Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atherton Baptist Home during CMS and state inspections, most recent first.
Failure to Provide Supervision in Activity Room and During a Fall Event: Two residents with mobility limitations and fall risk were left unsupervised in the activity room, and one resident was later found on the floor after a bed alarm sounded. The residents had diagnoses and MDS findings showing cognitive impairment or dementia, use of a walker and wheelchair, and assistance needs with transfers, toileting, dressing, bathing, and walking. The IPN, LVN, and DON stated staff should have been present in the activity room, but no staff were observed there during the event.
Failure to Act on CP MRR Recommendations: The DON and facility staff did not timely document physician review or action on CP medication regimen review findings for two residents. One resident on escitalopram and hydrocodone/acetaminophen had recommendations for a GDR, daytime dosing, and MAR clarification for respiratory monitoring, while another resident on lorazepam had a recommended GDR or explanation if contraindicated. Facility policy required recommendations to be acted upon and documented by staff and/or the prescriber.
Unnecessary Psychotropic Medication Use Not Supported by Specific Behavior Indication: A resident with dementia, depression, and anxiety was ordered Seroquel for psychosis with behavior monitoring for paranoia, but the order and care plan did not specify the exact paranoid behaviors to be monitored. An LVN and the DON stated the resident’s reported behaviors included hallucinations, agitation, aggression, and accusing staff of taking belongings, and staff noted the order should have identified the specific behavior so the medication’s effectiveness could be evaluated.
Incomplete Care Plan for HD CVC Access: A resident with ESRD receiving HD through a CVC did not have a comprehensive care plan addressing the CVC itself. The resident was cognitively intact, independent with many ADLs and mobility tasks, and reported HD three times weekly with an E-Kit kept at the bedside. The DON confirmed the existing ESRD care plan did not include CVC presence or management, and the facility policies reviewed did not specifically address what to do if the CVC became dislodged or damaged.
Failure to Follow Hearing-Impaired Communication Care Plan: A resident with dementia, severe cognitive impairment, and hearing difficulty was observed without hearing aids and without a writing board, paper, or pencil at bedside. The care plan called for assistive communication devices and for staff to put on the resident’s hearing aid during communication, but the IPN observed the resident yelling that she could not hear and had to look for a writing board. The DON confirmed the resident should have writing materials available to help communicate with staff.
Failure to assess and report bruising in a resident on anticoagulants. A resident with AFib, TIA, and HTN was receiving Aspirin and Xarelto, and care plan directions required q shift monitoring for bleeding and daily skin checks. The resident showed a dark purple bruise on the arm, but staff did not document or promptly report the discoloration to the MD; interviews showed CNA and LVN communication gaps and the IPN stated the change in condition should have been reported as soon as possible.
Personal belongings not fully documented on inventory list. A resident with age-related physical debility, unsteadiness on feet, muscle weakness, and moderately impaired cognitive skills had an inventory list that documented only one extender, while two extenders were observed in the room and the SSD confirmed the resident had two on readmission. The DON stated residents’ personal items are to be documented in the inventory, and the facility policy required personal belongings and clothing to be inventoried and documented upon admission and as items are replenished.
Two residents with significant pain management needs received PRN orders for Tramadol and Tylenol without pain scale parameters, resulting in a lack of guidance for nursing staff on when to administer each medication. Interviews with LPNs and the DON confirmed that the absence of pain scale parameters could lead to inappropriate administration, contrary to facility policy requiring such specifications for PRN medications.
The facility failed to prevent accidents for three residents by not ensuring functional bed sensor pads and accessible call lights, and by not addressing underlying causes of falls. A resident with severe cognitive impairment did not have a working bed sensor pad or reachable call light. Another resident with a history of falls lacked specific interventions in their care plan to prevent reoccurrence. A third resident's sensor pad alarm was not properly positioned or turned on, failing to alert staff when the resident attempted to stand.
The facility failed to label and store food items properly in accordance with its policy, as observed in the kitchen's walk-in refrigerator, freezer, and dry storage area. Items such as marinated fish, Jello, banana bread, frozen meat, snap peas, waffles, cream puffs, and biscuit mix were found without necessary labels or coverings, posing a risk of contamination. The dietary supervisor and director confirmed the labeling and covering requirements.
