Above average — CMS composite of the measures below.
A standard survey is most likely before around February 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 Linden Post Acute during CMS and state inspections, most recent first.
Staff failed to follow PPE and TBP requirements during a COVID-19 outbreak. Observations showed a NA wearing an N95 with straps tied behind the ears and then entering a COVID-19 room with a second N95, gown, and face shield kept in the room; another NA wore a non-N95 mask in resident hallways; an LPN entered a COVID-19 room with a beard that prevented an N95 seal; an RN performed COVID-19 testing with an N95 over a full beard and without eye protection; and an LPN reused a face shield after entering COVID-19 rooms. The DON, infection control nurse, and administrator stated staff entering COVID-19 positive rooms were required to wear fit-tested N95s, gowns, gloves, and eye protection, and disposable PPE was not to be reused.
A resident with stroke-related deficits, dementia with behavioral disturbances, and severely impaired cognition had multiple psychotropic med changes for agitation, exit seeking, and altered mental status, but the RR/guardian was not notified of the changes or the need to alter treatment. Staff also allowed the resident to leave with other residents without staff supervision on multiple occasions, and the guardian stated they were not informed of these outings until after the resident’s elopement.
Residents were not aware of how to file a grievance or who the Grievance Officer was. In Resident Council, three residents stated they did not know the grievance process, and staff reported that grievance forms were kept on a clipboard near the front door, though an observation found the clipboard empty and posted high on the wall. The Activities Director, Social Service Director, Administrator, and DON described shared grievance responsibilities, but residents had not been educated on the process.
A facility failed to develop resident-centered care plans for two residents with OSA and PAP device use. One resident with a CPAP had the device at bedside, reported staff were no longer filling the canister, and had no care plan goals or interventions related to CPAP use. Another resident with a BiPAP had the device on the nightstand, did not know when it was last serviced or whether settings were correct, and also had no care plan focus areas, goals, or interventions for OSA or BiPAP use.
Failure to provide consistent oral care and nail care for dependent residents. Three residents with significant care needs were observed or interviewed with long or dirty nails and inadequate oral hygiene, including one resident with jagged nails and another with white buildup on the gums and teeth. NAs stated oral care and nail care were missed because they were busy or forgot, despite residents needing daily assistance and set-up for hygiene tasks.
Failure to provide ordered CPAP care: A resident with OSA and a history of stroke had a CPAP device at bedside with an empty distilled-water canister, and the resident said staff had not been filling it and the CPAP had not been usable for months because it irritated the mouth and nose. The record lacked active CPAP orders for settings, cleaning, water refills, or refusal documentation, and staff confirmed the required CPAP care process was not followed.
Failure to offer pneumococcal vaccine to a resident’s RR: A resident with severe cognitive impairment, dementia, stroke-related deficits, dysphagia, and language disorder was not up to date on the pneumococcal vaccine and had no medical contraindication. The RR, who had legal authority to consent or refuse treatment, was not contacted to accept or decline the vaccine, and there was no documentation that vaccine education on benefits or potential side effects was provided; the DON confirmed the process was not followed.
A resident with stroke, dementia, apraxia, dysphagia, and mixed receptive/expressive language disorder had severely impaired cognition and was not up to date on the COVID-19 vaccine. The facility did not contact the resident’s representative to offer the vaccine or provide education on benefits and potential side effects, and there was no documentation that the representative was offered the chance to accept or decline the vaccine.
A resident with Parkinson's Disease and reduced mobility left the facility without notice, and staff were unaware of their whereabouts. The incident was not documented in the incident log, and the state agency was not notified as required. Social Services attempted to contact the resident and notified law enforcement, but did not log the event or inform the state agency.
Three resident rooms were found with significant wall damage, exposed sharp metal, peeling paint, and splintered closet doors, with maintenance logs showing no record of inspection or repair. The Maintenance Director and Administrator were unaware of the issues, despite facility policy requiring regular inspections.
The facility failed to ensure a safe environment for a resident who required a smoking apron due to dexterity issues, as they were not provided with the necessary protective equipment during smoking times. Additionally, compressed oxygen cylinders were left unsecured in a storage room, and toxic cleaning chemicals were accessible to residents in two hallways, increasing the risk of accidents and injuries.
