Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Forest Hills Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
Cold meal trays were repeatedly reported by residents during a council meeting, and the UM, CNAs, LNHA, and Acting DON all acknowledged that food was sometimes arriving cold. Staff described delays in tray delivery related to elevators and passing trays on the unit, and one CNA said she often reheated trays for residents because the food arrived cold.
Missing Ordered Meal Items on Resident Trays: Multiple resident meal trays were observed missing items listed on the tray tickets, including beverages, desserts, supplements, condiments, and protein portions. Affected residents had active diet and supplement orders, and care plans directed staff to provide ordered diets, supplements, and food preferences. The RD stated tray accuracy audits had not been completed, and the FSD stated trays needed to be double checked before going to the units.
Kitchen sanitation and food handling practices were deficient when surveyors observed multiple opened food items without open/use-by labels, including bread, pasta, seasonings, and cheese, along with dust and grease-like debris on kitchen equipment and in the walk-in refrigerator. Surveyors also observed a dietary aide with hair not fully restrained under a hairnet and a chef contaminating tray line foods by placing the plastic portion of a food thermometer into broccoli, roasted potatoes, and mashed potatoes.
Unsanitary Dumpster Area: The facility failed to keep the dumpster and surrounding area free of garbage and debris. During a tour with the FSD, the surveyor observed food wrappers, food containers, cups, gloves, paper products, and plastic utensils around the dumpster and nearby areas. The FSD stated the area should have been cleaned by the maintenance and dietary departments, and the facility policy required outside dumpsters or compactors to be kept closed and free of surrounding debris.
Failure to Address Weight Changes and Ordered Weighing: Two residents had significant weight-related concerns that were not handled as required. One resident with malnutrition, DM2, and moderate cognitive impairment had a large weight loss and late-entered RD notes, while another resident with diabetes, cellulitis, and a stage II heel PU had a physician order for weekly weights but only one weight was documented. The RD acknowledged the documentation gaps and that weekly weights were not entered as ordered.
Insufficient CNA staffing and delayed incontinence care were identified when a surveyor observed three residents with saturated briefs, including urine and feces, during a unit tour. The LPN/UM confirmed the findings, and the CNA assignment sheet showed 4 CNAs for 60 residents on the shift, with each CNA assigned 15 residents. The LPN/UM was unsure of the facility’s incontinence care policy and CNA-to-resident ratio, while the staffing coordinator confirmed the night shift assignments exceeded the 1:14 ratio.
Medication administration errors exceeded the 5% limit after surveyors observed an LPN and an RN make multiple errors during med passes. One resident received eye drops in the wrong eye and incorrect oral doses were prepared, while another resident’s Januvia and Ferrous Sulfate were crushed even though both were ordered to be taken whole. The report identified six errors in 25 opportunities, for a 24% error rate.
Infection Control and Hand Hygiene Failures: An LPN was observed handling a resident’s eye drops and vital sign equipment while wearing the same gloves after touching a trash bin, the resident’s bed, and contaminated equipment, without changing gloves or performing hand hygiene. Staff were also observed performing hand hygiene incorrectly, including rinsing soap off immediately, lathering for only a few seconds, and using the same paper towel to turn off faucets. In addition, the laundry area had uncovered clean linens and clothing, heavy dust on fans, pipes, and equipment, and the shower room lacked soap and paper towels, had standing water in the sink, and had garbage bags left on the floor next to open bins.
Three dependent residents with significant cognitive and physical impairments were found with saturated incontinence briefs, and in two cases, soiled sheets, during a survey. Staff interviews revealed uncertainty about the facility's incontinence care policy, despite care plans and facility policy requiring frequent care. The deficiency was confirmed through direct observation and staff acknowledgment.
A maintenance worker entered two residents' rooms without knocking, announcing himself, or waiting for permission, and two ambulance personnel entered another resident's room with a stretcher without knocking, announcing themselves, or stating their purpose. The RN/UM, UM, DOM, and LNHA all stated that staff and contractors are expected to knock, announce themselves, and seek permission before entering a resident's room.
Surveyors found multiple unsanitary conditions, including dusty vents, soiled shower and resident areas, broken fixtures, and privacy curtains that were missing hooks or heavily soiled. Residents and CNAs reported that clean towels and washcloths were often unavailable, with staff sometimes using top sheets to dry residents after bathing. Surveyors also observed soiled tube feeding pumps, poles, and an oxygen concentrator in resident rooms, and staff acknowledged several of the conditions.
