Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tucker House Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A nurse gave one resident an 800 mg gabapentin tablet from another resident’s blister pack after the first resident’s supply ran out. The resident said this had happened before and that it occurred that morning. The LPN confirmed she did not use the Pyxis machine, and the DON verified that the medication came from the other resident’s blister pack, despite the facility policy requiring resident identity verification and prohibiting administration of one resident’s medication to another.
Food and drink were not consistently palatable or served at proper temperatures. Several residents reported that meals were cold, repetitive, tasteless, too spicy, or otherwise poor quality, and one brittle diabetic said she did not receive an evening snack and could not have the apple juice sent with meals because it raised her blood sugar. A test tray found cold items above the acceptable range and hot items below the required holding temperature, and the FSD confirmed the results.
Ineffective Pest Control Program: Multiple residents reported ongoing mice, bugs, and cockroaches in rooms, hallways, and the dining room, with one resident stating roach traps were in his room but he still saw a cockroach on the sink and wall. Pest logs and pest control reports documented repeated mouse activity, droppings, voids and holes in walls and baseboards, and a heavy German cockroach infestation in a resident room, which the Administrator confirmed.
Failure to Maintain Privacy During Personal Care: A resident received personal care and dressing assistance with the room door and privacy curtain left open, making the care visible from the hallway. An aide said this was done because he believed the resident was claustrophobic, but the record contained no documentation of claustrophobia, and the resident stated he was not claustrophobic and preferred privacy during care.
Activities Program Not Directed by Qualified Professional: Review of the facility’s records showed that an Activities Director was listed as the Therapeutic Recreation Director, but the personnel file contained no evidence of certification, prior therapeutic recreation experience, OT qualification, or approved TR training. The employee had previously worked as a cook and housekeeper, and during observation was overseeing an activities program with residents while confirming no credentialling or prior experience in therapeutic activities.
Failure to follow hypoglycemia management occurred for a resident with DM2, ESRD, hypoglycemia, and dialysis dependence after an unwitnessed fall in the dining room. The resident was alert and talking with a large hematoma on the back of the head, but the record showed no post-fall BS check or VS, and hospital records later documented a BG of 43 mg/dl with mild lethargy from poor PO intake.
A resident with CVA, aphasia, and total dependence for transfers was moved with a Hoyer lift by one aide alone, despite facility policy requiring two staff members for lift transfers. In a separate incident, a resident was found after a smoking break with a head abrasion and conflicting fall documentation; the DON and administration stated the smoking area was not locked after smoking time and no one witnessed the fall.
A resident with stroke, hemiplegia, anxiety, depression, and muscle wasting atrophy was receiving oxycodone for pain, but the MAR showed the medication was administered even when the resident reported little or no pain. The DON confirmed the records were accurate and acknowledged the facility lacked a defined pain scale to distinguish pain levels, and the care plan did not include nonpharmacological pain interventions or comfort measures.
Medication storage was not maintained according to policy in two medication rooms. Refrigerated meds were required to be kept between 36 and 46 F with daily checks, but logs on both units had multiple missing temperature entries, dates, and initials. On the 3rd floor, the refrigerator was observed at 48 F and the charge nurse confirmed the out-of-range temp.
Food was not consistently palatable or served at acceptable temperatures for several residents. Residents reported cold meals, poor taste, rubbery meats, and watered-down beverages, and a test tray found hot items below the facility’s temperature standard; the FSD confirmed the food was outside the acceptable range and not palatable, and many residents were observed not eating the meal.
Food service areas contained multiple sanitation and storage problems, including roofing materials and old resident equipment stored near the trash compactor, dishware on the floor, no thermometer in the freezer, cooked roast beef held for 6 days, and chicken breast thawing in standing water. Resident pantry and refrigerator areas also had unlabeled and undated leftovers, milk, supplements, potato salad, almond milk, and sushi, while the steam table undershelf was dirty, dusty, and oxidizing.
Improper Disposal of Trash, Recyclables, and Construction Debris: Surveyors observed roofing adhesive, roofing sealant, screws, roofing caulk, and a pile of old resident equipment and a microwave oven left near the compactor and dumpster area. The FSD confirmed the findings, and the Administrator confirmed the materials from recent roof work should not have been left outside the dumpster.
Smoking Safety Policy Not Followed During Supervised Smoke Break: During an observed smoke break, a resident who required a smoking apron was smoking without one while staff monitoring the area did not know which residents needed aprons, where the aprons were stored, or where the emergency fire blanket was located. The Activities Director, who oversaw the smoking program, also did not have the smokers list readily available and could only find two aprons in a dining room kitchen cabinet, with no additional aprons available for all residents who were listed as needing them.
A resident with a history of breast cancer and cellulitis had a critical BNP lab value reported, but staff did not notify the ordering physician as required by facility policy. Documentation showed unsuccessful attempts to reach the physician, and there was no evidence that the prescriber was ever informed of the result.
The facility did not properly label or manage two residents' personal clothing, resulting in significant delays in returning laundry, mixing of personal items with bed linens, and multiple grievances about missing or delayed laundry. Laundry aides reported ongoing issues due to lack of labeling by nurse aides, and one family received a deceased resident's belongings in a wet condition.
