Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Alta Gardens Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to coordinate contracted transportation for a resident on hemodialysis, resulting in the resident independently navigating public transit and walking back while weak and anxious, without the facility’s knowledge. Staff did not perform or document a change-of-condition assessment, notify the MD, or provide same-day psychosocial follow-up despite the resident reporting fear, crying, and anxiety, and PRN anxiolytics were not available until days later. The same resident’s midodrine was administered significantly late without MD notification. Another resident with a scalp lesion had a dermatology appointment rescheduled when transportation failed, with no evidence that all alternative transport options were exhausted beforehand. For two residents receiving dialysis, nurses did not document departure and return times for multiple outpatient treatments, contrary to facility P&P, leaving gaps in tracking residents’ whereabouts and clinical status around appointments.
Incomplete informed consent for psychotropic meds: The facility did not fully document advance consent details for several residents receiving psychotropic drugs. For some residents, consent was obtained after the med started or was changed, and for others the disclosure forms omitted required details such as non-pharmacologic interventions, indications, or manifested behaviors. RN staff and the DON confirmed the missing documentation.
Psychotropic Medication Monitoring and Documentation Deficiencies: The facility failed to document required monitoring and related interventions for residents receiving psychotropic medications. A resident on prazosin for nightmares had no documented nightmare monitoring, a resident on Ativan had six restlessness episodes without documented nonpharmacological interventions, residents on aripiprazole and quetiapine lacked clear orthostatic BP monitoring documentation, and a resident on Zoloft had no monthly behavior summary available for review. The DON and nursing staff acknowledged the missing documentation.
Surveyors found multiple food safety and sanitation failures in the kitchen, including unlabeled and undated food, expired items that were not discarded, dirty and damaged food-contact surfaces, and poor monitoring of visitor food refrigerators. They also observed an employee in the puree area without a beard restraint, improper hand hygiene before donning gloves, and a blender used for different foods without being washed between items.
The facility failed to fully carry out its infection prevention and control program by not using McGeer’s criteria for residents with signs and symptoms of infection who were not on antimicrobials. Staff also left personal hygiene items unlabeled in a shared restroom, a CNA did not perform hand hygiene between assisting two residents with meals, and an LPN placed a resident’s call light back on the bed without disinfecting it after it had fallen on the floor.
The facility failed to protect a resident from physical abuse when two residents encountered each other in a hallway and one, who had severe cognitive impairment, became frustrated that the other resident in a wheelchair did not move quickly enough. The cognitively intact resident reported being struck in the face, and staff witnesses, including an RN and a Social Services Assistant, observed the aggressive resident yelling and then slapping the other resident’s head/face. Documentation noted redness on the affected resident’s face and forehead, and the incident was substantiated as physical abuse under the facility’s abuse prohibition policy.
Nonfunctioning Room Televisions: A resident council meeting and record review showed several residents who preferred watching TV in their rooms had nonfunctioning televisions for weeks, and another resident reported hers had not worked for about two weeks. Records showed TV viewing was an important leisure activity for these residents, including one resident with poor vision who relied on TV for news and world events. The DOR verified the televisions were not working, and only 3 of 118 room TVs were functioning at the time.
The facility failed to include key care plan interventions for two residents. One resident had an elopement risk identified on the elopement evaluation, but the care plan did not address that risk even though the resident had no capacity to make decisions and was observed self-propelling in a wheelchair. Another resident had a physician order to offload the heels and ankles while in bed for wound management, but the care plan did not include that intervention and staff observed the heels touching the mattress.
A facility failed to complete ordered neuro checks after a resident’s unwitnessed fall with head involvement and did not document physician notification or monitoring when the resident later had right-eye discoloration. It also failed to rotate insulin injection sites for another resident despite an order to do so, did not complete an ordered wheelchair evaluation for a resident whose wheelchair was too high and feet were dangling, and did not carry out ordered PT/OT evaluations after a resident’s functional decline.
A resident with severe cognitive impairment and no decision-making capacity had a physician order for heel and ankle offloading while in bed for wound management, but repeated observations showed the heels were touching the mattress and not offloaded. An LPN verified the issue during observation, and the DON was informed and acknowledged the findings.
Accident hazards and missing post-fall assessments were identified for two residents. One resident with no decision-making capacity and a recent unwitnessed fall had a bedside table placed on top of the floormat beside the bed, despite an order for floor mats on both sides of the bed. Another resident with severe cognitive impairment and no capacity for medical decisions had an unwitnessed fall, but the record lacked a post-fall risk assessment and the IDT Care Conference form was blank and incomplete.
Failure to follow RD recommendation for appetite stimulant. A resident with severe cognitive impairment was severely underweight, had poor intake, and refused some meals, with weights declining to 62 lbs. The RD recommended consulting the physician for an appetite stimulant, but the MAR/order record showed no order, and RN verified there was no documented evidence the MD was notified or that an order was obtained.
IV Site Not Labeled After Insertion: A resident with no decision-making capacity had a peripheral IV in the right hand, but the site was observed without the required date, time, and LPN/RN initials after insertion. The resident had orders for a short peripheral IV and IV NS at 75 ml/hr for poor PO intake, and the IV therapy record documented the IV was inserted to the right hand.
Pain management was not provided as ordered for two residents. For one resident, hydrocodone-acetaminophen was given outside the ordered pain scale range, and the record did not show non-pharmacological interventions were provided before administration. For another resident, acetaminophen was given for pain rated 4 even though the order was for mild pain only, and staff verified tramadol should have been used instead. The DON acknowledged the findings.
A resident with ESRD and dependence on renal dialysis had incomplete hemodialysis communication records and inconsistent AVF access assessments. The records lacked required pre- and post-dialysis documentation such as bruit/thrill checks, site condition, vital signs, and complications, and the MAR used unclear symbols for access-site monitoring. The DON acknowledged the missing documentation and that pain was not shown as addressed when P was recorded.
An LVN administered the wrong meds to one resident, giving sodium bicarbonate instead of ordered sodium chloride and lactobacillus acidophilus instead of lactobacillus rhamnosus GG, after failing to properly compare the label with the MAR. In a separate event, a controlled pain med was signed out for another resident, but the MAR did not document that the Norco was actually administered. The DON verified both medication administration and documentation errors.
A medication cart inspection found an oral sodium chloride tablet bottle stored with artificial tears eye drops in the same compartment of Medication Cart B. An LVN verified the finding and stated the meds should be stored separately because they are given by different routes. An RN later acknowledged that internal and external meds should be stored separately to prevent med error.
A dietary aide failed to respond when the low-temp dishwasher did not reach the required temperature during a warewashing cycle. The aide observed the machine at 104 degrees Fahrenheit, completed the cycle, and placed trays in the dishwasher despite the temperature being below the expected 120 degrees Fahrenheit. The DSS confirmed the temperature, and the Dietary Services District Manager stated the dishwasher was not reaching 120 degrees because hot water was being used for residents' showers.
Meals were not served as written for two residents. One resident on a pureed diet did not receive all menu items listed for lunch, and another resident’s breakfast tray contained only rice bowls instead of the items shown on the meal ticket, including omelet, bread and jelly, margarine, and juice. Staff verified the missing items during observation, and both residents had no capacity to make their own decisions.
A facility failed to serve two residents their preferred lunch beverages as listed on their meal tickets. One resident did not receive the juice of choice with a meal tray that included pureed foods and water, and an LVN later brought nectar thick apple juice. Another resident was observed with no beverage despite the meal ticket listing hot coffee, and an LVN confirmed the coffee was not served. Facility staff acknowledged that the beverages should have been provided as listed.
Unsafe Handling of Food Brought in by Visitors: The facility failed to ensure food brought in from outside was handled safely. Staff were educated on safe food handling in the facility, but the in-service did not include preparation and transport of food brought from home, and staff could not explain how visitors were educated. The DSD stated visitors were only told verbally to bring the correct diet texture and the facility did not provide written safe food handling information for family members.
Incomplete POLST documentation was found for two current residents and one closed record resident. The POLST forms had blank sections for advance directive information and, for one resident, a missing patient or decisionmaker signature. The residents had H&P findings showing no capacity to understand and make decisions, and the Social Services Assistant and DON acknowledged the incomplete records.
A facility failed to keep Water Heater 1 in safe operating condition when it was observed leaking water from the check valve. The DON stated he was aware of the leak, that the unit supplied water to resident rooms throughout the facility, and that the check valve was meant to prevent backflow of water.
