Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Campbell Healthcare & Senior Living during CMS and state inspections, most recent first.
Unsanitary food service practices were observed when the ice machine lacked the required air gap, a dietary aide with visible facial hair worked in the kitchen and dining room without a beard cover while handling resident trays and food, and uncovered trash cans with exposed food and waste were left by the dish machine and steam table. Facility staff and leadership acknowledged the expectations for beard covers, trash can lids, and an ice machine air gap.
The facility failed to timely transmit MDS assessments for three residents. Although the quarterly MDSs were completed, they were accepted/transmitted days to weeks late instead of being submitted per required iQIES/CMS timelines. The Administrator said a new MDS Coordinator had just been hired and was being trained, and the Corporate MDS Coordinator reported a software glitch had affected submissions.
A facility failed to develop and implement individualized care plans with specific interventions for three residents. Two residents admitted to hospice had care plans that did not address hospice services, and another resident’s care plan did not address smoking or Wander Guard use despite orders, assessments, and observations showing smoking supervision and elopement monitoring needs. The DON, Care Plan Coordinator, and Administrator stated these items should have been care planned with interventions.
Failure to Update Care Plans After Repeated Falls: The facility did not revise care plans for two residents with repeated falls and significant neurocognitive and medical diagnoses. One resident with Alzheimer's disease, dementia, and a history of falls had multiple falls, including one with a laceration, facial fracture, and subdural hematoma, but the care plan was not updated with safety interventions. Another resident with Parkinson's disease, Alzheimer's disease, bipolar disorder, and repeated unwitnessed and witnessed falls had a care plan that was not revised to add further fall-prevention interventions. The DON and Administrator stated fall interventions should be in place and the care plan should be updated.
Staff failed to reconcile narcotics at shift change for two med carts and one med room, with repeated missed counts documented in the narcotic logs. The facility policy required outgoing and incoming nurses to count controlled substances together and sign the Narcotic Count Book, and the DON, an LPN, a CMT, and the Administrator all stated that two staff should complete and document the count each shift.
Failure to use EBP occurred during incontinent care for one resident and catheter care for another resident. One resident had ESBL in the urine, an indwelling catheter, and skin concerns on both legs, yet a CNA entered the room and provided catheter care without a gown. Another resident had EBP signage and PPE available, but CNAs and an LPN entered the room without gowns during incontinent care and wound assessment, with inconsistent hand hygiene and glove changes.
Failure to inspect mobility rails and bed safety equipment: The facility did not document regular inspections of bed frames, mattresses, or side/mobility rails for several residents. A resident with CKD, depression, UTI, and HTN, a resident with COPD, anxiety, DM, dementia, and upper body weakness, a resident with CKD, depression, and UTI, and a resident with DM, chronic pain, and AFib all had U-shaped mobility rails that moved with minimal effort, and staff reported no monthly inspection documentation. The DON and ADON also gave conflicting information about whether one resident's rails should have been on the bed.
The facility failed to maintain sanitary conditions in food storage and distribution, affecting all 72 residents. Observations showed missing temperature checks for refrigerators, undated or expired food items, and unsanitary kitchen conditions, including trash cans without lids and a buildup of grease. Interviews confirmed these practices violated facility policies.
The facility failed to maintain resident dignity and privacy by exposing two residents during care. One resident with severe cognitive impairment was left exposed to a parking lot view during incontinent care, while another resident with dementia was exposed during wound care. Staff interviews confirmed that window curtains should have been closed to ensure privacy.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as peeled paint, exposed sheetrock, and unclean shower areas. Observations included damaged trim, unsecured electrical conduits, and unsanitary conditions in the shower room. Housekeeping staff were unaware of these issues, and the Maintenance Supervisor emphasized the need for written documentation of repairs.
The facility failed to provide written transfer or discharge notifications to residents, their responsible parties, and the LTC Ombudsman for three residents. The facility's policy did not include sending a monthly transfer log to the Ombudsman. Interviews revealed that the Regional LTC Ombudsman had not received any transfer logs this year, and the Administrator was unaware of the notification requirements.
