Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridgecrest Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment did not receive their 8:00 AM medications until after 11:00 AM due to an LPN being overwhelmed with tasks. The medications were administered by another staff member, contrary to facility policy, which requires the nurse who pulls the medication to administer it.
A resident with moderate cognitive impairment received medications from a Medicare Manager who did not prepare them, contrary to facility policy. The LPN who prepared the medications did not administer them, leading to a delay in the resident receiving their 8:00 AM medications. The DON confirmed the importance of the nurse who prepares medications also administering them to ensure accuracy.
Dietary staff in an LTC facility failed to practice proper hand hygiene, leading to potential cross-contamination affecting 103 residents. Observations showed staff handling clean items like glasses and plates without washing hands after touching contaminated surfaces, despite facility policies requiring handwashing to prevent foodborne illness.
The facility failed to maintain resident dignity during ADL care for two residents. One resident, moderately cognitively impaired, experienced a lack of privacy and embarrassment when CNAs did not pull the privacy curtain and passed soiled linen across their face. Another resident, severely cognitively impaired, also did not have the privacy curtain pulled during care. Both instances were acknowledged by the CNAs and the DON as inappropriate.
The facility failed to accurately document the use of an antipsychotic medication and a CPAP machine in the MDS for two residents. An MDS Nurse admitted to overlooking the antipsychotic medication, while the CPAP usage was not recorded despite being part of a resident's care plan. Both the ADON and DON confirmed the necessity of including these treatments in the MDS.
The facility failed to implement baseline care planning and enhanced barrier precautions for four residents upon admission, leading to deficiencies in care. Residents with pressure ulcers, PICC lines, and other conditions did not receive timely interventions, and necessary precautions were delayed. Interviews revealed systemic issues, including understaffing and high workloads, contributing to these deficiencies.
The facility failed to conduct proper wound assessments and follow physician orders for wound care for several residents. A resident with a traumatic amputation had inappropriate wound cleaning without a physician's order. Other residents with pressure ulcers and skin damage did not receive necessary wound evaluations. Staffing issues contributed to the delays in assessments, as new treatment nurses were in training and social services were understaffed.
The facility failed to ensure nursing staff had the necessary competencies to provide care as identified in care plans, leading to deficiencies in care planning and infection control. Several residents did not receive timely medications, and enhanced barrier precautions were not utilized. Additionally, contact isolation protocols were not followed, and a resident's CPAP usage was not documented. These issues highlight a lack of adherence to infection control measures and care planning protocols.
The facility failed to maintain the flavor, appearance, and appropriate temperature of meals, affecting residents' nutritional intake. Residents reported receiving cold and unappetizing food, with test trays confirming issues in seasoning and temperature. Unheated meal carts led to food being served at inappropriate temperatures, as confirmed by dietary staff and CNAs.
The facility failed to ensure proper infection control measures, as staff did not wear appropriate PPE or follow enhanced barrier precautions for residents on contact isolation. A resident on contact isolation had a roommate, and staff entered without PPE. Additionally, staff did not adhere to aseptic techniques during medication administration and wound care, indicating a lack of understanding and training in infection control protocols.
The facility failed to provide necessary ADL assistance for residents, particularly in maintaining hygiene and grooming. A resident with severe cognitive impairment had long, unclean fingernails despite needing assistance, while another diabetic resident had long, dirty toenails. Staff acknowledged the need for nail care, especially given the residents' conditions, but failed to provide it.
The facility failed to provide necessary pharmaceuticals for two residents during medication administration. One resident with COPD did not receive their prescribed inhaler and oral medication, while another with eye conditions did not receive their prescribed ointment. Staff acknowledged the absence of medications and the need to reorder them, highlighting a lapse in following the facility's medication ordering policy.
Two residents did not receive their prescribed medications due to unavailability during medication pass observations. One resident with COPD and asthma did not receive Advair and Montelukast, while another with eye conditions did not receive Refresh Lacri-Lube. Staff acknowledged the medications should have been available, citing reordering issues and pharmacy differences.
The facility failed to prepare and serve meals according to the planned menu and recipe, affecting residents on pureed and enhanced diets. A dietary staff member used incorrect scoop sizes for pureed oatmeal and did not follow the recipe for enhanced oatmeal, omitting key ingredients and using incorrect quantities.
