed pulling a rack of wet dishes from the dishwasher and reloading the machine with dirty dishes. Later, three racks of wet dishes were observed in the clean area while the Dietary Manager and another Dietary Aide were washing dishes. The Dietary Manager tested the dishwasher during the sanitizing cycle three times, and each test strip produced a color indicating sanitizer levels below the expected range. A review of the dish machine temperature log showed multiple blank entries across several meal periods in February, with missing temperature and/or PPM documentation for breakfast, lunch, and dinner on numerous days. The Dietary Manager stated the dishwasher chemicals should be tested on the first load of dishes for each meal and that the log should be completed every meal, but acknowledged the testing had not been done that morning and that some staff were new to the process. During meal service, the Dietary Manager was observed licking his fingers to flip through paper tickets and placing the tickets on meal trays, then handling a serving spoon and distributing food to plates while also using his right hand to place plates on trays. He touched his eyeglasses several times during service, and no hand hygiene was performed during these actions. The Dietary Manager stated employees should wash their hands after touching their face, glasses, or otherwise contaminating clean hands before touching serving utensils or dishes. The DON stated all 82 residents were served food prepared in the facility kitchen.
Missed Documentation of Ordered Wound Care and Medications
Penalty
Summary
The facility failed to ensure physician orders were followed for wound treatments and scheduled medications for multiple residents. For Resident 82, who had diagnoses including cellulitis, venous stasis ulcers, chronic congestive heart failure, coronary artery disease, and morbid obesity, physician-ordered wound care for arterial ulcers on the right foot and venous ulcers on the right calf was not documented as completed on multiple dates. The TAR also showed several missed or undocumented wound treatments, and progress notes did not document the wound care on those dates. For Resident 15, who had diagnoses including a right below-the-knee amputation, diabetes type 2, chronic kidney disease stage 3, peripheral vascular disease, and spastic hemiplegia, wound care for an abrasion on the right posterior knee was ordered daily but was not documented as completed on two dates. The MAR also showed that scheduled medications, including baclofen, dantrolene sodium, gabapentin, and hydrocodone-acetaminophen, were not given at the scheduled 2:00 PM time on one date. Progress notes did not document the missed medications and/or wound treatments on the dates identified. For Resident 36, who was admitted for rehabilitation after fractures of both lower legs and had diagnoses including heart failure, obesity, and swelling of the lower legs, the right foot wound treatment was not completed on several dates according to the MAR. Weekly skin assessments showed changes in the wound measurements over time, and during observation the wound was noted to be rectangular with red tissue in the middle, dark purple edges, and a small amount of clear pink drainage on the previous dressing. The DON stated that treatments should be signed after completion and that there should be no blank spaces in the MAR unless the nurse documents the reason the treatment was not done.
