Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookside Care Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, bipolar disorder, dementia, depression, and anxiety was started on multiple psychotropic meds, including mirtazapine, quetiapine, lorazepam, and divalproex, without documented ICO and without documented NPIs before use. Nursing and RT notes later showed the resident became progressively drowsy and difficult to arouse, but the MD was not informed of the full change in condition until the RP insisted on 9-1-1 transfer. The resident was sent to the hospital and admitted to the ICU with AMS, benzodiazepine intoxication, and hypoglycemia.
Failure to Obtain Informed Consent for Psychotropic Medications: Two residents received psychotropic medications without complete ICO documentation showing that the resident or RP was informed of the risks, benefits, alternatives, and right to refuse. One resident’s RP stated she was never informed about several psychotropic drugs and the facility could not locate consent forms; for the other resident, nursing notes showed attempts to obtain verbal consent, but consent forms were missing for multiple medications while the DON and MD confirmed ICO was required before initiation.
An LPN and other nursing staff used personal smart phones and iMessage to communicate resident PHI and receive medication orders from the MD, including the resident’s name, room number, diagnosis, behavior, and medication changes. Staff stated this was the common practice and that no secure alternative had been provided, while the DON and ADON stated physician communication was expected to occur by landline and that text messaging resident PHI was not secure and was prohibited.
Incomplete documentation after a medication error: A resident with COPD, dementia with agitation, and GAD took another resident’s valproic acid, and nursing progress notes were not consistently entered to document monitoring for neurological changes. The care plan called for monitoring and documenting tremors, rigidity, dizziness, LOC changes, and slurred speech, but the ADON confirmed multiple shifts had no progress notes, and an LPN acknowledged the monitoring was not documented.
Delayed Readmission After Hospital Clearance: A resident with cholecystitis, CRE, and functional quadriplegia was cleared by the GACH to return to the LTC facility but was not readmitted because no male isolation bed was available. Staff later confirmed an empty room and then two female rooms with one occupant each that could have been rearranged to accommodate the resident, but the resident remained at the hospital instead of returning to the facility.
A resident with dementia and other psychiatric diagnoses was identified as high risk for elopement and had orders for a wanderguard and monitoring of whereabouts, but the device was missing for about two weeks, was not replaced, and the care plan was not updated. The resident cut off the wanderguard, left the facility, and was later found after spending the night away from the facility. Staff and the DON confirmed missing documentation, inaccurate MAR entries, and lack of documented monitoring.
Failure to timely report alleged physical abuse: A resident-to-resident altercation was witnessed by staff, and the residents were separated immediately. An LPN completed the SOC-341 and notified the police and Ombudsman, but did not fax the report to the Department as required. The DON and ADM confirmed the report was not sent to the state agency, despite facility policy requiring immediate reporting of abuse allegations.
Delayed Nitroglycerin Order After Cardiology Visit: A resident with heart failure, HTN, and Takotsubo syndrome returned from a cardiology appointment reporting that her cardiologist had prescribed Nitroglycerin, but the facility did not have the order on file. The appointment paperwork was misplaced in another binder, and the nurse did not verify and enter the order until 3 days later after checking with the cardiology office and notifying the MD. The DON stated the nurse should have documented the visit and carried out the order when the resident returned.
A resident with paraplegia and depression was not protected from abuse when another resident approached him as staff were pushing him into a van, cursed at him, threatened to kill him, and struck him with a cane. The resident reported feeling threatened and later sought a restraining order. A receptionist witnessed the other resident run up behind him and hit the back of his wheelchair, while the other resident denied using the cane and said he slapped the resident after hearing him berate another resident.
A resident with intact cognition had no documented discharge plan in the EHR, and he stated he had asked the social services director about a plan but no one returned to discuss it. The ISSD confirmed there was no discharge planning documentation, and the DON stated discharge planning should have started on admission per facility policy.
Two residents who required substantial help with personal hygiene were found with long, unclean fingernails, and one resident also missed a scheduled shower. One resident with paraplegia had fingernails that were long, uneven, and soiled, and staff confirmed they needed trimming. Another resident was observed with unclean nails and said staff had not cut them. The same resident also did not receive his planned shower after the CNA assigned to him was removed for another task, and the DON acknowledged he required a lot of assistance and should have received the shower as scheduled.
Failure to hold resident council meetings: A resident council meeting was not held for two consecutive months even though the meetings were scheduled on the activities calendar. Several residents voiced concerns that their requested meetings did not occur, and the AD and ADM both confirmed there was no evidence the meetings were held. The facility policy stated resident groups, including Resident Council, are supported and meetings are noted on the Activities Calendar.
Room doors and cabinetry were not maintained in good repair for several residents. A resident with anxiety had a closet that would not close, a cabinet without a handle that was not flush, and a courtyard sliding door that opened only a few inches, making her feel trapped. Four other residents, including residents with anxiety, depression, quadriplegia, and stroke-related impairments, reported that their courtyard sliding doors could not be fully opened and made them feel trapped, anxious, or unable to get fresh air. Staff confirmed the doors were not functioning properly and that locks had been placed on the screens and doors so they could not open fully.
Care plans were not properly developed or implemented for several residents’ needs. A resident with ESBL was supposed to be on EBP, but staff were not following the PPE and precaution interventions. Another resident had an oxygen order, but no care plan was initiated for oxygen therapy. Two residents had low air loss mattresses, but one had no care plan at all and another had a mattress set at the wrong weight, with staff confirming the care plan was not implemented.
Inadequate activities programming affected four residents when activity reviews were not completed, one resident with depression and schizoaffective disorder did not receive documented one-to-one activities, one cognitively intact resident was not offered group activities after losing access to a wheelchair, and a legally blind resident did not receive the one-to-one reading and music support listed in his care plan. The AD confirmed the missed reviews, lack of participation notes, and absence of accessible activity supports for the visually impaired resident.
Kitchen food safety practices were not maintained when a dietary staff member was observed with an improperly worn hairnet, food prep surfaces and equipment were found dirty, wet containers were stored in the clean area, and an open yogurt container lacked proper labeling. Surveyors also observed heavy frost in the walk-in freezer, incomplete ice machine cleaning documentation, a discolored ice chute, no dry storage temperature log, and sticky, discolored floors and storage areas.
Multiple infection control failures were observed in the LTC facility. A resident’s oxygen tubing was left wrapped around the tank instead of stored in a clean bag, a resident on EBP had no signage or PPE kit at the doorway, shared glucometers were not properly cleaned and disinfected between residents, an LPN handled pills with bare hands during med pass, and a dusty loose vent was observed above the ADM in the med room.
Resident-to-resident abuse occurred when one resident struck another resident on the head after a verbal argument in the courtyard. The assaulted resident, who had depression and paraplegia, reported threats of harm and said he felt afraid afterward. An AA witnessed the strike, and the other resident admitted he hit the resident during the dispute.
Delayed reporting of resident-on-resident physical abuse: A resident with depression and paraplegia was struck in the back of the head by another resident after an argument in the courtyard. An AA witnessed the altercation and notified the ADM, but the abuse was not reported to required entities until the next day, despite the facility policy requiring reporting within 2 hours when abuse is involved.
A resident was prescribed trazodone for depression and insomnia, but the MAR showed repeated refusals of the medication. An LN said the refusals were being monitored, the MD was aware of them, and the ADON could not find documentation of informed consent in the EMR for the psychotropic medication.
Failure to reasonably accommodate a resident’s needs occurred when a resident who was assessed as able to use a manual wheelchair with supervision did not have a wheelchair available in his room. The resident stated he had previously used a wheelchair to attend group activities but had stopped going because he no longer had one, and the MDSC confirmed the wheelchair was not available and that he should have had one.
PRN psychotropic medication lacked a required stop date for a resident with depression and unspecified dementia. The resident received PRN lorazepam at least daily, and the DON confirmed the order had no end date even though it should have been limited to 14 days for physician review. The facility policy stated that medications continued without the original symptom should be re-evaluated to ensure they do not become a chemical restraint.
Inaccurate MDS assessments and missing diagnosis documentation were found for two residents. One resident’s MDS showed no visual impairment and wheelchair dependence even though the resident had macular degeneration, was legally blind, and walked without a wheelchair. Another resident’s EMR and MDS omitted diagnoses for GERD, anxiety, depression, Parkinson, and hypothyroidism even though those conditions were listed in the H&P and supported by medication orders. The MDSC and DON/ADON confirmed the documentation discrepancies.
LAL mattress pumps were not set according to resident weight for several residents with pressure injury risk or existing wounds. An LPN verified one resident’s mattress was set far above the resident’s actual weight, while another resident’s LAL was also set above the resident’s weight and the resident said the bed was uncomfortable. The ADON confirmed the orders called for settings based on comfort and/or weight, and the facility’s policy required prevention devices to be used per manufacturer guidance and resident weight.
Inaccurate urine output monitoring for a resident with an indwelling urinary catheter was identified during record review and DON interview. The resident had diagnoses including UTI and urogenital implants, and a physician order required urine output to be monitored every shift. Output was not documented for one evening shift and one night shift, and the DON stated this monitoring was important for assessing fluid status and identifying retention.
Undated Oxygen Tubing: A resident with COPD, SOB, and acute bronchiolitis had oxygen tubing connected to the concentrator that was not dated to show when it was last changed. An LPN confirmed the tubing was not dated and stated the facility's process was to date tubing when changed and replace it weekly. The DON stated the missing change date did not meet expectations and presented an infection control risk.
Emergency IV Kit Not Replaced After Use. The facility failed to ensure an Emergency IV Kit in a medication room was replaced in a timely manner after it was opened and used. An LPN found the kit open with missing IV saline and Dextrose 10% solution, and could not identify when it was opened or which resident the missing IV bag had been used for. The LPN and DON stated the nursing staff should have faxed the usage information to the pharmacy for replacement and documented the kit use, but that did not occur.
Medication administration errors exceeded the allowed rate, with multiple observed errors involving wrong drug selection, crushing ER potassium tablets, an incomplete insulin dose, and an early baclofen dose. An LPN gave Senna-Plus instead of ordered Senna for two residents, crushed potassium ER tablets despite labeling that said not to crush, gave only the sliding-scale insulin dose instead of the full ordered dose, and administered baclofen about 2 hours before it was due. The DON confirmed several of the errors and the facility policy required the six rights of medication administration.
A resident with breast cancer on active chemo and osteoporosis received ibandronate more than once in a month even though it was ordered as a monthly medication. The MAR and nursing notes showed inconsistent documentation, and a consultant pharmacist had already flagged the medication as a possible error and noted the manufacturer’s once-monthly directions. The ADON stated the order had been entered incorrectly and the instruction line was confusing, while the nurse said she followed the MAR as written.
Unsafe medication storage and labeling practices were found in the medication room and medication carts. An LN found a heavily frosted medication refrigerator storing insulin and vaccines, and multiple medications on the Long station cart were expired or missing required open-date markings. On the East station cart, an open vial of insulin, two inhalers, and eye drops were also missing open-date markings. The LNs and DON confirmed the findings and noted that staff should have followed label instructions for storage, dating, and discard times.
A resident with macular degeneration, neurologic disease, and unsteadiness was receiving PT using a white cane instead of an appropriate walking stick for balance and walking. The DOR stated therapy had been working with the resident on a walking stick, but during observation confirmed the white cane was not a walking stick and was not made for walking; the resident and an LPN stated the cane was used for blindness-related seeing assistance.
Failure to offer and document flu and pneumococcal vaccinations: The IP confirmed that three residents had no documentation that the influenza vaccine was offered for the current flu season, and one resident also had no documentation that the pneumococcal vaccine was offered. One resident reported uncertainty about prior immunization history and said records were at another facility, but the facility had no documented consent or vaccine history on file. The DON stated the facility needed immunization records to avoid double dosing and to document vaccine history.
Failure to Document COVID-19 Vaccine Offer and History: The facility did not document that a resident was offered the COVID-19 vaccine or obtain the resident’s vaccine history after admission. The IP confirmed the resident was unsure of prior COVID-19 vaccination status because records were at a previous facility, but there was no immunization record, no consent form, and no documentation that the vaccine was offered. The DON stated the facility needed immunization records to avoid double dosing and that vaccine history should have been documented.
