Below average — CMS composite of the measures below.
The next survey window likely opens 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 Lakewood A Continuing Care Center during CMS and state inspections, most recent first.
Unqualified Food Service Director: The FSD stated she lacked the qualifications for the role and was not enrolled in a qualifying course or Managerial Serve Safe course. The facility’s dietician was only a monthly consultant, and the Administrator confirmed the facility did not have a qualified Food Service Supervisor or a full-time dietician.
Surveyors found that care plans for several residents were incomplete or not updated to reflect current physical needs, including fall risk, mobility limitations, and toileting requirements. The plans lacked specific, person-centered interventions and did not accurately address changes in condition following hospitalizations or surgeries, as confirmed by facility staff.
Two residents were not properly assessed or documented for pneumococcal vaccination status as required by CDC guidelines and facility policy. One resident's consent form was incomplete and lacked evidence of vaccine administration or refusal, while another resident's record showed no documentation of being offered the vaccine.
Housekeeping and maintenance services were not adequately provided to keep the facility sanitary, orderly, and comfortable. Surveyors observed cracked and lifted linoleum in the lobby, dayroom, and unit entrances; missing or damaged privacy curtains; chipped, gouged, or rusted doors and equipment; ripped furniture; dislodged flooring and heating components; and stained ceiling tiles across Skilled, Moonlight Bay, and LTC areas. A maintenance worker and the Administrator confirmed the observations.
Failure to follow orders for PT, diet, and meds. A resident with hemiplegia, spasticity, and contractures had an active PT/OT order for trunk stability, but staff could not confirm the eval occurred. Another resident was observed receiving non-thickened liquids and not being fully supervised despite a diet order for mechanical soft foods, nectar-thick liquids, and full meal supervision. A third resident missed a scheduled cefuroxime dose even though the med was available in the emergency stock, and a fourth resident received midodrine without the ordered BP checks before administration.
Incomplete ADL, Vital Sign, Weight, and Medication Documentation: The facility failed to keep accurate clinical records for two residents and one medication observation. One resident with hemiplegia had a scheduled bath documented as Not Applicable without a nursing note explaining why it was missed, and another resident with HTN and CAD had missing weekly weights, VS, and bath documentation with no explanation in the record. During a med pass observation, a lidocaine patch remained in place past the ordered removal time before a new patch was applied.
Infection control practices were not consistently followed when staff worked with a resident on contact precautions, a resident on EBP with an indwelling urinary catheter, and during meal service. An LPN removed an N95 with bare hands and handled masks before hand hygiene, a CNA handled catheter equipment and transfer devices without proper PPE or cleaning, and another CNA touched her back and nose before assisting a resident’s meal without sanitizing her hands.
The facility failed to adequately screen and document the updated COVID-19 vaccine for 4 of 5 residents reviewed. During a surveyor interview with the IP, the clinical records for four residents lacked evidence that they were offered the updated COVID-19 vaccination or that signed informed consent and/or declination forms were obtained.
The facility failed to maintain an effective CNA education program. Records for three CNAs lacked evidence of required annual in-service training, including dementia care, communication, behavioral health, and ethics, and the staff educator confirmed there was no evidence the training had been provided.
Failure to maintain resident dignity during meal assistance: During a lunch meal observation on the Moonlight Bay unit, two residents at a table were assisted with eating while their two table mates were not served or assisted until later. During the same observation, a CNA was seen standing while assisting two residents with lunch, and the charge nurse stated she was not aware staff could not stand while assisting a resident with meals.
Failure to Provide Transfer and Bed Hold Notices: The facility did not provide written transfer/discharge notices or written bed hold notices, including cost of care, to the legal representatives of two residents who were sent to an acute care hospital. One resident had HF and CKD, and the other had repeated hospital transfers and readmissions. The Nurse Manager and Administrator confirmed the required notices were not given.
A resident with moderate cognitive impairment had a 6.34% weight loss in one month, but the provider note did not show the loss was identified or addressed. An LPN said staff would notify the provider of weight loss and the UM confirmed no SBAR was created, and the record lacked evidence that the resident's significant weight loss was recognized or evaluated.
Incomplete controlled substance shift count documentation was found in two LTC medication tech med carts. Surveyors identified multiple instances where the incoming and outgoing staff members did not sign the Shift Count page, and several entries were missing the date, time, and status of the count. The issue was discussed with the unit manager and DON.
Expired Lido-Nystatin 50/50 was found available for use in the LTC House med storage room during an observation with the LTC Unit Manager. The bottle was labeled for a resident and had a written date and expiration date showing it was past expiration, and the surveyor confirmed the finding before the medication was discarded. The issue was later discussed with the DON.
Kitchen sanitation and food storage deficiencies were identified during a kitchen tour. Surveyors observed a dish machine with food debris and dried residue, a rusty metal shelf, an open box of corn starch, debris on the floor under the stove and shelving, and items in the walk-in refrigerator that were not labeled, dated, sealed, or were past the use-by date. The FSD and a sister facility FSD confirmed the findings.