A resident with spinal stenosis and osteoporosis was not provided reasonable accommodation during meals, leading to discomfort and exhaustion. The resident was observed eating with her plate on her lap due to the dining table being too high, causing her to hunch and experience pain. Attempts to adjust her seating were ineffective, and the facility's policy on accommodating individual needs was not followed.
A resident experienced a significant weight loss of 23 pounds over three days, which was not reported to the physician until four days later, contrary to the facility's policy. The resident, with conditions including hyperlipidemia and dementia, had a care plan to maintain a weight of 184 pounds, but their weight dropped to 161 pounds. Interviews with staff revealed that the facility's protocol required notifying the physician of such weight loss within a shift, which was not followed, potentially delaying necessary care.
A resident's EHR was left exposed on an unattended computer screen in a hallway, violating HIPAA and facility policy. An LVN admitted the error, and another LVN emphasized the importance of protecting resident information.
A facility failed to provide Restorative Nursing Services as ordered for a resident with chronic conditions, who required AROM exercises five times a week. The services were only provided three times a week, with no documentation of refusals, despite the resident's need to maintain functional status and prevent contractures. The deficiency was confirmed by the Care Plan Coordinator and the Director of Occupational Therapy.
A facility failed to ensure a physician addressed a pharmacist's recommendation for a gradual dose reduction of Ativan for a resident with anxiety. Despite the recommendation, the physician assistant only changed the administration time and reduced the dose of another medication, mirtazapine, without decreasing the Ativan dose. The medical doctor did not document a reason for not accepting the recommendation, contrary to facility policy, potentially leading to adverse medication outcomes.
A facility failed to assess the continued need for Tylenol for a resident who had not received the medication as needed for over 90 days. The resident, with impaired cognitive skills and no reported pain, was still prescribed Tylenol every four hours as needed. The DON confirmed the medication was unnecessary, as the resident's pain was managed with a regular dose. The facility did not follow its policy to periodically re-evaluate medications.
A facility failed to label a medication bottle with the date it was opened, as required by policy, during administration to a resident with Parkinson's disease. The resident required significant assistance with daily activities and had moderately impaired cognitive skills. LVNs confirmed the importance of labeling for tracking and proper administration, aligning with the facility's policy to record the opening date on multi-dose containers.
A resident with a history of weight loss was not provided with food that matched her preferences, as observed during a survey. Despite having a care plan that required offering alternative meals, the resident's tray lacked items listed on her tray card. The CNA admitted to not checking the tray card, and the DON emphasized the importance of following food preferences to maintain dignity and encourage eating. Facility policies on accommodating dietary needs were not adhered to, resulting in the deficiency.
Failure to Provide Supervision in Activity Room and During Fall Event
Penalty
Summary
The facility failed to provide supervision for two residents in the activity room and during a fall event. Resident 12 had diagnoses including dementia, repeated falls, reduced mobility, unsteadiness on feet, generalized muscle weakness, difficulty walking, and osteoporosis. The MDS showed the resident used a walker and wheelchair and required varying levels of assistance with transfers, toileting, dressing, bathing, and walking. The care plan identified the resident as at risk for falls and included interventions such as anticipating and meeting needs, reviewing prior falls, and frequent visual monitoring during medication pass, activities of daily living care, mealtimes, activity, and therapy. On 1/12/2026, Resident 12’s progress notes documented that the bed alarm sounded and staff found the resident on the floor in a side-lying position with a bump on the left side of the forehead and discoloration below the knee. During a concurrent observation in the activity room, Resident 12 was seen sliding off the wheelchair while no staff were present in the room. The IPN stated there were no staff present in the activity room and that this was not acceptable because residents may need help and may fall. LVN 3 stated there should be staff present in the activity room to ensure residents are not left unattended, and the DON stated the care plan was not followed and that it could not be determined when Resident 12 was last seen by staff before the fall. Resident 18 also had diagnoses including hypertensive chronic kidney disease, age-related physical debility, unsteadiness on feet, and generalized muscle weakness. The MDS showed moderate cognitive impairment, use of a walker and wheelchair, and assistance needs with eating, oral hygiene, toileting, personal hygiene, transfers, walking, dressing, footwear, and bathing, along with urinary and bowel incontinence. During the same observation in the activity room, Resident 18 was unattended and no staff were observed in the room. Resident 18 stated there were no staff in the activity room, that he felt anxious and uneasy without staff available to help him use the restroom, and that he needed to go immediately when he had to use the restroom. LVN 3 and the DON stated residents should not be left unsupervised in the activity room and that staff should be present to ensure resident safety.
