Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 The Villa At The Park during CMS and state inspections, most recent first.
A CNA struck a resident with impaired cognition during an altercation, resulting in a visible bruise. The CNA admitted to not following abuse prevention training when responding to the resident's aggressive behavior. The DON confirmed awareness of the incident, which was reported as staff-to-resident abuse.
Failure to Assess Self-Administration of Medications: A resident with COPD and OSA, who had intact cognition and needed staff help with bed mobility and transfers, was observed with two Albuterol inhalers and eye drops at the bedside. The resident said they used the inhalers as prescribed and that the inhalers had been brought back from the hospital. An LPN later found the inhalers were empty and discarded them, while the DON stated bedside medications required a physician order and education form; the facility policy required an IDT assessment and documentation for respiratory inhalant self-administration.
Inaccurate advance directive documentation was found for a resident with ESRD, DM, and muscle weakness who was cognitively intact and needed extensive ADL assistance. The chart listed the resident as DNR, but there was no supporting DNR order, and the only code status form on file was signed by a former guardian whose guardianship had already ended, along with a former SW; the witness lines were blank. The resident also stated no one had ever spoken with them about an advance directive.
PASARR follow-up was not completed for a resident with epilepsy, depressive disorder, dementia, and focal traumatic brain injury. The Level I screening had multiple “Yes” responses requiring either an exemption certification on form DCH-3878 or a Level II OBRA evaluation, but the 3877 was incomplete and no 3878 or Level II referral was found. The SS Director stated it was unknown whether the 3878 had been completed.
The facility failed to develop complete care plans for two residents. One resident with dementia, anxiety, and adult failure to thrive was cognitively impaired, needed extensive ADL assistance, and was under DOC parole supervision, but the care plan did not address parole status. Another resident with bipolar disorder, PTSD, schizoaffective disorder, and impaired cognition had a care plan that only addressed sleep, with no additional interventions for behavioral needs; the NHA acknowledged social work services were an area needing improvement.
A resident with epilepsy, depressive disorder, dementia, and focal TBI had repeated behavioral incidents, including verbal aggression, refusal of care, intentional self-harm behavior, yelling, cursing, and a resident-to-resident incident. Although psychiatry orders were written to evaluate and treat mood/behavior concerns, the record showed no psychology or behavioral service follow-up notes, and the SSD confirmed none were available.
Failure to Document and Address Pharmacist MRR Irregularities: The facility did not document review of pharmacist-identified irregularities or the action taken, or not taken, for two residents reviewed for MRRs. One resident had paranoid schizophrenia and neuroleptic induced parkinsonism, and the full MRR report was not provided to surveyors despite repeated requests. Another resident with dementia and other diagnoses had MRR recommendations for periodic valproic acid levels, but there was no prescriber response or lab results documented in the record.
Failure to Maintain Resident Dignity and Respect: The AD was reported by multiple residents and a CNA to be rude, disrespectful, and profane, and to withhold cigarettes or activities as punishment. During a resident meeting, several residents said the AD talked to them meanly and inappropriately, and that activities were not age-appropriate. A confidential resident also reported the AD talked to residents "crazy" and shared other residents’ business, while the DON said they were not aware of the concerns.
Insufficient resident room square footage was identified when an environmental tour found 21 of 36 rooms did not meet the 80 sq ft per bed requirement. Multiple 2-bed, 3-bed, and 4-bed ward rooms were observed with documented sizes below the minimum, and a resident in a shared room stated the space was "too tight" and that the fourth bed remained in the room even when not occupied. The ADM and RDO discussed a proposed bed reduction plan, and a Resident's Rights policy requested by surveyors was not provided before exit.
The facility failed to control a cockroach infestation affecting all residents. Observations showed multiple rooms with cockroaches, and staff confirmed awareness of the issue. Structural issues and residents' personal food contributed to the problem. Despite increased pest control visits, the infestation persisted, indicating inadequate pest control measures.
The facility failed to prevent and document abuse incidents involving two residents, resulting in a broken leg and verbal abuse. One resident was pulled from their wheelchair by another resident with a history of aggression, while another resident reported being choked by an LPN. The facility did not complete required incident reports or investigations, highlighting deficiencies in abuse prevention and reporting procedures.
