Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Venetian Care & Rehabilitation Center, The during CMS and state inspections, most recent first.
Infection control deficiencies were identified when the facility could not produce complete IPCP surveillance, tracking, and trending data, and an LPN was observed caring for a resident on contact precautions without wearing a gown or gloves or performing hand hygiene on exit. The resident had osteomyelitis, was receiving IV antibiotics and antifungal therapy, and had ESBL-related wound isolation precautions posted at the door.
The facility completed inaccurate MDS assessments for five residents. One resident at risk for pressure ulcers was coded as having a pressure-reducing wheelchair device, but observation showed only a towel on the wheelchair and OT confirmed no appropriate cushion was in place. Four residents were incorrectly coded for pneumococcal vaccine status, with MDS entries stating the vaccine was offered, declined, or up to date despite the record lacking evidence that the vaccine was offered or, in one case, showing only prior PPSV23 documentation.
Failure to Offer Pneumococcal Vaccinations to Eligible Residents: The facility did not offer pneumococcal vaccines to four residents reviewed for flu/pneumonia vaccinations. Records for residents age 65 and older showed missing evidence of vaccine offers or follow-up doses, and the RDCM, MDSC, and IP confirmed the residents were not offered pneumococcal vaccination per CDC guidance and the facility’s vaccine policy.
A resident with dementia and severe cognitive impairment was observed using a transportation wheelchair, but the record did not show an assessment for whether she needed a transportation wheelchair or a standard wheelchair. OT documented mobility goals and wheelchair management, yet staff interviews confirmed there was no evaluation of the type of wheelchair required, and the DOR was unsure whether the resident could self-propel due to poor cognition.
Missing Window Screen in Resident Room: A resident with schizophrenia, dementia, and CKD had an open window in his room without a screen in place, with the screen resting against the wall. The room was observed with a heavy urine odor, feces on the wall, floor, and mattress, dirty laundry and used briefs on the floor, and several flies and other flying insects present. The MD stated the missing screen had not been reported to him and that staff were expected to create work orders for needed repairs.
Inadequate Monitoring of Psychotropic Medications: The facility failed to adequately monitor psychotropic use for two residents. One resident received aripiprazole for psychosis, but the care plan did not identify target behaviors and the MAR showed behaviors without corresponding progress notes describing the behavior, interventions, or effectiveness. Another resident received Risperdal for psychosis, but the record showed only one AIMS and no other documentation of monitoring for adverse side effects. Interviews with an LPN, a recreation aide, the LTCSW, and the DON confirmed the gaps in documentation and monitoring.
A resident was transferred to the hospital for surgical wound debridement evaluation and treatment, and the record showed admission with acute osteomyelitis. The EMR did not document that the resident or representative received the required written transfer notice, and the LTCSW stated the facility had stopped doing the notices in May and was not aware they still needed to be completed.
PASARR Level II recommendations were not developed or implemented for a resident with schizophrenia, dementia, and CKD who had delusions and daily rejection of care. The PASARR notification called for a behavioral modification plan and a crisis intervention/safety plan, but the EMR showed no evidence of either plan. The LTCSW said referrals were being made because the resident’s care could not be managed in the facility, and the DON said the resident had extreme behaviors and that staff approaches should have been included in the care plan or behavior plan.
Incomplete Comprehensive Care Plans: The facility failed to develop person-centered comprehensive care plans with measurable goals for two residents. One resident triggered in the CAA for pressure ulcer risk, but no pressure ulcer care plan was documented. Another resident had dementia, severe cognitive impairment, bladder and bowel incontinence, and needed substantial to maximum assistance with toileting hygiene, but the care plan did not address incontinence or toileting hygiene needs.
A resident with severe cognitive impairment and a left eye infection did not receive ordered tobramycin ophthalmic ointment for two days. An LPN documented the medication as unavailable or awaiting delivery, but did not contact the pharmacy or notify the physician about the missed doses, despite the facility policy for unavailable medication.
The facility failed to ensure pressure ulcer prevention measures were in place for two residents at risk for skin breakdown. One resident with severe cognitive impairment and wheelchair use was observed sitting on a towel in a transport chair instead of a gel or Roho cushion, despite staff noting she was at risk for pressure ulcers. Another resident with dementia, malnutrition, PVD, and a stage III heel ulcer did not have specific prevention interventions in the care plan, had no order for heel booties, and was repeatedly observed in a reclining wheelchair with her heels on a pillow and no booties in place.
A resident with dementia, muscle weakness, osteoarthritis, and a hand contracture did not have the ordered gauze roll applied to the affected hand during multiple observations. Her care plan did not address the contracture or the gauze roll intervention, even though the TAR showed the treatment as completed. An LPN confirmed the gauze roll was missing and the DON had no explanation for the discrepancy.
A resident with a tracheostomy related to respiratory failure did not have the required Ambu-bag at the bedside, even though the care plan called for emergency equipment to be immediately available. During observation, the RN Supervisor confirmed the Ambu-bag was missing, and the DON stated he was unsure why it was not there but acknowledged it was critical if the resident could not breathe on his own.
