Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Manor Nursing Home during CMS and state inspections, most recent first.
Surveyors found multiple food safety and sanitation deficiencies, including an unclean, discolored backsplash with dried splatterings behind a three-compartment sink, uncovered cookie dough stored open to air in a freezer, and improper utensil handling when the DM repeatedly rested chicken-serving tongs against a sanitizing towel between uses during meal service. A live roach was observed on an outlet near the three-compartment sink, despite the DM stating she had not seen live roaches and that pest control visits routinely. Kitchen staff reported that food should be covered in the freezer and that staff are responsible for ongoing and end-of-shift cleaning, while facility policy required food service areas to be kept clean, sanitary, and protected from pests, with the food services manager responsible for scheduling regular cleaning.
A resident with a history of exit-seeking and psychiatric diagnoses eloped by climbing a gazebo and jumping a courtyard wall while unsupervised, despite prior incidents and documented risks. The resident was found by law enforcement after leaving the property, and staff had not updated the care plan or implemented additional interventions following previous escape attempts.
Surveyors identified multiple environmental and sanitation deficiencies, including warped and cracked flooring in a dining room, uncovered transport of clean linens, dust and rust on overhead vents, and a shared shower room with broken tiles, unclean conditions, and a swarm of gnats and flies. A resident reported ongoing maintenance issues, and facility policy requirements for cleanliness and safe linen handling were not met.
A resident with multiple psychiatric diagnoses did not receive several doses of a prescribed antipsychotic medication after a change in their routine medications, due to the facility's inability to obtain the medication from the pharmacy. Staff documented the medication as unavailable on multiple occasions, and interviews confirmed ongoing difficulties in securing the medication, despite facility policy requiring follow-up with the pharmacy and use of emergency drug kits.
The facility did not ensure a safe and comfortable environment, as water temperatures in a resident room and shower room reached 140°F, far above policy limits. Air temperatures in a dining room were recorded as high as 89°F during meals and activities, with residents observed fanning themselves and no fans in use. Multiple areas, including resident rooms and the dining room, had damaged flooring, water leaks, and ceiling damage due to malfunctioning AC units, resulting in wet and uneven floors.
The facility's assessment was found to be incomplete and inaccurate, lacking a staffing plan, specific training topics, transportation details, and communication plans for residents and staff with communication barriers. The Administrator was unaware that the assessment could include detailed facility-specific information and relied on a template updated annually without a specific policy in place.
The facility did not designate a certified Infection Preventionist (IP) for its infection prevention and control program. An LPN, acting as the IP, lacked specialized training and could only dedicate limited time to the role. The facility also lacked a policy or job description for the IP position.
A facility enforced a policy to crush all narcotic medications without resident input or specific physician orders, affecting 10 residents. This decision, made by the Administrator, Medical Director, and DON, was based on concerns about potential misuse of medications. Resident 5, experiencing severe pain, refused her medication due to the unpleasant taste of crushed pills, leading to its discontinuation. The facility lacked a formal narcotic administration policy and did not inform residents of the change beforehand.
The facility failed to ensure accurate MDS assessments for five residents, resulting in discrepancies in documenting medication administration. Residents with various diagnoses were not recorded as taking prescribed antiplatelet, diuretic, or oxygen therapies. The DON was unaware that aspirin is an antiplatelet medication, contributing to the inaccuracies.
The facility failed to develop comprehensive care plans for residents on medications such as antipsychotics, antidepressants, and diuretics. A resident with a history of substance abuse and on antipsychotic medication lacked a care plan. Another resident with COPD and on oxygen also lacked care plans for their medications. The DON acknowledged the absence of care plans and indicated that updates were done quarterly, but care plans were expected for each medication.
The facility failed to provide adequate respiratory care for several residents, including maintaining clean oxygen equipment and ensuring proper documentation of oxygen orders. Residents were observed with dusty filters and undated tubing, and there was confusion about equipment ownership and maintenance responsibilities.
The facility failed to obtain necessary physician orders for medications and oxygen for several residents. A resident with diabetes received insulin without a current order, and three residents lacked current oxygen orders due to a pharmacy change. The facility's pharmacy policy was not followed, leading to these deficiencies.
The facility failed to ensure proper labeling and storage of medications, with several instances of medications lacking open dates and incomplete refrigerator temperature logs. Observations included inhalers, eye drops, and other medications without open dates, and missing temperature records in the medication storage room. The DON confirmed the requirement for open dates on multidose medications and daily temperature logging, but the facility lacked a specific policy for open dates.