A resident with a history of stroke and anxiety was found in a wheelchair with the call light out of reach, unable to call for assistance. The care plan required the call light to be within reach, but this was not adhered to. Additionally, the resident had a skin tear that was not treated promptly, causing distress. The nursing staff did not address the wound until later, leaving the resident upset and the wound exposed.
A facility failed to complete an Admission MDS in a timely manner for a resident. The MDS, required within 14 days of admission, was overdue due to staffing issues and training delays. The MDS Coordinator acknowledged the delay, citing overwork and training as contributing factors.
A resident with sleep apnea did not have their CPAP usage documented in their care plan, despite observations of the CPAP mask at the bedside and staff confirming the need for a physician's order and care plan inclusion. The facility's policy on comprehensive care plans was not followed, leading to a deficiency in addressing the resident's care needs.
The facility failed to update care plans for three residents, leading to potential negative outcomes. One resident's hearing loss was not addressed in the care plan, another's code status was inconsistently documented, and a third resident's elopement attempt was not reflected in their care plan. Staff interviews confirmed these deficiencies.
A facility failed to provide necessary foot care for a diabetic resident, resulting in long, dirty, thick, and yellow toenails. The resident, dependent on staff for care due to impaired mobility and other health issues, had not been seen by a podiatrist. Staff interviews revealed a misunderstanding of responsibilities, with CNAs not providing care due to the resident's diabetes, and nurses acknowledging the need for specialized care.
A resident with severe cognitive impairment and a history of traumatic brain injury experienced significant weight loss due to the facility's delay in implementing the RD's recommendation to increase bolus tube feedings. Despite the RD's advice to increase feedings from five to six times a day, the change was not made until several days later, resulting in a 5.2% weight loss for the month. The DON confirmed that the RD's recommendations should have been implemented within 72 hours.
A facility failed to administer enteral water flushes according to a physician's orders for a resident with a PEG tube. The resident, diagnosed with dysphagia and gastrostomy status, received only 330 mL of water flush instead of the 420 mL ordered. The DON confirmed the discrepancy, noting the resident should have received 120 mL with medications and 300 mL during the medication pass, as per the physician's order.
The facility's QAPI program failed to maintain necessary records for developing and implementing improvement plans. During a survey, the facility could not provide its QAPI plan to State surveyors. The administrator, new to the position, stated that QA committee meeting records were unavailable.
A facility failed to respect resident privacy and dignity by not knocking on doors before entering rooms. Observations showed a CNA entered multiple rooms without knocking, contrary to the facility's policy. The DON confirmed staff should knock before entering. Attempts to interview the CNA were unsuccessful.
The facility failed to ensure that licensed nurses had the necessary skills to provide individualized care for two residents. For one resident, the MDS was not completed, and care plans were outdated, while another resident's care plan lacked documentation for an indwelling catheter and a wound. Staff interviews revealed a lack of communication and training, contributing to these deficiencies.
The facility failed to implement proper infection prevention and control practices, as evidenced by multiple instances of inadequate hand hygiene by staff members during resident care. CNAs were observed not sanitizing hands between glove changes during perineal care, and a treatment nurse did not adhere to hand hygiene protocols during wound care. Additionally, there were issues with updating care plans and physician orders, contributing to the deficiencies observed.
The facility failed to provide a safe, clean, and homelike environment in a resident's room and surrounding areas. Observations showed missing paint, drywall damage, and a black substance on the floor. Staff confirmed the room's untidy state, with an unmade bed and trash present. Maintenance issues were acknowledged but not addressed, violating the facility's policy on maintaining a homelike environment.