A resident with a left femur fracture did not receive ordered specialized rehab services. The record showed active orders to continue PT/OT/ST under a new therapy provider, with PT ordered 5 times per week, but therapy documentation was missing, the care plan was not updated, and a ST eval was not completed. The LTC UM said PT was not always available and OT might cover both services, while the TC said therapy orders were often received by word of mouth or SBAR and staffing issues made it difficult to provide the ordered services.
Survey results were not posted in accessible locations for residents, family members, and legal representatives. Surveyors observed no postings on the Skilled Unit, Moonlight Bay secured dementia unit, or LTC Unit, and the only survey notice was in the front lobby, placed high on a bulletin board in a clear plastic cover. The posted survey was outdated and did not reflect more recent State Agency surveys or complaint/FRI investigations. The Administrator confirmed the finding.
A facility failed to post nurse staffing information in a predominant place that was readily accessible and visible to all residents on multiple units. The staffing information was only posted on a bulletin board in the front lobby, while it was not posted on the Skilled Unit, the secured dementia unit, or the LTC Unit; the Administrator confirmed the finding.
The facility failed to complete annual performance evaluations for 3 of 5 CNA-M personnel files reviewed. One CNA and two CNA-M staff had no evidence of a 2025 annual evaluation in their records, and the Administrator could not provide the evaluations or evidence they were reviewed with the staff during the surveyor interview.
Delayed notification after unwitnessed fall with head injury. A resident had an unwitnessed fall in the room and sustained a forehead injury, periorbital bruising, and skin tears. The RN documented the event on a risk management form for the provider to review at the next visit instead of immediately notifying the MD or Third Eye Health agency, and the DON confirmed the notification was not immediate.
Failure to report an unwitnessed fall with head injury: A resident had an unwitnessed fall in the room and sustained injuries to the forehead, periorbital area, lip, and wrist. The facility policy required falls with serious injury to be reported to the state survey agency within 24 hours, but the RN did not notify the Division of Licensing and Certification, and the DON confirmed the report was not made in a timely manner.
The facility failed to maintain a sanitary and comfortable environment across all units, with issues such as exposed sheetrock, chipped paint, and uncleanable surfaces on equipment and wheelchairs. Multiple resident rooms had unpainted walls and ceilings with holes, and common areas had dirty equipment. The Facilities Director confirmed these findings during an environmental tour.
The facility did not follow physician orders for a resident's oxygen therapy, consistently setting the concentrator at 3 liters instead of the prescribed 4 liters. Additionally, PT recommendations for another resident's ambulation were not implemented due to communication issues and staffing constraints.
The facility failed to maintain a sanitary environment for respiratory care, affecting five residents. Observations revealed unlabeled and improperly stored nebulizer masks and nasal cannula tubing, confirmed by the DON. Additionally, an oxygen concentrator had dusty filters, and a nebulizer machine was found with uncovered tubing.
The facility failed to properly store and secure medications across three units. Inappropriate storage in a dorm-style refrigerator led to temperature fluctuations affecting medications, including a vaccination. Temperature records showed a year-long failure to maintain recommended ranges. Additionally, medication and treatment carts were found unlocked and unattended in various units, with residents and staff nearby.
The facility failed to maintain cleanliness in the kitchen, with dusty fans, vents, and lights observed. Additionally, the kitchen and skilled unit ice machines were not plumbed according to code, risking contamination. These deficiencies were confirmed by the Food Service Director.
The facility failed to notify the State Agency of potential neglect concerns and did not investigate an unwitnessed fall with a major injury. A complaint was received about a CNA not providing adequate care, but the DON and Administrator were unaware of the incident reports. Additionally, the facility could not provide evidence of a completed investigation or a 5-day report for a resident's unwitnessed fall with a fracture.
The facility failed to secure a container of Clorox Healthcare Hydrogen Peroxide disinfectant wipes, which was found open with a wipe sticking out in a resident's bathroom. This was observed on two separate days, and the DON confirmed the wipes were not locked away, posing a potential hazard.
The facility failed to provide sufficient staffing, resulting in delayed call bell responses for residents. A resident reported waiting up to an hour for assistance, leading to incontinent episodes. Interviews with CNAs confirmed staffing issues, and the DON acknowledged the problem. The residents involved were cognitively intact, highlighting the impact on their care.
A resident's call bell was found non-functional despite previous reports of it being fixed. The issue was confirmed by a surveyor, RN, and CNA, with a temporary hand bell provided. The call bell briefly worked when the box was wiggled, indicating a potential battery issue.
A resident with a right-hand splint did not receive scheduled whirlpool baths for several weeks, impacting their self-determination and hygiene. The resident, unable to shave due to the injury, reported that staff were too busy to assist. Records lacked documentation of the baths on scheduled dates, and the issue was discussed with the DON.
