Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkside Homes during CMS and state inspections, most recent first.
Missing Annual Performance Review for PRN CNA: The facility failed to complete an annual performance review for a CNA employed more than one year. Review of personnel files showed the CNA lacked a yearly review, and the Administrative Nurse stated annual reviews were only completed for full-time and part-time staff, not PRN staff. The Employee Handbook stated that a performance review will be conducted once per year for each team member.
Unsanitary Kitchen Equipment and Food Service Surfaces: Surveyors observed dried-on food inside a microwave, food and liquid residue on a trash can, spilled syrup on a shelf, debris on a clean pan shelf, rust on food carts, dried-on food on hot carts, a sticky substance on a bread cart, and heavily gauged cutting boards. An LTC dietary staff member confirmed the areas needed to be added to the cleaning list, despite the facility policy requiring food to be stored, prepared, distributed, and served under professional food safety standards.
Walk-in freezer not maintained in clean, safe operating condition. Surveyors observed a heavy build-up of frost throughout the freezer, including on multiple boxes of food. Temperature logs showed the freezer stayed within range and the food remained solidly frozen, while an admin staff member stated rubber door flaps were being installed and a new freezer door had been ordered. The facility policy required kitchen equipment to be kept clean, neat, orderly, and well-maintained.
Failure to Complete CAA Analysis for Comprehensive MDS Assessments: The facility did not complete required CAA analyses for multiple residents after comprehensive MDS assessments triggered care areas such as cognition, communication, urinary incontinence, falls, nutrition, pressure injuries, pain, and psychotropic drug use. The Admin Nurse stated the facility used the RAI Manual for MDS/CAA guidance and acknowledged the CAA documentation lacked source documentation and individualized analysis for the triggered areas.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility lacked evidence that two residents or their representatives were informed about and consented to psychotropic meds, including buspirone, lorazepam, and Remeron. One resident could not recall her meds, and an LPN and admin nurse gave conflicting statements about whether psychoactive consents had been completed; the DPOA later said she had just signed the forms and that they were otherwise blank when signed.
Psychotropic Medication Monitoring and PRN Stop-Date Deficiencies: A resident with anxiety received a PRN anxiolytic order without the required 14-day stop date or documented duration/rationale, and another resident with depression and insomnia received multiple antidepressants without documented monitoring for target behaviors or side effects. Staff stated PRN psychotropic orders required a stop date and psychotropic meds were monitored each shift, but the EMR and care plan documentation did not reflect those requirements.
The facility failed to notify the State Ombudsman of two residents’ hospital transfers. EMRs for two residents documented hospital admissions, but there was no evidence that the Ombudsman was notified, and the facility could not provide proof when asked. During interview, Social Services stated she had not made the notifications. The facility policy stated the State Ombudsman will be notified of all transfers and discharges.
Failure to provide baseline care plans within 48 hours for two residents. One resident was observed in bed and said she did not feel good, and the other resident’s DPOA reported no care plan had been discussed since admission. EMR review showed no documentation that the written baseline care plan was given to or reviewed by the residents or their representatives, despite staff stating the baseline care plan should be completed on admission and within 48 hours.
Failure to provide ADL assistance and nail care for two residents. One resident with anxiety and DM, intact cognition, and high assistance needs was observed with long fingernails and chipped nail polish that remained unchanged. Another resident with DM and severely impaired cognition was also observed with long, dirty nails and chipped polish. Staff reported nail trimming and manicures were inconsistent, and the care plan lacked clear direction for one resident's nail care needs.
A resident with dementia, dysphagia, CKD, and influenza had a documented decline in intake and respiratory status, but meal percentages were inconsistently recorded and intake monitoring during the acute change was not adequately documented. In a separate issue, another resident with severe cognitive impairment had multiple purple bruises and a skin tear, yet weekly skin documentation did not capture the bruising, and ordered protective interventions such as a floor mat and arm sleeves were not consistently in place.
The facility failed to follow infection control practices for respiratory equipment and incontinent care. Two residents had oxygen tubing and nasal cannulas observed draped over wheelchairs, tanks, tables, or lying on the floor, and staff stated oxygen tubing should be placed in a bag when not in use. During incontinent care for another resident, an LPN/CNAs removed gloves and handled supplies and transfers without hand hygiene, despite the facility policy requiring hand hygiene before and after glove removal.
Loose Bed Assist Bar Left in Place on Resident’s Bed: A resident with anxiety, intact cognition, and moderate assistance needs for bed mobility had bed rail assessments that changed over time, with later documentation stating siderails/assist bars were not indicated. Despite this, two assist bars remained on the bed, and the left bar was observed to be loose and freely moving away from the bed. Staff reported the resident did not use the bars, maintenance did not perform monthly checks of bed positioning devices, and administrative staff were uncertain about inspection requirements.
Laundry Area Not Maintained in Safe and Sanitary Condition Surveyors observed unsanitary conditions in the laundry processing area, including missing paint/sealant on the concrete floor in front of the washers and throughout the area, along with peeling sheetrock above the intake ventilation screen. Housekeeping/Maintenance Staff U and Administrative Staff A confirmed the laundry floor and surrounding sheetrock needed repair to provide a safe and sanitary environment for staff processing residents' linen.
Incomplete Daily Staffing Postings: The facility failed to post accurate, publicly accessible staffing information on a daily basis. Review of Daily Staffing Sheets showed the facility name and actual hours worked were left blank, and an administrative staff member confirmed the omissions. The facility policy required the staffing form to include the facility name, current date, total number, and actual hours worked by RN, LPN, and CNA.
Dumpster Lid Left Open: The facility failed to ensure the dumpster lid was kept closed. Surveyors observed the dumpster covers open during multiple kitchen observations, and later saw the lid being held open by trash bags inside the dumpster. Dietary Staff BB confirmed the lid was not always kept closed, and the facility could not provide a dumpster policy.
A hospice resident with dementia and agitation received five times the prescribed dose of Ativan due to a nurse misreading the syringe. The error was discovered two days later, and the facility's policy requiring verification of medication details was not followed.
The facility failed to prevent falls and ensure safety for residents with high fall risks. One resident with severe cognitive impairment fell while attempting to put on socks, and another sustained deep lacerations requiring emergency treatment. The facility did not update care plans promptly or conduct thorough fall investigations, leaving residents at risk. Additionally, residents were left unattended in unsafe conditions, violating facility policies.