The facility failed to meet professional standards in food handling and kitchen sanitation. Staff did not wear proper hairnets or footwear, and food items were unlabeled. The dishwasher was not monitored for safe sanitation, with temperatures below the required minimum and no chemical checks documented. Handwashing protocols were not followed, and scoops were left in containers. The facility's policies on dishwashing, food storage, hairnet use, and thermometer sanitation were not adhered to.
The facility failed to ensure a sanitary environment, with staff not changing gloves between tasks, not sanitizing hands, and not implementing Enhanced Barrier Precautions for residents with wounds and catheters. Clean clothing was transported improperly, and ice was handled inappropriately, indicating a lack of adherence to infection control protocols.
The facility failed to ensure a safe, sanitary, and homelike environment, with issues such as brown substances around toilets, rusted fixtures, chipped doors, and missing tiles in communal restrooms and shower rooms. A couch had peeled fabric, and a courtyard door had a gap. The Maintenance Supervisor, also the Housekeeping Supervisor, was unaware of some issues and indicated a lack of formal policies and documentation for maintenance and cleaning tasks.
The facility failed to maintain an effective pest control program, as evidenced by the presence of insects and rodents in the downstairs dry storage room. Sticky pads were found full of insects and a dead mouse, with a live mouse also observed. The pest control company had visited recently but reported no concerns, despite ongoing issues with mice. The facility's policy required the building to be kept free of pests, but this was not achieved.
A facility failed to assess the clinical appropriateness of self-administration of medications for a resident with COPD and asthma. An Albuterol inhaler was found in the resident's room without an order to keep it at the bedside or a self-administration assessment. The resident was cognitively intact, but the facility did not follow its policy requiring an assessment by an interdisciplinary team.
The facility failed to update comprehensive care plans for three residents. A resident's care plan did not include bed rails as a fall intervention, another resident's care plan listed an outdated antidepressant, and a third resident's care plan was not revised after an antianxiety medication was discontinued. The DON acknowledged these oversights, noting that she was the only staff member able to update care plans in the electronic health record.
A resident at risk for pressure ulcers developed multiple stage two and a stage three pressure injury due to the facility's failure to provide effective care and documentation. Despite the resident's reports of pain and the presence of wounds, staff were unaware of the injuries, and there were inconsistencies in treatment records. The facility did not adhere to its pressure ulcer program policy, leading to inadequate assessments and care plans.
The facility failed to supervise and manage vaping devices among residents, leading to safety hazards. Two residents were found with vapes despite policies requiring storage at the nurse's station. Resident 15, with a history of substance abuse, had vapes on his bedside table, and staff did not address this. Resident 24, with cognitive impairment, was observed holding vapes, and staff failed to intervene. Staff interviews revealed inconsistencies in handling and documenting vaping incidents, and the facility's smoking policy was unclear.
The facility failed to maintain complete and accurate clinical documentation for two residents. One resident's records lacked details about an incident involving THC use and subsequent hospitalization, while another resident had an undated Band-Aid with no documented reason. Staff interviews revealed uncertainty and incomplete records, highlighting deficiencies in documentation practices.
The facility failed to provide adequate staff training for managing residents with substance abuse and PTSD. A resident with a history of substance abuse lacked a care plan for overdose risk, and staff were not trained on Narcan use. Another resident with PTSD had specific needs that were not addressed due to insufficient staff training.
A resident with severe cognitive impairment and documented behaviors eloped from the facility unwitnessed due to insufficient behavioral health care. The resident's care plan was not updated, and the incident was not documented in progress notes. The facility's behavior management program policy was not followed, and the resident's behavioral tracking log was missing.
The facility failed to maintain accurate records for two residents. One resident's elopement incident and behaviors were not documented, and another resident's wound treatment orders were not updated or recorded properly. Staff interviews confirmed the lack of proper documentation.
