Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Cottages At Garden Grove, A Skilled Nrsg Comm during CMS and state inspections, most recent first.
Failure to Provide Consistent Pressure Ulcer Care and Monitoring: A resident with severe cognitive impairment, malnutrition, and total dependence developed a Stage 2 coccyx pressure ulcer that progressed to Stage 3 and then an unstageable wound with eschar. The record showed wound treatment frequency was not clarified, the TAR reflected inconsistent scheduling, one treatment was missed because the resident was up in a chair, and there was no documented evidence of regular wound assessments during part of the course. Staff interviews indicated the wound care may have been ordered daily but was being done every three days, and the NP was concerned this may have contributed to the wound worsening.
Infection Control Lapses in Environmental Services and Urinary Drainage Care: Staff in one cottage were observed cleaning multiple rooms with the same gloves and without hand hygiene between rooms, despite policy and staff interviews stating gloves should be removed and hands sanitized before moving to the next room. A resident with neurogenic bladder and an indwelling urinary drainage device was also repeatedly observed with tubing dragging on the floor, sometimes with the bag uncovered or partially covered, even though the care plan directed staff to keep the tubing off the floor.
A resident with encephalopathy and epilepsy was care planned for mechanical lift transfers with two staff due to fall risk and dependence for transfers, but a CNA used a gait belt and attempted to stand the resident after the resident said they could walk to the bathroom. The resident’s legs gave out and the resident was lowered to the floor with no injuries. The incident report stated the care plan was not followed.
Two residents experienced significant medication errors involving crushed and improperly administered meds. One resident with hypokalemia had KCl ER crushed despite a do-not-crush order, and another resident with a feeding tube had multiple ordered meds crushed, mixed together with water, and given all at once via G-tube. Staff interviews showed confusion about crushing orders and whether meds should be administered together.
A resident with an indwelling urinary catheter and intact cognition was repeatedly observed in common areas, the dining room, and near the room doorway with the urinary drainage bag clipped to the wheelchair and left uncovered, with amber urine visible to staff, visitors, and other residents. The care plan called for keeping the bag covered to maintain dignity, and staff interviews confirmed the bag was not covered and that this was a dignity issue.
Two residents did not receive ordered care as documented. One resident with CHF had repeated missed daily weights, one significant weight gain without provider notification, and four missed doses of furosemide after return from the hospital because the LPN did not obtain the med from the ADC and there was no documented provider notification. Another resident with left-sided paralysis had an unwitnessed fall with bruising and a skin tear, but ordered neuro checks were not fully completed or documented.
A resident with a back compression fracture and severely impaired cognition had an order to wear a TLSO brace when upright, but was repeatedly observed sitting in a wheelchair without the brace, which was left on the floor, table, or chair in the room. The TAR documented multiple brace refusals, yet there was no documented evidence that the provider or therapy was notified, and staff interviews confirmed the refusals were supposed to be reported.
Failure to provide person-centered dementia care for a resident with behavioral symptoms. A resident with dementia, Parkinson’s disease, and anxiety had persistent wandering, room-entry, and socially inappropriate behaviors, including entering other residents’ rooms and beds and stripping down in others’ rooms. Staff mainly used general redirection, snacks, TV, and activities, while psychotropic medication was increased after a negative UA. The record lacked documented social work involvement and did not show individualized dementia care interventions tailored to the resident’s behavioral needs.
Expired and undated food items were found in Cottage 10, including opened and unopened milk, apple juice, and wilted salad, while staff said cooks and dietary staff were responsible for labeling, dating, and removing expired items. In Cottage 11, surveyors found expired eggs, lunch meat, and apricots, and observed a prep refrigerator at 55 degrees F with hot dogs, baked beans, carrots, yogurt, and soda inside. Logs also showed repeated out-of-range refrigerator temperatures, and staff stated food service was responsible for monitoring temperatures and reporting problems.
The facility failed to ensure residents had access to a grievance process, including grievance forms, anonymous filing, and information on the Grievance Officer. Residents in a group meeting said they did not know where forms were, how to file a grievance, or whether anonymous complaints were allowed, and staff in the cottages were also unsure of the process. Observations found no posted grievance information or forms in multiple cottages, despite the facility policy stating residents would be informed and the process would be posted.
Survey results binders were not readily accessible in 5 cottages. The binders were placed on top mantle shelves, behind signs, partially blocked, or inside a closed cabinet at heights not reachable by residents in wheelchairs. Several residents said they had never seen the survey results, and a CNA and RN mgr stated the binders were not accessible without asking for help.
A resident admitted with a hip fracture was not given a written summary of the baseline care plan within 48 hours, including initial goals, meds, diet instructions, and services/treatments. The resident and family met with staff but did not recall receiving the care plan or MD orders, and the RN Mgr and DON stated baseline care plans were not printed or provided to residents.
A resident with a history of Parkinson's Disease and chronic constipation did not receive timely bowel interventions or prescribed medication due to lapses in staff documentation, communication, and adherence to the facility's bowel protocol. The resident went several days without a bowel movement, staff failed to notify the provider about missed medications and ongoing constipation, and the care plan did not address constipation. The resident was eventually hospitalized for fecal impaction after experiencing symptoms related to constipation.
