Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glenoaks Senior Living Campus during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection surveillance program because it tracked infections only when antibiotics were used and did not document or trend resident signs and symptoms of possible infection, including diarrhea and other suspected infections. The facility also failed to ensure EBP PPE was used correctly for a resident with a feeding tube and wound care needs, as an LPN performed feeding tube medication administration and wound care without wearing a gown despite EBP signage and PPE being available.
The facility failed to manage psychotropic medications appropriately for two residents. One resident receiving an antipsychotic had missing monthly orthostatic BP monitoring documentation for multiple months, and another resident’s PRN lorazepam order lacked a stop date, specific duration, or documented prescriber rationale for use beyond 14 days. Staff and the DON confirmed the monitoring and PRN order requirements were not met.
Failure to Provide Written Bed Hold Notice: A resident with cognitive impairment, schizophrenia, bipolar disorder, and seizure disorder was transferred to the hospital after active seizure activity and unresponsiveness. The record lacked evidence that the resident or representative received the required written bed hold and return-rights notice at transfer, despite staff stating the process was usually completed and documented.
Failure to Include Wheelchair Seat Belt in Care Plan: A resident with dementia, paraplegia, and communication impairment was observed seated in a wheelchair with a lap seat belt secured, but the comprehensive care plan did not identify the device or include individualized interventions such as its purpose, required staff assistance, monitoring, safety considerations, or resident-specific needs. NAs reported the seat belt was not on the care sheet, staff attempted to apply it, and the resident often refused and yelled; the ADON and DON confirmed it should have been included in the care plan.
Care Plan Not Revised for Resident No Longer Considered an Elopement Risk: A resident with Alzheimer’s disease and severe cognitive impairment lived on a secured memory care unit and was dependent for all ADLs. The resident’s elopement risk assessment showed low risk, but the care plan still listed high elopement risk and wandering behaviors. Staff stated the resident was no longer actively exit seeking, and the DON and corporate nurse agreed the resident was no longer an elopement risk, yet the care plan had not been revised to reflect the change.
A resident with moderate cognitive impairment, paraplegia, and a contracted right hand did not have a current order for a right hand splint used for contracture management, and the EHR lacked instructions for application, duration, removal, and monitoring. Although NAs and the ADON said staff frequently attempted the splint and the resident often refused, there was no documentation of application attempts, refusals, skin checks, or use of the care-planned rolled washcloth alternative.
Failure to Clarify and Document Dialysis Fluid Restriction: A resident receiving dialysis with ESRD and other chronic conditions was identified as at risk for fluid overload, but the care plan did not specify a daily fluid allowance or direct staff to monitor intake. The EHR lacked a physician order or dialysis recommendation for fluid restriction, and there was no documentation that the facility clarified the restriction with the dialysis provider. Staff gave conflicting reports about whether a fluid restriction existed, while observations showed multiple water containers in the resident’s room and the resident stated he did not know how much fluid he was allowed.
A resident with moderate cognitive impairment, paraplegia, arthritis, aphasia, and dysarthria/anarthria had a provider order for OT to evaluate and treat a right hand contracture and decreased ROM, but the EHR showed no evidence the OT eval was completed or services were started. Therapy leadership said the resident’s prior quarterly screen did not identify a significant change and the new order was not initially received, while nursing leadership said orders were to be processed and communicated to therapy.
Failure to complete antibiotic time-outs for two residents. One resident with severe cognitive impairment and Alzheimer's disease received Macrobid for suspected UTI, and another resident with severe cognitive impairment, renal failure, and DM received five antibiotic courses, but the EHR lacked documentation of the required 72-hour review of response, symptoms, labs, and continued need for therapy. The IP and DON both stated antibiotic time-outs were expected and important for antibiotic stewardship.
A resident with impaired mobility and a history of falls sustained a head laceration after falling from a wheelchair lift during transport. The staff member operating the lift did not follow manufacturer safety guidelines, failed to ensure the resident was properly secured, and left the resident unattended on the lift. Incomplete staff training documentation and lack of adherence to facility policy on wheelchair securement contributed to the incident.
Several residents with varying medical and cognitive conditions reported that a nursing assistant provided care in a rushed, rough, and disrespectful manner, leading to increased anxiety, feelings of worthlessness, and avoidance of care. Staff also observed the nursing assistant intentionally agitating residents and using inappropriate language, with prior warnings documented in her employee file.
Multiple residents reported being treated harshly and roughly by a nursing assistant, including being moved in ways that caused pain and being subjected to demeaning remarks. Despite these allegations, facility leadership did not conduct a thorough investigation, failed to document or follow up on complaints, and allowed the nursing assistant to continue working with residents, contrary to facility policy.
The facility did not conduct required annual performance evaluations for four nursing assistants, with employee records and staff interviews confirming the absence of recent evaluations. The DON reported not performing evaluations during her tenure, and the Administrator stated there was no formal policy in place, despite an expectation that evaluations occur.
