Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ararat Post Acute during CMS and state inspections, most recent first.
Improper Food Storage in Kitchen: Surveyors observed undated uncooked celery and expired cabbage stored in the kitchen refrigerator for residents receiving meals from the kitchen. The DM stated the celery may have been forgotten without a label and the cabbage was not going to be used, while the DS stated expired food is thrown away immediately and the cabbage may have been left behind by accident. The facility policy required food to be stored, thawed, and prepared in accordance with good sanitary practice.
The facility failed to follow infection control practices for two residents. One resident receiving continuous O2 had a humidifier bottle that was not changed in line with the facility’s weekly oxygen equipment policy, despite staff stating the bottle and tubing should be changed every Sunday and labeled with the change date. Another resident with an indwelling urinary catheter was on EBP, but a CNA assisted the resident with toileting while wearing gloves only and not a gown, even though the care plan, signage, and staff interviews indicated gowns and gloves were required for high-contact care.
Two residents had room windows with missing vertical blind slats, exposing their rooms to the outside walkway and neighboring building. One resident had intact cognition and the other had moderately impaired cognition; both had diagnoses including CHF, DM, and other chronic conditions. RN and DON stated the rooms were not homelike and that the missing slats affected privacy and comfort, while the MTD said he was not aware of the issue and it was likely missed during room checks.
Advance Directive Information Not Offered or Documented: The facility failed to ensure two residents and their representatives were offered AD information and that the process was documented. One resident had pneumonia, dysphagia, and a history of prostate cancer with fluctuating decision-making capacity, and the other had CHF, CKD, and DM with moderately impaired cognition. Staff stated the AD acknowledgement should have been completed upon admission, but one resident's RP had not signed and the other resident's chart had no evidence the AD was offered or that the resident was informed.
Late Medicare Non-Coverage Notices: The facility failed to provide the SNF-ABN and NOMNC to a resident within the required timeframe before the last Medicare Part A covered day. The SSC stated he was responsible for issuing the notices, and both the SSC and DON confirmed the notices were late, which did not allow time for the resident to appeal the change in coverage.
Low Air Loss Mattress Left at Maximum Setting: A resident with hemiplegia, dementia, contractures, and high Braden risk was dependent on staff for most ADLs and turning/repositioning. Although ordered to use a LAL mattress for skin integrity, the resident was observed lying on the mattress set for a 350-lb person, which was the maximum setting, even though the resident weighed 140 lbs. The TX nurse stated the setting was not monitored every shift and was unsure why it was left at maximum; the DON stated it should not have been left there and that the maximum setting is for transfers out of bed.
A resident receiving IV Ceftriaxone had a peripheral catheter in the left forearm with dried blood under a transparent dressing. RN3 said the dressing was left in place because of concern for dislodgement and because the resident was considered a difficult stick, while the DON stated the dressing should have been changed to prevent infection and allow assessment for new findings such as redness. The facility policy stated peripheral IV catheter sites will be changed when clinically indicated.
Delayed Initial Physician Assessment and Face-to-Face Visit: A resident admitted with acute embolism/thrombosis of the L femoral vein and pneumonia did not receive the required resident evaluation and written physical exam within 72 hours of admission/readmission. The H&P was completed by a PA after the resident returned from the hospital, and the DON stated the initial comprehensive assessment needed to be done, documented, completed, and signed by the attending MD rather than an NP, PA, or CNS.
A resident with spinal stenosis, lumbar fractures, low back pain, and CKD had a lidocaine 4% patch ordered for 12 hours on and 12 hours off, but an LVN found the patch still in place the next morning and replaced it then. The LVN and DON both confirmed the patch should have been removed at 9 PM and reapplied at 9 AM per the order, but it remained on longer than prescribed.
Failure to monitor anticoagulant side effects: A resident receiving Apixaban was supposed to be monitored every shift for bruising and bleeding-related complications, but a purplish bruise on the hand was observed and was not reported by CNAs to the nurse. The TX nurse and DON stated the bruise should have been reported, and the care plan and facility policy required daily skin checks and reporting of unusual findings.
A resident with dementia, severe cognitive impairment, poor oral intake, and weight loss had weekly weights ordered and was started on Depakote for constant yelling. The LNWS did not document the resident’s weight loss issues, psychotropic medication use, or weekly behavioral changes, even though the MAR showed repeated yelling episodes and ongoing Depakote administration. The DON stated the LNWS should have reflected this information for communication to the physician and interdisciplinary team.