A resident with impaired balance, fall risk, and multiple medical diagnoses had a nonfunctioning call light system in the room. When the resident pressed the call light, it did not activate, and the resident reported the system had not worked since moving in and that the backup call bell could not be heard when the room door was closed. An LPN confirmed the call light had not been working for quite a while, and the DON stated the system should be audible to staff.
A resident with DM, glaucoma, paraplegia, and intact cognition reported difficulty seeing and reading and had requested an ophthalmology consult for months. The SSD scheduled the appointment, but it was rescheduled because the facility had no transportation vehicle available and there was no documentation of arranging the sister facility’s van, resulting in a missed ophthalmology visit due to a transportation conflict.
A resident with DM2 and paraplegia had long, thick toenails and multiple toenail avulsions, but was not seen by a podiatrist despite repeated recommendations and referrals. Staff confirmed the resident had missing toenails, toe wounds, drainage, and worsening toe condition, while the DON and LN found no documentation of podiatry care. The SSD stated referrals were sent but the resident was never seen, and the outside podiatry company later said the referral could not be processed because of the resident’s insurance.
A resident with dementia, severe cognitive impairment (BIMS 7), weakness, and unsteadiness, who had a high elopement risk score and physician orders for Q30-minute visual checks, eloped through a non-functioning, non-monitored front entrance door and was later found at a nearby gas station. The IDT had previously downgraded the resident’s supervision from 1:1 to Q30-minute visual checks without further documented reassessment of elopement risk. The main entrance door alarm system had been inoperative for months, its annunciator was not engaged, and no staff were assigned to monitor the door, as confirmed by interviews with nursing staff, the ADON, Maintenance Director, and Administrator, and by observations showing no staff at the front desk despite facility policies requiring adequate supervision and use of door alarms for residents at risk of elopement.
A resident with respiratory and heart failure, anxiety disorder, takotsubo syndrome, and moderate cognitive impairment was repeatedly unable to sleep due to a new roommate who continuously yelled “help me” whenever awake. The yelling, confirmed by staff observations and audible from the nurses’ station, caused the resident migraine headaches, sleep deprivation, and increased anxiety. Staff suggested earphones, but the resident was concerned about not hearing the TV or fire alarm and did not want to move rooms, stating she had been there first. The SSD reported there were no other rooms and referenced a practice of keeping rooms filled, while the roommate’s record documented vascular dementia with agitation, moderate cognitive impairment, and persistent yelling. Despite a facility policy allowing room changes for incompatibility and to protect residents’ well-being, the situation was not resolved, infringing on the resident’s right to a quiet environment.
A resident with respiratory failure, heart failure, muscle weakness, and moderate cognitive impairment had personal belongings transferred from another facility several days after admission. Staff were initially unable to locate the belongings, and when they were eventually brought to the room, the resident’s black safe box containing valuables and collectibles was missing. There was no documentation that the belongings were received upon delivery, and the Social Service Director and nursing staff could not confirm whether the safe box was ever accounted for. The resident’s personal belongings inventory was not completed until months after admission, did not list the safe box, and was not found in the electronic record as required. This was contrary to the facility’s theft and loss policy, which required completion and updating of an inventory on admission and when items were brought in, and the loss caused the resident emotional distress.
A resident with muscle weakness and moderate cognitive impairment, who required substantial assistance with bathing per her care plan, did not consistently receive scheduled showers or bed baths. She reported only receiving bed baths on certain days and at one point only once, while CNAs acknowledged missed baths despite a set Tuesday/Friday bathing schedule. Facility records showed multiple entries marked as not applicable or refused with no documentation of completed showers or bed baths on other days, and weekly checklists reflected refusals on some dates and only one documented bed bath. The DSD confirmed that no alternative bathing times were documented and that the resident’s hygiene needs were not met, contrary to the facility’s bathing policy.
Two residents did not receive needed care when staff failed to carry out a cardiology follow-up order and to notify a physician of poor intake and weight loss. One resident with heart failure and hypertension was discharged from an acute hospital with an order for a cardiologist follow-up within two weeks, but the referral was never entered into the electronic orders, scheduled appointments were missed, and the SSD did not upload or communicate the appointments to nursing or other departments. Another resident with CKD stage 3, diabetes, and vascular dementia had multiple consecutive meals refused or with 0–25% intake and a documented weight drop, despite physician notes directing staff to monitor weight and intake and notify the MD for poor PO intake; the PCP and RD were not notified of these changes until much later, contrary to facility policies on weight monitoring and nutritional management.
Two residents did not receive adequate pressure ulcer prevention and care. One resident with MASD on the buttocks and a physician order for a LAL mattress experienced a planned power shutoff during which the LAL mattress was allowed to deflate because an LN, who had been informed of the power interruption, did not know or implement the protocol to use emergency outlets or extension cords, and no immediate alternative was provided when the resident reported the mattress deflating. Another resident with diabetes and moderate cognitive impairment, who complained of buttock pain and had orders for coccyx skin treatment, was observed by staff to have progressing skin damage on the coccyx from redness to an open wound with drainage, and staff acknowledged the resident might not have been repositioned as frequently as ordered. Review of records showed there was no skin integrity care plan or documented pressure injury prevention interventions for this high-risk resident, despite facility policies requiring evidence-based interventions and comprehensive care plans for residents at risk of or with pressure injuries.
A resident with hearing loss, cognitive communication deficit, and a traumatic brain injury reported that a facility driver and an RNA used the resident’s money to buy food for themselves during an out‑of‑pass outing. Documentation and receipts showed that staff used the resident’s funds to pay for a restaurant order, and leadership confirmed that staff are not permitted to access resident money or accept gifts, including food, from residents. The driver and RNA acknowledged that the resident gave them cash to order food and that they shared the meal, and facility policies identified such use of resident funds as misappropriation.
Two residents with traumatic brain injuries and a known history of aggressive behavior and prior altercation were care planned to be kept separate after an initial physical conflict in the dining room, but staff failed to consistently implement the separation and monitoring interventions. Despite documented plans to separate them by station and monitor for behavioral issues, the residents were again together in the dining room, where one resident approached the other in a wheelchair and struck him multiple times in the head and face, causing facial and wrist injuries that required hospital evaluation and treatment. Staff interviews confirmed that the aggressive resident had ongoing behavioral issues, that the separation intervention was not followed, and that closer monitoring and keeping the residents apart could have prevented the second incident, while the resident who was injured, listed as his own responsible party, was later transferred to another facility without documented discussion with him or notification of his financial contact.
A resident with dementia, traumatic brain injury, and a BIMS score indicating intact cognition was involved in two altercations with another resident, in which he was the victim and sustained facial and wrist injuries. After the second incident, he was transferred to the ER with the initial expectation of return, but the ADM later decided, without discussing it with the resident, to have him discharged from the hospital to a sister facility, citing his safety due to the aggressor remaining in the building. The facility’s own policy allowed facility-initiated discharge only under specific conditions, such as unmet needs, improved health, danger posed by the resident, nonpayment, or closure, none of which were documented as applicable. No physician note supported the discharge or described unmet needs, and no written bed-hold notice was provided despite an order allowing a seven-day bed hold and a policy requiring written bed-hold information at or shortly after transfer. The resident’s financial RP was not notified and confirmed she was not responsible for healthcare decisions, resulting in an inappropriate facility-initiated discharge and failure to honor the resident’s right to return after hospitalization.
A resident with a history of traumatic brain injury and dementia, but documented as cognitively intact on BIMS and acting as his own responsible party, was involved in a resident-to-resident altercation that resulted in facial and wrist injuries and transfer to the ER. While the resident was in the hospital, facility leadership decided to discharge him and have him admitted to a sister facility for safety and separation from the other resident. The ADM contacted the hospital to arrange admission to the sister facility, and the hospital record reflected this plan, but facility staff, including the ADM and SSD, could not produce any written notice informing the resident of the facility-initiated discharge or his appeal rights, and the Ombudsman confirmed no notice was received. This was contrary to the facility’s transfer/discharge policy, which requires written notice with reasons, effective date, receiving location, appeal information, and Ombudsman notification.
A resident reported that a nurse twisted his arm and took away his cat food, and informed the DON and police of the alleged abuse. Despite being aware of the allegation, the DON did not report it to the state agency or conduct an internal investigation, citing unverified information from police. Required notifications and documentation were not completed, resulting in a delayed abuse investigation.
A resident alleged that a nurse twisted his arm and took away his cat food, with the incident witnessed by a CNA. The DON was informed but did not conduct a thorough investigation, relying on a police officer's statement that the resident recanted, without confirming with the resident or interviewing other witnesses. Required documentation and investigative steps were not completed.
A resident with limited mobility experienced the loss of a cell phone and wallet containing cash and identification after being hospitalized. The resident had asked CNAs to secure his belongings, but upon return, several items were missing. Staff interviews revealed that belongings were stored in unsecured areas without proper tracking, and inventory documentation was inconsistent. Facility policies required protection and documentation of personal property, but these were not followed, resulting in the resident's loss and emotional distress.
The facility failed to maintain its boiler heating system, resulting in an inoperable boiler that affected all residents and smoke compartments. The heating system was observed to be nonfunctional during a survey, and multiple attempts to repair it were unsuccessful, leading to the inability to maintain required temperature levels throughout the building.
Psychotropic Medications Started Without Consent or Adequate Monitoring
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary psychotropic medications, failed to obtain informed consent before starting psychotropic medications, failed to monitor for adverse side effects of multiple psychotropic medications with black box warnings, and failed to assess, intervene, and transfer the resident to an acute care setting until the evening when the responsible party insisted on hospital transfer. The resident had diagnoses that included Parkinson’s disease, bipolar disorder, depression, dementia, and anxiety, and the MDS indicated moderate cognitive impairment. The resident’s baseline was described as alert, calm, cooperative, and able to interact with staff and family. The resident’s MAR showed psychotropic medications including mirtazapine, quetiapine, lorazepam, and divalproex. The record did not show nursing documentation of non-pharmacological interventions for anxiety, depression, or mood symptoms before or during the medication use, and the record did not show informed consent for these medications before they were started. The pharmacist’s medication regimen review noted that the resident would need monitoring for CNS adverse effects and that quetiapine and mirtazapine required a consent form from the resident or responsible party. The care plan also referenced black box warning medications and monitoring for side effects, but the record lacked documentation showing that the resident and responsible party were informed of the risks before the medications were initiated. On the evening when the resident was reported as agitated and verbally aggressive, the physician ordered lorazepam and divalproex after being told the resident was combative, although staff later stated the resident had calmed down after redirection and was not physically aggressive. Nursing staff confirmed that informed consent was not obtained before the psychotropic medications were started. The resident then became progressively drowsy and difficult to arouse. Respiratory therapy documented that the resident was difficult to arouse and required sternal rubs on two separate days, and nursing notes described the resident as sleepy or drowsy. The responsible party reported finding the resident unable to wake, later on the floor, and insisted on calling 9-1-1 after the facility initially planned to monitor the resident. The resident was transported to the hospital and admitted to the ICU with altered mental status, toxic metabolic encephalopathy due to polypharmacy, benzodiazepine intoxication, and hypoglycemia. The hospital record stated the resident was obtunded, had a presumptive positive urine toxicology for benzodiazepines, and required flumazenil and dextrose treatment. The physician stated he had not been informed of the resident’s altered level of consciousness or that the resident was only arousable to painful stimulus, and he said he would have sent the resident to the hospital if that information had been communicated.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained for psychotropic medications for two residents, including documentation of the risks, benefits, alternatives, and the right to refuse treatment. The deficiency involved medications identified in the record as antidepressants, antipsychotics, anti-anxiety agents, and other psychotropic drugs, and the facility was unable to locate completed informed consent documentation for several of the medications reviewed. For one resident, the electronic record showed use of mirtazapine, quetiapine, lorazepam, and divalproex for depression, bipolar disorder, anxiety, and mood stabilization. During interview, the resident’s responsible party stated she had never been informed by nursing staff or the MD about the psychotropic medications and was upset that lorazepam and divalproex had been given without discussion of benefits, risks, alternatives, or the right to decline. She also reported the resident was very drowsy and difficult to wake when she visited. The ADON and DON reviewed the record and could not locate any informed consent forms, paper copies, or other documentation showing the resident or responsible party had been informed and consented to these medications. For the second resident, the record showed duloxetine, sertraline, pregabalin, olanzapine, and diazepam for depression, anxiety, bipolar disorder, and related symptoms. Nursing notes documented attempts to obtain verbal consent from the family member, but the family member stated she was waiting to speak with an attorney before deciding. The facility was able to produce signed informed consent forms for sertraline and olanzapine, but not for duloxetine, pregabalin, or diazepam. The DON confirmed all five medications required informed consent before administration, and the MD stated he expected psychotropic medications to have informed consent completed before initiation and that the resident or representative should be informed of the reason for the medication, probable side effects, risks, and alternatives.
