Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Bradford Oaks during CMS and state inspections, most recent first.
Respiratory care was not provided consistently with professional standards for multiple residents receiving O2. A resident was observed receiving O2 above the ordered flow rate with unlabeled tubing and other oxygen equipment, while several other residents had unlabeled nasal cannulas and no O2-in-use signage on their doors. Another resident also had O2 in use without the required door signage, despite an active physician order for O2 via NC.
The facility failed to consistently conduct and document care plan meetings and to revise care plans after changes in condition. Several residents reported either not having care plan meetings or not knowing about them, and record reviews showed only single, outdated care plan meeting entries with no subsequent documentation despite multiple MDS assessments that should have prompted quarterly IDT reviews. In addition, a resident who had been discharged from hospice services continued to have an active hospice physician order and an active hospice-related care plan, indicating that the care plan was not revised to reflect the resident’s discontinued hospice status.
A resident’s total program of care was not accurately reviewed and documented by the primary medical provider, resulting in conflicting information about catheter type, medication route, and cognitive status. The NP documented that the resident had a suprapubic catheter and received meds and hydration via PEG tube, while active orders included flushing a suprapubic catheter, enhanced barrier precautions for a Foley catheter, and administration of all meds orally. The UM confirmed the resident actually had a Foley catheter and received meds through the PEG tube, and the NP later acknowledged errors in documenting the catheter type, medication route, and the resident’s cognitive status, creating discrepancies between assessments, progress notes, and physician orders.
Surveyors identified that two residents did not have accessible call light cords in their room, as the cords were found tied and curled on the floor against the wall, despite both residents being alert and ambulatory. In a separate case, a resident reported intermittent problems with a call light that, when tested by the resident, a GNA, and later the NHA, failed to illuminate in the room or hallway on two separate occasions, with staff attributing the issue to a loose wall adapter.
A resident was assigned a new roommate without written notice to the resident or resident representative before the change. The Admissions Director said the resident was verbally informed 24 hours in advance, but confirmed no written notice was provided, and the Administrator acknowledged that written notification should have been issued.
A resident with an indwelling catheter was observed in bed with the urinary drainage bag hanging on the bed frame and visible without a privacy bag. The unit manager acknowledged the bag was not covered, even though facility policy required catheter bags to be covered at all times and the resident’s care plan included privacy and a privacy bag.
Poorly Maintained Resident Rooms and Common Areas: Surveyors observed damaged furniture, stained and torn surfaces, cracked counters, marred doors and walls, loose baseboards, dust accumulation on bathroom and shower vents, and an inadequately sealed hole in a resident room. The NHA and Maintenance Director acknowledged the concerns, and some items had not been ordered because staff were unaware of the damage.
Failure to document Ombudsman notification for hospital transfers. Two residents had multiple hospital transfers, and the facility could not produce complete proof that the Ombudsman was notified for all of the transfers. The SSD reported that monthly emails were sent, but several notifications could not be located in the record or by email review.
Failure to Provide Activities to Meet a Resident’s Needs: A resident with cognitive communication deficit, schizoaffective disorder, and palliative care needs was observed in bed with no activity provided in the room. Although the care plan called for invitations to all activities and 1:1 room visits, the record showed no evidence that activities were provided or that the resident refused them. The Activities Aide stated the resident was not invited to activities after transitioning to hospice, and no 1:1 activities were provided.
A resident had a rodent incident in the bed and the physician recommended a nurse complete a head-to-toe assessment, but the assessment was not documented in the EHR. An LPN said the assessment was done but forgotten in documentation, while hospice notes also described a scratch/skin tear on the resident’s lower extremities and the resident reported feeling like something bit him/her. The facility could not produce the assessment for the incident date and instead provided an assessment from one month earlier.
A resident receiving tube feeding was observed with the feeding infusing and no date on the tubing or bottle. An LPN confirmed the missing date and stated the tubing and bottle should be dated when hung, and the DON later acknowledged the concern.
A resident’s MRRs were not consistently reviewed and acted on after the provider signed off on recommendations. The record showed an inhaler order was not updated with rinse instructions until later, an agreed-upon GDR for alprazolam was not carried out and the rationale for continuing the dose was not documented until a later psych note, and a metoclopramide review recommendation was not addressed for 42 days.
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs. Record review showed the resident had separate pain medication orders for low-to-moderate pain and severe pain, but the MAR documented that oxycodone was given when the resident's pain was rated 4-5. A unit manager stated that the medication was ordered for severe pain and that giving it outside the ordered parameters could make it ineffective or cause overmedication.
Unlocked Medication Carts Left Unattended: An RN left a med cart unlocked and unattended after giving pain medication to a resident, with stock meds, vials, and Narcan stored inside. Later, an LPN’s two med carts were also found unlocked and unattended, containing stock meds, blister packs, glucometers, and insulin pens. Both nurses confirmed the carts should have been locked when unattended.
Unclean kitchen conditions and improper food storage and documentation. Surveyors observed undated dessert bowls, moldlike cucumbers, and unclean prep, dry storage, and dishwashing areas with stains and trash debris while staff were serving breakfast. Food temp logs were also incomplete, and cracked trays were later found drying by the dish machine.