A resident without cognitive impairment alleged to a physician that staff were physically abusing them. The administrator was informed of the allegation but did not report it to the State Agency, citing lack of specific details from the resident. Later, the DON received a related grievance about rough care but also did not report it, believing it was not a reportable event. Facility policy requires immediate reporting of all abuse allegations, which was not followed.
The facility did not have a formal QAPI plan or documentation to track and measure performance, establish goals, or implement corrective actions, despite holding quarterly meetings attended by the DON. This deficiency had the potential to affect all residents.
The facility did not ensure its QAPI team developed or revised a quality improvement program to address infection control concerns, as shown by incomplete meeting documentation and lack of program focus, benchmarks, or current PIP initiatives. The administrator was unable to provide program-specific information prior to her arrival, and the facility was only beginning to formalize its QAPI process, potentially affecting all residents.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance logs, lack of antibiotic stewardship practices, and insufficient tracking of staff illnesses. Staff were observed transporting soiled linens without proper bagging and cleaning a glucometer with an inappropriate product. The infection preventionist reported being unable to provide adequate oversight due to multiple responsibilities, and the facility's infection control policy was outdated and lacked necessary procedures.
The facility did not ensure the infection preventionist had adequate time or competency to oversee the infection control program, resulting in incomplete infection surveillance, lack of antibiotic stewardship practices, and insufficient documentation of infection management for residents and staff. Staff also failed to follow proper procedures for handling soiled linens, and the facility lacked updated policies for infection control and employee health.
A bottle of Lysol toilet bowl cleaner was found left out and spilled on the counter in an unlocked soiled utility room, with hazardous chemicals not properly secured as required. The maintenance director could not recall the last inspection of the utility rooms, and staff confirmed that chemicals are expected to be kept locked away from resident areas.
Two residents received medications not in accordance with physician orders or manufacturer guidelines, including one instance where a topical medication was administered in an unmeasured amount and another where multiple oral medications were crushed and given without a provider order. Staff were unsure of the correct procedures, and required documentation and orders were missing from the EMR, resulting in a medication error rate of 26.9%.
The facility did not have an effective antibiotic stewardship program in place, resulting in antibiotics being prescribed and administered without consistent documentation of symptoms, cultures, or antibiotic time outs. Multiple residents received antibiotics without clear indication or follow-up, and staff lacked training and awareness of stewardship practices. Facility policies did not provide specific guidance for monitoring or communicating about antibiotic use, leading to inadequate oversight and documentation.
Two residents with severe cognitive impairment and dependent on staff for ADLs were found with overgrown, unclean nails despite care plans and documentation indicating nail care should be provided. Observations and family reports showed nail care was not performed as required, and staff interviews revealed a lack of oversight by licensed nurses, who relied on nursing assistant documentation without verification.
A resident with severe cognitive impairment and multiple diagnoses was receiving hospice services, but the facility's care plan did not specify the services hospice was to provide during visits. The nurse consultant confirmed the lack of integration between the hospice and facility care plans, which was not in accordance with facility policy.
A resident with multiple diagnoses did not have pharmacy consultant recommendations regarding psychotropic medication reassessment, prednisone dosing, and diagnosis documentation addressed or communicated to the physician in a timely manner. Facility staff confirmed the absence of an organized process and required documentation for following up on these recommendations.
A resident with multiple medical conditions was given Tramadol by an LPN according to a scheduled order, but the medication label incorrectly indicated it was to be given as needed. The LPN and DON confirmed that labels should match current provider orders, but the label did not reflect the scheduled dosing, contrary to facility policy requiring accurate label checks before administration.
The facility did not ensure proper cleanliness, temperature monitoring, and food dating in both a dining room refrigerator and personal refrigerators in resident rooms. Several refrigerators contained undated and unlabeled foods, lacked temperature logs, and in some cases, did not have thermometers. Staff were unclear about their responsibilities for monitoring and cleaning, and the facility's policy did not address personal refrigerators, leading to improper food storage and sanitation practices.
Infection Surveillance and EBP PPE Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control surveillance program to identify, track, and analyze potential infections, including signs and symptoms of infections that did not result in antibiotic treatment. Infection surveillance tracking logs from 3/1/26 through 5/31/26 showed the facility tracked infections only when a resident received antibiotic treatment. The logs did not include monitoring or tracking of resident signs and symptoms of potential infections, including infections or communicable illnesses that had not resulted in antibiotic use. During interview, the Infection Preventionist confirmed the facility only tracked infections related to antibiotic use and stated resident signs and symptoms of potential infections were treated as they occurred, but were not documented on the surveillance logs unless antibiotic treatment was initiated. The Infection Preventionist also stated concerns such as diarrhea were discussed during morning meetings, including whether other residents had similar symptoms, but the facility did not have a tracking process in place for those symptoms. The DON stated the expectation was that the infection prevention and control program included monitoring and tracking of all suspected and confirmed infections to identify trends and implement interventions. The facility also failed to ensure appropriate PPE was used during enhanced barrier precautions for one resident who had severe cognitive impairment, was dependent on staff for all ADLs, and had diagnoses including gastrostomy status, acid reflux, quadriplegia, epilepsy, and anemia. The resident's care plan required EBP related to an indwelling medical device, and the room door sign directed staff to wear gown and gloves for feeding tube and wound care. During observation, an LPN entered the room, obtained water, applied gloves, left the room twice to get supplies, administered medications through the feeding tube, and completed wound care at the feeding tube site, but did not wear a gown during the feeding tube activities and wound care. The LPN stated gown and gloves should have been worn before the medications were administered and wound care was provided, and the Infection Preventionist and DON stated staff were expected to wear gown and gloves for high-contact care when EBP signage and PPE bins were present.