Failure to Act on Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that physician review and action occurred in a timely manner on medication regimen review irregularities identified by the consultant pharmacist for two residents. One resident had diagnoses including dementia with psychotic disturbance, depression, pain in the right hip, and anxiety disorder, and was receiving escitalopram 20 mg at bedtime and hydrocodone/acetaminophen 5-325 mg, 0.5 tablet as needed. The consultant pharmacist identified that escitalopram did not appear to be showing behaviors to support continued use at the current dose, recommended considering a gradual dose reduction to 10 mg daily with the goal of discontinuance, and suggested changing the administration time to daytime. The consultant pharmacist also recommended clarifying hydrocodone/acetaminophen MAR instructions by adding a respiratory rate hold parameter and documenting respiratory rate on the MAR. For that same resident, the record review showed severe impairment in cognitive skills for daily decision making, partial/moderate assistance with some activities of daily living, scheduled pain medication use, and no mood or behavior symptoms documented on the December MAR. During interview, the LVN stated the DON was responsible for the medication regimen review and that neither physician notification nor changes related to the consultant pharmacist’s recommendations were documented. The DON stated there was no specific time frame for completing the medication regimen review, that it should at least be completed within the month, and that follow-up was needed to see whether the physician agreed with the consultant pharmacist’s recommendations. The facility policy stated recommendations are to be acted upon and documented by facility staff and/or the prescriber, and that the physician accepts and acts upon the suggestion or rejects it with an explanation by the next physician visit. A second resident had diagnoses including dementia, depression, anxiety, and impulse disorder, with severe impairment in cognitive skills for daily decision making and no mood or behavior symptoms documented. The resident was ordered lorazepam 0.25 mg in the afternoon for anxiety and lorazepam 1 mg in the evening for anxiety. The consultant pharmacist recommended considering a dose reduction by discontinuing the afternoon dose or decreasing the evening dose to 0.5 mg, and asked that if a gradual dose reduction was contraindicated, the reason be specified. The DON stated the medication regimen review with the gradual dose reduction recommendation was not addressed by the resident’s primary care physician and that the recommendation should have been reported within a week, while the facility policy stated recommendations are to be acted upon and documented by facility staff and/or the prescriber and that the physician accepts, acts upon, or rejects the suggestion with an explanation by the next physician visit.
Unnecessary Psychotropic Medication Use Not Supported by Specific Behavior Indication
Penalty
Summary
The facility failed to follow its policy to ensure a resident’s drug regimen was free from unnecessary medication use for one sampled resident. Resident 2 was admitted with diagnoses including unspecified dementia, depression, and anxiety disorder, and the MDS dated 10/31/2025 indicated severely impaired cognitive skills for daily decision making, need for assistance with multiple ADLs, and no mood or behavior symptoms. Resident 2’s order summary dated 12/24/2025 showed an order for Seroquel 25 mg by mouth twice daily for psychosis manifested by periods of paranoia, with behavior monitoring every shift for psychosis manifested by periods of paranoia. The care plan dated 1/29/2025 identified psychotropic medication use related to psychosis and included interventions to monitor and record target behavior symptoms of periods of paranoia and document per facility protocol. During interviews, LVN 1, LVN 2, and the DON stated that Resident 2’s behavior monitoring order did not specify the exact paranoid behavior to be monitored. LVN 1 stated the resident’s reported behaviors included seeing things that were not there and saying someone took her daughter or was going to hurt her, and stated those behaviors were hallucinations and not paranoia. LVN 2 stated the resident’s behaviors also included agitation, aggressive behavior, and accusing staff of taking her things, and stated the specific paranoid behavior should have been identified in the physician’s order. The facility policy stated antipsychotic medications should only be used when necessary for specific conditions for which they are indicated and effective, and that staff should gather and document information to clarify the resident’s specific symptoms and risks.