A facility failed to provide a safe smoking area for two residents who smoked. Surveyors observed extinguished cigarettes on the ground near the entrance/portico, with no ashtrays or other receptacles available at the time and no fire extinguishers or fire blankets in the area. One resident with intact cognition and a smoking care plan said staff directed him/her to smoke there and discard cigarette butts in a trash can, while another resident with intact cognition said the same area had been used for smoking since admission. The facility’s smoking policy stated smoking was prohibited in the building and portico and that residents should smoke off premises.
A resident with urinary retention, severe cognitive impairment, and an indwelling catheter had a urinary drainage bag observed visible from the hallway and not placed in a privacy bag. The resident’s care plan and physician orders required the drainage bag to be covered with a privacy cover, and an RN stated she was unsure about the privacy bag requirement for infection control and dignity.
Improper Storage of Oxygen Tubing: A resident with COPD and severely impaired cognition received oxygen via NC at 3 LPM, but surveyors observed the oxygen concentrator soiled and dusty and the NC tubing not in use and not stored in a plastic bag. The RN and MDS coordinator stated that unused oxygen tubing should be stored in a plastic bag for infection control, and the facility policy also required tubing not in use to be stored in plastic bags.
An LPN administered eye drops to a resident based on the pharmacy label instead of the e-MAR/PO directions. During a med pass, Combigan and Dorzolamide were given only to one eye even though both the e-MAR and PO directed use in both eyes twice daily. The LPN acknowledged the discrepancy and stated the label was confusing.
A CP failed to identify and report that two ordered meds, Januvia and Ferrous Sulfate, should not be crushed. During med pass, an RN crushed both meds and gave them in applesauce to a resident with DM2, dysphagia, and severe cognitive impairment. The MAR and physician orders showed daily orders for both meds, while manufacturer guidance stated Januvia must be swallowed whole and Ferrous Sulfate should not be crushed, chewed, or broken apart. The CP later acknowledged the crushing restrictions but said she did not think reporting them was necessary.
An LPN improperly handled medication disposal during a med pass for a resident who was in bed and eating breakfast. While preparing nine medications, the nurse placed two Aspirin 81 mg tablets instead of one and a Vitamin C 500 mg tablet instead of a 250 mg tablet into the med cup. The nurse then handled the extra tablets on tissue paper and was about to discard them in the cart trash bin before being stopped; she stated medications should be disposed of in a Drug Buster, and the medications were then discarded there.
Cold Meal Trays Delivered to Residents
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature for 6 of 6 residents who participated in the Resident Council Meeting, identified as Residents #1, #19, #20, #29, #69, and #78. During the meeting, all 6 residents stated they received cold food at meals. The Unit Manager for the 5th floor confirmed that residents occasionally ask for their food to be heated because it arrives cold, and stated that cold food is heated on the unit in a microwave. The Unit Manager also stated that trays are started as soon as they reach the floor, but there are delays getting trays to the floor because of the elevators. Two CNAs stated that residents complain about cold food, that elevator delays slow food arrival, and that trays are sometimes passed out slowly because staff are busy; one CNA said she heats trays for residents almost every day and noted only one elevator had been working for a long time. The LNHA and Acting DON acknowledged the food temperature and tray delivery delay issues and stated residents should receive food at appropriate temperatures.
Missing Ordered Meal Items on Resident Trays
Penalty
Summary
The facility failed to ensure that resident dietary preferences and ordered meal items were consistently provided for 6 of 6 residents reviewed during meal observations. During lunch meal observations on the 4th and 5th floor units, multiple trays were missing items listed on the tray tickets, including coffee, strawberry short cake, health shake supplements, sour cream, pot roast, bread, tea, and double portions of protein. The missing items were observed on trays for residents with varying cognitive status, including residents with intact cognition and residents with moderate to severe cognitive impairment. Record review showed that each affected resident had active diet or supplement orders and nutrition care plan interventions. One resident had an order for Health Shake three times daily for malnutrition and a care plan directing that supplements be provided as ordered. Another resident had orders for a regular diet with easy-to-chew texture and thin liquids, with care plan interventions to provide diet as ordered, fortified foods, and supplements per orders. A third resident had an order for no added salt, regular texture, and thin liquids, with a care plan intervention to honor food preferences and provide diet as ordered. Additional residents had orders for regular diets, easy-to-chew or regular textures, thin liquids, health shake supplements, or double protein portions, and their care plans directed staff to provide the ordered diet and supplements. The Registered Dietitian stated tray accuracy audits had not been completed, and the Food Service Director stated kitchen staff needed to double check trays before they went to the units and that more tray accuracy audits were needed. The facility policy titled Meal Pass stated staff must check the meal ticket upon removing the tray from the food truck and ensure the items on the meal ticket are present on the tray.