A resident with hypotension, atrial fibrillation, and a bone infection had Midodrine ordered q8h with a 10:00 PM dose listed on the MAR. The consultant pharmacist twice noted that Midodrine should not be dosed after 5 PM and requested MD order and MAR updates, but there was no documentation that the physician responded to the recommendations. The DON stated the reports were sent electronically or placed in the physician folder, but the physician did not return them timely.
Incomplete and inaccurate documentation was found for three residents. One resident’s care plan listed anti-psychotic use related to psychosis even though the EMR did not show psychosis or anti-psychotic administration, another resident with anoxic brain injury and NPO status had an inaccurate bottled water order, and a third resident’s MAR showed invalid blood sugar entries without matching progress note documentation; the DON, ADON, and RN confirmed the data entry error.
A facility failed to thoroughly investigate an alleged abuse incident involving a cognitively intact resident with visual and hearing impairments. The resident reported distressing care provided by a CNA, which was also described by a family member with video evidence. The facility's investigation was incomplete, lacking interviews with all relevant staff and residents, and the administrator did not review the video or collect necessary statements, contrary to facility policy.
The facility failed to identify and prevent the worsening of a contracture in a resident's right hand. Despite multiple observations and interviews, there was no documentation or care planning for the resident's condition. Staff were unaware of the contracture, and the resident did not receive any restorative care or therapy. The facility's policies on restorative nursing and comprehensive care plans were not followed.
The facility failed to maintain the required emergency water supply for its 123 residents, having only 132 gallons instead of the required 369 gallons. The FSD acknowledged the deficiency, and the LNHA confirmed the policy requirement of 1 gallon per resident per day for 3 days.
The facility failed to complete weekly skin evaluations for three residents, leading to a deficiency in pressure ulcer care and prevention. The residents, who had varying degrees of cognitive impairment and pressure ulcers, did not receive consistent evaluations as required by physician orders. The lack of documentation and adherence to protocol was confirmed through interviews with staff and review of the Electronic Medical Records (EMR) and Treatment Administration Records (TAR).
The facility failed to provide pharmaceutical services in accordance with professional standards, resulting in several deficiencies. One resident did not have their blood sugar levels documented prior to insulin administration, another resident was found with unattended medication, and the facility failed to maintain an accurate inventory of controlled medications. These oversights were confirmed by the ADON, RN/UM, and DON, highlighting a failure to adhere to physician's orders and facility policies.
The facility failed to provide adequate nail care to a resident requiring extensive assistance with ADLs. The resident had elongated, thickened, and jagged nails, and their care plan did not reflect their need for assistance with ADLs. Interviews revealed inconsistencies in nail care provision and documentation.
A facility failed to obtain and carry out an order to discontinue a Peripheral Intravenous (IV) line and to maintain the site according to professional standards of practice for a resident. The IV line was not assessed or removed in a timely manner, and the care plan did not include a focus on IV-line care or IV antibiotics. The facility's policy on catheter insertion and care was not followed, and the IV line was not removed until after the surveyor's inquiry.
The facility failed to ensure safe and appetizing food temperatures for residents, as identified during a Resident Council meeting and confirmed during a lunchtime meal service. Food temperatures on the 2nd floor unit were significantly below the required levels for hot foods and above the required levels for cold foods. The Food Service Director confirmed that temperatures were taken in the kitchen but not recorded once the food was on the truck.
The facility failed to provide meals according to physician's orders and resident preferences for two residents. One resident did not receive prescribed fortified foods and a low-sugar shake, while another did not receive the correct portions of protein, whole milk, or specified beverages. Staff acknowledged the discrepancies and lack of accountability for tray accuracy.
Infection Control Program and PPE Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for recording infections identified under the IPCP, including surveillance, tracking and trending, and documenting corrective actions taken by the facility. During interview, the Infection Preventionist and a second IP provided tracking data only from 04/25 through 07/25, and the Administrator stated there was no access to any other surveillance data because the previous company had taken the tracking and trending data. Facility policy stated the infection control personnel is responsible for gathering and interpreting surveillance data, and surveillance may include review of laboratory records, skin care sheets, infection control rounds or interviews, verbal reports from staff, infection documentation records, temperature logs, pharmacy records, antibiotic review, and transfer logs or summaries. The facility also failed to ensure proper PPE use for a resident on contact precautions. The resident had acute osteomyelitis, was receiving IV cefiderocol and IV micafungin, and had an active or colonized multidrug resistant organism related to ESBL in a wound. A contact precautions sign at the room doorway directed staff to sanitize hands and don a gown and gloves before entering. An LPN was observed entering the room, administering medications, taking vital signs, and touching the overbed table without wearing a gown or gloves, and she did not sanitize her hands when leaving. The LPN stated she believed PPE was only required for high-contact activities, while the LPN/UM stated staff were to wear a gown and gloves any time they entered the room.