Unsecured Text Messaging of Resident PHI
Penalty
Summary
The facility failed to ensure secure and confidential communication of resident medical information when nursing staff used personal smart phones and iMessage to exchange medication orders with the physician. During observation and interview, a Licensed Nurse showed text message exchanges that included the resident’s full name, room number, behavior, and medication instructions. In one exchange, the nurse told the physician the resident was very combative and was being sent to the hospital, and the physician responded with instructions to start Depakote 250 mg three times daily, Ativan 1 mg twice daily, and tramadol if needed for pain. A second nurse stated that on another occasion the resident’s family member reported the resident was drowsy and hard to wake up, and the nurse texted the physician using her personal smart phone. That message included the resident’s diagnosis of bipolar depression, symptoms of drowsiness, weakness, and the possibility that the family wanted to reduce medications or send the resident to the hospital. The physician replied by text to hold Ativan and Depakote until the resident was more awake, then decrease Ativan to 0.5 mg twice daily and obtain CMP, CBC, and Depakote levels. Nurses stated that texting the physician from their personal smart phones was the common way they communicated and that they had no other secure option provided. One nurse said she was not sure whether it violated privacy laws, while another said it was not safe because PHI could possibly be seen by others. The ADON and DON stated nurses were expected to use the landline only for physician communication and that text messaging involving resident PHI was not secure and prohibited. Facility policies also stated that personal cell phones were prohibited on nursing units and that resident records were to remain confidential.
Incomplete Documentation After Medication Error
Penalty
Summary
Facility failed to ensure accurate documentation in the medical record for one of three sampled residents when nursing progress notes were not recorded consistently after a medication error involving Resident 2. Resident 2 was admitted with multiple diagnoses including chronic obstructive pulmonary disease with acute exacerbation, dementia with agitation, and generalized anxiety disorder. The record showed that a medication error occurred when Resident 2 took valproic acid intended for another resident. The care plan directed staff to monitor and document signs and symptoms of neurological changes related to the medication error, including tremors, rigidity, dizziness, changes in level of consciousness, and slurred speech. During record review and interviews, the Assistant Director of Nursing confirmed there were no progress notes for multiple shifts after the event, including the evening, night, and subsequent shifts over several days. A licensed nurse stated that monitoring was started as a standard 72-hour procedure but acknowledged that progress notes were not documented, and the ADON stated that documentation was expected every shift for 72 hours.
Delayed Readmission After Hospital Clearance
Penalty
Summary
The facility failed to ensure that a resident who had been transferred to a GACH was readmitted after being cleared to return on 6/4/26. The resident had been admitted to the facility in early 2013 and was later readmitted in July 2026 with diagnoses including cholecystitis, resistance to carbapenem, and functional quadriplegia. During interview, the Admissions Coordinator confirmed the resident was ready to come back from the hospital but was not readmitted because the facility did not have a male bed or an empty room available for isolation due to the resident’s carbapenem-resistant diagnosis. Record review and interviews showed that on 6/21/26 a two-bed room was empty, and the Assistant DON confirmed another resident was admitted later. Further review showed that from 6/24/26 to 6/28/26, two rooms each had only one female resident and one empty bed, and both residents were female. The ADON and Admissions Coordinator stated the facility could have moved the female residents together to create an isolation room and readmit the resident sooner. The ADON stated the resident should have been admitted back as soon as there was availability and noted the delay had the potential to cause stress and anxiety to the resident and family members.
Failure to Maintain Elopement Monitoring for a High-Risk Resident
Penalty
Summary
The facility failed to implement person-centered interventions to keep a resident safe after she was identified as a high elopement risk. The resident had diagnoses including dementia, generalized anxiety disorder, psychotic disorder with delusions, and major depressive disorder. Her physician orders included a wanderguard on the left wrist for elopement risk and a separate order to monitor her whereabouts every 30 minutes, and her care plan identified her as a high elopement risk with a wander guard in use. On 7/4/26, the resident removed and cut off her wanderguard with scissors and left the facility. A nurse reported hearing that the resident had left, then ran outside and saw her past the parking lot and near the street. The nurse attempted to bring her back, but the resident refused, became aggressive and threatening, and the nurse followed her until losing sight of her. The resident later stated she walked six to seven blocks away, slept outside overnight, and asked for help at a gas station the next morning. Record review and staff interviews showed the wanderguard had been missing for about two weeks before the elopement and was not replaced. Staff confirmed there was no documentation of the resident refusing the device, no documentation of monitoring her whereabouts in June, and the care plan had not been updated to reflect her current status or add additional interventions. The DON acknowledged the wanderguard was not transferred correctly to the MAR, that a nurse documented the device as present when it was not, and that the resident’s elopement risk evaluation remained high while the planned interventions were not followed as intended.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse immediately to the Department for two sampled residents after a resident-to-resident altercation occurred. On 6/16/26, the front desk receptionist witnessed the physical altercation between Resident 3 and Resident 2 and stated that staff separated both residents immediately. Licensed Nurse 1 reported that the incident was brought to her attention by the receptionist and that the facility’s protocol for suspected abuse was to separate the residents, call the police, and notify the Administrator and Director of Nursing. She completed the SOC-341 form and sent it to the Ombudsman and police department, but confirmed she did not fax the form to the Department and was not aware that it was required. The Director of Staff Development stated that nurses were expected to report abuse allegations immediately to the police, Ombudsman, and Department, and to notify the doctor, DON, ADM, and responsible party. The DON reviewed the SOC-341 form dated 6/16/26 and confirmed it was not faxed to the Department, stating the nurse should have done so. The ADM also stated staff needed to follow the facility’s protocol and fax the SOC-341 form to the Department, and that failing to do so was not acceptable. The facility policy required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies immediately, but not later than 2 hours after an allegation involving abuse or serious bodily injury, or not later than 24 hours if abuse and serious bodily injury were not involved.
Delayed Nitroglycerin Order After Cardiology Visit
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure routine and emergency drugs were available for a resident who had been prescribed Nitroglycerin by her cardiologist. The resident had diagnoses including heart failure, hypertension, and Takotsubo syndrome. After the cardiology appointment, the resident returned to the facility and reported that Nitroglycerin had been prescribed, but the medication was not on file in the facility's electronic record at that time. The resident told staff she had received the prescription during the appointment and that the paperwork from the visit was handed to the nurse on the evening shift, but the documents were later found in another binder. A nurse stated she eventually located the paperwork, verified the order with the cardiologist's office, notified the facility physician, and entered the order in the EHR. The medication order for Nitroglycerin was placed 3 days after the appointment. The DON stated the nurse should have notified the facility doctor, carried out the order, and documented the visit when the resident returned, and confirmed the Nitroglycerin order was delayed for 3 days.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure one resident remained free from abuse when another resident struck him with a cane. The resident who was struck had diagnoses including paraplegia and depression, and his MDS indicated a BIMS score of 15, suggesting intact cognition. During interview, he stated that after prior conflict with the other resident, he was being pushed up a ramp into a van by two staff members when the other resident came up behind him, cursed at him, said he was going to kill him, got between the staff members, and hit him on the head. He also stated he later requested a temporary restraining order against the other resident. A facility receptionist stated she observed the other resident running up behind the resident as he was being pushed into the van and saw him hold his cane horizontally and hit the back of the resident's high-backed wheelchair. The receptionist then stood in front of the other resident until staff arrived. The other resident stated he slapped the resident after hearing him verbally berate another resident, but denied hitting him with the cane. A CNA stated she did not see the other resident come up behind them, but was told by the resident that he had been hit, and the receptionist then stood with the other resident. The DON stated staff are taught to be aware of and intervene in situations that could lead to abuse, and that the facility had tried to prevent an altercation by assigning 1:1 staff to both residents, but they were later monitored from a distance.
Missing Discharge Planning Documentation
Penalty
Summary
The facility failed to follow its discharge planning policy for one of four sampled residents when the resident’s EHR did not contain documentation of discharge goals and needs. Resident 1 was admitted to the facility in late 2025, and the MDS dated 5/22/26 showed a BIMS Summary Score of 15, indicating cognition was intact. During an interview on 6/4/26, Resident 1 stated he had no discharge plan and said that when he asked the social services director about a plan, he was told they would return to discuss it, but they never came back. During a concurrent interview and record review on 6/5/26, the interim social services director confirmed there was no documentation in Resident 1’s EHR showing a discharge plan had been created and stated she would expect discharge planning notes on admission and on the social services evaluation. The DON also stated it was her expectation that Resident 1 would have a discharge plan implemented and that discharge planning should have started on admission. The facility policy stated discharge planning generally begins on admission, includes identifying discharge goals and needs, and that discharge goals will be included in the resident’s comprehensive plan of care.
Failure to Provide Nail Care and Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide ADL assistance to maintain proper hygiene for two residents who required substantial help with personal care. Resident 1, who had paraplegia and depression, was observed with fingernails on both hands that were long, uneven, and had a thick brown substance under the right thumbnail. Resident 1 stated the fingernails were digging into his contracted right hand and could cause it to bleed. A licensed nurse confirmed the nails were long and soiled and needed to be trimmed, and another nurse stated the long, unclean nails could dig into the contracted hands and cause wounds. Resident 4, who had depression and required substantial assistance with personal hygiene, was observed with long, unclean fingernails on the right hand and a brownish substance under the nails. Resident 4 stated facility staff did not cut her fingernails. A licensed nurse stated CNAs usually trimmed residents’ nails on Sundays and confirmed Resident 4’s nails did not appear to have been trimmed or cleaned. The DON stated she was aware of the issue with both residents’ fingernails being long and unclean and acknowledged the residents were at risk of injury and/or infection. Resident 1 also did not receive a scheduled shower. His care plan and MDS indicated he was dependent for bathing and had a shower schedule of Tuesday, Thursday, and Saturday after lunch. Resident 1 stated he had missed showers on several occasions when scheduled on the evening shift and expected to receive a shower after lunch, but it did not occur because the CNA assigned to him was sent out of the facility with another resident. The CNA confirmed she could not provide the shower because she was sent out, and the DSD stated he removed her from Resident 1’s assignment without checking with the nurse. The DON stated Resident 1 required a lot of assistance, was not aware the CNA had been removed, and that it was important for him to receive his scheduled shower to remain clean and prevent infection.
Failure to Hold Resident Council Meetings
Penalty
Summary
The facility failed to hold the monthly resident council meeting for a census of 88 residents when meetings were not held in February 2026 and March 2026. During the resident council meeting on 5/11/26, Residents 29, 32, 44, 52, 61, and 66 voiced concerns that the meetings had not been held despite their request to have them. During a concurrent interview and record review on 5/11/26, the Activity Director reviewed resident council meeting minutes and the monthly activities calendar and confirmed there was no evidence of resident council meetings during both February 2026 and March 2026. The Activity Director stated the meetings were scheduled for February 19, 2026 and March 19, 2026 on the activities calendar but were not held, and confirmed the meetings should be held monthly because it was the residents' right. On 5/13/26, the Administrator also confirmed the facility did not provide resident council meetings for those two months. The facility policy titled Resident Council Meetings, dated 2025, stated the facility supports residents' rights to organize and participate in resident groups, including a Resident Council, and that the meetings are noted on the Activities Calendar.
