Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Brooking Park during CMS and state inspections, most recent first.
Staff failed to provide necessary feeding assistance to two residents during meals and did not ensure oral hygiene or check for food debris after meals for a resident with severe cognitive impairment and a history of pocketing food. Observations showed that residents struggled to eat independently or did not eat at all until prompted or fed by staff, and staff were unclear about which residents required assistance, leading to inconsistent care.
A resident with severe cognitive impairment and limited mobility was transferred by a single staff member without the required mechanical lift or two-person assistance, contrary to the care plan and facility policy. The resident expressed pain during the manual transfer, and staff interviews confirmed knowledge of the proper procedures, which were not followed.
A resident admitted with a wound vac for an open abdominal surgical wound did not receive wound care as ordered by the hospital because facility staff failed to verify or obtain wound care orders and did not provide necessary treatments or supplies. The deficiency was discovered after the resident and family raised concerns, leading to the resident's discharge for hospital evaluation.
A resident was found unresponsive on the floor by a CNA, and the RN on duty failed to complete or document required physical and neurological assessments, including vital signs, lung sounds, oxygen saturation, and blood glucose, while waiting for EMS. The RN only checked the resident's pulse, which was not documented, and did not instruct the CNA to perform any assessments. This lack of assessment and documentation was confirmed by interviews and review of the resident's medical record.
Staff did not maintain privacy for a resident with severe cognitive impairment and multiple diagnoses during perineal care, leaving the door and window blinds open and failing to use privacy curtains or draping, which resulted in the resident being exposed to view from outside and anyone entering the room.
A resident with severe cognitive impairment and multiple diagnoses experienced repeated lapses in care, including missed rounds, improper medication administration, and lack of personal hygiene, as reported by a family member. The facility failed to follow its grievance policy, with incomplete documentation, lack of investigation, and poor communication with the complainant. The Social Services Director and DON did not ensure grievances were properly tracked, investigated, or resolved, and the family member was not informed of outcomes.
A resident with severe cognitive impairment and total dependence on staff did not receive required assistance with personal hygiene, including scheduled showers and grooming. Observations and interviews revealed the resident had poor hygiene, oily hair, and body odor, with missing documentation for showers over several weeks. Staff and family confirmed the lack of regular bathing and grooming, and the DON acknowledged incomplete records and failure to follow care plans.
Staff failed to follow policy and care plan requirements for safe transfers using a sit-to-stand mechanical lift for a resident with severe cognitive and physical impairments. Transfers were performed with only one staff member present and without properly securing the safety belt, despite the resident's need for maximum assistance and mechanical lift use.
A treatment cart was found unattended and unlocked with medications, including Exelon patches and Tamiflu, left on top and accessible to residents in the hallway. Facility policy requires medication carts to be locked unless under direct observation, and the DON confirmed that medications should not be left unsupervised.
A resident with severe cognitive impairment and multiple diagnoses did not receive breakfast within the facility's scheduled mealtime due to staff failing to assist the resident out of bed and into the dining room on time. Documentation of meal service was inconsistent, and staff interviews revealed a lack of coordination between nursing and dietary departments, resulting in meals being served late or missed.
The facility failed to maintain an effective grievance process, as a resident's family member received no response to multiple communications regarding care concerns. The facility's grievance policy lacked clarity on the designated Grievance Official, and staff interviews revealed confusion and inadequate follow-through on complaints. Resident Council meeting minutes indicated unresolved grievances, and the grievance log showed only two recorded grievances over several months.
The facility failed to serve meals in a timely manner due to staffing shortages and late arrivals, affecting residents with severe cognitive impairments who required assistance. Observations and interviews confirmed that meals were consistently late, with some residents missing meals. The Director of Culinary Services and other staff acknowledged the issues, but the facility's practices did not align with scheduled meal times.
The facility failed to provide necessary assistance with ADLs for two residents, leading to inadequate personal hygiene. One resident, with severe cognitive impairment, was observed with oily hair and strong body odor, and had not received a shower since admission. Another resident, also with severe cognitive impairment, was observed with oily hair and an unshaven beard, with no shower documentation for two months. Staff interviews revealed that showers were rarely completed as scheduled, and there was a lack of accountability due to the absence of a nursing manager.
The facility failed to provide adequate pressure ulcer care and prevention for two residents. One resident developed a new pressure ulcer without timely physician notification or treatment orders, and another resident did not receive required weekly skin assessments. Staff interviews revealed systemic issues in completing and documenting skin assessments, leading to deficiencies in care.
A facility failed to follow its policy requiring two-person assistance for a resident's mechanical lift transfers. Despite the resident's severe cognitive impairment and dependency on staff for transfers, video footage showed a CNA performing the transfer alone, leaving the resident unattended while attached to the lift. Interviews with staff confirmed the necessity of two-person assistance for safe transfers.