Food Storage, Sanitation, and Pest Control Deficiencies in Kitchen
Penalty
Summary
Surveyors identified that the facility failed to store and handle food in accordance with food safety standards during two kitchen observations. During one observation, the backsplash behind the three-compartment sink appeared unclean, discolored, and had several dried splatterings. In a downstairs standing freezer, surveyors found an open bag of individual cookie dough balls exposed to air. Kitchen Staff 4 later stated that food should be covered when stored in the freezer and that staff are responsible for cleaning during their shifts and performing a full kitchen cleaning at the end of each shift. In a separate observation during meal service, the Dietary Manager used a pair of tongs to plate chicken and repeatedly set the tongs down on a tabletop so that the serving end rested against a cleaning towel that had been dipped in sanitizing solution, then used the same tongs to plate the next piece of chicken. Additionally, a live roach was observed on an outlet near the three-compartment sink. The Dietary Manager reported not having seen any live roaches in the kitchen and indicated that pest control visits the facility routinely. The facility’s written sanitization policy required that food service areas be kept clean, sanitary, and protected from rodents, roaches, flies, and other insects, and assigned the food services manager responsibility for scheduling regular cleaning of kitchen and dining areas.
Failure to Prevent Elopement of Resident with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for a resident with a known history of exit-seeking and elopement behaviors. The resident, who had diagnoses including anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia, was assessed as having moderately impaired cognitive skills and required supervision for mobility and transfers. Despite a care plan identifying the resident as at risk for elopement and documenting previous incidents of exit-seeking, interventions such as personal safety alarms or devices were not implemented. The resident had previously exhibited exit-seeking behaviors, including climbing over a courtyard wall when frightened by EMTs and moving furniture to facilitate escape attempts. On the evening of the incident, the resident climbed a gazebo in the facility's walled courtyard, jumped over the 66-inch wall, and left the property. The event occurred while the nurse was occupied assisting EMS with another resident, leaving the at-risk resident unsupervised. The resident was located approximately 0.6 miles from the facility, hiding behind an air conditioning unit near a busy intersection, and attempted to flee from law enforcement before being apprehended. The facility's records and staff interviews confirmed that the resident had previously used the same method to attempt elopement and that staff were aware of the resident's behaviors and triggers, such as being frightened by EMS presence. The facility's policy required that residents identified as at risk for wandering or elopement have care plans with appropriate interventions to maintain safety. However, the resident's care plan and supervision were not updated in response to repeated exit-seeking behaviors and prior incidents. Staff interviews indicated that elopement risk assessments and care plan updates were not consistently performed when the resident exhibited increased exit-seeking behavior, contributing to the failure to prevent the elopement event.
Removal Plan
- Completed audits of clinical records for residents at risk for exit-seeking behavior or elopement.
- Removed the Gazebo from the courtyard.
- Removed a tree in the courtyard.
- Secured patio furniture.
- Equipped all exit doors with Wander-guard key pad.
- Provided in-service training to staff on the elopement exit seeking policy.
- Monitoring changes in residents' behavior.
Environmental and Sanitation Deficiencies in Resident Areas
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's environment, including a lack of maintenance and cleanliness in key resident areas. In the North Unit dining room, the flooring was found to be uneven, warped, and cracked, with a towel placed under an in-wall air conditioning unit. Clean linens were transported through the South Unit in an open laundry basket, exposing them to potential contamination. Overhead air vents in both the North Unit hall and the shared shower room were noted to have a significant build-up of dust, and one vent appeared rusted. The shared shower room in the middle hall, used by residents from both the North and South Units, had three broken floor tiles near the base of the commode, which itself appeared unclean. A small swarm of gnats and flies was observed around the commode, indicating unsanitary conditions. During an interview, a resident reported that the shower room required maintenance and that the maintenance staff could not keep up with the facility's needs. Facility policy requires the environment to be safe, functional, sanitary, and comfortable, and for clean linens to be transported in a manner that prevents contamination, but these standards were not met in the areas observed.
Failure to Provide Ordered Routine Medication Due to Pharmacy Service Issues
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident who required routine physician-prescribed medication. Following a change in the resident's medication regimen, the facility did not obtain the ordered medication, Geodon 40 mg, resulting in multiple missed doses over several days. Documentation in the Medication Administration Record and nurse's progress notes repeatedly indicated that the medication was unavailable or not in stock on specific dates. The resident's diagnoses included anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia, and the resident was noted to have moderately impaired cognitive skills and was rarely to never understood. Interviews with staff revealed ongoing difficulties in obtaining the medication from the pharmacy, attributed in part to the resident's payor source. Nursing staff reported that when a routine medication was unavailable, they were expected to check the emergency drug kit, document missed doses, and notify the physician. Despite these procedures, the resident did not receive the prescribed medication as ordered, and the facility's policy required contacting the pharmacy and using after-hours emergency numbers if necessary. The deficiency was identified through record review and staff interviews, confirming that the facility did not ensure the resident received all ordered medications.
