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 Asbury Park Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Call systems were not reasonably accommodated for two residents. One resident with dementia, non-verbal status, and extensive dependence had no call system within reach, and the call light button was found several feet away from the bed. Another resident with schizophrenia, parkinsonism, and shaky hands was given a standard call light button that staff and the resident confirmed could not be held or pressed, with staff stating a soft touch system would have been more appropriate.
Restorative nursing services were not provided at the ordered frequency for a resident with DM, polyneuropathy, and muscle weakness. The resident’s care plan and physician orders called for bed mobility exercises and RLE PROM 3x weekly, but restorative records showed the resident received the exercises less often than ordered. RNA staff confirmed the missed frequency, and the DSD and DON stated the ordered frequency should have been followed.
A resident with a recent femur fracture, orthopedic pain, and rheumatoid arthritis had pain medication orders that were not consistently followed. The MAR showed acetaminophen ordered for mild pain was given for moderate pain, and oxycodone ordered for severe pain was given for moderate pain. The resident reported poor pain control and feeling overmedicated at times, and an LN, DSD, and DON confirmed the ordered pain parameters should have been followed.
Controlled substance counts did not match CSRs in medication carts, with nurses confirming doses were not signed out at the time of administration. Discontinued controlled meds were also left stored in a med refrigerator and cart after residents had been discharged, and MARs did not match CSRs for two residents because doses were signed out on the CSR without corresponding MAR documentation. The DON and CP acknowledged the documentation and storage issues.
Medication administration errors resulted in a rate above the allowed threshold. A nurse gave a resident a much higher-than-ordered dose of vitamin D, another resident received the wrong insulin dose and missed an ordered NPH insulin dose, and a third resident received acetaminophen that did not match the ordered pain scale. The DON acknowledged the errors after record review and observation.
Opened medications and diagnostic strips were found without open dates in multiple med carts and a med room refrigerator. Undated items included insulin glargine, Breo Ellipta, Trelegy Ellipta, Epidiolex, EvenCare G3 blood glucose test strips, and a Forteo pen. The DON acknowledged that medications are to be dated when opened per manufacturer guidance and facility policy.
Food service staff failed to follow required hygiene and sanitation practices during meal prep and dishwashing. A dietary aide wore a beanie with exposed hair, and two staff members with facial hair did not wear beard restraints while preparing food. In the dish room, a dietary aide touched dirty dishes and then clean dishes without washing hands, contrary to facility policy requiring separate soiled and clean-side handling and strict hand hygiene.
A facility failed to maintain its infection prevention and control program when a CNA provided high-contact care to a resident on EBP without wearing the required gown, even though signage and the care plan directed gown and glove use for hygiene, brief changes, dressing, and urinary catheter care. The facility also stored money inside a medication cart compartment with controlled substances and antibiotics, and it failed to change a resident’s PICC dressing weekly as ordered; the dressing was found dated weeks earlier and beginning to peel, while the resident was receiving IV antibiotics for bacteremia.
Delayed Sliding-Scale Insulin Administration: An LPN administered Regular Insulin to a resident more than 2 hours after the FSG was obtained, despite a sliding-scale order tied to the blood glucose result. The MAR showed the 8:00 a.m. dose was given after 10:00 a.m., and the DON confirmed this was outside the facility’s standard practice of giving insulin within 30 minutes of the glucose check.
A resident with a suprapubic catheter, impaired cognition, and urinary retention was observed in bed with the catheter drainage bag left on the floor. An LN confirmed the bag remained on the floor, and the DSD and DON stated catheter bags should be hung bedside and kept off the floor. The facility policy also required catheter tubing and drainage bags to be kept off the floor.
The facility did not maintain an effective pest control program, as flies were observed in the rooms of two residents whose sliding doors were open and lacked screens. Staff and maintenance confirmed that most sliding doors in the building had no screens, and the DON acknowledged concerns about flies, expecting staff to keep doors closed until screens were installed. Pest control service records were reviewed, but the fly issue persisted.
A resident with muscle atrophy and incontinence was left in a soiled brief for an extended period, despite expressing discomfort and using the call light. Staff, including CNAs and the DON, acknowledged the importance of timely changing to prevent dignity issues, but failed to act promptly. The facility's dignity policy, which emphasizes prompt response to toileting needs, was not followed.
Three residents were not protected from peer abuse, including physical altercations and racial slurs. One resident with cognitive impairment was slapped by another, a second was punched in the thigh by a peer, and a third experienced emotional distress after being subjected to racial and verbal abuse by a roommate. Staff and documentation confirmed these incidents, and the affected residents had varying degrees of cognitive and physical impairment.
The facility did not follow the planned menu for therapeutic diets, affecting 128 residents. Twenty residents on CCHO diets received margarine, two residents on CCHO and renal diets did not receive the correct meal components, and nine residents on puree diets did not receive the puree wheat roll. Additionally, all residents missed the parsley garnish. The Director of Dietary Services acknowledged the issues, and the Registered Dietitian emphasized the need to adhere to the menu.
The facility failed to ensure food safety, with an unclean ice machine, improperly stored kitchenware, a missing air gap in a prep sink, incorrect dishwashing procedures, and staff without proper beard restraints. These issues posed a risk of food contamination for all residents.
The facility failed to securely close one of two garbage dumpsters outside, leaving gaps that could attract pests. The Dietary Assistant Manager confirmed the issue, and the Registered Dietitian emphasized the need for tightly closed lids to prevent pest problems. Facility policy and the FDA Food Code require secure, tight-fitting lids for waste receptacles.
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents, with discrepancies between the Controlled Drug Record (CDR) and Medication Administration Record (MAR). Additionally, medication accountability was lacking during shift changes, with missing signatures on controlled drug sign-in/sign-out sheets. The facility also did not have an efficient system to document and secure emergency medications (E-Kit), and medications were not secured safely, with retrievable crushed and partially crushed medications found in multiple medication carts.
The facility failed to ensure three residents were free from unnecessary psychotropic medication use. A resident received Seroquel without non-pharmacological interventions for bipolar disorder. Another resident was given Seroquel without adequate indication, and staff confirmed no symptoms of schizophrenia. A third resident's Lorazepam order did not match the behavior being monitored, with no documented non-drug interventions. Facility policies requiring non-pharmacological approaches were not followed.
A facility failed to maintain a medication error rate below 5%, with errors observed during medication passes for three residents. Errors included incorrect dosing of diclofenac gel, failure to prime an insulin pen, incorrect measurement of ClearLax, and administering glipizide without a meal. These actions were not in accordance with prescriber's orders or manufacturer's specifications.