Inaccurate Nurse Staffing Posting: The facility posted nurse staffing information for the overnight shift before that shift began, showing one LVN and two CNAs assigned in advance rather than leaving the posting blank until the start of the shift. RN and DON interviews confirmed the posting was an error and did not follow the facility policy requiring staffing data to be posted daily at the beginning of each shift.
A resident with dementia and a history of wandering was left unsupervised in the Activity/Dining Room near an exit after an LPN handed off the resident to an activity staff member who was not informed of the resident's elopement risk. The activity staff member left at the end of her shift without ensuring clinical staff supervision, resulting in the resident leaving the facility unsupervised and being found by a family member at a nearby bus stop.
The facility failed to ensure that the POLST and Advance Directive Acknowledgment forms for two residents accurately reflected their wishes. One resident's POLST did not indicate if they had an Advance Directive, despite having the capacity to make decisions. The Social Services Director acknowledged the discrepancy and clarified with the family that the resident did not have an Advance Directive. Similarly, another resident's POLST lacked indication of an Advance Directive, and there was no evidence that an acknowledgment form was offered. This inconsistency could lead to misinformation about the residents' medical care preferences.
The facility failed to follow proper sanitation and safe food handling practices, as observed during an inspection. Rotten plums and expired kale were found in the refrigerator, while Danishes with an expired use-by date were in the freezer. A can of sliced apples with an expired discard date was also found in storage. The Dietary Supervisor confirmed that staff should have discarded these items by their discard dates or when spoiled.
The facility failed to ensure infection control by not properly sanitizing, labeling, and storing cloth gait belts, which were found in restrooms accessible to multiple residents. Observations confirmed that these belts were not labeled with resident names and were sometimes shared among residents without proper cleaning. Staff acknowledged the issue, and the facility's policy on cleaning resident care equipment was not followed.
A resident with type 2 diabetes and impaired cognition repeatedly refused Insulin Lispro injections, with refusals documented but not reported to the physician. The resident's family member was involved in the refusals, citing concerns about low blood sugar. The facility's policy required physician notification for treatment refusals, which was not followed, potentially impacting the resident's care plan.
A resident with diabetes and impaired cognition repeatedly refused Insulin Lispro injections, leading to high blood sugar levels. Despite family concerns about low blood sugar, the facility did not document alternative interventions or notify the physician, failing to develop a comprehensive care plan.
A resident's request for information on Advance Directives was not addressed by the facility's Social Services Director, leading to a delay in receiving necessary information. The resident, with diagnoses including dysphagia and dementia, was unable to make her own decisions, and her representative's request for assistance was overlooked due to a lack of follow-up by the SSD.
A resident with severely impaired cognition and diabetes did not receive the prescribed insulin dosage due to a family member's intervention, leading to a failure to follow physician orders. The facility's policy requires medications to be administered as prescribed, but only 1 unit of insulin was given instead of the ordered 2 units, increasing the risk of adverse effects.
A resident at moderate risk for falls and with osteoporosis did not have an individualized care plan, and the facility failed to monitor and document neurological assessments after a fall. The resident was on multiple anticoagulants, and a severe drug interaction warning was not addressed. After a fall, the resident developed a head injury and altered consciousness, requiring hospital transfer and intensive care.
A resident at moderate risk for falls experienced an unwitnessed fall and reported it to the Dietary Manager, who informed the DON. Despite the facility's policy requiring physician notification, the DON did not document the fall or notify the physician, as no injury was observed. The family was also not informed, leading to a deficiency in care.
The facility failed to properly dispose of refused or contaminated medications in a safe and secure manner. Medications were placed in an easily accessible blue container labeled 'pharmaceutical waste' in a medication cart, contrary to the facility's policy. This practice increased the risk of accidental exposure and diversion of prescription drugs.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to ensure that food for all 24 residents receiving meals from the kitchen was stored, prepared, distributed, and served in accordance with professional food service standards and the facility's Food Storage policy dated 11/1/2014. During an initial kitchen tour with the Dietary Manager, surveyors observed undated uncooked celery stored in a box in the refrigerator and expired cabbage in the refrigerator with a use-by date of 1/16/2026. During the observation, the Dietary Manager stated that all kitchen stored food is labeled and that someone must have forgotten to label the celery, and stated that the cabbage was not going to be used and someone must have forgotten to throw it away. On the following day, the Dietary Supervisor stated that all expired food gets thrown away immediately and that the cabbage must have been left behind by accident. The facility policy stated that all food items will be stored, thawed, and prepared in accordance with good sanitary practice.