A resident with dementia, anxiety, depression, PTSD, and agoraphobia was forcibly dressed and transferred by a CNA, leading to physical and emotional distress. Despite being asked to stop by another CNA, the abusive behavior continued, resulting in the resident experiencing pain and yelling for help. The incident was corroborated by witness statements and led to the dismissal of the CNA involved.
A nurse failed to follow infection control procedures during a medication pass, neglecting to perform hand hygiene before and after glove use. Despite receiving education on the facility's hand hygiene policy, the nurse admitted to forgetting to sanitize and expressed difficulty with glove application after using sanitizer. The Director of Nursing confirmed the nurse's training and expectations for compliance.
The facility did not ensure the Medical Director's attendance at three required quarterly Quality Assurance Committee meetings, as confirmed by attendance sheets and an interview with the Administrator.
Unqualified Food Service Director
Penalty
Summary
The facility failed to ensure the Food Service Director met the qualifications of a Certified Food Service Director. During an interview on 12/9/25 at 9:16 a.m., the Food Service Director stated she had been in the role for about ten months, did not have the qualifications for the job, and was not enrolled in any qualifying course or a Managerial Serve Safe course. She also stated that the facility’s dietician worked on a consultant basis and came in monthly. During a later interview on 12/11/25 at 9:30 a.m., the Administrator confirmed that the facility did not have a qualified Food Service Supervisor and used a consultant dietician who was not employed by the facility in a full-time position.
Failure to Develop and Revise Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and revise comprehensive care plans that accurately addressed the physical needs of four sampled residents. For one resident with chronic pain and bilateral hand and knee contractures, the care plan did not specify the current fall risk status and included interventions for conditions not present in the resident's clinical record. The care plan was not updated to reflect the resident's actual diagnoses and needs, as confirmed by the DON and MDS Coordinator during review. Another resident with a recent left femur fracture and an indwelling urinary catheter had a care plan that did not reflect current ADL and toileting needs, despite changes in condition following hospitalizations and surgical interventions. Additional residents with recent fractures and mobility limitations had care plans that lacked person-centered details, such as specific assistance requirements, frequency, and interventions tailored to their post-operative and rehabilitative needs. In each case, the care plans were not revised or completed to address the residents' current physical conditions and care requirements, as confirmed by facility staff during surveyor interviews.
Failure to Offer and Document Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccinations in accordance with CDC recommendations, as required by facility policy. Record review and interviews revealed that two residents were not properly assessed or documented for pneumococcal vaccination status within the required timeframe. For one resident, a consent form for the Prevnar20 vaccine was present in the paper chart and signed, but the form was left blank regarding whether the vaccine was accepted or declined, and there was no evidence in the clinical record that the vaccine was offered, administered, or refused. For another resident, the clinical record lacked any documentation indicating that the pneumococcal vaccine was offered, administered, or refused. These findings were confirmed during an interview with the Infection Preventionist.
Housekeeping and Maintenance Deficiencies
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on the Skilled, Moonlight Bay, and Long-Term Care units, as well as in a common area. During an environmental tour, surveyors observed cracked and lifted linoleum in the main lobby near the desk and outdoor door, at the activity/dayroom threshold, and at entrances leading to the Skilled and Moonlight Bay units, all creating uncleanable surfaces. Additional observations included missing hooks and disrepair on privacy curtains in a Skilled unit resident room, chipped and gouged wood on a dirty utility room door, numerous vinyl planking floor edges coming up throughout Moonlight Bay, and a chair with ripped material in the sitting area. On the Long-Term Care unit, surveyors observed exit doors with chipped paint and rust, chipped or missing paint on patient lifts and a sit-to-stand lift, chipped or missing paint on resident room walls and bathroom walls, a dislodged section of a bathroom floor heating unit, a bookshelf with chipped and gouged areas exposing untreated wood, and a bathroom ceiling tile with brownish stains. A maintenance worker and the Administrator confirmed these findings during interview.
Failure to Follow PT, Diet, and Medication Orders
Penalty
Summary
The facility failed to ensure physician orders were followed for a PT evaluation for a resident with hemiplegia, muscle spasticity, and bilateral hand and knee contractures. The resident’s provider note documented that the resident was seated in a wheelchair leaning to the right, and an SBAR communication form dated 10/29/25 requested an order for the resident to use a seatbelt while in the wheelchair, with a written physician order for a PT/OT evaluation for trunk stability. The electronic record showed an active order starting 10/30/25 for PT/OT evaluation one time a day for trunk stability. During interview, the PTA stated the resident had not received therapy since 10/10/24, and the RN stated that after PT orders are received, the nurse enters the order and places a copy in the therapy folder so PT can evaluate the resident, but he did not know whether the resident had been evaluated as ordered. The facility also failed to follow diet and medication orders for other residents. One resident had an order for mechanical soft foods with nectar/mildly thick liquids, cut meat small with extra gravy/butter, extra soft fruits and vegetables, and full supervision and assistance as needed, but was observed with a breakfast tray that included non-thickened milk and water and without full supervision; the same issue was observed again later with non-thickened water and no supervision. Another resident returned from the hospital with an order for cefuroxime 250 mg twice daily for 7 days for a UTI, but the scheduled dose was not given because the medication had not arrived, even though the emergency medication box contained cefuroxime 250 mg in stock. A third resident had an order to wean midodrine to 2.5 mg twice daily and to monitor blood pressure twice daily before administration, with notification to the provider if systolic BP was above 140, but the MAR showed the medication was given without evidence that blood pressure was monitored as ordered.