The facility failed to serve meals at safe and appetizing temperatures, as observed through resident complaints and staff actions. Two residents reported cold food, and dietary staff were seen serving food below acceptable temperatures. Food was left uncovered, and thermometers were not sanitized between uses, leading to potential cross-contamination. The facility's policy required food to be held at specific temperatures, but several items were served outside this range, placing residents at risk for impaired nutrition.
The facility failed to maintain sanitary conditions in food storage and preparation, with numerous food items improperly labeled and stored, and staff not adhering to hand hygiene protocols. Observations revealed opened and unsealed food items without dates or labels, and staff handling food without washing hands. The kitchen equipment was also found to be in poor condition, with burned food debris and damaged utensils.
The facility failed to maintain an effective infection control program, with deficiencies including improper cleaning and storage of respiratory equipment, lack of hand hygiene by dietary staff, and improper sterile technique during a PICC line dressing change. Additionally, a resident with open wounds was not placed on enhanced barrier precautions, and staff failed to perform hand hygiene after removing soiled gloves during catheter care.
The facility failed to adhere to antibiotic stewardship principles, resulting in inappropriate antibiotic use. The Infection Preventionist reported challenges in tracking antibiotic use due to incomplete infection evaluations and lack of adherence to McGeer's Criteria. Antibiotics were administered and completed before proper evaluation, and the Antibiotic Assessment Tool was not used. Unnecessary prophylactic antibiotics were prescribed without consulting the prescribing provider or medical director, violating the facility's Infection Control Policy.
The facility failed to address recurring food temperature concerns reported by the Resident Council over a year. Despite repeated complaints about cold food, such as icy corn dogs and cold hamburgers, no actions or outcomes were documented. The Social Services Designee could not produce a grievance log, and the kitchen's plate warmer was intermittently operational, violating the facility's grievance policy and risking residents' psychosocial well-being.
A medication cart was found unlocked and unattended in a common area, potentially affecting 14 residents. A CMA left the cart to get ice, acknowledging it should have been locked. The facility's policy lacked documentation on securing medication carts.
A resident with dementia and depression, requiring total assistance with ADLs, had a DNR order that was only signed by a physician, lacking necessary additional signatures. The facility's policy required a fully completed advanced directive, which was not met, potentially leading to uncommunicated end-of-life care needs.
A resident with dementia and encephalopathy experienced a change in their Seroquel dosage, but the facility failed to notify the responsible party. Interviews confirmed the lack of notification, and the facility lacked a policy on notification of change.
The facility failed to provide written bed hold notices to three residents during hospital transfers, placing them at risk of not returning to their original rooms. Despite having policies in place, the facility relied on verbal communication, which was insufficient and undocumented, leading to this deficiency.
A resident with hypertension experienced elevated blood pressure and low oxygen saturation levels, which were not reported to the physician as required. The resident also had episodes of involuntary movements and a significant headache, with medications held but no thorough investigation of symptoms. A new bruise was found but not documented or analyzed. Staff interviews revealed inconsistencies in care and documentation, highlighting a failure in communication and monitoring of the resident's health status.
The facility failed to accurately assess and document the care needs of several residents, leading to deficiencies in their care plans and MDS assessments. A resident with a history of falls experienced an uninvestigated fall, while another resident's MDS failed to document insulin injections and falls. Additionally, a third resident's MDS did not reflect the use of a Foley catheter and oxygen, despite their documented use in progress notes.
A facility failed to develop a person-centered baseline care plan for a resident with a complex medical history, including a high risk for falls. Despite the resident's history of falls and a high Morse Fall Scale score, the care plan lacked necessary interventions, leading to a fall with serious injuries. Staff interviews revealed that the baseline care plan was not adequately completed, contributing to an unsafe environment.
A facility failed to implement enhanced barrier precautions for a resident with venous stasis ulcers, compromising infection control. The resident frequently refused prescribed Tubigrip bandages, and staff inconsistently used PPE during care activities. Observations noted the absence of dressings on the resident's legs, and staff interviews revealed confusion about precautionary measures, highlighting a deficiency in care planning and infection control.
The facility failed to update care plans for two residents after falls, leading to uncommunicated care needs and increased fall risk. One resident's care plan lacked an intervention after a fall, and another resident's care plan was not updated until ten days post-fall. Both residents were at high risk for falls, and the facility did not adhere to its policy of timely care plan updates.
A resident with a history of chronic conditions and venous ulcers experienced inadequate care for her skin issues in the facility. Despite documented potential for skin impairment, the care plan lacked specific interventions, and the resident frequently refused prescribed treatments without documented follow-up. Observations showed untreated open areas and drainage on the resident's legs, and staff interviews revealed inconsistent adherence to skin integrity policies, leading to increased risk for further complications.
The facility failed to provide proper respiratory care and equipment storage for several residents, including improper cleaning and storage of a nebulizer for a resident with asthma, and inadequate labeling and storage of oxygen equipment for two other residents. These deficiencies posed a risk of respiratory complications.
The facility failed to document declination forms for pneumococcal and influenza vaccines for several residents, as required by policy. The EHRs lacked necessary documentation, and administrative nurses could not locate the forms. One resident did not receive a requested pneumococcal vaccine due to therapy concerns, and a verbal declination for the influenza vaccine was accepted without proper documentation.
A cognitively impaired resident with dementia and amnesia eloped from the facility due to inadequate supervision and failure to implement safety measures like a Wanderguard bracelet. The resident exhibited exit-seeking behaviors throughout the day, but staff did not take sufficient action to prevent the elopement, placing the resident in immediate jeopardy.
Missing Annual Performance Review for PRN CNA
Penalty
Summary
The facility failed to complete an annual performance review at least once every 12 months for one Certified Nurse Aide (CNA) employed for more than one year. Review of five CNA personnel files showed that CNA N, hired 12/04/2017, lacked an annual performance review. During interview on 07/21/2026 at 02:30 PM, the Administrative Nurse stated the facility completed annual performance reviews for full-time and part-time employees but did not complete them for as-needed (PRN) employees such as CNA N. The facility's Employee Handbook stated that PRN team members are scheduled no more than 19 hours per week, must work at least two shifts per pay period or four shifts each calendar month to remain employed, and that a performance review will be conducted once per year for each team member.