Kitchen sanitation and food labeling deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices during surveyor observations in the kitchen and food storage areas. In the bread storage area, opened loaves of sliced white bread, sliced whole wheat bread, hotdog buns, and rye bread were observed without open/use-by labels. On a dry storage shelf, an open bag of penne pasta dated 3/26/25 was present without a use-by label, and the Food Service Director (FSD) acknowledged it was past the facility’s 90-day limit after opening. On the chef preparatory table, three opened seasoning containers, including granulated garlic, Italian seasoning, and red pepper flakes, were also missing open/use-by labels and were discarded by the FSD. In the walk-in refrigerator, wrapped sliced American cheese was observed without an open/use-by label, and dust-like debris was noted on the interior fans. The surveyor also observed a dietary aide with hair not fully restrained under a hairnet, and the FSD stated the hairnet was corrected by the aide. Additional sanitation concerns were observed on kitchen equipment and during food handling. The dual ovens had black burnt debris on the bottom area, the top of the standing steamer had a sticky grease-like substance, and the ice machine vent had dust-like debris. During the follow-up kitchen observation, the chef contaminated food while taking tray line temperatures by inserting the food thermometer so that the plastic portion touched the broccoli, then did the same with roasted potatoes and mashed potatoes. The chef stated they had not realized the plastic had touched the food, and the FSD stated the contaminated food would need to be disposed of. The facility policies provided by the LNHA addressed storage of non-perishable goods, kitchen cleaning, and employee hygiene, but no policy for labeling and dating food items was provided.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public by not keeping the dumpster and surrounding area free of garbage and debris. During a kitchen and garbage area tour with the Food Service Director, the surveyor observed garbage debris around the dumpster and surrounding areas, including food wrappers, food containers, cups, gloves, paper products, and plastic utensils. The Food Service Director stated that the area should have been cleaned by the maintenance and dietary departments. The facility policy titled, Disposal of Refuge, stated that outside dumpsters or compactors provided by waste management services will be kept closed and free of surrounding debris.
Failure to Address Significant Weight Changes and Weekly Weighing
Penalty
Summary
The facility failed to ensure that residents with significant weight changes were addressed by the Registered Dietitian in a timely manner and failed to ensure that a resident was weighed weekly in accordance with physician orders and facility policy. The deficiency was identified for two residents reviewed for significant weight changes. One resident had diagnoses including unspecified protein-calorie malnutrition, type 2 diabetes mellitus, and anxiety disorder, and had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The resident’s weight history showed a marked drop from 102.2 pounds to the mid-80s over the review period, and the RD’s nutrition progress notes included late entries with effective dates in June but created on 7/22/25. During interview, the RD stated she was the Regional RD covering the building until a part-time RD could be hired and was in the building three times per week. She acknowledged that the June weight loss note for the resident was backdated and that the recommended Mighty Shakes intervention could not have been entered at that time, although she stated the supplements were already in place. The facility policy titled Nutritional Assessment/Documentation stated that the Dietitian, with nursing staff and healthcare practitioners, would conduct a nutritional assessment upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. A second resident had diagnoses including diabetes, cellulitis of the left lower extremity, and a stage II pressure ulcer of the left heel. The physician ordered weekly weights for four weeks, but only one weight was documented during that ordered period. The unit manager stated that on Mondays the RD provided a list of residents to be weighed and that CNAs and nurses obtained the weights and returned the list to the RD, who then entered the weights into the medical record. The RD acknowledged that the weekly weights should have been obtained and documented weekly as ordered and stated that she did not document follow-up on every weight and did not enter the weights or follow up to ensure they were entered into the resident’s record.
