Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Arden Park Post Acute during CMS and state inspections, most recent first.
Staff failed to notify the physician of an abnormal high K+ result for a resident with kidney disease and an abnormal low Hgb result for a resident with anemia, with no documentation of provider notification in the EHR. Staff also set oxygen at the wrong flow rate for two residents: one resident ordered 2 LPM was observed at 3 LPM, and another resident ordered 3 LPM was observed at 2.5 LPM. LNs and the DON confirmed the lab notification gaps and oxygen settings did not match the MD orders.
Emergency Medication Kit Not Replaced After Use: During a medication storage inspection, an E-Kit in the east station med room was found secured with a red zip tie, showing it had been previously opened and used on nine occasions. An LPN confirmed the kit’s documentation reflected repeated use, and the DON stated the used kit should have been replaced with a new kit so emergency meds would be available for resident use.
Medication storage and labeling were not maintained on two med carts. An opened budesonide/formoterol inhaler had an incorrect expiration date on its label, and a bag of pharmaceutical product was found behind the drawers of another cart after the resident had been discharged. The DON stated the inhaler’s efficacy could be compromised and that all medications should be stored inside the cart.
Food was not prepared and served under sanitary conditions for 149 residents. Multiple bowls, decanter lids, and thermal lids were stored upright on the kitchen counter instead of protected from dust, and two of five frozen turkey breasts were thawed in a container without being completely submerged in cold running water. The DD verified both observations, and the facility policy required covered or inverted storage and complete submersion during thawing.
Privacy curtains did not fully enclose the bed spaces for several residents, and staff confirmed the curtains did not reach around the beds. Residents reported being exposed when using the bathroom in bed or receiving bed baths, and said staff and visitors passed by their beds to reach roommates. The DON stated the curtains should reach around the bed for privacy, while housekeeping reported limited curtain supply and no maintenance requests were found.
Insufficient Room Size in Multiple Resident Rooms: The facility failed to ensure 33 resident rooms met the minimum square footage requirement per resident. Observations showed cramped conditions in some rooms, including a wheelchair and bedside furniture limiting maneuverability and privacy, with residents stating staff had to move items to provide care and visitors had little space.
Failure to protect a resident from abuse by a roommate: a cognitively intact resident reported that his roommate, who had significant cognitive impairment, became frustrated when curtains were opened, cursed at him, and threw a full water pitcher that struck the right side of his head and caused pain. The incident was documented in the PN and confirmed by the SSA, CNA, and LN as abuse; the facility policy states residents have the right to be free from verbal and physical abuse.
Failure to report resident-to-resident abuse allegation: A resident reported that his roommate threw a water pitcher at him after a verbal altercation, and an LPN confirmed the event would be considered abuse and reported it to management. The ADM acknowledged awareness of the incident and investigation but did not report it to the state agency because he decided it did not rise to the level of abuse, despite facility policy requiring abuse allegations to be reported.
A resident with a PICC line and IV Vancomycin for a serious lung infection had incomplete charting in the MAR and IVAR. The PICC dressing was dated but had no staff initials or time, and the record did not show a dressing change on that date. The MAR was also blank for a scheduled Vancomycin dose, and an LPN later stated he gave the medication but forgot to document it.
Damaged Wheelchair Armrests Not Maintained: Three residents’ wheelchairs were observed with cracked armrests and missing upholstery, making them unable to be sanitized. A CNA and the DON verified the disrepair, and the DON stated skin could get caught where the cover was worn and fabric was exposed. No wheelchair repair request was documented in the facility work order record, despite the facility policy stating defective or worn devices are discarded or repaired.
A resident with COPD was receiving continuous oxygen therapy without a physician's order, contrary to the facility's policy. Despite being cognitively intact, the resident's records showed conflicting information about oxygen use, and interviews with nursing staff revealed a lack of clarity on the initiation of the therapy.
A resident with mild memory impairment and hemiplegia was physically abused by a CNA, resulting in a cut on the nose and a bruise under the eye. The incident occurred after the resident requested assistance and expressed a preference not to be helped by the CNA due to rough handling. The CNA allegedly became angry, yanked the call button from the resident's hand, and subsequently hit the resident with it, followed by a punch to the face. The resident's roommate confirmed the altercation and derogatory remarks made by the CNA.
A facility failed to ensure proper infection control when an LPN did not disinfect a shared glucometer between uses for two residents with diabetes mellitus. The LPN was unaware of the requirement, and the DON confirmed the expectation to disinfect with bleach to prevent cross-contamination. The facility's policy also required cleaning and disinfecting between uses.
A resident with dementia and a G-tube experienced two incidents of G-tube dislodgement during ADL care due to the facility's failure to follow the care plan. The care plan required a licensed nurse to be present during ADL care to monitor the G-tube, but on both occasions, the G-tube was dislodged, leading to the resident's transfer to the hospital. The nurse on duty was not supervising the CNA during the second incident, contributing to the deficiency.
A resident, identified as high risk for falls, fell from a power chair in an unsafe area of the facility's driveway, resulting in a head injury and hospital transfer. Despite the facility's policy for supervision and safety, the resident was unsupervised and allowed to use a power chair, which was later removed after a previous fall. Staff acknowledged the area was hazardous and in need of repair.
The facility failed to maintain food safety standards, with an unclean ice machine, improperly stored kitchenware, and incorrect food labeling and storage. The resident's food refrigeration unit had expired and improperly stored food, and staff were unable to correctly perform dishwashing and sanitizing procedures. These issues were confirmed by the dietary manager and registered dietitian, indicating a lapse in adherence to food safety protocols.
The facility failed to maintain proper pharmaceutical services, as expired glucagon emergency medications, ear wax drops, and COVID test kits were found in the medication room. Additionally, a discharged resident's medication was not properly disposed of, and a discrepancy in narcotic administration records was identified. The DON and ADON were responsible for monitoring these areas but failed to address these issues until discovered during the survey.
A facility failed to maintain a medication administration error rate below five percent, with errors involving two residents. One resident did not receive insulin and bowel care medication as ordered, and another resident did not receive the correct dose of Vitamin D. The errors were confirmed by an LPN and the DON emphasized the importance of verifying medication orders and documentation.
Two residents experienced significant medication errors in an LTC facility. A resident received only 2 units of Humalog insulin instead of the ordered 4 units, while another resident received five duplicate doses of Baclofen due to unclarified duplicate orders. The facility's policies on medication administration and error reporting were not followed.
The facility failed to ensure food service personnel had the necessary skills for safe and effective food and nutrition services. Dietary Aide 2 was observed using improper cleaning procedures and could not verify sanitizer concentration. The Dietary Manager confirmed incorrect practices, and the Registered Dietitian acknowledged the need for better staff education. Despite having completed job competency and orientation training, DA 2 was unable to demonstrate the required skills during the survey.
The facility failed to follow prescribed dietary menus, affecting residents with specific dietary needs. Residents on CCHO diets received incorrect bread and dessert portions, while those on fortified diets missed additional nutrients. Mechanical soft and regular diet residents received inappropriate dessert textures. These discrepancies were confirmed through staff interviews and menu reviews.
The facility failed to maintain proper infection control for eight residents, with issues such as undated and improperly stored medical equipment, lack of hand hygiene by staff, improper disposal of sharps, and a visitor not using PPE in an isolation room. These deficiencies posed potential infection risks, as confirmed by staff and observations.