Medication Administration Delay
Penalty
Summary
The facility failed to administer medications within the recommended time frame for a resident with moderate cognitive impairment. The resident, who had a Brief Interview for Mental Status (BIMS) score of 09, was supposed to receive 8:00 AM medications between 7:00 AM and 9:00 AM. However, due to delays, the medications were administered at 11:14 AM and 11:19 AM. The delay was attributed to the Licensed Practical Nurse (LPN) being overwhelmed with tasks, as she mentioned having '17,000 things happen.' The LPN was observed pulling medications late and leaving them on the medication cart, which were then administered by another staff member, the Medicare Manager. This practice was against the facility's policy, which states that the nurse who pulls the medication should be the one to administer it to ensure the correct medication is given to the resident. The Director of Nursing (DON) confirmed the policy and the expected time frame for medication administration.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered by the nurse who prepared them, leading to a deficiency in medication administration for a resident with moderate cognitive impairment. On the specified date, an LPN was observed preparing medications for a resident and placing them in a medication cup on top of the medication cart. Subsequently, the Medicare Manager, without verifying the medications herself, administered them to the resident based on the LPN's assurance that they were correct. This action was contrary to the facility's policy, which requires the nurse who pulls the medications to be the one administering them to ensure accuracy. The resident involved had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment and was receiving pain medication as part of their care plan. The incident occurred when the resident received their 8:00 AM medications late, at 11:14 AM and 11:19 AM, and expressed confusion about the timing of their medication. The Director of Nursing confirmed that the medications should have been administered between 7:00 AM and 9:00 AM, and emphasized the importance of the nurse who prepares the medications also administering them to the resident.
Failure in Dietary Staff Hand Hygiene
Penalty
Summary
The facility failed to ensure that dietary staff practiced proper hand hygiene, leading to potential cross-contamination affecting 103 residents. Observations revealed that dietary aides repeatedly handled clean items such as glasses, plates, and bowls without washing their hands after touching potentially contaminated surfaces. For instance, a dietary aide was seen picking up tray cards and condiments, contaminating her hands, and then handling clean glasses by their rims without washing her hands. Another aide washed her hands but then used the same tissue to turn off the faucet, contaminating her hands again before handling clean dishes. The facility's policy on preventing foodborne illness requires staff to wash their hands whenever entering or re-entering the kitchen, before contacting food surfaces, and as often as necessary to prevent cross-contamination. Despite this policy, multiple instances were observed where dietary staff failed to adhere to these guidelines, such as handling clean plates and bowls with unwashed hands after touching dirty objects. These actions were confirmed through interviews with the staff, who acknowledged the need to wash their hands after handling dirty items and before touching clean equipment.
Failure to Maintain Resident Dignity During ADL Care
Penalty
Summary
The facility failed to maintain resident dignity during the provision of Activities of Daily Living (ADL) care for two residents. For Resident #22, who was moderately cognitively impaired with a BIMS score of 11 and had a diagnosis of acute and chronic respiratory failure and chronic obstructive pulmonary disease, the deficiency occurred when Certified Nursing Assistants (CNAs) #3 and #4 did not pull the privacy curtain while performing incontinent care. Additionally, CNA #3 passed a bag of soiled linen across the resident's face, which was acknowledged by both CNAs as inappropriate. Resident #22 expressed feeling embarrassed by these actions. Similarly, Resident #66, who was severely cognitively impaired with a BIMS score of 6 and had a diagnosis of cerebral infarction and dysphagia, experienced a lack of privacy when CNAs #1 and #2 failed to pull the privacy curtain during incontinent care. Both CNAs admitted to not pulling the curtain, which was confirmed as a requirement by the Director of Nursing (DON). The DON also acknowledged that the privacy curtain should have been used for both residents to ensure their dignity was maintained.
Inaccurate MDS Documentation for Antipsychotic and CPAP Usage
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) for two residents, leading to deficiencies in their care documentation. For one resident, the MDS Nurse confirmed that an antipsychotic medication, Olanzapine, was prescribed but not documented in the MDS. The nurse admitted to possibly overlooking or miscoding the medication, acknowledging that it should have been identified in the MDS. For another resident, the facility did not document the use of a Continuous Positive Airway Pressure (CPAP) machine in the MDS, despite the resident having a diagnosis of sleep apnea and the CPAP being observed at the bedside. The resident confirmed their condition, and both the Assistant Director of Nursing and the Director of Nursing acknowledged that CPAP usage should be included in the MDS as it is part of the resident's treatment and care plan. The oversight was confirmed by the MDS Nurse, who stated that documenting CPAP usage is essential for staff awareness and resident care.