A resident with recurrent major depressive disorder and no capacity to understand and make decisions had an inaccurate PASRR level 1 that stated there was no serious mental illness and no psychotropic medication use. The record also showed orders for quetiapine for psychosis and divalproex for mood stabilization, while the DON stated the PASRR should have been reviewed for accuracy and a resident review should have been done when the divalproex was prescribed.
Care Plan Not Revised After Resident Fall: A resident who was at risk for falls and had no capacity to make decisions experienced an unwitnessed fall with a small bump to the cheek after trying to get up from bed. The medical record did not show the care plan was revised to address the fall, and the MDS Nurse and DON both verified the omission during record review.
Nebulizer Equipment Not Labeled or Properly Stored: A resident receiving PRN breathing treatments had a nebulizer mask observed undated and stored in a bedside drawer instead of a clear set-up bag. An LPN stated the mask should be kept in the bag when not in use, and the DON stated the mask and tubing should be dated and changed every 7 days for infection control purposes.
Facility Assessment missing required input and staffing plans: The Facility Assessment did not show active involvement of direct care staff, resident/family representatives, or other required participants in its development. It also lacked a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs. The Administrator verified these omissions and stated he was not aware of the current CMS guidance.
The facility failed to provide necessary care and services for IV access maintenance for six residents, including inadequate documentation of PICC and midline catheter measurements, unlabeled dressings, and lack of care plans. These deficiencies could delay the identification of catheter-related complications.
The facility failed to follow dietary guidelines and menu plans, serving residents incorrect items such as yellow cake instead of carrot cake and vanilla pudding instead of chocolate ice cream. A resident on a renal diet did not receive the appropriate diet or double protein portion. The CDM acknowledged these issues, noting that the menu was not updated to reflect substitutions, and residents were not informed of changes.
A facility failed to implement the care plan intervention of placing floor mats on both sides of the bed for a resident with severe cognitive impairment and high fall risk. The mats were found leaning against the wall instead of on the floor, as confirmed by an LVN. The DON and Interim Administrator were informed of this oversight.
The facility failed to manage gastrostomy tubes (GT) appropriately for three residents. A resident's enteral feeding formula and water bag were not labeled correctly, and a CNA resumed GT feeding without verifying placement. Another resident's GT placement was not checked before medication administration, and an abdominal binder was not used as required. Additionally, a third resident's head of the bed was not elevated properly during feeding, increasing the risk of aspiration.
The facility failed to provide safe respiratory care for two residents. One resident did not receive oxygen as per the physician's order, leading to low oxygen saturation levels. Another resident's sterile water for humidification was not labeled with an opened date, violating facility policy. Staff acknowledged these deficiencies.
A resident who underwent orthopedic surgery did not receive appropriate pain management as per physician's orders. The facility failed to administer hydrocodone-acetaminophen for moderate pain and inconsistently provided non-pharmacological interventions before administering morphine. Interviews confirmed these deficiencies, highlighting a lack of adherence to the facility's pain management policy.
A resident requiring dialysis care did not receive appropriate services as the facility failed to hold hypertension medications on dialysis days, assess the AV shunt post-treatment, and document fluid intake. The facility also did not notify the physician of new recommendations or significant status changes, as confirmed by staff interviews and medical record reviews.
The facility failed to provide accurate pharmaceutical services for two residents, leading to potential medication errors. A resident's medications were ordered for oral administration instead of via GT, and a nurse did not administer a complete dose. Another resident's sodium chloride was unavailable, and its administration was undocumented. These lapses posed health risks due to potential complications or delays in interventions.
The facility failed to monitor two residents for signs of bleeding related to anticoagulant use. One resident was on enoxaparin, and another on apixaban, both without documented monitoring for adverse effects. Staff confirmed the lack of monitoring, and the Interim Administrator and DON acknowledged the findings.
The facility failed to monitor antipsychotic medication use for three residents, leading to potential adverse effects. One resident was not accurately monitored for orthostatic hypotension related to Seroquel, and their informed consent was incomplete. Another resident's informed consent for Risperdal lacked necessary details, and they were not monitored for orthostatic hypotension. A third resident was also not monitored for orthostatic hypotension as ordered. Staff acknowledged these deficiencies.
The facility's medication error rate was 11.54%, exceeding the acceptable threshold. Errors included a nurse failing to administer zinc due to unavailability, and two nurses administering polyethylene glycol 3350 without verifying residents' bowel movement history, contrary to physician orders. These oversights led to improper medication administration.
The facility failed to ensure kitchen staff had the necessary skills for safe operations in the Food and Nutrition Services Department. Dietary Aide 1 incorrectly demonstrated the procedure for testing sanitizing solution concentration, and both Dietary Aides 1 and 2 were unable to accurately describe the manual dishwashing process. These failures could lead to foodborne illnesses among residents.
The facility failed to ensure food safety and sanitation in the kitchen by not labeling and dating food items in the freezer and improperly storing maintenance tools. Unlabeled and undated food items, such as veggie vegan patties, French toast, and hamburger buns, were found, violating the facility's policy. Additionally, brooms were improperly stored on the ground outside the kitchen, contrary to the USDA Food Code 2022. These issues posed a risk of foodborne illnesses to residents.
The facility failed to educate staff on safe food handling for food brought in by family members, leading to potential food safety risks. Staff, including CNAs and LVNs, were not trained on proper reheating practices, and there was no designated microwave for family use. The DSD admitted to not providing necessary education, and the Interim Administrator and DON acknowledged these deficiencies.
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies. The infection surveillance tool did not include all residents with infections, only those prescribed antibiotics. Additionally, staff did not consistently use proper PPE when caring for residents with infections, and medical equipment was not maintained in a sanitary condition. These failures posed a risk for the transmission of infections within the facility.
The facility failed to maintain complete advance directives in the medical records for two residents, risking their healthcare decisions not being honored. For one resident, only part of the directive was uploaded, missing key healthcare instructions. For another, no directive was found, and there was no documentation of attempts to obtain it. The DON and Interim Administrator acknowledged these deficiencies.
A facility failed to provide a resident or their representative with written information about the bed hold policy during a hospital transfer. Despite the facility's policy requiring notification at the time of transfer, there was no documentation in the medical records. Staff interviews confirmed the absence of the required notification, and the Interim Administrator and DON acknowledged the deficiency.
The facility failed to properly store garbage in one of six dumpsters, which was observed propped open on two consecutive days. This was against the FDA Food Code 2022, which mandates that outdoor refuse receptacles be covered with tight-fitting lids. The Maintenance Assistant confirmed the deficiency and acknowledged the importance of keeping lids closed for infection control.
The facility failed to remove expired medications from Medication Cart B, as observed during an inspection with an RN. Fourteen packets of Vitamin A & D ointment, expired since October 2023, were found in the cart. The facility's policy requires immediate removal and disposal of outdated medications, which was not followed in this instance.
The facility failed to maintain infection control practices in the laundry room, risking disease transmission. Personal items, including food and drink, were found on laundry detergent boxes, and a fragrance mist spray was on the clean area counter. Staff confirmed these findings, acknowledging that such items should not be present to maintain infection prevention.
A resident at risk for falls did not have a floor mat as specified in their care plan, despite being identified as needing substantial assistance and having a history of falls. Staff familiar with the resident confirmed the absence of the floor mat, which was a required intervention to minimize injury risk.
