Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Longmeadow Healthcare Center during CMS and state inspections, most recent first.
A facility failed to ensure bathroom call lights were accessible in shared resident bathrooms. Surveyors found the pull strings were too short for two shared bathrooms, and residents with dementia, visual impairment, and severe cognitive impairment used those bathrooms. An LPN, maintenance, and a CNA acknowledged the strings were short and that a resident who fell would not be able to reach the call light.
Failure to Deliver Residents’ Mail on Saturdays: Residents reported that mail arriving on Saturdays was not distributed because no office staff checked the mailbox that day. The BOM stated she checked mail Monday through Friday only and usually retrieved Saturday mail on Monday, while the Administrator later said the Dietary Mgr would be given the mailbox key to check and distribute mail on Saturdays. The facility policy stated residents have the right to send and receive mail and to privacy of such communications.
A resident with CKD, intellectual disability, depressive disorders, and a cognitive communication deficit was observed with a stained fitted sheet that remained unchanged across multiple observations, while staff gave inconsistent accounts of who was responsible for changing linens. In a separate finding, a shower room had cracked, moldy caulking and missing floor tiles near the drain, and staff were unaware of how long the damage had been present.
Failure to provide scheduled resident activities: the facility did not carry out activities listed on the calendar, including appetizers and a wheelchair car wash, after the Activities Director left. Residents reported they were not being offered all scheduled activities, an LVN was unaware of the wheelchair car wash, and the DON and Administrator acknowledged the calendar was not being followed while the facility was without an Activities Director.
Late Lunch Meal Service: Lunch was not served at the posted times for multiple halls and the dining room. Trays for the 400 hall, dining room, 200 hall, and 100 hall were delayed, with the last 100 hall tray served at 1:30 PM. Nine residents reported lunch was often 45 minutes to 1 hour late, and the Dietary Mgr stated missing meal tickets delayed service.
Kitchen Food Storage and Dish Machine Temperature Deficiencies: The facility failed to keep the chest freezer free of ice buildup and failed to keep multiple sherbert and ice cream containers sealed, with freezer burn noted and a dead bug found in one open container. The facility also failed to ensure the low-temp dish machine reached the required 120 degrees F wash and rinse temperatures, and the Dishwasher did not check or document temps or ppm before use; the dish machine log was blank.
A resident with dementia and severe cognitive impairment was observed with facial hair on her chin and upper lip after staff had not offered shaving during the past few days. The resident stated she preferred to be shaved, and interviews with an LVN, CNA, DON, and the Administrator confirmed staff were responsible for female residents’ shaving during shower days and as needed, but this resident had not refused care. The facility also stated it did not have a policy on female resident facial hair.
A resident with traumatic brain injury, vascular dementia, and limited ROM was observed with his left hand drawn into a fist and no ordered resting hand splint in place. The care plan and OT notes included use of the splint, and the physician order directed staff to apply it as the resident would allow and check skin each shift. Staff including CNA, PTA, OT, RN, and DON stated the splint had not been seen in use for about a month or longer, and the resident said he would wear it if provided.
Inadequate Perineal Care During Incontinent Episode: A male resident who was incontinent of bladder and dependent on toileting and personal hygiene did not receive complete perineal care during an incontinent episode. CNA B cleaned the front pubic area but failed to clean the penis and scrotum before completing care, and later acknowledged the omission. The DON stated male residents’ scrotum and penis were to be cleaned during incontinent care, consistent with the facility’s perineal care policy.
A facility failed to properly label medications on 2 carts. One resident’s controlled pain medication had a broken blister seal with the pill still inside, and an insulin pen for another resident had no open date even though it appeared used. The LVN stated blister packs were not checked during narcotic counts, and the DON stated opened controlled meds should be discarded and insulin pens must be dated when opened because they have a limited shelf life.
The facility failed to maintain infection control during care for two residents. During incontinent care, a CNA used the same gloves while moving from dirty to clean tasks and did not change gloves or perform hand hygiene until after leaving the room. For another resident on EBP for a wound, an LPN performed wound care without wearing a gown despite the care plan and posted PPE instructions requiring gown and glove use for high-contact care.
Several residents with cognitive or physical impairments did not receive necessary assistance with nail care, resulting in long, dirty fingernails that were not cleaned or trimmed as required. Staff interviews and observations indicated a lack of consistent monitoring and unclear responsibilities among CNAs and nurses, despite facility policy mandating regular nail care to prevent infection and injury.
The facility did not ensure that food items in the kitchen were properly labeled, dated, or covered, and served hot food below the required holding temperature. Multiple perishable items were found without dates or labels, and a pureed burger was served at 133.7°F, below the required standard. Staff interviews revealed inconsistent knowledge of proper procedures, and facility policies were not followed, affecting all residents receiving meals, including a resident on dialysis.
Staff failed to follow infection control protocols during incontinence and catheter care for two residents, including not changing gloves or performing hand hygiene between dirty and clean tasks, and not donning required PPE for a resident on Enhanced Barrier Precautions. Staff also improperly disposed of used linens and trash, and did not consistently sanitize hands after glove removal, despite being aware of facility policies and procedures.
The facility failed to provide accessible and working call lights in two shower rooms, with one lacking a reachable cord and the other having a nonfunctional call light. Interviews and observations confirmed that staff were responsible for checking and reporting issues, but maintenance checks were infrequent and the Administrator was unaware of the deficiencies until the survey.
A resident who was incontinent of bladder and dependent on staff for personal hygiene did not receive complete perineal care after an incontinent episode. An LVN failed to clean the resident's penis and scrotum as required by facility policy, despite the resident's care plan indicating the need for such care to prevent complications like UTIs and skin breakdown.
