Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Chasehealth Rehab And Residential Care during CMS and state inspections, most recent first.
The facility did not properly install the emergency generator's remote annunciator panel in a readily observed work location. It was found at the loading dock hall entrance, a location not monitored by staff, as confirmed by the Director of Environmental Services.
The facility was cited for failing to maintain hazardous areas, including the tub room, activities office, clean linen room, therapy storage room, and kitchen dry storage room. Issues included non-fire-rated doors, unsealed penetrations, and incomplete documentation. The Director of Environmental Services acknowledged the deficiencies.
The facility did not ensure emergency illumination along the means of egress, as the first-floor hallway lights were controlled by a wall switch and lacked automatic operation. The Director of Environmental Services confirmed that while the lights were connected to the generator, they would not work if the switch was off, acknowledging the importance of illumination for evacuation.
The facility failed to maintain clear egress and properly rated fire doors, with multiple deficiencies observed, including illegible fire ratings, non-fire-rated doors, and a tripping hazard at an exit. The Director of Environmental Services acknowledged awareness of some issues but not all identified during the survey.
The facility did not maintain fire extinguishers as per NFPA standards. The annual inspection report lacked details on maintenance and location, and a fire extinguisher in the maintenance closet missed monthly inspections for two months. The facility also failed to keep inspection records for the past year. The Director of Environmental Services was unaware of these lapses.
The facility failed to ensure electrical safety in six areas, including the director of nursing office and main kitchen, where outlets were not protected with ground fault circuit interrupters (GFCI) and power strips were improperly placed on the floor. The Director of Environmental Services was aware of the need for water protection but did not realize the extent of unprotected equipment.
The facility did not maintain an updated Emergency Preparedness Program, with the last reviews documented on two separate occasions, leaving a significant gap in compliance. This deficiency could impact all residents.
The facility failed to maintain patient care related electrical equipment according to NFPA 99 standards. A hair dryer in the beauty shop had outdated inspection records, and a nebulizer at the nurse's station lacked inspection documentation. The Director of Environmental Services confirmed the absence of necessary records, highlighting the importance of equipment maintenance for safety.
The facility did not ensure proper maintenance of its diesel emergency generator as per NFPA 99 standards. Vendor reports highlighted issues with hard and brittle fuel lines and cooling system hoses, as well as temporary battery cable repairs. The Director of Environmental Services was aware of these concerns but delayed corrective actions due to plans for a new facility.
The facility did not maintain the electrical system as required, as observed during a Life Safety Code recertification survey. An open junction box with exposed wires was found in the main kitchen, resulting from the removal of a hard-wired clock. The Director of Environmental Services noted that several rooms had similar clocks removed, but the wiring was not yet covered.
A ventilation unit in a soiled utility room was not working properly, resulting in a strong foul odor and no draw from the vent. The Director of Environmental Services noted that a vendor had recently repaired the rooftop unit, but suspected an obstruction in the ductwork.
A survey found that the fire-rated door label in the north stairwell was painted over, making it illegible. This issue was noted in previous inspection reports, and during an interview, the Director of Environmental Services was unaware of the painted label, despite knowing the importance of its visibility for evacuation and door rating verification.
The facility did not maintain proper documentation of annual Emergency Preparedness Plan training for two staff members. An LPN had no training records for 2024, and the Kitchen General Manager's 2024 training lacked a specific date, with no records for 2023. The Administrator cited the LPN's leave as a reason for missing documentation and was unsure about the Kitchen General Manager's training due to their contracted status.
The facility failed to maintain subsistence needs for residents and staff during an emergency. The Emergency Preparedness Plan did not account for staff or visitors' water needs, and medication refrigerators were not supported by the emergency generator. Observations and interviews confirmed the lack of emergency cold medication supplies and oversight regarding generator support.
The facility failed to provide residents with meals that were palatable and at appropriate temperatures. Observations during two meals showed food served below required temperatures, and residents reported dissatisfaction with the taste and texture. Staff acknowledged the issues, noting that vegetables were often overcooked due to boiling, and residents frequently complained about the menu choices and food quality.
A recertification survey revealed unsanitary conditions in the facility's main kitchen, including rusty shelves, pet beds in storage areas, and improper dishwashing practices. Staff interviews confirmed these issues, which violated the facility's sanitary policy and risked food contamination.
A resident with a spinal fracture was observed wearing a TLSO brace incorrectly due to inadequate staff training and lack of a comprehensive care plan. The brace was consistently positioned incorrectly, and staff were not properly educated on its application. The facility failed to document and implement appropriate interventions for the brace, leading to the deficiency.