Incomplete Care Plan for HD CVC Access
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for one resident with ESRD who was receiving HD through a CVC. The resident was admitted with diagnoses including ESRD with dependence on renal dialysis and hypertension. The MDS dated 12/29/2025 indicated the resident had intact cognitive skills for daily decision making, was independent with many activities of daily living and mobility tasks, and was on dialysis with intravenous access. During an observation and interview on 1/13/2026, the resident stated she received HD every Monday, Wednesday, and Friday and had a CVC for access. She also stated there was an E-Kit on the shelf next to her bedside table. During a concurrent interview and record review with the DON, the facility’s policies on access and care of HD catheters and care of a resident with ESRD were reviewed. The DON stated the policies did not specifically address care of the CVC if accidental dislodgement occurred and stated that, for best practice, the policy should include how to manage the CVC if it became dislodged or damaged. The DON also reviewed the resident’s care plans focused on potential complications of HD related to ESRD and ESRD care. The DON stated the resident had a CVC on the right upper chest and did not have, but should have had, a care plan specifically for the CVC to address risks, complications, and interventions. The reviewed ESRD care plan did not indicate the presence and management of HD CVC access. The facility’s policy for comprehensive person-centered care plans stated that care plans must include measurable objectives and timetables to meet the resident’s physical, psychosocial, and functional needs and be revised as the resident’s condition changes.
Failure to Follow Hearing-Impaired Communication Care Plan
Penalty
Summary
The facility failed to implement Resident 47’s care plan for communication related to hearing impairment by not ensuring the resident had her hearing aid on and by not providing a pencil and paper or writing board for communication. Resident 47 was admitted and later readmitted with diagnoses including dementia, muscle weakness, and need for assistance with personal care. Her MDS dated 10/20/2025 indicated severe cognitive impairment for daily decision making, substantial/maximal assistance with lower body dressing, showering/bathing, and toileting hygiene, partial/moderate assistance with upper body dressing, footwear, personal hygiene, and chair/bed transfers, and moderate difficulty hearing. The care plan revised 1/16/2025 identified interventions to provide assistive communication devices, including a hearing amplifier and writing board, and stated staff were to put on the resident’s hearing aid with communication. During observation on 1/13/2026, the resident was sitting in her wheelchair and asked to be put back to bed; the IPN replied, the resident yelled that she could not hear, and the IPN was observed looking for a writing board. The resident was without hearing aids and without a writing board, paper, or pencil at bedside. In interview, the IPN stated the resident was not wearing hearing aids and did not have writing materials, and the DON stated the resident should have a writing pad or pen and paper to communicate with staff. The facility’s policy on care of hearing-impaired residents also stated staff would provide pencil and paper or a tablet to communicate in writing, if the resident is able.
Failure to Assess and Report Bruising in a Resident on Anticoagulants
Penalty
Summary
The facility failed to monitor, assess, and inform the physician about a skin discoloration on a resident's left arm for one resident receiving anticoagulant medications. The resident had diagnoses including transient cerebral ischemic attack, atrial fibrillation, and hypertension, and was receiving Aspirin 81 mg daily and Xarelto 10 mg in the evening. The resident's care plan directed staff to monitor for signs and symptoms of bleeding every shift, perform daily skin inspections, and report abnormalities to the nurse and physician. During observation, the resident stated that the anticoagulant medications caused bruising and showed a dark purple bruise on the left upper arm. A review of the resident's POC Response History form showed an old discoloration on the left arm, and the LVN stated she was not aware of the bruise. The IPN stated there was no documentation of discoloration or bruising on the resident's left lower arm in the progress notes reviewed, and that the discoloration was a change in condition that should have been reported to the MD as soon as possible or by the end of the shift. Staff interviews showed CNA staff reported bruises to the LVN during ADL care, but one CNA stated the bruise had been present for approximately three months and had been mentioned to an unknown LVN, after which the CNA believed it had already been reported to the MD. The DON stated signs and symptoms of bleeding observed by the CNA should be reported immediately to the LVN, the LVN should assess and intervene, and the MD should be notified immediately and no more than 24 hours after signs and symptoms of bleeding were reported. Facility policy also stated that if a resident on anticoagulation therapy shows excessive bruising or other evidence of bleeding, the nurse will discuss the situation with the physician before the next scheduled dose.