Dialysis Transportation, Assessment, and Documentation Failures
Penalty
Summary
The deficiency involves multiple failures to coordinate and document transportation and clinical care for residents receiving dialysis and specialty appointments. For one resident with ESRD on hemodialysis, the facility’s transportation arrangements to and from the dialysis clinic were not properly coordinated. On one dialysis day, the contracted transportation left because the resident’s treatment was not yet complete, and the resident was not picked up from the clinic. The resident, who had muscle weakness, difficulty walking, and an ileostomy, reported walking to a nearby restaurant, emptying his ostomy bag, taking two public buses, stopping at a bank, and then walking the remaining distance back to the facility, including crossing major intersections. Staff interviews confirmed ongoing transportation issues for this resident, including prior occasions when transportation left the resident at the clinic and a family member had to pick him up. The facility also failed to assess, document, and notify the physician when this resident returned to the facility approximately seven to eight hours after dialysis. There was no documentation of the resident’s clinical condition, no change-of-condition assessment, no progress notes, and no monitoring despite the resident reporting fear, anxiety, and crying related to being followed by a man and involving the police while returning by public transit. Nursing staff acknowledged that the resident’s symptoms of being tired, weak, fearful, and crying constituted a change of condition and that the physician was not notified. The DON and DSD verified there was no assessment upon arrival, no physician notification of the incident, and no documentation of the resident’s status at the time of return. The facility further failed to provide timely psychosocial support and timely medication management for this resident. The resident’s PRN lorazepam for anxiety had been discontinued the day before the incident and was not available on the day the resident reported fear, anxiety, and crying; it was reordered the following day and first administered two days after the incident. There was no documented social services follow-up with the resident on the day of the incident, and the SSD confirmed she had not spoken with the resident until the following day. Additionally, the resident’s midodrine, ordered three times daily with meals for hypotension, was administered significantly late on one dialysis day, outside the facility’s one-hour window, and the physician was not notified of the late administration. Another resident experienced a failure in transportation coordination for a dermatology appointment. This resident had a documented brown scalp lesion and a dermatology consultation scheduled, which was rescheduled to a later date. Nursing notes showed the appointment was moved, and social services notes later documented that transportation did not arrive for the rescheduled appointment, requiring another rescheduling and arrangement of private transportation. Staff interviews indicated that alternative transportation options such as private ride-share and CNA accompaniment were available, but there was no evidence that all transportation methods were exhausted before rescheduling the earlier appointment, despite having time to arrange alternatives. The facility also failed to document departure and arrival times for two residents who regularly left the facility for outpatient dialysis. For one resident, progress notes for multiple dialysis dates lacked documentation of either departure time, arrival time, or both. For the second resident, treatment records showed multiple dialysis sessions, but corresponding progress notes were missing departure and/or arrival times on numerous dates. The DSD stated that nurses were responsible for documenting residents’ departure and arrival times in progress notes, and the DON confirmed that this documentation was missing for the identified dates.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to ensure residents or their representatives were fully informed in advance of proposed psychotropic medication treatment for five residents reviewed. The report states that the facility’s psychotropic medication policy required staff and the physician to review non-pharmacological alternatives, the indication and rationale, potential risks and benefits, and the resident’s or representative’s right to accept or decline treatment before obtaining documented consent or refusal. For Resident 28, who was documented as having capacity to understand and make decisions, sertraline was ordered for depression manifested by verbalizing sadness, but the informed consent was obtained five days after the medication had already started. The same resident later had Ativan changed from as-needed use to a routine once-daily order for anxiety and restlessness, but the record did not show documentation that informed consent was obtained when the frequency changed. For Resident 47, who also had capacity to understand and make decisions, hydroxyzine had an informed consent form for a 30-day order for agitation/anxiety manifested by inability to relax, but the record did not show consent when the order was changed from a 30-day duration to a routine order with no stop date. The record also did not show that informed consent was obtained before prazosin was administered for nightmares. The DON acknowledged that prazosin was used off-label as a psychotropic medication and that consent should have been obtained before administration and when frequency or duration changed. For Resident 9, who had no capacity to understand and make medical decisions, Zoloft was ordered for anxiety manifested by defecating on the floor, and consent was obtained from the responsible party, but the psychotropic medication disclosure did not include the list of possible non-pharmacological approaches related to the behavior. For Resident 25, who also had no capacity, Risperdal was ordered for psychosis manifested by aggressive behavior and striking out, but the disclosure did not include possible non-pharmacological approaches. For Resident 38, who had an order for escitalopram for anxiety manifested by being unable to keep still, the disclosure did not include the indication and manifested behaviors. Interviews with nursing staff and the DON confirmed these omissions in the consent documentation.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure five sampled residents were free from unnecessary psychotropic medication-related deficiencies and related monitoring requirements. The report identified failures involving prazosin used for nightmares, Ativan used for anxiety/restlessness, aripiprazole used for agitation, quetiapine used for psychosis, and Zoloft used for anxiety. Facility policy stated that residents should not receive psychotropic medications that are not clinically indicated and necessary, and that behavioral and other nonpharmacological approaches should be used unless contraindicated, with monitoring of response to treatment documented. For one resident, prazosin was ordered at bedtime for nightmares, but the medical record did not show that nightmares related to the medication were monitored. RN 2 confirmed there was no documented evidence of monitoring. For another resident receiving Ativan for anxiety and restlessness, the order required monitoring of restlessness and documentation of nonpharmacological interventions. The MAR showed six episodes of restlessness on one evening shift, but the record did not show that nonpharmacological interventions were provided during those episodes, and RN 2 confirmed the lack of documentation. The report also found monitoring deficiencies for residents receiving antipsychotic medications. One resident on aripiprazole had a care plan addressing black box warning side effects including orthostatic hypotension, but the record did not show monitoring for orthostatic hypotension. Another resident on quetiapine had standing orders for orthostatic blood pressure checks, but the MAR showed incomplete and unclear documentation, including readings that did not identify sitting versus lying positions. In addition, a resident receiving Zoloft had behavior monitoring for defecating on the floor, but the medical record did not show the required monthly summary of the behavior for physician review. The DON and other staff acknowledged the findings during interviews.
Food Storage, Sanitation, and Food Preparation Deficiencies
Penalty
Summary
Food storage and sanitation practices in the kitchen were not followed during survey observations and record review. During the initial kitchen tour, multiple food items were found without proper labeling or dating, including peeled garlic in the refrigerator with no open date, pinto beans with an unreadable date, an opened cereal bag with no open date, cookies stored in an open aluminum basin, and sage without a proper use-by date. The facility’s own food storage policy required refrigerated and dry foods to be wrapped or covered, labeled, dated, and stored to prevent cross contamination. Surveyors also found expired food items that had not been discarded. These included opened coleslaw dressing with a use-by date of 2/1/26, shredded cheese with a use-by date of 1/5/26 and expiration date of 2/2/26, salt with a use-by date of 6/17/25, sesame seed with a use-by date of 11/20/25, and six cans of peaches labeled with a use-by date of 5/10/24 in the emergency food supply. The facility’s policy required foods to be stored according to FDA Food Code guidance, and the DSS verified the expired items during observation. Kitchen equipment and food-contact areas were also observed in unclean or damaged condition. Surveyors noted frying pans with deep scratches exposing metal, spice containers with grime, trays with oily and sticky residue, a drawer with dry food particles, and a can opener with food residue and brownish-orange material resembling rust. Clean plates were stored near an oven motor with grayish, fuzzy dust residue, and five cutting boards were heavily marred and fuzzy with knife marks. The ice machine storage bin had black residue, and the refrigerator used for visitor food had no thermometer, inconsistent temperature logs, ice buildup, brown sticky grime, and unlabeled food items brought in by family, including soy and drinkable jelly with an expired date. Staff practices observed during food preparation also did not follow infection control and food safety procedures. A staff member entering the kitchen was not wearing a beard restraint while in the puree food preparation area. Another staff member removed gloves, handled kitchen surfaces and utensils, and put on new gloves without washing hands first. During puree preparation, the blender was used for different foods without being washed in between items, and food remained in the blender when the next food was added. The Dietary Services District Manager stated the blender should have been washed between food types to prevent cross contamination and allergy.
Infection Control Program and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement its infection prevention and control program in accordance with its policy and procedure. The Infection Preventionist stated the facility used McGeer’s criteria to determine whether a resident had a true infection and that residents who exhibited signs and/or symptoms of infection and were prescribed antimicrobial medication were entered on an Antibiotic Surveillance Data Collection Form for review. However, the facility’s Infection Control Monthly Summary from March 2025 through January 2026 showed counts for healthcare-acquired infections, community-acquired infections, and residents who did not meet McGeer’s criteria, and the Infection Preventionist stated the facility did not initiate the McGeer’s criteria form for residents who had signs and/or symptoms of infection but were not prescribed antimicrobial medications. The Infection Preventionist stated only a change of condition assessment was performed for those residents and was uncertain how many residents met McGeer’s criteria without receiving antimicrobial medications during that period. The facility also failed to ensure personal care items were properly labeled in a shared restroom. During the initial tour, two basins were observed in the restroom in Room A, one gray and one pink, with a comb, emesis basin, toothbrush, toothpaste, and drinking cup stored inside and on top of the toilet tank without the resident’s name. Room A was occupied by two residents. RNA 1 verified the items were unlabeled and stated the items should have been labeled with the resident’s name and room number and stored in a bag. LVN 4 also stated the resident’s personal hygiene items should be labeled with the resident’s name and stored in a bag inside the resident’s drawer. The facility further failed to maintain hand hygiene between resident contacts and to disinfect a resident item after contamination. CNA 5 was observed assisting one resident with eating and then feeding another resident without performing hand hygiene in between. CNA 5 confirmed the observation. In a separate observation, Resident 94’s call light was found on the floor behind the bed, and LVN 1 picked it up and placed it on the resident’s bed without disinfecting it first. LVN 1 acknowledged the call light should have been disinfected before being returned to the bed, and the DON later stated that call lights that fall on the ground should be disinfected before being placed back on the resident’s bed.
