Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edgewood Rehab & Living Ctr during CMS and state inspections, most recent first.
Housekeeping and maintenance services were not adequately provided to keep the facility sanitary, orderly, and comfortable. Surveyors observed stained ceiling tiles, heavy dust, chipped and missing paint, dirty floors, cracked floor tiles, worn chairs with uncleanable surfaces, a stained and leaking whirlpool tub, and disrepair in resident rooms and common areas. The Maintenance Director and Healthcare Services District Manager confirmed the findings.
Failure to provide transfer/discharge and bed hold notices: The facility did not give written transfer/discharge notices or bed hold notices to the POA/family member/legal representative for two residents who were transferred to an acute hospital, and the Ombudsman was not notified. The DON confirmed the notices were not received, and the SW stated that notices were not being mailed to residents’ representatives and that Ombudsman notifications for hospital transfers were not being done.
Care plans were not updated to include measurable goals and interventions for two residents' oxygen-related needs and one resident's activity preferences. One resident had oxygen therapy and shortness of breath documented, another had COPD with orders for oxygen and nebulizer treatments, and a third resident's activity assessment identified preferred reading, pets, news, groups, and favorite activities, but these needs were not reflected in the care plans.
A facility failed to provide a continuous resident-centered activities program for 3 residents reviewed. Activity assessments and care plans showed individualized interests and needs, but activity logs documented very few group or 1:1 activities and no evidence that other activities were offered or refused. Resident council minutes said residents wanted more activities, calendars lacked many day, evening, and weekend activities, and residents reported there were no evening or weekend activities; the AD said this was because she only worked 40 hours a week.
Respiratory care was not kept sanitary for two residents, as unbagged, undated oxygen tubing and cannulas were observed draped over concentrators, and one resident also had nebulizer tubing touching the floor. The chart for one resident lacked a physician order for oxygen despite documented oxygen use, and the other resident's chart lacked an order for the oxygen delivery method and flow rate; both residents' TARs lacked evidence of tubing changes.
Missing Controlled Substance Shift Count Signatures: The facility failed to ensure that incoming and outgoing med admins signed the Shift Count page to document controlled substance counts at shift change for a CNA-M med cart book. Review of the book showed multiple instances where the incoming nurse, the outgoing nurse, or both failed to sign the count sheet, despite the facility policy requiring documentation of Schedule II and other abuse-risk meds at each shift change. The DON stated she had audited the count book and was aware of the missing signatures.
Kitchen sanitation and food storage practices were deficient, with dirty vents, ceiling tiles, walls, equipment, floors, and storage areas, along with food items left unlabeled, undated, or open to the air in multiple storage locations and the activity room snack area. Surveyors also observed kitchen staff without required hair or facial hair protection, and the dish machine temperature/sanitizer log had missing entries for multiple meal periods; the FSD and Administrator confirmed the findings.
Improper Disposal of Refuse Under Dumpster: Surveyors observed a mattress on the ground under the trash dumpster on two survey days. The Maintenance Director confirmed the mattress was trash and said it had been under the dumpster for about a month, and it was still there on the next day’s observation.
A resident with COPD was observed lying in bed on O2 at 2 L/min via nasal cannula, but both the admission MDS and the most recent quarterly MDS coded no shortness of breath and no oxygen use in the health conditions and special treatments sections. The DON stated the resident had been using oxygen at bedtime and when lying in bed during the day since admission.
Delayed Baseline Care Plan Development: The facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with B-cell lymphoma, anxiety, and hospice services. Record review showed the care plan with goals and interventions was not completed until 8 days after admission, and the DON confirmed the delay.
Failure to Hold IDT Meeting After MDS Assessment: The facility failed to review and revise a resident's care plan by an IDT after an MDS quarterly assessment. The record showed the assessment was completed, but there was no evidence of an IDT meeting within 7 days afterward. The DON confirmed that no IDT meeting was held following the assessment.
Failure to monitor after falls and notify provider: A resident had multiple unwitnessed falls with incomplete neuro checks, including missing or incomplete assessments after head injury and falls. The record also lacked timely provider notification after a witnessed fall and lacked evidence the provider was notified after a later fall with a head bump, headache, and altered command following; staff stated the nurse must call the provider after a fall and document the communication log.
