Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Park View Haven Nursing Home during CMS and state inspections, most recent first.
Dishwasher temperatures were not consistently maintained at the required level for sanitization. Observation and log review showed repeated wash cycles starting below 120 degrees, and the CDM confirmed the temperatures were not consistently at or above 120 degrees even though sanitizer concentration was within range.
Incomplete informed consent for psychotropic medications was identified for several residents. Records showed psychotropic drugs were given for conditions such as anxiety, depression, dementia, and behavioral symptoms, but consent was often obtained after the meds had already started, and the forms did not include the doses or alternative treatment plans. An LPN confirmed the facility did not obtain consent before administration and did not secure new consent when doses were increased.
Failure to test a symptomatic resident for Covid-19. A resident with chronic lung disease and cognitive impairment developed a prolonged respiratory illness with cough, congestion, hoarseness, wheezing, and CPAP refusal due to coughing. The care plan and facility policy called for Covid testing when symptoms were present, but there was no documentation that the resident was tested, and the IP confirmed the facility had no evidence of testing.
Failure to Provide Required Medicare Non-Coverage Notices: The facility did not provide the required NOMNC to two residents when Medicare-covered skilled services were being discontinued. The notices stated the residents would be responsible for the cost of care, but there was no evidence they were informed of their right to appeal the decision or the cost of continued services. The SSD confirmed the facility initiated the discharges but did not provide the required forms.
A resident with severe cognitive impairment and a history of wandering experienced multiple falls and altercations in an LTC facility. Despite interventions like sensor alarms and medication adjustments, the facility failed to consistently assess causal factors or revise interventions effectively. The resident's condition, complicated by medications causing sleepiness and unsteadiness, led to a significant fall resulting in hospitalization and death due to a brain hemorrhage.
The facility failed to implement effective infection prevention and control measures, leading to the spread of COVID-19 and inadequate Enhanced Barrier Precautions (EBP) for residents at risk of multidrug-resistant organisms (MDROs). A resident with COVID-19 was observed without a mask, and staff did not conduct timely contact tracing or testing. Additionally, residents with wounds did not receive proper gown use during care activities, indicating a lack of adherence to the facility's EBP policy.
A facility failed to report and investigate a potential abuse/neglect incident involving a resident with multiple health conditions who was launched from their wheelchair due to staff inattention. The incident was not reported to the State Agency, and no investigation was conducted, despite facility policy requiring such actions.
A resident exited the facility through the front door, triggering an alarm that staff initially attributed to the wind. The resident was later found outside by housekeeping staff and returned inside without issue. The facility did not report this potential elopement to the State Agency or submit the investigation results within the required 5 working days, as confirmed by the Administrator and DON.
Two residents at risk for falls were not assessed for safe use of motorized recliners in their rooms. One resident, with severe cognitive impairment, fell and sustained injuries after accidentally elevating the recliner seat. Another resident, with moderate cognitive impairment, was observed with recliner controls out of reach. The facility did not evaluate either resident's ability to safely operate the recliners.
Dishwasher temperatures below required sanitization levels
Penalty
Summary
The facility failed to ensure dishwasher temperatures were maintained at levels needed for adequate sanitization, as required by its Nursing Home Dishwashing Policy. The policy stated that sanitization was to be achieved either through a high-temperature rinse of 180 degrees Fahrenheit or through chemical sanitization with 50-100 ppm chlorine, and that a chemical sanitizing machine required a wash cycle reaching a minimum of 120 degrees Fahrenheit with sanitizer concentration of 50-100 ppm chlorine. The deficiency was identified through observation, record review, and interview, and the facility census was 21 residents. During observation on 4/6/26, the dishwasher temperature reached 100 degrees at 9:17 AM and the water temperature reached 110 degrees after 3 wash cycles; later that day at 11:58 AM, the dishwasher temperature reached 115 degrees after 2 wash cycles. Review of the dishwasher temperature and sanitizer log for March and April 2026 showed repeated instances where water temperatures began below 120 degrees during breakfast, lunch, and supper dishwashing, including readings of 117, 118, 119, 112, 114, 115, 116, and 110 degrees on multiple dates. In interview on 4/6/26 at 12:05 PM, the Certified Dietary Manager confirmed that the dishwasher temperatures were not consistently at 120 degrees or above, although the sanitizer concentration was within the proper range.