Above 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 Pearl's Ii Eden For Elders during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen and food storage areas, despite policies requiring clean, contaminant-free storage and regular defrosting of freezers. Observations showed grease on floors, dirty and debris-covered windows in dry storage, refrigerators and freezers with dirt, food debris, unreadable thermometers, and thick ice buildup, as well as dusty pipes and cords hanging over prep tables and food-contact surfaces. Dishes were stored face up under dusty ceilings with visible dust inside, and equipment surfaces such as the steam table and shelves near the mixer were coated with dust, sticky residue, and food splatter. The DM, RD, and Administrator all stated they expected clean, sanitary conditions and confirmed that dietary staff and the DM were responsible for cleaning, while all refrigerators and freezers observed were used to store resident food for a census of 34 residents.
The facility has not had a full-time Director of Nursing (DON) for the past two years, despite a census of 40 residents. Efforts to fill the position through local advertisements and posters have been unsuccessful. The absence of a DON was confirmed through observations and interviews with the Administrator, Administrative Assistant, and MDS Coordinator, who all acknowledged the necessity of having a DON.
The facility failed to address grievances and recommendations from the resident council, affecting all residents involved. Residents were unaware of grievance procedures, lacked access to forms, and were not informed of resolutions. Meetings were led by staff without a council president, and concerns about showers, call light wait times, and other issues were not formally addressed.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in addressing specific needs such as side rail usage, shower preferences, PTSD, and weight loss. The care plans did not accurately reflect the residents' needs and preferences, and there was a lack of physician orders for side rails. The MDS/Care Plan Coordinator acknowledged the need for updates, highlighting a disconnect between documented care plans and actual resident needs.
The facility failed to provide necessary personal hygiene services to residents due to staffing shortages, resulting in missed showers for several residents. A resident with hemiplegia and other conditions did not receive showers as scheduled, feeling unclean as a result. Another resident, dependent on staff for mobility and hygiene, missed 17 out of 34 shower opportunities, going 31 days without a shower. A cognitively impaired resident missed 8 out of 25 showers, and another resident missed 3 out of 8 showers in July. Staff cited frequent call-ins and lack of a designated shower aide as reasons for the deficiency.
The facility failed to implement preventative skin risk measures for a resident with severe cognitive impairment, leading to a worsening stage II pressure ulcer due to inadequate repositioning and toileting. Additionally, another resident at risk for pressure ulcers did not have documented wound care treatments on four occasions, indicating a failure to follow physician orders. The facility was unable to provide a wound care policy, highlighting gaps in procedures for managing pressure ulcers.
The facility failed to assess and manage bed rail use for four residents, leading to potential safety risks. Residents had bed rails installed without proper assessment, informed consent, or care planning. Staff interviews revealed confusion and lack of communication regarding the necessity and use of side rails.
The facility experienced significant staffing shortages, resulting in delayed call light responses, missed showers, and unclean living conditions for residents. Residents reported waiting over 30 minutes for assistance, with some waiting over an hour. Missed showers were common, with one resident going 31 days without a shower. Observations noted unclean rooms with food crumbs and trash. Staff interviews confirmed the impact of staffing shortages on care quality.
The facility failed to ensure five nurse aides completed a state-approved competency evaluation program within four months of hire. Nurse Aides A, D, and E were not enrolled in a certification course, while Nurse Aides B and C completed the course but awaited testing. The facility's practice of waiting 30 days to evaluate new hires before enrolling them contributed to this deficiency.
A facility failed to maintain a medication error rate below five percent, resulting in a 30% error rate affecting three residents. Errors included improper administration of nasal spray, eye drops, and insulin. The RN did not follow manufacturer's guidelines, leading to incorrect administration techniques.
The facility failed to securely store medications, leaving them at the bedside for three residents and an unattended, unlocked medication cart. A resident with impaired cognition had an inhaler left on their bedside table without an order for self-administration. Another resident with cognitive impairment had a cream left on their bedside table, and a third resident with no cognitive impairment had medication cups with tablets on a table next to them. Additionally, a medication cart was left unlocked and unattended in the hallway.
The facility exhibited multiple deficiencies in food safety and sanitation, including improper food labeling, inadequate hand hygiene, and insufficient sanitation practices. Staff failed to follow policies on food storage and preparation, leading to potential cross-contamination. Additionally, the facility's stove was not fully operational, affecting meal preparation.