Room Doors and Cabinetry Not Maintained in Good Repair
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 26 sampled residents when room cabinetry and sliding doors were not in good repair and did not function properly. Resident 54, who had an anxiety disorder, was observed in the room with a closet whose bottom hinge was not screwed in, leaving the door unable to close and exposing belongings, a cabinet without a handle that was not flush, and a sliding door to the courtyard that opened only a few inches. Resident 54 stated the exposed belongings and cabinet condition were concerning and that the limited door opening made her feel trapped. Four other residents had sliding doors to the courtyard that were not functioning as doors and could only be opened a few inches. Resident 90, who had quadriplegia, stated the door had recently stopped fully functioning and made her feel trapped and did not provide a home-like environment. Resident 44, who had generalized anxiety disorder and depression, stated she was unable to open the door fully, which made her feel anxious, and that the fan provided was not comparable to having the door fully open. Resident 63, who had depression and shortness of breath, stated he wanted to fully open the door for fresh air and felt trapped when he could not. Resident 17, who had depression and hemiplegia and hemiparesis following cerebral infarction, was observed with a sliding door that opened only a few inches. Resident 17 stated a lock had been placed on the screen and the door could not be fully opened, which made him feel trapped and annoyed. Staff interviews confirmed that residents were unable to fully open their room sliding doors and that the doors functioned like windows to the courtyard. The Maintenance Director stated locks had been placed on the courtyard screens and sliding doors about two months earlier to prevent insects from entering, prevent full opening for resident safety, and due to a wild cat in the courtyard.
Care Plans Not Developed or Implemented for EBP, Oxygen Therapy, and Low Air Loss Mattress Use
Penalty
Summary
The facility failed to develop, implement, and update comprehensive care plans for multiple residents. The report identified that Resident 95 had a care plan for Enhanced Barrier Precautions related to ESBL, but the intervention was not implemented. During observation, Resident 95 stated he had recently been transferred to the hospital for a pelvic infection, had completed IV antibiotics a few days earlier, and reported that no precautions were in place and staff were not wearing PPE. The Infection Preventionist confirmed the care plan called for staff to follow EBP during care such as dressing, bathing/showering, and changing linens, but there was no evidence of PPE supplies or signage with instructions for use, and the expected interventions were not being followed. Resident 62 had an order for oxygen therapy, including oxygen 2 LPM and titration up to 5 LPM as needed for respiratory distress, but no care plan had been initiated for oxygen therapy or respiratory treatment. During observation, Resident 62’s nasal cannula was wrapped around the oxygen tank without any container, and the resident stated she used oxygen in the evening while in bed. The IP stated oxygen therapy should be care planned because it was part of the intervention and there was an order for it, and the ADON confirmed there was no care plan for the oxygen therapy. Resident 111 was observed with a low air loss mattress, but there was no order for the mattress in the EHR and no care plan initiated regarding the mattress. The resident stated the bed was uncomfortable and a little flat and needed more air. The ADON confirmed there was no care plan initiated prior to the observation for the low air loss mattress. Resident 105 was also observed on a low air loss mattress, and LN 6 verified the mattress was set to 350 lb even though the resident weighed 175.6 lb. LN 6 stated the mattress should have been set to the resident’s weight and that the incorrect setting placed the resident at risk for skin breakdown. LN 10 reviewed the care plan and stated the low air loss mattress care plan was not implemented when the mattress was set incorrectly.
Inadequate Activities Program and Failure to Provide Individualized Activity Support
Penalty
Summary
The facility failed to implement an adequate activities program for four sampled residents by not completing required activity reviews, not providing one-to-one activities, and not offering accessible group activity opportunities. The report states that Resident 5, who was admitted with paraplegia, major depressive disorder, and schizoaffective disorder, had two Activities-Initial Review documents that were not completed. The Activities Director confirmed the reviews should have been done and that they were used to determine resident activity preferences. Resident 69, admitted with major depressive disorder, secondary malignant neoplasm of the brain, and cognitive communication deficit, had a BIMS score of 12 out of 15. During interview, the resident stated she had not received any activities and that it would get quiet in the room. The Activities Director reviewed the initial activity review, which showed a preference for one-to-one activities, and confirmed there were no participation notes for activities since admission. Resident 85, admitted with retention of urine, COPD, and asthma, had a BIMS score of 13 out of 15. He stated he stopped going to group activities because he no longer had a wheelchair and said he would have liked to participate more often. The Activities Director confirmed he was last offered group activities on 11/14/25 and last provided an activity on 1/19/26. Resident 49, who had macular degeneration, vertebral artery occlusion and stenosis, degenerative disease of the nervous system, and unsteadiness on his feet, stated he was legally blind and could not see the numbers on BINGO cards or the monthly activities calendar. The Activities Director confirmed Resident 49 should have been receiving one-to-one activities such as reading and music in his room, but was not receiving those services, and that the facility did not have assistive devices for residents with visual impairment.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
Food storage and preparation practices in the kitchen were not maintained in accordance with professional food safety standards during the initial kitchen tour and related interviews. A dietary staff member was observed walking in the kitchen without a hairnet properly worn, and she acknowledged that the hairnet was not covering all hair. The Certified Dietary Manager and Registered Dietitian stated that hair restraints were expected to be worn properly to prevent hair from contacting food, dishes, equipment, or the kitchen environment. Multiple food-contact and nonfood-contact surfaces and equipment were observed in unclean condition. A large sheet pan stored in the ready-to-use area had food debris, food residue, oil and grease buildup, and black residue along the inner rims. Food preparation tables had debris and residue on them. The steamer, oven, stove, and oven beneath the stove had dark brown stains and food residue, and the rack above the stove was dusty. Staff interviews confirmed that these surfaces and equipment were expected to be cleaned routinely, and the facility policy and the FDA Food Code cited in the report required clean food-contact surfaces and clean nonfood-contact surfaces. Additional kitchen storage and sanitation issues were observed. Three wet containers were stacked in the clean area instead of being air-dried before storage, and an open container of yogurt in the walk-in refrigerator was not properly labeled with the required dates. The walk-in freezer had heavy frost buildup, the ice machine cleaning log was incomplete, and the chute/slide inside the ice machine was visibly discolored. The dry storage area did not have a temperature log available, and the kitchen floor and dry storage floor were observed to be sticky and discolored. The report also notes that the facility’s policies required proper labeling, drying, temperature monitoring, and sanitation of storage and kitchen areas.
Infection Control Lapses in Oxygen Storage, EBP, Glucometer Disinfection, Medication Handling, and Medication Room Cleanliness
Penalty
Summary
Resident 62’s oxygen tubing was observed wrapped around the oxygen tank without being kept in a clean bag when not in use. Resident 62 had diagnoses including shortness of breath and asthma and stated she used oxygen in the evening while in bed. The resident’s oxygen order allowed 2 LPM via nasal cannula as needed for respiratory distress, and multiple staff members, including the LN, ADON, IP, RT, and DON, stated the tubing should be dated, changed weekly, and stored in a plastic bag when not in use. The report states the tubing was not stored that way at the time of observation. Resident 95 had an active order for Enhanced Barrier Precautions due to a recent ESBL infection history, but no EBP signage was present and no PPE supply kit was observed at the doorway. The resident stated he had recently been hospitalized for a pelvic infection and had completed IV antibiotics a few days earlier. The IP confirmed the EBP order and stated the signage and PPE supplies were expected to alert staff to wear gowns and gloves during high-contact care. Staff interviews, including with an LN, CNA, MD, and DON, confirmed that the signage and PPE supplies were not in place as expected. Shared glucometer use was observed without proper cleaning and disinfection between residents. One LN cleaned the glucometer with alcohol pads instead of the facility-approved disinfecting wipes after testing Resident 4, another LN placed an uncleaned glucometer back into the cart after testing Resident 39, and the same LN wrapped the glucometer with wipes without cleaning it after testing Resident 50. The IP stated staff were expected to use a two-step cleaning and disinfecting process between resident uses, and the facility policy required glucometers to be cleaned and disinfected after each use according to manufacturer instructions. The manufacturer instructions for the EvenCare G2 glucometer required cleaning with a moist lint-free wipe and then disinfecting with a validated wipe until visibly clean and wet for the required contact time. Medication administration practices also showed staff handling pills with bare hands. An LN popped bubble-pack medications into her bare hand before placing them in a medication cup for Resident 13, and the same LN poured Tylenol tablets into her bare hand before placing them in a cup for Resident 93. The LN stated she should have placed the pills directly into the medication cup and agreed her bare hand could be a source of infection. The facility policy stated medication should be removed from the source without touching it with bare hands. In the medication room, the ceiling air vent above the ADM was observed loose with dust, black and brown particles, and fluff/fuzzy clumps of dust, with debris covering the back of the ADM. An LN stated the vent should be cleaned and that the issue needed to be reported to the facility manager. The DON stated nursing staff should have noticed the dust and debris and notified the facility manager or created a work order, and that the accumulation could affect staff health and contaminate medications stored in the room. The facility policy required medications stored in medication rooms to be maintained with proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that one resident remained free from abuse when another resident struck him on the head during an argument in the courtyard. The resident who was struck had diagnoses of depression and paraplegia. He stated that the other resident threatened to physically harm him, referenced gang affiliation and past violence, and then walked toward him while yelling. The resident reported that he felt afraid after the incident and called the police for protection. An Activities Assistant stated she heard the two residents arguing, saw the other resident walk toward the resident in a wheelchair, and witnessed him hit the resident on the back of the head before returning to the facility. The assistant stated she tried to diffuse the situation and separate the residents but was unable to prevent the strike. The other resident admitted that he hit the resident in the back of the head after the verbal argument and stated he felt the resident deserved it. The Administrator stated the facility investigated the incident and acknowledged the negative impact physical abuse can have on the resident's mental health.
Delayed reporting of resident-on-resident physical abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported within 2 hours to the required department for 2 of 26 sampled residents when Resident 95 hit Resident 68 on 5/4/26 and the report was not made until the following day. Resident 68’s record showed diagnoses of depression and paraplegia. During interview, Resident 68 stated that around 10:30 AM on 5/4/26 he was assaulted by another resident in the courtyard while smoking a cigarette, that multiple staff witnessed the incident, and that he waited in his room for hours expecting staff to check on him or notify police before calling police himself at 3:30 PM. Resident 68 stated he was afraid because of threats made to him and his inability to defend himself. An Activities Assistant stated she heard Resident 68 and Resident 95 arguing in the courtyard, saw Resident 95 approach Resident 68, stood between them while calling for help, and saw Resident 95 hit Resident 68 in the back of the head before walking back into the facility. She reported the incident to the Administrator. Resident 95 stated he struck Resident 68 once after an argument and believed Resident 68 deserved it. The Administrator stated she was aware of the incident, initiated an investigation, and reported the abuse to required entities the next day at about 11 AM, stating she believed the reporting time was 24 hours rather than 2 hours. The facility policy stated alleged abuse must be reported immediately, but no later than 2 hours after the allegation is made when abuse is involved.
Failure to Document Informed Consent for Trazodone
Penalty
Summary
The facility failed to inform and document informed consent for the use of trazodone for one resident reviewed for unnecessary drug use. The resident’s MAR showed an order for trazodone HCl 50 mg, 0.5 tablet by mouth at bedtime for depression and insomnia, and the record also showed the resident had been refusing the medication regularly, including five refusals between May 1 and May 12, 2026. During interviews, an LN stated the resident refused medications regularly without explanation and that refusals were being monitored each shift. The MD stated he was aware of the refusals and was not sure whether the resident or her representative had been involved in medication use. The ADON reviewed the resident’s record and could not locate documentation of informed consent for trazodone, stating that all paper records, including the informed consent sheet, should have been scanned into the EMR and that informed consent was required for all mind-altering medications.