The facility failed to maintain an effective pest control program, resulting in roach and mice infestations across three nursing floors. Observations revealed live and dead roaches in resident rooms, along with clutter and food waste. Residents reported frequent sightings of pests, and pest control reports recommended improved sanitation and decluttering, which were not adequately addressed.
The facility did not maintain the means of egress on one floor, as a designated exit door from the ground floor dining room was padlocked on the corridor side, despite being marked with an illuminated exit sign. This was confirmed by the administrator and other representatives during an interview.
The facility failed to maintain stairways according to NFPA 101 standards. The 3rd floor South stairtower door did not latch properly, and environmental services supplies were stored in the East stairtower on the ground floor. These issues were confirmed by facility representatives during an interview.
The facility failed to maintain proper safety measures for hazardous area doors on two of five floors. Observations revealed that doors to the basement level medical waste room and elevator equipment room did not latch properly, and the Business office on the ground floor had excess combustible storage without a self or automatic closing door. These issues were confirmed during an exit conference with facility representatives.
The facility failed to monitor the installation of alcohol-based hand rub dispensers, with one found directly over a light switch in the 3rd floor dining room, placing it too close to an ignition source. This was confirmed during an exit conference with the facility's administration and maintenance representatives.
The facility failed to maintain corridor doors on three floors, with several doors either not smoke tight or lacking proper latching. This was confirmed during an exit conference with facility representatives.
The facility failed to maintain smoke barrier doors on one of its floors. Observations revealed that the East corridor smoke barrier doors did not close smoke tight, as required for proper smoke containment. This issue was confirmed during an exit conference with the facility's administrator and representatives.
The facility did not maintain electrical outlets as required, with a missing outlet cover observed in the Nurse lounge on the 4th floor. This was confirmed during an exit conference with the administrator and other representatives.
The facility failed to develop comprehensive care plans for residents, including one with a contracted hand and another with vision issues, leading to unaddressed health needs. A resident with heel protectors ordered did not have this intervention documented in their care plan, highlighting a lack of person-centered planning.
The facility failed to update care plans for two residents. One resident with significant weight loss had an outdated care plan that did not reflect the current order for two house shakes daily. Another resident requiring two-person assistance for mobility had a care plan indicating only one person was needed. These discrepancies were confirmed by staff.
A facility failed to provide adequate nail care for a resident who was cognitively impaired and had hemiplegia and muscle weakness. The resident was dependent on staff for personal hygiene, as noted in their care plan, which included checking and trimming nails on bath day and as necessary. Despite receiving a bed bath, observations revealed that the resident's fingernails were significantly long and required trimming. The resident's left hand was contracted, making regular nail care essential.
The facility failed to address the nutritional needs of two residents, leading to significant weight loss that was not promptly managed. One resident with cognitive impairment and diagnoses of failure to thrive and dementia lost 7.9% of their weight in one week without timely intervention. Another resident, who was physically active and cognitively impaired, lost 5.19% of their weight over a month, with no prompt action taken by the Registered Dietitian. Both cases lacked timely documentation and intervention adjustments.
A facility failed to provide appropriate pain management for a resident with myalgia, as staff did not document the administration of Tylenol or conduct a required pain assessment. The resident was observed tearful and requesting pain medication, but the necessary documentation and evaluation of non-pharmacological interventions were missing, as confirmed by staff interviews.
A facility failed to identify possible triggers for re-traumatization in a resident's PTSD care plan. The resident, with a history of childhood abuse and diagnoses including PTSD, had a care plan that lacked identification of potential triggers. This deficiency was confirmed by interviews with the DON and a Regional nurse.
A facility failed to maintain effective infection control during a medication administration and a peg tube dressing change. A nurse handled medication without disinfecting hands, and another nurse did not use PPE or change gloves during a dressing change for a resident on Enhanced Barrier Precautions.
A facility failed to provide proper incontinence management for a resident with Neuromuscular Dysfunction of the Bladder. The resident was ordered a 16FR/10ML Foley catheter but was observed with an 18FR/10ML catheter instead. This error was confirmed by a Registered Nurse.
A facility failed to provide a resident with timely access to their personal funds after discharge, as required by policy. The resident's account was closed late, and a refund request was delayed and never received by the corporate office, resulting in a refund of $3,418.20 not being sent to the resident.
A facility failed to ensure ongoing collaboration with a dialysis center, resulting in a resident not receiving prescribed medications before and after hemodialysis sessions. The resident, with end-stage kidney disease, missed multiple doses of Lispro insulin, Phos lo, apixaban, and isosorbide mononitrate ER in March 2024, as confirmed by the DON.
