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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at King Manor Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with DM, PVD, and other chronic conditions was observed over several days with swollen, discolored, weeping feet and reported not having had a shower since January, despite a shower schedule and a signed TAR showing care was completed. The resident also missed a vascular f/u appointment, and a physician later documented bilateral leg cellulitis. In separate findings, one resident was left without a wheelchair for 12 days after transfer, and another resident did not receive ordered bilateral ace wraps consistently, with blank TAR entries and undocumented refusal/pain.
The facility failed to adequately supervise a resident with repeated unwitnessed falls and injuries, including head trauma and a right periorbital hematoma, and did not consistently implement effective fall-prevention measures. It also lacked a reliable system for residents who signed out on pass, as one resident with a substance use history repeatedly left with incomplete LOA documentation and was later hospitalized after an e-scooter crash, while another resident who required supervised smoking was observed leaving alone and smoking outside before the scheduled smoke break.
Failure to Provide Quarterly PNA Statements: The facility did not have a system to ensure quarterly PNA statements were given to residents with facility-held funds. Seven residents at a council meeting said they did not receive statements and would have to request them, and the BOM confirmed he did not distribute statements even though he knew residents were supposed to get them quarterly. The issue affected all residents with PNA accounts, including one resident with a balance over $2,000 who was unaware of available funds for needed clothing and personal items.
A resident with dementia, anxiety, and osteoarthritic conditions had a PNA balance over $2,000, but staff did not have a clear process to notify the resident or document discussion of needed purchases. Interviews showed the BOM, SWs, and Activities each had partial roles in monitoring funds, yet the resident was unaware of available money and had unmet clothing needs; the PNA record showed no purchases or withdrawals over the review period.
Insufficient staffing and missed resident care led to multiple deficiencies. Residents were found saturated with urine, a CNA had not yet provided care during the morning meal period, and staff gave inconsistent accounts of incontinence and nail care routines. One resident had long, dirty fingernails, another requested nail trimming but remained unchanged on repeated observations, and another reported not having a shower for an extended period while wearing the same pajamas for days. Staffing records also showed repeated CNA shortages and several shifts below required staffing levels.
Failure to complete CNA performance reviews: The facility did not conduct yearly performance evaluations for 5 of 5 CNAs reviewed and could not provide evaluations for the selected CNAs or an LPN. The nurse educator said the DON and LNHA were responsible for the reviews, and the LNHA acknowledged that performance reviews had not been done recently and were not available for the survey team.
Failure to coordinate care for residents attending PACE. A resident with schizoaffective disorder, intact cognition, and active discharge planning was observed leaving the facility and smoking independently while staff said the resident routinely left, smoked, and went to the liquor store. The care plan did not address PACE attendance or discharge planning, staff said PACE had its own SWs and the facility was not involved in discharge planning, and the LNHA acknowledged there was no process in place to ensure oversight and integration between the facility and PACE.
The facility failed to ensure a binding arbitration agreement in the admission packet was clearly explained to residents or representatives in a way they understood, and failed to document that understanding. Seven residents at a council meeting said they did not recall signing the agreement, with one stating the tablet text was too small and no copy was provided. A resident with severely impaired cognition had an arbitration agreement signed by the resident and LNHA, but no legal rep signature was present, and the LNHA confirmed signatures were not obtained in the resident’s presence and no documentation of review was made.
QAPI failed to identify and review multiple resident care and facility concerns, including pest activity, room disrepair, incontinence care, nail hygiene, PNA issues, and PACE-related oversight. Surveyors observed cockroach activity and environmental disrepair in resident rooms and bathrooms, found a resident saturated with urine after reported missed overnight care, and observed another resident with long, dirty fingernails. The LNHA stated the facility did not review significant events in QAPI and had no QAPI initiatives for several of the concerns identified during the survey.
The facility QAPI committee failed to use the PIP process to measure and use data to develop quantitative, measurable goals. Surveyors reviewed PIPs for activities participation, missed reimbursement for respiratory treatments, CNA staffing, MDS modifications, and baseline care plans, and none included goals or thresholds for performance measurements. The LNHA stated department heads reviewed PIPs quarterly and that current QAPI initiatives included activities attendance, CNA staffing, MDS accuracy, kitchen food preferences, and call bell audits, but there were no specific quantitative goals, outcomes, or audits written down.
Surveyors found multiple resident rooms and a shower room with broken tiles, deteriorated ceiling tiles around a sprinkler head, an unfastened plywood bathtub cover, rust-colored and blackish-brown sediment, broken blinds, damaged molding, and missing caulking around a sink/vanity. Staff and leadership acknowledged the disrepair, said maintenance issues were supposed to be logged, but could not provide documentation of routine audits or preventative maintenance.
Failure to Provide Needed ADL Assistance: A resident was left saturated with urine after reported incontinence care was not provided, another resident’s long, dirty fingernails were not trimmed despite repeated requests, a third resident went without a shower for an extended period and remained in the same clothing over several days, and a fourth resident also had overdue nail care. Staff interviews and record review showed dependent residents were not consistently receiving needed bathing, grooming, and hygiene assistance.
A resident with moderately impaired cognition and documented low mood was not provided an adequately supported individualized activity program. The resident said they liked jewelry, dancing, and trips, while the care plan listed preferred activities such as music, game shows, shopping, and 1:1 visits. However, the AD stated trip refusals were not documented, room visits were only supported by an incomplete handwritten log, and the record did not show all expected weekly visits.
A resident with severe epilepsy, dysphagia, and a nectar thickened liquid diet was given levetiracetam oral solution during a med pass even though the LPN did not have thickening powder available and had to use a pre-thickened nectar liquid. The CP had recommended notifying the prescriber and confirming whether the medication’s consistency was safe, but the recommendation was signed and not acted upon. The LPN later stated the thin liquid could cause aspiration, and the Regional DON acknowledged the recommendation had not been followed.
