Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Beatitudes Campus during CMS and state inspections, most recent first.
Food Temperatures Not Maintained at Required Levels: Staff failed to keep meals at palatable temperatures and within required hot and cold holding ranges. Residents reported breakfast, lunch, and dinner were not hot, tasteless, or cold to the touch. Observations and temp checks showed multiple lunch items on 3rd and 4th floors outside facility policy and FDA Food Code limits, while the Nutrition Care Manager acknowledged the items did not meet the facility’s stated holding standards.
Food items in the kitchen were stored without required labels showing when they were created, opened, thawed, or when they should be used by. During kitchen observations, Jell-O, raw meats, opened rolls and biscuits, fish filets, brown rice, white rice, and lasagna pasta were found without date markings. The Nutrition Care Manager stated that opened items were expected to be labeled and acknowledged that unlabeled food could lead to expired items being used.
Verbal abuse toward a resident: A resident with intact cognition and multiple medical issues was verbally abused by an LPN during a medication-related interaction. A CNA reported the LPN yelled at the resident, used a middle finger gesture, and made derogatory comments, and the resident later described the nurse as aggressive and threatening. Other staff interviews supported the account, and the facility substantiated the allegation of verbal abuse.
Failure to investigate and assess injury after alleged abuse: A resident with Parkinson's disease, tremor, DM2, HTN, PVD, and pain conditions reported that a CNA was rough during morning care and caused bruising to his forearm. The clinical record lacked documentation of a skin or injury assessment after the allegation, and the DON and Administrator could not find evidence that a skin assessment was completed. Facility policy required an immediate, thorough investigation and examination of the alleged victim for signs of injury.
Failure to encode and transmit MDS assessments for two residents. One resident had a death tracking record that remained in process before later showing finalized status without documentation supporting encoding or transmission, and another resident’s quarterly MDS was finalized after RN completion but still lacked support that it was encoded or transmitted. The DON, RN MDS Coordinator, and ED discussed MDS submission expectations, grace periods, and facility transition issues involving an EHR upgrade, staffing changes, and transmission access problems.
A resident with dementia and other conditions reported to a nurse that a CNA had pulled her hair during care. Although the incident was documented as a grievance and an internal investigation was conducted, there was no evidence that the allegation was self-reported to the State Agency as required by facility policy. Staff interviews revealed confusion about the reporting process, and the incident was not included in the facility's list of self-reported incidents.
The facility failed to develop comprehensive care plans for two residents, one requiring oxygen therapy and another using mobility aids. Despite physician orders and assessments, the care plan for a resident with COPD lacked specific interventions for oxygen use. Another resident's care plan did not address the use of a power wheelchair seatbelt or bedrails, contrary to the facility's policy on restraint-free environments. These deficiencies could result in residents not receiving necessary care according to their needs.
The facility failed to properly administer oxygen to two residents, leading to potential complications. One resident, with COPD, was found without oxygen despite being dependent, and the equipment was not maintained. Another resident received oxygen therapy without a physician order, violating facility policy. Staff interviews revealed non-compliance with policies, highlighting deficiencies in respiratory care practices.
The facility failed to follow infection control practices, including improper sanitization of wound care supplies, lack of Enhanced Barrier Precautions signage, inadequate hand hygiene, and failure to disinfect reusable equipment. Observations revealed CNAs not performing hand hygiene between resident interactions, and a resident's catheter bag was found on the floor, posing infection risks.
The facility failed to maintain a safe and comfortable environment for residents, as observed during a walk-through of the 4th floor unit. Issues included water stains on ceiling tiles, a brown substance on a door frame, and a leaking temperature probe. These problems were not reported in the work order system, indicating a lapse in maintenance processes. Despite regular walkthroughs by maintenance staff, the deficiencies persisted, contradicting the facility's policies for a safe and homelike environment.
The facility failed to maintain an effective training program for a registered nurse and a housekeeper, with no evidence of required annual training modules being completed after their respective hire dates. Interviews revealed a lack of clarity regarding training requirements, and the facility had not updated their training since COVID-19, with a new policy currently being written.
The facility failed to provide ongoing education on resident rights for a registered nurse and a housekeeper, as required by their annual training policy. The RN and housekeeper completed their initial training upon hire but did not receive further training, leading to potential deficits in staff knowledge. Interviews revealed that the facility's training policy had not been updated since COVID-19, and a new policy was being developed.
