Below 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 Stonebridge Adams Street during CMS and state inspections, most recent first.
Staff failed to follow safe transfer practices for two residents, including improper use of a mechanical lift and failure to use a gait belt. One resident, cognitively intact and dependent for transfers, was moved with a mechanical lift whose legs closed during the transfer, and staff interviews indicated the legs may not have been locked despite education to keep them open and locked for stability. Another resident, moderately cognitively impaired and dependent for transfers, was moved by a single CNA who lifted the resident from a wheelchair to a bed without a gait belt, even though a gait belt was available in the room, and contrary to facility expectations that staff use a gait belt for all transfers.
Surveyors found that staff failed to follow infection prevention and control policies during care for a resident who required extensive toileting assistance and had a Foley catheter. Despite EBP signage on the door, two CNAs entered without gowns, and one CNA performed perineal care and multiple high-contact tasks (repositioning, dressing, hygiene, oral care, and denture care) while wearing the same soiled gloves, repeatedly omitting required hand hygiene. The CNA removed the resident’s nasal cannula, placed it unprotected on a bedside table with tubing on the floor, later picked up the tubing from the floor, attached it to a portable tank, and reapplied the cannula without changing the tubing or performing hand hygiene. In interviews, the CNA admitted missing hand hygiene and PPE use, and an LPN, the administrator, and the DON confirmed that EBP requires gown and gloves for physical contact and that oxygen tubing must be replaced if it touches the floor.
Facility staff did not consistently provide the number of CNA/NA and CMTs required by their own facility assessment and staffing policy for their census, with multiple days showing insufficient staffing on day and evening shifts. The administrator acknowledged responsibility for scheduling and indicated plans to adjust the assessment to match current staffing practices.
A resident with severe cognitive impairment and dysphagia did not consistently receive or have documentation of prescribed G-tube feedings, as required by physician orders. Review of records showed multiple missed or undocumented administrations, and staff interviews confirmed that documentation was expected but not completed. Facility policy lacked clear direction on documentation, and oversight was attributed to changes in nursing leadership.
Staff failed to deliver hot meals to residents in a timely manner, resulting in food being served at temperatures below the required 120°F. Meals were left on an un-enclosed cart for extended periods before being delivered to rooms, and temperature checks confirmed that food was not hot when served. Residents reported receiving cold meals, and staff interviews revealed lapses in monitoring and adherence to facility policies regarding food safety and timely meal distribution.
The facility failed to conduct required Employee Disqualification List (EDL) and criminal background checks (CBC) for eight out of ten sampled employees before hiring, contrary to their policy. Additionally, the facility did not have a policy to check the Nursing Assistant (NA) registry for all employees prior to hire, resulting in seven employees being hired without these checks. The Business Office Manager (BOM) admitted to bypassing these procedures due to staffing shortages, and both the Director of Nursing (DON) and Administrator were unaware of these lapses.
Facility staff failed to accurately assess side rail use and complete entrapment risk assessments for several residents, leading to deficiencies in care. Observations showed residents using side rails or grab bars, contrary to their assessments. Interviews revealed inconsistencies and lack of clarity among staff regarding assessment responsibilities and procedures. Maintenance staff conducted entrapment measurements without residents in bed, potentially leading to inaccurate risk evaluations.
The facility did not meet the requirement of having an RN on duty for at least eight consecutive hours per day, seven days a week. Time-keeping records from August to October 2024 showed several instances of insufficient RN coverage, with one day lacking any RN presence. The DON and administrator acknowledged the deficiency but could not fully explain the lapses.
The facility staff did not adhere to standardized recipes, resulting in a failure to provide residents with a nourishing, palatable, well-balanced diet. The dietary staff served shepherd's pie with insufficient beef and no tomatoes, contrary to the recipe, leading to a runny consistency and incorrect portion size. The Dietary Supervisor reduced beef to avoid waste, and the Registered Dietician was unaware of these deviations.
The facility staff failed to properly store and handle food, leading to potential contamination. Observations showed undated and improperly stored food items in refrigerators, freezers, and dry storage. Ice scoops were improperly stored in ice, and meal plates were covered with lids that had holes, exposing food. The ice machine lacked a proper air gap. Staff interviews revealed a lack of awareness and adherence to protocols.