Incomplete ADL, Vital Sign, Weight, and Medication Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents reviewed for ADL care and one resident observed for medication administration. For one resident with hemiplegia and a care plan noting lethargy on bath days, the EMR showed a scheduled whirlpool or shower bath on day shift, but the task was documented as Not Applicable by CNA #3 without any nursing progress note or other documentation explaining why the bath was not provided. CNA #3 stated she used Not Applicable when a resident had been bathed on the night shift or when the resident was too lethargic and the nurse documented the reason, but the record lacked evidence that the resident had been bathed the prior night or that a nurse documented why the bath was missed. RN #1 stated that if a resident could not be bathed as scheduled, the reason should be documented in a nursing progress note or on the bath schedule. For another resident with hypertension and coronary artery disease, the clinical record showed an active order for weekly weight and vital signs on whirlpool day, but the record lacked documentation of blood pressure, weekly vital signs, and weekly weights on multiple scheduled dates. The bathing task record also showed several scheduled whirlpool or shower baths documented as Not Applicable, again without nursing progress notes or other documentation explaining why the baths were not completed. During a medication observation for a third resident, a lidocaine patch dated the prior day was still in place when the CNA-Medication Tech applied a new patch, even though the MAR ordered the patch to be removed daily at 8:00 p.m.; the MAR showed another CNA documented removal later that night.
Infection Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a sanitary environment and help prevent the development and transmission of disease and infection. During observation of a room on contact precautions for COVID, the door was left open after housekeeping staff exited, and an LPN entered the room using PPE. When the LPN exited, she removed her N95 mask with bare hands, reached into a container of simple masks with soiled hands, then donned a simple mask and performed hand hygiene afterward. The Infection Preventionist confirmed the door would normally be closed to prevent the spread of infection and observed the hand hygiene lapse at the time of the event. The facility also failed to follow its Enhanced Barrier Precautions policy for a resident with an indwelling urinary catheter and a sit-to-stand transfer. CNA1 handled the resident’s catheter drainage bag without gown or gloves, did not sanitize her hands before adjusting her clothing, and then positioned the sling and transfer equipment so that the leg strap touched the catheter tubing. After transferring the resident, CNA1 moved the lift and sling to the hallway without cleaning them and returned to her med cart. In a separate observation during breakfast service, CNA2 scratched her back and rubbed her nose, then without sanitizing her hands took a resident’s plated meal, delivered it, and began cutting the resident’s food.
Incomplete COVID-19 Vaccine Screening and Documentation
Penalty
Summary
The facility failed to perform adequate screening and documentation for the updated COVID-19 vaccine for 4 of 5 residents reviewed for COVID-19 immunizations. During a surveyor interview with the Infection Preventionist, the clinical records for Resident #7, Resident #8, Resident #71, and Resident #85 were reviewed and found to lack evidence that each resident was offered the updated COVID-19 vaccination or that signed informed consent and/or declination for the updated COVID-19 immunization was obtained. Each of the four residents had been admitted to the facility, but their records did not show documentation of the vaccine offer or the resident's response.
Missing Required CNA Annual Training
Penalty
Summary
The facility failed to implement and maintain an effective CNA training program to ensure required annual in-service education was completed, including dementia care, communication, behavioral health, and ethics. Review of the employee records for CNA4, CNA-M3, and CNA-M4 showed that their education files lacked evidence of annual training in these required areas, including annual dementia training. During an interview with the staff educator RN4, the reviewed education files were discussed and there was no evidence that the trainings had been provided, and the surveyor confirmed this finding.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote residents’ dignity and respect during the lunch meal on the Moonlight Bay unit when two residents seated at a table were being assisted with eating while their two table mates at the same table were not assisted at the same time. At 12:08 p.m., the surveyor observed the two residents nearest the window cutout receiving meal assistance while the two residents seated across from them were not served or assisted until 12:24 p.m.; this observation was confirmed by a corporate consultant during the meal observation. During the same meal observation at 12:13 p.m., a CNA was observed standing while assisting two residents with their lunch meals. The charge nurse stated she was not aware that staff could not stand while assisting a resident with meals, and the surveyor confirmed this finding with the charge nurse at the time of the observation.
