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 Arlington Gardens Care Center during CMS and state inspections, most recent first.
A resident had an unlabeled nasal spray at bedside without a physician order or self-administration assessment, another resident had an opened box of Salonpas at bedside without an order and no self-administration authorization, and a third resident had a low BP reading that was not rechecked or communicated to the physician. The DON confirmed the BP should have been rechecked and documented, and that further assessment and physician notification were needed if it remained low.
Controlled medication accountability was not maintained when CSR entries for two residents did not match the MAR, with doses of Percocet and Norco signed out but not documented as administered. In addition, a fentanyl patch for a resident was stored in the medication cart in an opened foil packet after removal, and staff described keeping used patches in the cart until the DON was available for destruction. The facility’s records and observed cart contents did not align with its controlled substance documentation and fentanyl disposal practices.
Medication administration errors resulted in an 8.82% error rate when an LVN gave metformin and potassium chloride ER to residents without following orders to administer the medications with food or with meals. The LVN confirmed the medications were given after eating or without food, and the CP and DON stated this did not follow the prescriber’s orders.
Infection control practices were not followed for a resident on O2 and for shared equipment used on multiple residents. A resident's nasal cannula tubing was observed dated beyond the weekly change interval, and an LPN confirmed it should have been changed weekly. In addition, an LPN used the same glucometer and BP cuff on multiple residents and used alcohol wipes instead of the bleach wipes required by facility policy and the device instructions.
Failure to obtain informed consent for psychotropic medications was identified for two residents. One resident received buspirone for anxiety/restlessness without documented consent, and another received trazodone for depression/insomnia without consent on file at the time treatment began. The DON confirmed the missing consents during record review, and the facility policy required written informed consent before starting psychotropic medication.
Unsupported Schizophrenia Diagnosis Used to Justify Antipsychotic Orders: A resident with dementia was given quetiapine for schizophrenia with hallucinations, but the record did not contain documentation supporting a schizophrenia diagnosis. The DON confirmed there was no prior history of schizophrenia, the hospital discharge record and psych eval did not diagnose it, and the PASRR indicated no serious mental illness. The MAR showed no hallucinations were documented while the antipsychotic orders were active.
Smoking Materials Not Secured for Independent Smoker: A resident assessed as an independent smoker was observed smoking unsupervised and stated he kept his smoking materials with him. The SSD and DON stated independent smokers were allowed to smoke unsupervised only if their smoking materials were kept in a locked box, but the resident did not have one available. The resident shared a room with another resident on oxygen, and the room sign indicated oxygen in use and no smoking.
A resident with edema, HF, and pneumonia was still listed on a 240 ml fluid restriction after the physician order to discontinue it had ended. The resident said she was not told why she was restricted and was unsure what it included, while the meal ticket still showed the restriction and staff confirmed the current diet order was not reflected in the kitchen system or communicated timely.
Failure to monitor a resident for bleeding while receiving heparin. A resident received heparin for DVT prophylaxis, and the MARs showed doses were given before the order to monitor for S/S of bleeding was in place. The DON stated residents on anticoagulants were monitored for bleeding and bruising, and the resident's care plan included monitoring for blood loss and bruising, but the record did not show that this monitoring occurred during the earlier heparin doses.
Medication labeling and storage were not maintained as required. An LVN found a resident’s epinephrine auto-injector stored in the medication refrigerator even though it should not have been refrigerated, and the same medication was expired. In another medication cart, an opened Symbicort inhaler for a resident with COPD was missing an open date, despite facility policy requiring multi-dose containers to be dated when opened.
Expired Boost was found in a residents' refrigerator at a nurse's station and was readily available for consumption. An LPN stated it should have been discarded, while the DON, DS, and RD stated food brought from home should be labeled, dated, and checked for expiration, and that expired food should not be in the refrigerator.
A deficiency was identified when an LVN prepared and administered medications to a resident but failed to document the administration in the eMAR, resulting in an inaccurate medication record. Facility policy requires the nurse who administers medications to record this in the eMAR at the time of administration.
A resident with dementia and dysphagia, requiring constant supervision and a pureed diet, was discharged to an unlicensed room and board without caregivers or knowledge of her medical needs. The facility did not verify the receiving environment's ability to meet the resident's care requirements, and the placement agency did not assess the resident or confirm the suitability of the new setting. The resident's significant needs were not communicated or addressed, resulting in an unsafe discharge.
A resident with severe cognitive impairment was discharged without proper documentation of the Notice of Proposed Discharge, including inaccurate signatures and lack of clear notification to the responsible party. Additionally, after a witnessed fall, the LVN did not accurately document the time or details of family notification, and the required information was missing from the medical record.
A resident with dementia, hypertension, and acute kidney failure was found with excessively long fingernails and expressed a desire to have them trimmed. The treatment nurse and CNA did not provide the required nail care during routine care, despite facility policy mandating daily cleaning and regular trimming. The DON confirmed that nail care should have been addressed by staff.
A resident with a history of dementia, hypertension, and acute kidney failure was found to have long, painful toenails and had not received ongoing podiatry care despite previous diagnoses of onychomycosis, dystrophic nails, and paronychia. Nursing staff acknowledged responsibility for nail care and the need to notify podiatry, but there was no evidence of follow-up, resulting in the resident's toenails remaining untrimmed and painful.
A resident with significant neurological and medical conditions experienced four unwitnessed falls within a week due to the facility's failure to provide adequate supervision and timely interventions. Despite being identified as a fall risk and having several interventions in place, the resident continued to fall, and requests for increased monitoring and a sitter were not implemented until after multiple incidents. The DON acknowledged that the supervision provided was insufficient to prevent these repeated falls.
The facility did not provide the required transfer/discharge notice to the LTC Ombudsman at the same time as to two residents and their representatives. For both a resident with a pelvic fracture discharged to hospice and another with coronary artery disease discharged home, the Ombudsman was notified a day after the residents or their representatives received notice, contrary to facility policy.
The facility failed to follow its infection control policy for N95 mask usage. Two CNAs wore N95 masks over surgical masks, compromising the seal. An agency CNA, not fit tested, cared for a COVID-19 positive resident. The facility did not verify fit testing with the agency, contrary to policy requirements.