Unsanitary Kitchen Equipment and Food Service Surfaces
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions to residents. During an initial kitchen tour, surveyors observed dried-on food inside the front of the microwave, dried food and liquids on a covered black plastic trash can, spilled and dried syrup on a wire shelf holding gallon jugs of pancake syrup, scattered food debris on a shelf holding clean steam table pans, multiple areas of rust on two three-tiered wire carts used to transport food and drinks to residents, multiple areas of dried-on food on two hot carts used to transport residents' food to another dining room, a sticky substance on the runners of a bread cart, and six colored plastic cutting boards that were heavily gauged and discolored. Dietary Staff BB later confirmed these areas needed to be added to the cleaning list. The facility policy for Food Preparation and Handling stated that food would be stored, prepared, distributed, and served in accordance with professional standards for food safety services and that cutting boards would be washed and sanitized after each use.
Walk-in freezer not maintained in clean, safe operating condition
Penalty
Summary
The facility failed to ensure the walk-in freezer in the kitchen was kept in clean, safe operating condition. During an initial tour of the kitchen, surveyors observed a heavy build-up of frost inside the walk-in freezer on all areas, including multiple boxes of food. Review of the freezer temperature records showed the freezer remained within the appropriate temperature range and that all foods stored inside were solidly frozen. An administrative staff member stated staff were installing rubber door flaps inside the freezer at the door to help keep cold air inside, and that a new freezer door had been ordered and would be installed the following week. The facility policy for Food Preparation and Handling stated that the kitchen and equipment would be kept clean, neat, orderly, and well-maintained.
Failure to Complete CAA Analysis for Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis for multiple residents after comprehensive MDS assessments were completed. Review of the most recent comprehensive MDS documentation for R2, R9, R12, R21, R29, R33, and R38 showed that triggered CAAs were not completed for multiple care areas, including cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, psychosocial well-being, nutritional status, pressure ulcer/injury, psychotropic drug use, functional abilities, falls, behavioral symptoms, pain, dehydration/fluid maintenance, dental care, and visual function, depending on the resident. On 07/22/2026, the Administrative Nurse stated the facility used the RAI Manual for guidance in completing MDSs and CAAs for comprehensive assessments and reported she was not aware that CAA completion should include the location of the information and resource materials used to support the individualized analysis for triggered areas until training on 04/26/2026. She verified that the CAA documentation for the named residents lacked source documentation showing analysis of the collected data, other than narrative identifying where the triggering data was located, and lacked the analysis described in the RAI Manual.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform two residents and/or their representatives about the risks related to psychotropic medications. One resident had physician orders for buspirone 5 mg three times daily for anxiety and lorazepam 0.5 mg every 4 hours as needed for anxiety/restlessness, but the electronic medical record lacked evidence that the resident or representative received education or informed consent for either medication. During interview, the resident was sitting in a recliner, wearing glasses and hearing aids, reported feeling safe and that staff listened to her, and could not recall what medications she was given. A second resident had an order for Remeron 15 mg at bedtime for insomnia, but the record lacked evidence of education or informed consent for that medication. The resident was observed in bed and reported not feeling good. A licensed nurse stated that psychoactive consents were completed by an administrative nurse, but the administrative nurse later reported she had not completed an informed consent for the resident’s Remeron. For the first resident, the administrative nurse produced two informed consent forms for buspirone and lorazepam; the DPOA signature was undated, the witness signature was added later, and the DPOA stated she had just signed the forms and that there were no other signatures or dates when she signed them. The administrative nurse also stated she expected informed consents for all psychotropic medications to be completed upon admission or before a resident started a psychotropic medication.
Psychotropic Medication Monitoring and PRN Stop-Date Deficiencies
Penalty
Summary
The facility failed to ensure a resident’s PRN psychotropic medication had a 14-day stop date or a specified duration with a physician rationale for extended use. The resident had a diagnosis of anxiety, a BIMS score of 13 indicating intact cognition, and was documented as receiving an anti-anxiety medication. The psychotropic drug use CAA identified the resident as receiving high-risk psychotropic medications and at high risk for falls. The care plan instructed staff to administer anti-anxiety medications as ordered and to monitor and document side effects and effectiveness. The EMR showed an order for lorazepam 0.5 mg by mouth every four hours as needed for anxiety/restlessness dated 05/29/2026, and the order lacked a stop date. Staff interviews confirmed that PRN psychotropic medication orders required a 14-day stop date and that the nurse entering the order was responsible for documenting it. The facility also failed to monitor another resident for target behaviors or side effects of psychotropic medications. That resident had diagnoses of depression and insomnia, a BIMS score of 15 indicating intact cognition, and received antidepressant medications during the assessment process. The psychotropic drug use CAA documented antidepressant use and fall risk, but the care plan lacked staff instruction regarding administration and monitoring of target behaviors and side effects of psychotropic drug use. The EMR showed orders for trazodone 50 mg at bedtime for insomnia, sertraline 50 mg in the morning for depression, and bupropion 300 mg in the morning for depression, and the MAR showed the medications were administered as ordered. The EMR lacked documentation of monitoring for target behaviors or side effects, while staff stated psychotropic medications were monitored every shift and that care plans should include staff instruction for residents receiving psychotropic medications.
Failure to Notify State Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the State Ombudsman of two residents’ hospital discharges, involving R1 and R3. Record review showed that R1’s EMR documented a hospital admission on [DATE], but there was no documentation that the State Ombudsman had been notified, and the facility could not provide evidence of notification when requested. R3’s EMR also documented a hospital admission on [DATE], but likewise lacked documentation that the State Ombudsman had been notified, and the facility was unable to provide evidence upon request. During interview on 07/22/2026 at 10:30 AM, Social Services X stated she had not notified the State Ombudsman of R1 and R3’s hospital admissions. The facility policy for Admission, Transfer and Discharge, revised 01/2026, stated that the State Ombudsman will be notified of all transfers and discharges.