The facility failed to meet the required 80 square feet per resident in 45 rooms, with most rooms measuring only 74.3 square feet. Despite this, residents and staff reported no issues with space, although one nurse noted potential difficulties with mechanical lifts. The Administrator acknowledged some rooms were not included in the waiver, and the Department recommended continuing the waiver for these rooms.
A resident experienced verbal abuse from a roommate, leading to emotional distress and a delayed room change. Despite reporting the incident, the facility staff did not immediately separate the residents or report the abuse, contrary to the facility's policies. The affected resident, with a history of anxiety and depression, felt unsafe until the room change was facilitated the next day.
The facility failed to ensure informed consent for medications was correctly obtained for two residents. One resident received Clozapine for schizophrenia, but the consent form incorrectly indicated it was for anxiety. Another resident's Buspirone dosage was increased without documented informed consent. These errors were confirmed by the Pharmacy Consultant and DON, highlighting a lapse in following the facility's policy on psychotropic medication use.
Two residents experienced deficiencies in their living conditions due to the facility's failure to maintain a homelike environment. One resident's bathroom was in disrepair with a torn baseboard and discoloration, while another resident's bedside table was chipped and peeling. Both issues were not reported in the maintenance log, and the DON confirmed these conditions were unacceptable.
The facility failed to develop timely care plans for two residents, one using Clozapine for Schizophrenia and another with a hearing impairment. The care plan for the antipsychotic medication was delayed by nearly two months, while the hearing impairment care plan was developed 16 days post-admission. These oversights could impact the residents' well-being and care.
The facility failed to meet professional standards in medication administration and disposal. A nurse administered incorrect insulin dosage to a resident and improperly disposed of used medical supplies. Another resident with cognitive impairment was left with medication at bedside, contrary to policy.
A resident with diabetes and vision impairment did not receive timely vision services as ordered, including a referral to ophthalmology. Despite physician orders for glaucoma management and a referral to optometry, there was no follow-up on the ophthalmology referral. Staff interviews revealed a lack of communication and documentation regarding the resident's vision changes.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care. One resident developed a pressure injury after admission due to delayed intervention and inadequate repositioning, while another resident's existing wounds were not properly assessed upon admission, lacking necessary measurements. These failures increased the risk of infection and health decline.
A resident with osteoarthritis and upper extremity contractures did not receive necessary services to maintain mobility, as outlined in her care plan. Despite an OT evaluation recommending further services, no RNA order was in place, and the facility's policy on maintaining range of motion was not followed.
Two residents were administered psychotropic medications without proper monitoring and evaluation. One resident received Clozapine for schizophrenia without appropriate behavior and side effect monitoring, while another was prescribed Quetiapine for BPSD without adequate indication. Despite recommendations for dose reduction and psychiatric evaluation, these actions were not documented or implemented, leading to the continued use of potentially unnecessary medications.
The facility failed to maintain written agreements for dialysis services for two residents with chronic kidney disease and end-stage renal disease. Despite attempts by the Administrator to obtain the necessary contracts, they were not in place, contrary to the facility's policy requiring such agreements for outside services.
A resident was discharged from a facility without proper arrangements for home health services, resulting in an 8-day delay in receiving wound care and therapy. The case manager nurse claimed to have faxed the referral documents, but there was no evidence of this, and the home health agency did not receive the referral until six days later. The facility's discharge plan lacked specific details on when services were to begin, leading to a miscommunication and failure to meet the resident's needs.
A resident with ESRD missed multiple dialysis appointments due to transportation issues, and the facility failed to notify the responsible party or physician. The resident's severe memory loss and dependence on dialysis increased the risk of complications. Facility staff acknowledged the communication failure and the need for emergency intervention if treatments were missed.
A resident with chronic lung disorders was not provided care according to a physician's fluid restriction order, leading to excessive fluid intake. The facility failed to monitor and document the resident's fluid intake accurately, and the kitchen staff was unaware of the restriction. The resident's condition worsened, resulting in hospitalization. The facility's policy on fluid restriction was not adhered to, and no care plan was developed to address the resident's needs.
A resident with a history of wandering and cognitive impairment engaged in inappropriate behavior, including entering other residents' rooms unsupervised, leading to incidents of abuse and emotional distress. Despite complaints from residents about feeling unsafe, the facility failed to investigate or address these concerns adequately, resulting in a deficiency in protecting residents' rights.
A resident reported being slapped by another resident and later witnessed the same resident entering her room unsupervised, masturbating, and defecating on the floor. Despite the presence of staff during the first incident and video evidence of the second, the facility failed to report these allegations to state agencies as required by their policy.
The facility failed to investigate abuse allegations involving multiple residents, leading to feelings of fear and helplessness. Despite reports of incidents, staff did not take action, and the administrator was unaware of the allegations. The facility's policy on reporting and investigating abuse was not followed.
A resident with multiple sclerosis and paraplegia was unable to access a phone to contact her significant other or receive calls from a State Agency. Despite the facility having sufficient cordless phones, staff failed to provide one to the resident or connect her with outside callers. The facility's policy required residents to have access to telephones and assistance if needed, but this was not followed.
A facility failed to provide accurate documentation of ADL services for a resident, particularly regarding bathing. The resident's records showed missing documentation, and interviews revealed inconsistent charting of refusals and services offered. The resident appeared unkempt and reported not having a shower in eight weeks.
A resident with a high fall risk fell and sustained severe injuries due to inadequate supervision and an uneven surface in the smoking area. Despite being marked with caution signs, the area was not safe, leading to the resident's wheelchair tipping over and causing multiple cervical fractures.
The facility failed to ensure that a resident was treated with respect and dignity when a CNA was on the phone while providing care. The resident, who required assistance with toileting hygiene, reported that the CNA rolled his eyes and walked out without saying anything when she tried to explain her concerns. Other staff members were also reported to frequently use their phones during shifts. The facility's policy prohibits cell phone use in resident care areas and emphasizes treating residents with respect and dignity.
Failure to Notify Physicians of Abnormal Labs and Follow Oxygen Orders
Penalty
Summary
Staff failed to notify the physician of an abnormal high potassium result for a resident admitted with kidney disease. The resident’s CMP ordered on 2/23/26 showed a potassium level of 5.6 mEq/L, which met the facility’s AIMS criteria for provider notification when potassium was greater than 5.5. The EHR contained no documentation that the physician was notified, and both an LN and the DON confirmed there was no record of notification. The MD also confirmed the result met the criteria for provider notification and that the facility did not call the physician. Staff also failed to notify the physician of an abnormal low hemoglobin result for a resident admitted with anemia. The resident’s lab report dated 2/28/26 showed hemoglobin of 7.6 g/dL, and the EHR contained no documentation that the physician was notified. During record review and interview, an LN confirmed the hemoglobin was low, the lab was not marked reviewed in the EHR, and there was no documentation that the physician had been notified. The facility policy for lab and diagnostic test results stated that a nurse would first review the labs and that the physician could be notified by phone, fax, or voicemail, with documentation entered in the Progress Notes. Two residents were observed receiving oxygen at flow rates that did not match their physician orders. One resident with congestive heart failure and respiratory failure was observed with oxygen set at 3 LPM, although the OSR and care plan ordered continuous oxygen at 2 LPM via nasal cannula. Another resident with congestive heart failure and respiratory disorder was observed with oxygen set at 2.5 LPM, although the OSR ordered continuous oxygen at 3 LPM via nasal cannula. In both cases, staff confirmed the oxygen settings and acknowledged that the settings should have matched the physician orders.