A facility failed to review risks and benefits or obtain informed consent before installing bed rails for a resident with morbid obesity, heart failure, and respiratory failure. Despite the resident's need for assist rails to maintain independence, the facility did not document the use of bed rails in the care plan or obtain consent. Interviews revealed staff were unclear about the policy, leading to systemic non-compliance.
A facility failed to ensure proper labeling and storage of medications, as observed during a survey. Multiple eye drops in a medication cart were not labeled or dated, with resident names written inside the boxes. Staff interviews confirmed that all medications should have pharmacy labels, and the absence of such labels posed a risk of administering the wrong medication. The Director of Nursing emphasized the importance of proper labeling to prevent errors.
A malfunction in the call bell system in a resident's bathroom led to a situation where residents could not effectively call for assistance. The bathroom call bell, when activated, would be canceled if the room call bell was pressed, leaving residents without a means to alert staff. Observations and staff interviews confirmed the issue, with maintenance acknowledging the outdated system and lack of corrective action. The DON was unaware of the failures, highlighting a gap in communication and response protocols.
The facility did not maintain an effective infection prevention and control program for Legionella bacteria. The water management plan was not reviewed in 2024 and lacked a sampling plan and control measures. The Director of Maintenance admitted to collecting samples annually without a formal plan and was unaware of the need for one.
Improper Installation of Emergency Generator Annunciator Panel
Penalty
Summary
The facility failed to ensure that the emergency generator's remote annunciator panel was properly installed in a readily observed regular work location. During the Life Safety Code recertification survey, it was observed that the 85-kilowatt diesel generator's remote annunciator panel was located at the loading dock hall entrance. Although there was a camera at this location because it served as the staff entrance, the Director of Environmental Services confirmed that staff did not work or monitor this area.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Maintenance will relocate the annunciator panel to the first-floor nursing station when supplies are received. Conduit placed for wiring to run to new location. Panel to be relocated 4/15/2025. All employees received training on the new location of the annunciator panel, purpose of panel, and process if alarm sounds. The Director of Environmental Services will monitor the annunciator panel for proper functioning monthly. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance.
Deficiencies in Hazardous Area Maintenance
Penalty
Summary
The facility failed to maintain hazardous areas in compliance with safety regulations, as observed during a Life Safety Code recertification survey. Specifically, five locations within the facility were identified with deficiencies. The tub room, used for storage, was not fire-rated, had a transfer grille, and lacked a self-closing door. Similarly, the activities office, also used for storage, was not fire-rated, had a door propped open by an unapproved holder, and was not self-closing. The clean linen room had a residential doorknob that was not fire-rated, and the fire-rated label on the door was missing. Further deficiencies were noted in the therapy storage room, which had unsealed penetrations through the walls and ceiling. The kitchen dry storage room had multiple unsealed penetrations, painted-over fire ratings, and a door propped open by an unapproved holder. The facility's documentation for fire-rated smoke door assemblies was incomplete, lacking records for the clean linen door, therapy storage room, and kitchen dry storage room. The Director of Environmental Services acknowledged awareness of these deficiencies and the importance of maintaining hazardous areas for safety.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The three lifts, dining room chair, scale, fall mats, and wheelchair were removed from the tub room. The magnetic holder was removed from the door to make it self-closing. The unapproved door holder was removed from the Activity office door, and a door-closer was installed making the door self-closing. All Maintenance Employees will be educated on hazardous areas, including identifying rooms used for storage and ensuring the doors are self-closing and properly rated. The linen room doorknob was replaced with a fire-rated knob. The door will be included in the quote for recertification/replacement with an outside vendor. The Therapy Storage room unsealed penetrations through the walls and ceiling were sealed. The unapproved door holder was removed from the dry storage door. The door will be included in the quote for fire-rated recertification/replacement. The Director of Environmental Services will audit the tub room monthly with environmental rounds to ensure it is not used for storage, to ensure there are no unapproved [MEDICATION NAME] in use, and to monitor for any unsealed penetrations in the walls and sealings. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services
Failure to Provide Emergency Illumination
Penalty
Summary
