Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Big Oak Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
Uncovered Dumpsters and Litter in Garbage Area: Surveyors observed 3 of 3 garbage dumpsters with lids left open, exposing bagged trash, and found garbage and debris scattered around the dumpster area, including cups, gloves, plastic bags, paper products, and other debris. The FSD said the area was a shared responsibility between kitchen and environmental staff, and the LNHA stated he usually ensured the area was free of debris and covered. A facility policy required outside dumpsters to be kept closed and free of surrounding litter.
Failure to consistently monitor antibiotic use occurred when five residents were prescribed antibiotics for SSTI, URI, or UTI even though McGeer criteria were not met. The IP, CP, MD, and DON all described antibiotic stewardship review processes, but the record showed repeated instances where infection assessment tools and McGeer checklists did not support the antibiotic orders. Facility logs also documented multiple episodes over the prior year in which providers prescribed antibiotics despite not meeting criteria.
Staff failed to follow the posted menu when the cook and FSD were out sick, and residents were served cold cereal, sandwiches, and wraps instead of the planned hot meals. A DA confirmed the meals were limited to foods that did not require cooking, and the RD admitted the meals did not meet daily nutritional needs.
A surveyor observed several kitchen sanitation deficiencies, including the misuse of a handwashing sink, rust on shelving units, a black substance in the dishwashing area, and chipped ceramic plates. The Food Service Director and Licensed Nursing Home Administrator acknowledged these issues, which were contrary to the facility's policies on handwashing, food storage, and sanitization.
The facility failed to follow infection control practices during a meal pass, as a CNA did not perform hand hygiene between handling meal trays for different residents. Additionally, the facility lacked a water management program to prevent Legionella growth, with no documented monitoring for waterborne pathogens. The LNHA and DM relied on an outside company's assurance that chemicals used in water treatment would prevent Legionella, but there was no formal process or documentation to support this.
A facility failed to develop comprehensive care plans for a resident on anticoagulant medication and another on hospice care. The first resident's ICCP lacked details on their atrial fibrillation diagnosis and anticoagulant use, despite physician orders for monitoring. The second resident's ICCP included advanced directives but omitted hospice care interventions. Interviews with nursing staff confirmed these omissions, highlighting a failure to follow facility policies and regulatory requirements.
The facility failed to use an infection assessment tool accurately for seven residents prescribed antibiotics, as the criteria for antibiotic use were not met. The Infection Preventionist, who also served as an LPN and Unit Manager, did not document physician notifications when criteria were unmet, despite tracking data on the Infection Log. The facility's policy required review and provider notification, which was not followed.
The facility failed to offer pneumococcal and influenza vaccinations to four residents upon admission, as required by their policies. Despite having intact cognition, these residents were not documented as having been offered the vaccines, and consents or declinations were only obtained after surveyor inquiries. This deficiency highlights lapses in the facility's admission procedures and documentation practices.
The facility failed to offer an updated COVID-19 vaccine to four residents, despite their various medical conditions. The investigation revealed inadequate processes for offering and documenting vaccinations, with records either lacking documentation or showing consents obtained only after surveyor inquiry. The facility's policy required offering the vaccine and documenting refusals, but this was not adhered to, as residents' immunization statuses were not accurately reflected.
A surveyor found the West Wing medication storage room in disrepair, with a musty odor, stained and buckled floors, a cracked ceiling, and detached piping. The sink was nonfunctional for about a month, with water leaking onto the floor, and no hand sanitizer was available. Staff were aware of the issues, but no corrective actions were taken during the maintenance director's absence. The Consultant Pharmacist deemed the environment unacceptable for medication storage.
A resident's room in the facility was found to be in poor condition, with a dirty floor, rusty over bed table, and non-functional television. The resident, who had multiple medical conditions, was tearful and lacked personal effects in the room. Housekeeping and maintenance staff acknowledged the issues, and the facility's policy on maintaining a homelike environment was not followed.
A CNA failed to immediately report an allegation of abuse involving a resident's fingers being twisted by an aide, as required by the facility's policy. The incident involved two residents, one with intact cognition and the other with severe cognitive impairment. The resident with intact cognition initially reported the abuse but later retracted the statement. The facility's policy mandates immediate reporting of any suspected abuse to the administrator and relevant authorities.