A resident with hypertension was improperly monitored, leading to the administration of blood pressure medications without appropriate assessment. Carvedilol and Spironolactone were given without documented blood pressure readings, and the physician was not notified of low blood pressure. The resident was transferred to the hospital and passed away shortly after. Interviews with staff revealed inconsistencies in following medication protocols.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 104 residents. Surveyors observed soiled door gaskets and light lens covers in the food service area, violating the 2017 FDA Model Food Code. Additionally, the door gaskets of a cooler were worn and torn, further breaching code requirements. The facility's policy mandates that all equipment be clean, sanitary, and in proper working order.
The facility failed to maintain its outdoor waste and recycling receptacles, affecting 104 residents. Observations revealed missing lids, bent metal rods, and a heavily soiled cement pad. The waste grease container was rancid, and the facility did not adhere to its policy on garbage disposal, which requires maintaining a clean area and providing appropriate lids.
The facility failed to maintain a clean and safe environment, with surveyors observing numerous issues such as heavily soiled air conditioning units, disorganized storage rooms, and pest infestations. Maintenance issues like non-functional ventilation systems and leaking faucets were also noted. The facility's maintenance system, TELS, lacked entries addressing these concerns, indicating poor communication and follow-up.
The facility failed to manage pest control effectively, impacting 104 residents. Observations included a broken door sweep allowing pest entry, cockroaches in various locations, and a housefly in the Administrator's Office. The pest control contract lacked specific treatments for targeted pests, and glue boards with dead cockroaches were found in resident rooms. A resident confirmed seeing cockroaches in their room.
The facility failed to date and store oxygen tubing properly for a resident with respiratory conditions, and staff members did not perform proper hand hygiene. Oxygen tubing was found undated and improperly stored, while hand sanitizer dispensers were empty, and staff did not wash hands after handling soiled items or before resident care. The ADON confirmed expectations for tubing storage and hand hygiene but provided incomplete education materials.
A resident with Parkinson's Disease and Dementia, standing six feet, four inches tall, was not provided with an appropriately sized bed, resulting in discomfort as their feet rested on the footboard. The resident expressed a preference for a bed that accommodated their height, but the facility failed to address this need. Observations showed the resident was unable to adjust themselves in the bed due to manual adjustments lacking a remote control. The facility's policy emphasized individualized care, which was not met.
The facility failed to investigate two incidents of alleged abuse involving residents and staff. In one case, a resident was injured after being pulled from their wheelchair by another resident, but no investigation was conducted. In another case, a resident alleged choking by a staff member, but the incident was not documented or reported. The facility did not follow its policy for investigating and reporting abuse, leading to significant deficiencies.
A facility failed to create a care plan for a resident with dementia who exhibited aggressive behaviors towards staff and other residents. Despite multiple documented incidents of aggression, the resident's care plan lacked interventions to address these behaviors, leading to safety concerns. The ADON confirmed the absence of a care plan for managing the resident's aggression.
A resident with cognitive impairment and a history of bacterial meningitis and aphasia did not receive consistent oral care, as observed over several days. Despite needing assistance, the resident's mouth remained dry and their teeth coated with residue. Interviews with staff confirmed the resident's dependency on assistance for oral hygiene, yet care was inconsistent, and the facility failed to provide a policy on ADL care.
A resident with a wound on their toe did not receive proper wound care as prescribed. Observations showed the bandage was not changed over several days, and staff interviews revealed a lack of adherence to treatment orders. The whirlpool tub needed for treatment was unusable, and the facility's wound care policy was not provided.
The facility failed to document or offer influenza and pneumonia vaccinations for two residents. One resident, with intact cognition, had no vaccine consents or records of being offered vaccines. Another resident's record showed a guardian-signed consent, but the resident refused the vaccines, and there was no documentation that the guardian was informed of this refusal.
The facility failed to offer and document the COVID-19 vaccine for a resident. During a review, it was found that the resident's medical record lacked vaccine consents and documentation of the vaccine being offered or administered. The resident had intact cognition, suggesting they could make informed decisions about vaccination. The ADON could not explain the oversight, indicating a lapse in the facility's vaccination protocol.