The facility failed to provide emergency illumination that would operate automatically along the means of egress, as required by NFPA 101, 2012 Edition, Section 19.2.8 and 7.8. During an observation, it was noted that the first-floor hallway lights were all controlled by a wall switch, and when the switch was turned off, there was no illumination available for the means of egress. This lack of emergency lighting was confirmed during an interview with the Director of Environmental Services, who acknowledged that although the lights were connected to the generator, they would not function if the switch was off. The Director was aware of the requirement for the egress pathway to have illumination, especially for evacuation purposes at night.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 The light switch was removed from one side of the hall on both north and south hallways on both the first and second floors, allowing the lights to offer continuous illumination. All Maintenance Employees will receive education on illumination on means of egress, including exit discharge and the importance of illumination in the event of an emergency and evacuation is necessary. The Director of Environmental Services or designee will audit lighting monthly to ensure the lights are in proper working order. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement committee for 1 year to ensure compliance. Person Responsible: The Director of Environmental Services
Fire Door and Egress Deficiencies
Penalty
Summary
The facility failed to maintain the means of egress free of obstructions or impediments, as required by the Life Safety Code. During the survey, it was observed that multiple fire doors were not properly maintained, and a tripping hazard was present at one direct exit. Specifically, the fire doors in the boiler room, kitchen main door, and kitchen doors leading to the dining room had illegible or missing fire ratings. Additionally, the clean linen door, evening maintenance closet, and kitchen dry storage room lacked documentation of fire door ratings. Observations included a non-fire-rated door in the new office side, fire doors held open by magnetic holders not connected to the fire alarm system, and linoleum curling up in front of the North Stairwell exit door, creating a tripping hazard. Further deficiencies were noted with the boiler room door assembly having its fire ratings painted over, and the kitchen door from the service hallway having an illegible fire rating. The kitchen double doors had their fire-rated labels painted over and did not close and latch properly when tested. During an interview, the Director of Environmental Services acknowledged being unaware of all the doors identified during the survey but confirmed awareness of several doors with painted fire-rated labels. The importance of maintaining clear exits and properly rated doors for evacuation and fire protection was emphasized.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Quote has been requested by Director of Facilities from an outside vendor known as Intertek, which specializes in inspecting fire and egress door assemblies to the NFPA 80 Standard. The quote will include affected boiler room, kitchen main door, kitchen doors going to dining room, clean linen door, evening maintenance closet, and the kitchen dry storage room for either re-certification and/or replacement. Intertek scheduled to be onsite for door repairs 4/9/2025. The Magnetic holders were removed from the fire doors that connect two offices to the building. A threshold was placed over the curled linoleum in the north stairwell. All Maintenance Employees were educated on maintaining clear means of egress continuously and properly maintaining fire doors. The Director of Environmental Services or designee will audit the doors monthly to ensure they are still fire-rated with legible tag, and no doors are held open by magnetic holder, unauthorized door [MEDICATION NAME], or floor obstructions blocking egress. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services
Fire Extinguisher Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that fire extinguishers were maintained according to the National Fire Protection Association 10 Standard for Portable Fire Extinguishers. The annual fire extinguisher inspection report provided by the facility was merely a receipt and did not include details about the maintenance or location of the fire extinguishers. Additionally, a fire extinguisher located in the evening maintenance closet had not undergone the required monthly inspections for two months in 2024. The facility also did not maintain the past twelve months of inspection records on site. During an interview, the Director of Environmental Services admitted to being unaware of the missed monthly inspections and acknowledged the importance of proper maintenance for the safety of residents and staff.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 The Vendor responsible for providing the annual fire extinguisher was contacted for a summary analysis outlining the maintenance and location of the fire extinguishers within the facility. The analysis will be maintained onsite. The vendor was requested to inspect the fire extinguisher in the evening maintenance closet. Vendor inspected the fire extinguisher in the evening maintenance closet on 3/20/2025. Maintenance employees received education on consistently maintaining portable fire extinguishers monthly, reviewing vendor invoices for details such as location of extinguishers, and keeping at minimum of 1 years' worth of inspections records onsite and readily available for review. The Director of Environmental Services or designee will audit all extinguishers monthly to ensure that monthly inspection is performed and documented adequately. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for one year to ensure compliance. Person Responsible for Completion: The Director of Environmental Services.