Inaccurate MDS Coding for Pressure Relief and Pneumococcal Vaccine Status
Penalty
Summary
The facility failed to ensure accurate MDS assessments for five sampled residents: R116, R21, R114, R121, and R26. Review of the RAI Manual stated that information used for MDS items must reflect the resident’s actual status during the observation period and be validated by the interdisciplinary team completing the assessment. In each of the five cases, the MDS contained information that did not match the resident record or observed status, and the MDS Coordinator and Regional Director of Case Management confirmed during interview that the assessments were incorrect. For R116, the quarterly MDS indicated a pressure-reducing device was present on the wheelchair, but observation showed the resident sitting on a towel in a transportation wheelchair with no pressure-reducing cushion, and OT confirmed this was not appropriate for a resident at risk for pressure ulcers. For R21, the annual MDS stated the resident was offered and declined the pneumococcal vaccine, but the immunization record contained no evidence the vaccine was offered. For R114, the annual MDS stated the resident was up to date with pneumococcal vaccination, but the record showed only Pneumovax Dose 2 (PPSV23) and staff confirmed there was no evidence the vaccine was offered. For R121, the annual MDS stated the resident was offered and declined the pneumococcal vaccine, but the immunization record lacked evidence that the resident or representative was offered the vaccine. For R26, the annual MDS stated the resident was offered and declined the pneumococcal vaccine, but the immunization record did not show the vaccine was offered.
Failure to Offer Pneumococcal Vaccinations to Eligible Residents
Penalty
Summary
The facility failed to offer pneumococcal vaccination to four of five residents reviewed for flu/pneumonia vaccinations, including R21, R26, R114, and R121, out of a sample of 35 residents. Review of the CDC guidance titled "PCV20 or PCV21 Vaccination for Adults 65 Years or Older" and the facility policy titled "Pneumococcal Vaccine" showed that residents age 65 and older were to be assessed for eligibility and offered pneumococcal vaccines unless medically contraindicated or already current with the recommended series. The report stated that all residents were to be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. R21’s EMR did not contain evidence of a pneumococcal vaccine being received, and the Regional Director of Case Management and MDS Coordinator confirmed there was no evidence the resident had been offered one per CDC recommendations. R26’s record showed a prior PPSV23 dose, but the Immunizations section did not indicate the resident was offered a second pneumococcal vaccine a year later, and staff confirmed this was not done. R114’s record showed Pneumovax Dose 2 (PPSV23), but staff confirmed there was no evidence the resident had been offered a second pneumococcal vaccination per CDC recommendations. R121’s Immunization record and the facility-provided immunization report did not show that the resident was offered a pneumococcal vaccine, and staff confirmed the resident did not receive one per CDC recommendations. An IP stated that if a resident had PCV13 and PPSV23, the resident would be technically up to date and then five years later would be offered PCV20 or PCV21, and that the goal was to provide the resident with the opportunity to be vaccinated.
Resident Not Assessed for Appropriate Wheelchair
Penalty
Summary
The facility failed to ensure that one resident was provided and assessed for an appropriate wheelchair. The resident was admitted with a diagnosis of dementia and had a BIMS score of 5 out of 15, indicating severe cognitive impairment. The quarterly MDS indicated no impairments of the upper or lower extremities and that the resident required partial to moderate assistance with activities of daily living. The care plan identified decreased safety awareness, endurance, and dynamic balance, and included OT to evaluate and treat, with therapeutic activities and wheelchair management. An OT evaluation and plan of treatment noted a goal for the resident to complete functional transfers from the wheelchair, toilet, and bed, but there was no further assessment addressing whether the resident needed a transportation wheelchair or a standard wheelchair. During observation, the resident was sitting in a transportation wheelchair with both legs on the leg rests while participating in activities. Staff interviews indicated the transportation wheelchair may have been brought in by the resident's family, and the DOR stated residents were normally assessed for a standard wheelchair and measurements taken for fit, but he was unsure whether the resident could propel herself because of poor cognition. The DOR confirmed OT completed an evaluation, but there was no evaluation for which type of wheelchair the resident required. The OT stated the therapy department typically did not place residents into transportation wheelchairs because they could not be positioned properly in them, and confirmed the resident would be dependent on staff for mobility. CNA staff stated the resident always had a transportation wheelchair, and the Administrator stated she believed the family brought it in and that staff had provided risks versus benefits, but she would verify whether that information was in the medical record.