Fall Risk Assessments Inaccurate and Hazardous Chemicals Left Accessible
Penalty
Summary
The facility failed to ensure safety measures were identified and implemented for residents at risk for falls. Resident 1 had diagnoses including hypertension, seizure disorder, schizoaffective disorder, left side hemiplegia, PTSD, and chronic pain, and was receiving an antipsychotic, antidepressant, diuretic, opioid, and anticonvulsant. The resident’s care plan identified a fall risk problem, but a fall risk assessment dated 2/17/26 scored the resident as not at risk for falls despite the resident’s medical conditions and medication profile. Progress notes showed the resident fell asleep in a wheelchair and slid onto the floor, and an LPN stated the resident’s score should have reflected a higher fall risk based on use of assistive devices, 3-4 high-risk medications, and predisposed diseases. Resident 35 also had fall-related safety concerns that were not accurately reflected in the assessment process. The resident had Alzheimer’s disease, hypertension, and adult failure to thrive, with a BIMS score of 6 indicating cognitive impairment. The resident used a wheelchair and required maximal assistance for standing, transfers, and toileting. The care plan identified impaired safety related to malnutrition, weakness, and a history of frequent falls, and progress notes documented that the resident rolled out of bed and later slid out of the wheelchair and was found on the floor in the dining room. Despite this history, a fall risk assessment dated 12/8/25 indicated the resident was alert and oriented with no falls in the prior 3 months, and another assessment dated 1/8/26 indicated no predisposing diseases that elevated fall risk. The facility also failed to store hazardous chemicals properly in a resident room. During observation, bleach, a bottle of Fabuloso cleaning product, a can of Raid ant spray, and buckets containing murky liquid and a mop were found in Resident 56’s room, including items on the bedside table and window ledge. The room had a strong chemical odor. Resident 56 stated he had high standards for cleanliness, that grandchildren visited and touched the floor, and that prayer mats were placed on the floor for family use. The ESD stated the resident frequently refused housekeeping services and acknowledged that bleach, chemical cleaning products, and ant spray were hazardous chemicals that should be stored in secured areas and inaccessible to residents. Resident 56’s record showed bipolar disorder with rapid mood cycling and a BIMS score of 15.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure oxygen was administered according to physician orders for one resident with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. During observation, a portable oxygen tank was seen at the resident’s bedside set to deliver 5 liters per minute, but the resident was not in the room. Minutes later, the resident was observed propelling a motorized wheelchair without oxygen in place. The resident’s record showed a physician order for oxygen at 4 liters per minute via nasal cannula continuously, and the current MDS indicated the resident used oxygen and had a BIMS score of 9, showing cognitive impairment. Record review and staff interviews showed no documentation of refusal of oxygen in the progress notes, care plan, or monthly treatment record. The care plan did not address oxygen use or refusal, even though the resident’s Kardex indicated oxygen should be provided according to physician orders. Staff interviews reflected conflicting information about the resident’s oxygen use: one CNA stated the resident used oxygen off and on and managed it himself, an LPN stated the resident only used oxygen at night and did not use it during the day because he propelled himself around the building and went outside to smoke, and an ADON stated the resident did what he wanted regarding oxygen use. The facility’s oxygen administration policy stated that physicians’ orders and care plans should be reviewed, refusals should be documented with the reason and interventions, and the supervisor should be notified.
Failure to Maintain 8-Hour Consecutive RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours each day, as required. Review of the nursing schedule for the period of 4/3/25 through 4/10/25 showed that on multiple days, the only RN scheduled worked less than 8 consecutive hours. Specifically, on 4/4/25, 4/5/25, and 4/7/25, the RN's time clock entries indicated shifts significantly shorter than 8 hours. The Director of Nursing (DON) stated that on some days, the DON or Assistant Director of Nursing (ADON) covered the remaining hours, but there was no time clock or other documentation available to confirm that the 8-hour RN coverage requirement was met on those days. At the time of the survey exit, the facility could not provide evidence that the consecutive 8-hour RN coverage was maintained.
Failure to Properly Store, Label, and Date Food Items and Ensure Employee Hygiene
Penalty
Summary
The facility failed to ensure proper food storage, labeling, dating, and employee hygiene practices in the kitchen and unit refrigerators. Observations revealed multiple open food items in the walk-in cooler and freezer, such as a container of bananas foster, a bag of parsley, strawberries, and corn, that were not labeled or dated. Additionally, leftover salads and fruit cocktail were left uncovered and undated on a cart adjacent to the tray line, and these items were not properly stored or discarded. The Dietary Manager confirmed that these practices did not align with facility policy, which requires all leftovers and opened produce to be labeled, dated, and covered. Furthermore, a Certified Nurse Aide was observed in the kitchen without a hairnet, contrary to the facility's hygiene policy. Additional observations in unit refrigerators showed containers of grapes, cheese and crackers, and other food items without labels or dates, some of which belonged to residents and others to staff. Items such as ice cream and a candy bar were also found without proper labeling or dating. Staff interviews confirmed that all items should be labeled with the resident's name and date, and that staff should not store personal food in resident-designated refrigerators. The facility's policies on food preparation, handling, and storage were not followed, resulting in the deficiency affecting all residents served by the kitchen.