Uncovered Clean Linen Cart Observed on North Unit: During the annual survey, a clean linen cart on the North unit was observed uncovered outside a room with sheets, towels, and washcloths on 3 shelves, while the blue plastic cover was resting on top of the cart. An RN stated the cart should be covered and then covered it after the observation.
Failure to provide individual closet space for a resident in a shared room. Surveyors observed two stand-alone closets on one resident’s side of the room, both filled with another resident’s clothing, while the resident repeatedly tried to close the closet door near the bed and indicated it was bothering them. An LPN was unsure whose clothing was in the closets, and the roommate confirmed the clothing and both closets were theirs; the roommate had a BIMS score of 15.
A resident’s room had repeated rodent activity, including a rodent seen running in the room and later found in the resident’s bed during a bathing setup. Hospice notes documented a scratch/skin tear and the resident’s statement that it felt like something bit me, while pest logs and invoices showed multiple mouse sightings and treatments on the East unit and in resident rooms and common areas.
Facility staff failed to notify a resident’s responsible party when the resident’s sacral pressure ulcer worsened from Stage 3 to Stage 4. The resident, admitted with multiple skin injuries and serious comorbidities, initially had an unstageable sacral ulcer that resolved and later reopened, at which time the responsible party was documented as notified and the wound was assessed as Stage 3. After a hospital transfer and return, the wound consultant documented the sacral ulcer as a worsening Stage 4 and new treatments were ordered, but there was no documentation that the responsible party was informed of this change in condition, contrary to the DON’s stated expectations.
A resident was admitted without having a baseline care plan completed and signed within the required 48 hours. Review of the medical record showed that the baseline care plan, which is intended to outline how to provide care for a new resident and is required to be created within 48 hours of admission, was not finalized until more than two weeks after the admission date. The resident’s representative confirmed this delay, and the DON acknowledged that facility policy and requirements call for baseline care plans to be completed, signed, and provided to the resident or representative within 48 hours of admission.
The facility failed to conduct and document required IDT care plan meetings with a resident and their responsible party following quarterly MDS assessments, despite multiple completed assessments and the responsible party reporting they were never invited to such meetings. For another resident with a Stage 3 sacral pressure ulcer, a suprapubic skin tear, and bilateral heel calluses present on admission, the facility initiated a care plan that only noted risk for impaired skin integrity and did not specifically address these existing wounds. When this resident later developed a new wound, the care plan and interventions were not revised to reflect the change in condition, even though the DON stated that care plans are to be updated upon changes in condition.
A resident developed swelling of the left lower lip, and nursing progress notes repeatedly documented that a physician or on-call physician was notified and gave a new order to apply a warm compress, followed later by an order for a cold compress, routine mouth care, and Vaseline. However, review of the physician orders showed that the warm compress order was never entered into the medical record, a fact confirmed by the DON. This failure occurred despite facility policy and an LPN’s statement that telephone orders received after a change in condition must be documented on the physician order form and properly verified and transcribed.
Surveyors found that two residents received multiple scheduled medications late, with delays of several hours, and an LPN left pre-poured medications unattended in a resident's room during administration. The DON confirmed that these practices did not meet professional standards, as medications were not administered or documented at the correct times and were improperly handled during administration.
The facility failed to maintain a sanitary environment, with litter observed in the parking lot and unsanitary conditions in the East hallway. Masks, gloves, and other debris were repeatedly found outside, while inside, stained ceiling tiles, torn flooring, and unclean handrails were noted. Maintenance and Environmental Services staff acknowledged the issues but cited access problems and ongoing renovations as contributing factors.
A facility failed to report an abuse allegation to the state agency within the required timeframe. An LPN reported a resident's abuse allegation to the RN supervisor, but the RN did not document notifying the DON and NHA. The NHA was informed the next day, leading to a delay in reporting to the SA, resulting in a deficiency.
A facility failed to suspend a GNA accused of abuse, allowing her to continue working with vulnerable residents. The investigation was inadequate, lacking documentation and interviews with other staff or residents. The NHA and HR Director could not explain discrepancies in the handling of the allegation, revealing lapses in adherence to abuse policies.
A facility failed to provide a baseline care plan to a resident's representative, which is necessary for proper care upon admission. The representative was not given a copy of the care plan or informed about the resident's medications. This deficiency was confirmed through a review of records and acknowledged by the Regional DON.
The facility staff failed to maintain complete and accurate medical records for two residents. One resident's records showed discrepancies between GNA and nurse documentation regarding turning and repositioning, while another resident's records lacked signatures for bowel, bladder, and personal hygiene care. The Regional DON confirmed these issues, but no rationale was provided for the inconsistencies.
The facility failed to discard expired food items in the dry storage area, including Med Plus 2.0 vanilla nutritional supplements and Thickened Dairy Drink. The Dietary Manager admitted that the items were not in rotation, posing a potential risk to residents consuming these products. The facility's policy mandates proper food storage to prevent deterioration or contamination.
A resident with RSV was not properly isolated due to staff failing to follow droplet precautions. Despite clear signage and available PPE, an LPN and the Activities Director entered the resident's room without the necessary protective equipment, risking cross-contamination. The facility's infection control policies were not adhered to, as confirmed by staff interviews.
