Average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviara Healthcare Center during CMS and state inspections, most recent first.
A resident with impaired cognition and a history of flaccid neuropathic bladder was admitted without a physician's order for intermittent self-catheterization, despite performing the procedure multiple times per shift. Staff interviews and record reviews confirmed the absence of the required order, which was contrary to facility policy requiring physician orders for all treatments.
A resident with a flaccid neuropathic bladder and impaired cognition was admitted without a care plan that included specific interventions for intermittent catheterization. Nursing staff and the ADON confirmed that the omission led to confusion and inadequate communication about the resident's care needs, and the resident was later transferred to a hospital due to altered mentation and inability to self-catheterize.
Failure to Document Advance Directive Information: The facility did not document that Advance Directive information was provided to multiple residents, including residents with POLST forms showing blank sections or no Advance Directive, and in some cases no copy of an existing AD was in the chart. An LN said she asked new admissions about ADs but did not document refusals, and the SWD confirmed there was no documentation that AD information was provided to the affected residents, families, or representatives.
Failure to provide and document Advance Directive information for multiple residents. Survey review found that several residents had POLST forms with blank Advance Directive sections, no documentation that Advance Directive information was offered to the resident or representative, or no copy of an existing AD in the chart. The SWD stated the facility usually requested POLST/AD paperwork after admission, and the DON stated a POLST is not the same as an AD and that she expected documentation showing the AD was offered or refused.
An infection prevention and control deficiency involved multiple lapses during resident care and medication administration. An exposed resident was not retested for Covid-19 as expected, an LPN failed to wear a gown for EBP G-tube medication administration, another LPN used a personal BP device on two residents without cleaning it, hand hygiene was missed between glove changes, eye ointment was given after the nurse handled tray items with the same gloves, and a nebulizer piece dropped on the floor was reused while the nurse’s EBP gown was unsecured.
A resident with bipolar disorder, depression, and dementia was ordered mirtazapine, oxcarbazepine, and risperidone for psychotropic use, but the MAR showed these medications were started before informed consent was documented and signed. The LN and DON verified that consent was recorded after administration had already begun, despite facility policy requiring informed consent before psychotropic meds are given.
A resident with dementia, aphasia, dysphagia, and G-tube status was exposed during medication administration when an LPN entered the room with the curtain open and the door left open. The resident’s gown and sheet were not adjusted, leaving the stomach and brief exposed while meds were given through the G-tube. The LPN acknowledged the privacy lapse, and the DON stated the curtain should have been closed and the resident covered.
Unnecessary psychotropic medication use was identified for a resident with bipolar disorder, depression, and dementia when risperidone and oxcarbazepine were given without documented behavior monitoring, side effect monitoring, or resident-specific nonpharmacological interventions. The record also showed no admission evaluation for dose reduction or discontinuation, and the LN, NP, and DON verified the resident had not been seen by psychiatry and that the monthly psychotropic summary was not documented.
A resident who reported missing glasses was left without timely vision services or replacement eyewear. Staff knew he could not read, watch TV, or see the activity calendar, and the SSD placed him on the optometrist list after he was identified as needing glasses, but he still had not received them and was unsure when he would. The DON stated the optometrist should have been notified as soon as the need was identified and that the resident should not have waited two months for the visit.
Unsafe water temperature and wanderguard monitoring failure: A resident reported that bathroom sink water was very hot, and surveyors measured the water at 122.9 degrees Fahrenheit, above the facility’s stated safe range. In a separate finding, a resident with dementia and a high wandering risk score had an order for a wanderguard with placement checks every shift, but the record review and LN interview showed the device’s function was not being checked as expected per policy and the manufacturer manual.
IV therapy care was not managed per policy for three residents. One resident with osteomyelitis had PICC dressing changes documented without the ordered arm circumference measurement, another resident with osteomyelitis had no order for external catheter length and arm circumference checks during dressing changes, and a third resident receiving IV ertapenem had IV fluid intake not recorded on two occasions. An LPN stated the missing measurements and documentation were needed to monitor PICC function and IV intake.
Controlled medication records did not match the EMAR for four residents receiving opioid pain medications. A resident with a femur fracture had oxycodone removed from the CDR without matching EMAR documentation, and a waste entry had only one nurse signature. Three other residents with serious orthopedic or surgical diagnoses also had oxycodone or Norco removed from the CDR without corresponding EMAR administration entries. The DON and LNs verified the discrepancies, and the DON stated controlled meds must be documented on both records and that two nurses must sign for waste.
Failure to Respond to Pharmacist Medication Review Recommendations: The facility did not ensure provider response to a consultant pharmacist’s interim MRR for a resident with bipolar disorder, depression, and dementia. The resident was ordered mirtazapine, oxcarbazepine, and risperidone, but the chart lacked documented target behaviors, behavior and side effect monitoring, an AIMS test, and an initial psychotropic evaluation for possible dose reduction or discontinuation. The DON acknowledged the provider did not respond to the pharmacist’s recommendations, and the psychiatry NP stated he had not been consulted.
Medication administration errors exceeded the allowed rate when surveyors observed 5 errors in 33 opportunities. An LPN gave a resident the wrong aspirin form, another LPN administered pioglitazone more than an hour past the scheduled time, and a third LPN gave chewable aspirin without ensuring it was chewed and mixed polyethylene glycol with less water than ordered. The DON stated medications should be given according to the physician orders and eMAR.
A facility failed to store and label medications and supplies properly in several carts. The crash cart was missing alcohol wipes, sterile water, and K-Y jelly listed on the checklist; a treatment cart contained an expired iodoform packing strip and Clotrimazole cream for a resident without an active order; and a medication cart contained expired glucometer drops beyond the 90-day open-use period. The DON confirmed the items should not have been present.
Failure to offer and document pneumococcal vaccination for a newly admitted resident with diabetes and other comorbidities. The IP reviewed the vaccine record and found no documentation that the resident was offered or refused the pneumococcal vaccine, and the Vaccine Informed Consent form was blank except for signatures. The DON stated all new admissions were to be offered the vaccine and the LPN was expected to document receipt or refusal.
A resident admitted with orthopedic aftercare following a surgical amputation and diabetes mellitus did not have documentation showing that COVID-19 vaccination was offered or refused. The IP reviewed the vaccine record and found the Vaccine Informed Consent form blank, with no recorded vaccinations, while the DON stated all new residents should be offered the COVID-19 vaccine and refusals documented.
Staff failed to tie and cover trash bags and bins, leading to overflowing waste and foul odors in utility rooms. An LPN did not wear a gown while providing wound care to a resident on enhanced barrier precautions, despite clear signage and orders. Additionally, newly admitted residents were not screened for TB upon admission, contrary to facility policy.
A resident with intact cognition repeatedly reported staff performance issues and frequently changed food preferences, leading to the removal of multiple caregivers from her care. Despite staff awareness of these ongoing behavioral concerns, no care plan was developed or implemented to address or manage the behaviors, as required by facility policy.
A resident with paraplegia, osteomyelitis, and pressure ulcers was discharged against medical advice after returning late from an out on pass. The facility failed to document communication with the attending physician or obtain a physician's order for the discharge, violating their policy and potentially compromising the resident's safety.
A facility failed to develop a baseline care plan for a resident who frequently left the facility and did not comply with the ordered duration of hours while out on pass. Despite the resident being cognitively intact and having significant medical conditions, no care plan was created to address their non-compliance, as confirmed by both an LPN and the DON. This oversight was contrary to the facility's care planning policy, which requires comprehensive, person-centered care plans based on resident assessments.
A facility failed to follow its policy for a resident's out on pass (OOP) by not obtaining physician's orders, documenting return times, or completing OOP forms. The resident, with paraplegia and other conditions, went out multiple times without proper documentation, risking their safety. Staff interviews confirmed the lack of adherence to expected procedures.