A resident with severe cognitive impairment and a history of UTIs did not receive proper urinary catheter care due to the facility's failure to have necessary supplies available, leading to delays in catheter change and urine specimen collection. Additionally, during a transfer, the resident's catheter bag was improperly positioned above the bladder, increasing infection risk. Staff interviews confirmed the facility's failure to adhere to catheter care policies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter, as staff did not wear isolation gowns or perform proper hand hygiene. Additionally, an LPN improperly handled medications by popping pills directly into their hands, contrary to policy. Interviews with staff confirmed these lapses in infection control and medication administration practices.
A resident with a history of falls and cognitive impairment was placed on a low air loss (LAL) mattress with bed rails by therapy staff without proper assessment, evaluation, or consent, as required by facility policy. Staff were unaware of protocols for combining LAL mattresses with siderails, and no documentation of safety checks or monitoring was found. The resident was later found with their head trapped between the rail and mattress, resulting in asphyxiation and death.
The facility failed to meet food safety standards, with numerous unlabeled and expired food items found during a kitchen tour. The Executive Chef admitted responsibility for ensuring proper labeling but failed to do so. Moldy onions and expired dairy products were not discarded promptly. Additionally, the facility did not maintain a clean food preparation area, with wet dishware used for meal service, uncovered food near trash cans, and unsanitary conditions like food debris and dust accumulation. Water dripped from the ceiling onto the steam table during meal service.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents at risk of MDROs, with no signage or PPE available. Respiratory equipment was improperly stored, lacking proper dating and bagging. Additionally, the facility did not adhere to its TB screening policy for employees, with missing documentation for required tests.
The facility failed to complete baseline care plans within 48 hours of admission for several residents, including those with severe medical conditions such as acute respiratory failure, dementia, and pressure ulcers. The absence of a unit manager or charge nurse to oversee the process contributed to this deficiency.
An LPN failed to verify the identity of a resident before performing a fingerstick blood sugar test, resulting in the wrong resident being tested. The resident, who had no diagnosis of diabetes, was tested without a physician's order. Interviews revealed that the LPN had the wrong administration record, and the facility lacked a specific policy for verifying orders, relying instead on standard practice expectations.
A resident with COPD and dependence on supplemental oxygen was observed using an oxygen concentrator without a physician's order, contrary to facility policy. The absence of an order was confirmed by an LPN, the DON, and the Administrator, highlighting a deficiency in respiratory care.
A facility failed to properly store and provide medications for two residents, leading to missed doses. One resident's gabapentin was misplaced in the medication cart, while another resident's medications were delayed due to late pharmacy orders. Staff interviews revealed issues with medication storage and delivery procedures.
Two residents were found with unsecured medications in their rooms without physician's orders or assessments for self-administration. Staff were unaware of proper procedures, and the facility's policy on secure medication storage was not followed, leading to a deficiency in medication management.
A resident with a history of knee fracture was administered oxycodone from the emergency supply, but staff failed to document the administration in the Treatment Administration Record. Interviews with two LPNs confirmed the medication was given, but documentation was overlooked, contrary to facility policy.
Failure to Provide Required Feeding Assistance and Oral Hygiene
Penalty
Summary
The facility failed to ensure that residents requiring assistance with Activities of Daily Living (ADLs), specifically grooming, eating, and oral hygiene, received the necessary services as outlined in their care plans and facility policies. Observations and interviews revealed that two residents who needed feeding assistance during meals did not consistently receive the required help. One resident with chronic fatigue, high blood pressure, and oropharyngeal dysphagia experienced significant weight loss and was observed struggling to feed themselves due to hand tremors and decreased alertness. Despite being listed as needing feeding assistance, staff were unclear about the resident's needs, and there was no documentation indicating the requirement for feeding assistance. Staff often relied on verbal reports rather than written care plans, leading to inconsistent care during mealtimes. Another resident with Alzheimer's disease, tremors, and cognitive deficits was documented in physician orders as needing to be fed at all meals. However, this resident was not included on the facility's list of residents requiring feeding assistance, and staff did not consistently provide the necessary help. Observations showed the resident playing with food and not eating until prompted and fed by staff, indicating a lack of awareness among staff regarding the resident's care needs. Interviews with staff and the DON revealed a lack of knowledge about which residents required feeding assistance, with some staff believing the resident only needed encouragement rather than direct feeding. Additionally, a resident with severe cognitive impairment and a history of pocketing food was left with a meal tray in their room without staff attempting to wake them to eat or providing oral hygiene after meals, as directed in the care plan. Observations showed that staff did not check the resident's mouth for debris or provide oral care after meals, and documentation of meal intake and episodes of falling asleep during meals was incomplete. Staff interviews confirmed that oral care was typically only provided in the morning and evening, not after meals, even when care plans specified otherwise. These failures demonstrate a lack of adherence to individualized care plans and facility policies regarding ADL support, particularly in feeding and oral hygiene.