Electrical Safety Deficiency in Multiple Facility Areas
Penalty
Summary
The facility failed to ensure that electrical equipment had approved wiring and electrical outlets in accordance with NFPA 70, 2011 Edition, in six different areas. Specifically, the director of nursing office, nursing main supply room, first-floor nurse's station, main kitchen, foyer, and therapy department had outlets that were not protected from water with a proper ground fault circuit interrupter (GFCI). Additionally, power strips were found on the floor, which posed a potential risk when the floors were swept and mopped. Observations included a coffee pot in the director of nursing office plugged into a regular outlet about 7 feet from a sink, and a power strip on the floor in the nursing main supply room. Further observations revealed that the first-floor nurse's station had a water cooler plugged into a red outlet without a GFCI, and the main kitchen had a residential refrigerator plugged into a regular outlet about 6 feet from a 3-bay sink. In the foyer, a water cooler was plugged into a regular outlet without a GFCI, and in the therapy department, water coolers, coffee makers, and medication equipment were plugged into regular outlets. During an interview, the Director of Environmental Services acknowledged awareness of the need for outlets to be protected from water but was unaware of the improper protection of power strips on the floor and the extent of water-containing electrical equipment not properly protected.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 The Outlet in the Director of Nursing Office was replaced with a ground fault circuit interrupter. The Power Strip in the nursing main supply room was mounted to the wall. A ground fault circuit interrupter was added to the red outlet at the first-floor nurses’ station. The outlet in the main kitchen 6 feet from the 3-bay sink was changed to a ground fault circuit interrupter. The outlet in the foyer was changed to a ground fault circuit interrupter. The outlets in the therapy department were changed to ground fault circuit interrupters. All maintenance employees received education on electrical outlets and the need for ground fault circuit interrupter outlets for any water containing electrical equipment, and approved power strips should be properly mounted and not present in close proximity to water. The Director of Environmental Services or designee will audit outlets monthly and install ground fault circuit interrupters where any water products are contained. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services
Deficient Emergency Preparedness Program
Penalty
Summary
The facility failed to establish and maintain a comprehensive Emergency Preparedness Program that was updated at least annually. During the Emergency Preparedness Plan review, it was found that the plan was last reviewed and updated on January 2, 2024, and November 10, 2021. No other documentation was available to indicate any further updates or reviews. This deficiency could potentially affect all residents in the facility.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 The Emergency Management Plan was reviewed and revised on 3/6/2025. Each section of the Emergency Management Plan reflects the review date and if revisions occurred. All Department Managers will receive education on developing, maintaining, and reviewing/updating the emergency preparedness program annually. The Director of Environmental Services and Administrator will review the Plan quarterly to ensure it is updated and revised. Any changes or revisions will be reviewed with the Quality Assurance and Performance Improvement Committee quarterly for 1 year to ensure compliance. Person Responsible for Completion: Administrator
Deficiency in Maintenance of Patient Care Electrical Equipment
Penalty
Summary
The facility failed to maintain patient care related electrical equipment (PCREE) in accordance with NFPA 99 standards, as observed during a Life Safety Code recertification survey. Specifically, the facility lacked a policy and documentation for the maintenance of selected equipment. During an observation, a hair dryer in the beauty shop was found to have been last inspected in 2017, with no recent inspection documentation available except for a sticker indicating an inspection by the Director of Environmental Services. Additionally, a nebulizer at the second-floor nurse's station had no inspection or maintenance records available prior to the survey. The Director of Environmental Services confirmed the absence of inspection information for the nebulizer and additional details for the hair dryer, acknowledging the importance of proper equipment inspection and maintenance for resident and staff safety.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 The Director of Environmental Services removed the hair dryer from the facility due to its age and lack of necessity. The Nebulizer located at the second-floor nurses’ station was inspected and labeled, and added to the facility’s electrical equipment. All staff were re-educated on the Electrical Equipment Policy and the necessity of inspection prior to use. The Director of Environmental Services will audit the electrical equipment monthly to ensure any are due for annual inspection. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services
Failure to Maintain Diesel Emergency Generator
Penalty
Summary
The facility failed to properly maintain its diesel emergency generator in accordance with NFPA 99 standards. During a Life Safety Code recertification survey, it was found that deficiencies noted in vendor reports from routine preventative maintenance were not corrected in a timely manner. These reports, dated 12/11/2024, 6/26/2024, and 12/12/2023, indicated that the fuel lines had become hard and brittle, beginning to crack, and the cooling system hoses were also hard, brittle, and seeping slightly. Additionally, the battery cable ends were temporary repair ends instead of permanent crimp style ends. The Director of Environmental Services acknowledged awareness of these issues but stated that the facility was hesitant to make changes due to their long-term plans to build a new facility.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Estimate received from Vendor, (NAME) Cat, to replace fuel lines, cooling system hoses, and to change temporary repair ends to permanent crimp style battery cable ends. Estimate was approved and we are awaiting vendor repair date. Milton Cat scheduled to perform repairs on generator on 4/15/2025. Maintenance employees to receive education on reviewing generator maintenance invoices and addressing maintenance concerns and repairs. The Director of Environmental Services or designee will audit the vendor report from routine preventative maintenance every 6 months, or earlier if as needed visit occurs to address repair needs. The Audit will be reviewed with the Quality Assurance and Performance Committee at the quarterly meeting following the 6-month preventative maintenance to ensure compliance.