The facility failed to implement comprehensive infection control measures, including incomplete Legionella control plans, inadequate TB testing for employees, and improper hand hygiene during resident care. Staff were not adequately trained on Enhanced Barrier Precautions, leading to improper use of PPE.
The facility failed to develop comprehensive care plans for three residents, each with various medical conditions and cognitive impairments. The MDS/Care Plan Coordinator and DON acknowledged the oversight, admitting that the care plans were not completed within the required timeframe, contrary to the facility's policy.
Staff in an LTC facility failed to safely transfer two residents using a mechanical lift, contrary to the facility's policy requiring two staff members for such transfers. Observations showed a CNA left a resident suspended in the sling without assistance, and there was confusion among staff about the correct position of the lift's legs during transfers. Both residents had severe cognitive impairment and were dependent on staff for transfers.
The facility staff failed to maintain a medication error rate below 5%, resulting in a 25.93% error rate affecting two residents. A CMT administered incorrect insulin dosages without dating the insulin pens and gave multiple medications outside the prescribed timeframe. These errors were not reported or documented as required, as confirmed by interviews with the LPN, DON, and Administrator.
Facility staff failed to properly label and discard expired insulin medications, with observations revealing multiple opened and undated insulin pens in medication carts. Interviews with staff, including CMTs, an LPN, the DON, and the administrator, highlighted inconsistencies in understanding the expiration period and responsibility for dating insulin pens. The facility's policy requires checking expiration dates and recording the opening date, but adherence was lacking.
The facility failed to notify the Ombudsman about the transfer of four residents to the hospital, as required. Medical records lacked documentation of such notifications, and there was no policy in place for this process. Interviews revealed that the Social Services Director was unaware of the notification process, and the Administrator, responsible for the task, had not completed it due to time constraints.
Facility staff failed to provide written notification of the bed-hold policy to residents or their representatives during hospital transfers. The policy requires notification upon admission and prior to transfer, but records for four residents lacked documentation of such notifications. Interviews revealed that the Social Services Director was aware of the requirement but had not completed any notifications, and the Administrator acknowledged the lapse, citing the need for training the new SSD.
The facility failed to post and retain daily nurse staffing information as required by policy, with missing records for several months in 2024. Observations showed outdated postings, and interviews revealed confusion among staff about responsibilities for updating and retaining these records. The DON, who started in April, was unaware of prior processes, and the administrator cited staffing shortages as a reason for incomplete postings.
The facility failed to employ a qualified Director of Food and Nutrition Services, as the Dietary Supervisor lacked the necessary qualifications and experience. The DS, previously employed in hotels and restaurants, assumed the role without formal training or experience in a nursing facility. The HR Manager and administrator were unaware of the requirement for qualifications upon hire, leading to the absence of a full-time qualified dietitian or nutrition professional.
Facility staff failed to notify a resident's responsible party and physician after an unwitnessed fall. The resident, with severe cognitive impairment and other conditions, was found on the floor after sliding from their wheelchair. Despite facility policy requiring notification, the LPN did not inform the physician or family, considering it not a fall. Interviews confirmed the protocol was not followed.
Facility staff failed to conduct neurological checks for 72 hours after unwitnessed falls for three residents, as required by facility policy. Despite the expectation confirmed by LPNs and the DON, the necessary checks were not documented, leading to a deficiency.
Facility staff failed to complete neurological checks and fall follow-up documentation for three residents after unwitnessed falls. Despite protocols requiring 72-hour monitoring, documentation was missing for a cognitively impaired resident dependent on mobility, a cognitively intact resident using a wheelchair, and another resident with similar conditions. Interviews with LPNs and the DON confirmed the responsibility for these checks, but they were not completed.
Facility staff failed to follow the care plan for a resident requiring two-person assistance for transfers, resulting in a leg injury. Despite the care plan's directive, a CNA transferred the resident alone, leading to a commuted moderately displaced tibia-fibula distal shaft fracture. Interviews revealed inconsistencies in staff awareness and adherence to the resident's transfer needs.