Medication Given From Another Resident’s Blister Pack
Penalty
Summary
The facility did not ensure that residents were free from misappropriation of resident property when a nurse gave one resident another resident’s medication. The facility policy on administering medications stated that medications ordered for one resident may not be administered to another resident unless permitted by State law and facility policy and approved by the DON, and that the nurse must verify the resident’s identity before giving medications. The policy also listed methods for identifying the resident, including checking the identification band, checking the photograph in PCC, calling the resident by name, and verifying identification with other facility personnel if needed. Resident R1 stated that when his medication runs out, the nurse takes it from another resident, and said this happened that morning with his 800 mg gabapentin. His clinical record showed an order for gabapentin 800 mg by mouth three times a day for nerve pain and seizures. The LPN confirmed that R1’s gabapentin had run out and that she gave him an 800 mg tablet from Resident R4’s blister pack instead of obtaining it from the Pyxis machine. The DON verified that R1 did not have a blister pack for his gabapentin and confirmed with the LPN that the medication had been taken from R4’s blister pack. The DON stated she could not believe the nurse gave another resident’s medication to a different resident and thought she would know better and use the Pyxis machine.
Food Served at Improper Temperatures and Poor Quality
Penalty
Summary
Food and drink were not consistently palatable, attractive, or served at safe and appetizing temperatures for multiple residents reviewed. During resident interviews, one resident stated the food was overprocessed and made him sick to his stomach, another said the food was really bad, always cold, and that she could not have the apple juice sent with meals because it raised her blood sugar; she also reported missing an evening snack on Friday and identified herself as a brittle diabetic. Other residents reported that meals were bad and repetitive, that food was either tasteless or too spicy, that the food was horrible and they had to get sandwiches instead, and that the food was no good and not always hot or was always cold. A test tray observed with the Food Service Director showed multiple temperature failures. The apple juice was served at 55 degrees Fahrenheit and sliced apples dessert at 68 degrees Fahrenheit, both above the acceptable cold range, while pulled pork was 126 degrees Fahrenheit, diced potatoes 111 degrees Fahrenheit, peas 109 degrees Fahrenheit, and coffee 124 degrees Fahrenheit, all below the required hot holding temperature. The Food Service Director confirmed the test tray results.
Ineffective Pest Control Program
Penalty
Summary
The facility was not maintaining an effective pest control program despite a policy stating that it maintains an ongoing program to keep the building free of insects and rodents. During interviews, multiple residents reported ongoing pest activity, including mice seen in rooms and hallways, bugs, and cockroaches in resident areas and the dining room. One resident stated that roach traps had been placed in his room, but he still saw a cockroach on the sink and another on the wall in the dining room, describing the situation as disgusting. Facility pest logs for the third floor documented repeated mouse activity and droppings in multiple resident rooms, the dining room, and near the hall over several dates. Pest control company reports also documented mouse droppings in the maintenance office, mouse activity in resident rooms, voids and holes in walls and baseboards, and a heavy infestation of German cockroaches in a resident room. The Administrator confirmed the third floor pest log entries and the pest control reports showing voids, holes, and cockroach and mouse activity in the building over the prior three months.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
The facility failed to maintain and protect personal privacy and dignity while providing care to one resident. During an observation on the fourth-floor nursing unit, the resident’s room door was left wide open while a nurse aide provided personal care and assisted with dressing, and the privacy curtain was also open, making the care visible from the hallway. The nurse aide stated he left the curtain and door open purposely because he believed the resident was claustrophobic. Review of the resident’s quarterly MDS showed the resident was admitted to the facility, had a BIMS score of 15 indicating cognitive intactness, and had diagnoses including CVA, aphasia, anxiety, and depression. The resident required maximal assistance with toileting, dressing, and personal hygiene, and was totally dependent for bed mobility and transfers. Review of the nursing notes, care plan, and psychological note found no evidence that the resident was claustrophobic and no documentation of any preference or need related to claustrophobia. When interviewed, the resident stated he was not claustrophobic and would prefer privacy during care.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The activities program was not directed by a qualified professional for one of one activities personnel files reviewed, Employee E7. Review of the facility’s Department Heads Contact List identified Employee E7 as the Therapeutic Recreation Director, and the personnel file showed that Employee E7 was hired on March 17, 2025, as the Activities Director. The signed job description stated that the Activities Director assumes administrative authority, responsibility, and accountability for providing a program of therapeutic activities designed to meet residents’ interests and enhance functional abilities and self-esteem. Further review of the personnel file showed that Employee E7 previously worked as a cook and a housekeeper, and there was no evidence that the employee was a certified therapeutic recreation specialist, had previous experience in a therapeutic activities program, was a qualified occupational therapist, or had completed an approved training course for therapeutic recreation specialists. During an observation in the main dining room, Employee E7 was overseeing and assisting with an activities program with residents, and during interview Employee E7 confirmed having no credentialling or training courses to be a qualified therapeutic recreation specialist and stated that he had only trained with another employee for two weeks after being hired and had no prior experience in therapeutic activities programs.
Failure to Follow Hypoglycemia Management After Fall
Penalty
Summary
Facility did not ensure care was provided according to professional standards of practice for a resident with type 2 diabetes mellitus, end stage renal disease, hypoglycemia, and dependence on renal dialysis. The facility policy for hypoglycemic management required licensed nurses to monitor for signs of hypoglycemia, complete a finger stick when symptoms were present, and follow the standard protocol for diabetic patients unless otherwise ordered by a physician. After the resident had an unwitnessed fall in the main dining room, he was found lying on his side, alert and talking, and denied pain. The writer observed a large hematoma on the back of his head, and the resident stated he had been sitting in a chair and was about to use the restroom when he fell. Review of the clinical record and investigation report found no evidence that the facility followed its hypoglycemic management protocol after the incident, including no blood sugar check and no vital signs taken after the fall. The resident was transferred to the emergency room later that evening, and hospital records showed a blood glucose of 43 mg/dl with mild lethargy from poor PO intake.
