Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Glen Center during CMS and state inspections, most recent first.
Pest control failed to control roach activity in the kitchen and related areas. The surveyor found dead roaches on glue boards inside unused lower oven compartments while the stove and grill on top were still being used to prepare residents’ food, and there was no signage indicating the ovens were out of order. Pest control records showed repeated roach captures in the kitchen, dishwash area, utility room, storage area, under the prep sink, and by the ovens, and the health dept. had previously noted a dead cockroach near the grease trap.
A facility failed to fully investigate and resolve resident grievances related to laundry services and did not clearly communicate the outcome of a resident council concern. Residents reported confusion about laundry pickup and return times, ongoing delays in clothing being returned, and at least one instance of another resident’s clothing being received. Staff gave inconsistent accounts of the laundry process, and a DH stated a complaint about missing clothes was not entered as a grievance because the clothes were later found in a resident’s room.
A facility failed to keep call bells within reach for two residents. One resident’s call bell was clipped to the wall and out of reach while the resident lay in a low bed, and another resident’s call bell was found on the floor during an incontinence round. The RN/UMs acknowledged the call bells were not accessible, and facility leadership confirmed call bells should always be within reach per policy.
A resident with CKD, PVD, HTN, difficulty walking, moderate cognitive impairment, and frequent incontinence had an MDS-triggered CAA indicating a care plan for urinary incontinence should be initiated, along with a physician order for scheduled toileting. However, the EMR did not contain a specific care plan or interventions for urinary incontinence and toileting; the DON and CL could only identify a PPE-related intervention in an EBP care plan, with no additional documentation for toileting care.
A facility failed to keep care plans current for two residents. One resident’s chart contained inconsistent psychiatric diagnoses across the AR, MDS, physician notes, psychiatric notes, and care plan, while a psychiatric PA stated the diagnosis in the notes was not accurate. Another resident had a fall, and the fall investigation called for a toileting schedule, but the care plan did not include that intervention. Staff and leadership acknowledged the care plans did not reflect the residents’ current conditions or documented interventions.
A resident with a history of ETOH abuse, depression, and PTSD reported wanting alcohol and feeling like they were going to crack. The RN notified the MD, who ordered Ativan and Librium for withdrawal, but the Librium was not administered for seven doses because it was awaiting pharmacy delivery or unavailable. During this time, the resident attempted to leave the building to get to a liquor store, and surveyor review confirmed the physician was not notified for further orders when the med was not available.
A resident receiving hemodialysis M-W-F had incomplete post-dialysis communication record documentation. Surveyors found that the facility’s HDCR forms were not fully completed after return from the dialysis center, including missing vital signs and access site assessments, and the RN/UM confirmed the forms were not filled out according to facility practice. The resident had ESRD, DM with hyperglycemia, and intact cognition, and the required form included checks for access site swelling, drainage, pain, bruit, thrill, and new dialysis orders.
Inaccurate daily staffing reports were posted in a visible area and did not match unit staffing information or the facility’s staffing sheets on multiple days. Surveyors found mismatches between posted CNA counts, staff interviews, and internal staffing records, including day and night shifts. The LNHA stated the Staffing Coordinator handled weekday posting and that weekends lacked assigned coverage, with reports corrected on Monday for the prior weekend.
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not adequately monitoring an antipsychotic, leaving PRN pain meds unsequenced and unclear, and allowing duplicate PRN bowel regimen orders for two residents. One resident had moderate cognitive impairment and was receiving psychoactive meds, but the eMAR lacked behavior monitoring documentation for olanzapine. Two residents also had overlapping PRN constipation orders, and one resident’s PRN tramadol order lacked a clear pain indication.
Improper Medication Storage and Labeling: Surveyors found an opened bottle of Acetylcysteine in a med refrigerator beyond the manufacturer’s 96-hour discard time and unidentified tablets stored in a med cup in a med cart. The RN could not identify the tablets, and the LNHA and consultant pharmacist confirmed the meds were not stored in proper packaging or per labeling requirements.
Failure to retain former employee health files affected 2 of 20 new hire files reviewed. The surveyor requested medical files for new hires, but the LNHA could not provide two of the requested files. The NPE stated that when a staff member was no longer employed, the file was given to HR, and the LNHA later confirmed the two medical files were not available.
A facility failed to follow infection control practices when the designated soiled utility area on one unit was located in a storage room that also held clean, stored items. The RN/UM observed soiled linen bins, waste bins, and bags of linen in the room alongside storage racks, boxes, and exposed recreation and decor items. The IP was unfamiliar with the area, and a CNA stated soiled linens and diapers were placed there because there was no other soiled utility area on the unit. The facility policy addressed safe linen handling but did not further address soiled utility and storage areas.
Unsafe and unsanitary conditions were observed in dining areas, a unit hallway, and resident rooms. The 2nd floor dining/activity area had debris inside heating system grills, puzzles stored on top of a heater, cobwebs, ripped wallpaper, and blackish-gray residue on the floor; the 1st floor dining room also had blackish-gray residue and a stained chair. A unit hallway had dirty air vents and stained ceiling tiles, and two resident rooms had trash on the floor and a short overhead light string that the RN/UM said should not be that way.