Medication administration errors exceeded the 5% threshold when surveyors observed three errors during 26 opportunities. An LPN administered a topical pain medication without the ordered cream being available, another LPN prepared a topical gel without a specified dose on the order, and an LPN crushed a Lamictal tablet despite the label and eMAR instructions to swallow it whole and not crush it.
A resident with intact cognition reported seeing cockroaches scatter in the bathroom at night and showed surveyors a bag of dead insects, while also pointing out a gap in the room where the pests could enter. Pest control records showed repeated roach activity in multiple areas of the facility, and the MD and Housekeeping Director confirmed ongoing reports and treatments, with the LNHSA stating he did not believe it was a widespread concern.
Medications Left Unattended at Bedside: An LPN left a resident’s scheduled meds at the bedside with a cup of water, and the resident stated the nurse told them to take the meds. The surveyor later found the tablets still at the bedside, while the MAR had already been signed as administered. The resident had intact cognition, and the facility policy stated meds are to be given safely and the MAR initialed after each medication is administered.
A resident with severe cognitive impairment and multiple medical conditions developed a fever, but staff failed to document follow-up actions or notify the physician and responsible party as required by facility policy. Nursing staff interviews confirmed that the expected protocol was not followed, resulting in a deficiency related to notification and documentation of a significant change in condition.
A resident with severe cognitive impairment and multiple medical conditions did not receive acetaminophen as ordered for a documented fever, and there was no documentation of medication administration, follow-up monitoring, or nursing assessment. Facility staff interviews and policy review confirmed that required protocols for medication administration and documentation were not followed.
Two residents in a facility did not receive timely incontinence care, leading to prolonged periods of being soiled. One resident was found wearing two saturated briefs, and staff were unaware of this practice. Another resident experienced issues with a Condom Catheter, resulting in frequent wetness due to improper application and delayed care. The facility's policy on ADLs was not followed, as care was not documented or provided consistently.
A facility failed to implement a turning and repositioning program for a resident with pressure ulcers, who was dependent on staff for care. Despite the resident's high risk for pressure sores and a care plan requiring repositioning every 2-3 hours, there was no documentation of these interventions being followed. Staff interviews confirmed the lack of adherence to the care plan, and the facility's policy on pressure ulcer prevention was not implemented.
The facility failed to ensure staff were trained and competent in caring for residents requiring hemodialysis, specifically in assessing different dialysis access sites. Two residents with dialysis needs were affected, as staff did not perform required checks on their access sites due to a lack of training. The facility's policy required trained staff for such tasks, but this was not implemented, leading to the deficiency.
A resident with Moisture-Associated Skin Damage (MASD) did not receive the prescribed Nystatin cream treatment due to a failure to transcribe the physician's order onto the Treatment Administration Record (TAR). The resident was observed with saturated incontinence briefs and reddened skin, and the treatment was not administered for several days. The DON and AA were unaware of the oversight until informed by the survey team.
The facility was found deficient in hand hygiene practices, as observed during a survey. An LPN washed hands for insufficient durations during medication administration, and both a DA and a CNA failed to perform hand hygiene between resident interactions during meal service. Despite having completed hand hygiene competency validations, their actions did not align with the facility's policy, which mandates handwashing before and after contact with residents, equipment, and food.
The facility failed to maintain a functioning call bell system in one of the tested rooms. During an observation, the call bell button for a resident's window bed was found non-functional when tested by the DOM. This issue was identified in the presence of the DOM and AA and communicated during the Life Safety Code exit conference.
Failure to Provide Ordered Care, Shower Assistance, and Treatment Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for three residents. For Resident #58, survey observations from 3/22/26 through 3/25/26 showed the resident sitting in a wheelchair in pajamas with bare, swollen, discolored feet and dry scaly skin, with clear fluid weeping from the left foot and a bluish, swollen right third toe. The resident told the surveyor they had been asking for a shower for quite some time and stated the last shower was in January. The shower log showed the resident was scheduled for showers twice weekly, and the TAR was signed as if a shower and skin assessment had been completed on 3/22/26, although the resident was observed repeatedly in the same pajamas and later asked the surveyor for help getting a shower. Resident #58’s record showed diagnoses including anemia, type 2 diabetes with complications, peripheral vascular disease, and osteoarthritis. The quarterly MDS indicated the resident required partial/moderate assistance with showering/bathing, and the care plan included bathing/showering interventions and staff reminders for dressing, but the plan had not been revised to make it current. The record also showed a vascular follow-up appointment scheduled after a prior vascular visit, but the resident missed the follow-up on 1/26/26, and the facility could not locate the appointment when asked. During survey observations, the resident’s lower extremities remained swollen and discolored with weeping, and the medical director stated she had not been contacted about the condition until survey inquiry. A physician note dated 3/25/26 documented bilateral leg cellulitis, with the left side worse, and ordered antibiotic treatment, vascular consultation, and venous doppler. For Resident #7, the surveyor observed the resident in bed and the resident stated they wanted to get out of bed but did not have a wheelchair. The UM confirmed the resident had been transferred to the unit 12 days earlier and that the wheelchair had not been transferred with the resident. The resident’s record showed a care plan intervention for out-of-bed activity daily via Hoyer lift and a mechanical lift transfer with 2 staff assistance, but there was no documentation that the resident refused to get out of bed. For Resident #8, the surveyor observed bilateral lower-extremity edema while the resident wore an ace wrap only on the right leg, and the resident stated they previously wore ace wraps on both legs and thought the left one had been lost. The physician’s order required bilateral ace wraps daily before getting out of bed, but the March TAR had multiple blank entries showing no documentation that the treatment was provided on several dates. An LPN stated the left wrap was not on because it was dirty and needed to be washed, then acknowledged the resident had pain in the left leg and refused the wrap, but this was not documented and the physician was not notified.