Failure to Use Mechanical Lift and Two-Person Assistance During Resident Transfer
Penalty
Summary
Staff failed to provide adequate supervision and assistance during a transfer for a resident with severe cognitive impairment, arthritis, dementia, depression, and spinal stenosis. According to the resident's care plan and the facility's Safe Resident Handling/Transfer Policy, the resident required a mechanical lift with two-person assistance for all transfers. However, video footage showed a single staff member transferring the resident manually using a 'bear hug' technique, without the required mechanical lift or a second staff member present. During the transfer, the resident expressed discomfort and pain, specifically mentioning back pain, while the staff member continued the transfer without seeking additional help. Interviews with facility staff, including a CNA, RN, DON, and the Administrator, confirmed that staff were aware of the resident's need for two-person mechanical lift transfers and that manual lifting was not appropriate for this resident. The DON and Administrator were not aware of the incident until it was brought to their attention. The failure to follow the resident's care plan and facility policy resulted in a transfer being performed in a manner inconsistent with established safety protocols.
Failure to Verify and Provide Wound Vac Care Upon Admission
Penalty
Summary
The facility failed to ensure acceptable nursing standards of practice when a resident was admitted from the hospital with a wound vacuum (wound vac) in place for an open surgical abdominal wound. Upon admission, the facility did not verify or obtain the necessary wound vacuum treatment orders, including dressing change schedules and required supplies, as indicated in the hospital discharge summary. The resident's admission physician order sheet and treatment administration record did not contain any wound care orders for the abdominal wound vac, and the initial nursing assessment did not address the surgical wound or the wound vac. Throughout the resident's stay, there was no documentation of wound care being provided to the abdominal wound vac. Nursing staff, including the DON and LPNs, confirmed that the admitting nurse and subsequent staff did not verify or solicit wound care orders from the hospital or the resident's physician. The resident and family raised concerns about the lack of wound vac changes, noting that in the hospital, the wound vac was changed every 72 hours. Despite these concerns, the facility did not have wound care supplies available, and no orders were located or obtained during the resident's stay. As a result, the resident did not receive any wound care or wound vac changes while at the facility. The deficiency was identified when the resident and family requested discharge to the hospital for wound evaluation and treatment after discovering that no wound care had been provided since admission. Interviews with facility staff confirmed that the required assessments and order verifications were not completed, and the resident's wound care needs were not met during their stay.
Failure to Assess and Document Resident After Unresponsiveness
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed and documented required physical and neurological assessments for a resident who was found unresponsive in their room. According to the report, a Certified Nursing Assistant (CNA) discovered the resident sitting on the floor, leaning against a recliner, and notified the RN. Upon arrival, the RN attempted to arouse the resident, who remained unresponsive, and then left the room to call 911 and the physician, leaving the CNA with the resident. The RN did not perform or document a full assessment, including vital signs, lung sounds, oxygen saturation, blood glucose, or neurological checks, as required by facility policy. The facility's policy on observing, recording, and reporting condition changes specifies that after a fall, injury, or change in condition, staff must monitor for a range of symptoms, check vital signs, and document all observations and assessments. The RN's job description also requires charting all accidents or incidents and providing detailed, objective documentation of care and resident response. In this incident, the RN only checked the resident's pulse, which was not documented, and did not perform any other assessments or instruct the CNA to do so. The resident continued to exhibit snoring respirations until EMS arrived, at which point CPR was initiated. Interviews with the CNA, RN, Director of Nursing (DON), and the resident's physician confirmed that the expected assessments and documentation were not completed. Both the DON and the physician stated that they would have expected ongoing assessments and documentation until EMS arrived, in accordance with facility policy. The lack of assessment and documentation was also evident in the resident's electronic health record and the RN's written statement, which did not include required details about the resident's condition or care provided during the event.
Failure to Ensure Resident Privacy During Perineal Care
Penalty
Summary
Staff failed to maintain resident dignity and privacy during perineal care for one resident with severe cognitive impairment and multiple medical conditions, including diabetes, Alzheimer's disease, and Parkinson's disease. On two separate occasions, staff provided perineal care without closing the resident's door or window blinds, and without using privacy curtains or draping, resulting in the resident's genitalia and buttocks being exposed. The resident's room was visible from an outside walkway, and the absence of privacy curtains meant that anyone entering the room could see the resident exposed. Video footage and direct observation confirmed that staff did not take appropriate measures to protect the resident's privacy while changing briefs and providing personal care. Interviews with facility leadership revealed that staff were expected to close blinds and use privacy measures, but these steps were not followed, and the room lacked privacy curtains despite having tracks for them. The sample included seven residents, with a facility census of 63 and 28 in certified beds.