A resident with multiple chronic conditions experienced significant lethargy, low oxygen saturation, and inability to eat or take medications. Despite these changes and staff awareness, the physician was not notified for several hours, and action was only taken after the resident's family requested hospital transfer. Facility policy required immediate physician notification for such changes, but this was not followed.
A resident with significant medical needs and cognitive impairment alleged rough handling by a CNA and HHA during a transfer, resulting in a bruise. Despite the allegation, the accused CNA continued to care for other residents without additional supervision, and the facility did not follow its abuse policy requiring immediate removal of the accused staff and thorough investigation, including interviews with other residents. The DON confirmed that these steps were not taken, leading to Immediate Jeopardy.
The facility failed to have the LNHA and DON present at required QAPI meetings, potentially affecting the care of 111 residents. The LNHA and IP were absent from a January meeting, and the DON was absent from a July meeting, with the LNHA citing vacations as the reason. However, the IP's timesheet showed they were working on the day of the meeting.
A facility failed to provide a resident and their representative with written notification of the bed hold policy during multiple hospital transfers. Despite the policy requiring notification prior to transfer, documentation was only available for one transfer date. The resident, who was cognitively intact, was transferred on several occasions, but the Business Office Manager confirmed the absence of notifications for other dates.
The facility inaccurately coded the MDS for three residents, leading to deficiencies in care management. A resident was incorrectly coded as discharged to a hospital instead of the community. Another resident's MDS failed to reflect venous ulcers despite treatment records. A third resident's MDS did not document an unstageable sacral wound present at admission. The facility lacked a specific MDS policy, relying on RAI manual guidelines.
The facility failed to act on a urologist's recommendations for a resident with an indwelling catheter, delaying the start of Tamsulosin for nearly three months. Additionally, the facility did not adjust medication administration times for a dialysis resident, resulting in Vitamin D3 being documented as given at 5 PM despite the resident returning from dialysis after 6 PM. Both the LPN and RN/UM acknowledged the need for timing adjustments, but the facility's policies did not address this issue.
A facility failed to maintain an active smoking care plan for a resident identified as an independent smoker. The resident's smoking evaluation was incomplete, and the care plan section was not filled out, despite being on the facility's list of smokers. The resident, with intact cognitive status, was observed smoking in the designated area, and staff confirmed the need for a care plan. The facility's policy required regular re-evaluation and updates to the care plan, which were not followed.
A facility failed to comprehensively evaluate and care plan for a resident with a history of PTSD, despite staff awareness of the condition. The resident's medical records did not list PTSD as a diagnosis, and care plans lacked any mention of PTSD or its triggers. Interviews with staff, including an LPN and a PPA, confirmed the absence of a comprehensive interdisciplinary evaluation or care plan, despite the resident exhibiting symptoms indicative of PTSD. The facility's policy on Trauma Informed Care was not effectively implemented for this resident.
A facility failed to monitor the target behavior for a resident prescribed an antipsychotic medication, Aripiprazole, for psychosis. The resident's care plan did not include the target behavior of hallucinations, and there was no order for behavior monitoring in the eMAR. Interviews with staff confirmed the absence of necessary documentation and orders, which should have been included according to facility policy.
The facility failed to follow proper hand hygiene and transmission-based precautions. A housekeeper did not perform hand hygiene after glove removal due to the absence of ABHR. A resident with ESBL in urine lacked documentation for contact precautions, and another resident on enhanced barrier precautions had no care plan or physician order. These deficiencies indicate lapses in infection control practices and documentation.
A resident with dementia and hypertension sustained an injury of unknown origin, with a bluish-purplish discoloration around the left eye. The facility's investigation suggested the injury was caused by leaning on a bedside rail, but there was no supporting documentation or witness statements. The care plan lacked specific interventions for the injury, and there were no documented visual checks or orders for monitoring the resident's location. The facility's policy on person-centered care plans was not effectively implemented.
A resident with severe cognitive impairment and multiple pressure ulcers did not receive consistent care as per professional standards. The facility failed to document and investigate all acquired wounds, and several treatment orders were left unsigned, indicating potential lapses in care. Interviews with staff revealed inconsistencies in following wound care protocols, highlighting deficiencies in the facility's pressure ulcer management.
Pest Control Program Failed to Control Roach Activity in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen. During the initial tour, the surveyor observed the dual conventional oven with a stove and grill on top being used to cook residents’ food, while the lower ovens were not being used and had no signage indicating they were out of order or not to be used. When the surveyor opened the lower ovens, four glue board traps with dead roaches were found inside, including five dead roaches on one glue board and seven on another in the first oven, and two dead roaches on one glue board and seven on another in the second oven. The FSD stated there had been a roach problem since the prior month and that the glue boards were changed when pest control came, while also stating the ovens had not worked for three years. Review of pest control records and the local health department inspection showed repeated roach activity in the kitchen and related areas over several months, including the dishwash area, utility room, storage area, under the prep sink, and back by the ovens. The records documented minor to moderate roach captures on glue boards, liquid applications, gel bait, and spot treatments on multiple dates, and the health department inspection noted one dead cockroach in the kitchen near the grease trap with a directive to contact pest control. Interviews with the MD, LNHA, District Manager, and CL showed they were not aware of the extent of the roach problem or did not respond when asked about the reports, and the LNHA stated the issue had not been brought to her attention until the surveyor’s inquiry.