Falls, unsupervised leave, and unsafe smoking practices
Penalty
Summary
The facility failed to provide adequate supervision and targeted fall interventions for a resident with repeated falls and injuries. Resident #58 had multiple unwitnessed falls between 12/5/25 and 2/27/26, including falls that resulted in emergency department transfers and hospitalization. The resident was admitted with diagnoses including peripheral vascular disease, osteoarthritis, obesity, and a history of altered mobility, and the record showed fluctuating fall-risk scores over time. The care plan included interventions such as non-skid socks, assist rails, morning care assistance, a fall strip, and reminders to call for help, but the record also showed that the resident continued to fall, including falls associated with head injury, bruising, lacerations, and a right periorbital hematoma. Survey review found that after the resident’s falls, the facility documented varying contributing factors such as poor lighting, crowding, furniture, confusion, gait imbalance, impaired memory, wet floor, incontinence, and recent change in condition. The resident was found on the floor on several occasions, including beside the bed, on the floor with blood and a laceration to the right eyebrow, and sliding onto the floor while trying to transfer from the bed to the wheelchair. The record also showed that the resident was observed without shoes or non-skid socks during surveyor visits, and the facility could not provide documentation that therapy for strengthening and balance training or reinforcement of safe transfer techniques had been implemented as recommended by the physician. The facility also failed to have a system in place to identify vulnerabilities and reduce accidents for residents who signed themselves out on pass, and failed to ensure safe smoking practices. Resident #5 had a history of substance use disorder and repeatedly signed themself out of the facility on pass, often with incomplete leave-of-absence documentation and blank return fields. The resident had previously been hospitalized after an e-scooter accident that occurred while out on pass and later again signed out without a clear system showing oversight of the leave process. Resident #115, who required supervised smoking and was at high risk for falls, was observed exiting the facility alone while smoking a cigarette before the scheduled smoking break, despite a smoking policy requiring designated smoking areas and direct supervision for residents needing monitoring. The resident’s record showed a care plan for smoking safety and substance use history, but the surveyor observed the resident smoking independently outside the facility.
Failure to Provide Quarterly PNA Statements
Penalty
Summary
The facility failed to have a system in place to ensure quarterly financial statements were provided to residents who maintained Personal Needs Account (PNA) funds with the facility. Survey review identified 84 total PNA accounts with a balance of $33,770.89 held by the facility, and the deficiency affected all 84 residents with facility PNA accounts. During a resident council meeting, 7 residents stated they were not provided quarterly PNA statements and would have to request a statement from the facility. During an interview, the Business Office Manager stated residents could withdraw money through the receptionist as needed and that he provided the receptionist with a daily report of PNA funds. He later confirmed that he did not distribute any statements, that he maintained access to the PNA management program, and that he was aware residents were supposed to receive PNA statements quarterly. He also stated that one family had requested a statement a few months earlier and confirmed the facility was not providing quarterly PNA statements. A review of the facility's Resident Funds Management System policy stated the facility would maintain a PNA account for residents who chose to deposit funds, with secure handling, accurate accounting, and timely access to funds upon request, but the policy did not include a process for providing quarterly statements.
Failure to Notify Resident of High PNA Balance
Penalty
Summary
The facility failed to ensure a process was in place to notify residents whose Personal Needs Account (PNA) balances approached the limit that could affect Medicaid or SSI eligibility. Survey review identified Resident #56 with a PNA balance of $2,036.12, and the facility’s trial balance showed 84 resident accounts totaling $33,770.89. Interviews with the SWs and BOM showed that the Activity Director, SWs, and business office each had some role in monitoring resident spending, but there was no clear, consistent process described for notifying residents when balances were high. The BOM stated he would tell SWs when a resident needed to spend down funds, but also said he had not noticed anyone needing to do so and was unsure of the official policy. Resident #56 had diagnoses including poly-osteoarthritis, unspecified dementia, and anxiety. During interview, the resident was unaware that they had funds available to spend on needed items, and the CNA stated the resident needed clothing because the closet contained fewer than five pairs of pants and blouses. The quarterly IDT note did not document resident needs or the available PNA, and the PNA statement from 3/3/25 through 3/3/26 showed no personal needs purchases or cash withdrawals. After surveyor inquiry, SW and Activities met with the resident to discuss spending down the PNA, and the resident identified items such as bracelets, clothing, undergarments, snacks, chocolates, earrings, and necklaces.