Inadequate supervision during smoking break and unsafe solo Hoyer lift transfer
Penalty
Summary
The facility did not ensure adequate supervision during a smoking break and during a Hoyer lift transfer for two residents. Facility policy stated that abuse and neglect include failures to provide necessary services and that Hoyer lift transfers require two staff members working together to safely position, operate, monitor, and complete the transfer. The report also cited facility policies requiring prompt investigation of abuse and neglect incidents. Resident R7 had a history of CVA, aphasia, anxiety, and depression, and the quarterly MDS showed he had impaired function on one side, required maximal assistance with toileting, dressing, and personal hygiene, and was totally dependent for bed mobility, sit-to-stand transfers, and bed-to-chair transfers. During observation, a nurse aide was seen providing care in bed, then positioned the Hoyer lift and closed the door. About five minutes later, the resident was observed sitting in his wheelchair, and the aide was the only staff member in the room. The aide stated he alone transferred the resident using the Hoyer lift and then into the wheelchair without assistance, even though another aide stated lift transfers for this resident were always required to be performed by two staff members. Resident R111 was involved in a fall incident while on the ground floor near the elevators after a smoking break. The incident report documented that he was found sleeping in a chair, had an abrasion on the top of his head with scant red blood, and stated he fell outside and tripped over a bench. The fall documentation contained contradictory information about whether he had injuries and whether he was oriented to one or four spheres. A statement from the activities therapist said residents were supervised during smoke break and that R111 did not fall, while the DON and administration stated the activities employee forgot to lock the smoking section area after smoking time was over and that no one witnessed the fall incident.
Inadequate Pain Assessment and Oxycodone Administration
Penalty
Summary
The facility failed to provide pain management in accordance with professional standards of practice for one resident who had a history of stroke, hemiplegia, anxiety, depression, and muscle wasting atrophy and who routinely received antidepressant and opioid medications. The resident’s care plan identified risk for pain related to spasms and nerve pain and included interventions such as administering analgesics as ordered, anticipating the resident’s need for pain relief, responding promptly, and evaluating effectiveness while notifying the physician if interventions were unsuccessful or if pain complaints indicated a significant change in condition. The resident had an order for oxycodone 5 mg every 8 hours as needed for moderate pain, with documentation of pain level, location, and non-pharmacological interventions. The medication had been given continuously since admission without documented re-evaluation or tapering. MAR review showed oxycodone was administered on multiple occasions when the resident reported pain levels of 0 or 1, including several instances in July, August, September, and October 2025. The DON confirmed the MAR was accurate and acknowledged the resident received oxycodone even when reporting little or no pain. The DON also acknowledged the facility did not have a defined pain scale to distinguish mild, moderate, or severe pain, and the resident’s care plan did not include any nonpharmacological interventions or comfort measures for pain management.
Medication Storage Temperature Monitoring Deficiencies
Penalty
Summary
Drugs and biologicals were not stored according to professional standards of practice in two medication storage rooms, on the 2nd floor and 3rd floor units. Facility policy for medication storage required medication preparation and storage areas to have sufficient lighting and for refrigerated medications to be kept between 2 and 8 degrees Celsius (36 to 46 degrees F), with temperatures checked daily and adjusted if out of range. The refrigerator temperature control log for the 3rd floor unit showed multiple missing entries for temperature monitoring and documentation across several day, evening, and night shifts in October 2025. During observation of the 3rd floor medication storage room, the refrigerator temperature was found to be 48 F, and the charge nurse confirmed the out-of-range temperature at the time of observation. Review of the 2nd floor medication storage room temperature log also showed numerous missing temperature checks, dates, and initials across day, evening, and night shifts in October 2025. The missing documentation and out-of-range refrigerator temperature were confirmed with the 2nd floor unit charge nurse.