Failure to Investigate and Resolve Laundry Grievances
Penalty
Summary
The facility failed to follow its Grievance/Concern Policy by not thoroughly investigating a grievance filed by an unsampled resident, not following through on concerns raised during a resident council meeting, and not notifying residents of the full resolution regarding laundry concerns. During review of the last three months of Resident Council Minutes, the surveyor found that residents discussed laundry pickup and return issues during the 10/14/25 meeting. Resident #23 voiced concerns about the laundry process and clothing return, and an attached Departmental Response Form stated that the resident was given the facility’s laundry process and reminded that clothes were washed at the facility and delivered back in a timely manner. The surveyor later interviewed Residents #23, #31, #42, #61, and #65, who stated they were not satisfied with the response because they were not given clear information about when laundry was picked up and returned. They reported that they believed laundry was picked up on Mondays and returned on Fridays, but they were told only that laundry was being picked up and was downstairs. Resident #65 also stated there were times when residents’ clothing was not returned for several days and that one resident had to use another resident’s clothing because their own clothing had not come back from laundry. The residents confirmed the concern persisted and that they still did not have a definite answer about the laundry schedule. The surveyor also interviewed CNA #1, CNA #2, the Laundry Staff, and the Director of Housekeeping. CNA #1 stated that CNAs were responsible for sending dirty clothes to laundry via chute, but that clothes were sometimes forgotten and sent the next day. CNA #2 believed clothing was laundered two times a week but was unsure when. The Laundry Staff stated resident clothing was laundered daily except weekends and returned the same day, while the Director of Housekeeping stated he had found dirty clothes inside a resident’s room after a complaint about missing clothes and that the CNA had forgotten to send them to laundry. He stated no grievance form was completed, the Administrator was not notified, and he was unsure whether a grievance should have been filed. The facility’s Grievance/Concern Policy required leadership to investigate, document, and follow up on all concerns and grievances, and the Administrator to oversee the grievance process through conclusion.
Call bells not within reach for two residents
Penalty
Summary
The facility failed to ensure that the call bells for 2 of 21 residents were within reach and usable, and did not follow its call light policy. During observation, Resident #39 was found lying in a low bed with a cane by the side, while the resident’s call bell was wrapped in a loop and clipped to the wall where the system was attached, making it out of reach. When asked whether the resident could reach it, the RN/UM stated the resident could not, and then moved the call bell onto the bed next to the resident and explained it should stay where it could be reached if needed. Resident #20 was observed lying on the bed during an incontinence round, awake and agreeable to the check, while the call bell was on the floor and not accessible. The RN/UM immediately picked up the call bell and clipped it to the resident’s bed, stating that it should not be on the floor and acknowledging it was not within reach. Facility leadership later confirmed that residents’ call bells should always be within reach, and the facility’s call light policy stated that each patient should have a call light or alternative communication device at the bedside and that staff will ensure it is within reach and accessible while in bed or other sleeping accommodations.
Missing Care Plan for Urinary Incontinence and Toileting
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with chronic kidney disease, peripheral vascular disease, hypertension, and difficulty walking. The resident’s comprehensive MDS, with an ARD of 8/12/24, showed a BIMS score of 12/15 indicating moderate cognitive impairment, substantial/maximal assistance needed for toileting hygiene, and frequent incontinence without a toileting program. The CAA indicated a care plan for urinary incontinence would be initiated, and a physician order dated 8/24/24 directed toileting before and after meals, before bed, and as needed every shift for comfort care. During record review, the resident’s care plan did not contain a specific plan or interventions related to urinary incontinence and/or toileting. The DON and CL reviewed the EMR and could not find a care plan for urinary incontinence and toileting, and the DON later stated the only related intervention found was to wear protective personal equipment to support toileting in the EBP care plan. The surveyor confirmed there was no additional documentation related to toileting or urinary incontinence care, despite the CAA trigger and the facility policy requiring a comprehensive individualized care plan with measurable objectives, timetables, and interventions for triggered CAAs.