The facility failed to provide required annual training on abuse, neglect, and exploitation to a registered nurse and a housekeeper. The RN completed training in November 2022, and the housekeeper in August 2023, with no further training documented. Interviews revealed confusion about mandatory training requirements, and the facility had not updated training since COVID-19, prompting a new policy development.
The facility failed to provide annual infection control training for a registered nurse and a housekeeper, as required by their policy. The RN completed the training upon hire but had no further training, while the housekeeper also lacked subsequent training. Interviews revealed confusion about training requirements, and the facility had not updated its training since COVID-19, leading to this deficiency.
A resident with severe cognitive impairment was moved to a different room without prior written notice or consent from their POA. The Social Worker had initially informed the POA of a planned room change, which was later canceled, but the change occurred while the SW was out of town, resulting in miscommunication and non-compliance with the facility's notification policy.
A facility failed to assess and care plan for a resident's use of a power wheelchair seatbelt and bed rails/mobility bars, which are potential restraints. The resident, with conditions like transverse myelitis and hemiplegia, had no documented assessments or interventions for these devices. Observations confirmed their presence, but staff interviews revealed a lack of awareness and process for restraint assessment, contrary to facility policy.
The facility failed to ensure daily staff postings were current and visible at the beginning of each shift. Observations showed outdated or missing postings on the 4th floor, while the 3rd floor had postings with altered dates. The DON and administrator confirmed the postings were primarily on the 3rd floor, and residents were not informed about this arrangement.
The facility failed to store food properly in the third-floor nourishment refrigerator, as observed with two undated and partially uncovered fruit plates. The registered dietician confirmed the oversight by night-shift staff, who did not label or cover the plates according to policy, leading to potential food safety risks.
Food Temperatures Not Maintained at Required Levels
Penalty
Summary
The facility failed to ensure food and drinks were palatable and maintained at safe, appetizing temperatures. A review of food temperatures from the prior 30 days showed that on August 26, 2025, lunch items on the 4th floor included Beet and Feta Salad at 48.3 degrees F, Honey Glazed Pork Tenderloin at 133.1 degrees F, and Pina Colada Cheesecake at 51.1 degrees F. The same review for the 3rd floor at 12:00 PM showed Beet and Feta Salad at 37.6 degrees F, Honey Glazed Pork Tenderloin at 173.8 degrees F, and Pina Colada Cheesecake at 41.6 degrees F. During interviews, Resident #69 stated that breakfast and lunch meals were not hot, and Resident #18 stated that the food from the kitchen had no taste and was not hot. During an observation of lunch tray assembly, dietary staff took initial temperatures of food before it was sent to the assigned floors. The Nutrition Care Manager stated that floors 3 and 4 each receive an initial temperature check before transport and that each floor has its own hot box and cold-item cart. Later that day, a test tray from the 4th-floor steam table showed holding temperatures of Pork at 126 degrees F, Vegetables at 133 degrees F, Sandwich Melt at 154 degrees F, Beans at 122 degrees F, Cottage Cheese at 57 degrees F, and Watermelon Puree at 56 degrees F. The Nutrition Care Manager stated that hot items are expected to be maintained at 140 degrees F and cold items at 41 degrees F per facility policy, although the temperatures taken were considered safe and palatable to her standards despite the policy. Another resident stated that lunch and dinner food was underwhelming and had been served at a cold-to-the-touch temperature.
Food items stored without required dates
Penalty
Summary
The facility failed to ensure that prepared food was stored in accordance with professional standards for food safety. During an initial kitchen observation with the Nutrition Care Manager, Refrigerator #1 contained Jell-O with no label showing the creation date or use-by date. Refrigerator #2 contained raw meats with no label showing when they were taken out of the freezer or a use-by date. The Nutrition Care Manager stated that staff were expected to review the menu and defrost raw meat products three days before preparation, but she was unsure when the meats had been placed in the refrigerator and assumed dietary staff had kept track. The Freezer contained two opened bags of rolls and biscuits and an open bag of fish filets, each with no label showing when the items were opened or a use-by date. The dry storage area contained an open bag of brown rice, an open bag of white rice, and an open box of lasagna pasta, all without evidence of an open date or use-by date. The Nutrition Care Manager stated that opened items returned to storage were expected to be labeled with the date opened and a use-by date, and later acknowledged that not labeling food items stored in the kitchen was not within the facility's expectations and could pose the risk of preparing meals with expired food items. A facility policy titled "Food Safety Requirement" stated that refrigerated food, including leftovers, was to be labeled, dated, and monitored so it was used by its use-by date, or frozen/discarded.