A resident with impaired cognition and brittle bones was injured when a CNA provided care alone, contrary to the care plan requiring two staff members. The resident sustained a skin tear and a fracture, which the facility attributed to the resident's medical condition. The CNA admitted to not following the care plan, and disciplinary action was taken.
A resident with full cognition refused incontinence care during the night, but a CNA proceeded with the care against the resident's wishes, violating their rights. The resident's care plan indicated they should not be disturbed unless they requested assistance. The CNA's actions were based on previous incontinence incidents, but did not align with the resident's expressed refusal at the time.
A facility failed to investigate and report an alleged abuse incident involving a CNA and a resident with dementia and anxiety. The CNA had a physical altercation with the resident, resulting in a skin tear, but was not removed from care duties pending investigation. The incident was not reported to the Department of Health in a timely manner, and a full investigation was delayed until surveyors arrived.
A resident with dementia and multiple sclerosis was observed leaning far to the right in their wheelchair, affecting their ability to eat. Despite facility policy requiring assistance for repositioning, staff did not consistently intervene or trigger a physical therapy evaluation. Interviews revealed a lack of clarity and action regarding the resident's needs, and no adaptive equipment was implemented to address the issue.
A resident with dementia and anxiety did not receive necessary assistance with personal hygiene, including shaving and nail care, despite requiring substantial assistance and not refusing care. Observations showed the resident had thick facial hair and unclean fingernails over several days. Staff interviews revealed that personal hygiene tasks were not consistently performed due to time constraints, contrary to facility policy.
A resident with peripheral vascular disease, diabetes, and chronic kidney disease was not provided with activities that matched their interests, such as classical music, religious services, and outdoor time. The facility's activity program failed to meet the resident's preferences, leading to feelings of loneliness and lack of engagement. Staff cited time constraints and resource limitations as reasons for the deficiency.
Two residents with pressure ulcers did not receive necessary care due to facility oversights. One resident's wound treatments were missed due to unavailable supplies, while another did not have the ordered alternating pressure overlay in place. Staff failed to communicate and ensure proper equipment use, leading to deficiencies in care.
The facility failed to serve food and drinks at appropriate temperatures during two observed lunch meals. A resident in Cottage 60 received a meal with a cheeseburger at 130°F and drinks above the acceptable cold range. Another resident in Cottage 31 was served a carrot salad and apple juice also above the cold range. Staff interviews revealed inconsistencies in adhering to food handling guidelines, resulting in dissatisfaction with food temperature and taste.
A facility failed to maintain effective infection control practices, as an LPN and CNA did not perform proper hand hygiene or wear gowns while caring for a resident with a Stage 4 pressure ulcer on enhanced barrier precautions. The LPN did not change gloves during wound care, and both staff members disregarded the facility's infection control policies, potentially compromising the resident's health.
The facility failed to thoroughly investigate alleged violations involving mistreatment, neglect, or abuse for two residents. Investigations were incomplete, lacking timely assessments, staff statements, and documentation of care plan adherence.
Failure to Provide Consistent Pressure Ulcer Treatment and Monitoring
Penalty
Summary
The facility failed to ensure a resident with significant risk factors received necessary pressure ulcer treatment and services consistent with professional standards of practice. Resident #153 had diagnoses including stroke, protein-calorie malnutrition, and pressure ulcers, was severely cognitively impaired, dependent on staff for all mobility and functional abilities, weighed 80 pounds, and had pressure-reducing devices and nutrition/hydration interventions in place. The resident developed a new Stage 2 pressure area on the gluteal cleft/coccyx, and prior orders were in place to protect the area because the coccyx protruded and the resident had little fat for protection. The record showed wound care orders were not clearly followed or clarified. A Nurse Practitioner order documented Triad paste and Allevyn to the open area every three days, while the treatment administration record also reflected daily Triad paste with dressing changes every three days. There was no documented evidence that the frequency was clarified with the Nurse Practitioner to determine whether the treatment was daily or every three days. On one occasion, the treatment was not completed because the resident was already up in the chair. The record also lacked documented wound assessments for a period between the documented treatment changes. The resident’s pressure ulcer worsened over time, progressing from Stage 2 to Stage 3, then to an unstageable wound with eschar, and later to a larger wound with 100% loose eschar. Staff interviews indicated the wound had worsened during February 2026, that the resident was frail, and that the treatment should have been applied daily rather than every three days. The Nurse Practitioner stated they were not aware the wound treatments were only being done every three days and were concerned this could have caused the ulcer to increase in size and delayed healing, possibly causing harm to the resident. The resident later expired.