Unsafe Mechanical Lift and Transfer Practices Without Gait Belt Use
Penalty
Summary
Facility staff failed to ensure safe mechanical lift transfers and proper use of gait belts, resulting in deficiencies related to accident hazards and inadequate supervision. For one resident, assessed as cognitively intact and dependent on staff for transfers and toileting hygiene, the care plan required assistance from two staff for transfers. During an observed transfer, two CNAs used a mechanical lift but the legs of the lift closed while the resident was being lowered into a wheelchair. CNA interviews revealed they had been educated to open and lock the legs of the mechanical lift for stability, and one CNA reported there had been issues with the lift legs opening and closing on their own and did not believe the legs were locked during the transfer. The administrator, DON, ADON, and an LPN all stated staff were directed to open and lock the legs of the mechanical lift during transfers for stability, and that staff should report equipment issues to maintenance, although the facility’s Hoyer Safety policy did not specify when to close the base of the lift. For another resident, assessed as moderately cognitively impaired and dependent on staff for transfers, the care plan required assistance from two staff members. Observation showed a CNA entered the resident’s room and transferred the resident alone by placing arms around the resident’s waist, lifting the resident out of the wheelchair with the resident’s feet in the air, and moving the resident to the bed without using a gait belt, despite a gait belt hanging inside the room by the door. The resident confirmed staff did not use a gait belt when transferring. The CNA stated the resident required assistance from one staff member, admitted not using the gait belt because it slipped their mind, and acknowledged the concern for potential injury when a gait belt is not used. An LPN, the administrator, and the DON each stated that staff are required to use a gait belt any time they are transferring a resident to prevent potential injury, and the facility did not provide a written policy regarding safe transfers using a gait belt.
Failure to Follow Hand Hygiene, EBP, and Oxygen Handling Practices During Resident Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene, use of Enhanced Barrier Precautions (EBP), and oxygen equipment handling. Facility policies required weekly and as-needed changes of oxygen tubing and masks/cannulas, implementation of EBP (gown and gloves) for residents colonized or infected with multidrug-resistant organisms or at increased risk, and strict hand hygiene before and after resident contact and personal care. Policies also specified that high-contact resident care activities such as dressing, transferring, providing hygiene, changing linens and briefs, toileting assistance, and device care required gown and glove use, and that hand hygiene was necessary when hands were visibly soiled, before and after direct resident contact, and after contact with body fluids or soiled items. The deficiency involved one resident who was cognitively intact, required substantial assistance with toileting hygiene, was incontinent of bowel, and had a Foley catheter. The resident’s door displayed EBP signage. Two CNAs entered the resident’s room to provide care without donning gowns, contrary to the EBP requirements posted on the door and outlined in facility policy. During perineal care, one CNA removed gloves and then applied clean gloves taken from another CNA’s pocket without performing hand hygiene. The CNA then continued care, including placing a clean brief, assisting with repositioning, and dressing the resident, while wearing the same soiled gloves. The same CNA continued to wear the soiled gloves while placing a mechanical lift sling, removing the resident’s nasal cannula, placing the cannula on the bedside table without a protective barrier or storage bag, and allowing the oxygen tubing to lie on the floor. The CNA then removed the resident’s shirt, put on a clean shirt, brushed the resident’s hair, washed the resident’s face, brushed the resident’s tongue, and left and re-entered the room without performing hand hygiene. The CNA later cleaned the resident’s dentures, applied and removed denture adhesive, and picked up oxygen tubing from the floor to attach it to a portable tank and reapply the nasal cannula, again without appropriate hand hygiene or glove changes. In interviews, the CNA acknowledged missing hand hygiene opportunities and not using PPE despite seeing the EBP signage, while the LPN, administrator, and DON confirmed that PPE use is required for EBP rooms and that oxygen tubing should be replaced if it touches the floor.
Failure to Provide Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
Facility staff failed to provide adequate nursing staff as determined by their own facility assessment and staffing policy. The facility assessment specified that, for an average daily census of approximately 54 residents, staffing should include six CNA/NA on day shift, four CNA/NA on evening shift, three CNA/NA on night shift, and two CMTs on day and evening shifts. However, review of staffing schedules over several weeks showed repeated instances where only three or four CNA/NA were scheduled on day shifts, and there were also days with insufficient CMT coverage. These staffing levels did not meet the requirements outlined in the facility's own assessment and policy. Interviews and record reviews confirmed that the administrator was responsible for scheduling and was training a new staffing coordinator. The administrator stated that staffing decisions were based on the facility assessment, census, and resident acuity, but also indicated an intention to change the assessment to reflect current staffing practices. The deficiency was identified through observation, interviews, and review of staffing records, which demonstrated that the facility did not consistently provide the number of direct care staff required to meet the needs of all residents as per their own standards.