Food Not Served at Palatable Temperatures
Penalty
Summary
Food and drink were not consistently palatable or served at safe, appetizing temperatures for four of 32 residents reviewed, including Residents R24, R79, R32, and R63. The facility’s Bedrock Food and Nutrition Services Test Tray Evaluation form listed acceptable temperatures as greater than 135 degrees for hot food and beverages, 50 degrees or less for cold food and beverage, and 45 degrees or less for milk. During interviews, R24 stated she did not like a lot of the food served, R79 stated she could not eat the meals because the food was really bad and that she could usually only eat chicken noodle soup, R63 stated the food was served cold, meats were rubbery, coffee did not taste good, and beverages tasted watered down, and R32 stated the food was not good and was served cold. During a test tray observation, the last tray was passed at 12:45 p.m., and temperatures taken by the FSD showed chicken and dumplings served over rice at 129.4 degrees and spinach at 123.4 degrees, both below the acceptable range. During tasting, the spinach was described as very bland and not warm enough, and the dumplings were melted and stuck to the chicken, tasting like slimy and uncooked dough and being very starchy and unpleasant. The FSD confirmed the items were outside the acceptable temperature range and not palatable, and stated the cook was having trouble with the dumplings and that they did not turn out right. Observations in the second-floor dining room showed many residents were not eating the chicken and dumplings.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, surveyors observed a large blue container of roofing adhesive, roofing sealant, screws, and roofing caulk stored near the compacting dumpster, along with a pile of old resident equipment including a bedside commode, wheelchair parts, a walker, a bedside nightstand, and a microwave oven next to the trash compactor. In the dry food storage room, a large cardboard box of dishware was sitting directly on the floor, and the walk-in freezer had no thermometer to monitor temperatures. In the walk-in cooler, a stainless-steel pan of cooked roast beef was labeled September 24, 2025, making it six days old, and the prep sink contained semi-frozen chicken breast floating in standing water. Additional observations showed unsanitary and improperly labeled food storage in resident dining and pantry areas. The second-floor dining room steam table undershelf was covered in dirt and dust, and the metal was oxidizing and could not be wiped clean. In the second-floor pantry refrigerator, three Styrofoam containers of leftover food, seven plastic leftover food containers, one gallon jug of milk, and three plastic shopping bags of food were all unlabeled and undated; three nutritional supplements labeled with resident names were dated September 14, 2025. In the 4th floor resident food pantry, surveyors found a frozen Styrofoam cup of juice with a straw that was unlabeled and undated, a container of potato salad dated September 8 but unlabeled, an open container of almond milk with no label or open date, and two containers of sushi purchased on September 29, 2025 that were unlabeled. Staff interviews confirmed these findings.
Improper Disposal of Trash, Recyclables, and Construction Debris
Penalty
Summary
The facility did not ensure that trash and recyclables were properly disposed of in the receiving and dumpster area. During an initial tour of the Food Service Department, surveyors observed a large blue 10-gallon container of roofing adhesive, a case of four silver pouches of roofing sealant with 6 long screws, and several tubes of roofing caulk near the compacting dumpster. Surveyors also observed a large pile of old resident equipment, including a bedside commode, wheelchair, leg rests, walker, bedside nightstand, and a microwave oven, piled up next to the trash compactor. The Food Service Director confirmed these findings during interview, and the Administrator later confirmed that roof work had recently been completed and that the chemicals and other debris should not have been left outside of the dumpster.
Smoking Safety Policy Not Followed During Supervised Smoke Break
Penalty
Summary
The facility failed to ensure that staff were knowledgeable of smoking policies during an observed morning smoke break. The facility policy required a safe smoking environment and stated that safety equipment, including an emergency fire blanket, fire extinguisher, and smoking aprons for residents who did not have them in their possession, would be maintained near or at the designated smoking area. The smokers list showed that four residents required smoking aprons, including Resident R83. During the smoke break observation, Resident R83 was smoking in the designated smoking area while seated in a wheelchair with a cigarette hanging from her lips and her hands resting at her sides. Resident R83 was not wearing a smoking apron. The Business Office Manager, who was monitoring the residents, stated that she did not know which residents required smoking aprons and had not been provided a list of smokers or aprons. She also did not know where the smoking aprons or emergency fire blanket were located and did not know what a fire blanket was or how to use one. The Activities Director, who was responsible for overseeing the resident smoking program, did not have the smokers list readily available, confirmed there was no emergency fire blanket in the storage box by the smoking area entrance, did not know where the smoking aprons were stored, and found only two aprons in a dining room kitchen cabinet, with no additional aprons available for all residents listed as needing them.
Failure to Notify Physician of Critical Lab Result
Penalty
Summary
Facility staff failed to notify the ordering physician of a critical laboratory result for one resident. According to facility policy, staff are required to inform the prescriber of results that are outside clinical reference ranges and document this notification. In this case, a resident with diagnoses including breast cancer and cellulitis of the left lower limb had a critical BNP laboratory value reported. The clinical record showed that the critical result was received by a registered nurse, who documented unsuccessful attempts to reach the physician for review and indicated that further attempts would be made. Despite these efforts, there was no documented evidence that the physician was ever informed of the critical laboratory result. Interviews with facility leadership and the medical director confirmed a lack of clarity regarding why the nurse was unable to notify the physician. The clinical record review did not show any follow-up or confirmation that the prescriber was made aware of the critical value, as required by facility policy.
Failure to Properly Identify and Manage Residents' Personal Clothing
Penalty
Summary
The facility failed to ensure that residents' clothing was properly identified and managed, as required by facility policy. Specifically, two residents' personal clothing was not labeled with their names, resulting in delays and confusion in returning laundry. One resident and their relative reported waiting approximately two weeks for personal laundry to be returned. Interviews with laundry aides revealed that the lack of labeling by nurse aides led to ongoing delays, with personal items left unclaimed until complaints were made. Observations in the laundry room showed residents' clothing mixed with bed linens and a pile of unidentified clothing. Additionally, review of facility grievances over two months showed ten complaints related to laundry delays and missing items, and one report documented that a deceased resident's belongings were returned to family in a wet condition.