Failure to Provide Wheelchair Accommodation
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not met for Resident 85 when he did not have a wheelchair available to him. Resident 85 was admitted with diagnoses including retention of urine, COPD, and unspecified asthma. His MDS dated 4/7/26 indicated he was able to use a manual wheelchair with supervision, and his BIMS score was 13 out of 15, indicating he was cognitively intact. During observation and interview on 5/10/26, Resident 85 stated he did not have a wheelchair in his room, said he used to have one, and reported that he had stopped attending group activities because he no longer had a wheelchair. During a later observation and interview, the MDS Coordinator confirmed that Resident 85 did not have a wheelchair available and stated he should have had one and was not able to leave his room when he liked to. The facility policy stated that residents would be treated with respect and dignity and that reasonable accommodations would be made for individual needs and preferences.
PRN Psychotropic Medication Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication was limited to 14 days for one sampled resident, Resident 12, because the resident’s PRN lorazepam order did not have a stop date. Resident 12 was admitted with diagnoses including depression and unspecified dementia. A review of the Medication Administration Record showed that Resident 12 received PRN lorazepam at least daily. During a concurrent interview and record review, the DON reviewed Resident 12’s order summary and confirmed that the PRN lorazepam order started on 4/7/26 and had no stop date. The DON stated the order should have had an end date after 14 days so the physician could evaluate whether the medication should be stopped, continued as PRN, or continued long term. The facility policy titled Restraint Free Environment stated that residents should attain and maintain their highest practicable well-being in an environment that prohibits physical or chemical restraints and that medications continued without the original symptom should be re-evaluated to ensure they do not sedate the resident or make it easier for staff to care for the resident.
Inaccurate MDS Assessments and Missing Diagnosis Documentation
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 2 of 26 sampled residents. For Resident 49, the quarterly MDS completed on 4/22/26 was reviewed with the MDSC, who confirmed Section B indicated no visual impairment and that the resident could see fine details such as regular print, even though the resident’s diagnoses included macular degeneration and the care plan identified him as legally blind and needing accommodation. The MDSC stated the section was not accurate and did not align with the resident’s diagnosis and care plan. Resident 49’s MDS Section GG also indicated he was wheelchair bound. During observation and interview, the resident stated he did not own a wheelchair and walked around the facility without one, and no wheelchair was observed in his room. LN 5 stated she had been the resident’s nurse since admission and had never seen him in a wheelchair. The DOR reviewed rehabilitation records and stated there was no indication the resident had been assessed for or needed a wheelchair. The DON confirmed the discrepancy between the MDS documentation, the resident’s actual mobility, and his visual impairment. For Resident 29, the electronic medical record and MDS diagnosis information did not include diagnoses documented in the H&P and medication orders. The order summary listed medications for GERD, anxiety, depression, Parkinson, and hypothyroidism, but the diagnosis section of the record and MDS Section I did not include those five diagnoses. The MDSC confirmed the diagnoses were missing from the record and stated the facility entered diagnoses from the hospital discharge summary and H&P, but was not sure why these diagnoses were not added. The ADON confirmed the diagnosis information was missing from both the computer record and the MDS database.
LAL Mattress Settings Not Adjusted to Resident Weight
Penalty
Summary
The facility failed to provide adequate care and services to promote healing and prevent pressure injury for 4 of 8 sampled residents when low-air loss (LAL) mattress pumps were not adjusted according to resident weight for Residents 105, 64, and 4. The report also identified Resident 111 as part of the affected sample, with the deficiency described as placing these residents at increased risk for developing pressure injury and/or skin breakdown. Resident 105 was admitted with diagnoses including nontraumatic intracranial hemorrhage, dysphagia, and need for gastrostomy care. A Braden Scale dated 9/18/25 showed a score of 15, indicating risk for pressure ulcer development. On 5/10/26, Resident 105 was observed lying on an LAL mattress set at 350 lb. During a concurrent observation and interview, LN 6 verified the setting and stated the resident did not weigh 350 lb, but instead weighed 175.6 lb. LN 6 stated the mattress should have been set to the resident’s weight and that the resident was at risk of skin breakdown because the LAL was not adjusted correctly. LN 10 later stated that if the LAL setting was not adjusted to the resident’s weight and was set too high, the resident would be at risk of developing skin breakdown and the LAL would not be implemented as intended. Resident 64 was diagnosed with morbid obesity due to excess calories and generalized muscle weakness. During observation on 5/10/26, Resident 64 was on an LAL mattress with a bariatric bed and bed extender and stated the bed was uncomfortable. LN 4 confirmed the resident’s latest recorded weight was 415 lb and confirmed the LAL mattress pressure scale pump was at the maximum 460. The ADON reviewed the order summary dated 4/21/26, which directed that the LAL mattress be set based on comfort and/or weight, and stated that if the pressure was on the lower side it would not be effective and if it was on the higher side it would be over inflated. Resident 4 had diagnoses including paraplegia, morbid obesity with alveolar hypoventilation, generalized muscle weakness, and a right hip open wound. On 5/10/26, Resident 4 was observed on a bariatric bed with an LAL mattress and stated the bed was uncomfortable. LN 4 confirmed the resident’s latest recorded weight was 215 lb and confirmed the LAL mattress pressure scale pump was set at 350. The ADON reviewed the order summary and Braden Scale, which showed a score of 12 indicating high risk, and stated the resident should have been on a scale less than 250 pounds in the pressure scale pump. The facility’s policy stated that prevention devices were to be used in accordance with manufacturer recommendations and that specialized support surfaces should consider the resident’s medical condition and weight.
Inaccurate Urine Output Monitoring for Resident With Indwelling Catheter
Penalty
Summary
The facility failed to ensure accurate intake and output was recorded in the EHR for one of 26 sampled residents who had an indwelling urinary catheter. The resident was admitted with diagnoses that included UTI, presence of urogenital implants, and anxiety disorder. During interview and record review, the DON reviewed the resident’s order summary and MAR and verified that there was a physician order to monitor urine output every shift, but urinary output was not monitored and documented on one evening shift and one night shift. The DON stated that monitoring urinary output was important for determining the resident’s fluid status and whether he was retaining fluid, and that without monitoring every shift the resident’s fluid status or a delayed response to fluid status abnormalities would not be known.
Undated Oxygen Tubing
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured when Resident 29's oxygen tubing was observed not dated and labeled to show when it was last changed. Resident 29 was admitted with diagnoses of COPD, shortness of breath, and acute bronchiolitis. During a concurrent observation and interview in the resident's room, LN 3 confirmed the oxygen tubing connected to the concentrator was not dated and stated the facility's process was to write the date on the tubing when it was changed. LN 3 also stated the tubing should be changed and dated every week and explained that old tubing could develop cracks and be ineffective. During an interview, the DON stated the oxygen nasal cannula tubing needed a change date on it and that this did not meet her expectations. The DON further stated it presented an infection control risk to residents in the facility. The facility's Oxygen Administration policy stated oxygen tubing and mask/cannula are to be changed weekly and as needed if soiled or contaminated, and the Infection Prevention and Control Program policy stated the facility maintains an infection prevention and control program and staff receive training related to their job function.
Emergency IV Kit Not Replaced or Documented After Use
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure the Emergency IV Kit in the [NAME] station medication room was replaced in a timely manner after it was opened and used. During observation of the medication room, the IV-Ekit was found on the floor with an opened red tag, and the contents were checked. A one liter IV bag of saline was missing, and an out-of-wrap bag of Dextrose 10% solution was also missing from the kit. During interview, LN 1 stated that once the kit was opened based on a doctor's order for medication removal, the pharmacy should have been notified for replacement, and that the provider pharmacy delivered daily to the facility. LN 1 also stated the nursing staff should complete the duplicate Emergency Drug Kit Usage Report, fax the white copy to the provider pharmacy, and keep the yellow copy for facility documentation, but was not sure who opened the IV-Ekit, when it was opened, or which resident the missing IV bag had been used for. The DON stated she expected nursing staff to fax emergency kit medication use to the pharmacy for processing and timely replacement and to communicate the information to the next shift for follow up. Review of the facility policy stated that upon removal of any medication or supply item from the emergency kit, the nurse documents the item used on an emergency kit log and immediately faxes one copy to the pharmacy or places it within a resealed emergency kit until exchange.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices when its medication error rate was 19.35% based on 6 errors out of 31 opportunities during observation of medication passes for 16 residents. The report identified errors involving five residents, including administration of the wrong laxative product, crushing potassium extended-release tablets when the product labeling said not to crush, giving an incorrect insulin dose, and administering baclofen earlier than the scheduled time. The facility policy required the six rights of medication administration, including the right drug, dosage, route, time, and documentation. For Resident 69, LN 2 administered Senna-Plus instead of the ordered Senna tablet and also crushed a potassium chloride ER tablet and mixed it with pudding, despite the pharmacy label stating not to chew or crush the medication and no order to crush medications being present. For Resident 12, LN 2 administered Senna-Plus instead of the ordered Senna tablet while the resident also had a separate docusate order. For Resident 7, LN 4 crushed a potassium ER tablet and mixed it with applesauce even though the label stated not to chew or crush it and the MAR did not authorize crushing. For Resident 50, LN 3 administered 10 units of NovoLOG based on the sliding scale for a blood glucose of 284, but did not also give the scheduled 5-unit pre-meal dose ordered by the provider. For Resident 13, LN 6 administered baclofen about 2 hours before the scheduled 5 p.m. dose time. The DON confirmed that potassium should not have been crushed, Senna-Plus should not have been substituted for Senna, and insulin administration required both the sliding scale dose and the pre-meal dose as ordered.
Repeated Ibandronate Administration Error
Penalty
Summary
Resident 69, who was admitted with multiple diagnoses including breast cancer on active chemotherapy, age-related osteoporosis, and difficulty walking, had an order for ibandronate sodium 150 mg to be given once monthly for osteoporosis prevention. The medication administration record showed the drug was administered more than once in the same month, including on 5/1/26, 5/12/26, and 5/13/26, even though it was intended to be given monthly. The MAR also showed the medication marked as not given on multiple days with notes indicating it was waiting on pharmacy. During a medication administration observation, the nurse administered the resident’s 9:00 AM medications but did not give ibandronate, which was documented as not given. In the resident’s electronic record, nursing notes from 5/2/26 through 5/12/26 also reflected ibandronate as not given and waiting on pharmacy. When interviewed, the nurse stated she followed the order as written in the MAR. The consultant pharmacist had previously identified a possible medication error and documented that ibandronate once monthly had been incorrectly administered three times in two weeks, noting that the manufacturer labeling intended the 150 mg dose for once-monthly administration on the same calendar day each month. The pharmacist asked whether the next dose should be held or delayed, and the physician response indicated agreement with a handwritten note to hold for 60 days then resume monthly. The facility did not follow or document that response, and the medication continued to be administered multiple times during the following month. The ADON stated the order had been entered incorrectly in the computer and that the long instruction line was confusing, while the DON stated pharmacy recommendations were printed and reviewed with staff and physicians.
Unsafe Medication Storage and Labeling Practices
Penalty
Summary
Safe medication storage practices were not maintained in the medication room and medication carts for a resident census of 88. During inspection of the medication room at the Long station, the refrigerator used to store resident medications was heavily frosted while insulin and vaccines were stored inside and next to it. The LN present confirmed the condition of the refrigerator and stated she was not sure when or who was responsible for upkeep and defrosting. During inspection of the Long station medication cart, medications were found expired or without required open-date markings. The cart contained Novolog insulin with a discard-after date of 4/19/26, Budesonide inhalation suspension out of foil wrap with the box marked 01/06, and two Ipratropium Bromide and Albuterol Sulfate unit-dose packages out of foil wrap with open dates of 4/10/26 and 3/25/26. The LN confirmed the findings and stated the medications should have been discarded in a timely manner based on label instructions. During inspection of the East station medication cart, an open vial of Lantus insulin, two open containers of Breo Ellipta inhalers, and Vyzulta eye drops were found without dates marking when they were first opened. The LN confirmed the findings and stated the medications should have been dated when first opened and discarded according to the drug label instructions. The DON stated the nursing staff documenting the refrigerator should have notified management and helped with defrosting the refrigerator, and that nursing care standards required staff to read the label for storage and handling instructions.