The facility failed to provide appetizing and palatable food to several residents, including those with diabetes and dysphagia, leading to dissatisfaction and potential nutritional inadequacy. Delays in meal service and inadequate equipment for maintaining food temperatures were observed, with staff acknowledging the need for better communication and adherence to meal service times.
The facility failed to ensure proper sanitation of food preparation surfaces, appropriate labeling of open foods, and cleanliness of food delivery carts, risking foodborne illnesses. Expired test strips were used for sanitizing solutions, and open foods were improperly labeled and stored. Food delivery carts were dirty, with visible debris and rusty wheels. The dietary manager and administrator acknowledged training issues in food safety.
Two residents with severe cognitive impairments and additional disabilities experienced significant delays in receiving meal assistance, compromising their dignity. One resident, who is legally blind, waited 16 and 17 minutes on separate occasions for help, while another resident, who is deaf, waited 30 and 31 minutes. Delays were due to staff being occupied with other duties, as confirmed by the facility's administrator.
The facility failed to properly review and validate PASARR screenings for two residents with serious mental illness (SMI), leading to a deficiency. One resident was admitted with PTSD and depression without a Level II referral, while another had an incorrect initial PASARR screening that was not followed by a necessary Level II referral. These oversights placed the residents at risk of not receiving appropriate care.
The facility failed to effectively plan and document discharge processes for two residents, leading to unsafe discharges. One resident, admitted with heart failure and dehydration, was discharged AMA without a documented plan, despite expressing a desire to return to the community. Another resident, with cellulitis and paraplegia, left AMA with a PICC line in place, without notifying the provider or authorities, posing a risk of infection.
A resident with type two diabetes mellitus received insulin therapy based on unconfirmed blood glucose readings from a FreeStyle Libre 2 sensor, contrary to manufacturer's guidelines. Facility staff were unaware of the need to confirm sensor readings with a fingerstick glucose device within the first 12 hours after changing the sensor, leading to potential health risks due to incorrect insulin dosing.
A facility failed to identify and utilize an implanted bladder stimulator device for a resident with urinary incontinence. The resident, who was cognitively intact, reported not having the remote to control the device and had not seen a urologist since admission. Staff interviews revealed a lack of awareness about the device, and the care plan did not document its presence or any related interventions.
A resident with PTSD and a history of military service was not provided with trauma-informed care at the facility. Despite being able to communicate their needs, the resident's known triggers, such as being startled by loud noises, were not identified or documented in their care plan. Staff interviews confirmed awareness of the resident's condition, but no specific interventions were implemented to prevent re-traumatization.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.41 percent error rate. Two residents were affected: one received insulin without proper pen priming, and another was nearly given expired medication. Staff involved were unaware of the insulin pen priming requirement and assumed new medications were not expired.
The facility failed to properly dispose of kitchen refuse, leading to unsanitary conditions with flies observed on plates and trash bags left outside attracting pests. Staff interviews revealed that trash was not taken to the dumpster immediately as required.
A facility failed to ensure a resident with severe cognitive impairment understood a binding arbitration agreement, which waived their right to a jury trial. The resident, admitted with congestive heart failure and bipolar disorder, had a BIMS score indicating severe cognitive impairment. Despite this, the resident signed the agreement without a power of attorney or legal guardian, and later expressed a lack of understanding of the process.