A facility failed to verify the competency of two registry nurses responsible for administering medications, leading to a discrepancy in the medication administration for a resident with low back pain. The resident was prescribed Norco, a controlled pain medication, but did not receive the scheduled dose due to a lack of documentation and verification of the nurses' competency. Interviews with staff confirmed the oversight, highlighting the facility's failure to adhere to its policy on ensuring competent nursing staff.
A resident with low back pain did not receive his routine Norco medication as scheduled, leading to a potential for pain. The medication was not administered on a specific day, as confirmed by discrepancies in the medication count and interviews with staff and the resident's family. The facility's policy on medication administration was not adhered to.
A resident receiving enoxaparin for DVT prevention, with a history of encephalopathy and a G-tube, was hospitalized for bleeding at the G-tube site. Review showed that no person-centered care plan was developed for anticoagulant therapy, and staff interviews confirmed that such a care plan is necessary for monitoring and consistent care. The facility's policy requiring comprehensive care plans was not followed.
A resident felt disrespected when a CNA failed to provide a clean bowl for breakfast cereals, instead discarding cereal in the toilet and rinsing the bowl in the bathroom sink. The CNA initially denied the action but later admitted to possible confusion. Observations confirmed the presence of cereal in the toilet, and both the Infection Preventionist and DON acknowledged the incident as disrespectful and an infection control issue.
A CNA in an LTC facility discarded cereal into a toilet bowl and did not flush it, leading to unsanitary conditions. A resident, who was cognitively intact, reported the incident after requesting a clean bowl for her cereal. The CNA initially denied the action but later admitted to the possibility due to confusion. The Maintenance Director, Infection Preventionist, and DON confirmed the practice was unacceptable and posed an infection control issue.
The facility failed to maintain the required room temperature range of 71 to 81 degrees Fahrenheit in 44 out of 68 rooms, leading to resident discomfort. Observations and interviews revealed residents using extra blankets and clothing to stay warm, with room temperatures recorded as low as 63 degrees. The facility's policy on maintaining comfortable room temperatures was not followed.
A facility failed to maintain a PICC line for a resident, lacking a physician's order and documentation for flushing the line. Despite protocols requiring regular flushing to maintain patency, interviews with staff revealed no such actions were documented, posing a risk of line obstruction and infection.
The facility failed to create and implement care plans for two residents, one with an amputation and another with dementia, leading to potential unawareness of their care needs by staff. A resident with an amputation did not comply with wound care instructions, and another resident with dementia exhibited combative behavior, yet neither had care plans addressing these issues. The DON acknowledged the absence of necessary care plans, which are crucial for ensuring resident safety and meeting their needs.
The facility failed to provide and document wound care for two residents, leading to potential risks for worsening skin conditions. A resident with an amputation developed a new wound on the stump, and prescribed treatments were not consistently applied or documented. Another resident with dementia missed multiple wound treatments and monitoring sessions. The DON acknowledged the failure to follow physician orders and the lack of documentation.
A resident with a history of traumatic intracranial hemorrhage was not properly monitored after being assaulted by another resident. Despite initiating neuro checks, the facility's LNs missed crucial blood pressure entries. The DON acknowledged the oversight, and no policy was provided to ensure complete neuro checks.
A resident with a high fall risk and complex medical history experienced two falls due to the facility's failure to implement fall prevention measures and communicate incidents between shifts. A nurse did not perform a neurological check or notify the responsible party after the falls, leading to the resident being found unresponsive and seizing. The Director of Nursing acknowledged the lapses in communication and adherence to facility policies.
The facility failed to conduct a new PASARR for two residents who received new mental illness diagnoses. One resident was diagnosed with schizophrenia and anxiety disorder, and another with depression, schizoaffective disorder, and OCD. Despite these diagnoses, there was no evidence of PASARR referrals. Interviews with staff indicated a lack of follow-through in submitting necessary screenings and evaluations.
The facility failed to include the use of bed rails and supplemental oxygen in the care plans for two residents. One resident, with a history of Alzheimer's and other conditions, was observed using bed rails and oxygen, but these were not documented in their care plan. Another resident, with a history of vascular dementia and falls, was observed with bed rails, yet this was also not included in their care plan. Staff interviews confirmed these omissions, highlighting a lapse in adhering to care planning policies.
A resident with a complex medical history was observed using supplemental oxygen without a physician's order, contrary to facility policy. Interviews with staff, including the LVN, Assistant Director of Nursing, DON, and Executive Director, confirmed the absence of the required order, highlighting a deficiency in respiratory care.
A facility failed to complete an assessment and obtain informed consent and a physician order for bed rail use for a resident with Alzheimer's and other conditions. Despite policy requirements, the resident was observed with bed rails without proper documentation. Staff interviews revealed confusion about the policy, and the bed rails were installed at the family's request without formal assessment.
A resident with a history of severe pain conditions did not receive scheduled morphine sulfate due to the facility running out of the medication. Staff interviews revealed delays in reordering and communication issues, with the pharmacy experiencing fax problems. The DON acknowledged the lack of timely reordering, and both the ED and Medical Director emphasized that residents should not be without their scheduled pain medications.
A facility experienced a 10% medication error rate due to improper administration practices. One resident with diabetes did not receive a primed insulin dose as required by the manufacturer's guidelines, while another resident with anemia and vitamin D deficiency received an incorrect dose of Vitamin D and missed a multivitamin. The errors were attributed to staff not following proper medication administration protocols.
A resident's respiratory equipment was improperly stored, with a nasal cannula on the floor and a yanker on a dresser, contrary to the facility's infection control policy. Staff interviews confirmed non-compliance, as equipment should be stored in bags to prevent contamination.
A resident with a history of hemiplegia, hemiparesis, and dementia was not offered the influenza vaccine during the 2023-2024 season, despite the facility's policy to offer it annually. The last recorded vaccination for the resident was in early 2023. Interviews with staff confirmed the oversight and the importance of annual vaccinations due to changing flu strains.
The facility failed to develop care plans for two residents following a resident-resident altercation. Both residents, with diagnoses including Bi-Polar disorder and dementia or a history of falls, were interviewed and felt safe, but their medical records lacked care plans addressing the incident. The DON confirmed that care plans should have been created according to facility policy.
A resident reported that call lights in the facility could take 1 to 3 hours to be answered, a concern echoed by another resident and noted in Resident Council Meeting Minutes. Interviews with the ADON and a CNA indicated that a 15-minute response time is reasonable, while 1 to 3 hours is too long. The facility's Call Light Policy requires prompt responses.
The facility failed to prevent cross-contamination of resident ice scoops stored at the water/ice stations for two nursing stations. Ice scoops were stored in uncovered bins, exposing them to the environment. Interviews with the DSS and DON confirmed that the ice scoops should have been stored in covered containers to prevent contamination, as per the facility's policy.
A resident with chronic conditions was mistakenly given two 200 mg tablets of Seroquel by a registry nurse who failed to verify the correct medication. The error led to the resident becoming drowsy. Interviews revealed non-compliance with the facility's medication administration policy.
Failure to Obtain Physician Order for Intermittent Catheterization at Admission
Penalty
Summary
The facility failed to obtain a physician's order for intermittent self-catheterization upon admission for a resident with a diagnosis of flaccid neuropathic bladder and a thoracic vertebra fracture. Despite information from the resident's daughter that the resident had been performing intermittent catheterization at home, there was no physician order documented in the medical record at the time of admission. Multiple staff interviews confirmed that the resident was performing intermittent catheterization several times per shift without a physician's order in place. Record reviews, including the Minimum Data Set (MDS), indicated the resident had impaired cognition and required intermittent catheterization. Facility policy requires a physician's order for all treatments, including catheterization, to guide care and prevent complications. Both nursing staff and the Assistant Director of Nursing acknowledged the importance of having such orders documented to ensure proper care planning and resident safety, but this was not done for the resident in question.