Inadequate PT Device Used for Visually Impaired Resident
Penalty
Summary
The facility failed to provide adequate physical therapy services to Resident 49, who was admitted with macular degeneration, occlusion and stenosis of the vertebral artery, degenerative disease of the nervous system, and unsteadiness on his feet. During an observation in the resident’s room, a white cane was found within arm’s reach next to the bed, and the resident stated he was legally blind and used the white cane to help him see. He also stated the cane had been given to him by a place that supports people with blindness and visual challenges. The Director of Rehabilitation stated the rehabilitation department had been working with the resident on using a walking stick for balance and walking, and that the resident had been evaluated and cleared by therapy to use the walking stick for therapy sessions. However, during observation, the Director of Rehabilitation confirmed the white cane being used as a walking aid was not a walking stick and was not made for walking. The Director of Rehabilitation also stated the resident must be evaluated with an actual walking stick, and that if the stick was not a walking stick it could break and harm the resident. The Licensed Nurse stated the resident had the white cane due to blindness and used it for seeing assistance to walk around the facility.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to implement an effective immunization program to offer, obtain informed consent for, and provide education about influenza and pneumococcal vaccines for three sampled residents. Resident 64, Resident 46, and Resident 96 were not offered the influenza vaccine for the 2025-2026 flu season, and Resident 64 was also not offered the pneumococcal vaccine. The report states these failures involved three out of five sampled residents. Resident 64 was admitted in early 2026. The IP documented speaking with the resident about immunization records, and the resident stated he was not sure about his vaccine history and that his records were at another facility. The IP called the other facility and left a message, but there was no response. During interview and record review, the IP confirmed there was no documentation that Resident 64 was offered the influenza vaccine or that consent was signed, and no documentation that the pneumococcal vaccine was offered or that consent was signed. Resident 46 was admitted in 2023, and the IP confirmed there was no documentation that the influenza vaccine was offered for the 2025-2026 flu season. Resident 96 was admitted in 2025, and the IP confirmed there was no documentation that the influenza vaccine was offered and no consent form was obtained. The IP stated the facility offered the flu vaccine between October 1 and March 31 and offered pneumococcal vaccine upon admission, and the DON stated the facility needed residents' immunization records to prevent double dosing and document vaccine history.
Failure to Document COVID-19 Vaccine Offer and History
Penalty
Summary
The facility failed to provide the COVID-19 vaccine for one sampled resident, Resident 64, because there was no documentation in the resident’s medical record that the vaccine was offered and the resident’s COVID-19 vaccine history was not obtained. Resident 64 was admitted to the facility in early 2026. During a concurrent interview and record review, the Infection Preventionist stated the facility offered the COVID-19 vaccine to residents upon admission, obtained consent, and provided education when there was a new vaccine, but confirmed there was no immunization record for Resident 64 and no documentation that the vaccine had been offered or that a consent form was signed. The Infection Preventionist stated Resident 64 reported being unsure whether the COVID-19 vaccine had been received because the immunization record was at a previous facility. The Infection Preventionist said he requested the record from that facility but did not receive a response. The Director of Nursing stated the facility obtained immunization consents for newly admitted residents and needed immunization records to prevent double dosing, and confirmed the facility should have documented the resident’s vaccine history if a vaccine was offered and when a new vaccine was given. A progress note dated 3/24/26 documented that the Infection Preventionist spoke with Resident 64 about the immunization record and called the prior facility to request information.
Nonfunctioning Call Light for Resident with Mobility and Fall Risk
Penalty
Summary
The facility failed to ensure a functioning call light system was available for Resident 63, who was admitted with diagnoses including cellulitis of the right lower limb, unsteadiness on feet, acquired absence of the right great toe, and shortness of breath. The resident’s care plan directed staff to encourage use of the bell to call for assistance and to keep the call light within reach because of impaired balance and fall risk, with a need for prompt response to requests for assistance. During a concurrent observation and interview, Resident 63 pressed the call light, but it did not activate. The resident stated the call light system had not been functioning since moving into the room and that staff could not hear the call bell when the room door was closed. A licensed nurse stated the call light system had not been functioning for quite a while and that there was a possibility of delayed care and longer response times when the resident needed assistance. The DON stated the call light system should be audible to staff and that if it was not functioning, an alternative option should still be effective and audible even with the room door closed.
Missed Ophthalmology Appointment Due to Transportation Conflict
Penalty
Summary
The facility failed to arrange transportation to and from an ophthalmologist’s office for a resident who had diagnoses including type 2 diabetes mellitus, unspecified osteoarthritis, unspecified glaucoma, and paraplegia. The resident’s MDS dated 2/24/26 showed a BIMS score of 15 out of 15, indicating intact cognition. During interview, the resident stated he had requested to be seen by an ophthalmologist since 11/25 and reported that he was almost blind and having difficulty seeing and reading. The Social Services Director stated an ophthalmology appointment had been scheduled for 4/2/26, then rescheduled to 5/22/26 because of a transportation conflict. The SSD stated the facility did not have its transportation vehicle available and the sister facility’s van was also not available. The Director of Staff Development stated the resident had a doctor’s order dated 11/19/25 for an ophthalmology consult for cataract, and that the SSD should have facilitated the appointment when there was an order from the physician. The DSD and Administrator stated there was no documentation showing communication with the sister facility to arrange transportation for the appointment. The resident’s progress notes documented the ophthalmology consult was scheduled for right eye redness and later rescheduled due to transportation conflict.
Failure to Obtain Podiatry Care for a Diabetic Resident With Toenail Avulsions
Penalty
Summary
The facility failed to ensure one resident received proper foot treatment and care when the resident was not seen by a podiatrist despite having diabetes, paraplegia, long and thickened toenails, and multiple toenail avulsions. The resident was admitted with type 2 diabetes mellitus and paraplegia, and the MDS showed intact cognition. During interviews, the resident stated that a wound care doctor had said he needed to be seen by a podiatrist and that he had requested podiatry services from the SSD months earlier. The resident also stated that no one at the facility had provided nail care since admission and that toenails had grown long and caught in socks, causing nail loss. Facility staff confirmed the resident had long and thick toenails on the right foot and missing toenails on the left foot and right pinky toe. A CNA stated the resident had thick toenails and had complained that his toenails and feet hurt when socks were put on. An LN confirmed the resident had long and thick toenails and multiple missing toenails, and stated the resident should have been seen by a podiatrist for nail care. The LN also stated there was no documentation showing the resident had been seen by a podiatrist. The DON likewise confirmed the resident had missing toenails and no documentation of podiatry care, and stated the resident should have been seen because he was diabetic and had missing toenails. The resident’s record showed repeated nail and toe problems, including detached and partially detached toenails, avulsed nails, drainage, an open wound, deterioration, exposed bone, and later eschar on the left second toe. Physician orders and nursing evaluations documented recommendations for podiatry consultation. The SSD stated a referral was sent to the in-house podiatry company and later to an outside podiatry clinic, but the resident was not seen by a podiatrist. The SSD also stated the resident had not been seen by a podiatrist since admission and acknowledged he should have followed up to schedule the appointment. The outside podiatry company stated the referral was under review and later determined the resident could not be seen by their company because of his insurance.
Failure to Supervise High-Risk Resident and Maintain Functional Front Door Alarm Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, alarmed exit, which allowed a resident at high risk for elopement to leave the building unnoticed. The resident had dementia, weakness, and unsteadiness of feet, and an MDS BIMS score of 7 indicating severe cognitive and memory impairment. The resident’s orders included visual checks every 30 minutes, and an IDT note documented that supervision had been downgraded from 1:1 to visual location checks every 15 minutes, later changed to every 30 minutes, after several months without an elopement attempt. A Nursing Elopement Evaluation completed shortly before the incident showed an elopement risk score of 28, indicating high elopement risk, but progress notes from the time supervision was downgraded through the date of elopement showed no further assessment of elopement risk. The resident eloped from the facility at approximately 11:00 a.m. and was found about 25 minutes later at a nearby gas station, as documented in an eINTERACT Change in Condition Evaluation. At the time of the elopement, the main entrance door alarm system was not functioning and had been inoperative for months, according to interviews with the ADON, Maintenance Director, and Administrator. The Maintenance Director stated that all exit doors, including the main entrance, had annunciator alarm devices, but the annunciator on the main entrance door was not engaged because it would alarm continuously with routine traffic. The ADON confirmed that the resident was on 30-minute visual location checks at the time of the elopement. Interviews with nursing staff and leadership revealed that the main entrance door was not alarmed and was not consistently monitored by staff. LN 1 and LN 2 stated that the front main entrance door was not alarmed and that there was not always someone at the desk by that door, and LN 2 was unaware of any staff assigned to monitor that door for unescorted resident exits. The ADON and Administrator both confirmed that no staff member had been assigned to monitor the front door at the time of the elopement and acknowledged that the door had not been monitored despite the known elopement risk. Observations on multiple occasions showed no staff member present at the desk by the main entrance door. These conditions occurred despite facility policies stating that residents at risk for elopement would receive adequate supervision, that the facility was equipped with door alarms to help avoid elopements, and that alarms were not a replacement for necessary supervision.
Failure to Protect Resident’s Right to a Quiet and Dignified Environment
Penalty
Summary
The facility failed to ensure a resident’s right to a quiet environment when one resident was unable to rest due to continuous yelling from her roommate over several days. The affected resident had respiratory failure, heart failure, anxiety disorder, and takotsubo syndrome, and an MDS dated 2/19/26 showed a BIMS score of 12/15, indicating moderate cognitive impairment. During an interview, the resident reported that since her roommate’s admission about a week earlier, the roommate had been constantly yelling whenever awake, day or night, which caused migraine headaches and kept her from sleeping. Staff reportedly told the resident to use earphones, but she expressed concern that she would not be able to hear her TV or the fire alarm. She also stated she had been in the room first and did not want to move, and that when she reported her concerns to the Social Services Director, she was told there were no other rooms available and that the facility’s policy was to keep rooms filled. Observations on 3/5/26 confirmed that the roommate repeatedly yelled “help me” while awake, and her yelling could be heard from the nurses’ station and conference room. The roommate’s record showed a diagnosis of vascular dementia with agitation, a BIMS score of 8/15 indicating moderate cognitive impairment, and an admission nursing evaluation noting non-compliance, anxiety, psychosis, poor safety awareness, and that she kept yelling “help me” throughout the shift. A licensed nurse stated that the roommate yelled constantly and that the affected resident had complained of headaches, sleep deprivation, and anxiety, and that attempts to calm the roommate were only temporarily effective. The Social Services Director stated that his understanding of the process was that the resident with noise issues would be moved, regardless of who had been in the room longer, and could not describe the facility’s process for pairing roommates. The facility’s policy on room or roommate changes allowed changes for incompatibility and for the safety, health, and well-being of residents, but the resident’s complaints and the ongoing disruptive behavior were not effectively addressed, resulting in the resident’s sleepless nights, migraines, and emotional and psychological distress.
Failure to Inventory and Safeguard a Resident’s Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to protect and account for a resident’s personal belongings, specifically a black safe box containing valuables and collectibles, following admission. The resident was admitted with diagnoses including respiratory failure, heart failure, and muscle weakness, and had a BIMS score of 12/15 indicating moderate cognitive impairment. Her personal belongings were transferred from another facility three days after admission. The resident reported that she did not receive her belongings in her room until days after delivery because staff could not locate them, and when the belongings were finally brought to her room, the black safe box was missing. A CNA confirmed that the resident reported the missing safe and that the CNA had never seen it in the room. The Social Service Director stated that the resident’s belongings were transported from another facility but there was no documentation that the belongings were received upon delivery, and it was unclear whether the black safe box was included. The Social Service Director also stated that a personal inventory was completed after admission but could not identify the date. A nurse reviewing the electronic record could not locate the resident’s personal inventory and explained that the facility no longer kept paper charts and the inventory should have been uploaded but likely was not. The DON stated that an inventory sheet should have been completed at the time the belongings were delivered and within 24 hours of admission. Review of the Resident Personal Belongings Inventory showed that the inventory was not completed until months after admission, and the black safe box was not listed. The facility’s Theft and Loss policy required that an inventory of resident belongings be completed on admission and that items brought in after admission be added to the inventory list, which was not followed in this case, resulting in the resident’s black safe box being unaccounted for and causing her emotional distress.
