Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgeview Post Acute during CMS and state inspections, most recent first.
A resident receiving Eliquis developed slurred speech, facial drooping, right arm weakness, and fatigue, but nursing staff did not complete a timely comprehensive assessment or notify the provider when concerns were first raised by the AD, CNA, and others. The resident was later taken to the hospital by a family member and diagnosed with an intracranial hemorrhage/thalamic bleed, requiring reversal of Eliquis and transfer for higher-level care; afterward, the resident had permanent loss of right arm function and decreased independence with personal care.
A resident with COPD, HF, emphysema, and HTN developed stroke-like symptoms, including right arm weakness, facial drooping, slurred speech, and fatigue, but nursing staff did not promptly complete and document a comprehensive assessment or notify the MD and resident representative when the change was first reported. The AD alerted RN B, and later an LVN assessed the resident and found the right arm could not be raised, but EMS and the provider were not contacted before a family member transported the resident to the hospital. The DON and ADMIN confirmed there was no documentation of timely provider or family notification.
The facility failed to implement physician orders for psychiatric evaluation and treatment and to integrate these services into the care plans for two residents with diagnosed depression. One resident was admitted with major depressive disorder and a hospital discharge order for an antidepressant that was not continued, had an MDS showing depression, repeatedly refused therapy, showed low motivation and withdrawal after learning of a divorce, and had psychiatric referrals ordered but never completed. Another resident with major depressive disorder, cognitive decline, and cancer had documented depressive symptoms, including crying and poor intake, and had two separate psychiatric referral orders with no evidence of any psychiatric evaluation or treatment in the record. Staff interviews confirmed that psychiatric referrals were not followed through and that no counseling or psychological services were provided, resulting in both residents not receiving ordered mental health evaluations and services.
Kitchen staff stored multiple dishes and pans while still wet, and some cookware had soil and damaged food-contact surfaces. A dietary staff member could not correctly describe the 3-compartment sink dishwashing process, and the walk-in cooler had ready-to-eat foods stored next to raw meats. A dietary staff member also worked with facial hair uncovered, and the resident food refrigerator contained unlabeled and expired items, including foods without resident identifiers or opened dates.
A facility failed to maintain resident dignity and quality of life when staff spoke a non-English language in resident rooms and other resident areas despite an English-only policy and repeated resident complaints. Multiple residents said the practice made them uncomfortable, isolated, or worried staff were talking about them, and the DON and Admin confirmed staff were not following the policy. The facility also failed to assist a resident with stroke-related mobility needs during lunch, where he had to use his hands to eat and had to be directed to his silverware even though he required supervision or touching assistance with eating.
Medication administration errors exceeded the 5% threshold when 3 errors were identified in 25 observed opportunities. An RN gave a resident canagliflozin after breakfast even though the manufacturer’s directions said it should be taken before the first meal of the day, and an LVN administered spironolactone and megestrol acetate without gloves despite physician orders requiring glove use for both hazardous medications.
A facility failed to follow its planned menus and therapeutic diet orders during lunch meal service. Residents on soft and bite size, minced and moist, low fat/low cholesterol, 2 g sodium, consistent carbohydrate, renal, and renal 60 g protein diets received incorrect foods, incorrect portions, or missing items such as green beans, fruit, rolls, cake, fish, tartar sauce, and margarine instead of the items listed on the menu spreadsheet. The RD and CDM confirmed the discrepancies and noted staff were expected to follow the spreadsheet, menu, recipe, and meal tickets.
Dietary staff failed to prepare SBS, MM, and puree foods according to IDDSI standards. A cook and a dietary aide were observed making carrots, tater tots, crisp fish, and dinner rolls without measuring portions, reviewing recipes, or performing required texture tests. The RD confirmed the MM foods were sticky or gluey and agreed the SBS and MM items were not prepared correctly.
A resident continued receiving divalproex sodium, a psychotropic medication, for an incorrect seizure diagnosis despite no seizure history being documented. The resident had a history of psychosis, hallucinations, and behavioral outbursts, and the DON and NP both confirmed the seizure indication was wrong and that the order had been entered incorrectly.
Failure to Provide Nail Care and Maintain Hand Hygiene: A resident with weakness, poor endurance, and poor balance had long, jagged, and dirty fingernails with dirt and food on and under the nails. CNA review sheets showed the resident did not receive nail care, and during observation the resident said staff could cut his nails and wash his hands anytime, while CNA confirmed the dirty hands and broken, jagged nails. There was no documentation that nail care was provided.
A resident with a g-tube, dysphagia, and a hx of cerebral infarction had meds administered via the enteral tube using tap water to dissolve and flush the meds, despite the facility policy requiring warm purified or sterile water. RN stated this was her standard practice and had done it for years, and the DON confirmed the facility was using tap water or kitchen water for tube flushing.
The facility failed to ensure bed rail safety assessments were completed for two residents using bed canes. One resident with a fx of the L femur, DM2, and muscle weakness had a physician order for bed canes but no bed safety assessment, and another resident with HF, acute respiratory failure, and muscle weakness did not have the assessment completed until after the bed canes were installed, as confirmed by the DON.
Incomplete E-kit Medication Accountability: The facility failed to maintain accurate record keeping for an emergency drug kit when one sulfamethoxazole/trimethoprim tablet was unaccounted for in a kit that should have contained four tablets. Surveyors found the kit previously opened, with one tablet present and receipts showing two tablets removed for resident use, while an LVN confirmed one pill was missing and the DON acknowledged the E-kit was not accounted for.
A resident’s med regimen review was not accurately completed when divalproex sodium ER 500 mg daily was ordered for seizures despite no seizure dx in the chart. RN and NP interviews confirmed the resident had no hx of seizures and that the medication should have been for behavior, while the clinical pharmacist was unavailable for interview during survey hours.
Medication Storage Temperature Errors: The facility failed to store medications at the correct temperatures. Two residents' acetaminophen suppositories and one resident's hydrocortisone AC suppository were found in a refrigerator at 34 degrees F even though manufacturer directions required storage at 68-77 degrees F. In addition, liquid gabapentin was found in a med cart drawer at room temperature even though the manufacturer required refrigeration. An LVN stated she thought the gabapentin could be kept in the med cart after opening, and the DON said pharmacy and nurses were responsible for checking proper storage.
Inaccurate Advance Directive Documentation on POLST Forms: Two residents had POLST forms that incorrectly indicated the presence of advance directives, but no advance directives were found in either medical record. The DON, SSD, and MRD all confirmed the entries were documentation errors, and the MRD stated nursing staff had only asked about advance directives during admission.
A resident with dementia, hemiplegia, and a high fall risk was left unsupervised on an outdoor patio by an RNA for about 30 minutes. The resident, dependent on staff for mobility and unable to call for help, was later found on the ground with a major head injury. The care plan did not specify supervision needs for outdoor activities, and staff were unaware of the resident's location. The resident suffered a subdural hematoma and died after emergency care.
A resident with significant cognitive and physical impairments was left unattended on a patio by a staff member, resulting in a fall that caused a subdural hematoma. The facility did not report the major injury to authorities, as required, because leadership did not consider it significant or unusual. This failure delayed investigation into the incident.
A resident with dementia and left-sided weakness, who enjoyed being outdoors, was not provided with outdoor activities as specified in their care plan. Activity staff were unaware of the care plan directive, and no documentation showed the resident was taken outside. The care plan also lacked clear instructions for supervision and frequency of outdoor activities, and staff did not facilitate the resident's participation due to not getting the resident up in a wheelchair.
A resident with vascular dementia, hemiplegia, and a history of falls was left unsupervised on a patio by an RNA for approximately 30 minutes, resulting in a major head injury and subsequent death. The resident was dependent on staff for all mobility and required close supervision, but staff failed to communicate the resident's location and did not provide adequate monitoring. The patio area could not be fully visualized from the nursing stations, and there was no call system available for the resident to request help.