Failure to Develop Resident-Centered Care Plan for Intermittent Catheterization
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident with a flaccid neuropathic bladder and a thoracic vertebra fracture. The resident was admitted with a history of performing intermittent catheterization at home, but the care plan did not include specific interventions or mention intermittent catheterization. Interviews with nursing staff and record reviews confirmed that the care plan lacked necessary details to guide staff in providing appropriate care for the resident's condition. The resident's Minimum Data Set (MDS) assessment indicated impaired cognition, further emphasizing the need for a comprehensive and clear care plan. Staff interviews revealed that the omission of intermittent catheterization from the care plan led to confusion among staff and inadequate communication regarding the resident's care needs. The Assistant Director of Nursing and licensed nurses acknowledged the importance of a detailed care plan for ensuring consistent care and preventing confusion. The resident was eventually transferred to an acute hospital due to altered mentation, which included an inability to self-catheterize, highlighting the impact of the incomplete care plan.
Failure to Document Advance Directive Information
Penalty
Summary
The facility failed to ensure Advance Directive information was provided to multiple sampled residents, including residents 2, 6, 7, 8, 12, 13, 14, 15, 18, 22, 24, 74, and 94. The report states that these residents did not have documentation showing they were given Advance Directive information, and for several residents the POLST Section D Advance Directives area was blank or marked as having no Advance Directive. For resident 14 and resident 94, the record indicated an Advance Directive existed, but a copy was not present in the clinical record. Record review showed that resident 2 was admitted with CHF and had a POLST dated 7/30/25 indicating no Advance Directive, but the clinical record did not show that Advance Directive information was provided. Similar findings were documented for residents 6, 7, 8, 12, 13, 15, 18, 24, 74, and 94, where the POLST either had blank Advance Directive information or indicated no Advance Directive, with no documentation that the facility provided the information. For resident 22, the POLST indicated no Advance Directive, but there was no documentation that the facility provided Advance Directive information to the resident's legally recognized decisionmaker. Interviews with facility staff confirmed the lack of documentation. The LN stated that during admissions she would ask whether the resident had or wanted an Advance Directive and would refer the resident to the SW if needed, but also stated that if a new admission refused, she would not document it. The SWD stated that if a resident did not bring in an Advance Directive, the family or representative was contacted, and that there was no documentation that Advance Directive information was provided to the affected residents, family, and/or representatives. The DON stated that a POLST is not the same as an Advance Directive and expected documentation in the medical record that an Advance Directive was offered or refused, and that any Advance Directive should have been uploaded into the clinical record.
Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to identify a system-wide issue involving the provision and documentation of Advance Directive information for 13 of 27 sampled residents, including Residents 2, 6, 7, 8, 12, 13, 14, 15, 18, 22, 24, 74, and 94. Survey review found that several residents had POLST forms in the record with the Advance Directives section left blank, marked as having no Advance Directive, or marked as having an Advance Directive without a copy present in the clinical record. In multiple cases, there was no documentation that Advance Directive information had been provided to the resident, family, or representative. Resident records reviewed showed repeated omissions. Resident 7, 12, 13, 18, 79, and 94 had POLST forms with the Advance Directives section blank and no documentation that information was provided. Resident 8, 15, 22, and 24 had POLST forms indicating no Advance Directive, but the record did not show that Advance Directive information was offered or provided. Resident 14 and 94 had POLST entries indicating an Advance Directive existed, but a copy was not in the clinical record. Resident 2, who was admitted with CHF, also had a POLST indicating no Advance Directive and no documentation that Advance Directive information was provided. During interview, the Social Worker Director stated that if a resident did not bring in an Advance Directive, the family or representative was contacted to obtain one, and that the POLST or Advance Directive was requested as soon as possible after admission. The DON stated that a POLST is not the same as an Advance Directive and that she expected documentation showing that an Advance Directive was offered or refused, with a copy uploaded if one existed. At the time of the survey, the DON stated the facility had failed to identify that Advance Directives were not being offered or documented by staff.
Infection Control Failures During Resident Care and Medication Administration
Penalty
Summary
The facility failed to implement its infection prevention and control program for multiple residents during medication administration and resident care activities. Resident 103, who had been the roommate of Resident 132 after Resident 132 returned from the hospital with a positive Covid-19 result, was tested once for Covid-19 on 9/10/25 with negative results but was not tested again on 9/12/25 and 9/14/25 as identified by the Infection Preventionist Nurse and Infection Preventionist Consultant. The Director of Nursing stated the expected testing schedule for the exposed resident should have been day 1, day 3, and day 5. Resident 15 had an order for Enhanced Barrier Precautions during high-contact care activities. During medication administration through the G-tube, LN 35 entered the room wearing gloves but without a precaution gown, despite an EBP sign on the door stating staff must clean hands, wear a gown, and wear gloves for high-contact care. LN 35 later stated she should have worn a gown while providing care to the resident. Resident 113 and Resident 82 were both on EBP-related precautions, and LN 36 used a personal blood pressure device brought from home to obtain blood pressures for both residents. The device had a soft fabric cuff that could not be properly sanitized, and LN 36 did not clean it between use on the two residents. Resident 10’s medication administration also involved improper glove use and hand hygiene, as LN 37 removed gloves, retrieved an item from the medication cart, applied a new pair of gloves without performing hand hygiene, and continued care in the resident’s room. Resident 140 received oral medications and then erythromycin ophthalmic ointment while LN 39 wore the same pair of gloves and handled items on the bedside tray before applying the eye ointment. Resident 4, who had asthma, immunodeficiency, and an order for nebulized ipratropium-albuterol, was on EBP. During nebulizer treatment, LN 38 entered the room with a precaution gown that was not tied and was falling off her shoulders. LN 38 dropped a nebulizer piece on the floor, picked it up, rinsed it in the bathroom, and used the same piece for the resident’s treatment. The resident later placed a hand on LN 38’s exposed scrub top while the gown remained unsecured. LN 38 stated she should have discarded the dropped piece and used a new one, and the DON stated the gown should have been tied and secured.
Psychotropic medications administered before informed consent was documented
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering psychotropic medications to one resident. Resident 67 was admitted for rehabilitation therapy and had a medical history that included bipolar disorder, depression, and dementia. The resident’s medication orders included mirtazapine 30 mg by mouth daily for depression, oxcarbazepine 300 mg by mouth twice daily for bipolar disorder, and risperidone 1 mg by mouth in the morning for bipolar disorder, all ordered on 7/23/25. The resident’s record showed informed consent for oxcarbazepine, mirtazapine, and risperidone was documented by an LN on 7/28/25 and signed by the physician on 7/29/25, but the July 2025 MAR showed administration of these medications began on 7/24/25. During interviews, the LN verified the consent documentation dates, and the DON stated there should be documented informed consent for each psychotropic medication prior to administration. The facility policy also stated that prior to administration of psychotropic medication, the prescribing clinician will obtain informed consent and a licensed nurse must verify that consent has been obtained before administering the medication.
Failure to Protect Resident Privacy During Medication Administration
Penalty
Summary
Resident 15, who was admitted with unspecified dementia, aphasia, dysphagia, and gastrostomy status, had active orders for NPO status, enteral feeding, and medications that could be crushed unless contraindicated. During medication administration through the resident’s G-tube, Licensed Nurse 35 entered the room while the resident was lying in bed with the bed sheet pulled down and the hospital gown pulled up, exposing the stomach and adult brief. The privacy curtain was not closed and the room door remained open while the nurse began administering the medications. During the medication pass, Resident 15 was observed attempting to pull down the hospital gown and cover the brief, but the nurse completed the medication administration and left the room without adjusting the resident’s clothing or covering. In interview, the nurse stated she did not close the door or pull the curtain and acknowledged she should have protected the resident’s privacy and covered the resident. The DON stated the curtain should have been pulled and the resident should have been covered before care was provided, and the facility policy stated staff must promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Unnecessary Psychotropic Medication Use Not Monitored
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary psychotropic medications when nonpharmacological interventions were not implemented and side effects and behaviors were not monitored for risperidone and oxcarbazepine. Resident 67 was admitted for rehabilitation therapy and had a medical history that included bipolar disorder, depression, and dementia. The resident’s medication list included mirtazapine for depression, oxcarbazepine for bipolar disorder, and risperidone for bipolar disorder. Review of the medical record showed no specific behaviors were identified and documented to support the use of oxcarbazepine and risperidone. The medication administration record and order summary did not show behavior monitoring or side effect monitoring for these medications, including monitoring for high blood sugar, orthostatic hypotension, or involuntary movement disorder. Abnormal involuntary movement scale testing was also not performed for the resident. The record further showed there was no admission assessment or evaluation of mirtazapine, oxcarbazepine, and risperidone to determine whether they could be reduced or discontinued. During interviews, the LN, NP, and DON verified that the resident had not been seen by a psychiatry provider, that psychotropic medications had not been evaluated, that no behavior or side effect monitoring had been completed, and that no resident-specific nonpharmacological interventions had been implemented. The DON also stated the facility did not use a psychotropic administration record and that the monthly psychotropic summary report was not documented for the resident.