Failure to Sustain QAPI Oversight for Kitchen and Waste Deficiencies
Penalty
Summary
The facility failed to maintain an ongoing process within its Quality Assurance and Performance Improvement (QAPI) program to address and prevent the recurrence of previously identified deficiencies. Specifically, during an annual survey, surveyors found non-compliance related to labeling and dating food items in the kitchen and the maintenance of facility waste in the dumpster. Although these issues were identified and the facility committed to correcting them, a review of the current QAPI program revealed that performance improvement plans did not include ongoing monitoring or actions related to these specific deficiencies. The Administrator confirmed that after six months of review, the concerns were considered closed and the QAPI team shifted focus to other areas, without ensuring sustained improvement in the previously cited areas.
Failure to Maintain Clean and Sanitary Air Vents Throughout Facility
Penalty
Summary
The facility failed to maintain a clean and sanitary environment on all three units observed, affecting 65 residents. During a facility tour, multiple air vents were found to be covered with numerous grey clumps of dust, including those above the 200 hall nurses' station, near the 300-hall entrance, and near a resident room. Further observation revealed pencil eraser-sized grey clumps on the vented cover of a return air duct above the hallway near the east nurses' station, and when the Maintenance Director opened the cover, clumps of dust fell onto the nurses' station counter and floor. The filter inside the return air duct, dated 3/26/25, was visibly covered in dust. Interviews with the Maintenance Director and Administrator confirmed that filters and vent covers were scheduled for monthly cleaning, and that the area in question typically accumulated significant dust due to its proximity to the residents' smoking area and high traffic. Facility policy required monthly cleaning of exhaust fans and removal of dust from vents.
Failure to Ensure Accurate Weight Monitoring for Two Residents
Penalty
Summary
The facility failed to ensure accurate weights were obtained for two residents, resulting in inconsistent and unreliable weight records. For one resident with diagnoses including adult failure to thrive, major depressive disorder, and type 2 diabetes, the medical record showed significant fluctuations in recorded weights over several months, with no documentation of weight refusals. The care plan identified the resident as severely underweight and required regular weight monitoring and reporting of significant changes. However, progress notes indicated that reweights requested by the dietician were not always obtained, and staff did not consistently use the same scale or subtract wheelchair weight as needed. The Director of Nursing acknowledged noticing weight inconsistencies and attributed them to improper weighing practices. Another resident with multiple chronic conditions, including heart failure and chronic kidney disease, also had significant discrepancies in recorded weights, with large variations between measurements. The facility's policy required accurate and consistent weight measurement, including zeroing the scale and immediate recording, but the documented weights for this resident showed substantial differences within short timeframes. Staff interviews confirmed that unusual weight readings were to be reported, but the records did not reflect consistent adherence to these procedures.
Failure to Provide Resident-Specific Behavioral Health Interventions
Penalty
Summary
The facility failed to provide resident-specific behavioral health interventions for a resident with multiple diagnoses, including congestive heart failure, emphysema, cognitive communication deficit, and a history of substance abuse. The resident exhibited ongoing behaviors such as frequent yelling, refusal of medications and care, and expressions of emotional distress, including being tearful and missing family. Despite repeated documentation of these behaviors and their ineffectiveness to redirection, the care plan did not address these specific behaviors or identify resident-specific stressors. The care plan only included general interventions such as encouraging socialization, providing non-judgmental support, and offering psychiatric services as needed. Staff interviews revealed that the Social Service Director was not aware of the resident's specific behaviors, such as yelling and refusal of medications, until they were noted in behavior logs and report sheets. Regular interdisciplinary team meetings, where new behaviors would typically be reviewed, had not occurred during the week due to the annual state survey. Although the resident had signed up for substance abuse counseling, they refused to participate in the sessions. Facility policy required precise documentation of behaviors and inclusion of identified behaviors in the resident's plan of care, which was not followed in this case.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored and labeled in two of four storage areas. In the 200 hall medication room, six out of seven boxes of Pulmicort were found to be expired. In the 200 hall medication cart, two open vials of insulin lacked an opened date, and a bottle of liquid Konvomep was expired and not refrigerated as required by its label. Interviews with an LPN and the Director of Nursing confirmed that expired medications should be removed and that opened medications should be labeled, in accordance with facility policy. The facility's policy also states that medications requiring refrigeration should not be stored in the medication cart and that outdated medications should be removed immediately from stock.