Electrical System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the electrical system as required by NFPA 99, 2012 Edition, Section 6, during a Life Safety Code recertification survey. An open junction box with exposed wires was observed on the wall above the window in the director's office within the main kitchen. This condition was identified during an observation and interview conducted on February 11, 2025, at 12:52 PM. The Director of Environmental Services explained that the exposed wiring resulted from the removal of a hard-wired clock, which had not yet been addressed. Several rooms in the facility had similar hard-wired clocks that had been removed, but the wiring had not been properly enclosed or covered, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 The open junction box in the main kitchen was repaired. A cover was installed over the exposed wires. Maintenance Employees received education on maintaining the electrical system by not leaving open junction boxes and exposed wires upon completing a task. The Director of Environmental Services or designee will monitor outlets with monthly environmental rounds for exposed wires and open junction boxes. The Audit will be reviewed monthly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: The Director of Environmental Services
Ventilation Unit Malfunction in Soiled Utility Room
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that a ventilation unit in a soiled utility room on one resident floor was not functioning properly. This issue was identified near a specific resident room, where a strong foul odor was present, and the vent showed no draw. The Director of Environmental Services indicated that the vent should have been operational since a vendor had reportedly fixed the rooftop unit the previous day. However, they suggested that there might be an obstruction in the ductwork, which was causing the malfunction.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Maintenance employees cleaned the dampers and the duct work in the soiled utility room near resident room [ROOM NUMBER], which increased the suction of the exhaust fan. All maintenance and environmental services employees received education on ensuring vents are free of dust or debris to prevent obstruction in the duct work. The Director of Environmental Services or designee will inspect the ventilation units/exhaust fans with monthly environmental rounds for proper functioning. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: The Director of Environmental Services
Fire-Rated Door Label Illegibility in North Stairwell
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that the facility failed to maintain the fire-rated door label in the north stairwell. Specifically, the label on the second-floor north stairwell door was painted over, rendering it illegible. This issue was documented in the Swing Door Assembly Inspection Criteria reports from August 2023 and August 2024, which noted the illegibility of the door rating label. On February 11, 2025, at 11:07 AM, the painted-over label was observed, and during an interview on February 14, 2025, the Director of Environmental Services admitted to being unaware of the painted label, despite acknowledging the importance of the label's visibility for resident evacuation and door rating verification.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Quote has been requested by Director of Facilities from an outside vendor known as Intertek, which specializes in inspecting fire and egress door assemblies to the NFPA 80 Standard. The quote will include second-floor north stairwell door. Intertek scheduled 4/9/2025 for door repairs. All Maintenance employees received education on Stairways and smokeproof enclosures and identifying if doors are properly rated to protect in the event of a fire. The Director of Environmental Services will audit the doors monthly to ensure they are still fire-rated with legible tag, and no doors are held open by magnetic holder, unauthorized door [MEDICATION NAME], or floor obstructions blocking egress. Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible: Director of Environmental Services
Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
The facility failed to maintain an appropriate Emergency Preparedness Plan training program for its staff, as evidenced by the lack of documented annual training for two staff members. The facility's Emergency Preparedness Plan requires staff to receive training at orientation and an annual in-service on emergency preparedness policies and procedures. However, the training records for an LPN showed that the last documented training was completed in July 2023, with no records for 2024. Additionally, the training records for the Kitchen General Manager indicated training was completed in 2024, but the specific day was not documented, and there were no records for 2023. During interviews, the Administrator acknowledged the absence of documentation for the LPN's 2024 training, attributing it to the LPN being on leave when the training occurred. The Administrator also expressed uncertainty about the Kitchen General Manager's training, as they were contracted through another company, but noted that they should have received orientation training upon starting in 2023. The Administrator admitted that a second attempt to complete the LPN's training should have been made upon their return to work.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Licensed Practical Nurse #13 was provided Emergency Preparedness Training. Kitchen General Manager was provided Emergency Management Training. All Facility Staff were assigned Emergency Management Training to complete with exam at end to ensure competence. All Department Managers received education on Emergency Preparedness Training and ensuring their employees complete them on an annual basis. Human Resources assigns Emergency Management training upon hire, and employees will not start work until training is completed. The training software automatically assigns the training on an annual basis to all employees. The Director of Nursing or designee will monitor the training record monthly to ensure all staff have completed the emergency management training. Audits will be reviewed Quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Nursing
Emergency Preparedness Deficiency in Water and Medication Supply
Penalty
Summary