Failure to Administer and Document Physician-Ordered G-Tube Feedings
Penalty
Summary
Facility staff failed to ensure that a resident receiving supplemental nutrition via a gastrostomy tube (G-tube) was administered tube feedings as ordered by the physician. The resident, who had severe cognitive impairment and was dependent on staff for eating due to dysphagia, had a physician's order for Fibersource HN Oral Liquid to be given through the G-tube four times daily. Review of the Treatment Administration Record (TAR) revealed multiple dates where there was no documentation that the ordered tube feedings were administered. The facility's enteral nutrition policy did not provide specific direction regarding documentation of scheduled tube feedings in the medical record. Interviews with nursing staff, the administrator, and the DON confirmed that staff are expected to document administration of nutritional supplements in the resident's medical record after each feeding. Both the administrator and DON stated that if documentation was missing in the TAR, it was assumed the feeding was not administered. The Regional Director of Operations acknowledged that audits of the TARs to verify completion of documentation had not been performed due to changes in the DON position, resulting in an oversight.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
Facility staff failed to ensure that prepared food items were served at a safe and appetizing temperature due to delays in meal delivery and inadequate maintenance of hot food temperatures. Observations showed that meals were plated by dietary staff and then left on an un-enclosed cart, covered with insulated dome plate covers, before being delivered to residents on the 300 and 400 halls. Staff prioritized serving residents in the dining room before delivering trays to those eating in their rooms, resulting in extended periods where trays remained on the cart. Temperature checks revealed that hot food items, such as fish and rice, were served at internal temperatures significantly below the required 120°F, with recorded temperatures of 91.5°F and 98°F, respectively. Interviews with residents confirmed that meals were often received cold, with one resident stating that breakfast was cold and lunch was only slightly warmer. Staff interviews indicated that nursing staff were responsible for timely meal delivery to residents' rooms, but the Director of Nursing had not monitored meal service for several weeks. The administrator acknowledged that meals should not have been served at temperatures below 98°F and that hot foods should be above 120°F when served. Facility policies required food to be kept out of the danger zone (41°F to 135°F) and distributed in a timely manner to prevent contamination and maintain proper temperature, but these procedures were not followed during the observed meal service.
Failure to Conduct Required Background and Registry Checks for New Employees
Penalty
Summary
The facility staff failed to adhere to their own policies and procedures regarding background checks and registry checks for new employees, leading to a deficiency in ensuring the safety of residents. Specifically, the facility did not conduct Employee Disqualification List (EDL) checks and/or criminal background checks (CBC) prior to hiring eight out of ten sampled employees, including CNAs, LPNs, and other staff members. This oversight was contrary to the facility's policy, which mandates that such checks be completed before employment. The Business Office Manager (BOM) admitted to pushing employees through the hiring process without completing the necessary screenings due to being shorthanded, and only initiated the paperwork during orientation. Additionally, the facility lacked a policy directing staff to check the Nursing Assistant (NA) registry for all employees prior to hire. This resulted in seven employees being hired without the necessary NA registry checks, which are crucial for identifying individuals with federal indicators of abuse or neglect. The BOM was unaware that the NA registry checks were required for all employees and mistakenly believed they were only necessary for verifying certification. The Director of Nursing (DON) and the Administrator were also unaware of these lapses in procedure. Interviews with the BOM, DON, and Administrator revealed a lack of awareness and communication regarding the importance of these checks and the facility's policies. The BOM acknowledged the responsibility for conducting these checks but failed to do so, while the DON and Administrator expressed expectations that these checks should be completed prior to hire. The deficiency highlights a significant gap in the facility's hiring process, potentially exposing residents to individuals who may pose a risk to their safety.