Failure to Notify Physician of Critically High Blood Glucose Results
Penalty
Summary
The facility failed to notify the physician of significant abnormal laboratory results for a resident with diagnoses including type 2 diabetes, obesity, depression, and hypertension. Record review revealed that the resident had two critically high blood glucose readings, one at 527 mg/dL and another at 560 mg/dL, both of which exceeded the facility's policy threshold for physician notification (>500 mg/dL). Progress notes did not indicate that the physician was notified of either result. During an interview, an LPN confirmed that it was facility policy to notify a physician when a glucose measurement was over 500 mg/dL. The current policy, as provided by the DON, also required physician notification for glucose levels above 500 mg/dL.
Failure to Provide Consistent Nighttime Snack Availability
Penalty
Summary
The facility failed to ensure that snacks were consistently available to residents during nighttime hours, as required by policy and resident needs. Observations revealed that the west hall refrigerator only contained a few resident-labeled snack packages, with no general snacks accessible to all residents, and no dry snack storage was present on the unit. Interviews with staff confirmed that general snacks were not stored on the unit and were only available when delivered by kitchen staff. When snacks were delivered, they were distributed to residents, but leftovers were kept at the nurses' station and often ran out, leaving nothing available for residents during the night. Multiple residents reported that snacks were frequently unavailable in the evening and nighttime, with some noting that available snacks were not suitable for diabetic residents or those with dental issues. Residents also described situations where snacks were taken by a few individuals, leaving others without access. Staff interviews corroborated these accounts, indicating that when snacks ran out, there was no way to provide more, and staff were not permitted to access the kitchen to obtain additional food. The facility's policy required snacks to be offered at bedtime, but this was not consistently achieved.
Improper Containment and Disposal of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not properly contained within the facility's dumpster during multiple observations. On two separate occasions, the dumpster was found with its lid or side door open, and trash bags were observed partially hanging out. There were multiple tears in the trash bags, with items such as fast-food cups, lids, straws, and other refuse visible and accessible. Additionally, various types of trash, including cups, snack wrappers, gloves, and cigarette packs, were found scattered throughout the lawn, parking lot, sidewalks, and grassy enclosures near the dumpster area. Interviews with facility staff confirmed that all dumpster doors and lids should be closed to prevent rodent access and that trash should not be present in the surrounding outdoor areas. The facility's policy required the maintenance supervisor or designee to verify that dumpster lids were closed three times daily after each meal service, and that waste should be stored to protect it from animals. Despite these policies, the observations indicated that proper procedures were not consistently followed, resulting in the deficiency.