PPE and N95 Use Not Followed During COVID-19 Precautions
Penalty
Summary
The facility failed to ensure staff followed infection control standards of practice for residents on transmission-based precautions during a COVID-19 outbreak. The deficiency involved staff use of PPE, including N95 respirators, gowns, gloves, and eye protection, when entering COVID-19 positive resident rooms and while performing COVID-19 testing. The report states that multiple staff and residents were COVID-19 positive, and the facility had implemented facility-wide N95 respirators for exposure control. During observation, Staff I wore an N95 respirator with the head straps cut and tied behind the ears, then entered a COVID-19 resident room and placed a second N95 respirator from the resident’s closet door, along with a gown and face shield that had been hanging on a used biohazard container. Staff I stated they preferred to wear two N95 respirators and kept these items in the resident COVID-19 rooms. Staff P was observed wearing a purple mask that was not an N95 respirator while working in resident hallways, and Staff Q was observed wearing a BYD DE2322 N95 respirator while caring for residents. Staff J entered a COVID-19 resident room wearing an N95 respirator, but had a beard protruding about two inches from the mask and stated they would never shave their beard and that the N95 did not form a seal as it should. Staff F was observed performing COVID-19 testing while wearing an N95 respirator over a full beard that crossed under the respirator seal, then donned a gown and gloves. Staff F entered and exited four resident rooms while wearing the same N95, gown, and gloves, but did not wear eye protection during the testing. Staff F stated they had not had a full beard when originally fit-tested and did not currently have a tight seal with the beard. Staff K was observed using a face shield from a medication cart, entering a COVID-19 resident room, then removing gown and gloves, carrying the face shield out, wiping it with a sanitizer cloth, and rehanging it on the cart; Staff K repeated this reuse of the face shield and stated they had no reason why they reused it. The infection control nurse, DON, and administrator stated staff entering COVID-19 positive rooms were required to wear fit-tested N95 respirators, gowns, gloves, and eye protection, and that disposable PPE was not to be reused.
Failure to Notify Guardian of Behavior Changes and Medication Changes
Penalty
Summary
The facility failed to notify the resident’s representative/guardian of changes in the resident’s mental and psychosocial status and of the need to alter treatment for a resident with a history of stroke, dysphagia, apraxia, dementia with behavioral disturbances, mixed receptive/expressive language disorder, and depression. The resident’s assessments showed severely impaired cognition and use of psychotropic medication, and the guardianship document identified the representative as the decision-maker for medical treatment. The resident was also identified as high risk for elopement due to cognitive impairment, poor decision-making, behavioral changes, new medications, and dementia-related diagnoses. The resident’s record showed multiple psychotropic medication changes and behavior-related events, including initiation of Seroquel for dementia with behavioral disturbances, initiation of Trazodone for agitation and sleep issues, a one-time Seroquel dose for behaviors and exit seeking, an increase in Trazodone for altered mental state and agitation, and PRN Seroquel for behaviors. Progress notes documented repeated episodes of agitation, aggression, exit seeking, confusion, and attempts to leave the facility, along with medication changes ordered by the provider. The record did not show notification to the representative regarding these changes in status or treatment. The resident also left the facility on multiple occasions with other residents and without staff supervision, including 17 sign-out events documented on the sign in/out sheets. Staff stated the resident had severe cognitive impairment, dementia, behavioral disturbances, and was on psychotropic medications, yet was allowed to leave with another resident to eat at a restaurant without staff supervision. The representative stated they had not been informed of the medication changes or the resident leaving the facility unsupervised until after the resident’s elopement from the facility.
Residents Unaware of Grievance Process and Grievance Officer
Penalty
Summary
The facility failed to have a system in place to ensure residents were aware of how to file a grievance and who the facility’s Grievance Officer was. During a Resident Council meeting, Resident 26 stated they had been in the facility for a while, that the council met monthly, and that they did not know how to file a grievance or who the Grievance Officer was. Residents 39 and 75 also stated they were not sure how to file a grievance or who the facility Grievance Officer was. These concerns were voiced by 3 of 5 residents present at the meeting. Record review showed the facility had a Resident Grievance policy updated 08/01/2024 stating residents have the right to voice concerns or grievances verbally or in writing, and that the Social Services Director was responsible for overseeing the grievance process. Staff N, the Activities Director, stated they helped organize monthly Resident Council meetings, reviewed residents’ rights, and took minutes, and that concerns from the meeting would be documented and a grievance form completed. Staff N stated they were unaware residents did not know how to file a grievance or who the grievance officer was. Staff A, the Administrator, and Staff M, the Social Service Director, stated they shared grievance officer responsibilities and said grievance forms were located on a clipboard near the front door, but an observation showed an empty clipboard hanging five feet up on the wall where the forms were supposed to be. Staff A and Staff M stated the signs could be lowered so residents could see and grab a grievance form. Staff B, the DON, stated staff had been educated about the grievance process but residents had not been educated.