Respiratory Care and Oxygen Administration Deficiencies
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for oxygen administration for 6 of 7 residents reviewed for respiratory care, including Residents #13, #23, #41, #133, #149, and #171. On 4/6/26, Resident #13 was observed receiving 4.5 liters/minute of oxygen by nasal cannula from an oxygen concentrator, with no date on the tubing, a partially used humidification bottle that was not dated, and nebulizer tubing in the bedside drawer that was also not dated. The resident’s order was for oxygen at 3 liters/minute via nasal cannula with tubing to be changed weekly and each oxygen component labeled with date and initials. On 4/7/26, Resident #13 was observed receiving oxygen at 5 liters/minute, and the Unit Manager confirmed that if oxygen was adjusted outside the order, the provider should be notified and the order adjusted if needed; no additional documentation was provided to explain why the oxygen was being administered outside the order. On 4/6/26, Residents #41, #133, #149, and #171 were observed with oxygen nasal cannulas that were not labeled and without Oxygen in Use signage on their doors. An LPN verified the unlabeled cannulas and missing signage and stated staff should label new oxygen nasal cannulas every 72 hours and have Oxygen in Use signage on the door. Resident #23 was observed on 4/6/26 and again on 4/7/26 with oxygen in use through nasal cannula tubing connected to an oxygen concentrator, but there was no oxygen signage on the room door or door frame. The resident had an active physician order for oxygen at 3 liters/minute via nasal cannula. The facility’s Oxygen Concentrator policy required an oxygen warning sign on the resident’s door, and the DON acknowledged the concern about unlabeled nasal cannulas and missing oxygen signage.
Failure to Conduct, Document, and Revise Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document timely, regular care plan meetings and to revise care plans following changes in residents’ conditions. One resident reported not having had a care plan meeting in a while, and record review showed the last documented care plan meeting occurred in May 2025, despite multiple subsequent MDS assessments, including an annual and several quarterly assessments. The DON confirmed that care plan meetings were missed following these MDS assessments. Another resident stated that they did not have care plan meetings, and the Social Services Director (SSD) confirmed that this resident had no documented care plan meeting since July 2025, despite multiple MDS assessments that should have triggered additional meetings. A third resident reported being unaware of care plan meetings, and record review showed only one documented care plan meeting in June 2025 with no further documentation of care plan meetings over the following year. Similarly, a fourth resident stated not knowing about care plans or care plan meetings, and the medical record showed a single documented care plan meeting in April 2025 with no additional care plan meeting documentation over the subsequent year. The facility also failed to revise a care plan after a significant change in a resident’s condition related to hospice services. One resident had been admitted to hospice services in March 2024 and discharged from hospice in July 2025 at the request of the resident’s daughter. However, record review revealed that the resident still had an active physician order for hospice and an active care plan for unavoidable decline due to hospice status and hospice care, even though hospice services had been discontinued. The DON acknowledged that the care plan had not been updated to reflect the resident’s change in status when hospice services ended.
Inaccurate Provider Documentation and Conflicting Orders for Catheter and Medication Administration
Penalty
Summary
The deficiency involves the primary medical provider’s failure to accurately review and document a resident’s total program of care, resulting in conflicting and inaccurate clinical information in the medical record. Record review showed that a nurse practitioner documented in a progress note that the resident had a neurogenic bladder with a suprapubic catheter (SPC) and a PEG tube used for medications and hydration, and also described the resident as a poor historian due to cognitive/psychiatric impairment. However, active orders directed that all medications be given orally rather than via PEG tube, there were orders to flush an SPC every shift, and there were separate orders for enhanced barrier precautions related to a Foley catheter, indicating simultaneous orders for two different types of urinary catheters. During interviews, the unit manager confirmed that the resident currently had a Foley catheter, not an SPC, and reported having recently changed the Foley catheter. The unit manager also stated that the resident actually received medications through the PEG tube, despite the orders specifying oral administration, and could not explain why the orders did not match the provider’s note. In a subsequent interview, the nurse practitioner acknowledged documenting the SPC in error, stated that the resident had advanced in diet and could take medications orally, and admitted that her notes did not reflect this change. She also reported that, upon reevaluation, the resident was capable of making his or her own decisions and that the previously documented cognitive impairment was not accurate, further highlighting discrepancies between the resident’s assessment, the documentation, and the written orders.
Inaccessible and Malfunctioning Resident Call Systems
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call systems were accessible and functioning properly in resident rooms and bathrooms. During a tour of the North Nursing Unit, the surveyor observed that two alert and ambulatory residents did not have accessible call lights in their room. The call light cords for both residents were found on the floor next to the wall, curled up and tied together, rather than positioned so the residents could use them. When notified, the North Unit Nurse Manager observed the same condition in the room. In a separate incident, another resident reported that his/her call light did not always work. When the surveyor asked the resident to activate the call light, neither the light in the room nor the hallway door light illuminated. A GNA then attempted to use the call light and confirmed it was not working, stating that sometimes the wall adapters can get loose; after adjusting the adapter, the call light became functional. Later, when the NHA was asked to evaluate the same resident’s call light, activation again failed to produce any illumination, marking the second time the call light did not function properly.