Failure to Follow Infection Control Procedures During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control procedures during multiple observed instances involving a licensed practical nurse (LPN). In one case, the LPN placed a laptop on a resident's mattress during a blood glucose measurement, allowing the resident's covered foot to come into contact with the device. After use, the LPN did not disinfect the laptop or the glucometer before placing them on the medication cart and storing the glucometer in a drawer. The LPN stated that the glucometer was only used for that resident. Additionally, the LPN was observed administering an intramuscular injection while wearing gloves, but did not perform hand hygiene after removing the gloves and before touching the medication cart. In another instance, the LPN handled a water pitcher and ice scoop without performing hand hygiene after returning from the medication room. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that these actions were not in accordance with facility policies, which require cleaning and disinfecting equipment between uses and performing hand hygiene at specified times.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident following a fall. The resident, who had diagnoses including non-alcohol related cirrhosis of the liver with liver cancer, dementia, and other chronic conditions, was admitted for rehabilitation services after a fall that resulted in a fractured neck vertebrae. On a specific date, the resident was found on the floor next to his bed, having slid out of it, but was initially reported to have no apparent injuries and was alert and oriented. However, later that day, the resident exhibited an acute change in mental status, including confusion and unclear speech, which was not communicated to the physician or Nurse Practitioner until later that night. The facility's documentation did not indicate that the physician was notified of the resident's acute change in mental status and unclear speech until several hours after the incident. The Administrator confirmed that the physician should be notified of such changes and that this notification should be documented in the resident's record. However, there was no policy provided by the facility regarding the notification of changes in resident condition to the physician.
Inaccurate MDS Assessment for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure an accurate quarterly Minimum Data Set (MDS) assessment for a resident, identified as Resident F, who was reviewed for assessments. Resident F had a medical history that included chronic obstructive pulmonary disease, chronic kidney disease, and lymph edema. Following a hospitalization for encephalopathy, the resident was readmitted to the facility with a pressure area on her left heel and a pressure wound on her right ankle. However, the quarterly MDS assessment dated 10/3/24 inaccurately indicated that Resident F had no unhealed pressure ulcers, despite the presence of these wounds. A subsequent MDS assessment dated 10/4/24 corrected this error, indicating that Resident F had one unhealed pressure ulcer, which was unstageable with suspected deep tissue injury. The facility's Administrator and Regional Nurse Consultant acknowledged that MDS assessments should be completed according to the Resident Assessment Instrument (RAI) guidance, which requires reviewing medical records, interviewing direct care staff, and examining the resident to accurately code skin conditions. This deficiency was related to a complaint identified as IN00447233.
Failure to Monitor Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure proper monitoring and assessments for a resident with a history of substance use disorder and multiple falls. Resident C, who had a history of substance use disorder, was hospitalized following multiple falls and an acute illness. During hospitalization, a urine drug test was positive for illegal drugs, although the resident had not used drugs or alcohol in the past year. The facility was aware of the resident's substance use disorder prior to admission but did not have a care plan addressing potential relapse or positive drug tests. Resident C had several falls within a short period, and staff noted increased drowsiness, which led to adjustments in her medication regimen. Despite these adjustments, the resident continued to experience falls and was found to have a positive urine drug screen for substances she was not prescribed. The facility's guidelines for residents with a history of substance abuse included random drug screens and potential medication adjustments, but there was no specific care plan for addressing a relapse or positive drug test results. Interviews with staff revealed a lack of awareness regarding the resident's positive drug test and the necessary monitoring or assessments following such results. The facility did not have a policy or procedure for monitoring or assessing residents with a substance use diagnosis who tested positive for drugs. This lack of protocol and communication contributed to the facility's failure to adequately address the resident's condition and ensure her safety.