Insufficient Staffing and Missed Resident Care
Penalty
Summary
The facility failed to provide sufficient competent staff to ensure residents received timely incontinence care, nail care, showers, and other daily services, and it also failed to maintain the minimum staffing requirements based on resident acuity. The deficient practice was identified for five residents reviewed and had the potential to affect all residents in the facility. The report states that staffing levels were below the required CNA and total staffing ratios on multiple day, evening, and overnight shifts during the review period. Resident #122 was observed in bed after breakfast and stated they had not been changed overnight. The resident later was found saturated with urine through the gown and bed sheets, with a strong urine odor present. The CNA assigned to the resident stated she had not yet provided care and was assisting other residents with breakfast. The staffing record for the overnight shift showed a census of 59 with only 3 CNAs working, and the CNA assignment sheet showed a unit census of 58 residents with five assigned aides. An LPN stated incontinent care should be completed every two hours during the day shift and every four hours on the overnight shift, and the RN unit manager confirmed incontinent care should be provided every two hours and as needed during the day shift. Resident #68 was observed in bed with a brief saturated with urine, and the resident stated they had been provided incontinence care around 4:00 in the morning. The CNA who assisted with care stated the resident should have been checked and changed before breakfast. Resident #31 stated they wanted their fingernails cut because they could not do it themselves, and the surveyor observed all 10 fingernails extended over the fingertips with a black substance underneath. The CNA and LPN gave conflicting statements about who should cut nails and when nail care should occur, while the LPN later stated nail care should be offered on shower days and should not require the resident to ask. Resident #10 was observed with long, jagged, soiled nails during breakfast, and the nails remained in the same condition on a later observation. The nurse educator stated nail care was to be provided on shower days, and the CNA assignment sheet showed the unit had a census of 58 residents with five assigned aides on that day shift. Resident #58 stated they had not had a shower since January, the shower log showed the resident was scheduled for a shower, and the resident was observed wearing the same pajamas for three days with dry flaky skin on the lower extremities. The physician had prescribed a medicated ointment for the legs, but the container delivered to the facility remained half full and another container delivered earlier was unopened. The unit manager confirmed nail care was to be provided on shower days and that incontinence care should be provided every two hours on the day shift and twice on the night shift.
Failure to Complete CNA Performance Reviews
Penalty
Summary
The facility failed to conduct yearly performance reviews for all Certified Nursing Aides (CNAs) and did not provide specific education aligned with the facility assessment and staff observed needs for improvement. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed. During the survey, the nurse educator stated that the DON and LNHA were responsible for employee performance evaluations, but the facility could not provide performance evaluations for the selected CNAs or for one LPN requested for review. During an interview, the LNHA stated that performance reviews had not been done recently for any CNAs or nurses and acknowledged that the facility should have completed them. The LNHA also stated that the facility did not have the evaluations available for the survey team and said they had “slacked off” regarding performance reviews. A review of the facility’s staffing policy stated that the facility provides sufficient staff with the skills and competency necessary to provide services in accordance with resident care plans and the facility assessment, and that staffing numbers and skill requirements are determined by resident needs based on each resident’s plan of care.
Failure to Coordinate Care for Residents Attending PACE
Penalty
Summary
The facility failed to maintain responsibility for the care and services provided to residents at all times and failed to ensure there was a process to integrate care and services for residents who regularly attended an outside PACE program. The deficiency was identified for one resident reviewed for accidents and for six residents who attended the PACE program. The report states the issue had the potential to affect all residents in the facility and all residents who attended PACE. Resident #115 had diagnoses including schizoaffective disorder, depressive type. The admission MDS dated 12/15/25 showed the resident was admitted from home/community, had a BIMS score of 13 out of 15 indicating intact cognition, and had discharge planning marked as active. The care plan addressed smoking, substance use, ineffective coping, and high fall risk, but did not include information about attendance at a PACE program or goals and interventions related to a discharge plan. Progress notes showed the resident was admitted from PACE and later documentation from the DON stated the team met with PACE via Zoom and that the clinical and discharge plans were updated, with the discharge plan listed as long term care and continued visits with the PACE program every Monday, Wednesday, and Friday with transportation. On survey observation, the resident was seen ambulating with a walker, leaving the facility, placing a cigarette in their mouth, and walking down a hill while smoking. The receptionist confirmed the person was Resident #115 and stated the resident left the facility routinely. The surveyor could not locate the resident shortly afterward. Staff interviews showed the CNA stated the resident left all day, smoked, and went to the liquor store, and that the resident did not need help. The LPN stated the resident went out to the PACE program Monday, Wednesday, and Friday and returned at 2:30 PM. Social workers stated the PACE program had its own social workers and that they were not involved in discharge planning for the resident. The LNHA later stated he was not aware the contract had blank liaison information, that there was no process in place, and that oversight and collaboration between the facility and PACE should have been documented in the medical record. The facility also maintained a Release of Responsibility for Leave of Absence form in the front desk book and in the resident’s record that stated the resident was voluntarily leaving the facility, that the absence was temporary and expected to last no more than 24 hours, and that failure to return within the specified timeframe without notice would be treated as AMA and could result in voluntary discharge. The LNHA provided a PACE contract signed by a former LNHA in 2020 that named a different PACE program and contained blank fields for the facility liaison. During interviews, the LNHA acknowledged the facility was responsible for ensuring care and services were provided for residents attending PACE and stated there should be oversight between the PACE program and the facility, but confirmed there was no process in place.
Arbitration Agreement Not Clearly Explained or Documented
Penalty
Summary
The facility failed to have a process in place to ensure that, before signing a binding arbitration agreement included in the admission packet, the agreement was clearly communicated to the resident or representative in a manner they understood and that they acknowledged understanding it. This deficiency was identified for 7 of 7 residents who attended a resident council meeting and for one resident with severely impaired cognition. During the entrance conference, the LNHA stated the admission department handled arbitration agreements, but later could not provide a list of residents who had signed them. Resident #105 was interviewed and appeared somewhat confused and unable to elaborate on care provided. The resident’s admission agreement showed the arbitration agreement was accepted with the resident’s signature and the LNHA’s signature as facility representative, but no legal representative signature was present; the LNHA’s signature date was later than the admission agreement date. The resident’s MDS showed a BIMS score of 5 out of 15, indicating severely impaired cognition, and the care area assessment triggered for cognitive loss and dementia. At the resident council meeting, seven residents stated they did not recall signing an arbitration agreement because the admission process was completed orally; one resident said the agreement was too small to see on the tablet and that a copy was promised but never provided. The admission and marketing staff stated the agreement was completed electronically after admission, that she did not document whether it was explained, and that residents did not receive a physical copy. The LNHA confirmed neither he nor the admission staff documented any review of the agreement with residents and stated he signed the agreement outside the presence of the resident.
