Above 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 Mcauley Residence during CMS and state inspections, most recent first.
A survey revealed that a suction machine and a portable lift in the facility were not inspected and tested according to manufacturer's recommendations. The suction machine had stickers from an outside contractor, but no inspection records were found. The lift's maintenance was overdue, and facility staff believed contractor visits were automatic, leading to oversight issues.
The facility's emergency generator was not properly maintained, with missing documentation for monthly load tests, weekly checks, and a four-hour continuous run. The generator's ability to meet 30% of its nameplate rating was unknown, and the main and feeder circuit breaker inspection was delayed. The facility lacked a Director of Plant Operations for a period, and maintenance records for 2024 were missing.
The facility failed to document the monthly testing of the Firefighter's Service in its two elevators, affecting all resident-use floors. Although the maintenance staff conducted the tests, they were not recorded. The new Director of Plant Operations expected documentation, but the facility had been without a director for some time, leaving uncertainty about past testing.
A survey found that exit signs in a LTC facility did not correctly indicate egress paths, affecting both resident-use floors. Signs lacked illuminated chevrons, misleading individuals about the correct exit routes. The Director of Plant Operations and the Administrator could not locate documentation of exit sign checks, despite claims of weekly inspections.
A survey revealed that fire-rated doors in the facility were not inspected and tested annually as required by NFPA standards. The Director of Plant Operations could not find documentation of these inspections, and the Administrator confirmed that records for NFPA 80 door inspections were not maintained, leading to a citation.
Medications for several residents were found unsecured on a shelf in a nurse's station without a door or lock, accessible to residents. Staff interviews revealed a lack of awareness and adherence to the facility's medication storage policy, with medications not being placed in secure locations like medication carts or locked cabinets. The Director of Nursing and Pharmacy Consultant confirmed the shelf was not a secure storage area, posing a potential safety issue.
A resident with complaints of tooth pain was not evaluated by a dentist, despite the facility's policy requiring a comprehensive oral assessment within 14 days of admission. The resident, who had conditions including dorsalgia and hemiplegia, consented to dental services but was not included in the schedule to be seen by the dentist. Interviews revealed a lack of communication and follow-up regarding the resident's dental complaints, leading to unmet dental needs.
A survey revealed that the facility stored 54 containers of alcohol-based hand sanitizer, totaling 17.1 gallons, in the basement without a flammable liquids storage cabinet, violating NFPA 30 code. The absence of a Director of Plant Operations led to continued ordering of supplies, resulting in excess storage. The facility also lacked a policy for storing such sanitizers.
A delayed egress door on the first floor of a facility failed to release after 15 seconds as designed, despite the alarm sounding. The malfunction was observed during a test by the Director of Plant Operations from a sister facility. The facility's policy requires regular testing, and logs indicated all doors passed recent tests, yet the door did not function properly during the survey.
Deficiency in Equipment Maintenance and Inspection
Penalty
Summary
During a Life Safety Code survey, it was found that patient care-related electrical equipment was not inspected and tested according to the manufacturer's recommendations. Specifically, a Brand A suction machine located on a crash cart in Unit 1 East had stickers from an outside contractor indicating upcoming preventative maintenance, but there was no record of the device in the contractor's inventory or any inspection having been performed. The Director of Plant Operations confirmed that the outside contractor was responsible for maintaining the suction machines, and in-house staff did not perform maintenance. However, the contractor admitted that their employee might have placed the stickers on the device without conducting proper inspection procedures. Additionally, nursing staff reported they did not perform maintenance tasks such as checking or replacing internal components of the suction machine. Similarly, a Brand B portable Hoyer-type resident lift in the 1 West Unit was found to have overdue preventative maintenance. The lift had stickers from the same outside contractor, but the last recorded inspection was on 11/15/23, indicating that the required twelve-month maintenance was overdue. The Director of Plant Operations stated that the outside contractor was responsible for maintaining the lifts, and the Director of Long Term Care Facilities believed that the contractor's visits were automatic and did not require scheduling by facility staff. This lack of oversight and communication led to the deficiency in ensuring that the equipment was properly maintained and inspected as per regulatory requirements.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 What corrective action will be accomplished: The suction machine on 1 East Unit and the Hoyer-type resident lift on 1 West unit have been removed from service and will not return to service until preventative maintenance is completed. All residents have the potential to be affected by the same deficient practice. Facility suction machines and Hoyer-type resident lifts will be audited by outside contractor beginning (MONTH) 3, 2025 to ensure that timely preventative maintenance has occurred. Measures to be put into place include audit of facility suction machines (monthly) and Hoyer-type resident lifts (weekly) to ensure preventative maintenance has occurred. Maintenance staff will be educated to ensure suction machine and portable resident lift are inspected, tested, and maintained per manufacturer's recommendations. Facility will maintain documentation for their inspections, testing, and maintenance. How the corrective action will be monitored: The audits will be reviewed by Administration and reported to the Quality Assurance Committee. Plant Operations Director will be responsible to ensure compliance.