The facility failed to ensure accurate PASRR Level I screenings for three residents. One resident's screening was not resubmitted after a 30-day exemption expired, another's screening inaccurately reported no serious mental disorder, and a third's screening was not updated after a short-term exemption. The DON was responsible for ensuring the accuracy and timeliness of these screenings.
A facility failed to complete a quarterly MDS assessment on time for a resident with encephalopathy. The MDS, with an ARD in mid-June, was not signed by the RN until early July, exceeding the 14-day completion requirement. Interviews revealed that staff were not adhering to the timeline, with the DON expecting the MDS Nurse to ensure timely submissions.
A facility failed to ensure the accuracy of the MDS for a resident, resulting in a documented discrepancy regarding the resident's discharge location. The MDS inaccurately stated the resident was discharged to a hospital, while progress notes and the discharge summary indicated a discharge to home. Interviews with staff confirmed the expectation for MDS accuracy, and the error was acknowledged by the MDS Nurse.
A resident with a known allergy to hydrocodone was administered Norco due to a failure in documenting the allergy upon admission. This led to behavioral changes in the resident, as noted by a family member. The oversight was acknowledged by the DON, but the cause of the error was unclear.
A resident with severe cognitive impairment eloped from a facility during a heat wave, leading to an emergency room visit. The resident, who had a history of stroke and muscle weakness, was not initially identified as an elopement risk. Despite being seen in the facility earlier, the resident was found wandering outside by police and taken to the hospital. Staff interviews revealed no prior indication of elopement risk, and the facility's security footage showed the resident exiting and re-entering the building twice.
A facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69%. During a medication pass, an LVN administered the wrong type of multivitamin and an incorrect dose of docusate sodium to a resident with multiple sclerosis and immunodeficiency. The LVN admitted to the errors, and both the DON and Administrator emphasized the importance of correct medication administration.
The facility failed to make survey results accessible to residents and family members as required by policy. A resident noted the survey binder was previously available but had not been seen for two years. Observations and staff interviews confirmed the binder was not at the designated location. It was eventually found in the DON's office, contrary to expectations.
The facility did not post daily direct care staffing information as required by its policy, potentially affecting all 98 residents. During an observation, the surveyor could not find the posting, and interviews revealed that a CNA and the Administrator were unaware of the requirement. The DON acknowledged the oversight, stating the information should have been posted daily.
A resident with multiple health conditions was discharged to an incorrect facility due to the failure of the Social Service Director and Case Manager to confirm the discharge address with the family. The resident, who required maximum assistance and lacked decision-making capacity, was returned to the nursing facility after the error was discovered.
A facility failed to update the transfer and discharge notice for a resident's responsible party and the Ombudsman, leading to the resident being found outside a board and care facility that had not agreed to admit him. The resident was subsequently taken to the hospital.
A resident was discharged to a Board and Care that had not accepted him, then transferred to another Board and Care that was unaware of his arrival, resulting in the resident being found outside and subsequently admitted to a hospital.
The facility failed to inform a resident's representative of the findings of an investigation related to an incident during a doctor's appointment, despite the resident being transferred to a hospital. The DON conducted an investigation but did not recall informing the family member of the results, violating the facility's grievance policy.
The facility failed to provide NOPDs and notify the Ombudsman for three residents who were transferred or discharged. Interviews with the SSD and DON confirmed that the NOPDs were not properly handled, and the facility's documentation showed non-compliance with its policy.
The facility failed to ensure that a resident had the call light button within reach. During an unannounced visit, it was observed that the call light button was on the floor, out of the resident's reach. The resident, who had severe cognitive impairment and muscle weakness, confirmed that the call light was usually near him. Both the LVN and DON acknowledged that the call light should be within the resident's reach.
The facility failed to schedule follow-up appointments with a cardiologist and pulmonologist for a resident with significant medical conditions, despite physician orders. Interviews revealed a lack of communication and urgency among staff, and the facility's policy on referrals was not followed, resulting in delayed medical follow-ups.
Unordered bedside medications and missed follow-up for low blood pressure
Penalty
Summary
Resident 123 had a used, unlabeled bottle of Equate nasal spray at the bedside during observation, and the resident stated she was using it for allergy symptoms and that nurses were aware of it. The bottle remained at the bedside on repeated observations, and when the LVN asked about it, the resident stated it was her own medication and that she used two squirts in the right nostril every morning. The LVN and DON both confirmed that Resident 123 did not have a physician’s order for the nasal spray and did not have an assessment for medication self-administration. Resident 123’s record showed diagnoses including asthma, and there was no order for the nasal spray or self-administration assessment in the chart. Resident 5 had an opened box of Salonpas medication pads at the bedside during observation. The resident stated she had an order for a lidocaine patch but did not like how it felt, so she would ask nurses to apply the Salonpas on various occasions, and she stated the doctor said she could use them. The LVN reviewed the resident’s orders and stated Resident 5 only had an order for lidocaine patches, had no other pain patch orders, and did not have orders to self-administer medications. The LVN also stated the Salonpas should not have been at the bedside and that there was no order for Salonpas to be applied. Review of the MAR showed lidocaine patches were administered per physician order, and there was no documented administration of a Salonpas patch. Resident 126 had a blood pressure reading of 94/54 mmHg documented in the vital signs trend log. The progress notes from the following day did not show communication to nursing staff, the physician, administration, or the representative party about the low blood pressure reading. The care plan identified the resident as at risk for decreased blood pressure and directed staff to monitor blood pressure as ordered, observe for signs and symptoms of abnormal blood pressure and complications, and notify the physician as needed. During interview, the DON stated that a low blood pressure should be rechecked, documented in the medical record, and if still low after recheck, the physician should be notified and assessments should be completed. The DON also stated that without a recheck there would be no way to know the resident’s condition and the physician should have been notified of the low blood pressure.