QAPI Program Failed to Identify and Review Multiple Resident Care and Facility Concerns
Penalty
Summary
The facility’s QAPI committee failed to self-identify systems and processes that could negatively affect resident quality of care and quality of life, and it did not review significant events or operate a data-driven QAPI program. During the survey, the Licensed Nursing Home Administrator stated that the facility did not currently review any significant events in QAPI and confirmed that the facility did not have QAPI initiatives for several concerns identified during the survey, including staff performance reviews, environmental concerns, pests, activity room visits, smoking and the waiver process, personal need account issues, and falls with injuries. Surveyors observed and documented multiple resident care and environmental concerns. A resident showed surveyors a bag containing dead cockroach-like insects and reported seeing cockroaches scatter in the bathroom at night. Facility pest control records showed a roach cleanout in the Rosewood wing with activity coming from the drop ceiling and molding around the ceiling. The Director of Housekeeping stated the facility had a little roach problem lately and confirmed the resident had reported cockroaches earlier in the month. Surveyors also observed disrepair in resident rooms and bathrooms, including broken molding, broken blinds, hanging dresser hardware, loose molding under a sink, missing calking around a vanity, broken tiles, deteriorated ceiling tiles with gaps around a sprinkler head, an unsecured piece of plywood over a bathtub, and sediment on bathroom surfaces. Resident care concerns were also observed. One resident stated they had not received incontinent care during the overnight shift, and surveyors found the resident’s bedding and gown saturated with urine; the LPN confirmed the resident needed to be changed and stated the CNA had reported the resident refused care, but the LPN had not spoken with the resident about incontinence care. Another resident was observed with long, jagged fingernails with black substance underneath and stated they wanted them trimmed and cleaned; the resident remained in that condition after a shower and was still observed that way several days later. The Medical Director stated she was not involved in facility policies regarding residents with substance use history or the PACE program, did not follow up with the PACE program, and did not review a scooter accident involving a resident who left the facility and was later involved in an accident and fractured a hip. The LNHA stated there was no process in place for PACE collaboration, that the facility did not know how many residents were enrolled in PACE until asked, and that the facility’s current QAPI plans did not address the concerns identified during the survey.
QAPI Plan Lacked Measurable Goals and Data Review
Penalty
Summary
The facility QAPI committee failed to use the facility Performance Improvement Plan process to measure and use data to develop quantitative and measurable goals. On 3/24/2026, the surveyor reviewed facility PIPs related to resident participation in activities, missed reimbursement tied to failure to capture respiratory treatments, CNA staffing, MDS modifications, and baseline care plans. None of the PIPs included quantitative or measurable goals, and none listed goals or thresholds for performance measurements. On 3/26/2026, the LNHA was interviewed about how the facility determined what was reviewed by the QAPI team and how QAPI plans were developed. The LNHA stated that each quarter department heads presented their PIPs and assessed their departments to determine where they could improve. When asked what current QAPI initiatives were in place and whether any data from the PIPs had been analyzed to determine effectiveness, the LNHA stated the facility had plans involving activities attendance and resident satisfaction, CNA staffing shortages, MDS accuracy and communication, kitchen food preferences, and call bell audits, but also stated there were no specific quantitative and measurable goals, outcomes, or audits written down, although he knew there had been improvement. The facility QAPI-Quality Control and Monitoring Plan, revised 7/20/25, stated that the QAPI plan should identify and use data to monitor performance, establish goals and thresholds, systematically analyze underlying causes, and ensure planned changes are implemented and effective.
Unsafe and Unkempt Resident Rooms and Shower Area
Penalty
Summary
The facility failed to maintain a resident living environment in a clean, comfortable, and homelike manner in multiple resident rooms and in one shower room. During observations, surveyors found broken tiles behind a toilet, deteriorated ceiling tiles with gaps around a sprinkler head, an unfastened plywood cover over a bathtub, and blackish-brownish and brownish-rust colored sediment on bathroom surfaces. In the shower room used by residents on one unit, surveyors observed blackish-brownish sediment under and around shower tiles and a whiteish-pinkish residue on the floor tiles; the Housekeeping Director stated the tiles could be cleaned with bleach and said the shower had last been cleaned 6 days earlier, while the cleaning schedule was twice weekly. Surveyors also observed significant disrepair in another resident room, including broken blinds, damaged floor molding, broken and hanging hardware on a dresser, molding under the sink that was not affixed to the wall and falling off, and missing caulking around the sink/vanity area. A CNA acknowledged that the broken blinds and damaged molding should have been repaired and stated she was unsure whether the issues had been reported. The Maintenance logbook at the nurse’s station had no entry for that room, and the last recorded entry was dated months earlier. Facility leadership and maintenance staff acknowledged the conditions during interviews. The Director of Maintenance stated that staff could report problems in logbooks and that he fixed logged issues, but he could not provide documentation of rounds or audits and stated he did not audit for mold or receive reports of mold-like substances. The VP of Environmental Services also stated he conducted room audits but could not provide documentation. The LNHA later stated the root cause was the age of the building and a transition that contributed to the absence of preventative maintenance, and acknowledged that repairs had been completed in one resident room.