Delayed Access to Vision Services and Replacement Glasses
Penalty
Summary
The facility did not provide timely vision services and replacement glasses for Resident 18 after he reported that his glasses were missing. Resident 18 was admitted to the facility and, during an observation and interview in his room, was seen sitting in a wheelchair reading a book while squinting. He stated he normally wore glasses to read but did not have any at the facility, believed they were lost in the ambulance, and said he had told staff multiple times that he needed his glasses. He also stated he could not see the clock, television, or the activity calendar on the wall, and that he was not participating in activities because he could not see what was offered. Record review showed a progress note indicating a referral for optometry was faxed and that the optometrist would be in the facility in September. Staff interviews confirmed that CNA staff had noticed the resident could not read or watch TV without glasses and had informed the nurse and social worker. The LN stated the resident was on a list to see the optometrist for replacement glasses, and the SSD stated the resident was identified as needing glasses in July, missed the June optometrist visit, and was placed on the list for the next visit in September. The DON stated her expectation was that the optometrist should have been notified as soon as the need for glasses was determined and that the resident should not have had to wait two months to see the optometrist.
Unsafe Water Temperature and Wanderguard Monitoring Failure
Penalty
Summary
The facility failed to ensure tap water temperatures were kept within a safe range in one resident room. Resident 76, who was admitted to the facility on the admission record date, told staff that the bathroom sink water was very hot and that she could not hold her hand under the running water. She stated she had reported the problem many times and nothing had been done. A CNA confirmed awareness that the bathroom sink water was very hot and said the issue had been reported to the maintenance director and a maintenance request had been placed. Survey observations found the bathroom sink water remained hot, and on one observation the water temperature measured 122.9 degrees Fahrenheit. The maintenance director stated the facility’s goal for resident room hot water was 110 to 113 degrees Fahrenheit and that it should never be above 120 degrees Fahrenheit. The DON stated that 122 degrees Fahrenheit was too hot and could cause a burn to a resident, and that the water should have been tested as soon as the resident reported it and fixed immediately. The facility also failed to check the function of a wanderguard for one resident at risk for wandering. Resident 67, who had dementia and was admitted for rehabilitation therapy, had an elopement and wandering risk assessment score of 24, which indicated the resident was at risk for wandering or elopement. The physician’s orders included a wanderguard and to check placement of the wanderguard every shift. During interview and record review, an LN stated that the placement and function of a wanderguard should be checked every day by the nurse and that daily checking should be ordered to ensure the device is working properly. The facility policy on wandering and elopements stated that residents identified as at risk for wandering should have care plan interventions to maintain safety, and the wanderguard manual indicated the signaling device needs to be tested daily and recorded in the resident’s record.
IV Therapy Documentation and PICC Line Care Deficiencies
Penalty
Summary
IV therapy care was not managed according to facility policy for three residents. For one resident admitted with osteomyelitis of the vertebra, the physician ordered IV assessment of the external catheter length and upper arm circumference during dressing changes, but the IV MAR showed PICC dressing changes were completed without documenting the arm circumference measurement on multiple dates. A nurse stated the arm circumference should have been measured as ordered to ensure the PICC line was working and intact. For another resident admitted with osteomyelitis of the left ankle and foot, the physician's orders did not include measuring the PICC line's external catheter length and arm circumference during every dressing change, and a nurse stated there should have been an order so nurses would know if there was a problem with the PICC line's functioning. For a third resident admitted with CHF and a UTI who received IV ertapenem, the clinical record showed IV fluid intake was not recorded on two dates during the IV course, and a nurse stated IV therapy residents need IV fluid intake monitored and documented to detect possible fluid overload.
Controlled Medication Records Did Not Reconcile With EMAR
Penalty
Summary
The facility failed to ensure controlled drug records reconciled with the electronic medication administration record for four sampled residents receiving controlled pain medications. Resident 62 was admitted with a displaced comminuted fracture of the right femur and had an order for oxycodone 5 mg for moderate to severe pain. The controlled drug record showed oxycodone removed on 8/10/25 at 3 A.M., but the EMAR did not show the medication was administered during the surrounding documented periods. The same resident also had oxycodone documented as wasted on 9/2/25 at 7:46 A.M. with only one nurse signature, and LN 31 stated two nurses must sign when a controlled drug is wasted. Resident 92 was admitted with a surgical amputation and migraine and had an order for oxycodone 10 mg for severe pain. The controlled drug record showed oxycodone removed on multiple dates and times, including 8/21/25, 8/22/25, 9/3/25, 9/5/25, and 9/8/25, but the EMAR did not show the medication was given at those times. Resident 88 was admitted with a displaced trimalleolar fracture of the right lower leg and had an order for oxycodone 5 mg for moderate or severe pain. The controlled drug record showed oxycodone removed on 6/24/25, 7/24/25, 7/25/25, 8/17/25, and 9/8/25, but the EMAR did not show administration at those times. Resident 142 was admitted with a stable burst fracture of the first lumbar vertebra and had an order for hydrocodone-acetaminophen 5-325 mg for severe pain. The controlled drug record showed Norco removed on 9/13/25 at 12 P.M., but the EMAR did not show it was administered. LN 34 verified the discrepancy for Resident 142, LN 31 verified the discrepancies for Residents 62, 92, and 88, and the DON stated controlled medications should be documented on both the CDR and EMAR and that two nurses must sign when wasting a controlled medication.
Failure to Respond to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure the provider responded to the interim medication regimen review recommendations made by the consultant pharmacist for one resident. Resident 67 was admitted for rehabilitation therapy with a medical history that included bipolar disorder, depression, and dementia. The resident’s order summary showed mirtazapine 30 mg daily for depression, oxcarbazepine 300 mg twice daily for bipolar disorder, and risperidone 1 mg each morning for bipolar disorder, ordered on 7/23/25. The record did not identify specific behaviors supporting the use of oxcarbazepine and risperidone, and the medication administration record did not show behavior and side effect monitoring for these medications. The resident also did not have an abnormal involuntary movement scale test performed, and there was no initial admission assessment or evaluation of the psychotropic medications to determine whether they could be reduced or discontinued. On 9/18/25, the resident’s interim medication regimen review dated 7/24/25 showed pharmacist recommendations for informed consent, behavior and side effect monitoring, an AIMS test within 30 days of admission and every 6 months or TCAPO daily monitoring, and evaluation of routine antipsychotic use by the prescriber on admission for possible dose reduction or discontinuation. During interviews, the psychiatry NP stated he had not been consulted for the resident, and the DON verified the resident had not been seen by any psychiatry provider and that the psychotropic medications had not been evaluated. The DON also acknowledged that the provider did not respond to the pharmacist’s recommendations.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent; surveyors calculated a 15.5 percent medication error rate based on 5 medication errors observed during 33 medication administration opportunities for three residents. The errors were identified during direct observation, interview, and record review of medication administration for residents with diagnoses including cerebral infarction, type 2 diabetes mellitus, and unspecified blepharitis of the left lower eyelid. For one resident with a history of cerebral infarction, an LPN prepared and administered aspirin 81 mg in an enteric-coated form, even though the physician order specified aspirin 81 mg chewable. During interview, the LPN reviewed the eMAR and stated the chewable form should have been given and that the form administered was considered an error. The same resident also had calcium carbonate chewable 500 mg ordered, and the LPN stated that medication should have been administered at that time instead. For another resident with type 2 diabetes mellitus, an LPN administered pioglitazone 30 mg at about 9:43 A.M., although the eMAR scheduled the medication for 7:30 A.M. The LPN stated the medication was given more than an hour past the due time and acknowledged it was a medication error. For a third resident, an LPN administered chewable aspirin 81 mg and polyethylene glycol 3350 mixed with approximately 6 ounces of water, although the order required the aspirin to be chewed and the polyethylene glycol to be mixed with 8 ounces of water. The DON stated medications should have been administered according to physician orders and verified against the eMAR.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled according to accepted standards of practice in four of eleven sampled medication carts. During observation of the crash cart, it was found to be missing alcohol wipes, sterile water, and K-Y jelly, even though the facility’s crash cart checklist listed those items. The Licensed Nurse who opened the cart confirmed the missing supplies and stated the cart should have contained all required items. In the treatment cart, an expired bottle of Derma Pak iodoform packing strip was observed, along with Clotrimazole cream labeled for Resident 57 despite the resident not having an active order for it. Resident 57 had been admitted with a diagnosis of displaced fracture of the base of the neck of the right femur, and the record showed the Clotrimazole cream order had ended. In a medication cart, Assure Dose glucometer drops were found with an open date beyond the 90-day use period printed on the box. The DON stated the expired packing strip, the resident’s cream without an active order, and the expired glucometer drops should not have been in the carts.