Missing Window Screen in Resident Room
Penalty
Summary
The facility failed to ensure an open window in Resident 73’s room was covered with a screen. Resident 73 was admitted with diagnoses including schizophrenia, dementia, and chronic kidney disease, and his quarterly MDS showed a BIMS score of 8 out of 15, indicating moderately impaired cognition. During observation, he was unable to answer most questions and was speaking nonsensically. His room had a heavy urine odor, feces smeared on the wall, floor, and mattress, dirty laundry and used incontinence briefs in bags on the floor, and crumbs and debris on the floor. The window in the room was observed open, with the screen resting against the wall rather than in place. Several flies and other flying insects were seen in the room during multiple observations. The Maintenance Director stated the missing window screen had not been reported to him, that staff were expected to create work orders for items needing repair, and that if he had known about the missing screen he would have addressed it right away. He also stated the resident had a habit of keeping his room dirty and that a window screen was important for keeping flies out of the room.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring for the use of psychotropic medications for two residents, R8 and R10, reviewed for unnecessary medications. For R8, the record showed an order for aripiprazole 7.5 mg at bedtime for psychosis, and the quarterly MDS indicated moderately impaired cognition with no mood or behavioral symptoms. Her care plan stated that psychotropic medication was being used for behavior management and included monitoring for side effects and effectiveness, but it did not describe target behaviors to be monitored to determine whether the medication was effective. R8’s MAR documented behaviors on multiple dates in August and September 2025, but the EMR contained no corresponding progress notes describing the nature of the behavior, its severity, any non-pharmacological intervention, or whether the intervention was effective. During interviews, an LPN and a recreation aide stated that R8 did not exhibit behavioral symptoms and was quiet, pleasant, and cooperative. The LTCSW stated the resident’s psychiatrist had documented that dose reduction was not indicated because the resident was experiencing auditory hallucinations, and the DON stated behavior tracking sheets were not yet in place and that at minimum a corresponding progress note should have been entered; the DON also stated the specific behaviors should have been outlined in the care plan. For R10, the record showed diagnoses including intellectual disabilities, anxiety disorder, major depressive disorder, and obsessive-compulsive disorder, and an order for Risperdal 1 mg every 12 hours for psychosis. The EMR showed one AIMS assessment with a score of zero and no evidence of any other AIMS or other monitoring for adverse side effects. The significant change MDS showed severe cognitive impairment and that the resident received an antipsychotic during the observation period. The DON confirmed there was no other documentation showing monitoring for adverse side effects for Risperdal and that there had been a lack of monitoring overall for the use of an antipsychotic.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to ensure that Resident R7 was provided with a written transfer notice after being sent to the hospital. R7 was admitted to the facility on 07/28/24, and progress notes documented that on 07/15/24 a medical doctor was seen, an order was received to send the resident to the hospital for surgical wound debridement evaluation and treatment, and on 07/16/25 the emergency room was called for a status update and the resident was admitted with a diagnosis of acute osteomyelitis. Review of the electronic medical record did not show documentation that R7 and/or the resident’s representative received the required written transfer notice regarding the hospital transfer. During interview on 09/10/25 at 11:36 AM, the LTCSW stated that the facility had stopped doing the transfer notices in May and was not aware they needed to continue.
PASARR Level II recommendations not implemented for resident with schizophrenia
Penalty
Summary
The facility failed to ensure that PASARR Level II Determination recommendations were developed and implemented for one resident with schizophrenia, dementia, and chronic kidney disease. The resident’s record showed a BIMS score of 8 out of 15, with delusions and daily rejection of care behaviors. The PASARR Level II Determination Notification included recommendations to formulate and implement a behavioral modification plan and to develop a crisis intervention/safety plan, but the resident’s care plan only documented medication monitoring, psychiatric and PCP follow-up, routine lab testing, case consultation, and structured social activities. Review of the resident’s EMR found no evidence of a behavior modification plan or a crisis intervention/safety plan. The LTCSW stated she was making referrals to behavioral health facilities because the resident’s care could not be managed in the facility and said the behavior modification program and crisis intervention/safety plan were not created because the resident refused care. The LTCSW also stated she was unsure why the PASARR Level II recommendations were not followed through. The DON stated the resident had extreme behaviors related to schizophrenia, that staff used a specific approach to avoid triggering behaviors, and that these approaches should have been included in the care plan or a behavior modification plan; the DON was unaware the PASARR Level II recommendations were not implemented.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan with measurable goals and timetables for two residents. For one resident, the admission MDS dated 03/19/25 indicated the resident could not determine BIMS, had no pressure ulcers, was at risk for pressure ulcers, and triggered in the CAA for pressure ulcer development, which directed staff to develop a care plan. However, the EMR care plan did not contain evidence that a pressure ulcer care plan had been developed. During interviews, the Director of Case Management, MDS Coordinator, Regional Director of Case Management, and DON confirmed that a care plan should have been developed for this resident and was not. For another resident, the admission record showed diagnoses including dementia, contracture, muscle weakness, and osteoarthritis. The quarterly MDS dated 07/20/25 showed the resident was rarely or never able to make herself understood, had severely impaired cognition, was always incontinent of bladder, frequently incontinent of bowel, required substantial to maximum assistance with toileting hygiene, and did not use the toilet. The care plan dated 06/27/25 stated the resident was dependent on staff for assistance with ADLs, but it did not address incontinence or toileting hygiene needs. The DON stated the resident’s toileting and changing schedule should be included in the care plan, and the MDS Coordinator stated the resident’s incontinence and toileting hygiene needs should have been addressed in the care plan.