Incomplete Care Plans for CPAP and BiPAP Use
Penalty
Summary
The facility failed to develop comprehensive resident-centered care plans for 2 of 6 residents reviewed for care planning, Residents 30 and 42. Resident 30 was admitted and later readmitted with diagnoses of stroke and obstructive sleep apnea (OSA). The 06/07/2025 comprehensive assessment showed intact cognition, ability to make needs known, and use of a non-invasive mechanical ventilator device. On 11/17/2025, Resident 30’s CPAP device was observed on the bedside table, and the resident stated staff were no longer filling the canister and could not remember the last time the device was cleaned. The current physician order only directed staff to encourage the resident to place the CPAP mask every night at bedtime, and the care plan last completed 09/09/2025 had no resident-focused goals or interventions related to CPAP use. Resident 42 was admitted with diagnoses including morbid obesity, OSA, and anxiety. The 09/26/2025 comprehensive assessment showed the resident required assistance from one to two staff members for activities of daily living and had intact cognition. The September 2025 TAR showed use of a BiPAP device. On 11/19/2025, the BiPAP was observed on the nightstand, and the resident stated it had been brought from home and did not know when it was last serviced or whether the settings were still correct. The care plan contained no focus areas, goals, or interventions related to the resident’s OSA or BiPAP use.
Failure to Provide Consistent Oral and Nail Care
Penalty
Summary
The facility failed to provide necessary care and services to residents who were dependent on staff for activities of daily living, specifically consistent oral care and nail care. The facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal and oral hygiene. The deficiency involved three residents who required substantial assistance or assistance with ADLs and who were observed or interviewed regarding missing or inconsistent grooming and oral care. Resident 1 was admitted with diagnoses including a right leg fracture, COPD, chronic pain, abnormal weight loss, dysphagia, and repeated falls, and the comprehensive assessment showed moderately impaired cognition with substantial assistance needed for all care. The physician ordered weekly fingernail and toenail checks and trimming as needed. During observations and interviews, Resident 1 stated they had not had nail care since admission, and staff observed long, jagged fingernails with yellow and dark brown substance underneath and long, jagged toenails curled inward toward the toes. Resident 1 also stated staff had not cleaned their nails or washed their hands or face, and a NA stated that nail care should be done during showers but that Resident 1’s nails had not been done after the shower because the NA was busy. Resident 3 was admitted with diagnoses including Parkinson’s disease, anxiety, muscle weakness, dysphagia, and falls, and the assessment showed moderately impaired cognition with substantial assistance needed for all care. During observations and interviews, Resident 3 was seen trying to brush their hair and beard while involuntary movements interfered, and their toothbrush was found on the floor under the bed. Resident 3 stated they had not received oral care or been offered oral care, had a used toothbrush head in their drawer and later in a cup of Listerine, and had white matter in between their teeth and buildup on the gums. Staff stated they assisted with morning care, grooming, and meals but did not provide oral care because they got busy and forgot. Resident 42 was admitted with morbid obesity, diabetes, and anxiety, and the assessment showed the resident required assistance from one to two staff members for ADLs with intact cognition. Resident 42 was observed with yellow teeth and an unopened toothbrush on the nightstand, stated they had been offered tooth brushing only once since arrival and needed set-up assistance for oral care, and later stated they still had not been offered help. A NA stated oral care required sitting the resident up and obtaining supplies, but oral care had not been offered for quite some time because work was busy.
Failure to Provide Ordered CPAP Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted standards of practice for a resident using CPAP therapy. The facility policy stated that CPAP devices should be cleaned weekly with the humidifier canister, disposable filters replaced monthly, and the mask and tubing cleaned daily, with documentation of the time and duration of use, the mode, and the resident’s tolerance. Resident 30 had diagnoses including stroke and obstructive sleep apnea, was cognitively intact, and had a non-invasive mechanical ventilator device noted on assessment. During observation, the resident’s CPAP device was on the bedside table and the canister for distilled water was empty. The resident stated staff were no longer filling the canister and that the CPAP could not be used without moisture because it irritated the mouth and nose; the resident also stated they had not been able to use the CPAP for months. Review of the record showed only an order to encourage the resident to place the CPAP mask every night, with no active orders for CPAP settings, cleaning, refilling distilled water, or documentation of refusal. Staff interviews confirmed they could not find the required CPAP orders or documentation of refusal, and staff stated the correct process for the resident’s CPAP care was not followed.
