Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Almond Vista Healthcare during CMS and state inspections, most recent first.
A resident with a recent right foot arthrodesis and intact cognition had orders to keep a sterile post-op dressing clean and dry. During a shower, a CNA placed a plastic bag over the foot, but water entered, leaving the dressing soaked; the resident reported the wet dressing remained for several days and was not changed or reinforced by nursing staff. At a follow-up visit, the podiatrist documented soiled, malodorous dressings, erythema, warmth, maceration, and some dehiscence, diagnosed cellulitis, and prescribed oral antibiotics, which were entered as facility orders. Subsequent interviews and record review with an LVN, the treatment nurse, and the DON confirmed there was no comprehensive care plan addressing the foot infection, cellulitis, or antibiotic therapy, despite facility policy requiring person-centered care plans to be developed and revised with changes in condition.
A cognitively intact post‑operative resident with diabetes and recent right foot arthrodesis had a physician order for a sterile surgical dressing to be kept clean and dry, with instructions to notify the physician if there was a problem with the bandage. During a shower, staff used a plastic trash bag and tape to protect the dressing, but water entered the bag, leaving several inches of water and a wet dressing. The resident reported the wet dressing to nursing staff, yet it was not changed or reinforced and remained in place for several days until a podiatry follow‑up, where the dressing was found soiled and malodorous with skin maceration, erythema, warmth, and some dehiscence, and cellulitis was diagnosed and treated with oral abx. There was no documentation that the physician was notified when the dressing became wet, no order to monitor the dressing’s condition, and no care plan addressing the cellulitis or abx use, despite job descriptions and a wound care policy requiring adherence to physician orders and professional standards of nursing practice.
Two residents did not have their care plans updated or revised after significant changes in condition, including post-surgical care for a hip procedure and wound care following a fall with laceration. Staff were unclear on wound care, bathing instructions, and weight-bearing status due to missing information in the care plans, despite physician orders being present elsewhere in the record. The interdisciplinary team did not review or update the care plans as required by facility policy.
A resident at high risk for falls suffered a broken hip after the facility failed to implement a physician-ordered intervention of placing a floor mat beside her bed. Despite a history of falls and severe cognitive impairment, the nursing staff did not follow the care plan, leading to the resident's fall and subsequent hospitalization. The resident's condition worsened, resulting in decreased mobility and placement on hospice care.
A resident with known swallowing difficulties and cognitive impairments was not provided adequate supervision during meals, leading to a choking incident. The resident was admitted with a history of dysphagia and required strict aspiration precautions, but the facility failed to develop a care plan for supervision. The resident choked during dinner, was diagnosed with respiratory failure and aspiration pneumonia, and subsequently died. The facility's SLP did not review hospital evaluations indicating the need for supervision, and the DON acknowledged the lack of a care plan.
The facility did not create and implement a comprehensive Facility Assessment to determine necessary resources for resident care. The 'SNF/NF Capabilities List' from July 2021 was not comprehensive, and the 'Facility Assessment Tool' was updated only after surveyors arrived. The Administrator confirmed the lack of annual assessments for 2020-2023, indicating insufficient planning for resident needs.
The facility did not have a Quality Assurance Performance Improvement (QAPI) plan in place, as required by their policy. This deficiency was confirmed through interviews and document reviews, with the Administrator acknowledging the absence of the plan. The lack of a QAPI plan had the potential to impact all 161 residents in the facility.
The QAPI committee failed to ensure required members attended quarterly meetings, potentially affecting all 161 residents. Facility policies lacked attendance expectations. The Administrator confirmed that meetings should include an Administrator, DON, IP, and MD. However, the MD missed meetings in the third and fourth quarters of 2023, and both the IP and MD were absent in the first quarter of 2024.
The facility failed to provide timely written transfer notices to residents or their representatives before or after hospital transfers. Four residents were transferred without receiving the required documentation, and the Ombudsman was not notified in some cases. Staff interviews revealed a lack of process for issuing written notices during emergent hospitalizations.
The facility failed to provide bed hold notices to five residents transferred to the hospital in emergencies, as required by policy. Despite the facility's guidelines, residents with conditions like sepsis, altered mental status, and catheter issues did not receive written notifications within 24 hours of their transfers. Interviews and record reviews confirmed the absence of these notices, highlighting a significant oversight in the facility's adherence to its bed hold policy.