Failure to Maintain Safe, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in several areas, as evidenced by observations and interviews. In one resident room and one shower room, water temperatures were found to be excessively high, reaching 140 degrees Fahrenheit, which exceeds the facility's policy limit of 120 degrees Fahrenheit. The Maintenance Director confirmed that these temperatures were too high and indicated that adjustments would be made. Additionally, a resident reported a lack of hot water in their restroom and shower room, further highlighting inconsistencies in water temperature regulation. In the North Unit dining room, air temperatures were consistently recorded as excessively high, with the thermostat indicating temperatures between 85 and 89 degrees Fahrenheit during meal times and activities. Residents were observed fanning themselves, and staff confirmed that the dining room became uncomfortably hot during a recent heat wave. No fans were in use to mitigate the heat, and the air conditioning unit was not functioning adequately. The Maintenance Director reported that the AC unit had frozen and required servicing, and an external HVAC company was scheduled to address the issue. Multiple areas of the facility were found to be in disrepair. In one resident room, a ceiling tile was damaged and stained due to a leaking AC unit, with an air vent and duct hanging from the ceiling. The same room had a hole and soft spot in the floor, and the closet floor was patched with plywood. Another resident room had broken flooring near the doorway. The North Unit dining room had a leaking AC unit, resulting in a wet, uneven, and soft floor, with water seeping through cracks. These conditions were confirmed by the Maintenance Director, who attributed the damage to previous incidents and ongoing maintenance issues.
Incomplete Facility Assessment Lacks Critical Details
Penalty
Summary
The facility failed to ensure a complete and accurate facility assessment that was based on the resident population and the identification of resources needed to provide necessary care and services. During the survey, it was found that the facility assessment form, revised on January 17, 2024, listed facility personnel but lacked a staffing plan to ensure sufficient staff were available to meet resident needs. The form also omitted training topics and competencies specific to the facility, transportation information including the use of a facility van, Enhanced Barrier Precautions, resident equipment, use of oxygen therapy, pharmacy information, and the facility's plan for communication with residents and staff who have communication barriers. The Administrator indicated that she was unaware that the facility assessment could include specific detailed information about the facility. She mentioned that a template was used to fill out the current facility assessment, which was updated annually, and that there was no facility policy in place, but regulation guidelines were followed to complete the assessment.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The current IP, an LPN, indicated that she did not have any specialized training or certification for the role and was only able to dedicate approximately 3-4 hours per week to the infection control program. Additionally, the facility's Administrator, through the Activity Director, confirmed that there was no policy or job description for the Infection Preventionist, and the role was simply assigned to someone without formal designation or training.
Facility's Blanket Policy on Crushing Narcotics Violates Resident Rights
Penalty
Summary
The facility failed to uphold residents' rights to participate in the development and implementation of their person-centered care plans by enforcing a blanket policy to crush all narcotic medications without resident input or obtaining specific physician orders. This policy affected 10 out of 32 residents reviewed for narcotic use. The decision to crush narcotics was made by the facility's Administrator, Medical Director, and Director of Nursing (DON) due to concerns about residents potentially hoarding or trading pills. However, this decision was implemented without consulting the residents or considering individual needs, leading to some residents, like Resident 5, refusing their medication due to the unpleasant taste of crushed pills. Resident 5, who suffered from severe pain, had her narcotic medication discontinued because she refused to take it in crushed form. Despite her complaints and the absence of any suspicion of her hoarding or selling narcotics, the facility continued with the policy. The facility did not have a formal narcotic administration policy, and the residents were not informed of the change prior to its implementation. The facility's actions were based on unverified concerns about residents' misuse of medications, and the policy was enforced without proper documentation or physician orders for each affected resident.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in the documentation of medication administration. Resident 16, who had diagnoses including COPD, anemia, and atrial fibrillation, was not recorded as taking antiplatelet medication or using oxygen, despite physician orders for aspirin and oxygen therapy. Similarly, Resident 28, with diagnoses of cerebral infarction, anemia, and heart failure, was not documented as using antiplatelet or diuretic medications, although physician orders indicated daily aspirin and furosemide. Resident 25, diagnosed with schizophrenia, renal insufficiency, and thyroid disorder, was not marked as taking antiplatelet medication, despite an order for daily aspirin. Resident 7, with diabetes mellitus, depression, and cancer, was also not recorded as taking antiplatelet medication, although there was an order for daily aspirin. The Director of Nursing was unaware that aspirin is an antiplatelet medication, indicating a lack of knowledge that contributed to the inaccurate MDS assessments.