The facility failed to implement proper infection prevention and control measures, affecting several residents. Staff did not use Enhanced Barrier Precautions for residents with COVID-19 or open wounds, and there were lapses in hand hygiene and PPE use. Additionally, laundry handling did not comply with facility policy, and staff were inadequately trained on infection control procedures.
A facility failed to manage a deceased resident's personal funds properly, resulting in unauthorized bank fees being charged due to an account balance below the bank's threshold. The facility could not provide a resident trust and banking policy, and a check issued with deducted fees was never cashed. The Administrator did not expect such charges on a resident's account.
A resident reported missing $1,300 from their purse, which was not protected by the facility. Despite the facility's policy to prevent misappropriation, staff were unaware of the resident's money and did not conduct thorough interviews or report the incident to law enforcement. The resident's family confirmed the money's existence, but the facility's investigation was insufficient.
A resident reported missing $1,300 from their purse, but the facility failed to notify law enforcement or the state survey agency as required by their policies. The resident, with intact cognitive skills, noticed the money missing and informed the staff. Despite the facility's policy mandating immediate reporting of such incidents, the Administrator admitted to not contacting the police or state agency, resulting in a deficiency.
A resident reported missing $1,300 from their purse, but the facility failed to follow its policy to investigate the allegation. The Administrator did not conduct interviews or notify law enforcement, and no police report was filed. Social Services confirmed the possibility of the missing money with the resident's daughter, but the investigation was incomplete, leading to a deficiency in handling the situation.
A resident's care plan was not updated to reflect an above-the-knee amputation, despite significant changes in their condition. The resident had a history of venous insufficiency ulcers, which led to the amputation. Facility staff acknowledged that care plans should be updated with significant changes, but the process was not followed.
A resident with a physician-ordered mechanical soft diet was served a regular hamburger, posing a choking risk. Despite the resident's cognitive impairment and dietary needs, staff failed to adhere to the prescribed diet. Interviews revealed a lack of awareness and adherence to dietary orders, with the facility's policy on diet order accuracy not being effectively implemented.
A facility failed to provide Trauma Informed Care for a resident with PTSD, as their care plan did not address the diagnosis or include triggers and interventions. Staff interviews revealed a lack of awareness and training on PTSD, and no Trauma Informed Care Assessment was completed. The facility also lacked a policy for trauma informed care.
A significant medication error occurred when an RN failed to prime an insulin pen before administering insulin to a resident with diabetes. The RN did not follow the necessary steps to ensure accurate dosing, such as priming the pen and leaving the needle in the skin for the recommended duration. The facility lacked a policy for insulin administration, contributing to the error.
Unsanitary Kitchen and Food Storage Conditions
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain the kitchen in a clean and sanitary condition in accordance with its own food storage and kitchen cleaning policies. The facility’s policies required food to be stored in clean, dry areas free of contaminants, with appropriate methods to ensure food safety, and called for regular defrosting of freezers as part of general and deep cleaning. During an observation of the kitchen, surveyors noted grease on the floor around the stove, an open dry storage room window covered with dirt, dust, and debris, and a freezer with dirt and debris on the door compartments and shelves, as well as a thick sheet of ice on the bottom. A subsequent observation showed that the dry storage room window remained open and dirty, and that multiple refrigerators and freezers used to store resident food contained dirt, food debris, and ice buildup. Further observations showed that dishes and food-contact items were stored in a manner that allowed contamination. Multiple blue bowls and white saucers were stored face up on a dish storage rack beneath a dusty ceiling, with visible dust inside the dishes. The freezer next to the dish storage rack had dirt and debris on the shelves and sides, and its bottom shelf still had a sheet of ice. Two metal pipes covered with dust and dirt hung over a prep table holding a food processor and microwave, and the top of the steam table and a shelf above the mixer were covered with thick dust and a sticky substance. An electrical cord covered in dust hung above a prep table containing silverware and glasses, and the wall behind the mixer had food splatter and dust. The Dietary Manager, Registered Dietitian, and Administrator each stated they expected the kitchen, including refrigerators and freezers, to be clean and sanitary, with freezers defrosted at least every six months (per DM and RD) or monthly (per Administrator), and dishes stored to prevent contamination, and confirmed that dietary staff and the Dietary Manager were responsible for cleaning and sanitation. The facility census at the time was 34 residents, and all kitchen refrigerators and freezers, including one in the back dining room, were used to store resident food.