Psychotropic Medication Monitoring and PRN Order Requirements Not Met
Penalty
Summary
The facility failed to manage psychotropic medications appropriately for two residents. One resident had moderate cognitive impairment and diagnoses including anxiety disorder, bipolar disorder, schizophrenia, and obsessive-compulsive disorder, and was receiving risperidone 2 mg twice daily for schizotypal disorder related to schizophrenia. Although an order was in place for monthly orthostatic blood pressure monitoring while receiving antipsychotic medications, the electronic health record showed the monitoring was completed only in April 2026 and lacked documentation for January, February, March, May, and June 2026. The assistant director of nursing reviewed the record and confirmed the missing monthly assessments were related to the resident’s psychotropic medication use and were intended to monitor for adverse effects. A second resident with moderate cognitive impairment and diagnoses including bipolar II disorder, anxiety disorder, and hallucinations had an order for lorazepam 0.5 mg by mouth every four hours as needed for anxiety. The order was initiated as a PRN psychotropic medication, but it did not include a stop date, specific duration, or documented prescriber rationale for continuing beyond 14 days. Staff interviews confirmed the PRN medication had been used after other coping mechanisms were attempted, and the DON stated PRN psychotropic medications required a 14-day end date unless the provider documented a rationale for continued use beyond that period.
Failure to Provide Written Bed Hold and Return Rights Notice
Penalty
Summary
The facility failed to provide written bed hold and return-rights information when a resident was transferred to the hospital. The resident had moderate cognitive impairment and diagnoses including mild cognitive impairment, schizophrenia, bipolar disorder, and seizure disorder/epilepsy. The resident’s progress note documented that the resident was transferred to the hospital after being found on the floor with active seizure activity, convulsions, and unresponsiveness. The resident’s electronic record did not contain evidence that the facility provided the resident and/or the resident representative with a written bed hold notice at the time of transfer. During interviews, staff stated that bed hold paperwork was completed when residents went to the hospital, that nurses obtained verbal bed hold information from the resident or representative, and that the information was documented in progress notes or uploaded to the record. However, the Assistant DON confirmed the resident’s clinical record lacked bed hold documentation for the hospitalization, and the DON stated nurses were expected to complete the paperwork and contact the resident representative if needed. The facility’s Bed Hold Notice policy required written notice to be provided in advance or at transfer, and within 24 hours for emergency transfers, with a signed and dated copy maintained in the resident’s file or medical record.
Failure to Include Wheelchair Seat Belt in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with moderate cognitive impairment, dementia, paraplegia, dysarthria, and anarthria. The resident’s quarterly MDS identified that he required assistance with ADLs, received antipsychotic and antidepressant medications, used a trunk restraint daily, and had no impairment of the upper extremities. During observation, he was seen seated in his wheelchair with a seat belt secured over his lap. The resident’s comprehensive care plan, dated 4/9/26, did not identify the wheelchair seat belt or include individualized interventions related to its use, including the purpose of the device, the level of staff assistance required, monitoring, safety considerations, or resident-specific needs. Nursing assistants stated the seat belt was not listed on the care sheet used to direct care, that staff attempted to apply it in the morning, and that the resident frequently refused it and yelled at staff. The ADON and DON confirmed the seat belt should have been included in the care plan because it directed staff on how to provide care.