Deficiency in Side Rail Assessments and Entrapment Risk Evaluations
Penalty
Summary
The facility staff failed to accurately assess the use of side rails for several residents, leading to deficiencies in the safety and care provided. Specifically, the staff did not complete entrapment risk assessments for five residents, despite the presence of side rails or grab bars in their beds. The facility's policy on the proper use of side rails requires such assessments to evaluate the risk of entrapment, but these were not documented in the medical records of the affected residents. Observations revealed that residents were using side rails or grab bars, contrary to the documentation in their assessments. For instance, one resident was observed with grab bars in the upright position, although their assessment indicated no use of such devices. Interviews with facility staff, including the MDS/Care Plan Coordinator and the Director of Nursing, highlighted inconsistencies and a lack of clarity regarding the responsibility for completing these assessments and the procedures for conducting entrapment measurements. The facility's maintenance staff conducted entrapment measurements without the residents in bed, which could lead to inaccurate assessments of the risk posed by the side rails. Interviews with the maintenance staff and nursing personnel revealed uncertainty about whether residents should be present during these measurements. The Director of Nursing and the Administrator acknowledged the need for coordination between maintenance and nursing staff to ensure that side rail assessments and entrapment measurements are completed accurately and in a timely manner.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week, as required by their policy. The facility's census was 53, and the review of the facility's time-keeping records for August, September, and October 2024 revealed multiple instances where RN coverage was less than the required eight hours. Specific dates included August 17 and 18, September 1, 7, 8, and 29, and October 5, 19, and 26, with hours ranging from 4.87 to 7.9 hours. Notably, on September 29, there was no RN coverage at all. During interviews, the Director of Nursing (DON) and the administrator acknowledged the deficiency. The DON mentioned that the shortfall in hours might have been due to lunch breaks and admitted to not having an explanation for the lack of RN coverage on September 29. The administrator also recognized the failure to meet the eight-hour requirement and similarly could not explain the absence of RN coverage on the specified date.
Failure to Follow Standardized Recipes for Resident Meals
Penalty
Summary
The facility staff failed to provide residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs due to not following standardized recipes. The facility's policy required the use of tested, standardized recipes, which should be adjusted to the number of portions required for a meal. However, during an observation, it was noted that the dietary staff served a #8 scoop (four ounces) of shepherd's pie that contained more potatoes than ground beef and lacked tomatoes, resulting in a runny consistency. This was contrary to the standardized recipe, which specified the inclusion of 16 pounds of ground beef, tomatoes, peas, carrots, and a specific portion size. Interviews revealed that the Dietary Supervisor admitted to using only about eight pounds of beef and omitting tomatoes to avoid leftovers, which would go to waste. The Registered Dietician was unaware of the deviation from the recipe and expected the staff to adhere to the standardized recipes. The RD also noted that the shepherd's pie should be firm and served as a three-inch by three-inch portion, not a four-ounce scoop, and was uncertain if the scoop size equated to the specified portion size. This failure to follow the standardized recipe led to the deficiency in providing a proper diet to the residents.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility staff failed to adhere to proper food storage and handling protocols, leading to potential contamination and outdated use of food items. Observations revealed that various food items in the kitchen refrigerators and freezers were opened and undated, including parmesan cheese, chopped garlic, dressings, juices, and various frozen goods. Additionally, dry storage areas contained open and undated packages of noodles, rice, and oatmeal, some of which were stored on the floor, contrary to the facility's policy. The Dietary Manager acknowledged that all dietary staff were responsible for labeling and dating items, but this was not consistently done. The facility also failed to store ice scoops in a manner that prevents contamination. Multiple staff members, including a shower aide, nurse aide, and housekeeper, were observed placing ice scoops back into the ice after use, rather than storing them in designated holders. Interviews with staff indicated a lack of awareness or adherence to proper ice scoop storage procedures, which could lead to bacterial growth and contamination. Furthermore, the facility did not maintain the ice machine drain air gap, as required. The ice machine drain ran to an open floor drain without an air gap, which was not recognized by the Dietary Manager or the plant supervisor. Additionally, meal plates delivered to residents were covered with lids that had holes, exposing the food to potential contamination. The Registered Dietician and Dietary Manager were unaware of these issues, indicating a lack of oversight and adherence to food safety protocols.