A resident with severe cognitive impairment and on hospice care was subjected to verbal abuse by a CNA, as reported by a roommate. The incident was reported internally but the resident's physician and representative were not notified, contrary to facility policy. Staff interviews and record review confirmed the lack of required notifications following the event.
A resident with severe cognitive impairment and on hospice care did not have their care plan reviewed or revised after a CNA was reported to have used inappropriate language while providing care. Although the incident was reported and investigated, the care plan was not updated to address the resident's psychosocial or emotional needs as required by facility policy.
A resident with significant cognitive and physical impairments sustained burns after spilling hot coffee on himself due to the facility's failure to provide a screw-on lid cup and adequate supervision as outlined in his care plan. The resident, who required extensive assistance and supervision, was left unsupervised, leading to the incident.
The facility failed to provide proper respiratory care for four residents by not labeling or dating oxygen supplies and improperly storing nasal cannulas. Staff interviews confirmed these oversights, which posed an infection risk. The facility lacked a formal policy on these procedures.
The facility's kitchen failed to meet professional food safety standards, with issues such as improper storage of ice scoops, unsealed and undated food items, and expired products. Observations included dried residues on containers and lack of visible expiration dates, posing contamination risks. Interviews with staff highlighted the importance of cleanliness and proper dating to ensure food safety.
A resident with mobility issues was found with an inaccessible call light, which is crucial for requesting assistance. Despite staff awareness of the importance of call lights, the resident's call light was not consistently placed within reach, leading to a deficiency. Interviews with staff highlighted the need for accessible call lights, but the facility lacked a specific policy to ensure this.
A resident experienced delays in accessing her trust fund at a facility, sometimes waiting days for money and being required to provide receipts for purchases. The facility limited withdrawals to $75 per month, citing the need to ensure funds for other residents. The Business Office Manager and Administrator confirmed these practices, which contradicted the facility's policy on residents' rights to manage their financial affairs.
The facility failed to ensure a homelike environment for two residents in the secure unit, both with impaired cognitive status and non-Alzheimer's dementia. One resident's room was bare, with only a comforter and baby dolls, while the other lacked decorations and a TV. The facility discouraged personal items due to theft concerns, and the DON was unaware of the residents' desires for a more homelike setting.
The facility failed to develop comprehensive care plans for three residents, including one requiring oxygen administration, another undergoing dialysis, and a third with behavior issues towards female residents. This lack of care planning could lead to inadequate care and safety concerns.
A resident with a G-tube did not receive appropriate care as the facility failed to follow protocols for enteral feeding. Medications were not administered one by one, remnants were left in the medication cup, and the feeding tube was not capped when detached. The syringe used for medication administration was not cleaned after use, increasing the risk of infection. The ADON acknowledged these failures, and the DON confirmed the importance of following the facility's policy.
A facility failed to document necessary physician orders for a resident undergoing dialysis, despite the resident's dependence on the treatment due to end-stage renal disease. The absence of orders, including dialysis type, schedule, and site assessments, was acknowledged by the ADON and DON, who stressed the importance of these orders for effective care. The facility's policy requiring confirmation of dialysis orders was not adhered to.
A facility failed to maintain accurate records for controlled drugs, specifically Fentanyl patches, for a resident with severe cognitive impairment and chronic pain. A box of patches went missing, and staff interviews revealed that the practice of counting medication cards during narcotic counts had been discontinued, contributing to the oversight. The incident was reported, but the alleged perpetrator was not identified.
A resident was administered Paliperidone ER, an antipsychotic medication, without a proper diagnosis of schizophrenia. The resident, who had severe cognitive impairment and a diagnosis of bipolar disorder, was prescribed the medication for schizophrenia related to bipolar disorder, despite not exhibiting schizophrenia symptoms. Facility staff, including the DON, were unaware of the reason for the medication order, and a request for diagnosis clarification was not addressed, violating the facility's policy on psychotropic medications.
Two CNAs failed to adhere to infection control protocols during incontinence care for two residents, leading to potential cross-contamination. One CNA did not wash hands before donning gloves and failed to change gloves after handling soiled briefs. The other CNA initially performed hand hygiene but did not change gloves or sanitize hands after cleaning a resident's buttocks, contaminating various items in the process. Interviews with facility leadership confirmed that these actions violated the facility's infection control policies.
Call Light Pull Strings Inaccessible in Shared Bathrooms
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences when the call light system in shared bathrooms inside resident rooms was not accessible to four residents. On 06/29/2026, surveyors observed that the call light pull strings in the shared bathrooms for Resident #24 and Resident #28 were about 2 feet above the floor, and the pull string in the shared bathroom for Resident #39 and Resident #62 was about 3.5 feet above the floor. Surveyors also observed that Resident #39 and Resident #62 shared a bathroom in their room, and Resident #24 and Resident #28 shared a bathroom in their room. Resident #24 was a female admitted on 11/08/2024 with diagnoses including dementia, Alzheimer’s disease, and type 2 diabetes, and had a BIMS score of 09 indicating moderate cognitive impairment. Her care plan noted impaired visual function related to presbyopia and that she had glasses but refused to wear them. Resident #28 was a male admitted on 05/16/2023 with diagnoses including dementia, Alzheimer’s disease, and blindness to the left eye, with a BIMS score of 10 indicating moderate cognitive impairment. His care plan noted impaired visual function related to left eye blindness. Resident #39 was a female admitted on 06/24/2025 with diagnoses including dementia, Alzheimer’s disease, diabetic retinopathy, and history of falling, with a BIMS score of 99 indicating severe cognitive impairment. Resident #62 was a female admitted on 09/26/2025 with diagnoses including dementia and type 2 diabetes, with a BIMS score of 04 indicating severe cognitive impairment. During interviews, Resident #28 stated he used the shared restroom and could not reach the call light if he fell on the floor. LVN G stated he was not aware the bathroom call light strings were short, and said if a resident fell in the shared toilet, he or she would not be able to reach the call light, which would put residents at risk for injury and delay in care. Maintenance stated he was responsible for ensuring the call light system was appropriately installed and working, and that he was not aware of the policies or regulations related to the height or length of the call light string. CNA H stated short call lights in resident bathrooms would put residents at risk of injury, not being able to reach staff in an emergency, and delay in care.