A facility failed to notify the State Long-Term Care Ombudsman about a resident's hospitalization for pneumonia, cellulitis, and acute kidney failure. The resident had intact cognition and multiple health issues. The Director of Social Work, responsible for notifications, admitted to not notifying the Ombudsman until months later, missing the resident's case. The Licensed Nursing Home Administrator assumed notifications were sent but did not verify. This oversight violated the facility's policy requiring timely notifications.
A facility failed to ensure a physician's order for monitoring a resident's blood glucose levels, despite the resident being on insulin and having diabetes mellitus. The oversight was identified during a medication administration record review, and the Medical Director acknowledged the need for regular monitoring. The facility's policy did not include blood glucose monitoring, contributing to the deficiency.
A resident with stage 4 pressure ulcers did not receive wound care as per physician's orders in an LTC facility. The LPN responsible failed to change the dressing on the resident's left heel as documented, leading to missed treatments. The DON confirmed the deficiency, acknowledging the risk of infection and improper documentation.
A resident with end-stage renal disease, COPD, and diabetes missed multiple doses of budesonide and Humalog due to the facility's failure to adjust medication administration times around scheduled dialysis sessions. The facility also did not notify the physician of these missed doses, as confirmed by interviews with the LPN and DON. The facility's policies did not address accommodating medication times for dialysis or notifying physicians of missed doses.
A surveyor observed that medications were improperly stored on a treatment cart in the hallway, left unattended by a nurse. An LPN confirmed the medications should have been secured in the cart, and the DON reiterated that medications must be stored in locked compartments as per policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive the adaptive dining equipment specified in their care plan during meal service. Observations revealed missing utensils like a curved spoon and sippy cup, leading to difficulty in eating. Staff interviews confirmed the oversight, despite clear indications on the resident's diet slip and facility policy requirements.
The facility failed to maintain a sanitary garbage disposal area, with two dumpsters left open and loose trash on the ground. The FSD, HD, and DM acknowledged the need for closed lids and a clean area to prevent infection and pests, as per facility policies.
The facility failed to ensure the presence of the LNHA at a QAPI meeting in January 2024, as required by their policy. The LNHA did not sign the attendance sheet, and there was no evidence of their participation in the meeting minutes. The LNHA confirmed their absence and highlighted the importance of their role in the QAPI process.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Uncovered Dumpsters and Litter in Garbage Area
Penalty
Summary
The facility failed to provide a sanitary environment by not keeping the garbage container area free of garbage and debris and by failing to keep covers closed over 3 of 3 garbage dumpsters. On 3/20/26 at approximately 10:00 AM, the surveyor and the Food Service Director observed three yard dumpsters in the facility parking lot that were designated for garbage. All 3 dumpsters had bagged trash exposed because the dumpster lids were not closed, even though each dumpster had two plastic lids intended to cover the opening. During the same observation, the area surrounding the dumpsters was found to have garbage on the ground, including plastic cups, disposable gloves, plastic bags, paper products, and other unidentified debris. The FSD stated that the garbage area was a shared responsibility between kitchen staff and environmental staff. On 3/25/26 at 12:37 PM, the LNHA stated in the presence of the DON, the Regional RN DON, and the survey team that he usually made sure the dumpster area was free of debris and covered since the facility had been cited before. A facility policy titled Food-Related Garbage and Refuse Disposal, dated September 2025, stated that outside dumpsters will be kept closed and free of surrounding litter.