Verbal abuse toward a resident
Penalty
Summary
The facility failed to protect Resident #60 from verbal abuse by a staff member. Resident #60 was admitted with diagnoses including C. difficile enterocolitis, UTI, type 2 DM with a foot ulcer, a sacral pressure ulcer, and muscle weakness. An admission MDS showed a BIMS score of 15, indicating intact cognition. The report states that on the evening of the incident, a CNA notified the DON that an LPN was yelling at Resident #60 and waving her middle finger in his face, and the LPN was suspended immediately. The facility investigation documented that the CNA reported the LPN was verbally abusive, used a middle finger gesture, and called the resident a derogatory name. The resident later stated that he had called the nurses station for medication, that the nurse came in talking aggressively, told him he just wanted staff to wash his ass, gave him the middle finger, and picked up a hand weight. The CNA stated the LPN told the resident he needed to get his shitty ass up and get in the shower, cursed at him, and gave him the middle finger. The LPN denied using the middle finger but admitted pointing at the resident and said her behavior was unprofessional. Additional interviews supported the allegation. An LPN who took statements said the resident reported being threatened physically and verbally abused, and the CNA corroborated the resident's account. Another LPN stated she heard yelling in the hallway, saw the LPN yelling at the CNA, and was told the LPN had used curse words toward the resident and was disrespectful and degrading. The resident's family later called upset that they had not been notified, and the resident reported feeling down and more anxious after the incident and thinking about moving to another facility. The facility investigation concluded the allegation of verbal abuse was substantiated, and the LPN was later involuntarily terminated.
Failure to Investigate and Assess Injury After Alleged Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was conducted and recorded after a resident reported an allegation of abuse by a CNA. Resident #66 was admitted with diagnoses including Parkinson's disease, tremor, type 2 diabetes mellitus, hypertension, peripheral vascular disease, cervicalgia, pain in the thoracic spine, and pain in the left knee. An admission MDS assessment showed a BIMS score of 13, indicating intact cognition. According to the facility self-report, the resident stated that the CNA was rough while getting him ready for the day before breakfast and that the CNA tossed him around and caused bruising to his left forearm. Review of the clinical record found no progress notes or assessments showing that the resident was assessed for injury after the allegation of staff-to-resident abuse. The DON reviewed the record and stated she could not find evidence that a skin assessment was completed on the resident after the incident. The DON stated that in cases of alleged physical abuse, staff are expected to report the incident immediately, separate the resident from the alleged abuser, and complete a skin assessment and pain assessment. The Administrator reviewed the investigation file and described the resident's allegation that the CNA grabbed his hand, tossed him around on the bed, yanked his socks, pulled on his legs and hands, and that he told the CNA not to abuse him like that. The Administrator stated she could not tell if a skin assessment should have been done after reviewing the incident. Facility policy required an immediate investigation, complete and thorough documentation, and examination of the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed.
Failure to Encode and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for two residents were encoded and transmitted according to regulatory requirements. For Resident #3, who was admitted with diagnoses including unspecified injury of the head and difficulty walking and had a quarterly MDS showing a BIMS score of 11, the Nursing Home Tracking Item Set MDS for death reporting was completed and attested to on the same date as the death event, but the MDS 3.0 Assessment Summary reports showed the June 4, 2025 death tracking record remained in an "In process" status during later review, and the documentation did not support that it was finalized, encoded, or transmitted at that time. A later review showed the death in facility discharge report as finalized, but the facility documentation still did not support that it had been encoded or transmitted. For Resident #12, who was admitted with COPD, anxiety, and resistant hypertension and had a quarterly MDS showing a BIMS score of 14, the verifying RN signed the assessment as complete on August 27, 2025. However, the MDS 3.0 Assessment Summary report showed the August 3, 2025 quarterly review assessment as finalized, and the facility documentation did not support that the assessment was encoded or transmitted. A later review again showed the assessment as finalized without documentation supporting encoding or transmission. During interviews, the DON and RN MDS Coordinator stated that MDS completion and submission are used to assess resident risk and support the plan of care, and that the RN verifies completeness before attesting. The panel acknowledged that the facility was out of the grace period for transmission for both residents. The DON and ED described staffing and system transition issues, including an EHR upgrade, resignation of the RN MDS Coordinator, difficulty connecting with the assigned RAI coordinator, and access problems for transmission, while also noting that the facility had discussed MDS submission issues in QAPI and had performed audits.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident with dementia, epilepsy, and major depressive disorder was properly reported to the State Agency. The resident, who was cognitively intact as indicated by a BIMS score of 15, reported to a nurse that a CNA had pulled her hair during care. This allegation was documented as a grievance, and an internal investigation was initiated, with the grievance marked as resolved several days later. Despite the facility's policy requiring immediate reporting of abuse allegations to the administrator, state agency, and other authorities within specified timeframes, there was no evidence that the incident was self-reported to the State Agency as required. When surveyors requested a list of self-reported incidents from the past ninety days, both the DON and the VP of Health Services stated that there had been no such reports, and a review of state agency records confirmed that no self-report had been submitted for this incident. Interviews with facility staff revealed confusion regarding the documentation and reporting process. The DON claimed to have submitted a report online and provided an email indicating a request for email verification, but there was no documentation confirming that the complaint was finalized and submitted. The VP of Health Services later attributed the omission from the self-report list to an oversight. The facility's failure to ensure timely and proper reporting of the abuse allegation constituted a deficiency.