Failure to Document and Monitor Behavioral Health in Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure an effective behavior care plan, behavioral assessments, behavior monitoring, and documentation for a resident diagnosed with multiple mental disorders, including major depressive disorder, bipolar disorder, and schizophrenia. The resident, who also had a history of urinary tract infections (UTIs), was not adequately monitored for changes in behavior associated with these infections. Despite having a care plan that included interventions for managing her mental health conditions, the plan did not account for her history of UTIs and the associated behavioral changes. On one occasion, the resident reported inappropriate touching by a staff member, which led to her being transported to the hospital. Upon her return, she continued to exhibit delusions and hallucinations, which were attributed to a UTI. However, these behaviors were not documented in the progress notes as required by the facility's policy. The resident's care plan was not updated to reflect her recent experiences and the potential impact of UTIs on her mental state. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that there was a lack of documentation regarding the resident's behaviors and the history of UTIs. The facility's policy on behavioral assessment and monitoring was not followed, as there was no thorough evaluation of the resident's changing behavioral symptoms, nor was there documentation of any improvements or worsening in her condition. This oversight contributed to the deficiency in providing appropriate care for the resident's mental health needs.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, affecting the food safety for all 59 residents who consumed meals prepared there. During an observation, red spots of dried liquid were found on the wall near the kitchen entry door, and a partially eaten piece of toast with jelly and a Styrofoam cup filled with oatmeal were left unattended in the meal service area. The back door leading to the outside was left open, allowing potential contamination from the nearby dumpsters. In the dry storage area, an open bag of thickener was exposed to air, and in the walk-in cooler, various food items were uncovered, undated, and open to air, including mixed fruit, chocolate pudding, parmesan cheese, shredded cheese, chopped lettuce, shredded carrots, hot dogs, and sliced black olives. Additionally, the kitchen floor was observed to be dirty with numerous spots and crumbs, and there was a lack of housekeeping or maintenance staff to clean it. The facility's staff also failed to adhere to proper handwashing protocols. The Dietary Manager washed her hands for only 11 seconds, and another staff member rinsed her hands for just 5 seconds after dropping a serving spoon on the floor. The facility's policies on employee hygiene, food safety, and sanitation were not followed, as evidenced by the lack of labeling, covering, and dating of food items, and the absence of an internal thermometer in the walk-in cooler and freezer. These deficiencies indicate a significant lapse in maintaining food safety and hygiene standards in the facility's kitchen.
Deficiency in Food Labeling and Dating Practices
Penalty
Summary
The facility failed to implement a process to identify and correct deficiencies, specifically regarding the labeling and dating of food products. During the annual survey, noncompliance was identified in the kitchen sanitation practices, particularly in the labeling and dating of food items. The facility had a policy in place that required all foods needing temperature control to be labeled, covered, and dated, and for opened food packages to be marked with the open date to determine when to discard them. However, the survey findings indicated that these procedures were not being followed, leading to the deficiency. The QAPI committee, which included various department heads such as the Executive Director, DON, and Director of Food Services, was responsible for reviewing segments of care, including dietary services, in their monthly meetings. Despite dietary being an ongoing topic in these meetings, the Performance Improvement Plan (PIP) for dietary was not included in the reviewed QAPI Plan. This oversight suggests a lack of effective communication and documentation within the committee, contributing to the recurrence of the deficiency in food labeling and dating practices.
Facility Fails to Maintain Clean Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment in four out of five rooms reviewed, affecting four residents. Observations revealed multiple cleanliness issues, including yellow/orange spots on the floor near a resident's bed with a foley catheter, wadded up incontinence pads, and a strong urine odor in Resident 35's room. Resident 14's room had gray spots and sticky marks consistent with wheelchair wheels. Resident 5's room had dirty clothes on the floor, and Resident 32's room had a pervasive urine odor emanating into the hall, which was attributed to the mattress by the Assistant Director of Nursing. The facility's housekeeping schedules indicated that rooms in the 300 Hall were cleaned on specific dates, but the cleaning was insufficient to address the observed issues. Interviews with the Chief Nursing Officer and the Executive Director revealed challenges in maintaining cleanliness due to residents refusing to bathe or leave their rooms. The facility's Quality Assurance and Performance Improvement plan focused on other halls, with no indication that the 300 Hall was included. The facility's policy required daily cleaning, including sweeping, mopping, and washing mattresses if needed, but these procedures were not adequately followed in the affected rooms.