Failure to Offer and Document Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure the pneumococcal vaccine was offered to one resident who was admitted with orthopedic aftercare following surgical amputation and had diabetes mellitus among other comorbidities. During interview and record review, the Infection Preventionist Nurse stated that new admissions were reviewed in the CAIRS vaccine registry to determine whether a pneumococcal vaccine was needed and that the physician would be contacted for orders if indicated. For this resident, the vaccination record did not show that the pneumococcal vaccine was offered or refused. The Infection Preventionist Nurse reviewed the resident’s Vaccine Informed Consent form and stated it was blank, with no recorded vaccinations. The form was signed by the resident but not dated, and was signed by a staff member on 9/6/25. The DON stated residents were given immunization information regarding pneumococcal vaccine upon admission and that the resident should have been offered the vaccine. The DON also stated the expectation was for all newly admitted residents to be offered the pneumococcal vaccine and for the LPN to document whether the resident received or refused it. The facility policy stated all residents would be offered vaccines to prevent infectious diseases, all new residents would be assessed for current vaccination status upon admission, and refusals would be documented in the medical record.
Failure to Document COVID-19 Vaccine Offer and Status
Penalty
Summary
The facility failed to ensure COVID-19 immunization was offered to one resident, Resident 124, and failed to document that the resident was offered or refused the vaccine. Resident 124 was admitted with orthopedic aftercare following a surgical amputation and had diabetes mellitus among other comorbidities. During interview and record review, the Infection Preventionist stated that new admissions were reviewed in CAIRS to determine whether COVID-19 vaccination was needed and that the physician would be contacted for orders if indicated, but Resident 124's record did not show documentation that the vaccine was offered or refused. The Infection Preventionist reviewed Resident 124's Vaccine Informed Consent form and stated it was blank, with no recorded vaccinations. The form was signed by Resident 124 but not dated, and was signed by a staff member dated 9/6/25. The DON stated residents were given immunization information regarding the COVID-19 vaccine upon admission and that Resident 124 should have been offered the vaccine. The facility policy stated all residents would be offered vaccines to prevent infectious diseases, all new residents would be assessed for current vaccination status upon admission, and refusals would be documented in the medical record.
Infection Control Failures in Waste Handling, Barrier Precautions, and TB Screening
Penalty
Summary
Staff failed to follow infection control procedures in several areas of the facility. Certified nursing assistants (CNAs) were observed transporting untied plastic trash bags to utility rooms and placing them on top of overflowing, uncovered trash bins. The utility rooms near two nurses' stations had foul odors, and the trash bins did not have lids. Both the Housekeeping Supervisor and Director of Staff Development confirmed that staff were expected to tie trash bags and cover bins, but these procedures were not followed. A licensed nurse provided wound care to a resident with a sacral pressure ulcer who was under enhanced barrier precautions (EBP) due to infection risk. Despite a posted EBP sign and a physician's order requiring gown and glove use during high-contact care, the nurse performed the wound treatment without wearing a gown. The nurse acknowledged forgetting to wear the gown and confirmed that gown use was required for infection prevention during such procedures. Additionally, newly admitted residents were not screened for tuberculosis (TB) upon admission as required by facility policy. Two residents were identified as not having received TB testing at the time of admission, with one resident only receiving the test several days later. The Infection Preventionist and Director of Nursing both stated that TB screening should occur upon admission to prevent the spread of infectious disease among vulnerable residents.
Failure to Develop and Implement Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing behavioral concerns for one resident. The resident, who was cognitively intact per a recent BIMS assessment, reported multiple issues with staff, including a medication error by a nurse and dissatisfaction with dietary services. The resident frequently changed food preferences and reported concerns to various staff members, including the DON. Documentation revealed that the resident had a pattern of reporting staff performance issues, resulting in the removal of approximately 15 caregivers from her care. Despite these ongoing behavioral concerns and the impact on staff assignments, there was no care plan in place to address or manage these behaviors. Interviews with facility staff, including the DON and dietary manager, confirmed awareness of the resident's behaviors and the challenges they posed. The DON acknowledged that fabricating issues with staff was a behavior used by the resident to control her care and that a care plan should have been developed to guide staff responses. A review of the resident's records confirmed the absence of a care plan related to these behaviors, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and interventions for each resident.
Improper Discharge of Resident Against Medical Advice
Penalty
Summary
The facility failed to appropriately manage the discharge process for a resident who was on an out on pass (OOP) with a physician's order. The resident, who had diagnoses including paraplegia, osteomyelitis, and pressure ulcers, was expected to return to the facility after a four-hour leave. However, the resident returned much later than expected, at 2 AM the following day, and was subsequently discharged against medical advice (AMA) without proper documentation or communication with the attending physician. The Licensed Nurse (LN) involved did not document any communication with the attending physician regarding the resident's AMA status, nor was there an order from the physician for the discharge. The facility's policy requires that a physician's order be obtained for discharges, and if a resident requests an immediate discharge, the attending physician must be promptly notified. This protocol was not followed, leading to the resident being discharged without the necessary physician's approval. The Director of Nursing (DON) confirmed that the expectation was for clear communication in the resident's record regarding the discharge and that the attending physician should be informed and involved in the decision. The failure to adhere to these procedures resulted in an unsafe discharge, potentially compromising the resident's health, safety, and well-being.
Failure to Develop Baseline Care Plan for Resident's Non-Compliance
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who had multiple episodes of leaving the facility and was non-compliant with the ordered duration of hours while out on pass (OOP). This deficiency was identified during an unannounced onsite visit following complaints related to admission, transfer, and discharge rights. The resident, who was admitted with diagnoses including paraplegia, osteomyelitis, and pressure ulcers, had a cognitive status indicating they were cognitively intact. Despite this, the facility did not create a care plan to address the resident's non-compliance with the ordered duration of hours while OOP, which was acknowledged by both a Licensed Nurse and the Director of Nursing during interviews. The facility's policy on care planning, revised in March 2022, states that the interdisciplinary team is responsible for developing comprehensive, person-centered care plans based on resident assessments. However, in this case, the facility did not adhere to its policy, as no care plan was developed for the resident's non-compliance when leaving the facility. This oversight had the potential to leave the resident uneducated on the risks and benefits of leaving the facility and without guidance for staff on how to manage the resident's care effectively.
