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 Beacon Healthcare Center during CMS and state inspections, most recent first.
Failure to Promptly Notify Physician of Change in Condition: Staff did not promptly notify the MD/attending physician of a resident’s change in condition, including increased bilateral leg edema and signs and symptoms of a UTI. The resident had dementia, was dependent for all ADLs, and had a care plan for edema monitoring with prompt reporting of increases. The TAR showed edema increased from +1 to +2, and the physician did not recall being informed. An SBAR also documented weight gain, generalized weakness, and urinary frequency/urgency, but staff only texted about weakness and poor intake, not the urinary symptoms.
Incomplete and inaccurate documentation of edema and turning/repositioning care: An LVN and the H&P documented no edema for one resident even though nursing records and staff interview indicated edema was present. In addition, the medical records for two residents on turning/repositioning programs lacked documentation that care was provided every 2 hours as required by their care plans, and the MTR for another resident on a repositioning program contained no entries for the reviewed period.
Inaccurate MDS Coding of Foot Wound: A resident with DM, dementia, and severe functional dependence developed a left fifth toe wound after the feet were noted to be contacting the bed footboard. The wound was documented by nursing and the WCS as a diabetic ulcer because the resident had diabetes, even though the etiology was not fully assessed and the supervising MD stated the wound could have been a pressure injury from prolonged footboard contact. Based on that documentation, the MDS was coded as having no pressure ulcer/injury at discharge.
A resident with DM and dementia developed a wound on the left fifth toe that was documented as a diabetic ulcer even though staff noted the foot had been pressing against the bed footboard. The WCS said the wound was classified as diabetic because the resident had diabetes and did not consider the wound etiology, while the supervising MD stated a diabetic resident can still have a pressure injury on the foot if the cause is pressure.
A resident with DM, dementia, and severe functional dependence developed a pressure injury to the left fifth toe after being placed in a bed that was too short and allowed to slide down until the feet contacted the footboard. The admitting LVN did not document the admission skin assessment, and the wound was later identified by the treatment nurse as non-blanchable redness caused by pressure from the footboard, although the wound care specialist labeled it a diabetic wound.
A resident with DM, ESRD, and hypertensive chronic kidney disease had significant weight changes identified by the IDT, including a notable gain and later loss. The DON stated the MD should have been notified and the notifications documented in the progress notes, but no such documentation could be found. The resident’s MDS showed severely impaired cognition for decision making.
Incomplete pain assessment for a resident with reported groin pain. A resident with CKD, UTI, and moderately impaired cognition reported pain with urination and groin/stomach discomfort, and MAR documentation showed pain rated 5/10 with Tylenol given. An LPN stated the resident was assessed but was not asked key pain-description questions such as whether the pain was throbbing or stabbing, despite the facility P&P requiring assessment of pain location, intensity, description, pattern, and timing.
Missing Visible Thermometer in Reach-in Refrigerator 2: A kitchen observation found Reach-in Refrigerator 2 without a thermometer visible inside, despite staff stating one should be there and that it is used to verify the outside thermometer. The DSS confirmed a second thermometer should be inside the unit to help ensure food is cooled properly, and the facility P&P required two easily visible thermometers in all walk-in and reach-in refrigerators.
The facility failed to ensure privacy for two residents during incontinence care. One resident with moderate impaired cognition and another with intact cognition but dependent on staff for toileting hygiene were observed without closed privacy curtains during care. This was contrary to the facility's policies on dignity and quality of life, which require maintaining resident privacy during personal care.
The facility failed to ensure safe food handling practices, as surveyors found unlabeled and undated open bags of hamburger patties and eggrolls in the freezer. The Dietary Supervisor acknowledged that open food items should be labeled and dated according to the facility's policies, which were not followed, potentially risking foodborne illnesses for residents.
A facility failed to accurately complete the MDS for a resident, not reflecting their hearing impairment. Despite being noted as having adequate hearing in the MDS, observations and interviews with family and staff revealed the resident was hard of hearing and required close communication. The MDS Coordinator acknowledged the inaccuracy, and the facility's policy emphasized the importance of accurate assessments and effective communication for hearing-impaired residents.