Missed Antibiotic Eye Medication and Failure to Notify Physician
Penalty
Summary
The facility failed to ensure that a resident with encephalopathy, sepsis, and dementia received tobramycin ophthalmic ointment as ordered for a left eye infection and failed to notify the physician when doses were missed. The resident’s annual MDS indicated she was rarely or never able to make herself understood and had severely impaired cognition. A physician ordered tobramycin ointment 0.3%, one application in the left eye three times daily for seven days, but the eMAR showed the medication was given twice on 09/04/25, three times on 09/05/25, not given at all on 09/06/25 or 09/07/25, and then given three times daily again on 09/08/25. During the missed-dose period, the LPN documented the medication as not administered and entered notes stating it was awaiting delivery or not available. In interview, the LPN stated she could not find the ointment over the weekend, looked for it, and did not see it anywhere. She also stated she did not alert the physician about the missed doses or contact the pharmacy to determine whether the medication had been delivered. The DON stated the LPN should have contacted the pharmacy to check the medication status and notified the physician of the missed doses. The facility policy on unavailable medication required nursing staff to contact the pharmacy, attempt to obtain the medication from the automated dispensing system or emergency kit, and notify the physician of the unavailable medication.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure pressure ulcer prevention measures were in place for two residents. Review of the RAI Manual and facility policies showed that pressure injury risk factors and interventions should be identified and included in the care plan, with support surfaces selected based on resident risk factors. The deficiency involved Resident 116 and Resident 3, both of whom were identified as being at risk for pressure ulcers, with Resident 3 also having an existing stage III pressure ulcer. Resident 116’s record showed severe cognitive impairment, wheelchair use, partial to moderate assistance with activities of daily living, and risk for pressure ulcers with pressure-reducing devices applied to the wheelchair. However, during observations, the resident was seated in a transportation wheelchair with a white towel under her instead of a gel cushion. The OT stated the resident was not on a gel cushion and recommended a Roho cushion because of the resident’s pressure ulcer risk. A CNA stated the resident never had a Roho cushion, while the MDSC stated the resident had one but the family member placed it behind the resident’s back instead of underneath her. Resident 3 had diagnoses including metabolic encephalopathy, protein-calorie malnutrition, peripheral vascular disease, and dementia, and was rarely or never able to make herself understood. Her care plan noted a pressure ulcer to the right heel, but it did not include specific prevention interventions. The wound care physician documented a new right heel pressure injury and instructed staff to offload heels per facility protocol using heel booties. Despite this, no physician order for heel booties was found, and repeated observations showed the resident seated in a reclining wheelchair with her heels directly on a pillow and no heel booties in place. Staff confirmed she was not wearing the booties, and the DON stated the booties should have been used at all times in bed and out of bed and included in the physician orders and care plan.
Failure to Apply Ordered Gauze Roll for Resident With Hand Contracture
Penalty
Summary
The facility failed to ensure interventions were in place for one resident with a left hand contracture and related ROM/mobility needs. The resident was admitted with diagnoses including dementia, contracture, muscle weakness, and osteoarthritis, and the quarterly MDS described severe cognitive impairment and that she was rarely or never able to make herself understood. Her care plan identified dependence on staff for activities of daily living, but it did not address the left hand contracture or any interventions to manage it. Although a physician ordered a gauze roll to be applied to the left hand daily with skin checks and hand hygiene in the morning and evening, the care plan did not include this intervention. During multiple observations, the resident was seated in her reclining wheelchair with her left hand balled into a fist and no gauze roll in place. She was observed in the sensory group and at the breakfast table without the gauze roll, and her left hand remained in a fist. During a concurrent observation and interview, an LPN confirmed the gauze roll was not in the resident's left hand and stated it was needed to protect her skin due to contracture; the LPN then placed the gauze roll in the hand and noted it was a challenge to get it in place. The DON stated there was no explanation for why the gauze roll was not applied as ordered even though it was documented as completed on the TAR.
Missing Ambu-bag at bedside for resident with tracheostomy
Penalty
Summary
The facility failed to provide respiratory care per standards of practice for one resident with a tracheostomy. Review of the resident’s care plan showed that emergency equipment was required at the bedside, including an Ambu-bag, due to respiratory failure. During an observation and interview, the Registered Nurse Supervisor entered the resident’s room and showed the emergency medical equipment at the bedside, but confirmed there was no Ambu-bag present. The facility policy titled Tracheostomy Care did not address the importance of storing an Ambu-bag at the bedside for a resident with a trach. During interview, the RN Supervisor stated that an Ambu-bag was important if the resident was unable to breathe on his own and required manual assistance. The DON stated he was unsure why the Ambu-bag was not at the bedside, but acknowledged it was critical for clinical staff to have access to it if the resident could not breathe on his own.