Deficiencies in Baseline Care Planning and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that baseline care planning was completed with necessary interventions upon admission for four residents, specifically concerning pressure ulcers, enhanced barrier precautions, and PICC lines. Resident #363, who had a diagnosis of malnutrition and an unstageable pressure ulcer, did not have enhanced barrier precautions set up immediately upon admission. It was observed that there was no signage or personal protective equipment available until several days after the resident's admission. Similarly, Resident #366, admitted with pressure ulcers, did not have these conditions included in the baseline care plan, and enhanced barrier precautions were not implemented until days later. Resident #367, with a diagnosis of type 2 diabetes mellitus and a traumatic partial amputation, also lacked immediate enhanced barrier precautions upon admission. The necessary signage and equipment were only set up after a delay. Additionally, Resident #371, who had endocarditis and a PICC line, did not have pressure ulcers or the PICC line included in the care plan. Enhanced barrier precautions for the PICC line were not established until after the resident's admission, and there was a lack of awareness about the resident's wounds, leading to inadequate precautions. Interviews with the MDS Nurse and the Director of Nursing revealed systemic issues, including understaffing and high workloads, which contributed to the delays in care planning and implementation of necessary precautions. The facility's policy requires comprehensive person-centered care plans to meet residents' needs, but these were not effectively developed or implemented for the residents in question, leading to deficiencies in care.
Failure to Conduct Wound Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to conduct proper wound assessments and follow physician orders for wound care treatment for several residents. Resident #367 was admitted with a partial traumatic amputation of the right foot and had an order for wound vac changes on specific days. However, during an observation, an LPN used Dankins Half Strength Solution to clean the wound without a physician's order, which was confirmed by the ADON and DON as inappropriate. The APRN later clarified that a wound cleanser should have been used instead. Additionally, the facility did not complete wound and skin evaluations for Residents #363, #366, and #367. Resident #363 had a diagnosis of malnutrition and an unstageable pressure ulcer, with orders for specific wound care treatments, but no assessments were conducted. Similarly, Resident #366, diagnosed with paralytic syndrome and other conditions, had orders for treating moisture-associated skin damage, but no evaluations were completed. Resident #371 had incomplete skin and wound evaluations, with no further assessments conducted since admission. Interviews with facility staff revealed that the lack of wound assessments was due to staffing issues, as new treatment nurses were in training after the previous ones quit unexpectedly. The MDS Coordinator confirmed that wound assessments were overdue for several residents, and the Quality-of-Life Specialist acknowledged delays in admission assessments due to understaffing in social services. The DON emphasized the importance of wound assessments for determining treatment plans and ensuring proper wound care.
Deficiencies in Care Planning and Infection Control
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skills to provide care and respond to individualized needs as identified in care plans. This deficiency was observed in several areas, including the failure to complete baseline and comprehensive care plans with interventions upon admission for pressure ulcers, enhanced barrier precautions, CPAP, elopement, and PICC line for multiple residents. Additionally, enhanced barrier precautions were not utilized upon admission or during care for several residents, and wound assessments were not set up to ensure healing and improvement of wounds. The facility also failed to ensure that medications were ordered timely, resulting in residents not receiving physician-ordered medications at scheduled times. For instance, a resident with COPD did not receive their prescribed inhalation aerosol and oral tablet due to a delay in reordering. Another resident did not receive their prescribed eye ointment and received an incorrect amount of water flush through a PEG tube, as the medication was last ordered months prior and required a manual reorder. Furthermore, the facility did not adhere to contact isolation protocols, as evidenced by a resident on contact isolation having a roommate and staff entering the room without appropriate PPE. Additionally, a resident's CPAP usage was not documented in their care plan or physician's orders, and another resident's attempted elopement was not reflected in their care plan. These deficiencies highlight a lack of adherence to infection control measures and care planning protocols, which are critical for ensuring resident safety and well-being.
Deficiency in Food Preparation and Serving Temperatures
Penalty
Summary
The facility failed to ensure that food was prepared and served in a manner that maintained its flavor, appearance, and appropriate temperature, affecting the palatability and nutritional intake of residents. Observations and interviews revealed that residents frequently received meals that were cold and unappetizing. For instance, one resident expressed dissatisfaction with the food, describing it as frequently cold and overly spicy. Another resident questioned the quality of the macaroni and cheese, stating it was cold and unpalatable. A test tray revealed issues with the food's seasoning and temperature, with the cheese forming an unpleasant film and the mashed potatoes lacking salt. The deficiency was further evidenced by the delivery of unheated meal carts to various halls, resulting in food items being served at inappropriate temperatures. For example, milk was recorded at 43.7 and 45.5 degrees Fahrenheit, and fried chicken was served at 114.8 degrees Fahrenheit, all of which are outside the recommended temperature ranges for safe and appetizing consumption. These findings were confirmed by dietary staff and CNAs who checked the temperatures of the food items after delivery, highlighting a systemic issue in the facility's food service process.
