Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Emerald Nursing & Rehab Brookside Llc during CMS and state inspections, most recent first.
Unlocked medication carts were observed unattended in the hall, including carts with computer screens left open and resident information displayed. An LPN confirmed the carts were unlocked and should always be locked with resident information hidden, and the DON confirmed another unattended cart outside a resident's room should have been locked with resident information concealed. The facility policy stated medication carts were to be locked when not in use and access limited to authorized personnel.
A resident who was incontinent and required substantial to maximal assistance with toileting hygiene had skin concerns documented on admission, including bruising, scabs, and redness in skin folds and the buttocks area. Although skilled observations, bathing, and incontinence care occurred during the stay, none of the skilled observation notes documented skin checks, and a later-created skin/wound form noted the resident refused a skin assessment. The DON confirmed there was no documentation of skin being observed or assessed during the stay.
Infection control standards were not followed during wound care and resident care for two residents. An LPN changed gloves during wound care without performing hand hygiene, and an RN and DON were observed doing a bed change without gowns for a resident on EBP. During wound care, the RN touched the resident’s foot with clean gloves, used scissors from a pocket without cleaning them, and later handled resident items and clean supplies without hand hygiene, with the RN and DON confirming cross contamination occurred.
Failure to Notify Physician and Legal Representatives of AMA Departures: The facility did not document timely notification to the MD/PA-C, guardian, or POA when multiple residents left or failed to return after signing out AMA. One resident with osteomyelitis, quadriplegia, and HTN left with a court-appointed guardian not notified; another resident with severe malnutrition, hepatic failure, and alcohol abuse left AMA without POA notification. Additional residents with metabolic encephalopathy, dementia, DM2, acute respiratory failure, CKD, and other conditions also had no documentation that the physician was notified when they left or did not return.
Surveyors identified multiple environmental and sanitation deficiencies across three units, including strong urine odors and numerous stains on hallway carpets, a crumbling and uncleanable bathroom doorway wall with debris on the floor, and an unclean resident refrigerator/freezer with multiple spills. On one unit, the ice machine room had a sink mounting coming apart with sharp edges, an ice machine with brown residue on the inner door, a missing rubber seal, dried white substance behind the unit, an illuminated "Clean" indicator, and an overflowing trash can touching the ice maker lid. Two residents reported lack of hot water in their room, one stating it had been cold for two months, and a CNA reported very slow-to-warm water after a pipe burst; subsequent checks showed hot water temperatures remaining in the low 80s°F despite running the tap, confirming inadequate hot water for resident use.
Bathroom ventilation was not functional in four sampled resident rooms, including rooms 308, 502, 504, and 505. Surveyors also found additional rooms with nonfunctioning exhaust fans during the initial tour, and the Adm confirmed the issue when retested. The facility had an undated exhaust fan inspection document, but the Adm stated there was no specific bathroom ventilation policy.
The facility failed to transmit a required MDS record for a resident who had an entry assessment and a discharge return not anticipated assessment completed, but the discharge MDS was not sent to CMS. An MDS RN said the discharge MDS was treated as part of the Medicare 5-day assessment and therefore not transmitted, while another MDS RN confirmed the facility missed the submission. The Administrator stated the facility used the RAI manual for MDS accuracy and that the MDS nurses had not logged into the state site since September 2025.
A resident with DM and needing supervision for personal hygiene did not receive documented nail care, and the EHR and CCP contained no nail-care task or refusal documentation. Observations showed the resident’s fingernails remained too long and jagged over multiple checks, while staff said nurses were responsible for trimming diabetic residents’ nails on bath days and the DON confirmed the nails were too long and needed trimming.
Failure to track and resolve repeated RC complaints about cold food. Multiple residents reported that meals, coffee, and other hot items were often served cold, and several said they had raised the issue in RC meetings without any meaningful response. RC minutes documented ongoing complaints and concern that grievances were not being followed up on, but grievance logs for several months did not include the reported issues. The SSD and SSA confirmed they attended RC meetings, took notes, and assumed GO duties, yet the complaints were not logged as required by facility policy.
Failure to Employ a Full-Time Qualified Social Worker: The facility did not employ a qualified social worker on a full-time basis. The SSA and SSD stated they did not have a bachelor's degree in social work or a human services field, and the SW consultant reported coming to the facility only once a week to every other week, at least two to three times a month, while confirming he was not a full-time employee.
An LPN did not follow Enhanced Barrier Precautions while providing wound care to a resident with diabetic foot ulcers, failing to don a gown and to perform hand hygiene between glove changes as required by facility policy. The LPN was unaware that EBP applied to wound care, and the DON confirmed that these precautions were expected for residents with chronic wounds.
The facility failed to report and investigate an incident involving two cognitively impaired residents found in a compromising situation, despite both being unable to provide details due to severe cognitive impairment. Staff observed and internally reported the event, but no external report or resident assessment was completed, contrary to facility policy requiring immediate investigation and reporting of suspected abuse.
Staff failed to properly store and handle medications for two residents, resulting in drugs being left unsecured in resident rooms and used inappropriately. In one case, a medication aide used Nystatin powder left on a toilet for a resident with severe cognitive impairment, and in another, a medication cup with cream was left on a bedside table for a resident with moderate cognitive impairment and no self-administration order. The facility lacked a medication storage policy, and staff interviews confirmed these practices.
Staff did not perform hand hygiene before donning gloves or between glove changes during peri-care and catheter care for two residents, including one with severe cognitive impairment and another with a Foley catheter. Staff also failed to wear gowns as required for Enhanced Barrier Precautions and did not dry cleansed areas, with these actions confirmed by the DON as inconsistent with facility policy.