Failure to Provide Needed ADL Assistance
Penalty
Summary
The facility failed to provide dependent residents with needed assistance for activities of daily living, including incontinence care, bathing, getting out of bed, and nail care. The deficiency was identified for 4 of 4 residents reviewed for ADLs: Resident #10, Resident #31, Resident #58, and Resident #122. Resident #122 was observed in bed with bedding, a blanket, and a gown saturated with urine and yellow staining after stating that incontinence care had not been provided during the overnight shift. A CNA was asked to assist with an incontinence check, and the resident agreed to be checked. The CNA and LPN both observed that the resident was saturated with urine, and the LPN stated the CNA reported the resident had refused care. The LPN confirmed the resident needed to be changed and stated she had not followed up with the resident after the reported refusal. The resident later stated staff checked them, saw they were saturated with urine, said the bedding had to be changed, and then left without returning, and breakfast was served while the resident remained saturated with urine. The resident’s record showed a BIMS score of 12 out of 15 and a care plan focus for refusal of care and ADL self-care performance deficit. Resident #10 was observed with long, jagged fingernails and black material under the nails while eating breakfast. The resident stated they wanted their nails trimmed and cleaned. The resident was supposed to have nail care on scheduled shower days, but the nails remained in the same condition over several days and were not trimmed and cleaned until after the surveyor inquired. Resident #31, who had diagnoses including CVA with hemiplegia/hemiparesis and was coded as dependent for showering and needing supervision or touching assistance for personal hygiene, stated they wanted their fingernails cut and had asked staff several times without success. The surveyor observed all 10 fingernails extended over the fingertips with black substance underneath. Staff interviews reflected that nail care should have been completed on shower day, that the resident did not ask for it, and that the resident did not have diabetes, although the CNA and LPN both indicated the resident’s nails had not been addressed. Resident #58 was observed seated in a wheelchair with dry, scaly lower extremities covered with flaky skin and was seen in the same pajamas over multiple days. The resident stated they had been trying to get a shower for a long time and that the last shower was in January. The resident’s record showed diagnoses including peripheral vascular disease, osteoarthritis, obesity, and a BIMS score of 13 out of 15, with a care plan for ADL self-care performance deficit and assistance as needed. The facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene, including bathing, dressing, grooming, and oral care.
Failure to Provide and Document Individualized Activities
Penalty
Summary
The facility failed to ensure an ongoing program was in place to support a resident’s individual activity preferences and psychosocial needs. Resident #56 stated they loved jewelry, liked to dance, and said they had never been asked about trips even though they would go on trips. The resident’s quarterly assessment showed a BIMS score of 11 out of 15, indicating moderately impaired cognition, and the resident had experienced episodes of feeling down, depressed, or hopeless on 3 occasions during the prior two weeks. The resident was also coded as having no impairment in upper or lower extremity mobility. The care plan identified the resident as dependent on staff for emotional, intellectual, physical, and social needs and at risk for social isolation, with interventions including staff conversation during care, recording interests, inviting the resident to activities, providing preferred activities, and offering 1:1 bedside/in-room visits. The activity assessment coded the resident as interested in Connect 4, trips/shopping, and movies/television/radio, but the sections for specific details were blank. The Activity Director stated trips were scheduled monthly and that the resident refused shopping trips because the bus was not private, but refusals were not documented. The Activity Director also stated room visits were provided three times per week, yet the only handwritten record provided did not identify staff, did not include time spent, and did not document all three weekly visits for January 2026.
Pharmacist Recommendation Not Acted Upon for Thickened-Liquid Medication
Penalty
Summary
The facility failed to ensure that a Consultant Pharmacist recommendation was acted upon in a timely manner for one resident who had a physician-ordered nectar thickened liquid diet. During a medication pass, an LPN prepared levetiracetam oral solution for the resident, who had diagnoses including Lennox-Gastaut syndrome and severe cognitive impairment, and the resident’s eMAR showed a nectar thickened diet order. Because the LPN did not have thickening powder in the cart, another staff member brought a pre-thickened nectar liquid, and the LPN poured an unmeasured amount into the medication cup with the Keppra solution. The LPN then stated that giving a thin liquid to a resident on a nectar thickened diet could cause aspiration and, after reviewing the eMR, said the Keppra solution was not appropriate for the resident and that she would call the physician for an alternative. The resident’s record also showed dysphagia of the oropharyngeal phase, and the Speech-Language Pathologist stated the resident had been upgraded from honey thickened to nectar thickened liquids to allow safer swallowing. Nursing staff stated that diet changes were reviewed by the CP and that nurses notified the physician. The surveyor later reviewed the CP recommendations report for the resident, which included a recommendation to notify the prescriber of the Keppra solution and ask whether the current consistency was safe for administration. A facility staff member had signed the report, and the Regional DON acknowledged that the recommendation was signed but not acted upon. The facility’s own protocol stated that pharmacist-identified irregularities must be acted upon and that the attending physician must review, decide on action, and document justification if no change is made.
Medication administration errors exceeded the allowed rate
Penalty
Summary
The facility failed to ensure that medications were administered without error at a rate of 5% or greater. During medication administration observations of six nurses giving medications to six residents, surveyors identified 26 opportunities and three errors, resulting in a medication error rate of 7.69%. The deficient practice was identified for two residents and involved two nurses during the observed medication passes. For one resident, an LPN prepared and administered eight oral medications, but the resident also had an order for Aspercreme with Lidocaine Cream 4% to the right shoulder that was not available in the medication cart at the time of administration. The LPN later stated she could not find the cream in the treatment cart and was not aware whether it was stocked as house stock. A new order for Diclofenac Gel 1% was then seen, and another LPN measured 2 grams of the cream and was about to administer it even though the physician order did not specify a dosage. When questioned, the LPN acknowledged that the order did not include a dosage and that it should have been clarified before administration. For another resident, an LPN prepared Lamotrigine 200 mg for a resident with Lennox-Gastaut syndrome and a nectar-thickened diet. The medication card stated, "Swallow tablet whole. Do Not Chew, Break or Crush," and the eMAR also included special instructions not to crush the medication. Despite this, the LPN crushed the tablet and mixed it into chocolate pudding. The LPN later stated she missed the cautionary label and the special instructions on the eMAR.