Infection Control Deficiencies in PPE Use and Isolation Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for residents on contact isolation and enhanced barrier precautions. Resident #31, who was on contact isolation due to a history of recurring urinary tract infections, was observed to have a roommate, which is against standard infection control practices. Staff members, including a registered nurse and certified nurse aides, were seen entering the room without wearing the appropriate personal protective equipment (PPE) such as gowns, masks, and gloves, despite the presence of contact precaution signs on the door. Interviews with staff revealed a lack of awareness and understanding of the necessity of PPE in preventing the spread of infection. Additionally, the facility did not ensure that staff adhered to enhanced barrier precautions for residents requiring such measures. For instance, during medication administration and wound care for residents #363, #366, #367, and #371, staff failed to wear gowns and sanitize their hands as required. Observations showed that staff did not follow proper aseptic techniques, such as changing gloves and performing hand hygiene between tasks, which are critical to preventing cross-contamination and infection. The report also highlights deficiencies in the facility's handling of residents with specific medical needs, such as those with percutaneous endoscopic gastrostomy (PEG) tubes and continuous positive airway pressure (CPAP) devices. Staff were observed not wearing PPE or sanitizing hands during PEG medication administration and tube feeding for Resident #28. Furthermore, CPAP face masks were not stored properly when not in use, increasing the risk of contamination. These lapses in infection control practices indicate a systemic issue with staff training and adherence to established protocols, as evidenced by the staff's own admissions of not understanding enhanced barrier precautions and the need for more education on infection control measures.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who required it, specifically in maintaining good hygiene and grooming. Resident #71, who has severe cognitive impairment and requires assistance with personal care, was observed with long, jagged fingernails that had a dark gritty substance underneath. Despite the care plan indicating that nail care should be performed on bath days and as needed, the resident's nails remained untrimmed and uncleaned over several days. Staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, acknowledged the need for nail care, especially given the resident's diabetic condition, which increases the risk of infection. Similarly, Resident #22, who is moderately impaired and dependent on staff for ADLs, was found with long, dirty toenails. The resident, diagnosed with diabetes and other health conditions, did not receive appropriate nail care due to their diabetic status, which requires a nurse to perform such tasks. Both the Assistant Director of Nursing and the Director of Nursing confirmed that a nurse should provide nail care for diabetic residents, yet this was not done, leading to the deficiency in care.
Failure to Provide Necessary Pharmaceuticals
Penalty
Summary
The facility failed to ensure that all pharmaceuticals were available for residents during medication administration, as observed in two separate cases. Resident #31, who has a medical history of asthma, chronic obstructive pulmonary disease (COPD), emphysema, wheezing, and chronic cough, did not receive their prescribed medications, Advair HFA Inhalation Aerosol and Montelukast Sodium, during a medication administration observation. The registered nurse responsible for administering the medication acknowledged the absence of these medications and stated that they had just reordered them. Similarly, Resident #28, diagnosed with Dry Eye Syndrome and other eye-related conditions, did not receive their prescribed Refresh Lacri-Lube Ointment. The Assistant Director of Nursing (ADON) noted that the medication had not been reordered since March and mentioned the need to call a different pharmacy to reorder it. The facility's policy requires medications to be ordered in advance, but this was not adhered to, resulting in the unavailability of necessary medications for the residents.
Medication Errors Due to Unavailable Prescriptions
Penalty
Summary
The facility failed to ensure physician orders were followed, resulting in medication errors for two residents. Resident #31, who has a history of asthma, COPD, emphysema, wheezing, and chronic cough, did not receive prescribed medications, Advair HFA Inhalation Aerosol and Montelukast Sodium, during a medication pass observed on 7/30/2024. The Registered Nurse responsible for administering the medication acknowledged that the medications should have been available and stated that they had just reordered them. The Medication Administration Record confirmed that the resident did not receive the medications as prescribed. Similarly, Resident #28, diagnosed with dry eye syndrome and other eye-related conditions, did not receive the prescribed Refresh Lacri-Lube Ointment for lagophthalmos. The Assistant Director of Nursing noted that the medication had not been reordered since March and mentioned difficulties in ordering due to the resident using a different pharmacy. During the observation of medication administration, it was confirmed that the resident did not receive the ointment. The ADON acknowledged that medications should be available when due but indicated that the issue was affecting her time management.