Failure to Provide Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to provide a written baseline care plan to two residents, R32 and R37, after their admissions. R32’s EMR did not contain documentation that a written baseline care plan was given to or reviewed by her or a representative since her admission, and on 07/20/2026 at 09:24 AM she was observed in bed and reported that she did not feel good. R37’s EMR also lacked documentation that a written baseline care plan was given or reviewed by her or a representative since admission. On 07/21/2026 at 08:01 AM, R37’s DPOA stated that no care plan had been discussed since the resident was admitted. On 07/21/2026 at 04:13 PM, LN G stated the nurse would complete the baseline care plan on admission in the EMR assessment tab, and on 07/21/2026 at 04:15 PM, Administrative Nurse D stated the baseline care plan was expected to be completed within 48 hours of admission.
Failure to Provide Nail Care and ADL Assistance
Penalty
Summary
The facility failed to ensure residents received assistance with activities of daily living, including nail care, for two residents. One resident had diagnoses of anxiety and diabetes mellitus, a BIMS score of 13 indicating intact cognition, and assessments showing she required maximal assistance with personal hygiene and assistance with all ADLs for safety. Her care plan instructed staff to keep her fingernails short and later noted she required moderate assistance with personal hygiene. During observations, she was seen with long fingernails and chipped nail polish, and the condition of her nails remained unchanged on a later observation. A licensed nurse reported that activity staff had not done a nail manicure activity lately, which was when residents would have new nail polish applied. A second resident had diagnoses of diabetes mellitus and needing assistance for personal care, a BIMS score of 3 indicating severely impaired cognition, and an assessment showing she required moderate assistance with personal hygiene. Her care plan instructed staff to ask yes/no questions to determine needs but lacked direction regarding nail care preferences and staff assistance required. She was observed with long fingernails, brown substance under some nails, and chipped nail polish, and the same condition was noted again on a later observation. A CNA reported residents' fingernails are trimmed and cleaned on shower days and as needed, and that the nurse would cut diabetic residents' nails. The Activity Director reported she had not completed a manicure activity for about 2 months, and an Administrative Nurse stated staff were expected to clean and trim residents' fingernails while activities completed manicures and new nail polish.
Failure to Monitor Intake During Acute Illness and Failure to Track Bruising and Skin Injury
Penalty
Summary
The facility failed to monitor Resident 38’s nutritional and hydration status during an acute change in condition. Resident 38 had diagnoses including Alzheimer’s disease, dysphagia, stage four chronic kidney disease, major depressive disorder, and Influenza A. His records showed a decline in intake and condition after he developed fever, cough, and later tested positive for influenza A. He was started on Tamiflu, but his oxygen saturation dropped to 88 to 92% on oxygen therapy, his respirations increased to 20 to 32 per minute, and staff noted coarse lung sounds and frequent checks. Meal documentation showed a pattern of declining intake during the illness, with multiple missing meal percentage entries and then progressively lower intake. After previously eating most meals, he began eating 26 to 50% at some meals, then 0 to 25% at several meals, and drank only limited supplements or fluids. Staff interviews indicated the CNA noticed his intake decreased over a period of weeks and that the nurse monitored intake and reported it to the physician, but the nurse also stated she did not review the CNA meal documentation because she did not have time and depended on CNAs to tell her if the resident ate or not. The administrative nurse confirmed there was a lack of documented intake monitoring expected during the resident’s change in condition. The facility also failed to monitor Resident 2 for complications related to multiple bruises and a skin tear. Resident 2 had dementia, severe cognitive impairment, and total dependence for ADLs. Her care plan included observing skin during daily care, using a floor mat beside the bed, and applying Tubi-grips to both arms for protection, but records showed missing documentation of bruises on the arms and right middle finger in weekly skin checks and skin issue reviews. A hospice visit log documented bruising on both upper forearms without sizes, colors, or whether staff were notified. During observation, staff saw several purple bruises on both posterior forearms and a purple bruise on the right hand middle finger, and the bruises remained present the next day. Staff also observed that the fall mat was not on the floor and the arm protectors were not in place.
Infection Control Lapses With Oxygen Equipment and Hand Hygiene
Penalty
Summary
The facility failed to implement adequate infection control practices related to respiratory equipment for two residents and hand hygiene during incontinent care for another resident. R1 was observed sitting in a recliner with a portable oxygen tank on the back of the wheelchair; the nasal cannula tubing was draped over the tank and the nose piece touched the tank. On a later observation, R1's oxygen tubing was lying on the floor. R37 was also observed with oxygen tubing wrapped up and placed on an overbed table, and later with a portable oxygen tank on the back of the wheelchair while the nasal cannula tubing was draped over the wheelchair seat and the nose piece lay on the wheelchair seat pad. On another observation, R37's nasal cannula was lying on the floor in the room. During incontinent care for R2, CMA R and CNA Q performed care without consistent hand hygiene after glove removal. CMA R cleansed R2's buttocks, removed gloves to retrieve a brief liner, then applied new gloves without hand hygiene. CNA Q cleansed R2's peri-area, left soiled gloves on while assisting with dressing, and later handled clean supplies with the same gloves used for care. Both staff removed gloves without hand hygiene, and R2 was transferred and taken through the facility without hand hygiene being performed. The facility's hand hygiene policy stated hand hygiene should occur before and after removing gloves, and the facility did not provide a policy for the care of respiratory equipment.
Loose Bed Assist Bar Left in Place on Resident’s Bed
Penalty
Summary
The facility failed to ensure a resident’s bed was in safe condition. The resident had a diagnosis of anxiety, a BIMS score of 13 indicating intact cognition, and required moderate assistance with bed mobility. Her care plan stated she preferred bed rails to help her reposition in bed, and bed rail assessments documented at different times that siderails/assist bars were indicated and served as an enabler to promote independence, while later assessments documented that siderails/assist bars were not indicated. During observation, the resident’s bed had a bed assist bar on each side in the upright position, and the left bed assist bar was quite loose and freely moved away from the bed. The loose condition was observed again the next day. A CMA reported the resident did not use the bed assist bars and staff did not realize they were loose. Maintenance staff reported he did not complete a monthly check of bed positioning devices and that once the device is applied to a resident’s bed, it is removed at discharge. Administrative staff reported they were uncertain whether the bed assist bars were required to be inspected, and an administrative nurse stated she was not aware of the later bed rail assessments documenting the rails were not required.