Failure to Offer Pneumococcal Vaccine to Resident Representative
Penalty
Summary
The facility failed to ensure that the representative of a cognitively impaired resident was offered the pneumococcal immunization and given the opportunity to accept or refuse it on the resident’s behalf, and failed to document education on the vaccine’s benefits and potential side effects. The facility’s policy titled, Vaccination of Residents, adopted 01/30/2025, stated that residents would be offered the pneumococcal vaccine unless medically contraindicated or already vaccinated, and that residents or their legal representatives would receive education regarding the benefits and potential side effects, with documentation in the medical record. Resident 61 was admitted with diagnoses including stroke, dysphagia, apraxia, dementia, and mixed receptive/expressive language disorder. The 10/27/2025 comprehensive assessment showed severely impaired cognition, that the resident was not up to date on the pneumococcal vaccine, and that there was no medical contraindication. The legal guardianship document dated 10/17/2024 showed the RR was appointed to make decisions about consenting to or refusing medical treatment on the resident’s behalf. Review of the immunization record showed no documented assessment or nursing progress note that the RR was offered the pneumococcal vaccine or educated about its benefits or potential side effects. During interview, the DON stated the RR was not contacted and that the correct process was not followed.
Failure to Offer and Document COVID-19 Vaccine Education and Status
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were educated on the COVID-19 vaccine and offered the vaccine for 1 of 5 sampled residents, Resident 61. The facility’s policy stated that all residents would be offered the COVID-19 vaccine unless medically contraindicated or already fully vaccinated, and that residents or their legal representatives would receive education on the benefits and potential side effects with documentation in the medical record. Resident 61 was admitted with diagnoses including stroke, dysphagia following the stroke, apraxia, dementia, and mixed receptive/expressive language disorder. The 10/27/2025 comprehensive assessment showed the resident had severely impaired cognition and was not up to date on the COVID-19 vaccine. Review of the immunization record showed no documented assessment or nursing progress note that the resident’s representative was offered the opportunity to accept or decline the COVID-19 vaccine, and no documentation that education on the benefits or potential side effects was provided. The DON stated during interview that the resident’s representative was not contacted to offer the vaccine or provide education, and that the correct process was not followed because the resident was unable to make care decisions.
Failure to Notify State Agency of Resident Elopement
Penalty
Summary
The facility failed to notify the state agency regarding an elopement incident involving a resident. The resident, who had diagnoses including high blood pressure, Parkinson's Disease, reduced mobility, and a history of homelessness, was admitted to the facility and required partial to substantial assistance with transfers, dressing, and toileting. According to the comprehensive assessment, the resident was alert and oriented. On the day of the incident, staff discovered the resident's breakfast tray untouched and their belongings missing, indicating the resident had left the facility without notice. Staff were unaware of the resident's location and the resident had not been assessed as an elopement risk. The incident was not documented in the facility's incident reporting log for the relevant months, and the state agency was not notified as required. The DON confirmed that staff did not know the resident's whereabouts and that the state agency was not contacted. Social Services attempted to reach the resident by phone, but the number was not working, and law enforcement was notified the following day. However, the incident was not logged, and Social Services staff were unaware of the requirement to notify the state agency.
Failure to Maintain Safe and Functional Resident Rooms
Penalty
Summary
The facility failed to provide a safe and comfortable environment in three of six resident rooms (Rooms 27, 28, and 29) due to lack of maintenance and repair. Observations revealed multiple issues, including four-foot-long cuts in the wall, gouges with missing paint, unfinished spackled areas, exposed metal plates with sharp edges, peeling paint, and splintered closet doors. Some areas were uncleanable due to peeling flakes, and significant damage such as broken sheet rock was visible behind a bed headboard. These deficiencies were directly observed during facility rounds and interviews with staff. Review of the facility's maintenance logs from April to June 2025 showed that these rooms were not identified for inspection or repair, despite the facility's policy requiring weekly building interior inspections. The Maintenance Director stated that this was the first time they had seen these areas needing repair and was unaware of the issues in these rooms. The Administrator acknowledged that the rooms should have been repaired promptly.