Emergency Generator Maintenance Deficiencies
Penalty
Summary
The emergency generator at the facility was not properly maintained, as evidenced by several deficiencies identified during a Life Safety Code survey. The generator, which provides emergency backup power to all resident use floors and the basement, had undocumented monthly load tests and weekly checks. Additionally, there was no record of a four-hour continuous generator run within the last 36 months, and the main and feeder circuit breaker inspection was not completed annually. It was also unknown if the generator met 30 percent of its nameplate kilowatt rating during load tests, as required. Interviews revealed that the facility was without a Director of Plant Operations for a period in 2024, during which the responsibility for generator maintenance fell to the Administrator. However, the Administrator was unable to locate maintenance records for 2024, and the Director of Plant Operations from a sister facility, who assisted during this time, was not specifically assigned generator maintenance duties. The Director of Long Term Care Facilities mentioned that an outside contractor had postponed the circuit breaker inspection, and a new date had not been scheduled. The facility did not have a specific policy for generator maintenance but followed the manufacturer's instructions.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 Corrective Action for Affected Area: Load test was completed (MONTH) 29, 2025, and weekly visual inspections began week of (MONTH) 20, 2025. The generator is scheduled to be run under load for four continuous hours on (MONTH) 13, 2025; at this time, the load bank test will reach its 30% as listed on the name plate. Inspection of the main and feeder circuit breakers is scheduled for (MONTH) 20, 2025. All residents have the potential to be affected by the same deficient practice. Steps to prevent recurrence include weekly visual inspection of the generator, a 30-minute load test occurred (MONTH) 29, 2025, and will occur monthly. The generator is scheduled to be run under load for four continuous hours on (MONTH) 13, 2025. Inspection of the main and feeder circuit breakers is scheduled for (MONTH) 20, 2025. Steps to Prevent Recurrence: Weekly and monthly generator audit/log forms which include weekly inspection and monthly load are being utilized. Maintenance staff will be educated to ensure monthly generator load tests are completed and documented, weekly generator checks are completed and documented, the generator is run under load for four continuous hours every 36 months and documented, an annual load bank test is completed on the generator and documented, and main and feeder circuit breaker inspection is completed annually if the generator does meet 30 percent of its nameplate kilowatt rating during load tests. How Corrective Action Will be Monitored: The audits will be completed to ensure the generator is run under load for four continuous hours every 36 months and documented, an annual load bank test is completed on the generator and documented, and main and feeder circuit breaker inspection is completed annually if the generator does meet 30 percent of its nameplate kilowatt rating during load tests. Audits will be reviewed by Administration and reported to the Quality Assurance committee. The Plant Operations Director will be responsible to ensure compliance.
Failure to Document Monthly Testing of Elevator Firefighter's Service
Penalty
Summary
During a Life Safety Code survey, it was observed that the Firefighter's Service in the facility's two elevators was not tested monthly. This deficiency affected both elevators, which serve the basement, first floor, and second floor of the facility. An interview with the Director of Plant Operations revealed that although the in-house maintenance staff was conducting monthly tests of the Firefighter's Service, they were not documenting these tests. The Director of Plant Operations had just started working at the facility and expected the testing to be documented. Additionally, the facility had been without a Director of Plant Operations for a period from 2024 to 2025, and the Administrator was unsure if the Firefighter's Service was tested during that time.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 Corrective Action for Affected Area: Director of Plant operations completed Firefighters Service on both elevators. Identification of other areas potentially affected: all residents have the potential to be affected by the same deficient practice. Both elevators had firefighters service completed. Steps to prevent further recurrence: Monthly audit to occur to ensure firefighters service is completed. Maintenance staff will be educated to ensure the firefighter's service is tested and documented for all of the facility elevators. How Corrective Action Will be Monitored: Monthly audits will be reviewed by Administrator and reported to quality assurance committee. Director of Plant operations will be responsible for compliance.