Care Plan Not Revised for Resident No Longer Considered an Elopement Risk
Penalty
Summary
The facility failed to ensure the comprehensive care plan was revised for a resident reviewed for elopement. The resident had diagnoses of Alzheimer's disease, major depression, anxiety disorder, hallucinations, and muscle weakness, and the quarterly MDS indicated severe cognitive impairment with substantial to maximal assistance needed for eating and dependence for all other ADLs. The resident lived on a secured memory care unit with a keypad code required to enter and exit the unit. The resident's last elopement risk assessment, dated 11/10/25, scored a 3, which indicated low risk for elopement, while the care plan, last revised 8/23/23, still identified the resident as high risk for elopement with wandering and attempts to open doors. During multiple observations from 6/8/26 through 6/10/26, the resident was seen being propelled by staff to and from the room, dining room, and activities off the secured memory care unit in the main dayroom. Staff interviews stated the resident was totally dependent for care, did not appear to be actively exit seeking, and had not been able to reach the keypads from the wheelchair. The DON stated the facility expected care plan revisions when changes were noted during assessments or care conferences, and the corporate nurse agreed the resident was no longer an elopement risk. The facility policy stated the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Missing Splint Order and Documentation for Contracture Management
Penalty
Summary
The facility failed to ensure a restorative device was implemented and monitored to maintain a resident’s highest practicable level of function when a right hand splint used for contracture management did not have a current physician order and staff did not document application attempts or refusals. The resident’s quarterly MDS identified moderate cognitive impairment and a need for assistance with ADLs, and diagnoses included arthritis, paraplegia, dysarthria, and anarthria. On observation, the resident’s right hand was completely contracted with the thumb positioned inside the curled hand, and the resident stated he thought he had a splint or something to put in his hand but was unsure. The care plan directed staff to apply the right hand splint as ordered and as the resident allowed, use a rolled washcloth if the splint was unavailable, check skin integrity with application and removal, and notify the PCP of abnormalities. However, the EHR showed the splint order had been discontinued in February 2026 and lacked a current order, instructions for when and how long to apply it, removal directions, and monitoring requirements. The record also lacked documentation showing staff attempted to apply the splint, used the rolled washcloth alternative, monitored skin integrity, or documented refusals, although NAs and the ADON stated staff frequently attempted the splint and the resident often refused.
Failure to Clarify and Document Dialysis Fluid Restriction
Penalty
Summary
The facility failed to ensure dialysis-related care needs were coordinated and implemented for a resident receiving dialysis, including failure to clarify and implement fluid restriction interventions for a resident at risk for fluid overload. The resident had intact cognition, required assistance with ADLs, and diagnoses including ESRD, hypertension, PVD, renal insufficiency, diabetes mellitus, schizophrenia, and polyneuropathy. The care plan identified the resident as receiving dialysis and at risk for fluid overload, with interventions to monitor for signs and symptoms of hypovolemia and hypervolemia, but it did not identify the amount of fluid the resident was allowed to receive daily or direct staff to monitor fluid intake. The resident’s EHR did not contain a physician order or dialysis recommendation specifying a daily fluid allowance. The record also did not show documentation that the facility communicated with the dialysis provider to clarify fluid restriction recommendations, obtain necessary orders, or implement interventions to guide staff in monitoring fluid intake. During observations, the resident was seen with multiple water pitchers, bottled water, and cups of water in the room, and the resident stated he was supposed to limit his water intake but did not know how much fluid he was allowed. Staff interviews showed conflicting understanding of whether the resident had a fluid restriction. An NA stated the resident had a renal diet but no fluid restriction on the care sheet, another NA stated the resident was not identified as having a fluid restriction, and a TMA stated fluid restrictions would be listed on the MAR but none was present. The ADON stated the resident was on a fluid restriction but, after reviewing the record, said no active fluid restriction was in place. The DON stated fluid restrictions depended on provider orders and that communication and formal conversations regarding dialysis-related needs should have been documented. The facility’s Fluid Restriction policy required nurses to obtain and verify physician orders for fluid restrictions, communicate them to appropriate departments, document them per protocol, and ensure bedside water was included in the resident’s daily fluid allowance.
OT Order Not Completed for Resident With Right Hand Contracture
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were provided as ordered when a physician ordered occupational therapy (OT) to evaluate and treat a resident’s right hand contracture and decreased range of motion, but the OT evaluation was not completed timely and there was no evidence the ordered services were initiated. The resident’s quarterly MDS identified moderate cognitive impairment, need for assistance with ADLs, diagnoses including arthritis, paraplegia, dorsalgia, aphasia, and dysarthria/anarthria, as well as impairment in both lower extremities and daily use of a trunk restraint. On provider rounds, the resident was noted to have decreased ROM in the right hand, and the provider entered the OT order into the EHR. The record showed the order was entered, but the EHR lacked evidence that OT assessed the resident’s right hand contracture and decreased ROM or that treatment began. Therapy leadership stated the resident had previously been seen for positioning needs and later received PT services, but the most recent quarterly screen did not identify significant changes and therapy was not aware of the new OT order until an email was later opened. Nursing leadership stated orders were to be processed, documented, scanned, and communicated to therapy, and morning meeting minutes showed therapy staff were aware of the new OT/PT orders.
Failure to Complete Antibiotic Time-Outs
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program by not completing antibiotic time-outs to evaluate the effectiveness and continued need for antibiotic therapy for 2 residents reviewed for antibiotic use. One resident had severe cognitive impairment and Alzheimer's disease and was prescribed Macrobid 100 mg twice daily for suspected UTI related to increased agitation for 5 days; the antibiotic was started and later discontinued, but the EHR lacked evidence that a 72-hour antibiotic time-out was completed to review the resident's response, monitor for improvement or worsening symptoms, review laboratory results, evaluate whether the antibiotic remained appropriate, or determine whether changes to the treatment plan were needed. The second resident had severe cognitive impairment, renal failure, and diabetes mellitus, and had five separate antibiotic courses prescribed between 3/28/26 and 6/13/26, including Bactrim, Amoxicillin, Ciprofloxacin HCl, Cephalexin, and Cipro. The EHR lacked evidence that antibiotic time-outs were completed for any of these courses to ensure the antibiotics remained appropriate and effective. During interview, the IP stated the facility used Loeb or McGeer criteria, expected a 72-hour antibiotic time-out to be documented in the EHR, and confirmed the time-outs were not consistently completed. The DON stated antibiotic use was expected to be monitored and time-outs completed, tracked, and trended, and the facility policy required monitoring the resident's response to antibiotics and laboratory results to determine whether the antibiotic should continue or be adjusted.