Failure to Provide Required Transfer, Discharge, and Bed Hold Notices
Penalty
Summary
The facility failed to issue a written transfer/discharge notice and a written bed hold notice, including the cost of care, to the legal representative for 2 of 3 residents reviewed who were transferred to an acute care hospital. Resident #82 was admitted to the facility in August 2022 with diagnoses including heart failure and chronic kidney disease. The resident was transported to an acute care hospital and subsequently admitted, but the clinical record lacked evidence that the resident representative received a written transfer/discharge notice and a written bed hold notice. Resident #2 was admitted to the facility in February 2025 and was transported to an acute care hospital on more than one occasion, with subsequent hospital admissions and readmission to the facility between those events. Review of the clinical record showed no evidence that the resident's representative received a written transfer/discharge notice or a written bed hold notice for the hospital transfers. During interviews, the Nurse Manager and the Administrator confirmed that the required written notices were not provided to the resident representatives.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure a resident's physician supervised and evaluated significant weight loss for Resident #7. Record review showed the resident's weight decreased from 119.8 pounds on 10/29/25 to 112.2 pounds on 11/28/25, a 6.34% loss in one month. The resident's brief interview for mental status dated 12/5/25 indicated moderate cognitive impairment. A provider progress note dated 12/5/25 documented that the resident denied weight loss, but it did not show that the potentially significant weight loss was identified or addressed. During interviews on 12/9/25, an LPN stated that staff would notify the provider of weight loss, try a nutritional supplement, and monitor weekly weights, and the UM stated staff notify the provider by submitting an SBAR; however, the UM confirmed that no SBAR had been created for the weight loss and the clinical record lacked evidence that the resident's potential significant weight loss was identified or addressed.
Incomplete Controlled Substance Shift Count Documentation
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. During review of the LTC House 5/6 medication tech med cart Controlled Substances Book, surveyors found multiple shift count entries where the incoming staff member did not sign, including counts documented on 4/14/25, 6/22/25, 6/27/25, and 7/15/25. The outgoing staff member also failed to sign on several dates, including 4/14/25, 5/3/25, 5/15/25, 5/23/25, and 7/14/25. In addition, several entries were incomplete and lacked the date, time, and status of the count. A similar issue was identified in the LTC House 7/8 medication tech med cart Controlled Substances Book. The incoming staff member did not sign for a count documented as occurring on 12/3/25 or 12/4/25, and the outgoing staff member failed to sign on 1/18/25, 5/16/25, 7/1/25, and 9/28/25. The record also contained an incomplete entry on 12/4/25 or 12/5/25 that lacked the date, time, and status of the count. These findings were discussed with the LTC House unit manager and the DON.
Expired Medication Left in Med Storage Room
Penalty
Summary
Expired medication was found available for use in the LTC House med storage room, showing that drugs and biologicals were not being kept in accordance with accepted storage and labeling practices. During an observation with the LTC Unit Manager, a bottle of Lido-Nystatin 50/50 (Magic Mouthwash) labeled for R74 was found with a written date of 10/8/24 and an expiration date of 10/8/25, yet it remained in the supply available for use. The surveyor confirmed the finding with the LTC House Unit Manager, who then discarded the expired medication. The issue was later discussed with the DON.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure foods were sealed, labeled, dated, and/or discarded when past the use-by date in the walk-in refrigerator. During a kitchen tour with the Food Service Director and a Food Service Director from a sister facility, surveyors observed the dish machine with large amounts of food debris, dried liquid residue, and dried chemical residue on the top and sides; a rusty metal shelf under the hot water booster; a one-pound box of corn starch open to the air and not sealed; food debris and dirt on the floor under the stove and shelving; a bag of alfredo sauce in the walk-in refrigerator that was not labeled or dated; and four 32-ounce containers of heavy cream available for use with a used-by date of 11/25/25. The Food Service Director and the sister facility Food Service Director confirmed these findings during interview.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services or obtain those services from an outside provider for one resident with a left femur fracture with routine healing. The resident’s record showed physician telephone orders signed on 11/5/25 to continue the current PT/OT/ST plan of care under a new therapy provider, Reliant Rehabilitation, effective 11/1/25, and the order summary also showed PT to see the resident 5 times per week. However, the care plan was not updated to address the resident’s physical needs related to the femur fracture, and the surveyor was unable to find therapy documentation in the record. During interviews, the LTC UM stated she did not have access to therapy notes and believed OT would try to cover both services because PT was not always available. The DON later provided a PT transitional evaluation and plan of treatment showing PT frequency of 5 times per week. The Therapy Coordinator stated therapy orders were received by word of mouth or SBAR, said she heard the resident had an order for speech therapy but did not receive the information herself, and confirmed that a speech therapy evaluation was not completed and that the resident did not receive PT 5 times per week as ordered and as recommended in the PT evaluation.