Failure to Implement Out on Pass Policy
Penalty
Summary
The facility failed to adhere to its policy regarding signing residents out for an out on pass (OOP) for one of the sampled residents. The staff did not consistently obtain a physician's order for the OOP, nor did they assess and document the time the resident returned from the OOP in the clinical record. Additionally, the OOP form was not consistently signed, which was a requirement per the facility's policy. The resident involved had a history of paraplegia, osteomyelitis, and pressure ulcers. Despite being cognitively intact, as indicated by a BIMS score of 15/15, the resident went out on pass multiple times without the necessary documentation and physician's orders. On several occasions, the OOP forms were incomplete, lacking details such as the time of return, the printed name, and the relationship of the person who took the resident out, as well as the initials of the licensed nurse. Interviews with the licensed nurse and the Director of Nursing revealed that the expectation was for staff to obtain a physician's order, write a progress note related to the resident's OOP, and educate the resident on safety if they returned late. However, these steps were not consistently followed, leading to a potential compromise of the resident's health, safety, and well-being.
Failure to Verify Competency of Registry Nurses for Medication Administration
Penalty
Summary
The facility failed to ensure that two of four licensed nurses (LN 1 and LN 4) were verified as competent to administer medications, specifically Norco, to residents. This deficiency was identified during a review of Resident 1's medication administration records. Resident 1 was admitted with a diagnosis of low back pain and was prescribed Norco, a controlled pain medication, to be administered daily at noon. However, discrepancies were found in the medication administration records, indicating that Resident 1 did not receive the medication as scheduled on 1/9/25, and there was no documentation verifying the competency of the nurses involved. Interviews with staff, including LN 3, the Director of Staff Development (DSD), and the Assistant Director of Nursing (ADON), revealed that the facility did not verify the competency of registry nurses, LN 1 and LN 4, who were responsible for administering medications. LN 1 admitted to not signing out the medication on the Controlled Drug Record (CDR) and acknowledged that Resident 1 did not receive the scheduled dose on 1/9/25. The DSD and ADON confirmed that the facility should have verified the competency of registry nurses, as it is a matter of resident safety. The facility's policy on staffing and competent nursing, revised in August 2022, requires that all nursing staff demonstrate the skills necessary for medication management. However, the facility did not have documentation verifying that LN 1 and LN 4 were assessed for medication administration competency, either by the facility or their registry agency. This oversight had the potential to result in unsafe medication administration to Resident 1 and other residents.
Failure to Administer Routine Pain Medication
Penalty
Summary
The facility failed to ensure that a resident received his routine pain medication as ordered, which had the potential to cause the resident to experience pain. The resident, who was admitted with a diagnosis of low back pain, was prescribed Norco (hydrocodone-acetaminophen) to be administered daily at noon. However, on 1/9/25, the medication was not administered as scheduled. This was confirmed through an interview with the resident's family member, who reported difficulties in receiving the medication on time, and a review of the medication administration record (MAR) and Controlled Drug Record (CDR), which showed discrepancies in the medication count. During an observation and interview with a licensed nurse, it was revealed that the nurse did not sign out the medication on the CDR for 1/10/25, and upon review, it was found that the medication was not administered on 1/9/25, as there were 18 pills left instead of 17. The assistant director of nursing confirmed that the resident had not left the facility on 1/9/25 and should have received the medication as scheduled. The facility's policy on administering medications, which requires adherence to prescriber orders and time frames, was not followed, leading to this deficiency.
Failure to Develop Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was receiving anticoagulant therapy with enoxaparin for deep vein thrombosis prevention. The resident, who had a diagnosis of encephalopathy and a G-tube, was admitted with physician orders for daily enoxaparin injections. On the day following the initiation of anticoagulant therapy, the resident was sent to the hospital due to bleeding at the G-tube site. Review of the clinical record revealed no documented evidence that a care plan addressing anticoagulant therapy had been developed for this resident. Interviews with nursing staff and facility leadership confirmed that care plans for anticoagulant therapy are necessary to ensure monitoring and consistent care, particularly to identify and address the risk of bleeding. Both licensed nurses and the Director of Nursing acknowledged that the absence of a care plan meant there was no structured approach for monitoring the resident for bleeding or other complications related to anticoagulant use. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed in the case of the resident on anticoagulant therapy.
Resident's Dignity Compromised by CNA's Actions
Penalty
Summary
The facility failed to ensure respect and dignity for a resident when a Certified Nursing Assistant (CNA) did not fulfill the resident's request for a clean bowl for her breakfast cereals. Instead, the CNA provided a bowl with cereal already in it, which the resident found to have food debris. The resident requested a clean bowl from the kitchen, but the CNA discarded the cereal in the bathroom toilet bowl, rinsed the bowl in the bathroom sink, and returned it to the resident. This action led the resident to feel disrespected and upset, as she expected a clean bowl and was concerned about the dignity and respect for herself and other residents who might not be able to speak for themselves. During the investigation, the CNA initially denied discarding the cereal in the toilet but later admitted to the possibility of having done so due to confusion while assisting another resident. Observations confirmed the presence of floating cereals and a paper towel in the toilet bowl. The Infection Preventionist and the Director of Nursing both acknowledged that the CNA's actions were disrespectful and posed an infection control issue. The facility's policy on dignity emphasizes treating residents with respect and honoring their preferences, which was not adhered to in this incident.
Unsanitary Food Disposal Practices in Resident's Bathroom
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and distribution practices for a resident, identified as Resident 1, when a Certified Nursing Assistant (CNA) discarded cereal into the toilet bowl and did not flush it. This incident was observed during an unannounced visit following a complaint related to residents' rights. Resident 1, who was cognitively intact with a BIMS score of 15/15, reported that she requested a clean bowl for her cereal, but the CNA provided a bowl with cereal already in it. Resident 1 refused the bowl and heard the CNA discard the cereal in the toilet, rinse the bowl in the bathroom sink, and return it to her. Resident 1 expressed concern about the unsanitary practice and its implications for other residents who might not be able to advocate for themselves. Upon investigation, floating cereal and a paper towel were found in the toilet bowl of Resident 1's bathroom. The CNA initially denied discarding the cereal in the toilet but later admitted to the possibility of having done so due to confusion while assisting Resident 1's roommate. The Maintenance Director, Infection Preventionist, and Director of Nursing all confirmed that the presence of cereal in the toilet was unacceptable and posed an infection control issue. The facility's policy on food preparation and service did not address the disposal of food in the toilet bowl, highlighting a gap in the facility's infection control practices.
Failure to Maintain Required Room Temperature
Penalty
Summary
The facility failed to maintain the required temperature range of 71 to 81 degrees Fahrenheit in 44 out of 68 resident rooms inspected. This deficiency was identified through observations, interviews, and record reviews. A complaint was received regarding the facility's physical environment, specifically noting the lack of heat and cold conditions. During an observation and interview with a resident, it was noted that the resident was using multiple blankets to keep warm and reported feeling cold during the night. The Maintenance Assistant confirmed that room temperatures were below the required range, with several rooms recorded at temperatures as low as 63 to 70 degrees Fahrenheit. Further observations and interviews with another resident and the facility's administrator confirmed the issue, with residents using additional clothing and blankets to stay warm. The administrator and Director of Nursing acknowledged the importance of maintaining room temperatures within the acceptable range for resident comfort. The facility's policy on maintaining comfortable and safe room temperature levels was not adhered to, as evidenced by the recorded temperatures and resident reports of discomfort due to the cold environment.
Failure to Maintain PICC Line Patency
Penalty
Summary
The facility failed to ensure the proper maintenance of a Peripherally Inserted Central Line catheter (PICC) for a resident, which is crucial for intravenous therapy. The deficiency was identified during an unannounced visit following a complaint related to quality of care. The resident in question was admitted with diagnoses including protein-calorie malnutrition and functional quadriplegia. Upon review, it was found that there was no physician order for flushing the PICC line, nor was there any documentation in the medication administration record (MAR) or a care plan specifically addressing PICC line care. Interviews with licensed nurses and the Director of Nursing (DON) revealed that the facility's protocol required a physician's order for intravenous medications and fluids, and that PICC lines should be flushed at least every shift or before and after medication administration to maintain patency. However, there was no such order or documentation for the resident's PICC line. The facility's policy indicated that catheters not used for intermittent infusion should be flushed at least every 24 hours, but this was not adhered to in the case of the resident, leading to the potential risk of a clogged line and infection.