A resident with multiple medical conditions and intact cognition reported being slapped by another resident, resulting in visible injuries. Although the incident was documented and known to facility leadership, it was not reported to the state agency as required by policy, due to staff misunderstanding about reporting requirements when the perpetrator has dementia.
Two residents with dementia and a history of falls experienced repeated incidents due to the facility's failure to determine the causes of falls, reevaluate care plan interventions, and develop new strategies to prevent further injuries. Direct care staff were not adequately informed about high fall risk residents or their care plans, and the electronic system used by CNAs did not provide sufficient information. The DON confirmed gaps in root cause analysis and communication regarding fall prevention interventions.
The facility failed to maintain a safe and homelike environment by storing construction materials in the rooms of three residents, creating potential hazards and cleanliness issues. Family members and residents raised concerns about tripping hazards and dustiness. The facility's policy required proper storage of supplies, which was not followed.
The facility failed to meet food safety and sanitation standards, with improper storage, labeling, and dating of food items in kitchen refrigerators. Expired and unlabeled food items were found, and kitchen equipment was unsanitary, with debris and grease on surfaces. Sanitizer levels were inconsistent, and dishwashing logs were incomplete. The kitchen environment was not clean, with food crumbs and spills on floors and walls. Resident food was not labeled or stored per policy, posing a risk of foodborne illness.
The facility failed to provide adequate social services and timely care for four residents, leading to unmet needs and potential delays in care. Care plans were not updated, financial assistance was not provided, and necessary referrals for outside services were delayed. Additionally, dental services were not promptly provided, resulting in significant delays for one resident.
The facility failed to properly store and label medications and supplies, with loose pills found in a medication cart, six medications opened but not dated, and expired Foley drainage bags and Pro-Stat liquid protein being used. The DON and ADON confirmed these actions were against facility policy.
Several residents in the facility reported issues with food being overcooked, undercooked, cold, or unappetizing. Despite complaints, the Dietary Manager failed to address these concerns effectively. Observations confirmed that food was not maintained at appropriate temperatures, with delays in meal service contributing to the problem. The facility's policies for food preparation and distribution were not followed, impacting the quality and safety of meals.
The facility failed to ensure resident dignity and privacy, as staff spoke in non-English languages in front of residents, night shift noise disturbed residents, and a CNA did not provide privacy during personal care. A resident was also inappropriately instructed to clean her own toilet, causing distress.
The facility failed to investigate and report alleged abuse involving three residents. A CNA did not report suspicions of abuse when a resident showed fear during care. Another resident was instructed by a housekeeper to clean her own toilet, and the incident was not reported. A third resident reported being held down by a CNA, but the incident was not investigated, and the CNA continued to care for the resident.
A facility failed to document essential details for a resident's transfer to a hospital, including the date, time, destination, and mode of transportation. The resident, who had undergone hip replacement surgery and experienced a change in condition, was transferred without proper documentation, as confirmed by the DON.
A resident with severe cognitive impairment and a history of falls was observed without non-skid footwear, contrary to his care plan. Despite requiring maximal assistance, he was left to dress himself, and his call light was out of reach. A CNA assisted him but did not provide footwear, as the resident was not assigned to him that day. The DSD confirmed the need for non-skid footwear to prevent falls.
Two residents with g-tubes in an LTC facility received inappropriate care due to staff not following Physician's orders. One resident received incorrect fluid amounts, risking fluid overload, while another was given excessive fluids, leading to aspiration pneumonia. Documentation and communication lapses contributed to these deficiencies.
The facility failed to ensure complete, signed, and dated physician progress notes for two residents. One resident, with chronic conditions, had no physician notes for several months and reported never seeing a doctor. Another resident, awaiting eye surgery, had only one incomplete note and reported missed surgeries and no doctor visits. The DON confirmed the documentation issues, and the MRA noted the previous doctor's incomplete and inaccurate notes.
The facility failed to ensure nursing staff competencies, leading to deficiencies in resident care. LNs did not reassess or notify physicians about a resident's potentially infected eye, and suspicions of abuse were not reported for multiple residents. Additionally, LNs did not adequately monitor gastrostomy tube feedings or check meal trays, resulting in discrepancies and unmet resident preferences.
A resident in a long-term care facility was prescribed both routine and PRN Ativan without an end date, contrary to CMS regulations. Despite recommendations from the consulting pharmacist to limit the PRN order to 14 days, the facility failed to address this in medication reviews. The resident, with a history of schizoaffective disorder and dementia, was at risk of adverse effects from excessive psychotropic medication use. Interviews revealed daily aggressive behaviors and unwitnessed falls, highlighting deficiencies in medication management.
A resident had teeth extracted and impressions taken for dentures, but due to an insurance change, the contracted dental service did not proceed with the dentures. The facility failed to follow up in a timely manner, leaving the resident unable to chew food properly.
The facility failed to honor food preferences for several residents, leading to dissatisfaction and potential negative impacts on their psychosocial health. Residents with specific dislikes, such as eggs, rice, tomatoes, and certain vegetables, were repeatedly served these items despite documented preferences. Staff admitted to oversight due to being rushed, and corporate menu controls limited options. These issues were noted in resident council meetings and satisfaction surveys, indicating ongoing problems with food service.
Two residents experienced abuse in a facility, leading to emotional distress. A CNA grabbed a resident's arm during personal care, despite the resident's distress and request for the CNA not to enter his room. The incident was not reported or investigated, and the CNA continued to be assigned to the resident's room. In another case, a housekeeper made a resident clean her own toilet after an episode of diarrhea, causing emotional distress. The housekeeper continued to be assigned to the resident's room until the issue was addressed. Both incidents highlight a failure in the facility's abuse prevention program.
The facility failed to report abuse allegations involving three residents. A CNA did not report suspicions of abuse when a resident showed fear during care. Another resident was instructed by a housekeeper to clean her own toilet, and the incident was not reported by a CNA. Additionally, a resident reported being physically restrained by a CNA, but the incident was not investigated. These failures to report and investigate abuse allegations were confirmed by facility staff.
Failure to Respond to Stroke-Like Symptoms and Notify Provider
Penalty
Summary
The facility failed to protect a resident from neglect when nursing staff did not recognize and appropriately respond to a significant change in condition that included slurred speech, facial drooping, right-sided arm weakness, and increased fatigue. The resident had diagnoses including COPD, emphysema, heart failure, and high blood pressure, and was receiving Eliquis for deep vein thrombosis. The record showed that the resident’s change in condition was reported to nursing staff, but the documented assessment on 4/13/26 was incomplete and did not identify the affected body area, severity, or onset and duration of the weakness. Multiple interviews showed that staff and others observed stroke-like symptoms over several days before the resident was taken to the hospital. A family member stated the resident had difficulty following conversations, could not use the right side normally, and had slurred speech. Another resident reported the resident’s right arm twitched and then could not be used, with speech sounding different and the resident appearing very tired. The Activities Director stated they observed facial drooping, slurred speech, and inability to use one arm and escorted the resident to the nurse’s station, where concerns about a possible stroke were communicated to nursing staff. CNA and nursing interviews also reflected that concerns were raised to nurses, but staff did not document a comprehensive assessment or notify the provider at that time. The record and interviews further showed that on the day the resident left the facility, nursing staff again assessed the resident after concerns were raised that the resident had not gone out for cigarette breaks and was not acting normally. LVN D stated the resident was unable to raise the right arm and needed hospital evaluation, but EMS and the provider were not notified before the resident was transported out of the facility by a family member. The Temporary DON and Administrator confirmed there was no documentation of provider notification on the earlier dates when staff first reported the change in condition. The resident was later diagnosed in the ED with a thalamic bleed and intracranial hemorrhage, required reversal of Eliquis, and was airlifted for higher-level care. After the event, the resident stated they had lost use of the right arm and hand and could no longer independently dress, button clothing, or write.