Controlled Medication Accountability and Fentanyl Disposal Deficiencies
Penalty
Summary
Accurate accountability of controlled medications was not maintained for two residents when the Controlled Substance Records did not reconcile with the Medication Administration Records. Resident 4 had an order for oxycodone with acetaminophen 5-325 mg, 12.5 mg by mouth every 8 hours as needed for moderate to severe pain, and the CSR showed one tablet signed out at 9:00 p.m. on one date, but the MAR did not document that the dose was administered. Resident 108 had an order for hydrocodone with acetaminophen 10-325 mg, 1 tablet by mouth every 6 hours as needed for moderate to severe pain, and the CSR showed one tablet signed out at 10:00 a.m. on one date, but the MAR did not document administration. Medication Cart 1 also did not match the narcotic contents for Resident 123. The cart contained a box of fentanyl 25 mcg/hr patches with four sealed patches and one opened foil packet containing a used patch, while the CSR indicated five patches had been received and should have resulted in four patches remaining in the cart. Staff stated used fentanyl patches were kept in the medication cart until the DON was available, and the DON stated nurses brought used patches to her for destruction and kept them in the cart until the box was empty. The DON acknowledged the risk of diversion for used fentanyl patches when stored in the medication cart. The facility also did not implement appropriate disposal of fentanyl patches for Resident 123. A used patch was observed stuck to the inside of an opened foil packet in the medication cart, and staff stated this was how used patches were stored before being given to the DON for destruction. The fentanyl administration record showed the patch had been applied and later removed by nursing staff. The DON stated nurses were supposed to fold used fentanyl patches in half after removal, while the facility policy described disposal by folding the patch sticky sides together and flushing it or using approved disposal products.
Medication Administration Errors With Food Instructions Not Followed
Penalty
Summary
The facility had a medication error rate of 8.82% based on three medication errors out of 34 opportunities during a medication administration observation involving three residents. During a medication pass observation, an LVN administered metformin 1000 mg to a resident with type 2 diabetes whose physician’s order required the medication to be given with food, but the resident stated he had not eaten breakfast and would eat a banana later. The LVN later stated the metformin was not given with food. During the same observation, the LVN administered potassium chloride ER 10 mEq to two residents whose physician’s orders required the medication to be given with meals or with food. For one resident, the LVN stated the potassium chloride was given after a meal, and for the other resident, the LVN stated it was administered after breakfast and that the order to give it with food was not followed. The consultant pharmacist stated that giving medications after eating was not following the order to give with food, and the DON stated that if an order indicated to give a medication with food, the nurse needed to give it with food.
Infection control practices not followed for oxygen tubing and shared equipment
Penalty
Summary
The facility failed to ensure infection control practices were followed for four residents reviewed for infection control practices. For Resident 125, who was admitted on December 28, 2025, with diagnoses including left hip joint replacement surgery and who had a physician order for continuous oxygen at 2 LPM via nasal cannula, the resident was observed on January 6, 2026, receiving oxygen through nasal cannula tubing dated December 29, 2025. The assigned LVN stated the tubing should have been changed every Sunday, and the DON confirmed the facility process was to change respiratory tubing weekly every Sunday. The facility policy for prevention of infection with respiratory equipment stated the oxygen cannula and tubing should be changed every seven days or as needed. For Resident 36, LVN 1 was observed checking blood sugar with an Assure Platinum glucometer and placing the used device on top of the medication cart without cleaning or disinfecting it afterward. LVN 1 stated he had wiped the glucometer with an alcohol wipe before checking Resident 36's blood sugar, and later stated he had used the same glucometer on Resident 103 and then Resident 36, using alcohol wipes rather than the bleach wipes required by the facility. The glucometer manual stated the meter should be cleaned and disinfected after use on each patient, and the facility policy required blood glucose meters intended for reuse to be cleaned and disinfected between residents according to the manufacturer's instructions. For Residents 36, 111, and 69, LVN 1 used the same shared blood pressure cuff on multiple residents and wiped it with alcohol wipes between uses. During observations, the cuff was used on Resident 36, then on Resident 111, and then on Resident 69, with alcohol wipes used before use on the later residents. LVN 1, LVN 3, LVN 6, and the Infection Preventionist stated bleach wipes were supposed to be used for the glucometer and BP cuff between residents, and the Infection Preventionist verified that alcohol wipes were not appropriate for sanitizing shared equipment between residents. The facility policy on cleaning and disinfection of environmental surfaces stated manufacturers' instructions would be followed for proper use of disinfecting products.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for two sampled residents. Resident 5 had a physician order for buspirone 5 mg by mouth three times daily for anxiety and restlessness, and the MAR showed the medication was administered from March 20, 2025, through March 28, 2025. During a concurrent interview and record review with the DON, the resident’s informed consents were reviewed, and the DON stated there was no informed consent for the buspirone started on March 19, 2025. Resident 19 had a physician order for trazodone 50 mg by mouth daily for depression manifested by inability to fall asleep, and the MAR showed the medication was administered from December 17, 2025, through December 31, 2025. During a concurrent interview and record review with the DON, the record showed informed consent was obtained for trazodone on January 1, 2026, but the DON stated there was no informed consent for the trazodone started on December 16, 2025, and verified there should have been informed consent on file from that start date. The facility policy stated that prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent and the facility must verify written informed consent is present before initiating treatment.
Unsupported Schizophrenia Diagnosis Used to Justify Antipsychotic Orders
Penalty
Summary
The facility failed to meet professional standards when Resident 19 was documented as having schizophrenia without supporting evidence in the medical record. Resident 19 was admitted from the hospital on December 10, 2025, with dementia and had physician orders for quetiapine for schizophrenia manifested by hallucinations. The medication administration record showed quetiapine was given from December 11, 2025, through December 16, 2025, and both quetiapine orders were discontinued on December 16, 2025. The MAR also directed staff to monitor for episodes of schizophrenia with hallucinations every shift, but no hallucinations were documented during that period. During interview and record review, the DON stated Resident 19 had no history of schizophrenia before admission and that the facility’s medical record did not contain documentation to support the new schizophrenia diagnosis. The hospital discharge records did not include schizophrenia, and the psychiatrist’s comprehensive psychiatric evaluation completed on December 16, 2025, did not diagnose schizophrenia. The DON stated the only documentation available was the physician’s medication orders and progress notes that listed schizophrenia and continued quetiapine. Additional record review showed the PASRR Level 1 Screening completed by the hospital indicated the resident did not have a serious mental illness such as schizophrenia, schizoaffective disorder, or psychosis. Earlier psychiatric consultation notes from January and February 2025 also did not identify schizophrenia and noted no evidence of hallucinations or delusional thoughts. The facility’s own policies stated antipsychotic use should be based on a comprehensive assessment and that a practitioner should not newly diagnose a resident with serious mental illness without evidence-based criteria documented in the record, including symptoms, duration, and functional impact.