The facility failed to complete bed hold audits as part of their performance improvement project, potentially affecting residents sent to the hospital. The QAPI Program policy required performance improvement projects, but the facility lacked a QAPI Plan. The DON confirmed a PIP for bed hold notifications, but audits were not conducted. The ADON assumed Medical Records was responsible, and the MRD confirmed incomplete audits. The Administrator was aware of the incomplete audits.
The facility failed to properly issue the SNFABN to two residents who completed therapy or skilled nursing services. The notices lacked clear explanations for Medicare's non-coverage and contained incorrect financial liability dates. Both residents confirmed understanding the notices and chose not to continue therapy. The Social Services Director misunderstood the form's requirements.
Two residents in a facility were improperly subjected to physical restraints without medical orders. One resident was positioned in bed to prevent getting out, with the bed's head down and foot elevated, which staff admitted was to prevent falls. Another resident had a sock and bandage on his hand, restricting movement, with no documented reason or physician's order. Both cases violated the facility's restraint policy, which requires restraints only for medical symptoms and not for staff convenience.
A facility failed to complete a required PASARR Level II assessment for a resident with schizoaffective and bipolar disorders. Despite a positive Level I screening, the facility did not resubmit the screening after the initial Level II evaluation could not be conducted. Interviews revealed a lack of process for ensuring follow-ups, and observations showed the resident exhibiting behaviors consistent with her care plan issues.
The facility failed to include a resident's code status in the baseline care plan, despite having a POLST and DNR order, and did not document the use of side rails for another resident with systemic lupus erythematosus and systemic sclerosis. The omissions were confirmed by the MDS Director and DON.
A resident admitted with COVID-19, type two diabetes, and acute kidney failure did not receive timely care for constipation, going ten days without a bowel movement. The facility delayed initiating the bowel protocol, which should have started after three days, and failed to create a care plan for the issue. Alerts in the EMR were not acted upon, and no constipation policy was provided during the survey.
A resident admitted with COVID-19, diabetes, and acute kidney failure did not receive adequate hydration due to the facility's failure to timely assess fluid needs and monitor intake. Despite being prescribed IV fluids, the care plan set an inadequate fluid intake goal, and health shakes were not documented as consumed. Staff interviews confirmed the delay in nutritional assessment and incorrect care plan goals, contrary to the facility's hydration policy.
A resident received Ativan, an antianxiety medication, on a PRN basis for more than 14 days without a physician's rationale for extending its use and without a specified stop date. The facility's policy requires PRN orders for psychotropic medications to be limited to 14 days unless a physician documents the rationale for extending the use. Interviews with the ADON and DON confirmed the oversight, which increased the risk of adverse reactions.
The facility failed to ensure proper infection control during catheter care for two residents. An LVN did not change gloves appropriately while providing suprapubic catheter care, risking cross-contamination. Another resident's urinary collection bag was found on the floor without a dignity bag, contrary to facility policy, increasing infection risk. These deficiencies were confirmed by staff, including the DON.
Failure to Care Plan for Post-Operative Foot Cellulitis and Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered, comprehensive care plan for a resident who developed cellulitis of a right foot surgical wound and was started on antibiotics. The resident had undergone right foot surgery involving arthrodesis of the 2nd, 3rd, and 4th toes and had orders for the sterile surgical bandages to be kept clean and dry with no bandage change needed, and to notify the physician’s office if there was a problem with the bandage. The resident was cognitively intact per a BIMS score of 15/15 and reported that about a week and a half after surgery, a CNA placed a clear plastic trash bag over the right foot and secured it with tape for a shower, but the tape slid down, allowing water to enter the bag and soak the dressing. The resident stated that after the shower there were about three inches of water in the bag, the dressing was wet, and the nurses did not change or reinforce the wet dressing. The resident reported that the wet dressing remained in place for four to five days until a post-operative visit with the podiatrist. At that visit, the podiatrist documented that the dressings were soiled and malodorous, with some wound dehiscence proximally to the 2nd toe incision, erythema and increased warmth to the dorsal midfoot, and skin maceration. The podiatrist assessed cellulitis and prescribed oral antibiotics. The facility’s Order Summary Report reflected an order for Amoxicillin-Pot Clavulanate 875-125 mg to be given every 12 hours for 14 days for bacterial infection, with the DON and treatment nurse confirming that the antibiotics were started after the post-operative appointment for a bacterial infection/cellulitis of the surgical wound. Despite the new diagnosis of cellulitis and the initiation of antibiotic therapy, interviews and record reviews with the LVN, treatment nurse, and DON showed there was no care plan addressing the resident’s foot infection, cellulitis, or antibiotic use. Both the LVN and treatment nurse were unable to locate any care plan related to the infection or antibiotic treatment, and the DON confirmed that no care plan had been entered for cellulitis or antibiotic use, despite the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives, time frames, and interventions that reflect current standards of practice and are revised as residents’ conditions change. The surveyors concluded that the facility failed to ensure a person-centered comprehensive care plan was implemented for this resident, which had the potential for the resident’s needs to go unmet.