Laundry Area Not Maintained in Safe and Sanitary Condition
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the laundry area. During a laundry tour with Housekeeping/Maintenance Staff U, surveyors observed the floor in front of the washers to be unsanitary with missing paint/sealant on the concrete floor in an approximately three-inch by three-foot section, and the floor throughout the laundry processing area was also unsanitary due to missing paint/sealant in an approximately three-inch by three-foot section. Surveyors also observed peeling sheetrock above the intake ventilation screen, measuring approximately six inches by five inches. Administrative Staff A and Housekeeping/Maintenance Staff U later confirmed that the laundry floor and the sheetrock surrounding the ventilation intake were in need of repair to provide a safe and sanitary environment for staff processing residents' linen. The facility policy titled Laundry Infection Control and Prevention Policy, dated 03/2026, stated that the facility must provide and maintain a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections.
Incomplete Daily Staffing Postings
Penalty
Summary
The facility failed to display accurate, publicly accessible, and identifiable staffing information on a daily basis for the 30 residents who resided in the facility. Review of the facility’s Daily Staffing Sheets from 06/20/2026 through 07/20/2026 showed that the actual hours worked and the facility name were not completed on the daily staffing sheets. On 07/21/2026 at 02:30 PM, Administrative Staff B confirmed that the daily staffing sheets lacked the actual hours worked and the facility name, as required. The facility policy for Posting Daily Nurse Staffing Form, dated 01/2025, stated that the Daily Nurse Staffing Form would include, but was not limited to, the facility name, current date, total number, and actual hours worked by RN, LPN, and CNA.
Dumpster Lid Left Open
Penalty
Summary
The facility failed to dispose of garbage and refuse properly by not ensuring the dumpster lid was kept closed. During an initial kitchen tour on 07/20/2026 at 09:02 AM, the dumpster covers were observed open. On 07/21/2026 at 10:30 AM, the dumpster lid was still open. On 07/22/2026 at 09:13 AM, the dumpster lid was observed being held open by trash bags inside the dumpster, and Dietary Staff BB confirmed the lid was not always kept closed. The facility was unable to provide a policy regarding the dumpsters.
Medication Error: Overdose of Ativan Administered to Hospice Resident
Penalty
Summary
The facility failed to prevent a significant medication error involving a hospice resident diagnosed with dementia and agitation. The resident's care plan required the administration of medications as ordered, with monitoring for side effects and effectiveness. However, a Licensed Nurse administered five times the prescribed dose of topical Ativan, a medication used to treat anxiety, due to misreading the syringe. The error was not discovered until two days later when another nurse identified the mistake. The facility's policy on medication administration mandates that the individual administering medication must verify the right medication, dosage, time, and method of administration by checking the label three times. Despite this policy, the Licensed Nurse did not adhere to these procedures, resulting in the medication error. The incident was reported to the physician, but no new orders were received, and the facility's documentation lacked details on the resident's response to the overdose.
Failure to Prevent Falls and Ensure Safety
Penalty
Summary
The facility failed to provide an environment free from accident hazards for several residents, leading to multiple deficiencies. One resident, with a history of falls and severe cognitive impairment, was found on the floor attempting to put on socks, indicating a lack of effective fall prevention interventions in their care plan. Despite being at high risk for falls, the resident's care plan lacked safety interventions until after a fall occurred. Additionally, the facility did not conduct a fall investigation following the incident. Another resident, who had a history of falls and was at high risk according to the Morse Fall Scale, fell and sustained deep lacerations requiring emergency treatment. The facility failed to include fall prevention interventions in the resident's care plan, and there was inadequate documentation of neurological assessments and follow-up care. The resident's care plan was not updated promptly to address the fall risk, and the facility did not provide a thorough investigation into the fall. The facility also failed to ensure adequate supervision for residents with high fall risks. One resident was left unattended in a bathroom while attached to a mechanical lift, and another resident was left in a wheelchair in their room, despite being at high risk for falls. These actions demonstrate a lack of adherence to the facility's policies on fall prevention and care planning, resulting in an environment that was not free from accident hazards.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to ensure that meals were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Two residents, including the President of the Resident Council, reported that food was often served cold when it should have been hot. During meal service, dietary staff were observed serving food at temperatures below the acceptable range. For instance, pureed sausage gravy and toast were served at 100 degrees Fahrenheit, which was acknowledged as unacceptable by the Dietary Manager. Additionally, food items such as chicken and hamburger patties were not consistently temped before being placed in delivery carts, leading to further temperature discrepancies upon arrival at the dining areas. The report highlights several instances where dietary staff failed to maintain proper food handling procedures. Food was left uncovered, and thermometers were not sanitized between uses, leading to potential cross-contamination. The facility's policy required food to be held at temperatures between 41 degrees F and 135 degrees F, yet several food items were served outside this range. The Dietary Manager and Administrative Staff confirmed the concerns regarding food temperatures, acknowledging the multiple complaints from residents about the palatability of food due to temperature issues. This deficiency placed residents at risk for impaired nutrition, as stated in the report.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illnesses among residents. During observations, numerous food items in both the small dining room kitchen and the main kitchen were found to be improperly stored. These items included opened and unsealed bags of various foods such as French toast, ice cream, muffins, bagels, and more, all lacking open dates or labels. Additionally, some food items, like a bag of salami, showed signs of spoilage with dried brown and green edges. The Dietary Manager confirmed these concerns, acknowledging the lack of proper labeling and sealing as unacceptable. Further issues were observed with staff hygiene practices. Dietary Staff G was seen handling food and interacting with residents without performing proper hand hygiene, even after touching his face and handling soiled dishes. This was confirmed by the Dietary Manager as a concern. Additionally, the kitchen equipment was found to be in poor condition, with ovens containing burned food debris and cutting boards and fry pans showing significant wear and damage. The facility's policies on hand hygiene and food preparation were not adhered to, as staff failed to follow proper procedures for hand washing and food storage.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. A resident's nebulizer was not properly cleaned and stored, with the nebulizer cup and mouthpiece left intact on the machine and not disassembled or rinsed after use. Additionally, oxygen concentrators in residents' rooms were found with undated tubing and humidifier bottles containing cloudy liquid, indicating improper maintenance and storage of respiratory equipment. Dietary staff were observed lacking proper hand hygiene during meal service, touching their face and handling soiled dishes without washing hands before serving food to residents. This was confirmed as a concern by both the Dietary Manager and the Administrative Nurse. Furthermore, a resident with open wounds and drainage was assisted to the dining area without appropriate enhanced barrier precautions, as there was no signage or PPE bag indicating the need for such precautions. The facility also demonstrated improper sterile technique during a PICC line dressing change, where the sterile field was contaminated by touching the outside of the package with sterile gloves. Additionally, staff failed to perform hand hygiene after removing soiled gloves during catheter care. These actions and inactions contributed to the facility's failure to implement an effective infection prevention and control program, potentially leading to the spread of infections among residents.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to ensure adherence to antibiotic stewardship principles, leading to inappropriate antibiotic use among residents. The Infection Preventionist, Administrative Nurse C, reported difficulties in tracking antibiotic use due to incomplete infection screening evaluations and lack of adherence to McGeer's Criteria by the nursing staff. This resulted in antibiotics being administered and completed before a proper evaluation could be conducted. Additionally, the Antibiotic Assessment Tool in the Electronic Health Record (EHR) was not utilized during the antibiotic treatment period, further complicating the monitoring process. Both Administrative Nurse C and Administrative Nurse B acknowledged the presence of unnecessary prophylactic antibiotics being prescribed without consultation with the prescribing provider or the medical director. The facility's Infection Control Policy, which includes guidelines for antibiotic stewardship, was not followed, as there was no collaboration with the Medical Director, Pharmacist, or Director of Nursing to monitor antibiotic use. This lack of communication and adherence to policy contributed to the failure in providing ongoing antibiotic stewardship, increasing the risk of antibiotic resistance and the spread of multidrug-resistant organisms within the facility.