Failure to Prevent Resident-to-Resident Physical Abuse in Hallway
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse by another resident, in violation of its Abuse Prohibition Policy and Procedure. The policy, dated 2/23/21, prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. On the date of the incident, a cognitively intact resident (Resident 105), who used a wheelchair, was in the Station 2 hallway when another resident (Resident 3), who had severe cognitive impairment, attempted to pass. Resident 3 yelled for Resident 105 to get out of the way and, when Resident 105 did not move quickly enough, Resident 3 swung his hand and struck Resident 105 in the face. The altercation was witnessed by staff and corroborated by interviews and documentation. An RN reported hearing Resident 3 yell "get out of my way" and observed both residents in the hallway, with Resident 3 unable to pass because Resident 105 was blocking his way; the RN stated that Resident 3 then swung his hand and slapped Resident 105’s head. The Social Services Assistant, who heard yelling from his office, also reported seeing Resident 3 slap Resident 105’s face. Resident 105 reported that he was sitting in his wheelchair in the hallway, that the other resident was going in the opposite direction, and that he could not move out of the way fast enough before being hit in the face, which he described as a closed-fist strike. An eINTERACT Change in Condition Evaluation documented that Resident 105 had redness on the face and forehead following the slap. The Administrator later confirmed that the facility substantiated the physical abuse based on the witnessed incident and the observed redness on Resident 105’s face.
Nonfunctioning Room Televisions
Penalty
Summary
The facility failed to maintain a homelike environment for residents who enjoyed watching television in their rooms because their televisions were not functioning. During a Resident Council meeting, Residents 20, 22, and 66 stated their room televisions had not worked for several weeks, and Resident 109 later stated her television had not worked for about two weeks. The report states these residents preferred watching television in their rooms and that the facility was aware the televisions were not working, but they had not yet been fixed. Resident 22’s record showed she enjoyed watching television and had poor vision, so she relied on television for news and world events. Resident 20’s record showed watching television was very important to him, including news, comedies, nature programs, reality TV, weather reports, and the history channel. Resident 66’s record showed he enjoyed watching television movies, news, mysteries, classics, and action/adventure programs. Resident 109’s record showed she enjoyed watching reality TV, comedies, soap operas, news, cooking programs, and Spanish television. The Director of Maintenance verified that Residents 20, 22, 66, and 109 had nonfunctioning televisions. He stated the facility had 118 residents and each resident had a television in their room, but only three of the 118 televisions were currently functioning. He also stated the facility was in the process of upgrading the television system.
Care Plan Did Not Reflect Elopement Risk or Heel Offloading Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that reflected the individual care needs of two residents. For one resident, the elopement evaluation documented that the resident was able to ambulate or self-propel in a wheelchair independently, had verbally expressed a desire to go home, packed belongings to go home, stayed near an exit door, and had recently been admitted or readmitted and was not accepting the situation. The evaluation identified the resident as at risk for elopement, and the H&P stated the resident had no capacity to understand and make decisions, but the care plan did not include a problem to address the elopement risk. The resident was observed wheeling himself down the hallway in a wheelchair using his left hand. For the second resident, the medical record showed a physician's order to offload the heels and ankles while in bed every shift for wound management, and the care plan identified the resident as at risk for skin breakdown related to limited mobility, thin and fragile skin, and incontinence. However, the care plan did not include an intervention to offload the heels and ankles, and the order was not implemented. The resident was observed asleep in bed on multiple occasions with the heels touching the mattress, and staff including a CNA and LVNs verified that the heels were not offloaded and that no care plan intervention addressed this need.
Failure to Carry Out Ordered Monitoring, Treatments, and Evaluations
Penalty
Summary
The facility failed to complete the ordered neurological monitoring after a resident’s unwitnessed fall with head involvement. Resident 105, who was cognitively intact, was found on the floor while still seated in his wheelchair with the wheelchair tipped backward and his head resting against the floor. The resident was transferred to an acute care hospital and later returned to the facility, but the neurological evaluation flow sheet did not show completion of the required monitoring at several documented times after the fall and after the resident returned from the hospital. The facility also failed to document physician notification and monitoring when Resident 105 was later observed with discoloration around the right eye after a prior fall. The record showed the resident had a documented fall with a small bump on the right forehead, and several days later skin discoloration was observed around the right eye with no skin breakdown. The resident’s representative was notified, but the record did not show whether the physician was notified or whether the area was monitored. For Resident 4, the facility did not rotate the insulin injection site as ordered. The physician ordered Humulin R insulin three times daily with instructions to rotate sites, but the location of administration record showed repeated injections at the same site on multiple occasions, including the right axilla and the left axilla. Staff interviews confirmed the insulin site was not rotated each time the medication was administered. The facility also failed to complete an ordered wheelchair evaluation for Resident 14 and failed to carry out ordered PT/OT evaluations for Resident 7 after a change in condition. Resident 14 was observed in a wheelchair that was too high, without footrests, with the resident’s feet dangling. The physician had ordered evaluation of the upper light-weight wheelchair height, but the record did not show the evaluation was completed. Resident 7 had a documented functional decline, and the physician ordered OT and PT evaluation and treatment, but the medical record did not show that the evaluations were conducted as ordered.
Failure to Offload Heels for Resident with Wound Management Order
Penalty
Summary
The facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of three sampled residents reviewed for pressure injuries. Resident 12 had a physician's order dated 9/18/24 to offload the heels and ankles while in bed every shift for wound management. The resident's MDS showed a BIMS score of 1, indicating severe impaired cognition, and the H&P dated 1/30/26 stated the resident had no capacity to understand and make decisions. During multiple observations, Resident 12 was found lying in bed with non-slip socks on and the heels touching the mattress rather than being offloaded. On 2/11/26 at 0859, on 2/13/26 at 0858 and 1214, and on 2/18/26 at 0945, the heels were observed not offloaded. On 2/13/26 at 1217, LVN 9 verified the heels were touching the mattress and not offloaded, and on 1/18/26 at 0955, LVN 4 verified the heels were not offloaded. On 2/18/26 at 1509, the DON was informed and acknowledged the findings.
Accident Hazards and Missing Post-Fall Assessments
Penalty
Summary
The facility failed to ensure Resident 18’s room was free from an accident hazard when the bedside table was observed placed on top of the floormat beside the bed. Resident 18 had been admitted and readmitted to the facility, had no capacity to understand and make medical decisions, and had a documented unwitnessed fall with a mid-forehead laceration, upper lip abrasion with slight bleeding and swelling, and a right third finger skin tear. A physician’s order required floor mats on both sides of the bed every shift, yet the bedside table was observed on the floormat during multiple observations, and staff confirmed the table was on the mat and that it posed potential harm when the resident attempted to get out of bed. The facility also failed to complete a post-fall assessment and IDT assessment for Resident 25 after an unwitnessed fall. Resident 25 had no capacity to understand and make medical decisions and had severe cognitive impairment with a BIMS score of 3. After the resident was found lying on the floor on the left side of the bed with a small bump on the left cheek, the medical record did not show a documented fall risk assessment, and the IDT Care Conference form was blank and incomplete. The MDS Nurse and DON both verified that the post-fall risk assessment and IDT Care Conference were not completed after the fall incident.
Failure to Follow RD Recommendation for Appetite Stimulant
Penalty
Summary
The facility failed to ensure that the RD’s nutritional recommendation was followed for Resident 48, who was severely underweight and had poor intake with some refusal of meals. The resident had no capacity to understand and make decisions, and the MDS showed a BIMS score of 2, indicating severe impaired cognition. The resident’s recorded weights showed a decline from 70 lbs on 1/12/26 to 62 lbs by 1/27/26, with the weight remaining at 62 lbs on subsequent recorded dates through 2/10/26. The RD’s nutritional assessment noted the resident was severely underweight and recommended consulting the physician for an appropriate appetite stimulant due to poor intake. Review of the Order Summary Report did not show a physician’s order for an appetite stimulant. During interview and concurrent record review, RN 2 verified the RD’s recommendation but there was no documented evidence that the physician was notified of the recommendation or that an order for an appetite stimulant was obtained. The DON was informed of these findings and acknowledged them.