Failure to Follow Wheelchair Lift Safety Protocols Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to follow the manufacturer's safety guidelines for operating a wheelchair lift, resulting in a resident falling from the facility transport bus and sustaining a head laceration that required emergency department treatment. The incident took place as the resident, who had a history of falls, impaired mobility, and required staff assistance for activities of daily living, was being loaded onto the bus by a staff member trained to operate the lift. The resident was dependent on staff for self-care, used a manual wheelchair, and had cognitive capacity but exhibited anxiety and behavioral symptoms on the day of the incident. During the transfer, the staff member backed the resident's wheelchair onto the lift, locked the brakes, and began raising the lift. The lift stopped unexpectedly about six inches from the ground. The staff member, while attempting to determine the cause of the stoppage, stepped off the lift, leaving the resident unattended. At this point, the resident's wheelchair rolled forward, and the resident fell off the lift, hitting her head on the ground. The investigation revealed that the front wheels of the wheelchair were not properly positioned behind the yellow foot stop, and the resident was not secured with a seatbelt or torso restraint. Additionally, the staff member did not instruct the resident to hold onto the handrails, and the wheelchair brakes were not fully engaged. Further review found that the facility did not have the owner's manual for the lift on hand, and staff training documentation was incomplete, with skills validation checklists lacking proper markings or evaluations. The facility's policy required staff to be trained in the use of wheelchair lifts and to ensure proper securement of residents during transport, including the use of occupant restraints. However, these procedures were not followed, directly contributing to the resident's fall and injury.
Failure to Ensure Dignified and Respectful Care by Nursing Assistant
Penalty
Summary
The facility failed to ensure that four residents were treated with dignity and respect during care provided by a nursing assistant (NA-P). Multiple grievances and interviews revealed that NA-P performed care too quickly, used a harsh tone, and made inappropriate or demeaning comments. One resident reported increased anxiety and feelings of worthlessness when assisted by NA-P, while another described NA-P as rough and preferred not to receive care from her. Additional residents stated they would avoid requesting assistance from NA-P due to her behavior, which included loud, inappropriate remarks and a lack of bedside manner. Staff interviews corroborated these concerns, with one nursing assistant observing NA-P intentionally agitating residents and reporting this behavior to management. Review of NA-P's employee file showed prior coaching and written warnings for disrespectful, condescending, and rushed care, as well as complaints from both staff and residents about her tone and conduct. Despite these documented issues, management responses focused on coaching NA-P to slow down and treat residents as individuals, but residents and staff did not observe significant improvement. Facility policy defines personal degradation and mental abuse as actions or statements that harm a resident's dignity or cause humiliation, fear, or agitation, which aligns with the behaviors reported in this case.
Failure to Investigate and Protect Residents After Allegations of Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was completed and to protect residents after allegations of rushed, harsh, and physically abusive care by a nursing assistant were reported. Multiple residents described ongoing inappropriate behavior and treatment by the nursing assistant, including being handled roughly during care, experiencing pain, and being subjected to demeaning or condescending remarks. Despite these complaints, there was no documentation of a comprehensive investigation, no identification of the residents involved in the initial written warning, and no evidence that follow-up with affected residents was completed. Interviews with residents revealed specific concerns about the nursing assistant's conduct, such as being moved too quickly or roughly during transfers, causing pain, and making residents feel anxious, worthless, or angry. Some residents reported avoiding care from the nursing assistant or refusing showers due to discomfort. Staff interviews confirmed that concerns about the nursing assistant's behavior had been reported to facility leadership, but there was no indication that these reports led to a formal investigation or protective measures for the residents. Facility records showed that the nursing assistant continued to work with all residents until the state agency brought the allegations to the attention of the administrator. The facility's own abuse prevention policy requires immediate notification of the administrator, documentation, investigation, and protective actions when abuse is alleged. However, the facility did not follow these procedures, as there was no evidence of resident assessments, witness interviews, or separation of the accused staff member from residents during the investigation period.