A resident with highly impaired hearing did not receive necessary treatment to prevent decline in hearing abilities. Despite being cognitively intact, the resident struggled to hear and required close communication, yet no hearing aids or ENT consult were provided. Staff interviews confirmed the oversight, which contradicted the facility's policy on caring for hearing-impaired residents.
A resident with a pressure ulcer on the right heel had a pressure relief boot (PRB) applied incorrectly by an LVN, who had not received training on its proper application. The resident, dependent on staff for care, had multiple pressure injuries. The Treatment Nurse confirmed the need for proper PRB application to relieve pressure and aid healing. The facility's policy emphasized reviewing care plans and implementing interventions, which was not followed.
A resident receiving oxygen therapy did not have a cautionary sign posted on their door, as required by the facility's policy. This oversight was observed during a survey, where the resident was found connected to an oxygen machine without any signage indicating oxygen use, posing a safety risk. Staff interviews confirmed the necessity of such signage for fire safety.
A resident with dementia and anxiety was not properly assessed for pain during a medication pass. Despite the resident's complaint of a stomachache, the LVN did not evaluate the pain, attributing it to the resident's usual behavior. This was against the physician's order for pain evaluation and the facility's pain management policy, potentially affecting the resident's well-being.
The facility did not post actual worked nursing hours at the start of each shift as required by their policy. On a specific date, the actual CNA direct care service hours were less than projected due to staffing discrepancies. The DSD admitted that posted hours were projections and not updated when staff called off, leading to potential misinformation about staffing levels.
A resident with spastic quadriplegic cerebral palsy was prescribed Cefepime for sepsis without completing the McGeer's criteria, which is necessary to confirm true infections. The Infection Prevention Nurse noted that the admission nurse did not fill out the criteria, despite the facility's policy requiring it for antibiotic use.
The facility failed to serve black bean soup at the required temperature, with a test tray showing the soup at 120F, below the policy's minimum of 140F. This was confirmed by the Dietary Supervisor during a tray-line inspection, highlighting a deficiency in meal service standards.
A resident with cognitive impairments signed an Arbitration Agreement without understanding it, as confirmed by interviews and records. The resident's family member was in the process of obtaining Power of Attorney due to the resident's inability to make decisions. The facility's policy required capacity documentation, but the resident's impairment was noted, and the agreement was signed without proper authorization.
A facility failed to document complete discharge planning for a resident with chronic ulcer and diabetes. Although the Director of Social Services discussed the option of staying at the current facility with the resident's family, this was not recorded in the medical record. The facility's policy requires all services and changes to be documented to ensure effective communication among the care team.
Failure to Promptly Notify Physician of Change in Condition
Penalty
Summary
The facility failed to promptly notify Resident 1’s physician of changes in condition in accordance with its Acute Condition Changes - Clinical Protocol. Resident 1 was admitted with diagnoses including multiple vertebral fractures, type 2 diabetes mellitus without complications, and dementia. The admission record did not indicate peripheral neuropathy. The MDS dated [DATE] showed Resident 1 was severely impaired in cognitive skills, dependent on staff for all ADLs and bed mobility/transfers, and at risk for pressure ulcers/injuries. Resident 1’s care plan identified impaired skin integrity related to edema on both legs and directed staff to monitor edema and report promptly to the doctor if edema increased. The TAR showed that on [DATE], Resident 1’s right and left leg edema increased from +1 to +2 and remained +2 until [DATE]. During interview, the DON confirmed the increase in edema was a change in condition and stated the physician should have been notified. DR 2 stated the facility did not recall informing them of the increased edema. Resident 1 also developed signs and symptoms of a UTI. The SBAR dated [DATE] documented that at 12:00 PM Resident 1 had gained 6.6 pounds in one week, had generalized weakness, and had frequency and urgency with urinating. The IP stated these were signs and symptoms of a UTI and that the nurse should have notified DR 2 or the MD within the same shift the symptoms started. Text message screenshots showed staff later informed DR 2 about generalized weakness and inability to eat independently, but did not inform DR 2 of the frequency and urgency with urinating.