Failure to Notify Provider and Family of Resident’s Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician and the resident representative when a resident experienced a significant change in condition. The facility policy titled, Change in a Resident's Condition or Status, stated that when a resident has a change in condition, nursing staff are to promptly complete a comprehensive assessment, document the changes, and notify the physician and resident representative. The resident involved had diagnoses including COPD, heart failure, emphysema, and high blood pressure, and had a BIMS score of 15 out of 15, indicating no cognitive impairment. On 4/11/26, another resident observed the resident's right arm twitch and then become unusable, with speech that sounded different and signs of fatigue. The change was reported to the Activities Director, who observed facial drooping, slurred speech, and inability to use one arm, and escorted the resident to the nurse's station to alert RN B. The Activities Director later returned and found the resident still in his room complaining of headache and neck pain. RN B stated that because it was near the end of the shift, LVN D assessed the resident, but RN B did not personally assess him and no physician or provider was notified because no concerns were communicated. LVN D later stated that on 4/13/26 the Activities Director again reported stroke-like symptoms, and LVN D found the resident unable to raise his right arm and needing hospital evaluation. Before EMS could be contacted, a family member removed the resident from the facility and transported him to the hospital. LVN D confirmed that neither EMS nor the provider had been notified before the resident left, and the provider was notified only after departure. The Temporary DON and Administrator both confirmed there was no documentation that the provider or family member had been notified on 4/11/26 or 4/12/26 when staff knew the resident's condition had changed, and the NP stated that immediate assessment and prompt provider notification were expected when stroke-like symptoms were reported.
Failure to Implement Psychiatric Evaluation Orders for Depressed Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for psychiatric evaluation and treatment and to incorporate these services into the care plans for two residents with diagnosed depression. Facility policy on Behavioral Assessment, Intervention and Monitoring requires nursing staff to identify and report changes in mental status and for the IDT to evaluate behavioral symptoms and underlying causes. Despite this, Resident 1, admitted with major depressive disorder, cognitive communication deficit, and a history of alcohol abuse, had a hospital discharge order for Paroxetine that was not continued in the facility, and no other antidepressant was prescribed from admission through several months. Resident 1’s MDS identified depression and documented symptoms such as feeling tired, poor appetite, feeling life was a failure, and little interest or pleasure in activities, yet the psychiatric evaluation and treatment orders dated shortly after admission were not carried out. For Resident 1, multiple clinical notes documented ongoing depressive indicators and functional decline without corresponding psychiatric intervention or care plan updates. The NP ordered a psychiatric referral to assess for depression, and therapy notes showed repeated refusals of PT and OT, low motivation, and refusal to get out of bed. A care plan was initiated for feelings of loneliness and later for refusing showers, and social services documented that the resident “shut down” and became nonverbal after being informed of a pending divorce. CNA interview confirmed the resident was upset about the divorce and minimally participated in personal hygiene. The SSD acknowledged that no counseling or psychological evaluation was provided and that no new care plan or change-in-condition assessment was initiated after the emotional event. The DON confirmed that the psychiatric referral “got away from them” and that the resident received no psychiatric services while in the facility, and the NP acknowledged being unaware that the psychiatric evaluation had not occurred. Resident 2 was admitted with major depressive disorder, cognitive decline, and cancer, and the MDS documented mild cognitive impairment and depression, including feeling bad about self, being down and depressed, having little pleasure in activities, and difficulty staying asleep. Physician orders included psychiatric referral, evaluation, and treatment on two separate dates, but no psychiatric evaluations were found in the medical record. NP progress notes documented monitoring for signs and symptoms of depression, including episodes of crying and poor oral intake, yet there was no evidence that the psychiatric referrals were implemented. RN B confirmed the absence of psychiatric evaluation or treatment documentation and stated that the nurse receiving the psychiatric referral order is responsible for entering it into the EHR and coordinating care. Additional interviews with activities and social services staff described the resident as emotional, crying, and upset about dying, further indicating ongoing depressive symptoms without documented follow-through on ordered psychiatric services. This failure resulted in both residents not receiving mental health evaluation and had the potential for them not to reach their highest practicable level of mental and psychosocial well-being.
Food Storage, Dishwashing, and Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional food service standards. During observation, several kitchenware items were found stacked while still wet, including plastic containers, pitchers, pitcher lids, and sippy cups. In the same area, multiple sheet pans were also observed stacked wet, and some of the pans had white substances on the inside. The Certified Dietary Manager confirmed that the pans were not clean and stated that all dishes, pots, and pans should be air-dried before being stored away. The Registered Dietitian also stated that dishes and kitchenware should be air-dried and checked before storage to prevent bacteria growth from moisture. Two cooking pans with coated surfaces were observed with significant deep scratches and brown substances on the cooking surfaces. The Certified Dietary Manager confirmed the pans were old and should be discarded. The facility’s sanitation policy required utensils and equipment to be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas. The report also cited the FDA Food Code requirement that food-contact surfaces of cooking equipment and pans be kept free of encrusted grease deposits and other soil accumulations. A dietary staff member was interviewed regarding manual dishwashing at the 3-compartment sink and was unable to state the correct wash and rinse water temperatures. The staff member also stated dishes would be submerged in sanitizer for 5 to 10 minutes, while the facility’s procedure required a sanitizer concentration of 150 to 400 ppm and immersion for at least 1 minute. The Certified Dietary Manager acknowledged the staff member had not practiced the 3-compartment sink process and that no in-service record existed for that procedure. The staff member’s competency assessment did not include the 3-compartment sink dishwashing process. Food storage in the walk-in refrigerator was also not arranged in a food-safe manner. Ready-to-eat raspberry jello and fully cooked sliced bacon were stored on the same bottom shelf level next to thawing raw ground pork and raw chicken. The Certified Dietary Manager confirmed that ready-to-eat and cooked foods should not be stored at the same level as raw meats. In addition, a dietary staff member was observed working with a mustache and beard without a beard restraint, and the Certified Dietary Manager confirmed the facial hair was not covered even though beard nets were available. The resident food refrigerator contained multiple items that were not stored and labeled properly. Items observed included opened and unopened foods without required resident identifiers or opened dates, and several items were expired, including almond milk, jello, yogurt, hummus dips, chocolate cups, sherbet tubes, and ice cream. The Infection Control Nurse confirmed that items such as opened beverages and foods should have an opened date and that expired items should be discarded. The facility policy required perishable foods brought by family or visitors to be labeled with the resident’s name, item, and use-by dates, and the nursing staff was responsible for discarding perishable foods on or before the use-by date.
Dignity and Eating Assistance Deficiencies
Penalty
Summary
The facility failed to provide care in a manner and environment that promoted dignity and quality of life for multiple residents when staff spoke a non-English language in resident rooms and other resident areas while residents’ primary language was English. The facility’s policy titled English Only Rule stated staff were to speak only English in resident rooms and in any area where a resident could hear staff speaking, and that speaking a language the resident did not understand could cause fear, confusion, and disturb residents. Resident council meeting notes documented repeated resident concerns about staff not speaking English in rooms, hallways, and at the nurse’s station, and the DSD confirmed staff had been educated on the policy more than once but the issue continued. Several residents stated during interviews that staff spoke another language in their rooms and that this made them uncomfortable, upset, isolated, or concerned that staff were talking about them. Resident 30 said this happened most often on the night shift. Resident 33 said it made him feel like staff were talking about him. Resident 117 stated the issue had been discussed many times in resident council meetings and made her feel isolated. Resident 122, Resident 124, and Resident 132 each stated they wanted staff to speak English so they could understand what was being said and know whether staff were talking about them. CNA A confirmed hearing staff speak another language in resident rooms and acknowledged the facility’s expectation that staff speak English in resident rooms. The DON and Admin also confirmed staff were not following the English-only policy and that residents had complained about it. The facility also failed to assist Resident 73 with eating in a manner consistent with his needs. Resident 73 had diagnoses including stroke affecting his right side and abnormal mobility. His MDS indicated he required supervision or touching assistance with eating. During observation, he was eating lunch with his left hand, his silverware was on the right side of the plate, and he asked where the silverware was after being asked if he wanted to eat with his hands. He had to be directed to where the silverware was, no staff assisted him with finding it, and some meal items still had lids on them. The DON stated residents should not have to eat with their hands if they do not want to.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure the medication administration error rate remained below 5% for 2 of 34 sampled residents, resulting in 3 errors out of 25 observed medication administration opportunities and a 12% error rate. During medication administration observation, RN C gave Resident 89 canagliflozin by mouth after the resident and RN C both confirmed breakfast had already been eaten around 8:00 a.m., even though the manufacturer’s specifications stated the medication should be taken before the first meal of the day. The resident had a physician order for canagliflozin 100 mg orally once daily for diabetes mellitus. During another medication administration observation, LVN B administered Resident 66’s spironolactone and megestrol acetate without wearing gloves during preparation, crushing, or administration, despite physician orders directing that gloves be worn when administering both medications. The orders included spironolactone 25 mg by mouth twice daily for edema and megestrol acetate suspension 400 mg/10 mL, 10 mL by mouth once daily for appetite stimulant. The DON stated that the nurse should have worn gloves for both medications because they are hazardous.