Failure to Deliver Residents’ Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods by not delivering residents’ mail on Saturdays. During a confidential group interview with 8 residents, it was reported that when mail arrived at the facility on Saturdays, it was not distributed because there was no office staff available to check the mail. One resident stated that residents helped with mail delivery during the week, but no mail had been delivered to residents on Saturdays. The Business Office Manager stated she was responsible for checking the mail, that she checked it every day at 2 PM and sorted mail Monday through Friday, and that she did not work on Saturdays. She stated she typically checked the mail first thing Monday morning to obtain mail delivered on Saturdays. The Administrator stated he gave the mailbox key to the Dietary Manager so she could check the mailbox every Saturday and distribute residents’ mail, and if she was off, the key would be available to dietary staff. Record review of the facility’s Resident Rights policy reflected that residents have the right to send and receive mail and to receive letters, packages, and other materials delivered to the facility through a means other than a postal service, including privacy of such communications.
Soiled Bed Linens and Damaged Shower Room
Penalty
Summary
The facility failed to provide clean bed linens for a resident who was admitted with chronic kidney disease, unspecified intellectual disabilities, depressive disorders, and a cognitive communication deficit. The resident’s care plan indicated she required staff assistance with bathing and dressing, used a wheelchair, and needed help with toileting. On 6/29/26, an observation of the resident’s bed showed a fitted sheet with a yellow circular stain about the size of a fist. The same stain remained visible during another observation later that day and was still present the next morning. The resident was not in the room during the observations and was unable to say when her sheets had last been changed. During interview and observation, a CNA stated the resident’s sheets had not been changed and that the yellow stain was still visible. The CNA said hospitality aides were changing bed sheets that morning and should have changed the resident’s sheets, and also stated the bottom sheet appeared dirty. A hospitality aide later stated the resident’s sheets were soiled and needed to be changed, and began removing items from the bed to change them. Staff interviews reflected differing views about who was responsible for changing linens, but multiple staff acknowledged that dirty sheets should be changed when soiled or on shower days. The facility also failed to ensure Shower room [ROOM NUMBER] was free from debris and in good working condition. During observation, the caulking between the floor and wall tile was cracked, discolored with green black mold, and broken off in the shower. Five floor tiles were missing near the drain, leaving jagged and dirty concrete exposed. The floor tech stated he had not noticed the caulking, was unsure when it had last been repaired, and was unsure whether the missing tiles had been reported. The Maintenance Director stated he had just been notified, had not received a maintenance request for the caulking, and was unable to say how long the tiles had been missing. The DON and Administrator stated they were not aware of the shower room condition.
Failure to Provide Scheduled Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities based on residents’ comprehensive assessments, care plans, and preferences for 8 of 8 confidential residents reviewed. The deficiency was identified when the June 2026 activities calendar listed an 11:00 a.m. appetizers activity and a 2:00 p.m. wheelchair car wash for 6/30/26, but those activities were not carried out as scheduled. During a confidential group interview, residents stated the Activities Director had been terminated a few weeks earlier and they had not been offered all activities listed on the calendar, which frustrated them because the activities were not being provided as scheduled. Observation and interview at 11:07 a.m. showed no appetizers being offered in the dining room, and two residents said the appetizers were not served because the Activities Director used to organize them and was no longer working at the facility. Later that day, an LVN stated she was not aware of a wheelchair car wash being scheduled, and observation did not show any staff or residents washing wheelchairs. The Business Office Manager said she assisted with activities since the Activities Director was gone, the Administrator was in charge, and she did not know who was covering specific activities for 6/30/26. The DON stated she was not aware the activities calendar was not being followed, and the Administrator stated the Activities Director had been gone for about 1.5 weeks and the facility was still trying to hire a replacement. The facility policy stated individual programs are developed and implemented regularly consistent with individualized leisure interests and based on the assessment.
Late Lunch Meal Service
Penalty
Summary
The facility failed to ensure that lunch was served at the scheduled times posted for the 400 hall, dining room, 300 hall, 200 hall, and 100 hall on 06/29/26. The posted schedule showed lunch service beginning at 11:30 AM for the 400 hall, 11:45 AM in the hall, 12:00 PM in the dining room, 12:15 PM on the 300 hall, 12:30 PM on the 200 hall, and 12:45 PM on the 100 hall. Observations showed the 400 hall trays were on the unit at 12:15 PM and the last resident tray there was served at 12:30 PM. The dining room lunch had not yet been served at 12:17 PM, and residents were still being served at 12:40 PM. Meal delivery to the 200 hall and 100 hall was also delayed. At 12:57 PM and 1:03 PM, trays for the 100 and 200 halls had not been delivered. An LVN stated at 1:04 PM that the 200 hall trays had not yet been passed, and by 1:11 PM all 200 hall trays had been served. At 1:09 PM the 100 hall trays had not yet been delivered, and at 1:21 PM they were being served; the last 100 hall tray was served at 1:30 PM. In a confidential group interview, nine residents stated lunch meals were served late and could be 45 minutes to 1 hour late. The Dietary Manager stated that when residents did not receive food per the posted meal times, it placed them at risk for a delay in receiving food, and she stated that not getting all resident meal tickets on time delayed meal service.