Pest Control Program Failed to Eliminate Cockroach Activity
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the building was free of cockroaches. A resident with intact cognition, as documented by a BIMS score of 15/15, reported that after moving into the facility about two months earlier and living in the third room, they repeatedly saw cockroaches scatter when turning on the bathroom light during the night. The resident showed surveyors a plastic bag containing four dead cockroach-like insects and stated that the facility had previously been given a first bag of dead insects. The resident also pointed out a gap between the door molding and the floor in the room and stated that cockroaches came in and out of that gap. Surveyors reviewed pest control records showing repeated roach activity in multiple areas, including rooms, bathrooms, the kitchen, dishwasher area, basement, floorboards, ceiling drop areas, and molding, with ongoing treatments and replacement of glue boards and monitors due to roach activity or wet traps. The Maintenance Director stated he was not aware of roaches in the resident’s room and that he did not document environmental rounds. The Director of Housekeeping confirmed the resident had reported cockroaches earlier in the month, that the pest company had assessed the room and found nothing, and that the resident had provided a bag of dead insects that was shown to the pest control company. The Licensed Nursing Home Administrator stated that every resident or employee who saw a bug called it a roach and did not believe it was a widespread concern.
Medications Left Unattended at Bedside
Penalty
Summary
Medication administration was not completed according to standards of practice for one resident observed with medications left unattended at the bedside. On 3/22/26 at 10:00 AM, the surveyor entered the resident’s room and observed a medication cup containing 6 tablets and a cup of water on the bedside table while the resident was seated in the room. The resident stated that the nurse had left the medications at the bedside for them to take. When the surveyor returned at 10:28 AM, the medications were still there. The resident had a BIMS score of 13 out of 15, indicating intact cognition. At 10:30 AM, the LPN stated the resident received medications at 9:00 AM and described the expected process as checking the identification bracelet, ensuring the resident swallowed the medication before leaving the room, and then signing the MAR after administration. However, when asked whether she had observed the resident swallow the medications, the LPN stated she saw the resident take the medications and drink the water before she left the room. The surveyor later showed the nurse the tablets and water still at the bedside 90 minutes later, and the nurse then went to the room and spoke with the resident. The MAR showed the LPN signed that metformin, cyanocobalamin, lisinopril, clopidogrel, and apixaban were administered at 9:00 AM. The facility’s policy stated medications are to be administered safely and that the individual administering the medication initials the MAR after giving each medication and before administering the next ones.
Failure to Notify Physician and Responsible Party of Resident's Change in Condition
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia, experienced a change in condition marked by a fever of 100.2°F. The resident, who had severely impaired cognition as indicated by a BIMS score of 3 out of 15, had this elevated temperature recorded on the Medication Administration Record (MAR) during the 11-7 shift. However, there were no corresponding nursing notes, no follow-up temperature checks, and no documentation of any actions taken in response to the fever during that shift. Further review revealed that neither the resident's physician nor the responsible party was notified of the fever, as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed that the expected protocol in such situations includes documenting the event, monitoring the resident, notifying the physician and family, and administering Tylenol if indicated. The facility's policies also require documentation of all services provided and notification of significant changes in a resident's condition. These steps were not followed in this instance, resulting in a failure to notify the appropriate parties of the resident's change in condition.
Failure to Administer and Document PRN Medication for Fever
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia, did not receive treatment and care in accordance with physician orders and professional standards. The resident, who had severely impaired cognition as indicated by a BIMS score of 3 out of 15, had a physician's order for acetaminophen 650 mg to be administered orally every 4 hours as needed for a temperature of 100°F or above, with a maximum daily dose of 3 grams. On a specific shift, the resident's temperature was recorded at 100.2°F, but there was no documentation that acetaminophen was administered, nor were there any nursing administration signatures on the MAR for that shift and the following one. Additionally, there were no nursing notes, follow-up temperature checks, assessments, or monitoring documented in the medical record after the fever was noted. Interviews with nursing staff and the DON confirmed that the expected protocol would be to administer acetaminophen, monitor the resident, document all actions, and notify the physician and family as appropriate. Facility policies also required documentation of all services provided, including medication administration and any changes in the resident's condition. These actions and inactions led to the identified deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and appropriate incontinence care for residents dependent on staff for Activities of Daily Living (ADLs). Resident #3 was observed in bed with a strong urine odor in the hallway. The resident reported being soiled and needing to be changed, stating that staff took a long time to respond to call lights, sometimes up to an hour. The surveyor observed that the resident was wearing two saturated incontinence briefs, which were not changed promptly. The care plan for Resident #3 did not specify the frequency of incontinence care, and the staff was unaware of the use of double briefs, which could lead to skin irritation. Resident #184 also experienced delays in receiving incontinence care. The resident, who wore a Condom Catheter (CC), reported that staff did not know how to apply it properly, leading to frequent dislodgement and wetness. The resident stated that staff sometimes took 4 to 5 hours to respond, resulting in prolonged periods of being soaked with urine. The surveyor confirmed that the resident's gown and brief were soaked, and the CNA did not check the resident before serving breakfast. The electronic record for ADL tasks was left blank for two consecutive days, indicating a lack of documentation of care provided. The facility's policy on Activities of Daily Living (ADL) Supporting, last revised in 2018, stated that residents unable to carry out ADLs independently would receive necessary services to maintain good hygiene. However, the facility failed to adhere to this policy, as evidenced by the lack of timely incontinence care for Residents #3 and #184. The Registered Nurse/Unit Manager (RN/UM) was unaware of the use of double briefs and stated that incontinence care should be provided every two hours, which was not consistently done.