Deficiencies in Infection Control and Employee TB Testing
Penalty
Summary
The facility failed to develop and implement comprehensive policies and procedures for the inspection, testing, and maintenance of its water systems to prevent the growth of waterborne pathogens, including Legionella. The facility's Risk Management Plan for Legionella Control was found to be incomplete, lacking specific policies related to water management, a description of the facility's water system, and control measures with acceptable ranges and corrective actions. Interviews with the Plant Supervisor and Housekeeping Supervisor revealed a lack of guidance and knowledge regarding the Legionella control plan, particularly concerning unused showers and bathtubs, which were identified as potential high-risk areas. The facility also failed to ensure that the two-step purified protein derivative (PPD) skin test for Tuberculosis (TB) was completed for six out of ten sampled employees. Employee files lacked documentation of the first or second step PPD completion, despite the facility's policy requiring TB screening for all new hires. Interviews with the Business Office Manager and the Director of Nursing (DON) indicated a lack of oversight and tracking of TB testing, resulting in staff members not completing the two-step TB test timely. Additionally, staff failed to perform proper hand hygiene during perineal care for four residents, as observed during the survey. Staff did not change gloves or wash hands between dirty and clean tasks, increasing the risk of infection spread. The facility's Enhanced Barrier Precautions (EBP) policy was not implemented effectively, as staff were not educated or alerted about residents requiring EBP, and appropriate personal protective equipment (PPE) was not placed in close proximity. Observations showed that staff did not wear gowns when required, and interviews revealed a lack of awareness and training on EBP among staff members.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, as required by their policy. Resident #20, who was admitted with cognitive impairment and multiple diagnoses including cancer and stroke, did not have a care plan addressing issues such as delirium, dementia, communication, and pain management. Similarly, Resident #49, with moderate cognitive impairment and conditions like renal failure and dementia, lacked a care plan for communication deficits, ADL care, and other identified needs. Resident #56, who was admitted from and discharged to an acute hospital, also did not have a care plan addressing visual deficits, ADL care, and other needs. Interviews with the MDS/Care Plan Coordinator and the Director of Nursing revealed that the care plans were overlooked and not completed within the required timeframe. The MDS Coordinator acknowledged the oversight, and the Director of Nursing admitted to not having a good reason for the care plans not being done or updated. The facility's policy mandates that comprehensive care plans be developed within seven days after the completion of the MDS assessment, but this was not adhered to for the residents in question.
Unsafe Mechanical Lift Transfers in LTC Facility
Penalty
Summary
Facility staff failed to safely transfer two residents using a mechanical lift, leading to potential accident hazards. The facility's policy requires at least two nursing assistants to perform transfers with a mechanical lift, ensuring one staff member controls the lift while the other guides the resident. However, during an observation, a CNA left a resident suspended in the sling without two staff present, contrary to the policy. The CNA acknowledged the mistake, stating that the resident should have been lowered back to the chair for safety before leaving the room. Additionally, there was confusion among staff regarding whether the legs of the mechanical lift should be opened or closed during transfers, with conflicting practices observed. Both residents involved were assessed as having severe cognitive impairment and were dependent on staff for transfers. The care plans for these residents specified that two staff members should assist with mechanical lift transfers. Despite this, observations showed that staff did not consistently follow the correct procedures, such as leaving a resident suspended in the air and closing the lift's legs during transfers, which could compromise stability. Interviews with staff revealed a lack of clarity and consistency in following the facility's policy, contributing to the unsafe transfer practices observed.
Medication Administration Errors and Lack of Reporting
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in a 25.93% error rate during the observation of 27 medication administration opportunities. This deficiency affected two residents. For Resident #16, the Certified Medication Technician (CMT) administered incorrect dosages of insulin, specifically 30 units of Fiasp and 65 units of Tresiba, without the insulin pens being dated with an open or beyond use date. The CMT acknowledged the requirement for dating insulin pens and the potential impact on insulin effectiveness if not dated, but relied on informal communication with nurses and other CMTs to determine the open date. For Resident #36, the CMT administered multiple medications, including ProFe, Pioglitazone, Metoprolol, Furosemide, and Glimepiride, outside the prescribed timeframe, specifically one hour and ten minutes late. The CMT attributed the delay to the resident leaving the dining room before receiving the medications and subsequently forgetting to administer them on time. The CMT typically documents late administration in the resident's chart and monitors subsequent medication timing. Interviews with the LPN, DON, and Administrator confirmed that these incidents were considered medication errors, yet they were not reported or documented as required.