Personal belongings not fully documented on inventory list
Penalty
Summary
The facility failed to ensure Resident 18’s personal belongings were documented on the inventory list in accordance with its Personal Property policy. Resident 18 was admitted and later readmitted with diagnoses including age-related physical debility, unsteadiness on feet, and muscle weakness. The resident’s MDS dated 10/24/2025 indicated moderately impaired cognitive skills for daily decision making and need for partial/moderate assistance with bathing, upper body dressing, lower body dressing, and putting on/taking off footwear, as well as supervision/touching assistance with toileting hygiene and personal hygiene. A review of Resident 18’s inventory list dated 11/10/2024 showed only one extender documented. During an observation on 1/13/2026, Resident 18 stated he had two extenders, one long and one short, and both were observed in the room. During a concurrent review and interview, the SSD stated that when Resident 18 was readmitted, he had two extenders but the inventory list only showed one, and that all residents’ belongings need to be accounted for on the inventory list. The DON stated that residents’ personal items are to be documented in the inventory, and the facility’s Personal Property policy stated that residents’ personal belongings and clothing shall be inventoried and documented upon admission and as items are replenished.
Failure to Specify Pain Scale Parameters in PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure proper pain management for two residents by not including pain scale parameters in their PRN pain medication orders. One resident, who had recently returned from a general acute care hospital following a right hip hemiarthroplasty, had physician orders for Tramadol and Tylenol, both as routine and PRN, but the PRN Tramadol order did not specify the pain scale (mild, moderate, or severe) for administration. Interviews with nursing staff and the Director of Nursing confirmed that the absence of pain scale parameters could lead to inappropriate administration of pain medication, as the medication could be given for any reported pain level, potentially resulting in overmedication or undermedication. Another resident with diagnoses including dementia, muscle weakness, and chronic right hip pain also had PRN orders for Tylenol Extra Strength and Tramadol without pain scale parameters. The care plan for this resident included interventions for pain management, but the medication orders did not specify which pain levels warranted the use of each medication. The Director of Nursing acknowledged during interviews that both PRN pain medications for this resident should have included pain scale parameters to guide nursing staff in appropriate administration. A review of facility policies indicated that PRN medication orders should specify the type, route, dosage, frequency, strength, and reason for administration, and that pain management should involve identifying and using specific strategies for different levels and sources of pain. Despite these policies, the orders for both residents lacked the necessary pain scale parameters, leading to a deficiency in the facility's pain management practices.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to provide adequate interventions to prevent accidents for three residents, leading to deficiencies in their care. Resident 61, who had severe cognitive impairment and required assistance with daily activities, was not provided with a functional bed sensor pad as ordered by the physician. Additionally, the resident's call light was not within reach, contrary to the fall care plan. Observations revealed that the pad alarm did not sound when the resident attempted to get out of bed, and the call light was placed on the opposite side of the bed, out of reach. Resident 24, with a history of falls and moderately impaired cognitive skills, experienced multiple falls within the facility. Despite the use of a sensor pad alarm, the care plan did not include specific interventions to address the underlying causes of the falls. The resident's care plan lacked detailed safety measures related to wheelchair safety and the risk of sliding from a recliner, which were identified as contributing factors to the falls. Interviews with staff indicated that the care plan should have been revised to include resident-centered interventions to prevent fall reoccurrence. Resident 29, who had severely impaired cognitive skills and a history of falls, was observed with a sensor pad alarm that was not properly positioned or turned on. The resident attempted to stand up from a chair without the alarm sounding, indicating that the sensor pad was not functioning as intended. Staff interviews confirmed that the sensor pad alarm was crucial for notifying staff when the resident needed assistance, and it was the responsibility of CNAs and charge nurses to ensure the alarm was operational. The facility's policy emphasized the importance of implementing resident-centered fall prevention plans and monitoring the efficacy of alarms.
Deficient Food Labeling and Storage Practices
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the labeling and storage of food items in the kitchen, as observed during a survey. In the walk-in refrigerator, four trays of marinated fish fillet, three trays of prepared Jello, and one loaf of banana bread were found without labels indicating the name of the food item, preparation date and time, and use-by date. Additionally, the Jello trays were not covered with lids, and the banana bread was not wrapped or covered, which is against the facility's policy. The dietary supervisor confirmed that all food trays should be labeled and covered to prevent contamination. Further observations in the walk-in freezer revealed three bags of frozen meat, two packages of snap peas, two packages of breakfast waffles, and one bag of cream puffs without proper labeling, including the food item name, purchase date, expiration date, or use-by date. In the dry food storage area, a bag of buttermilk biscuit mix was also found without a use-by date. The dietary service director and dietary supervisor acknowledged that all food items should be labeled with the food item name and use-by date, as per the facility's policy. The facility's policy, revised in January 2024, mandates that all food and supplies be stored to prevent contamination and maintain safety for consumption, including covering, labeling, and dating unused portions and open packages.