A resident with altered nutrition/hydration related to obesity, diabetes, liver failure, and adaptive equipment needs had a care plan directing staff to monitor eating patterns and record intake. However, the LTC meal intake record lacked documentation of intake or refusal for multiple breakfast, lunch, and dinner meals, and a CNA stated meal intakes should be documented 3 times daily with refusals and alternatives recorded and the charge nurse notified.
A resident with obstructive uropathy and an indwelling urinary catheter had a urinary catheter drainage bag with urine in the tubing and bottom of the bag observed hanging under the sink during multiple room observations. The DON also observed the drainage bag hanging under the sink when the surveyor reviewed the finding.
The facility was found to have multiple deficiencies in maintaining a sanitary and comfortable environment. Issues included debris in laundry room lights, untreated surfaces, soiled fans, chipped toilet seats, and missing floor tiles. Several resident rooms had peeling laminate, soiled wheelchairs, and damaged walls and heaters, creating uncleanable surfaces. These findings were confirmed by the Administrator and Maintenance Director.
The facility failed to monitor and maintain appropriate storage temperatures for medications and biologicals, as required by policy and USP guidelines. Logs from August to October showed missing temperature readings and temperatures out of range, confirmed by the DON.
The facility's kitchen was found to be unsanitary, with issues such as a soiled fan, chipped paint on a food mixer, and dirty ceiling vents. Additionally, there were lapses in monitoring and documenting refrigerator/freezer temperatures, dishwasher cycles, and sanitizer levels, as confirmed by the Food Service Director.
The facility failed to maintain sanitary garbage storage areas over three days. Observations included missing or open doors on dumpsters, exposed trash, and scattered plastic and paper waste around the dumpsters. Trash was also stored in an open top cart outside the laundry room exit. The Administrator confirmed these findings during interviews.
The facility's Quality Assurance Committee failed to implement an effective Plan of Correction for deficiencies identified in a previous survey. Persistent issues included inadequate housekeeping, failure to develop timely care plans, lack of resident monitoring post-fall, improper medication storage, unsanitary kitchen conditions, and failure to offer vaccines to residents. These deficiencies were noted during a revisit survey, indicating that corrective actions were not successfully executed.
The facility failed to implement its pneumococcal immunization policy for three residents, as their records lacked evidence of receiving the PCV 20 vaccine or related documentation. This deficiency was confirmed during an interview with the Infection Preventionist and DON, highlighting a lapse in following established vaccination protocols.
The facility did not offer updated COVID-19 vaccine doses to five residents, despite their policy requiring it. The residents' clinical records showed no evidence of being offered the updated 2023-2024 vaccinations, even though some had been diagnosed with COVID-19. This was confirmed during an interview with the DON and the Infection Preventionist.
The facility failed to conduct post-fall neurological assessments and appropriate fall assessments for three residents with cognitive impairments who experienced unwitnessed falls. Additionally, the facility did not follow physician orders for a resident who was supposed to wear a knee brace when out of bed. The absence of required documentation and adherence to physician orders was confirmed by staff interviews and record reviews.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted resident with a history of stroke, dementia, and atrial fibrillation. The resident was on multiple medications, but no care plan was in place to ensure safe and effective care. This was confirmed by the DON.
A survey found that a Soiled Utility room in an LTC facility was unlocked, with cabinets containing hazardous chemicals also unlocked. CNAs confirmed that the key was kept above the door and that the room and cabinets should have been locked. The MSDS for these chemicals indicated they should be kept out of reach of children, highlighting a failure to maintain a safe environment.
The facility did not post daily nurse staffing information, missing details on the total number and actual hours worked by RNs, LPNs, and unlicensed staff responsible for resident care. This was observed on two survey days and confirmed with the DON.