Infection Control Practices Not Followed for Oxygen Equipment and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control practices for a resident receiving continuous oxygen therapy. Resident 26 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, muscle weakness, and atrial fibrillation. The resident’s physician ordered continuous oxygen at 2 LPM with oxygen saturation to remain above 92 percent, and the resident’s MDS indicated severely impaired cognition and dependence on helpers for toileting and personal hygiene. During observation, the resident was found in bed on oxygen connected to a humidifier bottle that was labeled with an earlier date. The treatment nurse stated the humidifier bottle should have been changed when the oxygen tubing was changed and that tubing and humidifier bottles were changed every Sunday for infection control. The DON stated humidifier bottles and oxygen tubing should be changed every Sunday and labeled with the date changed. The facility policy required all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen to be changed weekly and when visibly soiled. The facility also failed to ensure staff used a gown while assisting a resident on enhanced barrier precautions. Resident 6 was admitted and readmitted with diagnoses including neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and urinary retention. The resident’s MDS indicated moderately impaired cognition and need for moderate assistance with toileting hygiene, showering, and personal hygiene. The resident had a physician’s order for an indwelling urinary catheter to gravity drain every shift and another order for EBP due to catheter use. The care plan directed staff to wear gowns and gloves during close-contact care activities such as assisting with toileting. During observation, EBP signage outside the room indicated staff must wear gloves and gowns for high-contact care activities, including toileting. A CNA put on gloves but did not wear a gown while assisting the resident to the bathroom. The CNA stated the gown was forgotten and acknowledged that gowns and gloves must be worn during direct contact care for residents on EBP. The RN and DON also stated gowns and gloves were required for close contact with residents on EBP to prevent spread of infection. The facility’s policy stated EBP uses targeted gown and glove use during high-contact resident care activities, including assisting with toileting, for residents with indwelling devices such as urinary catheters.
Missing Window Blind Slats Compromised Privacy and Homelike Environment
Penalty
Summary
The facility failed to provide privacy and a homelike environment for two residents by not reporting missing horizontal window blind slats to maintenance for replacement in their room. Resident 29 was originally admitted on 4/30/2024 and later readmitted with diagnoses including heart failure, diabetes mellitus, and osteoarthritis of both knees; a 11/13/2025 MDS indicated intact cognition. During a 1/20/2026 observation, Resident 29 was in bed near the window with vertical blinds that had two slats missing, exposing the room to the outside walkway and neighboring building. Resident 29 stated the missing slats had been absent for at least two days and that the blinds provided shade and privacy. Resident 39 was admitted with diagnoses including congestive heart failure, chronic kidney disease, and diabetes mellitus. A 1/11/2026 H&P indicated the resident was alert and oriented to place and time, and the MDS indicated moderately impaired cognition. During the same 1/20/2026 observation, Resident 39 was also in a room near the window with vertical blinds missing two slats, exposing the room to the outside walkway. Resident 39 nodded yes when asked if the missing blinds bothered her. RN 3 stated both rooms were missing window slats and that this was not homelike and could affect comfort and privacy. The MTD stated he was not aware of the missing slats and that they were probably missed during room checks, and the DON stated the blinds should have been replaced right away.
Advance Directive Information Not Offered or Documented
Penalty
Summary
The facility failed to ensure that two sampled residents, Resident 39 and Resident 41, and their representatives were offered information regarding Advance Directives in accordance with facility policy and regulatory requirements. Resident 41 was admitted with diagnoses including pneumonia, dysphagia, and a history of malignant neoplasm of the prostate. His Initial History & Physical noted fluctuating capacity to understand and make decisions. During a concurrent interview and record review, the Social Services Coordinator stated that Resident 41's Advance Directive Acknowledgement was not signed by the responsible party and that the Advance Directive was not completed at admission. Resident 39 was admitted with diagnoses including congestive heart failure, chronic kidney disease, and diabetes. His History & Physical indicated he was alert and oriented to place and time and able to make decisions, while the MDS showed moderately impaired cognitive status. During a concurrent interview and record review, staff found no documented evidence in Resident 39's clinical record that an Advance Directive or acknowledgement of an Advance Directive was offered or that the resident was informed. The DON and SSC stated that the Advance Directive acknowledgement should have been completed upon admission and maintained in the chart, and the facility policy required residents to be informed of their right to execute an Advance Directive upon admission.