Deficiencies in Care Planning for Oxygen Therapy and Mobility Aids
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #38, who was readmitted with chronic obstructive pulmonary disease (COPD) and chronic hypoxemic respiratory failure, was documented as being oxygen-dependent. Despite multiple physician orders and assessments indicating the need for continuous oxygen therapy, the care plan related to oxygen use was not developed with interventions until several months after the resident's readmission. Interviews with staff revealed that the resident was often encouraged to wear oxygen as ordered, but the care plan lacked specific interventions and measurable objectives as required by the facility's policy. Resident #44, admitted with acute transverse myelitis and hemiplegia following a cerebral infarction, also had deficiencies in their care plan. The care plan did not address the use of a power wheelchair seatbelt or bedrails/mobility bars, despite observations of these items being present and used by the resident. The facility's policy on a restraint-free environment required that care plans be updated to include interventions addressing any risks related to the use of restraints, which was not done in this case. The lack of comprehensive care plans for these residents could result in them not receiving the necessary care and services according to their assessed needs. The facility's policies on oxygen therapy and restraint-free environments were not followed, leading to the deficiencies identified during the survey. Staff interviews indicated a reliance on external hospice care for oxygen management and a lack of documentation for the use of mobility aids, contributing to the oversight in care planning.
Deficiencies in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to ensure proper administration of oxygen for two residents, leading to potential complications. Resident #38, who was readmitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, was observed without oxygen despite being oxygen-dependent. The resident's oxygen saturation levels were below the recommended threshold, and the oxygen equipment was not properly set up or maintained. The resident's nasal cannula was found on the floor, and the oxygen tank attached to the wheelchair was empty, indicating a lack of adherence to the physician's orders and facility policies regarding oxygen administration. Resident #50 was receiving oxygen therapy without a documented physician order, which is against the facility's policy. Despite being on continuous oxygen therapy, there was no evidence of a physician order for oxygen administration in the resident's medical records. Observations confirmed that the resident was receiving oxygen, but the necessary documentation and orders were missing, highlighting a significant oversight in the facility's medication administration process. Interviews with staff, including LPNs and the Director of Nursing, revealed a lack of compliance with facility policies requiring physician orders for oxygen administration. The absence of proper documentation and orders for oxygen use for Resident #50, along with the improper setup and monitoring of oxygen for Resident #38, demonstrate deficiencies in the facility's respiratory care practices, potentially leading to adverse outcomes for the residents involved.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as evidenced by several observations and staff interviews. During a wound care observation, an LPN used a multiuse wound wash solution and betadine container without sanitizing them after use, contrary to the facility's policy. The LPN admitted to not wiping down the containers before returning them to the treatment cart, which was confirmed by the Director of Nursing (DON) as a breach of protocol. Enhanced Barrier Precautions (EBP) were not properly communicated, as there were no EBP signs posted in the hallways of resident rooms. The DON acknowledged that the absence of signage was an issue and posed a risk of infection spread. Staff interviews revealed that EBP signs were placed only after the survey team arrived, indicating a lapse in maintaining consistent infection control measures. Hand hygiene practices were inadequate, with hand sanitizer not readily accessible inside or outside resident rooms. Observations showed CNAs failing to perform hand hygiene between resident interactions. The Assistant Director of Nursing (ADON) and DON confirmed the expectation for hand hygiene, but the lack of accessible sanitizer and inconsistent practices highlighted a deficiency in infection control. Additionally, reusable resident equipment, such as blood pressure cuffs, was not disinfected after use, and a resident's catheter bag was observed on the floor, both of which were acknowledged by staff as risks for infection.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for residents, as evidenced by multiple deficiencies observed during a walk-through of the 4th floor unit. Several rooms were found with water stains on the ceiling tiles, a door frame with a splatter of a brown substance, and a temperature probe above the dining area that had a built-up substance and appeared to be leaking. These issues were not reflected in the open work order report generated prior to the observations, indicating a lapse in the facility's maintenance and reporting processes. Interviews with staff revealed that there was a work order system in place, but the issues identified had not been reported or addressed. The Senior Maintenance Engineer stated that regular walkthroughs were conducted, yet the deficiencies persisted. The facility's policies emphasized the importance of maintaining a safe, clean, and homelike environment, but the observed conditions contradicted these standards. The administrator acknowledged the importance of a clean and safe environment for residents' quality of life and safety, yet the facility failed to meet these expectations, potentially putting residents at risk for injury and discomfort.