Smoking Materials Not Secured for Independent Smoker
Penalty
Summary
The facility failed to follow its established smoking policy for one resident who was identified as an independent smoker. On January 6, 2026, the resident was observed in the smoking patio area unsupervised and stated that he was an independent smoker and did not require supervision. He also stated that he was allowed to keep his smoking materials because he was an independent smoker. During a concurrent interview and record review, the SSD stated the facility process was to complete a smoking assessment to determine whether a resident was an independent or dependent smoker, and that independent smokers were allowed to smoke unsupervised with their smoking materials kept in a locked box. The resident shared a room with another resident who was on oxygen, and the sign outside the room indicated oxygen in use and no smoking. The SSD stated the resident did not have a locked box for his smoking materials and that the locked boxes were scheduled to arrive the next day, adding that the resident should have had a locked box prior to being allowed to smoke independently. The resident's record showed diagnoses including cervical spinal stenosis, a history and physical dated October 21, 2025 indicating he had decision-making capacity, and a smoking assessment indicating he smoked cigarettes and was independent. The DON also stated that independent residents were allowed to keep smoking materials in a locked box, but the facility did not currently have lock boxes available.
Fluid Restriction Order Not Timely Removed From Meal Ticket
Penalty
Summary
The facility failed to ensure nutritional care and services were provided for one resident when the physician order to stop a fluid restriction was not observed timely by nursing and kitchen staff. Resident 92 was admitted with edema, heart failure, and pneumonia, and had a BIMS score of 12. On January 5, 2026, the resident stated she was not made aware why she was on a fluid restriction and was unsure what it included. At that time, an 800 ml clear bottle was on the bedside table, and the meal ticket on the bedside table still indicated a 240 ml fluid restriction. The medical record showed a fluid restriction order dated December 19, 2025, with a discontinuation date of January 2, 2026, but the meal ticket dated January 7, 2026 still listed a fluid restriction of 240 ml. A nursing progress note documented that the physician left orders to remove the patient from fluid restriction per patient request and that the orders were initiated and discontinued, but there was no indication the restriction was continued after January 2, 2026 or that the change was communicated to the kitchen and nursing staff. The DS stated the fluid restriction should have been removed from the meal ticket, and the DON confirmed the current meal ticket did not reflect the current diet order. The RD stated the discontinuation of the fluid restriction should have been communicated and the resident's diet order updated.
Failure to Monitor for Bleeding With Heparin Therapy
Penalty
Summary
The facility failed to ensure one of five sampled residents, Resident 123, was free of unnecessary medications when side effects were not monitored with the administration of heparin, an anticoagulant ordered for DVT prophylaxis. Resident 123 had a physician's order for heparin 5000 units subcutaneously every 8 hours, and the record showed doses were given from December 28, 2025, through January 1, 2026. During interview, the DON stated residents on anticoagulants were monitored for bleeding and bruising, and the facility's protocol was to have orders to monitor bleeding for all residents on anticoagulants. A concurrent review of Resident 123's physician orders showed an order to monitor for signs and symptoms of bleeding every shift, including epistaxis, blood stool, and bruising, but the MARs did not indicate that this monitoring occurred on the dates heparin was administered before the monitoring order began. The resident's care plan, dated December 28, 2025, included anticoagulant medication interventions to assess for signs of blood loss and monitor for bruising or bleeding. The heparin prescribing information stated that fatal hemorrhages have occurred and that hemorrhage is the chief complication that may result from heparin therapy, and the facility's anticoagulation clinical protocol stated that staff and the physician would monitor for possible complications in individuals being anticoagulated.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications in accordance with its policies and procedures and manufacturer instructions. During observation and interview in one medication room, a box of epinephrine 0.3 mg auto-injector labeled for Resident 92 was found stored in the medication refrigerator, and the LVN stated it was not supposed to be refrigerated. The same resident’s epinephrine auto-injector was also found expired, and the DON acknowledged that expired medication needed to be discarded and that the resident’s epinephrine was expired and improperly stored in the refrigerator. In a separate medication cart review, an opened Symbicort 80-4.5 mcg inhaler for Resident 127 was found without an open date. The LVN stated inhalers were supposed to be labeled with an open date immediately after opening, and the DON confirmed the inhaler should have been labeled with the date it was opened. The resident had an order for Symbicort 2 puffs twice daily for COPD, and the facility policy stated that when opening a multi-dose container, the date opened is recorded on the container.
Expired Nutritional Supplement Stored in Residents' Refrigerator
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional food safety standards when an unopened 237 ml carton of Boost with an expiration date of September 24, 2025 was found in residents' refrigerator #1 at Nurse's Station 1. During the inspection on January 7, 2026, the expired supplement was observed readily available for consumption, and LVN 9 stated it should have been discarded because it had expired. LVN 9 also stated she was not sure why the expired Boost was still in the refrigerator when the residents' refrigerator was inspected daily by staff. During interviews, the DON stated the facility did not have Boost for nutritional supplements and that staff should check expiration dates when receiving food brought from home, with items labeled and dated. The DS stated there should be no expired food in the residents' refrigerator, and the RD stated food brought from home should be dated and labeled, nurses should check expiration dates, and expired food could cause the resident to get sick. The facility policy titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES, stated food items are inspected for safety before storage or serving and unopened refrigerated or frozen items are disposed of by the expiration date on the container. The policy titled, Foods Brought by Family/Visitors, stated nursing staff will discard perishable foods on or before the use by date.