Emergency Medication Kit Not Replaced After Use
Penalty
Summary
The facility failed to implement its Emergency Medications policy when Emergency Kit #082, a storage box containing emergency medications, was not replaced after it had been used. During a medication storage inspection in the east station medication room, the kit was observed secured with a red plastic zip tie, indicating it had been previously opened by the facility. In a concurrent interview and record review, LN 1 confirmed the kit contained documentation showing it had been used on nine occasions, with 3/8/25 noted as the first documented use by licensed nursing staff. The DON stated the used kit should have been replaced with a new kit and that emergency medications should be available for resident use.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medication storage and labeling were not maintained in accordance with the facility’s policy when an opened budesonide and formoterol inhaler on the 2 east medication cart was found without the correct expiration date. The inhaler had an open date recorded, and the carton instructions stated it should be discarded within three months after removal from the foil pouch. During interview, an LN verified that the inhaler label showed an incorrect expiration date instead of the correct date, and the DON stated the inhaler’s efficacy could be compromised when it did not have a correct expiration date. Medication storage was also deficient on the west station medication cart when a bag of pharmaceutical product was found behind the drawers at the back of the cart. An LN confirmed the bag was there and stated it belonged to a resident who had been discharged three weeks earlier. The LN stated the cart should have been checked daily to ensure medications did not fall behind the drawers. The DON stated all medications should be stored inside the medication cart and staff should have noticed and retrieved the medication bag that had fallen behind the drawers.
Unsanitary Food Storage and Improper Thawing
Penalty
Summary
Food was not prepared and served under sanitary conditions for 149 residents who received meals from the kitchen in a census of 152. During an initial kitchen observation with the Dietary Director, eight stacks of multiple bowls, 11 decanter lids, and 10 thermal lids available for food service were stored upright on the kitchen counter, and the Dietary Director verified they should have been stored face down to protect them from dust. During a subsequent observation, two of five ten-pound frozen turkey breasts were being thawed in a container but were not completely submerged in water, with only a low volume stream of water running over them. The Dietary Director verified the observation and stated they should be submerged with water running over them. A review of the facility policy titled Food Preparation and Service stated that frozen food is not to be thawed at room temperature and that appropriate thawing includes completely submerging food in cold running water that is running fast enough to agitate and remove loose ice particles.
Privacy Curtains Did Not Enclose Multiple Resident Bed Spaces
Penalty
Summary
The facility failed to ensure resident rights for privacy and a dignified existence were respected for seven residents when their privacy curtains did not enclose their bed spaces. During multiple observations from 3/16/26 through 3/19/26, Residents 31, 39, 66, 76, 130, 141, and 143 were observed with curtains that did not surround their beds for privacy. CNA 3 verified that the curtains did not reach around the beds of Residents 66 and 130 and stated they should be longer, and CNA 4 verified that the curtains did not reach around the beds of Residents 76 and 141. The DON stated the curtains should reach around the bed for privacy. Residents also described the lack of privacy during personal care and when staff or visitors passed by their beds. Resident 39 stated there was no privacy when using the bathroom in bed or taking a bed bath because staff could come in and pass by. Resident 31 stated staff and visitors passed by her bed to get to her roommate’s bed and that she was exposed without a privacy curtain, and she said she would like a privacy curtain to maintain her dignity. Resident 143 stated staff and visitors frequently passed by her to get to her roommate’s bed and said she would like the curtain to extend all the way around her bed. CNA 6 confirmed that Residents 31 and 143 had no privacy when staff or visitors passed through to adjacent beds. Housekeeping stated curtains are replaced between residents and as needed, but supplies had been very limited recently, and the maintenance log from 1/14/26 through 3/18/26 showed no request for curtain replacement or lengthening. The facility policy stated bedrooms are designed to provide full visual privacy with ceiling-suspended curtains that extend around the bed.
Insufficient Room Size in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure 33 of 60 resident rooms met the minimum requirement of 80 square feet per resident, including Rooms 100, 102, 103, 104, 105, 106, 107, 108, 111, 204, 205, 206, 207, 208, 209, 210, 212, 300, 301, 302, 303, 304, 305, 306, 307, 310, 311, 408, 410, 411, 503, 505, and 517. A facility letter dated 3/17/26 stated these rooms measured less than 80 square feet per resident and noted that residents in these rooms had a reasonable amount of privacy, closet, and storage space, with a bedside table and bedside nightstand available for use. The letter also stated residents were not restricted in mobility with a wheelchair or ambulation and had access to their toilet. During observations, staff were seen assisting residents in rooms with wheelchairs and walkers, and both staff and residents were able to maneuver without complaints in some rooms. However, in a concurrent observation and interview with Resident 120, the resident was observed in bed with a nightstand and bedside table next to the head of the bed, and a wheelchair at the end of the bed nearly touching the curtain separating the adjacent bed space. The observer stated there was no space to maneuver into the room to speak privately without moving the table, and Resident 120 stated the room was too small, staff always had to move things around to assist her, and visitors had nowhere to sit and would spill into the roommate's space. In another concurrent observation and interview, Resident 106 was observed sitting in bed with a wheelchair next to the bed, and the observer had no space to maneuver into the room without moving the wheelchair. Resident 106 stated the space was too cramped and did not provide enough privacy. CNA 5 later stated the bedside table needed to be moved to maneuver around the room. The Department recommended granting a room waiver for the listed rooms.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to protect one resident from physical and verbal abuse by another resident when a cognitively impaired roommate cursed at the resident and threw a full water pitcher at the resident's head. The affected resident was cognitively intact, had been admitted with rectal cancer, and reported that he was seated in his wheelchair between the two beds when he asked a CNA to open the curtains. He stated that the roommate became frustrated, threw the pitcher at him, yelled profanities, and struck the right side of his head, causing pain. Facility interviews and record review confirmed the incident. The resident's progress note documented a verbal altercation and that close contact of an aggressive nature had occurred. The SSA, CNA, and LN all confirmed that the event involved abuse and that the roommate threw the pitcher and cursed at the resident. The roommate had significant cognitive impairment with a BIMS score of 6, while the affected resident had a BIMS score of 15. The facility policy stated that residents have the right to be free from abuse, including verbal and physical abuse.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents after an incident on 2/26/26 was not reported to the Department. Resident 77’s progress note documented a verbal altercation with his roommate, Resident 79, and stated that Resident 77 reported his roommate threw water at him and that close contact of an aggressive nature was alleged to have occurred. During an interview, Resident 77 stated that while he was in his wheelchair between the two beds, he asked CNA 7 to open the curtains, which upset Resident 79, who then threw a full water pitcher at him and yelled profanities. Resident 77 said the pitcher struck the right side of his head and caused pain. CNA 7 confirmed witnessing Resident 79 throw the water pitcher at Resident 77 and hearing Resident 79 curse at him, and stated that he reported the incident to LN 6. LN 6 confirmed the incident would be considered abuse and would require reporting to facility management, and said she reported it to the ADM. The ADM confirmed he was aware of the incident but did not report it to the Department. He later stated he investigated the incident and decided it did not rise to the level of abuse, so he did not report it. The facility policy stated that all reports of resident abuse are to be reported to local, state, and federal agencies as required.