Failure to Consistently Monitor Antibiotic Use
Penalty
Summary
The facility failed to consistently implement its Antibiotic Stewardship Program by not ensuring that antibiotics were used only when infection criteria were met. A review of the antibiotic stewardship line list for February 2026 identified five residents who were prescribed antibiotics for cellulitis, URI, or UTI, and the corresponding infection assessment tools indicated that the criteria for antibiotic use were not met for any of them. The matching McGeer Criteria surveillance checklists for these five residents also showed that the described SSTI, URI, or UTI criteria had not been met. The Infection Preventionist stated that the McGeer surveillance tool was used for all residents prescribed antibiotics and that when criteria were not met, she would communicate with prescribing providers and discuss the issue in monthly QAPI meetings. She also stated that one provider had prescribed antibiotics despite McGeer criteria not being met and that she had to educate that provider. The antibiotic stewardship reports reviewed by the surveyor included infection logs from March 2025 through March 2026 showing 36 incidents in which McGeer criteria were not met, involving five prescribing providers. The Consultant Pharmacist stated that monthly reviews of prescribed antibiotics were performed, but feedback to the prescribing practitioner was not provided if there was a progress note supporting the antibiotic use. The Medical Director stated that if a resident did not meet McGeer criteria, the facility should notify the provider so the provider could review the findings and either document the rationale for antibiotic use or discontinue the antibiotic. The Director of Nursing stated that she audited antibiotic orders for clinical support and that the provider should discontinue the order or document the rationale when criteria were not met. The facility’s antibiotic stewardship and review policies stated that antibiotic use was to be monitored through the stewardship program and that all clinical infections treated with antibiotics were to undergo review by the Infection Preventionist or designee.
Menu Not Followed When Kitchen Staff Were Absent
Penalty
Summary
The facility failed to ensure that staff followed the posted menu and provided meals that met residents’ nutritional needs. During a Resident Council Meeting, 5 of 6 alert and oriented residents stated that there was no cook one day the prior week and that they were served cold food for all three meals. They reported that breakfast consisted of cereal and milk delivered on a cart, rather than the planned hot meal items. A Dietary Aide confirmed that the cook had called out sick and the FSD was also ill, and that the RD was notified. The aide stated that staff used only foods already available in the kitchen that did not require cooking, including cold cereal, milk, juice, cold cut sandwiches and chips for lunch, and cold cut lunchmeat wraps for dinner, with no vegetables offered because they would have required cooking. Review of the facility’s menu for that day showed breakfast, lunch, and dinner items that were not served. The FSD and RD later confirmed that the menu was not followed, and the RD admitted that the meals served did not meet the daily nutritional needs requirement.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner, as observed by a surveyor on multiple occasions. During an inspection, a dietary staff member was seen removing a fork and spatula from a designated handwashing sink, which lacked signage indicating its exclusive use for handwashing. Additionally, the walk-in refrigerator contained three metal shelving units with rust, and the dishwashing area had a build-up of black substance in the caulking between the counter and the wall. Furthermore, four ceramic meal plates in the storage area were found to be chipped. Interviews with the Food Service Director (FSD) revealed that the dietary staff had not yet cleaned the black substance in the dishwashing area and would require maintenance assistance. The FSD acknowledged that rust on shelving units and chipped dishware should not be present, as they pose contamination risks. The Licensed Nursing Home Administrator (LNHA) confirmed that used utensils should not be stored in the handwashing sink and that maintenance should have been notified about the rust on the shelving units. The LNHA also stated that chipped dishware should have been discarded. The facility's policies on handwashing, food storage, and sanitization were reviewed, highlighting the need for proper maintenance and cleanliness.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices during a meal pass on the West Wing unit. A Certified Nursing Assistant (CNA) was observed not performing hand hygiene between handling meal trays for different residents. The CNA handled meal trays and assisted residents with their meals without washing hands or changing gloves, which was confirmed by the CNA, Licensed Practical Nurse (LPN), and the Director of Nursing (DON) as a breach of the facility's hand hygiene policy. The facility's policy, updated in April 2024, required hand hygiene before and after assisting residents with meals. Additionally, the facility did not have a water management program in place to prevent the growth of Legionella, a waterborne pathogen. During the entrance conference, the surveyor requested evidence of a water management program, which the facility could not provide. The Licensed Nursing Home Administrator (LNHA) and the Director of Maintenance (DM) confirmed that while an outside company treated the water, there was no specific monitoring for Legionella. The LNHA later acknowledged that the facility did not have a water management program prior to the surveyor's inquiry and had only recently scheduled testing for Legionella. The facility's failure to implement a water management program was further evidenced by the lack of documented monitoring for waterborne pathogens, despite the facility's policy to maintain a sanitary water supply. The LNHA and DM relied on the outside company's assurance that chemicals used in water treatment would prevent Legionella, but there was no formal process or documentation to support this claim. The facility's Water Supply policy, reviewed in April 2024, emphasized the importance of controlling the spread of waterborne microorganisms, which was not adequately addressed in practice.