Infection Control Lapses in Environmental Services and Urinary Drainage Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. In Cottage 31, Custodian #25 was observed cleaning multiple resident rooms while wearing the same pair of gloves and not performing hand hygiene between rooms, including moving from one room to another, retrieving towels from the clean linen closet, entering bathrooms, and handling cleaning supplies without changing gloves or sanitizing hands until later when the gloves were removed and hands were washed at the sink off the kitchenette. Custodian #26 was also observed cleaning multiple rooms with the same gloves and without hand hygiene or glove changes while moving between rooms, cleaning floors, wiping furniture, and handling cleaning equipment. During interview, Custodian #25 stated gloves should be changed between cleaning rooms and removed before leaving a room, but acknowledged they did not change gloves between the rooms they cleaned because they were focused on making sure everything was clean. The Director of Environmental Services stated gloves should be removed before leaving a room and hands sanitized before entering the next room, and the Infection Control nurse stated housekeepers should remove gloves and perform hand hygiene prior to exiting a room to prevent spread of infection. Resident #35 had diagnoses including neurogenic bladder and urinary tract infections, was cognitively intact, and had an indwelling urinary drainage device. The care plan directed staff to always keep the tubing off the floor and keep the urine collection bag covered. However, the resident was observed multiple times sitting in a wheelchair with the urinary drainage tubing directly on the floor, including times when the bag was uncovered, partially covered, or fully covered, and at one point the resident's foot was on the tubing. The tubing also contained cloudy urine with sediment during some observations. CNA #42 stated the tubing and collection bag should be kept covered, and LPN #43 stated urinary drainage tubing should not be on the floor and that keeping it off the floor was part of the resident's care plan.
Failure to Follow Mechanical Lift Care Plan During Transfer
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who required a mechanical lift for transfers. Resident #151 had diagnoses including encephalopathy and epilepsy, and the 09/11/2025 MDS documented intact cognition and dependence for transfers. The comprehensive care plan, initiated 09/05/2025, identified the resident as at risk for falls and with a self-care deficit, and included an intervention to lift mechanically with two people for transfers. The 09/05/2025 RN Unit Manager fall assessment also documented the resident as high risk for falls. On 09/12/2025, Certified Nurse Aide #37 attempted to help the resident stand after the resident convinced the aide they could stand and walk into the bathroom. The aide applied a gait belt and stood the resident, but the resident’s legs gave out and the resident was lowered to the floor. The incident report documented no injuries. The report stated the care plan was not followed because the resident had been care planned for a mechanical lift, and the root cause identified was that the aide should not have listened to the resident.
Significant medication errors with crushed potassium and grouped G-tube medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for two residents. One resident had diagnoses including hypokalemia and was cognitively intact. The physician order for potassium chloride extended-release 20 mEq documented that it was to be given by mouth once daily and not crushed or chewed. During medication administration observation, an LPN crushed the potassium chloride extended-release tablet and mixed it with other crushed medications in applesauce before giving it to the resident. The MAR documented the potassium chloride extended-release tablet as administered by mouth, and the LPN later stated the pharmacy had approved crushing it if that was the only way the resident would take the medication. A second resident had diagnoses including right-sided paralysis, was dependent on most activities of daily living, and had a feeding tube. The care plan addressed nutritional risk due to tube feeding and included medications per physician order. Orders were present for multiple medications to be given by gastrostomy tube, including hydroxychloroquine, lisinopril, calcium with vitamin D3, metoprolol tartrate, aspirin, atorvastatin, venlafaxine, and baclofen, along with water flushes before and after the medication pass. During observation, an LPN crushed these medications, mixed them together with water, and administered them all at once through the gastrostomy tube, followed by water. Interviews showed staff understood the medications were being crushed and given together, but did not consistently follow the order instructions or the standards described in the report. The LPN stated they did not know whether all medications could be administered together. The unit manager and DON stated medications via gastrostomy tube could be crushed and given together unless otherwise specified, while the pharmacist stated crushed medications should be administered one at a time with water flushes in between and that potassium chloride could not be crushed. The NP stated an order was required to crush a medication and that they were not aware the potassium chloride was being crushed or that the feeding tube medications were being given together.
Uncovered urinary drainage bag visible to others
Penalty
Summary
The facility failed to ensure Resident #129 was treated with respect and dignity when the resident’s urinary catheter drainage bag was left uncovered and visible to other residents, visitors, and staff. Resident #129 had diagnoses including neurogenic bladder, intact cognition, required partial/moderate assistance with toileting hygiene and showering/bathing, required substantial/maximal assistance with personal hygiene, and had an indwelling urinary catheter. The resident’s care plan identified an alteration in elimination related to the use of an indwelling catheter and included interventions to keep the urinary drainage bag covered to maintain dignity and to use a leg drainage bag as appropriate. During multiple observations, Resident #129 was seen in a wheelchair in the room doorway, dining room, and common areas with the urinary drainage bag clipped to the bottom of the wheelchair and uncovered. The bag contained amber-colored urine during several observations, and at one point the tubing was resting directly on the floor. The resident stated the drainage bag was never kept covered but would like it covered if that was an option. A CNA stated they were unsure if privacy covers were available and acknowledged the bag was never covered and that it was a dignity issue. An LPN stated they noticed the bag was not covered and should have addressed it, and the RN manager stated CNAs were responsible for catheter care and ensuring urinary drainage bags had a privacy cover when the resident was not using a leg bag.