A facility failed to complete a significant change MDS assessment within 14 days for a resident admitted to hospice care. The policy requires a Significant Change in Status Assessment when a resident's condition changes, but lacks a specific timeframe. Interviews with staff confirmed the assessment should have been completed within 14 days. The facility uses a virtual MDS Coordinator, which may have contributed to the oversight.
The facility failed to accurately document MDS assessments for two residents. One resident with cerebral infarction and dysphagia had a fall that was not recorded in their MDS, while another resident with chronic atrial fibrillation and Type 2 diabetes had discrepancies in their MDS regarding insulin injections. Staff interviews confirmed the inaccuracies, and the administration acknowledged the expectation for accurate MDS coding.
The facility did not document a Level I PASARR for two residents, one with schizophrenia and anxiety disorder, and another with a psychotic disorder, TBI, and dementia. The Administrator confirmed the absence of these assessments and was unable to retrieve them from previous facilities.
A facility failed to provide a baseline care plan to a resident within 48 hours of admission, as required by policy. The resident, with multiple health conditions, did not receive a written summary of the care plan. The MDS coordinator worked offsite, and the Director of Nursing was unaware of the requirement to provide the care plan to the resident, indicating a gap in the facility's process.
A resident with epilepsy and muscle spasms had a physician's order for fall mats on both sides of their bed. Observations showed a mat only on the left side, contrary to the order. Interviews with the DON and Administrator confirmed the expectation for mats on both sides, highlighting a failure to follow the physician's directive.
A facility failed to identify and assess a resident with PTSD, resulting in a lack of supportive interventions. The resident's care plan did not address PTSD or document past trauma or triggers, despite having related diagnoses and medication orders. Interviews with the DON and Administrator revealed a lack of awareness and implementation of PTSD assessments.
The facility failed to provide sufficient nursing staff to answer call lights promptly, affecting residents' well-being. The call system report showed delays from over an hour to more than seven hours. Residents reported long wait times, especially at night, with some not receiving timely care. Staff practices contributed to the issue, as some CNAs cleared call light notifications without providing care, contrary to facility policy.
The facility failed to maintain proper infection control practices during incontinent and wound care, as well as in the kitchen. CNAs did not wear gowns or change gloves during resident care, and dietary staff did not perform hand hygiene between serving residents. Additionally, the facility lacked a risk management process for Legionella disease, as there was no water flow diagram identifying areas at risk for Legionella growth.
The facility did not document the provision of education on the benefits and side effects of influenza and pneumococcal vaccines for five residents. Despite policy requirements, there was no record of education being provided before vaccine administration or refusal. The DON confirmed the need for documentation, and the Administrator noted the absence of a Social Services Designee responsible for this task.
The facility did not provide the required twelve hours of annual in-service education for two CNAs, as mandated by their policy. Despite the policy's requirement for staff to participate in training to enhance residents' quality of life, records showed no documentation of such training for the CNAs hired in April and July 2023. The Administrator acknowledged the oversight and committed to ensuring proper documentation in the future.
Unsanitary Food Service Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions. Surveyors observed the ice machine with two plastic-like pipes inserted into a round floor opening with a steady flow of water and no air gap between the hoses and the floor opening on multiple observations. The facility policy required all ice machines used for resident dietary services, hydration, and medical needs to have a properly installed and maintained air gap to prevent contamination of potable water supplies. Surveyors also observed Dietary Aide F working in the kitchen and dining areas with visible facial hair and no beard covering. On multiple occasions, DA F discarded resident food from meal trays, cleaned kitchenware, sorted resident menu cards, drank from a beverage bottle while standing in front of the steam table, placed coleslaw on a serving plate, and delivered and retrieved resident meal trays without a beard covering. Staff interviews stated that kitchen staff should wear hair nets and beard covers when needed, and that employees with facial hair should wear a beard cover. In addition, surveyors observed large trash cans with no lids and exposed food and trash by the dish machine and by the steam table, with no dietary staff present. Facility policy required trash cans in kitchen and food service areas to have tight-fitting lids unless actively in use. The Dietary Manager, Maintenance Supervisor, and Administrator all acknowledged that trash cans should have lids when not in use, that staff with visible facial hair should wear beard covers, and that the ice machine should have an air gap to prevent potential backflow of contaminated water.