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain comprehensive informed consent for psychotropic medications for multiple residents, including consent before the medications were administered, the medication doses, and alternative treatment plans. The report states the facility policy required documentation of discussion with the resident and/or responsible party regarding risks and benefits, black box warnings or off-label use when applicable, and interdisciplinary review of psychoactive medications, but the records reviewed did not show that these requirements were met for the residents cited. For one resident with anxiety and depression, the record showed orders for sertraline, mirtazapine, and buspirone, but the informed consent forms were not obtained until after the medications had already been started. The forms also did not list the medication doses or any alternative treatment plans. Another resident with severe cognitive impairment, dementia, and behavioral symptoms had orders for sertraline, risperidone, and lorazepam, but the consent forms lacked the medication doses and alternative treatment plans. An LPN confirmed the facility had not obtained consent prior to administering psychotropic medications and that dose increases were not accompanied by signed consent. Additional residents had similar deficiencies. One resident with dementia, anxiety, depression, wandering, hallucinations, and delusions received risperidone, mirtazapine, lorazepam, and sertraline; the consent forms did not include dosages or alternative treatment options, and there was no evidence new consents were completed when doses increased. Another resident with cognitive intactness but diagnoses including dementia, anxiety, and psychotic disorder received quetiapine and fluvoxamine; the quetiapine consent lacked dosage and alternative treatment options, and there was no consent for fluvoxamine. A final resident with dementia, anxiety, and depression received clonazepam, quetiapine, and venlafaxine; the consent form did not include medication dosages or alternative treatment options, and the facility did not obtain new consents when psychotropic doses were increased.
Failure to Test Symptomatic Resident for Covid-19
Penalty
Summary
Provide and implement an infection prevention and control program was cited after the facility failed to test a symptomatic resident for Covid-19. The resident had moderate cognitive impairment and diagnoses of chronic lung disease, depression, anemia, and hypertension. The resident’s care plan stated the resident would be tested for Covid during an outbreak and for possible or suspected symptoms of Covid, and the facility policy stated residents with signs and symptoms of Covid would be tested. During February, the resident had a prolonged respiratory illness with repeated documentation of cough, congestion, hoarse voice, wheezing, inability to sleep in bed, refusal to wear CPAP due to coughing, requests for cough drops and cough syrup, and an order for a Z-Pak for an upper respiratory infection. The resident also requested to eat meals in the room because of coughing and stated they did not want to spread germs. The lab record showed an order for Covid testing as needed, but there was no documentation that the resident was tested for Covid-19 during the illness. The Infection Preventionist confirmed the resident had symptoms of Covid-19 and that staff were to test residents with symptoms, but the facility had no evidence the resident was tested.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue the required Notice of Medicare Non-Coverage for Resident 1 and Resident 4 when Medicare-covered skilled nursing services were being discontinued. For Resident 1, the Notice of Skilled Nursing Non-Coverage dated 2/19/26 stated the resident would be responsible for the cost of care and services beginning on 2/25/26, but there was no evidence the resident was informed of the right to appeal the facility decision to discontinue Medicare-covered services or of the cost of continued services in the facility. For Resident 4, the Notice of Skilled Nursing Non-Coverage dated 9/22/25 stated the resident would be responsible for the cost of care and services beginning on 9/23/25, but there was no evidence the resident was informed of the right to appeal the facility decision or of the cost of continued services. During interview on 4/9/26 at 8:29 AM, the Social Service Director confirmed the facility initiated the discharges for both residents but did not provide the required NOMNC forms.