Failure to Provide Scheduled Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living received scheduled bathing to maintain personal hygiene. The resident had muscle weakness and moderate cognitive impairment, with an MDS indicating a need for substantial/maximal assistance with showering/bathing. The resident’s ADL care plan documented that she required substantial assistance by one to two staff for bathing/showering as needed. The resident reported that she did not receive showers and that she was supposed to receive bed baths every Tuesday and Friday, but there was a period when she only received one bed bath. CNAs interviewed stated that the resident was scheduled for showers or bed baths on Tuesdays and Fridays, but one CNA reported there were times the resident did not receive her bed bath as scheduled, and another CNA stated she had not seen the resident receive showers or bed baths. Record reviews showed multiple missed or undocumented bathing opportunities during the review period. The facility’s shower schedule listed the resident for afternoon showers on Tuesdays and Fridays. Documentation for 2/1/26 through 2/28/26 showed “NA” entries for bathing/shower on several Mondays, with the DSD explaining that “NA” also indicated refusals, and there were no other days marked showing that showers or bed baths were provided. A task record for shower/bath showed refusals documented on three dates, with no other days marked as completed. Weekly shower checklists indicated refusals on two dates and one bed bath on another date, with no additional checklists available. Staff interviews indicated that when residents refused showers, they would typically offer bed baths or alternative times, but the DSD confirmed there were no other days documented when alternative schedules were offered and acknowledged that the resident’s needs were not met. The facility’s policy stated that residents were to be assisted with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues, but this was not consistently carried out for this resident during the review period.
Failure to Transcribe Specialist Follow-Up Order and Notify Physician of Poor Intake and Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered and needed care and treatment to two residents by not following hospital discharge instructions for a cardiology follow-up and by not notifying the physician of poor oral intake and weight loss. For the first resident, the admission record dated 3/6/26 showed diagnoses including respiratory failure, heart failure, and hypertension, and an MDS dated 2/19/26 documented a BIMS score of 12/15, indicating moderate cognitive impairment. The resident’s care plan report dated 12/2/25 identified altered cardiovascular status and hypertension, with an intervention to notify the MD of significant abnormalities. The acute hospital discharge summary dated 11/18/25 contained an order to follow up with a cardiologist in two weeks, but this order was not transcribed into the resident’s electronic order summary report. The first resident reported during interview that she had scheduled cardiology appointments on 1/7/26 and 1/21/26, that the Social Services Director (SSD) had been informed, and that both appointments were missed. She produced two letters from the cardiologist documenting the missed appointments. The resident stated she later called the cardiologist’s office on 2/23/26 to make an appointment and learned an appointment had already been scheduled for 2/25/26, which she had not been informed about by staff. Licensed nursing staff interviewed stated they were not aware of the cardiology appointments, and review of the order summary report confirmed there was no cardiologist referral order documented. The SSD acknowledged being aware of the 1/7/26 and 1/21/26 appointments, stated that the appointments were missed due to lack of communication and poor coordination between departments, and admitted he did not upload the appointment information into the resident’s electronic file, resulting in the referral order not being followed through or carried out. For the second resident, the admission record dated 3/10/26 showed diagnoses including stage 3 kidney disease, diabetes, and vascular dementia, with an MDS BIMS score of 11/15 indicating moderate cognitive impairment. A complainant reported that this resident had not been feeling well for several days and had not been eating for almost seven days before transfer to an acute hospital. The facility’s documentation survey report for February showed multiple consecutive meals from 2/13/26 through 2/17/26 where the resident either refused meals or consumed 0–25% of meals, including repeated entries of “RR” (resident refused) and “0” for intake. Weight and vitals documentation showed a decrease from 163.8 lbs on 2/8/26 to 155.8 lbs on 2/16/26. Physician progress notes dated 1/27/26 and 2/14/26 directed staff to monitor weight and intake/output and to notify the MD/provider if there was abnormal weight loss or poor PO intake. Certified nursing staff reported that when residents refused meals they informed the charge nurse and offered snacks or alternatives, and nursing staff stated that for low meal intake they would complete a change of condition form and notify the primary care physician (PCP) and registered dietitian (RD). However, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that, despite the documented poor intake and weight loss, the PCP and RD were not notified during the period of low intake and weight decline. The ADON later verified that the PCP and RD were not notified until 3/4/26. Facility policies on Weight Monitoring and Nutritional Management required that the physician be informed of significant changes in weight, intake, or nutritional status, but this notification did not occur during the days when the resident had repeated meal refusals and low intake and experienced documented weight loss.
Failure to Maintain LAL Mattress Function and Absence of Skin Integrity Care Plan Leading to Pressure Injury Worsening
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and care for two residents. For the first resident, who had diabetes, muscle weakness, musculoskeletal symptoms, moderate cognitive impairment, and documented MASD on bilateral buttocks, the care plan and orders required use of a low air loss (LAL) mattress and specific buttocks skin care with normal saline and calmoseptine every shift. During a planned power shutoff in the resident’s room while maintenance worked in an adjacent room, the resident’s oxygen concentrator was switched to an oxygen tank, and the resident reported to a licensed nurse that her LAL mattress was deflating. The nurse responded that the power would be off for 15–20 minutes and did not indicate any alternative plan to keep the LAL mattress functioning. Another nurse later stated the LAL mattress should have been plugged into an emergency outlet before the power was turned off and told the resident it would be plugged into an emergency outlet. In follow-up interviews, the first nurse stated that maintenance had informed her about the power shutoff but she did not know the protocol for using emergency extension cords to keep the LAL mattress operating. The Director of Staff Development confirmed that the orientation checklist for that nurse did not include training on the use of emergency extension cords and emergency outlets to maintain electrical equipment during power shutoffs. The Director of Nursing stated she would have expected the nurse to ask other nurses for assistance and acknowledged that a deflated LAL mattress could be uncomfortable and potentially a reason for skin breakdowns. The facility’s user manual for the LAL mattress system described its purpose as helping reduce the incidence of pressure ulcers, and the facility’s Pressure Injury Prevention Guidelines policy required prevention devices to be used in accordance with manufacturer recommendations. For the second resident, who also had diabetes, muscle weakness, musculoskeletal symptoms, and moderate cognitive impairment, there was a concern reported by a complainant that the resident experienced a burning sensation around the buttocks. The resident later stated his bottom was hurting. Physician orders and the Treatment Administration Record showed that the coccyx area was to be washed with soap and warm water, patted dry, and calmoseptine applied every shift. A CNA reported that the resident had skin issues on the buttocks and around the anal region, with a small peeled area of skin, and stated she repositioned the resident every two hours and kept him clean and dry. A licensed nurse reported that on the previous day she had observed only skin redness with no open area on the buttocks and coccyx, and that preventive measures included keeping the resident clean and dry, reporting skin changes, and rotating his position every two hours in bed. On a subsequent observation with the same nurse, the resident was found to have an area on the coccyx where the outer skin had come off, now an open wound measuring approximately 0.3 cm by 0.4 cm with slight drainage. The nurse stated that the area had been smaller and not open the day before and that it was now bigger and open, and she acknowledged the resident might not have been turned and repositioned as frequently as required. Review of the resident’s care plan documentation showed there was no care plan addressing his high risk for skin breakdown, and no documented interventions to prevent development or worsening of pressure ulcers. The nurse confirmed there was no skin integrity care plan and stated there should be one to guide staff, and that without a skin care plan there would be no interventions for staff to follow, which could increase the occurrence or worsening of pressure injuries. The Administrator also stated that residents at high risk for skin breakdown should have a care plan to help prevent further skin issues that could lead to infection and a decline in general health. The facility’s Pressure Injury Prevention Guidelines and Comprehensive Care Plans policies required evidence-based interventions for at-risk residents to be documented in the care plan and used to meet resident needs.
Staff Acceptance of Resident Funds for Personal Food Purchases
Penalty
Summary
The deficiency involves facility staff accepting and using a resident’s personal funds to purchase food for themselves while accompanying the resident out on pass. The resident involved had diagnoses including sensorineural hearing loss, cognitive communication deficit, and focal traumatic brain injury with loss of consciousness. According to the resident’s admission record and subsequent progress notes, the resident reported that the facility driver and a Restorative Nurse Assistant (RNA) used his own money to buy food during an outing. Interdisciplinary team documentation and care plan entries identified an allegation of financial abuse, noting that the resident stated the driver and RNA used his money to buy food. A facility form titled “Patient Loss/Refund Request Form” recorded that staff members used the resident’s debit card to purchase a lunch meal in the amount of $63.77, and a restaurant receipt showed a total of $63.77 paid in cash with change given. Interviews with leadership, including the Director of Staff Development, Social Services Director, and Assistant DON, confirmed that staff were not allowed to have access to residents’ money or cards and were not permitted to accept gifts, compensation, or food from residents, even if offered. These leaders acknowledged that in this incident the driver and RNA accepted the resident’s offer to buy them food and used the resident’s funds for that purpose. Interviews with the driver and RNA provided additional detail about the events. They stated that they transported the resident to a bank, a phone provider store, a restaurant, and a retail store. Both reported that the resident said he was hungry, offered to treat them with food, and gave the RNA $100 in cash to place the order at a local restaurant. After seeing the receipt and change, the resident became upset about the cost and cancelled part of the order, later complaining that staff had used his money to buy food. The Administrator confirmed that the resident told her he had offered to get food for staff but did not know how much it would cost and became upset when he saw the amount. Facility policy on Abuse, Neglect and Exploitation and the Code of Conduct identified misappropriation of patient funds as prohibited conduct, and staff acknowledged that by accepting food purchased with the resident’s money, they violated facility policy regarding misappropriation and acceptance of gifts.
Failure to Maintain Separation Between Residents With Known History of Altercations Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow effective interventions to keep two residents with a known history of altercations apart, resulting in a second physical altercation and injuries to one of the residents. Resident 1 was admitted in 2025 with diagnoses including traumatic subarachnoid hemorrhage and unspecified intracranial injury and was listed as his own responsible party, with a representative payee only for financial matters. Resident 2 was admitted in 2025 with diagnoses including unspecified intracranial injury and generalized anxiety disorder and had a documented history of aggressive behavior toward staff, including laying hands on a CNA during redirection. Staff interviews described Resident 2 as sometimes nice and sometimes not nice, with episodes of yelling at staff when he did not get his way, and being aggressive, including grabbing a CNA by the shirt. On 1/1/26, Resident 1 and Resident 2 were involved in a physical altercation in the dining room. The Director of Rehab (DOR) reported witnessing Resident 2 stand up from his wheelchair, push Resident 1, and then hit Resident 1, after Resident 1 allegedly tried to grab food from Resident 2’s mother’s plate. Documentation for both residents on 1/1/26 described a physical altercation and indicated that both residents were “physically abused.” Interdisciplinary notes for both residents stated that they would be separated by station and monitored for delayed mental and physical injuries. Resident 1’s care plan, initiated on 1/2/26 and revised on 1/7/26, identified a focus of an alleged resident-to-resident altercation with a goal of no altercation and included interventions such as monitoring for pain and separating the residents. Resident 2’s care plan, initiated on 1/2/26, also focused on an alleged resident-to-resident altercation with a goal of no altercation and an intervention to separate the residents. Despite these documented interventions, the residents were again together in the dining room on 1/5/26, when a second altercation occurred. Multiple staff, including the Social Services Director, DOR, DON, LNs, and CNAs, reported that Resident 2 approached Resident 1 in his wheelchair and struck Resident 1 multiple times in the head and face, while Resident 1 tried to shield himself with his left arm. The DON, SSD, LNs, and CNAs stated that Resident 2 had been aggressive in the past and that Resident 2 should have been monitored more closely and kept away from Resident 1 after the first incident. The DON and other staff acknowledged that the intervention to keep the residents separate was not followed and that the second altercation could have been avoided if Resident 2 had been monitored for aggressive behavior and the residents had been kept apart. As a result of the second altercation, Resident 1 sustained injuries including swelling of the left wrist and swelling under the left lower eye, a hematoma of the left zygoma, and an abrasion to the forehead. Progress notes and hospital emergency records documented that Resident 1 complained of pain, rated at 6 out of 10, and was nauseated and vomited. A splint was applied to Resident 1’s left wrist, and he was transferred to the hospital for further evaluation and treatment of his injuries. Resident 1, who had a traumatic brain injury and was described as unable to verbalize coherent thoughts and repetitive in his statements, was later transferred from the hospital to a sister facility. The Administrator stated that she did not discuss the transfer with Resident 1, and the Representative Payee stated she was not notified of the transfer and that she was only responsible for Resident 1’s financial matters. The facility’s abuse policy stated that it would identify, assess, care plan, and monitor residents with behaviors that might lead to conflict and ensure residents are protected from physical and psychosocial harm and additional abuse during and after investigations, but the documented separation interventions for these two residents were not implemented at the time of the second incident.