Survey Results Not Posted in Accessible Areas
Penalty
Summary
The facility failed to post the results of the most recent surveys in a place accessible to all residents, family members, and legal representatives for 4 of 4 survey days. On 12/10/25, between 1:15 p.m. and 1:30 p.m., surveyors observed that no survey results were posted on the Skilled Unit, Moonlight Bay Unit (secured dementia unit), or the Long Term Care Unit. The only survey result posted was pinned to a bulletin board in the front lobby inside a hard, clear plastic cover, approximately six feet or more from the floor. That posted survey was dated from a survey completed in 12/2021, even though the State Agency had completed surveys in 8/2023, 11/2024, and complaint/facility reported incident investigations. The report also noted that not all residents leave the Units to go to the front lobby. At 2:00 p.m., the surveyor confirmed this finding in an interview with the Administrator.
Nurse Staffing Information Not Posted on Multiple Units
Penalty
Summary
The facility failed to post the nurse staffing information in a predominant place that was readily accessible and visible to all residents in 3 of 4 areas of the facility for 4 of 4 survey days. On 12/10/25, between 1:15 p.m. and 1:30 p.m., the nurse staffing information was not posted on the Skilled Unit, Moonlight Bay Unit secured dementia unit, or the Long Term Care Unit. The only nurse staffing information observed was pinned to a bulletin board in the front lobby, and it was noted that not all residents leave the Units to go to the front lobby. At 2:00 p.m. on 12/10/25, the Administrator confirmed this finding in an interview.
Missing Annual Performance Evaluations for CNA-M Staff
Penalty
Summary
The facility failed to complete annual performance evaluations for Certified Nursing Assistants-Medication Aides at least every 12 months for 3 of 5 personnel files reviewed with employment greater than 1 year. CNA#4, hired on 1/17/21, had no evidence of a 2025 annual performance evaluation in the employee record. Two CNA-M staff members, hired on 1/2/83 and 6/17/12, also had no evidence of a 2025 annual performance evaluation in their records. During an interview on 12/11/25 at 10:01 a.m., the Administrator was unable to provide the 2025 evaluations for these staff and stated the evaluations had been prepared but there was no evidence they were reviewed with the staff. The surveyor confirmed the finding at that time.
Delayed Notification After Unwitnessed Fall With Head Injury
Penalty
Summary
The facility failed to timely notify the Medical Provider of an unwitnessed fall with head injury for one resident. On 11/7/25 at approximately 11:00 p.m., the resident had an unwitnessed fall in the room and sustained an injury to the left forehead, a black eye on the right periorbital area, a skin tear to the right upper lip, and a skin tear to the left wrist. The Charge Nurse/Registered Nurse who assessed the resident after the fall documented the event on a Risk Management Form and entered a message for the Medical Provider to review at the provider's next visit, rather than immediately notifying the provider or the Third Eye Health agency. The Medical Provider did not review the message and visit the resident until 11/10/25. During interviews, the RN confirmed he did not immediately notify the Medical Provider or Third Eye Health agency, and the DON confirmed that the Medical Provider and/or Third Eye were not notified immediately of the unwitnessed fall with head injury.
Failure to Report Unwitnessed Fall With Head Injury
Penalty
Summary
The facility failed to notify the State Agency (Division of Licensing and Certification) of an unwitnessed fall with head injury for 1 of 3 residents reviewed who sustained injuries from a fall. The resident had an unwitnessed fall in the room and sustained an injury to the left forehead, a black eye on the right periorbital area, a skin tear to the right upper lip, and a skin tear to the left wrist. The facility policy stated that falls with serious injury must be reported to the state survey agency within 24 hours, but the RN confirmed he did not notify the Division of Licensing and Certification of the fall with head injury, and the DON confirmed the agency was not notified in a timely manner.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment across all units, including the Skilled Unit, Long-Term Care Unit, and Memory Care Unit. During an environmental tour, surveyors observed several deficiencies, such as a ceiling in the activity room with exposed sheetrock and floor seams held down with black tape. In the skilled unit common area, sit-to-stand lifts were found with dirt and debris in the foot base areas, and one lift had ripped non-skid tape and chipped paint, creating uncleanable surfaces. Multiple resident rooms had unpainted ceilings and walls with holes, dusty bathroom ceiling vents, and dirty bathroom floors. Additionally, a hallway ceiling tile had a brown stain, and several rooms had large unpainted areas and chipped paint. In the Memory Care Unit, a resident's wheelchair had ripped armrests, and hallway walls had chipped paint and exposed metal corners. A sit-to-stand lift and baseboard heater register also had chipped paint. The Personal Care Room had cabinets with chipped laminate and missing pieces, and a linen warmer was improperly used to store a doll and blanket. In the Long-Term Care Unit, residents' wheelchairs had ripped armrests, creating uncleanable surfaces, and an electric wheelchair had tape on the armrest. The Facilities Director confirmed these findings during an interview with the surveyors.