Care Plans Not Updated for Changed Diagnoses and Fall Intervention
Penalty
Summary
The facility failed to update and revise comprehensive care plans for two residents after changes in their conditions and after an identified fall intervention. For one resident, the electronic record contained inconsistent psychiatric diagnoses across the admission record, MDS, care plan, physician progress notes, and psychiatric follow-up notes. The resident’s comprehensive care plan dated 11/21/25 included diagnoses such as cognitive loss/dementia, psychiatric disorders, and psychosis, while other records reflected diagnoses including major depressive disorder, psychotic disorder, and schizoaffective disorder. A psychiatric PA told the surveyor that schizoaffective disorder was not the resident’s diagnosis and that the notes were being simplified for billing codes, indicating the record had not been aligned with the resident’s current condition. For the second resident, the record showed a fall on 10/24/25 and the facility’s fall investigation documented a plan of correction/intervention to provide the resident with a toileting schedule. However, the resident’s comprehensive care plan did not contain an intervention for a toileting schedule. During interview, nursing staff stated the resident was a fall risk, was occasionally incontinent, and was not on a toileting schedule. The RN/UM stated that interventions implemented after a fall would be expected to be included in the resident’s care plan, but could not confirm that this had been done for the resident. Facility leadership acknowledged that the care plans did not match the residents’ current conditions or the interventions identified in the records. The CL stated the care plan should match the resident’s condition, and the DON stated the care plan should have reflected the new intervention after the fall. The facility policy stated that comprehensive care plans must be customized to each resident and reviewed and revised by the interdisciplinary team as needed to reflect changing needs and goals.
Delay in Administering Ordered Librium
Penalty
Summary
The facility failed to ensure that Resident #63 received the physician-ordered Librium in a timely manner and failed to notify the physician that the medication was unavailable for additional orders. Resident #63 was admitted with diagnoses including major depressive disorder, alcohol abuse, and homelessness, and had a BIMS score of 13, indicating intact cognition. The resident had a long history of ETOH abuse, depression, and PTSD, and on 11/22/25 expressed to the RN that they wanted alcohol and felt like they were going to crack. After the resident reported these concerns, the RN notified the MD and received new orders for a one-time dose of Ativan and Librium three times daily for alcohol withdrawal. The physician visit note documented Librium 10 mg three times daily and Ativan PRN for agitation/anxiety. The eMAR showed the Librium order had a start time of 11/22/25 at 10:00 PM, but seven doses were not administered over the next several shifts. The missed doses were documented as awaiting pharmacy delivery or not delivered, and two missed doses were noted with calls to the pharmacy stating the medication would be delivered later. The resident continued to exhibit alcohol-seeking behavior during this period, including an episode where the resident attempted to leave the building to go to a liquor store and police were called to assist with re-entry. The declining inventory sheet showed the medication was issued on 11/23/25 and received on 11/25/25. Surveyor review and interviews with facility leadership confirmed that the medication was ordered but not given for several shifts, and the physician was not notified for further orders when the medication was unavailable.
Incomplete Post-Dialysis Assessment Documentation
Penalty
Summary
The facility failed to complete post-dialysis communication record assessments for a resident who received hemodialysis three times per week. The resident had diagnoses including end stage renal disease, type 2 diabetes mellitus with hyperglycemia, and neuromuscular dysfunction of the bladder, and the most recent MDS reflected a BIMS score of 13, indicating intact cognition. The physician’s order directed hemodialysis at an outside dialysis center on Monday, Wednesday, and Friday with a 2:00 PM chair time. Surveyors reviewed the resident’s Hemodialysis Communication Records and found that the facility’s process was for the morning nurse to complete the top portion of the form before dialysis, the dialysis center to complete the middle portion, and the facility nurse to complete the bottom portion when the resident returned. The RN/UM confirmed that the forms were not completed according to facility practice and stated they should have included vital signs and dialysis access site assessment upon return for resident safety. The form also required documentation of access site swelling, drainage, pain, AV shunt bruit and thrill, and whether there were new orders from the dialysis center. A handwritten list of nurses showed that 3 of 8 post-dialysis forms could not be located with documentation that vital signs and dialysis access site assessments were completed for three dialysis dates. Surveyors also observed the resident in the room with an indwelling catheter and confirmed the resident went to dialysis every Monday, Wednesday, and Friday. The facility reviewed the incomplete forms with surveyors, and the LNHA stated that one nurse had received 1:1 education for not thoroughly completing the post-dialysis HDCR documentation.
Inaccurate Daily Staffing Reports Were Posted
Penalty
Summary
The facility failed to post an accurate Nursing Home Resident Care Staffing Report daily for 3 of 5 days in a prominent location that was readily accessible and visible to residents and visitors. On 12/1/25, surveyors interviewed unit nursing staff and determined the total CNAs on duty were 11, yet the posted report in the reception area showed a census of 98 with 14 CNAs, and the facility’s Daily Staffing Sheet showed 13 CNAs. On 12/2/25, the posted Day Shift report showed a census of 99 with 12 CNAs, while the facility’s Daily Staffing Sheet showed 11 CNAs, and the two reports did not match. On 12/8/25, surveyors observed the posted Day Shift staffing report showing a census of 98 with 12 CNAs, but interviews with nursing staff on the units indicated only 2 CNAs on unit 1 and 3 CNAs on the second floor units during the overnight shift, while the facility’s Daily Staffing Sheet showed 5 CNAs and the posted report showed 7 CNAs for that shift. On 12/9/25, the LNHA stated the Staffing Coordinator was responsible for weekday posting and that there was no one assigned for weekends, and that the facility corrected the report on Monday for the prior weekend. The facility’s staffing policy stated the report should be completed daily at the beginning of each shift and adjusted if staffing changes.