Insufficient CNA Staffing and Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure sufficient and competent staff were available to provide incontinence care to dependent residents. During an incontinence tour on the 4th-floor nursing unit, the surveyor and the LPN/UM observed three residents in bed with saturated incontinence briefs: one resident’s brief was saturated with urine, another resident’s brief was saturated with urine and feces, and a third resident’s brief was also saturated with urine and feces. The LPN/UM confirmed each observation. The CNA assignment sheet for the 11-7 AM shift showed the unit had a census of 60 residents with 4 CNAs assigned, and the CNA assigned to each of the observed residents had an assignment of 15 residents on that shift. The LPN/UM stated that the 11-7 AM shift should provide incontinence care before the end of the shift between 5 AM and 7 AM, but was not sure what the facility policy was on providing incontinence care and was not sure what the CNA-to-resident ratio was on the 11-7 AM shift. The staffing coordinator confirmed that the night shift census on the 4th floor was 60 and that CNAs had 15 residents on each assignment, and stated awareness of the 1 CNA to 14 resident ratio for the night shift. The report also documented staffing shortages on multiple day shifts during the two weeks before survey and during a prior complaint staffing period, with CNA staffing below required ratios on several dates.
Medication Administration Errors Exceeded Threshold
Penalty
Summary
Medication administration errors exceeded the 5% threshold after surveyors observed three nurses administer medications to six residents and identified six errors in 25 opportunities, for an error rate of 24%. The deficient practice involved two residents and occurred during morning medication passes observed on separate days. The report identified errors in how medications were prepared and administered, including incorrect eye drop administration and crushing medications that were ordered to be given whole. For one resident with diagnoses including hypertension, type II diabetes, and chronic kidney disease, an LPN administered ophthalmic medications incorrectly. The resident was cognitively intact and had orders for Combigan eye drops and Dorzolamide eye drops, both directed to be instilled as 1 drop in both eyes twice daily. During the observation, the LPN told the surveyor the resident received both eye drops in the left eye only, administered one drop of Combigan to the left eye, later administered one drop of Dorzolamide to the left eye, and initially prepared oral medications with dose errors, including placing two aspirin 81 mg chewable tablets instead of one and a Vitamin C 500 mg tablet instead of the ordered Vitamin C 250 mg tablet. For another resident with diagnoses including type II diabetes, syncope and collapse, and dysphagia, an RN crushed medications that were ordered to be swallowed whole. The resident had severe cognitive impairment and orders for Januvia 50 mg and Ferrous Sulfate 325 mg, both scheduled for 9 AM. The RN stated the resident’s medications were administered crushed in applesauce and crushed both Januvia and Ferrous Sulfate before administration. The report states manufacturer specifications indicated Januvia should not be split, crushed, or chewed, and Ferrous Sulfate should not be crushed, chewed, or broken apart.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain a sanitary clean environment and failed to minimize the spread of infection during medication administration and hand hygiene practices. During medication pass, an LPN prepared eye drops for a resident, applied hand sanitizer, put on gloves, touched the lid of a trash bin attached to the medication cart, entered the resident’s room, placed medications on the overbed table, and then touched the resident’s bed and headrest without removing the gloves or performing hand hygiene. The same LPN then instilled an eye drop and wiped the resident’s eye with a tissue while still wearing the same gloves. When interviewed, the LPN acknowledged that after touching the trash bin and the resident’s bed, she should have removed her gloves, performed hand hygiene, and reapplied gloves before continuing. During another medication administration observation, the same LPN cleaned a blood pressure monitor, pulse oximeter, and thermometer with a disinfectant wipe, allowed them to dry, and then took a resident’s vital signs without removing gloves or performing hand hygiene. The LPN acknowledged that after cleaning the equipment, she should have removed her gloves, performed hand hygiene, and reapplied gloves before taking the resident’s vitals. The facility’s hand hygiene policy stated that alcohol-based hand rub should be used before and after direct contact with residents, before handling medications, after handling contaminated equipment, and after removing gloves. The facility also failed to keep the laundry area and shower room sanitary. In the laundry area, clean resident clothing, towels, linens, and blankets were left uncovered on folding tables and metal racks, while fans and pipes had heavy dust accumulation and rehab supplies and equipment were heavily covered with dust. The area was unattended and there was no accountability log for cleaning. In the 4th floor shower room, the door was open, the sink was clogged with standing water, soap and paper towels were unavailable, and two large garbage bags were left on the floor next to open three-compartment bins. During an incontinence tour, an LPN/unit manager and a CNA were observed performing hand hygiene incorrectly by applying soap and immediately placing their hands under running water without first lathering and applying friction; the LPN/unit manager also used the same paper towel to turn off the faucet. The CNA was observed lathering for only 6 seconds outside the stream of water. The ADON stated she instructed staff to lather their hands outside the stream of water for a minimum of 20 seconds, and the LNHA and MDS coordinator confirmed that hand hygiene included lathering and applying friction for at least 20 seconds out of the stream of water.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