Failure to Maintain Effective Grievance Process and Prompt Resolution
Penalty
Summary
The facility failed to maintain an effective grievance process for residents and family members, as evidenced by the handling of grievances submitted on behalf of a resident with severe cognitive impairment, Alzheimer's disease, and Parkinson's disease. The facility's grievance policy requires prompt resolution, tracking, investigation, and communication with the complainant, but these procedures were not followed. Grievance forms submitted by the resident's family member detailed multiple concerns, including missed rounds, improper medication administration, missed meals, lack of personal hygiene care, and inappropriate staff behavior. The forms lacked essential documentation such as investigation details, tracking numbers, assigned investigators, and dates of response letters. Interviews revealed that the Social Services Director (SSD), who served as the Grievance Officer, did not consistently oversee or document the investigation and resolution process. The SSD reported forwarding grievances to relevant department heads but was unsure of the required response time and did not ensure that investigations were completed or communicated back to the complainant. The Director of Nursing (DON) admitted to not investigating specific allegations, such as staff failing to check on the resident, improper medication administration, and staff tampering with the resident's camera. The DON also did not interview staff or provide investigation documentation related to the grievances. The family member who filed the grievances reported ongoing issues with communication and lack of follow-up from facility staff. Despite providing specific dates and times for the alleged incidents, the family member was not informed of the results of the grievances and was not provided with the facility's grievance policy upon request. The grievance forms available in the facility did not include instructions on submission, expected response times, or identification of the grievance officer, further contributing to the ineffective grievance process.
Failure to Provide Required ADL Assistance and Hygiene Care
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), specifically personal hygiene, bathing, and grooming, to a resident with severe cognitive impairment and diagnoses of Alzheimer's and Parkinson's disease. The resident was documented as being fully dependent on staff for toileting hygiene, showers/baths, dressing, and transfers. Physician orders and the resident's care plan required showers or baths twice weekly, with additional interventions for good hygiene due to a history of urinary tract infections. However, observation revealed the resident had oily, unkempt hair, long facial hair, and a strong body odor, indicating a lack of regular hygiene care. Family and staff interviews confirmed that the resident had not received showers as scheduled, and documentation for required showers was missing or incomplete for several weeks. Review of facility records showed only sporadic documentation of showers provided, with significant gaps in both February and March. Staff interviews indicated that showers were supposed to be given twice weekly and that nurses were responsible for signing off on shower sheets, but the Director of Nursing confirmed that no additional documentation was available. The resident's appearance and hygiene were consistently poor, and staff failed to provide shaving as required. These failures resulted in the resident not receiving the ordered and care planned hygiene services necessary to maintain personal cleanliness and skin integrity.
Failure to Follow Safe Transfer Protocols with Mechanical Lift
Penalty
Summary
Facility staff failed to follow established policy and the resident's care plan regarding the use of a sit-to-stand mechanical lift for a resident with severe cognitive impairment, Alzheimer's disease, and Parkinson's disease. The policy required two nursing staff to be present for each transfer and for the safety belt to be fastened securely around the resident's waist. However, video footage and direct observation revealed that staff repeatedly performed transfers with only one staff member present and did not secure the safety belt as required. In one instance, a CNA transferred the resident alone, with the belt hanging unattached. In another, a CNA turned the camera away during the transfer, and no second staff member was present, while the resident expressed discomfort. During a separate observed transfer, two CNAs assisted, but the belt was not properly clasped around the resident's waist. Interviews with staff confirmed a lack of adherence to the policy, with one CNA stating they thought the belt was secured but did not check the buckle, and the DON confirming that two-person assistance and proper belt fastening were expected. The resident involved was dependent on staff for all transfers and required maximum assistance due to significant physical and cognitive limitations. The failure to follow policy and care plan interventions resulted in unsafe transfer practices for a vulnerable resident.
Unattended and Unlocked Treatment Cart with Medications
Penalty
Summary
Surveyors observed that a treatment cart on the Avalon unit was left unattended and unlocked for a period of 17 minutes, with multiple medications, including two Exelon patches and one Tamiflu tablet, left on top of the cart. The cart was accessible to residents who were present in the hallway near the cart, and all drawers containing treatment supplies and various medications could be opened. The facility's policy requires all medication storage areas, including carts, to be locked at all times unless in use and under the direct observation of the medication nurse or aide. During an interview, the Director of Nursing confirmed that the expectation is for all treatment and medication carts to be locked and secured, and that medications should not be left unsupervised.