The facility failed to provide the required 80 square feet of living space per bed in multiple resident rooms, with 21 out of 36 rooms not meeting the standard. Despite this, residents interviewed stated they were not affected by the room sizes. The facility's policy emphasizes a safe and comfortable environment, which is contradicted by the observed room sizes.
Failure to Prevent Staff-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically struck a resident during an incident. The resident, who had diagnoses including Paranoid Schizophrenia, Encephalopathy, Anxiety Disorder, and Depressive Disorder, and was assessed as having impaired cognition, was observed with a purplish bruise under their left eye. The CNA reported that while working the midnight shift, the resident came out of their room swinging and punching, and in response, the CNA hit the resident in the face as a reflexive action. The CNA acknowledged having received training on abuse prevention and managing aggressive resident behaviors but admitted to not implementing this training during the incident. The Director of Nursing confirmed awareness of the incident and stated the expectation that residents are to be free from abuse and neglect by staff. The facility's policy prohibits all forms of abuse and mandates protection of residents from harm. The incident was reported to the state agency as an allegation of staff-to-resident abuse, and the deficiency was identified based on observation, interviews, and record review.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess one resident for self-administration of medications. The resident was admitted on 9/5/2025 with diagnoses of Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea, and the MDS showed a Brief Interview for Mental Status score of 13/15, indicating intact cognition. The resident also required staff assistance with bed mobility and transfers. On 9/15/2025, the resident was observed in their room sitting in a wheelchair and eating breakfast, with two Albuterol Sulfate inhalers and eye drops at the bedside. The resident stated they used the inhalers as prescribed. During a medication observation on 9/17/2025, an LPN was asked about the inhalers at the bedside, retrieved them, and asked the resident where they came from. The resident stated the inhalers were given to them at the hospital and brought back when they returned on 9/5/2025. The LPN stated the inhalers were empty and discarded them at the cart. The DON stated that to have medications at bedside, the facility needed a physician's order and an education form depending on the medication and the person. The facility policy stated that if a resident requests self-administration of respiratory inhalants only, the Self-Administration Evaluation of Respiratory Inhalants form is to be completed, and that the IDT determination of ability to self-administer medication is to be documented in the medical record and care plan.
Inaccurate Advance Directive Documentation
Penalty
Summary
The facility failed to formulate an accurate advance directive for one resident who was initially admitted on 7/10/20 and later readmitted with diagnoses of End Stage Renal Disease, Diabetes, and Muscle Weakness. The resident was cognitively intact and required extensive assistance with activities of daily living. The medical record face sheet listed the resident’s code status as Do Not Resuscitate (DNR), but the record did not contain additional documentation or orders supporting that status. The record included a Code Status Elective Form dated 3/25/25 indicating DNR was selected, but the form was signed by the resident’s previous guardian even though that guardianship had been terminated on 2/10/23. The form was also signed by the facility’s previous social worker, the two witness lines were blank, and the form stated that residents in the state should proceed to a DNR order form. When interviewed, the resident stated that no one had ever spoken with them about an advance directive. The facility’s Advance Directive and Care Planning policy required staff to provide the resident and/or resident representative with written information about advance directives and to identify the primary decision-maker, including providing information to the resident representative if the resident was incapacitated at admission.
PASARR Follow-Up Not Completed
Penalty
Summary
The facility failed to provide follow-up to the PASARR (preadmission screening/annual resident review) for one sampled resident, R42, who was admitted with diagnoses of epilepsy, depressive disorder, dementia, and focal traumatic brain injury. The clinical record showed the resident was cognitively intact. Review of the PASARR Level I Screening form showed “Yes” was checked in section two for questions one through four, and the form stated that a comprehensive Level II OBRA evaluation was required if any of those items were marked “Yes” unless a physician, nurse practitioner, or physician’s assistant certified an exemption on form DCH-3878. The record showed the 3877 was incomplete, and there was no 3878 or referral for a Level II evaluation. When questioned, the Social Service Director stated that the previous Social Worker completed the 3877, but it was unknown about the 3878. The facility’s PASARR policy was requested but not received by the end of the survey.