Missed Medication, Incomplete Weight Monitoring, and Uncompleted Neuro Checks
Penalty
Summary
The facility failed to provide treatment and care in accordance with orders and professional standards for two residents. One resident with congestive heart failure, COPD, and peripheral vascular disease had orders for daily weights and later an order for furosemide 40 mg daily. The record showed multiple dates when daily weights were not documented, including several refusals, days when no scale was available or broken, and at least one instance of a 2.9-pound weight gain in one day without documented evidence that the medical provider was notified. The resident also had a hospitalization for acute respiratory failure secondary to COPD with possible pneumonia, and after return to the facility the furosemide order was continued. After the resident returned from the hospital, the medication was not administered for four days. Nursing documentation stated the medication was not in the cart, not in from the pharmacy, or not available. The facility’s automated medication dispensing system listed furosemide in active inventory, but there was no documented evidence that staff checked the system, assessed the resident after the missed doses, or notified the medical provider of the omission. The investigation later documented that the LPN did not retrieve the medication from the automated dispensing system and instead ordered it from the pharmacy. A second resident with left-sided paralysis and moderately impaired cognition had an unwitnessed fall in the room with bruising to the forehead and a skin tear to the left elbow. A physician order required neurological checks every 4 hours for the first 16 hours and then every 8 hours for 48 hours. The treatment record scheduled multiple neuro checks, but nursing progress notes did not document that several of the required checks were completed as scheduled. Staff interviews confirmed that neurological checks were expected after unwitnessed falls and that missed checks should be reported to a supervisor, but the record did not show completion of all ordered assessments.
Failure to Ensure Use and Reporting of Ordered TLSO Brace
Penalty
Summary
The facility did not ensure a resident with limited ROM received appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence. Resident #66 had diagnoses including a compression fracture of the back, severely impaired cognition, and an order for a thoracolumbar sacral orthosis (TLSO) brace when out of bed or sitting upright, with removal allowed when lying down or sleeping. The resident’s comprehensive care plan did not document the spine fracture or the use of the back brace, and the April 2026 treatment record showed the TLSO order was active beginning 04/03/2026. During observations, the resident was sitting upright in a wheelchair without the brace on multiple occasions, and the brace was found placed on the floor, bedside table, or draped over a chair in the room. The treatment record documented repeated refusals of the brace during the day shift, including refusals on several dates and on multiple consecutive days late in the month. There was no documented evidence that the provider or therapy was notified of the refusals. Staff interviews confirmed that refusals should have been reported, that the brace was intended to promote healing and prevent twisting or bending of the spine, and that the therapist had not been informed of the resident’s noncompliance.
Failure to Provide Person-Centered Dementia Care for a Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to ensure a resident with dementia received appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident #134 had diagnoses including dementia with psychotic disturbance, Parkinson’s disease, and anxiety, and the 04/17/2026 MDS documented severely impaired daily decision-making, fluctuating inattention, wandering, supervision needs for mobility, and routine antipsychotic use. The resident’s care plan included general interventions for cognitive deficits, wandering risk, and behavioral symptoms, but the record did not show a person-centered care plan that specifically supported the resident’s dementia-related behavioral needs. The resident exhibited ongoing wandering and socially inappropriate behaviors, including entering other residents’ rooms, going into other residents’ beds, pulling down clothing, using other residents’ bathrooms, and attempting to exit through doors. Nursing notes and CNA documentation described repeated wandering, resistive care, verbal abuse, physical abuse, and disruptive behavior over multiple shifts. Staff documented that the resident’s behaviors were sometimes easily redirected, but at other times were not easily altered. Observations by surveyors also showed the resident repeatedly moving from chair to chair, wandering through the hallway and common areas, and entering other residents’ rooms despite staff redirection. The record showed behavioral changes were discussed with nursing leadership and the medical provider, and psychotropic medication was increased after a negative urinalysis ruled out infection. However, there were no documented social services progress notes addressing the resident’s behaviors, increased wandering, or psychotropic medication changes. Interviews with staff and the physician indicated that nonpharmacological interventions should be prioritized and individualized, but staff also stated they were mainly redirecting the resident, offering snacks, drinks, television, bingo, or other diversion, and were unaware of any new personalized interventions beyond medication changes. The social worker stated involvement with behavioral residents was minimal and that they coordinated mainly with nursing and psychiatric services.