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. Medications were not stored according to manufacturer specifications, and discontinued medications were not disposed of properly. Medication carts were disorganized, with controlled medications not stored securely and some medications lacking resident-specific labels. Resident 81, with multiple diagnoses, was found with an albuterol inhaler at the bedside without authorization to self-administer, highlighting further issues with medication management.
The facility failed to have written agreements with dialysis clinics for three residents receiving dialysis treatment. Despite multiple attempts to secure contracts, the facility was unable to provide valid agreements, leading to potential accountability issues in the dialysis services provided.
The facility failed to maintain effective infection control practices, as evidenced by improper storage of nasal cannulas and nebulizer equipment for several residents, and environmental cleanliness issues in the laundry room. Staff confirmed these deficiencies, acknowledging the potential for contamination and infection risk.
The facility failed to maintain the laundry room in a safe and operable condition, with observations of wet floors and corroded, leaking pipes. The Director of Environmental Services confirmed the issue, noting that repairs were pending. The Infection Preventionist also observed moisture and lint on the ground, contrary to facility expectations.
A facility failed to obtain informed consents from the authorized representative for a resident with severe cognitive impairment. Consents for treatment, POLST, and psychotropic medication were signed by individuals not listed as the responsible party, such as the resident's daughter-in-law and son. Staff interviews confirmed the discrepancy, acknowledging that the responsible party's name was on the resident's chart, and the expectation was for them to sign the consents. Facility policies emphasized obtaining consents from the resident representative, which was not adhered to, leading to the deficiency.
The facility failed to secure confidential resident health data when a computer on Medication Cart 2A was left unattended with a resident profile open, facing the hallway. A nurse acknowledged the breach, and the DON confirmed the expectation for staff to protect resident records. The facility's policy requires only authorized access to electronic medical records.
A facility failed to provide written notice of bed hold to a resident's responsible party when the resident, who was severely cognitively impaired, was transferred to a hospital. Despite attempts to contact the RP, no written notice was documented, violating the facility's policy requiring notification within 24 hours of transfer.
A resident did not receive their prescribed Citalopram for eight days due to a failure in the facility's admission process to carry over the medication order. The resident, who was cognitively intact and had a history of depression, experienced withdrawal symptoms and reported these to the staff, but the medication was still not administered. The admitting nurse and DON confirmed the oversight, which was contrary to the facility's medication reconciliation policy.
A resident with diabetes and chronic kidney disease did not receive necessary podiatry care, resulting in long and thick toenails. Despite a physician's order for podiatry care every two months, the resident had not seen a podiatrist since admission. Internal communication failures led to the oversight, as the need for toenail clipping was noted but not addressed. Facility policy requires diabetic residents to be referred to podiatry services, but there was no evidence of rescheduled appointments.
A facility failed to ensure proper communication with a dialysis clinic regarding a resident's anemia management. The resident, with ESRD and anemia, was supposed to receive Epoetin Alfa at dialysis, but records showed it was not administered. Instead, the resident received Mircera, a different medication, without the facility's knowledge, impacting their ability to monitor treatment effectiveness.
A facility failed to ensure a consultant pharmacist conducted a Medication Regimen Review (MRR) for a resident with Major Depressive Disorder, schizophrenia, and diabetes. The resident had multiple orders for Seroquel, but the CP did not complete an MRR as required by the facility's policy. This oversight was confirmed by the Pharmacy Manager and the Director of Nursing, highlighting a lapse in monitoring the resident's medication regimen.
The facility failed to meet the dietary needs of two residents. A resident with dysphagia was served broccoli, which he dislikes, and another resident on a mechanical soft diet did not receive his preferred gelato. Staff confirmed these oversights, and the facility's policy requires honoring food preferences and substituting disliked items.
Two residents in the facility were found with inaccessible call lights, potentially leading to unmet needs and delayed staff response. One resident, with moderate cognitive impairment and requiring substantial assistance, had their call light on the floor, while another resident, cognitively intact but dependent on staff, had their call light pinned between the bed rail and bed frame. The DON confirmed the issue, which contradicts the facility's policy requiring accessible call lights.
A resident with multiple medical conditions left an LTC facility unsupervised without a physician's order for a Leave of Absence (LOA). The resident, who required assistance for mobility, used a rideshare service to visit his son. Facility staff, including a new CNA, failed to follow the LOA policy, leading to the resident's unsupervised departure. Miscommunication and misunderstanding of discharge procedures contributed to the incident.
A facility failed to maintain an effective IPCP for 134 residents, as staff did not wear required PPE during catheter care for a resident on ESP. PPE was not available outside the rooms of three residents on ESP, increasing cross-contamination risk. The LN was unfamiliar with PPE requirements, and the DON acknowledged the infection risk. Facility policies and CDC guidelines stress PPE availability and staff training for effective EBP implementation.
The facility failed to respond promptly to call lights, compromising the dignity and care of three residents. A resident's family reported long waits for assistance, leading to incontinence. Another resident expressed dissatisfaction with delayed responses, risking spills. Observations showed a resident left waiting over an hour for help, visibly distressed. Staff interviews revealed non-compliance with timely response policies, acknowledged by the DON.
The facility failed to report the results of a 5-day investigation within the required timeframe after an altercation between two residents, where one resident scratched the other. The facility did not provide evidence to the CDPH that a summary of the investigation and corrective actions were submitted on time. The DON confirmed the delay in submission.
The facility failed to ensure safe evacuation routes, as they were cluttered with carts, commodes, linen bins, and garbage bins. A resident demonstrated the issue by attempting to navigate an emergency exit in a wheelchair, finding it obstructed. The DON confirmed the clutter and non-functional alarms, acknowledging the routes should have been clear and bins covered for infection control.
Call systems were not accessible or appropriate for two residents
Penalty
Summary
Reasonable accommodation of resident needs was not provided for two residents when their call systems were not appropriate or not within reach. One resident had diagnoses including Alzheimer’s disease, dementia, and muscle weakness, was rarely or never understood, and was dependent for most activities of daily living and transfers. Although the care plan identified a communication problem related to dementia and directed that a call light be in reach, the resident was observed in bed with no call system available within reach. The resident’s call light button was later found on the bottom of a bedside drawer about 4 to 5 feet away, and staff confirmed the resident could not use the button and needed a soft touch call system. A second resident had diagnoses including schizophrenia, parkinsonism, and muscle weakness, and had intact cognition with a BIMS score of 14 out of 15. The resident was dependent for several ADLs and transfers. During observations, the resident was in bed with a standard call light button while the resident’s hands were shaking repeatedly. The resident stated the resident could not hold and press the button because the hands were very shaky. Staff confirmed the resident had tremors and would not be able to hold and use the call light button, and stated that a soft touch call system would be better. The DON and DSD stated that residents’ call systems should be appropriate and within reach so they could call for help whenever needed. The facility policy stated residents are to be provided a means to call staff for assistance from the bed, toileting/bathing facilities, and the floor, and that if a disability prevents use of the call system, an alternative usable means of communication is to be provided and documented in the care plan.