Menu and therapeutic diet orders not followed during lunch meal service
Penalty
Summary
The facility failed to follow the planned menus for therapeutic and regular diets during lunch meal service on 1/6/26 and 1/7/26. During the 1/6/26 dining observation, a resident on a soft and bite size texture diet received green salad instead of the hot canned green beans listed on the menu, and a resident on a low fat and low cholesterol diet received a cranberry crunch square instead of fresh fruit for dessert. Eight additional residents on soft and bite size and minced and moist diets did not receive the hot canned green beans listed on the spreadsheet menu. During the 1/7/26 lunch meal distribution, multiple residents received items that did not match their ordered diets. Seven residents on a 2 g sodium diet received a whole serving of cake, crisp fish with tartar sauce, and tator tots with ketchup instead of the listed reduced portions and lower sodium substitutions. Twenty-four residents on a regular consistent carbohydrate diet received dinner rolls and margarine even though the spreadsheet indicated they should not receive them. Two residents on a soft and bite size texture diet received whole regular dinner rolls instead of chopped rolls soaked in milk, five residents on a renal diet received oven crisp fish instead of baked fish, and four residents on a low fat and low cholesterol diet received tartar sauce and margarine instead of the listed lemon wedge and no margarine. Additional meal service errors were identified on 1/7/26. Eleven residents who should have received dinner rolls did not receive them, and two residents who should have received cake did not receive it. Two residents on a renal 60 g protein diet received 3 ounces of fish instead of the 2 ounces listed on the spreadsheet. The registered dietitian and certified dietary manager confirmed the discrepancies during interview and stated that dietary staff needed to follow the spreadsheet, menu, recipe, and meal tickets. The facility policy stated menus are to be planned to meet residents' nutritional needs and written for regular and therapeutic diets in compliance with the diet manual.
Dietary Staff Failed to Prepare IDDSI Texture Diets Correctly
Penalty
Summary
The facility failed to ensure that dietary staff prepared food in the correct IDDSI texture for residents on Soft and Bite Size (SBS), Mince and Moist (MM), and puree diets. During observation, CK M prepared carrots, tater tots, and crisp fish for SBS, MM, and puree textures without measuring the food portions, without reviewing the recipes, and without performing the required texture tests. The observed final products included items that looked like lumpy puree with chunks, dry minced food, coarse puree with lumps, sticky food, and smooth pudding-like food, depending on the item and texture being prepared. For the carrot preparation, CK M scooped carrots into the food processor without measurement and blended them for SBS, MM, and puree textures. The SBS carrots were not measured or tested and appeared like lumpy puree with chunks of carrot. The MM carrots were prepared with thickened broth, but the final product looked puree-like and gluey, and CK M did not measure or test the texture. The puree carrots were blended longer and appeared smoother, but CK M still did not test the final product or review the recipe during preparation. Similar issues were observed with tater tots and crisp fish. CK M prepared SBS tater tots and SBS crisp fish without measuring the food or testing the final texture, and the products appeared dry minced. The MM tater tots and MM crisp fish were also prepared without measurement or texture testing, and the final products were described as puree-like with lumps, sticky, or coarse puree. The puree versions of tater tots and fish were also prepared without recipe review or confirmation testing. The RD stated the MM texture should not be sticky or gluey and confirmed CK M did not prepare the SBS and MM textures correctly without measurement and confirmation testing. A separate observation of DA O showed similar deficiencies with SBS and MM dinner rolls. DA O cut the rolls in half for SBS, soaked them in milk, and drained them without measuring or testing the texture or reviewing the recipe. For MM rolls, DA O placed the rolls in a food processor, added an unmeasured amount of milk, blended them, and drained the milk; the final product looked like oatmeal. The RD stated the SBS rolls should be chopped to 1.5 cm by 1.5 cm and the MM rolls should be chopped or processed to 4 mm by 15 mm, and agreed DA O did not make the rolls correctly. The report also noted that both CK M and DA O had completed IDDSI training, which included measurement and critical tests for puree, MM, and SBS textures, and facility recipes and job descriptions required food to be prepared according to standardized recipes and therapeutic diet texture needs.
Unnecessary Psychotropic Medication Ordered for Incorrect Diagnosis
Penalty
Summary
The facility failed to ensure that one sampled resident was free of unnecessary medication when the resident continued to receive divalproex sodium, a psychotropic medication, based on an inaccurate seizure diagnosis. Facility policy required that a written diagnosis, indication, and/or documented objective findings support each medication, but the resident’s record showed divalproex sodium ordered for seizures despite no seizure history being documented. Resident 8’s records showed diagnoses including atrial fibrillation, metabolic encephalopathy, COPD, CHF, and unspecified psychosis not due to a substance or known physiological condition. The MDS indicated a history of psychosis and hallucinations and a BIMS score of 99, reflecting severe cognitive impairment. RN K stated the resident had prior psychosis, hallucinations, and behavioral outbursts, but no history of seizures. The order summary showed divalproex sodium 500 mg daily for seizures beginning on 9/30/25 and continuing through the survey date. The DON acknowledged the seizure diagnosis was incorrect, and the NP confirmed there was no seizure diagnosis and stated the medication should have been for behavior and had been entered incorrectly.
Failure to Provide Nail Care and Maintain Hand Hygiene
Penalty
Summary
The facility failed to provide necessary ADL care to maintain good personal hygiene when Resident 26’s fingernails were left long, untrimmed, jagged, and dirty. The facility policy titled Fingernails/Toenails, Care of, dated 2/2018, stated that nail care includes regular cleaning and trimming, that trimmed nails prevent injury, and can aid in the prevention of skin problems. Resident 26 was admitted with diagnoses including muscle weakness, infection of the lower leg, and heart failure. The care plan identified an ADL self-care performance deficit related to weakness, poor endurance, and poor balance. Facility CNA Shower Review sheets showed that on 1/3/26 Resident 26 did not have his fingernails cut or cleaned. On 1/6/26, an observation found Resident 26’s nails long, jagged, and dirty under the nails. On 1/7/26, Resident 26 stated he could not remember the last time staff cut his nails and said staff could cut his nails and wash his hands any time they wanted; he also stated that two nails were broken and jagged and needed to be cut. During the same observation, his fingers were noted to have dirt and food on top of and under them, and CNA H confirmed the hands were dirty and that two nails were broken and jagged. CNA H stated someone would come in and clean Resident 26’s hands and cut his nails. There was no documentation that any nail care had been done on 1/7/26.