Pest Control Deficiency in Resident Care Areas
Penalty
Summary
The facility failed to maintain an effective pest control program across three nursing floors, as evidenced by multiple observations and interviews. In one resident room, live and dead roaches were found inside a nightstand drawer, along with what appeared to be pest droppings. The room was also noted to have trash and food particles on the floor. A resident reported seeing a mouse emerge from a hole in the baseboard and frequently observed roaches in his room. Another resident demonstrated a roach infestation problem by showing live roaches inside a dresser drawer. The room was cluttered, and food waste was present on the floor. Additionally, a resident had placed traps under the dresser, which caught numerous dead and live roaches. The pest control reports reviewed indicated ongoing issues with roach activity and recommended improvements in sanitation and decluttering in specific rooms and the kitchen area. The reports highlighted positive roach acceptance on monitors placed under the dishwasher area and recommended fixing leaks and improving sanitation practices. Despite these recommendations, the facility continued to experience pest issues, as evidenced by the observations and resident reports. The facility's failure to address these recommendations and maintain cleanliness contributed to the persistent pest problem.
Plan Of Correction
Rooms 218, 311, and 421 were cleaned and treated by pest control. Rooms 226, 232, 410, and 425 were cleaned, decluttered, and treated by pest control. The elevator and tracks were cleaned. The kitchen and dishwasher area were cleaned, leaks were fixed, and treated by pest control. Current residents' rooms were audited; targeted rooms were identified. Current staff were re-educated on the homelike environment and the process for pest management and control. The NHA or designee will conduct 5 random room audits per week to ensure rooms are cleaned, orderly, and free of debris and bugs per policy. Results will be reviewed during the facility's monthly QAPI meeting. The NHA or designee will conduct a weekly review of pest management reports to ensure recommendations are followed through. Results will be reviewed during the facility's monthly QAPI meeting.
Failure to Maintain Means of Egress
Penalty
Summary
The facility failed to maintain the means of egress on one of its five floors, as observed during a survey. Specifically, on December 12, 2024, at 11:22 a.m., it was noted that the right side exit door from the ground floor dining room was secured with a padlock on the corridor side. This door is designated as an exit and is marked with an illuminated exit sign within the dining room. During an interview at the exit conference on the same day, the administrator, maintenance representative, and regional facility representative confirmed that the exit was locked, preventing egress.
Plan Of Correction
Padlocks removed to ensure means of egress. NHA will educate the Maintenance Director on maintaining means of egress. An initial audit was completed to ensure means of egress throughout the facility. NHA/designee will audit weekly x 4, then monthly x 3. Findings will be reviewed in the monthly QAPI.
Stairway Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain stairways in compliance with NFPA 101 standards, as evidenced by two specific deficiencies observed during a survey. Firstly, on the 3rd floor, the South stairtower door was found to not latch properly in its frame when tested. This issue was confirmed during an interview with the administrator, maintenance representative, and regional facility representative. Secondly, environmental services supplies, including wet floor signs and various other items, were improperly stored in the East stairtower on the ground floor. This storage issue was also confirmed during the exit conference interview with the same facility representatives.
Plan Of Correction
Stair tower door fixed to ensure positive latch. Environmental supplies removed from stair tower. NHA educated the Maintenance Director on maintaining stair towers. An initial audit was completed to ensure maintenance of the stair towers. NHA/designee will audit weekly x 4, then monthly x 3. Findings will be reviewed in the monthly QAPI.
Deficient Hazardous Area Door Maintenance
Penalty
Summary
The facility failed to maintain proper safety measures for hazardous area doors on two of five floors. During an observation on December 12, 2024, it was noted that several doors to hazardous areas did not latch properly or lacked self-closing capabilities. Specifically, the basement level medical waste room and the basement level elevator equipment room had doors that failed to latch in their frames. Additionally, the Business office on the ground floor contained excess combustible storage and did not have a self or automatic closing door. These deficiencies were confirmed during an exit conference with the facility's administrator, maintenance representative, and regional facility representative.
Plan Of Correction
The doors observed were fixed to ensure self-closing and positive latching. NHA educated the Maintenance Director on maintaining doors to hazardous areas. An initial audit was completed to ensure self-closing and positive latching of doors to hazardous areas. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.
Improper Installation of ABHR Dispenser
Penalty
Summary
The facility failed to properly monitor the installation of alcohol-based hand rub dispensers (ABHR) on one of its five floors. During an observation on December 12, 2024, at 10:18 a.m., it was noted that an ABHR dispenser was installed directly over a light switch in the 3rd floor dining room. This placement is non-compliant with safety regulations, as it positions the dispenser too close to an ignition source. The issue was confirmed during an exit conference on the same day at 11:45 a.m. with the facility's administrator, maintenance representative, and regional facility representative.
Plan Of Correction
The hand sanitizer dispenser was removed. NHA educated the Maintenance Director on monitoring the location and installation of alcohol-based hand rub dispensers. An initial audit was completed to ensure location and installation of all alcohol-based hand rub dispensers. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.