Failure to Appoint a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis for the past two years, despite having a census of 40 residents. The facility did not provide a policy regarding the DON position. Observations during the survey confirmed the absence of a DON. Interviews with the Administrator and Administrative Assistant revealed that the facility had not had a DON for a couple of years, and efforts to fill the position through advertisements in the local paper and posters had not been successful. The Minimum Data Set (MDS) Coordinator and Administrator acknowledged that the facility should have a DON.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not considering the views of the resident council and not acting promptly upon grievances and recommendations made by the group. The facility did not demonstrate their response or provide a rationale for such responses, nor did they maintain documentation of attempts to resolve concerns or communicate follow-up actions to the council. This affected all residents serving on the resident council and potentially other residents in the facility, which had a census of 40. During interviews, resident council participants expressed that they were unaware of how to complete a grievance, lacked access to grievance forms, and did not know where to submit them. They also did not know they could hold meetings without staff present. Concerns were raised about showers not being given, long wait times for call lights, and slow responses from the facility on planned solutions. The review of resident council minutes from March to May 2024 showed no old business was documented or reviewed, no council president was assigned, and meetings were led by staff members. New business items such as lack of showers, crowded living areas, and other issues were noted, but no formal responses were provided to the council. Interviews with Activity Directors and the Administrator revealed that grievances or recommendations from meetings were forwarded to the Administrator but there was uncertainty about how residents were notified of resolutions. Meetings were advertised through various means, but families were not notified, and there was a lack of understanding about the resident council president's role. The Administrator expected residents to be satisfied with explanations for unmet concerns due to staffing issues and assumed residents knew how to file grievances, although they could not do so anonymously.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing specific care needs. For Resident #3, the care plan did not include the use of side rails, which the resident used for repositioning, nor did it address the resident's shower preferences, which were not consistently met due to staffing issues. Despite the resident's cognitive intactness and physical limitations, the care plan inaccurately described the resident as independent with physical limitations and did not reflect the resident's actual needs and preferences. Resident #19, who was severely cognitively impaired and dependent on a walker, had a care plan that failed to include the use of side rails, which were observed in use. The resident's care plan inaccurately stated that the resident could transfer independently, despite requiring substantial assistance. The MDS Coordinator acknowledged that side rails should have been included in the care plan, and there was a lack of physician orders for the side rails, indicating a disconnect between the resident's needs and the documented care plan. For Resident #6, the care plan did not address the diagnosis of PTSD, including potential triggers and interventions, despite the resident having intact cognition and a history of mental health conditions. Additionally, Resident #21's care plan did not address significant weight loss, which was documented over several months. The resident, who was severely cognitively impaired and dependent on staff for eating, reported a lack of appetite. The MDS/Care Plan Coordinator confirmed that the care plans should have addressed both the weight loss and PTSD diagnosis, highlighting a failure to update care plans with significant changes in residents' conditions.
Staffing Shortages Lead to Missed Showers for Residents
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. This deficiency was observed in four of the twelve sampled residents, who did not receive their scheduled showers. The facility did not have a policy for showers, and staffing shortages were cited as a primary reason for the failure to provide adequate care. Resident #6, who required substantial to maximum assistance for ADLs due to hemiplegia and other medical conditions, did not receive showers twice weekly as per their care plan. The resident expressed feeling dirty when showers were missed. Staff interviews revealed that the lack of a designated shower aide and frequent staff call-ins contributed to the inconsistency in providing showers. Resident #3, who was dependent on nursing staff for mobility and personal hygiene, missed 17 out of 34 scheduled shower opportunities over several months. The resident went 31 days without a shower, expressing dissatisfaction with the lack of care. Similarly, Resident #19, who was severely cognitively impaired, missed 8 out of 25 shower opportunities, going 18 days without a shower. Resident #37, who was cognitively impaired and required substantial assistance, missed 3 out of 8 shower opportunities in July, going 10 days without a shower. Staff interviews consistently highlighted staffing shortages as a barrier to completing scheduled showers.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure preventative skin risk measures were in place for a resident with severe cognitive impairment, who required assistance with mobility and was incontinent. The resident was identified as having a stage II pressure ulcer and was supposed to be frequently repositioned and have skin assessments conducted weekly. However, observations showed the resident remained in a wheelchair for extended periods without being repositioned or toileted, leading to a worsening of the pressure ulcer. Staff interviews revealed a lack of adherence to repositioning schedules and inadequate use of pressure-reducing devices. Another resident, who was at risk for pressure ulcers and required assistance with mobility, did not have documented wound care treatments on four occasions as per physician orders. The resident's treatment record lacked documentation for specific dates, indicating a failure to follow and document prescribed wound care treatments. Interviews with staff confirmed that treatments should be documented when completed, highlighting a lapse in following physician orders and maintaining accurate records. The facility was unable to provide a wound care policy when requested, indicating a potential gap in established procedures for managing and preventing pressure ulcers. The lack of documentation and adherence to care plans and physician orders contributed to the deficiencies observed in the care of these residents, affecting their overall skin integrity and health outcomes.