Housekeeping and Maintenance Deficiencies in Common Areas, Laundry, and Resident Rooms
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment. During an environmental tour with the Maintenance Director and the Healthcare Services District Manager, surveyors observed multiple areas of disrepair and soiling, including stained ceiling tiles and heavy dust behind a dryer in the laundry room, chipped and missing paint on walls and a baseboard heating unit, a wall air conditioning unit heavily soiled with dust and yellowish-brown stains, and a public bathroom with a dirty floor, dirt buildup around the edges, and a toilet seat with chipped and missing enamel. Surveyors also observed five cracked or broken floor tiles at the entrance to the LTC wing and chairs in a sitting area with worn or missing edging and chipped or missing finish on the armrests, creating uncleanable surfaces. Additional findings included a whirlpool tub and jets stained yellowish-brown with continuous water leaking into the tub, walls with chipped or gouged paint exposing sheetrock, and a damaged wall corner missing paint and sheetrock. In resident rooms, surveyors observed a commode bucket and lid on the floor under a sink, and another room with chipped or missing paint on the inside bathroom door, a dirty and black-stained linoleum floor around the toilet base, two stained ceiling tiles above the toilet, and a ripped or torn frame protector on the bottom left side of the room entrance door frame. The Maintenance Director and Healthcare Services District Manager confirmed these findings during interview.
Failure to Provide Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to issue written transfer/discharge notices and bed hold notices to the resident’s known family member or legal representative for facility-initiated transfers/discharges for 2 of 4 sampled residents transferred to an acute care facility, identified as R1 and R8. The record for R1 showed a transfer to an acute hospital on 6/15/25 and subsequent admission, but there was no evidence that a written transfer/discharge notice or bed hold notice was provided to the POA, family member, or legal representative, and no evidence that the Ombudsman’s office was notified. The DON confirmed that the POA/family member/legal representative for R1 did not receive the required written notices. The record for R8 showed transfers to an acute hospital on 4/11/25 and 4/17/25, with subsequent admission for both events, but the clinical record lacked evidence of written transfer/discharge notices or bed hold notices being issued to the POA, family member, or legal representative, and lacked evidence that the Ombudsman’s office was notified. During interviews, the DON confirmed that the POA/family member/legal representative for R8 did not receive transfer/discharge notices or bed hold notices in writing for either hospital transfer. The Social Worker also stated that no one mails transfer/discharge notices or bed hold notices to residents’ representatives and that she was supposed to notify the Ombudsman of hospital transfers but had not been doing so.
Care plans lacked oxygen, nebulizer, and activity interventions
Penalty
Summary
The facility failed to update and include interventions on the comprehensive care plans for oxygen use for two residents and for activities for one resident. Resident R11 had an oxygen concentrator observed next to the bed on 8/18/25 and 8/19/25. The clinical record showed a quarterly MDS dated 6/5/25 indicating shortness of breath with exertion and when lying flat, oxygen therapy use, and an IDT note dated 6/12/25 stating the resident was wearing oxygen most of the time and was happy to have assistance to reapply it. The comprehensive care plan did not contain evidence that goals and interventions were implemented for R11's oxygen use. Resident R34 had an oxygen concentrator next to the bed and a nebulizer machine on the nightstand, and was later observed lying in bed wearing oxygen at 2 liters per minute via nasal cannula. The record showed diagnoses including COPD, transfer records with an order for oxygen at 2 L/min via nasal cannula, and active physician orders for weekly nebulizer kit changes and budesonide nebulization twice daily. The comprehensive care plan did not include goals and interventions for oxygen or nebulizer use. For Resident R15, the activity assessment identified preferences including books, newspapers, magazines, animals/pets, keeping up with the news, being around groups of people, and favorite activities, but the updated care plan lacked goals and interventions for activities.
Lack of Continuous Resident-Centered Activities
Penalty
Summary
The facility failed to provide a continuous resident-centered activities program for 3 of 3 residents reviewed for activity participation. One resident’s care plan stated the resident needed assistance to develop an activity program that met abilities and interests and that the resident would participate in activities or social events of choice, but the activity log from May through August 2025 showed only 2 group activities and 6 one-to-one visits, with no evidence the resident was offered or refused the remaining activities. Another resident’s activity assessment identified interests such as reading books, newspapers, and magazines, being around animals, keeping up with the news, being around groups of people, and doing favorite activities, but the activity participation log for the same period showed only 2 one-to-one visits and no evidence of other activities being offered or refused. A third resident’s activity assessment identified interests including listening to music, being around animals, being around groups of people, and doing favorite activities, and the care plan stated the resident needed assistance to develop an activity program that met abilities and interests and would participate in activities or social events of choice. The activity log showed only 1 group activity during the reviewed period, with no evidence the resident was offered or refused other activities. Resident council meeting minutes from January and February 2025 stated residents wanted more activities. Monthly activity calendars also lacked documented day, evening, and weekend activities on multiple dates in May, June, July, and August 2025, and residents stated there were no evening or weekend activities. The Activity Director stated there were no evening or weekend activities because she only worked 40 hours a week.