Failure to Implement Care Plans for Noncompliance and Combative Behavior
Penalty
Summary
The facility failed to initiate and implement care plans for two residents, which could lead to staff being unaware of the residents' care needs. Resident 1 was admitted with an amputation and required wound care for the stump. Despite being educated on the importance of keeping the dressing on, Resident 1 removed it and did not comply with instructions to avoid pressure on the stump. The care plans reviewed for Resident 1 did not include a plan for noncompliance, which was acknowledged by the Director of Nursing (DON) as necessary for staff awareness and assistance. Resident 2, diagnosed with dementia, exhibited combative behavior, making it difficult for staff to provide wound care. The nursing notes indicated that Resident 2 was forgetful, combative, and refused assessments, kicking and biting staff. However, there was no care plan addressing noncompliance or combative behavior for Resident 2. The DON confirmed the absence of such a care plan, which is essential for meeting the resident's needs and ensuring safety. The facility's policy emphasizes the importance of comprehensive, person-centered care plans with measurable objectives and timetables.
Failure in Wound Care and Documentation
Penalty
Summary
The facility failed to ensure proper wound care and documentation for two residents, leading to potential risks for worsening skin conditions. Resident 1, admitted with an amputation, developed a new wound on the stump after a fall. Despite physician orders for treatment, the Treatment Administration Record (TAR) showed that the prescribed ointment for a moisture-related rash was not applied eight out of 38 times, and no treatment was recorded for the stump wound on two specified days. Consequently, the dressing on the stump was found soaked with blood, and the surgical site had opened, necessitating hospital evaluation. Resident 2, diagnosed with dementia, required wound care for multiple skin sites and monitoring for bruising. The TAR indicated that wound treatments were not performed on three out of ten days, and daily monitoring for bruising was missed on four out of 23 days. Additionally, dressings were not applied on one of the six prescribed days, and treatments to the buttocks were missed 22 out of 69 times. The Director of Nursing acknowledged the failure to follow physician orders and the lack of documentation, which could lead to worsening of the residents' wounds.
Failure to Complete Neurological Examination After Resident Assault
Penalty
Summary
The facility's Licensed Nurses (LNs) failed to complete a neurological examination for a resident after a physical assault incident. A Certified Nursing Assistant (CNA) witnessed another resident physically assaulting the affected resident by hitting them in the head with an empty pitcher. Despite the initiation of neuro checks, there were missed entries for blood pressure monitoring, which was crucial given the resident's medical history of traumatic intracranial hemorrhage and the goal to maintain systolic blood pressure below 140. Interviews with staff revealed that the resident who was assaulted was non-verbal, bedbound, and dependent on staff for activities of daily living. The Director of Nursing (DON) acknowledged the missed blood pressure entries and emphasized the importance of monitoring to detect any changes in the resident's status. The facility did not provide a policy related to the completion of neuro checks, highlighting a gap in ensuring comprehensive monitoring post-incident.
Failure to Implement Fall Prevention and Communication Protocols
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for a resident identified as high fall risk. The staff did not implement fall prevention measures for the resident, who had a history of falls and was diagnosed with Parkinson's disease and a sacrum fracture. The resident was dependent on staff for mobility and required maximum assistance to walk. Despite these needs, the facility did not ensure the presence of fall prevention tools such as bed alarms and fall mats. A Licensed Nurse (LN 1) did not complete a neurological examination for the resident after an unwitnessed fall and failed to communicate the fall incident to the incoming shift nurse. This lack of communication resulted in the subsequent shift being unaware of the resident's fall history and the absence of necessary fall prevention measures. The resident was later found unresponsive and seizing, with no prior notification of the fall incidents to the responsible party (RP). The Director of Nursing (DON) confirmed that the resident experienced two falls and emphasized the need for fall prevention measures and communication between staff regarding resident incidents. The facility's policies required staff to inform residents and their representatives of health status changes, which was not adhered to in this case. The failure to notify the RP and conduct proper monitoring after the falls contributed to the deficiency identified in the report.
Failure to Complete PASARR for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for two residents who received new mental illness diagnoses. Resident #35 was originally admitted on 02/03/2022 and later diagnosed with schizophrenia and anxiety disorder on 07/14/2022. Despite these new diagnoses, there was no evidence in the medical record that the resident was referred for a PASARR evaluation. The resident's care plan, initiated on 07/19/2022, indicated a risk for altered mood related to schizophrenia, but the necessary PASARR process was not completed. Similarly, Resident #11, admitted on 02/27/2011, received new diagnoses of depression, schizoaffective disorder, and obsessive-compulsive disorder in September 2022. The resident's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment and active diagnoses, yet there was no documentation of a PASARR referral. Interviews with facility staff, including the Social Services Director and the Director of Nursing (DON), revealed a lack of follow-through in submitting a new Level I screening and ensuring a PASARR evaluation was conducted following the new mental illness diagnoses.
Failure to Include Bed Rails and Oxygen in Care Plans
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, specifically neglecting to include the use of bed rails and supplemental oxygen. Resident #16, who was readmitted with a medical history of Alzheimer's disease, Parkinson's disease, hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation, was observed multiple times with bed rails in the up position and using supplemental oxygen. However, these were not included in the resident's comprehensive care plan. Interviews with various staff members, including a Licensed Vocational Nurse, the Assistant Director of Nursing, the MDS Assistant, and the Director of Nursing, revealed a consensus that both bed rails and supplemental oxygen should be included in the care plan, yet they were not. Similarly, Resident #38, admitted with a history of vascular dementia, hemiplegia, hemiparesis following a stroke, and a history of falling, was observed with bed rails in the up position. Despite this, the resident's care plan did not include the use of bed rails. The Director of Nursing acknowledged responsibility for signing off on care plans and confirmed that residents assessed to need bed rails should have them included in their care plans. The oversight in care planning for both residents indicates a failure to adhere to the facility's policy on comprehensive, person-centered care plans.
Lack of Physician Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain physician orders for the use of supplemental oxygen for a resident, leading to a deficiency in respiratory care. The facility's policy on oxygen administration requires verification of a physician's order before administering supplemental oxygen. Resident #16, who was readmitted to the facility with a medical history including Alzheimer's disease, Parkinson's disease, hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation, was observed using supplemental oxygen without a physician's order. Despite the resident's use of oxygen via a nasal cannula, the Order Summary Report showed no active order for supplemental oxygen. Interviews with the LVN, Assistant Director of Nursing, Director of Nursing, and Executive Director confirmed the absence of a physician's order for the resident's supplemental oxygen use, acknowledging that such an order was necessary.
Failure to Obtain Assessment and Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that an assessment was completed and informed consent and a physician order were obtained for the use of bed rails for Resident #16. The facility's policy on bed safety, revised in August 2022, prohibits the use of bed rails unless specific criteria are met, including attempting alternatives and conducting an interdisciplinary evaluation. However, Resident #16, who was readmitted to the facility with a medical history of Alzheimer's disease, Parkinson's disease, hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation, was observed on multiple occasions with bed rails in the up position without any documented assessment, informed consent, or physician order. Interviews with facility staff, including an LVN, CNA, ADON, DON, and the Executive Director, revealed a lack of clarity and adherence to the facility's policy regarding bed rail use. The LVN and ADON were unsure about the need for evaluation or consent, while the DON confirmed that there should be a physician's order and consent for bed rail use. The bed rails were reportedly installed at the family's request when the resident's bed was switched to a hospice bed, but no formal assessment or documentation was completed to justify their use, leading to the deficiency.