Deficient Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for two staff members, a registered nurse and a housekeeper, which could potentially affect resident care. The registered nurse was hired on November 7, 2022, and completed the required training modules on November 8, 2022. However, there was no evidence of any further training modules being completed after that date. Similarly, the housekeeper, hired on August 21, 2023, completed the required training modules on the same day of hire, with no further training documented thereafter. Interviews with facility staff revealed a lack of clarity and awareness regarding the annual training requirements. The human resources assistant was unable to specify which training modules were required for all employees, contract staff, and volunteers. The administrator confirmed the absence of annual training module transcripts for the two staff members and acknowledged that annual training should occur within the past 365 days. The VP of Human Resources and Risk Management admitted that the facility had not updated their training since the onset of COVID-19 and was in the process of writing a new policy to address the missing old policy.
Deficiency in Staff Training on Resident Rights
Penalty
Summary
The facility failed to ensure that two staff members, a registered nurse and a housekeeper, received ongoing education on resident rights, which is a required component of their annual training. The registered nurse was hired on November 7, 2022, and completed the required training modules on November 8, 2022, but there was no evidence of further training on resident rights after that date. Similarly, the housekeeper, hired on August 21, 2023, completed the required training on the same day but had no subsequent training on resident rights. This lack of ongoing education could lead to a deficit in staff knowledge and skills, potentially affecting resident care. Interviews with facility staff revealed gaps in the understanding and implementation of the annual training requirements. The HR assistant was unable to specify which training modules were required for all employees, and the administrator acknowledged the absence of annual training module transcripts for the two staff members. The VP of HR indicated that the facility's training policy had not been updated since the onset of COVID-19, and a new policy was being written to address these deficiencies. The facility's existing policy mandates that orientation and annual training include topics such as resident rights, infection control, and other essential areas, but this was not adhered to in the cases of the RN and housekeeper.
Deficiency in Staff Training on Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to ensure that two staff members, a registered nurse and a housekeeper, received the required annual training on abuse, neglect, and exploitation. The registered nurse, hired on November 7, 2022, completed the necessary training on November 8, 2022, but there was no evidence of further training after that date. Similarly, the housekeeper, hired on August 21, 2023, completed the required training on the same day but had not received any additional training since then. This lack of ongoing training could lead to a deficit in staff knowledge and skills, potentially affecting resident care and leading to harm. Interviews with facility staff revealed a lack of clarity regarding the required annual training modules. The human resources assistant was unable to specify which training modules were mandatory for all employees, contract staff, and volunteers. The administrator confirmed the absence of recent training records for the two staff members and acknowledged that annual training should occur within the past 365 days. The Vice President of Human Resources and Risk Management noted that the facility had not updated their training since the onset of COVID-19 and was in the process of writing a new policy to address this issue. The facility's existing policy outlined the need for orientation and annual training on various topics, including resident rights and infection control.
Deficiency in Annual Infection Control Training for Staff
Penalty
Summary
The facility failed to ensure that two staff members, a registered nurse and a housekeeper, received the required annual training on infection control. The registered nurse was hired on November 7, 2022, and completed the required training modules, including infection control, on November 8, 2022. However, there was no evidence of any further infection control training after that date. Similarly, the housekeeper, hired on August 21, 2023, completed the required training on the same day but had no subsequent infection control training. This lack of ongoing training was identified during a review of personnel files and interviews with staff. Interviews with the human resources assistant and the administrator revealed a lack of clarity regarding the specific annual training requirements for all employees. The administrator confirmed that there were no updated training records for the two staff members within the past 365 days. The Vice President of Human Resources and Risk Management acknowledged that the facility had not updated their training since the onset of COVID-19 and was in the process of writing a new policy. The facility's existing policy required annual training on various topics, including infection control, but this was not adhered to, leading to the deficiency.