IV Site Not Labeled After Insertion
Penalty
Summary
The facility failed to provide the necessary care and services to maintain IV access for one resident reviewed for IV care. Resident 48 had a peripheral IV line in the right hand, and the facility’s policy for peripheral venous catheter insertion required the IV dressing label to include the date, time, and initials after insertion. During observation on 2/11/26, the resident was lying in bed with the IV site visible, and the site was not labeled with the date, time, or initials of the licensed nurse who inserted it. The resident’s medical record showed that the resident was admitted and later readmitted to the facility, had no capacity to understand and make decisions per the H&P dated 1/12/26, and had physician orders dated 2/10/26 for a short peripheral IV as needed with documentation of location and labeling with date/time/initials, as well as sodium chloride IV at 75 ml/hr every shift for poor PO intake for two liters. The IV therapy medication record documented that the peripheral IV was inserted to the right hand on 2/10/26. RN 4 verified during the observation that the IV site lacked the required label, and the DON was later informed and acknowledged the findings.
Pain medication given outside ordered parameters and without documented nonpharmacological interventions
Penalty
Summary
Appropriate pain management was not provided for two residents who required pain services. The facility’s pain management policy stated that residents receiving pain interventions should be provided care consistent with professional standards and that non-pharmacological interventions, medication effectiveness, and ineffective routine or PRN medication use should be documented. For one resident, who had capacity to understand and make decisions, the record showed orders for hydrocodone-acetaminophen 10-325 mg for severe pain rated 8-10 and 5-325 mg for moderate pain rated 4-7. The MAR showed the 10-325 mg dose was given for pain levels of 9 and 8, but also given once for pain level 6, which was outside the ordered parameters. The record did not show whether non-pharmacological interventions were provided before the pain medication was administered. For the second resident, who had no capacity to understand and make decisions, the record showed orders for tramadol 25 mg every 6 hours PRN for moderate/severe pain rated 4-10 and acetaminophen 325 mg, 2 tablets every 4 hours PRN for mild pain rated 1-3. The MAR showed acetaminophen was administered three times for pain level 4. During interview and record review, staff verified that tramadol should have been given for pain level 4 instead of acetaminophen because the acetaminophen order was for pain levels 1-3. The DON acknowledged the findings for both residents.
Incomplete Dialysis Access Monitoring and Hemodialysis Documentation
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of dialysis care for one resident receiving hemodialysis. The resident had ESRD and dependence on renal dialysis, with physician orders for hemodialysis on Tuesday, Wednesday, Thursday, and Saturday for four hours at 0930. Facility policy required communication with the dialysis provider, inspection of the AV shunt site for functionality and signs and symptoms of complications, and completion of the hemodialysis communication record for each off-site dialysis treatment. Review of the resident’s Hemodialysis Communication Records showed missing documentation on multiple treatment dates. The pre-hemodialysis sections did not consistently include licensed nurse documentation of AV shunt assessment for bruit and thrill, and several records did not include assessment of the dialysis site for swelling, drainage, or pain. The post-hemodialysis sections also lacked documentation of the resident’s dialysis site type, swelling, drainage, pain, vital signs, assessment of bruit and thrill, and any post-hemodialysis complications after return to the facility. The resident also had an order to monitor the AVF hemodialysis access site in the left upper arm every shift for redness, swelling, bleeding, and pain. The MAR showed multiple entries using symbols such as -, +, 0, and P, but the DON stated she did not know what the + and - meant and acknowledged there was no documentation that pain was addressed or that pain medication was given on the dates marked P. The DON and Administrator were informed of and acknowledged the findings.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration for one resident observed during medication pass. During observation, an LVN administered sodium bicarbonate 650 mg oral tablet instead of the ordered sodium chloride 1 gram oral tablet to a cognitively intact resident with an order for sodium chloride three times daily for hyponatremia. The same resident was also given lactobacillus acidophilus instead of the ordered lactobacillus rhamnosus GG (Culturelle) oral capsule for probiotic use. During the medication administration observation, the LVN retrieved the medications from the cart and administered them without correctly matching the medication labels to the MAR and physician orders. The LVN later verified that the wrong medication had been given and stated she did not double check whether she was administering the right medication. The DON acknowledged that the licensed nurse should have read the label completely and compared it to the MAR. The facility also failed to document administration of a controlled pain medication for another resident. A resident with capacity to understand and make decisions had an order for hydrocodone-acetaminophen 5-325 mg every six hours as needed for moderate pain. The controlled drug record showed the medication was signed out, but the MAR did not show documentation that the Norco was administered at the recorded time. The DON verified that the medication had been removed but there was no documented evidence that it was administered on the MAR.
Improper Storage of Oral and External Medications in Medication Cart
Penalty
Summary
The facility failed to provide necessary pharmacy services to ensure proper storage of medications for Medication Cart B. During a cart inspection with an LVN, a bottle of sodium chloride tablets for oral use was found stored in the same compartment as four boxes of artificial tears lubricant eye drops in the first drawer of the medication cart. The facility's policy stated that medications for external use, hazardous drugs, and biologicals are to be clearly marked and stored separately from other medications. The LVN verified the finding and stated the medications should be stored separately because they are administered by different routes. An RN was later informed of the observation and acknowledged that internal and external medications should be stored separately to prevent medication error.
Incompetent Warewashing Procedure by Dietary Aide
Penalty
Summary
The facility failed to ensure that one kitchen employee, Dietary Aide 1, was competent in duties related to warewashing. The facility's policy stated that all dishware, serviceware, and utensils would be cleaned and sanitized after each use, that dining services staff would be knowledgeable in proper dish machine processing, and that dish machine water temperatures would be maintained according to manufacturer recommendations. The facility also had an in-service on pots and warewashing that Dietary Aide 1 attended. During observation and interview, Dietary Aide 1 was seen placing plate lids on trays and completing a dishwashing cycle while the low-temperature dishwasher was showing 104 degrees Fahrenheit. Dietary Aide 1 confirmed the temperature during the cycle was 104 degrees Fahrenheit and stated the temperature had been 120 degrees Fahrenheit when checked at the start of the shift. The DSS verified the dishwasher temperature was 104 degrees Fahrenheit during the cycle, and the Dietary Services District Manager stated the dishwasher was not reaching 120 degrees Fahrenheit because hot water was being used simultaneously for residents' showers. The Dietary Services District Manager then ran the dishwasher twice to reach 120 degrees Fahrenheit and instructed Dietary Aide 1 to run the dishwasher twice and verify the temperature reached 120 degrees Fahrenheit before loading it.
Meals Not Served as Listed on Menu and Meal Ticket
Penalty
Summary
The facility failed to ensure menus and meal tickets were followed for two residents during meal observations. Resident 87 had an order for a regular, pureed texture diet with moderately thick consistency and was observed at lunch with pureed barbecued chicken, pureed green beans with bean sprouts, and pureed rice, but was not observed with the pureed beef rice soup or pureed cranberry crunch bar listed on the menu and diet guide sheet. RN 4 verified the missing items and went to the kitchen to retrieve them. Resident 87's H&P stated the resident had no capacity to understand and make decisions. The facility also failed to serve Resident 39 the breakfast items listed on the meal ticket. Resident 39 was observed with only two rice bowls at breakfast and stated she was hungry and that her food was not enough. Her meal ticket listed cranberry juice, congee, breakfast omelet, bread and jelly, and margarine, but the tray did not include those items. CNA 1 verified the missing food items and stated she would go to the kitchen to inform staff and get the food. Resident 39's H&P stated she had no capacity to understand and make her own decisions.
Missed Beverage Preferences at Lunch
Penalty
Summary
The facility failed to accommodate drink preferences for two residents who received food prepared in the kitchen. Facility policy stated that individual dining, food, and beverage preferences are identified for all residents and entered into the menu management software, and that the individual tray assembly ticket identifies all food items appropriate for the resident based on diet order, allergies, intolerances, and preferences. During a meal observation in the dining room, one resident was observed eating lunch with a tray that included pureed items and water, but the tray did not include the four ounces of the juice of choice listed on the meal ticket under Special Requests. The LVN verified that the resident should have been served what was listed on the meal ticket and then returned with a nectar thick apple juice, which the resident drank after it was placed on the tray. During another meal observation, a second resident was observed with no beverage served at lunch even though the meal ticket listed hot coffee, six ounces, for lunch beverages. An LVN verified that the resident was not served hot coffee and stated that hot beverages listed on the meal ticket should be in the resident's meal tray from the kitchen. The resident stated he would like to have coffee with his meal when asked. Medical record review showed one resident had capacity to understand and make decisions, while the other resident had no capacity to understand and make his own decisions. The Administrator, DON, and DSS were informed of the findings and acknowledged them.