Incomplete Care Plans for Resident Status and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive care plan interventions that reflected the current status of two residents reviewed for care plans. One resident was admitted with diagnoses including Dementia, Anxiety, and Adult Failure to Thrive, was cognitively impaired, required extensive assistance with activities of daily living, and had a parole order showing supervision by the department of corrections until 8/21/26; however, the care plan did not address the resident’s status as a parolee. Another resident was admitted with diagnoses including Bi-Polar Disorder, PTSD, Schizoaffective Disorder, and Acute Cystitis with Hematuria, and was noted to have significantly impaired cognition and to require assistance with activities of daily living. The care plan identified a mood problem related to the psychiatric diagnoses and included only one intervention related to sleep, with no additional interventions documented for the resident’s behavioral needs. On 9/17/25, the NHA acknowledged that social work services had been identified in QA as an area needing improvement, and the facility did not provide the requested care plan policy by the end of the survey.
Failure to Provide Behavioral Services for Resident With Recurrent Behavioral Incidents
Penalty
Summary
The facility failed to ensure behavioral services were provided for one resident who had diagnoses including epilepsy, depressive disorder, dementia, and focal traumatic brain injury, and who was documented as cognitively intact. The resident had physician orders for psychiatry to evaluate and treat, including an order on 11/20/24 and another on 6/29/25 for psychiatry consult to re-evaluate and treat bipolar/mood disorder and complete a competency evaluation. The clinical record documented multiple behavioral incidents over time, including verbal aggression toward staff, confusion, refusal to stay in bed, intentionally throwing themself on the floor, refusal of ADL care and bed placement, name-calling toward staff, yelling and cursing at staff, and a resident-to-resident incident. Despite these behaviors and the psychiatry orders, the record did not show any follow-up notes or consultations from psychology or behavioral services. When asked, the SSD stated there were no psychology or behavioral notes available, and the SSD and DON acknowledged that behavioral services and physician orders should have been followed.
Failure to Document and Address Pharmacist MRR Irregularities
Penalty
Summary
The facility failed to review the pharmacist’s identified irregularities and failed to document the action taken, or not taken, to address those irregularities for two residents reviewed for medication regimen reviews. For one resident with diagnoses of paranoid schizophrenia and neuroleptic induced parkinsonism, the record showed a pharmacist MRR completed on 4/16/25 with a note to see the report for comment, but the full MRR report was not provided to surveyors despite multiple requests. The resident also had impaired cognition and required staff assistance with bed mobility and transfers. For another resident with diagnoses including dementia, anxiety, and adult failure to thrive, the record showed MRRs completed on 3/14/25 and 4/16/25 recommending a valproic acid level every 6 months due to valproic acid therapy. Neither recommendation showed a response from the prescriber, and the medical record did not reveal valproic acid lab results. The resident had an order for valproic acid oral solution for mood disorder that was later discontinued. The DON stated they would look into the pharmacy recommendations not being addressed, and the facility’s policy required irregularities to be documented and sent to the attending physician, medical director, and DON, with the physician documenting review and any action taken or rationale for no change.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure two confidential residents were treated with dignity and respect. The complaint intake stated that the Activity Director (AD) was rude, mean, disrespectful, and used profanity toward residents, and that when residents asked for anything, the AD would get mad and cut off the television as punishment. During an observed resident meeting on the second floor, nine residents voiced dissatisfaction with the AD, stating that the AD did not know what they were doing, talked to them meanly and inappropriately, and that the activities were not appropriate for their age and needed to be better and more fun. Additional interviews and observations showed continued resident concern about the AD’s interactions. A resident who wished to remain confidential stated they did not like the AD’s attitude and said the AD talked to residents "crazy" when they went out to smoke and had discussed other residents’ business with other residents. A CNA who wished to remain confidential stated they had witnessed the AD withhold cigarettes or not provide activities on both floors and speak rudely to residents. When interviewed, the AD stated they were new to the position and that the building and some residents were challenging, and the residents were used to the prior director and were adjusting to changes. The DON stated they were not aware of any pertinent concerns, while the Regional Director stated that changes were coming.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to provide 80 square feet of living space per bed in 21 of 36 resident rooms. During an environmental tour on 09/17/2025 at 1:45 PM, the surveyor observed multiple rooms that did not meet the minimum square footage requirement, including several three-bed, two-bed, and four-bed ward rooms. The listed rooms included 102, 103, 104, 105, 106, 107, 108, 112, 115, 119, 201, 202, 203, 204, 207, 209, 211, 212, 214, 218, and 219, with room sizes documented as ranging from 149 to 294 square feet. At 2:00 PM, R32 was interviewed in a room shared with three other residents and stated the room was "too tight" and that they had raised the concern before without any change. R32 also reported that the room sometimes had only three residents, but the fourth bed remained in the room whether occupied or not, leaving the space essentially the same. At 2:13 PM, the Administrator and Regional Director of Operations were interviewed about any plan to address rooms requiring waivers; the RDO stated the governing company had requested a proposal for reduction of beds and that the facility planned to submit it. The RDO also stated residents were surveyed intermittently about comfort with room arrangements. A Resident's Rights policy/procedure requested at 2:16 PM was not received before survey exit.