Failure to Implement Comprehensive Care Plans for Residents on Medications
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents who were on various medications, including antipsychotics, antidepressants, antianxiety, diuretics, and oxygen. The deficiency was identified through observation, interviews, and record reviews. For instance, Resident 15, who had a history of substance abuse and was taking antipsychotic medication, did not have a care plan addressing these issues. The Director of Nursing (DON) acknowledged that care plans should have been in place but indicated that she was the only staff member capable of entering care plans into the electronic health record. Resident 16, who had diagnoses including COPD, anemia, and atrial fibrillation, was on medications such as antiplatelets, anticoagulants, and diuretics, and required oxygen. However, the clinical record lacked care plans for these medications and oxygen use. Similarly, Resident 28, with diagnoses of cerebral infarction, anemia, and heart failure, was taking antidepressants, antiplatelets, and diuretics, but did not have corresponding care plans. The DON confirmed that care plans should have been implemented for these medications and treatments. Other residents, such as Resident 7, Resident 25, and Resident 6, also lacked appropriate care plans for their prescribed medications, including antidepressants, antiplatelets, antipsychotics, and diuretics. The DON indicated that care plans were updated quarterly and with the MDS, but acknowledged the expectation for care plans to be in place for each specific medication administered to residents. The facility's care planning policy, dated May 2013, required comprehensive care plans for each resident, which were not adhered to in these cases.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for several residents. Resident 6's oxygen tank was observed with debris, and the filter was caked with dust. Despite having a care plan that included oxygen as an intervention, Resident 6's clinical record lacked a current order for oxygen. The resident was using oxygen at night due to a sleep study, but there was no documentation or order in the clinical record to support this. Resident 5 was observed using an oxygen concentrator without a filter, and the tubing was undated. The resident's clinical records indicated diagnoses of COPD, emphysema, and asthma, but lacked orders to change the oxygen tubing and clean the filter. The care plan did not include interventions for changing the tubing or cleaning the filter. There was confusion about the ownership and maintenance of the oxygen concentrator, with conflicting information from the DON, the resident, and the Administrator. Resident 23 was observed with undated oxygen tubing and a dust-covered filter on the oxygen concentrator. The resident's clinical records indicated a diagnosis of COPD with acute exacerbation, but lacked orders to change the tubing and clean the filter. Similarly, Resident 14 was observed with a dust-covered filter on the oxygen concentrator and lacked a current physician order for oxygen. The facility's respiratory therapy policy required changing the oxygen cannula and tubing every seven days and washing the filters weekly, but these actions were not documented or consistently performed.
Deficiency in Obtaining Physician Orders for Medications and Oxygen
Penalty
Summary
The facility failed to ensure that all physician's orders were obtained from the pharmacy for certain residents, leading to deficiencies in medication administration and respiratory care. Specifically, Resident 2, who has a severe cognitive impairment and diabetes mellitus, did not have a current physician order for Tresiba Flextouch insulin, despite receiving it daily as indicated in the August blood sugar log. This oversight was confirmed by RN 5 and the Director of Nursing (DON), who provided evidence of the insulin administration without a corresponding physician order. Additionally, the facility did not have current physician orders for oxygen for Residents 14, 5, and 23. Resident 14, who has a mild cognitive impairment and uses oxygen, was observed with oxygen administered via nasal cannula, but lacked a current order for it. The DON explained that a change in pharmacy at the beginning of August resulted in the failure to transfer oxygen orders from the previous pharmacy to the current one. The facility's pharmacy policy requires maintaining a medication profile for each resident, but this was not adhered to, contributing to the deficiency.