Respiratory Care Sanitation and Oxygen Order Deficiencies
Penalty
Summary
The facility failed to provide a sanitary environment for respiratory care and failed to obtain a physician order for oxygen for 2 residents reviewed for respiratory care. Facility policy stated that a sanitary environment must be maintained to prevent transmission of disease and infection, that nasal cannulas must be discarded and changed every 2 weeks, and that when not in use the cannula must be stored in a plastic bag to avoid contamination. It also stated that nebulizer parts should be rinsed after each use, allowed to air dry, and placed in the respiratory set-up bag once dried, with respiratory set-ups changed every 2 weeks and documented on the TAR. Surveyors observed one resident's unbagged, undated oxygen tubing draped over the oxygen concentrator with the nasal cannula prongs touching the front surface of the concentrator, and undated nebulizer tubing draped over the nightstand and extending to the floor with exposed tubing in contact with the floor by the head of the bed. That resident's record showed use of oxygen therapy and an IDT note stating the resident was wearing oxygen most of the time, but the chart lacked a physician order for oxygen and the August 2025 TAR lacked evidence of tubing changes or respiratory set-up changes. A second resident was observed with undated, unbagged oxygen tubing draped over the oxygen concentrator with the nasal cannula prongs touching the front surface of the concentrator; the resident was later observed in bed wearing oxygen at 2 liters per minute via nasal cannula. That resident's transfer records included an order for oxygen at 2 L/min via nasal cannula, but the facility's physician orders lacked an order for the oxygen delivery method and flow rate, and the August 2025 TAR lacked evidence of oxygen tubing changes.
Missing Controlled Substance Shift Count Signatures
Penalty
Summary
The facility failed to ensure that two people authorized to administer medications signed the Shift Count page to document that all controlled substances were counted at the change of shift for multiple shifts in 1 of 3 Controlled Substance Books reviewed, the CNA-M medication cart book. During a medication storage observation on 8/19/25, review of the Controlled Substances Book and Shift Counts showed that the incoming medication administrator failed to sign for counts on multiple dates and times, including 4/9/25 at 10:00 p.m., 4/22/25 at 6:00 a.m., 4/24/25 at 10:00 a.m., 5/1/25 at 6:00 a.m., 5/11/25 at 6:00 a.m., 5/15/25 at 7:00 p.m., 5/17/25 at 6:00 p.m., 6/4/25 at 7:00 p.m., 6/10/25 at 6:00 a.m., 6/11/25 at 7:00 p.m., 6/22/25 at 7:00 p.m., 7/17/25 at 7:00 p.m., 7/25/25 at 7:00 p.m., 7/29/25 at 6:00 a.m., and 8/14/25 at 7:00 p.m. The outgoing medication administrator also failed to sign the Shift Count page on multiple dates and times, including 4/1/25 at 6:30 a.m., 4/13/25 at 6:00 a.m., 4/13/25 at 6:30 a.m., 4/22/25 at 6:30 a.m., 4/24/25 at 6:30 a.m., 4/24/25 at 10:30 a.m., 4/27/25 at 6:30 a.m., 5/1/25 at 6:30 a.m., 5/2/25 at 6:15 a.m., 5/9/25 at 6:30 a.m., 5/11/25 at 6:30 a.m., 5/15/25 at 6:30 a.m., 5/16/25 at 6:00 a.m., 5/16/25 at 6:00 p.m., 5/18/25 at 6:00 a.m., 6/5/25 at 6:00 a.m., 6/10/25 at 6:30 a.m., 6/12/25 at 6:00 a.m., 6/20/25 at 6:00 a.m., 6/23/25 at 6:00 a.m., 7/16/25 at 7:00 p.m., 7/26/25 at 6:00 a.m., 7/29/25 at 6:30 a.m., 8/6/25 at 7:00 p.m., and 8/15/25 at 6:30 p.m. On 4/3/25 at 6:00 a.m., 4/10/25 at 6:00 a.m., and 8/15/25 at 6:00 a.m., both the incoming and outgoing medication administrators failed to sign the Shift Count page. The facility policy stated that incoming and outgoing nurses should count all Schedule II controlled substances and other medications with a risk of abuse or diversion at each shift change and document the results on the Controlled Substance Count Verification/Shift Count Sheet.