Cockroach Infestation Due to Inadequate Pest Control
Penalty
Summary
The facility failed to provide adequate pest control, resulting in a cockroach infestation that had the potential to affect all 102 residents. Observations revealed multiple rooms with adult cockroaches and nymphs in pest glue traps. Staff interviews confirmed awareness of the issue, with LPN B acknowledging the concern and Housekeeping Staff C noting the presence of dead cockroaches during cleaning. An anonymous resident reported seeing five bugs in their room within a week. The Nursing Home Administrator (NHA), Director of Nursing (DON), and Maintenance Director acknowledged the infestation, noting increased pest control visits in response. Further investigation revealed structural issues, such as a crack in the South door, which could facilitate pest entry. The Maintenance Director attributed the infestation to residents' personal food and hoarding behaviors. A review of pest control invoices indicated extensive cockroach activity in at least 18 resident rooms, primarily on the second floor. Despite ongoing pest control efforts, residents continued to report sightings of cockroaches, expressing concerns about their clothing. The facility's pest control contract outlined bi-monthly services, but the infestation persisted, indicating a failure in the pest control measures.
Failure to Prevent and Document Abuse Incidents
Penalty
Summary
The facility failed to prevent abuse involving two residents, R24 and R40, resulting in physical harm and verbal abuse. Resident R24 was reportedly pulled out of their wheelchair by another resident, R38, leading to a broken leg. Despite R38's history of aggressive behavior, including verbal and physical aggression towards staff and other residents, there was no care plan in place to address these behaviors. The incident was not properly documented, as the incident and accident report was incomplete and unsigned, and the facility's policy regarding incident documentation was not provided. Resident R40 reported being choked by LPN C, with CNA E corroborating the claim by noting redness on R40's neck and taking a photograph. Despite the serious nature of the allegation, there was no record of an incident report or investigation in R40's medical record. The facility's policy requires immediate reporting and investigation of abuse allegations, but this was not adhered to in R40's case. The ADON was unable to locate documentation of the incident or any investigation, indicating a failure in the facility's abuse prevention and reporting procedures. The facility's leadership, including the Nursing Home Administrator and Assistant Director of Nursing, failed to ensure that incidents of abuse were properly documented and investigated. The lack of a completed incident report for R24 and the absence of documentation for R40's allegations highlight significant deficiencies in the facility's handling of abuse cases. These failures are contrary to the facility's stated policy of preventing abuse and ensuring the safety and well-being of its residents.
Failure to Monitor and Administer Blood Pressure Medications Appropriately
Penalty
Summary
The facility failed to properly monitor and assess the blood pressure of a resident diagnosed with hypertension, leading to the inappropriate administration of blood pressure medications. The resident, identified as R104, was admitted with a diagnosis of Hidradenitis suppurativa and hypertension. The facility's records showed that Carvedilol, a medication to lower blood pressure, was administered without prior blood pressure documentation. Additionally, Spironolactone was given without a recorded blood pressure, and there was no evidence that the physician was contacted regarding the resident's low blood pressure. The resident's medical record lacked progress notes indicating physician notification, and the Medication Administration Record (MAR) did not include hold parameters for the blood pressure medications. Interviews with the Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) revealed inconsistencies in following protocols for administering blood pressure medications, particularly when blood pressure readings were low. The resident was eventually transferred to the hospital due to a change in condition and subsequently passed away within 24 hours of the transfer. The facility did not provide a medication administration policy by the end of the survey.