Failure to Assess and Manage Bed Rail Use
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for four residents, leading to potential safety risks. For Resident #3, the facility did not assess the risk of entrapment or obtain informed consent before installing bed rails, despite the resident's cognitive intactness and physical limitations. The resident used the side rails for repositioning, but there was no care plan in place for their use, and the facility did not provide a policy on entrapment or side rails. Resident #19, who was severely cognitively impaired, had a side rail installed without a physician's order or care plan. The resident was not able to verbalize the reason for the side rail, and staff interviews revealed confusion about its necessity. Similarly, Resident #1, who was also severely cognitively impaired, had side rails installed without proper assessment or care planning, despite being independent in some mobility aspects. Resident #192, with moderately impaired cognition, had side rails installed without a physician's order or proper assessment. The resident was unaware of the reason for the side rails, and staff interviews indicated a lack of understanding and communication regarding their use. The facility's failure to conduct entrapment assessments and ensure proper documentation and communication contributed to these deficiencies.
Staffing Shortages Lead to Delayed Care and Unclean Conditions
Penalty
Summary
The facility failed to maintain adequate staffing levels to meet the needs of its residents, resulting in delayed response times to call lights, missed showers, and unclean living conditions. Several residents reported waiting extended periods for assistance, with call light response times frequently exceeding 30 minutes and, in some cases, over an hour. This delay in response was corroborated by call light logs and interviews with residents and their family members. The lack of timely assistance led to residents feeling neglected and, in some instances, experiencing accidents due to the inability to reach the bathroom in time. In addition to delayed call light responses, the facility did not provide the required number of showers for some residents. For example, one resident missed 17 out of 34 scheduled shower opportunities, going as long as 31 days without a shower. Another resident missed 8 out of 25 scheduled showers, with a gap of 18 days between showers. Interviews with staff revealed that the facility's staffing shortages often resulted in the shower aide being reassigned to other duties, further contributing to the missed showers. The facility also failed to maintain resident rooms in a clean and sanitary manner. Observations noted food crumbs, sticky spots, and trash scattered across the floors and furniture in several residents' rooms. Housekeeping staff reported difficulties in maintaining cleanliness due to the residents' presence in the rooms and the facility's staffing challenges. Interviews with staff and residents highlighted the ongoing issues with cleanliness and the impact of staffing shortages on the facility's ability to provide a clean and safe environment for its residents.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that five nurse aides completed a competency evaluation program approved by the state within four months of hire. The facility's census was 40, and the deficiency was identified through interviews and record reviews. Nurse Aide A was hired on April 24, 2024, but was not enrolled in a state-approved certification program. During an interview, Nurse Aide A confirmed that they had not yet enrolled in a Certified Nurses Aide (CNA) course, despite being aware of the requirement. Similarly, Nurse Aides B, C, D, and E were not registered as CNAs in the state registry, although Nurse Aides B and C had completed the certification course and were awaiting testing. The facility's administrative assistant revealed that the facility typically waited 30 days after hiring a nurse aide to assess their performance before enrolling them in a certification course. This evaluation included reviewing the quality of work and attendance. However, this practice resulted in Nurse Aides A, D, and E not being enrolled in the certification course within the required timeframe. The administrator acknowledged that nurse aides should be certified within four months of hire, indicating a lapse in the facility's adherence to regulatory requirements.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 30% error rate. This deficiency affected three residents out of a sample of 12, with the facility census being 40. The facility did not provide policies for medication administration, including nasal sprays, eye drops, or insulin administration. For Resident #30, the registered nurse (RN) did not follow the manufacturer's guidelines for administering Flonase nasal spray. The nurse failed to have the resident blow their nose and did not close one side of the nostril before administering the spray. The nurse acknowledged the oversight during an interview, admitting that the manufacturer's instructions should have been followed. Resident #6 received Systane Balance Solution eye drops, but the RN allowed the dropper tip to touch the resident's eyelashes and did not apply lacrimal pressure as required. The nurse admitted to not following the correct procedure. For Resident #22, the RN did not prime the insulin pen before administering insulin and failed to leave the needle in the skin for the recommended time. The nurse acknowledged these errors during an interview.