Late Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to follow its Medicare denial process by not providing the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) to Resident 45 within 2 days of the last Medicare Part A covered day. During a concurrent interview and record review, the social service coordinator stated he was responsible for giving the notices to the resident or responsible party, and the facility record showed the SNF-ABN was dated 6/19/2025 and the NOMNC was dated 6/18/2025, while Resident 45’s last Medicare Part A covered day was 6/18/2025. The documents were signed by Resident 45 on 6/18/2025, and the social service coordinator stated the notices were late. The Director of Nurses also stated the SNF-ABN and NOMNC should have been provided at least 2 days before the last Medicare Part A covered day to allow time for medical coverage decisions and an appeal of the change in coverage. The facility policy titled Medicare Denial Process, dated 10/24/2022, stated that the Medicare Status Change form may be completed by a designee a minimum of 2 days prior to the last Medicare Part A covered day and that the designee prepares and issues the Medicare Status Change, including the SNF-ABN and NOMNC, to the beneficiary or representative.
Low Air Loss Mattress Left at Maximum Setting
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Resident 32 was admitted with diagnoses including hemiplegia, dementia, and left knee and hand contractures. The resident’s MDS dated 11/20/2025 indicated severe impaired cognitive skills and dependence on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and turning and repositioning in bed. The initial H&P stated the resident did not have the capacity to understand and make decisions. The resident’s Braden Scale dated 8/21/2025 indicated high risk for pressure ulcer development, and the care plan identified risk for pressure ulcers and skin breakdown due to impaired mobility with an intervention to apply a pressure relieving/reducing device when in bed, including a low air loss mattress. The physician’s order summary dated 1/5/2026 included a low air loss mattress for skin integrity. During observation on 1/20/2026, the resident was lying on the low air loss mattress with the setting adjusted for a person weighing 350 pounds, which was the maximum setting on the mattress. The treatment nurse stated the resident weighed 140 pounds and that nursing did not monitor the bed setting every shift, and was not sure why the mattress was set at the maximum setting. The DON stated the mattress setting should not have been left at the maximum of 350 pounds and should have been adjusted by nursing, and stated the maximum setting is to be used when transferring out of bed.
Peripheral IV Site Dressing Not Changed Despite Dried Blood
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for Resident 41. Resident 41 was admitted with pneumonia, dysphagia, and a history of malignant neoplasm of the prostate, and the Initial History & Physical noted fluctuating capacity to understand and make decisions. A progress note indicated the resident was to continue IV Ceftriaxone for three days from the admission date, and the physician's order directed IV Ceftriaxone 1 gram on 1/18/2026, 1/19/2026, and 1/20/2026. During observation, Resident 41 was lying in bed with a peripheral catheter in the left forearm between the elbow and wrist, covered by a transparent dressing with dried blood around the site. RN3 stated the resident had the peripheral catheter upon admission and that dried red fluid was noticed around the site, but the dressing was left in place because of concern for dislodgement and because the resident was believed to be a difficult stick. The DON stated nursing should have changed the peripheral catheter dressing to prevent infection and to assess for new findings such as redness. The facility policy stated peripheral IV catheter sites will be changed when clinically indicated.
Delayed Initial Physician Assessment and Required Face-to-Face Visit
Penalty
Summary
The facility failed to ensure that Resident 17 received the required resident evaluations, including a written report of a physical examination, within 72 hours following admission. Resident 17 was admitted and later readmitted with diagnoses of acute embolism and thrombosis of the left femoral vein and pneumonia. The resident’s MDS dated 12/28/2025 showed intact cognition and partial to moderate dependence on staff for personal hygiene, dressing, toileting hygiene, oral hygiene, and eating. A review of Resident 17’s history and physical assessment report showed it was completed after the resident was readmitted from the hospital on 1/16/2026, with the assessment dated 1/19/2026 and documented and signed on 1/20/2026 by a PA. During interview, the DON stated the PA came in on 1/22/2026 to assess the resident and that the initial comprehensive assessment needed to be performed, documented, completed, and signed by the attending physician. The facility policy titled Physician Services & Visits stated that resident evaluations, including a written report of a physical examination, were required within 5 days prior to admission or within 72 hours following admission, and that the initial comprehensive visit could not be done by the NP, PA, or CNS.