Deficiency in Food Service Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 104 residents. During an initial tour of the food service area, surveyors observed that the door gaskets and upper door ledge of a 2-door reach-in cooler were soiled with accumulated and encrusted food residue. Additionally, all 12 overhead plastic light lens covers were found to be soiled with accumulated dust, dirt, and food residue. These observations indicate a failure to adhere to the 2017 FDA Model Food Code, which requires that equipment food-contact surfaces and utensils be clean to sight and touch, and that non-food-contact surfaces of equipment be kept free of an accumulation of dust, dirt, food residue, and other debris. Furthermore, the door gaskets of the 2-door reach-in cooler were observed to be worn and torn, with damaged gasket surfaces measuring approximately 12 inches and 8 inches long, respectively. This condition violates the 2017 FDA Model Food Code, which mandates that equipment be maintained in a state of repair and condition that meets specified requirements, including keeping equipment components such as doors and seals intact and tight. The facility's policy on kitchen equipment, dated 9-1-21, also requires that all food service equipment be clean, sanitary, and in proper working order, and that equipment be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.
Improper Disposal and Maintenance of Waste Receptacles
Penalty
Summary
The facility failed to properly clean and maintain its outdoor waste and cardboard recycling receptacles, affecting 104 residents. During an environmental tour, it was observed that the cardboard waste receptacle was missing one of its two plastic lids, and the metal mounting rod was bent and convoluted. Additionally, the drain plug was missing from the cardboard waste receptacle port. The solid waste receptacle had offset plastic lids, and its metal mounting rod and rear metal brace bars were bent, unattached, and convoluted. These deficiencies were noted by the Regional Director of Dietary Services, who acknowledged the need for repairs. The cement pad surface where the waste receptacles were located was heavily soiled with accumulated and encrusted dirt and debris. A large plastic container with wheel castors was full of water, and two wooden containers were resting on the cement pad near the rear fence line. The waste grease container was observed with rancid and malodorous used grease product, and a large wooden skid was resting against it. The facility's policy on garbage and refuse disposal, dated 09/01/2021, requires that all garbage and refuse be collected and disposed of safely and efficiently, with the area surrounding the exterior dumpster maintained free of rubbish or debris, and appropriate lids provided for all containers. These observations indicate a failure to adhere to the facility's established policies and procedures.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, staff, and visitors, as evidenced by numerous observations of unclean and poorly maintained areas throughout the building. During an environmental tour, surveyors noted significant issues such as corroded and broken door sweeps, heavily soiled air conditioning units, and disorganized storage rooms. These conditions were observed in various locations, including dining rooms, utility rooms, and restrooms, where dust, dirt, and grime had accumulated, creating potential health hazards. In addition to the general lack of cleanliness, specific maintenance issues were identified, such as non-functional ventilation systems, leaking faucets, and missing or damaged fixtures. The surveyors also found evidence of pest infestations, with cockroaches observed in several areas, including resident rooms and the nurses' station. The facility's maintenance work order system, TELS, did not contain any entries addressing these concerns, indicating a lack of effective communication and follow-up on maintenance issues. The facility's failure to adhere to its own cleaning and maintenance policies further contributed to the deficiencies. The policies outlined procedures for daily cleaning and preventative maintenance, yet the observations made during the survey indicated that these procedures were not being followed. The accumulation of dust, dirt, and debris, along with the presence of pests, suggests a systemic issue in maintaining a safe and sanitary environment for residents and staff.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to effectively implement a pest control program, impacting 104 residents and increasing the likelihood of pest attraction and harborage. Observations revealed a corroded and broken door sweep at the rear building entrance, creating a significant air gap that could allow pests to enter. Cockroaches were observed in various locations, including the 1st floor Back Dining Room entrance, the 2nd Floor Nurses Station, and resident rooms. A housefly was also noted in the Administrator's Office during a team meeting. The facility's pest control contract outlined treatment categories and frequencies, but a review of the Pest Control Technician Treatment Invoices for the past 12 months showed no specific treatments for targeted pests, only general pest treatments. During an environmental tour, glue boards with numerous dead cockroaches were found in resident rooms, indicating ongoing pest issues. An interview with a resident confirmed sightings of cockroaches in their room, further highlighting the facility's failure to manage pest control effectively.