Failure to Develop Comprehensive Care Plans for Anticoagulant and Hospice Residents
Penalty
Summary
The facility failed to develop an individual comprehensive care plan (ICCP) for a resident using anticoagulant medication and another resident receiving hospice services. For the first resident, the surveyor observed the resident eating lunch and reviewed their medical record, which showed a diagnosis of atrial fibrillation and the use of anticoagulant medication, apixaban. Despite the presence of physician orders for monitoring potential side effects of the medication, the resident's ICCP did not include their diagnosis or the use of anticoagulant medications. Interviews with nursing staff, including LPNs and the Director of Nursing, confirmed that the ICCP should have included these details to ensure proper care. For the second resident, the surveyor observed the resident in bed and confirmed through interview and medical record review that the resident was on hospice care due to multiple cancer diagnoses. The resident's ICCP included advanced directives but lacked a focus area or interventions related to hospice care. Interviews with nursing staff, including LPNs and a Unit Manager, revealed that the care plan should have been developed within 72 hours of the resident being admitted to hospice. The facility's policies on care plans and hospice services were reviewed, indicating that the ICCP should reflect the resident's needs and include hospice care coordination. The surveyor's findings highlighted the facility's failure to adhere to its policies and regulatory requirements for developing comprehensive, person-centered care plans. The absence of specific care plans for residents on anticoagulant medication and hospice services indicated a lack of coordination and communication among the interdisciplinary team responsible for resident care.
Failure to Utilize Infection Assessment Tool for Antibiotic Use
Penalty
Summary
The facility failed to accurately utilize an infection assessment tool for seven residents who were prescribed antibiotics. The Antibiotic Stewardship line list for September, October, and November 2024 revealed that these residents were prescribed antibiotics despite the infection assessment tool indicating that the antibiotic use criteria were not met. The residents were prescribed antibiotics for various infections, including skin infections, tooth infections, and urinary tract infections (UTIs). The Infection Preventionist (IP) confirmed that the criteria for antibiotic use were not met for these residents, and there was no documentation that the physician was notified about the inappropriate antibiotic use. The IP, who also worked as a Licensed Practical Nurse (LPN) and Unit Manager (UM), stated that she used the McGeer criteria for infection surveillance to determine the appropriateness of antibiotic use. Despite tracking the data on the Infection Log and surveillance checklist, the IP did not notice any trends and failed to document physician notifications when criteria were not met. The facility's Antibiotic Stewardship policy required the IP or designee to review antibiotic utilization and notify providers of findings, but this was not done for the seven residents. The Nurse Consultant acknowledged the need to revamp the antibiotic stewardship program to ensure compliance with the criteria.
Failure to Offer Vaccinations Upon Admission
Penalty
Summary
The facility failed to ensure that pneumococcal and influenza vaccinations were offered to residents upon admission, as evidenced by the cases of four residents. Resident #14, who had diagnoses including urinary tract infection and chronic hepatitis C, was not documented as having been offered the pneumococcal vaccine upon admission. Although the resident's cognition was intact, the declination of the vaccine was only documented after the surveyor's inquiry, indicating a lapse in the initial admission process. Resident #70, with a history of immunodeficiency due to drugs, had received a pneumococcal vaccine in 2018 but was not documented as having been offered a subsequent dose upon admission. Despite the resident's intact cognition, the consent for the pneumococcal vaccine was only obtained after the surveyor's inquiry, highlighting a failure in the facility's procedure to ensure timely vaccination offers. Resident #69, who had conditions such as high blood pressure and chronic respiratory failure, was not documented as having been offered the pneumococcal vaccine upon admission. Similarly, Resident #66, with multiple health issues including severe obesity and pressure ulcers, was not documented as having been offered either the influenza or pneumococcal vaccines. The facility's policies required that these vaccines be offered upon admission, but the documentation and follow-up were inadequate, leading to the deficiency noted by the surveyors.