Restorative Nursing Program Frequency Not Followed
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM and/or mobility, unless a decline is for a medical reason. The facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in ROM for one resident when the restorative nursing program frequency was not followed. The resident was admitted in March 2021 and had diagnoses including diabetes mellitus, polyneuropathy, and muscle weakness. The resident’s MDS dated 3/19/26 showed intact cognition with a BIMS score of 15 out of 15, but also showed significant functional dependence, including dependence for toileting hygiene, footwear, transfers, and several bed mobility and dressing tasks. The resident’s care plan identified a risk for physical decline and included restorative nursing assistance for therapeutic exercises/ROM and bed mobility. Physician orders dated 1/8/26 directed restorative nursing services for bed mobility and right lower extremity PROM three times weekly or as tolerated. Review of March 2026 restorative records showed the resident only received bed mobility exercises on 3/7, 3/13, 3/14, and 3/15, and PROM exercises on 3/7, 3/13, 3/14, 3/15, and 3/24. RNA staff confirmed the resident did not receive the ordered frequency, and the DSD and DON stated the frequency should have been followed.
Pain Medication Orders Not Consistently Followed
Penalty
Summary
The facility failed to ensure appropriate pain management for one resident who had been admitted with diagnoses including a right femur fracture, pain due to internal orthopedic prosthetic devices, muscle weakness, and rheumatoid arthritis. The resident’s MDS indicated intact cognition and that she received scheduled and as-needed pain medications and non-medication interventions for pain. Her care plan identified her as at risk for pain related to surgical incision and chronic pain syndrome and directed that medication be administered as ordered. During interview, the resident stated her pain had not been controlled because sometimes the medication did not relieve her pain and other times it was too much and made her feel like things were floating. The MAR showed that acetaminophen ordered for mild pain was given when the documented pain level was moderate, and oxycodone ordered for severe pain was given when the documented pain level was moderate. A concurrent review with an LN confirmed the pain medication orders were not consistently followed and stated nurses should follow the physician’s order when administering pain medications. The DSD and DON also stated nurses should follow the ordered parameters and that pain would not be controlled if the physician’s orders were not consistently followed.
Controlled Substance Accounting and Documentation Failures
Penalty
Summary
Strict controls were not maintained for controlled substances in the medication carts and refrigerator, and controlled substance counts did not reconcile with the facility’s controlled substance records for multiple residents. During inspection of the 1C medication cart, discrepancies were found between the physical inventory and the CSR for buprenorphine 5 mcg/hour patch for Resident 149, oxycodone 5 mg for Resident 155, and pregabalin 200 mg and 25 mg for Resident 125. The nurse present confirmed the discrepancies and stated the morning nurse would sign out the medications later. The morning nurse later acknowledged he had not signed out those medications during the medication pass and stated he would sign them out then. A similar discrepancy was identified in the 2B medication cart for lacosamide 100 mg for Residents 166 and 133. The physical count did not match the CSR, and the nurse confirmed she had not signed out the medication during the morning medication pass. The DON stated her expectation was that nurses check the order, pull the medication from the cart, then log it out of the CSR, and acknowledged nurses did not sign out medications at the time of removal or after administration. The consultant pharmacist stated controlled medications should be signed out at the time of administration to minimize documentation errors and diversion risk. Discontinued controlled substances were also found stored in the facility after the residents had been discharged. A bottle of lorazepam 2 mg/mL for Resident 163 was found in a lockbox inside the medication refrigerator, even though the resident had been discharged 28 days earlier. In the 1B medication cart, discontinued oxycodone, tramadol, and oxycontin for Residents 165, 69, 50, 15, and 7 were still wrapped with their CSRs and stored in the cart; the DON acknowledged receiving these medications and the residents’ discharge dates. In addition, MARs did not reconcile with CSRs for Resident 67 and Resident 20: oxycodone and tramadol were signed out on the CSRs, but there was no corresponding documentation on the MARs showing administration, and the DON confirmed the missing MAR documentation.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication errors occurred during medication administration for three residents, resulting in a facility medication error rate of 6.45% based on four errors out of 62 opportunities. During observation of a medication pass, a nurse prepared and administered cholecalciferol to one resident from a bottle labeled BioTech D3-50. The resident had a physician order for cholecalciferol 50 mcg daily, but the bottle used contained 1,250 mcg per capsule, and the nurse acknowledged that 1 capsule of 1,250 mcg was given instead of the ordered 50 mcg tablet. During another observed medication pass, a nurse administered insulin to a resident with diabetes. The resident had orders for Humulin R 2 units based on a blood glucose reading between 201 and 250, and Humulin N 6 units twice daily. The nurse stated she would give 8 units total, drew up and injected 8 units of Humulin R, and did not administer the ordered Humulin N. Record review and interview confirmed the resident should have received 2 units of Humulin R and that the Humulin N dose was omitted. A third resident requested pain medication and was assessed by a nurse as having back pain rated 5 out of 10. The resident had orders for acetaminophen 325 mg every 4 hours as needed for mild pain rated 1 to 3, and ibuprofen 400 mg every 4 hours as needed for mild or moderate pain. The nurse administered acetaminophen 325 mg and ibuprofen 400 mg, but documented acetaminophen for pain rated 5 out of 10, which did not follow the physician-ordered pain scale. The DON reviewed the record and acknowledged the acetaminophen administration did not follow the order.
Opened medications and test strips were left undated
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to manufacturer guidelines when several opened medications and one opened container of glucose test strips were found without open dates in medication carts, and one opened Forteo pen was found without an open date in a medication room refrigerator. During inspection of the 1 C medication cart, an opened, undated vial of Insulin Glargine for Resident 110 was observed, along with an opened Breo Ellipta inhaler for Resident 161 and an opened Trelegy Ellipta inhaler for Resident 148, both without open dates. In the 1 A medication cart, Resident 156’s opened Epidiolex bottle was also observed without an open date. In the 1 B medication cart, an opened container of EvenCare G3 Blood Glucose Test Strips was found without an open date. In the medication room refrigerator, an opened and undated Forteo pen for Resident 162 was observed. The DON stated medications are to be dated when opened in accordance with manufacturer guidelines and acknowledged that the undated, opened medications could expose residents to medications that may be expired or unstable. The facility policy titled Administering Medications stated that the expiration or beyond-use date is checked prior to administering and that when opening a multi-dose container, the date opened is recorded on the container.