Deficiencies in Corridor Door Maintenance
Penalty
Summary
The facility failed to maintain corridor doors on three of its five floors, as observed during a survey conducted on December 12, 2024. The survey revealed that several corridor doors were either not smoke tight when latched or failed to positively latch in the frame. Specifically, the door to room 419 on the 4th floor was not smoke tight, the 3rd floor nurse lounge door had no latch, and doors to rooms 203, 217, and 227 on the 2nd floor were either not smoke tight or lacked a latch. During an exit conference on the same day, the administrator, maintenance representative, and regional facility representative confirmed these deficiencies. The report highlights that the facility did not meet the requirements for corridor doors as outlined by the NFPA 101 standards, which are crucial for ensuring the safety and containment of smoke in the event of a fire.
Plan Of Correction
All the observed doors were fixed to ensure positive latch and smoke tightness. NHA educated the Maintenance Director on maintaining corridor doors. An initial audit was completed to ensure positive latch and smoke tightness of corridor doors. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.
Smoke Barrier Doors Not Closing Smoke Tight
Penalty
Summary
The facility failed to maintain smoke barrier doors on one of its five floors, as observed during a survey. On December 12, 2024, at 10:12 a.m., it was noted that the smoke barrier doors in the East corridor did not close smoke tight, which is a requirement for ensuring proper smoke containment. This deficiency was confirmed during an exit conference on the same day at 11:45 a.m. with the facility's administrator, maintenance representative, and regional facility representative, who acknowledged that the doors did not fit together smoke tight.
Plan Of Correction
The east corridor smoke barrier doors were fixed to close smoke tight. NHA educated the Maintenance Director on maintaining smoke barrier doors. An initial audit was completed to ensure smoke tightness of all smoke barrier doors. NHA/designee will audit weekly x 4, then monthly x 3.
Missing Outlet Cover in Nurse Lounge
Penalty
Summary
The facility failed to maintain electrical outlets in compliance with NFPA 101 standards in one of its smoke compartments. During an observation on December 12, 2024, at 9:56 a.m., it was noted that an outlet cover was missing in the Nurse lounge on the 4th floor. This deficiency was confirmed during an exit conference on the same day at 11:45 a.m. with the administrator, maintenance representative, and regional facility representative.
Plan Of Correction
An outlet cover was installed in the Nurse lounge on the 4th floor. NHA educated the Maintenance Director on maintaining electrical outlets. An initial audit was completed to ensure compliance of electrical outlets. NHA/designee will audit weekly x 4, then monthly X 3. Findings will be reviewed in the monthly QAPI.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific health needs. Resident R65, who was cognitively impaired and diagnosed with hemiplegia and muscle weakness, had a contracted left hand that was not addressed in their care plan. Despite being dependent on staff for feeding assistance due to limited mobility, there was no documented evidence of a care plan to maintain or improve the resident's range of motion and mobility. Resident R1, diagnosed with glaucoma and cataracts, had a care plan that only addressed vision problems in the context of fall risk, without specific interventions for the new diagnoses. Additionally, Resident R102, who had chronic respiratory failure and other conditions, had an order for heel protectors that was not included in their care plan. The resident sometimes refused to wear the protectors, but this refusal was not documented in the care plan. These omissions indicate a failure to provide person-centered care plans as required by facility policy.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents were updated to reflect their specific care needs. Resident R85, who was admitted with conditions including diabetes mellitus, anxiety disorder, and dementia, experienced significant weight loss from June 2024 through November 2024. Despite an order dated October 8, 2024, for two house shakes a day to address the weight loss, the care plan only included one house shake daily. Additionally, the care plan's goal for weight stability was not revised to reflect the resident's current weight of 107.6 lbs, which was below the goal of maintaining within 3% of 115.8 lbs. The dietician confirmed the resident's current weight and the order for two shakes daily. Resident R89, admitted with diagnoses including thrombotic pulmonary embolism, muscle wasting, and lack of coordination, required two or more persons for physical assistance with bed mobility and transfer, as per the Minimum Data Set assessment dated October 14, 2024. However, the care plan inaccurately indicated that only one person was needed for assistance. A licensed nurse confirmed that the resident required two persons for assistance with repositioning in bed and transferring.
Failure to Provide Adequate Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a dependent resident, identified as Resident R65, who was cognitively impaired and had diagnoses of hemiplegia affecting the left side and muscle weakness. The resident was dependent on staff for personal hygiene, as noted in the quarterly Minimum Data Set (MDS) dated August 21, 2024. The comprehensive care plan, revised on August 25, 2021, indicated that the resident had a self-care performance deficit related to decreased mobility, with an intervention to check nail length and trim and clean on bath day and as necessary. Despite receiving a bed bath on November 14, 2024, observations on November 12 and November 15, 2024, revealed that Resident R65's fingernails on both hands were significantly long and required trimming. The resident's left hand was contracted, and they made a fist due to the contracture, which further emphasized the need for regular nail care. This deficiency was identified during an observation with Licensed Nurse, Employee E10.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate and address the nutritional needs of two residents, leading to significant weight loss that was not promptly addressed. Resident R84, who had moderate cognitive impairment and diagnoses of adult failure to thrive, muscle wasting, and dementia, experienced a 7.9% weight loss in one week. Despite this significant weight loss, there was no documented evidence that the Registered Dietitian was informed or that any interventions were reviewed or modified to address the resident's needs until a nutrition assessment was conducted months later. Similarly, Resident R107, who was cognitively impaired and had diagnoses of alcohol dependence and cognitive communication deficit, experienced a 5.19% weight loss over one month. The resident was noted to be physically active, often wandering and not sitting for full meals, which contributed to the weight loss. Despite these observations, there was no documented evidence that the Registered Dietitian was made aware of the weight loss or that any interventions were promptly reviewed or modified. The Registered Dietitian did not address the significant weight loss until a nutrition assessment was conducted two months later.