Failure to Document Medication Administration in eMAR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN 2) prepared and administered some of a resident's medications but did not sign the electronic Medication Administration Record (eMAR) to document the administration. On the day in question, LVN 2 assisted another nurse (LVN 1) with the 9 a.m. medication pass for a resident who had moderate cognitive impairment and multiple diagnoses, including diabetes mellitus. LVN 2 prepared prescription and over-the-counter medications, placed them in a medicine cup, and administered them to the resident. However, there was no documentation in the eMAR reflecting that LVN 2 had administered these medications. Facility policy and statements from the Director of Nursing confirmed that the standard practice requires the nurse who prepares and administers medications to document the administration in the eMAR at the time the medication is given. The failure to document the medication administration resulted in an inaccurate medication record for the resident. The facility's own policies specify that only the licensed or legally authorized personnel who prepare a medication may administer it and must record the administration on the resident's MAR.
Failure to Ensure Safe and Appropriate Discharge for High-Needs Resident
Penalty
Summary
A facility failed to ensure a safe and appropriate discharge for a resident with dementia and dysphagia who required constant supervision and a pureed diet. The resident was discharged to an unlicensed room and board facility that did not provide caregivers or understand the resident's medical and dietary needs. The facility did not verify whether the receiving environment could meet the resident's care requirements, and there was no documentation that the facility communicated with the receiving location to confirm its suitability. The resident's care plans indicated significant needs, including 1:1 supervision for elopement risk, assistance with all activities of daily living, and a specialized diet due to swallowing difficulties. Despite these documented needs, the discharge process relied on a placement agency that did not assess the resident in person or ensure the receiving facility was licensed or capable of providing the required care. The Social Services Director admitted to not verifying the receiving facility's ability to meet the resident's needs and assumed that such facilities would not accept residents they could not care for. Upon arrival at the unlicensed room and board, the owner was unaware of the resident's dietary restrictions and did not provide 24-hour care or supervision. The resident did not have family support or in-home services at the new location. Within a week, the resident was transferred to a hospital due to concerns about care. The facility did not have a specific policy or procedure for managing safe discharges, and the only relevant policy referenced the need to consider the resident's needs, choices, and best interests when determining transfer locations.
Removal Plan
- The Social Service Director (SSD) and the Case Manager (CM)/Discharge Planner (DCP) reviewed residents scheduled for possible discharge to ensure that each resident was appropriately assessed for discharge placement and that the receiving facility will be able to meet the residents' needs.
- The SSD and CM/DCP reviewed residents who were discharged and ensured that each resident was safely discharged and the receiving facility was able to meet the residents' needs.
- The Director of Nursing (DON) conducted an in-service to the SSD and CM/CDP regarding appropriate discharge placement to ensure that residents are discharged to a safe location that can meet their needs.
- The receiving facility will send a representative to assess the resident's current condition and plan of care, which includes evaluation of diet, medications, functional abilities (such as transfers, bed mobility, and ambulation), and cognitive status.
- A checklist was created to identify the residents' needs and will be used to verify and acknowledge that they can manage the care of the resident.
- The SSD will continue to conduct admission assessments with initial plans for discharge in collaboration with IDT and during their stay at the facility and coordinate with the resident or the responsible party for changes in the discharge plans and provide assistance as needed.
- The SSD and CM/DCP will continue to conduct post discharge follow-up to ensure safe discharge.
- The SSD will report the number of discharges to different levels of care and report concerns as presented by residents or the responsible party on post discharge follow-up during quarterly QAA meetings. The QAA will monitor compliance and trends and provide recommendations during the meeting.
Failure to Maintain Accurate Clinical Records and Notification Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with severe cognitive impairment. The resident, who had a diagnosis of dementia and a Brief Interview of Mental Status (BIMS) score indicating severe impairment, was issued a Notice of Proposed Discharge (NOPD) on the same day as discharge. The NOPD was signed by both the resident and her responsible party (RP), despite the RP not being present at the facility on that day. Interviews confirmed that the RP did not sign the document and would not have used the signature shown. The Social Service Director (SSD) and Director of Nursing (DON) acknowledged that the RP was not present and that the documentation did not accurately reflect the method of notification or the actual signature process. Additionally, the facility did not accurately document the time of family notification following a witnessed fall involving the same resident. The SBAR Communication Form indicated that the resident's daughter was notified at midnight, but the DON stated this was likely incorrect, and the Licensed Vocational Nurse (LVN) could not recall the exact time of the incident or the calls made. The LVN admitted to not updating the documentation to reflect the actual time of notification and was unsure if the calls were documented in the progress notes. There was no other documentation to support the timing or occurrence of family notification. Facility policies required that all services, changes in condition, and notifications be documented completely and accurately in the resident's medical record. The failures in documentation and record-keeping resulted in the resident and her family not being able to exercise their right to appeal the discharge and had the potential to prevent the family from making informed decisions or being present during a crisis.
Failure to Provide Ongoing Nail Care for Resident
Penalty
Summary
A resident with diagnoses including dementia, hypertension, and acute kidney failure was observed to have long fingernails on her right hand during a complaint investigation. The resident, who was alert and oriented at the time of observation, expressed a desire to have her fingernails cut. Measurements taken by the treatment nurse showed fingernail lengths ranging from 1.6 cm to 1.9 cm. The treatment nurse acknowledged that it was the responsibility of both the treatment nurse and the certified nurse assistant to provide nail care, and that the resident's long fingernails should have been addressed during routine care. A review of the resident's medical record indicated she had no decision-making capacity, and the facility's policy required daily cleaning and regular trimming of fingernails by CNAs, treatment nurses, or licensed nurses. The Director of Nursing confirmed that nail care should have been provided during routine care. The facility's policy also stated that proper nail care helps prevent skin problems and injuries. The failure to provide ongoing grooming services, specifically nail care, resulted in the resident having excessively long fingernails.
Failure to Provide Ongoing Foot Care and Podiatry Services
Penalty
Summary
A resident was observed with long, curved toenails on both feet, with measurements indicating significant overgrowth. The resident reported experiencing painful toenails. During an interview and observation, the Treatment Nurse confirmed the responsibility for toenail care lies with the nursing staff, including CNAs and licensed nurses, and acknowledged that podiatry should have been notified about the resident's condition. The resident's medical record showed a history of dementia, hypertension, and acute kidney failure, and documented a previous podiatry visit diagnosing onychomycosis, dystrophic nails, and paronychia with painful nail borders. However, there was no evidence of ongoing podiatry care after the last documented visit. The Director of Nursing stated that facility policy requires regular nail care by nursing staff and that podiatry services should have been scheduled for the resident. The facility's policy emphasizes daily cleaning and regular trimming of nails to prevent skin problems and injuries. Despite these policies, the resident did not receive appropriate foot care, and there was no documentation of podiatry follow-up after the initial assessment, resulting in the resident having long, painful toenails.