Deficiencies in Resident Safety and Hazard Management
Penalty
Summary
The facility failed to ensure a safe environment for Resident 29, who required a smoking apron for safety due to dexterity issues following a stroke. Despite the resident's need for supervision and protective equipment when smoking, observations revealed that the resident was not provided with a smoking apron during designated smoking times. Staff members, including a clerk/nursing assistant and the activities director, were unaware or did not enforce the requirement for the resident to wear a smoking apron, despite the resident's history of cigarette burns on clothing and the facility's policy. In the East/West storage room, the facility did not secure compressed oxygen cylinders as required. An observation showed that four cylinders were left unsecured, posing a potential hazard. The maintenance director acknowledged the oversight and indicated that the process for checking the storage rooms weekly was not effective, as evidenced by the unsecured cylinders. The administrator confirmed that the oxygen delivery driver had left the cylinders unsecured, which was not the standard procedure. Additionally, the facility failed to safely store toxic cleaning chemicals, as observed in two hallways. Containers of germicidal wipes were left within reach of residents, including in unsupervised areas. The director of nursing services stated that residents liked to use the wipes to clean their wheelchairs, indicating a lack of awareness of the potential hazards posed by the chemicals. This oversight in chemical storage increased the risk of accidents and injuries among residents.
Deficiency in Food Quality and Service Timeliness
Penalty
Summary
The facility failed to consistently provide appetizing and palatable food to four residents, leading to dissatisfaction and potential nutritional inadequacy. Resident 44, who has diabetes and COPD, reported that their meals were often cold and unappetizing, with specific complaints about mushy pasta and leathery eggs. Resident 34, with dysphagia and COPD, expressed dissatisfaction with the taste and appearance of their meals, resorting to using barbeque sauce to mask the flavor and relying on food brought by others. Resident 21, also diabetic, was unhappy with the cold and unappetizing food, and noted that their dietary preferences, such as avoiding beets, were not respected. Resident 57, another diabetic resident, reported that their dietary restrictions were not followed, and despite complaints, no changes were made. These issues were compounded by the kitchen's delay in meal service, resulting in cold food being served to residents. Observations in the kitchen revealed that meal service was delayed due to staff breaks and cleaning, leading to insufficient pellet inserts for plate warmers and cold meals being served. The Dietary Manager acknowledged the issues with food temperatures and the need for better communication between kitchen and nursing staff. The Administrator recognized the need to adhere to meal service times and ensure adequate equipment to maintain food temperatures.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper sanitation of food preparation surfaces, appropriate labeling of open foods, and cleanliness of food delivery carts, which placed residents, staff, and visitors at risk for foodborne illnesses and the spread of infectious diseases. During an observation, a dietary aide was found using expired test strips to check the concentration of a sanitizing solution, which repeatedly failed to pass the test. The dietary manager admitted to not having a process in place for the safe use of the sanitation solution and acknowledged that the sanitation log was likely inaccurate. There was no documentation of training or return demonstration for testing the sanitation solution, indicating a lack of proper oversight and training. In addition to the issues with sanitizing solutions, the facility also failed to properly label and store open foods. During a kitchen tour, several items, including a health shake, hard-boiled eggs, chopped ham and cheese, and various vegetables, were found without proper labeling or dating. Some items were also improperly sealed, which could lead to contamination. The dietary manager admitted that the process for storing leftovers and open packages of food was not being followed consistently, and the responsibility for maintaining the foods in the refrigerator was not being upheld by the cooks. Furthermore, the food delivery carts used for meal service were observed to be dirty, with visible debris, rusty wheels, and sticky rubber bumpers. The dietary manager acknowledged that the carts looked dirty and that the staff were supposed to clean the insides of the carts daily, but the outside of the carts was not being cleaned regularly. The administrator confirmed that there was a training issue in the kitchen regarding food safety, highlighting a systemic problem in maintaining hygiene standards in the facility's food service operations.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to ensure timely assistance with meals for residents requiring help, compromising their dignity and quality of life. Resident 14, who is legally blind and severely cognitively impaired, was observed waiting for assistance with meals on two separate occasions. On the first occasion, the resident waited 16 minutes after their meal was served before receiving help from a nursing assistant. On the second occasion, the resident waited 17 minutes, during which they expressed frustration and attempted to smell their food. The delay was attributed to staff being occupied with other residents in different areas of the facility. Similarly, Resident 3, who is deaf and severely cognitively impaired, experienced delays in receiving meal assistance. On one occasion, the resident waited 30 minutes before a staff member cued them to start eating. On another occasion, the resident waited 31 minutes for assistance. The delays were due to the nursing assistant's responsibilities in assisting other residents who dined in their rooms, which often caused them to be late in providing help in the dining room. The facility's administrator acknowledged that it was inappropriate for residents to wait for assistance while others were already eating.