Expired food and improper refrigerator temperatures in kitchen storage areas
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards in two kitchens, Cottage 10 and Cottage 11. The cited policy stated that food and non-food items used in food preparation were to be stored to prevent contamination and maintain safety, and that food was to be discarded past the use-by or expiration date. Surveyors observed that Cottage 10 had an opened carton of honey thick milk with a best used by date of 01/14/2026, an undated foil-covered carton of wilted salad in the refrigerator, two unopened cartons of honey thick milk with best used by dates of 01/14/2026 and 04/04/2026, and two unopened cartons of honey thick apple juice with best used by dates of 04/07/2026 and 04/26/2026. Staff interviews indicated the cook was responsible for ensuring items were labeled and dated, and dietary staff were responsible for removing expired items, with daily checks expected. In Cottage 11, the pantry refrigerator temperature log documented repeated temperatures above the acceptable range, including 43 degrees Fahrenheit with no follow-up temperature, 46 degrees Fahrenheit rising to 52 degrees Fahrenheit with management informed, 44 degrees Fahrenheit, 53 degrees Fahrenheit, 50 degrees Fahrenheit, 45 degrees Fahrenheit, and a defrost mode reading. During observation, the resident refrigerator contained boiled eggs, turkey, and ham lunch meat with an expiration date of 04/26/2026, the large prepped meal refrigerator read 55 degrees Fahrenheit and contained hot dogs, baked beans, carrots, yogurt, and soda, and a small refrigerator under the ice machine contained apricots with an expiration date of 03/06/2026. Staff stated the boiled eggs, turkey, and ham were supposed to be discarded on the day they expired, and that the apricots should not have remained in the refrigerator with that date. Interviews further showed that food service staff were responsible for checking refrigerator temperatures and reporting issues, while management stated weekly rounds included checking refrigerators and temperature sheets. The Food Service Director stated staff should check refrigerator temperatures before placing food inside and should not put food into a refrigerator reading 55 degrees Fahrenheit. The Assistant Director of Food Service stated all food from the main kitchen should have labels with preparation and discard dates, and items in refrigerators should either have an orange label or a handwritten label, with food discarded at the end of the labeled discard date.
Grievance Process Not Available or Accessible to Residents
Penalty
Summary
The facility failed to ensure a process was in place for residents to have grievances addressed for 138 of 138 residents. Information on how to file a grievance and grievance forms were not available to residents, and there was no process for residents to file an anonymous grievance in 13 of 13 cottages. During a resident group meeting, three anonymous residents stated they did not know whether grievance forms existed or where they were located, did not know their right to file grievances anonymously, did not know who the Grievance Officer was, and said there was not always follow-up on how their concerns were addressed. The facility policy stated residents would be advised of their right to voice complaints and the process for doing so upon admission, and that the information would be posted throughout the facility. However, observations found no signs in Cottage 11, Cottage 21, Cottage 31, or Cottage 10 showing the grievance process, the Grievance Officer, grievance forms, or a way to file anonymously. Staff interviews showed CNA #19 and LPN #32 did not know the grievance process or who the Grievance Officer was, and RN Manager #20 was unsure whether anonymous grievances were possible and whether grievance forms were available in the cottages. The Director of Resident Services stated concerns were supposed to be written on a grievance form and investigated, while the Administrator stated residents, families, or staff could request a form, but residents and families did not have access to forms without asking staff and there were no posted signs in the cottages.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure the results of the most recent Federal and State surveys were posted in a place readily accessible to residents and others who wished to review them without asking for assistance in 5 of 13 cottages: Cottages 10, 11, 21, 31, and 77. In those cottages, the State survey results binders were observed on top of mantle shelves, behind signs, partially obscured by other items, inside a closed cabinet, or otherwise placed above average standing head height and not at a wheelchair-accessible level. In Cottage 10, the binder was on the top mantle shelf behind a sign; in Cottage 11, it was above average standing head height and not accessible to residents in wheelchairs; in Cottage 21, it was on the top mantle shelf and partially blocked by a sign; in Cottage 31, it was behind a sign that was obstructed by artificial flowers; and in Cottage 77, it was inside a closed cabinet about 4 feet from the ground. During an anonymous resident group meeting, four residents stated they had never seen any previous survey results and did not know where they were located. A CNA stated they did not know where the State inspection binder was and, after observing it on the top shelf above average head height, stated it did not appear accessible to residents. An RN manager stated the previous State inspections were posted in the common area and that residents could ask to see them, while the Administrator stated the binders were supposed to be in a bookshelf within reach of residents or by the activity area and was unaware they were being kept on the top mantle shelf and not at a wheelchair-accessible level.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide Resident #14 and their representative with a written summary of the baseline care plan within 48 hours of admission, including initial goals, a summary of medications and dietary instructions, and services and treatments to be administered. Resident #14 was admitted with diagnoses including a left hip fracture, and the comprehensive care plan initiated on 04/06/2026 documented that the resident was alert, oriented, and independent in decision making, with interventions to encourage involvement in the care planning process. During interview, Resident #14 stated they and their two children had met with several staff members but did not recall receiving a copy of the care plan or physician orders. The RN Manager stated care plans were initiated on admission and that the facility held 72-hour care plan meetings, but residents were never provided a copy of the baseline care plan and Resident #14 did not receive one. The DON stated the facility did not complete baseline care plans and that, during their five years at the facility, baseline care plans were not printed and given to residents.