Failure to Provide Adequate Supervision Resulting in Multiple Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who experienced four unwitnessed falls within a seven-day period. The resident, who had diagnoses including hemiplegia, hemipheresis, diabetes mellitus, and Parkinson's disease, was identified as being at risk for falls upon admission. Despite this, the resident continued to fall multiple times, with each incident documented in the medical record. After the first and second falls, interventions such as keeping the bed in a low position, using side rails, bed and wheelchair alarms, floor mats, and every two-hour monitoring were implemented. However, these measures did not prevent subsequent falls. The Director of Nursing confirmed that after the second fall, the resident's family requested a sitter and for the resident to be moved closer to the nursing station, but these requests were not fulfilled due to room availability and a desire to avoid restrictive measures. The DON acknowledged that monitoring every two hours was not a sufficient intervention for this resident and that more frequent rounding and a sitter should have been provided prior to the fourth fall. The facility's own policy required staff and physicians to identify and implement pertinent interventions to prevent subsequent falls, but the lack of timely and adequate supervision contributed to the repeated incidents.
Failure to Timely Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The facility failed to provide the required proposed transfer and discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman at the same time the notice was given to the resident and/or their representative for two sampled residents. For one resident with a history of pelvic fracture who was being discharged to board and care on hospice, the notice was signed by the resident and given to the family member, but the Ombudsman was not notified until the following day. Similarly, for another resident with coronary artery disease and a history of coronary artery bypass grafting, the discharge notice was provided to the resident's representative, but the Ombudsman received the notice a day later. Interviews and record reviews confirmed that the facility's Director of Social Services typically sent the notice to the Ombudsman on the day of discharge, rather than concurrently with the notice to the resident or representative. The facility's policy requires that the Ombudsman be notified at the same time as the resident and representative. This lapse resulted in the Ombudsman not being informed in a timely manner, as required by policy and regulation.
Improper Use of N95 Masks and Lack of Fit Testing
Penalty
Summary
The facility failed to adhere to its infection control policy regarding the proper use of N95 masks, as observed during a survey. Two CNAs were found wearing an N95 mask over a surgical mask, which is against the facility's guidelines. This practice can compromise the seal of the N95 mask, reducing its effectiveness. One CNA admitted to alternating between the N95 and surgical mask depending on their location, while the other CNA, who was an agency staff member, was not aware of the proper use of N95 masks and had not undergone a fit test. Additionally, the facility did not verify whether the agency staff had been fit tested for the N95 mask before assigning them to care for a COVID-19 positive resident. The Director of Nursing and the Infection Control Nurse acknowledged these lapses, noting that the facility should have confirmed the fit testing status with the agency. The facility's policy requires fit testing and training on respirator use before initial assignment, which was not followed in this instance.
Inaccurate PASRR Screenings for Three Residents
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) Level I screenings for three residents. Resident #3 was admitted with a history of dementia, bipolar disorder, major depressive disorder, and schizophrenia. The Level I PASRR screening was initially exempt due to a short-term stay expectation, but it was not resubmitted after the resident remained in the facility beyond 30 days. Both the Administrator and the Director of Nursing (DON) acknowledged that the screening should have been resubmitted timely. Resident #18 was admitted with diagnoses of unspecified psychosis and major depressive disorder. However, the Level I PASRR screening incorrectly indicated that the resident did not have a serious mental disorder, resulting in a negative screening outcome. The DON admitted that the screening was inaccurate and should have included the resident's diagnoses. The responsibility for ensuring accurate PASRR screenings was attributed to the DON, who was also responsible for revising any inaccurate screenings. Resident #59 was admitted with a history of anxiety disorder and major depressive disorder. The initial Level I PASRR screening was negative due to a 30-day exempted hospital discharge. However, the screening was not resubmitted after the resident stayed beyond 30 days. The Administrator and the DON both confirmed that the DON was responsible for ensuring the accuracy and timeliness of PASRR screenings, and the failure to resubmit the screening was acknowledged as an oversight.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a quarterly Minimum Data Set (MDS) assessment for a resident with a diagnosis of encephalopathy. The facility's policy on resident assessments, revised in October 2023, specifies that non-comprehensive MDS assessments, including quarterly assessments, must be completed within 14 days after the Assessment Reference Date (ARD). However, the quarterly MDS for the resident, with an ARD of June 14, 2024, was not completed on time. The section for the Signature of the RN Assessment Coordinator Verifying Assessment Completion was left blank, indicating the assessment was incomplete. Interviews with facility staff revealed a lack of adherence to the required timeline for MDS completion. The MDS Nurse stated that the assessment should have been completed within 14 days from the ARD, but it was not signed by the RN until July 10, 2024, well past the deadline. The Director of Nursing was unsure of the exact timeline for MDS completion but expected the MDS Nurse to ensure timely submission. This oversight resulted in the resident's quarterly MDS not being completed within the required timeframe, as per the facility's policy and CMS guidelines.
Inaccurate MDS Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment process. The facility's policy requires that all individuals who complete any portion of the MDS sign the document to attest to its accuracy and that the information in the MDS should consistently reflect the progress notes, care plans, and resident observations. However, for one resident, the discharge MDS inaccurately documented that the resident was discharged to a short-term general hospital, while the progress notes and discharge summary indicated that the resident was discharged home with a family member. Interviews with facility staff, including the Administrator, MDS Nurse, and Director of Nursing (DON), revealed an expectation for the MDS to be accurate. The MDS Nurse acknowledged the mistake in documenting the discharge location and stated that the MDS should have reflected the resident's discharge to home. The DON also emphasized the importance of reviewing progress notes to ensure MDS accuracy. This discrepancy between the MDS and other documentation led to the identified deficiency.