Kitchen Food Storage and Dish Machine Temperature Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards in the kitchen. During observation, the chest freezer had about 1 to 2 inches of ice accumulation around the inside, and several frozen dessert containers were found unsealed, including orange sherbert and multiple chocolate and vanilla ice cream containers with freezer burn. One chocolate ice cream container was open around the rim and contained a dead black bug. The Asst. Dietary Manager stated the freezer should be cleaned out and the ice cream and sherbert should be sealed to prevent freezer burn and contaminants such as bugs. The facility also failed to ensure the low-temperature dish machine reached the required minimum temperatures. Observation showed wash and rinse temperatures below 120 degrees F, with readings of 100/110 degrees F and then 110/115 degrees F. The Dishwasher stated she did not check the dish machine temperatures or ppm before using it, and the dish machine log for the two days reviewed was blank with no temperatures or ppm documented. The Asst. Dietary Manager stated the machine could not be used to sanitize dishes if the water temperatures did not meet the minimum 120 degrees F and acknowledged the temperatures and ppm were not documented or checked.
Failure to Provide Grooming Assistance for a Female Resident
Penalty
Summary
The facility failed to ensure a resident who was unable to complete activities of daily living received the necessary assistance to maintain grooming and personal hygiene. Resident #60 was a female admitted on 05/20/2026 with diagnoses including dementia and hypertension. Her MDS dated 05/27/2026 showed a BIMS score of 06, indicating severe cognitive impairment, and she required supervision or touching assistance with toileting hygiene. Her care plan, revised 06/04/2026, identified an ADL self-care performance deficit related to cognitive deficits/dementia and directed staff to assist with personal hygiene as required, including hair, shaving, and oral care. During observation on 06/29/2026, Resident #60 was sitting in the dining area with approximately 1/4 inch-long facial hair on her chin and upper lip. She stated she had received showers, but staff had not offered to shave her during the past few days, and she did not feel comfortable having facial hair because she liked it shaved. Interviews with an LVN, a CNA, the DON, and the Administrator confirmed that staff were responsible for shaving female residents as needed and during shower days, and that Resident #60 had not refused facial hair removal. The Administrator also stated the facility did not have a policy on female resident facial hair and did not submit a general ADL care policy by the exit date and time.
Failure to Provide Ordered Hand Splint for Resident With Limited ROM
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to maintain or improve ROM and prevent further decrease in ROM. Resident #13 was a male with diagnoses including traumatic subdural hemorrhage, vascular dementia, and traumatic brain injury. His quarterly MDS reflected a BIMS score of 9, indicating moderate cognitive impairment, and documented limited ROM on one side of both the upper and lower extremities with partial to substantial assistance needed for ADLs and mobility. The resident’s care plan, last reviewed on 05/01/26, included use of a left resting hand splint for left hand contracture and skin checks each shift, but it did not reflect that he refused the splint. An OT progress report stated the resident was to use the resting hand splint for 2.5 hours to support anatomical alignment, skin integrity, proper joint alignment, and functional use of the extremity. The physician order directed use of the left resting hand splint as the resident would allow, with skin integrity checks each shift and removal at bedtime. On 06/29/26 and 06/30/26, surveyors observed the resident sitting in his wheelchair and later in the therapy room with his left hand drawn into a fist and no splint in place. The resident stated staff had taken the splint away and he had not had it applied for a couple of months, though he said it helped and he would wear it if provided. CNA L, PTA R, OT Q, and RN O each stated they had not seen the splint used for about a month or longer, and RN O said the resident did not have the splint on about 90% of the time when he worked. The DON stated nurses were responsible for placing the splint and assessing skin each shift if the resident allowed it.
Inadequate Perineal Care During Incontinent Episode
Penalty
Summary
The facility failed to ensure appropriate perineal care for a male resident who was incontinent of bladder and dependent on toileting and personal hygiene. The resident’s record showed diagnoses including dementia, elevated blood pressure, and diabetes mellitus, and his care plan directed staff to provide care at least every 2 hours and monitor for signs and symptoms of urinary tract infection. During an observation of incontinent care, CNA B and LVN A entered the resident’s room, washed their hands, donned gloves, and transferred the resident from a geri-chair to the bed. CNA B cleaned the resident’s front pubic area, but did not clean the resident’s penis or scrotum before continuing with care. The observation continued with LVN A rolling the resident onto his side while CNA B cleaned the anal area and buttocks, changed the draw sheet, placed a clean brief under the resident, and assisted with dressing. After leaving the room, CNA B stated she realized she had not cleaned the resident’s scrotum and penis. The DON stated staff were to clean the scrotum and penis of male residents during incontinent care and acknowledged that not providing accurate incontinent care placed residents at risk for urinary tract infections, skin breakdown, and poor hygiene. The facility policy for perineal care directed staff to wash the penis in a circular motion from the tip down to the base and continue care to the scrotum and inner thigh.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to label drugs and biologicals used in accordance with accepted professional principles for 2 medication carts reviewed. On Medication Aide Cart Hall 200, the blister pack for Resident #50’s Tylenol codeine 300-30 mg tablet had one blister seal broken with the pill still inside the broken blister. The medication count sheet was reviewed and the count was correct, but the blister pack itself had not been checked during the count. The LVN stated she was unaware when the seal was broken and did not know who damaged it, and she stated nurses were responsible for checking medication blister packs for broken seals during narcotic counts at shift change. On Nurses Medication Cart Hall 200, the insulin pen for Resident #77 had no open date even though the pen appeared used. The pen instructions stated it should be discarded after 28 days of use, and the LVN stated nurses were responsible for checking insulin pens for open dates before administration and labeling the pen when first opened. The DON stated that a broken blister pack medication should be discarded and that insulin pens and vials needed to be dated when opened because they had a specific shelf life and could lose effectiveness if not used within that time.