The facility was cited for failing to ensure that subsistence needs for residents and staff were maintained during an emergency. The Emergency Preparedness Plan, last updated by the previous Administrator, accounted for 1 gallon of water per resident per day for three days, totaling 240 gallons, but did not include provisions for staff or visitors. Additionally, the facility did not have an emergency supply of temperature-dependent medications. Observations revealed that medication room refrigerators on both the first and second floors were plugged into regular outlets, not supported by the emergency generator. Interviews with the LPN and the Administrator confirmed the lack of emergency cold medication supplies and the oversight regarding the generator support for medication refrigerators. The Director of Environmental Services stated that the generator supported other critical systems but not the medication refrigerators.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Loss of Food Service Policy has been revised to reflect that additional water will be on hand to account for staff and others, including volunteers or unexpected visitors. All Department Managers received education on the updated Emergency Preparedness Plan as pertains to the water supply on hand and that emergency medication refrigerators need to be on generator outlet. The refrigerator on the second-floor medication room was placed on a generator outlet for use for temperature dependent medication supply during an emergency. Will review the Loss of Water and Loss of Food Supply as part of the Emergency Preparedness Plan Quarterly. Will Review any updates with Quality Assurance and Performance Improvement Committee Quarterly for 1 year to ensure compliance. Person Responsible For Completion: Director of Environmental Services
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to provide residents with food and drink that were palatable, flavorful, and at an appetizing temperature during the recertification survey. Observations and interviews revealed that during two meals, the food was not served at appropriate temperatures, and residents expressed dissatisfaction with the taste and texture of the meals. Specifically, during a lunch meal, a hamburger was served at 125.2 degrees Fahrenheit, which is below the required temperature of 140 degrees Fahrenheit, and the dessert and juice were also not at appropriate temperatures. Similarly, during a breakfast meal, scrambled eggs were served at 121.6 degrees Fahrenheit, and the milk was not cold enough. Residents reported that the food was often cold, mushy, and not flavorful. Several residents, including those interviewed individually and during a resident council meeting, stated that the vegetables were overcooked and sometimes pureed, which was not to their liking. Dietary aides and kitchen staff acknowledged these complaints and noted that the facility's lack of a steamer led to vegetables being boiled, causing them to become mushy. Additionally, residents were dissatisfied with the menu choices and the frequency of certain items like sandwiches. Staff interviews confirmed that residents frequently complained about the food's temperature and quality. Dietary aides and kitchen management were aware of the issues, and there were plans to update the menu. However, the current practices led to meals being served at temperatures that did not meet the facility's policy requirements, resulting in unpalatable meals for the residents. The failure to provide meals at the correct temperature and consistency was a significant deficiency noted during the survey.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 The Dietary Shift supervisor or designee will conduct a tasting panel evaluation daily before every meal to ensure palatability of food served to the residents. Tasting Panel will include check for food texture, flavor and consistency. Foods found to be unpalatable will be corrected to correct consistency or replaced. The Dietary Manager, or designee, will perform three test trays weekly to ensure that food and drink is palatable, attractive and at a safe and appetizing temperature. Dietary employees will conduct pre-service temps and test trays will be tested for hot holding within state guidelines. The Audits will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Date of Correction: 03/07/2025 Person Responsible for Correction: Dietary Manager
Unsanitary Conditions in Facility's Main Kitchen
Penalty
Summary
During a recertification survey, the facility's main kitchen was found to have several deficiencies in maintaining sanitary conditions for food storage, preparation, distribution, and service. Observations revealed rusty shelves in the walk-in cooler, pet beds stored under dry storage room racks, and clean dishware stored in a soiled pan by the hand sink. Additionally, the hand sink was improperly secured with bare wood, and there was a leaking plumbing issue under the 3-bay sink, which had been ongoing for a year. The walk-in freezer had icing on the compressor lines, and there was uncertainty about whether a work order had been placed to address this issue. Interviews with staff, including the General Manager and a kitchen worker, confirmed these unsanitary conditions. The General Manager acknowledged that the rusty shelves and bare wood were not easily cleanable and that pets were not allowed in the kitchen or storage rooms to prevent contamination. The kitchen worker admitted to using the preparation sink for washing dishes due to the unavailability of proper facilities. These conditions were in violation of the facility's policy on sanitary conditions and posed a risk of food contamination and compromised food safety.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 Corrective Actions: The rusty shelves in the walk-in cooler have been sanded and painted. The pet beds in the dry storage area have been removed and the door remains closed to prevent them from entering. The clean dishware in pan was removed from the hand sink, rewashed and stored in their appropriate area. The hand sink was replaced and is secured properly to the wall. The leaking was fixed under the 3-bay sink. The service vendor was contacted to address the icing on the walk-in freezer lines. The dietary employees responsible for washing dishes received re-education from the dietary manager on how and where to wash and store dirty and clean dishes. All kitchen staff will be retrained on cleaning and maintaining a sanitary environment. The Dietary Manager updated the daily cleaning schedule to ensure the kitchen is maintained within sanitary conditions. An environmental audit of the kitchen will occur monthly with the Dietary Manager and Director of Environmental Services to ensure the walk-in cooler and plumbing are working efficiently. The audit will include kitchen and food storage areas to ensure proper functioning of equipment and identification of unsanitary conditions. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Date of Correction: 3/7/2025 Person Responsible for Deficiency: Dietary Manager and Director of Environmental Services