The facility did not accurately code MDS assessments for falls in three residents. One resident's fall with a cervical fracture and other falls with injury were not properly documented on the MDS, while another resident's MDS incorrectly indicated recent falls with injury despite no supporting documentation. A third resident's unwitnessed fall was not recorded on the MDS. These errors were confirmed by the MDS nurse coordinator and identified through record review and staff interviews.
A resident with severe protein calorie malnutrition and GERD was administered Omeprazole only 18 minutes before breakfast, despite a physician's order to give the medication 60 minutes prior to eating. The medication aide and corporate nurse consultant confirmed the timing did not meet the order, resulting in a failure to follow professional standards for medication administration.
A resident's bathroom floor was found to be unsanitary, with cracked tiles, a large brown stain, and cracked caulking with brown stains around the toilet. These conditions were confirmed by the Administrator, indicating a failure to maintain cleanliness.
A resident suffered burns from using a rice cooker in their room, which staff failed to remove despite being aware of it. Another resident, at risk for falls, was improperly assisted off the floor without a full assessment. These deficiencies led to an immediate jeopardy situation, later resolved with corrective actions.
The facility did not ensure residents could access their personal fund money during weekends, holidays, or evening/overnight hours, affecting 65 residents. A resident expressed concerns about limited access, and the Business Office Manager confirmed that funds could only be accessed during business hours. The facility's policy lacked provisions for ongoing access to petty cash for resident requests outside these hours.
The facility failed to maintain proper infection control practices, including a non-functional handwashing sink in the laundry area, inadequate enhanced barrier precautions for a resident with a catheter, improper hand hygiene during peri-care, and incorrect storage of oxygen tubing for multiple residents. Staff interviews revealed a lack of understanding and adherence to infection control protocols, contributing to the risk of cross-contamination.
The facility did not provide the required 12 hours of ongoing training for five direct care staff members, including Medication Aides and Nurse Aides, who had been employed for over a year. This deficiency was confirmed by the Human Resources Director and had the potential to impact all 112 residents in the facility.
A facility failed to follow its standardized recipes during meal preparation, affecting the nutritional needs of 110 residents. An observation revealed that a cook did not measure ingredients as per the meatloaf recipe and admitted to not being trained for the task. The facility's policy requires adherence to written menus and recipes, but this was not followed, as confirmed by the facility administrator.
The facility failed to ensure proper storage and labeling of medications at multiple nursing stations. Temperature logs for medication refrigerators were incomplete, and medication bottles lacked opening dates. Additionally, a resident with moderately impaired cognition had unauthorized access to medication in their room without a self-administration order.
A facility failed to evaluate a resident's ability to self-administer medications and ensure medication security. The resident, diagnosed with COPD and unspecified intellectual disabilities, was cognitively intact but had no care plan for self-administration. Observations showed the resident self-administering inhalers without staff presence, and the DON confirmed no evaluation or physician's order for self-administration.
The facility failed to provide written notices of transfer to three residents when they were transferred to the hospital, as required by policy. A resident with hemiplegia and hemiparesis, another with chronic respiratory failure, and a third resident were all transferred without the necessary documentation. Interviews confirmed the absence of written notices, indicating non-compliance with state requirements.
The facility failed to provide written bed hold notices to three residents or their representatives within 24 hours of hospital transfer, as required by policy. This oversight was confirmed through record reviews and interviews with facility staff, including the DON and CNC.
A resident with severe cognitive impairment suffered a head injury when accidentally hit by a door. Despite facility policy requiring neurological assessments for head trauma, no such assessments were documented. The facility's Corporate Nurse Consultant confirmed the oversight, indicating a failure to follow established protocols.
The facility failed to maintain cleanliness in Stations 1, 3, and 4, compromising residents' right to a safe environment. Observations revealed insulation pieces at Station 1, and Station 3's hallway had debris, food stains, and dead bugs. Station 4's hallway was dirty with debris, and the activity area had torn paper towels and dried food. Interviews confirmed the hallways were scheduled for daily cleaning but were not adequately maintained.
The facility failed to maintain a clean environment in several rooms and hallways, with dirty tray tables, sticky floors, and dirty carpets observed. The Nurse Consultant confirmed these issues and noted the difficulty in hiring weekend housekeeping staff. The facility census was 107.
The facility failed to obtain daily weights for a resident with congestive heart failure and did not complete a Basic Metabolic Panel (BMP) for another resident as ordered by the physician. The Director of Nursing and Nursing Consultant confirmed these deficiencies.
The facility failed to ensure proper hand hygiene and glove changes during and after catheter care for a resident. The Medication Aide did not perform hand hygiene before donning gloves and entering the resident's room, and did not change gloves or perform hand hygiene after handling various items and completing catheter care. The Nurse Consultant confirmed these lapses, which were against the facility's policy on catheter care.
Unlocked Medication Carts and Visible Resident Information
Penalty
Summary
The facility failed to ensure medications were stored and locked in a secure manner. During an observation on 05/18/2026 at 8:02 AM, three medication carts in the 300 hall were left unattended and unlocked, and two of the carts had computer screens left open with resident information displayed. An LPN confirmed at 8:05 AM that all three carts were unattended and unlocked and that two computer screens were open with resident information visible, and stated the carts should always be locked with resident information hidden. Later that morning, an observation at 9:56 AM revealed another unlocked and unattended medication cart outside a resident's room with a piece of paper containing resident information on top. The DON confirmed at 9:57 AM that medication carts should have been locked when left unattended and resident information should be concealed. The facility's Medication Storage & Security policy stated medication carts were to be locked when not in use and access was limited to authorized personnel.