Infection Control and PPE Failures During Resident Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two residents observed for infection control. One resident was dependent on toileting and personal hygiene and had diagnoses including dementia, elevated blood pressure, and diabetes mellitus. During incontinent care, two staff members entered the room, washed their hands, and donned gloves before transferring the resident from a geri-chair to the bed and providing peri care. During the care, CNA B cleaned the resident’s front pubic area, then the anal area and buttocks, and pushed the soiled draw sheet under the resident while still wearing the same soiled gloves. She placed a clean brief under the resident and fastened it without changing gloves, then assisted the resident with dressing before removing her gloves and sanitizing her hands in the hallway. In interview, CNA B stated she should change her gloves and perform hand hygiene when going from dirty to clean and acknowledged that failing to do so would expose residents to infections. A second resident had dementia and a sacral pressure ulcer and was on enhanced barrier precautions. The care plan directed staff to don gloves and a gown for high-contact activities including wound care. During observation, LVN E entered the room without PPE, washed her hands, donned gloves, and performed wound care without wearing a gown. She then adjusted the resident in bed, covered her, removed her gloves, washed her hands, gathered the trash bag, and exited. LVN E stated she knew she was supposed to wear a gown for high-contact care on enhanced barrier precautions but forgot, and the DON stated staff were expected to remove gloves and sanitize hands when going from dirty to clean and to wear gowns before touching residents with a port of entry.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene for four residents who were unable to perform these tasks independently. Observations and interviews revealed that these residents had long, dirty fingernails that had not been cleaned or trimmed as required. In each case, the residents either expressed discomfort with the condition of their nails or were unable to recall when they were last trimmed, and staff were either unaware of the issue or had not addressed it. Resident assessments and care plans indicated that these individuals had significant cognitive or physical impairments, such as hemiplegia, dementia, or other conditions requiring staff assistance with personal hygiene. Despite these documented needs, staff did not ensure that nail care was performed regularly. Interviews with CNAs, nurses, and administrative staff confirmed that there was a lack of consistent monitoring and follow-through regarding nail care, with some staff unaware of their responsibilities or the current condition of the residents' nails. Facility policy required regular nail care to prevent infection and injury, with specific instructions for staff roles based on resident diagnoses such as diabetes. However, observations showed that these policies were not consistently implemented, as evidenced by the presence of long, discolored, and dirty fingernails on multiple residents. Staff interviews further revealed gaps in communication and accountability regarding nail care duties.
Failure to Properly Store and Serve Food According to Professional Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen. During an observation of the facility's reach-in refrigerator, multiple food items were found not dated, labeled, or properly covered. These included a cup of cut mixed fruit, three plates of cut salad, six small cups of white dressing, cheese slices left uncovered and loosely wrapped, and a snack bag with a half sandwich and apple. Staff interviews confirmed that all kitchen personnel were responsible for labeling, dating, and covering food items, but several items were not properly managed, and staff were unsure of their preparation dates or who prepared them. Additionally, the facility failed to ensure that hot food was held at the required temperature during meal service. During lunch service, a pureed burger intended for residents on a pureed texture diet was measured at 133.7°F, below the required holding temperature. Despite this, the food was served to residents. Staff interviews revealed confusion and inconsistency regarding the correct holding temperature, with some staff stating it should be 160°F, others 140°F, and the facility dietitian stating 135°F. The Dietary Manager acknowledged that the food was served below the facility's policy requirement and that it was not reheated due to time constraints. Record reviews of facility policies and the FDA Food Code confirmed the requirements for labeling, dating, and covering food items, as well as maintaining hot food at safe temperatures. Staff interviews consistently indicated awareness of these requirements, but the observed practices did not align with policy or regulatory standards. The deficiencies were observed to potentially affect all residents receiving meals from the facility's kitchen, including a resident on dialysis who received an improperly labeled snack bag.
Failure to Follow Infection Control Protocols During Incontinence and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during incontinence and catheter care for two residents. In the case of one resident with severe cognitive impairment and total dependence for personal hygiene, both an LVN and a CNA performed peri care without changing gloves or performing hand hygiene between dirty and clean tasks. The staff also failed to sanitize their hands after glove removal, and one staff member left the resident's room without performing hand hygiene. Both staff acknowledged during interviews that they did not follow proper procedures, including not bringing hand sanitizer into the room. For another resident with intact cognition and a Foley catheter, a CNA provided catheter and incontinence care without donning the required gown for Enhanced Barrier Precautions (EBP), despite signage and supplies being available outside the room. The CNA changed gloves multiple times without performing hand hygiene and placed used linens and trash bags on the floor, contrary to infection control protocols. The CNA admitted to forgetting to wear the required PPE and recognized the importance of hand hygiene and proper disposal of contaminated materials. Record reviews confirmed that both residents required assistance with personal hygiene and were at risk for infection due to their medical conditions. Facility policies required hand hygiene after glove removal and the use of appropriate PPE for residents on EBP, especially those with indwelling medical devices. Staff interviews further confirmed awareness of the correct procedures, but these were not followed during the observed care activities.