Failure to Follow Physician Orders and PT Recommendations
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy for Resident #3. The resident had a physician order for continuous oxygen therapy at 4 liters per minute via nasal cannula, documented since August 26, 2024. However, observations by surveyors on multiple occasions from November 12 to November 14, 2024, revealed that the oxygen concentrator was consistently set at 3 liters instead of the prescribed 4 liters. The Director of Nursing confirmed that staff were not following the physician's orders, and an LPN admitted to setting the concentrator at 3 liters, stating that the resident did not need 4 liters, despite the physician's directive. Additionally, the facility did not implement the recommendations provided by Physical Therapy for Resident #87's restorative care. The PT note from October 8, 2024, outlined a Functional Maintenance Program for ambulation, which included specific instructions for the resident to be out of bed for meals and to receive consistent verbal cues during walks. However, the resident reported that staff frequently cited insufficient staffing as a reason for not assisting with walks. The Administrator acknowledged a lack of communication, resulting in the failure to follow up on the PT recommendations.
Failure to Maintain Sanitary Respiratory Care Environment
Penalty
Summary
The facility failed to maintain a sanitary environment for respiratory care, affecting five residents. Observations revealed that a resident's nebulizer mask was unlabeled and stored on their bedside table, while another resident's nasal cannula tubing was similarly unlabeled and stored on their bedside table. Additionally, a resident's nasal cannula tubing was found unlabeled and stored on a wheelchair in the hallway. The Director of Nursing confirmed these findings. Furthermore, an oxygen concentrator in a resident's bathroom had tubing taped to the floor and filters heavily built up with dust. Another resident's nebulizer machine was found with a mask and oxygen tubing resting uncovered on a chest of drawers, which was also confirmed by the Director of Nursing.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly store medications and biologicals across three units, as observed by surveyors. In the long-term care unit, a dorm-style refrigerator with a freezer compartment was used inappropriately for medication storage, leading to significant temperature fluctuations. The refrigerator showed a 10-degree Fahrenheit difference in temperatures, with ice buildup and pooled water affecting medications, including a Spice Vax vaccination. The temperature records for this refrigerator indicated a year-long failure to maintain the recommended range of 36-46 degrees Fahrenheit, with no follow-up actions taken. Similarly, in the Skilled Nursing unit, influenza vaccinations were stored without documented temperature checks for the past year, confirmed by the Unit Manager. Additionally, the facility failed to secure medication and treatment carts. An unlocked and unattended medication cart was observed in the Skilled Unit hallway for approximately five minutes, with residents and staff nearby. This was brought to the attention of an LPN by a surveyor. Similarly, two treatment carts containing insulin and ointments were found unlocked and unattended in the Long Term Care Unit hallway, with residents nearby. This was confirmed with an LPN. Another incident involved an unlocked and unattended medication cart in the Memory Care Unit nurses station, observed for about three minutes with residents and a Hospice CNA nearby. This was confirmed with a Certified Medication Technician.
Sanitation and Plumbing Deficiencies in Kitchen and Ice Machines
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey conducted by a surveyor and the Food Service Director (FSD). The surveyor noted that the dish room contained two wall-mounted fans that were dusty and dirty. Additionally, there were two ceiling vents over food preparation areas that were also dusty and dirty. Furthermore, five ceiling lights in the kitchen were heavily soiled with dust and debris. These observations indicate a lack of adherence to professional standards for cleanliness in food preparation areas. Moreover, the facility did not ensure that the kitchen ice machine and the skilled unit ice machine were plumbed in accordance with code requirements, specifically regarding the air-gap separation needed to prevent food contamination. The direct connection of wastewater and potable water was in violation of the State of Maine Rules Chapter 226 and the Code of Federal Regulation, Title 21, Part 1250, Section 1250, 30 (d). This deficiency was confirmed by the FSD during an interview, highlighting a significant oversight in maintaining sanitary conditions and preventing potential contamination in the facility's water supply and food handling processes.
Failure to Report and Investigate Incidents
Penalty
Summary
The facility failed to notify the State Agency after identifying potential neglect concerns and did not investigate an unwitnessed fall resulting in a major injury. In the first incident, a complaint was received by the Division of Licensing and Certification alleging that a CNA did not provide adequate care during a night shift, resulting in residents being soaked with urine. An email from the facility confirmed the complaint, but the Director of Nursing (DON) was unaware of the incident reports due to her recent start at the facility. The Administrator was also not informed of the complaint and confirmed that the State Agency was not notified of the concerns. In the second incident, the facility reported an unwitnessed fall with a fracture involving a resident to the State Agency. However, the facility could not provide evidence of a completed investigation or a 5-day report sent to the State Agency. The DON confirmed the absence of the investigation and report during an interview. These failures were identified during an annual survey, highlighting deficiencies in the facility's reporting and investigation processes.
Improper Storage of Disinfectant Wipes
Penalty
Summary
The facility failed to ensure that the resident's environment was free of accident hazards due to improper storage of chemicals. During the survey, it was observed that a container of Clorox Healthcare Hydrogen Peroxide disinfectant wipes was left open with a wipe sticking out in the bathroom of a resident's room. This occurred on two separate days of the survey. The Director of Nursing confirmed that the wipes were not secured in a locked cabinet, making them accessible and posing a potential hazard.