Kitchen Sanitation, Food Labeling, and Dish Machine Monitoring Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen and related food storage areas in a clean and sanitary manner and failed to ensure proper food labeling and dating. During a kitchen tour with the Food Service Director, a male kitchen worker was observed without hair and facial hair protection, and a male cook was later observed without facial hair protection for his moustache. Surveyors observed heavily soiled ceiling vents, dirty and stained ceiling tiles, dirty and rusty ceiling grid areas, dirty walls with chipped and missing paint, a food mixer with chipped and missing paint and dried residue, a food disposal with dried food particles and dried liquid residue, a wash rack with residue, and food debris and trash on the kitchen floor and under equipment. Similar debris and trash were observed in the walk-in refrigerator and dry storage room. Surveyors also found multiple food items that were not labeled and dated, including pie shells in a reach-in freezer, manicotti and hamburgers in another freezer, soft taco wraps in the dry storage room, bread in the bread freezer, and bread in the activity room snack area. Some items were also found open to the air, including a box of hamburgers and a bag of chips. The facility's Refrigerator/Freezer Food Storage policy required foods to be covered, labeled, and dated, and the Food Service Director confirmed the findings. In addition, review of the Dish Machine Temperature and Sanitizer Log Form showed missing documentation for dish machine temperatures across multiple lunch and supper periods in May, June, and July 2025, and the Administrator confirmed the missing entries.
Improper Disposal of Refuse Under Dumpster
Penalty
Summary
The facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 2 of 3 survey days. On 8/18/25 at 9:03 a.m., a surveyor observed a mattress on the ground under the trash dumpster. During an interview at 9:41 a.m., the Maintenance Director confirmed that the mattress was trash and stated that it had been under the dumpster for about a month. On 8/19/25 at 8:00 a.m., a surveyor again observed the mattress on the ground under the trash dumpster, and at 8:24 a.m. the Maintenance Director confirmed that it was still there.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Version 3.0 assessments were accurately coded for one resident with COPD. The resident was admitted from an out-of-state facility with diagnoses including chronic obstructive pulmonary disease and had a transfer order for oxygen at 2 liters per minute via nasal cannula. On observation, the resident was lying in bed wearing oxygen at 2 liters per minute via nasal cannula. However, the admission MDS dated 9/11/24 and the most recent quarterly MDS dated 5/22/25 both coded Section J for health conditions as none of the above for shortness of breath and Section O for special treatments as none of the above for oxygen use. During interview, the DON stated the resident had been using oxygen at bedtime and when lying in bed during the day since admission.
Delayed Baseline Care Plan Development
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #11, who was admitted in December 2024 with diagnoses including B-cell lymphoma and anxiety and was receiving hospice services on admission. Record review showed that the baseline care plan, including goals and interventions and the instructions needed to provide minimum healthcare information necessary to care for the resident, was not developed and implemented until 8 days after admission. During an interview on 8/20/25 at 10:22 a.m., the Director of Nursing reviewed Resident #11's baseline care plan and confirmed that it had not been developed and implemented until 8 days after admission.
Failure to Hold IDT Meeting After MDS Assessment
Penalty
Summary
The facility failed to review and revise the care plan by an interdisciplinary team (IDT), including, to the extent possible, the resident and/or the resident's representative, after each MDS assessment for Resident 11. Review of the clinical record showed that an MDS Quarterly Assessment was completed on 3/13/25, but the record lacked evidence that an IDT meeting was held within 7 days following that assessment. During an interview on 8/20/2025 at 10:22 a.m., the DON reviewed Resident 11's clinical record and confirmed that no IDT meeting was held following the 3/13/25 MDS assessment.