Failure in Pain Management Documentation and Assessment
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R70, who was cognitively impaired and diagnosed with myalgia of the head and neck. The facility's policy on administering pain medication required staff to assess the resident's level of pain, including location and intensity, before administering medication, and to document these assessments in the resident's electronic health record. However, on November 12, 2024, Resident R70 was observed tearful and requesting pain medication, but the Registered Nurse, Employee E11, did not document the administration of the as-needed Tylenol or conduct a pain assessment as required by the facility's policy. Further review of Resident R70's clinical record revealed no evidence that non-pharmacological interventions were implemented prior to administering pain medication, nor was there any documented follow-up to evaluate the effectiveness of the medication given. Interviews with Registered Nurse, Employee E11, and Regional Registered Nurse, Employee E3, confirmed the lack of documentation for the administration of Tylenol and the absence of a pain assessment. This deficiency was identified under 28 Pa. Code 211.9 (a)(1) Pharmacy services and 28 Pa. Code 211.12 (d)(5) Nursing services.
Failure to Identify PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to identify possible triggers that may cause re-traumatization for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted with diagnoses including suicidal ideations, major depressive disorder, and PTSD, had a history of sexual and physical abuse by his father during childhood. Despite having a care plan for PTSD, the plan did not include identification of potential triggers for re-traumatization. This deficiency was confirmed through interviews with the Director of Nursing and a Regional nurse, who acknowledged the omission in the resident's care plan.
Infection Control Deficiencies in Medication Administration and Dressing Change
Penalty
Summary
The facility failed to maintain an effective infection control program during a medication administration review and a peg tube dressing change. During the medication administration to Resident R85, a licensed nurse, Employee E5, was observed touching the medication cart drawer, computer mouse, and medication-blister-pack with bare hands. Without disinfecting her hands, Employee E5 then picked up medication tablets and placed them in a dispensing cup. This action was confirmed by Employee E5 at the time of the observation. In another instance, during a peg-site dressing change for Resident R98, who was on Enhanced Barrier Precautions due to tube feeding, a licensed nurse, Employee E6, did not wear the necessary Personal Protective Equipment (PPE) as required by the Enhanced Barrier Precautions. Additionally, Employee E6 failed to remove soiled gloves and did not put on clean gloves before placing a new dressing around the peg site. This lapse in protocol was also confirmed by Employee E6 at the time of the observation.
Incontinence Management Deficiency Due to Incorrect Catheter Size
Penalty
Summary
The facility failed to implement appropriate treatment and services for incontinence management for a resident with incontinence concerns. The resident, identified as having Neuromuscular Dysfunction of the Bladder, was admitted with a physician's order for a urinary Foley catheter size 16FR/10ML. However, during an observation, it was found that the resident had a Foley catheter of 18FR/10ML instead. This discrepancy was confirmed by a Registered Nurse at the facility.
Failure to Provide Timely Access to Resident's Personal Funds
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to their personal funds, as required by their policy. The policy stated that upon discharge, eviction, or death, the facility must convey the resident's funds and a final accounting within 90 days. Resident CL1 was discharged and transferred to another facility on November 30, 2023. However, the resident's account was not closed until February 1, 2024, and the refund request was sent to corporate on February 20, 2024. An interview with the business office confirmed the delay, and the Nursing Home Administrator revealed that the corporate office never received the refund request, resulting in the refund check not being sent to the resident. The facility still owed the resident $3,418.20.
Failure to Administer Prescribed Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure ongoing collaboration with the dialysis facility for the provision of medications as ordered by the physician for a resident requiring hemodialysis. The clinical record review revealed that the resident, who had a diagnosis of end-stage kidney disease, was scheduled for hemodialysis three times a week. However, the nursing staff did not administer the prescribed medications, including Lispro insulin, Phos lo, apixaban, and isosorbide mononitrate ER, at the required times before and after dialysis sessions on multiple occasions in March 2024. This failure was confirmed by the director of nursing during an interview. The facility's policies on administering medications and dialysis care emphasized the responsibility of the licensed nurse to administer and document medications according to physician orders and the need for effective communication and collaboration with the dialysis center. Despite these policies, the resident did not receive the necessary medications as ordered, leading to a deficiency in the provision of safe and appropriate dialysis care. The facility's contract with the dialysis center also required ongoing communication and collaboration, which was not adequately maintained in this case.
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 1,824 citations issued within 25 miles in the last 12 months — including the 24 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 Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Logan Square Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 26 | 0 |
| Graduate Post Acute | 1.5 mi | ★★★★★ | 33 | 0 |
| University City Rehabilitation And Healthcare Ctr | 2.3 mi | ★★★★★ | 11 | 0 |
| Rittenhouse Post Acute | 2.3 mi | ★★★★★ | 2 | 0 |
| Abigail House For Nursing & Rehabilitation | 2.5 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.