Failure to Serve Meals Within Designated Timeframes
Penalty
Summary
The facility failed to ensure that a resident received meals in a timely manner according to the designated meal times. Facility records showed that breakfast was to be served between 7:30 A.M. and 9:00 A.M., but on the observed date, the resident was not assisted out of bed and brought to the dining room until 9:57 A.M., after the scheduled breakfast period had ended. Camera footage confirmed that no breakfast tray was brought to the resident's room during the scheduled breakfast hours. The resident, who had severe cognitive impairment, required moderate assistance with eating, and had diagnoses including diabetes, Alzheimer's disease, and Parkinson's disease, was dependent on staff to be assisted out of bed and to receive meals. Family members reported that the resident was frequently left in bed during breakfast and sometimes went long periods, up to 14 to 16 hours, between dinner and breakfast. Interviews with dietary and nursing staff revealed a lack of coordination and communication regarding meal service, with dietary staff relying on nursing staff to bring residents to the dining room or notify them if meals needed to be served in resident rooms. Documentation of meal service times was inconsistent, and there was no effective system in place to ensure that every resident received a meal at each mealtime. Staff acknowledged that agency nurses were unfamiliar with the mealtime process, contributing to the failure to serve meals within the designated timeframes.
Failure to Maintain Effective Grievance Process
Penalty
Summary
The facility failed to maintain an effective grievance process for residents and family members, as evidenced by the case of a resident with severe cognitive impairment and diagnoses of Alzheimer's and Parkinson's disease. The resident's family member, who lived out of town, attempted to communicate concerns regarding the resident's care through multiple emails and voicemails to the Director of Nursing (DON) but received no response. The family member was informed by a staff member that the DON was on vacation and that there were issues with the facility's new phone system. Despite these attempts, the family member did not receive any follow-up until the DON returned from vacation and left a message requesting a meeting. The facility's grievance policy, dated 2017, outlines the requirement for a designated Grievance Official to oversee the grievance process, but the policy did not specify the name or title of this individual. Interviews with various staff members, including the Life Enrichment Director, Licensed Practical Nurse (LPN), Registered Nurse (RN), and Social Service Director (SSD), revealed a lack of clarity and communication regarding the grievance process. Staff members were unsure of who the Grievance Officer was, and there was a consensus that there was little follow-through on resident complaints. The absence of Unit Managers, who previously assisted with resident issues, was noted as a factor contributing to the lack of resolution for grievances. The Resident Council meeting minutes further highlighted the facility's failure to address grievances, as residents expressed that their questions and concerns were not being answered. The Life Enrichment Director mentioned that department heads were emailed the meeting minutes but did not respond or follow through on the issues raised. The Administrator acknowledged the lack of communication and expected staff to address grievances promptly, but there was no evidence of a systematic approach to resolving resident concerns. The facility's grievance log showed only two grievances recorded from June to December 2024, indicating a potential underreporting or mishandling of grievances.
Delayed Meal Service Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner, affecting at least two residents with severe cognitive impairments who required assistance with eating and transfers. Observations revealed that Resident #1 was left in bed until after breakfast, resulting in being served cold food or leftovers. Similarly, Resident #2 was observed being dressed and brought to the dining room late, receiving breakfast items after the scheduled meal time. Interviews with family members and staff confirmed that meals were consistently served late, with residents sometimes missing meals entirely. The delay in meal service was attributed to a shortage of staff and late arrivals of both dietary and nursing staff, including agency staff unfamiliar with the residents and meal processes. The Director of Culinary Services acknowledged the staffing issues and the impact on meal timing, while the Director of Nursing and the Administrator expressed expectations for timely meal service. Despite these expectations, the facility's current practices did not align with the scheduled meal times, leading to deficiencies in meeting residents' nutritional needs.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, resulting in inadequate personal hygiene. Resident #1, who has severe cognitive impairment and requires substantial assistance with toileting hygiene, showering, and bathing, was observed with oily, flat, and stringy hair and a strong body odor. Despite the care plan indicating the need for extensive assistance with showering, the resident's family member reported that the resident had not received a shower since admission, and the Director of Nurses (DON) confirmed the absence of shower documentation. Similarly, Resident #2, also with severe cognitive impairment and dependent on staff for showering and bathing, was observed with very oily hair and an unshaven beard. The care plan required maximum assistance for showering twice weekly, but the DON confirmed that there were no shower sheets for November and December, indicating a lack of showers during this period. Interviews with staff revealed that showers were rarely completed as scheduled, and there was a lack of accountability due to the absence of a nursing manager, contributing to the deficiency in care.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility staff failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident #1, who was at moderate risk for developing pressure ulcers, developed a new pressure ulcer on the sacrum. The facility staff did not complete weekly skin assessments as required by the resident's care plan and facility policy. Additionally, the staff failed to notify the physician of the new pressure wound and did not obtain new treatment orders in a timely manner. Observations showed that the resident had deep red maroon-colored circles on the sacrum, indicating a pressure wound, but there was no documentation of physician notification or new treatment orders in the resident's progress notes. Resident #2, who had a history of pressure ulcers and was also at moderate risk, did not receive the required weekly skin assessments according to facility policy. The resident's care plan indicated a need for weekly treatment documentation, but there were no documented skin assessments after an initial observation of a Stage 2 pressure ulcer on the buttocks. The facility's Director of Nursing confirmed that there were missing shower sheets for November and December, which should have included skin assessments. Interviews with facility staff revealed systemic issues in completing and documenting skin assessments. The staff acknowledged that skin assessments were not being completed as required, and there was a lack of follow-up to ensure compliance with the facility's policy. The Director of Nursing and other staff members confirmed that newly acquired skin conditions should be reported to the physician and family immediately, but this was not done for the residents involved.