Failure to Offer Updated COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer an updated COVID-19 vaccine to four out of five residents reviewed for immunizations. This deficiency was identified through interviews, record reviews, and examination of facility documents. The residents involved had various medical conditions, including urinary tract infection, chronic viral hepatitis C, immunodeficiency due to drugs, high blood pressure, pneumonia, chronic respiratory failure, morbid obesity, osteomyelitis, pressure ulcers, diabetes, and depression. Despite these conditions, there was no documentation that these residents received or declined an updated COVID-19 vaccination after 2022. The surveyor's investigation revealed that the facility's process for offering and documenting COVID-19 vaccinations was inadequate. Interviews with the Infection Preventionist (IP), Licensed Practical Nurse (LPN), Director of Nursing (DON), and other staff members confirmed that the administration or declination of vaccinations should have been documented in the residents' electronic medical records. However, the records for the residents in question either lacked documentation of an updated COVID-19 vaccine or showed that consents or declinations were obtained only after the surveyor's inquiry. The facility's policy required that each resident and staff member be offered the COVID-19 vaccine when available, with informed consent obtained prior to vaccination. The policy also stated that refusals should be documented. Despite this, the surveyor found that the facility did not adhere to its policy, as evidenced by the lack of timely documentation and offering of the updated COVID-19 vaccine to the residents. The deficiency was further highlighted by the fact that the residents' immunization statuses were not accurately reflected in their records, and attempts to contact responsible parties for vaccination history were not documented.
Deficient Medication Storage Room Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary medication storage room in the West Wing, as observed by the surveyor. Upon entering the room, a musty odor was detected, and several issues were noted, including discolored and stained floor tiles, a raised and buckled floor, a crack in the ceiling, and detached piping on the floor. Additionally, a moist, soiled blanket with brown stains and debris was found under the sink, and the interior of the cabinet was discolored. The Director of Maintenance acknowledged the issues, stating that the pipes broke three weeks prior and that he had ordered parts for repair but was absent for a week, during which no repairs were made. Interviews with various staff members, including LPNs and the Licensed Nursing Home Administrator, revealed that the sink had been nonfunctional for about a month, with water dripping under the sink and onto the floor. Despite being aware of the issues, no signage was posted to indicate the sink was out of order, and there was no hand sanitizer available in the room. The Consultant Pharmacist confirmed that the medication storage environment was unacceptable and emphasized the need for a clean, dry, and sanitary space. The facility's policies on medication storage and maintenance service were reviewed, highlighting the responsibility of nursing staff and maintenance personnel to ensure safe and operable conditions.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident #66, on the West Unit. Upon entering the resident's room, the surveyor observed a visibly dirty floor with dried paint and debris, a rusty over bed table frame, and a television that was not in service. The resident, who had intact cognition and multiple medical diagnoses including severe obesity, osteomyelitis, and stage 4 pressure ulcers, was found tearful and crying in bed. The room lacked personal effects or decor to offer a homelike environment. Further observations revealed the flooring was heavily soiled with a black substance, and there were red and pink substances identified as ketchup and cranberry juice, respectively, on the floor. The wood around the window frame was peeling and chipped, and the protective cover on the over bed table was chipped with exposed wood. Housekeeping staff claimed the room had been cleaned, but the Housekeeping Director acknowledged the issues and stated that the table should be replaced due to safety concerns. The Director of Maintenance was unaware of the room's condition and had reported the flooring issue to the Licensed Nursing Home Administrator multiple times. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the lack of cleanliness and maintenance in the resident's room. The Licensed Nursing Home Administrator admitted that environmental rounds were conducted twice weekly, but acknowledged that the resident's room should have been maintained in better condition. The facility's failure to provide a clean, comfortable, and personalized environment for the resident was a clear deficiency in meeting the resident's rights and needs.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse was immediately reported to a supervisor, as required by the facility's abuse policy. This deficiency was identified during a survey when a Certified Nursing Assistant (CNA) did not report an allegation of abuse involving a resident's fingers being twisted by an aide. The CNA stated that the resident wanted to speak with the state surveyor first, which delayed the reporting process. The facility's policy mandates immediate reporting of any suspected abuse to the administrator and relevant authorities. The incident involved two residents, one of whom had a BIMS score indicating intact cognition, while the other had a severely impaired cognition due to Alzheimer's Disease and other mental health conditions. The resident with intact cognition initially reported the abuse but later retracted the statement, claiming the other resident twisted the staff's fingers. The Licensed Nursing Home Administrator and the Director of Nursing were unaware of the allegation until the surveyor's inquiry, highlighting a lapse in the immediate reporting process as per the facility's policy.