Failure to Maintain Resident's Posture in Wheelchair
Penalty
Summary
The facility failed to provide adequate care to maintain correct posture for a resident, identified as Resident 4, who was observed multiple times leaning to the right side while seated in a wheelchair. Despite staff interventions to assist the resident into an upright position, the resident continued to lean, indicating a lack of effective measures to address the issue. The resident's medical history included generalized muscle weakness, wheelchair dependence, and right-sided weakness due to a traumatic brain injury, which contributed to their difficulty in maintaining an upright posture. The resident's care plan did not adequately address the risk of leaning to the right while in the wheelchair, nor did it include necessary assistive devices to prevent this posture. Although the resident had been evaluated by therapy services, the care plan lacked specific interventions to address the resident's postural issues. The resident had a history of falls and injuries related to their right-sided weakness, yet the care plan did not reflect these risks or provide appropriate strategies to mitigate them. Interviews with facility staff revealed a lack of awareness and action regarding the resident's postural needs. The Chief Nursing Officer and Physical Therapy Assistant acknowledged the resident's refusal of assistive devices and therapy recommendations but did not ensure these were incorporated into the care plan. The facility's policy required care to prevent functional decline, yet the resident's posture and associated risks were not adequately managed, leading to the deficiency identified by surveyors.
Inadequate Supervision and Fall Risk Management for Resident
Penalty
Summary
The facility failed to provide adequate supervision and address the risk of falls for a resident, identified as Resident 4, who was observed multiple times leaning dangerously to the right side while seated in a wheelchair. Despite being assisted occasionally by staff to an upright position, the resident was often left in a precarious position without further assistance. The resident's care plan did not address the specific issue of leaning to the right, which was a significant factor in their fall risk. Resident 4 had a complex medical history, including traumatic brain injury, generalized muscle weakness, and vascular dementia, contributing to their impaired mobility and increased fall risk. The resident's care plan acknowledged various risk factors for falls but failed to include interventions specifically targeting the resident's tendency to lean to the right in their wheelchair. Despite multiple falls and a high fall risk score, the care plan lacked specific actions or interventions to mitigate the risk associated with the resident's leaning posture. Interviews with facility staff, including the Chief Nursing Officer and a Physical Therapy Assistant, revealed a lack of awareness and action regarding the resident's leaning posture and its contribution to falls. The facility's policy required a resident-centered plan of care for fall risks, but this was not adequately implemented for Resident 4. The resident's fall risk assessments consistently indicated high scores, yet no new interventions were added to address the ongoing issue of falls, particularly those related to the resident's posture in the wheelchair.
Failure to Maintain Respiratory Equipment Properly
Penalty
Summary
The facility failed to maintain respiratory equipment properly for a resident, leading to potential contamination. During an observation, a respiratory face mask was found lying on top of a nebulizer machine without a bag or date, and cloudiness was noted on the edges of the mask. Additionally, a suction machine with a container full of cloudy liquid and an open tube was observed, with no dates on the container or tubing. The resident involved had a history of cerebral infarction, type 2 diabetes, and acute respiratory failure, and required tracheostomy care and suctioning. The facility's policies required that respiratory equipment, including nebulizer masks and tubing, be replaced weekly, labeled, and dated. However, these guidelines were not followed, as indicated by the Corporate Nursing Officer, who confirmed that the equipment should have been bagged, dated, and covered. The facility's policy on tracheostomy care did not address storage guidelines for respiratory equipment not in use, and no additional policies were available for review.