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to store medications securely, resulting in medications being left at the bedside for three residents and an unattended, unlocked medication cart. Resident #15, who had moderately impaired cognition and required assistance with various activities, was observed with a Combivent inhaler left on the bedside table without an order for self-administration. The resident's care plan did not include an assessment for self-administration, and staff confirmed that the resident did not self-administer medications. Resident #192, also with moderately impaired cognition and dependent on staff for assistance, had Clobestasol Propionate cream left on the bedside table. There was no assessment for self-administration, and staff confirmed that the resident did not self-administer medications. The MDS Coordinator mentioned that medications were left in rooms for residents with COVID-19, which was the case for Resident #192. Resident #27, who had no cognitive impairment, was found with a stack of medication cups containing various tablets on a table next to them. The resident did not remember when they received the medication. Additionally, a medication cart was observed unlocked and unattended in the hallway, which was acknowledged by RN B as a mistake. The facility lacked a policy on medication storage, and the administrator stated that medications should never be left at the bedside or carts left unlocked and unattended.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food labeling, storage, preparation, and sanitation practices. Observations revealed that food items in the refrigerator were not properly labeled or dated, including opened containers of milk, chocolate syrup, and bread. The Dietary Manager and staff demonstrated a lack of understanding of the facility's policies, with inconsistent practices regarding the dating and discarding of leftovers. Additionally, the facility did not follow standardized recipes or production charts, leading to inconsistencies in meal preparation, particularly for pureed meals. Hand hygiene and glove use were also found to be inadequate, with staff failing to wash hands between tasks and improperly using gloves. Observations showed staff touching various surfaces and residents without changing gloves or washing hands, which could lead to cross-contamination. The facility's policies on handwashing and glove use were not consistently followed, and staff were not adequately trained on these procedures. The facility's sanitation practices were insufficient, with improper testing of the dishwasher for sanitation levels and inadequate cleaning of food preparation surfaces. The use of inappropriate cleaning solutions, such as mixing dish soap with Comet cleaner, was observed, and staff were not aware of the correct procedures for sanitizing surfaces. Additionally, the facility's stove was not fully operational, impacting the ability to prepare meals effectively. The Dietary Manager and Administrator acknowledged the stove's issues but had not resolved them due to financial constraints.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, affecting five residents out of the 12 sampled. Resident #142, who tested positive for COVID-19 and required intermittent urinary catheterization, was not placed on Enhanced Barrier Precautions (EBP). The care plan did not address the resident's care needs after testing positive for COVID-19, and staff were observed not using proper precautions when providing care. Similarly, Resident #17, who had a stage II pressure ulcer, was not placed on EBP, and staff failed to sanitize their hands or use personal protective equipment (PPE) appropriately when providing care. The facility also failed to ensure proper handling of soiled laundry and adherence to hand hygiene guidelines. Laundry Aide A was observed transporting uncovered carts of clean laundry, contrary to facility policy, and was not adequately trained on the need to cover laundry inside the building. Additionally, staff members, including CNAs and RNs, were observed not following hand hygiene protocols, such as washing hands after glove removal or before administering medications. This was evident in the handling of medications for Residents #30, #6, and #37, where staff used bare hands to handle medications, violating standard precautions. Furthermore, the facility did not ensure that staff were adequately trained on infection control procedures, particularly in the context of COVID-19 precautions. Staff members, including CNAs and housekeepers, were observed entering COVID isolation rooms without proper PPE, such as N95 masks, and failing to sanitize between resident interactions. Interviews with staff revealed a lack of training and understanding of infection control measures, contributing to the deficiencies observed during the survey.