Failure to Notify Ombudsman of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman about a resident's hospitalization, which was identified during a survey. This deficiency involved a resident who was hospitalized for pneumonia, cellulitis, and acute kidney failure. The resident had a cognitive communication deficit, chronic respiratory failure with hypoxia, and muscle weakness, but their cognition was intact as indicated by a BIMS score of 14 out of 15. The surveyor discovered the omission during a review of the resident's medical records and interviews with facility staff. The Licensed Nursing Home Administrator (LNHA) and the Director of Social Work (DSW) were responsible for ensuring notifications were sent to the Ombudsman's office. However, the DSW, who started in May 2024, admitted to not notifying the Ombudsman's office until September 2024, missing the notification for the resident in June 2024. The LNHA assumed notifications were being sent monthly but did not verify this. The facility's policy required notifications to be sent as soon as practicable, but this was not adhered to, leading to the deficiency.
Failure to Ensure Physician's Order for Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain a professional standard of practice by not ensuring a physician's order was in place for monitoring a resident's blood glucose levels. This deficiency was identified during a medication administration record review for a resident on dialysis. The resident, who was readmitted from an acute care hospital, had diagnoses including end-stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease with acute exacerbation, and diabetes mellitus. Despite the resident's comprehensive care plan indicating a risk for complications related to diabetes mellitus and the need for finger stick monitoring, there were no active physician orders for blood glucose monitoring. The Medical Director acknowledged the oversight, noting that the resident was on insulin and should have their blood glucose levels checked at least three times per week. The facility's Nurse Consultant, in the presence of the Director of Nursing and the Licensed Nursing Home Administrator, stated that if there was a discrepancy with monitoring after the resident's return from the hospital, the expectation would be for the nurse to confirm with the physician whether to reorder the monitoring. The facility's policy on Reconciliation of Medications on Admission did not include blood glucose monitoring, contributing to the oversight.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to provide appropriate wound treatment for a resident with pressure ulcers, as per the physician's orders and facility policy. The resident, who had a history of morbid obesity, osteomyelitis, and stage 4 pressure ulcers, was observed with a dressing on the left ankle and shin that was dated several days prior to the surveyor's visit. The resident also reported having a wound on their bottom. The medical record indicated that the resident had a stage 4 pressure ulcer on the left heel and sacrum, and was on IV antibiotics for osteomyelitis. The facility's care plan included specific interventions for wound care, but these were not followed. The surveyor found discrepancies in the documentation of wound care. The Treatment Administration Record (TAR) showed that the dressing on the resident's left heel was signed out as changed on specific dates, but the dressing observed was dated earlier, indicating it had not been changed as documented. Interviews with the LPN responsible for the resident's care revealed that the dressing change was not performed as required, and the LPN admitted to signing off on the treatment without completing it. The LPN also failed to communicate the incomplete treatment to the oncoming nurse, leading to missed wound care. The Director of Nursing (DON) confirmed that the wound treatment was not administered as ordered, which posed a risk of infection and potential worsening of the wound. The facility's wound care policy required documentation of wound care, including the date, time, type of care, and any changes in the resident's condition, which was not adhered to in this case. The failure to follow the physician's orders and facility policy for wound care was acknowledged by the DON and the Licensed Nursing Home Administrator in the presence of the survey team.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to adjust medication administration times for a resident who required dialysis, leading to missed doses of critical medications. The resident, who had diagnoses including end-stage renal disease, COPD, and diabetes, was scheduled for dialysis on Mondays, Wednesdays, and Fridays with a chair time of 5:15 AM. Despite this schedule, the facility did not adjust the administration times for the resident's medications, including budesonide and Humalog, resulting in multiple missed doses on dialysis days. The facility's comprehensive care plan for the resident did not include interventions to schedule medications around dialysis times. Additionally, the facility did not notify the physician of the missed medication doses. The October, November, and December Medication Administration Records (MAR) showed numerous missed doses of budesonide and Humalog on the resident's dialysis days, with no documented evidence that the physician was informed. Interviews with the LPN/Unit Manager and the Director of Nursing confirmed that medication times should accommodate dialysis schedules and that the physician should be notified of missed doses. However, the facility's policies on dialysis and medication administration did not address these issues.