Incomplete and inaccurate documentation of edema and turning/repositioning care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for three sampled residents. For one resident, an LVN documented that the resident did not have edema, and the resident’s H&P also stated there was no edema, even though the TAR and the LVN’s interview indicated the resident had edema in the arms and legs at the time of assessment. The DON and MD reviewed the record and confirmed the nursing documentation should have reflected the edema that was present. The record also did not contain documentation that two residents were turned and repositioned every two hours as required by their care plans. One resident was admitted with diagnoses including enterocolitis, acute respiratory failure with hypoxia, and muscle weakness, had moderate cognitive impairment, and was dependent on staff for ADLs. Another resident was admitted with diagnoses including a fracture of the fifth metatarsal bone and Alzheimer’s disease, had severe cognitive impairment, and was dependent on staff for multiple ADLs. Both residents had care plans calling for turning and repositioning every two hours and as needed, but the medical record contained no documentation of those interventions. For the third resident, the MTR for turning and repositioning contained no documentation for the stated date range after the resident was placed on a turning and repositioning program for altered skin integrity and a coccyx pressure injury. CNA interviews stated that repositioning should be documented after care is provided, and the DON confirmed there was no turning and repositioning documentation for the residents in question. The facility policy also stated that documentation in the medical record will be complete and accurate.
Inaccurate MDS Coding of Foot Wound
Penalty
Summary
The facility failed to ensure an accurate MDS for one resident when the discharge assessment incorrectly indicated the resident did not have any pressure ulcer/injury at discharge on 2/3/2026. The resident was admitted on 1/8/2026 with diagnoses including multiple vertebral fractures, type 2 diabetes mellitus without complications, and dementia. The admission record did not indicate peripheral neuropathy, and the resident was severely cognitively impaired, dependent on staff for all ADLs, and dependent for bed mobility and transfers. The resident was also identified as being at risk for developing pressure ulcers/injuries on the 1/11/2026 MDS. The resident’s family member filed multiple complaints on 1/21/2026, including that a nurse had mischaracterized the resident’s pressure sores as diabetic ulcers. On 1/13/2026, treatment staff documented a new wound on the resident’s left fifth toe after noting the resident had been sliding down in bed and that the feet were contacting the footboard. The treatment nurse stated the wound was observed as non-blanchable redness and was documented as a diabetic ulcer because the resident had diabetes, without consulting the wound care specialist or the physician before assigning that diagnosis. The wound care specialist later evaluated the wound and also identified it as a diabetic wound, stating the etiology of the wound was not considered when making that determination. The supervising physician stated a diabetic resident can have a pressure ulcer on the foot and explained that if the wound resulted from prolonged contact with the footboard, it would be considered a pressure injury. The physician also stated the wound care note did not show that poor sensation in the feet had been assessed. Based on the wound being documented as a diabetic ulcer, the MDS coordinator entered that the resident did not have any pressure ulcer/injury on the MDS, resulting in an inaccurate assessment.
Wound on Toe Misclassified as Diabetic Ulcer
Penalty
Summary
The Wound Care Specialist inaccurately diagnosed a wound on a resident’s left fifth toe as a diabetic wound instead of a pressure injury. The resident was admitted with diagnoses including type 2 diabetes mellitus and dementia, and the admission record did not indicate peripheral neuropathy. The Minimum Data Set showed the resident was severely cognitively impaired, dependent on staff for all ADLs and bed mobility, and at risk for pressure ulcers/injuries. The care plan identified a skin breakdown on the resident’s left lateral metatarsal head of the fifth toe and directed a wound assessment and treatment as ordered. The grievance record showed the resident’s family member complained that staff had mischaracterized the resident’s pressure sores as diabetic ulcers. During interview, the family member stated the resident’s bed had been too short and that the resident’s feet had been pressed against the footboard until staff extended the bed frame. Treatment staff stated the wound was first noted as a new wound on the left fifth toe after the resident’s foot had been contacting the footboard, and the wound was documented as a diabetic ulcer because the resident had diabetes. The WCS stated the wound was determined to be diabetic without considering the wound’s etiology and acknowledged that the cause was pressure from the footboard. The supervising physician stated a diabetic resident can have a pressure ulcer on the foot and that if the wound area was discovered sitting against the footboard and the resident could not move the feet, the wound would be considered a pressure injury.