Failure to Implement Turning and Repositioning Program for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure a system was in place for turning and repositioning a resident with pressure ulcers, who was dependent on staff for care. The deficiency was identified for a resident who was observed multiple times lying on their back in bed on a scoop mattress, with no documentation of being turned or repositioned. Certified Nursing Aides (CNAs) were aware of the resident's wound dressing but did not have documentation to confirm that the resident was being turned every two hours as required. The resident's medical record revealed multiple diagnoses, including toxic encephalopathy, muscle weakness, and osteoporosis, and indicated the presence of pressure ulcers at various stages. The care plan included interventions such as turning and repositioning every 2-3 hours, but there was no evidence of these interventions being documented or followed. The resident was assessed as being at very high risk for pressure sores, with a Braden Scale score of 8, yet the facility failed to implement a documented turning and repositioning program. Interviews with facility staff, including the Registered Nurse, Director of Nursing, and Rehabilitation Director, confirmed the lack of documentation and adherence to the care plan. The facility's policy on pressure ulcer prevention required repositioning at least every two hours for residents who are bed-bound and dependent on staff, but this was not followed for the resident in question. The Assistant Licensed Nursing Home Administrator acknowledged the absence of a documented turning and repositioning schedule for the resident.
Inadequate Staff Training for Dialysis Care
Penalty
Summary
The facility failed to ensure that staff were adequately trained and competent in the care of residents requiring hemodialysis, specifically in the assessment and care of different types of dialysis access sites. This deficiency was identified for two residents who required dialysis. Resident #185, who had a Permacath for dialysis, was observed and reported that staff were supposed to check for a bruit at the access site, as per the medical orders. However, RN #1, responsible for monitoring the Permacath, admitted to not having received competency training for assessing the Permacath and incorrectly stated that a bruit should be checked for a Permacath, which is not standard practice. Similarly, Resident #57, who had an arteriovenous fistula (AVF) for dialysis, reported that facility staff did not check their dialysis site. The medical record indicated that staff were required to check the AVF for a bruit and thrill every shift. RN #2, responsible for monitoring this resident, also admitted to not having received competency training for the assessment and care of the AVF. The facility's policy on hemodialysis catheters stated that only trained and competent medical staff should access these catheters, but this was not adhered to. The Assistant Licensed Nursing Home Administrator confirmed that the facility did not have nurse competencies for the assessment and care of hemodialysis accesses. The facility's failure to provide necessary training and ensure staff competency in the care of dialysis access sites led to the deficiency, as staff were not adequately prepared to perform the required assessments and care for residents with hemodialysis needs.
Failure to Administer Prescribed Treatment for Skin Condition
Penalty
Summary
The facility failed to follow a physician's order for treating a resident diagnosed with Moisture-Associated Skin Damage (MASD). The deficiency was identified when a surveyor observed that the resident was wearing two saturated incontinence briefs, and the bed pad was stained. The resident had visible redness on the groin and buttocks areas, which was reported to the RN Unit Manager, leading to a wound consult. The wound practitioner diagnosed the resident with MASD and ordered Nystatin cream to be applied to the affected areas every shift after washing and drying the area. However, the order was not transcribed onto the Treatment Administration Record (TAR), and the resident did not receive the prescribed treatment on multiple occasions. Further investigation revealed that the order from the wound practitioner was not located on the TAR, and the resident continued to be observed with soiled briefs and reddened skin. The Director of Nursing (DON) and the Assistant Administrator (AA) were unaware that the treatment had not been administered as ordered. The AA later informed the survey team that the Unit Manager failed to transcribe the order, resulting in the resident not receiving the necessary treatment for several days.
Inconsistent Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to consistently perform hand hygiene to prevent the spread of potential infection, as observed during a survey. One Licensed Practical Nurse (LPN) was observed washing hands for insufficient durations during medication administration, contrary to the facility's policy which requires handwashing for at least 20 seconds. The LPN admitted to not following the correct procedure, which involves applying friction for 20-30 seconds outside the stream of water. The facility's documentation indicated that the LPN had previously been observed successfully performing hand hygiene, yet the observed practice did not align with the established guidelines. Additionally, the Director of Activities (DA) and a Certified Nursing Aide (CNA) were observed failing to perform hand hygiene between resident interactions during meal service. The DA handled a portable oxygen tank and distributed drinks without washing hands, while the CNA did not perform hand hygiene after removing gloves and before assisting residents with meals. Both staff members acknowledged the importance of hand hygiene and the facility's policy, which mandates handwashing before and after contact with residents, equipment, and food. Despite having completed hand hygiene competency validations, their actions during the survey did not reflect adherence to these standards.
Deficient Call Bell System in Resident's Room
Penalty
Summary
The facility failed to ensure that the call bell system was properly functioning in one of the five tested rooms. During an observation at 1:45 PM, it was revealed that the call bell button for the window bed in the specified room did not function when tested by the Director of Maintenance. This deficiency was identified in the presence of the Director of Maintenance and the Assistant Administrator and was communicated to the facility's Assistant Administrator during the Life Safety Code exit conference.
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Illustrative
What surveyors actually found near you
We read the 476 citations issued within 25 miles in the last 12 months — including the 11 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Neptune
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coral Harbor Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 14 | 0 |
| Jersey Shore Post Acute Rehabilitation And Nursing | 0.9 mi | ★★★★★ | 0 | 0 |
| Complete Care At Ocean Grove Llc | 1.4 mi | ★★★★★ | 1 | 0 |
| Imperial Care Center | 1.7 mi | ★★★★★ | 17 | 0 |
| Continuing Care At Seabrook | 2.5 mi | ★★★★★ | 10 | 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 October 2026) and official state health department websites.