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to maintain safe and secure storage of medications, as observed in two medication carts and one medication storage room. During the review of the Back Hall Medication Cart, several medications were found without open dates, including an Albuterol Sulfate inhaler, Breyna inhaler, and allergy relief nasal spray. Additionally, a ferrous sulfate pill was found in a medication cup without identification, and a Trelegy Ellipta inhaler was observed with an open date of 5/21/24. Another Trelegy Ellipta inhaler had a tag to discard after six weeks but lacked an open date. Furthermore, Neo/Poly/HC otic drops, which should have been discarded after 8/22/24, were still present in the drawer. In the Back Hall Medication Storage Room, the medication refrigerator temperature log was incomplete, with missing entries for several days in August 2024. The Front Hall Medication Cart also had medications without open dates, such as Polymyxin B TMP eye drops and artificial tears. A Ventolin inhaler was found with an open date of 6/30/23 and an expiration date of 6/30/24. The Director of Nursing confirmed that multidose medications should have open dates, and the medication refrigerator temperature should be logged daily. The facility's Medication Storage Policy, dated 5/2013, requires daily monitoring of refrigerator temperatures, but there was no specific policy for open dates on multidose medications, although it was their practice to do so.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, distribution, and service, as observed in the kitchen. Staff members did not wear hairnets that adequately covered all their hair, and inappropriate footwear was noted. Additionally, food items were not properly labeled, and the dishwasher was not monitored daily for safe sanitation. Observations revealed that the dishwasher's temperature was below the required minimum, and there was no documentation of chemical checks. Staff members also did not wash their hands for the appropriate length of time, and scoops were left in containers, which is against the facility's policies. During the inspection, it was noted that the kitchen lacked soap in the handwashing sink, and the Dietary Manager and Kitchen Staff 1 did not wear hairnets that fully covered their hair. The freezer and refrigerator contained opened and unlabeled food items, and there was stagnant water in the freezer room. The dishwasher was not properly checked for chemical levels, and the staff was unaware of the correct procedures for ensuring sanitation. Interviews with the Dietary Manager and Maintenance Supervisor revealed a lack of training and knowledge regarding the dishwasher's operation and chemical monitoring. Further observations showed that the ice scoop was left uncovered on a dusty machine, and staff members did not follow proper handwashing protocols. The Dietary Manager used a washcloth to clean a thermometer probe, which was not in line with the facility's policy. The facility's policies on dishwashing machine use, food receiving and storage, hairnet use, and thermometer sanitation were not followed, leading to the deficiencies noted during the survey.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment, leading to the potential transmission of infections. Observations revealed that staff did not change gloves between dirty and clean tasks, nor did they sanitize their hands between glove changes. In one instance, a resident was not completely cleaned during incontinence care, and fecal matter was transferred onto the resident's back and clean sheet. Additionally, staff did not offer residents the opportunity to wash their hands after toileting, which is a basic hygiene practice. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds, urinary catheters, and a stoma. The Director of Nursing was unaware of any residents on EBP, and the Infection Preventionist did not know what EBP was. This lack of knowledge and implementation of EBP could contribute to the spread of infections among vulnerable residents. Furthermore, clean clothing was not handled properly, as staff transported it uncovered and against their uniforms, risking contamination. Ice was also transported inappropriately in a trash bag, which was then used to serve residents. These practices indicate a lack of adherence to infection control protocols, potentially compromising resident safety and health.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in several areas, including a communal restroom and three shower rooms. Observations revealed various issues such as a brown substance around the bottom of toilets, rusted toilet paper holders, chipped doors, and missing tiles in the shower rooms. Additionally, there were gnats on the floor, spiderwebs on the ceiling, and soiled grout. These deficiencies were consistently observed over multiple days, indicating a lack of timely maintenance and cleaning. Further observations included a couch in a common area with peeled fabric and a courtyard door with a three-quarter inch gap, which the Maintenance Supervisor was unaware of and unable to fix immediately. The Maintenance Supervisor, who also served as the Housekeeping Supervisor, indicated there were no formal policies for maintenance or housekeeping, and tasks were not documented. Despite daily walkthroughs and a cleaning schedule, the facility failed to address these issues promptly, leading to the observed deficiencies.