Deficiencies in Oxygen Tubing Storage and Hand Hygiene
Penalty
Summary
The facility failed to properly date and store oxygen tubing for a resident with Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. The resident's oxygen tubing was observed on multiple occasions to be undated and improperly stored, with extra tubing lying on the floor and not bagged. The Assistant Director of Nursing (ADON) confirmed that the expectation was for oxygen tubing to be dated and stored in a bag when not in use. However, the facility's policy only addressed storage and safety related to oxygen cylinders or tanks, not tubing. Additionally, the facility failed to ensure proper hand hygiene among staff members. Observations revealed that four staff members did not perform hand hygiene after handling soiled items or before providing care to residents. Hand sanitizer dispensers in the hallway were found to be empty, and the ADON explained that hand sanitizer is sometimes removed due to residents eating it. The ADON provided hand hygiene education materials, but they were incomplete and lacked signatures. A facility policy on hand hygiene was requested but not provided by the completion of the survey.
Failure to Provide Appropriately Sized Bed for Resident
Penalty
Summary
The facility failed to provide an appropriately sized bed for a resident, identified as R255, who was six feet, four inches tall and had diagnoses including Parkinson's Disease and Dementia. Observations over several days revealed that the resident's feet were consistently resting on the footboard of the bed, indicating that the bed was too small to accommodate their height. The resident expressed discomfort and a preference for a bed that would better fit their stature, as they were only able to fit on the mattress by bending their legs. Further observations showed that the resident was unable to adjust themselves in the bed independently due to the manual nature of the bed adjustments, which lacked a remote control. The Assistant Director of Nursing acknowledged that the expectation was for residents to have beds that fit their bodies and that direct care staff should have identified and addressed the issue. The facility's policy on Accommodation of Needs and Preferences emphasized the importance of creating an individualized, home-like environment to maintain the resident's dignity and well-being, which was not met in this case.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to investigate two separate incidents of alleged abuse involving residents and staff. In the first incident, a resident was reportedly pulled from their wheelchair by another resident, resulting in a fracture. Despite the severity of the injury and the resident's impaired cognition, the facility did not conduct a thorough investigation to determine the exact circumstances of the altercation. The Nursing Home Administrator was unable to provide clarity on the incident, and no statements were collected from involved parties. In the second incident, a resident alleged that they were choked by a staff member during an altercation. The resident's neck appeared red, and a picture was taken by another staff member who reported the incident. However, the facility did not document the incident in the resident's medical record, nor did they report it to the state agency as required. The Nursing Home Administrator admitted to not conducting a proper investigation and failing to report the incident. The facility's policy mandates immediate investigation and reporting of abuse, but these procedures were not followed in either case. The lack of documentation, investigation, and reporting highlights significant deficiencies in the facility's handling of abuse allegations, potentially compromising resident safety and compliance with state and federal regulations.
Failure to Develop Care Plan for Aggressive Behavior
Penalty
Summary
The facility failed to develop a comprehensive care plan to address aggressive behaviors for a resident with a history of such behaviors. The resident, diagnosed with dementia and exhibiting moderate cognitive impairment, was involved in multiple incidents of verbal and physical aggression towards staff and other residents. These incidents were documented in the resident's progress notes over several months, indicating a pattern of aggressive behavior that included verbal aggression, physical aggression, and refusal of care. Despite these documented behaviors, the resident's care plan did not include any interventions or strategies to manage or mitigate the aggressive behavior. The deficiency was highlighted when another resident reported being pulled out of their wheelchair by the aggressive resident, leading to concerns about safety and the lack of appropriate interventions. The Assistant Director of Nursing acknowledged the absence of a care plan addressing the aggressive behavior, despite the resident's known history. This oversight in care planning represents a failure to meet the resident's needs and ensure the safety of both the resident and others in the facility.