Food Handling and Dishwashing Safety Failures
Penalty
Summary
The facility failed to ensure food was prepared, stored, served, and distributed in accordance with professional standards of food service safety when dietary staff did not follow required hair restraint practices during food preparation. During observation, Dietary Aide 2 wore a beanie in the kitchen without a hair restraint, and hair was exposed on the back and sides of the head. In addition, Dietary Aide 1 and a cook had beards without beard restraints while preparing food. During interview, the Dietary Supervisor confirmed the staff were not wearing the required hair net and beard restraints and stated these items were needed to prevent hair from contaminating food or food prep surfaces. The facility also failed to follow proper dishwashing procedures when a dietary aide touched dirty dishes on the soiled side of the dishwashing machine and then touched clean dishes without washing hands. During interview, the Dietary Supervisor confirmed this was not the correct process and stated the person working the soiled side should not touch the clean side without handwashing to prevent cross contamination and spreading bacteria. The facility policy required two employees for machine dishwashing, with one handling the soiled area and one handling the clean side, and required strict handwashing if an employee moved from the soiled to the clean end.
Infection Control Failures With PPE Use, Medication Cart Storage, and PICC Care
Penalty
Summary
The facility failed to follow and maintain an effective infection prevention and control program when staff did not wear required PPE while providing high-contact care to a resident on Enhanced Barrier Precautions (EBP). Resident 130 was admitted with diagnoses including UTI, hydronephrosis, kidney stones, and neuromuscular dysfunction of the bladder, had intact cognition, and used an indwelling catheter. The resident’s care plan and physician orders indicated EBP for the indwelling catheter, and the posted EBP signage directed staff to wear gloves and a gown for dressing, hygiene, changing briefs, and urinary catheter care. During observation, a CNA changed the resident’s gown, provided hygiene care, changed briefs, and handled the indwelling catheter while wearing gloves only and not a gown; the CNA later confirmed this, and the IP and DON stated staff should have worn both gloves and gown for high-contact care. The facility also failed to maintain proper medication cart storage when money was found inside the secondary locked section of a medication cart. During inspection, bills wrapped in paper were observed stored in the compartment containing controlled substance medications and antibiotics. The nurse present confirmed the money was stored in the cart and stated her understanding that money should not be kept there. The DON also acknowledged that money should not be stored in the medication cart. The facility policy stated that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The facility further failed to perform PICC line dressing changes as ordered for Resident 132. The resident was admitted with diagnoses including bacteremia and infection following a procedure, had intact cognition, and had a PICC line in the right upper extremity. The physician’s order required the PICC dressing to be changed weekly and as needed for soiling or displacement, and the care plan reflected the same. On observation, the dressing was dated 3/7/26, the tape securing it was peeling, and the dressing edge appeared brownish in color. The nurse confirmed the dressing should have been changed weekly to prevent infection, and the DON stated the dressing should be changed every week and labeled and dated to verify who changed it.
Delayed Sliding-Scale Insulin Administration
Penalty
Summary
The facility failed to administer Regular Insulin according to the sliding scale in a timely manner for one resident. During a medication observation, a Licensed Nurse was seen preparing medications for the resident and later administered Regular Insulin at 10:15 a.m. A review of the physician order showed the insulin was ordered as a sliding scale based on finger stick glucose results, with the resident’s 8:00 a.m. dose scheduled on the MAR. The MAR showed the 8:00 a.m. dose was given at 10:11 a.m., more than 2 hours after the blood glucose reading. During interview and record review, the Licensed Nurse stated the resident’s blood sugar was taken around 7:00 a.m. with a result of 239, and she acknowledged the Regular Insulin scheduled for 8:00 a.m. was administered after 10:00 a.m. The DON reviewed the record and confirmed the insulin was given outside the facility’s standard practice of administering insulin within 30 minutes of obtaining the blood glucose reading. The facility policy stated medications are to be administered in accordance with prescriber orders, including any required time frame, and that medication administration times are determined by resident need and benefit.
Suprapubic catheter drainage bag left on the floor
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with a suprapubic catheter. Resident 160 was admitted in March 2026 with diagnoses including malnutrition, benign prostatic hyperplasia, and obstructive and reflux uropathy. The resident’s MDS indicated moderately impaired cognition and that the resident used an indwelling catheter. The care plan identified the resident as having an indwelling catheter related to urinary retention and included goals to remain free from urinary infection and catheter-related trauma. The physician’s order specified a suprapubic catheter with a gravity drainage bag due to obstructive and reflux uropathy. During observation, Resident 160 was lying in bed awake with the urinary catheter tubing attached to a drainage bag that was on the floor. A later concurrent observation and interview with an LN confirmed the bag was still on the floor, and the LN stated it should not be left there because it could become contaminated and cause infection and urinary complications. The DSD and DON both stated catheter bags should be hanging on the bedside and not touching the floor, and that leaving the bag on the floor could cause infection, backflow of urine, and urinary complications. The facility policy titled Catheter Care, Urinary stated that catheter tubing and drainage bags should be kept off the floor.
Failure to Maintain Effective Pest Control Program Due to Missing Door Screens
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in residents' rooms. Observations and interviews revealed that two residents had flies in their rooms, with one resident confirming that flies were present all the time. Both rooms had sliding doors that were open and lacked screens, which was confirmed by a CNA. The Director of Maintenance acknowledged that 14 out of 16 sliding doors in the building did not have screening doors and confirmed an ongoing fly issue. The Director of Nursing also confirmed concerns regarding flies and expected staff to keep sliding doors closed until screens could be installed. A review of pest control service invoices for the preceding months showed ongoing pest control efforts, but these were not effective in preventing the fly issue. The facility's policy required an ongoing pest control program to keep the building free of insects and rodents, but the lack of screens on most sliding doors and the presence of flies in resident rooms demonstrated a failure to meet this standard.
Failure to Maintain Resident Dignity Due to Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure the dignity of a resident, who was admitted in the summer of 2016 with a diagnosis of muscle atrophy and wasting, by leaving him in a soiled brief for an extended period. The resident, who was totally dependent on staff for toileting, was observed to have a strong odor coming from his room, indicating he was soiled. Despite the resident's call light being on and his verbal expression of discomfort and upset due to being soiled, staff members, including CNAs and an Infection Preventionist, did not promptly address his needs. The resident remained in a soiled brief for an extended period, which was confirmed by multiple staff members, including a CNA and the Director of Nursing, who acknowledged the importance of timely changing to prevent dignity issues and skin problems. Interviews with staff, including CNAs, a Licensed Nurse, and the Director of Nursing, revealed a lack of timely response to the resident's needs, with staff indicating that they would inform the primary CNA or wait for another staff member to address the issue. The facility's policy on dignity, which prohibits demeaning practices and emphasizes the importance of promptly responding to residents' requests for toileting assistance, was not adhered to in this instance. The Social Service Director confirmed that the resident was alert and oriented, capable of expressing his needs, yet his requests were not promptly met, compromising his dignity and comfort.