Pest Control Deficiency in Storage Room
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations made in the downstairs dry storage room. On two separate occasions, a sticky pad intended for catching insects and rodents was found full of insects, with a dead mouse attached to it. Additionally, a live mouse was observed stuck to the sticky pad, and flying insects, both dead and alive, were present in the area. The refrigerator door in the storage room was not properly closed, which may have contributed to the presence of flying insects. The facility's pest control contract indicated that the pest control company was scheduled to visit monthly, with additional visits in January, to monitor for specific pests such as spiders, mice, and German cockroaches. Despite this arrangement, the facility had ongoing issues with mice, which the Administrator was not aware of until notified. The pest control company had visited approximately two weeks prior and reported no concerns. The facility's Pest Control Policy, dated January 2024, stated that the building should be kept free of insects and rodents, with maintenance services assisting as necessary.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to determine the clinical appropriateness of self-administration of medications for a resident. An Albuterol inhaler was found in the room of a resident diagnosed with chronic obstructive pulmonary disease (COPD) and asthma, without an order to keep it at the bedside or a self-administration assessment. The resident was cognitively intact according to the most recent Minimum Data Set (MDS) assessment. The physician's order for the inhaler did not specify that it should be kept at the bedside, and the clinical record lacked a self-administration assessment. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration of medications was safe and clinically appropriate, but this was not done for the resident in question.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised for three residents. For Resident 2, the care plan was not updated to include the use of bed rails as a fall intervention, despite the resident being observed with a bed rail in use and having a severe cognitive impairment requiring extensive assistance. The Director of Nursing (DON) acknowledged that the care plan should have included the bed rail intervention. Resident 16's care plan was outdated, as it still listed Lexapro as the antidepressant medication, even though the resident was currently prescribed venlafaxine. The DON admitted to not updating care plans with specific medication names due to potential changes. Similarly, Resident 15's care plan was not revised to reflect the discontinuation of Klonopin, an antianxiety medication, and the current use of Hydroxyzine, which is not classified as an antianxiety medication. The DON was the only staff member capable of updating care plans in the electronic health record, which contributed to the oversight.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide effective services to prevent the development of pressure injuries for a resident who was admitted without any pressure ulcers but was identified as being at risk. The resident, who had a history of cerebral infarction, anemia, and heart failure, required extensive assistance with mobility and was incontinent of bowel. Despite being at risk, the resident developed multiple stage two pressure injuries and a stage three pressure injury over time. The facility's records showed inconsistencies and omissions in documenting the resident's skin condition and wound treatments. Observations revealed that the resident had been experiencing pain in the buttocks for several weeks, which he had reported to the staff. However, the clinical records lacked specific care plans for the actual pressure ulcers, and there were missing entries for wound treatments in August. The facility's staff, including the DON and LPN, were unaware of the resident's wounds until they were observed during incontinence care. The staff failed to perform hand hygiene before and after providing care, and there was a lack of timely notification and documentation of new wounds. The facility's pressure ulcer program policy required comprehensive assessments and individual care plans for residents at risk, but these were not adequately implemented for the resident. The DON indicated that risk assessments would only be updated with significant health changes, and the resident's record lacked updated care plans for the new wounds. The facility's failure to adhere to its policy and ensure proper wound care and documentation contributed to the development and worsening of the resident's pressure injuries.
Inadequate Supervision and Management of Vaping Devices
Penalty
Summary
The facility failed to ensure adequate supervision and management of vaping devices among residents, leading to potential safety hazards. During observations, two residents were found with vapes in their possession, despite facility policies requiring these devices to be stored at the nurse's station and used only in designated smoking areas. Resident 15, who has a history of substance abuse, was observed with vapes on his bedside table, and staff members, including a Qualified Medication Aide and the Dietary Manager, did not address the presence of these devices. The resident's clinical record lacked a care plan addressing his history of substance abuse and risk of overdose, and there was no documentation of a previous incident where the resident allegedly smoked a THC-containing vape, resulting in a change of condition and hospitalization. Resident 24, who has moderate cognitive impairment and requires extensive assistance, was observed holding vapes on multiple occasions. Despite a behavior care plan indicating the need to remind the resident to return vaping materials to staff, the resident was seen with vapes in his possession, and staff did not intervene. An anonymous resident reported that vaping and smoking occurred in the building, affecting their allergies. A Registered Nurse acknowledged that some residents, including Resident 24, were reluctant to return vapes to staff, and there was confusion among staff about the facility's policy on vapes. Interviews with facility staff, including the Director of Nursing and the Social Services Director, revealed inconsistencies in the handling and documentation of vaping incidents. The facility's smoking policy, dated October 2021, did not require a smoking evaluation for e-cigarette use, and vapes were to be kept at the nurse's station. However, staff were unclear about the policy, and there was a lack of documentation regarding incidents involving vapes. The Administrator admitted to wanting to change the policy but had not done so, contributing to the ongoing issue of residents possessing and using vapes within the facility.