Failure to Provide Consistent Oral Care for a Dependent Resident
Penalty
Summary
The facility failed to provide proper oral care for a resident, identified as R83, who was dependent on staff for activities of daily living (ADLs) due to cognitive impairment and a history of bacterial meningitis and aphasia. Over several days, observations revealed that R83's mouth was consistently dry, and their teeth were coated with a noticeable layer of white residue. Despite R83's need for assistance with oral hygiene, as confirmed by both the resident and staff interviews, the necessary care was not provided. R83 reported not having brushed their teeth for about 4 or 5 days, and their oral condition remained unchanged across multiple observations. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA), confirmed that R83 required help with oral care. The CNA stated that R83 received oral care only when they were assigned to them, indicating inconsistency in care provision. The Assistant Director of Nursing (ADON) acknowledged that dependent residents should receive daily oral hygiene and that any refusal should be documented. However, there was no documentation of refusal, and the facility failed to provide a policy on ADL care upon request, highlighting a deficiency in ensuring consistent oral care for R83.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care treatment for a resident with a wound on the third toe of their right foot. Observations over several days revealed that the bandage on the wound was not changed, despite the resident indicating it had been there for too long. The resident was observed in various locations, including in bed and in a gerichair, with the same unchanged bandage. A Certified Nurse Assistant was seen putting a sock over the wound without changing the bandage. The resident's medical records indicated orders for specific wound care treatments, including soaking the foot and applying antibiotic with a dry dressing, which were not followed. Interviews with facility staff, including a wound care nurse and the Assistant Director of Nursing, revealed a lack of awareness and adherence to the prescribed wound care orders. The wound care nurse incorrectly stated that the resident did not have any wounds and admitted to only performing treatments as needed, rather than as ordered. Additionally, the whirlpool tub required for the treatment was found to be unusable, filled with bags of linen and other belongings. The facility's wound care policy was requested but not provided by the end of the survey.
Failure to Document and Offer Vaccinations
Penalty
Summary
The facility failed to document or offer influenza or pneumonia vaccinations for two residents, R23 and R305, out of five reviewed. R23 was admitted with intact cognition, as indicated by a mental status score of 15, but there were no vaccine consents or records of vaccines being offered or provided. The Assistant Director of Nursing (ADON) was unable to explain how this oversight occurred. For R305, the medical record showed a consent signed by the resident's guardian for both vaccines, but the vaccinations were documented as refused by the resident. Although a progress note indicated that the resident was educated about the vaccines, there was no documentation that the guardian was informed of the resident's refusal.
Failure to Offer and Document COVID-19 Vaccine for a Resident
Penalty
Summary
The facility failed to offer and document the COVID-19 vaccine for a resident identified as R23. During an interview with the Assistant Director of Nursing (ADON) on August 28, 2024, it was discovered that R23's medical record did not contain any COVID-19 vaccine consents, nor was there any indication that the vaccine had been offered or administered. R23 was admitted to the facility with a mental status score of 15, indicating intact cognition, which suggests that the resident was capable of making informed decisions regarding vaccination. The ADON was unable to explain how this oversight occurred, indicating a lapse in the facility's vaccination protocol for this resident.
Inadequate Room Size in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum square footage of living space per bed in multiple resident rooms, as observed during an environmental tour conducted by the surveyor. Specifically, 21 out of 36 rooms did not meet the standard of 80 square feet per bed for multiple resident rooms. The rooms in question included various configurations, such as 3-bed wards with only 216 square feet and 4-bed wards with as little as 272 square feet, all falling short of the required space. This deficiency was identified through direct measurements of the rooms, which revealed that the space allocated per resident was insufficient according to regulatory standards. Despite the spatial inadequacies, residents interviewed in the affected rooms expressed that they were not impacted by the current room sizes. The facility's policy on Resident Rights, dated 11/28/17, emphasizes the importance of providing a safe, clean, comfortable, and homelike environment that supports resident independence. However, the observed room sizes contradict this policy, as they do not provide the mandated space necessary to ensure a comfortable living environment for the residents.
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 1,169 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Highland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nursing & Physical Rehabilitation Ce | 1.8 mi | ★★★★★ | 4 | 0 |
| St. Joseph's, A Villa Center | 2.7 mi | ★★★★★ | 6 | 0 |
| Boulevard Temple Care Center, Llc | 2.9 mi | ★★★★★ | 5 | 0 |
| Heritage Manor Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 26 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 3.9 mi | ★★★★★ | 26 | 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.