Failure to Accommodate Resident's Dining Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident, identified as Resident 9, during meal times. Resident 9, who has diagnoses of spinal stenosis, osteoporosis, and reduced mobility, was observed eating in a hunched position with her plate on her lap because the dining table was too high for her. Despite attempts to adjust her seating with a cushion, this solution was not effective as it caused her feet to hang, which she found uncomfortable. The resident expressed that eating at the table was painful and exhausting, as she had to tilt her head back to reach her food, leading to discomfort and fatigue. Interviews with the Restorative Nursing Aide and the Director of Nursing confirmed that the resident's dining setup was inappropriate, with the table positioned at her eye level rather than at a comfortable height above the waist. The facility's policy on accommodating residents' needs, which includes evaluating and modifying the physical environment, was not adhered to in this case. This oversight resulted in the resident experiencing discomfort and exhaustion during meals, highlighting a failure to provide reasonable accommodation for her specific needs.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to adhere to its policy regarding notifying a physician of a significant change in a resident's condition, specifically concerning a substantial weight loss. Resident 31, who was admitted with diagnoses including hyperlipidemia, dementia, and a left artificial hip joint, experienced a significant weight loss of 23 pounds over three days, which was not reported to the physician until four days later. The care plan for Resident 31 indicated a weight goal of maintaining 184 pounds plus or minus six pounds, but the resident's weight dropped to 161 pounds, representing a 12.5% weight loss, which was not promptly communicated to the physician as required by the facility's policy. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that the facility's protocol required notifying the physician of a weight loss of more than five pounds within a shift or endorsing it to the next shift. However, this protocol was not followed, as the physician was not informed immediately upon noticing the weight loss. The facility's policy, revised in February 2021, mandates that significant changes in a resident's condition be reported to the attending physician within 24 hours, which was not adhered to in this case, potentially delaying necessary care and services for Resident 31.
Failure to Maintain Resident EHR Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's electronic health record (EHR) by leaving a computer screen unattended and visible to unauthorized individuals. This incident involved a resident who was admitted with conditions including Parkinson's disease, benign prostatic hyperplasia, and insomnia. The resident was assessed to have moderately impaired cognitive skills and required substantial assistance with daily activities. During an observation, a Licensed Vocational Nurse (LVN) left the computer monitor on top of a medication cart turned on and unattended in a hallway, exposing the resident's sensitive medical information to passersby. The LVN acknowledged the oversight, recognizing the importance of closing the chart monitor to protect the resident's privacy in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Another LVN confirmed that it is the responsibility of licensed nurses to ensure that EHRs are not exposed to unauthorized individuals. The facility's policy on confidentiality and personal privacy, revised in 2017, mandates the protection of resident information, limiting access to authorized personnel only.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide Restorative Nursing Services as ordered by the physician for a resident, identified as Resident 2, to maintain or improve their range of motion (ROM). The physician had ordered active range of motion (AROM) exercises for both upper and lower extremities to be performed five times a week. However, the facility only provided these services three times a week, which was not in compliance with the physician's orders. There were no documented notes indicating that Resident 2 refused the services for the missing two sessions per week. Resident 2 had a medical history of chronic obstructive pulmonary disease, atrial fibrillation, and heart failure. The resident required substantial assistance with daily activities and had intact cognitive skills for decision-making. The care plan for Resident 2 included RNA services for AROM to be performed five times a week, but the facility's records showed that this was not consistently done. The Care Plan Coordinator confirmed that the services were not provided as ordered, and there was no documentation of refusals by the resident. Interviews with the Restorative Nursing Aide and the Director of Occupational Therapy revealed that the RNA services were crucial for maintaining Resident 2's functional status and preventing contractures, especially since the resident spent most of their time in bed. The facility's policy indicated that residents with limited ROM should receive treatment to prevent further decrease, but this was not adhered to in Resident 2's case. The lack of adherence to the physician's orders and the facility's policy led to the deficiency noted in the report.