Failure to Protect Residents from Peer Abuse
Penalty
Summary
The facility failed to protect three residents from abuse by their peers, resulting in incidents of physical and verbal abuse. In one case, a resident with major depressive disorder and schizophrenia, but who was cognitively intact, slapped another resident with severe cognitive impairment after an altercation involving personal belongings. Staff documentation and interviews confirmed that the physical contact occurred before staff could intervene, and the resident who was slapped was unable to recall the incident due to cognitive impairment. In another incident, a cognitively intact resident with a history of cellulitis and diabetes was observed by staff grabbing and punching the thigh of a severely cognitively impaired resident with end-stage renal disease and chronic respiratory failure. The staff member witnessed the physical aggression and noted that the aggressor had exhibited similar behaviors with a previous roommate during the same shift. The resident who was struck verbally threatened staff during an interview and did not wish to continue the conversation. A third incident involved a resident with difficulty walking and muscle weakness who experienced racial and verbal abuse from a roommate, leading to emotional distress and a panic attack. Staff and family members confirmed that the resident was subjected to racial slurs and mocking language, resulting in the resident being moved to another room and requiring medication for anxiety. The facility's policy prohibits all forms of abuse, including verbal and physical, but these incidents demonstrate that residents were not adequately protected from peer abuse.
Failure to Follow Therapeutic Diet Menus
Penalty
Summary
The facility failed to adhere to the planned menu for therapeutic diets during a lunch meal distribution, affecting 128 residents. Specifically, 20 residents on controlled carbohydrate (CCHO) diets received margarine, which was not part of their prescribed diet. Two residents on CCHO and renal diets did not receive the correct meal components, such as baked fish and wheat rolls, as indicated on the menu. Additionally, nine residents on puree diets did not receive the puree wheat roll as specified. Furthermore, all 128 residents did not receive the parsley garnish that was supposed to accompany their meals. These deficiencies were identified through observation, interviews, and record reviews. The Director of Dietary Services acknowledged the issues, attributing the lack of parsley garnish to a failure to order it. The Registered Dietitian confirmed awareness of the issues and emphasized the importance of following the menu/spreadsheet. The facility's policy mandates that menus meet the nutritional needs of residents and comply with the diet manual, which was not followed in this instance.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety in several areas, as observed during a survey. The ice machine was found to be unclean, with significant dark brown and yellow substances identified as calcium buildups on the evaporator unit. The maintenance department was responsible for monthly cleaning, while an outside vendor was tasked with deep cleaning every three months. However, despite a recent service, the machine was still dirty, indicating a lapse in the cleaning process. Additionally, various kitchenware items were improperly stored while still wet and with food particles, contrary to the facility's policy that requires them to be clean and air-dried before storage. The facility also failed to maintain proper sanitation standards in other areas. An air gap was missing from the fruit and vegetable prep sink, which is necessary to prevent backflow and contamination. Furthermore, a dietary aide incorrectly verbalized the manual dishwashing process, stating that dishes were immersed in sanitizer for only two seconds instead of the required 60 seconds. This discrepancy highlights a lack of proper training or adherence to established procedures, which could compromise the sanitation of kitchenware. Lastly, two kitchen staff members were observed without proper beard restraints, using medical masks instead. This was against the facility's dress code policy, which mandates beard restraints to prevent hair from contacting food and clean equipment. These deficiencies collectively posed a risk of food contamination, potentially affecting all 128 residents who rely on the facility's kitchen for their meals.
Improperly Secured Garbage Dumpster
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors by not securely closing one of two garbage dumpsters located outside the facility. During an observation and interview with the Dietary Assistant Manager, it was noted that the lids of one dumpster were not securely covering the bin, leaving gaps on both sides. The Dietary Assistant Manager confirmed that the lids lacked integrity and agreed that this was unacceptable. In a subsequent interview, the Registered Dietitian stated that the dumpster lids should be tightly closed without any openings or gaps to prevent pest and rodent issues. A review of the facility's policy indicated that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers, and the trash collection area must be kept clean to avoid attracting vermin and rodents. The 2022 FDA Food Code also requires outside receptacles containing food residue to have tight-fitting lids, doors, or covers.
Controlled Medication Accountability and Storage Deficiencies
Penalty
Summary
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents. Controlled medications were signed out of the Controlled Drug Record (CDR) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. For instance, Resident 69 had tramadol signed out on two occasions, but the MAR did not reflect administration. Similarly, Resident 58 had discrepancies between the CDR and MAR for oxycodone, and Resident 65 had tramadol signed out without corresponding MAR documentation. The Director of Nursing (DON) confirmed that nursing staff were expected to document administered doses on both the MAR and CDR. The facility also failed to maintain medication accountability during shift changes, as evidenced by missing signatures on controlled drug sign-in/sign-out sheets for two medication carts. Nine signatures were missing for Medication Cart 2A, and five were missing for Medication Cart 1C. Licensed Nurses 7 and 8 acknowledged the missing signatures and confirmed the expectation for both outgoing and incoming nurses to sign the sheets during shift changes. The facility's policy required controlled substances to be reconciled at the end of each shift, with both nurses determining the count together. Additionally, the facility did not have an efficient system to document and secure emergency medications (E-Kit). An inspection revealed discrepancies in the E-kit log, with missing documentation for removed oxycodone tablets and Ativan vials. The DON stated that nursing staff were expected to ensure accurate E-kit logs and request replacements promptly. Furthermore, medications were not secured safely, as multiple medication carts contained retrievable crushed and partially crushed medications, including controlled substances. The DON confirmed that medications should be rendered irretrievable before disposal, as per the facility's policy.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use. Resident 7 was administered Seroquel for bipolar disorder without the implementation of non-pharmacological interventions to attempt a gradual dose reduction or discontinuation of the medication. The Director of Nursing confirmed that the care plans did not include non-drug interventions, despite the facility's policy requiring such measures to minimize medication use. Resident 128 was given Seroquel without adequate indication for its use. The resident's medical records showed a series of orders for Seroquel with varying dosages and indications, none of which were supported by documented evidence of hallucinations or delusions. Interviews with staff and the resident revealed that the resident did not exhibit symptoms of schizophrenia, and the resident expressed concern over a misdiagnosis. The facility's policy stated that antipsychotic medications should only be used when clinically indicated, which was not adhered to in this case. Resident 25's behavior order for Lorazepam did not match the behavior being monitored, and there was no documented evidence of non-pharmacological interventions being used when behaviors occurred. The resident's care plan and medication administration records showed inconsistencies in the behavior being monitored and the behavior for which the medication was prescribed. Interviews with staff indicated that non-drug interventions were not consistently documented, despite the facility's policy requiring such documentation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 12.5% during a medication pass. This was based on four medication errors out of 32 opportunities observed for three residents. The errors included incorrect dosing and administration of medications, which were not in accordance with the prescriber's orders or manufacturer's specifications. For Resident 110, a Licensed Nurse (LN 2) was observed preparing diclofenac gel but measured only 2 grams instead of the prescribed 4 grams. This discrepancy was confirmed during a review of the resident's medical record and an interview with LN 2. The facility's policy required medications to be administered as per the prescriber's orders, which was not followed in this instance. Resident 104 experienced two medication errors. LN 2 failed to prime an insulin aspart pen before administration and incorrectly measured ClearLax, not filling it to the indicated line for the correct dose. These errors were acknowledged by LN 2 during interviews. Additionally, Resident 12 was given glipizide without a meal, contrary to the manufacturer's instructions, which could lead to hypoglycemia. LN 3, who administered the medication, was unsure of the timing considerations for glipizide. The facility's policy emphasized the importance of administering medications in a safe and timely manner, which was not adhered to in these cases.