Failure to Document Skin Assessments for a Resident at Risk for Impaired Skin Integrity
Penalty
Summary
The facility failed to perform or document skin assessments for a resident who was admitted on 04/09/2026 and later discharged after transfer to the hospital. On admission, the resident was frequently incontinent of both bladder and bowel and required substantial to maximal assistance with toileting hygiene. The nursing admission data collection documented bruising to both arms, scabs to both knees, redness in the abdominal folds and under the breasts, and a bottom area described as red but not open, with no measurements or further descriptions recorded. The baseline care plan identified the resident as at risk for impaired skin integrity. Skilled observations were completed on multiple days between 04/10/2026 and 04/20/2026, but none included skin observations. The record also documented refusals of incontinence care on 04/10/2026, 04/12/2026, and 04/16/2026, and bathing was documented on 04/15/2026 and 04/18/2026. A skin/wound weekly observation dated 04/16/2026 stated the resident had refused the skin assessment, but the form was created later on 04/23/2026. The DON confirmed that staff performing bathing or toileting should look at skin and report concerns to the nurse, and that the nurse should follow up on a red area present on admission; the DON also confirmed there was no documentation of the resident's skin being observed or assessed between 04/09/2026 and 04/21/2026.
Infection Control Failures During Wound Care and Resident Care
Penalty
Summary
Infection control standards were not followed during wound care for one resident when an LPN performed hand hygiene before entering the room and putting on gloves, but after washing the resident’s wounds changed gloves without performing hand hygiene before continuing treatment. The facility’s policy required hand hygiene before and after resident contact, before aseptic tasks, after removing PPE, and when changing gloves to prevent cross-contamination. The LPN later confirmed hand hygiene should have been performed when the gloves were changed and was not. In a separate observation involving another resident, the DON and an RN were seen at the bedside during a complete bed change without gowns on, even though the resident was on EBP. During wound care, the RN cleaned an exposed buttock wound, changed gloves and performed hand hygiene at one point, but then touched the resident’s foot with clean gloves without changing them, used the same gloves to pack the wound, reached into a pocket for scissors and used them to cut gauze, placed the scissors on the bed pad, changed gloves again, and then returned the dirty scissors to the pocket with clean gloves on. After applying the dressing, the RN removed gloves but did not perform hand hygiene before touching the resident’s glasses, remote, call light, pillow, and garbage bag, and then handled a box of clean gloves and supplies. The RN and DON both confirmed the gown was not worn during the bed change and that cross contamination occurred during the wound care.
Failure to Notify Physician and Legal Representatives of AMA Departures
Penalty
Summary
The facility failed to notify residents’ physicians and, in two cases, the resident’s guardian or power of attorney when residents left the facility against medical advice (AMA) or otherwise did not return as expected. The facility policy stated that the resident and family/legal representative should be informed of the risks involved, the benefits of staying, and alternatives, and that the physician should be notified and encouraged to speak with the resident. The policy also required documentation of the notification in nursing notes and social services progress notes. Resident 5, who had diagnoses including osteomyelitis, quadriplegia C5-C7 incomplete, and hypertension, had a court-appointed guardian and a BIMS score of 13, indicating cognitive intactness. The resident signed an AMA form and left the facility with personal belongings. The record contained no documentation that the guardian was notified at the time of departure, and the guardian confirmed during interview that the facility did not notify them. The guardian stated they learned of the departure from the resident’s sister the next day. The record also contained no documentation that the physician or PA-C was notified when the resident left AMA; the PA-C confirmed they were not notified until they came to the facility the following day. Resident 8, who had severe protein-calorie malnutrition, hepatic failure, alcohol abuse, chest pain, osteoarthritis, and falls, left the facility AMA and had a power of attorney for healthcare. The record contained no documentation that the power of attorney was notified of the AMA departure, and the administrator confirmed there was no such documentation. Resident 6, with diagnoses including metabolic encephalopathy, atrial fibrillation, emphysema, alcohol dependence, ischemic cardiomyopathy, and aortocoronary bypass graft, signed out to go to church and there was no documentation that the resident returned or that the physician was notified when the resident did not return. Resident 7’s family transferred the resident to another facility and signed AMA paperwork because discharge orders could not be obtained the same day, but there was no documentation that the physician was notified. Resident 9 left to spend the night with a brother, and the record did not document whether the resident returned or that the physician was notified. The administrator confirmed the lack of physician notification for these residents.
Environmental Sanitation and Hot Water Deficiencies Across Multiple Units
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable interior environment, including safe and adequate hot water, for residents on multiple units. On Unit 1, surveyors observed a strong urine odor in the carpeted hallway and more than a dozen stains of various sizes and colors on the hallway carpet. The shared bathroom doorway wall between two resident rooms was flaking, with pieces broken away and framing visible; over a dozen pieces of wall material were on the floor, and the remaining wall surface was rough and uncleanable. On Unit 2, the hallway carpet also had multiple stains of various sizes and colors. On Unit 3, the resident refrigerator/freezer contained spills of brown, white, and yellow substances, and the sink mounting in the ice machine room was coming apart with sharp edges exposed. Hot water issues were also identified on Unit 3. Two residents in one room reported there was no hot water available to them, with one resident stating the water had been cold for two months. A CNA reported that water on Unit 3 was very slow to warm and that a recently burst pipe had resulted in no hot water. Subsequent temperature checks in two different bathrooms on Unit 3 showed that, after running the hot water for over a minute to two minutes, the water only reached 80.2°F and 83.5°F. Additional observations in the Unit 3 ice machine room revealed a brown unidentifiable substance along the inner door of the ice machine, a missing rubber seal on the underside of the ice maker door, a hard white substance on the floor behind the unit, an orange “Clean” indicator light illuminated on the ice maker, and a garbage can overflowing with trash and touching the ice maker lid. These unsanitary conditions and environmental deficiencies were confirmed by the corporate consultant and the DON, who acknowledged the stained and dirty carpets and the unclean resident refrigerator, ice maker, and surrounding area.