Staffing Deficiency Leads to Delayed Call Bell Responses
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents on the Long Term Care Unit. This deficiency was identified through interviews and record reviews, revealing that residents experienced significant delays in response times to their call bells. Resident #4 reported waiting between 30 minutes to 1 hour for staff to respond, with records showing waits of 25 minutes to 1 hour and 18 minutes on multiple occasions. Resident #45 also experienced delays, leading to incontinent episodes, with waits ranging from 27 minutes to 1 hour and 26 minutes. Resident #87 reported similar issues, with waits of 25 minutes to 1 hour and 18 minutes. Interviews with Certified Nursing Assistants (CNAs) confirmed the staffing issues, with CNA #1 and CNA #2 acknowledging difficulties in responding to call bells promptly due to limited staff. The Director of Nursing confirmed the information provided by the CNAs. The residents involved were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores, which further emphasizes the impact of the staffing deficiency on their care and daily living activities.
Non-Functional Call Bell for Resident
Penalty
Summary
The facility failed to ensure that a call bell was functional for one of the sampled residents. During an interview, the resident reported that their call bell had not been working despite being told it was fixed. When the surveyor tested the call bell, the light above the door did not illuminate, and the call bell screen at the nurse's station did not show an active call. A Certified Nurses Aid confirmed the call bell was not working. The Minimum Data Set project manager provided a hand bell for the resident to use temporarily. RN #3 attempted to fix the call bell, which briefly illuminated when the call bell box was wiggled, suggesting a possible battery issue. The resident mentioned that the call bell had been reported as fixed recently.
Failure to Provide Scheduled Whirlpool Baths
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not adhering to the resident's preferred bathing schedule. Resident #37, who had a splint on his/her right hand, expressed that he/she had not received the scheduled whirlpool baths on Tuesdays for several weeks. The resident, who was unable to shave him/herself due to the injury, also reported that staff were too busy to assist with shaving. Observations confirmed that the resident was unshaven and had not received the whirlpool bath as scheduled. Further review of the resident's Activities of Daily Living records revealed a lack of documentation for whirlpool baths on the scheduled dates, as well as missing records of bathing on several occasions. The issue was discussed with the Director of Nursing, and it was noted that the resident did not receive the whirlpool bath on the day of the survey but was scheduled to have one the following day.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and emotional abuse by staff when a Certified Nursing Assistant (CNA) forcibly dressed and transferred a resident. The incident involved a resident with a medical history of dementia, anxiety, depression, PTSD, and agoraphobia, who requires a gentle and patient approach due to their condition. On the day of the incident, the resident was subjected to forceful handling by CNA #1, who dressed the resident with an abrasive attitude and forced them into a sit/stand position without proper securement, causing the resident to yell for help. Witnesses, including another CNA and an RN, reported that CNA #1 continued to manhandle the resident despite being asked to stop. The resident expressed pain in their back following the incident, which was noted to be reddened. CNA #1 admitted to forcing the resident's arm into a shirt and acknowledged that it was a mistake. The facility's internal investigation and witness statements corroborated the occurrence of abuse, leading to the dismissal of CNA #1.
Infection Control Deficiency During Medication Pass
Penalty
Summary
The facility failed to adhere to its infection control procedures during a medication pass observation on the Memory Lane unit. Registered Nurse (RN) #2 was observed checking a resident's blood sugar with gloved hands and then exiting the room without performing hand hygiene. RN #2 removed her gloves and, without using hand sanitizer, handled a pen and a set of keys, and accessed the medication cart. She then donned a new pair of gloves without sanitizing her hands, prepared insulin, and administered it to the resident. After discarding the gloves, RN #2 again failed to perform hand hygiene before donning another pair of gloves to attend to another resident. During an interview, the Director of Nursing confirmed that RN #2 had received education on the facility's hand hygiene policy, which requires sanitizing hands before and after glove use. Despite this, RN #2 admitted to forgetting to sanitize and expressed difficulty in donning gloves after using sanitizer due to stickiness. The surveyor intervened to ensure compliance with the hand hygiene policy, highlighting the deficiency in infection control practices.
Medical Director's Absence from QA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director attended the required quarterly Quality Assurance Committee meetings. A review of the attendance sheets for these meetings revealed that the Medical Director was absent from all three meetings held on January 17, April 17, and July 24, 2024. This deficiency was confirmed during an interview with the Administrator on November 14, 2024.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 87 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Grove Center | 1 mi | ★★★★★ | 1 | 0 |
| Waterville Center For Health And Rehab | 2.7 mi | ★★★★★ | 22 | 0 |
| Maine Veterans Home - Augusta | 13.5 mi | ★★★★★ | 12 | 0 |
| Woodlawn Rehabilitation & Nursing Center | 15.3 mi | ★★★★★ | 6 | 0 |
| Cedar Ridge Center | 16.7 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.