Failure to Maintain and Monitor Post‑Operative Surgical Dressing per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing services met professional standards of practice for a post‑operative resident whose surgical dressing was ordered to be kept clean and dry, with instructions to notify the physician if there was a problem with the bandage. The resident, cognitively intact per a BIMS score of 15/15, had undergone right foot surgery involving arthrodesis of the 2nd, 3rd, and 4th toes and had comorbidities including type 2 diabetes mellitus, orthopedic aftercare needs, and osteoarthritis. The physician’s post‑operative order directed that the sterile surgical bandages be kept clean and dry, that no bandage change was needed, and that the office be notified if there was a problem with the bandage. There was no order in the record to monitor the dressing for cleanliness or dryness, and the DON later stated there was no policy and procedure available for following physician orders or professional standards of practice. The resident reported that approximately a week and a half after surgery, a CNA prepared him for a shower by placing a clear plastic trash bag over his right foot and securing it with tape to keep the dressing dry. During the shower, the tape slid down his leg, allowing water to enter the bag. After the shower, when the resident removed his foot from the bag, he observed about three inches of water in the bottom of the bag and noted that his dressing was wet. The resident stated he notified the nurses that his dressing was wet, but the nurses did not change or reinforce the dressing, and he kept the wet dressing in place for four to five days until his post‑operative visit with the podiatrist. CNA 1 confirmed that the process used to keep a dressing dry during showers was to place a plastic trash bag around the foot and secure it with tape. At the podiatry follow‑up visit, the podiatrist documented that the resident reported he had wet his dressings in the shower the prior Wednesday and did not think they needed to be changed or that it was a serious matter. The podiatrist’s exam noted that the dressings were soiled and malodorous, with some dehiscence proximally to the 2nd toe incision, erythema and increased warmth to the dorsal midfoot, and skin maceration. The podiatrist assessed cellulitis and prescribed oral antibiotics, which were later approved by the attending physician and started at the facility. The treatment nurse and DON both stated that, based on the order to keep the dressing clean and dry, nursing staff should have contacted the physician if the dressing became wet, and the DON acknowledged there were no nurses’ notes indicating whether the bandage became wet during showers and no care plan addressing the cellulitis or antibiotic use. The facility’s LVN and DON job descriptions required adherence to professional standards of nursing practice and physician orders, and the wound care policy referenced reporting information in accordance with facility policy and professional standards of practice, but these standards were not followed when the resident’s wet, soiled surgical dressing was not addressed or reported as ordered. A subsequent office visit note from the podiatrist documented that the resident reported the forefoot dressing had come off and the foot was soaked in water for an unknown period, with persistent swelling and burning between the lesser toes, and that he was taking the prescribed antibiotic. The DON stated she did not have documentation that the dressing became wet in the facility shower and that the resident sometimes refused to allow staff to check his dressing, but also stated that the expectation was for staff to keep extremity dressings dry during showers using plastic wrap secured with tape and to call the physician if the dressing became wet. The professional reference reviewed by surveyors indicated that nurses cannot arbitrarily decide which physician orders to follow and that failing to carry out orders can be grounds for discipline and may be deemed neglect, underscoring that the failure to keep the surgical dressing dry and to notify the physician when it became wet did not meet professional standards of practice.