Incomplete Documentation for PICC Dressing Change and IV Antibiotic Dose
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident 157, who was admitted with diagnoses including a serious lung infection caused by a staph bacteria resistant to many common antibiotics. During observation, the resident had a PICC line in the left upper arm, and the dressing was dated 3/15 with no staff initials or time written on it. However, the IV Administration Record showed PICC dressing changes on 3/3/26, 3/8/26, and 3/10/26, and there was no documentation that the dressing was changed on 3/15/26. A licensed nurse confirmed there were no initials on the dressing and no documentation in the IVAR or progress notes for a dressing change on that date. The record also lacked documentation for a scheduled Vancomycin dose. The resident had an order for Vancomycin IV every 12 hours, but the MAR was blank for the 9 p.m. dose on 3/11/26. A licensed nurse confirmed there was no documentation in the MAR or progress notes showing the medication was given, and the DON also confirmed the missing documentation. The nurse later stated he administered the Vancomycin dose but forgot to document it in the medical record. The facility policy required the administering nurse to initial the MAR after giving each medication and to record the date and time of administration, and the IV dressing change policy required documentation of the date, time, type of dressing, and reason for change.
Damaged Wheelchair Armrests Not Maintained
Penalty
Summary
The facility failed to maintain three resident wheelchairs in safe operating order when the armrests were damaged, cracked, and missing pieces of upholstery, making them unable to be sanitized. During observations, wheelchairs used by Resident 80, Resident 130, and Resident 143 were found in disrepair with both armrests affected. A CNA verified that Resident 130’s wheelchair armrests were cracked and missing upholstery and could not be sanitized. During a concurrent observation and interview, the DON verified that the wheelchair armrests for Residents 80 and 143 were in disrepair and unable to be sanitized, and stated that skin could get caught on the armrests when the cover is worn and the fabric is showing through. The Maintenance Supervisor stated that maintenance repairs are checked from the log each morning and completed right away, but no wheelchair repair request was documented in the facility’s work order/repair request record from 1/14/26 through 3/18/26. The facility policy stated that defective or worn devices are discarded or repaired.
Oxygen Therapy Administered Without Physician's Order
Penalty
Summary
The facility failed to ensure that services were provided to meet professional standards of quality for a resident who was receiving ongoing oxygen therapy without a physician's order. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), was observed using oxygen via nasal cannula at 2 liters per minute. Despite the resident's cognitive intactness, as indicated by a Brief Interview for Mental Status (BIMS) score of 13 out of 15, there was no physician order documented for the oxygen use. The resident's clinical records showed conflicting information, with a weekly summary note indicating PRN (as needed) oxygen use and another note indicating continuous oxygen use. Interviews with licensed nurses revealed a lack of clarity and communication regarding the initiation and continuation of the resident's oxygen therapy. One nurse confirmed the absence of a physician's order and acknowledged that an order should have been in place. Another nurse, responsible for the resident's care, was unable to identify who initiated the oxygen therapy and confirmed that the resident had been on continuous oxygen for weeks. The facility's policy on oxygen administration, which requires a physician's order and proper documentation, was not followed, leading to this deficiency.
Resident Abuse by CNA Resulting in Physical Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in physical harm and emotional distress. A certified nursing assistant (CNA) was reported to have hit a resident in the face, causing a cut on the nose bridge and a bruise under the left eye. The incident occurred after the resident, who had mild memory impairment and hemiplegia, requested assistance and expressed a preference not to be helped by the CNA due to rough handling. The CNA allegedly became angry, yanked the call button from the resident's hand, and subsequently hit the resident with it, followed by a punch to the face. The resident reported feeling demeaned and expressed that the CNA mocked him, exacerbating his emotional distress. The incident was corroborated by the resident's roommate, who witnessed the altercation and confirmed the CNA's derogatory remarks. Staff interviews and record reviews indicated that the resident's injuries were not present prior to the incident, as confirmed by multiple staff members who had interacted with the resident before the event. The facility's policy on abuse prevention, which mandates residents' right to be free from abuse, was not adhered to, leading to this deficiency.
Failure to Disinfect Shared Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper infection control practices when a Licensed Nurse (LN 1) did not sanitize a shared glucometer between uses for two residents diagnosed with diabetes mellitus. Resident 1 was admitted in February 2025, and Resident 2 in January 2024, both requiring blood sugar monitoring as part of their diabetes management. On March 3, 2025, LN 1 used the same glucometer to check the blood sugar levels of both residents without disinfecting it between uses, which was observed during a survey. During an interview, LN 1 confirmed the failure to disinfect the glucometer and was unaware of the requirement to do so. The Director of Nursing (DON) stated that the expectation was for nurses to disinfect the glucometer with bleach between uses to prevent cross-contamination. The facility's policy, dated 2001, also indicated that blood glucose meters intended for reuse should be cleaned and disinfected between resident uses.
Failure to Follow Care Plan Results in G-Tube Dislodgement
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when the comprehensive person-centered care plan was not followed. The resident, who was admitted to the facility with multiple diagnoses including dementia, was dependent on assistance for Activities of Daily Living (ADLs) and had a gastrostomy tube (G-tube) for feeding. The care plan required a licensed nurse to be present during ADL care to monitor the G-tube and prevent it from being dislodged. On two occasions, the resident's G-tube was dislodged during ADL care. The first incident was documented in a Change in Condition Evaluation on January 27, 2025, when the G-tube was dislodged during ADL care. The responsible party expressed concern, and it was explained that licensed nurses would be instructed to be present during ADL care. Despite this, on February 16, 2025, the G-tube was again accidentally pulled out by a CNA while changing the resident's diaper, necessitating the resident's transfer to the hospital. Interviews with the licensed nurse on duty at the time of the second incident revealed that she was on a lunch break when the CNA notified her of the dislodged G-tube. The nurse confirmed that a licensed nurse was not supervising the CNA during the ADL care when the G-tube was dislodged. This lack of supervision and failure to adhere to the care plan contributed to the deficiency in care provided to the resident.
Resident Fall Due to Inadequate Supervision and Unsafe Environment
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a resident, resulting in the resident's fall and subsequent transfer to an acute care hospital. The resident, who was cognitively intact and used a motorized scooter, was identified as high risk for falls due to decreased muscular coordination, history of falls, visual impairment, and poor safety awareness. Despite these risks, the resident was allowed to use a power chair, which was later removed after an unwitnessed fall outside the facility. On the day of the incident, the resident was found on the ground with a bump and cut on the right forehead after falling from the power chair. The fall occurred in the facility's driveway, where a sewer cap was lower than the surrounding concrete surface, creating a hazard. The resident was returning from a convenience store and was not supervised, despite the facility's policy requiring residents to sign out when leaving the building. Interviews with staff revealed that the area where the fall occurred was known to be unsafe, and the Maintenance Supervisor acknowledged the need for repairs. The facility's policy emphasized the importance of making the environment free from accident hazards and providing appropriate supervision based on individual resident needs, but these measures were not effectively implemented for the resident involved.