Enteral Tube Medication Administration Used Tap Water Instead of Purified or Sterile Water
Penalty
Summary
The facility failed to follow its enteral tube medication administration policy when staff did not use purified or distilled water to flush an enteral feeding tube during medication administration. The policy titled, Enteral Tube Medication Administration, revised August 2014, stated that warm purified or sterile water is to be used for dissolving medications and flushing the tube. During observation, RN L was seen using tap water to dissolve and flush medications through Resident 2’s enteral feeding tube instead of the water specified in the policy. Resident 2 was admitted with diagnoses including cerebral infarction, dysphagia, and a gastrostomy tube for nutrition and hydration. The resident had a physician order to flush the tube with 75 ml of water every 6 hours. During interview, RN L stated that she used sink water for administering medications via an enteral tube as her standard practice and had done so for 14 years without instruction on another method. The DON reviewed the policy and verified that it required warm purified or sterile water for flushing enteral feeding tubes during medication administration, while also acknowledging that the facility’s current practice was to use tap water or water from the kitchen.
Bed Rail Safety Assessments Not Completed for Two Residents
Penalty
Summary
The facility failed to ensure the risk and benefits of bed rails were assessed for two sampled residents who were using bed canes. The facility policy titled Bed Safety and Bed Rails, dated 8/2022, stated that bed rails are prohibited unless criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The policy also stated that the resident assessment determines the risk for entrapment, accidents and hazards, mobility restrictions, and psychosocial outcomes. Resident 10 was admitted with diagnoses including fracture of the left femur, type 2 diabetes, and muscle weakness, and had a physician order for bed canes dated 12/30/25. During a concurrent interview and record review, the DON confirmed that Resident 10 did not have a bed safety assessment to ensure the safe use of the bed rails. Resident 14 was admitted with diagnoses including heart failure, acute respiratory failure, and muscle weakness, and had a physician order for bed canes dated 10/25/25. During a concurrent interview and record review, the DON confirmed that Resident 14 did not have a bed safety assessment completed until 11/22/25, and stated it should have been completed when the bed canes were first installed.
Incomplete E-kit Medication Accountability
Penalty
Summary
The facility failed to ensure accurate and complete record keeping for its emergency drug kits when one tablet of sulfamethoxazole/trimethoprim 800/160 mg was unaccounted for in emergency supply kit box #PO-27. During review of the medication storage room, the kit was observed to have been previously opened and accessed, with one tablet present and receipts showing that two tablets had been removed for resident use, while the kit was supposed to contain four tablets. Facility policy stated that the nurse records medication use from the emergency kit on the medication order/use form and calls the pharmacy for replacement after administration. During interview, an LVN stated that there had to be four pills and one was missing, and the DON acknowledged that the E-kit box was not accounted for.
Pharmacy Review Failed to Identify Incorrect Divalproex Order
Penalty
Summary
The facility failed to ensure that pharmacy staff completed accurate medication regimen reviews for 1 of 34 sampled residents. Resident 8’s record showed an admission diagnosis list that included unspecified atrial fibrillation, metabolic encephalopathy, COPD, chronic diastolic CHF, and unspecified psychosis, but did not include any seizure diagnosis. Facility policy stated that when a resident receives a new medication, the order is evaluated to ensure a written diagnosis, indication, and/or documented objective findings support each medication, and that the interdisciplinary team reviews the medication regimen for efficacy and medication-related problems on an ongoing basis. Resident 8’s medication record showed divalproex sodium ER 500 mg daily ordered for seizures beginning on 9/30/25 and continuing through the survey date. RN K stated Resident 8 had no history of seizures and had previously experienced psychosis, hallucinations, and behavioral outbursts. The clinical pharmacist could not be interviewed during survey hours. During a concurrent interview and record review, NP D confirmed the active medication orders and diagnoses, stated there was no seizure diagnosis for the resident, and said the medication should have been for behavior; NP D also stated the divalproex sodium order was entered incorrectly.
Medication Storage Temperature Errors
Penalty
Summary
The facility failed to ensure that medications were stored at the correct temperatures. During observation of the medication storage room, two types of rectal suppository medications were found inside a refrigerator that was reading 34 degrees Fahrenheit: acetaminophen suppository 650 mg, with packages for two residents, and hydrocortisone AC suppository 25 mg, with a package for one resident. Manufacturer specifications reviewed for both medications indicated they should be stored at 20-25 degrees C (68-77 degrees F). During observation of Medication Storage Cart 1, one 120 mL amber bottle of liquid gabapentin was found in a drawer in the hallway and was being stored at room temperature, approximately 70 degrees Fahrenheit. Manufacturer specifications for liquid oral gabapentin indicated it should be refrigerated at 2 C to 8 C (36 F to 46 F). During interview, an LVN stated she thought it was okay to store the liquid gabapentin in the med cart after opening, and the DON stated that pharmacy was responsible for labeling medications with temperatures and putting them away properly, but nurses were also responsible for checking where medications should be stored.
Inaccurate Advance Directive Documentation on POLST Forms
Penalty
Summary
The facility failed to ensure accurate medical record documentation for two sampled residents when their POLST forms incorrectly indicated that they had advance directives. Resident 13 was admitted with diagnoses including stroke and high blood pressure, and Resident 65 was admitted with diagnoses including dementia and atrial fibrillation. Review of each resident’s POLST showed that an advance directive was marked as present, but review of the medical records found no advance directive for either resident. During interview, the DON stated that there were no advance directives for Resident 13 or Resident 65 and that she could not find them in the electronic health record. The SSD confirmed that the POLSTs checked off the presence of an advance directive and that none were in either resident’s record. The MRD stated that the POLST entries were documentation errors and that neither resident had an advance directive; the MRD also stated that nursing staff had been responsible for determining whether an advance directive existed and that no further documentation or process was done beyond asking during admission.
Resident Left Unsupervised on Patio Resulting in Fatal Fall
Penalty
Summary
A deficiency occurred when a restorative nursing assistant (RNA) left a resident, who was at moderate risk for falls and had significant cognitive and physical impairments, unsupervised on an outdoor patio for approximately 30 minutes. The resident had a history of vascular dementia, hemiplegia, muscle weakness, and was dependent on staff for all mobility and activities of daily living. The resident's care plan identified a need for a safe environment, assistance with all ADLs, and interventions to minimize fall risk, but did not specify supervision requirements for outdoor activities. On the day of the incident, the RNA took the resident outside in a wheelchair and left him alone on the patio, without informing other staff or ensuring supervision. The patio was not fully visible from the nursing stations, and there was no method for the resident to call for help. Staff interviews confirmed that the resident was not alert, was dependent on staff, and should not have been left unsupervised. The resident was later found on the ground, unresponsive, next to his wheelchair, having sustained a major head injury. Medical evaluation revealed a subdural hematoma with midline shift, and the resident was transported to the hospital for emergency care. The incident resulted in a significant decline in the resident's condition and ultimately led to death. Staff statements and record reviews confirmed that the lack of supervision and failure to communicate the resident's location contributed directly to the fall and subsequent injury.
Failure to Report Major Injury After Resident Fall
Penalty
Summary
The facility failed to report a major injury involving a resident who was left unattended on a patio by a Restorative Nursing Assistant for 30 minutes. During this time, the resident, who had vascular dementia, hemiplegia, hemiparesis, and muscle weakness, fell and was found unresponsive with shallow breathing and unstable vital signs. The resident was transported to a hospital, where a CT scan revealed a small acute subdural hematoma with a midline shift. The resident was later returned to the facility on hospice care and subsequently died that evening. Despite the severity of the injury, which met the CMS definition of a major injury, the facility did not report the incident to the appropriate authorities. Both the Administrator and the Director of Nursing stated in interviews that they did not consider the injury significant or an unusual occurrence, and therefore did not report it. This failure delayed the investigation into the major injury and was not in accordance with facility policy or professional standards of practice.