Inaccessible and Nonfunctional Call Lights in Shower Rooms
Penalty
Summary
The facility failed to ensure that resident shower rooms were adequately equipped with functioning call systems. Specifically, in the 100 hall shower room, the call light in the shower area was missing a cord, making it inaccessible to residents. In the 200 hall shower room, the call light in the shower area was not working. These deficiencies were identified through resident interviews, which revealed ongoing complaints about the lack of an accessible call light cord, and through direct observations with facility staff confirming the missing and nonfunctional call lights. Interviews with staff indicated that CNAs and nurses were responsible for checking the functionality of call lights during cleaning and were expected to report issues to maintenance using a QR code system. However, the Maintenance Director was unaware of the nonfunctional call light in the 200 hall shower room until it was brought to his attention during the survey. The facility did not have a specific policy regarding call lights, and maintenance checks of shower rooms occurred infrequently, sometimes as seldom as once a month. The Administrator was not aware of the deficiencies until the survey and expected staff to report maintenance concerns as they arose.
Failure to Provide Complete Perineal Care for Incontinent Resident
Penalty
Summary
A deficiency occurred when a male resident who was incontinent of bladder did not receive appropriate perineal care following an incontinent episode. During an observed care episode, an LVN and a CNA provided peri care to the resident, who was dependent on staff for toileting and personal hygiene due to severe cognitive impairment and impaired mobility. The LVN cleaned the resident's front pubic area but failed to clean the penis and scrotum, which is required per the facility's perineal care policy. The LVN then completed care of the anal area and buttocks, and the resident was assisted with dressing and transferred to a chair. The resident's care plan indicated a need for monitoring and providing incontinent care to prevent complications such as urinary tract infections and skin breakdown. The LVN later confirmed in an interview that she did not clean the scrotum and penis and acknowledged that this was not adequate incontinent care. The facility's policy specifically directs staff to clean the penis and scrotum for male residents during perineal care.
Failure to Notify Physician and Representative After Verbal Abuse Incident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was protected from verbal abuse and that appropriate notifications were made following an incident. A certified nursing assistant (CNA) was reported by a roommate to have loudly used inappropriate language, specifically saying 'shut the fuck up,' while providing care to a resident who was on hospice and had severe cognitive impairment. The incident was overheard by the roommate, who then reported it to the Assistant Director of Nursing (ADON). The resident involved was dependent on staff for most self-care needs, had a BIMS score of 00 indicating severe cognitive impairment, and was unable to communicate effectively due to her condition and hearing impairment. Following the report of the incident, there was no documentation that the resident's attending physician or representative was notified, as required by facility policy. Interviews with staff, including the Director of Nursing (DON), ADON, and a Licensed Vocational Nurse (LVN), confirmed that the incident was reported internally but not communicated to the resident's family or physician. The resident's family member, who visited daily, stated she was not informed of the incident by the facility and only learned of it through the survey process. The social worker was also unaware of any facility report involving the resident. Record review and staff interviews further revealed that the facility's policy required immediate notification of the physician and family in the event of a significant change in status, but this protocol was not followed in this case. The roommate who reported the incident did not observe any changes in the resident's behavior following the event, and there was no documentation of any changes in medication or care. The failure to notify the appropriate parties after the incident constituted a deficiency in protecting the resident from abuse and ensuring proper communication as outlined in facility policy.
Failure to Update Care Plan After Staff-to-Resident Verbal Incident
Penalty
Summary
The facility failed to review and revise the comprehensive, person-centered care plan for a resident after an incident in which a certified nursing assistant (CNA) raised her voice and used inappropriate language while providing care. The incident was reported by the resident's roommate, who overheard the CNA loudly using profane language during care. Despite this report, the resident's care plan was not updated to address the incident or to ensure that the resident's needs were being met in light of the event. The resident involved had significant medical and cognitive impairments, including senile degeneration of the brain, epilepsy, and unspecified psychosis, and was dependent on staff for most self-care needs. The resident was also on hospice care and had a BIMS score indicating severe cognitive impairment. Observations and interviews confirmed that the resident was unable to communicate effectively and relied on staff for emotional, intellectual, physical, and social needs. The care plan in place prior to the incident included general interventions for staff interaction but was not revised following the reported event. Interviews with staff and review of records revealed that although the incident was reported to facility leadership and investigated, there was no documentation of a care plan update or new interventions to address the resident's psychosocial or emotional needs after the incident. The facility's policy required ongoing review and revision of care plans to reflect changes in residents' needs and preferences, but this was not followed in this case.
Failure to Prevent Resident Burn Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, resulting in the resident spilling hot coffee on himself and sustaining burns. The resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, aphasia, and lack of coordination, required extensive assistance for most activities of daily living and supervision while eating. Despite these needs, the facility did not provide a cup with a screw-on lid as specified in the resident's care plan, nor did they ensure one-person supervision while the resident was eating. On the day of the incident, the resident spilled coffee on himself, which went unwitnessed and unassessed for an undetermined amount of time. The resident sustained burns to his forearm, hip, and waist. The coffee was served in a water cup with a lid, straw, and handle, which the resident had been using since his admission in 2017. The resident reported that the lid fell off when he dropped the cup, leading to the spill. The facility's failure to adhere to the care plan and provide the necessary supervision and equipment directly contributed to the incident. The resident's care plan had identified a risk of burns due to hot liquids, with specific interventions to prevent such injuries. However, these interventions were not followed, as evidenced by the use of an inappropriate cup and lack of supervision. The facility's oversight in implementing the care plan and ensuring the resident's safety measures were in place led to the resident's injury.