Improper Exit Signage and Documentation Issues
Penalty
Summary
During a Life Safety Code survey, it was observed that required exit signs in a long-term care facility did not correctly indicate the egress path, affecting both the first and second floors used by residents. On the second floor, an illuminated exit sign in the Activities Suite was mounted perpendicular to the suite entrance, with the word 'Exit' illuminated on both sides but without chevrons to indicate the correct path of egress. This misled individuals to believe the path of egress was into rooms without exits. The Director of Plant Operations confirmed that the chevrons should have been lit to indicate the main suite entrance as the egress path. Similar issues were found on the first floor in the 1 West and 1 East Units, where exit signs at stairway entrances lacked illuminated chevrons, misleading individuals to believe the path of egress was at the end of corridors with no exits. The Director of Long Term Care Facilities noted that many exit signs had been replaced months prior. Additionally, there was a lack of documented checks of illuminated exit signs, as confirmed by the Director of Plant Operations and the Administrator, despite claims from a Maintenance Technician that checks were conducted weekly.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 Corrective action for affected area: The plant operations director corrected activities in the suite, 1 West Unit north/south stairway, 1 East Unit north and south stairway, and 2 West Unit north and south stairways exit sign chevrons so they illuminated and indicate the path of egress. Steps to prevent further recurrence: A walk-through of the facility has been conducted to identify any exit signs that needed adjustment; any needed corrections were made. Steps to prevent further recurrence: Use of a monthly exit sign audit where the auditor ensures the sign reflects the correct direction. Maintenance staff will be educated on the importance of ensuring the illuminated exit signs properly identify the path of egress. How corrective action will be monitored: Audits will be reviewed by administration and reported to the quality assurance committee. The plant operations director will be responsible for correction.
Failure to Maintain Fire-Rated Doors as per NFPA Standards
Penalty
Summary
During a Life Safety Code survey, it was found that fire-rated doors in the facility were not maintained according to the National Fire Protection Association (NFPA) requirements. Specifically, the fire-rated door assemblies were not inspected and tested annually as required. This deficiency affected all resident use floors and the basement. The facility's policy, effective from November 5, 2024, stated that all fire door assemblies should be inspected and tested annually, with a written record kept for review. However, upon reviewing the facility's maintenance inspection records, there was no documentation that met the NFPA 80 requirements. Interviews conducted during the survey revealed a lack of proper record-keeping and communication regarding the inspections. The Director of Plant Operations, who had just started working at the facility, was unable to locate any documentation of the required door inspections. A Maintenance Technician mentioned that doors were checked weekly and that the Administrator had the records. However, the Administrator confirmed that while they kept logs for testing delayed egress doors, they did not maintain records for NFPA 80 door inspections. This lack of documentation and adherence to the NFPA standards led to the citation.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 Corrective Action for Affected Areas: All fire rated doors were inspected and tested. Identification of other areas potentially affected: All residents have the potential to be affected by the same deficient practice. The corrective action which took place was all fire rated doors were inspected and tested. Steps to prevent further recurrence: All fire rated doors were inspected/tested and will be inspected annually. Maintenance staff will be educated to ensure the facility's fire rated door assemblies are inspected and tested annually per National Fire Protection Association requirements. How will corrective action be monitored: Results of the fire rated doors inspection and testing is to be reported to the quality assurance committee by Plant Operations Director. Plant Operations Director will be responsible for compliance.