Failure to Provide Outdoor Activity per Resident's Care Plan
Penalty
Summary
The facility failed to honor an activity preference that was documented in the activity care plan for a resident with dementia and left-sided weakness, who was unable to make his own health care decisions. The resident's care plan specified that staff should take him outside to sit in the sun when the weather was nice, and a quarterly activity review indicated he enjoyed being outdoors. However, a review of activity participation notes over several months showed no documentation of the resident being taken outside to the patio. Interviews with the Activity Assistant and Activity Director revealed that neither was aware of the care plan directive for outdoor activities for this resident. The Activity Assistant confirmed that she had not taken the resident outside and that there was no group activity for residents to go outdoors. The Activity Director also confirmed the lack of outdoor activities and stated that the care plan did not provide clear instructions regarding supervision or frequency for outdoor time. Additionally, the Activity Director noted that staff had not facilitated the resident's participation in outdoor activities due to not getting him up in his wheelchair, and that not all areas of the patio were visible from inside, raising concerns about supervision.
Resident Left Unsupervised on Patio Resulting in Fatal Fall
Penalty
Summary
A deficiency occurred when a Restorative Nursing Assistant (RNA) left a resident with vascular dementia, hemiplegia, and a history of falls alone on a facility patio for approximately 30 minutes. The resident was known to be dependent on staff for all mobility, had impaired cognition, and was classified as a moderate fall risk. The resident's care plan required staff to provide a safe environment, prompt response to requests for assistance, and appropriate supervision, especially during activities that could increase the risk of falls. On the day of the incident, the RNA took the resident outside in a wheelchair and left them unsupervised on the patio. The RNA did not inform other staff members of the resident's location, and the nursing station was unstaffed at the time. The resident was later found unresponsive on the ground outside, having sustained a major head injury. The resident was transported to an acute care hospital, experienced a decline in condition, and subsequently died. Multiple staff interviews confirmed that the resident required total supervision due to their cognitive and physical impairments, and that the patio area could not be fully visualized or monitored from the nursing stations. Staff members, including CNAs and nurses, stated that it was common knowledge that residents with dementia or high fall risk should not be left unsupervised, particularly in areas where they could not be easily seen or heard. The RNA acknowledged the mistake of leaving the resident alone, and other staff confirmed that proper communication and supervision protocols were not followed. The facility's Director of Nursing also confirmed that there was no method for residents on the patio to call for help, such as a call light, further contributing to the lack of supervision and safety for the resident.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving one of five sampled residents. A resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including Parkinson's Disease, COPD, hypertension, and muscle weakness, informed staff that another resident had slapped them on the face and chest, resulting in discoloration and scratches. The incident was documented in the resident's progress notes and a report of suspected dependent adult/elder abuse was completed, confirming the physical altercation between the two residents. Despite the facility's policy requiring all reports and findings of resident abuse to be reported to local, state, and federal agencies, the incident was not reported to the state licensing/certification agency. Both the Administrator and the DON confirmed the incident occurred but stated their belief, based on an All Facilities Letter, that abuse involving a perpetrator with a dementia diagnosis did not require reporting. As a result, the abuse allegation was not reported as required by facility policy.
Failure to Prevent Repeated Falls Due to Inadequate Evaluation and Communication of Fall Interventions
Penalty
Summary
The facility failed to ensure that two of three sampled residents were free from accident hazards and received adequate supervision to prevent accidents. Post-fall evaluations did not determine the reasons for repeated falls, and the care plan interventions for these residents were not reevaluated for effectiveness. New interventions were not consistently developed to prevent further falls and injuries, and direct care staff were not adequately informed on how to identify high-risk fall residents or locate their fall plans of care. One resident, with diagnoses including dementia, difficulty walking, anxiety disorder, and a history of repeated falls, experienced multiple falls during their stay. Despite being identified as a high fall risk, the resident's care plan interventions, such as one-to-one supervision and toileting programs, were inconsistently applied and not evaluated for effectiveness. Several falls occurred during shifts not covered by the interventions, and repeated interventions were implemented without assessing their impact. Documentation showed that the interdisciplinary team did not address falls occurring during the day shift, and there was no clear rationale for changes in supervision levels. Another resident, also with dementia and a history of falls, was assessed as a moderate fall risk and had significant cognitive impairment. The care plan included interventions such as frequent checks and reminders to use the call light, despite the resident's inability to use the call light due to cognitive limitations. Staff interviews revealed a lack of awareness of the resident's fall risk status and care plan details, and the electronic care plan system used by CNAs did not provide comprehensive information. The Director of Nursing confirmed gaps in root cause analysis, care planning, and communication of fall risk interventions to direct care staff.
Improper Storage of Construction Materials in Resident Rooms
Penalty
Summary
The facility failed to honor residents' rights to a safe, clean, comfortable, and homelike environment by improperly storing construction materials in the room of three residents. The materials included piles of flooring and adhesive or paint, which were stored in a manner that created potential hazards and made the environment less homelike. Family members and residents expressed concerns about the tripping hazards and the difficulty in maintaining cleanliness due to the presence of these materials. The facility administrator acknowledged the situation, stating that the room had been vacant and was used for storage, but later needed for residents. Interviews with staff and residents confirmed the presence of the materials, with some residents noting the stuffiness and dustiness caused by the storage. The facility's maintenance director admitted that storing the materials in the residents' room was against the facility's policy and recognized it as a poor decision. The facility's policy on the receipt and storage of supplies and equipment clearly indicated that supplies should be stored in designated areas and that hazardous materials must be properly stored and labeled, which was not adhered to in this case.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met, as evidenced by improper storage, labeling, and dating of food items in the kitchen refrigerator/freezers. Observations revealed expired food items, such as an open jar of applesauce and a foil-covered container of puree bread without a use-by date. Additionally, there were unlabeled and undated food items, including boiled eggs and sliced bread, which were not stored according to the facility's policy and procedure. The Registered Dietitian and Dietary Manager acknowledged these issues, noting that compromised packaging and improper labeling could allow bacteria or pests to enter, posing an infection control risk. The kitchen and food service equipment were found to be in unsanitary conditions, with thick, black debris under stovetop burners, greasy substances on the stove backsplash, and food crumbs on various surfaces. The sanitizer solution in the dishwashing sink was tested and found to be outside the acceptable range, indicating improper sanitization. The Dietary Manager acknowledged the cleanliness issues and the potential infection risks posed by the unclean equipment and utensils. Additionally, the dishwashing log entries were incomplete, and the sanitizer levels were not consistently monitored, further contributing to the unsanitary conditions. The kitchen environment was not maintained in a sanitary condition, with food crumbs, spills, and stains observed on the floors and walls. The dry storage room floor was visibly dirty, and the fan over the food preparation area was dusty. The facility's policy required the kitchen to be kept clean and sanitary, but observations revealed that these standards were not met. The Dietary Manager and Maintenance Supervisor acknowledged the cleanliness issues, and the Dietary Manager indicated that disciplinary actions would be taken due to the general lack of cleanliness in the kitchen. Additionally, resident food in the refrigerator was not labeled or stored according to policy, with expired and unlabeled items present, posing a risk of foodborne illness to residents.
Failure to Provide Adequate Social Services and Timely Care
Penalty
Summary
The facility failed to provide adequate medically-related social services for four residents, leading to unmet needs and potential delays in care. For two residents, the social service care plans were not updated quarterly or as needed, failing to reflect their discharge plans. One resident's care plan inaccurately indicated long-term care instead of short-term care, and another resident's discharge plan was uncertain, with no updates made to reflect their needs. Additionally, the facility did not assist one resident with financial documents when requested, hindering their ability to obtain necessary income for discharge. The Social Services Director (SSD) failed to assist with disability paperwork, despite the resident's request, and did not provide adequate support for discharge planning. This lack of assistance was confirmed by the facility's administrator, who stated that the SSD should have helped the resident with their financial needs. The facility also failed to make timely referrals for outside services for another resident, who required an ophthalmology consultation for a visual deficit. The SSD did not send the necessary referral, and the resident expressed concern about losing their vision due to the lack of timely intervention. Furthermore, dental services were not provided promptly for another resident, who had teeth extracted but did not receive dentures due to insurance issues. The SSD did not follow up on the dental services until prompted by the resident's family, resulting in a significant delay.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications and medical supplies were stored and labeled according to professional standards. During an inspection of medication cart 2, two loose pills were found in a drawer, which was confirmed by the Assistant Director of Nursing (ADON) as inappropriate. Additionally, six medications being dispensed were opened but not dated, including two bottles of Tuberculin, one tube of Muscle Rub Cream, two bottles of Enulose, and a bottle of Geri tussin DM. The Director of Nursing (DON) and ADON confirmed that it was the facility's policy to date medications upon opening and discard them within 30 days. Furthermore, the facility stored expired medical supplies and medications. Four Foley drainage bags in the medication storage room were past their expiration date, and Pro-Stat concentrated liquid protein medical food was being dispensed despite being expired. The DON confirmed that expired items should be discarded and not available for use. The facility's policy indicated that no expired medication should be administered, and opened medications should be dated, which was not adhered to in these instances.