Failure to Ensure Proper Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who required oxygen therapy. Specifically, the facility did not ensure that the nasal cannula tubing and humidity bottles for two residents were labeled or dated, which is a part of the nursing protocol to prevent infection. Observations revealed that the oxygen supplies for these residents were not dated or labeled, and interviews with staff confirmed that this was a responsibility of the night shift nurses, as per the facility's protocol. Additionally, the facility did not properly store the nasal cannula for two other residents. Observations showed that the nasal cannulas were not bagged when not in use, which could lead to contamination and infection. Staff interviews indicated that the nasal cannulas should be bagged to maintain cleanliness, but this procedure was not followed, resulting in the nasal cannulas being exposed to potentially unclean surfaces. The Director of Nursing (DON) and other staff members acknowledged the importance of dating, labeling, and properly storing oxygen supplies to prevent infection. However, the facility did not have a formal policy regarding these procedures, which contributed to the oversight. The lack of adherence to these protocols posed a risk of infection to the residents receiving oxygen therapy.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The deficiencies included improper storage of ice machine scoops, with one scoop found inside the ice machine and another placed on a shelf next to it. This improper storage could lead to contamination of the ice. Additionally, several food items in the dry goods pantry were not properly sealed or dated, including opened bags of potato chips, tortillas, cornbread mix, and grits, which were not marked with an opened date. These practices exposed the food to air-borne contaminants and potentially compromised their freshness. Further observations revealed that several containers, such as those holding chocolate syrup, red food coloring, and various sauces, had dried product residue on their lids and sides, which could attract insects and compromise cleanliness. Many of these containers lacked visible expiration or use-by dates, including items like Worcestershire sauce, apple cider vinegar, cooking wine, and pancake syrup. The presence of expired food items, such as jars of sliced pepperoncini peppers, was also noted, which could affect the taste and safety of the food served to residents. Interviews with the Dietary Manager and the Administrator confirmed the importance of maintaining cleanliness and proper dating of food items to ensure safety and freshness. The facility's policy on food storage emphasized the need for orderly maintenance of storage areas, proper sealing and dating of opened packages, and the discarding of expired products. The U.S. FDA Code was also referenced, highlighting the requirement for proper labeling and protection of food from contamination.
Inaccessible Call Light Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light system was accessible, which is a critical component for residents to obtain assistance and communicate their needs. Resident #76, an elderly female with muscle wasting, unsteadiness of feet, and abnormalities of gait, was observed to have her call light hanging on the wall near the privacy curtain, out of her reach. Despite being informed of this, LVN A did not reposition the call light within the resident's reach, leaving the resident unable to call for help. Interviews with staff, including CNA A, ADON B, HA A, and the DON, consistently highlighted the importance of having the call light within reach for residents to communicate their needs and request assistance. CNA A and HA A both took action to place the call light within reach after being informed of its inaccessibility. The staff acknowledged that without the call light, residents might attempt to stand up, risking falls and other injuries, and their needs would not be addressed. The facility's policy on resident rights emphasizes the right to reasonable accommodation of needs and preferences, yet there was no specific policy for ensuring call lights are within reach. The Administrator and DON both recognized the importance of the call light as a lifeline for residents and expressed the expectation that staff should ensure call lights are accessible. However, the lack of a specific policy and consistent monitoring led to the deficiency observed in Resident #76's case.
Failure to Provide Timely Access to Resident Trust Funds
Penalty
Summary
The facility failed to honor a resident's right to manage her financial affairs, specifically regarding access to her trust fund. The resident, who was cognitively intact and had diagnoses including diabetes and cerebral ischemia, reported delays in accessing her funds, sometimes waiting days to receive money. She was also required to provide receipts for purchases made with her own money, which she felt violated her privacy. The facility limited her withdrawals to $75 per month, citing the need to ensure other residents could also access funds. Interviews with the Business Office Manager (BOM) and the Administrator revealed that the facility had a policy of writing checks for amounts over $100, which the resident had difficulty cashing. The BOM confirmed that the facility only kept $500 on hand and replenished it every other day, leading to instances where residents were asked to wait for their funds. The Administrator acknowledged that residents were sometimes asked to wait until staff went to the store to access their money. The facility's policy stated that residents have the right to manage their financial affairs, but the practice of requiring receipts and limiting access to funds contradicted this policy.
Failure to Provide Homelike Environment in Secure Unit
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents residing in the secure unit. Resident #14, a female with severely impaired cognitive status and diagnosed with non-Alzheimer's dementia, was observed to have a room lacking personal effects, with only a comforter and two baby dolls present. A family member reported being discouraged from bringing personal items due to concerns about theft by other residents. Similarly, Resident #40, a female with moderately impaired cognitive status and diagnosed with non-Alzheimer's dementia, was found in a room devoid of decorations, personal effects, or a TV, expressing a desire for decorations. Interviews with the DON and Corporate Nurse revealed a lack of awareness regarding the residents' desires for a more homelike environment. The facility's policy on resident rights allows for personal possessions unless they infringe on others' rights or safety. However, the facility discouraged families from bringing items that might be taken by other residents, as residents often wandered into each other's rooms. The facility did not provide locks on closets, contributing to the issue of personal items being taken.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which could potentially place them at risk of not receiving necessary care and services. Resident #100, a male with cerebral infarction and anemia, was not care planned for oxygen administration despite having a history of acute respiratory failure and ongoing oxygen supplementation. The resident's progress notes indicated multiple instances of low oxygen saturation and the need for oxygen therapy, yet no care plan was in place to address this critical need. Resident #30, a male with end-stage renal disease and acute kidney failure, was undergoing dialysis but did not have a care plan for this treatment. Despite the resident's dependence on dialysis and the presence of a port and fistula for the procedure, the facility failed to document a care plan outlining the goals and interventions necessary for managing his condition. Interviews with staff revealed a lack of awareness and communication regarding the resident's dialysis needs, leading to the oversight in care planning. Resident #49, a male with cerebrovascular disease and dementia, exhibited inappropriate behavior towards female residents, yet there was no care plan to address these behavior concerns. Despite reports from staff and residents about the resident's inappropriate touching, the facility did not document or implement a care plan to manage and monitor his behavior. This lack of documentation and intervention could result in female residents feeling unsafe and violated within the facility.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. The resident, a cognitively intact male with a history of gastrostomy and dysphagia, was observed receiving medications via a G-tube in a manner inconsistent with facility policy. The Assistant Director of Nursing (ADON) prepared and administered the resident's medications by crushing them together and not dissolving them fully before administration, which left remnants in the medication cup. This was contrary to the policy that requires medications to be administered one by one with a flush of water between each. Additionally, the ADON did not cap the feeding formula tubing when it was detached from the G-tube port, allowing it to touch the enteral feeding pump, which could lead to contamination. The syringe used for medication administration was not cleaned after use, which is against the facility's policy that requires syringes to be cleaned after each use to prevent infection. These actions were acknowledged by the ADON during an interview, where she admitted to not following the correct procedures. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered separately unless there is an order for them to be given together. The DON also emphasized the importance of capping the feeding tube to prevent contamination and ensuring medications are fully dissolved to avoid blockages. The Administrator was unaware of the specific procedures for tube feeding but stated that the facility's policy should be followed to meet the medical needs of the residents.