Failure to Respond to Pharmacist Medication Review
Penalty
Summary
The facility failed to ensure the physician responded to consultant pharmacist medication regimen reviews for one resident, R7, who was reviewed for unnecessary medications. The facility policy stated that a licensed pharmacist reviews each resident’s medication regimen at least monthly, and that the attending physician reviews and responds to the report and documents what actions were taken. If the physician does not provide a timely or adequate response, the consultant pharmacist contacts the medical director or administrator. R7 was admitted to the facility and later readmitted after a hospital stay with diagnoses including hypotension, atrial fibrillation, and a bone infection of the left ankle and foot. A pharmacist consultant report noted that R7 had an order for Midodrine every 8 hours and stated that it should not be dosed after 5 PM to minimize the potential for supine hypertension, requesting that the MD orders and MAR be updated. The report provided no documentation that the physician responded. Review of the MARs showed Midodrine was restarted on 06/20/25 at 2.5 mg every 8 hours with dosing times of 6:00 AM, 2:00 PM, and 10:00 PM, and the August and September MARs continued to show Midodrine every 8 hours with the 10:00 PM dose. A later pharmacist consultant report again stated that Midodrine should not be dosed after 5 PM, and there was no documentation that the physician had been notified or that the order had been changed. During interviews, the DON stated the physician was not good with electronics and did not return the reports timely, and the pharmacist consultant stated the physician had not responded.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for three residents. For one resident with major depressive disorder, the comprehensive care plan stated the resident used anti-psychotic medication related to psychosis, but the electronic medical record did not show a diagnosis of psychosis or administration of an anti-psychotic medication. During interview, the UM stated this was an error and that the care plan should have said anti-anxiety instead of anti-psychotic, and that the resident did not have psychosis. For another resident with anoxic brain injury and an NPO status with tube feeding, the record included an order for bottled water despite the resident being NPO. The UM stated the order was inaccurate because the resident was NPO. For a third resident, the MAR documented blood sugar results of 11111 on multiple occasions, but the nursing progress notes did not contain corresponding documentation of abnormal blood sugar results. The DON, ADON, and RN confirmed the blood sugar entry was incorrect, and the RN stated she was unaware there was a code for unapplicable since the resident did not require insulin.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of abuse involving a resident with visual and hearing impairments, who was cognitively intact and required supervision or touch assistance with activities of daily living. The resident reported that an unknown individual entered their room after supper, pulled down their pants, cleaned them, put a diaper on them despite not wearing diapers, and attempted to put a hospital gown on them. The resident became distressed and the individual eventually put their clothes back on. The resident informed a family member, who had video evidence of the incident and described that a CNA entered the room, attempted to change the resident, and was told by another aide that such care was not needed for this resident, who was independent. The facility's investigation was incomplete. The administrator did not collect statements from all staff present at the time of the incident, nor from other alert and oriented residents assigned to the staff member involved. The administrator also did not review the video recording provided by the family. The LPN who was present during the incident and the LPN/Infection Control Nurse who reviewed the video and performed a skin assessment were not asked to provide written statements. The CNA involved was not reached for an interview, and no documentation was provided regarding their account of the incident. Facility policy requires that all allegations of abuse be thoroughly investigated, including reviewing documentation and evidence, interviewing all relevant staff and residents, and documenting the investigation completely. The investigation conducted did not meet these requirements, as key interviews and evidence review were omitted, and the findings were not fully documented as per policy.
Failure to Address Resident's Contracture
Penalty
Summary
The facility failed to identify and prevent the worsening of a contracture in a resident's right hand. The resident, who was observed multiple times by the surveyor, had a contracture in the right hand with no brace or any intervention in place. The resident reported being unable to use the right hand and stated that the staff did not provide any support or items to help manage the contracture. The resident's medical records did not include any documentation or care planning for the upper extremity impairment or contracture, despite the resident being cognitively intact and able to communicate their needs and condition. Interviews with the facility staff, including CNAs, the Unit Manager, and the Occupational Therapist, revealed a lack of awareness and action regarding the resident's contracture. The CNAs mentioned that they would perform range of motion exercises and inform the nurse if they noticed a contracture, but there was no evidence of such actions being taken for this resident. The Unit Manager and Occupational Therapist were unaware of the contracture and did not have the resident on a restorative program or therapy for the condition. The facility's policies on restorative nursing and comprehensive care plans were not followed, as there was no documentation or intervention for the resident's contracture. The facility's failure to address the resident's contracture was further evidenced by the lack of physician's orders for a splint or brace and the absence of any restorative care for range of motion exercises in the resident's treatment records. The Director of Rehabilitation confirmed that the resident had not received therapy services and that staff should make referrals to therapy if they identified any decline in function or limitations with activities of daily living. The facility's documentation and care planning deficiencies were acknowledged by the Licensed Nursing Home Administrator, who provided a timeline and other documentation that did not include any interventions for the resident's contracture.