Failure to Complete Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to provide annual performance evaluations for four nursing assistants, as required. Employee records showed that one nursing assistant, hired in October 2023, had not received any performance evaluation since hire. Two other nursing assistants, hired in November 2022 and April 2022, each had only one performance evaluation on file from March 2023, with no subsequent evaluations documented. Another nursing assistant, hired in February 2020, had a performance evaluation from 2022 but none after that. Interviews with the nursing assistants confirmed they did not recall receiving recent evaluations. The Director of Nursing stated she had not conducted any performance evaluations for nursing assistants during her three-year tenure, and the Administrator acknowledged there was no policy for annual evaluations, though it was expected they be completed.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident physical abuse to the State Agency as required. On 8/28/25, a resident without cognitive impairment made a statement to a physician during a clinic appointment, alleging that staff at the facility were 'beating me up.' The facility scheduler who heard the allegation informed the administrator the same day. However, the administrator did not consider the incident reportable because the resident could not provide specific details or identify the staff member involved and was unwilling to discuss the incident further. As a result, the allegation was not reported to the State Agency at that time. Additionally, the DON became aware of a related grievance from the same resident on 9/5/25, regarding rough care by a nursing assistant. The DON completed a grievance form and spoke with the staff member involved but did not report the incident to the State Agency, as she did not consider rough care to be a reportable event. Facility policy requires that all allegations of abuse be reported immediately to the administrator and to the appropriate state entity within two hours of the allegation. The failure to report the resident's allegation of abuse in a timely manner constitutes a deficiency.
Lack of Formalized QAPI Plan and Documentation
Penalty
Summary
The facility failed to provide a formalized Quality Assurance and Performance Improvement (QAPI) plan that included necessary policies and procedures for identifying and correcting quality deficiencies. During interviews, the administrator acknowledged that there was no QAPI plan in place to track and measure performance, no established goals, and no evidence of corrective action or performance improvement activities. Although attendance rosters for quarterly QAPI meetings were available, there was no documentation reflecting the QAPI process, and the administrator, who was new to the facility, had not yet implemented such a process. Further review revealed that while the director of nursing (DON) attended quarterly quality assurance meetings and provided updates on infection control and facility status, there was no documentation of QAPI presentations or evidence of any current or previous QAPI programs. The only policy provided was a general QAPI/QAA plan updated earlier in the year, which referenced facility-specific goals and documentation that could not be produced for the current year. This deficiency had the potential to affect all 29 residents in the facility.
Failure to Develop and Document Effective QAPI Program for Infection Control
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) team developed and revised a quality improvement program to address infection control concerns identified through tracking and trending, as well as the infection control process presented by the DON during routine QAPI meetings. Review of QAPI meeting attendance rosters and minutes revealed a lack of documentation regarding the program's focus, benchmarks, goals, or current Performance Improvement Plan (PIP) initiatives. Handwritten notes from a meeting referenced infection control but did not provide context or identify patterns of infection, despite noting staff illness and COVID-19 cases. Subsequent meeting records were incomplete, with gaps in documentation and minimal information on infection control activities or action plans. During an interview, the administrator reported being unable to locate any program-specific information about the QAPI program or PIP initiatives prior to her recent arrival. She stated that the facility was only beginning to formalize the QAPI program and develop a PIP, with plans to use current survey results to identify focus areas. The facility's QAPI policy indicated that the program should be ongoing and comprehensive, but the documentation and interviews demonstrated that these requirements were not being met, potentially affecting all 28 residents in the facility.
Infection Control Program Deficiencies and Lapses in Surveillance, Staff Illness Tracking, and Daily Practices
Penalty
Summary
The facility failed to maintain a current and effective infection prevention and control program, as evidenced by incomplete and inconsistent infection surveillance logs, lack of data analysis, and insufficient tracking of infections and staff illnesses. Infection surveillance logs from January to March 2025 were missing critical information such as dates of symptom onset, details of implemented precautions, symptoms, culture results, and documentation of antibiotic time outs (ATO). In several cases, there was no evidence that appropriate cultures were taken, that the appropriateness of antibiotic therapy was evaluated, or that follow-up was conducted to determine if infections resolved or if treatment needed to be altered. The infection preventionist (IP) reported being unable to provide adequate oversight due to multiple competing responsibilities and insufficient time, and the director of nursing (DON) was unaware of the requirement for antibiotic time outs. Employee illness surveillance was also deficient. For example, a staff member diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting CDC-recommended criteria for return, such as being fever-free and having received antibiotics for the appropriate duration. The facility lacked a policy specifying when staff should be excluded from work or the criteria for returning to work after illness. The infection control policy had not been updated since 2022 and did not reflect current standards or include necessary procedures for employee health surveillance. Additional infection control lapses were observed in daily practices. Staff were seen transporting soiled linens without proper bagging, allowing them to come into contact with their clothing and the environment, despite being aware of the correct procedure. In another instance, a nurse cleaned a resident's glucometer with an alcohol wipe instead of an EPA-approved disinfectant wipe, contrary to manufacturer recommendations and facility policy. The facility's policy on glucometer cleaning was vague and did not specify the required cleaning product. These failures in infection control practices and oversight had the potential to affect all residents in the facility.