Failure to Monitor After Falls and Notify Provider
Penalty
Summary
The facility failed to document and adequately monitor a resident after multiple unwitnessed falls and failed to notify the physician after a fall for one resident. Resident 34 sustained unwitnessed falls on 6/22/25, 8/2/25, 8/17/25 at 4:15 a.m., and 8/17/25 at 11:00 p.m. The neurological check flow sheet for the 6/22/25 fall lacked evidence of an initial neurological assessment at the time of the fall and lacked documentation of the 1-hour assessments due at 6:10 a.m., 7:10 a.m., and 8:10 a.m.; the 9:30 a.m. assessment was incomplete, and the 8-hour assessment due at 1:30 a.m. was not performed until 5:30 a.m. on 6/23/25. The flow sheet for the 8/2/25 fall lacked evidence of continued neurological assessments after the 1-hour assessment completed at 4:30 a.m., the flow sheet for the 8/17/25 4:15 a.m. fall lacked evidence of continued neurological assessments after the 30-minute assessment completed at 5:30 a.m., and the flow sheet for the 8/17/25 11:00 p.m. fall lacked evidence of the 8-hour neurological check. Resident 34 also sustained a witnessed fall on 8/10/25. The incident report and communication log indicated the provider was notified at 2:00 p.m., but the communication log lacked evidence that the provider was made aware of the concern until 8/14/25, 4 days after the fall. For the 8/17/25 fall with a head bump, headache, and inability to follow some commands, the nursing progress note stated the resident was sent to the hospital at 10:30 a.m. and that the grandson was notified, but it lacked evidence that the medical provider was notified of the fall or head injury. The incident report for that event also lacked evidence of provider notification. During interview, RN1 stated the nurse assesses the resident, decides whether hospital transfer is needed, and notifies the provider by phone, and the DON stated the nurse must call the provider after a fall in addition to completing the communication log.
Incomplete Meal Intake Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for one sampled resident reviewed for nutrition. The resident’s care plan, updated 5/8/25, identified altered nutrition/hydration related to obesity, diabetes, liver failure, and the need for adaptive equipment, with a goal for the resident to make food choices within prescribed therapeutic diet parameters and maintain or demonstrate weight loss of 1-2 pounds per week over 90 days. The intervention directed staff to monitor eating patterns and record intake, but the resident’s LTC meal intake record for August 2025 did not show intake or refusal documentation for breakfast on 8/9/25, lunch on 8/6/25, 8/9/25, and 8/11/25, or dinner on 8/1/25, 8/8/25, and 8/15/25. During interview, a CNA stated meal intakes are supposed to be documented 3 times a day and that if a meal is refused, an alternative should be offered and refusal documented with notification to the charge nurse. The Clinical Coordinator later confirmed the missing intake documentation findings.
Improper Storage of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the storage of a urinary catheter drainage bag for 2 of 3 days of the survey. R4 had diagnoses including obstructive uropathy and an indwelling urinary catheter. During observations of R4's room on 8/18/25 at 12:04 p.m. and 8/19/25 at 9:38 a.m., R4's urinary catheter drainage bag, with urine in the tubing and bottom of the drainage bag, was observed hanging under the sink. On 8/19/25 at 3:05 p.m., a surveyor and the DON observed R4's drainage bag hanging under the sink, and the surveyor discussed the findings with the DON at that time.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in several areas, as observed during an Environmental Tour. The laundry room had debris in the ceiling lights and an untreated wooden stand under the washing machine's chemicals, creating an uncleanable surface. The large dining room's standing floor fan was heavily soiled with dust and dirt. The bathroom near the nurses' station had a chipped toilet seat and a heavily soiled floor. In the whirlpool room, floor tiles were missing along the wall edge, and a ceiling tile had a large brown stain. In several resident rooms, various issues were noted, including peeling laminate on a bed footboard, soiled floor fans, and broken surface protectors on door jambs. Some resident wheelchairs were soiled or had damaged armrests. Walls in certain rooms were marred, chipped, and gouged, creating uncleanable surfaces. Additionally, baseboard heaters had chipped or missing paint, and some entrance doors were chipped or gouged. These findings were confirmed by the Administrator and the Maintenance Director during the tour.
Medication Storage Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored at appropriate temperatures, as required by their policy and the United States Pharmacopeia (USP) guidelines. During an observation of the medication storage room, a refrigerator containing insulin, influenza vaccinations, and Tuberculin Purified Protein was found. The Registered Nurse (RN) stated that refrigerator temperatures are checked twice daily, but the facility's Medication Refrigerator log showed otherwise. The logs from August 2024 to October 2024 lacked evidence of temperatures being monitored twice daily and showed that temperatures were not maintained within the required range. Specifically, in August 2024, temperature readings were missing for 16 out of 31 days, and temperatures were out of range for 11 days. In September 2024, temperature readings were missing for 17 out of 30 days, and temperatures were out of range for 11 days. In October 2024, temperature readings were missing for 5 out of 15 days, and temperatures were out of range for 2 days. These findings were confirmed with the Director of Nursing, indicating a systemic issue in monitoring and maintaining the appropriate storage conditions for medications and biologicals.