Unnecessary Drug Regimen: Inadequate Monitoring and Duplicate PRN Orders
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs by not adequately monitoring the use of an antipsychotic medication and by not reviewing, clarifying, and sequencing PRN medications. Resident #7 was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, PTSD, restlessness and agitation, adjustment disorder with anxiety, and mood disorder due to a known physiological condition with mixed features. The most recent MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and the resident was receiving psychoactive medications, including an antipsychotic, an antidepressant, an opioid, and routine and PRN pain medications. For Resident #7, the November and December 2025 eMAR showed an order for olanzapine 5 mg at bedtime for mood adjustment disorder with mixed anxiety target behavior for delusions, hallucinations, and paranoia. The medication was charted as administered at 9:00 PM, but there was no further documentation in the eMAR showing that behavior was monitored on other shifts for the antipsychotic use. The same resident also had PRN pain orders for acetaminophen, oxycodone, and tramadol; the tramadol order did not specify what kind of pain it was for and was not sequenced from the other PRN pain medications. The facility also had duplicate PRN bowel regimen orders for Resident #7, including Dulcolax suppository, Miralax, and MOM, all ordered for constipation with overlapping directions and no indication of which to use first. A similar issue was identified for Resident #35, whose record showed PRN MOM and Miralax orders for constipation with no indication of which to use first. The consultant pharmacist stated that PRN orders would usually be clarified if incomplete or duplicative, but the facility records showed these duplicate and unsequenced orders remained in place at the time of the survey.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to properly store medications in accordance with manufacturer specifications and standards of practice. During inspection of the 2nd floor medication refrigerator, a surveyor observed a plastic bag containing three bottles of liquid Acetylcysteine, including two unopened bottles and one opened bottle. The opened bottle had a date opened of 11/25 written on it, while the manufacturer label stated, in bold print, "Warning: Discard opened containers after 96 hours." When questioned, the UM stated that the bottle had been open longer than 96 hours and should have been disposed of, but it remained in the refrigerator. In a separate observation of the 1st floor medication cart, the surveyor found a plastic med cup with four white tablets and a souffle cup labeled "magnesium 400 mg" handwritten on it. The RN assigned to the cart stated they did not place the tablets there and could not positively identify them, and stated that medications should not be stored that way and should be thrown out. The LNHA later confirmed that the Acetylcysteine should not have been in the refrigerator and that medications should be kept in proper packaging until used. The consultant pharmacist also stated that the open Acetylcysteine should have been discarded within 96 hours and that medications should not be stored in med cups in the cart.
Failure to Retain Former Employee Health Files
Penalty
Summary
The facility failed to retain health files for staff who were no longer employed for the required timeframe, affecting 2 of 20 new employee files reviewed. During the entrance conference, the surveyor requested the medical files for 20 new hires since the last recertification survey. When additional files were requested later, the LNHA stated that files for former employees were sent to storage and that she was calling to obtain them. The NPE stated that when a staff member was no longer employed, the file was given to human resources. The surveyor then notified the LNHA and CL that 2 of the 20 requested medical files could not be provided, and the LNHA later confirmed in the presence of the DON and CL that she did not have the two requested medical files.
Soiled Utility Area Shared With Stored Clean Items
Penalty
Summary
The facility failed to follow appropriate infection control practices for soiled linens and waste when the designated soiled utility area on Unit #1 was located in a storage room that also contained clean, stored items. During the tour, the surveyor and RN/UM observed the room had signage indicating it was a storage room and was secured with a keypad lock. Inside the room were a covered yellow bin labeled for soiled diapers, a transport bin with clear plastic bags containing linen items, and three smaller covered garbage bins, including one labeled soiled gowns, alongside storage racks, piled boxes and containers, and uncovered exposed items such as recreation and decor items. The RN/UM stated the soiled utility bins had previously been kept in the shower room and were moved into the storage room, and could not explain why the soiled utility area was kept there, acknowledging that clean and soiled items should be stored in separate areas. The IP stated she was not familiar with Unit #1's soiled utility area and referred the surveyor to the LNHA for designated storage areas. A CNA assigned to the unit stated soiled linens, including personal clothing items in plastic bags, were placed in the soiled utility area in the storage room, and that soiled diapers were disposed of in the designated bin there. The facility's policy stated linen would be handled, stored, and transported in a safe and sanitary method to prevent the spread of infection, but did not further address soiled utility and storage areas.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in the 2nd floor dining/activity area, the 1st floor dining room, one unit hallway, and two resident rooms. During observation with the RN/UM, the 2nd floor dining area contained six heating system grills with dried leaves, plastics, puzzle pieces, papers, and grayish dust-like buildup inside the grills. Multiple boxes of puzzles were stored on top of one heating system, and cobwebs, ripped wallpaper, and blackish-gray dried substances were observed on the dining room floor. The RN/UM acknowledged the conditions and stated housekeeping would be notified, while the DH stated the floor residue was from germicidal spray and that there was no accountability log for daily cleaning of the dining area. The same environmental concerns were also observed in the 1st floor dining room, where blackish-gray substances were seen on the floor and a chair was stained with blackish substances. In the Unit 2 hallway, two ceiling air vents had gray-brown accumulation on and inside them, and ceiling tiles near the ice room and door 4 had brown stains. The LNHA later stated that the vents and ceiling tiles should not look that way and that thorough cleaning and ceiling tile replacement had been done after the observations were shown to facility leadership. Resident room conditions were also not maintained. In Resident #33's room, assorted trash and paper were observed on the floor of the room and bathroom floor. In Resident #20's room, the overhead metal light string was observed to be short, measuring approximately three centimeters, and the RN/UM confirmed it should not be like that. The facility policy provided by the LNHA stated that residents have the right to a safe, clean, comfortable, and homelike environment and that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior.