Inadequate Infection Prevention Oversight and Documentation
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) had sufficient time and competency to oversee the infection prevention and control program. The IP was responsible for multiple duties, including wound care, supply ordering, and occasionally working floor shifts, which limited her ability to focus on infection control tasks. The IP reported not having enough time to complete her infection control responsibilities and lacked documentation of competencies related to oversight of the infection control program. Surveillance logs maintained by the IP were incomplete, missing critical information such as infection onset dates, symptoms, culture results, antibiotic time outs (ATO), and follow-up on the effectiveness or appropriateness of prescribed antibiotics. The IP only documented infections treated with medication and did not monitor all infections as required. Multiple instances were identified where residents with infections did not have complete documentation regarding cultures, causative organisms, isolation precautions, or ATOs. For example, one resident was prescribed antibiotics for both a viral and bacterial infection without clear justification, and another resident with a surgical site infection was not placed on enhanced barrier precautions upon return from the hospital. There was also a lack of evidence that the facility followed up on culture results or communicated with providers regarding antibiotic appropriateness. Additionally, the facility's antibiotic stewardship policy did not specify how the IP should monitor or communicate with providers about antibiotic use, and there was no evidence that the policy had been updated since 2022 to reflect current standards. Employee infection surveillance was also deficient. An employee diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting criteria for return, such as being fever-free and having received antibiotics for the recommended period. The facility lacked a policy specifying when staff should be excluded from work due to infection. Observations revealed improper handling of soiled linens, with staff failing to bag contaminated items before transport, increasing the risk of cross-contamination. Staff interviews confirmed awareness of proper procedures but admitted to not following them due to being in a hurry. The director of nursing was unaware of the requirement for antibiotic time outs, and the infection preventionist had not performed or documented any such reviews.
Hazardous Chemical Left Unsecured in Unlocked Utility Room
Penalty
Summary
A deficiency was identified when a bottle of Lysol toilet bowl cleaner was found sitting on the counter in an unlocked soiled utility room in hall A, with some of the cleaner spilled on the countertop. This area was accessible and not secured, potentially affecting 16 of 29 residents in that hall. The maintenance director confirmed the presence of the hazardous chemical and was unable to recall the last time the utility rooms were checked, noting that hazardous chemicals are supposed to be stored in a locked closet. The nurse consultant and administrator stated that staff are expected to keep all hazardous chemicals locked away from resident areas. Facility policy requires ongoing assessment for hazards and measures to prevent resident access to hazardous areas.
Failure to Administer Medications per Physician Orders and Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for two residents, resulting in a medication error rate of 26.9%. In one instance, an LPN administered Voltaren External Gel to a resident without using the required dispensing film to measure the prescribed two grams, instead providing a 'pea-sized' amount at the resident's request. The LPN was unsure how this amount compared to the ordered dose and did not contact the provider for clarification or an alternate order, despite the medication administration record and label specifying the required dosage. For another resident, a TMA prepared and administered multiple medications by crushing them and mixing with applesauce, including medications such as Aspirin, Colace, Furosemide, Metoprolol, Acetaminophen, and Vitamin D3. The Gabapentin capsule was opened and mixed with applesauce, and Potassium Chloride ER was mixed with water. The TMA stated that orders to crush medications typically came from therapy and would be communicated during shift reports or displayed in the electronic medical record (EMR) banner. However, a review of the EMR and order summary revealed no provider order authorizing the crushing of medications for this resident. Interviews with the ADON, DON, and consulting pharmacist confirmed that a provider order is required before medications can be crushed and administered in this manner. The facility's own policies also require physician authorization and documentation for crushing medications. Despite this, medications were administered crushed without the necessary provider order, and the required documentation was not present in the EMR or on the medication administration record.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program to monitor and ensure the appropriate use of antibiotics for all sampled residents. Review of infection surveillance logs from January through March 2025 revealed that antibiotics were prescribed and administered without consistent documentation of symptoms, cultures, or evidence of antibiotic time outs (ATO) to assess the appropriateness of therapy. In several cases, antibiotics were given for viral infections, such as COVID, or without clear indication, and there was no documentation of start and stop dates, symptom resolution, or follow-up on culture results. For example, one resident received antibiotics for both COVID and a urinary tract infection without documentation of symptoms or rationale, and another was treated for pneumonia without evidence of an ATO or follow-up on culture results. Interviews with facility staff, including the director of nursing (DON) and the infection preventionist (IP), revealed a lack of awareness and training regarding antibiotic stewardship practices, specifically the use of ATOs. The IP, who also served as the assistant director of nursing and had multiple other responsibilities, acknowledged missing information in the surveillance logs and not performing ATOs or following professional criteria for antibiotic appropriateness. The IP also reported being unable to provide adequate oversight of the infection control program due to time constraints and competing duties, and only documented infections that were treated with medication, omitting others. Policy review showed that while the facility had an antibiotic stewardship policy and an infection prevention and control program policy, these documents lacked specific processes for monitoring antibiotic use, communicating with prescribers, or performing ATOs. The policies did not outline criteria for determining the appropriateness of antibiotics or require documentation of key elements such as symptoms, culture results, or therapy adjustments. As a result, the facility did not have a functional system in place to ensure antibiotics were used appropriately, and staff were not adequately trained or competent in antibiotic stewardship practices.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents who were dependent on staff for activities of daily living. One resident, with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and cerebral palsy, was observed on multiple occasions to have untrimmed nails extending beyond the fingertips with a black substance underneath. Despite the care plan specifying nail care twice weekly on bath days, and documentation indicating nail care was completed, direct observation contradicted these records. A family member also reported repeated requests for nail care that were not addressed. Another resident, also with severe cognitive impairment and multiple diagnoses, was observed to have overgrown, unkempt nails with sharp, broken edges and a black dirt-like substance underneath. Documentation for this resident did not indicate that nail care was completed as required. Interviews with nursing staff revealed that while nursing assistants were responsible for documenting nail care on bath sheets, licensed nurses did not verify whether the care was actually provided, relying solely on the documentation submitted. The facility was unable to provide a policy regarding nail care during the survey.