Failure to Follow Two-Person Assistance Policy for Mechanical Lift Transfers
Penalty
Summary
The facility failed to adhere to its policy and the resident's care plan by not ensuring that two staff members assisted a resident who required a sit-to-stand mechanical lift for transfers. The facility's policy, dated September 2017, mandates that two nursing personnel must be used for a Sara lift transfer. However, video footage from two separate occasions showed that a Certified Nursing Assistant (CNA) performed the transfer alone, without a second staff member present to assist or supervise, leaving the resident unattended while attached to the lift. This was contrary to the resident's care plan, which specified the need for two-person assistance for transfers. The resident involved had severe cognitive impairment and was dependent on staff for various activities of daily living, including transfers. Interviews with facility staff, including a Physical Therapist, Registered Nurse, and the Director of Nursing, confirmed that the resident required two-person assistance for safe transfers using the mechanical lift. The staff also emphasized that the resident should not be left unattended in the lift, and the second staff member should be actively involved in the transfer process to prevent potential accidents.
Deficiency in Urinary Catheter Care and Supply Management
Penalty
Summary
The facility failed to provide proper urinary catheter care for a resident, as they did not have the necessary catheter supplies readily available to change the resident's catheter according to physician orders. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, had a history of urinary tract infections (UTIs) and an indwelling urinary catheter. Despite physician orders to change the catheter and obtain a urine culture, the facility did not have the correct supplies, leading to a delay in the catheter change and urine specimen collection. The resident's catheter was not changed on the day it was ordered due to the unavailability of the correct Foley catheter supplies. The Central Supply Technician was unable to check or order the supplies due to a computer issue, and the nurse did not change the catheter until three days later. Additionally, the urine specimen was not picked up by the lab on the weekend, causing further delays in obtaining the necessary urine culture. During a transfer, the resident's urinary catheter bag was positioned above the bladder, contrary to the facility's catheter policy, which increased the risk of infection. Interviews with staff, including a CNA and the DON, confirmed that the catheter bag should always be kept below the bladder to prevent UTIs. The facility's failure to have adequate supplies and to follow proper catheter positioning procedures contributed to the deficiency in care for the resident.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards by not implementing Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. Despite having a policy in place that required the use of gowns and gloves during high-contact care activities for residents at risk of multi-drug resistant organisms (MDROs), staff did not follow these guidelines. Observations revealed that staff did not wear isolation gowns while providing care to the resident, and there was no EBP sign posted outside the resident's room. Additionally, staff did not perform proper hand hygiene after removing gloves, which is a critical step in preventing the spread of infections. Another deficiency was observed in the administration of medications to a resident. A Licensed Practical Nurse (LPN) was seen popping pills from bubble packs directly into their hands before crushing and mixing them with applesauce for administration. This practice is against the facility's medication administration policy, which requires medications to be popped directly into a medicine cup to maintain hygiene and prevent contamination. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the expected procedures were not followed. The RN stated that gloves should be changed during peri-care, and hand hygiene should be performed before applying new gloves. The DON emphasized that signs should be posted for residents requiring EBP, and staff should use gowns and gloves for residents with catheters or other indwelling medical devices. The failure to adhere to these infection control practices indicates a significant lapse in maintaining a safe environment for residents.