Unsafe Handling of Food Brought in by Visitors
Penalty
Summary
The facility failed to ensure that food brought from outside for resident consumption was handled safely. The facility's policy titled "Food Brought in by Visitors" revised 3/28/24 stated that family members and visitors would be educated to inform nursing staff of their desire to bring food into the facility and were asked to prepare and transport food using safe food handling practices. However, the facility's in-service lesson plan and attendance record titled "Safe Food Handling in a Skilled Nursing Facility" dated 6/19/25 showed education was provided to nursing staff, but it did not include safe food handling preparation and transport of food brought in from home. During observation of the refrigerator used to store residents' food brought in from outside, LVN 4 stated she was not sure how visitors were educated on safe food handling practices and could not remember receiving education on it, though she knew resident food should be labeled with the resident's name and the date it was brought in. CNA 4 also stated she was not sure how visitors were educated and did not know about safe handling of food. The DSD confirmed she conducted the in-service for nursing staff and stated visitors were informed verbally by staff to bring the correct diet texture and were educated regarding the facility's policy, but the facility did not provide safe food handling information in writing for family members. The DON was informed and acknowledged the findings.
Incomplete POLST Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two current residents and one closed record resident by leaving POLST forms incomplete. For two residents, the POLST Section D information and signatures area had blank check boxes for Advance Directive, Advance directive not available, and No Advance Directive. Both residents had H&P examinations showing they had no capacity to understand and make decisions, and the Social Services Assistant reviewed the records and acknowledged that the POLST sections were incomplete. For the closed record resident, the POLST did not include the Signature of Patient or Legally Recognized Decisionmaker, and the form also indicated that a valid POLST must be signed by a physician, NP, or PA and the patient or decisionmaker. The Social Services Assistant verified that the signature section was blank and stated all sections should have been completed to avoid delay of care. The DON also acknowledged the incomplete POLST, and the Administrator and DON were informed of the findings.
Leaking Water Heater Check Valve
Penalty
Summary
The facility failed to maintain Water Heater 1 in safe operating condition when it was observed leaking water from the check valve. During the observation, Water Heater 1 was noted to be leaking from the check valve, and the Director of Maintenance later stated he was aware of the leak. He also stated that Water Heater 1 supplied water to resident rooms throughout the facility and that the check valve was intended to prevent backflow of water. The Director of Maintenance stated the facility was in the process of repairing the leak.
Inaccurate PASRR Screening for a Resident With Mental Illness and Psychotropic Medication Use
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was inaccurate for one sampled resident. Resident 3 had a diagnosis of recurrent major depressive disorder and later had physician orders for quetiapine 50 mg twice daily for psychosis manifested by striking out, as well as divalproex 125 mg twice daily for mood stabilization related to sudden verbal aggression, yelling, and cursing. The resident's admission MDS also showed use of an antipsychotic medication, and the H&P stated the resident had no capacity to understand and make decisions. The facility's PASRR level 1 dated 5/22/25 stated Resident 3 had no diagnosed serious mental illness and was not prescribed any psychotropic medications, and it was marked negative with no level 2 evaluation required. The DON stated the facility was responsible for reviewing the PASRR level 1 for accuracy and that a resident review should have been conducted when Resident 3 was prescribed divalproex. The Administrator and DON reviewed the record and acknowledged the findings.
Care Plan Not Revised After Resident Fall
Penalty
Summary
The facility failed to ensure the care plan was revised for Resident 25 after an unwitnessed fall on 1/4/26. Resident 25 was admitted to the facility and, according to the H&P dated 12/28/25, had no capacity to understand and make decisions. The resident’s care plan report dated 12/11/25 identified the resident as at risk for falls/injury, and the eINTERACT Change in Condition Evaluation documented that the resident fell while attempting to get up from the bed and had a small bump on the left cheek. Review of the medical record did not show documented evidence that the care plan was revised to address the fall. During interviews and concurrent record review on 2/17/26, the MDS Nurse verified that the resident’s plan of care had not been revised to address the fall and stated it should have been completed to prevent further episodes of fall. The DON also verified that the care plan was not revised to address the fall, and later acknowledged the findings.
Nebulizer Equipment Not Labeled or Properly Stored
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 79. Resident 79 was admitted and later readmitted to the facility, and the H&P dated 1/10/26 stated the resident had no capacity to understand and make decisions. During an observation on 2/11/26 at 0844 hours, Resident 79's nebulizer mask was observed undated and stored inside the bedside drawer rather than in a set-up bag, and CNA 1 verified the finding. During an interview and medical record review on 2/17/26, LVN 5 stated Resident 79 was on room air and received breathing treatments as needed every six hours for shortness of breath or wheezing, and that the nebulizer mask should be placed inside a clear set-up bag when not in use. The DON stated the nebulizer mask and tubing should be changed every seven days, the mask should be labeled with the date, and the equipment should be stored in the clear set-up bag for infection control purposes. On 2/18/26, the Administrator and DON were informed and acknowledged the findings.
Facility Assessment Missing Required Input and Staffing Plans
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that included the active involvement of required individuals in developing the assessment, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. The report states that the assessment was reviewed by the facility on 7/29/25, but it did not show that direct care staff members, direct care representatives, residents, residents' representatives, or residents' family members were actively involved in developing it. On 2/12/26 at 1216 hours, the Administrator was interviewed while the Facility Assessment was reviewed. The Administrator verified that there were no direct care staff members, direct care representatives, residents' representatives, or family members actively involved in developing the Facility Assessment. The Administrator also verified that there was no documentation of a plan to maximize recruitment and retention of direct care staff and no contingency plan for staffing needs in the Facility Assessment, and stated he was not aware of the current guidance. The Administrator acknowledged that the Facility Assessment was not updated based on the latest CMS guidance.
Deficiencies in IV Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for the administration and maintenance of IV accesses for six residents. For Resident 83, the facility did not document the initial PICC line external catheter measurements or confirm baseline measurements of the PICC line external catheters and arm circumferences before administering IV antibiotics. Additionally, the PICC dressing was not labeled with the date, and a care plan was not developed for the use of the PICC line. Resident 60's care was compromised as the facility did not accurately document the monitoring of the right arm midline, and a care plan was not developed for its use. The external catheter length measurements were found to be inaccurate, and the documentation of monitoring was for the wrong arm. Resident 716's midline dressing was not changed as required, and Resident 110's PIV site was not labeled with the date and initials of the staff. For Resident 816, the PIV site was not labeled with the date and the nurse's initials, and Resident 818's midline external catheter and arm circumference measurements were not performed and documented upon admission. These failures had the potential to delay the identification of catheter-related complications for the residents, as confirmed by interviews with the facility's RN, DON, and Interim Administrator.
Failure to Follow Dietary Guidelines and Menu Plans
Penalty
Summary
The facility failed to adhere to the dietary requirements and menu plans for its residents, leading to several deficiencies. Residents were served yellow cake instead of the carrot cake with cream cheese frosting as indicated on the menu. Additionally, two residents were not provided with chocolate ice cream as per the menu, and a resident on a renal diet did not receive the appropriate renal diet or the double portion of protein as ordered. These discrepancies were confirmed through observations and interviews with the Certified Dietary Manager (CDM) and other staff members, who acknowledged the substitutions and the lack of notification to residents about these changes. The facility's policies and procedures require that menus be served as written unless a substitution is necessary due to preference, unavailability, or special meals, and that any substitutions be documented and communicated. However, the CDM admitted that the menu was not updated to reflect the substitutions, and residents were not informed of the changes. The facility's failure to follow its own dietary guidelines and communicate effectively with residents about menu changes resulted in the potential for residents not receiving adequate nutrition and appropriate servings to meet their individual needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement the care plan intervention of placing bilateral floor mats on both sides of the bed for Resident 4, who was at high risk for falls and had severe cognitive impairment. On observation, the floor mats were found leaning against the wall instead of being placed on the floor as required by the care plan. This oversight was confirmed by LVN 4, who acknowledged the necessity of the floor mats to prevent potential falls. The Director of Nursing and Interim Administrator were informed of these findings, which highlighted the facility's failure to adhere to the care plan designed to mitigate fall risks for Resident 4.