Unauthorized Bank Fees Charged to Deceased Resident's Account
Penalty
Summary
The facility failed to properly manage and account for a deceased resident's personal funds, resulting in unauthorized bank fees being charged to the resident's account. Specifically, the facility charged a deceased resident's account with bank service fees of five dollars per month over a period, totaling twenty dollars, without reimbursement to the resident's guardian or responsible party. The issue arose because the account balance fell below the bank's threshold of two thousand dollars, leading to service charges. The facility was unable to provide a resident trust and banking policy when requested. Interviews with the Administrative Assistant and the Administrator revealed that a check was mailed on behalf of the closed resident's account, which included the deduction of the unauthorized bank fees, and the check was never cashed. The Administrator stated that they would not expect a resident's personal funds account to incur bank fees.
Failure to Protect Resident's Property
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a resident reported missing $1,300. The resident, who had intact cognitive skills and required assistance with certain activities, reported the missing money to a Certified Nurse Aide and a Registered Nurse. The resident stated that the money was kept in an envelope in their purse, and they were unsure when it went missing. The facility's policy requires reporting and investigating such incidents, but the facility did not provide a copy of the resident's care plan. The facility's investigation involved a handwritten statement by a Registered Nurse and a typed statement by the Administrator. The resident's family was informed, and Social Services searched the resident's room but could not locate the missing money. The resident's daughter confirmed that the resident received a monthly check, which was cashed and kept in the resident's purse. Despite the facility's policy to protect residents from misappropriation, the staff was unaware of the resident's money or the presence of a safe in the room. Interviews with the resident, Social Services, and the Administrator revealed that the facility did not conduct individual staff interviews or contact the police to file a report. The Administrator acknowledged the lack of interviews and the failure to report the incident to law enforcement. The facility's inaction and lack of thorough investigation contributed to the deficiency in protecting the resident's property.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of funds for a resident who reported missing $1,300. Despite the resident's report, the facility did not notify law enforcement or the state survey agency as required by their policies. The facility's policy mandates that any alleged violations involving misappropriation of property be reported immediately to the appropriate authorities, including the state licensing agency and local law enforcement. However, the Administrator admitted to not notifying the police or the state survey agency, stating that she did not consider contacting law enforcement. The resident involved, identified as having intact cognitive skills, reported the missing money to the staff. The resident had approximately $1,500 in a purse and noticed the money was missing around mid-July. The resident's family was aware of the money and was informed of its disappearance. The facility's social services department searched the resident's room, but the money was not found. The resident was advised not to keep money in the room, and staff were reminded to be vigilant. The facility's policies, revised in 2017, clearly outline the procedures for reporting such incidents, including the requirement to notify various agencies and individuals within specific time frames. Despite these guidelines, the Administrator failed to follow the protocol, resulting in a deficiency in the facility's handling of the situation. The lack of immediate reporting to the appropriate authorities constitutes a breach of the facility's established procedures for managing allegations of misappropriation.
Failure to Investigate Misappropriation Allegation
Penalty
Summary
The facility failed to follow its policy and investigate an allegation of misappropriation when a resident reported missing $1,300. The resident, who had intact cognitive skills and required assistance with daily activities, reported the missing money to a Certified Nurse Aide and a Registered Nurse. The resident stated that the money was kept in an envelope in their purse, and upon checking, the envelopes were missing. The facility's policy requires the Administrator to assign an investigation to an appropriate individual and keep the resident informed of the progress, but this was not done. The Administrator did not conduct a thorough investigation as required by the facility's policy. Although the Administrator and Social Services were informed of the missing money, no police report was filed, and the state survey agency was not notified. The Administrator did not interview staff members or witnesses, nor did they notify the Ombudsman. The Administrator admitted to not seeing the need to interview each individual person and did not consider notifying law enforcement. Social Services attempted to verify the resident's claim by speaking with the resident's daughter, who confirmed the possibility of the resident having such an amount of money. Despite this, the investigation was not completed according to the facility's policy, as no statements from staff were collected, and the investigation's findings were not documented. The lack of a proper investigation and failure to report the incident to the appropriate authorities constituted a deficiency in the facility's handling of the situation.