Food Safety Deficiencies in Facility
Penalty
Summary
The facility failed to maintain food safety standards in several areas, leading to potential food contamination risks for all 153 residents. The ice machine was found to be unclean, with a buildup of slimy and grainy substances, despite being scheduled for regular cleaning by both the maintenance supervisor and an outside vendor. The dietary manager and maintenance supervisor confirmed the presence of these substances, which were also verified by an outside vendor technician. The facility's policy required monthly cleaning of the ice machine, but the actual condition of the machine indicated a lapse in adherence to these standards. In the kitchen, various kitchenware items were improperly stored, with some being stacked while still wet and others containing food debris. Cooking pans were found with black substance buildup and deep scratches, rendering them unsuitable for use. Additionally, opened food packages in the dry storage, walk-in refrigerator, and freezer were not properly dated, and some were improperly stored, leading to freezer burn and potential contamination. The registered dietitian and dietary manager acknowledged these issues, which were in direct violation of the facility's policies on food storage and sanitation. The resident's food refrigeration unit also exhibited several deficiencies, including improper labeling and dating of food items, storage of partially eaten and expired food, and the presence of frozen foods in the refrigerator. The interior of the refrigerator was unclean, with a foul odor, and the dietary aide was unable to correctly verbalize the manual dishwashing process. Furthermore, the dietary aide improperly cleaned and sanitized food contact surfaces, failing to maintain the correct concentration of sanitizer solution. These failures were confirmed by the dietary manager and registered dietitian, highlighting a lack of adherence to established food safety protocols.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to maintain proper pharmaceutical services for its residents, as evidenced by several deficiencies. During an observation, expired glucagon emergency medications were found in the emergency supply kit, with expiration dates ranging from June to November 2024. Licensed Nurse 9 confirmed the presence of these expired medications and stated that best practice required nurses to check expiration dates before administering medications. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible for monitoring medication rooms, but the expired glucagon was not removed until after it was discovered during the survey. Additionally, expired ear wax drops and COVID test kits were found in the central station medication room. Licensed Nurse 9 confirmed the presence of 12 boxes of expired ear wax drops and 28 expired COVID test kits. The facility's policy required nursing staff to maintain storage areas and contact the dispensing pharmacy for instructions on returning or destroying outdated medications. However, these expired items were not addressed until identified during the survey. The facility also failed to properly manage medications for discharged residents. Diclofenac sodium gel for a resident who had been discharged over a month ago was found in the medication room. The DON confirmed that the expectation was for licensed nurses to place discharge medications in a destruction bin. Furthermore, a discrepancy was found in the narcotic administration record for a resident, where a tablet of oxycodone-acetaminophen was not documented as administered in the electronic Medication Administration Record (eMAR). The DON stated that licensed nurses were expected to document narcotic administration on both the narcotic log and the eMAR.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as evidenced by five medication errors occurring out of 31 opportunities during medication administration for two residents. Resident 28 did not receive insulin according to physician orders, receiving only 2 units of Humalog insulin instead of the prescribed 4 units. Additionally, Resident 28 was administered only one Senna plus tablet instead of the ordered two tablets, and did not receive the prescribed Advair medication due to its unavailability. These errors were confirmed by Licensed Nurse 14 during interviews and record reviews. Resident 3 also experienced a medication error when they were given only one tablet of Vitamin D instead of the two tablets as ordered. The Director of Nursing confirmed that the expectation is for licensed nurses to check medication orders prior to administration and to document medication in the electronic medication administration record after administration. The facility's policy and procedure for administering medications emphasizes verifying the right resident, medication, dosage, time, and method of administration before giving the medication.
Medication Errors in Insulin and Baclofen Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident 28, a licensed nurse administered only 2 units of Humalog insulin instead of the 4 units as ordered. The nurse signed for both insulin orders but only administered 2 units, which was confirmed during a follow-up interview. The facility's policy requires checking the medication order, preparing the insulin, and signing the medication record after administration, which was not followed in this case. Resident 56 received five duplicate doses of Baclofen due to a failure to clarify a duplicate order. The resident's clinical record showed that Baclofen was administered at a higher dose than ordered on multiple occasions. Despite nursing progress notes indicating a need for clarification of the duplicate order, there was no documented evidence that the facility reported the issue to the physician or clarified the order for five days. The facility's policy requires contacting the physician to discuss concerns about inappropriate or excessive dosages, which was not adhered to. The Director of Nursing confirmed that the nursing staff were expected to hold the medication and contact the physician immediately to clarify the dose. The facility's policy on administering medications emphasizes the importance of administering medications safely and documenting and reporting medication errors, which was not done in these instances.
Deficiency in Food Service Personnel Training and Sanitation Procedures
Penalty
Summary
The facility failed to ensure that food service personnel had the necessary skills to safely and effectively carry out the functions of the food and nutrition services. During an observation, Dietary Aide (DA) 2 was seen using a rag from a red bucket, which contained sanitizer solution, to wipe a heavily soiled countertop. DA 2 was unable to verbalize or demonstrate the correct procedure for cleaning and sanitizing food contact surfaces and could not verify the sanitizer concentration. The Dietary Manager (DM) confirmed that DA 2 should have used soapy water from a green bucket before using the sanitizer solution from the red bucket and that the sanitizer solution should be changed every two hours or when it becomes cloudy. Further interviews revealed that the facility had not conducted an in-service training for staff on the procedure for cleaning and sanitizing food contact surfaces. The Registered Dietitian (RD) acknowledged the need for improved staff education and stated that the sanitizer concentration should be at least 200 ppm. A review of DA 2's employee file showed that DA 2 was hired with a valid food handler certificate and had completed job competency and orientation training. However, the facility's documents indicated that the Food and Nutrition Services Director is responsible for instructing employees in sanitation fundamentals, and each employee should know how to clean equipment in their work area. Despite this, DA 2 was not able to demonstrate the required competency during the survey.
Dietary Menu Non-Compliance
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents with specific dietary needs during lunch meals on two consecutive days. On the first day, five residents on consistent or controlled carbohydrate (CCHO) diets received a full slice of bread instead of the prescribed half slice. Additionally, a resident on both CCHO and renal diets was served white rice instead of the required brown rice. These discrepancies were observed during a dining observation and confirmed through interviews with the registered dietician (RD) and a review of the facility's menu spreadsheet. On the following day, further dietary inconsistencies were noted during meal service distribution. Four residents on fortified diets did not receive the additional butter and cheese specified for their meals. Twenty-one residents on CCHO diets were given a full serving of dessert instead of the prescribed half serving. Furthermore, six residents on mechanical soft texture diets received regular texture desserts, while nineteen residents on regular diets were served mechanical soft texture desserts. These issues were confirmed through interviews with dietary staff and a review of the facility's menu documentation. The dietary manager (DM) acknowledged the errors in meal preparation and distribution, confirming that the meals served did not align with the dietary requirements outlined in the facility's menu spreadsheet. The RD also noted the need for staff to follow the recipes and menu guidelines to ensure compliance with residents' dietary needs. The facility's job descriptions for the dietary manager and registered dietician emphasize the importance of adhering to nutritional and quality standards, which were not met in these instances.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control for eight residents, leading to potential infection risks. Resident 129's nebulizer mask and tubing were found on the floor and not labeled with the date of change, which was confirmed by multiple staff members as a contamination risk. Similarly, Resident 13's nasal cannula was undated and improperly stored, and Resident 361's BIPAP machine and mask were found on the floor and not stored in a protective bag, increasing the risk of infection. Resident 14's oxygen mask was undated and improperly stored, and the oxygen humidifier was outdated by six months, posing a risk of contamination. Resident 41's nebulizer mask and tubing were also found on the floor and undated, while Resident 96's nasal cannula was observed on the floor, both situations confirmed by staff as potential infection risks. Additionally, licensed staff failed to sanitize equipment and perform hand hygiene when entering and exiting Resident 28's room, and used lancets and glucose strips were not disposed of in biohazard sharps containers. A visitor entered and exited Resident 16's room without proper PPE, despite the room being under isolation precautions, which was confirmed by staff as a risk for spreading infections. The facility's policies and procedures for infection control, hand hygiene, and PPE use were not adhered to, leading to these deficiencies and potential risks of infection among residents.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 45 resident rooms met the required 80 square feet per resident, as observed during a survey. The Client Accommodation Analysis indicated that multiple rooms were below the required space, with most rooms measuring only 74.3 square feet per resident. Despite this, during interviews, several residents and staff members reported no issues with the space available in the rooms. However, one Licensed Nurse mentioned that CNAs might struggle in certain rooms when using mechanical lifts, and another resident expressed a desire to be moved to a different bed for better visibility. The Administrator acknowledged that some rooms were not included in the approved waiver, which had been the case since his tenure began. The Department recommended the continuation of the waiver for the rooms that did not meet the space requirement. Despite the lack of complaints from most residents and staff, the deficiency was noted due to the potential impact on care provision and quality of life, as the rooms did not meet the regulatory space requirements.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident 311, from verbal abuse by another resident, Resident 312. Resident 311, who was admitted with diagnoses including prostate cancer, seizures, anxiety disorder, and depression, reported feeling unsafe and emotionally distressed after being subjected to racial slurs by Resident 312. The incident occurred during a verbal altercation over the television being on at night, which Resident 311 preferred due to claustrophobia. Despite Resident 311's request to be moved immediately, the room change did not occur until the following afternoon. Resident 312, who was moderately cognitively impaired with a history of stroke and traumatic brain injury, allegedly used racial slurs during the altercation. The facility's staff, including a Licensed Nurse (LN 5), were informed of the incident shortly after it occurred. However, the night nurse did not report the incident immediately or evaluate the need for an immediate room change, citing a lack of available rooms. The incident was only reported to Social Services the following day, and the room change was facilitated after Resident 311's family intervened. The facility's policies on abuse prevention and resident-to-resident altercations were not adequately followed. The policies require immediate reporting and investigation of abuse allegations and protection of residents from further harm. In this case, the night nurse's failure to report the incident promptly and assess the need for immediate separation of the residents contributed to the deficiency. The facility's response did not align with its policy to protect residents from verbal abuse and ensure their safety during investigations.