Deficiencies in Gastrostomy Tube Management
Penalty
Summary
The facility failed to provide appropriate care and services related to the management of gastrostomy tubes (GT) for three residents. For Resident 55, the facility did not ensure that the enteral feeding formula and water bag were properly labeled with the date, time, and contents. Additionally, a CNA resumed the GT feeding after providing incontinent care without verifying the GT placement, which is a task that should be performed by licensed nurses to prevent potential dislodgment. For Resident 58, the facility did not ensure that the licensed vocational nurse (LVN) checked the GT placement via auscultation before administering medications through the GT. Furthermore, the resident's care plan required the use of an abdominal binder to prevent the resident from pulling out the GT, but the resident was observed not wearing the binder during medication administration, despite having a history of dislodging the GT. Resident 74 was observed receiving enteral feeding with the head of the bed (HOB) elevated less than the required 30 degrees, which is necessary to prevent aspiration. The LVN confirmed the improper elevation of the HOB, acknowledging that it should have been elevated to at least 30 degrees during feeding. These deficiencies posed risks for complications related to the use of GTs for the residents involved.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide safe respiratory care for two residents, Resident 816 and Resident 55, as observed during a survey. For Resident 816, the facility did not administer oxygen according to the physician's order. The resident was observed receiving oxygen at three liters per minute, despite a physician's order for six liters per minute to maintain an oxygen saturation level greater than 92%. The resident expressed difficulty breathing, and the oxygen saturation level was recorded at 92%, below the desired range of 95-97%. The Licensed Vocational Nurse (LVN) acknowledged the discrepancy and increased the oxygen flow to six liters per minute, which improved the resident's oxygen saturation level to 95-96%. The Director of Nursing (DON) confirmed that staff should adhere to the physician's orders for oxygen administration. For Resident 55, the facility failed to label the sterile water used for the humidifier with an opened date, as required by the facility's policy and procedure for respiratory equipment care. The resident was observed receiving oxygen via nasal cannula with a bottle of sterile water for humidification that lacked an opened date. The LVN verified the observation and acknowledged that the sterile water should have been dated when opened. The Interim Administrator and DON were informed of these findings and acknowledged the deficiencies.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for Resident 818, who was admitted following an orthopedic surgical procedure and was experiencing severe pain. The facility did not administer pain medication as per the physician's order, which specified morphine for severe pain and hydrocodone-acetaminophen for moderate pain. The medical records showed that the resident was consistently administered morphine for pain levels that were sometimes outside the prescribed parameters, and the hydrocodone-acetaminophen was not administered at all. Additionally, the facility did not consistently provide or document non-pharmacological interventions (NPI) prior to administering narcotic pain medication, as required by the facility's pain management policy. The medical records lacked evidence that NPIs were offered before administering morphine on multiple occasions. The facility's documentation also failed to include a legend explaining the codes used for NPIs, leading to further confusion and lack of clarity in the resident's care. Interviews with Resident 818, RN 1, and the Director of Nursing (DON) confirmed these findings. Resident 818 reported experiencing agonizing pain and taking morphine every four hours. RN 1 and the DON verified that the morphine was administered outside the pain scale parameters and that NPIs were not consistently provided before administering pain medication. This lack of adherence to the pain management protocol potentially compromised the effective management of the resident's pain.
Deficiency in Dialysis Care for a Resident
Penalty
Summary
The facility failed to provide necessary dialysis care and services for Resident 21, who required hemodialysis. The facility did not adhere to the physician's orders to hold hypertension medications on dialysis days, as hydralazine Hcl and nifedipine ER were administered on those days without notifying the physician. This oversight was confirmed by RN 1, who verified that the medications were not held as ordered and that there was no documentation of physician notification. Additionally, the facility did not assess Resident 21's AV shunt after dialysis treatment on specific dates, as required by the facility's policy and procedure. LVN 11 confirmed the absence of documented evidence for the assessment of the AV shunt on 1/8/25. Furthermore, the facility failed to document the total daily fluid intake for Resident 21, which was crucial given the fluid restriction orders and recommendations from the dialysis center to monitor for signs of fluid overload. The facility also did not notify the physician of new recommendations from the dialysis center or significant status changes in Resident 21's condition. This included recommendations to limit fluid intake and monitor for fluid overload, as well as the inability to remove interdialytic weight gain due to low blood pressure. The DON acknowledged these findings, indicating a lapse in communication and documentation regarding Resident 21's dialysis care.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure accurate pharmaceutical services for two residents, leading to potential medication administration errors. For Resident 58, the physician's orders inaccurately specified oral administration for medications that should have been given via a gastrostomy tube (GT). This discrepancy was not clarified by the licensed nurses responsible for entering and executing the physician's orders. During a medication administration observation, a licensed nurse failed to administer the complete dose of a multivitamin to Resident 58, as a significant residue was left in the medication cup after administration via GT. Additionally, the facility did not ensure proper documentation and availability of medication for Resident 50. A licensed nurse was unable to administer a scheduled dose of sodium chloride because it was not available in the medication cart and failed to check the central supply or contact the pharmacy promptly. Although the nurse later obtained and administered the medication, there was no documentation in the resident's medical administration record (MAR) or progress notes to reflect this action or the reason for the initial delay. These deficiencies in medication administration and documentation posed risks to the residents' health conditions, as they could lead to complications or delays in necessary interventions. The facility's policies and procedures for medication administration were not followed, resulting in these lapses in care.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to properly monitor two residents, Resident 60 and Resident 110, for signs and symptoms of bleeding related to their use of anticoagulant medications. Resident 110 was prescribed enoxaparin to prevent clotting, with a care plan in place to monitor for potential adverse reactions such as bruising, skin tears, and bleeding. However, there was no documented evidence that Resident 110 was monitored for these signs, as confirmed by LVN 7 during an interview. The Interim Administrator and DON acknowledged the lack of monitoring documentation. Similarly, Resident 60 was prescribed apixaban for the treatment and prevention of blood clots. The physician's orders did not include monitoring for side effects, and the Medication Administration Record (MAR) for February 2025 showed no documentation of monitoring for bleeding signs. Resident 60's care plan also included monitoring for adverse reactions, but this was not carried out as verified by RN 1. The Interim Administrator and DON were informed of these findings and acknowledged the deficiency.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to properly monitor the use of antipsychotic medications for three residents, leading to potential adverse effects and incorrect data for prescribers. For one resident, the facility did not accurately monitor orthostatic hypotension as ordered by the physician for the use of Seroquel. The resident's informed consent for Seroquel was also incomplete, lacking the indication for its use and a stop date. Interviews with nursing staff confirmed that the orthostatic blood pressure readings were inaccurately recorded, posing a risk for unrecognized low blood pressure. Another resident's informed consent for Risperdal was missing documentation of frequency and behavior manifestations. The facility also failed to monitor this resident for orthostatic hypotension related to Risperdal use. The physician did not document justification for the continued daily use and the absence of a stop date for the PRN Risperdal. The facility's pharmacist had recommended ensuring physician documentation for the continued use of Risperdal, but this was not followed up in a timely manner. A third resident was not monitored for orthostatic hypotension as ordered by the physician for Seroquel use. The facility's staff acknowledged that the orthostatic blood pressure readings were not conducted as required, which could lead to unrecognized side effects from the medication. The Director of Nursing confirmed these findings and acknowledged the lapses in monitoring and documentation.
Medication Error Rate Exceeds 5% Due to Administration Oversights
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11.54%. During medication administration observations, three licensed nurses were found to have made errors. One nurse, LVN 1, did not administer zinc to a resident as ordered due to the medication's unavailability in the medication cart. The nurse did not check the central supply or contact the pharmacy in a timely manner to obtain the medication, resulting in the resident missing a dose that was prescribed for wound healing. Another nurse, LVN 2, administered polyethylene glycol 3350 to a resident without verifying the resident's bowel movement history and stool consistency, as required by the physician's order. The resident had a recent bowel movement and loose stools, which should have contraindicated the administration of the laxative. This oversight occurred because the nurse did not review the resident's medical record before administering the medication. Similarly, LVN 10 administered polyethylene glycol 3350 to another resident without checking if the resident had a bowel movement within the last 72 hours. The resident had a bowel movement less than 72 hours prior, which should have prevented the administration of the laxative. The nurse failed to verify the resident's bowel movement history before proceeding with the medication administration.