Failure to Address Resident Council's Food Temperature Concerns
Penalty
Summary
The facility failed to address and resolve recurring issues reported by the Resident Council, specifically concerning food temperatures. Over the course of a year, from September 2023 to September 2024, the Resident Council minutes documented repeated concerns about food being served at inappropriate temperatures. Specific instances included corn dogs being served icy inside, and hamburgers and tater tots being served cold. Despite these recurring complaints, the minutes lacked documentation of actions taken or outcomes achieved to address these issues. Interviews and observations revealed further deficiencies in the facility's grievance handling process. The Social Services Designee (SSD) was unable to produce a grievance log reflecting the residents' multiple concerns about food temperatures. Additionally, the SSD mentioned that the kitchen staff had access to a plate warmer that was intermittently operational, but was unsure of its current status. The facility's policy on the right to voice grievances stated that residents had the right to expect prompt efforts by the facility staff to resolve grievances, yet this was not adhered to, placing residents at risk for decreased psychosocial well-being and impaired quality of life.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that one of the four medication carts observed was locked while unattended, which had the potential to affect 14 residents on the main campus. During an observation, an unlocked medication cart was found unattended in the main common area, with all medication drawers easily accessible. No staff was present for approximately two minutes until a Certified Medication Aide (CMA) returned from obtaining ice for the cart. The CMA acknowledged that the cart should have been locked when unattended and not in her line of sight. Administrative Staff confirmed the concern, noting that the cart should have been secured when not attended by staff. The facility's policy on Medication Labeling and Storage did not include documentation requiring medication carts to be locked or secured.
Incomplete Advanced Directive for Resident with DNR Order
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were thoroughly completed, specifically for a resident with a Do Not Resuscitate (DNR) order. The resident, identified as R16, had a DNR order that was only signed by a physician, lacking the necessary additional signatures to validate the document according to the facility's policy and state law. This oversight was confirmed by the Social Service Designee, who acknowledged that the DNR uploaded in the Electronic Health Record (EHR) was incorrect. R16 was a resident with diagnoses of dementia and depression, exhibiting severely impaired cognition and requiring total assistance with activities of daily living. The resident's care plan and physician orders indicated a DNR status, which was visually represented by a red dot on the resident's name tag outside their room. Despite these indicators, the facility's failure to ensure a fully completed advanced directive had the potential to lead to uncommunicated needs, particularly concerning end-of-life care.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to notify the responsible party of a resident when there was a change in the resident's medication order. The resident, who had diagnoses of dementia and encephalopathy, was receiving Seroquel, an antipsychotic medication, for delusional behaviors. On September 6, 2024, the physician ordered a decrease in the Seroquel dosage to once daily at bedtime for a gradual dose reduction. However, the facility's progress notes did not show evidence that the resident's responsible party was informed of this medication change. Interviews with the resident's family member and facility staff confirmed the lack of notification. The family member reported that the last notification received from the facility was regarding a fall in August 2024. Licensed Nurse K and Social Service Designee E stated that it was the charge nurse's responsibility to notify the responsible party of any medication change and document it in the electronic health record. Administrative Nurse C also confirmed this procedure. Despite these protocols, the facility did not have a policy regarding notification of change, leading to the deficiency.
Failure to Provide Written Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to three residents or their representatives during hospital transfers. This deficiency was identified for residents R2, R10, and R31, who were transferred to hospitals without receiving the required written notice about the facility's bed hold policy. The absence of this documentation placed these residents at risk of not being able to return to their original rooms upon discharge from the hospital. For Resident R2, the electronic health record indicated diagnoses including cellulitis, pseudomonas, urinary tract infection, and dementia. Despite having intact cognition, as evidenced by a BIMS score of 15, there was no documentation in the care plan or progress notes regarding the notification of the bed hold policy during hospital transfers on two occasions. Interviews with facility staff revealed that the licensed nurse on duty was responsible for completing bed hold documentation, but this was not done, and no written notice was provided to the resident or their representative. Resident R31, who had severe cognitive impairment and required substantial assistance with activities of daily living, was also transferred to a hospital without receiving a written bed hold notice. Similarly, Resident R10, with moderately impaired cognition and multiple diagnoses including dementia and West Nile virus, was transferred without the required documentation. Facility staff confirmed that the bed hold policy was communicated verbally, but no written documentation was provided, contrary to the facility's policy requiring written notice at the time of transfer.