Failure to Obtain Correct Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that two residents were fully informed of the risks and benefits of their medications. For one resident with schizophrenia, the informed consent for Clozapine incorrectly indicated that the medication was for anxiety, not schizophrenia, and listed the target behavior as restlessness instead of auditory hallucinations. This error was confirmed by both the Pharmacy Consultant and the Director of Nursing, who acknowledged that the consent form provided incorrect information to the resident and their family. For another resident with an anxiety disorder, there was no informed consent obtained for an increase in the dosage of Buspirone from twice a day to three times a day. The Director of Nursing confirmed the absence of documented informed consent for this dosage change, which was contrary to the facility's policy requiring verification of informed consent for psychotropic medication changes. This oversight was identified during a review of the resident's clinical records and confirmed through interviews with facility staff.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, leading to deficiencies in their living conditions. Resident 142's bathroom was in disrepair, with the baseboard coming off and blackish discoloration observed, which the resident identified as mold. The Maintenance Supervisor confirmed the disrepair but denied the presence of mold, stating the baseboard needed replacement. There was no record of this issue in the maintenance log, indicating a lack of reporting and follow-up on maintenance concerns. Resident 109's bedside table was chipped and peeling, with the resident having used it for two months. A Certified Nursing Assistant confirmed the table's poor condition and acknowledged it was used for meals and drinks. However, this issue was also not reported in the maintenance log. The Director of Nursing confirmed the findings and stated that the conditions were unacceptable and not in line with the facility's policy for maintaining a homelike environment.
Failure to Develop Timely Care Plans for Antipsychotic Use and Hearing Impairment
Penalty
Summary
The facility failed to develop timely and person-centered care plans for two residents, which could potentially impact their well-being. Resident 147, who was admitted with a diagnosis of Schizophrenia, began receiving Clozapine for auditory hallucinations. However, the care plan for the use of this antipsychotic medication was not developed until nearly two months after the medication was started. The Director of Nursing acknowledged that the care plan should have been initiated as soon as the medication order and consent were obtained to ensure proper monitoring and intervention. Similarly, Resident 361, who was admitted with depression and muscle weakness, was noted to have a hearing impairment and used a hearing aid. Despite this, a care plan addressing the resident's hearing needs was not developed until 16 days after admission. Observations showed that the resident was not wearing the hearing aid, which affected communication. The Director of Nursing confirmed that the care plan should have been developed upon admission to ensure staff awareness and appropriate monitoring of the resident's hearing needs.
Deficiencies in Medication Administration and Disposal Practices
Penalty
Summary
The facility failed to ensure professional standards of quality in the administration of insulin for Resident 28. During an observation, a licensed nurse administered 2 units of Humalog insulin to Resident 28 based on a sliding scale, despite the physician's order indicating 4 units were required. The nurse signed the medication administration record before administering the insulin, contrary to best practices and facility policy, which state that the record should be signed after administration. This discrepancy was confirmed during interviews with the nurse and the Director of Nursing. Additionally, the facility did not adhere to proper disposal protocols for used medical supplies. During an observation, the same licensed nurse was seen discarding used glucose strips and lancets into a regular trash bin instead of a biohazard sharps container. This practice was acknowledged by the nurse and confirmed by the Director of Nursing, who stated that used lancets and strips should be disposed of in designated sharps containers, as per the facility's policy. The facility also failed to ensure the safe administration of medication for Resident 116, who has moderate cognitive impairment. A licensed nurse left an iron pill at the resident's bedside, which the resident later dropped and could not identify. The nurse confirmed leaving the medication at the bedside, which is against facility policy that prohibits leaving medications unattended. This incident was observed and confirmed during interviews, highlighting a lapse in following established medication administration procedures.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with type 2 diabetes mellitus and vision impairment, received timely vision services as ordered. The resident had several physician orders for ophthalmic solutions to manage glaucoma and a referral to optometry for an examination. Despite these orders, there was a lack of follow-up on the referral to ophthalmology after the resident was seen by an optometrist. The resident reported worsening vision, and interviews with staff revealed that there was no communication or documentation regarding changes in the resident's vision from October to November. The Director of Nursing stated that staff are expected to notify the physician of any changes or complaints and to follow through with physician orders. However, the Social Services Assistant confirmed that no follow-up was made on the ophthalmology referral, and the Medical Records Director could not find any nursing progress notes regarding the resident's vision during the specified period. The facility's policy on hearing and vision services requires employees to refer any identified need for vision services to the social worker, who is responsible for assisting residents in accessing necessary resources, but this process was not followed in this case.
Deficiencies in Pressure Ulcer Care and Assessment
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident 311, who was admitted with multiple diagnoses including prostate cancer and diabetes, developed a pressure injury to the sacrum after admission. Despite being identified as at risk for pressure injuries upon admission, the resident did not receive a low air loss mattress until several days later, which may have contributed to the development of the pressure injury. The resident reported not being repositioned every two hours as required, and the wound was not documented until several days after admission. Resident 318 was admitted with multiple diagnoses and had existing deep tissue injuries (DTIs) upon admission. However, the facility failed to conduct an accurate skin assessment, as no wound measurements were taken on the day of admission. The lack of initial wound measurements meant that changes in the condition of the wounds could not be accurately tracked. The facility's policy required skin assessments, including wound measurements, to be conducted upon admission, but this was not followed. The Director of Nursing acknowledged the deficiencies in both cases, confirming that the pressure injury for Resident 311 was facility-acquired and that the lack of timely intervention may have contributed to its development. For Resident 318, the failure to take wound measurements upon admission was recognized as a deviation from the facility's policy. These failures placed both residents at increased risk for infection and health status decline.