Failure to Follow Meal Preparation and Serving Guidelines
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written quantified recipe and menu, which compromised the nutritional needs of residents. During a breakfast observation, it was noted that residents on pureed diets were served a smaller portion of oatmeal than specified. Dietary staff used a #16 scoop (1/4 cup) instead of the required #8 scoop (1/2 cup) as per the facility menu. This discrepancy was confirmed when the dietary staff member admitted to using the incorrect scoop size and serving only one portion to each resident. Additionally, the facility did not adhere to the recipe for enhanced oatmeal intended for residents requiring enhanced food diets. The dietary staff member responsible for preparing the meal did not follow the recipe, omitting key ingredients such as margarine and using incorrect quantities of brown sugar and dry milk. When questioned, the staff member admitted to not consulting the recipe before preparation. This failure to follow the specified recipe and menu had the potential to affect the nutritional intake of residents receiving pureed and enhanced diets.
Failure to Ensure Call Light Accessibility and Timely Wound Care
Penalty
Summary
The facility failed to ensure that the needs and preferences of a resident were reasonably accommodated, specifically by not ensuring the call light was within reach. The resident, who had a history of paralytic syndrome affecting the right side due to a stroke, anxiety disorder, and major depressive disorder, was observed in a wheelchair with the call light attached to the bed rail on the right side, out of reach. The resident was unable to self-propel to reach the call light and had been in this position for approximately forty minutes. The care plan for the resident explicitly stated that the call light should be within reach and that the resident required prompt responses to requests for assistance. Additionally, the resident had a skin tear on the left arm that required treatment, which was not addressed promptly. The resident expressed distress and was tearful while waiting for the nursing staff to treat the skin tear. The surveyor observed that the nursing staff did not attend to the skin tear until later, leaving the resident upset and the wound exposed for an extended period. This incident highlights a failure in the facility's responsibility to accommodate the resident's needs and ensure timely medical attention.
Delayed Completion of Admission MDS
Penalty
Summary
The facility failed to complete an Admission Minimum Data Set (MDS) in a timely manner for a resident. The MDS, which was supposed to be completed within 14 days of the resident's admission, was started on July 8, 2024, with an Assessment Reference Date of July 11, 2024, but was 18 days overdue for completion as of July 29, 2024. The facility's policy requires the Assessment Coordinator to ensure timely assessments, but due to staffing issues and training delays, the MDS was not completed on time. MDS Coordinator #19 acknowledged the delay, citing that both she and MDS Coordinator #20, who was still in training, were overworked, leading to the oversight.
Deficiency in Comprehensive Care Plan for Resident with Sleep Apnea
Penalty
Summary
The facility failed to ensure that a comprehensive care plan addressed and individualized appropriate care and services for a resident diagnosed with sleep apnea. The resident's admission record indicated a diagnosis of sleep apnea, yet the care plan did not document the use of a Continuous Positive Airway Pressure (CPAP) machine. Observations by the surveyor revealed that the CPAP mask was left on the bedside table without a storage bag, and there was no physician's order for CPAP usage documented in the resident's order summary report. Additionally, the Admission Minimum Data Set (MDS) inaccurately documented that the resident did not use a CPAP. Interviews with facility staff, including the Assistant Director of Nursing, Director of Nursing, and MDS Nurse, confirmed that the CPAP machine usage should have been included in the care plan as it is a treatment and part of the resident's plan of care. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs, which was not adhered to in this case. The lack of documentation and inclusion of CPAP usage in the care plan represents a deficiency in meeting the resident's care needs.