Bathroom Ventilation Not Functional in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure resident bathroom ventilation was functional in four resident rooms, 308, 502, 504, and 505, out of 14 resident rooms sampled. During the initial tour, bathroom ventilation was not functioning in resident rooms 100, 308, 315, 318, 319, 502, 504, and 505 when tested with a one-ply tissue. On a later facility tour with the Administrator, the bathroom ventilation was still not functioning in rooms 308, 502, 504, and 505 when tested the same way. The Administrator confirmed that the bathroom ventilation was not functioning in those rooms and stated it should have been. A record review showed the facility had an undated document for inspecting exhaust fans for proper operation and cleaning them if necessary, with task completion marked done on time on 12.29.2025, 9.29.2025, 6.19.2025, and 3.25.2025. During interview, the Administrator confirmed the facility did not have a specific bathroom ventilation policy and that it was included with the document already provided with the task completion dates.
Failure to Transmit Required MDS Record
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) record to CMS within the required time frame for one resident. Resident 88 had an entry MDS completed on 9/5/2025 and a discharge return not anticipated MDS completed on 9/13/2025, but the discharge MDS was not transmitted to CMS. Record review showed the resident entered the facility on 9/5/2025 and left on 9/13/2025. During interviews, an MDS registered nurse stated the discharge MDS should have been separate from the Medicare 5-day MDS and was not transmitted because it was considered a Medicare assessment. Another MDS registered nurse confirmed the facility had missed submitting the MDS and stated the MDS nurse would modify it and submit it to CMS. The Administrator confirmed the facility used the RAI manual for MDS accuracy and stated the MDS nurses had not logged into the state site since September 2025.
Failure to Provide Nail Care for a Resident with DM
Penalty
Summary
The facility failed to provide assistance with nail care for one resident who was unable to complete activities of daily living independently. Resident 10 was readmitted from the hospital on 1/23/26, had a diagnosis of diabetes mellitus, and required supervision with personal hygiene per the MDS dated 1/29/26. The facility’s ADL policy stated that residents unable to carry out ADLs would receive necessary services to maintain grooming and personal and oral hygiene, but Resident 10’s EHR from 1/23/26 through 2/11/26 contained no documentation of nail care being provided or refused, and the comprehensive care plan contained no task or intervention related to diabetic nail care. Observations on 2/8/26, 2/9/26, and 2/11/26 showed Resident 10’s fingernails on both hands were approximately 1/8 to 1/4 cm past the fingertips, with some nails jagged, and there was no change across the observations. Resident 10 stated the fingernails needed to be trimmed and later said they bothered [gender] because of their length. Staff interviews indicated bath aides provided nail care for residents who were not diabetic, while nurses were expected to trim diabetic residents’ nails on bath days. The DON confirmed nurses were to trim diabetic residents’ fingernails on bath days and acknowledged Resident 10’s fingernails were too long and needed to be trimmed; the DON also stated refusals to have the nails trimmed were probably not documented.
Failure to Track and Resolve Resident Council Complaints About Cold Food
Penalty
Summary
The facility failed to ensure that the Grievance Official responded to and followed up on repeated resident council concerns about cold food being served. Resident interviews during the annual survey showed multiple residents reporting that meals, coffee, and other hot items were often served cold, and several residents stated that they had raised the issue in resident council meetings without seeing any change. One resident also reported that complaints had been made to social workers but were not addressed. Resident Council minutes documented that residents reported ice cold food and later voiced concern that complaints and grievances were not being addressed or followed up on. The RC president confirmed that cold food complaints were routinely included in prior meeting minutes. The facility was unable to provide RC minutes for several months, and grievance tracking logs for multiple months did not include the cold food complaints that were reported in RC meetings. The Social Services Director and Social Services Assistant stated that they attended the monthly RC meetings, took notes, and assumed the responsibilities of the Grievance Official. They confirmed that the RC minutes for several meetings contained complaints about cold food and that those complaints were not entered into the grievance logs as they should have been. The facility policy required prompt resolution of grievances and stated that grievances identified during RC meetings were to be submitted immediately to the GO for investigation and resolution, but the Administrator confirmed there was no official job description for the Grievance Official.
Failure to Employ a Full-Time Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis in a facility licensed for 173 residents. A review of the facility assessment and the Social Work Consultant job summary showed that the facility had a social work consultant role requiring a bachelor's degree in a human services field and responsibilities for guiding and counseling the social service team and advocating for residents and families. During interviews, the Social Services Assistant stated that she did not have a bachelor's degree in social work or a human services field and reported that the social work consultant came to the facility only once a week to every other week, at least two to three times a month. The Social Services Director also stated that she did not have a bachelor's degree in social work or human services. The Social Work Consultant confirmed that he had a bachelor's degree in social work and that he was not a full-time employee at the facility.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with diabetes mellitus type 2 and bilateral toe wounds. The LPN gathered supplies, performed hand hygiene, and donned gloves before entering the resident's room. During the wound care process, the LPN changed gloves but did not don a gown as required by the facility's EBP policy for residents with chronic wounds, such as diabetic foot ulcers. Additionally, the LPN did not perform hand hygiene between glove changes, which is also required by facility policy. The resident involved had a diagnosis of diabetes mellitus type 2, which can lead to poor blood flow and slow-healing wounds, and was under an order for daily wound care with Medi Honey and Band-Aids. The facility's policy specifies that EBP, including gown and glove use, must be followed for residents with chronic wounds. Interviews revealed that the LPN was unaware that EBP applied to wound care and believed it was only necessary for catheter and tube feeding care. The Director of Nursing confirmed that the resident was on EBP and that staff are expected to use gowns and perform hand hygiene as outlined in the policy.