Improper Application of TLSO Brace for Resident
Penalty
Summary
The facility failed to ensure that Resident #57 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #57, who had a diagnosis of osteoporosis with a current pathological fracture of vertebrae, was observed wearing a thoracolumbar sacral orthosis (TLSO) brace incorrectly. The comprehensive care plan did not address interventions for the TLSO brace, and staff involved in the resident's care were not adequately educated on the application of the brace. Observations revealed that the TLSO brace was consistently positioned incorrectly on the resident, resting on their breasts instead of fitting around their lower torso and abdomen. Interviews with staff, including certified nurse aides and therapy personnel, indicated a lack of proper training and understanding of how to apply the brace correctly. Although some staff recalled initial education on the brace when the resident was first admitted, there was no documentation or sign-in sheet to confirm which staff received training, and many staff members reported not being educated on the brace's application. The facility's failure to document and implement a comprehensive care plan for the TLSO brace, along with inadequate staff training, led to the resident wearing the brace incorrectly. This deficiency was compounded by the absence of physician orders for the brace and a lack of consistent monitoring and documentation of its use. The Director of Nursing and other staff members acknowledged the issue but did not take effective action to address the incorrect fit and frequent removal of the brace by the resident.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 The effected resident (#57) order for thoracolumbar sacral orthosis brace was updated by the physician. The resident’s care plan was updated to reflect the brace and interventions, and monitoring related. The resident had a follow-up with orthopedics and her brace was discontinued on 3/7/2025. All other residents with DME records were reviewed to ensure that they had proper physician order, and care plan included interventions and monitoring for the DME. No other residents were identified. Facility-wide training regarding TLSE DME was initiated on 3/3/2025. All clinical staff to receive training on DME specific to braces. Upon identifying a new brace, Therapy will initiate training and systematically ensure clinical staff receive training prior to caring for resident. The Director of Nursing will review records of residents with DME on a bimonthly basis to ensure that there is an order, and care plan reflects DME and any intentions and monitoring is included in the record. The audit tool and findings will be reviewed quarterly with the Quality Assurance and Performance Improvement committee. The findings will be monitored for 1 year to ensure compliance. Date of Correction: 3/7/2025 Person Responsible: Director of Nursing
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with Resident #12 or their representative and did not obtain informed consent prior to the installation of bilateral bed rails. The facility's policy required that residents be evaluated for the need and safety of bed rails, and that informed consent be obtained after discussing the risks and benefits. However, there was no documented evidence that these steps were followed for Resident #12, who had bilateral assist bed rails installed on their bed. Resident #12 had diagnoses including morbid obesity, heart failure, and respiratory failure, and was assessed as having intact cognition and independence with bed mobility and transfers. Despite this, the resident expressed a need for assist rails to maintain independence with bed mobility and avoid excessive desaturation. The facility's comprehensive care plan did not document the use of bed rails, and the resident did not recall being informed of the risks and benefits or signing a consent form. Interviews with facility staff revealed a lack of clarity and adherence to the policy regarding the use of bed rails. Staff members, including CNAs, LPNs, and the Rehabilitation Coordinator, acknowledged the importance of obtaining consent and documenting the use of bed rails in the care plan. However, it was noted that the process was not consistently followed, and many residents, including Resident #12, did not have the necessary documentation or consent forms completed, highlighting a systemic issue in the facility's compliance with its own policies.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 Resident #12’s record was reviewed. Resident was evaluated for the appropriateness of bed rails. Resident was educated on risks and benefits of siderail use and consent was obtained on 2/13/2025. All residents with side rails were reviewed to ensure that education on risks and benefits of siderails was provided and consent was obtained. No other records were identified as deficient. All residents identified as having enablers or bed rails had a care plan that reflected their use and purpose. Clinical Nursing staff receive training on the bedrails policy and procedure including determination. The Director of Nursing will review records of all residents with siderails monthly to ensure that education on the risks and benefits was provided and that consent was obtained. The Audit tool will be reviewed quarterly with the Quality Assurance and Performance Improvement Meeting for 1 year to ensure compliance. Date of Correction: 2/13/2025 Person Responsible for Correction: Director of Nursing