Lidocaine Patch Left On Beyond Ordered Time
Penalty
Summary
The facility failed to remove a lidocaine patch at 9 PM and apply a new patch at 9 AM for one resident, resulting in the patch remaining on longer than the physician ordered 12 hours on and 12 hours off. The resident was admitted with spinal stenosis, lumbar vertebral fractures, low back pain, and chronic kidney disease, and the care plan identified pain related to these conditions with an intervention for licensed nursing staff to administer the lidocaine patch every 12 hours as ordered. The resident’s MDS indicated intact cognition and need for moderate assistance with toileting, showering, and personal hygiene. The physician’s order directed that one lidocaine 4% external patch be applied to the left lower back at 9 AM and removed at 9 PM. During observation, an LVN removed the patch from the resident’s left lower back at 8:52 AM and placed a new patch on the same area, stating the patch should have been removed the prior night and replaced at 9 AM as scheduled. The DON stated the patch should be placed at 9 AM and removed at 9 PM, and that it should be removed after 12 hours to prevent unnecessary absorption of lidocaine. The facility’s medication administration policy required medications to be administered by a licensed nurse per physician order, and the transdermal patch policy required the licensed nurse to verify the patch at least every shift.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that one resident receiving Apixaban 5 mg twice daily was monitored for complications of anticoagulant therapy as indicated in the resident’s care plan and physician’s order. The resident was admitted and later readmitted with diagnoses including atrial fibrillation and dementia, and the MDS dated 12/31/2025 indicated the resident’s cognitive level was intact. The MAR showed Apixaban was administered from 1/1/2026 through 1/20/2026, and the order summary directed staff to monitor every shift for signs such as discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, and nose bleeds. During observation on 1/20/2025 at 9:39 AM, the resident was seen with purplish skin discoloration of irregular shape on the left anterior hand. The resident stated he did not know how he got the bruise and thought he may have bumped his hand on furniture. The TX nurse stated she did not receive a report from CNAs about the bruising or skin abnormality, and said the CNA should have reported it for continuous monitoring and investigation. The DON stated CNAs should have reported the bruise to the licensed nurse and that monitoring anticoagulant side effects helps prevent serious complications such as uncontrollable bleeding. The care plan for anticoagulant therapy required daily skin inspection and reporting of abnormalities to the nurse, and the facility policy stated CNAs are required to inspect skin during ADL care and report unusual findings to the licensed nurse.
LNWS Did Not Reflect Resident’s Weight Loss and Yelling Episodes
Penalty
Summary
The facility failed to ensure that the Licensed Nursing Weekly Summary (LNWS) accurately reflected Resident 5’s status regarding unplanned weight loss and behavioral symptoms requiring psychotropic medication. Resident 5 was admitted with diagnoses including dementia with agitation and chronic kidney disease stage 4, had severely impaired cognitive skills on the MDS, and was dependent on staff for multiple activities of daily living. The record also showed that hospice services were discontinued on 12/2/2025, and a physician order on 12/12/2025 placed the resident on weekly weights for poor oral intake and weight loss. A physician order on 12/22/2025 started Depakote 125 mg twice daily for mood disorder related to constant yelling, and the MAR showed the resident received Depakote twice daily from 1/1/2026 through 1/23/2026 with multiple documented episodes of yelling across day, evening, and night shifts. However, the LNWS dated 12/1/2025, 12/8/2025, 12/22/2025, 1/12/2026, and 1/19/2026 documented no weight loss issues, no antipsychotic medications administered for mood manifestation and side effects, and no weekly documentation of mood or behavioral changes. The DON stated that the weight loss and Depakote use with yelling episodes should have been reflected in the LNWS, and that inaccurate documentation could result in missed important information and communication to the physician and interdisciplinary team.