Failure to Notify Resident and POA of Room Change
Penalty
Summary
The facility failed to notify a resident and their Power of Attorney (POA) prior to a room change, which is a violation of the resident's rights. The resident, who was admitted with severe cognitive impairment due to vascular dementia and other conditions, was moved from the 4th floor to the 3rd floor without prior written notice or consent. The resident's POA was unaware of the room change until visiting the facility and discovering the resident had been relocated. Interviews and documentation revealed that the Social Worker (SW) had initially communicated with the POA about a planned room change, which was later canceled. However, the room change was implemented while the SW was out of town, leading to a miscommunication and failure to follow the facility's policy on room change notifications. The policy requires a 30-day notice and a signed consent form from the resident or their legal representative, which was not completed in this case.
Failure to Assess and Care Plan for Potential Restraints
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and care planned for the use of a power wheelchair seatbelt and bed rails/mobility bars, which are considered potential restraints. The resident, who was admitted with diagnoses including acute transverse myelitis, hemiplegia following cerebral infarction, major depressive disorder, and myocardial infarction, had a care plan that did not address the use of these devices. There were no physician orders or clinical record assessments regarding the seatbelt or bedrails/mobility bars, and the Treatment Administration Record for July 2024 showed no assessment, intervention, or monitoring for these items. Observations and interviews revealed that the resident had intact cognition and confirmed the presence of mobility bars and a seatbelt on her power wheelchair. However, staff interviews indicated a lack of awareness and process for assessing and monitoring potential restraints. The Director of Nursing acknowledged the absence of assessments for the resident's seatbelt and bedrails/mobility bars, which contradicted the facility's policy on maintaining a restraint-free environment. The policy required specific assessments and care plan updates for any potential restraints, which were not conducted in this case.
Failure to Post Current Daily Staff Information
Penalty
Summary
The facility failed to ensure that daily staff postings were current and posted at the beginning of each shift, as required. Observations conducted on the 4th floor on multiple occasions revealed that the daily staff postings were either outdated or missing entirely. On August 26, 2024, the posting on the 4th floor was dated January 3, 2024, and on the 3rd floor, it was dated August 6, 2024. Subsequent observations on August 27 and 28, 2024, found no staff postings on the 4th floor. Interviews with staff, including the Director of Nursing (DON) and a registered nurse (RN), confirmed the absence of current postings on the 4th floor and indicated that the postings were available on the 3rd floor. The DON admitted that the daily staff posting was located on the 3rd floor and that residents and their families from the 4th floor could request this information. The DON also provided a copy of a staff posting with an altered date, suggesting an attempt to update the posting date from August 6 to August 26, 2024. The administrator acknowledged that residents from the 4th floor often visited the 3rd floor for various activities and could view the postings there, but also admitted that residents and families had not been informed about the location of the postings. The RN on the 4th floor pointed out the usual location for the posting, which was empty, indicating a lack of adherence to the requirement for visible and current staff postings on each floor.
Improper Food Storage in Nourishment Refrigerator
Penalty
Summary
The facility failed to ensure proper storage of food in the third-floor resident nourishment refrigerator, which did not comply with professional standards for food service safety. During an observation, it was found that two fruit plates were undated and partially uncovered. The plates contained green grapes and banana slices, with red liquid puddles and stains on the paper plates. The clear plastic wrap was pulled back, leaving the fruit exposed, which could lead to the growth of harmful bacteria and pose a risk of foodborne illness. An interview with the registered dietician revealed that the fruit plates were prepared by the night-shift staff, who neglected to place a use-by dated sticker and properly cover the plates with saran wrap. The registered dietician acknowledged the oversight and disposed of the undated fruit plates. The facility's policy requires that unused portions and open packages be covered, labeled, and dated with an orange-color label system, and food should be discarded past the use-by or expiration date.
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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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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rehabilitation Center At The Palazzo | 0.7 mi | ★★★★★ | 1 | 0 |
| Maryland Gardens Post Acute | 1.8 mi | ★★★★★ | 0 | 0 |
| North Mountain Medical And Rehabilitation Center | 2.7 mi | ★★★★★ | 2 | 0 |
| Haven Of Phoenix | 2.9 mi | ★★★★★ | 12 | 0 |
| The Terraces Of Phoenix | 2.9 mi | ★★★★★ | 0 | 0 |
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