Late MDS Transmission
Penalty
Summary
The facility failed to electronically transmit MDS assessments in a timely manner and in accordance with required guidelines for three residents. Review of the facility policy showed that all required MDS assessments were to be completed and submitted electronically through iQIES, with successful transmission confirmed by validation reports. However, the records for the three sampled residents showed multiple quarterly MDS assessments that were completed but not accepted/transmitted until days to weeks after completion, including delays of 41 days, 30 days, 5 days, 30 days, 22 days, and 16 days. Resident #27 had quarterly MDS assessments with ARDs of 04/01/25 and 07/01/25 that were completed on time but accepted/transmitted 41 days late and 30 days late, respectively. Resident #36 had quarterly MDS assessments with ARDs of 04/01/25 and 07/01/25 that were completed on time but accepted/transmitted 5 days late and 30 days late, respectively. Resident #51 had quarterly MDS assessments with ARDs of 4/18/25 and 07/18/25 that were completed on time but accepted/transmitted 22 days late and 16 days late, respectively. During interviews, the Administrator stated a new MDS Coordinator had just been hired and was being trained, and the Corporate MDS Coordinator stated there had been a software glitch that was later fixed.
Failure to Individualize Care Plans for Hospice, Smoking, and Safety Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans with specific interventions for three sampled residents. Review of the facility policy showed that care plans were to be person-centered, address clinical needs such as hospice, smoking, and safety issues, and contain measurable objectives and timetables. For Resident #5, who was admitted to hospice on 07/01/25 and had diagnoses including chronic kidney disease stage three, depression, UTI, and hypertension, the care plan revised 08/16/15 did not address hospice services with specific interventions. For Resident #51, who was admitted to hospice on 09/24/24 and had protein malnutrition, the care plan revised 07/23/25 also did not address hospice services with specific interventions. For Resident #71, the August 2025 physician order sheet included an order to check the Wander Guard every shift, the smoking assessment identified the resident as a safe smoker, and the admission MDS indicated the resident was not a smoker and had an elopement alarm used daily. The care plan revised 8/15/25 did not address smoking with specific interventions and did not address the Wander Guard with specific interventions. During observations, the resident was seen smoking in the designated smoking area with staff supervision and later was observed sitting on the side of the bed with a Wander Guard on the left ankle. Interviews with the Care Plan Coordinator, DON, and Administrator confirmed that hospice services and smoking should have been addressed on the care plans with interventions.
Failure to Update Care Plans After Repeated Falls
Penalty
Summary
The facility failed to update and revise comprehensive care plans with specific interventions tailored to individual needs for two residents. Resident #12 had diagnoses including Alzheimer's disease, dementia, history of falls, UTI, hypertension, and an unspecified head injury. The resident experienced multiple falls, including a fall with no injury on 01/10/25, another fall with no injury on 01/29/25, and a fall on 02/03/25 that resulted in a laceration to the left eye, a facial fracture, and a subdural hematoma. The care plan, revised on 04/04/25, was not revised or updated after these multiple reported falls and did not include interventions for safety measures. Resident #58 had diagnoses including Parkinson's disease, Alzheimer's disease, bipolar disorder, UTI, and hypertension. The resident had repeated falls, including an unwitnessed fall on 03/25/25, a witnessed fall on 05/09/25, and additional unwitnessed falls on 06/06/25, 06/23/25, 07/07/25, 07/30/25, and 08/21/25. The care plan, revised on 05/28/25, included an intervention for the resident rolling off the bed frequently with checks throughout the shift, but it was not revised or updated after the multiple falls and did not add further safety interventions. During interviews, the DON and Administrator stated that fall interventions should be in place and the care plan should be updated to ensure safety measures for the residents.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility failed to ensure staff reconciled narcotics at each shift change for two medication carts and one medication storage room. The facility policy required narcotic medications to be reconciled at key transition points, including change of shift counts, with outgoing and incoming nurses performing the count together and resolving any discrepancies before the outgoing nurse left. Review of the narcotic count logs showed repeated missed opportunities to reconcile controlled substances on the 100/200 Hall medication cart, the 500 Hall medication cart, and the medication room over multiple date ranges. The DON stated that oncoming and outgoing staff should count the narcotics before leaving or starting their shift and that two signatures should be in the Narcotic Count Book on every medication cart and in the medication room. A CMT and an LPN both stated that two staff members count the narcotics together and sign the Narcotic Count Book on the medication cart. The Administrator also stated that the oncoming and outgoing staff should count the cart together and sign the Narcotic Count Book every shift.