Deficiency in Monitoring and Reporting Resident's Health Status
Penalty
Summary
The report highlights a deficiency related to the monitoring and reporting of a resident's vital signs and health status. A resident with a history of hypertension had a blood pressure reading of 163/112, which exceeded the parameters set for reporting to the primary care physician. However, there is no documentation indicating that this elevated blood pressure was reported to the physician or hospice, as expected by the facility's protocol. Additionally, there was an incident where the resident's oxygen saturation level dropped to 73, yet it was not reported, which is considered unacceptable by the facility's standards. The resident experienced several health episodes, including involuntary movements, rapid respirations, and a significant headache, which were not adequately addressed. The resident's medications were held due to her altered state, but there is no indication that the underlying causes of her symptoms were thoroughly investigated or that appropriate interventions were implemented. Furthermore, the resident's skin assessment revealed a new bruise on her lower arm, which was not documented or analyzed for root cause, as required by the facility's procedures. Interviews with staff members revealed inconsistencies in the care provided, particularly in the monitoring and documentation of the resident's condition. The LPN acknowledged the need to manually recheck abnormal vital signs and notify the doctor, but there was a lack of follow-through in documenting these actions. The facility's policy on checking and changing residents was also noted to have been altered, potentially impacting the resident's care. Overall, the report indicates a failure in communication and documentation, leading to inadequate monitoring and response to the resident's health needs.
Inaccurate MDS Assessments and Care Plan Documentation
Penalty
Summary
The facility failed to accurately assess and document the care needs of several residents, leading to deficiencies in their care plans and Minimum Data Set (MDS) assessments. Resident 24, who had a history of falls and was at high risk for future falls, experienced a fall on 06/21/24 that was not properly investigated or documented in the care plan. The fall investigation report was delayed, lacked immediate interventions, and was missing a staff signature. This oversight resulted in uncommunicated care needs and placed the resident at risk for ongoing falls. Resident 35's MDS was inaccurately completed, failing to document insulin injections and falls with minor injuries. Despite having a history of falls and receiving insulin injections, these were not captured in the MDS, which could lead to uncommunicated care needs. The facility's policy required accurate MDS assessments, but the failure to adhere to this policy resulted in a lack of proper documentation and communication regarding the resident's care needs. Resident 31's MDS also contained inaccuracies, as it did not reflect the use of a Foley catheter and oxygen, which were part of the resident's care. The resident's care plan and physician orders lacked documentation of these interventions, despite progress notes indicating their use. This discrepancy between the resident's actual care needs and the documented MDS assessments could lead to uncommunicated care needs and potential risks to the resident's health.
Failure to Develop Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered baseline care plan for a resident, identified as R238, within 48 hours of admission, as required by their policy. The resident had a complex medical history, including conditions such as extradural and subdural abscess, MRSA infection, sepsis, anxiety, severe protein-calorie malnutrition, acute kidney failure, and management of a vascular device. Despite these significant health issues, the baseline care plan did not include necessary interventions to prevent falls, even though the resident had a documented history of falls prior to admission. The resident was assessed with a high risk for falls, as indicated by a Morse Fall Scale score of 95. However, the baseline care plan lacked specific interventions to address this risk. The resident experienced a fall on 09/26/24, resulting in serious injuries, including multiple lacerations to the head and face, which required medical attention and stitches. The incident note from the fall indicated that the resident was found on the floor with blood present, and the resident was not able to recall how the fall occurred. Interviews with facility staff revealed that the baseline care plan was supposed to be completed by a nurse and reviewed with the resident and/or their family. However, the care plan did not adequately address the resident's fall risk or provide enhanced barrier precautions for the resident's surgical wound. The facility's failure to implement a comprehensive baseline care plan contributed to an environment that was not free from accident hazards, as evidenced by the resident's fall and subsequent injuries.
Failure to Implement Enhanced Barrier Precautions for Resident's Wounds
Penalty
Summary
The facility failed to develop a comprehensive care plan with interventions to address enhanced barrier precautions for a resident's wounds, which compromised infection control measures and placed other residents at risk. The resident, identified as R12, had a history of hypertension, chronic kidney disease, venous thrombosis, and vascular implants. She was assessed to have venous stasis ulcers on both lower legs, which required nonsurgical dressing. Despite the presence of these wounds, the care plan lacked specific interventions related to enhanced barrier precautions, and the resident frequently refused to wear prescribed Tubigrip bandages due to pain. Observations and interviews revealed that the facility did not consistently implement enhanced barrier precautions for R12. Staff members, including a licensed nurse and certified nurse aides, were observed not using appropriate personal protective equipment (PPE) during care activities. The facility's policy required enhanced barrier precautions for wounds that could serve as a reservoir for multidrug-resistant organisms, yet there was no consistent signage or PPE setup to indicate the need for such precautions. Interviews with staff indicated confusion and inconsistency in the application of these precautions, with some staff unaware of the need for enhanced barrier precautions for R12. The resident's wounds were documented to have increased drainage, redness, and inflammation, with observations noting the absence of dressings or coverings on her legs. Despite the presence of drainage and the resident's mobility in common areas, the facility did not ensure that enhanced barrier precautions were consistently applied. This oversight in infection control measures, coupled with the resident's refusal to adhere to treatment orders, highlighted a significant deficiency in the facility's care planning and infection control practices.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for two residents, R24 and R31, related to falls and accident hazards. For Resident 24, the care plan did not include an intervention related to a fall that occurred on 06/21/24. The resident was found on the floor in the pantry area after attempting to get a soda, and although the fall was documented, there was no immediate intervention to prevent further falls. Additionally, the fall investigation report was not completed in a timely manner and lacked a signature from the staff member or licensed nurse who completed it. Resident 31's care plan also lacked timely updates following a fall. The resident, who had severely impaired cognition and required maximal assistance with activities of daily living, experienced a fall on 02/17/24 while attempting to put on socks. The care plan was not updated with fall prevention interventions until ten days after the incident. The facility failed to provide a fall investigation report upon inquiry, and observations revealed that the resident's call pendant was not always within reach, which could have contributed to the risk of falls. The facility's policy required care plans to be updated with interventions related to changes such as falls, but this was not adhered to in the cases of R24 and R31. The lack of timely updates to the care plans placed both residents at risk for uncommunicated care needs and further falls, potentially impacting their physical and psychosocial well-being.