Failure to Honor Right to Return and Follow Transfer/Discharge and Bed-Hold Requirements
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to return following a transfer to the emergency room and to follow required transfer/discharge and bed-hold procedures. The resident had been admitted in 2025 with traumatic subarachnoid hemorrhage, unspecified intracranial injury, dementia, cognitive decline secondary to traumatic brain injury, and anxiety, and was documented as his own responsible party. Staff, including the SSD, DOR, CNA, and LN, consistently described the resident as friendly, approachable, and generally without behavioral issues, though he sometimes repeated himself and could be confused. A BIMS score of 13 indicated he was cognitively intact prior to the transfer. The resident was involved in resident-to-resident altercations on two dates, with documentation on 1/1/26 of a physical altercation and on 1/5/26 of an incident in which another resident struck him multiple times in the face, causing swelling to his left wrist and lower left eye. Following the 1/5/26 altercation, the resident was sent to the hospital for evaluation. The Administrator stated that at the time the resident was sent to the emergency room, it was considered a transfer with the expectation that he would return to the facility. However, after the Administrator’s investigation of the incident and review with the team, it was decided that the resident would be discharged from the facility and admitted to a sister facility, with the Administrator calling the hospital to inform them of this plan. The Administrator confirmed that the discharge was facility-initiated and that the stated reason was that the resident’s safety was endangered by his own presence in the facility due to the continued presence of the other resident involved in the altercations. The Administrator also confirmed that the resident was not endangering the safety of others. The facility’s own transfer/discharge policy listed limited, specific reasons for facility-initiated discharge, including when the resident’s needs cannot be met, when the resident’s health has improved, when the resident endangers the safety or health of others, nonpayment, or facility closure; the documentation did not show that any of these criteria were met in this case. The facility also failed to provide required notices and documentation associated with the transfer and discharge. The Administrator acknowledged that she did not discuss the transfer to the sister facility with the resident, even though he was listed as his own responsible party. The Representative Payee confirmed she was not notified about the transfer and clarified that she was only responsible for financial decisions, not healthcare decisions. Review of the electronic medical record showed no physician note regarding the resident’s discharge from the facility, and no physician documentation of needs that could not be met by the facility, what was attempted to meet those needs, or what needs the accepting facility could meet that the current facility could not. Although there was a physician order allowing a seven-day bed hold, the Administrator confirmed that a bed-hold notice was not given to the resident, despite the facility’s bed-hold policy requiring written information about bed-hold practices at the time of transfer or within 24 hours in an emergency. As a result of these actions and omissions, the resident was inappropriately discharged to a sister facility after an emergency room visit and was not afforded the right to return to his original facility following the transfer.
Failure to Provide Required Transfer/Discharge Notice and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide a required written notice of transfer/discharge to a resident and to the State Long-Term Care Ombudsman when the resident was transferred to the emergency room and subsequently discharged to a sister facility. The resident had been admitted in 2025 with diagnoses including traumatic subarachnoid hemorrhage and unspecified intracranial injury, and a physician progress note documented dementia, cognitive decline secondary to traumatic brain injury, anxiety, and a need for frequent reorientation and redirection. The admission record identified the resident as his own responsible party, and the Social Services Director reported that the resident had a BIMS score of 13, indicating cognitive intactness, prior to transfer to the sister facility. On the date of the incident, the resident was involved in a resident-to-resident altercation in which another resident struck him multiple times on the left side of the face. Facility documentation described physical abuse with swelling of the left wrist and lower left eye, and progress notes indicated the resident was struck multiple times and transported by ambulance to the hospital. Interviews with the ADON, DON, and Administrator confirmed that the resident was sent to the hospital following the altercation and that the decision was later made by facility leadership to discharge the resident and have him admitted to a sister facility, characterized as being for the resident’s safety and to keep him separated from the other resident involved in the altercations. The Administrator stated she contacted the hospital and informed them that, upon discharge from the emergency room, the resident would be admitted to the sister facility, and the hospital emergency record documented this communication. However, the Administrator, Social Services Director, and other staff were unable to locate any documentation that the resident was notified of the facility-initiated discharge or transfer to the sister facility, and the Administrator confirmed that a discharge notice was not given. The Ombudsman confirmed that no notice of transfer/discharge was received regarding this resident. This was inconsistent with the facility’s own transfer and discharge policy, which requires written notice to the resident and resident representative, including reasons for transfer/discharge, effective date, receiving location, appeal rights, and Ombudsman contact information, and requires evidence that notice was sent to the Ombudsman.
Failure to Timely Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of employee-to-resident physical abuse was reported to the state agency as required. A resident alleged that a Licensed Nurse twisted his arm and took away his cat food, an incident reportedly witnessed by a CNA. The resident stated he informed the DON about being physically hurt and also called the police to make a report. Despite the resident's statements and the police being involved, the facility did not report the allegation to the state agency or other required authorities. Interviews and record reviews revealed that the DON was aware of the abuse allegation but did not report it, citing information from a police officer that the resident had recanted the story. However, review of the police report showed no evidence that the resident recanted, and the DON did not confirm this with the resident or document it in the medical record. The DON also did not interview other potential witnesses, such as the resident's roommate, nor did the facility conduct its own investigation or complete the required notifications per facility policy. Facility policy required immediate investigation and reporting of all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified time frames. The Administrator confirmed that the expectation was for all staff to report allegations immediately and make all required notifications within two hours. The failure to follow these procedures resulted in a delayed abuse investigation and a lack of required notifications.
Failure to Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of employee-to-resident physical abuse in a timely manner. A resident reported that a licensed nurse twisted his arm and took away his cat food, an incident witnessed by a certified nursing assistant. The resident stated he informed the Director of Nursing (DON) about being physically hurt and expressed that he no longer wanted the nurse to care for him. The resident also contacted the police and made a report regarding the alleged abuse. Despite being made aware of the allegation, the DON did not conduct a complete investigation, relying instead on information from a police officer who stated the resident had recanted the story and that no police report would be made. The DON did not confirm this with the resident, nor did she document this information or interview other potential witnesses, such as the resident's roommate. The facility's policy requires immediate and thorough investigation of abuse allegations, including interviewing all involved parties and documenting the process, which was not followed in this case.
Failure to Protect Resident's Personal Belongings During Hospitalization
Penalty
Summary
A deficiency occurred when a resident's personal belongings, including a cell phone and wallet containing cash and important identification cards, went missing while the resident was hospitalized. The resident, who had incomplete paraplegia and limited mobility, had requested that CNAs secure his wallet, cell phone, and other personal items prior to his transfer to the hospital. Upon his return, the resident discovered that his wallet, clothing, and cell phone were missing. Although the wallet was eventually found by a housekeeper, only the identification card was returned, and the cell phone and other items remained missing. The resident reported emotional distress due to the loss and was using a loaner phone from a friend. Facility staff interviews and record reviews revealed that the process for handling and storing residents' belongings during hospitalizations was inconsistent and lacked proper tracking. Staff described that belongings were typically bagged and placed in a former shower room or storage area, sometimes with a four-digit code accessible to all staff. Inventory sheets were supposed to be completed and signed by both a CNA and a licensed nurse, but there were discrepancies in documentation, and the missing cell phone was not consistently listed on inventory records. The Social Services Director and other staff acknowledged that valuable items were not always separated or securely stored, and the Administrator confirmed that there was no effective tracking or monitoring process for residents' belongings during absences. Facility policies required that all resident possessions be inventoried, treated with respect, and protected from loss or theft, with documentation retained in the medical record. However, the actual practices did not align with these policies, as belongings were stored in unsecured areas and not adequately tracked. This failure resulted in the loss of the resident's property and caused emotional distress, with the potential for similar incidents affecting other residents.
Failure to Maintain Boiler Heating System
Penalty
Summary
The facility failed to maintain its boiler heating system, resulting in an inoperable boiler that affected all 95 residents and all five smoke compartments. During an onsite investigation and interview with the Administrator, surveyors observed that the boiler heating system located in the mechanical room was not operational. This deficiency was identified through direct observation and confirmed by facility staff. As a result of the inoperable boiler, the facility was unable to maintain the required temperature levels throughout the building. The deficiency impacted the entire resident population, as the heating system is essential for maintaining a safe and comfortable environment. The report notes that the boiler could not be repaired after multiple attempts by heating and air system vendors, and the system remained nonfunctional for a period of time. The failure to maintain the boiler system and ensure its operability led to the inability to provide adequate heating for the residents. The deficiency was directly related to the lack of a functioning heating system, as evidenced by the observations and interviews conducted during the survey.
Plan Of Correction
1/5/26: POC approved by Cynthia Luc, SSM-I The facility will monitor the plan of correction in the QAPI meeting. The weekly parameter checks and monthly safety shutoff testing will be completed and logged by the Maintenance Director and reported weekly and monthly to the Administrator. Quarterly vendor inspection reports will be reviewed by the Maintenance Director and reported to the Administrator. These findings will be reported in the QAPI meeting for trending, analysis, and any further recommendations. Any audit discrepancies will trigger immediate corrective action, retraining, and evaluation. If no negative trends are identified after six months, the item will be removed from the QAPI agenda. All corrective actions will be fully implemented by 1/4/2026. The facility will monitor the plan of correction in the QAPI meeting. The weekly parameter checks and monthly safety shutoff testing will be completed and logged by the Maintenance Director and reported weekly and monthly to the Administrator. Quarterly vendor inspection reports will be reviewed by the Maintenance Director and reported to the Administrator. These findings will be reported in the QAPI meeting for trending, analysis, and any further recommendations. Any audit discrepancies will trigger immediate corrective action, retraining, and evaluation. If no negative trends are identified after six months, the item will be removed from the QAPI agenda. All corrective actions will be fully implemented by 1/4/2026. HVAC - Operating Features: The facility will follow the Emergency Operations Plan for notification to state survey agency of nursing home situation. Immediately upon discovering the failure to report the unusual occurrence, the facility discussed the incident in question with the CDPH surveyor who was conducting an abbreviated survey. An internal review of the incident was completed to determine root causes. The Administrator was interviewed and re-educated on reporting requirements. To ensure no similar oversight occurred, the previous 30 days of incident logs, nursing notes, and daily shift reports were audited by the Administrator on 12/19/25. Any event fitting CDPH's definition of an unusual occurrence was reviewed to verify it had been properly reported. No additional unreported unusual occurrences were identified. On 12/16/25, the Administrator received education from the Regional Operations Director on Title 22 §72541 reporting requirements, definitions of unusual occurrences, and required timelines and reporting processes. A CDPH Reporting Log was implemented to track all facility reported incidents from initial notice through CDPH submission. To ensure sustained correction, the Administrator will perform a weekly audit of all incidents for 12 weeks. After 12 weeks, audits will continue monthly for an additional 6 months. Findings will be reported at the Quality Assurance Performance Improvement (QAPI) meeting each month. Any identified gaps will result in immediate retraining and corrective action. All corrective actions will be fully implemented by 1/4/2026.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 506 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestwood Manor - 104 | 0.1 mi | ★★★★★ | 3 | 0 |
| Oak Grove Post Acute | 1.2 mi | ★★★★★ | 62 | 0 |
| Fulton Gardens Post Acute, Llc | 1.6 mi | ★★★★★ | 20 | 0 |
| Noble Care Center | 1.8 mi | ★★★★★ | 8 | 0 |
| Good Samaritan Rehab And Care Center | 1.8 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.