Failure to Use EBP During Resident Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during incontinent care for one resident and catheter care for another resident. The facility policy stated EBP was to be used for residents with wounds, indwelling medical devices, or other risk factors, and required gloves and gowns for high-contact care activities before entering the resident’s space. Resident #13 had a history of ESBL bacteria in the urine, an indwelling catheter order, and EBP for skin concerns on both legs. During observation of catheter care, CNA A performed hand hygiene and put on gloves but did not put on a gown before entering the resident’s room and providing catheter care. CNA A later stated a gown should have been worn because the resident had a catheter and wounds to the legs. Resident #6 had EBP signage on the door and PPE available in the room. During observation of incontinent care, CNA B and CNA C entered the room without gowns, performed hand hygiene inconsistently, and donned gloves while providing care. LPN D also entered the room without a gown, performed hand hygiene, and put on gloves before assessing a new open area on the resident’s inner thigh and assisting with repositioning. CNA C stated he/she was not aware of what EBP meant, and CNA B and LPN D stated they should have worn gowns before entering the room. The DON and Administrator stated staff were expected to put on PPE before entering rooms for residents on EBP.
Failure to Inspect Mobility Rails and Bed Safety Equipment
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and side rails for three sampled residents and one resident outside the sample. Review of the facility policy showed side rails were to be assessed for safety and checked each shift, but the policy did not address inspections of side rails or mobility rails used for repositioning. The maintenance supervisor stated side/mobility rails were inspected quarterly and that there was no documentation of a monthly inspection, while the administrator said staff would be expected to check side rails at least monthly per policy. Resident #5 had diagnoses including chronic kidney disease stage three, depression, UTI, and hypertension, and no maintenance inspection was documented for the mobility rail. Observations showed a U-shaped mobility rail on both sides of the bed that moved with minimal effort, and the resident stated the right rail was loose. Resident #40 had COPD, anxiety, diabetes mellitus, dementia, and upper body weakness, with no maintenance inspection documented; observations again showed U-shaped mobility rails on both sides of the bed that moved with minimal effort, and the resident said the rails were used to turn over in bed. Resident #43 had chronic kidney disease stage three, depression, and UTI, with no maintenance inspection documented; the mobility rail on the right side of the bed moved with minimal effort, and the resident said it was used to get up and go to the bathroom at night. Resident #52 had diabetes mellitus, chronic pain, and atrial fibrillation, with no maintenance inspection documented; observations showed U-shaped mobility rails on both sides of the bed that moved with minimal effort, and staff gave conflicting information about whether the rails belonged on the bed.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and distribution processes, which could potentially affect all 72 residents. Observations revealed that temperature checks for two standup refrigerators were not conducted over several days, and various food items in the freezers were either undated or past their expiration dates. Additionally, the kitchen was found to have unsanitary conditions, including trash cans without lids, a buildup of grease and grime on kitchen equipment, and broken floor tiles. Further observations in the canned goods area showed expired food items, and the dish machine area had a buildup of dirt and debris, with a bristle brush and a panel unattached from the wall lying on the floor. Interviews with the Dietary Manager and the Administrator confirmed that these practices were not in line with the facility's policies, which require daily cleaning and monitoring of kitchen equipment and food storage areas.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect by exposing two residents during care. Resident #9, who has severe cognitive impairment and is always incontinent of bowel, was observed on 09/11/24 during incontinent care performed by two CNAs. The CNAs did not close the window curtains, leaving the resident's breast and genitalia exposed to the view of the parking lot and yard outside. This lack of privacy was contrary to the facility's expected practice as described by staff interviews. Similarly, Resident #11, who has diagnoses including dementia and metabolic encephalopathy, was observed on 09/12/24 during wound care. The CNAs and an LPN assisting with the care closed the door to the hallway but left the window curtains open, exposing the resident's genitalia and buttocks to the outside. Interviews with staff, including a CNA and the DON, confirmed that the standard procedure should have included closing the window curtains to maintain resident privacy during such care activities.