Failure to Maintain Adequate Emergency Water Supply
Penalty
Summary
The facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. During a survey, it was observed that the facility, which had a census of 123 residents, only had 132 gallons of emergency water available, whereas the requirement was 369 gallons (1 gallon per resident per day for 3 days). The Food Service Director (FSD) acknowledged the deficiency and mentioned that some water had been discarded due to expiration, and an order had been placed to replenish the supply. However, the provided invoices did not show that water had been ordered prior to the surveyor's inquiry. The Licensed Nursing Home Administrator (LNHA) and the FSD confirmed that the facility's policy required maintaining a 3-day emergency water supply based on the current census. The LNHA stated that the responsibility for ensuring the emergency supply was sufficient lay with the FSD, and there was no delay in approval or delivery of the order. Despite this, the surveyor found that the facility did not have the required amount of emergency water at the time of the survey, and the FSD admitted that the emergency water supply was insufficient based on the resident census.
Failure to Complete Weekly Skin Evaluations
Penalty
Summary
The facility failed to complete weekly skin evaluations for three residents, leading to a deficiency in pressure ulcer care and prevention. Resident #5, who was moderately cognitively impaired and had a Stage 3 pressure ulcer, did not have consistent weekly skin evaluations documented in the Electronic Medical Record (EMR) as required by the physician's order. The Treatment Administration Record (TAR) showed several instances where the evaluations were not completed, and the Licensed Practical Nurse (LPN) and Unit Manager (UM) confirmed the lack of documentation and adherence to the protocol during interviews with the surveyor. Resident #49, who was severely cognitively impaired and had a Stage 4 pressure ulcer, also did not receive the mandated weekly skin evaluations. The TAR indicated missed evaluations, and the EMR lacked documentation of these assessments. The LPN/UM verified the deficiency, acknowledging that the only documented skin assessment was from February, despite the requirement for weekly evaluations. The resident's care plan highlighted the high risk for pressure ulcers, yet the facility failed to follow through with the necessary preventive measures. Resident #86, who had a history of pneumonia and dysphagia and was severely cognitively impaired, similarly did not receive consistent weekly skin evaluations. The TAR showed missed evaluations, and the EMR had incomplete documentation of the required assessments. Interviews with the CNA, Desk Nurse/Registered Nurse (DN/RN), and Assistant Director of Nursing (ADON) confirmed the lapses in protocol. The Regional Clinical Operations/Registered Nurse (RCO/RN) reviewed the records and verified the deficiencies, emphasizing the importance of weekly skin assessments to monitor and prevent skin abnormalities.
Failure to Provide Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, resulting in several deficiencies. One resident, who was prescribed insulin Glargine with specific parameters to hold the medication if blood sugar was less than 100, did not have their blood sugar levels documented prior to administration. This oversight was confirmed by the Assisted Director of Nursing (ADON) and the Registered Nurse/Unit Manager (RN/UM), who acknowledged that the blood sugars were not documented on the electronic Medication Administration Record (eMAR) as required. The resident had a history of diabetes mellitus type 2, cerebral infarction, and occlusion and stenosis of the left carotid artery, and their cognition was intact as indicated by a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Despite the physician's order, the facility failed to ensure proper monitoring and documentation of blood sugar levels before administering insulin, which is crucial for preventing hypoglycemia. The ADON and RN/UM both confirmed the lack of documentation and the importance of following the parameters set by the physician's order. Another deficiency was observed when a resident was found with a medication cup containing four tablets on their overbed table. The RN/UM, who was responsible for administering the medication, could not explain how the medication ended up on the table and acknowledged that it was the nurse's responsibility to ensure that the medication was not left unattended and that the resident consumed all their medications. The resident had a history of heart failure, acute pulmonary edema, adjustment disorder with depression, and hypertension, and their cognition was moderately impaired with a BIMS score of 8 out of 15. The medications found included a multivitamin with minerals, Coreg, Eliquis, and Lasix, all of which were signed off as administered on the eMAR. The Director of Nursing (DON) confirmed that medications should never be left unattended and that the nurse should ensure the resident consumes their medication. The facility also failed to maintain an accurate inventory of controlled medications dispensed from the automated medication dispensing system (AMDS) on the 2nd floor nursing unit. The surveyor found that the daily count narcotic back-up sheets were not consistently maintained, with the DON only able to provide records for two days in March. The DON acknowledged the importance of daily inventory counts for controlled substances to ensure accountability and prevent medication diversion. The facility had recently created a new form for daily counts of narcotics and controlled substances, but the lack of consistent documentation prior to this change indicated a failure to adhere to their own policies and procedures for controlled substances and the AMDS system.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care to a resident who required extensive assistance with Activities of Daily Living (ADL). During an initial tour, a surveyor observed the resident with elongated, thickened, and jagged nails, indicating a lack of proper nail care. The resident's medical records showed that they had significant impairments, including cerebrovascular disease, a right leg above-knee amputation, and atherosclerotic heart disease. The resident was cognitively intact but required extensive assistance for most ADLs and personal hygiene. Despite this, the resident's care plan did not reflect their need for assistance with ADLs, including nail care. Interviews with CNAs and the Unit Manager revealed inconsistencies in the provision and documentation of nail care, with no log maintained for such care. The resident expressed dissatisfaction with the length of their nails and confirmed that staff did not clean their nails during care. The Unit Manager acknowledged the importance of nail care to prevent infection and other issues but admitted that the resident's nails were long and needed trimming. The facility's policies on ADL care and comprehensive care planning were reviewed, showing that the care plan should include the level of assistance needed for ADLs and be culturally competent and trauma-informed. However, these policies were not adequately followed in the case of this resident, leading to the identified deficiency.