Failure to Update and Implement Person-Centered Care Plans After Change in Condition
Penalty
Summary
The facility failed to review, revise, and implement person-centered comprehensive care plans for two residents following significant changes in their conditions. For one resident who underwent a left hip hemiarthroplasty, the care plan did not specify the frequency of dressing changes, instructions for bathing with respect to the surgical site, or clarify the resident's weight-bearing status. Interviews with staff revealed a lack of awareness regarding the resident's surgical history and uncertainty about wound care and mobility instructions, despite existing physician orders. The care plan lacked clear guidance, and staff were unable to reference it for necessary care details. Another resident experienced a fall resulting in a laceration above the left eyebrow, which required repair with sutures. The care plan for this resident did not include instructions for wound care of the laceration, even though physician orders specified the wound care regimen and suture removal timeline. Staff interviews and record reviews confirmed that the care plan was not updated to reflect these new care needs after the resident returned from the hospital. Both the Director of Nursing and the Administrator acknowledged that the interdisciplinary team did not update the care plans after the residents returned from the hospital, as required by facility policy. The policy mandates that care plans be reviewed and revised after significant changes in a resident's condition or after hospital readmission. The lack of updated, accessible care plans meant that staff could not easily determine or implement the required care for these residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a resident, who was assessed as a high risk for falls, was free from accident hazards. The resident had a history of falls and a physician's order for a floor mat to prevent injury in the event of a fall. However, the nursing staff did not implement the care plan intervention for the use of the floor mat, which was not placed beside the resident's bed. This oversight led to the resident experiencing a fall from her bed, resulting in a broken left hip and severe pain, necessitating hospitalization and administration of fentanyl for pain management. The resident, who had severe cognitive impairment and was non-ambulatory, attempted to get out of bed unassisted, leading to the fall. The resident's care plan had been revised multiple times to include the use of floor mats, but these were not in place at the time of the fall. Interviews with staff revealed that the floor mats had been removed at some point, and there was no clear understanding among the staff as to why they were not replaced. The Director of Nursing confirmed that the order for the floor mats was never discontinued, indicating a lapse in following the care plan. The resident's condition was further complicated by her medical history, which included senile degeneration of the brain, syncope, and dysarthria. The fall resulted in a significant decline in the resident's mobility and comfort, as she was no longer able to turn herself in bed and was placed on hospice care. The facility's failure to adhere to the care plan and ensure the presence of fall mats directly contributed to the resident's injury and subsequent decline in health.
Failure to Provide Supervision During Meals Leads to Resident's Death
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with known swallowing difficulties and cognitive impairments, leading to a choking incident. The resident was admitted from an acute care hospital with a history of dysphagia and required strict aspiration precautions, including supervision during meals. However, the facility did not develop a care plan to address the need for supervision, and the resident was allowed to feed himself unsupervised. On the day of the incident, the resident choked during dinner and was found unresponsive by a CNA. Despite immediate intervention with the Heimlich maneuver and CPR, the resident was transported to an acute care hospital where he was diagnosed with respiratory failure, aspiration pneumonia, severe protein-calorie malnutrition, and chronic kidney disease. The resident subsequently passed away due to these conditions. Interviews with facility staff revealed that the facility's SLP did not obtain or review the hospital's SLP evaluations and recommendations, which indicated the need for supervision during meals. The Director of Nursing acknowledged that a care plan was not developed to address the resident's specific needs during meals, and the Administrator confirmed that the aspiration could have been avoided with proper supervision. The facility's policy required comprehensive, person-centered care plans, which were not implemented in this case.
Failure to Implement Comprehensive Facility Assessment
Penalty
Summary
The facility failed to create and implement a comprehensive Facility Assessment to determine the necessary resources to meet the needs of its residents. The review of the 'SNF/NF Capabilities List' dated July 2021 revealed it was not a comprehensive Facility Assessment. Additionally, the 'Facility Assessment Tool' provided by the facility was updated on July 30, 2024, after the surveyors had already entered the facility. During an interview, the Administrator confirmed that the current Facility Assessment was created after the surveyors' arrival. Furthermore, the Administrator was unable to provide annual Facility Assessments for the years 2020, 2021, 2022, and 2023, indicating a lack of ongoing assessment and planning to ensure resident needs are met.
Absence of QAPI Plan in Facility
Penalty
Summary
The facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI) plan, which is essential for driving quality assurance measures. This deficiency was identified through interviews, facility document reviews, and policy reviews. The facility's policy, revised in April 2014, outlined the need for a QAPI plan to guide quality efforts and support QAPI implementation. However, upon review, it was found that the facility did not have a QAPI plan in place. During an interview, the Administrator confirmed the absence of a QAPI plan, which had the potential to affect all 161 residents currently living in the facility.