Failure to Provide Written Notice Before Roommate Change
Penalty
Summary
The facility failed to provide the resident and/or resident representative with written notification before assigning a new roommate to Resident #73. During an interview, Resident #73 stated that he or she was not informed in advance about the new roommate. Review of the clinical record showed that Resident #73 received a new roommate on 02/04/26, and further review found no evidence that the facility notified the resident or resident representative before that roommate arrived. The Admissions Director stated that the Admissions Department was responsible for notification and that she verbally informed Resident #73 twenty-four hours before the roommate’s arrival, but confirmed that no written notice was given. The Administrator was later informed of the findings and stated that he was aware the written notification should have been issued.
Visible Urinary Drainage Bag Not Covered for Privacy
Penalty
Summary
The facility failed to ensure the personal privacy of a resident with an indwelling urinary catheter. Resident #72 was observed in bed with a urinary drainage bag hanging on the bed frame and visible, including an observation of a yellow substance in the bag. On a later observation, the urinary drainage bag was again seen in view hanging on the bed frame without a privacy bag covering it. During interview, the North Unit Nurse Manager stated that the urinary drainage bag should be placed in a plastic blue privacy bag and acknowledged that Resident #72's drainage bag was not covered. The surveyor also observed the blue privacy bags at the nursing station. Review of the facility's catheter care policy showed that privacy bags were to be available and catheter bags covered at all times, and the resident's care plan included interventions to provide privacy and a privacy bag.
Poorly Maintained Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain a safe, comfortable, homelike environment for residents based on multiple observations of damaged and poorly maintained resident rooms, bathrooms, and common areas. During the initial tour, a resident’s wardrobe cabinet door and nightstand were observed with scraped and worn surfaces exposing the wood underneath, the bathroom toilet seat had brown stains, and two Geri chairs in the hallway had torn armrest coverings exposing foam. The Nursing Home Administrator and Maintenance Director were informed of these conditions and stated that some replacement items had been ordered, but the report also notes that the damaged Geri chairs and toilet seats had not been ordered because staff were not aware of the damage until it was pointed out. Additional observations on the North Nursing Unit found several resident rooms not in good repair, including cracked and splintered sink counters, marred bathroom doors and walls, cracked doorframes, water spots, loose baseboards, marred dressers, and chipped wood on a bed foot board. The surveyor also observed dust accumulating on bathroom and shower room ceiling vents after a resident raised concerns about the vents. In another room, a hole in the corner had been sealed with a yellow substance, which was described by the NHA as a temporary fix for rodent entry while other renovations were in progress. The NHA acknowledged the concerns when they were shown to him.
Failure to Document Ombudsman Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide documentation that the Ombudsman of Residents was notified when residents transferred to the hospital. For Resident #10, the medical record showed multiple hospital transfers over the past year, including 7/20/2025, 9/3/2025, 9/20/2025, 10/5/2025, 10/11/2025, and 3/25/2026. The record review found no documentation that the Ombudsman was notified of these transfers, and the Social Services Director initially stated that the department sends monthly emails to the Ombudsman listing residents who transferred or discharged to the hospital. When the surveyor requested proof of notification for Resident #10, the Social Services Director was able to provide emails for the 7/20/2025 and 3/25/2026 transfers, but could not locate emails for the September and October 2025 transfers and contacted IT for assistance. A similar finding was identified for Resident #72, whose record showed hospital transfers on 3/19/2025, 5/22/2025, 9/17/2025, 3/6/2026, and 3/31/2026, with no documentation that the Ombudsman was notified. The Social Services Director provided emails for the 3/19/2025, 5/22/2025, 3/6/2026, and 3/31/2026 transfers, but could not locate the email for the 9/17/2025 transfer, and no additional documentation was provided by the time of exit.
Failure to Provide Activities to Meet a Resident’s Needs
Penalty
Summary
An activities deficiency was identified for a resident with Cognitive Communication Deficit, Other Schizoaffective Disorders, and an encounter for palliative care, who had been admitted to hospice in November 2025. Survey observations on 04/06/26 and 04/07/26 found the resident lying in bed with no form of activity being provided in the room. The resident’s care plan, initiated on 06/17/25 and revised on 03/25/26, stated that the resident had some group setting interest, could verbally make needs known, and should be invited to all activities with 1:1 room visits as desired or available. However, review of the clinical record found no evidence that activities were provided to meet the resident’s needs and no documentation that the resident refused activities. The Director of Activities stated she had only been employed for 2 weeks and was unaware of documentation showing activities were offered during the past 6 months, and the Activities Aide stated that after the resident transitioned to hospice a few months earlier, the resident was not invited to activities and 1:1 activities were not provided in the room.
Missing Documented Skin Assessment After Rodent Incident
Penalty
Summary
The facility failed to ensure a follow-up skin/head-to-toe assessment was completed and documented in accordance with professional standards of practice for Resident #168. The resident’s surrogate reported concerns about an undocumented rodent incident involving the resident’s bed on 03/19/26 and about the facility’s skin checks and monitoring. Hospice notes provided by the surrogate documented a scratch/skin tear on the resident’s lower extremities, and the resident reportedly stated, “It feels like something bit me,” although the facility believed the resident was confused and could not rely on the statement’s accuracy. LPN #18 stated he/she was present on the day of the incident and completed a skin/head-to-toe assessment, but the assessment was not documented in the EHR. Weekly skin evaluations in the record showed a wound on the right top ankle on 02/19/26, no concerns on several subsequent weekly checks, and a scab on the right top ankle on 03/30/26. The NHA stated the physician was notified about the rodent in the resident’s bed and recommended a nurse perform a head-to-toe assessment, but the facility was unable to produce an assessment dated for the incident date and instead provided an assessment dated one month earlier. The DON acknowledged the concerns.