Medication Storage and Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. During an inspection of medication carts and storage rooms, it was observed that medications were not stored according to manufacturer specifications. For instance, a bottle of acidophilus was not refrigerated as required, and an acetic acid irrigation solution was opened without an open or discard date. Additionally, discontinued medications were not disposed of properly, as evidenced by an opened box of aformoterol left on a shelf instead of being placed in the drug disposal bin. Medication carts were found to be disorganized and not securely locked when unattended. Controlled medications, such as phenobarbital, were not stored in the designated controlled drug drawer, and medications like clonidine patches were comingled with oral medications. Furthermore, several inhalers and nasal sprays lacked resident-specific labels, increasing the risk of incorrect administration. Expired medications, such as labetalol, were also found in the carts, and some medications were stored without proper labeling or dating, such as EvenCare G3 test strips and budesonide inhalation solution. Resident 81's case highlighted additional issues with medication management. The resident, who had multiple diagnoses including COPD and moderate cognitive impairment, was found with an albuterol inhaler at the bedside without an assessment or order to self-administer. Despite staff acknowledging the risk of overmedication and the need for the inhaler to be stored in the med cart, it remained at the bedside. The facility's policies indicated that medications should not be stored at the bedside unless authorized, which was not the case for Resident 81.
Lack of Written Agreements for Dialysis Services
Penalty
Summary
The facility failed to ensure that services provided by outside resources, specifically dialysis services, had written agreements in place. This deficiency was identified for three residents who were receiving dialysis treatment without existing agreements with the dialysis clinics. The absence of these agreements could lead to a lack of responsibility and accountability in the dialysis services provided to the residents. Resident 36 was admitted with end-stage renal disease and required dialysis. The care plan and physician orders indicated the need for dialysis, but during interviews, the Administrator and Director of Transportation Services admitted that there was no current contract with the dialysis clinic. The agreement provided was outdated and lacked specific details, and the facility was unable to produce a valid contract during the survey. Similarly, Resident 15, who was severely cognitively impaired and dependent on dialysis, was also receiving dialysis services without a contract in place. Despite multiple attempts by the Director of Transportation Services to obtain a contract from the dialysis clinic, the facility was unable to secure one. Resident 51, also dependent on dialysis, was in a similar situation, with the facility still waiting for a contract from the dialysis center at the time of the survey.
Infection Control Deficiencies in Equipment Handling and Environmental Cleanliness
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper handling and storage of medical equipment and environmental cleanliness issues. Resident 36's nasal cannula was repeatedly observed on the floor in their room, both when the resident was present and absent, despite the facility's policy requiring such equipment to be stored in a protective bag. Similarly, Resident 46's nasal cannula was also found on the floor, contrary to the facility's infection control expectations. Interviews with staff confirmed these observations and acknowledged the potential for contamination. Environmental issues were also noted in the facility's laundry room, where dust particles were observed on vents above the clean linen area, and moisture and dust were present at the back of the washers. The Director of Environmental Services confirmed these observations, acknowledging that the dust could contaminate clean linens and that the moisture and lint on the ground were not acceptable. The facility's policies require maintenance personnel to follow infection control precautions, which were not adhered to in this instance. Resident 71's nebulizer tubing and mask were improperly stored in a drawer without a protective bag and were not labeled with the date of change, as required by the facility's policy. The oxygen concentrator humidifier bottle was also not labeled with the date of change. The Infection Preventionist and Director of Nursing confirmed these deficiencies, noting that the improper storage and lack of labeling put the resident at risk for infection. Resident 3's oxygen tubing was similarly found on the floor, with the nasal cannula not properly stored, which was confirmed by a Certified Nursing Assistant and the Director of Nursing.
Deficiency in Laundry Room Maintenance
Penalty
Summary
The facility failed to maintain the building and equipment in a functional and operable manner, as evidenced by the condition of the laundry room. During an observation and interview, it was noted that the floor at the back of the washer was wet, and the pipes were dirty, corroded, and leaking. One pipe was observed to be corroded with a greenish color, and the leakage was confirmed to be coming from this pipe. The Director of Environmental Services acknowledged the issue and mentioned that a company had been contacted for repairs, but no confirmation on the repair timeline was available. The Infection Preventionist also confirmed the presence of moisture and lint on the ground, which was not in line with the facility's expectations. A review of the facility's maintenance policy indicated that maintenance service should ensure all areas of the building, grounds, and equipment are safe and operable at all times.