Unsecured Medication Storage in Nurse's Station
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments, as observed during a survey on Unit 2 East. Specifically, 16 medications for seven residents were found unattended and unsecured on a shelf in the nurse's station, which lacked a door or means to lock the area. The medications included Chlorhexidine mouth rinse, Lactulose, Sorbitol, Ipratropium Bromide and Albuterol Sulfate inhalation, Citrucel Powder, Lanta liquid, Refresh tears, and Betadine solution. These medications were accessible to residents, as the nurse's station was located near a common area where residents were present, and there was no staff within visual view to monitor the area. Interviews with various nursing staff revealed a lack of awareness and adherence to the facility's medication storage policy. Licensed Practical Nurse #2 acknowledged the medications should not have been stored on the shelf and were unsure how long they had been there. Unit Manager Licensed Practical Nurse #4 and Licensed Practical Nurse #5 were unaware that overflow medications could not be stored on the shelf, and both confirmed that the nurse's station was not a secure location. Licensed Practical Nurse #3 noticed the medications but did not take action to secure them or inform the Nursing Supervisor. The Director of Nursing and the Pharmacy Consultant both confirmed that medications should be stored in a locked, secure area, and the nurse's station shelf was not appropriate for medication storage. The Pharmacy Consultant noted that storing medications on the shelf could potentially allow resident access, posing a safety issue. The facility's process for receiving medications involved the Nursing Supervisor delivering them to the appropriate unit, expecting staff nurses to secure them in a medication cart or locked cabinet, which was not followed in this instance.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F761- Label/store Drugs and Biologicals** 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? a. For Resident number 94 the eye drops were removed and ordered directly through pharmacy with patient label. b. For Resident number 267 the [MEDICATION NAME] was discarded. c. For Residents 17, 22, 68, 70, 72 immediately removed the medications from the unsecure shelf and placed all their medications in their locked med cabinet and or med cart. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. a. All residents who receive medication and or biologicals have the potential to be affected by this deficient practice. b. On (MONTH) 9, 2025 the DON, ADON and Manager of the unit did a complete med audit. This included all shelves in the center of the unit near common areas where residents sit and no medications were found. An audit was also completed on all medication orders as they relate to supplies on hand. (01) 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur. a. Three (3) cabinets on 2 east were identified to use for stock meds and overflow meds. Maintenance installed locks and all stock and overflow medications are now in the 3 locked cabinets located in the common area above the sink off the nurse’s station. The cabinets are located high on a wall that is in the common area to residents and staff and open to the nurse’s station; the cabinets will remain locked at all times. They are against the wall above the sink. The cabinets are sufficient to hold any overflow medications which do not fit in the locked medication cart and also for stock meds. No narcotics are stored in this area. The narcotics are kept in a double locked cabinet in the nurses stations. There is no overflow area necessary for narcotics. Nursing staff will unlock and obtain overflow medication/biologicals or stock meds as needed per specific orders for patients, lock the cabinet and bring the medication/biological directly to the respective medication cart to be administered and secured and stored. All RN’s, LPN’s will be in serviced by our ADON or nurse managers on all aspects of medication administration & storage, including proper receiving of medications and biologicals from pharmacy and the immediate delivery of the medications and biologicals to the appropriate secured storage area. All RN’s and LPN’s will have the P&P reviewed regarding Medication Cart audits, Medication room audits or medication cabinet audit, medication administration & documentation, storage of medication, and ordering and receiving medications from the dispensing pharmacy. (02) 4. How the corrective action will be monitored to ensure the deficient practice will not reoccur a. Our nurse manager or designee will be completing weekly audits in the common area and nurse’s station to ensure no medications are in an unlocked area. The manager will also conduct weekly medication cart and storage cabinet audits to ensure there are no discontinued medications. Medication administration audits will also be conducted yearly with each RN and LPN’s evaluations to ensure adherence to policy & procedure. (03) b. The nurse manager and or designee is responsible for conducting medication cart audits, medication room audits, medication storage audits, and audits of any medication storage cabinet and refrigerator storage of medications weekly on all Nursing units within TMR. Any negative findings will be addressed and corrected immediately. The results of these audits are given to quality and to the DON who also reports on them at our Quarterly Quality and Resident Safety Committee for review. (04) c. Any negative findings will be addressed and corrected immediately. The results of these audits will be reported by the DON at our Quarterly Quality and Resident Safety Committee for review. d. The pharmacy consultant agreed with the decision for the new location for stock and overflow meds and the security of medications. The pharmacy consultant will audit med storage areas every 2 weeks until we achieve 100% compliance for 8 consecutive audits. Thereafter, the pharmacy consultant will conduct spot audits and a full audit of med carts and med storage yearly throughout the building. (05) e. The Audits done by the nurse manager and or designee will be done weekly until we achieve 100% compliance over 8 consecutive weeks, after which, the findings will be reviewed by the Quality Assurance Committee for compliance. The Quality Committee will provide us with a schedule to follow for future medication cart and storage cabinet audits throughout the year. Medication administration audits will continue to be conducted yearly with each RN and LPN’s evaluations. The results of these audits will be given to the Quality Department and to the DON who also reports on them at our Quarterly Quality and Resident Safety Committee for review. f. While the primary responsibility for audits will be the unit manager, weekly audits may be done by a designee. The designee may include the DON, ADON, the Quality Team, other unit manager and or supervisor. The manager of each unit will be responsible for the delegation each week depending on staff schedules. 5. The date of the correction and the title of the person responsible for the correction of the deficiency. Date of Correction: (MONTH) 5, 2025 Person Responsible: Director of Nursing