Deficiency in PASARR Process for Residents with SMI
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for two residents, leading to a deficiency in ensuring that individuals with serious mental illness (SMI) or intellectual/developmental disabilities (ID/DD) were not inappropriately placed in the nursing home. Resident 29 was admitted with diagnoses including PTSD and depression, but their PASARR Level I screening was not accurate, and a Level II referral was not completed prior to admission. Staff H, the Social Service Director, acknowledged the oversight in the PASARR process for Resident 29, which required a Level II evaluation due to the SMI indicators. Similarly, Resident 56 was admitted with PTSD and anxiety, but their initial PASARR Level I screening did not indicate any SMI indicators. A subsequent PASARR Level I screening correctly identified the SMI indicators, but a Level II referral was not made. Staff H was responsible for reviewing the PASARR screenings, and both Staff H and the Director of Nursing Services confirmed the errors in the PASARR process for Resident 56. These failures placed the residents at risk of not receiving appropriate care and services for their needs.
Deficiencies in Discharge Planning and Safety
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for Resident 264, who was admitted with diagnoses including fainting, heart failure, and dehydration. Despite being cognitively intact and requiring partial assistance with activities of daily living, Resident 264 expressed a desire to return to the community. However, the care plan lacked documentation of discharge planning, and the resident was discharged home against medical advice (AMA) without a proper plan in place. This oversight in discharge planning was evident as the social services director noted the resident's request to discharge and the subsequent upset when the process was explained, yet no formal discharge plan was documented. Additionally, the facility failed to ensure a safe discharge for Resident 61, who was admitted with cellulitis, osteomyelitis, and paraplegia, and required substantial assistance with activities of daily living. Resident 61 was receiving antibiotics through a PICC line, which was scheduled to end after their discharge. However, the resident left the facility AMA with the PICC line still in place, and there was no documentation that the provider or relevant authorities were notified of this unsafe discharge. The director of nursing services acknowledged the lack of notification and the risk associated with discharging a resident with a PICC line.
Failure to Adhere to Blood Glucose Monitoring Guidelines
Penalty
Summary
The facility failed to ensure proper treatment and care for a resident with type two diabetes mellitus, specifically in the administration of insulin therapy. The resident, who was cognitively intact and able to communicate their needs, was using a FreeStyle Libre 2 sensor for continuous blood glucose monitoring. However, the facility staff did not adhere to the manufacturer's recommendations, which stated that blood glucose readings from the sensor should not be used for treatment decisions within the first 12 hours after changing the sensor without confirmation from a fingerstick glucose monitor. The resident reported that their blood glucose levels were inconsistent, with readings sometimes higher or lower than expected. Despite this, the nursing staff continued to administer sliding scale insulin based on the sensor's readings without confirming these values with a fingerstick glucose device. This practice was contrary to the facility's policy and the manufacturer's guidelines, which could lead to incorrect insulin dosing and potential health risks for the resident. Interviews with facility staff, including a registered nurse and the resident case manager, revealed a lack of awareness regarding the manufacturer's recommendations for the FreeStyle Libre 2 sensor. The facility did not have a policy in place to confirm the sensor's readings after a sensor change, which contributed to the deficiency. The administrator and director of nursing services acknowledged the absence of a process to ensure compliance with the manufacturer's guidelines, highlighting a gap in the facility's procedures for managing diabetes care.