Failure to Document Admission Skin Assessment and Provide Proper Bed Support
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent a new pressure injury for one resident who was admitted with multiple vertebral fractures, type 2 diabetes mellitus, and dementia. The resident’s Minimum Data Set showed severe cognitive impairment, dependence on staff for all activities of daily living and bed mobility, and risk for pressure ulcers. The resident was also 75 inches tall. The admission record did not indicate peripheral neuropathy, and the admission skin assessment was not documented by the admitting LVN, who later stated the resident had scabs on the arms and legs but forgot to document them on the admission assessment. The resident was admitted to a standard bed that the facility used for all residents. The bed frame measured 81 inches from headboard to footboard, and the facility’s manual showed the sleep surface was 76 inches, or 80 inches when extended. The resident’s family caregiver reported that the resident was placed in a bed that was too short and later found the resident’s feet pressed against the footboard. The caregiver stated staff were notified and the bed frame was extended after the issue was discovered. The DON stated the facility ordered a mattress extension because the resident slid down in bed and the resident’s feet might touch the footboard. On 1/13/2026, the treatment nurse documented a new wound on the resident’s left fifth toe and noted the resident had been sliding down in bed, causing the feet to contact the footboard. The treatment nurse stated the foot contact caused the skin injury and described it as non-blanchable redness. The wound care specialist later evaluated the wound and identified it as a diabetic wound, stating diabetes was the reason for that determination and acknowledging that the wound’s etiology from pressure was not denied. The supervising physician stated a diabetic resident can have a pressure ulcer on the foot and that if the foot rested against the footboard for a long time, the wound would be considered a pressure injury. The facility’s pressure injury prevention policy required a comprehensive skin assessment upon or soon after admission and selection of appropriate support surfaces based on resident risk factors.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician of Resident 8’s significant weight changes. Resident 8 was admitted on 7/16/2025 with diagnoses including type 2 DM, ESRD, and hypertensive chronic kidney disease. The resident’s IDT Weight Change Review dated 9/1/2025 documented a 12.3 lb weight gain in one month, and the IDT Weight Change Review dated 10/7/2025 documented an 8 lb weight loss in one month. During interview, the DON stated that Physician 1 should have been contacted and the notification documented in the progress notes for both weight changes. The DON also stated that licensed nursing staff should have notified Physician 1 about the weight gain and that no progress notes could be found showing notification on either 9/1/2025 or 10/7/2025. The resident’s MDS dated 10/19/2025 indicated severely impaired cognition for decision making.
Incomplete Pain Assessment for Resident with Reported Groin Pain
Penalty
Summary
The facility failed to effectively assess the characteristics of pain for one resident who had stage 3 chronic kidney disease, a urinary tract infection, and moderately impaired cognition. The resident’s MAR documented 5 out of 10 pain on 1/13/2026 and that 500 mg of Tylenol was given. During an interview, the resident stated that family had spoken to staff about pain related to urination even after antibiotics were completed, that staff and therapists were aware of the pain, and that the pain interfered with sleep. An LVN stated that on 1/13/2026 the resident complained of pain “under there” and was rubbing the stomach, and that the resident was assisted back to the room and assessed. The LVN stated that questions about the nature of the pain, such as whether it was throbbing or stabbing, were not asked, although the resident reported 6 out of 10 inguinal pain. The DON stated that pain assessments should include the nature, intensity, location, description, pattern, frequency, timing, and duration of pain, and the facility’s P&P titled Pain Assessment required those characteristics to be gathered during a comprehensive pain assessment.