Missing Date on Enteral Feeding Tubing and Bottle
Penalty
Summary
The facility failed to administer enteral feeding consistent with professional standards of practice for Resident #74, the only resident observed for tube feeding during the recertification survey. During an observation on 04/06/2026 at 9:13 AM, the surveyor saw tube feeding infusing with no date on the tubing or bottle. An LPN verified that the tube feeding bottle and tubing were missing a date and stated that they should be dated when hung. On 04/07/2026 at 7:38 AM, the DON acknowledged the concern about the missing date on Resident #74's enteral feeding.
Medication Regimen Review Recommendations Not Timely Addressed
Penalty
Summary
The facility failed to have a process in place to ensure that a resident’s medication irregularity reports were reviewed by the primary care physician and that the actions taken based on the recommendations were documented. This deficiency was identified for Resident #13 during record review and interviews, and involved the monthly medication regimen review process, which includes review of the medical chart and reporting of medication-related irregularities. Resident #13’s medication regimen review reports showed multiple recommendations that were signed by the provider but were not acted on in a timely manner or were not documented as addressed. One review recommended adding rinse-after-use instructions to the Advair inhaler order to help avoid thrush, but the order was not updated until months later after the same recommendation was repeated. Another review recommended a gradual dose reduction of alprazolam from 0.5 mg three times daily to 0.25 mg three times daily; although the provider signed the form and agreed, the medication order remained unchanged and the rationale for continuing the dose was not documented until a later psychology note. A third review recommended reassessment of metoclopramide 5 mg every 6 hours for continued therapy and possible gradual dose reduction or discontinuation, and the medication was not discontinued until 42 days later.
Unnecessary Pain Medication Administration
Penalty
Summary
The facility failed to ensure that Resident #4's medication regimen was free from unnecessary medications. Record review showed two pain medication orders: Tylenol for pain levels 1-5 and Oxycodone HCl 20 mg every 8 hours as needed for pain levels 6-10. Review of the March 2026 MAR showed that on 3/6, 3/7, 3/28, and 3/29, Resident #4 received oxycodone when the documented pain levels were 4-5. During interview, a unit manager explained that pain levels 1-5 indicate low to moderate pain and 6-10 indicate severe pain, and stated that giving a medication ordered for a different pain range could make it ineffective or result in overmedication. The DON was informed of the concern and agreed she would follow up.
Unlocked Medication Carts Left Unattended
Penalty
Summary
The facility failed to store medications in locked compartments. On 4/7/26 at 6:31 AM, the surveyor observed an unlocked and unattended medication cart on the East hallway next to a resident room and across from another resident room. The cart contained stock medications in bottles in the top drawer, medications and vials in the second drawer, additional medications including Narcan in the third drawer, and supplies in the fourth drawer. When interviewed, RN #14 stated she had just given pain medication to a resident and must have forgotten to lock the cart, and she confirmed the cart was supposed to be locked when unattended. Later that morning, the surveyor observed two medication carts on the North hallway between room [ROOM NUMBER] and 39, and both were unlocked and unattended. The first cart contained stock medication in the first drawer, blister packs of medications in the second, and additional stock medications in the third. The second cart contained stock medications in the first drawer, blister packs of medications in the second, and glucometers and insulin pens in the third. LPN #15 stated she was responsible for both carts but had recently been pulled away from them, and she confirmed both carts should have been locked when unattended. The Nursing Home Administration was informed of the observations at 7:18 AM.
Unclean kitchen conditions and improper food storage and documentation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a manner that prevents foodborne illness to residents. During an initial kitchen tour, surveyors observed about 60 dessert bowls with no dates on them left on roll-in refrigerator tray racks containing cinnamon apples and pears, as well as two cucumbers covered with white moldlike substances in a Ziplock bag on a refrigerator shelf. A temporary CDM stated that the desserts should have been dated and that the cucumbers were bad, then discarded them. Surveyors also observed the kitchen prep area, dry storage area, and dishwashing area with unclean floors, including white patches, brown stains, red and dark stains, and trash debris. Kitchen staff were actively dishing out breakfast while the floor was not clean or sanitary. Review of the service line checklist log showed that food temperature documentation was not completed for breakfast and lunch on one day and for lunch on another day. On a later kitchen visit, surveyors observed about 8 trays drying by the dishwashing machine, and 4 of the 8 trays were cracked at the edges.
Uncovered Clean Linen Cart Observed on North Unit
Penalty
Summary
The facility failed to maintain infection prevention and control practices on the North Nursing Unit during the annual recertification survey. At 10:00 AM, the surveyor observed a clean linen cart outside of room [ROOM NUMBER] that was uncovered, with 3 shelves of linen including bed sheets, towels, and washcloths, and a blue plastic cover resting on top of the cart. During an interview at 10:35 AM, staff nurse #21 stated that the clean linen cart should be covered with the cover and then covered the cart. The North Unit Nurse Manager was notified of the concern on 4/7/2026, and the LNHA was notified on 4/8/2026.