Surveyors determined that the facility failed to provide timely incontinence care to dependent residents on one nursing unit, as evidenced by direct observation, interviews, and record reviews. During an incontinence care tour, three residents were found in bed with saturated incontinence briefs; two of these residents also had soiled sheets. The residents involved had significant medical histories, including diabetes mellitus, dementia, and urinary tract infection, and all were documented as always incontinent of bowel and bladder, with care plans specifying the need for frequent incontinence care to prevent complications such as pressure ulcers. The care plans for these residents required incontinence care every two hours or every shift and as needed, but this was not provided as observed during the survey. Interviews with facility staff, including the LPN/Unit Manager and the Assistant Director of Nursing, revealed uncertainty regarding the facility's policy on incontinence care frequency, though both acknowledged that best practice would be care every two to three hours or at the end of the overnight shift. The CNAs responsible for the residents during the overnight shift were unavailable for interview. Review of the facility's Activities of Daily Living policy confirmed the expectation to monitor for incontinence and provide appropriate hygiene. The failure to provide timely incontinence care was confirmed by both observation and staff acknowledgment.
Failure to Knock and Announce Before Entering Resident Rooms
Penalty
Summary
The facility failed to treat residents with respect and dignity and violated privacy for 3 of 28 residents reviewed for residents' rights. While interviewing Resident #70, the surveyor observed a maintenance worker enter the room without knocking or announcing themselves. The maintenance worker opened a step ladder, inspected the privacy curtain, and then exited the room. Shortly afterward, the same maintenance worker entered Resident #71's room without knocking, waiting for permission, or introducing themselves before entering. The surveyor also observed two transport ambulance personnel enter Resident #123's room with a stretcher without knocking, announcing themselves, or stating their purpose. During interviews, the maintenance worker and the ambulance personnel acknowledged they should have knocked and announced themselves before entering. The 5th floor RN/UM, the 5th floor UM, the Director of Maintenance, and the LNHA each stated that staff and contractors are expected to knock, announce themselves, and seek permission before entering a resident's room.
Unsanitary environment, linen shortages, soiled equipment, and broken privacy curtains
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment in multiple areas of the nursing units and resident rooms. During a tour of the 4th floor unit, surveyors observed the clean linen room with a vent covered in heavy gray dust and a ceiling tile with dried brown discoloration. In the shower room, there were missing and broken floor tiles, a shower curtain with missing hooks, an exhaust and vent covered with blackish substance, a clogged sink with water accumulation, and shower cubicle vents heavily covered with dust. In resident rooms, surveyors observed privacy curtains with missing hooks, broken room fixtures, dusty vents, broken blinds, and accumulation of dust and blackish substances on windowsills, air-conditioning units, and floors. Staff interviewed during the tour acknowledged several of these conditions and stated that some areas should have been cleaned or repaired. The facility also failed to ensure that clean linens were provided daily to residents. Residents in a group meeting stated they were not receiving clean towels or washcloths daily and that top sheets were not changed often. Multiple CNAs stated they often did not have enough towels or washcloths for resident care and sometimes used top sheets to dry residents after bathing or bed baths. The Director of Housekeeping/Maintenance stated he did not keep records of linen par levels or linen orders and did not know how much linen the facility had. Surveyors observed the emergency linen closet and found no fitted sheets or top sheets, only 180 towels and 120 washcloths for a census of 106 residents, and the DHK acknowledged there were not 3 days of emergency linen supplies. The facility also failed to keep resident care equipment clean and to maintain privacy curtains in working order. In one resident room, a tube feeding pump and pole were observed soiled with yellow and brown substances, with the floor behind the bed heavily soiled and the oxygen concentrator splattered with substance and dust. In another resident room, a tube feeding pump and pole were observed with dried brown and yellow substances, and the pole legs were heavily crusted with reddish-brown substance. Surveyors also observed a privacy curtain heavily soiled with a brown substance across the bottom, and another resident’s privacy curtain could only close halfway because multiple rings were missing; staff stated the curtain had been broken for a long time and the facility was aware of it.