Failure to Obtain Informed Consent from Authorized Representative
Penalty
Summary
The facility failed to obtain informed consents from the authorized resident representative for a resident, identified as Resident 97, who was admitted with major depressive disorder and dementia. The resident's records indicated severe cognitive impairment, and the spouse was designated as the responsible party (RP). However, consents for treatment, Physician Orders for Life-Sustaining Treatment (POLST), and psychotropic medication were signed by individuals not listed as the RP, such as the resident's daughter-in-law and son. Interviews with facility staff, including a licensed nurse, the Assistant Director of Staff Development, and the Nurse Supervisor, revealed that verbal consents were obtained from individuals other than the RP, contrary to the facility's policy. The staff acknowledged that the RP's name was on the resident's chart, and the expectation was for the RP to sign the consents. The Director of Nursing and Nurse Consultant confirmed the discrepancy and stated that the RP should have been contacted for consent, as the RP has the decision-making capacity for the resident's care. The facility's policies and procedures emphasized the importance of obtaining consents from the resident representative, especially when the resident is deemed incompetent. The policies outlined that the RP should be informed of the care, risks, and benefits of treatments, and that informed consent for psychotropic medications should be verified and documented. The failure to adhere to these policies resulted in the deficiency, as the consents were not obtained from the designated RP, potentially compromising the resident's rights and care decisions.
Failure to Secure Resident Health Data
Penalty
Summary
The facility failed to protect and secure confidential resident health data and records for a census of 132 residents. During an observation, a computer on Medication Cart 2A was left unattended with a resident profile open, facing the resident hallway. This incident occurred in hallway 2A and was observed at 4:30 p.m. on January 7, 2025. Licensed Nurse 7 acknowledged the computer was left unlocked and unattended, making resident records accessible to unauthorized individuals, which he recognized as a violation of confidentiality. The Director of Nursing confirmed that nursing staff are expected to ensure resident records are not visible to unauthorized staff. The facility's policy, dated March 2014, states that only authorized persons with a password and user ID should access the electronic medical records system.
Failure to Notify Resident's Representative of Bed Hold
Penalty
Summary
The facility failed to provide written notice of bed hold to the responsible party (RP) of a resident when the resident was transferred to a hospital. The resident, who was severely cognitively impaired and unable to make their own decisions, was transferred to an acute care hospital for further evaluation due to hypotension and an infected catheter site. Despite attempts to contact the RP, the call went to voicemail, and no written notice of the bed hold was documented in the resident's clinical record for this transfer. The facility's policy requires that all residents or their representatives be provided with written information regarding bed-hold policies at the time of transfer or within 24 hours in the case of an emergency. However, the Director of Nursing acknowledged that the Transfer and Bed Hold Form was not completed, and the RP was not notified of the bed hold for the resident's transfer to the hospital. This oversight was identified during a review of the resident's clinical records and interviews with facility staff.
Failure to Administer Psychotropic Medication Upon Admission
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following their admission policy and procedure, resulting in a psychotropic medication order not being carried over for a resident upon admission. This oversight led to the resident not receiving their prescribed Citalopram, a medication for depression, for eight days. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a history of depression and was on Citalopram 20 mg daily as per their hospital discharge orders. However, the medication was not documented in the facility's records upon admission, and the resident experienced withdrawal symptoms as a result. The resident reported symptoms such as shaking, crying, nausea, dizziness, and muscle pain, which they attributed to the lack of their antidepressant medication. Despite informing the facility staff multiple times, the medication was not administered. The admitting nurse and the Director of Nursing confirmed that the medication order was missed during the admission process, which involved reviewing and reconciling hospital discharge orders with the admitting physician. The facility's policy on medication reconciliation, which aims to prevent medication errors and ensure accurate communication of medication orders, was not followed in this instance.
Failure to Provide Necessary Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide necessary foot care for a resident, identified as Resident 51, who had long and thick toenails. Resident 51, who was admitted with type 2 diabetes mellitus and diabetic chronic kidney disease, had not received podiatry care since admission, despite a physician's order for podiatry care every two months. The resident, who was cognitively intact, reported not having seen a podiatrist since admission, and observations confirmed the toenails were long and thick. Certified Nursing Assistant 2 noted the need for toenail clipping about a month prior, but the issue was not addressed. The facility's internal communication failed to ensure the resident received podiatry care. The Assistant Director of Staff Development stated that concerns noted in shower sheets should be directed to the responsible person, but the Social Services Director did not receive any notification regarding the resident's toenails. The Nurse Supervisor confirmed the need for podiatry care upon observing the resident's toenails. The facility's policy indicated that diabetic residents should not have their toenails trimmed by staff, and they should be referred to podiatry services if necessary. However, there was no documented evidence that the resident's podiatry appointments were rescheduled after being missed.
Failure in Communication of Anemia Management for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication and collaboration between the facility and the dialysis clinic regarding the anemia management of a resident with end-stage renal disease (ESRD) and anemia. The resident was admitted with diagnoses including ESRD and anemia, and their care plan required the administration of Epoetin Alfa at the dialysis center. However, the facility's Medication Administration Records (MARs) indicated that the medication was signed off as given at dialysis, despite the dialysis communication sheets showing that the resident did not receive Epoetin Alfa during dialysis. Instead, the resident was receiving Mircera, a different anemia medication, every two weeks, which was not communicated to the facility. The dialysis nurse confirmed that Epoetin Alfa had been discontinued and replaced with Mircera. The Director of Nursing and Nurse Consultant acknowledged the lack of communication regarding the medication change, which resulted in the facility being unaware of the resident's current anemia management. This oversight decreased the facility's ability to monitor the medication's effectiveness and side effects, as outlined in their policies and procedures.
Failure to Conduct Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to ensure that the consultant pharmacist (CP) conducted a Medication Regimen Review (MRR) for a resident, identified as Resident 128, who was admitted with diagnoses including Major Depressive Disorder, schizophrenia unspecified, and diabetes. The resident had several physician's orders for Seroquel, an antipsychotic medication, with varying dosages and indications for use. Despite these orders, the CP did not complete an MRR for Resident 128 in December 2024, as confirmed by both the Pharmacy Manager and the Director of Nursing during interviews and record reviews. The facility's policy and procedure, dated May 2019, clearly stated that the CP is responsible for performing an MRR for every resident receiving medication, particularly upon admission. However, the CP failed to adhere to this policy, resulting in inadequate monitoring of Resident 128's medication regimen. This oversight had the potential to impact the optimization of the resident's medications for the best possible health outcome, as the irregularities in the medication regimen were not identified or reported by the CP.