Failure to Address Skin Issues in Resident
Penalty
Summary
The facility failed to adequately assess and address skin issues for a resident, identified as R12, who had a history of hypertension, chronic kidney disease, and venous thrombosis, among other conditions. Despite having a potential for skin impairment documented in the resident's care assessments, the facility did not implement or document any interventions related to the resident's skin or wounds in the comprehensive care plan. The resident had venous ulcers on her lower extremities, but the care plan lacked specific interventions to manage these conditions. The resident's medical records revealed multiple refusals of prescribed treatments, such as Tubigrip, which were intended to manage her skin condition. Despite these refusals, there was no documented follow-up or alternative interventions noted in the records. Observations showed that the resident's legs were swollen, red, and had open areas with drainage, yet there were instances where no dressings or coverings were applied. The facility's documentation was inconsistent, with missing assessments and a lack of follow-up on identified skin issues. Interviews with facility staff indicated a lack of adherence to the facility's policy on skin integrity, which required documentation and follow-up on skin deviations. The staff failed to consistently document skin assessments and did not perform regular evaluations as expected. This lack of action and documentation placed the resident at an increased risk for further medical complications, as the facility did not adequately address the resident's skin issues in a timely and effective manner.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, leading to potential respiratory complications. Resident 13, who had a diagnosis of asthma, was observed with a nebulizer that was not properly cleaned or stored. The nebulizer was left intact and draped over the arm of a recliner, contrary to the facility's policy which required disassembly, rinsing with tap water, and air drying on a paper towel after each use. The care plan for Resident 13 lacked documentation related to the care and use of the nebulizer, and the staff did not follow the cleaning schedule outlined in the physician's orders. Resident 31, who had severe cognitive impairment and required substantial assistance with activities of daily living, had an oxygen concentrator in her room with tubing that was not dated and a humidifier bottle filled with cloudy liquid. The nasal cannula was improperly stored, wrapped around the concentrator and exposed to the environment. The facility's policy did not include proper labeling and storage instructions for oxygen equipment, and there was no physician order reflecting Resident 31's oxygen use, despite hospital admission orders indicating the need for supplemental oxygen. Resident 3, who had multiple diagnoses including congestive heart failure and obstructive sleep apnea, was observed with oxygen tubing that lacked a date and was improperly stored, with nasal prongs resting on the floor. The facility's policy required oxygen tubing to be changed and dated regularly, but this was not adhered to. The improper storage of oxygen equipment for Resident 3 posed a risk of contamination and potential respiratory complications.
Deficiency in Vaccine Declination Documentation
Penalty
Summary
The facility failed to provide the necessary declination forms for pneumococcal and influenza vaccines for several residents, as required by their policies. Specifically, the electronic health records for four residents lacked documentation of the pneumococcal vaccine declination form, and one resident's record lacked documentation of the influenza vaccine declination form. The facility's policy mandates that residents or their legal representatives receive education about the benefits and potential side effects of these vaccines, and that the medical record should document whether the vaccine was administered or declined due to medical contradictions or refusal. During interviews, it was revealed that the administrative nurses could not locate the signed consent or declination forms for the pneumococcal vaccine for the affected residents. Additionally, one resident who requested the pneumococcal vaccine had not received it due to ongoing therapy and concerns about the vaccine's side effects interfering with therapy. The administrative nurse also confirmed that a verbal declination for the influenza vaccine was considered acceptable by the pharmacy, although this was not documented in the resident's record.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident, leading to an elopement incident. The resident, diagnosed with dementia and amnesia, exhibited severe cognitive impairment and was independently mobile. On the day of the incident, the resident attempted to leave the facility multiple times, expressing agitation and a desire to leave. Despite these clear exit-seeking behaviors, the staff did not apply a Wanderguard bracelet or take sufficient measures to prevent the resident from eloping. The resident first attempted to exit the front door and then moved to the gated courtyard, followed by staff. After spending approximately 45 to 60 minutes outside with staff, the resident was brought back inside the main building. Later in the day, the resident was let out of the front entrance by a visitor and was found 11 minutes later in the parking lot by a CNA. The staff was unaware of the resident's elopement until the CNA saw the resident outside. Interviews with staff revealed that the resident had been displaying exit-seeking behaviors throughout the day, including packing belongings and expressing a desire to leave. Despite these behaviors, the staff did not implement the facility's elopement policy, which included placing a Wanderguard bracelet on the resident. The facility's failure to provide adequate supervision and implement necessary safety measures placed the resident in immediate jeopardy.
Removal Plan
- R1 placed on one-to-one observation following the elopement until she went to bed and LN G educated the visitor about not letting others out without speaking to the nurse first.
- An elopement assessment completed, care plan updated, and a Wanderguard bracelet placed on R1.
- An elopement action plan completed.
- A Root Cause completed for R1 which determined she was on isolation for COVID prior to the day of the incident.
- The facility medical director, who was also R1's primary care physician, contacted and reviewed the action plan, root cause, policy changes, education plans and advised to place a sign on the exit doors to keep visitors from allowing exit advising them to see the nurse for assistance before opening the door.
- The facility contacted the resident representative to inform about care plan updates with interventions to new elopement risks.
- A full audit on elopement assessments completed and updated pictures placed at all nurse's stations for all residents with identified elopement risks to educate all staff and all agency staff of residents at risk.
- All staff provided immediate education on elopement policy update.
- Signs placed on all exit doors: Elopement Risk - do not open the door for someone you do not know or allow someone to follow you out the door unless they are with your party. For assistance please call [specified number] and a nurse will come to assist you. Thank you for keeping our resident's safe.
- Elopement Drill completed to test staff competency of elopement policy and procedure with an incident after action plan completed. A new intervention to add sign to the gate exits: Make sure gate is closed behind you, if you find the gate door open notify a nurse immediately.
- All staff educated on non-pharmacological approaches to support individuals living with dementia, maintain isolation precautions, interventions to help prevent behaviors and exit seeking, Abuse, Neglect, and Exploitation policy, and updated policy for resident isolation procedures.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 96 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Salem Home | 0.1 mi | ★★★★★ | 11 | 0 |
| Bethesda Home | 10.1 mi | ★★★★★ | 0 | 0 |
| St Luke Living Center | 10.6 mi | ★★★★★ | 0 | 0 |
| Access Mental Health | 12.9 mi | — | 21 | 1 |
| Peabody Health And Rehab | 13.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.