Missing Visible Thermometer in Reach-in Refrigerator 2
Penalty
Summary
The facility failed to ensure a thermometer was easily visible inside Reach-in Refrigerator 2 in the kitchen, as required by the facility’s Policy and Procedure titled, Procedure for Refrigerated Storage. During a concurrent observation and interview on 1/12/2026 at 8:45 AM, Reach-in Refrigerator 2 was observed without a thermometer visible on the inside of the refrigerator. CK 1 stated the thermometer could not be found and that it should be located inside Reach-in Refrigerator 2. CK 1 stated the thermometer was used to verify the temperature on the thermometer located on the outside of Reach-in Refrigerator 2 and that a second thermometer inside the refrigerator was important to ensure the refrigerator was at the correct temperature. During an interview on 1/14/2026 at 2:41 PM, the Dietary Supervisor stated there should be a second thermometer located on the inside of Reach-in Refrigerator 2 to ensure the food inside was cooled properly. The facility’s P&P stated that two thermometers, placed to be easily visible for checking, should be inside all walk-in and reach-in refrigerators, and that the second thermometer is a check against the first thermometer for accuracy.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The facility failed to ensure privacy for two residents during incontinence care, as observed by surveyors. Resident 7, who was admitted with diagnoses including encephalopathy, dysphagia, and contractures, was found to have moderate impaired cognition and depended on staff for activities of daily living (ADLs). During an observation, it was noted that Resident 7's privacy curtain was not completely closed during incontinence care, compromising their privacy. Similarly, Resident 15, who had diagnoses of dysphagia, abnormal posture, and unsteadiness on feet, was observed to have an intact cognition but also depended on staff for toileting hygiene. During incontinence care, Resident 15's privacy curtain was not closed, failing to protect their bodily privacy. The facility's policies on dignity and quality of life, revised in November 2023, emphasize the importance of maintaining resident privacy during personal care, which was not adhered to in these instances.
Deficient Food Handling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food handling practices in its kitchen. During an initial tour of the kitchen, surveyors observed one open bag of four hamburger patties and one open bag of eggrolls in the facility freezer that were unlabeled and undated. The Dietary Supervisor confirmed that open food items should be labeled and dated to identify the contents and determine their good-by date, as per the facility's policies and procedures. The facility's policies, titled 'Procedure for Frozen Storage: Freezer Storage' and 'Labeling and Dating of Foods,' both dated 2023, require all frozen food to be labeled and dated. This deficiency had the potential to result in foodborne illnesses for the residents.
Inaccurate MDS Assessment of Resident's Hearing Abilities
Penalty
Summary
The facility failed to ensure an accurate completion of the Minimum Data Set (MDS) for a resident, which did not accurately reflect the resident's hearing abilities and limitations. The resident was admitted with diagnoses including intestinal obstruction, hydronephrosis, atelectasis, and lack of coordination. The MDS indicated the resident was cognitively intact and had adequate hearing without the use of hearing aids. However, observations and interviews revealed that the resident was hard of hearing, requiring individuals to speak close to their ear for effective communication. Family members and staff, including a CNA, Activities Director, MDS Coordinator, RN, and LVN, confirmed the resident's hearing impairment, noting the absence of hearing aids or devices. The MDS Coordinator acknowledged the inaccuracy in the MDS assessment, which was crucial for providing quality care. The facility's policy and procedure for hearing-impaired residents emphasized maintaining effective communication and evaluating the resident's preferred communication method. Despite this, the resident's physician was not informed of the hearing impairment, and no ENT consult was ordered. The facility's policy required accurate MDS completion, and the MDS Coordinator's job description included evaluating residents' conditions and completing accurate MDS coding based on medical records, observations, and interviews.
Failure to Address Hearing Impairment in Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 99, received necessary treatment to prevent a decline in hearing abilities and maintain quality of life. Upon admission, Resident 99 was noted to have highly impaired hearing, yet the Minimum Data Set (MDS) indicated the resident was cognitively intact and had adequate hearing without the use of hearing aids. Observations and interviews revealed that Resident 99 struggled to hear and required others to speak very close to their ear or rely on lip reading for communication. Despite these challenges, no hearing aids or devices were provided, and there was no documentation of an Ear, Nose, and Throat (ENT) consult being ordered. Interviews with staff, including a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), and a Registered Nurse (RN), confirmed that Resident 99 was hard of hearing and that the necessary steps to address this issue, such as informing the physician or arranging for an ENT consult, were not taken. The facility's policy on the care of hearing-impaired residents emphasized the importance of maintaining effective communication and utilizing available resources, yet these procedures were not followed. This oversight had the potential to negatively impact Resident 99's social interaction and overall quality of life.