Failure to Maintain Range of Motion for a Resident
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion for Resident 27, who was admitted with unspecified osteoarthritis and had functional limitations in her upper extremities. The resident's care plan, revised in August 2024, indicated a self-care performance deficit related to left side weakness and contractures in the right hand, requiring extensive assistance. However, the intervention only included encouraging the resident to participate to the fullest extent possible, without specific therapeutic measures to address the contractures. Observations and interviews revealed that Resident 27 had been in the facility for many years and was unable to open her hands due to contracted fingers. An OT evaluation from March 2023 noted bilateral upper extremity contractures and recommended further OT services, which were not authorized by insurance. Despite the resident's expressed desire for therapy and worsening condition, there was no RNA order in place to address her needs. The facility's policy on resident mobility and range of motion, revised in July 2017, stated that residents with limited range of motion should receive treatments to prevent further decrease, which was not adhered to in this case.
Inadequate Monitoring and Evaluation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. Resident 147 was administered Clozapine for schizophrenia without appropriate monitoring of target behaviors and side effects. The orders for monitoring were incorrectly focused on anxiety rather than the intended schizophrenia symptoms, leading to a mismatch in the monitoring process. This oversight was confirmed by both the Pharmacy Consultant and the Director of Nursing, who acknowledged that the monitoring was not aligned with the medication's intended use. Resident 30 was prescribed Quetiapine for behavioral and psychological symptoms of dementia (BPSD) without adequate indication for its use. The resident's behavior monitoring was initially for physical aggression but was later changed to verbalization of terrifying dreams. Despite recommendations for a gradual dose reduction (GDR) and a psychiatric evaluation, there was no documented evidence of these actions being implemented. The Pharmacy Consultant and the Director of Nursing confirmed the lack of dose reduction and the absence of a psychiatric evaluation after the recommendation. The facility's policies on psychotropic medication use were not adhered to, as evidenced by the lack of proper monitoring and evaluation of the residents' conditions and medication needs. The interdisciplinary team failed to implement necessary evaluations and adjustments to the residents' medication regimens, resulting in the continued use of potentially unnecessary psychotropic medications. This failure to follow established protocols and guidelines contributed to the deficiency identified in the report.
Lack of Written Agreements for Dialysis Services
Penalty
Summary
The facility failed to ensure that services provided by outside resources had written agreements in place, specifically for dialysis services for two residents. Resident 41, who was admitted with chronic kidney disease and required dialysis, was receiving dialysis services from a clinic without a formal agreement. Similarly, Resident 50, diagnosed with end-stage renal disease and dependent on dialysis, was also receiving dialysis services without an existing agreement with the dialysis center. This lack of agreements was identified during a review of the residents' records and confirmed through interviews with the facility's Administrator. The Administrator acknowledged the absence of contracts with the dialysis clinics and made attempts to obtain them, but was unsuccessful. The facility's policy required maintaining written agreements with agencies providing services to residents, which was not adhered to in these cases. The absence of these agreements could potentially lead to a lack of responsibility and accountability in the dialysis services provided to the residents.
Failure in Discharge Planning Leads to Delay in Home Health Services
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was discharged home without proper arrangements for home health services. The resident, who had a recent colostomy and a large surgical wound, was discharged with the expectation that home health services would be provided for wound care and therapy. However, the necessary arrangements were not confirmed, and the resident did not receive the required care for over eight days after discharge. The case manager nurse (CMN) was responsible for ensuring a safe discharge and claimed to have verbally discussed the resident's needs with the home health agency (HHA) and faxed the referral documents. However, there was no documented evidence of the fax being sent, and the HHA reported not receiving the referral until six days after the resident's discharge. The facility's nurse practitioner and assistant director of nursing were unaware of the delay in services, and the resident ran out of wound supplies provided upon discharge. The facility's discharge policy required a post-discharge plan to be developed with arrangements for follow-up care and services. However, the discharge plan for the resident did not specify when home health services were to begin, and there was a lack of communication and documentation to ensure the resident's needs were met. The administrator acknowledged a miscommunication and the inability to locate fax confirmation of the referral being sent.
Failure to Provide Consistent Dialysis Care
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident with end-stage renal disease (ESRD). The resident missed multiple scheduled dialysis appointments due to transportation issues, specifically because transportation did not arrive or the resident was not transported due to being in a wheelchair instead of a gurney. These missed appointments were not communicated to the resident's responsible party or physician, which is a failure to adhere to the facility's policy on notifying changes in a resident's condition or status. The resident, who had severe memory loss and was dependent on renal dialysis, was at risk for serious medical complications due to these missed treatments. The facility's staff, including the unit clerk, licensed nurse, nurse practitioner, and director of nursing, acknowledged the lack of communication and the need for immediate action, such as sending the resident to the emergency room if multiple dialysis treatments were missed. The facility's policies on change in condition and care for residents with ESRD were not followed, contributing to the deficiency.
Failure to Follow Fluid Restriction Order for Resident
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following a physician's order for fluid restriction for a resident with chronic lung disorders. The resident was admitted in 2022 and had a physician order dated 6/28/24 for a fluid restriction of 1500 ml per day due to pulmonary edema. However, the resident's fluid intake flow sheet from 6/28/24 to 7/6/24 showed that the daily fluid intake consistently exceeded the prescribed limit. Additionally, the eMAR indicated that extra fluids were administered with medications, further surpassing the fluid restriction. The resident's nutritional risk assessment did not reflect the fluid restriction, and the kitchen staff was unaware of the order, leading to unrestricted fluid provision. The deficiency was further compounded by the lack of a care plan to address the resident's fluid restriction needs. On 7/6/24, the resident exhibited signs of fluid overload, including low blood pressure, reduced oxygen saturation, and lethargy, resulting in a transfer to the hospital. Interviews with the Registered Dietician and the Corporate Consultant confirmed the oversight in monitoring and documenting the resident's fluid intake. The facility's policy on fluid restriction, which required verification of physician orders and accurate documentation, was not followed, contributing to the resident's condition worsening.