Failure to Provide Individual Closet Space
Penalty
Summary
The facility failed to provide individual closet space for a resident in a shared room during the annual re-certification survey. During observation, two stand-alone closets were located on one resident’s side of the room behind the dividing curtain, and the resident repeatedly tried to close the closet door near the bed and indicated that the open door was bothering them. Both closets contained shirts and pants, and when asked whose clothing was inside, the roommate stated that all of the clothing in both closets belonged to them. Staff were unable to immediately confirm ownership of the clothing when questioned, and the roommate again stated that both closets and all of the clothing belonged to them. The roommate had a BIMS score of 15 on 1/12/2026. To verify ownership, surveyors removed clothing items from the closets on the resident’s side of the room, and the roommate confirmed the items were theirs as well as all other clothing in the closets. A UM later acknowledged that the roommate’s clothing was occupying the other resident’s closet space.
Pest Control Program Failed After Repeated Rodent Sightings
Penalty
Summary
The facility failed to ensure an effective pest control program after repeated rodent activity was identified in the East unit and in a resident’s room. During the initial tour, the surveyor observed a rodent bait box and a hole sealed with a yellow substance in the resident’s room. The resident’s surrogate reported concerns about rodent activity and provided hospice documentation showing that a large fat rodent was seen running in the resident’s room during a social work visit, and that on another occasion a rodent was discovered in the resident’s bed while the resident was being prepared for bathing. Hospice staff documented that the resident’s nurse and facility caregiver verified the rodent in the bed and that maintenance killed it. The hospice nursing note also documented a scratch/skin tear on the resident’s lower extremities and that the resident stated, “It feels like something bit me,” although the facility reported the resident was confused and could not rely on the accuracy of the statement. The surveyor also reviewed the facility’s pest logs and invoices, which showed multiple mouse sightings and treatments on the East unit, including mice observed in a room on several occasions and droppings noted during service. The pest control records documented treatment in resident rooms and common areas such as the kitchen, nursing stations, soiled linen rooms, laundry area, dining room, dry food storage, pantries, and lobby. The Administrator acknowledged the concern and described the incident as an environmental issue, but the deficiency was based on the repeated rodent sightings and the facility’s failure to ensure an effective pest control program.
Failure to Notify Responsible Party of Worsening Pressure Ulcer
Penalty
Summary
Facility staff failed to notify the responsible party when a resident’s sacral pressure ulcer worsened. The resident was admitted from the hospital with multiple skin injuries, including an unstageable sacral pressure ulcer, and had diagnoses such as COPD, peripheral vascular disease, and pressure-induced deep tissue damage to the right heel and another site. The sacral pressure ulcer was documented as resolved and later reopened, at which time a Change in Condition form indicated that the responsible party was notified in person, and the wound consultant assessed the reopened ulcer as a Stage 3 pressure ulcer. The wound consultant continued weekly evaluations, and the resident was later transferred to the hospital for a change in condition and then returned to the facility. Following the resident’s return, the wound consultant evaluated the sacral ulcer again and documented that it had worsened to a Stage 4 pressure ulcer, and a new treatment order for Santyl and calcium alginate dressing was implemented. However, review of the clinical record did not show any documentation that the responsible party was informed of this worsening of the sacral pressure ulcer. In an interview, the DON stated that her expectation was that nursing staff notify the responsible party of any change in condition, and that worsening of a pressure ulcer to Stage 4 was considered a change in condition for which the responsible party should have been notified. After further review of the record, the DON confirmed there was no documentation that the responsible party had been notified of the worsening pressure ulcer.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review on 1/8/26 at 11:30 AM showed that this resident was admitted on 10/13/25, but the baseline care plan was not completed and signed until 10/28/25, which exceeded the required 48-hour timeframe. The baseline care plan is described in the report as a document that outlines how to provide care for a new nursing home resident, created within 48 hours of admission to reduce the risk of adverse events and ensure the resident receives quality care. This delay in completing the baseline care plan was confirmed by the resident’s representative. During an interview on 1/8/25 at 12:23 PM, the DON acknowledged that baseline care plans are required to be completed and signed within 48 hours of admission and that a copy must be provided to the resident or their representative, thereby confirming that the facility did not meet this requirement for the identified resident.