Improper Application of Pressure Relief Boot
Penalty
Summary
The facility failed to properly apply a pressure relief boot (PRB) for a resident with a pressure ulcer on the right heel. The resident, who was admitted with diagnoses including pressure-induced deep tissue damage, type 2 diabetes mellitus, and cognitive communication deficit, was dependent on staff for daily activities and had multiple pressure injuries. During an observation, a Licensed Vocational Nurse (LVN) was found to have incorrectly applied the PRB upside-down on the resident's right foot. The LVN admitted to not having received training on how to apply the PRB and was unaware of who had initially applied it incorrectly. Further observations and interviews revealed that the Treatment Nurse (TN) confirmed the presence of a deep tissue injury on the resident's right heel and emphasized the importance of the PRB in relieving pressure to aid in healing. The Director of Nursing (DON) reviewed the resident's care plan, which indicated the need for heel protection to offload pressure. The facility's policy on the prevention of pressure injuries highlighted the need to review care plans and implement interventions to reduce modifiable risk factors, which was not adhered to in this case.
Failure to Post Oxygen Use Signage
Penalty
Summary
The facility failed to ensure the safety of a resident receiving oxygen therapy by not posting a cautionary sign on the resident's door indicating that oxygen was in use. This oversight was identified during an observation where the resident was found asleep in bed, connected to an oxygen machine via a nasal cannula, without any signage to alert others of the oxygen use. The absence of a sign posed a risk to the resident's safety, as it did not remind visitors or other residents to be cautious and avoid smoking near the oxygen source. The resident in question had been admitted with diagnoses including a compression fracture of the vertebra, hypertension, and hyperlipidemia, and was receiving oxygen therapy to maintain oxygen saturation above 93%. The facility's policy and procedure on oxygen administration, revised in March 2024, clearly stated the need for 'No Smoking/Oxygen in Use' signs as part of the equipment and supplies necessary for safe oxygen administration. Interviews with staff, including an LVN and the Director of Staff Development, confirmed the requirement for such signage to ensure fire safety, as oxygen is combustible.
Failure to Assess and Manage Pain for a Resident
Penalty
Summary
The facility failed to properly assess and manage pain for a resident during a medication pass observation. The resident, who was admitted with diagnoses including dementia and anxiety, was observed by a Licensed Vocational Nurse (LVN) complaining of a stomachache. Despite the complaint, the LVN did not assess the resident's pain, attributing the complaint to the resident's usual behavior of complaining about back pain when sitting in a wheelchair. This inaction was contrary to the physician's order for pain evaluation every shift and the facility's policy on pain assessment and management. The facility's policy, revised in November 2024, outlines a comprehensive approach to pain management, including recognizing, assessing, and identifying the cause of pain, as well as defining goals and implementing strategies for pain management. However, during the incident, the LVN failed to follow these procedures, potentially affecting the resident's physical comfort and psychosocial well-being. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for moderate to maximal assistance with daily activities, highlighting the importance of proper pain assessment and management for this resident.
Failure to Post Actual Nursing Hours
Penalty
Summary
The facility failed to post the actual worked nursing hours at the start of each shift for one specific date, as required by their policy and procedure titled 'Consumer Information.' On November 14, 2024, the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) indicated that the actual total Certified Nursing Assistant (CNA) direct care service hours were 92.34 hours, whereas the Projection of Nursing Hours had scheduled 97.5 hours. This discrepancy was due to the fact that only three CNAs worked the entire second shift, and one CNA worked only three hours during that shift, contrary to the projection of four CNAs working the full shift. The Director of Staff Development (DSD) acknowledged that the posted nursing hours were merely projections and were not updated when a staff member called off. The facility's policy requires that the actual number of nursing staff on duty for each shift be posted daily at the beginning of each shift, in a clear and readable format, and in a prominent place accessible to residents and visitors. The failure to update the posted hours to reflect actual staffing levels could lead to inaccurate information being available to residents and visitors, potentially misrepresenting the level of care provided.