Kitchen Sanitation and Monitoring Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a kitchen tour. The surveyor noted several issues, including a heavily soiled standing floor fan, a food mixer with chipped paint, and dirty ceiling vents and fans. Additionally, the kitchen office had a ceiling light missing its lens and lacked bulb protectors, while some ceiling tiles were stained. The reach-in freezer had an open bag of french fries, and the walk-in cooler door threshold was rusty and broken. These observations were confirmed by the Administrator during an interview. The facility also failed to monitor and document the temperatures of the walk-in freezer and refrigerator, as well as the dishwasher wash and rinse cycle temperatures and chemical sanitizer levels. The review of logs for July, August, September, and October 2024 revealed missing entries for refrigerator/freezer temperatures, sink/bucket sanitizer levels, and daily high-temperature ware wash checklists. These lapses in monitoring and documentation were confirmed by the Food Service Director during an interview.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain garbage storage areas in a sanitary condition, which was observed over three consecutive days. On the first day, a surveyor noted that the large trash dumpster had a missing or open left side slide door and an open top left front door, exposing trash. Additionally, a small dumpster had its front right top open, and there was plastic and paper trash scattered on the ground around the dumpsters. Trash was also stored in an open top cart outside the laundry room exit. The Administrator confirmed these findings during an interview. On the second day, the surveyor observed the left side door missing and the right side door of the large trash dumpster fully open, again exposing trash. Plastic and paper trash were still present on the ground around the dumpster. The Administrator confirmed these observations in a subsequent interview. On the third day, the surveyor found the left side door of the large trash dumpster missing and fully open, with trash exposed. The ground around the dumpster continued to have plastic and paper trash scattered. Trash was also observed in an open top cart outside the laundry room exit. The Administrator confirmed these findings during an interview.
Quality Assurance Failures in Implementing Plan of Correction
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction (POC) for deficiencies identified during the annual Long Term Care Recertification Survey. During a revisit survey, several issues were found to persist, indicating that the corrective measures were not successfully implemented. Specifically, the facility did not maintain adequate housekeeping and maintenance services, as evidenced by the failure to keep the interior sanitary, orderly, and comfortable. Additionally, the facility did not develop and implement baseline care plans within 48 hours for new admissions, which are necessary to provide essential healthcare information. Further deficiencies included the failure to monitor residents after a fall, despite staff education on the Neurological Assessment and Fall Policies. The facility also did not ensure proper storage and temperature monitoring of medications and biologics, as required by pharmacy policies. The kitchen was not maintained in a clean and sanitary manner, and the facility failed to identify residents who were not offered the vaccine. Moreover, the Infection Preventionist did not ensure that residents were educated about, offered, and administered the updated COVID-19 vaccines for 2024-2025.
Failure to Implement Pneumococcal Immunization Policy
Penalty
Summary
The facility failed to implement its pneumococcal immunization policy for three out of five residents whose immunization records were reviewed. The policy required that each resident, or their legal representative, receive educational material about the benefits and potential side effects of the vaccines, with documentation of receipt and understanding. Additionally, the policy mandated that each resident be offered a pneumococcal vaccine upon admission unless contraindicated or previously immunized. However, the clinical records for Residents #18, #19, and #28 lacked evidence that the PCV 20 vaccine was current, offered, or administered as per the facility's policy. The deficiency was confirmed during an interview with the Infection Preventionist and the Director of Nursing. The surveyor found that the facility did not adhere to its own immunization procedures, as the required documentation and vaccine administration were not evident in the residents' records. This oversight indicates a failure to follow established protocols for ensuring residents receive necessary vaccinations, potentially impacting their health and safety.