Failure to Document Medication Allergy
Penalty
Summary
The facility failed to document a known medication allergy for a resident, leading to the administration of a medication that the resident was allergic to. The resident, who had a medical history including a fracture, joint replacement surgery, and dementia, was admitted to the facility with a documented allergy to hydrocodone. Despite this, the resident's Order Summary Report did not list any known allergies, and the resident was prescribed Norco, a medication containing hydrocodone, for pain management. The resident received Norco multiple times over several days, resulting in behavioral changes such as increased aggression and uncooperativeness, as noted by a family member. Interviews with facility staff revealed that the allergy information was supposed to be entered into the resident's chart by the unit supervisor upon admission, but this step was missed. The Director of Nursing acknowledged the oversight but could not explain how the allergy documentation was overlooked.
Resident Elopement During Heat Wave
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident #91, who eloped from the facility during an excessive heat wave. Resident #91, who had a history of cerebral infarction, muscle weakness, and difficulty walking, was admitted to the facility for short-term care. The resident had a severe cognitive impairment with a BIMS score of 3, indicating a high level of cognitive dysfunction. Despite this, initial assessments did not identify the resident as an elopement risk, and the care plan was not updated to reflect any potential wandering behavior until after the incident. On the day of the incident, Resident #91 was last seen in the facility at around 10:30 AM. The resident's spouse reported them missing around 11:50 AM, prompting a search by the facility staff. The resident was found by a police officer wandering outside in 95-degree weather and was subsequently taken to the emergency department for evaluation. The facility's security footage later revealed that Resident #91 had exited and re-entered the building twice that morning, although the exact doors used were not captured on camera. Interviews with facility staff indicated that while Resident #91 was known to walk around the building, there was no prior indication or report of them attempting to leave the premises. The Director of Nursing and other staff members were unaware of any elopement risk associated with Resident #91, and the family had not communicated any concerns about wandering behavior. The facility's failure to identify and monitor the resident's elopement risk contributed to the incident, resulting in the resident's exposure to hazardous conditions outside the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69%. This deficiency was identified during a medication administration observation involving a resident with a medical history of multiple sclerosis and immunodeficiency. The resident's care plan included interventions for constipation and malnutrition, requiring specific medications to be administered as per physician orders. However, during the medication pass, a Licensed Vocational Nurse (LVN) administered the wrong type of multivitamin and an incorrect dose of docusate sodium to the resident. The LVN prepared and administered a multivitamin without minerals instead of the prescribed multivitamin with minerals, and only gave 100 mg of docusate sodium instead of the ordered 200 mg. The LVN acknowledged the errors during interviews, attributing the mistakes to nervousness. The Director of Nursing (DON) and the Administrator both stated their expectations for medications to be administered correctly according to physician orders, emphasizing the importance of verifying the five rights of medication administration.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were accessible to residents and family members, as required by their policy. The policy, dated March 2017, stated that survey reports and plans of correction should be readily available in a binder located in the resident's day room. However, during an interview, a resident revealed that the survey binder, which was previously available at the front entrance, had been moved and was no longer accessible. The resident had not seen the binder for two years. Observations confirmed that the binder was not at the receptionist desk, where signage indicated it should be. Further interviews with facility staff, including the receptionist, HR Payroll, and the Director of Nursing (DON), revealed that none of them were aware of the binder's location. The receptionist, who had been at the facility for a year, had never seen the binder. The HR Payroll and DON were also unable to locate it initially. Eventually, the binder was found in the DON's office, contrary to the expected location. The Administrator acknowledged that the binder had been removed from the receptionist area after an incident, but expected it to be accessible to residents and family members.
Failure to Post Daily Direct Care Staffing Information
Penalty
Summary
The facility failed to ensure the daily direct care staffing information was posted, which had the potential to affect all 98 residents residing in the facility. The facility's policy, revised in July 2016, required the posting of the number of nursing personnel responsible for providing direct care to residents on a daily basis for each shift. During an observation, the surveyor was unable to locate the daily direct care staff posting. Interviews revealed that a Certified Nurse Aide (CNA) was unaware of the requirement for a daily staff posting, and the Administrator did not know it was required. The Director of Nursing (DON) acknowledged the oversight and stated that the staffing information should have been posted daily.
Failure to Confirm Discharge Address Leads to Incorrect Transfer
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident when the discharge location was not confirmed with the family before transferring the resident. The resident, who had multiple diagnoses including acute respiratory failure, Type 2 diabetes, chronic kidney disease, and hypertension, was discharged without the capacity to understand and make decisions. The resident required maximum assistance with activities of daily living. The discharge was initially planned for May 29, 2024, to the family member's home, but the address was not confirmed, leading to the resident being taken to an incorrect facility instead. The Social Service Director (SSD) and the Case Manager (CM) were responsible for confirming the resident's address, but the address was not verified between May 22 and May 29, 2024. The SSD only confirmed the correct address with the family after the transportation company reported an insufficient address. The resident was returned to the skilled nursing facility for the night after the family member requested the discharge be postponed. The facility's policy required written notification of the discharge location, but this was not adequately followed, resulting in the resident being taken to the wrong address.
Failure to Update Transfer and Discharge Notice
Penalty
Summary
The facility failed to provide an updated notice of transfer and discharge for a resident's responsible party and the Long-term Care Ombudsman, indicating changes to the discharge location. The Social Service Director (SSD) initially arranged for the resident to be discharged to a board and care facility (Board and Care 1), but upon arrival, the facility refused to accept the resident because he was male. The SSD then arranged for the resident to be admitted to another board and care facility (Board and Care 2) without notifying the resident's family or the Ombudsman of the change. The resident was later found outside Board and Care 2, and the staff there called 911 as they were unaware of the resident's arrival and had not agreed to admit him. Interviews with the SSD, facility administrator, hospital social worker, and Board and Care 2's house manager confirmed the sequence of events. The facility's policy requires that any changes to the discharge location be communicated to the resident, their representative, and the Ombudsman. However, this protocol was not followed, leading to the resident being found outside the second board and care facility and subsequently taken to the hospital. The failure to update the notice of transfer and discharge had the potential to compromise the resident's safety and well-being.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident when the resident was discharged to a Board and Care that had not accepted the resident for admission. The resident was then transferred to another Board and Care that was unaware of the resident's arrival. This resulted in the resident being found outside the second Board and Care and subsequently being transferred to a general acute care hospital. The Social Service Director (SSD) received a call from the transporter on the day of discharge, informing her that the first Board and Care refused to accept the resident because he was male. The SSD then called other Board and Care facilities in the area and spoke with an employee at a second Board and Care, who agreed to admit the resident over the phone. The SSD emailed the necessary paperwork and provided the new address to the transporter. However, the next day, the SSD was informed by a hospital social worker that the resident had been found outside the second Board and Care and was admitted to the hospital. Interviews with the facility administrator and the hospital's social worker confirmed the events. The administrator acknowledged that the discharge did not follow the normal protocol. The House Manager of the second Board and Care stated that they had no prior knowledge of the resident's arrival and called 911 when they found him outside their facility. The facility's policy and procedure for discharge planning were reviewed, indicating that the resident and their family should be involved in the discharge planning process and informed of the final plan, which was not followed in this case.