Delayed Physician Notification After Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician in a timely manner following a significant change in a resident's condition. The resident, who had a history of congestive heart failure, COPD, and obstructive sleep apnea, was found lethargic, slow to respond, and unable to eat or take medications. Vital signs showed low oxygen saturation, and the respiratory therapist documented that the resident was not wearing the oxygen cannula properly, resulting in a SpO2 of 67%. Interventions were initiated, including the use of a non-rebreather mask, which improved the resident's oxygen saturation. Despite these interventions and the resident's continued lethargy and inability to take medications, the physician was not notified immediately. Documentation revealed that the resident's condition remained concerning throughout the morning, with multiple staff members, including the respiratory therapist, nurse, and nursing supervisor, being made aware of the situation. The resident was unable to participate in incentive spirometry and continued to be lethargic and unresponsive to commands. The physician was not contacted until the resident's daughter arrived in the early afternoon, expressed concern, and requested that the resident be sent to the hospital. Only at that point was the physician notified and orders obtained for hospital transfer. Interviews with facility staff confirmed that the expected protocol for a change in condition, such as desaturation and lethargy, was to assess the resident and notify the physician promptly. However, in this case, there was a delay of approximately three to four hours between the initial episode of desaturation and the notification of the physician. Facility policy also required immediate notification of the physician and the resident's representative in the event of a significant change in condition, which was not followed in this instance.
Failure to Remove Accused Staff and Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a Certified Nursing Assistant (CNA), a Home Health Aide (HHA), and a resident. The incident began when the resident reported that their skin was bruised due to rough handling by two staff members during a transfer. Despite this allegation, the accused CNA continued to care for other residents without additional supervision after the complaint was made and again on a subsequent date before the investigation was completed. Interviews with facility leadership confirmed that the investigation was not thorough and that the facility did not follow its own abuse policy. The facility's abuse policy required immediate removal of the accused employee from duty pending investigation, as well as prompt initiation of an investigation within 24 hours, including interviews with the accused staff, the resident, and other residents under the accused staff's care. However, the accused CNA was not sent home and continued to work with other residents. The DON acknowledged that other residents assigned to the accused CNA were not interviewed, and there was no increased supervision of the accused staff member. The investigation was considered complete by the DON without these required steps, and the facility's policy was not followed. The resident involved had significant medical conditions, including sepsis, metabolic encephalopathy, acute kidney failure, diabetes, heart failure, anemia, and was receiving palliative care. The resident was cognitively impaired and dependent on staff for all activities of daily living, requiring assistance from two or more helpers for mobility and transfers. The failure to remove the accused staff from duty and to conduct a thorough investigation as per policy placed all residents under the care of the accused CNA at risk and resulted in the identification of Immediate Jeopardy.
Absence of Key Personnel in QAPI Meetings
Penalty
Summary
The facility failed to ensure the presence of required members at the Quality Assurance Performance Improvement (QAPI) meetings, which are crucial for maintaining the quality of care for all residents. Specifically, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were absent from one of the three quarterly QAPI meetings. The absence of these key personnel was confirmed through interviews and a review of the QAPI sign-in sheets. On January 17, 2024, the LNHA and the Infection Preventionist (IP) did not attend the meeting, and on July 17, 2024, the DON was absent. The LNHA explained that these absences were due to vacations, but the IP's timesheet indicated that they were working on the day of the meeting, raising questions about their absence. The facility's policies require the QAPI committee to include the Administrator, DON, Medical Director (MD), IP, and other interdisciplinary team members, and to meet at least quarterly. The failure to have the LNHA and DON present at the meetings could potentially affect the quality of care for all 111 residents in the facility. The survey team noted these deficiencies during their review and communicated the findings to the facility management, who did not provide additional information or refute the findings.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident or their representative during multiple hospital transfers. Resident #82, who was cognitively intact with a BIMS score of 14 out of 15, was transferred to the hospital on several occasions as documented by various nursing staff. However, the Business Office Manager (BOM) only provided a Bed Hold Notice for one of these transfers, dated 5/15/24, and confirmed that no other notifications were available for the other transfer dates of 5/05/24, 5/23/24, and 7/05/24. The facility's policy requires that the Bed Hold Policy Notice & Authorization form be given to the resident and their representative prior to transfer, with the representative's copy delivered within 24 hours if not present. Despite this policy, the facility did not have documentation to show compliance for the specified dates. The surveyor's findings were communicated to the Licensed Nursing Home Administrator (LNHA) and Director of Nursing during the exit conference, and the facility did not provide additional information or refute the findings.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of care. For Resident #109, the MDS assessment inaccurately coded the discharge status as being to a short-term general hospital, while progress notes indicated the resident was discharged to the community. This discrepancy was identified during a review of the electronic health record and was acknowledged by the Director of Nursing (DON) after a discussion with the surveyor. Resident #23's MDS assessment was also inaccurately coded. Although the resident had chronic non-pressure ulcers on both lower legs and was receiving treatment for venous ulcers, the MDS assessment indicated that the resident had no venous or arterial ulcers. This error was discovered through observation and review of the resident's health records, which included wound consultant notes confirming the presence of venous ulcers. For Resident #167, the MDS assessment failed to document an unstageable, necrotic sacral wound that was present upon admission from the hospital. The hospital records indicated the presence of this wound, but the MDS was coded as having no unhealed pressure ulcers. This inaccuracy was brought to the attention of the DON, who confirmed the error after consulting with the MDS Coordinator. The facility did not have a specific MDS policy and relied on the Resident Assessment Instrument (RAI) manual guidelines.