Failure to Update Care Plans for Residents' Needs
Penalty
Summary
The facility failed to update person-centered care plans to accurately reflect the needs of three residents, leading to potential negative outcomes. For one resident with moderate hearing loss, the care plan did not include any interventions to address this issue, despite confirmation from an Advanced Practice Nurse and documentation in the Minimum Data Set (MDS) indicating the impairment. Another resident expressed a desire to be a Do Not Resuscitate (DNR), but the care plan inconsistently documented both full code and DNR statuses, creating confusion among staff about the resident's true code status. Additionally, the facility did not update the care plan for a resident who attempted to elope from the facility, despite documentation of the incident in nursing progress notes. The resident, diagnosed with Alzheimer's disease and dementia with agitation, was able to exit the building, but the care plan did not reflect this elopement attempt or include interventions to prevent future occurrences. Interviews with staff confirmed the lack of updates to the care plan, which is necessary to protect the resident and inform staff of the risks.
Failure to Provide Necessary Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary foot and toenail care for a resident who was dependent on staff for such care. The resident, who had a history of acute and chronic respiratory failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus with a foot ulcer, was observed to have long, dirty, thick, and yellow toenails. The resident's care plan indicated a self-care performance deficit related to impaired mobility, morbid obesity, and dementia, requiring staff assistance for activities of daily living. During an observation, a CNA stated that she did not provide foot/toenail care for the resident because the resident was diabetic. Both the ADON and DON confirmed that a nurse should provide nail care for diabetic residents. Upon inspection, the DON noted the resident's foot appeared puffy and stiff, with toenails that were thick, yellow, long, and dirty. It was also revealed that a podiatrist had not visited the resident, indicating a lack of appropriate foot care management for the resident.
Delay in Implementing RD Recommendations for Tube Feeding
Penalty
Summary
The facility failed to implement the Registered Dietitian's (RD) recommendations in a timely manner for a resident with severe cognitive impairment and a history of post-traumatic seizures and traumatic brain injury. The resident was admitted with a care plan that included regular evaluations by the RD to monitor nutritional intake and make necessary adjustments to tube feeding. On a recent RD visit, it was noted that the resident had lost 8.9 pounds over a short period, prompting the RD to recommend increasing the resident's bolus tube feedings from five to six times a day to address the weight loss. Despite the RD's recommendation on 7/25/2024, the facility did not increase the bolus feedings until 7/30/2024, which was beyond the 72-hour window that the Director of Nursing (DON) stated was the expected timeframe for implementing such recommendations. This delay was confirmed through interviews with the Assistant Director of Nursing (ADON) and the DON, who acknowledged that the increase should have occurred sooner. As a result, the resident experienced a significant weight loss of 5.2% for the month of July, indicating a failure to provide adequate nutrition in a timely manner.
Failure to Administer Enteral Water Flush Per Physician's Orders
Penalty
Summary
The facility failed to administer enteral water flushes according to the physician's orders for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Resident #28, who has diagnoses of dysphagia and gastrostomy status, was observed during a medication pass where the total water flush administered was 330 milliliters (mL), which was less than the 420 mL ordered by the physician. The physician's order specified 60 mL of water flush before and after medication administration and an additional 300 mL of enteral water flush, but the resident only received 210 mL of water flush during the medication pass. The Director of Nursing confirmed that the resident should have received 120 mL of water flush with medications and 300 mL of water flush during the medication pass, as per the physician's order. The facility's policy on enteral tube feeding via syringe, revised in November 2018, requires verification of a physician's order and review of the resident's care plan. However, the facility did not adhere to these standards, resulting in the deficiency observed by the surveyor.
QAPI Records Unavailable During Survey
Penalty
Summary
The facility's Quality Assurance Performance Improvement Program (QAPI) failed to maintain records of their program, which are necessary for developing and implementing effective improvement plans to address identified areas of concern. During a recertification survey, the facility was unable to provide its QAPI plan to the State surveyors upon request. The administrator, who had been in the position for a week, stated that he was unable to provide records of the Quality Assurance (QA) committee meetings because they could not be found.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to honor residents' rights to privacy and dignity by not knocking on doors before entering their rooms. Observations revealed that a Certified Nursing Assistant (CNA) entered multiple resident rooms without knocking, which is against the facility's policy on resident rights. The policy, revised in December 2016, mandates that employees treat all residents with kindness, respect, and dignity, including respecting their privacy and confidentiality. During the observations, CNA #4 entered rooms 609, 610, 612, and 613 without knocking, turned on lights, and interacted with residents without explaining her actions. The Director of Nursing (DON) confirmed that staff should knock before entering a resident's room. Attempts to interview CNA #4 were unsuccessful as she left the facility before the interview could be conducted and did not return calls. This lack of adherence to the facility's policy on resident rights was observed multiple times, indicating a systemic issue with respecting residents' privacy and dignity.