Failure to Report and Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
A deficiency was identified when the facility failed to report an allegation of abuse involving two residents with severe cognitive impairment. Both residents had diagnoses including dementia and Alzheimer's disease, and their care plans indicated significant cognitive and decision-making deficits. On the date of the incident, one resident was found standing next to their bed pulling up their pants, while the other was lying on the same bed with their pants and brief down. Both residents were unable to provide details about the incident due to their mental status and medical history. Despite the circumstances and the residents' inability to consent or recall the event, no assessment was completed for one of the residents following the incident, and the event was not reported to the appropriate authorities as required. Staff interviews confirmed that the incident was observed and reported internally to the charge nurse, but facility leadership determined there was no contact and therefore did not initiate a report or further assessment. Additionally, a subsequent similar incident occurred, and again, the response was limited to internal notification without external reporting or immediate resident protection measures. A review of the facility's Abuse, Neglect, and Exploitation policy indicated that any suspected abuse must be reported and investigated immediately, especially when residents may lack the capacity to consent. However, there was no documentation of a report to authorities or a completed investigation for the incidents involving these two residents. The administrator confirmed that the event was not considered reportable, and no body assessment was performed, contrary to facility policy and regulatory requirements.
Improper Medication Storage and Handling in Resident Rooms
Penalty
Summary
Facility staff failed to properly store medications for two residents, resulting in drugs being left unsecured in resident rooms and used inappropriately. For one resident with severe cognitive impairment and a diagnosis of Alzheimer's disease and unspecified dementia, a medication aide used Nystatin powder that had been left on the toilet in the resident's bathroom, rather than obtaining it directly from the medication cart. The aide admitted to using the powder found in the room and not bringing it in from the cart prior to care. The Director of Nursing confirmed that medications should not be stored in resident rooms or used if not brought in for the specific procedure. In another instance, a resident with moderate cognitive impairment and a history of mental health conditions had a medication cup containing cream left on the bedside table in their room. The resident did not have an order to self-administer medications, nor was there an assessment for self-administration. Staff interviews revealed that the night shift nurse routinely placed Nystatin cream in a cup on the bedside table for use by the next nurse, rather than storing it securely. The nurse who applied the cream discarded the cup left in the room and confirmed that medications should not be stored in resident rooms. Both incidents were observed by surveyors and confirmed through staff interviews. The facility did not have a medication storage policy in place at the time of the survey, contributing to the improper storage and handling of medications for these residents.
Failure to Perform Hand Hygiene and Use PPE During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene before donning gloves and between glove changes during peri-care and catheter care for two residents. In one instance, a medication aide (MA-E) did not wash hands before putting on gloves, nor between glove changes, while providing peri-care to a resident with severe cognitive impairment, Alzheimer's disease, and a history of urinary tract infection. The aide also used Nystatin powder found in the resident's bathroom, which was not brought in from the medication cart, and did not dry the resident's groin area after cleaning. After removing gloves, the aide continued to assist the resident with personal grooming without performing hand hygiene. In another case, two nursing assistants (NA-A and NA-B) provided peri-care and catheter care to a resident with an indwelling Foley catheter and moderate cognitive impairment. Both assistants put on gloves without performing hand hygiene and did not wear gowns as required under Enhanced Barrier Precautions for residents with indwelling devices. During the care, they changed gloves without hand hygiene and did not dry the cleansed areas. After completing care, they performed hand hygiene, but not at the required intervals. Additionally, a registered nurse (RN-C) entered the resident's room already wearing gloves, disposed of a medication cup, applied topical medication, and left the room without performing hand hygiene after glove removal. Interviews with the Director of Nursing confirmed that staff did not follow facility policy, which requires hand hygiene before donning gloves, between glove changes, and after glove removal, as well as the use of gowns for residents under Enhanced Barrier Precautions. The observed failures were consistent with the facility's own infection control policies and procedures, as documented in the report.
Inaccurate MDS Coding for Falls Among Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments related to falls for three out of five sampled residents. For one resident, a fall resulting in a C1 vertebra fracture was not marked as a fall with injury on the Discharge MDS, despite documentation in the progress notes and confirmation by the MDS nurse coordinator. Additionally, this same resident had multiple falls, including incidents resulting in an abrasion and complaints of pain, which were not correctly coded as falls with injury on the Annual MDS. The MDS nurse coordinator confirmed these omissions during interviews. Another resident's MDS was incorrectly marked for falls with major injury, even though there was no documentation of recent falls in the progress notes, care plan, or fall risk assessments, and the last fall occurred over two years prior. For a third resident, an unwitnessed fall was documented in an incident report, but the corresponding Quarterly MDS did not indicate any falls. The MDS nurse coordinator acknowledged that this was an error. These inaccuracies were identified through record reviews and staff interviews, and the facility's policy requires the use of the RAI manual and evidence-based assessment tools to ensure MDS accuracy.