Failure to Provide Timely Bowel Care and Notify Provider for Resident with Constipation
Penalty
Summary
A deficiency was identified when a resident with Parkinson's Disease, constipation, and irritable bowel syndrome did not receive timely treatment or interventions for constipation, as required by the facility's bowel protocol. The resident did not have a bowel movement for several days after admission, and there was no documented evidence that bowel interventions were implemented in accordance with the protocol. The resident's prescribed bowel medication, Linzess, was not available or administered for several days, and there was no documentation that the medical provider was notified of the missed doses or the resident's ongoing constipation. The facility's bowel protocol required certified nursing assistants to record bowel movements every shift and licensed nursing staff to monitor bowel patterns daily, applying interventions as needed. However, documentation showed that the resident went multiple days without a bowel movement, and interventions such as suppositories were delayed or not documented. Additionally, the medical provider was not notified when the resident failed to have a bowel movement for several days, nor when bowel medications were unavailable. The resident's care plan did not address constipation as a problem area, and there was no plan for ongoing management of the resident's constipation. Interviews with staff revealed inconsistencies in following the bowel protocol, uncertainty about the accuracy of bowel movement tracking reports, and a lack of communication regarding interventions and outcomes. The electronic system used to track bowel movements did not consistently transfer accurate data, leading to discrepancies between reports and actual documentation. Ultimately, the resident was transferred to the hospital with a diagnosis of fecal impaction after experiencing chest pain and diaphoresis, and hospital records confirmed ongoing constipation and the need for multiple interventions.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who was care planned for two staff assistance. The resident, who had moderately impaired cognition and was dependent on staff for mobility and toileting, was left in the care of a single Certified Nurse Aide (CNA). This CNA provided care alone, contrary to the care plan that required two staff members to assist due to the resident's history of false accusations against staff. During this time, the resident sustained a skin tear and later reported pain in the left arm, which was found to have a fracture. The incident report documented that the resident had risk factors for fractures due to a medical condition that caused brittle bones. Despite the facility's investigation, they could not determine when the fracture occurred, but they concluded it was likely due to the resident's comorbidities rather than the incident itself. The CNA involved admitted to providing care alone and acknowledged the oversight in not following the care plan, which required two staff members to assist the resident. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that the CNA did not adhere to the care plan, which was designed to prevent such incidents. The facility's investigation did not find evidence of abuse, neglect, or mistreatment, but disciplinary action was taken against the CNA for not following the care plan. The facility believed the fracture was due to the resident's brittle bones, although the exact timing of the fracture could not be determined.
Plan Of Correction
Plan of Correction: Approved April 15, 2025 Resident #2’s ADL care plan has been reviewed and was found to be accurate. All other residents’ care plans will be reviewed to ensure that they reflect the appropriate level of assistance required by the residents. The following policy will be reviewed and revised as deemed necessary to ensure that appropriate levels of assistance are care planned for all residents: Comprehensive Care Plan Policy. Clinical Staff will be inserviced on the previously mentioned policy including any revisions and/or policy changes implemented after reviewing such policies. Staff will also be inserviced on “Promoting Resident’s Independence, Resident Rights and Abuse.” The “Promoting Resident Rights and Independence Questionnaire,” which will include components of the ADL Critical Element Pathway, will be conducted weekly and the results of the audits will be compiled and reported monthly to the QAA Committee. The audit will be completed monthly until we achieve 100% for three consecutive months. The Monitoring Log that is used to track Accidents and Incidents across the facility has been edited to include the names of staff members involved in each incident. This will allow for increased surveillance. The findings will be reported in QAA Monthly as part of the Investigation of Accidents/Incidents Audit that is completed by the ADON. The Director of Nursing will be responsible for overseeing this process.
Violation of Resident's Right to Refuse Care
Penalty
Summary
The facility failed to uphold a resident's right to self-determination and choice, leading to a deficiency. A resident, who had diagnoses including impaired hearing and full cognition, refused incontinence care during the night shift. Despite the resident's clear refusal and statement that they were not incontinent, Certified Nurse Aide #4 proceeded to provide incontinence care, rolling the resident in bed and pulling down their incontinence brief. This action was against the resident's wishes and violated their rights. The resident's care plan, updated prior to the incident, indicated that the resident preferred not to be disturbed during the night unless they requested assistance. The aide's rationale for providing care was based on the resident's previous incontinence during the night and prior acceptance of care. However, the resident explicitly stated they did not need incontinence care at the time of the incident, and the aide's actions were not in alignment with the resident's expressed wishes or the care plan. The incident was documented in an incident report, and the facility's investigation confirmed that the aide violated the resident's rights by not respecting their refusal of care. The resident expressed initial upset and anger over the situation, although there were no psychological concerns noted post-incident. The facility's policies and staff expectations clearly outlined the importance of respecting resident rights and documenting refusals, which were not adhered to in this case.