Failure to Accommodate Dietary Preferences and Requirements
Penalty
Summary
The facility failed to accommodate the special dietary requirements for two residents during a lunch observation. Resident 106, who has dysphagia, was served a puree meal that included broccoli, despite having a documented dislike for broccoli on his meal ticket. The Certified Nursing Assistant (CNA) confirmed the presence of broccoli and acknowledged that the resident did not want it. The Director of Nursing (DON) stated that staff are expected to review meal tickets and provide alternatives if a disliked food is served. Resident 108, who is on a mechanical soft diet, did not receive the gelato he preferred, as indicated on his meal ticket. The Assistant Director of Staff Development (ADSD) confirmed the absence of gelato on the meal tray and acknowledged that it should have been provided. The Director of Dietary Services (DDS) stated that resident preferences, as indicated on meal tickets, should be honored. The facility's policy on food preferences requires that dislikes be substituted with appropriate alternatives.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible for two residents, leading to potential unmet needs and delayed staff response. Resident 22, who was admitted with multiple diagnoses including generalized muscle weakness, had a moderate cognitive impairment and required substantial assistance for mobility. During an observation, Resident 22's call light was found on the floor, out of reach, despite the care plan indicating it should be within reach and monitored every two hours and as needed. Similarly, Resident 82, who was cognitively intact but dependent on staff for mobility, had their call light pinned between the bed rail and bed frame, making it inaccessible. Resident 82 expressed difficulty in calling for help due to the call light's position. The Director of Nursing confirmed the call lights were out of reach for both residents and stated that staff are expected to ensure call lights are accessible. The facility's policy requires each resident to have a means to call staff directly for assistance from their bed.
Resident Leaves Facility Unsupervised Due to LOA Policy Failure
Penalty
Summary
The facility failed to identify and prevent a resident from leaving the premises without staff awareness or a physician's order for a Leave of Absence (LOA). The resident, who was admitted with multiple diagnoses including acute osteomyelitis, pressure injury, and generalized muscle weakness, was cognitively intact but dependent on assistance for mobility. Despite these needs, the resident left the facility with an unidentified person and was not noticed missing until he returned on his own. The incident occurred when the resident, who was wheelchair-bound and required assistance for transfers, left the facility using a rideshare service to visit his son. The staff, including the assigned CNA and charge nurse, were unaware of the resident's departure due to a lack of communication and understanding of the LOA policy. The CNA, a new hire, mistakenly believed the person taking the resident was his son and did not verify the LOA process, leading to the resident's unsupervised exit. Interviews with facility staff and family members revealed confusion and miscommunication regarding the resident's whereabouts and the facility's discharge procedures. The Director of Nursing acknowledged the mistake, attributing it to the resident's room change and possible misunderstanding of being discharged. The facility's policy required a physician's order and proper documentation for LOA, which was not followed, resulting in the resident's unsupervised and potentially unsafe absence from the facility.
Inadequate PPE Use and Availability for Residents on Enhanced Standard Precautions
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (IPCP) for a census of 134 residents. Specifically, a staff member did not wear the required personal protective equipment (PPE) while providing catheter care for a resident on Enhanced Standard Precautions (ESP). Additionally, PPE was not readily available outside the rooms of three residents on ESP, increasing the risk of cross-contamination and potential infections among residents. The Licensed Nurse (LN) was unfamiliar with the necessary PPE requirements and did not use a gown or mask when changing the resident's indwelling urinary catheter. Observations and interviews revealed that PPE, including gowns, gloves, and masks, were not available outside the rooms of residents on ESP. The Director of Nursing (DON) acknowledged that not using required PPE could lead to infection. The facility's policy and procedure, as well as CDC guidelines, emphasize the importance of PPE availability and staff training for effective implementation of Enhanced Barrier Precautions. The deficiency was identified through a review of admission records, care plans, and physician's orders, highlighting the facility's failure to adhere to established infection control protocols.
Failure to Respond to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to promote individual care and dignity by not responding to the call lights of three residents in a timely manner, leading to unmet needs and feelings of discomfort, embarrassment, and helplessness. Resident 1's family member reported that the resident, who was cognitively intact and had control over bladder and bowel functions, often had to wait over an hour for assistance, resulting in incontinence. The resident's care plan indicated a need for assistance with activities of daily living (ADLs) and maintaining skin integrity, but these needs were not met due to delayed staff response. Resident 5, who was also cognitively intact, expressed dissatisfaction with the call light response, stating that he often had to wait 30 minutes or longer for help, which put him at risk of spilling his urine bottle. Observations confirmed that Resident 2, who had multiple diagnoses including difficulty walking and a recent shoulder dislocation, was left waiting for over an hour for assistance to use the commode. The resident was found standing in the doorway with wet incontinence briefs, visibly distressed and tearful, as staff walked by without offering help. Interviews with staff, including CNAs and the Director of Nursing (DON), revealed a lack of adherence to the facility's policy on timely call light response. CNA 1 and LN 1 failed to assist Resident 2 promptly, and CNA 3, who was late for her shift, assumed other staff would attend to her residents. The DON acknowledged the issue and stated that call lights should be answered within 5-10 minutes, but observations showed that this standard was not met, resulting in compromised resident dignity and care.
Failure to Timely Report Investigation Results
Penalty
Summary
The facility failed to report the results of a 5-day investigation within the required timeframe for two residents involved in an altercation. Resident 1 scratched Resident 2 during an incident where Resident 2 approached Resident 1, exclaiming for her to leave, and swiped her hand towards Resident 1. In response, Resident 1 grabbed Resident 2's hand and swiped her own hand towards Resident 2's chest, resulting in three prominent scratch marks. The facility did not provide documented evidence to the California Department of Public Health (CDPH) that a summary of the investigation and appropriate corrective actions were submitted within 5 working days of the incident. The Director of Nursing (DON) confirmed during an interview that the 5-day follow-up investigation summary was not submitted within the required timeframe.
Cluttered Evacuation Routes and Non-Functional Alarms
Penalty
Summary
The facility failed to ensure a safe environment for residents, staff, and the public by allowing evacuation routes to be cluttered with carts, bedside commodes, linen bins, and garbage bins. This deficiency was observed in a 139-bed facility and was highlighted by Resident 4, who expressed concerns about safety. Resident 4, admitted for aftercare of back surgery, demonstrated the issue by attempting to navigate an emergency exit route in his wheelchair. The route was obstructed by various items, making it impossible for him to pass through safely. Additionally, the emergency exit alarms did not sound when the doors were opened, further compromising safety. The Director of Nursing (DON) confirmed the presence of clutter and non-functional alarms during a concurrent observation and interview. The DON acknowledged that the evacuation routes should have been kept clear and that the garbage and linen bins should have been covered for infection control. A Certified Nurse Assistant (CNA) also confirmed that the bins were regularly placed outside the exit doors for staff use, despite knowing that these routes were designated for emergency use. The facility's policy stipulated that exits should be kept clear at all times to allow for rapid evacuation, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodside Healthcare Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Sherwood Healthcare Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Gramercy Court | 2.2 mi | ★★★★★ | 16 | 0 |
| Arden Park Post Acute | 2.3 mi | ★★★★★ | 15 | 0 |
| Mckinley Park Care Center | 2.7 mi | ★★★★★ | 31 | 0 |
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