Inaccurate Nurse Staffing Posting
Penalty
Summary
The facility failed to post accurate nurse staffing information for the 11PM to 7AM shift in accordance with its policy titled Nursing Department - Staffing, Scheduling & Posting. During a concurrent interview and record review on 1/20/2026 at 11:34 AM, the posted nurse staffing information showed that one LVN and two CNAs were assigned to the 11PM to 7AM shift, even though that shift had not yet begun. The posting had been completed in advance rather than at the beginning of the shift, and RN 1 stated that the actual staffing for the 11PM to 7AM shift should have remained blank until the shift started. RN 1, who stated she was the DSD and also responsible with charge nurses for posting actual nursing staff per shift, identified the posting as an error and misleading to residents, responsible parties, and visitors. During an interview on 1/21/2026 at 3:30 PM, the DON stated the daily nursing postings are intended to inform residents, responsible parties, and visitors about the type and hours of nursing care provided in the facility, and that it is not acceptable to write in the actual nursing staff ahead of time. The facility policy stated that nursing staffing data must be posted daily at the beginning of each shift and must include the total number and actual hours worked by RNs, LVNs, and CNAs directly responsible for resident care.
Resident Elopement Due to Inadequate Supervision and Staff Communication
Penalty
Summary
A deficiency occurred when a resident identified as high risk for elopement and wandering was left unsupervised in the Activity/Dining Room, which was adjacent to an exit door. The resident, who had diagnoses including dementia with psychosis, multiple rib fractures from recent falls, and severely impaired cognition, required hourly monitoring and specific supervision interventions as documented in their care plan. On the day of the incident, the resident was escorted to the Activity Room by an LVN, who did not confirm that the activity staff member was aware of the resident's elopement risk or the need for close monitoring. The activity staff member, who was not informed of the resident's high elopement risk and was unfamiliar with the resident's medical history, left the resident in the Activity Room at the end of her shift without ensuring that a clinical staff member would supervise the resident. Although two dietary staff members were present in the room, they were not responsible for resident supervision. The activity staff member left to notify a nurse at the nursing station but did not remain with the resident until relieved by appropriate staff. As a result of these actions and lack of communication among staff, the resident was left unsupervised and subsequently exited the facility. The resident was later found by a family member at a bus stop 0.4 miles from the facility, appearing lost and sweating heavily. The incident was reported to the charge nurse after the resident was discovered missing, and interviews with staff confirmed that supervision protocols and communication regarding the resident's risk status were not adequately followed.
Inconsistent Documentation of POLST and Advance Directives
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) and Advance Directive Acknowledgment forms for two residents accurately reflected their wishes. For Resident 20, the POLST did not indicate whether the resident had received information about an Advance Directive or if one was on file, despite the resident having intact cognition and the capacity to make decisions. The Social Services Director (SSD) acknowledged the discrepancy and noted that the POLST should be fully completed to reflect the resident's healthcare decisions. The SSD clarified with the family that Resident 20 did not have an Advance Directive and expressed the importance of consistent documentation. Similarly, for Resident 15, the POLST did not indicate the presence of an Advance Directive, and there was no evidence that an Advance Directive acknowledgment form was offered. The SSD confirmed that this information should have been completed upon admission as part of the resident's paperwork. The facility's policy requires providing residents with the opportunity to make healthcare decisions, but this was not adhered to, leading to potential misinformation about the residents' medical care and treatment preferences.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and safe food handling practices as per their policy and procedure. During an inspection, it was observed that the kitchen's walk-in refrigerator contained a plastic container with two rotten plums and a carton box of kale labeled with a discard date of 12/9/2024, which had not been discarded. Additionally, a clear plastic bag containing Danishes with a use-by date of 12/11/2024 was found in the walk-in freezer, and a metal can of sliced apples with an expired discard date was found in the dry storage area. The Dietary Supervisor acknowledged that all staff are expected to check the refrigerator every morning for spoiled food and produce. The supervisor stated that the spoiled plums, kale, and Danishes should have been discarded by their respective discard dates or when they were observed to be spoiled. The can of sliced apples should have been removed from storage on its discard date to prevent potential foodborne illnesses among residents.
Inadequate Infection Control: Improper Storage and Labeling of Gait Belts
Penalty
Summary
The facility failed to implement its infection control policy and procedure by not ensuring that resident care equipment, specifically cloth gait belts, was sanitary, labeled, and properly stored. Observations revealed that cloth gait belts were found in restrooms accessible to multiple residents, with no resident names labeled on them. This was noted for eight sampled residents, including those with various medical conditions such as periprosthetic fracture, pulmonary aspergillosis, and chronic kidney disease. During observations and interviews, it was confirmed that soiled cloth gait belts were present in restrooms of residents who either did not use the restroom or shared the space with others. In some cases, the belts were labeled as belonging to the Rehab department, but there was no clear indication of ownership for individual residents. Staff members, including a Registered Nurse and an Infection Prevention Nurse, acknowledged the presence of these belts and the lack of proper labeling and sanitation. The facility's policy on cleaning and disinfection of resident care equipment was not followed, as there was no way to properly sanitize the cloth gait belts between uses. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, revealed that the belts were sometimes wiped down with a wipe, but there was no consistent method for cleaning them. The Director of Nursing admitted that cloth gait belts could not be sanitized effectively, highlighting a significant gap in infection control practices.