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for its residents, as evidenced by several observations made during a survey. On the 500 hall unit, issues included a three-foot piece of base trim peeled off the bottom wall of a closet, a piece of wood trim hanging off the bottom of another closet, and several areas of exposed sheetrock and peeled paint on a wall above a bed. In the courtyard, two electrical conduits with broken zip ties were observed hanging low from a wooden awning. Additionally, in one room, five stuffed animals were placed on top of an overbed light fixture. Further deficiencies were noted in the shower room on the 400 hall, where a four-foot cove base trim was missing, and the floor of the shower stall had a buildup of brown grime near the drain. The toilet had dried fecal matter on the lid, and a large shower chair had a dried brown substance on its seat and surrounding surfaces. Interviews with housekeeping staff revealed that they had not yet cleaned the showers and bathrooms on the morning of the survey, and they were unaware of any environmental issues to report to maintenance. The Maintenance Supervisor indicated that repairs should be documented in writing to ensure timely addressing of issues.
Failure to Provide Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide a written copy of the notice of transfer or discharge to the residents and/or their responsible parties, as well as to the representative of the Office of Long-Term Care (LTC) Ombudsman, for three residents out of four sampled. This deficiency was identified during a review of the facility's policy and resident records. The facility's policy, revised in March 2021, mandates that residents and/or their representatives be notified in writing, in a language and format they understand, prior to transfer or discharge. However, the policy did not address the requirement to send a monthly transfer log to the Office of the State LTC Ombudsman. For Resident #9, there was no documentation of written notification with the reason for the hospital transfer provided to the resident and/or the responsible party, nor was there documentation of the written transfer/discharge notification provided to the representative of the Office of the LTC Ombudsman. Similarly, for Resident #21, there was no documentation of written notification for two hospital transfers. Interviews revealed that the Regional LTC Ombudsman had not received any transfer logs from the facility this year, and the Administrator was unaware of the requirement to provide written notices and send transfer logs to the Ombudsman.
Failure to Complete Timely Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days for a resident who was admitted to hospice care. This deficiency was identified for one resident out of three sampled closed resident records, with the facility's census being 72. The facility's policy on comprehensive assessments, revised in October 2023, mandates that a Significant Change in Status Assessment (SCSA) should be conducted when the Interdisciplinary Team determines a resident meets the significant change guidelines. However, the policy did not specify a timeframe for submitting a significant change assessment. The medical record review for the resident showed that they were admitted to hospice care on June 7, 2024, but the facility did not complete the significant change MDS within the required 14 days. Interviews with the RN, Director of Nursing (DON), and the Administrator confirmed that a significant change assessment should have been completed within 14 days upon the resident receiving hospice services. The facility does not have an in-house MDS Coordinator and relies on a virtual coordinator from the corporate office, which may have contributed to the oversight.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the accuracy of resident records. Resident #9, who was admitted with diagnoses including cerebral infarction and dysphagia, experienced a fall and was sent to the hospital on July 18, 2024. However, the resident's admission and quarterly MDS did not reflect any prior falls, indicating a failure to accurately code the resident's MDS. Interviews with facility staff confirmed that the fall occurred and should have been documented in the MDS. Similarly, Resident #15, admitted with chronic atrial fibrillation, insomnia, and Type 2 diabetes, had discrepancies in their MDS regarding insulin injections. The resident's annual MDS inaccurately showed that they received one insulin injection weekly, while the quarterly MDS indicated zero injections. A review of the Physician's Order Sheet from April to September 2024 showed no insulin injections prescribed, further highlighting the inaccuracy in the MDS documentation. Interviews with the facility's LPN and RN confirmed that changes in a resident's condition should be accurately reflected in the MDS, and the facility's administration acknowledged the expectation for accurate MDS coding.