Failure to Review Antibiotic Necessity for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics, as required by their antibiotic stewardship program. Resident 149, who was admitted with spastic quadriplegic cerebral palsy and multiple joint contractures, was prescribed Cefepime Hydrochloride for sepsis. However, the necessary McGeer's criteria, which are used to confirm true infections, were not completed for this resident, indicating a lack of proper review for the necessity of the antibiotic. During an interview and record review, the Infection Prevention Nurse acknowledged that the admission nurse did not fill out the McGeer's criteria for Resident 149, despite the resident being prescribed antibiotics in the hospital. The facility's policy on antibiotic stewardship requires that antibiotics be prescribed and administered under specific guidelines, including meeting the McGeer's criteria for active infection or suspected sepsis. The failure to complete this criteria review suggests a lapse in adherence to the facility's policy and procedure.
Deficient Food Temperature in Meal Service
Penalty
Summary
The facility failed to prepare and serve food at a safe and appetizing temperature, as observed during a tray-line inspection. Specifically, the black bean soup served during dinner was found to be at 120 degrees Fahrenheit, which is below the facility's policy requirement of a minimum holding temperature of 140 degrees Fahrenheit for hot foods. This observation was made during a test tray tasting with the Dietary Supervisor, who confirmed that the soup was lukewarm and not within acceptable temperature ranges. The deficiency was identified during an initial facility tour where complaints about the food's texture, flavor, and temperature were noted. The facility's policy and procedure for meal service, dated 2023, mandates that meals meet the nutritional needs of residents and are served at appropriate temperatures, with hot foods like soups expected to be between 170F to 190F. The failure to adhere to these standards had the potential to result in meal dissatisfaction and decreased intake, placing residents at risk for unplanned weight loss.
Resident Signed Arbitration Agreement Without Capacity
Penalty
Summary
The facility failed to ensure that a resident, who signed an Arbitration Agreement, had the capacity to understand and make an informed decision. The resident was admitted with diagnoses including pressure-induced deep tissue damage, type 2 diabetes mellitus, and a cognitive communication deficit. The Minimum Data Set (MDS) indicated the resident was moderately impaired in cognitive skills, requiring supervision for decisions and assistance with daily activities. During an interview, the resident was unable to explain what an arbitration agreement was and did not recall being informed about it by the facility. The resident's family member, who was present during the interview, confirmed the resident's confusion and stated they were in the process of obtaining Power of Attorney due to the resident's inability to make medical decisions. The Case Manager claimed to have explained the arbitration agreement to the resident, who signed it despite documented cognitive impairments. The facility's policy stated that residents are presumed to have capacity unless otherwise documented, and consents should be signed by the resident or a legally authorized representative if the resident lacks capacity. However, the resident's cognitive impairment was documented, and the family member indicated the resident should not make decisions independently.
Incomplete Documentation of Discharge Planning
Penalty
Summary
The facility failed to ensure complete documentation regarding discharge planning for a resident, which was identified during a review of the resident's medical records. The resident was admitted with diagnoses including a non-pressure chronic ulcer, local infection of the skin and subcutaneous tissue, and type 2 diabetes mellitus. The Minimum Data Set (MDS) indicated the resident was dependent on assistance for certain activities of daily living. A late entry Social Service Note (SSN) documented a meeting between the resident's family member and the interdisciplinary team to discuss discharge plans, where assistance with long-term placement to another skilled nursing facility was requested. However, the SSN did not document whether the option to remain at the current facility was offered or discussed. Interviews with the Director of Social Services (DSS) revealed that the option for the resident to stay at the current facility was indeed discussed with the family member, but this was not documented in the resident's medical record. The facility's policy on charting and documentation requires that all services, progress, and changes in the resident's condition be documented to facilitate communication among the interdisciplinary team. The DSS acknowledged the importance of documentation, stating that if it was not documented, it did not happen, highlighting the deficiency in maintaining complete and accurate records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden View Post Acute Rehabilitation | 1.1 mi | ★★★★★ | 20 | 0 |
| West Covina Healthcare Center | 1.4 mi | ★★★★★ | 17 | 0 |
| West Haven Healthcare | 1.6 mi | ★★★★★ | 17 | 0 |
| West Covina Medical Center D/p Snf | 1.7 mi | ★★★★★ | 15 | 0 |
| Victoria Care Center | 1.8 mi | ★★★★★ | 13 | 0 |
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