Failure to Assess Bed Rail and Mattress Combination Leads to Resident Entrapment and Death
Penalty
Summary
The facility failed to assess a resident for the risk of entrapment when installing bed rails in combination with a low air loss (LAL) mattress. The resident, who had a history of falls, moderate cognitive impairment, and required substantial assistance with mobility and activities of daily living, was admitted with a physician's order for a LAL mattress to prevent skin breakdown. Despite facility policy requiring evaluation and consent prior to the use of adaptive devices such as siderails and LAL mattresses, there was no documentation of an assessment, evaluation, or consent for the use of these devices in the resident's medical record. Therapy staff, upon noticing the LAL mattress in the resident's room, installed it on the bed with existing siderails without following any protocol or notifying appropriate nursing leadership. Both therapy and nursing staff were unaware of the required procedures for assessing the safety of bed rails in combination with specialty mattresses. The facility's policy specified that such combinations must be evaluated for safety and risk prior to placement, especially when a mattress is changed, but this was not done. There was also no evidence of monitoring or reassessment after the installation of the LAL mattress and siderails. The resident was later found on the floor with their head trapped between the bed rail and the mattress, resulting in asphyxiation and subsequent death. Staff statements and medical record reviews confirmed that no assessment or evaluation was performed for the use of assistive devices with the LAL mattress, and no consent was obtained. The lack of adherence to facility policy and absence of required safety checks directly contributed to the incident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improperly labeled and stored food items. During a kitchen tour, numerous open food items were found without labels or dates, including containers of flour, onions, and various condiments. The Executive Chef acknowledged responsibility for ensuring items were dated but admitted to lapses in this duty. The Director of Dining Services and the Director of Nursing also confirmed that all dietary staff were responsible for dating food items, and the Executive Chef was expected to check daily to ensure compliance. Additionally, the facility did not discard expired or moldy food items promptly. Moldy onions and expired dairy products were found in storage, and the Executive Chef admitted to being aware of the moldy onions but failed to discard them. The Director of Dietary Services and the Director of Nursing both stated that expired or moldy food should have been thrown away immediately, indicating a breakdown in the facility's food safety protocols. The facility also failed to maintain a clean and sanitary food preparation area. Observations included wet dishware being used for meal service, uncovered food items placed near trash cans, and unsanitary conditions such as food debris on floors and dust accumulation on ceiling vents. Water was observed dripping from the ceiling onto the steam table during meal service, a recurring issue when it rained. The Executive Chef and the Director of Dietary Services acknowledged these issues, with the latter noting that the kitchen floors were supposed to be cleaned nightly and the microwave daily, but these tasks were not consistently performed.
Infection Control Deficiencies in EBP and Respiratory Equipment
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who were at increased risk for acquiring multidrug-resistant organisms (MDROs) due to their medical conditions. Observations revealed that there was no signage indicating EBP at the residents' rooms, and personal protective equipment (PPE) such as gowns was not available or used by staff during high-contact care activities. Interviews with staff indicated a lack of awareness and communication regarding which residents required EBP, despite the facility's policy mandating gown and glove use for residents with wounds, indwelling medical devices, or MDRO colonization. Additionally, the facility did not store respiratory equipment properly to decrease the risk of infection for three residents receiving respiratory care. Observations showed that oxygen tubing and nebulizer masks were not dated or stored in bags when not in use, contrary to the facility's policy. Interviews with staff confirmed that there were no orders in place to change the oxygen or nebulizer tubing regularly, and the equipment was not maintained according to the facility's standards. The facility also failed to adhere to its infection control policy regarding tuberculosis (TB) screening tests for employees. The review of employee files revealed that several staff members did not have documentation of the required two-step or annual one-step TB tests. Interviews with the Director of Nursing (DON) and the Administrator indicated that the facility's policy was not followed, and there was a lack of oversight in ensuring that TB testing was completed in a timely manner.
Failure to Complete Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for five residents. The facility's policy required that a baseline care plan be created upon admission, with a comprehensive care plan to be developed by day 21 of the resident's stay. However, the facility did not have a unit manager or charge nurse to oversee the completion of these care plans, leading to the deficiency. Resident #178 was admitted with a medical history of acute respiratory failure, congestive heart failure, and chronic obstructive pulmonary disease, but no baseline care plan was developed. Similarly, Resident #228, with chronic obstructive pulmonary disease, unspecified dementia, and a urinary tract infection, also lacked a baseline care plan. The absence of a unit manager left the responsibility for ensuring the completion of these plans unclear. Resident #230, who required assistance with personal care and had a urinary tract infection, did not have a baseline care plan completed by the admitting nurse. Residents #22 and #21, both readmitted with severe medical conditions, including pressure ulcers and cognitive impairments, also lacked baseline care plans. The facility's failure to have a designated staff member responsible for completing and verifying these plans contributed to the deficiency.
Failure to Verify Resident Identity Before Blood Sugar Test
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) verified the identity of the intended resident before performing a fingerstick blood sugar test, resulting in the wrong resident being tested. This incident involved Resident #17, who was admitted to the facility on June 18, 2024, with a medical history of quadriplegia and no diagnosis of diabetes or hypoglycemia. The Minimum Data Set (MDS) assessment indicated that Resident #17 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. However, during an observation on July 16, 2024, LPN #3 conducted a fingerstick blood sugar test on Resident #17 without verifying the resident's identity or checking the physician's orders, which did not include an order for such a test. Interviews conducted with facility staff revealed that the Quality Control and Wound Care Specialist expected staff to follow physician's orders as a standard practice, although there was no specific policy addressing this. LPN #3 admitted to having the wrong resident's administration record during the test, and the Director of Nursing (DON) confirmed that LPN #3, as the charge nurse, should have verified the physician's orders before proceeding. The facility administrator also acknowledged that the nurse should have ensured the correct resident was identified before performing the blood sugar check.