Unsafe Smoking Area and Missing Fire Safety Equipment
Penalty
Summary
The facility failed to provide a safe smoking environment for two residents who were identified as smokers. Surveyors observed the smoking area by the facility entrance and portico had extinguished cigarettes on the ground in several areas, with no receptacles or ashtrays available for safe disposal of cigarette butts. Surveyors also observed that there were no fire extinguishers or fire blankets in the area. One resident was observed smoking in the portico and stated that staff told him/her this was the permitted smoking location and that cigarette butts were extinguished on the outside of the trash can before being thrown away. Another resident was also observed smoking near the entrance and stated that this had been the designated smoking area since admission, with cigarette butts previously extinguished in a bucket of sand when available. Resident #3 was admitted with diagnoses including seizures and hemiplegia/hemiparesis following cerebrovascular disease. The resident had a BIMS score of 15/15, indicating intact cognition, and the MDS indicated the resident was not currently using tobacco. The care plan identified the resident as a known smoker with a goal to smoke safely within the designated smoking area, and the smoking regulation agreement stated the resident was aware of the smoking rules and responsible for securing matches or lighters. The smoking assessment reflected that the resident demonstrated an accurate understanding of smoking policy and guidelines. Resident #72 was admitted with diagnoses including depression, anxiety, and COPD. The resident had a BIMS score of 14/15, indicating intact cognition, and the MDS indicated current tobacco use. The care plan identified the resident as a known daily smoker with a goal to smoke safely within the designated smoking area and included supervision as needed. However, no smoking regulation agreement was provided for this resident when requested. During interviews, the receptionist confirmed there was no fire extinguisher in the front lobby, and the LNHA stated the designated smoking area was near the building entrance and that residents were supposed to extinguish cigarettes in an ashtray, although none was observed at the time. The facility's smoking policy stated the center maintained a smoke-free environment and prohibited smoking within the building, parking area, delivery area, and portico covered entryway, directing residents and visitors to smoke off premises on public domain.
Urinary Drainage Bag Not Secured in Privacy Cover
Penalty
Summary
A urinary drainage bag for Resident #113 was observed not secured in a privacy bag and visible from the hallway. The resident was admitted with diagnoses including urinary retention, chronic obstructive pulmonary disease, and gastrostomy status, and the admission MDS dated 7/24/25 reflected severely impaired cognition and an indwelling catheter. The current order summary and TAR included physician orders to check the urinary catheter for proper placement, provide urinary care, record urine output at the end of each shift, and maintain the catheter in a privacy bag every 8 hours. The resident’s comprehensive care plan, initiated on 7/18/25, identified a focus area for the Foley catheter for urinary retention and included the intervention to cover the drainage bag with a privacy cover at all times. During interview, the RN stated she was unsure whether the urinary drainage bag should be secured in a privacy bag for infection control prevention and dignity. The MDS coordinator later confirmed that the urinary drainage bag should be stored in a privacy bag for infection control and dignity, and the facility policy on catheter care stated to cover urinary drainage bags with privacy covers.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to ensure that oxygen nasal cannula tubing was stored in accordance with infection control measures for one resident receiving oxygen therapy. On 7/29/25, the surveyor observed an oxygen concentrator in the resident’s room that was not in use, soiled with a brown and yellow substance, and covered with dust. On 7/30/25, the surveyor again observed the oxygen concentrator soiled and dusty, and the nasal cannula oxygen tubing was connected to the concentrator, not in use, and not stored in a plastic bag. The resident’s record showed diagnoses including COPD and gastrostomy status, and the current physician order directed oxygen at 3 liters per minute via nasal cannula with oxygen saturation checks every shift. The admission MDS indicated severely impaired cognition and that the resident received respiratory treatments, including oxygen therapy. The comprehensive care plan did not include a care plan for oxygen therapy. During interview, the assigned RN stated that oxygen tubing should be stored in a plastic bag for infection control prevention, and the MDS coordinator confirmed that when oxygen tubing was not in use, it should be stored in a plastic bag. The facility policy on Oxygen Administration also stated that tubing not in use should be stored in plastic bags.