Failure to Properly Label and Discard Expired Insulin Pens
Penalty
Summary
The facility staff failed to store medications safely and effectively by not properly labeling or discarding expired insulin medications. During observations, it was found that two medication carts contained multiple opened and undated insulin pens, including Lantus, Novolog, Novolin, Glargine, Aspart, Fiasp, and Tresiba. Interviews with staff, including Certified Medication Technicians (CMTs), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the administrator, revealed inconsistencies in understanding the expiration period of insulin pens and the responsibility for dating them upon opening. The facility's policy requires that the expiration or beyond-use date be checked before administering medications and that the date of opening be recorded on multi-dose containers. However, staff interviews indicated a lack of adherence to this policy, with some staff unsure of the expiration period and others unaware of the undated insulin pens. The DON and administrator acknowledged that the Assistant Director of Nursing (ADON) and DON should monitor the dating of insulin pens, but they were not aware of the issue until it was brought to their attention.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility staff failed to notify the Ombudsman regarding the transfer of four residents to the hospital. The residents involved were transferred on various dates, and their medical records lacked documentation of Ombudsman notification. The facility's policy review revealed that there was no existing policy for notifying the Ombudsman about resident transfers. Interviews with facility staff highlighted a lack of awareness and responsibility regarding the notification process. The Social Services Director was unaware of the process, and the Administrator admitted that the task of notifying the Ombudsman was her responsibility, but she had not had time to complete it. This oversight affected four residents, indicating a systemic issue in the facility's communication and notification procedures.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility staff failed to provide written information to residents and/or their representatives regarding the facility's bed-hold policy at the time of transfer to a hospital for four residents out of a sample of 14. The facility's policy, dated March 2022, mandates that residents be informed of the bed-hold policy upon admission and prior to any transfer for hospitalization or therapeutic leave. However, the medical records of Residents #25, #34, #38, and #54 showed no documentation that they or their responsible parties were notified of this policy when they were discharged and subsequently readmitted. Interviews with facility staff revealed a lack of clarity and execution regarding the bed-hold policy. The Social Services Director (SSD) acknowledged awareness of the requirement but indicated that the charge nurse was responsible for the task, which was not being completed. The SSD admitted to not having completed any bed-hold notifications for residents upon transfer or discharge. The facility's Administrator confirmed that the bed-hold notifications were not being conducted, attributing the oversight to the previous SSD's failure to perform the task and the need for training the new SSD.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis, which is a violation of their policy and regulatory requirements. The policy mandates that the facility must post the number of nursing personnel responsible for providing direct care to residents for each shift, and this information should be readily available to residents and visitors. Additionally, the facility is required to maintain these records for a minimum of 18 months. However, the facility did not retain nurse staffing postings for several months in 2024, including January, February, March, April, and various dates in May, June, July, August, September, and October. Observations and interviews revealed that the facility's daily nurse staffing postings were not consistently updated or retained. On December 1, 2024, the posting displayed was dated November 22, 2024. The Director of Nursing (DON), who started in April, was unaware of the process for retaining the staff posting sheets prior to their tenure and could not explain the missing records. The administrator and Assistant Director of Nursing (ADON) shared responsibilities for posting the sheets, but there was confusion about who was responsible for updating the postings with call-outs or illnesses. The administrator admitted that the postings for January through April were not completed due to staffing shortages and the absence of a permanent DON during that period.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to designate a qualified individual to serve as the Director of Food and Nutrition Services. The facility's policy requires the director to meet specific qualifications, such as being a Certified Dietary Manager (CDM), a certified food service manager, or having two or more years of experience in a similar role in a nursing facility setting with completed coursework in food safety and management. However, the Dietary Supervisor (DS) did not possess any of these qualifications. The DS, who had previously worked in hotels and restaurants, was hired as a cook and later assumed the DS position without any formal dietary manager training or experience in a nursing facility. Interviews with the DS, Human Resources (HR) Manager, and the administrator revealed a lack of awareness and understanding of the qualification requirements for the DS role. The HR Manager and the administrator acknowledged the absence of the necessary qualifications at the time of hire, mistakenly believing that the DS could complete the required training after being hired. The DS was enrolled in a food service manager course through the facility's food service vendor, but no course date had been set. This oversight resulted in the facility not employing a qualified dietitian or clinically qualified nutrition professional full-time, as required.