Failure to Notify Physician of Insulin Refusal
Penalty
Summary
The facility failed to notify the physician when a resident, identified as Resident 18, refused to receive Insulin Lispro injections on multiple occasions. Resident 18, who was admitted with several diagnoses including type 2 diabetes mellitus with complications, had severely impaired cognition and lacked the capacity to make decisions. Despite this, the resident's family member, referred to as FM 1, was present during some refusals and declined the administration of insulin, citing concerns about low blood sugar levels. The Medication Administration Record (MAR) indicated that Resident 18 refused Insulin Lispro on several dates, with blood sugar levels recorded above the normal range. Progress notes documented the refusals and the family member's involvement but did not show evidence of physician notification. The Minimum Data Set Registered Nurse confirmed the lack of documentation regarding physician notification, which was necessary for planning the resident's care. The Director of Nursing acknowledged that staff should have notified the physician about the refusals, as it was considered a significant change in condition. The facility's policy on refusal of treatment required documentation of physician notification, which was not adhered to in this case. This oversight had the potential to impact the resident's care and treatment plan, as the physician was not informed to provide new orders or adjustments to the care plan.
Failure to Develop Care Plan for Insulin Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with diabetes who repeatedly refused to receive Insulin Lispro injections. The resident, who had severely impaired cognition and lacked the capacity to make decisions, was admitted with multiple diagnoses, including type 2 diabetes mellitus with unspecified diabetic retinopathy and macular edema. Despite the physician's orders for Insulin Lispro to be administered according to a sliding scale, the resident's blood sugar levels remained high due to frequent refusals of the medication. The resident's refusals were documented on several occasions, with blood sugar levels recorded as elevated each time. Family member 1, who was present during some of these refusals, expressed concerns about the resident's blood sugar levels dropping too low and declined the full dose of insulin on multiple occasions. Despite the staff explaining the risks and benefits of the medication, the refusals were respected, and no alternative interventions were documented in the care plan. Interviews with the MDS RN and the Director of Nursing revealed that there was no documented evidence of a care plan addressing the resident's refusal to take Insulin Lispro. The facility's policy on refusal of treatment indicated that the interdisciplinary team should assess the resident's needs and offer alternative treatments, but this was not done. The Director of Nursing stated that the physician should have been notified of the refusals to adjust the care plan accordingly.
Failure to Provide Requested Advance Directive Information
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as Resident 11, in accordance with its policy and procedure titled Social Services Program. The Social Services Director (SSD) did not follow up or assist when Resident 11's representative requested additional information about the Advance Directive (AD), a legal document that states a person's wishes about receiving medical care if they are no longer able to make medical decisions. This oversight led to a delay in receiving the requested AD information, which could impact the resident's healthcare decisions in an emergency. Resident 11 was readmitted to the facility with diagnoses including dysphagia and unspecified dementia, and was noted to be unable to make her own decisions. The resident's Physician's Order of Life Sustaining Treatment (POLST) indicated the absence of an Advance Directive. Despite the resident's representative signing an Advance Healthcare Directive Acknowledgement form requesting more information, the SSD did not refer the representative to the Ombudsman for assistance, as he was unaware of the request made to the previous SSD. The facility's policy requires medically related social services to maintain and improve residents' wellbeing, which was not adhered to in this case.
Failure to Administer Insulin as Prescribed
Penalty
Summary
The facility failed to follow physician's orders for a resident who was receiving insulin to manage diabetes. The resident, who had severely impaired cognition and lacked the capacity to make decisions, was prescribed Insulin Lispro to be administered subcutaneously before meals according to a sliding scale. On a specific occasion, only 1 unit of insulin was administered instead of the prescribed 2 units because the resident's family member declined the full dose, citing concerns about low blood sugar levels earlier in the day. This action was contrary to the physician's orders and the facility's policy, which requires medication to be administered as prescribed. The Director of Nursing (DON) stated that staff are expected to follow physician orders to prevent negative reactions. The facility's policy on medication administration emphasizes that medications should be administered by a licensed nurse per the physician's order, with checks to ensure accuracy. The failure to administer the correct insulin dosage as ordered by the physician increased the risk of adverse effects for the resident, who had a history of type 2 diabetes mellitus with unspecified diabetic retinopathy and macular edema.