Plan Of Correction
Plan of Correction: Approved April 15, 2025 Resident #1’s care plan has been reviewed and was found to be accurate. There is a care plan intervention under “Self – Care Deficit” that states “Allow to make choices in care, i.e., clothing, ADL routine, etc.” All other residents' care plans will be audited to ensure that there is a care plan intervention under “Self – Care Deficit” that states “Allow to make choices in care, i.e., clothing, ADL routine, etc.” The following policies will be reviewed and revised as deemed necessary to ensure that residents’ choices and preferences regarding their care are carefully planned for as well as followed by the staff members when providing care: - Comprehensive Care Plan Policy - Resident Right to Refusal Policy Clinical Staff will be inserviced on the previously mentioned policies including any revisions and/or policy changes implemented after reviewing such policies. Staff will also be inserviced on “Promoting Resident’s Independence, Resident Rights and Abuse.” The “Promoting Resident Rights and Independence Questionnaire,” which will include components of the ADL Critical Element Pathway, will be conducted weekly and the results of the audits will be compiled and reported monthly to the QAA Committee. The audit will be completed monthly until we achieve 100% for three consecutive months. The Director of Nursing will be responsible for overseeing this process.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated or reported to the New York State Department of Health as required. This deficiency involved a physical altercation between a Certified Nurse Aide (CNA) and a resident, resulting in a skin tear on the resident's arm. The CNA was not immediately removed from direct resident care pending investigation, and the incident was not reported to the Department of Health in a timely manner. The resident involved had diagnoses of restlessness, agitation, and mild dementia with anxiety. The resident was known to have severely impaired cognition and required moderate assistance for most activities of daily living. On the day of the incident, the resident reportedly became combative and struck the CNA several times. In response, the CNA grabbed the resident's arm, causing a skin tear. Despite the incident, the CNA continued to work their scheduled shifts without suspension pending investigation. The facility's policies required that any witnessed or suspected incidents of abuse be reported to the Department of Health and that the accused employee be placed on immediate temporary suspension pending investigation. However, the facility did not initiate a full investigation until four days after the incident, following the arrival of the New York State Department of Health for a recertification survey. The Director of Nursing and the Administrator were not immediately informed of the incident, and the CNA was not removed from resident care during this period.
Failure to Assist Resident with Proper Positioning in Wheelchair
Penalty
Summary
The facility failed to ensure that a resident maintained their ability to perform activities of daily living, specifically in maintaining proper posture while seated in a wheelchair. The resident, who had diagnoses including unspecified dementia and multiple sclerosis, was observed multiple times leaning far to the right in their wheelchair without assistance for repositioning. This leaning affected their ability to eat, as food and drink were observed falling to the floor during meals. The facility's policy required that residents receive necessary assistance for repositioning based on assessments from the interdisciplinary team. Despite this, the resident was not consistently repositioned, and staff interviews revealed a lack of clarity and action regarding the resident's needs. Certified Nurse Aide #12 and Licensed Practical Nurse #16 acknowledged the resident's leaning issue but did not ensure consistent intervention or trigger a physical therapy evaluation. Interviews with the Assistant Director of Nursing and Occupational Therapist indicated that proper positioning was crucial for the resident's safety and comfort. However, there was no evidence of a reassessment or implementation of adaptive equipment to address the resident's leaning. The Occupational Therapist suggested that lateral supports might not have been tried due to concerns about the resident's behavior, but alternative solutions like blankets were not documented as being implemented.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #100, received necessary assistance with personal hygiene, specifically in removing unwanted facial hair and maintaining clean and trimmed fingernails. Resident #100, who had diagnoses of dementia and anxiety, required substantial assistance with personal hygiene and did not refuse care. Despite this, observations over several days revealed that the resident had thick facial hair and long, unclean fingernails with debris underneath, indicating a lack of proper grooming and hygiene care. Interviews with staff, including Certified Nurse Aides and a Licensed Practical Nurse, confirmed that personal hygiene tasks such as shaving and nail care were not consistently performed for Resident #100. Staff acknowledged noticing the resident's facial hair and unkempt nails but cited time constraints and other priorities as reasons for not addressing these issues promptly. The facility's policy required daily personal hygiene care, including shaving and nail care, to maintain residents' dignity, which was not adhered to in this case.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities that supported the interests and preferences of Resident #120, as required by their own policies and the resident's care plan. Resident #120, who had diagnoses of peripheral vascular disease, diabetes, and chronic kidney disease, was noted to have moderately impaired cognition and expressed feelings of depression. Their preferences included listening to classical music, attending religious services, and spending time outdoors. However, the facility did not offer activities that aligned with these interests, as evidenced by the lack of attendance records for music, spiritual services, or outdoor activities. Observations and interviews revealed that Resident #120 was not provided with meaningful activities. The activity calendar was not easily visible, and the resident was only invited to activities they did not enjoy, such as BINGO. The resident expressed a desire for social interaction with others of the same sex and to participate in religious services, but these needs were not met. The resident was observed sitting alone or with cognitively impaired residents without interaction, and their request to go outdoors was denied by staff. Interviews with facility staff, including the Recreation Specialist and the Director of Therapeutic Recreation, highlighted systemic issues in the activity program. The Recreation Specialist admitted to time constraints and a lack of resources, which prevented them from incorporating Resident #120's preferences into the activity schedule. The Director of Therapeutic Recreation confirmed the absence of outside vendors and social groups, and restrictions on outdoor activities due to temperature policies. These deficiencies contributed to the resident's feelings of loneliness and lack of engagement in meaningful activities.
