Center on Aging and Health

In the surveyor’s words

From the most serious findings on record at Center on Aging and Health, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF552Apr 15, 2026

  Based on medical record review and interviews, the facility failed to obtain consent for administration of psychotropic medications for 5 of 5 residents (Resident #21, #33, #8, #42 and #3) reviewed for unnecessary medications.The findings include: 1.Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Delusional Disorder, and Psychotic Disorder. Review of a Physician's Order for Resident #21 dated 6/14/2024, revealed .Memantine [a medication used to treat dementia] .Oral Tablet 1000 mg . Give 1 tablet by mouth two times a day . Review of a Physician's Order for Resident #21 dated 7/24/2024, revealed .Sertraline [a medication used to treat depression] .Oral Tablet 100 mg . […]

• No harm, potential for more than minimal, isolatedF583Apr 15, 2026

  Based on facility policy review and observations the facility failed to ensure Protected Health Information (PHI) was safeguarded from access and public view for 19 of 19 residents visible on the screen (Residents #15, #2, #69, #9, #13, #68, #30, #29, #14, #49, #24, #7, #41, #60, #23, #1, #11, #31, and #32) on 2 of 3 medication carts observed. The findings include: Review of the facility policy titled, Corporate Compliance and Ethics Manual, dated 7/2024 revealed .Safeguarding Protected Health Information (PHI) .the company shall have in place .appropriate physical and technical safeguards to protect PHI .Staff members shall log off their workstation when leaving the work area .computer monitors shall be positioned so that unauthorized persons cannot easily view information on the screen… […]

• No harm, potential for more than minimal, isolatedF677Apr 15, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure nail care had been provided to 1 resident (resident #42) of 3 residents reviewed for nail care. The findings include:Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, revealed .Residents will be provided with care, treatment and services as appropriate .residents who are unable to carry out activities of daily living [ADLs] independently will receive the services necessary to maintain .grooming .appropriate care and services will be provided for residents who are unable to carry out ADLs independently . […]

• No harm, potential for more than minimal, isolatedF687Apr 15, 2026

  Based on facility policy review, medical record review, observations and interviews, the facility failed to ensure foot and nail care had been provided for 1 resident (Resident #25) of 3 residents reviewed. The findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, revealed .Residents will be provided with care, treatment and services as appropriate .residents who are unable to carry out activities of daily living [ADLs] independently will receive the services necessary to maintain .grooming .appropriate care and services will be provided for residents who are unable to carry out ADLs independently .report any changes .in skin .skin between the toes .if nails are too hard or too thick to cut .Documentation .should be recorded in… […]

• No harm, potential for more than minimal, isolatedF761Apr 15, 2026

  Based on facility policy review, observation, and interview, the facility failed to ensure 1 of 1 wound treatment carts, which contained topical medications and supplies, was locked and secured allowing unauthorized persons including residents, staff, and visitors access to the cart and the contents. The findings include: Review of the facility policy titled, Security of Medication Cart, dated 4/2007, revealed .the nurse must secure .the cart .to prevent unauthorized entry .the cart must be locked before entering a resident's room .carts must be securely locked at all times when out of the nurses view . During an observation on 4/13/2026 at 11:09 AM, in the East hallway, revealed a treatment cart unlocked and unattended against the wall. […]