Failure to Follow Urologist Recommendations and Adjust Medication Times for Dialysis
Penalty
Summary
The facility failed to act upon the recommendations of a urologist for a resident with an indwelling catheter. The resident, who was cognitively intact, had been admitted with diagnoses including benign prostatic hyperplasia and urinary retention. A urology consultation on 5/15/24 recommended starting Tamsulosin, but there was no evidence that the medical doctor was notified or that the medication was ordered. The Director of Nursing (DON) acknowledged that the recommendations were not acted upon until almost three months later, following the surveyor's inquiry. Another deficiency involved a resident undergoing dialysis, where the facility failed to adjust medication administration times to accommodate the resident's dialysis schedule. The resident, who was also cognitively intact, had a physician's order for Vitamin D3 to be administered daily at 5 PM. However, on dialysis days, the resident returned to the facility after 6 PM, and the medication was still documented as administered at the scheduled time. Both the Licensed Practical Nurse (LPN) and the Registered Nurse Unit Manager (RN/UM) acknowledged that medication times should be adjusted for dialysis schedules, but this was not done. The surveyor reviewed the facility's policies and found that the provided dialysis policy did not address the adjustment of medication schedules for dialysis residents. The facility's general medication administration policy stated that medications should be administered according to the prescriber's written orders, but did not specifically address the issue of timing adjustments for dialysis. The DON confirmed that the medication schedule for the resident was clarified after the surveyor's inquiry.
Failure to Maintain Active Smoking Care Plan
Penalty
Summary
The facility failed to maintain an active care plan for a resident who was identified as an independent smoker. The deficiency was identified during a survey when it was discovered that the resident's smoking evaluation was incomplete, and the care plan section was not filled out. Despite being on the facility's list of smokers, the resident did not have an active care plan for smoking until the surveyor's inquiry prompted a revision. The resident, who had intact cognitive status as per the most recent Minimum Data Set (MDS) assessment, was observed smoking in the designated area, and staff confirmed that the resident should have had a care plan for smoking. The facility's policy required a smoking evaluation and care plan for residents who smoke, which should include necessary supervision and safety measures. However, the resident's care plan had been resolved earlier in the year and was not reactivated until the surveyor's inquiry. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the oversight, noting that the care plan should have been active. The facility's policy also mandated regular re-evaluation and updates to the care plan, which were not adhered to in this case.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a history of post-traumatic stress disorder (PTSD) was comprehensively evaluated and care planned to receive appropriate treatment and services. This deficiency was identified for a resident who was reviewed for mood and behavior. The resident, who had diagnoses including depression, hemiplegia, hemiparesis following a stroke, and hypertension, did not have PTSD listed as a diagnosis in their admission record. The comprehensive Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and only coded for depression under psychiatric/mood disorders. The facility's medication administration records for June and July 2024 did not address the resident's history of PTSD or any identified triggers. Additionally, the resident's care plans did not include any plans addressing PTSD. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Psychiatry Physician Assistant (PPA), revealed that while the staff were aware of the resident's history of PTSD, there was no comprehensive interdisciplinary evaluation or care plan in place. The PPA noted that the resident exhibited symptoms such as being jumpy and anxious, which could be indicative of a history of PTSD. The Director of Social Services (DSS) and the Director of Nursing (DON) acknowledged that a resident with a reported history of PTSD should be evaluated and care planned, as unknown PTSD triggers could cause the resident to re-experience trauma. The facility's policy on Trauma Informed Care emphasized the importance of identifying triggers and collaborating with healthcare professionals to develop individualized care plan interventions. However, the facility did not provide additional information or evidence of such evaluations or care plans for the resident in question.