Failure to Follow Physician's Order for Medication Timing
Penalty
Summary
The facility failed to follow a physician's order regarding medication administration for one resident with a primary diagnosis of severe protein calorie malnutrition. The resident, who was cognitively intact, had an order for Omeprazole 20 mg to be administered by mouth every day, specifically 60 minutes before breakfast, for the treatment of GERD. On the day of observation, the medication was given at 7:45 AM, but the resident began eating breakfast at 8:01 AM, only 18 minutes after receiving the Omeprazole, rather than the ordered 60 minutes. The medication aide confirmed during interview that the medication had not been given the full hour prior to breakfast as ordered. The facility's medication administration checklist included a step for correct dose timing, but this was not followed in this instance. The corporate nurse consultant also confirmed, after consulting with the facility pharmacist, that 18 minutes was not sufficient time prior to breakfast for the Omeprazole administration, thus verifying the failure to comply with the physician's order.
Unsanitary Bathroom Conditions for a Resident
Penalty
Summary
The facility failed to maintain a clean and sanitary bathroom floor for one of the sampled residents. During observations on January 21 and January 22, 2025, the bathroom floor of a resident was found to have four cracked tiles in front of the toilet, with one tile having a missing area. Additionally, there was a large brown stained area extending from the base of the toilet, and the caulking around the base of the toilet was cracked and had brown stains around the front. These conditions were confirmed by the Administrator during an interview on January 22, 2025, indicating that the bathroom floor was not maintained in a clean and sanitary manner.
Failure to Prevent Burns and Improper Fall Management
Penalty
Summary
The facility staff failed to implement interventions to prevent hot liquid burns for a resident who was cognitively intact and independent with activities of daily living. The resident was admitted with several diagnoses, including a burn of unspecified body region and muscle weakness. Despite having a history of burns from hot liquids, the resident's care plan did not address skin issues related to burns. The resident used a rice cooker in their room to make hot beverages and food, which led to multiple burn incidents, including a significant burn that required hospitalization. Staff were aware of the rice cooker but did not take action to remove it, assuming it was allowed. Another deficiency involved the facility's failure to evaluate a resident for potential injuries from a fall before moving them. This resident, who was severely cognitively impaired and at risk for falls, was found on the floor by a surveyor. A nursing assistant assisted the resident off the floor without conducting a full body assessment, contrary to the facility's fall management policy. Interviews with the RN and DON confirmed that the nursing assistant should not have moved the resident before an assessment was completed. The facility's failure to address these issues resulted in an immediate jeopardy situation, which was later removed after corrective actions were implemented. However, the initial inaction and lack of adherence to protocols contributed to the deficiencies observed during the survey.
Removal Plan
- Residents wound was assessed, Physician notified and orders received.
- Education provided to resident's Power of Attorney (POA) on what resident can/cannot have in room.
- Items removed from resident room to be returned to son.
- Staff education completed related to items that could potentially cause injury and what to do if items are found.
- Staff education completed on reporting skin issues to Administrator, DON and or Assistant Director of Nursing (ADON) at time wound is found.
- Hot Liquid evaluation for Risk Residents completed on all residents.
- Care plans updated on any resident identified as being at risk for potential injury due to hot liquids.
- All residents have hot liquid evaluation completed on admission and quarterly.
- Nursing staff education related to wound identification who and how to report any potential wounds.
- All new hires will be educated regarding the skin protocol, potential for injury and process of reporting wounds.
- Wounds will be discussed daily as part of morning clinical.
- Residents rooms will be audited weekly for potential hazardous equipment.
- Affected resident room will be audited daily.
- Hot liquid eval's will be completed on admission and quarterly.
- Items that are a potential risk will be identified on admission with personal inventories.
- The plan of correction will be reviewed by the Quality Assurance and Performance Improvement (QAPI) program committee.
- Staff education outlining fall protocol: staff to call for nurse to assess resident prior to moving resident to chair or bed.
- High fall risk residents will be identified.
- Care plan audited to ensure risk for falls or actual falls identified as a focus with resident centered appropriate interventions in place.
- Residents profiles updated indicating fall risk.
- All new admissions fall risk will be identified.
- Resident centered interventions will be put into place on care plans.
- All falls will be reviewed daily in morning clinical.
- Fall packet will be put into place.
- Fall policy and procedure will be gone over with all new nursing hire by DON/ADON.
- All staff education on fall policy and procedure will be ongoing with all staff meetings.
- Post fall huddle will be completed by nursing staff immediately following fall.
- Random gait belt audits will be done on all nursing staff.
- Monitoring will be ongoing.
Restricted Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents could access their personal fund money during weekends, holidays, or evening/overnight hours. This deficiency affected all 65 residents with a personal fund account, out of a total facility census of 112. An interview with a resident revealed concerns about the limited access to their funds, as they could only access their money during business hours when the business office was open or when certain front receptionists were available. The Business Office Manager confirmed that access to personal fund accounts was restricted to Monday through Friday, 8:00 AM to 5:00 PM, at the front desk or the Business Office. A review of the facility's policy showed no evidence of provisions for ongoing access to petty cash to honor resident requests for accessing their personal funds outside of these hours.