Deficiency in Pain Medication Management
Penalty
Summary
The facility failed to ensure that routine, scheduled pain medication was available for a resident, leading to a deficiency in pharmaceutical services. The resident, who had a medical history of spinal stenosis, acute transverse myelitis, neuralgia, neuritis, and muscle weakness, was admitted to the facility and had a care plan indicating a risk for pain. The resident was prescribed morphine sulfate extended-release tablets for pain management, to be administered twice daily. However, the facility ran out of the medication, and the resident did not receive the scheduled doses for two and a half days. Interviews and record reviews revealed that the facility's staff did not reorder the medication in a timely manner. The resident reported that the facility ran out of their pain medication towards the end of the month, and they had to wait for the doctor to order more. The medication administration record showed that the last tablet was administered on the morning of June 20, and subsequent doses were not given due to the medication being out of stock. Progress notes indicated that the morphine sulfate was pending delivery and on order during this period. Staff interviews highlighted communication and procedural issues. LVN #5 stated that she usually contacted the pharmacy for refills when there were 10 to 12 tablets remaining, but in this case, someone else had already ordered the medication. LVN #3 mentioned that the pharmacy was having fax issues, which delayed the order. The Director of Nursing acknowledged that staff should not wait until a resident is out of medication to reorder and that there was no documentation of a refill request before the medication ran out. The Executive Director and Medical Director both stated that residents should not go without their scheduled pain medications.
Medication Administration Errors Lead to 10% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during the survey. This deficiency was observed in the administration of medications to two residents. For one resident with type 2 diabetes mellitus, a Licensed Vocational Nurse (LVN) did not perform the required safety check of priming the insulin pen needle before administering the dose. The LVN was unaware of the need to prime the needle, which was contrary to the manufacturer's guidelines. This oversight was identified by the surveyor before the medication was administered, and the LVN corrected the procedure after being informed. In another instance, a resident with a history of anemia and vitamin D deficiency received an incorrect dose of Vitamin D and did not receive a prescribed multivitamin with minerals. The LVN responsible for this error admitted to administering only 400 units of Vitamin D instead of the ordered 2,000 units and forgetting the multivitamin due to nervousness. The Director of Nursing and other staff members acknowledged the importance of following physician orders and the five rights of medication administration to prevent such errors.
Infection Control Deficiency in Respiratory Equipment Storage
Penalty
Summary
The facility failed to adhere to its infection control procedures for the storage of respiratory equipment for a resident who was readmitted with a medical history including Alzheimer's disease, Parkinson's disease, hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation. Observations revealed that the resident's nasal cannula was found on the floor, and the yanker used for suctioning was placed on top of the dresser, with its tip touching the surface. Additionally, a nebulizer mask was observed on top of a plastic bag next to the nebulizer machine, rather than being stored inside the bag as required by the facility's policy. Interviews with staff, including an LVN, the Assistant Director of Nursing, the DON, and the Executive Director, confirmed that the observed practices were not in compliance with the facility's infection control policy. The LVN acknowledged that the oxygen tubing and yanker were contaminated and needed replacement, while the nebulizer mask should have been stored in a plastic bag. The Assistant Director of Nursing and the DON reiterated that respiratory equipment should be stored in a bag to prevent contamination, and the Executive Director expected staff to follow the established policy.
Failure to Offer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to ensure that the influenza vaccine was offered to a resident during the specified influenza season. According to the facility's policy, the influenza vaccine should be offered to residents and employees between October 1st and March 31st each year unless medically contraindicated or already immunized. Resident #69, who was admitted on March 11, 2022, with a medical history of hemiplegia, hemiparesis following a stroke, and dementia, was not offered the influenza vaccine during the 2023-2024 influenza season. The resident's immunization record indicated that the last influenza vaccine was administered on January 19, 2023. Interviews with the Infection Prevention Nurse, Director of Nursing, and Executive Director confirmed that the resident should have been offered the influenza vaccine for the 2023-2024 season. The staff acknowledged the importance of annual influenza vaccinations due to the changing strains of the virus each year. However, there was no evidence to show that the resident was offered the vaccine during the specified period, leading to a deficiency in the facility's compliance with its vaccination policy.
Failure to Develop Care Plans After Resident Altercation
Penalty
Summary
The facility failed to develop care plans for two residents following a resident-resident altercation, which was reported to the district office. An unannounced on-site visit was conducted, revealing that neither resident involved in the altercation had a care plan addressing the incident. Resident 1, who has diagnoses of Bi-Polar disorder and dementia, was observed and interviewed with the help of a translator. She stated she felt safe and did not remember much of the incident. However, a review of her medical records showed no care plan was developed for the altercation. Similarly, Resident 2, who has diagnoses of Bi-Polar disorder and a history of falls, was also observed and interviewed. She expressed satisfaction with a room change and recalled the incident but felt safe. A review of her medical records also indicated the absence of a care plan for the altercation. The Director of Nursing confirmed during interviews that care plans should have been developed for both residents following the altercation, as per the facility's policy on comprehensive, person-centered care plans.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for a resident, which had the potential to impact the accommodation of the resident's needs. The resident, who was admitted with diagnoses including muscle weakness and difficulty in walking, reported that call lights could take 1 to 3 hours to be answered. Another resident corroborated this, stating that call lights could take up to 3 hours to be answered. The Resident Council Meeting Minutes from March, April, and May 2024 indicated concerns about the delay in answering call lights, with the April minutes specifically highlighting this issue. Interviews with the Assistant Director of Nursing and a certified nursing assistant revealed that they considered a 15-minute response time reasonable, while 1 to 3 hours was deemed too long. The facility's Call Light Policy, dated 2001, stated that call lights should be answered as soon as possible.
Failure to Prevent Cross-Contamination of Ice Scoops
Penalty
Summary
The facility failed to prevent cross-contamination of resident ice scoops stored at the water/ice stations for two nursing stations. During an unannounced visit, it was observed that the ice scoops were stored in clear plastic bins that were uncovered, exposing the scoops to the environment. On the Acadia unit, the ice scoop was face up in the bin, while on the Oceana unit, the ice scoop was face down. Both instances left the ice scoops exposed to potential contamination. Interviews with the Dietary Staff Supervisor (DSS) and the Director of Nursing (DON) confirmed that the ice scoops should have been stored in covered containers to prevent contamination. The DSS acknowledged that the current storage method posed a risk of contaminating the ice, which could then be ingested by residents. The facility's policy, titled Ice Chest Policy and Procedure, also stipulated that ice scoops should be stored in covered containers, a procedure that was not followed in these instances.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident received only medications prescribed for him, leading to the administration of incorrect medication. Resident 1, who had diagnoses including chronic congestive heart failure, chronic respiratory failure, and Marfan Syndrome, was mistakenly given two 200 mg tablets of Seroquel, a medication used to treat psychiatric disorders, despite having no psychiatric diagnosis. This error occurred because a registry nurse mixed up medication cards and did not verify the correct resident's name, medication, and dosage before administration. As a result, Resident 1 became drowsy after receiving the high dose of Seroquel. Interviews with the Director of Nursing (DON) and a licensed nurse (LN) revealed that the registry nurse failed to follow the facility's medication administration policy, which requires checking the medication label three times to verify the right resident, medication, dosage, time, and route of administration. The registry nurse was no longer contracted by the facility and was unavailable for an interview. The facility's policy explicitly states that medications ordered for one resident may not be administered to another resident, highlighting the importance of adherence to proper medication administration procedures.
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 422 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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.
Nursing homes near Encinitas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Encinitas Post-acute | 0.6 mi | ★★★★★ | 0 | 0 |
| The Dorothy & Joseph Goldberg Healthcare Center | 0.9 mi | ★★★★★ | 20 | 0 |
| Glenbrook | 2.5 mi | ★★★★★ | 18 | 0 |
| Bayshire Torrey Pines Post-acute | 6.5 mi | ★★★★★ | 1 | 0 |
| Village Square Healthcare Center | 7.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Aviara Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.