Failure to Document PASARR for Two Residents
Penalty
Summary
The facility failed to provide documentation of a Level I Preadmission Screening and Resident Review (PASARR) for two residents out of 18 sampled. Resident #21, who was admitted on an unspecified date, had diagnoses of schizophrenia, violent behavior, and generalized anxiety disorder, yet lacked a Level I PASARR in their medical record. Similarly, Resident #43, admitted on another unspecified date, had diagnoses of a psychotic disorder, traumatic brain injury, and dementia, but also did not have a Level I PASARR documented. During an interview, the Administrator acknowledged the absence of the PASARR documentation for these residents and mentioned efforts to obtain them from previous facilities, with plans to initiate new assessments.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and provided to a resident within 48 hours of admission, as required by their policy. The baseline care plan is intended to meet the resident's immediate health and safety needs and should include specific interventions and a written summary for the resident or their representative. In this case, the facility did not document a written summary of the baseline care plan for a resident who was admitted with diagnoses of coronary artery disease, renal insufficiency, diabetes mellitus, and depression. The resident reported not receiving any paperwork, and the Director of Nursing was unaware that the baseline care plan needed to be given to the resident or their representative. The facility's process for creating and distributing baseline care plans was inadequate, as the MDS coordinator and care plan coordinator worked offsite, and a part-time nurse was not responsible for completing MDS and care plans. The Director of Nursing stated that the MDS coordinator always generates a computer-based care plan upon admission, but there was no evidence that this plan was shared with the resident. The Administrator confirmed that the MDS coordinator worked offsite but had access to the facility's computer system, indicating a potential gap in communication and execution of the baseline care plan process.
Failure to Follow Physician's Order for Fall Mats
Penalty
Summary
The facility failed to adhere to a physician's order for the placement of fall mats for a resident. The resident, who was admitted with diagnoses including abnormal involuntary movements, epilepsy, and muscle spasms, had a physician's order dated January 29, 2024, for fall mats to be placed on both sides of their bed. However, observations on multiple occasions in September 2024 revealed that a fall mat was only placed on the left side of the resident's bed, with no mat on the right side as ordered. Interviews with the Director of Nursing and the Administrator confirmed that they expected fall mats to be placed on both sides of the bed when ordered by a physician. This oversight indicates a failure to follow the physician's directive, potentially compromising the resident's safety.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted with diagnoses of PTSD, major depressive disorder, and anxiety disorder, did not have a documented PTSD assessment in their medical record. Despite having physician orders for medications related to PTSD and anxiety, the resident's care plan did not address PTSD or include any documentation of past trauma or triggers that could lead to behaviors. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of awareness and implementation of PTSD assessments for residents with such diagnoses. The DON acknowledged the absence of a PTSD assessment and stated that it should be part of the resident's care plan, including triggers and interventions. The Administrator also expressed an expectation for residents with PTSD to have care plans addressing their condition, including triggers and interventions.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to provide sufficient nursing staff to answer call lights in a timely manner, impacting the residents' rights and their physical, mental, and psychosocial well-being. The facility's policy on answering call lights was not adhered to, as evidenced by the wireless nurse call system report log, which showed numerous instances of delayed response times ranging from over an hour to more than seven hours. Interviews with residents revealed consistent complaints about the long wait times for call lights to be answered, particularly during the night shift. Several residents reported that their call lights were not answered promptly, with some waiting for hours without receiving assistance. One resident mentioned having a bowel movement and not being changed all night, while another resident stated that they had to wait until their lunch tray was brought to them before their call light was addressed. The issue was further compounded by staff practices, where some CNAs admitted to clearing call light notifications on their facility-issued iPhones without providing the necessary care to the residents. The facility's call light system involves a two-step process, which requires staff to acknowledge the alert on their iPhones and then turn off the call light in the resident's room after providing care. However, interviews with CNAs revealed that this process was not consistently followed, as some staff members turned off call lights without attending to the residents' needs. The facility administrator expressed that staff should not turn off call lights without providing care, indicating a disconnect between policy expectations and actual practice.