Medication Given Contrary to e-MAR Directions
Penalty
Summary
Medication administration was not carried out according to the physician's orders and acceptable standards of practice for one resident. During a medication pass, an LPN informed the resident that medications would be given while the resident was in bed eating breakfast, then prepared nine medications, including two ophthalmic medications: Combigan and Dorzolamide. The LPN instilled one drop of each eye medication into the resident's left eye. After the medications were given, the surveyor reviewed the physician orders, the pharmacy packaging, and the e-MAR with the LPN. The pharmacy label for Dorzolamide directed 1 drop to the left eye twice daily, while the pharmacy label for Combigan directed 1 drop to both eyes twice daily. The e-MAR, however, contained physician orders for both Combigan and Dorzolamide to be instilled in both eyes twice daily. The LPN acknowledged that both medications should have been administered to both eyes and stated she followed the pharmacy label instead of the e-MAR, noting that the label directions were confusing and could cause an error. The resident had diagnoses including hypertension, type II diabetes, and chronic kidney disease. The resident's quarterly MDS indicated intact cognition with a score of 15 out of 15 for daily decision-making. The physician orders and e-MAR both reflected the intended directions for the eye drops, but the medication was administered based on the pharmacy label directions rather than the resident's documented orders.
Consultant Pharmacist Failed to Report Crushing Restrictions for Two Medications
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported medication irregularities in a resident’s medical record to facility staff and the attending physician. During a medication administration pass, a Registered Nurse prepared and administered five medications for the resident, including Januvia 50 mg and Ferrous Sulfate 325 mg, and crushed both medications into applesauce before giving them to the resident. The resident was observed sitting up in bed and eating breakfast at the time, and the nurse stated the resident’s medications were administered crushed in applesauce. The resident had diagnoses including type II diabetes, syncope and collapse, and dysphagia, and the annual MDS reflected severe cognitive impairment. The July 2025 physician order summary and eMAR showed orders for Januvia 50 mg by mouth daily and Ferrous Sulfate 325 mg by mouth daily. Manufacturer specifications reviewed by the surveyor stated that Januvia must be swallowed whole and must not be split, crushed, or chewed, and that Ferrous Sulfate should not be crushed, chewed, or broken apart. The Consultant Pharmacist’s monthly reports from 5/1/25 through 7/31/25 did not include a recommendation that Januvia or Ferrous Sulfate should not be crushed, and there was no recommendation to make the physician or nurses aware of the manufacturer instructions. The nurse stated she was not aware that either medication could not be crushed and said she would not have crushed them if she had known. The Consultant Pharmacist later acknowledged that both medications should be taken whole and not crushed or split, but stated she did not think it was necessary to make that recommendation because crushing would not affect the medication’s activity or harm the resident.
Improper Disposal of Medications During Medication Pass
Penalty
Summary
The facility failed to properly dispose of medications during a medication administration pass for one of three nurses observed. During observation on 7/30/25, an LPN was preparing nine medications for Resident #16, who was in bed and eating breakfast. While preparing the medications, the LPN added two Aspirin 81 mg chewable tablets instead of one and added a Vitamin C 500 mg tablet instead of the ordered Vitamin C 250 mg tablet into the medication cup. The surveyor stopped the nurse before administration and asked her to leave the room with the medications. The surveyor then asked the LPN to identify the extra tablets, and the nurse poured two Aspirin 81 mg chewable tablets from a stock bottle onto a tissue paper while reviewing the medications. The LPN acknowledged that she had accidentally added two Aspirin tablets to the medication cup. When she picked up the tissue paper containing the two tablets and was about to throw them into the trash bin attached to the medication cart, the surveyor stopped her and asked if that was the proper way to dispose of medications. The LPN stated that medications should be disposed of in a Drug Buster and not in a trash bin. The surveyor then observed the nurse use the Drug Buster to dispose of the two Aspirin tablets and all medications in the cup, and the medications were then re-prepared for administration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newark
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Broadway House For Continuing Care | 0.5 mi | ★★★★★ | 1 | 0 |
| New Vista Nursing & Rehabilitation Ctr | 0.5 mi | ★★★★★ | 2 | 0 |
| Alaris Health At Belgrove | 0.9 mi | ★★★★★ | 16 | 0 |
| Alaris Health At Kearny | 1.3 mi | ★★★★★ | 17 | 0 |
| Job Haines Home For Aged People | 1.6 mi | ★★★★★ | 0 | 0 |
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