Failure to Provide Routine Dental Care for Resident
Penalty
Summary
The facility failed to provide routine dental services to meet the needs of Resident #101, who had complaints of tooth pain while chewing but was not evaluated by a dentist. The facility's policy required that within 14 days of admission, a comprehensive oral assessment should be completed by a dentist or dental hygienist unless refused by the resident. However, Resident #101, who was admitted with conditions including dorsalgia, hemiplegia, and hypertension, did not receive the necessary dental care despite documented complaints of mouth or facial pain and difficulty with chewing. The nursing admission assessment noted Resident #101's complaints of mouth or facial pain, but there was no evidence in the nursing progress notes that the resident was seen by a dentist or that a medical provider was notified of the tooth pain. Although the resident consented to dental services, they were not included in the schedule of residents to be seen by the dentist. Interviews with nursing staff revealed a lack of communication and follow-up regarding the resident's dental complaints, and the Health Information Management Clerk did not keep track of referral forms for dental issues. The facility's dental contractor stated that the dentist was not informed of Resident #101's pain, and the resident was not seen during the dentist's visits to the facility. The Director of Nursing and the Administrator both expressed expectations that the resident should have been seen by the dentist, and that communication regarding dental complaints should have been made to ensure the resident's comfort and care. The deficiency highlights a breakdown in communication and adherence to the facility's dental care policy, resulting in unmet dental needs for Resident #101.
Plan Of Correction
Plan of Correction: Approved February 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F790 Routine/Emergency Dental Services in SNF’s** 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? a. For Resident 101, Dent Serv was immediately notified of need for patient to be seen for dental pain while chewing, patient was in isolation for COVID and an appointment was made for patient when out of quarantine. Patient was seen by dental service on 1/27/25. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. All residents have the potential to be affected by the same deficient practice. b. An MDS report was run on the most recent MDS completed on all in house residents questioning L0200F Mouth or facial pain, discomfort or difficulty with chewing. A look back period went from (MONTH) 2024 to [DATE]. No other resident’s triggered for this question. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur? a. All RN’s who complete admission assessments will be in-serviced on P&P CBC-NUR-402 community based dental care and notifying the medical provider immediately of any resident complaints related to mouth or facial pain, discomfort or difficulty with chewing. They will also be in-serviced on placing a call to our dental service to schedule a visit and fill out the Dental visit form with concern for visit and fax to the Dent Serv. b. C.N.A’s and nursing staff will be in serviced to notify the patients primary nurse and or nurse manager if any resident complains of any mouth or facial pain, discomfort or difficulty with chewing. c. All RN’s will be in-serviced to ensure all new admissions sign the dental consent service form, those who wish to receive dental services will be scheduled to have a comprehensive oral assessment by the dentist or dental hygienist within 14 days of admission. d. All nursing staff will be in-serviced to add any resident complaints related to mouth or facial pain, discomfort or difficulty with chewing to 24 hour report for Nurse Manager to bring to am report. This will also include the follow up to the medical and dental provider notification. 4. How the corrective action will be monitored to ensure the deficient practice will not reoccur? a. All new admissions and readmissions will be audited within 72 hrs. of admission by nurse manager or designee to see if dental service consent form is completed, signed and also to see if any resident complains of mouth or facial pain, discomfort or difficulty chewing. b. The DON will run the MDS analyzer report each week to see if there is any resident with any complaints of mouth or facial pain, discomfort or difficulty chewing for appropriate follow up. Any deficient findings would be corrected immediately. c. The ADON will complete an audit to be filled in after am huddle with the name of each resident who is on 24 hour report with complaints of oral pain and note that medical provider and dental provider were notified and follow up visit and care is documented. Any deficient findings would be corrected immediately. d. The results of these audits will be reported by the Director of Nursing at our quarterly Quality and Resident Safety committee for review. These audits will continue until we achieve 100% compliance for 8 consecutive weeks. 5. The date of the correction and the title of the person responsible for the correction of the deficiency Date of corrections: (MONTH) 5, 2025 Person Responsible: Director of Nursing
Excessive Storage of Alcohol-Based Hand Sanitizer
Penalty
Summary
During a Life Safety Code survey, it was observed that the facility stored an excessive amount of alcohol-based hand sanitizer in the basement, exceeding the allowable limit set by the 2012 NFPA 30 code. Specifically, 54 containers, each holding 1.2 liters of sanitizer with 76 percent alcohol content, were found on open shelving in the Main Storage Room, totaling 64.8 liters or 17.1 gallons. This storage practice did not comply with the requirement to store such quantities in a flammable liquids storage cabinet. The facility lacked a Director of Plant Operations for a period, during which another individual continued ordering supplies, inadvertently leading to the accumulation of excess sanitizer. Additionally, the facility did not have a policy in place regarding the storage of alcohol-based hand sanitizers.