Failure to Conduct IDT Care Plan Meetings and Update Wound Care Plans
Penalty
Summary
The facility failed to hold and document required care plan meetings with the Interdisciplinary Team (IDT) and the resident or responsible party (RP) within 7 days of quarterly MDS assessments for one resident, and failed to review and revise care plans to address identified skin conditions and new wounds for another resident. For Resident #2, who had diagnoses including COPD, peripheral vascular disease, and multiple pressure-related injuries (sacral pressure ulcer, deep tissue damage of the right heel and another site) and later expired, quarterly MDS assessments were completed on three separate dates. However, there was no evidence in the clinical record that care conferences were held with the resident/RP and the IDT around the time of these assessments. The RP reported not being invited to participate in care plan meetings, the Social Services Director could not find documentation of care conferences or invitations to the RP, and the Administrator, despite stating he believed conferences were held and that attempts had been made to contact the RP, did not provide any supporting documentation by the time of survey exit. The facility also failed to ensure that a resident’s care plan was specific to existing wounds and revised when a new wound developed. For Resident #5, a family member submitted a complaint regarding wound care, and review of wound progress notes showed that on admission the resident had a Stage 3 pressure ulcer to the sacrum, a suprapubic skin tear, and calluses on both heels. The care plan initiated after admission only identified the resident as being at risk for alteration in skin integrity and did not specify or address these ongoing skin conditions. Further review of wound progress notes showed that the resident acquired a new wound on a later date, yet the care plan and its interventions were not revised to reflect this change in condition. During interview, the DON stated that care plans were initiated on admission by the admitting nurse and updated by the Unit Manager or designated staff when there was a change in condition or as needed, and was informed of the failure to include and update the resident’s wound conditions in the care plan.
Failure to Document Telephone Order for Warm Compress
Penalty
Summary
The deficiency involves the facility’s failure to document a physician’s order for a warm compress in accordance with professional standards and facility policy. A resident was noted on multiple occasions to have swelling of the left lower lip with skin intact, no pain observed, and no tongue swelling or airway compromise. Progress notes dated over several days documented that the physician or on-call physician was notified of the change in condition and that new orders were received to apply a warm compress to the affected area. A subsequent note indicated that the physician was again notified and a new order was received to apply a cold compress, provide routine mouth care, and apply Vaseline to moisten the mouth. On review of the physician orders, surveyors found no evidence that the warm compress order was ever written in the medical record, despite repeated nursing documentation that such an order had been received. The DON confirmed that the warm compress order was not documented for this resident. Facility policy for consulting physician/practitioner orders required that telephone orders be documented on the physician order form with time, date, name and title of the person providing the order, and the signature and title of the person receiving the order, as well as verification by the attending physician and appropriate transcription. An LPN stated that when a change in condition occurs and a telephone order is received, nurses are expected to record the order in the medical record, which did not occur for the warm compress order in this case.
Failure to Adhere to Professional Standards in Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to adhere to professional standards of practice in medication administration for multiple residents. One resident reported ongoing concerns about medications being administered late, which was confirmed by a review of the medical record showing that several scheduled morning medications, including those for hypertension, COPD, atrial fibrillation, and bowel regimen, were documented as given over two hours past the scheduled time. Another resident's medication administration audit revealed that numerous morning medications, including those for pain management, nerve pain, hypertension, asthma, GERD, and wound support, were also administered significantly later than scheduled, with some medications given several hours late. The Director of Nursing acknowledged these delays and attributed some of the issues to agency nurses not documenting medication administration at the time it occurred, despite the facility's standard practice requiring real-time documentation. Additionally, during a medication administration observation, an LPN was seen preparing and bringing scheduled medications into a resident's room while the resident was receiving morning care. During this process, one pill was dropped onto the bed, and the nurse left the room to retrieve a replacement, leaving the cup with the prepared medications unattended on the bedside table. The nurse admitted that leaving pre-poured medications unattended was not the accepted standard of practice. The DON confirmed that medications should never be left unattended and that the standard is to sign off medications at the time of administration. These findings were based on resident interviews, direct observation, and medical record reviews, and were discussed with the facility's administration team. The deficiencies involved both the timing of medication administration and the improper handling of medications during administration, affecting residents with complex medical needs such as hypertension, COPD, atrial fibrillation, pain management, and wound care.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, visitors, and staff, as evidenced by multiple observations of litter and debris in the parking lot and unsanitary conditions in the East hallway. Over several days, surveyors observed masks, gloves, and various paper packaging littering the parking lot, with additional trash such as a pile of nonsterile gloves and a piece of cardboard. Interviews with the Maintenance Director revealed that the parking lot was supposed to be cleaned daily, but the issue persisted despite staff being informed. Inside the facility, the East hallway exhibited several maintenance and cleanliness issues, including a ceiling vent with a gap and black spots, stained ceiling tiles, and a torn flooring tile. Boxes of medical supplies were left piled up near a dummy waiter, and the hallway walls and handrails were stained with a reddish-brown substance. Environmental Services staff were supposed to clean these areas daily, but the Director of Environmental Services noted issues with access due to equipment blocking the way. The Director of Maintenance acknowledged the need for vent cleaning but did not provide a reason for the neglect. The Nursing Home Administrator was aware of the trash issue but did not offer a rationale for the ongoing housekeeping concerns.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the state agency (SA) within the required timeframe. A Licensed Practical Nurse (LPN) became aware of a resident's allegation of abuse against a Geriatric Nursing Assistant (GNA) during the evening shift. The LPN reported the allegation to the Registered Nurse (RN) on duty, who was the supervisor for that shift. However, the RN did not document the date, time, and manner of notifying the Director of Nursing (DON) and the Nursing Home Administrator (NHA) about the incident. The facility's documentation indicated that the abuse allegation was reported to the SA the following day, outside the required 2-hour timeframe. The Nursing Home Administrator stated that he was informed of the allegation by the previous DON the day after the incident and denied being notified by the RN on the day of the incident. He acknowledged awareness of the regulatory requirement to report such allegations within two hours but noted that staff often do not report incidents to him immediately if he is not in the building. This lack of immediate reporting and documentation led to a delay in notifying the SA, resulting in a deficiency in the facility's process for handling abuse allegations.