Failure to Address Trauma Triggers and Mental Health Needs
Penalty
Summary
The facility failed to ensure that triggers were identified, communicated, and interventions were in place to avoid or alleviate re-traumatization for two residents, Resident 2 and Resident 22. Resident 2 was observed with a flat facial expression and avoided eye contact during an interview. The resident's medical history included anxiety, major depressive disorder, nicotine use, and PTSD. Despite having a care plan that addressed psychosocial impairment, the plan did not include specific focuses for anxiety, depression, delusions, paranoia, or PTSD. Additionally, the care plan lacked details on resident-specific behaviors, signs of distress, and stressors such as loud noises, touch, affection, or certain smells. Resident 22, who was observed sitting in a wheelchair and smiling, reported experiencing bad feelings related to being a trauma survivor. The resident's medical history included generalized anxiety disorder, major depressive disorder, traumatic brain injury, impulsiveness, nicotine use, and PTSD. Although the resident's care plan addressed altered activity patterns and risk of impaired safety, it did not include a focus on depression, anxiety, or PTSD. The care plan also failed to identify resident-specific behaviors, signs of distress, and stressors such as changes in routine or living arrangements. Interviews with facility staff revealed a lack of awareness regarding the residents' triggers and mental health diagnoses. A Qualified Medication Aide was unaware of Resident 22's triggers and plans for relocation, while the Chief Nursing Officer was not informed about the facility's process for monitoring behaviors or the absence of care plans for mental health diagnoses. The facility's policy required identifying trauma survivors and their triggers, but this was not effectively implemented, leading to deficiencies in the care provided to the residents.
Medication Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were secured for two residents, leading to deficiencies in medication management. For one resident, two Tylenol pills were left unsecured on the bedside table, with the resident indicating that the nurse had left them for him to take at his convenience. The resident, who was cognitively intact, was not informed that medications needed to be secured if not taken immediately. The Chief Nursing Officer confirmed that there was no assessment for the resident to self-administer medications, and the facility's policy required staff to ensure medications were ingested before leaving the room. In another instance, a bottle of povidone iodine was left unsecured on a resident's dresser, visible from the hallway. The resident explained that staff left the dressing supplies in the room for convenience. The resident had mild cognitive impairment and a stage 3 pressure ulcer, with physician orders for wound care involving the iodine solution. There were no physician orders or assessments for self-administration of medications for this resident. The facility's policy required all medications to be secured in a locked storage area, accessible only to authorized personnel.
Improper Garbage Disposal and Containment
Penalty
Summary
The facility failed to ensure proper containment and disposal of garbage and refuse, as observed during a survey. The kitchen door leading to the outside loading dock was found propped open, with all kitchen staff occupied at the opposite end of the kitchen. The dumpster, located approximately 34 feet from the kitchen door, had its lids open with bags of trash inside. Additionally, a bag of trash was observed torn open on the ground in front of the dumpster. Various food debris, including partial pieces of pizza, open Chinese food containers, fast food cups, straws, bags, soda bottles, cans, used gloves, lip balm, plastic bags, and other debris, were scattered around the dumpster, in the grassy area nearby, and throughout the parking lot. Numerous cigarette butts were also noted on the pavement in the loading area. Interviews with staff revealed that all departments were responsible for ensuring the dumpster lids were closed and that no trash was left on the ground. The Regional Director of Operations confirmed that the dumpster lids should be closed, and the area around the dumpster should be free of debris. Additionally, the kitchen door should not be propped open when unattended. The facility's policy, titled "Store, Distribute, and Serve Food Safely and Disposal of Garbage and Refuse," dated November 2022, was reviewed and indicated that dumpsters should always remain covered, with no garbage on the ground, and waste properly contained. The policy also stated that loading docks used for garbage and clean food transport should be kept clean and free of debris, and the garbage storage area should be maintained in a sanitary condition to prevent pest harborage and feeding.
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 320 citations issued within 25 miles in the last 12 months — including the 2 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 Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenbrook Rehabilitation & Skilled Nursing Center | 0.9 mi | ★★★★★ | 10 | 0 |
| Towne House Retirement Community | 0.9 mi | ★★★★★ | 1 | 0 |
| Canterbury Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 7 | 0 |
| Kingston Health Center Of Fort Wayne | 1.6 mi | ★★★★★ | 3 | 0 |
| Summit City Nursing And Rehabilitation | 1.7 mi | ★★★★★ | 9 | 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.