Improper Storage of Medications
Penalty
Summary
The facility failed to properly store medications, as observed by a surveyor on the East Wing high treatment cart. A tube of Santyl ointment and a bottle of Nystatin External Powder were left unattended on the treatment cart in the hallway next to the conference room. This was confirmed by an LPN/Unit Manager who acknowledged that the medications should have been stored in a plastic bag and secured in the treatment cart. The Director of Nursing also confirmed that medications should be stored inside the locked cart, as per the facility's Storage of Medications policy, which mandates that drugs and biologicals be stored in locked compartments under proper conditions and only accessible to authorized personnel.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment to a resident during meal service as ordered by the physician and indicated on the resident's individual comprehensive care plan (ICCP). This deficiency was observed during a lunch meal where the resident's tray lacked the necessary adaptive equipment, such as a curved spoon and a sippy cup, which were specified in the resident's diet slip. The resident, who has severe cognitive impairment and multiple diagnoses including cerebral palsy and dysphagia, was observed with food droppings on their clothes, indicating difficulty in eating without the proper utensils. Interviews with staff, including an LPN, the Director of Rehabilitation, the Food Service Director, and the Director of Nursing, confirmed the oversight in providing the required adaptive equipment. The staff acknowledged that the resident's diet slip clearly indicated the need for specific utensils, but these were not consistently provided. The facility's policy on assistance with meals, which mandates the provision of adaptive devices for residents who need them, was not adhered to in this instance.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to maintain a sanitary environment in the designated garbage disposal area, as observed by a surveyor on December 4, 2024. During the inspection, it was noted that two out of three garbage dumpsters had one lid open, exposing trash bags inside. Additionally, there was loose garbage on the ground between the dumpsters, including single-use gloves, plastic water bottles, plastic packaging, single-serve juice containers, plastic cup lids, paper debris, and cardboard. The Food Service Director (FSD) acknowledged that the dumpster lids should be closed and that there should not be loose trash surrounding the dumpsters. Further interviews with the Housekeeping Director (HD) and the Director of Maintenance (DM) revealed that dietary, housekeeping, and maintenance staff were responsible for taking their own trash to the dumpsters. Both directors confirmed that the dumpster lids should be kept closed and that there should not be trash and debris surrounding the dumpsters to prevent infection and pest issues. The Licensed Nursing Home Administrator (LNHA) also acknowledged that the dumpster area should be kept clean with the lids closed. The facility's policies on sanitization and food-related garbage disposal, which were reviewed, also stipulated that garbage containers should be kept closed and free of surrounding litter.
LNHA Absence at QAPI Meeting
Penalty
Summary
The facility failed to ensure the presence of the Licensed Nursing Home Administrator (LNHA) at one of the Quality Assurance and Performance Improvement (QAPI) quarterly meetings, specifically the meeting held in January 2024. During the survey, it was discovered that the LNHA did not sign the attendance sheet for this meeting, and there was no documented evidence of their attendance in the QAPI minutes. The LNHA, who was present during the survey, confirmed the absence of their signature and stated that they were not the LNHA at the time of the January meeting. The LNHA emphasized the importance of their role in the QAPI meetings, as they are responsible for chairing the committee and ensuring that all concerns are addressed and presented. The facility's policy on QAPI governance leadership, updated in April 2024, specifies that the administrator is ultimately responsible for the QAPI program and its results. The policy also lists the administrator as a required member of the QAPI committee. Despite this, the LNHA was not present at the January 2024 meeting, which constitutes a deficiency in meeting the regulatory requirements for QAPI committee composition and attendance.
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 132 citations issued within 25 miles in the last 12 months — including the 6 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 Pittsgrove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Jersey Veterans Memorial Vineland | 5.2 mi | ★★★★★ | 2 | 1 |
| Bishop Mccarthy Center For Rehab & Healthcare | 5.9 mi | ★★★★★ | 0 | 0 |
| South Jersey Extended Care | 6.5 mi | ★★★★★ | 16 | 0 |
| Millville Center | 6.6 mi | ★★★★★ | 2 | 2 |
| Autumn Lake Healthcare At Vineland | 7.6 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.