Failure to Inform Resident's Representative of Investigation Findings
Penalty
Summary
The facility failed to ensure that Resident 1's representative was informed of the findings of an investigation related to an incident that occurred while the resident was at a doctor's appointment. Resident 1 experienced a change of condition during the appointment and was subsequently transferred to an acute care hospital. Despite the Director of Nursing (DON) conducting an investigation, including checking the resident's vital signs and attempting to contact the doctor's office and the transporter, the DON did not recall if the family member was informed of the investigation results. Resident 1 had a medical history that included hemiplegia, hemiparesis following a stroke, atrial fibrillation, benign prostatic hyperplasia, urinary tract infection, and obstructive and reflux uropathy. The facility's policy required that grievances be investigated and that the findings be communicated to the resident or their representative within five working days. However, this policy was not followed, leading to the deficiency noted in the report.
Failure to Provide Transfer/Discharge Notices and Notify Ombudsman
Penalty
Summary
The facility failed to initiate and provide notices of proposed transfer/discharge (NOPD) to three residents and/or their responsible parties, and also failed to notify the Long-Term Care Ombudsman of these transfers/discharges. Resident 4, who had a history of stroke, diabetes mellitus type 2, and heart failure, was transferred to the hospital for shortness of breath without an NOPD being initiated or the Ombudsman being notified. Resident 5, with diagnoses including heart failure, atrial fibrillation, and hyperlipidemia, was discharged home with an incomplete NOPD and no notification to the Ombudsman. Resident 7, diagnosed with epilepsy, hypertension, and osteoporosis, was discharged home without an NOPD being initiated or the Ombudsman being notified. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) revealed that the NOPDs were not properly handled. The SSD admitted that the NOPD for Resident 4 was not initiated and that the Ombudsman was not notified. For Resident 5, the SSD acknowledged that the NOPD was incomplete and the Ombudsman was not informed. Similarly, for Resident 7, the SSD confirmed that the NOPD was not initiated and the Ombudsman was not notified. The SSD also mentioned that she sends NOPDs to the Ombudsman weekly, but did not send any on April 12, 2024, because she had sent some on April 9, 2024. The DON confirmed that the NOPDs should have been completed and sent to the Ombudsman immediately after the residents left the facility. A review of the facility's policy and procedure titled Transfer or Discharge Notice indicated that the resident and representative should be notified in writing of the transfer or discharge, and a copy of the notice should be sent to the Ombudsman at the same time. However, the facility's documentation showed that Residents 4 and 5 were not included in the NOPDs faxed to the Ombudsman on April 9, 2024, indicating a failure to follow the established policy and procedure.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident 9 had the call light button within his reach. During an unannounced visit, it was observed that Resident 9's call light button was on the floor, out of his reach. Resident 9, who was lying in bed, alert, and conversant, confirmed that his call light was usually near him. The Licensed Vocational Nurse (LVN) also acknowledged that the call light button should be within Resident 9's reach and that he would not be able to ask for help if it was on the floor. Resident 9 was admitted to the facility with diagnoses including dementia, hypertension, diabetes mellitus, and muscle weakness. The Minimum Data Set (MDS) dated April 13, 2024, indicated that Resident 9 had severe cognitive impairment. The care plan dated April 9, 2024, specified that the call light should be within Resident 9's reach due to his musculoskeletal issues and mobility limitations. The Director of Nursing (DON) confirmed that Resident 9 would not be able to ask for help when his call light was on the floor. The facility's policy and procedure titled 'Answering the Call Light' also indicated that the call light should be within easy reach of the resident.
Failure to Schedule Follow-Up Appointments for Resident
Penalty
Summary
The facility failed to ensure that follow-up appointments with a cardiologist and pulmonologist were scheduled for Resident 8, who had significant medical conditions including myocardial infarction, heart failure, atrial fibrillation, and acute respiratory failure. Despite having physician orders dated March 30, 2024, for follow-up appointments within one to two weeks, these appointments were not scheduled. Resident 8 expressed concerns about her cardiology appointment and had not received any updates from the Social Service Designee (SSD) or Case Manager (CM), who were responsible for scheduling these appointments. Interviews with the Licensed Vocational Nurse (LVN), SSD, CM, and Director of Nursing (DON) revealed a lack of communication and urgency in scheduling the necessary follow-up appointments. The LVN was unaware of whether the appointments had been scheduled, and the SSD admitted to not sending multiple referrals or making additional phone calls to secure the appointments. The CM also failed to document her attempts to schedule the pulmonology appointment and did not notify the physician about the scheduling difficulties. The facility's policy on referrals and consults, dated December 2008, requires social services or designees to coordinate resident referrals based on physician orders and to document these referrals in the resident's medical record. However, this policy was not followed, as evidenced by the lack of scheduled appointments and documentation for Resident 8. The DON acknowledged the importance of the cardiology appointment, given Resident 8's use of a cardiac life vest, but stated that the facility's policy did not specify a timeframe for scheduling appointments, leading to a delay in necessary medical follow-ups.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,403 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverwalk Post Acute | 1.5 mi | ★★★★★ | 21 | 0 |
| Villa Health Care Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Alta Vista Healthcare & Wellness Centre | 2.3 mi | ★★★★★ | 6 | 0 |
| Citrus Grove Post Acute | 2.4 mi | ★★★★★ | 20 | 0 |
| Palm Terrace Care Center | 2.7 mi | ★★★★★ | 4 | 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.