Failure to Suspend Staff Accused of Abuse
Penalty
Summary
The facility staff failed to ensure that an alleged perpetrator, GNA12, had no further access to vulnerable residents during an investigation of an abuse allegation. On 7/13/24, LPN5 became aware of an allegation of abuse involving GNA12 and resident R40. Although LPN5 reassigned GNA12 to prevent her from caring for R40, she continued to work her shift and had access to other vulnerable residents. This was contrary to the facility's policy, which requires immediate suspension of staff accused of abuse. The investigation into the allegation was inadequate. While LPN5 reported the incident to RN6, the evening shift supervisor, there was no documentation of RN6's actions following the report. RN6 claimed to have informed the DON and NHA and instructed GNA12 to go home, but she did not document these actions. Furthermore, the investigation did not include interviews with other staff or residents to determine if GNA12 had abused other residents, nor was there a thorough review of the type of care she provided. The NHA and Director of Human Resources were unable to provide a clear rationale for the discrepancies in the investigation and the handling of the alleged abuse. The NHA stated that staff accused of abuse should be suspended immediately, but GNA12 continued to work her shift after the allegation was reported. The Director of Human Resources confirmed that GNA12's time punches indicated she worked on the day of the allegation, contradicting the NHA's assertion that she was suspended immediately. These failures highlight significant lapses in the facility's adherence to its abuse policies and procedures.
Failure to Provide Baseline Care Plan to Resident's Representative
Penalty
Summary
The facility failed to provide a baseline care plan to a resident's representative, which is a requirement to ensure proper care upon admission. This deficiency was identified for one resident who was reviewed for care to prevent pressure ulcers. The complaint revealed that the resident's representative was not given a copy of the baseline care plan or informed about the medications the resident was taking. A review of the closed record and the electronic medical record confirmed the absence of documentation showing that the baseline care plan or medication list was provided to the resident or their representative. The Regional Director of Nursing confirmed these findings during the review process.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility staff failed to ensure the completeness and accuracy of medical records for two residents. For one resident, there was a discrepancy between the documentation by geriatric nursing assistants (GNAs) and nurses regarding the turning and repositioning of the resident to prevent skin breakdown. The GNAs documented that the resident was not turned and repositioned on several specific dates, while the nurses documented on the Treatment Administration Record (TAR) that the resident was being turned and repositioned on those same dates. The Regional Director of Nursing (DON) acknowledged the inconsistency but could not provide a rationale for the conflicting information. For another resident, the medical record review revealed that tasks related to bowel and bladder care and personal hygiene were not signed off as completed on multiple occasions. The resident, who required assistance with activities of daily living, had family concerns about not being changed regularly. The Regional DON and the administrator confirmed that the lack of signatures meant it could not be verified whether the care was provided or if the nurse failed to document it.
Expired Food Items Found in Storage
Penalty
Summary
The facility failed to ensure that food items in the dry storage area were discarded upon reaching their use-by dates, as observed during a survey. Specifically, two cases of Med Plus 2.0 vanilla nutritional supplements and one case of Thickened Dairy Drink were found with expired use-by dates. The Dietary Manager acknowledged the oversight and indicated that the items were not in rotation, which could potentially make residents who consume these products sick. The facility's policy on food safety requires that food be stored in a manner that prevents deterioration or contamination, including from the growth of microorganisms.
Failure to Follow Droplet Precautions for Resident with RSV
Penalty
Summary
The facility failed to adhere to infection control procedures related to droplet precautions for a resident diagnosed with respiratory syncytial virus (RSV). The resident, who was cognitively intact and dependent on staff for daily activities, had a physician's order for droplet precautions. Despite clear signage on the resident's door and the availability of personal protective equipment (PPE) outside the room, staff members did not consistently follow the required precautions. Specifically, an LPN entered the resident's room to assist with a meal without wearing a gown or eye protection, and the Activities Director also entered the room without the necessary PPE. Interviews with the Director of Nursing and the involved staff confirmed the lapses in following the facility's infection control policies. The facility's policy on transmission-based precautions required staff to wear a gown, mask, gloves, and eye protection when entering the room of a resident on droplet precautions. The failure to comply with these procedures had the potential to cause cross-contamination with other residents and staff, as the facility's policies were not adequately followed by the staff members involved.
What surveyors are citing around you — mapped
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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 1,016 citations issued within 25 miles in the last 12 months — including the 14 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 Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hidden Waters Rehabilitation And Wellness Center | 1 mi | ★★★★★ | 30 | 0 |
| Future Care Pineview | 1.2 mi | ★★★★★ | 3 | 0 |
| Ft Washington Rehabilitation And Wellness Center | 6.4 mi | ★★★★★ | 35 | 0 |
| Forestville Rehabilitation And Wellness Center | 6.8 mi | ★★★★★ | 51 | 0 |
| Serenity Rehabilitation And Health Center Llc | 8.3 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.