Plan Of Correction
Plan of Correction: Approved February 5, 2025 Corrective action for affected area: The excess alcohol-based hand sanitizer was removed from the Main Store room. Identification of other areas potentially affected: All residents have the potential to be affected by the same deficient practice; all storage areas were checked for alcohol-based hand sanitizer. Steps to prevent further recurrence: Measures to be put in place include a monthly audit of the Main Store room to monitor the amount of alcohol-based hand sanitizer in stock. An updated policy was implemented to ensure safe use and storage of alcohol-based hand sanitizer. Maintenance staff will be educated to ensure containers of alcohol-based hand sanitizer in an aggregate amount of greater than ten gallons are not stored in a single smoke compartment outside of a flammable liquids storage cabinet. How corrective action will be monitored: Monthly audit will be reviewed by administration and reported to the Quality Assurance Committee. The Director of Plant Operations will be responsible to ensure compliance.
Delayed Egress Door Malfunction
Penalty
Summary
During a Life Safety Code survey, a deficiency was identified involving a delayed egress door locking mechanism on the first floor of a facility. The mechanism, which is designed to release the door after 15 seconds when pressure is applied, failed to function as intended. This issue was observed during a test conducted by the Director of Plant Operations from a sister facility, who noted that the door did not open even after 30 seconds of pressure, despite the alarm sounding. The doors in question were located outside the Physical Therapy Gym and were equipped with signs indicating that they should open after 15 seconds of pressure. The facility's policy, titled Fire and Egress Door Inspection and Maintenance, mandates regular testing of delayed egress doors to ensure proper operation. According to the facility's log, the doors were tested weekly for alarm function and monthly for the 15-second release function, with the most recent tests conducted in December 2024 showing all doors as passing. However, during the survey, the door failed to operate as designed, and the Director of Plant Operations was unable to explain the malfunction. This deficiency affected one of the two resident use floors in the facility.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 Corrective action for Affected Area: Physical Therapy gym doors were repaired on 1/6/25. Identification of other areas potentially affected: All residents have the potential to be affected by the same deficient practice. All of the facilities delayed egress door locking mechanisms were audited and are in working order. Steps to prevent further recurrence: Maintenance staff were reeducated on exit door delayed egress testing. Weekly testing of exit door alarms with delayed egress is occurring. How corrective action will be monitored: Director of Plant Operations will conduct monthly audits on each door to assure delayed egress doors are working properly. Results will be reported to the quality assurance committee. Director of Plant Operations will ensure compliance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 164 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kenmore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Schofield Residence | 0.8 mi | ★★★★★ | 0 | 0 |
| Safire Rehabilitation Of Northtowns, L L C | 2.8 mi | ★★★★★ | 2 | 0 |
| Degraff Memorial Hospital-skilled Nursing Facility | 3.6 mi | ★★★★★ | 1 | 0 |
| Elderwood At Amherst | 3.6 mi | ★★★★★ | 1 | 0 |
| St Catherine Laboure Health Care Center | 3.8 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mcauley Residence.
100% money-back within 48 hours.
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.