Lack of Physician's Order for Oxygen Use
Penalty
Summary
The facility failed to ensure a physician's order was in place for the use of oxygen for a resident, leading to a deficiency in respiratory care. The facility's policy, dated February 2019, clearly states that a physician's order is required to apply oxygen, except in emergencies. Resident #228, who was admitted on July 10, 2024, had a medical history of chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. However, as of July 16, 2024, the resident's Order Summary Report did not include any orders for the use of oxygen. Observations on July 15 and July 16, 2024, confirmed that Resident #228 was using a nasal cannula with an oxygen concentrator set at four liters per minute without a physician's order. LPN #3 acknowledged the absence of an order for the resident's oxygen use. The Director of Nursing and the Administrator both confirmed that physician's orders should be in place for oxygen use, and the charge nurse should ensure these orders are obtained. Despite these acknowledgments, the deficiency remained unaddressed at the time of the survey.
Medication Storage and Availability Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and availability of medications for two residents, leading to deficiencies in pharmaceutical services. For Resident #8, who had a medical history of hereditary spastic paraplegia and was cognitively intact, the facility did not administer gabapentin as ordered due to improper storage. Although the medication was delivered, it was misplaced in the medication cart, leading to missed doses. Staff interviews revealed that the medication was placed in an overflow drawer instead of behind the resident's name, causing confusion and delay in administration. Resident #232, who had multiple medical conditions including diabetes and hypertension, did not receive several medications upon admission due to a delay in pharmacy delivery. The facility faxed the medication orders after the pharmacy's cutoff time, resulting in a next-day delivery. The staff did not utilize the emergency kit to provide the necessary medications in the interim, leading to a lapse in care. Interviews with staff, including the DON and the pharmacist, highlighted a lack of communication and adherence to procedures for medication delivery and storage. The facility's policy required medications to be administered without interruption, but the failure to follow these guidelines resulted in deficiencies in meeting the residents' pharmaceutical needs.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were securely stored for two residents, leading to a deficiency in medication management. Resident #228 was observed with a small bottle of artificial tear eyedrops, hydrocortisone cream, and a package of cough drops on their bedside table. The resident did not have physician's orders for these medications or permission to store them at their bedside. The resident was unaware of the medications' presence, and staff members, including a CNA and an LPN, were not aware of the proper procedures for handling such situations. The Director of Nursing confirmed that the resident had not been assessed for self-administration of medications, and the Administrator stated that medications should not be stored on bedside tables. Similarly, Resident #21 was found with a tube of Triad hydrophilic wound dressing paste and a medication cup containing a white cream on their dresser. The resident had no physician's order to store medications at their bedside. An LPN admitted to leaving the Triad paste in the room after completing a dressing change, contrary to the facility's policy that required such medications to be stored in the treatment cart. Another LPN confirmed that medications should only be left in residents' rooms if there was a physician's order and the resident had been assessed for self-administration. The DON reiterated that all medications should be locked unless specific conditions were met. The facility's policy on medication storage, dated July 2021, mandates that medications and biologicals be stored safely and securely, accessible only to authorized personnel. However, the observations and interviews revealed lapses in adherence to this policy, as medications were found unsecured in residents' rooms without proper authorization or assessment. The DON and Administrator both emphasized the expectation for medications to be locked up unless residents were assessed and authorized to self-administer them.
Failure to Document Oxycodone Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident, specifically concerning the administration of oxycodone, a narcotic pain medication. The resident, who had a medical history of a periprosthetic fracture around an internal prosthetic right knee joint, was admitted to the facility and had an order for oxycodone hydrochloride 10 mg to be administered as needed for pain. On a specific day, the facility's emergency medication supply was accessed multiple times to provide the resident with oxycodone, yet there was no documentation in the Treatment Administration Record (TAR) indicating that the medication was administered. Interviews with staff revealed that the medication was indeed administered but not documented. An LPN admitted to administering the medication during her shift but forgot to document it in the TAR. Another LPN also confirmed administering the medication during his shift. The Director of Nursing stated that it was expected for staff to document the administration of pain medications in the TAR, highlighting a lapse in following the facility's policy on medication administration documentation.
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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.
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Nursing homes near Chesterfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mason Pointe Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens West | 1 mi | ★★★★★ | 0 | 0 |
| Athene Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 46 | 0 |
| Westchester House, The | 1.7 mi | ★★★★★ | 0 | 0 |
| Garden View Care Center Of Chesterfield | 2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.