Failure to Prevent Falls and Injury in Resident with Cognitive Impairment
Penalty
Summary
The facility failed to adequately address and prevent ongoing falls and a significant injury for a resident with severe cognitive impairment and a history of wandering and falls. The resident, who was admitted with diagnoses including non-Alzheimer's dementia and previous stroke, experienced multiple falls and altercations with other residents. Despite the implementation of various interventions such as sensor alarms, medication adjustments, and increased supervision, the facility did not consistently assess causal factors or revise interventions effectively after each incident. The resident's condition was complicated by severe cognitive impairment, requiring partial to moderate assistance with daily activities and exhibiting behaviors such as wandering and aggression. The facility's interventions included the use of medications like Seroquel, Trazodone, Haldol, and Clonazepam to manage agitation and insomnia. However, these medications contributed to increased sleepiness and unsteadiness, further complicating the resident's ability to safely ambulate and increasing the risk of falls. Despite repeated falls and incidents, the facility did not consistently identify causal factors or develop new interventions to prevent further occurrences. The resident continued to experience falls, including a significant fall resulting in a laceration and a large bump on the head, ultimately leading to hospitalization and death due to a brain hemorrhage. The facility's failure to effectively manage the resident's fall risk and behaviors contributed to the ongoing safety hazards and the resident's eventual injury and death.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to implement effective infection prevention and control measures to prevent the spread of COVID-19 and multidrug-resistant organisms (MDROs). Observations and interviews revealed that the facility did not adhere to its own COVID-19 policy, which required staff to wear surgical masks during an outbreak and N95 masks when entering the room of a COVID-positive resident. Resident 19, who tested positive for COVID-19, was observed in a common area without a properly worn mask, and staff did not encourage mask-wearing. The facility also failed to conduct timely contact tracing and testing of staff and residents after a COVID-19 case was identified, leading to additional positive cases. The facility's Enhanced Barrier Precautions (EBP) policy was not properly implemented for residents at risk of MDROs. Resident 10, who had a venous ulcer and required assistance with daily activities, was not provided with appropriate gown use during high-contact care activities. Nursing assistants and registered nurses were observed performing care activities without wearing gowns, contrary to the facility's EBP policy. Interviews with staff confirmed a misunderstanding of when gowns were required, indicating a lack of adherence to the policy. Resident 4, who had a recurring pressure ulcer, was also not placed on EBP despite the presence of a wound. Staff provided care, including wound dressing changes and insulin administration, without wearing gowns. The facility's failure to implement EBP for residents with wounds or indwelling medical devices, as outlined in their policy, contributed to the deficiency. The lack of documentation for contact tracing and the failure to implement timely measures to prevent the spread of infections were significant factors in the facility's deficiency.
Failure to Report and Investigate Potential Abuse/Neglect Incident
Penalty
Summary
The facility failed to report an allegation of potential abuse and/or neglect to the State Agency, as well as to complete an investigation and submit the results for one resident. The incident involved a resident with multiple sclerosis, diabetes, heart disease, depression, and Alzheimer's disease, who required substantial assistance with daily activities and used a wheelchair as the primary means of locomotion. On the day of the incident, staff were assisting the resident with wheelchair mobility to the facility van when the resident's wheelchair rolled down a sloped parking lot, causing the resident to be launched out of the wheelchair. Fortunately, the resident did not sustain any injuries. Despite the incident, the facility did not file a report to the State Agency regarding the potential allegation of staff to resident abuse and/or neglect. The facility's policy required reporting any alleged abuse/neglect and conducting an investigation in accordance with state law, but these steps were not taken. During an interview, the facility Administrator and an LPN confirmed the failure to report and investigate the incident, acknowledging that the incident should have been reported and investigated to rule out potential abuse and/or neglect.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report a potential elopement incident involving a resident to the State Agency and did not submit the investigation results within the required 5 working days. The incident occurred when the resident exited the facility through the front door early in the morning. Although the door alarm was triggered, staff initially believed it was set off by the wind and did not see anyone outside. The resident was later found outside by housekeeping staff and was safely brought back inside without difficulty. The facility's policy requires immediate reporting of potential incidents of abuse or neglect to the State Agency, with an investigation to be conducted and results submitted within 5 working days. However, a review of the facility's records showed no evidence that the potential elopement was reported or that the investigation was submitted as required. Interviews with the Administrator and the DON confirmed that while an investigation was completed, it was not reported to the State Agency in a timely manner.
Failure to Assess Safe Use of Motorized Recliners for At-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as being at risk for falls, were free from accident hazards related to the independent use of motorized recliners in their rooms. Resident 1, with severe cognitive impairment and a history of falls, was found on the floor with injuries after accidentally elevating the seat of the motorized recliner, which led to a fall. The resident's care plan included fall prevention interventions, but there was no evidence of an assessment to determine the resident's safe use of the recliner. Similarly, Resident 3, who had moderate cognitive impairment and was also at risk for falls, was observed seated in a motorized recliner with the controls not within reach. The resident's care plan included various fall prevention strategies, but like Resident 1, there was no assessment conducted to evaluate the resident's ability to safely operate the recliner. The Director of Nursing confirmed that neither resident had been evaluated for safe use of the motorized recliners.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Coleridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Hartington | 8.2 mi | ★★★★★ | 5 | 0 |
| Hillcrest Care Center | 8.5 mi | — | 0 | 0 |
| Colonial Manor Of Randolph | 12.2 mi | ★★★★★ | 13 | 0 |
| Wayne Countryview Care And Rehabilitation | 21.1 mi | ★★★★★ | 8 | 0 |
| Good Samaritan Society - Bloomfield | 23.6 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.