Deficiencies in Pressure Ulcer Management
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as observed during the recertification and abbreviated surveys. Resident #7, who had an unstageable pressure ulcer on the right heel, did not receive the prescribed wound treatments due to a lack of supplies. The treatment administration record indicated that the treatment was not completed on multiple days, and the responsible LPN did not notify a supervisor about the unavailability of supplies. This oversight was only discovered after several days, highlighting a lapse in communication and supply management. Resident #125, diagnosed with dementia and Stage 2 pressure ulcers on both heels, did not have the ordered alternating pressure overlay in place on their bed. Observations over several days showed the overlay was not being used, despite documentation indicating it was checked and functioning. Interviews with staff revealed a lack of awareness and responsibility in ensuring the overlay was in place and operational, which was crucial for preventing further skin breakdown. The facility's policies required regular assessment and documentation of pressure ulcers, as well as the use of pressure-relieving devices as ordered. However, the failure to adhere to these protocols for both residents resulted in deficiencies in care. The lack of proper wound care supplies and the absence of the alternating pressure overlay contributed to the facility's inability to meet professional standards of practice for pressure ulcer management.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink at palatable and appetizing temperatures during two lunch meals observed on 7/10/2024 and 7/15/2024. Specifically, during the lunch meal on 7/10/2024 in Cottage 60, Resident #40 was served a meal where the cheeseburger was measured at 130 degrees Fahrenheit, and the milk, apple juice, and water were all above the acceptable cold temperature range. Similarly, on 7/15/2024 in Cottage 31, Resident #105 received a meal where the carrot salad and apple juice were also above the acceptable cold temperature range. Both residents expressed dissatisfaction with the temperature and taste of the food. Interviews with staff revealed inconsistencies in food handling and serving practices. Dietary staff and certified nurse aides were not adhering to the facility's food handling guidelines, which required hot foods to be served at 135 degrees or higher and cold foods at 41 degrees or less. The Food Service Director and Registered Dietitian confirmed that the temperatures recorded during the observations were not acceptable and that there were lapses in ensuring drinks were served at the correct temperatures. The facility's policy was not effectively implemented, leading to the deficiency in food service quality.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two staff members, a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA), during the care of a resident with a Stage 4 pressure ulcer. The LPN did not perform hand hygiene or change gloves during wound care, and both the LPN and CNA failed to wear gowns while providing incontinence and wound care to the resident, who was on enhanced barrier precautions due to an active infection. These actions were contrary to the facility's policies on hand hygiene and enhanced barrier precautions. The resident involved had a severely impaired cognition, was dependent on most activities of daily living, and was incontinent of bowel and bladder. The resident's care plan included maintaining universal precautions and infection control practices through proper handwashing. Despite this, the LPN and CNA did not adhere to these protocols, as observed during their care of the resident. The LPN placed soiled linen on the floor and did not change gloves after removing the old dressing, while the CNA left the room without performing hand hygiene. Interviews with the staff revealed a lack of understanding and adherence to the facility's infection control policies. The CNA believed they had received precaution and handwashing training recently, while the LPN was unsure about enhanced barrier precautions and stated that the resident was on precautions for the first time on the day of observation. The Registered Unit Nurse Manager and Infection Preventionist confirmed that the resident had been on enhanced barrier precautions for about a month and that the staff's actions were unacceptable, potentially leading to infection or worsening of the resident's wound.
Incomplete Investigations of Alleged Violations
Penalty
Summary
The facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for two residents. Resident #1 was found with a bruise of unknown origin, and an assessment was not completed timely, nor was an investigation to rule out abuse/neglect initiated at the time of the report. Additionally, Resident #1 fell and sustained an injury, but the investigation did not identify if the resident's care plan was followed for toileting or if the resident's fall mat was in place at the time of the fall. The facility's investigation was incomplete, lacking follow-up with staff and proper documentation of the incident and care plan adherence. Resident #2 had a fall and was documented as clearly incontinent. The investigation did not determine when the resident was last provided incontinence care and whether the care plan for toileting was followed. Furthermore, Resident #2 had another fall while in another resident's room and was incontinent at the time. The facility's investigation did not identify if the resident's care plan was followed for toileting every 2 to 4 hours. The facility failed to document when the resident was last provided incontinence care and did not ensure the care plan was followed. The facility's policy required all reports of resident abuse or neglect to be promptly and thoroughly investigated by facility management. However, the investigations for both residents were incomplete and lacked critical information to rule out abuse, neglect, or mistreatment. The facility did not follow its own procedures for obtaining staff statements, assessing residents timely, and ensuring care plans were adhered to, leading to deficiencies in the quality of care provided to the residents.
What surveyors are citing around you — mapped
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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 214 citations issued within 25 miles in the last 12 months — including the 8 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cicero
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Liverpool | 5.2 mi | ★★★★★ | 15 | 0 |
| Sunnyside Care Center | 7.6 mi | ★★★★★ | 0 | 0 |
| Bishop Rehabilitation And Nursing Center | 9.3 mi | ★★★★★ | 37 | 0 |
| Onondaga Center For Rehabilitation And Nursing | 10.5 mi | ★★★★★ | 22 | 2 |
| Central Park Rehabilitation And Nursing Center | 11 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.