Infection Control Deficiencies in Hand Hygiene and Oxygen Tubing Storage
Penalty
Summary
The facility failed to ensure a functioning handwashing sink was available in the laundry area, which had been broken with no running water since December 2023. This was confirmed by both the Environmental Manager and the Regional Administrator Consultant during interviews. The absence of a working handwashing station in the laundry area was a significant oversight in maintaining proper hygiene and infection control practices. The facility also failed to maintain enhanced barrier precautions during the care of Resident 56, who had a supra pubic catheter and was at risk for urinary tract infections. Observations revealed that staff did not wear gowns during high-contact activities such as transferring and providing peri-care, despite the presence of a CDC.gov EBP sign on the resident's door indicating the need for such precautions. Interviews with staff members indicated a lack of understanding and adherence to the enhanced barrier precautions, contributing to the risk of cross-contamination. Additionally, the facility did not ensure proper hand hygiene during peri-care for Resident 56, as staff members did not wash their hands for the recommended 20 seconds and failed to change gloves appropriately during the procedure. Furthermore, the facility did not store oxygen tubing properly for several residents, with tubing found lying on the floor or draped over equipment, contrary to the facility's policy requiring storage in labeled plastic bags. These deficiencies in infection control practices were observed across multiple residents, indicating systemic issues in the facility's infection prevention and control program.
Failure to Provide Required Ongoing Training for Direct Care Staff
Penalty
Summary
The facility failed to provide the required 12 hours of ongoing training for five direct care staff members, including Medication Aides and Nurse Aides, who had been employed for a year or more. This deficiency was identified through interviews and record reviews, which revealed that none of the sampled staff had completed the necessary training. The Human Resources Director confirmed that the training had not been completed for any direct care staff, including the five sampled individuals. This oversight had the potential to affect all 112 residents residing in the facility.
Failure to Follow Standardized Recipes in Meal Preparation
Penalty
Summary
The facility failed to adhere to its established menus and standardized recipes during meal preparation, which had the potential to affect 110 residents who received food from the kitchen. An observation of meal preparation by Cook-A revealed that the cook did not follow the corporate recipe for meatloaf. Specifically, Cook-A was seen preparing meatloaf without measuring the ingredients as specified in the recipe, such as the amount of breadcrumbs added to the mixture. When questioned, Cook-A admitted to not being trained for the task, despite having been employed at the facility for two months. The facility's policy, titled Food Preparation Guidelines, mandates that cooks or their designees prepare menu items according to the facility's written menus and standardized recipes. However, the observation showed a deviation from this policy, as Cook-A did not follow the recipe for meatloaf preparation. The facility administrator confirmed that Cook-A should have adhered to the recipe, indicating a lapse in training and oversight in the kitchen operations. This deficiency in following the prescribed menu and recipe could potentially impact the nutritional needs of the residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple nursing stations, as observed during a survey. At stations 1, 2, and 4, the medication storage rooms contained refrigerators with temperature logs that were either incomplete or entirely blank, with no recorded temperatures for several months. Medication Aids and Licensed Practical Nurses interviewed were unsure of who was responsible for recording these temperatures, and no thermometers were found inside the refrigerators. The Corporate Nurse Consultant and Director of Nursing confirmed the lack of a specific policy for monitoring refrigerator temperatures. Additionally, the facility did not properly label medication bottles with opening dates. At station 4, an open bottle of iron and a pump bottle of Cetaphil were found without dates indicating when they were opened. Staff members acknowledged that these bottles should have been marked with the date of opening, but there was no specific policy found for the storage of stock medications. This lack of labeling could lead to potential issues with medication efficacy and safety. Furthermore, the facility failed to adhere to its policy regarding resident self-administration of medications. Resident 42, who has moderately impaired cognition, was found with an opened, undated bottle of ear drops in their room without a self-administration order. The medication should have been stored in a locked medication cart. Interviews with staff confirmed that Resident 42 did not have authorization for self-administration, and the presence of the medication in the room was unauthorized.
Failure to Evaluate Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to evaluate a resident's ability to self-administer medications and ensure the security of those medications. The resident, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease and unspecified intellectual disabilities, was found to be cognitively intact according to a recent BIMS assessment. Despite this, there was no evidence in the resident's care plan of any focus, goals, or interventions regarding self-administration of medications. The resident's physician orders included inhaled medications for COPD, but there was no documented evaluation of the resident's ability to self-medicate since an assessment in 2021, which indicated the resident did not wish to self-administer medications. Observations revealed that the resident had an Atrovent inhaler on their bed and was self-administering the medication without facility staff present. Interviews with the resident confirmed that they were self-administering the inhaler in a manner not consistent with the prescribed instructions. The Director of Nursing confirmed that the facility had not completed an evaluation of the resident's ability to safely self-administer medications and that there was no physician's order permitting the resident to do so.
Failure to Provide Written Notices of Hospital Transfer
Penalty
Summary
The facility failed to provide written notices of transfer to three residents, identified as Residents 42, 61, and 84, when they were transferred to the hospital. The facility's policy requires that residents and their representatives receive written information about the state's bed hold duration and payment amount before a transfer. However, record reviews and interviews revealed that no such documentation was provided for these residents. Resident 42 was discharged to the hospital on two occasions, and there was no evidence of written notice for either event. Interviews with the Director of Nursing and the Corporate Nurse Consultant confirmed the absence of the required documentation. Resident 61, who had a diagnosis of hemiplegia and hemiparesis following a brain bleed, was on hospital leave, but no written notice of transfer was documented. Similarly, Resident 84, who had chronic respiratory failure with hypoxia, was transferred to the hospital without a written notice of transfer. The Corporate Nurse Consultant confirmed that the facility did not complete the necessary documentation for these hospitalizations, indicating a failure to adhere to the facility's policy and state requirements.