Failure to Address Pharmacist's Recommendation for Medication Dose Reduction
Penalty
Summary
The facility failed to ensure that the physician addressed the medication regimen review (MRR) for a resident, specifically regarding the pharmacist's recommendation for a gradual dose reduction (GDR) of Ativan. The resident, who was admitted with diagnoses including major depressive disorder, unspecified pain, and anxiety disorder, was receiving Ativan for anxiety manifested by restlessness. Despite the pharmacist's recommendation to reduce the Ativan dose, the physician assistant altered the administration time and reduced the dose of another medication, mirtazapine, but did not decrease the Ativan dose as suggested. The medical doctor did not provide a documented explanation for not accepting the pharmacist's recommendation. The resident's care plan indicated a potential for drug-related complications due to the use of psychotropic medications, and the facility's policy required that recommendations be acted upon or rejected with an explanation. However, the physician did not document a reason for disagreeing with the pharmacist's recommendation. The Director of Nursing confirmed that the physician was informed of the recommendation but did not know why the physician did not provide an explanation for not reducing the Ativan dose. This oversight had the potential to result in adverse medication outcomes for the resident.
Failure to Assess Continued Need for PRN Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the facility did not assess the continued need for Tylenol (acetaminophen) for a resident who had not received the medication as needed for pain for over 90 days. The resident, who was admitted with diagnoses including major depressive disorder, unspecified pain, and anxiety disorder, was assessed to have severely impaired cognitive skills for daily decision-making. Despite having an order for Tylenol Extra Strength 500 mg to be taken every four hours as needed for pain, the resident did not receive this medication from August to November 2024, as their pain level was consistently assessed at 0. During a review of the resident's medication records and an interview with the Director of Nursing (DON), it was confirmed that the resident's pain was managed by a regular dose of Tylenol taken twice daily, and the as-needed order was deemed unnecessary. The facility's policy required periodic re-evaluation of medications to ensure their relevance and to avoid undesired complications. However, the facility did not adhere to this policy, resulting in the potential for the resident to suffer adverse reactions from unnecessary medication.
Failure to Label Medication Bottles with Opening Date
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services by not properly labeling medications with the date they were opened, as required by the facility's policy. This deficiency was observed during a medication administration for a resident diagnosed with Parkinson's disease, benign prostatic hyperplasia, and insomnia. The resident was assessed to have moderately impaired cognitive skills and required substantial assistance with daily activities. During the observation, it was noted that the medication bottle of carbidopa-levodopa, prescribed for the resident's Parkinson's disease, did not have the date it was opened labeled on it. Interviews with Licensed Vocational Nurses (LVNs) revealed that the facility's practice was to label medication containers with the date they were opened to ensure proper tracking and administration of medications. LVN 1 acknowledged the oversight and emphasized the importance of labeling to account for the medication's usage. LVN 2 further explained the procedure for counting and logging medications, especially those from outside pharmacies, and reiterated the necessity of labeling to prevent medication errors. The facility's policy, revised in 2019, mandates that the expiration or beyond-use date be checked before administering medications and that the date of opening be recorded on multi-dose containers.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated the preferences of a resident, identified as Resident 40, which was observed during a survey. Resident 40 was admitted with diagnoses including atrial fibrillation, heart failure, and hypertension. Despite being assessed with intact memory and cognitive skills for daily decision-making, the resident required assistance with eating and had a history of weight loss. The care plan indicated the need to offer alternative meals if the resident did not like what was being served, but this was not adhered to. On a specific day, Resident 40 was observed in the dining room with a food tray that did not include all the items listed on her tray card, such as white rice, soy milk, and Jello. The Certified Nursing Assistant (CNA) responsible for serving the meal admitted to not checking the tray card and acknowledged the importance of providing the resident with her preferred food due to her history of weight loss. The Director of Nursing emphasized the importance of following residents' food preferences to maintain their dignity and encourage meal intake. The facility's policies and procedures were reviewed, indicating that residents on modified diets should be offered similar choices as the main meal and that food substitutions should be of equal nutritional value. The policies also highlighted the importance of accommodating individual resident preferences unless it posed a health risk. However, these policies were not followed in the case of Resident 40, leading to the deficiency noted in the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7,144 citations issued within 25 miles in the last 12 months — including the 35 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alhambra Hospital Med Ctr Dp/snf | 0.6 mi | ★★★★★ | 0 | 0 |
| Alhambra Healthcare & Wellness Centre, Lp | 0.6 mi | ★★★★★ | 1 | 0 |
| Sunny Village Care Center | 1 mi | ★★★★★ | 24 | 0 |
| Royal Vista Care Center | 1.2 mi | ★★★★★ | 31 | 0 |
| Live Oak Rehab Center | 1.4 mi | ★★★★★ | 38 | 1 |
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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.