Incomplete Clinical Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate clinical record documentation for two residents. For Resident 15, the clinical record lacked documentation related to an incident where the resident allegedly smoked a vape containing THC, leading to a change in condition and hospitalization. The Administrator and DON were unsure of the exact details and dates, and the clinical record did not reflect the incident accurately. The resident admitted to smoking a vape from a local gas station, which led to unconsciousness and hospitalization. However, the Administrator later clarified that the hospitalization was due to sepsis from a fall, not the THC incident, indicating a lack of accurate documentation. For Resident 23, the facility failed to document the reason for a Band-Aid on the resident's left lower arm. The resident was observed with multiple bruises and an undated Band-Aid, but the clinical records and physician orders did not provide any information about a dressing or skin issue. Interviews with staff, including a QMA and LPN, revealed that they were unaware of the reason for the Band-Aid, and the nursing notes lacked documentation. The DON acknowledged that dressings should be dated, but there was no indication of a wound when the Band-Aid was removed, highlighting incomplete documentation.
Deficiency in Staff Training for Substance Abuse and PTSD
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff, which led to deficiencies in care for residents with specific needs. Resident 15, who had a history of substance abuse, was not provided with a care plan addressing the risk of overdose. Despite being prescribed Norco, a narcotic pain medication, there was no plan in place to manage the resident's substance abuse history. Additionally, staff were not trained on the use of Narcan, a medication used to treat narcotic overdoses, as evidenced by an LPN's uncertainty about its location and administration. Resident 24, diagnosed with PTSD, was also affected by the lack of staff training. The resident expressed that knocking on the door was a trigger, yet there was no indication that staff were trained to accommodate this need. The Director of Nursing confirmed the absence of specific in-services for PTSD, substance abuse, or Narcan administration, relying instead on common nurse knowledge. The facility lacked a policy for required in-services, contributing to the deficiency in addressing the residents' needs.
Failure to Provide Sufficient Behavioral Health Care Leading to Resident Elopement
Penalty
Summary
The facility failed to provide sufficient behavioral health care for a resident with documented behaviors, resulting in the resident eloping from the facility unwitnessed. The resident, who had severe cognitive impairment and used a wheelchair for mobilization, was upset about not being able to obtain cigarettes and exited the facility courtyard through an unlocked gate. The incident was not documented in the resident's progress notes, and the resident's care plan was not updated following the elopement. Additionally, the resident's behavioral tracking log was missing from their record, and the facility's behavior management program policy was not followed. The resident's diagnoses included undifferentiated schizophrenia, acquired absence of the right leg below the knee, partial traumatic amputation of the left midfoot, and nicotine dependence. Despite having a care plan that included interventions for behavior problems, the facility did not provide additional monitoring or services during the behavioral episode. The resident's physician orders included Lorazepam for agitation, but the medication was not administered during the month of the incident. Interviews with staff revealed that the resident had not previously attempted to elope and was not considered exit-seeking prior to the incident.
Failure to Maintain Accurate Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate records for two residents. For Resident B, there was no documentation of an elopement incident, the behaviors leading up to it, or any monitoring following the event. Resident B's diagnoses included undifferentiated schizophrenia, acquired absence of the right leg below the knee, partial traumatic amputation of the left midfoot, and nicotine dependence. Despite an incident where Resident B exited the facility to buy cigarettes, no records reflected this occurrence or the resident's behavior before and after the event. For Resident C, the facility did not update wound treatment orders in the resident's record, nor did they document wound treatment changes as required. Resident C, diagnosed with quadriplegia, overactive bladder, and neurogenic bowel, had specific wound care orders that were not consistently followed or recorded. The treatment administration record showed incomplete documentation, and interviews with staff confirmed that updates from the wound care center were not properly recorded in the resident's records. The DON acknowledged that maintaining accurate records is part of the nurse's job description, but there was no specific policy for documentation.
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What surveyors actually found near you
We read the 125 citations issued within 25 miles in the last 12 months — including the 1 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Village Nursing And Rehabilitation | 0.6 mi | — | 0 | 0 |
| Eastgate Manor Nursing And Rehabilitation | 0.8 mi | — | 0 | 0 |
| Villages At Oak Ridge, The | 1.5 mi | — | 1 | 0 |
| Amber Manor Care Center | 13 mi | — | 0 | 0 |
| Brickyard Healthcare - Petersburg Care Center | 13.4 mi | — | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.