Failure to Protect Residents from Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect the rights of five out of eight sampled residents from mental and physical abuse by another resident. Resident 2, who had a known history of wandering and severe cognitive impairment, entered the rooms of other residents unsupervised, leading to incidents of inappropriate behavior. Despite complaints from residents about feeling unsafe and fearful due to Resident 2's actions, the facility did not adequately investigate or address these concerns. Resident 1 reported being slapped by Resident 2 in the hallway, and other residents, including Resident 3 and Resident 5, expressed fear and distress due to Resident 2's behavior. Resident 2's actions included entering rooms uninvited, attempting to touch residents, and causing emotional distress. The facility staff were aware of these incidents, but there was a lack of appropriate response and investigation, leaving residents feeling unprotected and vulnerable. On one occasion, Resident 2 entered the room of Resident 1 and Resident 4, where he engaged in inappropriate behavior, including masturbation and defecating on the floor. This incident was captured on video by Resident 1, who reported feeling scared and stressed. Despite the known risks associated with Resident 2's behavior, the facility did not implement adequate supervision measures, such as one-on-one supervision, until after the incident occurred. The facility's policies on abuse prevention and resident supervision were not effectively followed, contributing to the deficiency.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of abuse in accordance with section 1150B of the Act. This deficiency involved two incidents concerning Resident 1. In the first incident, Resident 1 reported being slapped by another resident, Resident 2, on the arm while walking in the hallway near the Nurse's Station. Despite staff being present and aware of the incident, no action was taken by the facility staff, and the incident was not reported to state agencies. Resident 1 expressed fear of Resident 2 and concern over what he might do. In the second incident, Resident 1 reported to the Assistant Director of Nursing (ADON) that Resident 2 entered her room unsupervised, masturbated, and defecated on the floor. Resident 1 provided video evidence of the incident, which showed Resident 2 standing inside her room with his pants down. The ADON claimed to have reported the incident to the state agency, but no fax receipt of the report was provided despite multiple requests. Resident 1 had a history of bipolar disorder, major depressive disorder, and chronic pain, with an intact cognitive status as per her Minimum Data Set (MDS) assessment. Resident 2 had diagnoses of dementia and brief psychotic disorder, with severely impaired cognitive skills for daily decision-making. The facility's policy required immediate reporting of abuse allegations to local, state, and federal agencies, but this was not adhered to in these cases.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy for four of seven sampled residents. Specifically, the facility did not ensure that an allegation of abuse and mistreatment involving one resident was timely and thoroughly investigated. This failure resulted in several residents feeling emotionally unsafe, violated, and helpless, as the alleged perpetrator was not restricted from accessing other vulnerable residents. Resident 1, who had an intact cognition, reported being slapped on the arm by another resident while walking in the hallway. Despite staff being present and aware of the incident, no action was taken to investigate or protect Resident 1, who expressed fear and a sense of being unprotected. Other residents also reported incidents involving the same alleged perpetrator, including being grabbed and having objects thrown at them, but did not report these incidents to staff due to a lack of confidence in the facility's response. Interviews with staff revealed a lack of awareness and action regarding the allegations. The facility's administrator was not informed of the incidents and had not reported them to state agencies. The facility's policy required all reports of resident abuse to be reported to local, state, and federal agencies and thoroughly investigated, which was not adhered to in this case.
Failure to Provide Resident Access to Telephone
Penalty
Summary
The facility failed to ensure reasonable access to a telephone for a resident, preventing her from contacting her significant other and being reached by the State Agency. The resident, who was admitted in the summer of 2023 with multiple sclerosis, paraplegia, and major depressive disorder, was observed without a phone in her room. Despite expressing a desire to make a call, the facility's phone was not brought to her. Multiple attempts by a surveyor to contact the resident through the facility's main line were unsuccessful, as calls were either placed on hold indefinitely or dropped. The facility had four cordless phones available, but the staff failed to provide one to the resident or connect her with outside callers. The receptionist confirmed that the issue was not a shortage of phones but rather the nurses not picking up calls at the stations. The facility's policy indicated that residents should have access to telephones and receive assistance if needed, but this was not adhered to, as evidenced by the resident's report of having to wait for extended periods to access a phone.
Inconsistent Documentation of ADL Services
Penalty
Summary
The facility failed to provide accurate documentation of Activities of Daily Living (ADL) services for a resident, specifically regarding bathing services. The resident's clinical record did not reflect that bathing services were offered according to the facility's protocol. This discrepancy was identified through a review of the resident's shower/skin assessments and shower task reports, which showed missing documentation for several periods. Additionally, the resident's care plan indicated a risk for skin breakdown due to refusal of ADL care, but there was no consistent documentation to support that bathing services were offered or refused during the specified periods. During observations and interviews, it was noted that the resident appeared unkempt, with oily and uncombed hair and long hairs on her face. The resident reported not having had a shower in eight weeks and stated that bed baths were not offered. Interviews with CNAs and licensed nurses revealed that the resident frequently refused showers, but the refusals were not consistently documented. The Director of Staff Development (DSD) acknowledged the inconsistency in shower sheet documentation and the lack of available records after a certain date. Further interviews with the Nurse Consultant and the Administrator confirmed that the electronic records marked bathing tasks as 'Not Applicable' without indicating whether the resident refused the services. The facility's policy on ADLs emphasized the importance of providing necessary care to maintain hygiene, but the documentation did not align with this policy. The inconsistency in documentation and the lack of clear records contributed to the deficiency in providing appropriate bathing services to the resident.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for Resident 2, resulting in a fall and subsequent transfer to an acute care hospital. Resident 2, who had a history of hemiplegia, hemiparesis, and cognitive impairment, was identified as a high fall risk. Despite this, the resident was allowed to navigate an uneven surface in a wheelchair without proper supervision, leading to the fall and severe injuries, including multiple cervical fractures requiring surgical intervention. On the day of the incident, Resident 2 was observed propelling herself in a wheelchair towards the smoking area, which had an uneven surface due to recent removal of a large palm tree. The area was marked with a caution sign and cones, but these measures were insufficient to prevent the accident. The resident's wheelchair tipped over the edge of the uneven pavement, causing her to fall and hit her head. Multiple staff members, including the Social Services Director and a CNA, witnessed the aftermath of the fall but were unable to prevent it. Interviews with staff and other residents revealed that the uneven surface had been a known hazard, and the facility had not taken adequate steps to ensure the safety of residents in this area. The Director of Nursing and the Administrator were unable to confirm if the fall was preventable, but other staff members, including a Licensed Nurse and the Maintenance Supervisor, indicated that the fall could have been avoided if the surface had been even and proper supervision had been provided. The facility's policy on safety and supervision was not effectively implemented, leading to this serious incident.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to ensure that Resident 1 was treated with respect and dignity when a Certified Nursing Assistant (CNA 1) was on the phone while providing care. Resident 1, who was admitted with diagnoses including aftercare following joint replacement surgery, was cognitively intact and required assistance with toileting hygiene. The resident reported that CNA 1 rolled his eyes and walked out without saying anything when she tried to explain her concerns and was on the phone most of the time while giving care. Another resident also reported that several staff members frequently used their phones during mid and evening shifts, often making phone calls in resident rooms. Licensed Nurse 1 confirmed that CNA 1 was often disappearing during the PM shift, and the Human Resources Manager noted that CNA 1 had previous disciplinary actions for poor customer service and cell phone use while on the floor, which detracted from his responsibilities and professionalism. The facility's policy prohibits cell phone use while working in resident care areas and emphasizes the importance of treating residents with respect and dignity. The Director of Nursing (DON) and the Administrator (ADM) were informed of Resident 1's concerns, which included the way CNA 1 communicated with her and his use of the phone during care. The DON stated that CNAs are only to use their cellphones in case of a family emergency and that good customer service includes providing explanations to residents during care. The facility's policy on dignity, revised in February 2021, mandates that each resident be cared for in a manner that promotes their well-being, satisfaction with life, and self-worth. Staff are expected to speak respectfully to residents at all times and promptly respond to requests for toileting assistance. The failure to adhere to these policies and standards compromised Resident 1's dignity and sense of well-being.
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What surveyors actually found near you
We read the 692 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gramercy Court | 1.2 mi | ★★★★★ | 16 | 0 |
| Woodside Healthcare Center | 2 mi | ★★★★★ | 0 | 0 |
| Asbury Park Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 20 | 0 |
| Mission Carmichael Healthcare Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Whitney Oaks Care Center | 2.6 mi | ★★★★★ | 6 | 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.