Failure to Offer Updated COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer updated COVID-19 vaccine doses to five residents, as required by their policy. The policy, revised on 5/7/24, mandates that the facility educate residents and staff on vaccines and offer updated vaccines to all residents. However, during an interview with the Director of Nursing and the Infection Preventionist, it was confirmed that the updated 2023-2024 COVID-19 vaccinations were not offered to the residents reviewed. Resident #7, who was diagnosed with COVID-19 on 9/5/24, had their last documented COVID-19 vaccination on 12/21/23. Resident #15's last documented vaccination was on 12/20/22, and Resident #18, diagnosed with COVID-19 on 9/9/24, had their last vaccination on 10/20/22. Resident #19's last vaccination was on 7/8/22, and Resident #28, also diagnosed with COVID-19 on 9/9/24, had their last vaccination on 9/20/23. In all these cases, the clinical records lacked evidence of offering the updated COVID-19 vaccination, indicating a failure to comply with the facility's vaccination policy.
Failure to Conduct Post-Fall Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to complete post-fall neurological assessments and appropriate fall assessments for three residents who experienced falls. Resident #17, with severe cognitive impairment, had four unwitnessed falls, yet the facility did not continue monitoring for further injuries or neurological changes as required by their policy. The Director of Nursing and Quality Improvement Specialist confirmed the absence of post-fall observation tools and daily nursing notes for three days following each fall. Similarly, Resident #3, with moderate cognitive impairment, experienced an unwitnessed fall, and the facility did not document the incident in the nurse's notes for the subsequent three shifts as per policy. Resident #333, with severe cognitive impairment, also experienced an unwitnessed fall, and the facility failed to monitor for further injuries or neurological changes. Additionally, the facility did not follow physician orders for Resident #18, who was supposed to wear a knee brace on the left knee when out of bed. Despite a physician's order dated 9/24/24, the resident was observed without the knee brace while in a wheelchair. Interviews with a CNA and the resident confirmed that the knee brace was never provided. The Quality Improvement Specialist verified that the facility was not adhering to the physician's order for the knee brace, indicating a failure to provide appropriate treatment and care according to orders.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was newly admitted. The resident, who was admitted on July 12, 2024, had a medical history of an acute ischemic stroke with mild left upper extremity weakness, difficulty swallowing, mixed Alzheimer's and vascular dementia with agitation, and was newly anticoagulated for atrial fibrillation. The resident was prescribed an anticoagulant, antidepressant, beta blocker, and an opioid. As of October 17, 2024, there was no evidence of a baseline care plan that included the necessary instructions to provide safe and effective care for the resident. This information was confirmed with the Director of Nursing on October 17, 2024.
Unlocked Storage of Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that doors were locked where potentially dangerous chemicals were stored, as observed during a survey. On the Long-Term Care unit, the Soiled Utility room was found unlocked, containing cabinets with unlocked padlocks. These cabinets housed various cleaning and disinfectant products, including Eco lab Rapid Multi Surface Disinfectant cleaner, 3M Glass cleaner, Simplex scour power and instant chlorine bleach, WD-40, True Clean Emerald Optically Enhanced floor cleaner, and Apollos Power Clean Industrial Grade cleaner & detergent. The Material Safety Data Sheets for these products indicated that they should be kept out of reach of children and required specific first aid measures in case of exposure. During an interview, two Certified Nursing Assistants confirmed that the key to the Soiled Utility room was kept above the door and that the door should have been locked. They also stated that the padlocks on the cabinets inside the room were supposed to be locked. This oversight was discussed with the Administrator, highlighting a lapse in maintaining a safe environment free from accident hazards, as required by regulations.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff responsible for direct resident care. This deficiency was observed on two out of three survey days. On October 15 and 16, 2024, a surveyor noted that the nurse staffing information posted at the main entrance lacked the required details for Registered Nurses, Licensed Practical Nurses, and unlicensed nursing staff. This issue was confirmed with the Director of Nursing on October 16, 2024, at 9:26 a.m.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 91 citations issued within 25 miles in the last 12 months — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Park Rehab & Living Center | 0.7 mi | ★★★★★ | 18 | 0 |
| Sandy River Center | 3.9 mi | ★★★★★ | 21 | 0 |
| Maplecrest Rehab & Living Center | 16 mi | ★★★★★ | 0 | 0 |
| Pinnacle Health & Rehab Canton | 18.3 mi | ★★★★★ | 34 | 0 |
| Woodlawn Rehabilitation & Nursing Center | 22.1 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.