Inadequate Kitchen Staff Training in Sanitation Procedures
Penalty
Summary
The facility failed to ensure that the kitchen staff possessed the necessary skills to safely perform daily operations in the Food and Nutrition Services Department. Specifically, Dietary Aide 1 was unable to correctly demonstrate the procedure for testing the chemical concentration of the sanitizing solution used on food contact surfaces. During an observation, Dietary Aide 1 used a quaternary test strip incorrectly by dipping it for only four seconds instead of the required ten seconds, as per the guidelines. This incorrect procedure was confirmed by both the Dietary Aide and the Certified Dietary Manager (CDM), who acknowledged the error. Additionally, both Dietary Aides 1 and 2 were unable to accurately describe the manual dishwashing process. Dietary Aide 2 incorrectly stated that dishes were washed at 110 degrees Fahrenheit and sanitized at 171 degrees Fahrenheit for 30 seconds, which did not align with the facility's documented procedures. Dietary Aide 1 also provided an incorrect description of the dishwashing process, stating that dishes were sanitized for only three to five seconds. These failures in following proper sanitation procedures had the potential to lead to foodborne illnesses among the residents who consumed food prepared in the facility's kitchen.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation requirements in the kitchen, as evidenced by improper labeling and dating of food items in the freezer. During an initial tour of the kitchen, it was observed that an opened bag of veggie vegan patties, a package of French toast, and a bag of hamburger buns were all unlabeled and undated. The Certified Dietary Manager (CDM) confirmed these findings, which were in violation of the facility's policy and procedure titled 'Food Receiving and Storage,' which mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. Additionally, the facility did not properly store maintenance tools, which could compromise sanitation. According to the USDA Food Code 2022, maintenance tools such as brooms and mops should be stored in an orderly manner to facilitate cleaning. However, during an observation and interview, it was noted that three brooms were stored on the ground outside of the kitchen, contrary to the CDM's statement that cleaning materials should be kept hanging on the wall. These deficiencies had the potential to cause foodborne illnesses among the medically vulnerable resident population consuming food prepared in the kitchen.
Lack of Staff Education on Safe Food Handling for Outside Food
Penalty
Summary
The facility failed to ensure that staff received education on safe food handling practices for food brought in by family members and visitors. This deficiency was identified through interviews and observations, revealing that staff members, including CNAs and LVNs, were not adequately trained in handling and reheating food safely. The facility's policy required family members to inform nursing staff when bringing food, but there was no consistent practice or education provided to staff on how to manage these situations safely. The DSD admitted to not providing the necessary education, and the past in-service training lacked a clear lesson plan. During the survey, it was observed that food brought in by family members was not labeled, and there was no designated microwave for family use, contrary to what the IP stated. Family members and staff were unsure about safe reheating temperatures, and there was no resident refrigerator due to infection control concerns. The Interim Administrator and DON acknowledged these findings, indicating a systemic issue in ensuring food safety for residents consuming food from outside sources.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies. The infection surveillance tool used by the facility did not include all residents with infections, only those prescribed antibiotics. This oversight was acknowledged by the Infection Preventionist (IP) and the Director of Nursing (DON), who admitted that residents with signs and symptoms of infection but not on antibiotics were not tracked, potentially missing critical data on infection spread within the facility. Additionally, the facility did not ensure proper use of personal protective equipment (PPE) for staff entering the rooms of residents with infections. In one instance, a Certified Nursing Assistant (CNA) failed to wear a face shield or goggles while caring for a resident with COVID-19, despite facility policy requiring such precautions. This lapse was confirmed by the IP and acknowledged by the Interim Administrator and DON. Similarly, a Licensed Vocational Nurse (LVN) did not don a gown while administering medication to a resident under enhanced barrier precautions, contrary to the facility's infection control policies. Furthermore, the facility did not maintain sanitary conditions for medical equipment, as evidenced by a resident's nasal cannula tubing touching the ground and being placed under a trash can. This was observed and verified by an LVN, who recognized the infection control risk and corrected the situation. These failures collectively posed a risk for the transmission of disease-causing microorganisms and infections within the facility.
Failure to Maintain Complete Advance Directives in Medical Records
Penalty
Summary
The facility failed to obtain and maintain complete copies of advance directives in the medical records for two residents, which could potentially lead to their healthcare decisions not being honored. For Resident 18, only one page of the advance directive was uploaded into the electronic medical record, missing the crucial healthcare directives. This was confirmed during an interview with the SSA and SSD, who acknowledged that the complete document should be available to ensure the resident's wishes are respected if they lose decision-making capacity. For Resident 60, although the POLST indicated the presence of an advance directive, no copy was found in the medical record, and there was no documentation of attempts to obtain it. The SSA confirmed the inaccuracy of the POLST information. The DON explained that the admissions personnel and social services department are responsible for ensuring advance directives are obtained and documented, but this was not done for Resident 60. The Interim Administrator and DON acknowledged these findings during an interview.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written information regarding its bed hold policy to a resident or the resident's representative at the time of transfer to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews with staff. The facility's policy, revised in October 2022, mandates that residents and their representatives receive written notice of the bed hold policy both in advance of any transfer and at the time of transfer, or within 24 hours if the transfer is an emergency. In the case of a resident who was transferred to the hospital, there was no documentation in the medical records indicating that the bed hold notification was provided. Interviews with LVN 2 and RN 2 confirmed the absence of written documentation regarding the bed hold policy. The Interim Administrator and DON were informed of these findings and acknowledged the lack of compliance with the facility's policy.
Improper Garbage Storage in Facility Dumpster
Penalty
Summary
The facility failed to ensure proper storage of garbage in one of six dumpsters located outside the facility. Observations on two consecutive days revealed that one dumpster was propped open, contrary to the FDA Food Code 2022, which requires receptacles for refuse to be covered with tight-fitting lids or doors when kept outside. This deficiency was confirmed by the Maintenance Assistant, who acknowledged responsibility for maintaining the dumpsters and stated that the lids should be closed for infection control purposes.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure the removal of expired medications from one of its medication carts, specifically Medication Cart B. During an inspection conducted by RN 1, it was observed that 14 packets of Vitamin A & D ointment, which had expired in October 2023, were still present in the cart. The facility's policy and procedure, effective since April 2008, mandates that outdated medications be immediately removed from stock and disposed of according to established procedures. RN 1 confirmed the presence of the expired medications and acknowledged that they should have been removed and discarded.
Infection Control Breach in Laundry Room
Penalty
Summary
The facility failed to maintain proper infection control practices in the laundry room, which could potentially lead to the transmission of communicable diseases to residents. During an inspection, a black fabric bag containing a bottle of Gatorade, a can of soda, and a paper bag with food items was found on top of unopened boxes of laundry detergents. Additionally, a bottle of Sunshine Mimosa Fine Fragrance mist spray was observed on the counter in the clean area. Laundry Staff 1 confirmed these findings and acknowledged that personal belongings, including food and drink, should not be present in the laundry room to maintain infection prevention. The Housekeeping and Laundry Supervisor and the Infection Preventionist (IP) were informed of these findings and acknowledged that staff were expected to adhere to the facility's infection control practices in the laundry room area.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide a floor mat for Resident 2, as specified in the resident's care plan, to prevent or minimize injury in the event of a fall. This deficiency was identified through observation, interviews, and a review of medical records and facility policies. Resident 2, who was at risk for falls due to confusion, attempts to self-transfer, and requiring substantial assistance with activities of daily living, was observed without a floor mat beside her bed. Despite the care plan intervention to place a floor mat on the right side of the bed, both CNA 1 and LVN 1, who were familiar with Resident 2, confirmed that a floor mat had never been used in her room. Resident 2 had a history of falls, as indicated by a Change of Condition Evaluation dated 5/14/24, which documented an episode resulting in a skin tear to the right hand. The care plan, initiated on 7/3/23, specifically addressed the resident's fall risk and included the use of a floor mat as an intervention. However, during an interview and medical record review with RN 1, it was verified that the care plan's intervention to place a floor mat was not implemented. This oversight had the potential to place Resident 2 at risk for serious injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,091 citations issued within 25 miles in the last 12 months — including the 10 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.
Illustrative
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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Garden Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Park Care Center | 0.4 mi | ★★★★★ | 3 | 0 |
| The Grove Post Acute | 0.6 mi | ★★★★★ | 3 | 0 |
| Pacific Haven Subacute And Healthcare Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Citrus Post-acute | 0.9 mi | ★★★★★ | 3 | 0 |
| Chapman Care Center | 1.2 mi | ★★★★★ | 22 | 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 June 2026) and official state health department websites.