Failure to Discontinue and Maintain IV Line
Penalty
Summary
The facility failed to obtain and carry out an order to discontinue a Peripheral Intravenous (IV) line and to maintain the site according to professional standards of practice for a resident. The resident was admitted with an IV access site and had completed a course of IV antibiotics. However, there was no physician order to maintain or discontinue the IV line after the completion of the antibiotics, and the IV line was not assessed or removed in a timely manner. The IV line was observed to be covered by a transparent dressing with peeling tape and was not dated or initialed, indicating a lack of proper maintenance and documentation. The resident's care plan did not include a focus on IV-line care or IV antibiotics, and the staff failed to document the kind of access the resident had and when it was inserted upon admission. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the IV line should have been removed after the completion of the antibiotics and that the care plan should have been initiated for IV line care. The facility's policy on catheter insertion and care was not followed, as the IV dressing was not changed as needed to prevent catheter-related infections. Interviews with the resident's Registered Nurse (RN), Charge Nurse (RN/CN), MDS coordinator, and DON revealed a lack of awareness and proper documentation regarding the IV line. The RN/CN and surveyor confirmed the presence of the IV line, and the RN/CN acknowledged that it was unacceptable for the IV line to still be in place. The DON provided a timeline indicating that the IV line was not removed until after the surveyor's inquiry, despite recommendations from the Infectious Disease physician to discontinue the IV line earlier.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure the safe and appetizing temperatures of foods served to the residents. This deficiency was identified during a Resident Council meeting where five residents unanimously agreed that their food trays were not warm. Further investigation during the lunchtime meal service on the 2nd floor unit revealed that the food temperatures were significantly below the required levels. For instance, the roast beef was at 122.5 degrees F, roasted potatoes at 121.0 degrees F, and the Capri vegetable blend at 115.9 degrees F, all of which are below the acceptable hot food temperature. The cold items, such as the fruit cup and milk, were also above the required cold food temperature, with the fruit cup at 53.3 degrees F and the milk at 54.3 degrees F. The Food Service Director (FSD) confirmed that the food temperatures were taken in the kitchen before the trays were dispatched, and the temperatures were within the acceptable range at that time. However, the FSD admitted that he does not record the temperatures of the food once it has been on the truck for a while. The facility's policies on hot and cold food temperatures were reviewed, revealing that the kitchen is responsible for ensuring that hot foods are served at safe temperatures and cold foods at 41 degrees F or lower. Despite these policies, the facility failed to maintain the appropriate food temperatures during the delivery process, leading to the deficiency.
Failure to Provide Meals According to Physician's Orders and Resident Preferences
Penalty
Summary
The facility failed to ensure foods were provided in accordance with physician's orders and resident preferences as identified in their plan of care. This deficiency was observed in two residents. For Resident #114, the surveyor noted discrepancies in the meal tray items on multiple occasions. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's Disease and cachexia, did not receive the prescribed fortified mashed potatoes, low-sugar house shake, and was given chocolate ice cream instead of vanilla. The LPN/UM, RD, and FSD all acknowledged the missing items, and the FSD admitted that the facility was out of low-sugar health shakes. The RRD confirmed that the missing items were part of the resident's plan of care to promote weight gain, and there was no clear accountability for ensuring tray accuracy in the kitchen. For Resident #120, the surveyor observed that the resident's lunch tray did not match the meal ticket. The resident, who had intact cognition and diagnoses including type 2 diabetes and Parkinson's Disease, did not receive the correct portions of protein, whole milk, or the specified beverages. The FSD and RRD both acknowledged the discrepancies and stated that the meal ticket should have been followed. The FSD admitted that the facility was out of whole milk and that no one was assigned to check the trays for accuracy on the day of the observation. The LNHA acknowledged the concerns regarding tray accuracy but provided no additional information. The facility's policies on Medical Nutrition Therapy Documentation, Therapeutic Diets, Fortified Foods and Supplements, Dining and Food Preferences, and Tray Accuracy were reviewed. These policies outlined the responsibilities of the RD, FSD, and other dietary staff to ensure that residents received meals according to their diet orders and preferences. However, the observations and interviews indicated that these policies were not followed, leading to the deficiencies noted in the report.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near South Amboy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alameda Center For Rehabilitation And Healthcare | 2.1 mi | ★★★★★ | 1 | 0 |
| Spring Creek Healthcare Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Complete Care At Madison, Llc | 4.5 mi | ★★★★★ | 14 | 0 |
| St Joseph's Home Al & Nc, Inc | 5.5 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Respiratory And Nursing Center | 5.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.