Failure to Provide Bed Hold Notices to Hospitalized Residents
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to residents or their representatives within 24 hours of being transferred to the hospital. This deficiency was identified for three residents who were hospitalized. The facility's policy, revised in January 2024, mandates that residents or their representatives receive written information about the state's bed hold duration and payment amount before a transfer. However, record reviews and interviews revealed that this policy was not followed for the residents in question. Resident 42 was discharged to the hospital on two occasions, but there was no evidence of a bed hold notice being provided. Interviews with the Director of Nursing and the Corporate Nurse Consultant confirmed the absence of documentation. Similarly, Resident 61 was on hospital leave, and no bed hold notice was documented in their electronic health record. The Corporate Nurse Consultant confirmed this oversight. Lastly, Resident 84, who was hospitalized due to respiratory distress, also did not receive a bed hold notice, as confirmed by the Corporate Nurse Consultant.
Failure to Monitor and Document Head Injury
Penalty
Summary
The facility failed to adequately monitor and document a head injury for a resident, identified as Resident 165, who had severe cognitive impairment due to dementia. The incident occurred when a housekeeper accidentally hit the resident in the head with a door, resulting in a bruise on the forehead. Despite the facility's policy requiring neurological assessments following head trauma, no such assessments were documented for this incident. The lack of follow-up documentation and neurological checks was confirmed during an interview with the facility's Corporate Nurse Consultant. The consultant acknowledged that the necessary neurological assessments, referred to as crani checks, were not performed as required by the facility's procedures. This oversight represents a failure to adhere to established protocols for monitoring head injuries, potentially compromising the resident's safety and well-being.
Facility Fails to Maintain Cleanliness in Multiple Stations
Penalty
Summary
The facility failed to maintain cleanliness in several areas, compromising the residents' right to a safe, clean, and comfortable environment. Observations on multiple occasions revealed issues at Stations 1, 3, and 4. At Station 1, there were free-standing pieces of insulation along the window seal. Station 3's hallway floors were littered with clumps of a black substance, debris, food stains, and sticky areas of unknown substances. Additionally, there were colored candy pieces, dead bugs, and a mat covered with dirt, dust, and rubber bands. Cobwebs and dust were also found under a curio cabinet in the hallway. Station 4's hallway was similarly dirty, with brown and black debris and sticky areas. In the activity area, torn paper towels and dried food pieces were found smashed into the floor. Interviews with the Environmental Services Director and the Administrator confirmed the hallways were scheduled for daily cleaning, but acknowledged the areas were not clean and required attention.
Failure to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean environment in several rooms and hallways, as observed on 4/8/24. Specifically, rooms 113, 211, 212, and 312 had dirty tray tables with dry yellow and brown substances. Room 113 also had a brown sticky substance on the floor, and its bathroom trash can was overflowing with paper towels. Additionally, the floors in rooms 211 and 212 were sticky. The 300 and 400 hallways had dry rings of substances on the laminated floors, while the 100 and 200 hallways had dark rings of substances on the carpets. The kitchenette on the 200 hall had a rug with white and red dry substances and a dirty floor. During an interview and tour of the facility, the Nurse Consultant confirmed the observations, acknowledging that the tray tables, floors, and hallways were dirty and needed cleaning. The Nurse Consultant also mentioned that the facility was unable to hire housekeeping staff for weekends, as no one was willing to work during those times. The facility census was 107 at the time of the observations.
Failure to Obtain Daily Weights and Laboratory Services
Penalty
Summary
The facility failed to obtain daily weights for a resident with congestive heart failure as ordered by the physician. The resident had specific orders for daily weights to monitor their condition, with instructions to fax recordings weekly to the physician and to call if there was a weight gain of 2-3 pounds for two consecutive days or a weight gain of 5 pounds in one week. However, weights were not documented on multiple dates, and the Director of Nursing confirmed that the daily weights had not been completed as required by the physician's orders and the facility's weight monitoring policy. Additionally, the facility failed to obtain a Basic Metabolic Panel (BMP) for another resident as ordered by the physician following a hospitalization. The BMP was supposed to be completed on a specific date, but there was no record of the BMP being collected or any documentation in the progress notes to notify the physician that the BMP had not been completed. Interviews with the Director of Nursing and the Nursing Consultant confirmed that the BMP was not drawn and should have been, and there were no lab results found for the ordered BMP.
Failure to Ensure Proper Hand Hygiene and Glove Changes During Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during and after catheter care for one resident. The Medication Aide (MA) did not perform hand hygiene before donning gloves and entering the resident's room. The MA then proceeded to handle various items in the room, such as removing a trash bag, raising the bed, lowering the blinds, and obtaining supplies, without changing gloves or performing hand hygiene. After completing catheter care, the MA discovered the resident had been incontinent of stool and removed the soiled brief, cleansed the resident with one wipe, and then changed gloves and performed hand hygiene. However, the MA did not change gloves or perform hand hygiene again before placing a new brief on the resident and completing the care process. The Nurse Consultant (NC) confirmed these lapses in hand hygiene and glove changes during the care process. The facility's policy on catheter care, revised in 2014, outlines specific steps for hand hygiene and glove changes, which were not followed by the MA. The policy requires washing and drying hands thoroughly before donning gloves, changing gloves after handling soiled items, and performing hand hygiene after removing gloves. The MA's failure to adhere to these steps resulted in a deficiency in infection prevention and control, as confirmed by both the MA and the NC during interviews.
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 100 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eventide Williamsburg | 1.6 mi | ★★★★★ | 10 | 0 |
| Holmes Lake Rehabilitation & Care Center | 1.6 mi | ★★★★★ | 10 | 0 |
| St. Jane De Chantal | 1.7 mi | ★★★★★ | 27 | 0 |
| Ambassador Health Of Lincoln | 1.7 mi | ★★★★★ | 3 | 0 |
| Heartland Ridge Care Center | 2.8 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.