Failure to Document Dialysis Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident undergoing dialysis had the necessary physician orders in place, which is a requirement for providing safe and appropriate dialysis care. The resident, a male with end-stage renal disease and acute kidney failure, was dependent on dialysis. Despite being cognitively intact and aware of his dialysis needs, the resident's records lacked essential orders related to his dialysis treatment. These missing orders included the type and schedule of dialysis, as well as specific instructions for monitoring and assessing the dialysis site, such as checking for bleeding, bruits, and thrills, and weighing the resident before and after dialysis. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that there was an awareness of the missing orders and the importance of having them documented. The ADON acknowledged the absence of orders and emphasized their necessity for assessing the effectiveness of dialysis. The DON confirmed that staff should ensure dialysis orders are entered into the system to guide care. The facility's policy on dialysis care, which outlines the need for reviewing and confirming physician orders, was not followed, leading to this deficiency.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain a system of records for the receipt and disposition of controlled drugs, specifically Fentanyl patches, for a resident. On November 30, 2023, it was discovered that a box of five Fentanyl patches was missing from the narcotic box when a medication aide attempted to change the resident's patch. The narcotic count sheet and the box of patches were not accounted for, leading to a discrepancy in the controlled drug records. Interviews with staff revealed that the facility's practice of counting medication cards during narcotic counts had been discontinued, which contributed to the oversight. The resident involved was an elderly male with severe cognitive impairment and multiple diagnoses, including neurocognitive disorder with Lewy Bodies, Parkinson's disease, and chronic pain. The incident was reported to the medical director, DON, administrator, and police department, but the alleged perpetrator was not identified. The facility's policy required a narcotic audit at each shift change, but the lack of a system to account for medication cards and narcotic count sheets per shift led to the failure in maintaining accurate records.
Inappropriate Use of Antipsychotic Medication Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was administered Paliperidone ER, an antipsychotic medication used to treat schizophrenia and schizoaffective disorder, without an appropriate diagnosis of schizophrenia. The resident's admission MDS assessment indicated severe cognitive impairment and diagnoses of bipolar disorder and non-Alzheimer's disease, but not schizophrenia. Despite this, the resident was prescribed Paliperidone ER for schizophrenia related to bipolar disorder, and there was no care plan addressing the use of this antipsychotic medication. Interviews with facility staff, including LVNs and the DON, revealed that the resident did not exhibit behaviors associated with schizophrenia and primarily displayed wandering behavior. The DON acknowledged the absence of a schizophrenia diagnosis and was unaware of the reason for the medication order specifying schizophrenia. Additionally, the March Pharmacy Consultant Nursing Summary Report had requested clarification of the diagnosis, which was not addressed by the facility. The facility's policy on psychotropic medications mandates that such drugs should only be administered when necessary to treat a specific condition as diagnosed and documented, which was not adhered to in this case.
Infection Control Deficiencies in Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of two CNAs during incontinence care for two residents. The first incident involved a CNA who did not wash hands before donning gloves and failed to change gloves or perform hand hygiene after handling a soiled brief and before applying a clean one. This CNA acknowledged the importance of hand hygiene and glove changes to prevent contamination but did not adhere to these practices. The second incident involved another CNA who performed hand hygiene initially but failed to change gloves or perform hand hygiene after cleaning a resident's buttocks and before applying a clean brief and gown. This CNA also contaminated various items in the resident's room and the hallway with soiled gloves and hands, including the bed controller, call light, and door handles. The CNA admitted to not performing hand hygiene at critical points and recognized the importance of doing so for infection control. Interviews with the ADON, DON, and Administrator confirmed that the facility's policy required staff to perform hand hygiene before and after glove use and when moving from soiled to clean areas during care. The facility's hand hygiene policy and personal care procedures were not followed, leading to potential risks of cross-contamination and infection for the residents involved.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 746 citations issued within 25 miles in the last 12 months — including the 12 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 Justin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation - Fort W | 10.6 mi | ★★★★★ | 13 | 1 |
| Lake Forest Village By Purehealth | 10.9 mi | ★★★★★ | 1 | 0 |
| Vintage Health Care Center | 11.6 mi | ★★★★★ | 24 | 0 |
| The Carlyle At Stonebridge Park | 11.7 mi | ★★★★★ | 14 | 0 |
| Discovery Village At Southlake | 11.8 mi | ★★★★★ | 5 | 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 October 2026) and official state health department websites.