Deficiencies in Food Preparation and Service
Penalty
Summary
The facility failed to prepare and serve food that was palatable, attractive, and at a safe and appetizing temperature for several residents. Resident 77, who is the President of the Resident Council, reported that the food was consistently overcooked, such as burnt sausage, and cold, like the gravy served. Despite raising these issues with the Dietary Manager over several months, no effective solution was implemented. Resident 84 experienced undercooked pork, which led to digestive issues, and Resident 11 received melted ice cream, indicating improper food handling and timing during meal service. Resident 35 reported that his meals were often cold, his ice cream melted, and his biscuits burnt, which he found nauseating. The Dietary Manager acknowledged the complaints about cold food and mentioned that a new plate warmer had been acquired but not yet utilized. Observations during meal service confirmed that food carts were delayed, and the food was not maintained at appropriate temperatures, as evidenced by a pizza slice being served at 95 degrees, below the recommended 135 degrees for hot food. Resident 215 was served burnt pizza, which she found unpalatable, and this was confirmed by a CNA. The facility's policy and procedure for food preparation and meal distribution were not adhered to, as meals were not maintained at the required temperatures. The Dietary Manager admitted to being overwhelmed by complaints and recognized the need for better food temperature management. The report highlights systemic issues in the facility's food service operations, affecting the quality and safety of meals provided to residents.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination, as evidenced by several incidents involving six residents. Staff members were observed speaking in their native language in front of residents who did not understand, causing discomfort and feelings of disrespect. Residents 46, 90, and 100 reported feeling uncomfortable and disrespected when staff conversed in a language they did not understand, which was against the facility's policy that required staff to speak English in areas where residents could hear them. Additionally, the facility's night shift staff were reported to be loud, disturbing residents' sleep. Residents and their family members expressed concerns about the noise levels at night, which affected their well-being. Resident 106, who was not her own responsible party, expressed feelings of worthlessness and distress due to the noise, indicating a failure to maintain a peaceful environment conducive to rest and recovery. Furthermore, Resident 101 was not provided privacy during personal care, as observed when a CNA assisted the resident in dressing without drawing the privacy curtain or closing the door. This lack of privacy was acknowledged by the CNA, who admitted to forgetting to provide it. Resident 40 was instructed by a housekeeper to clean her own toilet, which was inappropriate and led to feelings of paranoia and distress. The housekeeper's actions were not reported immediately, contributing to the resident's emotional distress.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and protect residents from alleged abuse in three separate incidents involving Residents 22, 35, and 40. In the first incident, Certified Nurse Assistant (CNA) M did not report suspicions of abuse when Resident 22 exhibited fear during care, despite the resident's roommate corroborating rough handling by night shift CNAs. Resident 22, who had a moderately impaired memory, did not voice concerns directly, but CNA M noticed a change in behavior and failed to report it. In the second incident, Resident 40, who had no cognitive impairment, alleged that Housekeeper A instructed her to clean her own toilet after an episode of diarrhea. Despite informing CNA J of the incident, CNA J did not report it to the administration. The housekeeper was later suspended pending investigation, but the initial failure to report left Resident 40 in a state of emotional distress. The third incident involved Resident 35, who had intact cognition but required full assistance with daily activities. Resident 35 reported that CNA E held him down during care, which was corroborated by another CNA. Despite this, the incident was not reported or investigated, and CNA E continued to be assigned to care for Resident 35. The facility's administration was unaware of the incident until it was brought to their attention during the survey, highlighting a significant lapse in reporting and investigation procedures.
Incomplete Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident who was transferred to an acute care hospital. Specifically, the facility did not document the date and time of the transfer, the destination hospital, the mode of transportation, or the disposition of the resident's personal effects and medications. This lack of documentation was identified during a review of the resident's clinical record and was confirmed by the Director of Nurses (DON). The resident involved had been admitted to the facility with diagnoses including right hip joint replacement surgery, anxiety, and depression, and was their own healthcare decision maker. A Change in Condition Assessment/SBAR noted a change in the resident's condition, including pain and swelling in the right hip, which was assessed by a licensed nurse. However, the nursing progress note did not reflect the transfer details, and the DON acknowledged that the documentation should have included an assessment, intervention, and the doctor's order for the transfer.
Failure to Provide Non-Skid Footwear for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that Resident 101, who was at risk for falls, was wearing non-skid footwear as per his care plan. Resident 101 was admitted with diagnoses including stroke, muscle weakness, difficulty in walking, and major depressive disorder. His cognitive status was severely impaired, requiring maximal assistance for daily activities such as dressing and transferring. The care plan specifically indicated that Resident 101 should have appropriate footwear when out of bed or mobilizing in his wheelchair to prevent falls. During observations, Resident 101 was seen in his room without shoes or socks, struggling to dress himself, and his call light was on the floor, out of reach. A CNA assisted him with his pants but did not ensure he had footwear on, as the CNA was not assigned to him that day. Resident 101 expressed difficulty in finding his call light and mentioned a previous fall when trying to get up by himself. The Director of Staff Development confirmed that Resident 101 should have been wearing non-skid socks or shoes to prevent falls.
Deficiencies in G-Tube Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents with gastrostomy tubes (g-tubes), leading to significant deficiencies in their care. For Resident 87, Licensed Nurses (LNs) did not adhere to the Physician's orders regarding the prescribed amounts of liquid nutrition, hydration, and water flushes. The documentation of intake amounts was inaccurate, with instances of both excessive and insufficient fluid administration compared to the Physician's orders. Additionally, LNs provided g-tube care without a Physician's order and failed to document the care provided, including assessments of g-tube placement and residuals. Resident 214 experienced a similar lapse in care, receiving an excessive amount of fluids due to a failure to discontinue outdated orders. The Registered Dietitian (RD) had recommended a specific fluid intake, but the resident received significantly more than this amount, leading to fluid overload. This oversight was compounded by the fact that the RD was unaware of the excessive fluid administration, and the Nurse Practitioner (NP) confirmed the excessiveness of the fluid intake. The Assistant Director of Nursing (ADON) acknowledged that the order for 300 mL of water every four hours should have been discontinued but was not. These failures placed both residents at risk for serious health complications. Resident 87 was at risk for fluid overload and g-tube malfunction, while Resident 214 was sent to the emergency room due to formula leakage and was diagnosed with aspiration pneumonia. The deficiencies in care for both residents highlight significant lapses in following Physician's orders and ensuring accurate documentation and communication among the care team.
Incomplete Physician Documentation and Missed Visits
Penalty
Summary
The facility failed to ensure that physician progress notes were complete, signed, and dated at each required visit for two residents. Resident 34, who was admitted with chronic obstructive pulmonary disease, dementia, and bipolar disorder, had no physician notes for June and September 2024. Despite being in the facility for two years, Resident 34 reported never having seen a doctor. Resident 98, admitted with end-stage renal disease and a benign neoplasm on the right eyelid, had only one incomplete physician note without a date or assessment of the right eye. Resident 98 also reported that the doctor never visited, and his eye surgery was missed three times. During interviews, the Director of Nursing confirmed the absence and incompleteness of physician notes for both residents. The Medical Record Assistant revealed that the previous medical provider, who left the facility at the end of September 2024, often did not complete or date his notes, and his assessments were not always accurate. This lack of proper documentation and physician visits had the potential to negatively affect communication between disciplines and result in inappropriate care and service for the residents.