QAPI Committee Attendance Deficiency
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) committee at the facility failed to ensure the required members attended the quarterly meetings, which had the potential to affect all 161 residents. The facility's policies on QAPI, revised in 2014 and 2020, did not include expectations for attendance at these meetings. During an interview, the Administrator confirmed that the QAPI meetings were held quarterly and should include an Administrator, Director of Nursing (DON), Infection Preventionist (IP), and Medical Director (MD). However, it was confirmed that the MD did not attend the QAPI meetings for the third and fourth quarters of 2023, and neither the IP nor the MD attended the meeting for the first quarter of 2024, despite their required presence.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification to residents or their representatives before or immediately following transfers to the hospital. This deficiency was identified in four out of five residents reviewed for hospitalization. Resident 99, who was unimpaired in cognition, was transferred to the hospital due to severe infection without receiving a written discharge notice. Although the resident was notified in person, the section for the resident or representative's signature on the notice was left blank. Interviews with staff revealed that there was no process in place for providing written notices for emergent hospitalizations, and the Director of Nursing confirmed that the resident's family was only notified via phone call. Resident 126 was sent to the hospital due to unresponsiveness, but there was no evidence of a written transfer notice provided to the resident or their representative. The Director of Nursing confirmed the absence of a written notice for this hospitalization. Similarly, Resident 68 was transferred to the emergency department for a foley catheter evaluation without any documentation of a transfer/discharge notice being provided to the resident, representative, or Ombudsman. The Director of Nursing confirmed the lack of notification for this resident's hospitalization. Resident 102 was transferred to the emergency department for symptoms including diarrhea and high blood pressure, yet no documentation was found indicating a transfer/discharge notice was provided to the resident or representative. The Director of Nursing confirmed that the required notifications were not made. The facility's policy requires that residents and their representatives receive written notice of transfer or discharge as soon as practicable, and a copy of the notice should be sent to the Ombudsman. However, this policy was not followed in the cases reviewed.
Failure to Provide Bed Hold Notices After Emergency Transfers
Penalty
Summary
The facility failed to provide bed hold notices to five residents who were transferred to the hospital in emergency situations. This deficiency was identified through interviews, record reviews, and policy reviews. The residents involved were R99, R126, R151, R68, and R102, all of whom were transferred to the hospital for various medical reasons, including sepsis, altered mental status, lethargy, catheter issues, and myocardial infarction. Despite the facility's policy requiring written bed hold notices within 24 hours of an emergency transfer, none of these residents received such notices. Resident R99, who was her own responsible party, was transferred to the hospital due to sepsis and septic shock. She confirmed during an interview that she did not receive a bed hold notice at the time of her hospitalization. Similarly, R126 was transferred for altered mental status, and the facility's records showed no evidence of a bed hold notice being issued. The Director of Nursing confirmed the absence of bed hold notices for these residents during interviews. Other residents, including R151, R68, and R102, also did not receive bed hold notices following their hospital transfers. R151 was sent to the emergency department for lethargy and agitation but did not return to the facility. R68 and R102 were hospitalized for catheter issues and gastrointestinal symptoms, respectively, yet neither received the required bed hold notifications. The facility's policy, revised in October 2022, mandates that residents or their representatives receive written information about bed hold policies at least twice, including within 24 hours of an emergency transfer, which was not adhered to in these cases.
Failure to Complete Bed Hold Audits
Penalty
Summary
The facility failed to ensure that bed hold audits were completed as part of their performance improvement project (PIP), which had the potential to affect residents who were emergently sent out to the hospital. The facility's Quality Assurance and Performance Improvement (QAPI) Program policy required performance improvement projects to be initiated when problems were identified, with systematic actions targeted at the root causes of identified problems. However, the facility did not have a QAPI Plan in place, and the bed hold notifications were not being issued to residents or their responsible parties in advance of transfers or within 24 hours if emergent. The Director of Nursing (DON) confirmed that a PIP was in place for ensuring bed hold notifications, but audits were not conducted as required. The Assistant Director of Nursing (ADON) was aware of the PIP but did not conduct audits, assuming it was the responsibility of Medical Records. The Medical Records Director (MRD) began conducting bed hold audits in May 2024 but confirmed that the audits were incomplete. The Administrator was aware that the bed hold audits had not been completed per the facility's current PIP.