Failure to Update Care Plan After Resident's Amputation
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plan for a resident who had undergone an above-the-knee amputation of the left leg. Despite the significant change in the resident's condition, the care plan was not updated to reflect this amputation. The resident's annual minimum data set (MDS) indicated various dependencies and medical conditions, including venous insufficiency and surgical wounds. However, the care plan, last revised several months prior, did not include the amputation, which was a significant oversight given the resident's medical history and current condition. Interviews with facility staff, including the MDS Coordinator and the Administrator, revealed that care plans should be updated every ninety days and with significant changes, such as an amputation. The facility utilized a contract consolidator for care plan updates, but communication and timely updates were lacking. The resident expressed that the facility struggled to heal his/her venous insufficiency ulcers, which ultimately led to the amputation. The failure to update the care plan was a clear deficiency in the facility's care planning process.
Failure to Adhere to Physician-Ordered Diet
Penalty
Summary
The facility failed to ensure an environment free of accident hazards when a resident was not served a physician-ordered mechanical soft diet and was instead given a regular hamburger on a bun. This incident placed the resident at risk for choking hazards. The resident, who was severely cognitively impaired and had a mechanically altered diet, was observed eating a hamburger from a fast-food restaurant after returning from an out-of-facility doctor appointment. The dietary manager noted that the resident was motivated to leave the facility by receiving a fast-food meal after appointments. The resident's care plan indicated a need for a mechanical soft diet due to oral/dental health problems and GERD, with specific instructions to avoid certain foods. Despite this, the resident was served a regular hamburger, which was inconsistent with the physician's orders. Interviews with facility staff, including the MDS Coordinator, CNAs, and the Registered Dietician, revealed a lack of awareness and adherence to the prescribed diet. The MDS Coordinator and Registered Dietician both expressed that the mechanical soft diet should have been followed, and the resident should not have been served a regular hamburger. The facility's policy required regular checks for diet order accuracy, but the incident suggests a failure in this process. The MDS Coordinator mentioned that the facility had been serving the resident regular meals for years without observing any swallowing issues. The Administrator acknowledged the resident's motivation to attend appointments was linked to receiving hamburgers and fries, indicating a possible oversight in prioritizing dietary needs over motivational strategies.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide Trauma Informed Care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's quarterly Minimum Data Set (MDS) indicated intact cognitive skills, hemiplegia, depression, bipolar disorder, anxiety, psychotic disorder, and PTSD. However, the resident's care plan did not address the PTSD diagnosis, including potential triggers and interventions. Additionally, there was no Trauma Informed Care Assessment completed for the resident, and the facility lacked a policy for trauma informed care. Interviews with facility staff, including registered nurses, certified nurse aides, and the MDS/Care Plan Coordinator, revealed a lack of awareness and training regarding PTSD. Staff members were unsure if any residents had a PTSD diagnosis and had not received training on managing PTSD or identifying triggers. The Social Services staff was aware of the resident's brain injury and PTSD diagnosis, but this information was not effectively communicated or incorporated into the resident's care plan. The deficiency was further highlighted by the absence of any documented behaviors related to PTSD in the resident's records.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure a safe and effective medication administration system, resulting in a significant medication error involving a resident. The error occurred when a registered nurse (RN) did not prime an insulin pen before administering insulin to a resident with diabetes mellitus. The resident's physician's order sheet and medication administration record indicated the use of an Insulin Lispro insulin pen, with specific instructions for dosage before meals and per sliding scale based on blood sugar levels. However, during an observation, the RN attached the needle to the insulin pen but did not prime it, which is a necessary step to remove air from the needle and cartridge and ensure accurate dosing. The RN administered six units of insulin to the resident, whose blood sugar was 195, without priming the pen or leaving the needle in the skin for the recommended duration. During interviews, the RN acknowledged the mistake, stating that the pen should have been primed with two units and that the needle should have been left in the skin for five seconds. The MDS/Care Plan Coordinator confirmed that staff should prime the insulin pen and leave it in the skin for three to five seconds. The facility did not provide a policy for the administration of insulin or medications, contributing to the deficiency.
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 20 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Princeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastview Manor Care Center | 21.8 mi | ★★★★★ | 7 | 0 |
| Sunnyview Nursing Home & Apartments | 21.8 mi | ★★★★★ | 10 | 1 |
| Lamoni Specialty Care | 23.8 mi | ★★★★★ | 3 | 0 |
| Westview Acres Care Center | 24.8 mi | ★★★★★ | 0 | 0 |
| Crestview Home | 25.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.