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications in accordance with accepted professional principles, as observed during a recertification survey. Specifically, multiple eye drops in the Unit 1 medication cart were not appropriately labeled or dated. The facility's policy on Equipment and Supplies for Administering Medications did not address pharmaceutical labeling or medication safety. During an observation, it was found that several medications, including latanoprost eye drops and artificial tears, lacked pharmacy labels and had the tops of their boxes ripped off. The names of the residents were written inside the boxes with a black magic marker, but there were no visible instructions for administration. Interviews with staff revealed that all medications should have pharmaceutical labels, and the absence of such labels posed a risk of administering the wrong medication. Licensed Practical Nurse #2 acknowledged the issue and stated that the pharmacy should have been notified. The Unit Manager and the Director of Nursing confirmed that prescription medications like latanoprost should have proper labels, and artificial tears, although a stock item, should have a resident-specific label. The Director of Nursing emphasized that eye drops must be dated when opened and should remain in the original box with the pharmacy label to prevent the risk of residents receiving the wrong medication.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The medication carts were audited on 2/14/2025. All eye drops that were found outside of the box or unlabeled were discarded. New eye drops were obtained for each of the residents affected (Resident #8, Resident #12, and Resident #20). All residents with an order for [REDACTED]. All over-the-counter eye drops had a resident label with the date of open applied. The Director of Nursing will ensure an audit of each medication cart is done bimonthly to ensure that all eye drops are correctly labeled. LPN and RN employees were initiated education on 3/3/2025 on proper labeling of eye drops. The Audit tool will be reviewed quarterly with the Quality Assurance and Performance Improvement Meeting for 1 year to ensure compliance. Date of Correction: 3/3/2025 Person Responsible for Correction: Director of Nursing
Call Bell System Malfunction in Resident Bathroom
Penalty
Summary
The facility failed to ensure that the call bell system in room [ROOM NUMBER] on Unit 1 was functioning properly, which compromised the ability of residents to call for assistance while in the bathroom. During a resident meeting, it was reported that the bathroom call bell, when activated, would flash outside the door, but if the room call bell was pressed simultaneously, it would cancel out the bathroom call light. This malfunction left residents without a means to alert staff for help, as evidenced by one resident being left in the bathroom for up to an hour. Observations confirmed that the bathroom call bell, when pulled, would initially cause a rapid flashing blue light and a beeping sound. However, when the room call bell was activated, the light turned solid blue, and the beeping stopped, indicating a cancellation of the bathroom call. Staff interviews revealed a lack of awareness and understanding of the issue, with some staff unsure of how to identify when a resident needed assistance in the bathroom due to the call light cancellation. The Director of Environmental Services/Maintenance acknowledged the issue, stating that the call bell system was outdated and that no corrections had been attempted despite being aware of the problem for approximately six months. The Director of Nursing was unaware of the call bell failures and emphasized the importance of responding to call bells within three minutes. There was no documented evidence of a work order being submitted to address the malfunctioning call bell system.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In room [ROOM NUMBER] on unit one, bulbs were replaced on the call bell system. The bathroom call light flashes a different color than the room call light. All resident rooms have a call bell system. All rooms will have the call light bulbs modified. All call light bulbs in all rooms will be replaced. The bathroom bulb will flash a different color than the room call light, alerting employees to the difference in location. All employees will be educated on the difference in bulb color and flashing. The Director of Environmental Services will audit the call system monthly to ensure that it is alerting staff appropriately. The audit will be reported quarterly to the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Date of Correction: 3/6/2025 Person Responsible for Correction: Director of Environmental Services
Deficiency in Legionella Water Management Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding Legionella bacteria management. The water management plan was not reviewed in 2024 and lacked a water sampling plan and control measures. The facility's policy, 'Water Management Program to Reduce Legionella,' was undated and did not specify the number or location of samples to be collected. There was no documented evidence of an annual review of the Legionella program in 2024. During an interview, the Director of Maintenance revealed that they ordered testing kits from an outside agency and collected samples annually but did not have a sampling plan or control measures in place. The Director was unaware of the need for such a plan.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 The Water Management Program to Reduce Legionella was reviewed and updated. The Policy now reflects that an outside vendor will maintain the facility’s water testing and report and assist with any findings. The vendor will test samples from 6 locations of the facility for analysis and provide a certificate of Legionella Analysis on an annual basis. The Director of Environmental Services will report the Legionella report to the Quality Assurance and Performance Improvement Committee annually with each sampling result. The Director of Environmental Services will review the Water Management Program to Reduce Legionella annually with the Quality Assurance and Performance Improvement Committee to ensure update compliance. Date of Correction: 3/7/2025 Person Responsible for Correction: Director of Facilities
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — including the 1 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Berlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Manor Nursing Home | 11.2 mi | ★★★★★ | 12 | 0 |
| Norwich Rehabilitation & Nursing Center | 11.5 mi | ★★★★★ | 0 | 0 |
| Aurelia Osborn Fox Memorial Hospital | 16.5 mi | ★★★★★ | 0 | 0 |
| Chestnut Park Rehabilitation And Nursing Center | 17.2 mi | ★★★★★ | 4 | 1 |
| N Y S Veterans Home | 18.4 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.