Improper Issuance of SNFABN to Medicare Beneficiaries
Penalty
Summary
The facility failed to correctly issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to Medicare Part A beneficiaries, specifically for two residents who had completed therapy or skilled nursing services. For one resident, the SNFABN was issued with an incorrect financial liability start date and lacked a clear explanation of why Medicare would not cover the continued stay. The estimated cost section was filled out, but the reason for Medicare's potential non-payment was not sufficiently detailed to enable the resident to understand the denial. The resident confirmed signing the SNFABN and chose not to continue therapy. For the second resident, the SNFABN was issued with a financial responsibility start date that was incorrect by a year, and the estimated cost was listed as $0.00. The reason Medicare may not pay was similarly vague, lacking a specific explanation of why the resident's medical needs did not meet Medicare coverage guidelines. The resident confirmed understanding the SNFABN and opted not to continue therapy. The Social Services Director was unaware that the SNFABN should provide information related to the end of skilled services, indicating a misunderstanding of the form's completion requirements.
Improper Use of Physical Restraints on Residents
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, which were not ordered for medical treatment. The first resident, R78, was positioned in bed in a manner that prevented him from getting out of bed, which was used as a fall intervention. The bed was positioned with the head down and the foot elevated, with a foam wedge and blanket creating a barrier. Despite R78's requests to sit up and get out of bed, staff members continued to reposition him into a lying position, citing fall risk as the reason for the bed's positioning. This method was not documented in the care plan and was acknowledged by staff and the Director of Nursing as potentially functioning as a restraint. The second resident, R203, was observed with a bandage and sock combination on his left hand and forearm, which he could not remove. This was not ordered by a physician and was not documented in the care plan. Staff members were unaware of the reason for the application, and it was suggested that it might have been used to prevent the resident from accessing his incontinence brief. The Director of Nursing confirmed that such a combination could function as a restraint and should have been accompanied by a physician's order, assessment, and care plan. The facility's policy on the use of restraints specifies that restraints should only be used to treat medical symptoms and not for staff convenience or fall prevention. The policy also states that any device that restricts a resident's ability to change position or place is considered a restraint. In both cases, the use of positioning and the sock/bandage combination were not in compliance with the facility's policy, as they were used without proper documentation, orders, or assessments, and restricted the residents' mobility.
Failure to Complete PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a resident, identified as R95, received a Level II assessment as required by the Pre-Admission Screening and Resident Review (PASARR) program. R95, who was admitted and re-admitted to the facility, had primary medical diagnoses of schizoaffective disorder and bipolar disorder. The resident's admission Minimum Data Set (MDS) indicated moderate cognitive impairment and the use of antipsychotic medications. Despite a positive Level I PASARR screening indicating the need for a Level II evaluation, the facility did not resubmit the screening after the initial Level II evaluation could not be conducted due to the resident's inability to participate. The report highlights that the facility did not have a process in place to ensure follow-ups for PASARR screenings were completed. Interviews with the Social Services Director (SSD), Director of Nursing (DON), and Admissions Director (AD) revealed that the facility was not notified of the screening results unless direct contact was made, and the determination letter was not followed up. The PASRR Manager confirmed that the Level I screening was submitted, but the follow-up Level II evaluation was not completed because the available staff could not answer the necessary questions. Observations of R95 showed the resident exhibiting behaviors such as yelling and demanding attention, which were consistent with the issues noted in her care plan. The facility's policy required all new admissions to be screened for mental disorders, and if a Level I screen indicated potential issues, a Level II evaluation should be conducted. However, the facility failed to adhere to this policy, resulting in the deficiency noted in the report.
Deficiencies in Baseline Care Plans for Code Status and Side Rail Use
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed to include the code status for a resident admitted with diagnoses of secondary malignant neoplasm of unspecified ovary and cutaneous abscess of the abdominal wall, who was receiving hospice services. The resident had completed a POLST indicating a preference for no resuscitation, and a physician order for DNR was documented. However, the care plan did not reflect these advance directives or the resident's code status, which was confirmed by the MDS Director during an interview. Additionally, the facility did not include the use of side rails in the baseline care plan for another resident diagnosed with systemic lupus erythematosus and systemic sclerosis. Observations revealed that the resident used bilateral 1/4 side rails for repositioning, and a physician order indicated their use as an enabler for bed mobility. Despite this, the baseline care plan lacked documentation of the side rails being used for positioning, as confirmed by the Director of Nursing.