Failure to Identify and Utilize Implanted Bladder Stimulator Device
Penalty
Summary
The facility failed to identify and utilize an implanted bladder stimulator device, known as InterStim, for a resident with urinary incontinence. The resident, who was cognitively intact and required substantial assistance for daily activities, had a history of urinary incontinence after the InterStim device placement. Despite this, the care plan did not document the presence of the device or any consultation with a urologist. The resident reported not having the remote to control the device and had not seen a urologist since admission to the facility. Interviews with facility staff revealed a lack of awareness regarding the resident's implanted device. The nursing assistant responsible for the resident's daily care was unaware of any scheduled toileting plan, and the resident case manager was not informed about the device or any bladder retraining program. The Director of Nursing Services acknowledged that the process for ensuring accurate medical records on admission should have identified the device, but it was missed, and no care plan was in place for it.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident identified as a trauma survivor. The resident, who was admitted with diagnoses including PTSD, traumatic brain injury, and depression, reported having potential triggers related to their military service, such as being easily startled by loud noises or when woken from sleep. Despite the resident's ability to communicate their needs and history of trauma, no staff member had discussed these triggers with them, and the care plan lacked specific interventions to address the resident's PTSD and history of combat exposure. Interviews with various staff members, including the Social Services Director, Registered Nurse, and Resident Case Manager, revealed that the facility was aware of the resident's PTSD and history of military deployments. However, the staff failed to identify and document the resident's known triggers in the care plan, which should have included strategies to prevent re-traumatization. The oversight was acknowledged by the facility's Administrator and Director of Nursing Services, who admitted that the resident should have been accurately assessed for potential triggers, and an individualized care plan should have been implemented.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 7.41 percent error rate during 27 medication administration opportunities. This deficiency involved two residents, Resident 218 and Resident 1. Resident 218, who had a diagnosis of type two diabetes and required insulin administration, did not receive the correct procedure for insulin delivery. A registered nurse, Staff E, administered 20 units of Basaglar insulin without priming the insulin pen, which is necessary to ensure the correct dosage is delivered. Staff E was unaware of the need to prime the pen, which could lead to incorrect insulin dosage. Resident 1, who had diagnoses including dementia and heart failure, was at risk due to the administration of expired medication. Staff L, an LPN, initially prepared to administer a medication that had expired, assuming it was valid because it had just arrived from the pharmacy. Upon review, Staff L realized the error and replaced the expired medication. The Director of Nursing Services, Staff B, confirmed that the process for medication administration includes checking expiration dates, but was unaware of the priming requirement for insulin pens.
Improper Disposal of Kitchen Refuse
Penalty
Summary
The facility failed to properly dispose of kitchen refuse, which was observed during a survey. On two separate occasions, flies were seen on plates in the kitchen, indicating a potential unsanitary condition. Additionally, black trash bags containing kitchen food waste were left on a cart outside the emergency exit of the kitchen/laundry hallway, with snow peas scattered on the ground, attracting flies, bees, and gnats. Interviews with staff revealed that the trash was supposed to be taken to the dumpster immediately, but it had been left outside for at least 45 minutes. The facility had pest control measures in place, but the process for removing trash from the kitchen was not followed as required.
Failure to Ensure Resident's Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the cognitive capacity to understand the nature and implications of entering into a binding arbitration agreement. This agreement was intended to settle disputes without a jury trial. The deficiency was identified for one resident, who was admitted with diagnoses including congestive heart failure and bipolar disorder. The resident's comprehensive assessment indicated severe cognitive impairment, with a Brief Interview of Mental Status (BIMS) score of 3 out of 15, confirming their inability to comprehend complex legal documents. The arbitration agreement was signed by the resident upon admission, despite their severe cognitive impairment, as evidenced by their inability to sign their name properly. During interviews, the resident expressed a lack of understanding of the arbitration process. The Social Services Director, who presented the agreement, acknowledged that the resident did not have a power of attorney or legal guardian to sign on their behalf and was unsure if the resident comprehended the agreement. This oversight placed the resident at risk of not understanding the legal contract they had signed and their right to a jury trial in the event of a dispute with the facility.
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.
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What surveyors actually found near you
We read the 137 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Toppenish
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Care | 7.4 mi | ★★★★★ | 17 | 0 |
| Parkside Care | 14.6 mi | ★★★★★ | 36 | 0 |
| Sunnyside Healthcare Center | 15.4 mi | ★★★★★ | 24 | 0 |
| Garden Village | 18.1 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Health Care Ctr | 19.1 mi | ★★★★★ | 11 | 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.