Failure to Monitor Target Behavior for Antipsychotic Medication
Penalty
Summary
The facility failed to adequately monitor the target behavior for the use of a psychotropic medication, specifically an antipsychotic medication, for one of the residents reviewed for unnecessary medications. The deficiency was identified through observation, interview, and review of medical records and facility documentation. The resident in question, who was admitted with diagnoses including acute kidney failure, parkinsonism, and major depressive disorder, was prescribed Aripiprazole for psychosis. However, the resident's care plan did not indicate the target behavior of hallucinations to be monitored for the use of this medication. The surveyor's review of the resident's electronic Medication Administration Record (eMAR) for July and August revealed that there was no order for behavior monitoring related to a target behavior for the antipsychotic medication. Additionally, there was no documented evidence that the resident was being monitored for side effects of the medication. Interviews with the Registered Nurse and the Director of Nursing confirmed that there should have been an order for behavior monitoring, including a target behavior, and that this information should have been included in the resident's care plan. The facility's policy on behavior management emphasized the use of non-pharmacological interventions as the first line of approach and required behavior monitoring to be documented in the medical records. However, the facility did not have a specific policy for psychotropic or antipsychotic medications, only a general policy on behaviors. This lack of specific guidance contributed to the oversight in monitoring the resident's target behavior for the antipsychotic medication.
Infection Control Deficiencies in Hand Hygiene and Precaution Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene practices and transmission-based precautions, as observed by a surveyor. A housekeeper was seen exiting a toilet room wearing gloves and a surgical mask, then proceeding to a cleaning cart without removing the gloves or performing hand hygiene. The housekeeper continued to clean another area with the same gloves, and upon changing gloves, did not perform hand hygiene due to the absence of alcohol-based hand rub (ABHR) in the vicinity. This was contrary to the facility's policy, which mandates hand hygiene after glove removal and before donning new gloves. In another instance, the facility did not follow proper procedures for a resident with an indwelling catheter who tested positive for Extended Spectrum Beta Lactamase (ESBL) in urine. The resident's medical records lacked documentation of physician notification, a care plan, or a physician order for contact precautions, despite the positive lab results. The Director of Nursing acknowledged the oversight, noting that the infection preventionist nurse was on vacation, which may have contributed to the lapse in protocol adherence. Additionally, a resident undergoing hyperbaric treatment for a diabetic wound was observed to have no care plan or physician order for enhanced barrier precautions, despite being on such precautions due to the wound. The RN/UM confirmed the absence of necessary documentation, which should have been in place. These deficiencies highlight lapses in infection control practices and documentation within the facility.
Failure to Implement Appropriate Care Plan for Resident Injury
Penalty
Summary
The facility failed to ensure that a resident with an injury of unknown origin received appropriate treatment and interventions according to a comprehensive assessment and person-centered care plan. The resident, who had medical diagnoses including repeated falls, unspecified dementia, and hypertension, was found with a bluish-purplish discoloration around the left eye. The facility's investigation concluded that the injury was caused by the resident leaning or pushing their face on a bedside rail, but there was no documented evidence or witness statements to support this conclusion. The resident's care plan did not include specific interventions for the injury of unknown origin that occurred on 8/21/23. Although the care plan included interventions for fall risk, anticoagulation therapy, and pain management, it lacked a focus and interventions specifically addressing the injury to the left eye. The Director of Nursing (DON) provided a care plan with interventions for pillows and positioning, but these were initiated before the incident and did not specifically address the injury. During discussions with the surveyor, the DON acknowledged that there was no specific documentation or orders for visual checks of the resident's location every shift. The staff was expected to check the resident periodically, but there were no specific times or frequencies established. The facility's policy on person-centered care plans aimed to eliminate or mitigate triggers for re-traumatization, but it was not effectively implemented in this case, as the care plan did not address the specific incident of injury.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of clinical practice for a resident with pressure ulcers. This deficiency was identified for a resident with severe cognitive impairment, who had multiple diagnoses including dementia and muscle weakness. The resident's medical records revealed several instances where physician's orders for pressure ulcer care and prevention were not signed by the nurse and left blank, indicating that the treatments may not have been administered as required. The resident developed multiple pressure ulcers, including a right heel wound, a left lateral calf deep tissue injury (DTI), a sacral DTI, and a left heel DTI. Despite the presence of these wounds, the facility did not complete incident reports for all of them, particularly for the sacral and left lateral calf wounds acquired in December 2022. The lack of documentation and investigation into these wounds suggests a failure to adequately monitor and address the resident's skin integrity and wound care needs. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the expected protocols for wound care and incident reporting were not consistently followed. The facility's policy on skin integrity and wound management emphasized the importance of comprehensive assessments and timely interventions, yet these were not fully implemented for the resident in question. The absence of signed treatment administration records and incomplete incident reports highlight significant gaps in the facility's pressure ulcer care and prevention practices.
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 1,439 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cedar Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At St Vincents Llc | 0.7 mi | ★★★★★ | 0 | 0 |
| Alaris Health At Cedar Grove | 1.6 mi | ★★★★★ | 28 | 0 |
| Complete Care At Cedar Grove | 1.8 mi | ★★★★★ | 1 | 0 |
| Canterbury At Cedar Grove | 2 mi | ★★★★★ | 13 | 0 |
| Complete Care At West Caldwell Llc | 2.8 mi | ★★★★★ | 1 | 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.