Failure to Initiate Timely Bowel Protocol for Resident
Penalty
Summary
The facility failed to provide timely care for constipation for Resident 204, who was admitted with diagnoses including COVID-19, type two diabetes mellitus, and acute kidney failure. Despite being cognitively intact and continent of bowel upon admission, Resident 204 did not have a bowel movement for ten days. The bowel protocol, which included administering milk of magnesia (MOM) after three days without a bowel movement, was not initiated until the fifth day. This delay in initiating the bowel protocol was confirmed by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged that the protocol should have been started on the third day. The facility's electronic medical record (EMR) system flagged the need to initiate the bowel protocol after three days without a bowel movement, but the floor nurses did not act on these alerts for two days. Additionally, there was no care plan initiated to address the resident's constipation, and the DON confirmed that an episodic care plan should have been opened. The facility did not provide a constipation/bowel policy upon request during the survey, indicating a lack of documented procedures to guide staff in managing such issues.
Failure to Ensure Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure adequate hydration for one resident, identified as R204, who was at risk for dehydration and weight loss. R204 was admitted with diagnoses including COVID-19, type two diabetes mellitus, and acute kidney failure. Despite being prescribed intravenous fluids twice within the first ten days of admission due to poor nutritional and fluid intake, R204's fluid requirements were not assessed timely. The care plan goal for fluid intake was set at 1000 cc per day, which was inadequate compared to the 2400 ml per day calculated by the Registered Dietitian (RD) on 07/31/24. The facility's records revealed inconsistencies in monitoring and documenting R204's fluid intake. The Medication Administration Record (MAR) showed varying daily fluid intake levels, with several days falling significantly below the required 2400 ml. Additionally, health shakes ordered to supplement R204's nutrition were not documented as administered or consumed, and the facility did not record supplements given with meals. The RD acknowledged the delay in completing R204's nutritional assessment and the inadequacy of the care plan's fluid intake goal. Interviews with facility staff, including the Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), and the RD, confirmed the lack of timely assessment and monitoring of R204's hydration status. The RD stated that the provision of IV fluids should have triggered a high nutritional/dehydration risk assessment, which was not completed in a timely manner. The Director of Nursing (DON) verified that the care plan goal for fluid intake was incorrect and should have been aligned with the RD's assessment. The facility's policy on hydration and prevention of dehydration was not adhered to, as the dietitian did not assess R204's hydration needs within the standard timeframe.
Failure to Renew PRN Antianxiety Medication Order
Penalty
Summary
The facility failed to ensure that a resident did not receive an as-needed antianxiety medication, Ativan, for more than fourteen days without a physician's rationale for extending the use and without a specified stop date. The resident, who was admitted with diagnoses including major depressive disorder, psychotic disorder with delusions, and anxiety disorder, was prescribed Ativan on a PRN basis. The order did not include a stop date, and the medication was administered beyond the 14-day period without documentation for its continued use. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the PRN Ativan should have been renewed after 14 days, and there was no documentation of a physician's rationale for extending its use. The facility's policy on psychotropic medication use requires that PRN orders for such medications are limited to 14 days unless a physician documents the rationale for extending the use. The failure to adhere to this policy increased the risk of adverse reactions to medications that may not be needed to treat a clinical condition.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during catheter care for two residents. For one resident, a Licensed Vocational Nurse (LVN) did not change gloves appropriately while providing suprapubic catheter care. The LVN cleaned the catheter and then proceeded to rinse and pat it dry without changing gloves, which is a necessary step to prevent cross-contamination. This oversight was confirmed by the LVN, the Director of Nursing (DON), and the Infection Preventionist (IP), all acknowledging that gloves should be changed when transitioning from a dirty to a clean area. In another instance, a resident's urinary collection bag was observed on the floor without a dignity bag, contrary to the facility's policy. The resident, who had severe cognitive impairment and an indwelling catheter, was found with the collection bag on the floor, which poses a risk for infection. This was confirmed by another LVN and the DON, who stated that the expectation is for urinary collection bags to be kept off the floor and in a dignity bag to prevent infection. The facility's policy on catheter care explicitly states that catheter tubing and drainage bags should be kept off the floor to avoid urinary tract infections.
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Illustrative
What surveyors actually found near you
We read the 230 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden City Healthcare Center | 1.1 mi | ★★★★★ | 19 | 0 |
| English Oaks Convalescent & Rehabilitation Hospita | 1.1 mi | ★★★★★ | 12 | 0 |
| Vintage Faire Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 6 | 0 |
| Modesto Post Acute Center | 2.2 mi | ★★★★★ | 17 | 0 |
| Valley Skilled Nursing Center | 2.2 mi | ★★★★★ | 3 | 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 June 2026) and official state health department websites.