Deficiencies in Nursing Competencies and Reporting in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competencies in caring for residents, leading to several deficiencies. Licensed Nurses (LNs) did not reassess or notify the physician about a potentially infected right eye of a resident, who had been admitted with end-stage renal disease and a benign tumor on the right eyelid. Despite the resident's intact cognition and self-reported infection, there was no documentation or follow-up on the condition, and the Director of Nursing confirmed the lack of assessment and communication regarding the resident's eye condition. Additionally, the facility did not report suspicions or allegations of abuse for multiple residents. One resident reported rough handling by CNAs during personal care, which was witnessed by a roommate. A CNA suspected potential abuse due to the resident's change in behavior but failed to report it. Another resident reported emotional distress caused by a housekeeper's actions, which were not reported by a CNA who was informed of the incident. The facility's administrator confirmed that these incidents should have been reported immediately. Furthermore, LNs did not adequately monitor gastrostomy tube feedings, resulting in discrepancies between the physician's orders and the actual intake recorded. The LNs provided incorrect amounts of water flushes and did not document assessments of g-tube placement and residuals. Additionally, LNs failed to check meal trays properly, leading to a resident receiving a meal that included a disliked food item. The LN responsible admitted to not reviewing the meal trays for resident food preferences, resulting in the resident not eating the meal provided.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The deficiency involves the failure of a long-term care facility to adhere to regulations regarding the use of psychotropic medications for a resident, identified as Resident 61. The resident had both a routine and a PRN order for Ativan, an anti-anxiety medication, which was available for five months without an order end date. This was despite recommendations from the consulting pharmacist to discontinue the PRN order or limit it to 14 days, as per CMS regulations. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician examined the resident and documented the necessity for continuation. Resident 61, who had a history of multiple medical conditions including schizoaffective disorder, dementia, and anxiety disorder, was at risk of adverse effects from the excessive use of psychotropic medications. The resident's care plans indicated the use of Ativan for anxiety and aggressive behaviors, with interventions including monitoring for side effects and effectiveness. However, the facility failed to address the Ativan PRN order in the resident's medication regimen reviews, and the PRN order was not discontinued until four months after the initial recommendation by the consulting pharmacist. Interviews with facility staff revealed that the resident exhibited daily aggressive verbal behaviors and had experienced unwitnessed falls, which were not consistently documented. The consulting pharmacist noted the increased risk of serotonin syndrome toxicity due to the combination of medications the resident was receiving. Despite these risks, the facility did not conduct a Benefits v. Risks Review with physician documentation to justify the continuation of the PRN Ativan order, leading to the deficiency in medication management for Resident 61.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding dental services for a resident, leading to a deficiency. The policy required that residents needing dental services be promptly referred to a dentist. However, the facility did not ensure that a resident who had teeth extracted received the necessary follow-up care to obtain dentures. The resident, who was readmitted with multiple diagnoses including lung disease, depression, and left-sided paralysis, had his teeth extracted by a facility-contracted dental service. Impressions and x-rays for dentures were taken, but the process was halted due to an insurance change that the contracted dental service would not honor. The deficiency was further compounded by the facility's lack of timely follow-up. The Social Service Director admitted to not contacting the dental service to follow up on the resident's dentures until prompted by the resident's daughter during a care conference, five months after the extractions and impressions. This inaction resulted in the resident being unable to chew food properly, as he was left without dentures, impacting his ability to eat comfortably.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for five residents, leading to dissatisfaction and potential negative impacts on their psychosocial health. Resident 46, who has type 2 diabetes and anxiety, reported a dislike for eggs but continued to receive them for breakfast. Despite having a BIMS score indicating good memory, the resident's dietary profile did not reflect this preference. Similarly, Resident 90, also with type 2 diabetes and high blood pressure, expressed a dislike for rice, which was documented in their dietary profile, yet rice was frequently served. Resident 100, diagnosed with heart failure and depression, consistently received tomatoes despite a documented dislike. The resident expressed frustration, feeling that complaints about food led to worse service. An observation confirmed that tomatoes were served with their meal, and the facility's Infection Preventionist acknowledged the oversight. Resident 106, with dysphagia and poor memory, was served a tuna fish sandwich and an egg and cheese omelet, both of which were on their dislike list. The responsible Licensed Nurse admitted to not checking the meal trays for preferences due to being in a hurry. Resident 104, who often requested alternative meals like hamburgers and hot dogs, was served overcooked vegetables, including carrots, peas, and corn, which they disliked. The Dietary Manager confirmed that residents received items on their dislike lists due to corporate menu controls and the kitchen being rushed during a state survey. These failures to accommodate food preferences were documented in resident council meeting notes and satisfaction surveys, indicating ongoing issues with food service in the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, leading to emotional distress and mental anguish. In the first case, a Certified Nursing Assistant (CNA) grabbed and held a resident's arm during personal care, despite the resident's clear distress and request for the CNA not to enter his room. The resident, who had intact cognition and could make his own decisions, reported the incident to a nurse, but the CNA continued to be assigned to his room. The incident was not reported or investigated by the facility, and the CNA admitted to grabbing the resident's wrist during an altercation over the resident's personal items. In the second case, a housekeeper made a resident clean her own toilet after an episode of diarrhea, causing the resident to feel unwell and emotionally distressed. The resident, who had no cognitive impairment, reported that the housekeeper pointed to the toilet and handed her paper napkins to clean it. The resident informed a family member, who provided cleaning supplies, and reported the incident to a CNA, who did not escalate the complaint for investigation. The housekeeper continued to be assigned to the resident's room until the issue was brought to the attention of the housekeeping manager. Both incidents highlight a failure in the facility's abuse prevention program, as staff did not report or investigate the allegations of abuse. The facility's policies and procedures were not followed, resulting in continued exposure of the residents to the staff members involved in the incidents. The lack of immediate action and investigation contributed to the residents' emotional distress and the potential for ongoing abuse.
Failure to Report Abuse Allegations in LTC Facility
Penalty
Summary
The facility failed to report suspicions and allegations of abuse for three out of five sampled residents, which included incidents involving Residents 22, 35, and 40. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when Resident 22 showed fear during care, despite acknowledging a change in behavior that suggested potential abuse. Resident 22, who had a BIMS score indicating moderate memory impairment, expressed concerns about being handled roughly by night shift CNAs, which was corroborated by a roommate. However, CNA M did not escalate these suspicions to the appropriate authorities. In another incident, Resident 40, who had no cognitive impairment, reported that Housekeeper A instructed her to clean her own toilet after an episode of diarrhea. Despite being informed of this by Resident 40, CNA J failed to report the incident to the facility management. The resident expressed fear of Housekeeper A, who was also accused of waking her up by hitting the bed with a mop. The facility's administrator confirmed that the incident should have been reported and investigated, but it was not. Additionally, Resident 35, who had intact cognition, reported being physically restrained by CNA E during care. The resident expressed distress over the incident, which was not reported or investigated by the facility. CNA E admitted to holding down the resident and informed the Infection Preventionist and a charge nurse, but no further action was taken. The Director of Staff Development confirmed that the incident occurred and that there should have been an investigation, but none was conducted.
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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 Yuba City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yuba City Post Acute | 0.5 mi | ★★★★★ | 24 | 0 |
| Fountains, The | 0.6 mi | ★★★★★ | 1 | 0 |
| Marysville Post-acute | 2.1 mi | ★★★★★ | 0 | 0 |
| River Valley Care Center | 7.7 mi | ★★★★★ | 1 | 0 |
| Gridley Post Acute | 15.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.