Failure to Notify Physician and Family After Resident's Unwitnessed Fall
Penalty
Summary
Facility staff failed to notify a resident's responsible party and physician following an unwitnessed fall. The facility's policy requires staff to promptly inform the resident, their attending physician, and representative of any changes in the resident's condition or status, including accidents or incidents. The resident in question, who has severe cognitive impairment, right-sided paralysis, and vascular dementia, was found on the floor after sliding from their wheelchair. Despite the incident, staff did not document any notification to the physician or family. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that the protocol was not followed. The LPN involved did not consider the incident a fall and thus did not notify the necessary parties. However, the facility's policy and the Director of Nursing's statement indicate that any unwitnessed fall, including situations where a resident places themselves on the floor, should be reported to both the physician and family. The resident's family member confirmed they were not informed of the incident.
Failure to Conduct Neurological Checks After Unwitnessed Falls
Penalty
Summary
The facility staff failed to complete neurological checks for three residents who experienced unwitnessed falls. According to the facility's policies, neurological checks should be conducted for 72 hours following such incidents. However, for Resident #1, who had a fall with injury, there was no documentation of neurological checks being completed after the fall. Similarly, Resident #2, who had a fall with injury, also lacked documentation of the required neurological checks. Resident #3, who had an unwitnessed fall, did not have the necessary neurological checks documented either. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that neurological checks are expected to be performed for 72 hours following unwitnessed falls or falls with head injuries. Despite this expectation, the checks were not documented for the residents in question. The staff's failure to adhere to the facility's protocol for post-fall monitoring led to the deficiency identified in the report.
Failure to Complete Neurological Checks and Documentation Post-Fall
Penalty
Summary
The facility staff failed to complete required neurological checks and fall follow-up documentation for three residents who experienced unwitnessed falls. The facility's protocol mandates a post-fall initial clinical assessment immediately after each fall and a 72-hour monitoring period with neurological assessments. However, for Resident #1, who was assessed as cognitively impaired and dependent for mobility, there was no documentation of the 72-hour neurological checks following an unwitnessed fall. Similarly, Resident #2, who was cognitively intact and independent with a wheelchair, also lacked documentation of the required checks after an unwitnessed fall. Resident #3, who was cognitively intact but dependent on a wheelchair, did not have the necessary neurological checks documented after their fall. Interviews with facility staff, including two LPNs and the Director of Nursing (DON), revealed that the nurses were responsible for initiating and completing the neurological checks and fall follow-up documentation for 72 hours post-fall. The DON acknowledged the responsibility to ensure these checks were completed but was unable to explain why they were not done. The facility administrator also confirmed the expectation for nurses to conduct and document these checks, with the DON overseeing their completion. Despite these expectations, the required documentation was missing for all three residents.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
Facility staff failed to provide a proper transfer for a resident, resulting in an injury. The facility's Safe Lifting and Movement of Residents Policy mandates the use of appropriate techniques and devices for lifting and moving residents, with specific transfer assistance needs documented in the care plan. The resident in question had severe cognitive impairment, was dependent on transfers, had impairments in both lower extremities, and used a wheelchair for mobility. The care plan indicated that the resident required two-person assistance for transfers. However, on the day of the incident, a CNA transferred the resident alone, despite the resident's complaints of pain and visible signs of injury. This resulted in a commuted moderately displaced tibia-fibula distal shaft fracture, as confirmed by hospital discharge paperwork. Interviews with various staff members revealed inconsistencies in their understanding and adherence to the resident's transfer requirements. Some staff members were unaware of the resident's assessed transfer needs, while others had been transferring the resident alone despite the care plan's directive for two-person assistance. The physical therapist noted that the resident's transfer needs could vary depending on their behavior and dementia progression, but the care plan had consistently required two-person assistance for almost a year. The facility administrator acknowledged that staff should follow the care plan as per facility policy but was unaware that the resident had been assessed as needing two-person assistance for such an extended period.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 2 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jefferson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Villa Marie | 0.8 mi | ★★★★★ | 0 | 0 |
| Capitol River Wellness & Rehabilitation | 0.8 mi | ★★★★★ | 0 | 0 |
| Heisinger Bluffs Rehab And Healthcare Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Heisinger Bluffs Healthcare Western Campus | 1.6 mi | ★★★★★ | 0 | 0 |
| Jefferson City Manor Care Center | 1.8 mi | ★★★★★ | 8 | 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.