Failure to Provide Resident-Centered Care and Medication Management
Penalty
Summary
The facility failed to provide appropriate care and services to a resident, leading to several deficiencies. The resident, who was at moderate risk for falls and had a history of osteoporosis, did not have an individualized care plan addressing these specific needs. The facility also failed to monitor and document a neurological assessment after the resident experienced a fall, which was against the facility's policy. Additionally, the facility did not inform the physician before administering the resident's prescribed medication, Apixaban, after the fall, which is a deviation from professional standards of practice. The resident was on multiple anticoagulant medications, including Apixaban, Aspirin, and Plavix, which required careful monitoring due to the risk of severe drug interactions. Despite an alert in the electronic medical record system indicating a severe drug-to-drug interaction, the facility did not address this warning, potentially leading to adverse effects. The resident experienced a fall resulting in a head injury, and the facility did not complete a post-fall assessment or notify the physician promptly, as required by their policy. Following the fall, the resident developed a bump on the forehead and an altered level of consciousness, necessitating transfer to a general acute care hospital. The resident's condition deteriorated, leading to a critical state requiring intensive care. The facility's failure to develop a comprehensive care plan, monitor the resident's condition adequately, and address medication warnings contributed to the resident's adverse outcomes.
Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to notify the physician regarding an unwitnessed fall of a resident who was assessed as a moderate risk for falls. The resident, who had a history of osteoporosis and atrial fibrillation, was admitted with moderate cognitive impairment and required substantial assistance with daily activities. On the morning of the fall, the resident reported being unable to reach the call light and struggled to get back into bed. The Dietary Manager was informed by the resident about the fall and subsequently notified the Director of Nursing (DON). The DON conducted a body assessment and found no visible injury, leading to the decision not to document the fall or notify the physician. The facility's policy required prompt notification of the physician and family members in the event of a significant change in the resident's condition, such as a fall. Interviews with the DON and family members revealed that the family was not informed of the fall, and the physician was not consulted. The facility's policy and procedure documents emphasized the importance of notifying the physician and family in such situations, but these protocols were not followed, resulting in a deficiency in care.
Improper Disposal of Medications
Penalty
Summary
The facility failed to properly dispose of refused or contaminated medications in a safe and secure manner. During an observation, a blue container labeled 'pharmaceutical waste' was found in the top drawer of a medication cart. This container, which had a transparent lid that could be easily opened, contained multiple unknown medications. Licensed Vocational Nurse (LVN) 1 stated that refused or dropped medications were placed in this container and later discarded in the biohazard waste bin. However, LVN 1 could not specify what medications were in the container or when it was last emptied. LVN 2 confirmed that refused medications were documented and placed in the same container, which should be emptied at the end of each shift. The Director of Nursing (DON) stated that controlled medications were locked in the DON's office until the pharmacist arrived, while non-controlled medications were placed in a locked cabinet and then discarded in the biohazard bin. The DON acknowledged that the use of the blue container increased the risk of accidental exposure and diversion of prescription drugs because it was not secured and properly disposed of. Further interviews revealed that LVN 4 also placed refused medications in the blue container and could not specify how long the medications remained there before being properly discarded. The facility's policy and procedure (P&P) for medication disposal indicated that all medications should be placed in the proper waste container. However, the observed practice did not align with this policy, as the blue container was not a secure or proper method for disposing of medications. The facility's P&P for medication storage also required that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures, which was not followed in this case.
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What surveyors actually found near you
We read the 6,597 citations issued within 25 miles in the last 12 months — including the 34 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glendale Post Acute Center | 0.8 mi | ★★★★★ | 24 | 0 |
| Leisure Glen Post Acute Care Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Glendale Adventist Medical Center Dp/snf | 1 mi | ★★★★★ | 16 | 0 |
| Autumn Hills Health Care Center | 1.1 mi | ★★★★★ | 7 | 0 |
| Solheim Senior Community | 1.1 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.