Infection Control Deficiencies in Resident Care and Kitchen Practices
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinent care and wound care for several residents. Observations revealed that Certified Nurse Aides (CNAs) did not wear gowns while performing incontinent care for residents with gastrostomy tubes and Foley catheters, despite Enhanced Barrier Precautions (EBP) signage on the doors. Additionally, during incontinent care, CNAs did not change gloves or perform hand hygiene after cleaning the peri-area before placing a clean brief on a resident. Similarly, during wound care, a Licensed Practical Nurse (LPN) did not change gloves or perform hand hygiene between removing a soiled dressing and applying a clean dressing. The facility also failed to implement a risk management process specific to Legionella disease, as evidenced by the absence of a water flow diagram identifying areas at risk for Legionella growth. The Maintenance Supervisor confirmed the lack of such a diagram, although water temperatures were monitored weekly. This deficiency had the potential to affect all residents, staff, and the public. In the kitchen, dietary staff did not perform hand hygiene between serving residents' meal plates. Observations showed that dietary staff re-entered the kitchen and served meals without washing hands between residents, even after touching tables and residents. Interviews with dietary staff and management revealed a lack of awareness regarding the necessity of hand hygiene between serving each resident, contributing to the deficiency in infection control practices.
Failure to Document Vaccine Education
Penalty
Summary
The facility failed to document the provision of education regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines for five residents. The facility's policy requires that residents or their legal representatives receive this information prior to vaccination, and that the education provided is documented in the resident's medical record. However, for Residents #2, #6, #21, #24, and #31, there was no documentation of such education being provided, despite some of these residents receiving or refusing the vaccines. The Director of Nursing confirmed that education should be provided and documented before any vaccine administration. The Administrator indicated that the Social Services Designee was responsible for obtaining consents and providing education, but there was no Social Services Designee present during the annual survey. This lack of documentation and absence of a designated staff member to handle the education process contributed to the deficiency identified by the surveyors.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to conduct at least twelve hours of annual in-service education for two Certified Nurse Aides (CNAs) out of a sample of two, despite having a policy in place that mandates such training. The policy, revised in August 2022, requires all staff to participate in initial orientation and annual in-service training to ensure they can enhance residents' quality of life and demonstrate competency in training topics. However, a review of the in-service records for CNA N, hired in April 2023, and CNA O, hired in July 2023, showed no documentation of the required annual in-service trainings. During an interview, the Administrator acknowledged the requirement for CNAs to have at least 12 hours of training annually and noted that she believed the trainings had been documented, but committed to ensuring this would be done moving forward.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Campbell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Senior Living Malden | 8.6 mi | ★★★★★ | 0 | 0 |
| Gideon Care Center | 9.2 mi | ★★★★★ | 7 | 0 |
| Piggott Healthcare & Senior Living, Llc | 9.7 mi | ★★★★★ | 18 | 0 |
| Winchester Nursing Center, Inc | 13.8 mi | ★★★★★ | 0 | 0 |
| Heritage Nursing Center - Skilled Nursing By Ameri | 17.3 mi | ★★★★★ | 7 | 0 |
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