Deficiencies in Resident Care Due to Incomplete Assessments and Care Plans
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary knowledge, competencies, and skills to provide individualized care for residents, as evidenced by deficiencies in the care of two residents. For Resident #6, the Minimum Data Set (MDS) was not completed according to the guidelines, and care plans were not updated to reflect the resident's current physician orders and needs. The MDS Coordinator admitted to not being trained on Medicare and managed MDS, which contributed to the incomplete care plans. Additionally, the Medicare Manager was on vacation, and the MDS Coordinator did not fill in, leading to delays in completing necessary assessments. Resident #7's care was also compromised due to a lack of updated care plans and failure to follow physician orders. The resident had an indwelling catheter, but there was no documentation of catheter care, and the care plan did not address the catheter or the right gluteus wound. The treatment nurse, who was new to the role, was unaware of the need for documentation and did not update the care plans or physician orders as required. The Director of Nursing (DON) confirmed that the treatment nurse was responsible for care planning and updating orders, but these tasks were not completed, resulting in inadequate care for the resident. Interviews with facility staff revealed a lack of communication and training, contributing to the deficiencies. The LTC MDS Coordinator and the Medicare Manager were responsible for completing and submitting the MDS, but both acknowledged being behind on their duties. The treatment nurse and the MDS Coordinator did not collaborate effectively, leading to incomplete care plans and unaddressed resident needs. The facility's policies on care planning, wound care, and catheter care were not followed, resulting in a failure to provide appropriate care for the residents.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, as evidenced by multiple instances of inadequate hand hygiene by staff members during resident care. Certified Nursing Assistant (CNA) #4 was observed entering and exiting resident rooms without sanitizing hands before and after glove use, particularly during perineal care and other personal care tasks. This lack of hand hygiene was noted during interactions with a resident diagnosed with functional quadriplegia, who required assistance with personal care. The resident reported not being changed since midnight, and the surveyor observed soiled briefs and underpads, indicating neglect in care. Further observations revealed that CNA #1 and CNA #2 also failed to perform hand hygiene appropriately during perineal care. CNA #1 was seen changing gloves multiple times without sanitizing hands, touching various surfaces and the resident with the same gloves, and handling clean and dirty items interchangeably. This improper practice was consistent throughout the care process, including dressing the resident and using a mechanical lift for transfer, without changing gloves or sanitizing hands. Additionally, the treatment nurse responsible for wound care on another resident did not adhere to hand hygiene protocols. The nurse was observed handling wound care supplies and performing wound dressing changes without sanitizing hands between glove changes or after completing tasks. The nurse also failed to update care plans and physician orders accurately, as evidenced by outdated treatment orders and missing documentation for skin and wound evaluations. The facility's policies on infection control and hand hygiene were not followed, contributing to the deficiencies observed during the survey.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in room [ROOM NUMBER] and surrounding areas. Observations by the surveyor revealed missing paint and drywall on the walls, a black substance on the floor near the baseboards, and a cracked and bubbled ceiling near the light above the entrance. Additionally, personal items such as an open bag and cups were left unattended in the hallway near the room. Interviews with staff confirmed the room's untidy state, with an unmade bed and trash on an under pad, and the presence of a yellow substance, possibly soda, on the bed. The Maintenance Assistant acknowledged that the room had not been reported for maintenance, despite visible damage likely caused by a wheelchair and a bed. The assistant noted that the damage around the light was due to a previous winter incident involving a burst pipe. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the unsanitary and uncomfortable conditions observed in the room and hallways.
What surveyors are citing around you — mapped
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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 35 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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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 Jonesboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Elizabeth's Place | 4.3 mi | ★★★★★ | 1 | 1 |
| Arkansas Continued Care Hospital Of Jonesboro | 4.6 mi | — | 0 | 0 |
| The Springs Jonesboro | 5.4 mi | ★★★★★ | 2 | 0 |
| Lakeside Health And Rehab | 10.9 mi | ★★★★★ | 5 | 0 |
| Craighead Nursing Center | 11.1 mi | — | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.