Failure to Integrate Hospice and Facility Care Plans
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for one resident who was receiving hospice services. The resident had severe cognitive impairment, was dependent on staff for activities of daily living, and had diagnoses including Parkinson's disease, respiratory failure, and diabetes. Review of the resident's care plan showed it noted hospice involvement but did not specify what services hospice was to provide during their visits. The nurse consultant confirmed that the hospice care plan was not integrated with the facility care plan as required. Facility policy stated that care plans for residents on hospice should include the most recent hospice plan of care and delineate the care and services provided by both the facility and hospice.
Failure to Follow Up on Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure timely follow-up and documentation of pharmacy consultant recommendations for one resident. Multiple monthly drug regimen reviews by the pharmacy consultant included recommendations regarding the continued use and reassessment of divalproex, clarification of prednisone dosing, and the addition of diagnoses for certain medications. In each instance, there was no documentation that the physician had been updated or had addressed the recommendations, nor was there evidence of physician signatures on the pharmacy reviews. The facility was unable to provide records showing that these recommendations were communicated to or acted upon by the physician within the required timeframe. The resident involved had an intact cognitive status and was independent with activities of daily living, with diagnoses including adjustment disorder with depressed mood, hypertension, diabetes, anxiety, orthostatic hypotension, repeated falls, and stroke. Interviews with the DON and nurse consultant confirmed the lack of an effective process for organizing and following up on pharmacy consultant medication reviews, as well as the absence of required documentation in the medical record. No relevant policy was provided by the facility during the survey period.
Medication Labeling Discrepancy for Scheduled Tramadol Administration
Penalty
Summary
A deficiency occurred when a resident with intact cognition and multiple medical diagnoses, including a medically complex condition, was observed receiving medication from an LPN. During the medication pass, the LPN retrieved Tramadol HCl 50 mg from the locked medication cart and stated it was administered every eight hours on a routine basis. However, the medication label indicated it was to be given every eight hours as needed, not as a scheduled dose. Review of the electronic medical record and printed orders confirmed the medication was ordered to be given three times daily, not on an as-needed basis. The LPN acknowledged the discrepancy between the medication label and the physician's order, stating that prescription labels should accurately reflect provider orders. The DON confirmed that medication labels are required to match current orders and that staff are expected to verify and request corrections if discrepancies are found. Facility policy directs staff to check medication labels three times to ensure accuracy before administration. Despite these policies, the medication label did not reflect the current physician-ordered administration instructions, creating a risk for administration error.
Failure to Maintain Cleanliness and Temperature Monitoring in Facility and Personal Refrigerators
Penalty
Summary
The facility failed to ensure proper cleanliness, temperature monitoring, and food dating in both a dining room refrigerator and personal refrigerators located in resident rooms. Observations revealed that several personal refrigerators contained undated and unlabeled leftover foods, lacked temperature logs, and in some cases, did not have thermometers. One resident's refrigerator was found to be dirty, containing uncovered and undated juice and a spoiled banana. The dining room refrigerator had incomplete temperature logs, with many days missing entries, and was observed to be unclean, with substances and debris present in the freezer and on the ice dispenser. Staff were unclear about who was responsible for monitoring and cleaning these refrigerators, and there was no established cleaning schedule for the dining room refrigerator. Interviews with facility staff, including the kitchen manager and DON, revealed confusion regarding responsibility for monitoring and maintaining personal refrigerators in resident rooms. The facility's policy on refrigerator and freezer maintenance required daily temperature checks and regular cleaning, but did not address personal refrigerators in resident rooms. The lack of adherence to these procedures resulted in improper food storage and sanitation practices, as well as inadequate monitoring of refrigerator temperatures and food expiration dates.
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 48 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 New London
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belgrade Nursing Home | 10.4 mi | ★★★★★ | 6 | 0 |
| Cura Of Paynesville | 12.3 mi | ★★★★★ | 4 | 0 |
| Bethesda | 14 mi | ★★★★★ | 14 | 0 |
| Cura Of Willmar | 14.6 mi | ★★★★★ | 10 | 0 |
| Meeker Manor Rehablitation Center, Llc | 24.3 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.